Evaluation of Surveillance System Faridabad District, Haryana under Integrated Disease Surveillance Project.

EP-152 Design, Conduct, Document and Evaluate Surveillance System

By

II Semester, Batch 2011-13 Master of Public Health (Field Epidemiology) National Centre for Disease Control, Delhi

Under Guidance
Dr Himanshu Chauhan, Assistant Director Dr Neeti Rustagi, Assistant Director Division of Epidemiology

National Centre for Disease Control, Delhi

Contents
I. 1. 2. 3. 4. 5. 6. 7. Abbreviations Introduction Background Objectives Methodology Findings Gaps and constraints Conclusions and recommendations

Page
3 4 6 7 7 11 29 29

LIST OF ABBREVIATIONS
ADD AES ANM ARI CHC CSU DSO DSU GE IDSP IEC ILI JE OPD P form L form PHC RRT RU TB SC Acute Diarrheal Diseases Acute Encephalitic Syndrome Auxiliary Nurse Midwife Acute Respiratory Tract Infection Community Health Centre Central Surveillance Unit District Surveillance Officer District Surveillance Unit Gastroenteritis Integrated Diseases Surveillance Project Information, Education and Communication Influenza Like Illness Japanese Encephalitis Out Patient Department Presumptive diagnosis form Laboratory diagnosis form Primary Health Centre Rapid Response Team Reporting unit Tuberculosis Sub Centre

Introduction
Surveillance is the ongoing systematic collection, collation, analysis and interpretation of data, and dissemination of information to those who need to know in order that action may be taken in controlling and preventing diseases. An established disease surveillance system is an essential tool to detect, investigate and respond to the disease outbreaks in a timely and effective manner. Timely reporting and analysis of surveillance data gives the early warning signal of an impending outbreak through which middle level managers may alert their team for early response.

Under the support from the World Bank, Integrated Disease Surveillance Project (IDSP), a decentralized disease surveillance project was initiated by the Government of India (GoI) in November 2004. It has been renamed as Integrated Disease Surveillance Program and is being funded by the GoI from the 12th five year plan which began in March 2012. The main aim of this program is to detect early warning signals of impending outbreaks to help initiate an effective response in a timely manner. To achieve its goal the IDSP has been decentralized to the districts to strengthen and improve the traditional hospital based disease surveillance in the country. This program identifies the priority diseases of national and international public health importance from the Centre. Besides it has the flexibility for the states and the districts for inclusion of other diseases that are nuisance to local public health measures. The reports are generated from various health centres and data uploaded on a timely manner to detect an impending outbreak and to prevent the spread of disease in the community through available prevention and control methods.

Surveillance, thus, is collection of information for action. Disease surveillance is an ongoing systematic collection and analysis of data that leads to action being taken to prevent and control disease. By preventing outbreaks, the morbidity and mortality in the community is averted and the credibility of the health services is known. Hence, surveillance remains the watch dog of a good public health system enabling the public health specialists, decision makes, politicians and others to choose and decide on the measures to be taken efficiently and cost-effectively. The six main steps in surveillance

a link to public health program specially actions for prevention and control

Information flow under IDSP Under IDSP disease surveillance data is collected on a weekly (MondaySunday) basis and immediate (SOS) on imminent outbreaks. The weekly data gives the time trends and silent outbreaks. The IDSP has a web portal through which information can be directly uploaded at district and is accessible at www.idsp.nic.in.

Reporting formats under IDSP The information is collected on three specified reporting formats, namely S (suspected cases), P (presumptive cases) and L (Laboratory confirmed cases), the data for which is generated by Health Workers, Clinician and Clinical Laboratory staff respectively. Emphasis is being laid on

reporting of surveillance data from major hospitals both in public and private sector and also Infectious Disease hospitals. Paramedical staff and pharmacists can be crucial links in collating the P form data from hospitals.

