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273Introduction to Health Systems
2. DOT 99: It is an approach for monitoring and improving
TB medication adherence among patients. 99DOTS 99
introduces an antiTB blister pack wrapped in a custom
envelope, which includes hidden toll-free phone numbers
that are visible only when doses are dispensed. The patient
is expected to call this number as he takes out a tablet. It
was introduced to ensure a 99% cure rate.
Fig. 5.5: 99DOTS 99 Medicine Package
3. MERM container box: It is a medicine event reminder
box. This is a GPS-enabled box that detects when the
patient has taken the medicine and informs on the
NIKSHAY portal.
Fig. 5.6: MERM container box
Government Schemes under NTEP: Existing Government
Schemes under NTEP for the benefit of TB patients and
providers include:
1. Free pre-treatment evaluation of MDR patient with travel
support to the patient and one attendant.
274 Social Pharmacy
2. Free and quality treatment for all types of TB.
3. Free diagnosis of TB.
4. Free monthly routine diagnostic services to MDR TB
patients.
5. Free chest X-ray service to all eligible presumptive TB
cases.
6. Nikshay Poshan Yojana (NPY): Rs 500/month to all types
of TB patients for the complete duration of anti-TB
treatment.
7. Informers incentive: @ Rs 500 per confirmed TB Case.
Integrated Disease Surveillance Project (IDSP)
Disease surveillance is the backbone of public health programs
in India. Integrated Disease Surveillance Project (IDSP) is a
decentralized, state-based surveillance program in the country
launched with World Bank assistance in November 2004. It is
intended to detect early warning signals of impending
outbreaks, identify their causes, and take timely preventive and
responsive measures. It also provides essential data to monitor
the progress of ongoing disease control programs and helps
allocate health resources more efficiently and optimally. The
IDSP proposes a comprehensive strategy for improving disease
surveillance and response through an integrated approach.
Surveillance activities are carried out under various vertical
disease control programs like programs on malaria, tuber-
culosis, HIV/AIDS, and disease. Reproductive Child Health
(RCH) Program (measles, polio, acute diarrhea) as well as some
state-specific diseases have been integrated under IDSP. This
will be affected through data generation using uniform and
common reporting formats, collection, compilation, and
analysis, and using a common IT network for transmission to
state and central levels.
The data is collected and analyzed by the Surveillance Unit
(CSU) at Delhi, state surveillance units (SSU) at all state/UT
head quarters and district surveillance units (DSU) at all
districts in the country.
275Introduction to Health Systems
Objectives of IDSP
1. To strengthen/establish decentralized laboratory infor-
mation technology (IT) enabled disease surveillance
system for communicable and non-communicable
diseases.
2. To detect the early warning signals, monitor the progress
of ongoing disease trends, and detect and respond to
outbreaks in the early rising phase through trained rapid
response teams (RRTs) in the country at the district, state,
and national levels.
3. To strengthen the disease surveillance and response
system by placing one epidemiologist/microbiologist/
entomologist each at state/district headquarters and one
microbiologist and entomologist each at the state
headquarters.
Key Features of IDSP
1. Surveillance units have been established in all states/
districts (SSU/DSU).
2. Training of state/district surveillance teams and rapid
response teams (RRT) has been completed for all
35 states/UTs.
3. IT network connecting 776 sites in states/district HQ and
premier institutes has been established with the help of
National Informatics Centre (NIC) and Indian Space
Research Organization (ISRO) for data entry, training,
video conferencing, and outbreak discussion.
4. Under the project weekly disease surveillance data on
epidemic-prone diseases are being collected from
reporting units such as sub-centers, primary health
centers, community health centers, hospitals, and medical
colleges. The data are being collected on ‘S’ syndromic; ‘P’
probable; and ‘L’ laboratory formats using standard case
definitions. Presently, more than 90% of districts report
such weekly data through e-mail/portal. The weekly data
are analyzed by SSU/DSU for disease trends. Whenever
there is a rising trend of illnesses, it is investigated by the
RRT to diagnose and control the outbreak.
276 Social Pharmacy
5. States/districts have to notify the outbreaks immediately
to the system.
6. Establishment of media scanning and verification cells to
detect and share media alerts with the concerned states/
districts for verification and response.
7. Establishment of a 24/7 call center to receive disease alerts
on a toll-free telephone number (1075). The cell provides the
collected information to the States/districts’ surveillance
units for investigation and response.
8. Strengthening of district laboratories for diagnosis of
epidemic-prone diseases.
Programme Components
1. Integration and decentralization of surveillance activities
through the establishment of surveillance units at the
centre, state, and district levels.
2. Human resource development—training of state surveil-
lance officers, district surveillance officers, rapid response
team, and other medical and paramedical staff on
principles of disease surveillance.
3. Use of Information Communication Technology for
collection, collation, compilation, analysis, and dissemi-
nation of data.
