1.       Introduction 

Sri Guru Ram Das Institute of Medical Sciences and Research, Vallah, Mehta Road, Sri-Amritsar (SGRDIMSAR) is a tertiary health care institution in Punjab (India), for teaching the undergraduate, postgraduate students in medical sciences and conducting the research. It has a 900-bedded hospital. 

A document was produced jointly by technical clusters of WHO and UNAIDS to bring together WHO recommended standards for the surveillance of communicable diseases. The document serves as a guide to good practice and may help to harmonize surveillance activities. Effective communicable disease control relies on effective disease surveillance. A functional national communicable diseases surveillance system is essential for action on priority communicable diseases. It is a key part of public health decision- making in all countries (e.g. priority setting, planning, resource mobilization and allocation, prediction and early detection of epidemics, and monitoring and evaluation of disease prevention and control programmes). A multi-disease approach to communicable disease surveillance involves looking at all surveillance activities in a Member State as a common public service. An integrated approach to communicable disease surveillance is shown in (Figure 1).        

Disease surveillance should be based on collecting only the information that is required to achieve the control objectives. The data required may differ from disease to disease. Specialized surveillance systems are important, especially where surveillance is complex and has specific information needs. Eradication and elimination programmes require a very active surveillance programme aimed at detecting every case. In addition to the diseases taken in disease surveillance programme, some syndromes have also been included in this. These are as follows: (i) Acute haemorrhagic fever syndrome (ii) Acute lower respiratory tract infections (aLRTI) and pneumonia (iii) Acute (watery) diarrhoea (iv) Acute (bloody) diarrhoea (v) Antimicrobial resistance (vi) Anti-tuberculosis drug resistance (vii) Foodborne diseases (viii) Sexually transmitted diseases/syndromes. [1] 

A project works for a well-defined limited period of time, while a programme works for unlimited period of time to control, eliminate and eradicate the disease. Integrated Disease Surveillance Project (IDSP) was launched by Hon’ble Union Minister of Health & Family Welfare in November 2004 for a period up to March 2010. The project was restructured and extended up to March 2012. The project continues in the 12^th Plan with domestic budget as Integrated Disease Surveillance Programme under NHM for all States with budgetary allocation of 640 Cr. A Central Surveillance Unit (CSU) at Delhi, State Surveillance Units (SSU) at all State/UT headquarters and District Surveillance Units (DSU) at all Districts in the country have been established. 

1.1    Objectives: To strengthen/maintain decentralized laboratory based IT enabled disease surveillance system for epidemic prone diseases to monitor disease trends and to detect and respond to outbreaks in early rising phase through trained Rapid Response Team (RRTs). 

1.2    Programme Components: (i) Integration and decentralization of surveillance activities through establishment of surveillance units at Centre, State and District level. (ii) Human Resource Development - Training of State Surveillance Officers, District Surveillance Officers, Rapid Response Team and other Medical and Paramedical staff on principles of disease surveillance. (iii) Use of Information Communication Technology for collection, collation, compilation, analysis and dissemination of data (iv) Strengthening of public health laboratories. (v) Inter sectoral Co-ordination for zoonotic diseases. 

1.3    Data Management: Under IDSP data is collected on epidemic prone diseases on weekly basis (Monday–Sunday). 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. The weekly data gives information on the disease trends and seasonality of diseases. Whenever there is a rising trend of illnesses in any area, it is investigated by the Rapid Response Teams (RRT) to diagnose and control the outbreak. Data analysis and actions are being undertaken by respective State/District Surveillance Units. In the month of June 2016, about 94% Districts have reported weekly disease surveillance data from districts. 

1.4    Training: The Training in IDSP is three-tiered: (i) Master Trainers State and District Surveillance Officers and RRT members are trained at identified National level institutes. (ii) The Medical Officers and District Lab Technicians are trained by Master Trainers at State level. (ii) Health Workers & Lab Technician/Assistants at peripheral institutions are trained by District Surveillance officers/Medical Officers at District level [2]. Presently IDSP is in operation in all Districts of Punjab [3]. 

A meeting regarding involvement of Medical Colleges in implementation of National Vector Borne Disease Control Programme (NVBDCP) was held in Directorate of Health and Family Welfare, Punjab at Chandigarh on July 25,2013 under the Chairmanship of Director, Health and Family Welfare, Punjab. The representatives of all Medical Colleges in Punjab state were told in the meeting to establish separate dengue wards keeping in view the transmission season of dengue and to install mosquito nets on the beds for suspected cases in order to prevent the spread of infection to other patients. All Medical Colleges were directed to send daily report of dengue to district and state health authority to take remedial and preventive measures. Similarly, cases of malaria confirmed positive by microscopy were to be given immediately, the treatment of malaria including the radical treatment given by the District Health authority (Civil Surgeon). Line list of malaria cases was to be sent monthly to the district and state health authorities of Punjab [4].

Again, a meeting was held in Directorate of Health and Family Welfare, Punjab at Chandigarh on May 26,2015. In this meeting the representatives of all the Medical Colleges in Punjab state were told to report the cases of the diseases of IDSP in their institutions. These diseases contained the diseases of the NVBDCP and some additional diseases. It was told to report the IDSP diseases weekly on: (i) Form P called Weekly Reporting Format - IDSP, the probable cases of certain diseases diagnosed clinically, covered under National Integrated Disease Surveillance Project (IDSP) in their institutions. (ii) Form L called Weekly Reporting Format – IDSP, the cases of certain diseases diagnosed in the laboratory, covered under National Integrated Disease Surveillance Project (IDSP) in their institutions [5].                                                             

The present study was aimed to assess the probable cases of diseases under IDSP reported in OPD of SGRDIMSAR from 07-09-2015 to 03-09-2017.