Background:
Faridabad is located in the state of Haryana. Faridabad is about 25 Kilometers from Delhi in 28 25' 16" North Latitude and 77 18' 28" East Longitude. It is bounded by Union Territory of Delhi (National Capital) on its north, Gurgaon District on the west, Palwal District on the south and State of Utter Pradesh on its east. Delhi-Mathura National Highway No.2 (Shershah Suri Marg) passes thru middle of District. Faridabad district is divided into two sub divisions viz. Faridabad & Ballabgarh each headed by a Sub Divisional Magistrate. The Municipal Corporation, Faridabad provides the urban civic amenities to the citizens of Faridabad City. As per the 20011 census Faridabad has a population of 17,98,954 consisting of 9,61,532 males and 8,37,422 females.

Figure 1. District map of Faridabad

Objectives of the study:

To describe the Integrated Disease Surveillance Project (IDSP) in Faridabad district, Haryana. To study the attributes of IDSP in Faridabad district. To assess the effectiveness of the ongoing surveillance system.

Methodology:
Study design: Cross Sectional Study Quantitative data was used for the study. Quantitative data was collected by observing the formats/records. Study period:

The study was conducted from the February 27,2012 to February 29. 2012.

The study area

Figure2. District map of Faridabad showing the location of health facilities. Sampling: The existing integrated disease surveillance system of Faridabad district in Haryana state was selected for study. The District Surveillance Unit (DSU), one Community Health Center (CHC), one Primary Health Centers (PHC) and two Sub Centers (SC) were selected conveniently.

Figure 3: Sampling frame and unit DSU- Faridabad

CHC - Kurali

PHC- Dayalpur

Sub CentreChandawali Definitions:

Sub Centre-

Dayalpur

The following the definitions were used for the attributes of the surveillance system: Completeness: Completeness refers to proportion of formats expected to receive filled completely accuracy of data recorded. Timeliness: Number of reporting units submitting report to the next higher level within one week Sensitivity: The ability to detect outbreaks, including the ability to monitor changes in the number of cases over time. Completeness: 9 report generation.

A report is said to be complete if all the reporting units within its catchment area have submitted the reports within the time period.

Flexibility: It is the capacity of the form to accommodate diseases other than those mentioned

Data collection tools and methods:

Semi-structured questionnaire and observation checklist was used for data collection. Existing forms and formats, outbreak reports, feedback report were reviewed.

Data analysis:
Data management and analysis was done mainly by using MS Excel. Attributes including completeness and timeliness of the reporting were assessed, and the results compiled using tables as necessary.

Ethical considerations:
A request letter from NCDC, Delhi to the District Surveillance Officer, Faridabad, Haryana to conduct the study was forwarded. The objectives of the study and right of refusal to respond to the questionnaires were explained to each of the respondents before interviewed. Secondary data Health records, registers and other surveillance system related documents were reviewed upon the approval of responsible personnel and contents of the documents will be used only for learning purpose.

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Findings
Basic resource available:
Health Infrastructure: There were 10 hospitals (2 public hospitals, 6 private and 2 ESI).There was only one Medical college hospital (Private), there were 2 CHC, 12 PHC and 58 SC. There was one public laboratory attached to DSU under district Government authority and two public laboratory attached to each of the CHC. There were 8 dispensaries functional under ESI scheme in the district. Table No 1.Health institutions in Faridabad, Haryana Type of Health Intuitions Hospitals Medical College Hospital Government Taluk Hospitals Laboratory (District level) Laboratory (CHC Level) Dispensaries CHC PHCs SCs FRU Reporting Units Public 2 0 1 1 2 8 Private 6 1 0 ESI 2 0 0 Total 10 1 1 1 2 8 2 12 58 1 128

Population Covered in Selected study area Total population of district surveillance unit is 1364123. The population covered by our study is shown in table 5.The CHC was covering a population of 2, 50, 000, PHC Dayalpur covers a population of 20,000, SC Dayalpur catering to a population of 4,000 whereas sub centre Chandawali was catering to a population of 9,000 covering two villages.