4. Strengthening of public health laboratories.
5. Inter-sectoral co-ordination for zoonotic diseases.
Organization Structure
1. Central Surveillance Unit (CSU): Integrated adminis-
tratively and financially with the National Centre for
Disease Control (NCDC), Delhi.
2. State Surveillance Unit (SSU): One in each state/UT with a
regular officer identified as a State Surveillance Officer
(SSO).
3. District Surveillance Unit (DSU): One in each district with
a regular officer as District Surveillance Officer (DSO).
Types of Surveillance
Depending on the level of expertise and specificity, disease
surveillance in IDSP will be of the following three categories:
277Introduction to Health Systems
A. Syndromic
The diagnosis is made based on symptoms/clinical patterns
by paramedical personnel and members of the community.
Syndromes under surveillance in IDSP include:
1. Fever
a. Less than 7 days duration without any localizing signs
b. With rash
c. With altered sensorium or convulsions
d. Bleeding from skin or mucus membrane
e. Fever more than 7 days with or without localizing
signs
2. Cough more than 3 weeks duration
3. Acute flaccid paralysis
4. Diarrhea
5. Jaundice
6. Unusual events causing death or hospitalization.
Table 5.6. Clinical syndromes and diseases
S. Syndrome Diseases
no.
1. Fever with or without Malaria, typhoid, JE, dengue, measles
localizing signs
2. Cough more than 3 weeks Tuberculosis
3. Acute flaccid paralysis Polio
4. Diarrhea Cholera
5. Jaundice Hepatitis, laptospirosis, dengue,
malaria
6. Unusual syndromes Anthrax, plague, emerging epidemics
2. Presumptive
The clinical diagnosis is made based on typical history and
clinical examination by a medical officer, e.g. acute diarrheal
disease (including acute gastroenteritis), bacillary dysentery,
viral hepatitis, enteric fever, malaria, dengue, acute encephalitis
syndrome, meningitis, measles, diphtheria, pertussis, chicken
pox, fever of unknown origin, acute respiratory infection/
influenza-like illness, pneumonia, leptospirosis, acute flaccid
278 Social Pharmacy
paralysis <15 years of age, dog bite, snake bite, any other state-
specific disease, unusual syndromes not captured above.
3. Confirmed
In this, clinical diagnosis is made by a medical officer and/or
through positive laboratory identification, e.g. dengue/dengue
hemorrhagic fever (DHF)/dengue shock syndrome (DSS),
chikungunya, meningococcal meningitis, typhoid fever,
diphtheria, cholera, shigella dysentery, viral hepatitis A, viral
hepatitis, leptospirosis, malaria.
Methods of Surveillance
1. Active surveillance
Active search is carried out under some specific circumstances
such as during outbreaks. In active surveillance health worker
goes into the area or house to house and collects information,
i.e. active surveillance.
2. Passive surveillance
It is a universalized method of data collection. Health workers/
ANMs report all patients fulfilling the clinical syndrome from
an area covered by the subcenter. Medical Officers at the
Primary Health Centre (PHC) or Community Health Centre
(CHC) level will report probable or confirmed cases as
applicable. It is suggested that each of the units report at weekly
intervals. The data is received from as many health workers or
health facilities as possible.
3. Sentinel surveillance
This system is used to get high-quality data about a particular
disease. Reporting units, with a large number of cases of the
disease in question, good diagnostic laboratory facilities, and
experienced well-qualified medical staff are considered sentinel
centers. A sentinel system deliberately involves only a limited
network of carefully selected reporting sites. Data collected in
a well-designed sentinel system is used to signal trends, identify
outbreaks, and monitor the burden of disease in a community.
Because sentinel surveillance is conducted only in selected
279Introduction to Health Systems
locations, it may not be as effective for detecting rare diseases
or diseases that occur outside the catchment areas of the sentinel
sites. This form of surveillance will be used for sexually
transmitted diseases/blood borne (HIV/HBV, HCV), water
quality, air quality, etc.
4. Laboratory surveillance
The laboratory network reports independently all confirmed
cases and data is used to find changes in the pattern of
syndromes and helps in the diagnosis of new cases for case
management. The data help in the identification of new agents
and changes in the behavior of microorganisms especially
concerning susceptibility to anti-microbial drugs.
5. Sample surveys
Sample surveys may be conducted to collect baseline data
before the start of a large control program. In IDSP non
communicable diseases (NCD) risk factors may be collected
through regular surveys (3 to 5 yearly). Although surveys give
reliable epidemiological information they are difficult to
conduct and are relatively costly.
6. Outbreak investigations
Outbreak investigation is the basic method of confirming
emerging infections. It provides information on the magnitude,
distribution, and possible cause of the outbreak.
7. Special studies
Special studies are sometimes required to study a specific
problem (e.g. increased prevalence of disease cases due to
environmental pollution, multi-drug resistant microorga-
nisms).