2.       Material and Methods

Separate wards of dengue were established in SGRDIMSAR with 5 beds in Medicine and 3 beds in Paediatrics departments. These beds were covered with bed nets to prevent the spread of dengue infection from the dengue patients admitted in these wards to other patients, visitors, and staff of the institute by the mosquito bites [4].

Later on, as per the directions of the Directorate of Health and Family Welfare, Punjab, data were collected on P and L forms of IDSP with effect from 07-09-2015 onwards. P form cases are clinically diagnosed mainly in OPDs (out-patient departments) of Medicine (Internal Medicine), Paediatrics, Skin, Chest and Tuberculosis (Pulmonary Medicine) [4,5]. Data collected on P forms (probable cases) were compiled and analyzed in the Department of Community Medicine, SGRDIMSAR.

3.       Findings

The data were collected on P forms from the Departments of General Medicine, Paediatrics, Skin, and Pulmonary Medicine of SGRDIMSAR with effect from 07/09/2015 with the start of Integrated Disease Surveillance Programme in district Amritsar. The data of cases reported for about 2 years i.e. from 07/09/2015 to 10-09-2017 were compiled and analyzed. The total new OPD (outdoor patients) attendance recorded in these years was also complied and analyzed.

(Table 1) is showing the distribution of probable cases of diseases under IDSP in SGRDIMSAR, Amritsar. Total OPD attendance in these years was 435928 and out of this, it was 192085 (44.06%) in year 2015-16 and 243843 (55.94%) in year 2016-17. There were 7083 cases of IDSP diseases reported in these 2 years out of which 3792 (53.54) cases of IDSP diseases reported in the year 2015-16 and 3291 cases (46.46%) reported in the year 2016-17. This shows that the OPD attendance in the year 2016-17 increased by 11.08%, while the number of diseases under IDSP have decreased by 7.08%. The diseases that had shown increase in this period are as follows: (i) Dengue (ii) Chikungunya (iii) Bacillary dysentery (iv) Acute flaccid paralysis < 15 years of age. Among the diseases showing increase, unusual increase had been observed in dengue and chikungunya. All other diseases mentioned in the table 1 had shown decrease in number and percentage in year 2016-17as compared to year 2015-16. Any other state specific disease and unusual syndromes recorded in both the years were found zero. This is represented in by bar diagram in (Figure 2).

Diseases (Table 2) is showing the four-weekly distribution of probable cases of diseases under IDSP in SGRDIMSAR, Amritsar in year 2015-16. Four weekly fluctuations in the number and percentage of the cases of various diseases are given in the table 2. This four-weekly data provides information on trends and seasonality of diseases in this period. 

4.       Conclusion

The OPD attendance during the period of study in years 2016-17 had increased than in years 2015-16. This might be due expansion of departments in SGRDIMSAR and due its increasing popularity. The decrease in number of many diseases under IDSP had shown that it is very effective programme for prevention, control, elimination and eradication of diseases. The action had been taken at various levels for dengue and chikungunya diseases that had shown unusual rise.

“The names of unusual syndromes not captured above” had been recorded as zero in the Performa. This might be due to the reason that no names of such tentative syndromes were given in the performa. Hence the names of tentative unusual syndromes should be given in the Performa by the Central/State government as per WHO/National programme so that the medical staff working in SDRDIMSAR and other parts of the state may choose the appropriate syndrome out of those and record in the performa. “The names of any other State Specific Disease” had also been recorded as zero in the performa. Hence the state health authorities should include the names of such diseases in the performa so that the medical staff of SGRDIMSAR may fill the appropriate syndrome/disease in the performa out of those. If such deficiencies observed in the performa are rectified in the programme, it can become more effective and efficient.

From the tables of the four weekly reports prepared, the fluctuations in number and percentages of the diseases may be noted, compared with the reports of previous years to discern the trends and the seasonality of different diseases; and the action plans for the next year for different seasons may be prepared to reduce the morbidity and mortality of these diseases in future. The weekly reports need attention for any unusual rise in number and percentage of these diseases. When any unusual rise in the number of these cases is observed, the district health authorities and SDRDIMSAR should form the Rapid Response Teams, find the epidemiological factors concerned with the causation and transmission of disease; and take effective control and preventive measures.

Figure 1: A diagram showing integrated approach to communicable disease surveillance.

Figure 2: Bar diagram showing distribution of probable cases of diseases under IDSP.

Table 1: Distribution of probable cases of diseases under IDSP.

Table 2: Four weekly distribution of probable cases of diseases under IDSP in 2015-16

(Table 3) is like table 2. It is showing the four-weekly distribution of probable cases of diseases under IDSP in SGRDIMSAR, Amritsar in year 2016-17. Four weekly fluctuations in the number and percentage of the cases of various diseases are given in the table. This four-weekly data provides information on the disease trends and seasonality in this period.

Table 3: Four weekly distribution of probable cases of diseases under IDSP in 2016-17.

1.       WHO (1999) WHO recommended surveillance standards. 7-8.

2.       Government of India, Ministry of Health and Family Welfare, Directorate General of Health Services. National Centre for Disease Control. Integrated disease surveillance programme.

3.       Government of Punjab. (2017) Directorate of Health & Family Welfare. Integrated Disease Surveillance Project (IDSP): Note on IDSP (National Rural Health Mission).

4.       Source: Directorate of Health and Family Welfare, Punjab, Chandigarh. Letter No. ECCQ/TECH-2/PB/13/5021-28 Date 12-8-13

5.       Source: Directorate of Health and Family Welfare, Punjab, Chandigarh. Letter No. NVBDCP/TECH-2/3238-3245-28 Date 19-5-15.