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Table 2. Population of study area Faridabad, Haryana, 2001 Institution District Kurali CHC Dayalpur PHC Dayalpur SC Chandawali SC Total population 1364123 2,50,000 20,000 4,000 9,000

Human Resource Situation in the study area: There are 100 % staffs available at DSU and 66.66% staffs available at CHC Kurali. Dayalpur PHC has 100% staffs available. There was 100% staff available at sub centre Dayalpur while at the sub centre Chandawali there was 33.33% staffs available. . While both the Sub-centers have 100% staffs available. Overall in study area 83% staffs was available, against the sanctioned post.(Table no. 3 and 4)

Table No.3 Human resources in the study area, Faridabad district, Haryana

DSO

MO
Sanctioned Fulfilled

Lab Technician
Sanctioned Fulfilled

Pharmacist
Sanctioned Fulfilled

STAFF
DSU CHC (Kurali) PHC(Dayalpur)

Sanctioned

Fulfilled

1 4 1

1 2 1

1 1 1

1 1 1 1 1 1 1

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Table No.4 Human resources in the study area, Faridabad district, Haryana LEVEL DSU OTHER STAFF Municipal Health Officer Data MANAGER Data entry operator Training officer ANM ASHA HW Status of physical facilities: In the district surveillance unit, all data management, communication and lab facilities were available. Lab facilities, Computer and telephone, internet facilities were also available in CHC. At PHC Dayalpur also there were lab facilities, computer and telephone for communication. While Sub centre Dayalpur has both computer and telephone facility, the sub centre Chandawali has only telephone but no computer facility. Laboratory of CHC provide routine investigations and provides support to PHC and SCs. Table No.5 Status of physical facilities of study area, Faridabad district, Haryana Lab Computer Internet Telephone Facility facility Facility (Y/N) (Y/N) (Y/N) (Y/N) Yes Yes Yes Yes Yes Yes Yes No Yes Yes No No Yes Yes No No Yes Yes Yes Yes Fax (Y/N) Yes Yes No No No Scanner Hi-end VC (Y/N) Equipment (Y/N) Yes No No No No Yes No No No No 8 5 2 2 CHC PHC Sanct Fullf SC(DAYALPUR) SC(CHANDAWLI) Sanct Fullf Sanct Fullf

Sanct Fullf Sanct Fullf 1 1 1 1 1 1 1 1 1 1

2 7

2 7

4 2

0 2

Level
DSU CHC(Kurali) PHC( Dayalpur) SC (Dayalpur) SC (Chandawali)

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Existing Disease Surveillance System

Diseases Covered Under Surveillance System:

ADD, Bacillary Dysentery, Viral Hepatitis, Enteric Fever, Malaria, Dengue/DHF/DSS, Chikungunya, AES, Meningitis, Measles, Diphtheria, Pertussis, Chickenpox, PUO, ARI/ILI, Pneumonia, Leptospirosis, AFP, Dog Bite, Snake Bite are covered under the surveillance system. Malaria, Dengue and Cholera are notifiable diseases in the district. The Sub-centre covers six syndromes in S form as per the IDSP. PHC, CHC and Hospital report P Form which includes 20 diseases. CHC, District Hospital, PHC having Laboratory facility report L form which includes 8 diseases.

Table No.6 Diseases/Syndromes Reported under surveillance system Faridabad district. Filled by institutions SC No of disease reported 6

Types of forms S Form

Diseases Fever, cough with or with fever, Loose watery stools <2 weeks duration, Jaundice <4 week, AFP, Unusual symptoms leading to death or hospitalization ADD, Bacillary Dysentery, Viral Hepatitis, Enteric Fever, Malaria, Dengue/DHF/DSS, Chikungunya, AES, Meningitis, Measles, Diphtheria, Pertussis, Chickenpox, PUO, ARI/ILI, Pneumonia, Leptospirosis, AFP, Dog Bite, Snake Bite Dengue/DHF/DSS, Chikungunya, Typhoid Fever, Cholera, Shigella Dysentery, Viral Hepatitis A, Viral Hepatitis E, Malaria

P Forms

PHC, CHC, Hospital

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L Forms

CHC, Hospital, PHC

District surveillance unit was not getting any reports of these diseases from private practitioners including private nursing homes... From SC reporting is done by health worker on Phone/ in

person to PHC. From PHC reporting is done by medical officer by email/ in person to DSU.