IDSP Achievements
1. Central Surveillance Unit (CSU) is established and
integrated into the National Centre for Disease Control.
2. Surveillance units have also been established at all states
and district headquarters (SSUs, DSUs).
280 Social Pharmacy
3. Training of State/District Surveillances Teams has been
completed in all 36 states/UTs. The state-level training
focuses on the basics of disease surveillance, concepts of
epidemiology, and data management, whereas the district
training focuses on correct procedures of data collection,
compilation and reporting, and outbreak response. The
training in IDSP is three-tiered:
– Training of Master Trainers State and District
Surveillance Officers) at identified national level
institutes.
– Training of the Medical Officers and District Lab
Technicians by Master Trainers at the State level.
– Training of Health Workers and Lab Technician/
Assistants at peripheral institutions by District
Surveillance officers/Medical Officers at the District
level.
A special two-week Disease Surveillance and Field
Epidemiology Training Programme (FETP) has been
initiated for the district surveillance officers.
4. Decentralization of recruitment of contractual manpower
under IDSP, to ensure their early recruitment by the state
health societies.
5. Establishment of an IT network connecting 776 sites at all
states/districts HQ and premier institutes in the country
for data entry training, video conferencing, and outbreak
discussion.
6. Development of a portal under IDSP (
www.idsp.nic.in) for data
entry and analysis, to report outbreaks, and to download
reports, training modules, and other material related to
disease surveillance. Under IDSP, data is collected on
epidemic-prone diseases every week. The information is
collected on three specified reporting formats, namely ‘S’
(suspected cases), ‘P’ (presumptive cases), and ‘L;
(laboratory confirmed cases) filled by health workers,
clinicians, and laboratory staff respectively.
7. Presently, about 90% of districts in the country report
weekly surveillance data through the portal. The weekly
281Introduction to Health Systems
data gives information on the disease trends and
seasonality of diseases. Whenever there is a rising trend of
illness in any area, it is investigated by the rapid response
team to diagnose and control the outbreak. Data analysis
and actions are being undertaken by respective states/
district surveillance units.
8. CSU and IDSP receive disease outbreak reports from the
states/UTs every week. The weekly outbreak report
generated by the CSU is shared with all key stakeholders
including the Prime Minister’s Office. This is significant
because it indicates the paradigm shift in the outbreak
reporting attitude (from the traditional reluctance to report
outbreaks to one that encourages outbreak reporting and
response) enabled by the project.
9. Media scanning and verification cells established under
IDSP are an important component of surveillance to detect
early warning signals. It detects and shares media alerts
with concerned states/districts for verification and
response.
10. A 24 × 7 call center was established in February 2008 to
receive disease alerts all across the country on a toll-free
telephone number (1075). The information received is
provided to the states/districts’ surveillance units through
e-mail and telephone for investigation and response.
11. District laboratories are being strengthened for the
diagnosis of epidemic-prone diseases in a phased manner.
12. A state-based referral laboratory network has been
established by utilizing the existing functional labs in the
identified medical colleges and other major centers in the
states and linking them with adjoining districts for
providing diagnostic services for epidemic-prone diseases
during outbreaks.
13. Laboratories have been strengthened and made functional
under IDSP for Avian/ H1N1 influenza surveillance. The
animal component of avian influenza is being looked after
by the Ministry of Agriculture.
282 Social Pharmacy
National Leprosy Eradication Programme (NLEP)
Leprosy is the oldest disease known. India has already got its
status eliminated leprosy in December 2005. The National
Leprosy Eradication Programme is a centrally sponsored
Health Scheme of the Ministry of Health and Family Welfare,
Government of India. The programme is headed by the Deputy
Director of Health Services. The Programme is also supported
as Partners by the World Health Organization, The
International Federation of Anti-leprosy Associations (ILEP),
and a few other non-government organizations (NGOs).
Fig. 5.7: Logo of National Leprosy Eradication Programme
Initially, the program for leprosy control was launched as
the National Leprosy Control program in 1955 as a centrally
aided program with the main objective of controlling the
magnitude of leprosy through early detection of cases and
domiciliary treatment with dapsone through trained workers.
The National Leprosy Eradication Programme (NLEP) was
launched in the year 1983 to eliminate leprosy as a public health
problem by the year 2000 AD introducing multi-drug therapy.
The project was completed on 31st December 2004. Since
then, The National Leprosy Eradication Programme has been
continued with Govt. of India funds with additional technical
support from the WHO and the International Federation of
Anti-Leprosy Associations (ILEP) organizations. MDT was
supplied free of cost as of now by NOVARTIS through WHO.
Consequently, due to hard work and precisely planned and
executed activities, the country achieved the goal of eliminating
leprosy as a public health problem, defined as less than 1 case
per 10,000 population, at the national level in December 2005,