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From CHC reporting is done by medical officer on email/Phone/in person to DSU. From Hospitals reporting is done by medical officer on email/Phone to DSU. DSU sends weekly Communicable disease report to SSU Chandigarh by email/ fax as well as monthly by Fax, email, letter to state SSU. DSU gets weekly confirmed and probable cases report from Hospitals and Medical College for early case investigation and start preventive measures. CHC/PHCs/SCs are informed daily by email /phone to investigate confirmed and probable cases of epidemic prone diseases by the DSU.

Level

Day of reports Person responsible Mode of information flow

Report to

SC PHC CHC Hospital DSU

Monday Tuesday Tuesday Tuesday Wednesday

Health worker Medical officer Medical Officer Medical Officer DSO

Phone and in person E-mail and in person

PHC DSU

E-mail, phone and in person DSU E-mail, phone fax/ email DSU SSU

Table No.7 Data Transmission under IDSP, Faridabad district, Haryana.

Data Collection, Compilation and Transmission: There is one Medical college Hospital, ten Hospitals, two Community Health Centers, one District Laboratory and two CHC Laboratories. There are 2 CHCs, 12 PHCs, 63 Sub-centers and 6 dispensaries which are the reporting units of the district.

Data collection for disease surveillance system begins from the village level through the Health sub-centers passively from minor ailment conducted by the SC and actively through village 15

visits by the Auxiliary Nurse Mid-wife (ANM). PHCs, CHCs, and Hospitals also sent their communicable disease report weekly to the district surveillance unit on P forms through compilation of cases seen at the OPDs and laboratory data on L forms. Sub-center sends their reports to the respective PHC or CHC. PHC/CHC compiles the reports received from their subcentre in their P forms and send to DSU.

Table No.8 Reporting tool under IDSP at CHC and PHC in study area Faridabad district, Haryana REPORTING TOOL Reporting using "P" forms Reporting using "L" forms "P" form filled by "L" form filled by Pharmacist Lab Technician OPD register, P form register, In Forms Filled using Format of report Report Sent Patient register Hard Copies/Soft Copies Weekly ( Tuesday) Yes Medical officer Lab Technician OPD register, P form register, Patient ticket Hard Copies/Soft Copies Weekly ( Saturday) Yes Yes CHC PHC

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Figure3. Flow of Information under IDSP

CSU SSU DSU

CHC PHC District Hospital

SC

SC

ASHA

ASHA

Data Analysis and Interpretation:

Data analysis was done at PHC, CHC and DSU according to the capacity of personnel involved. Sub-centre staff gives information to their respective PHC or CHC on the unusual increase in any syndrome. DSO of district surveillance unit and Medical Officer of PHC and CHC are responsible for analysis in coordination with Entomologist, microbiologist and pharmacist. DSU enters the data daily and analyzed the data by weekly and compares with previous week. CHC/ PHC analyze their data during their weekly and monthly meetings. However we could not get any record of analysis and meeting minutes.

The interpretation of data was done at DSU in terms of time, place and person. PHC and CHC also interpret the data to identify the high risk population and outbreaks or potential outbreaks. 17

Decision and response:

Decision and response of the surveillance system is primarily by DSO and the MOs of CHC and PHC for technical part. If district surveillance unit receives any outbreak information within the district, initial response is taken by the Medical officer of respective PHC or CHC and finally District RRT are involved for outbreaks containment as per need. District Surveillance Officer is the focal person for outbreak investigation.

Feedback:

Feedback of disease surveillance is provided by DSU to all CHC, PHC and SC during monthly routine meeting. Review meeting at the SSU conducted once in three to four months. Informal feedback through phone calls in case reports are not received on time or incomplete reports are received.

Surveillance Support Functions:

Case definition: Case definitions were available in DSU, CHC and PHC. At SC though case definitions were available the health workers were not aware of the case definitions. Availability of forms and guidelines: The data from the S and P was maintained in separate registers at the CHC and PHC. At the DSU only the Medical Officer training manual was available and the paramedical staff training manual was not available. At the CHC there was no training material available. S, P, and L forms for weekly reporting forms were available at the DSU, CHC and PHC. At the SC S forms were not available. At the DSU the case definitions were displayed prominently at the lab 18

where as at the CHC no such information board was available. There were no guidelines available at the DSU regarding specimen collection or outbreak containment or at the CHC. At the CHC the OPD register was available for review and the diagnosis for each patient was written. The CHC had a list of reference laboratories for various tests. At the IDSP laboratory the new L form was available and were following biomedical waste management guidelines. However there were no guidelines regarding specimen collection, packaging and referral.

Table No.10 Availability of DSU forms and guidelines

Guideline Case definition Training manuals Medical Officer Para Medical Forms S P L1/L2 IEC materials for surveillance. Guidelines for - Specimen collection, packaging and referral. No - Outbreak containment. No Yes Yes Yes Yes Yes No Availability Yes

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Table No.11 Availability of CHC forms and guidelines

Register Rumor register OP register List of reference lab Case definition Training manuals Forms S P L1 IEC materials for surveillance. Surveillance standards and guidelines for priority diseases No Guidelines for -specimen collection, packaging and referral. -outbreak containment. No No Yes Yes Yes No Availability No Yes Yes Yes No

Table No.12 Availability of forms and guidelines at the District IDSP laboratory Guidelines Availability New L form Yes Guidelines for specimen collection, packaging and referral. No Bio-safety & Bio Medical Waste Management (BMWM) policy Personal Protective Equipment Gloves Mask Apron Others Yes

Yes Yes Yes

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Training: Only 42.11% of the staff involved in surveillance activities were trained by IDSP. At the DSU only 28.60% of the staff was trained. At the CHC, PHC and SC the health workers were trained where as the other staff were not trained for surveillance activities.

Table No.13 IDSP training status in study area Faridabad district, Haryana 2012 LEVEL IDSP TRAINING STATUS Fulfilled Trained Untrained % staff Trained DSU CHC PHC SC DAYALPUR SC CHANDAWALI Total Rapid Response Team (RRT): A district RRT exists which supports investigation of any outbreaks in the district. The District Rapid Response Team meets as and when required during outbreaks. In the district RRT only the epidemiologist and entomologist were trained under IDSP. There was no information regarding the RRT was not displayed in the DSU i.e. the contact number. 7 10 6 9 6 38 2 5 2 5 2 16 5 5 4 4 4 22 28.60% 50.00% 33.33% 55.55% 33.33% 42.11%

Table No.14 List of District RRT members of Faridabad district, Haryana 2012
District RRT Epidemiologist Entomologist Microbiologist Physician Sanctioned Fulfilled 1 1 1 1 1 1 1 1 Institution District Surveillance Unit. District Surveillance Unit. District Surveillance Unit. District Surveillance Unit Trained/Not Trained Trained Trained Not Trained Not Trained

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Laboratory Facilities The Laboratory facilities are available at the District Hospital and Community Health Center, however at the CHC, only routine laboratory investigations are being done. At the district IDSP lab not all tests as per the guidelines are performed. A majority of the tests were being performed at the laboratory of the district hospital and not the IDSP laboratory. There are no guidelines regarding the quality control at the DSU or at the CHC. The DSU did not take part in external quality assurance and did not conduct quality assurance of the CHC laboratory. Both the district lab and the CHC laboratory were forwarding 5% of samples to the state and district laboratories for verification. The district lab was only performing rapid diagnostic tests for malaria and dengue. Water analysis is done by public health laboratory as per need.

Table No.15 Tests performed at the IDSP Laboratory, District Government Hospital, Faridabad. Name of Disease Typhoid Cholera Dengue Leptospirosis Meningococcal Typhoid Diphtheria Viral Hepatitis Measles Other locally prevalent epidemic prone diseases Performed Yes Yes Yes No No Yes No No No Nil

MPN test for water quality No Malaria Chikungunya Yes Yes

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Table No.16 Functions of the IDSP Laboratory being performed. Function Internal quality controls (IQC) are being used External quality assessment scheme (EQAS) Quality assurance of L1 lab Performed No No No

Transport relevant samples for testing Yes at L3 lab Transport 5% of tested samples to L3 Yes for testing and QA Reporting test result to L1 lab for Yes sample received from L1 lab- no samples received Reporting test result weekly to DSO Yes

Table No.17 Functions of the Laboratory Community Health Centre, Kurali.

Lab Function Performed

1.Collection of samples for investigations 2.Perform the quality Laboratory tests assigned to the L1 levela. Microscopy for Malaria b. Microscopy for TB c. Typhidot test for Typhoid fever d. WIDAL test e. H2S test for water quality. f. Hanging drop for V. Cholera g. Stool for Ovacyst (Eh) h. Occult blood i. Grams Stain for Throat swab, sputum. 3. Transport of relevant sample to L2 lab for culture serological investigations 4. Assist rapid response team in sample collection 5. Participate in external quality assurance conducted by L2 lab

Yes Yes Yes No No No No No No No other Yes

and

Yes No

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Intersectoral Co-ordination: The intersectoral co-ordination activities were limited to the DSU receiving information on the vector indices from the Municipal Health officer who was then involved in vector control measures. The DSU was involved in forwarding samples to NICD last year when ELISA reader was working for testing of H1N1. Entomological surveys are carried out during the monsoon season by coordination between the DSU and the municipal health authorities.

Attributes of surveillance
Uniformity of reports: The report on outbreak and S P L forms observed are uniform in content. All levels of IDSP (SC, PHC, CHC, and DSU) send their reporting forms on fixed date by mail/phone or hard copies of reports. The reports are done on Monday of every week. Simplicity: The records were well documented in registers and communicated on time when verified with the concerned personnel. The institutions are well habituated to record and register the events and report it appropriately. The actual situation of simplicity (no. of forms to be filled, clarity, ease to use, process and procedures and working time to fill the forms) could be assessed as the S, P, L forms are readily available in SC, PHCs and CHCs. Table. No.18 Status of forms and their use in IDSP Faridabad district, Haryana 2012
DSU Observations Availability of formats (yes/no) Type of formats used Type of reports analyzed Analysis (computer or manual) Yes CHC Yes S,P,L (3) D, W, M Computer and manual PHC Yes S,P (2) Computer and manual SC Dayalpur Yes NA Manual SC Chandawali Yes NA Manual

D, W, M Computer

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Completeness of reporting: A total of 232=S, 144=P and 136= L forms for last two months January and February were expected from the health centres of entire district. These reports are for a total of 7 epidemiological week beginning week 1 and up to week 7. 97.41 % of S and 58.82 % of L forms were received while 65.27 % (94/144) P forms were received.

Table No.19 Completeness of reporting for surveillance system CATEGORY Total Weekly Report Monthly Report No. No. No. % No. No. expected Received expected Received S form 58 406 383 94.33 232 226 P form L form Total 36 34 128 252 238 896 155 134 672 61.5 144 56.30 136 75 512 94 80 402

% 97.41 65.27 58.82 78.51

Timeliness of reporting: The S, P L weekly reports for 1week period for the study area was assessed at the DSU to determine the timeliness. Reports are either received through phone call, email or hard copies. The total numbers of S P L forms received on time were 95 out of 128 expected which corresponds to 74.21 %.

Table No.20 Timelines of reporting for surveillance system Indicator

Proportion of RUs that No. of RUs that submitted Total no. of submitted surveillance reports surveillance reports on time-95 reporting units128 on time

Percentage
74.21%

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Sensitivity: Total three (3) outbreaks reported from Faridabad district were reviewed, for last 3 years. Dengue outbreak was detected by surveillance system comparing the weekly surveillance data. Chicken pox and H1N1were the other outbreaks. All three outbreaks were investigated and managed on time. Rumor registers were not available in any health centres.

Table No.21 Sensitivity of the surveillance system Indicator No. of Case detection: outbreaks Proportion of outbreaks detected last 3 years detected-3

No. of outbreaks that have occurred-3

Percentage 100%

Acceptability: The proportion of reporting units submitting reports were 103 out of total of 128 reporting units
which corresponds to 80.46% for the entire district of Faridabad.

Table No.22 Acceptability of the surveillance system Indicator

Proportion of reporting units submitting reports No. of reporting units Total no. of submitting reports-103 reporting units-128

Percentage
80.46%

Representativeness: The total numbers of reporting units are represented by both the Government health set up as well as the private reporting units. A total of 121 government reporting units and 7 private reporting units represented the total reporting units which correspond to 94.53% and 5.465 respectively.

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Table No. 23 Representativeness of surveillance system Indicator

Type of facilities participating in the system No. of government reporting units121 Total no. of 94.53% reporting units-128 No. of private reporting units-7 5.46% No. of reports received from 80.46% government reporting units-103 Total no. reports expected-128 No. of reports from private reporting 0% units-0 No. of Sentinel Practitioners-0 Private 0%

Percentage

Flexibility: It is the capacity of surveillance system to accommodate other diseases which are not as per the mandate of this system. No report of diseases other than the available list. Table No. 24 Flexibility of the surveillance system Indicator
Capacity of the form to accommodate other diseases

Percentage
No. of reports with diseases other than in list-None

Usefulness:

There is system of monthly meeting at DSU among the representatives of each health centre, a medical officer and data manager usually attends it. They provide verbal feedback during the meeting. Sometimes they get copies of meeting minute as written feedback, according to which they immediately take necessary action. The agenda of the review meetings are about

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strengthening of surveillance system, to be vigilant and conduct IEC activities. District expects few outbreaks related to water, food and vector in a year.

Preparedness for outbreaks: There is RRT available at district level with list of Rapid Response Team members (DSU) and their contact numbers being maintained. The investigation and the final reports are also

documented. RRT has investigated 2 outbreaks in the last one year out of the three out breaks detected. 1. Dengue 2. Chickenpox 3. H1N1 The surveillance system also has a preparedness plan for seasonal diseases. For vector borne diseases surveillance is conducted during the pre-monsoon and monsoon season. Information was given by health worker Investigation started as soon as information was got Confirmed by lab diagnosis RRT was involved in control measures

As a control measure they follow a weekly temephos application, fogging using pyrethrum as and when required, IEC activities and vector surveillance. Water quality monitoring is being done by Public Health Engineering Department.

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Gaps/Constraints
Human resource are inadequate at DSU,CHC,PHC and SC. Health workers and other staff to be trained for carrying out surveillance activities. To establish a system of feedback at all levels. No reporting from private sector. Rumor register not available at various levels.

Conclusion and Recommendations

Conclusion: Surveillance system seems to be functioning to an acceptable level to capture and manage outbreaks. Daily scenario of major epidemic prone diseases for prompt action and future planning is available Immediate action on outbreak investigation and management is evident. Inadequate capacity of health workers at peripheral level to conduct IDSP activities. Recommendations: According to the findings and conclusion of the study of the disease surveillance system in the district following recommendations were offered. Emphasis should be laid to increase the human resources for better and efficient working of the surveillance system. The general IDSP training coverage for the staffs should be increased at all level. Regular feedback system should be developed at all the levels. The private sectors should be facilitated to get involved more.

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