Framework for implementation of revised IHR 2005 in India Dr Sampath K Krishnan Coordinator CDS & IHR Contact Point World Health Organization Country Office - Presentation 1. 2. 3. Health Legislation & Governance Disease surveillance • NSPCD • IDSP Plan of action for implementation of IHR in India World Health Organization Country Office - Constitutional allocation of Government powers Federal structure - Health is a state subject in the main Central (Union) list, State list & Concurrent list Central list has more of public health legislations whereas state list also has legislations for health emergencies Concurrent list also contains important areas concerning public health which can be taken up by state or centre. Pandemic diseases could be declared as Public health disasters and centre could take controlWorld Health e.g. SARS, Avian Flu, Pandemic Flu Organization Country Office - Constitutional protections Constitution of India guarantees right to life (Article 21). Right to health as a pre-requisite recognized by the Supreme Court. Under Directive Principles of the State, health care is the responsibility of the State (Nation) Public health can override individual rights E.g. in Avian influenza-social isolation and limited quarantine were introduced in affected areas • Poultry farmers supported culling operations. • Protests could occur even if legislations are in place World Health Organization Country Office - Constitutional procedural requirements Enactments/ amendments would be required for effective implementation of IHR But presently, could be implemented under existing health/other legislations (even though some are quite old) Other legislations also may be used when necessary • E.g. Criminal Procedure Code (CrPC) in MP and Police Act in Maharashtra imposed during avian influenza outbreak (under maintenance of public law and order) World Health Organization Country Office - Federal system Health is a state subject in the main hence states usually enact their own health legislations States usually have their own surveillance systems in place. Were earlier reporting on a monthly basis to Central Bureau of Health Intelligence for about 30 diseases of PH importance NSPCD programme ensured that the 101 districts in these states reported outbreaks directly to Centre (NICD) States sometimes report late to Centre due to various reasons including awaiting lab confirmation of diagnosis States obtain significant funding from centre for • • • All sub-centres PHC/CHC- Temporary staff, drugs, lab equipment Anganwadis –ICDS (creche) World Health Organization Country Office - Role of centre in control of important diseases of public health importance Detailing of central teams for assisting investigation and response Capacity building and laboratory support Project mode-IDSP, NACP, RNTCP, NPSP. These then become National Health Programmes (may have some component of external funding) Emergencies (SARS, Avian Influenza) States can also directly obtain external funding for health but centre has to give clearance World Health Organization Country Office - National Health Programmes Significant surveillance component Disease specific and vertical in approach Malaria Filariasis Kala azar Leprosy Tuberculosis Poliomyelitis HIV/AIDS Vaccine preventable diseases RCH Cancer control Blindness Mental Health Iodine deficiency Water supply Total Sanitation World Health Organization Country Office - Statutory and administrative law issues Statutory reform • Changes to existing legislations at national and state levels is an ongoing process • Disease surveillance is not a legal requirement at central level, but some states have it • Examples of existing legislations governing key IHR related issues Public Health Act 1925 • Public Health emergencies Act being processed (Epidemic Diseases Act 1897 being repealed) Prevention of extension of Infectious disease from one state to another (Concurrent list Entry 29) Port quarantine (Union List entry 28, Constitution of India) National Disaster Act 2005 Right to Information Act 2005 World Health Organization Country Office - Public Health Emergencies Act (under process) To provide for the control and management of public health emergencies (including PHEIC) Scope of the Act: • Dangerous epidemic disease (potential to spread rapidly) • Epidemic prone diseases (29 diseases + PHEIC when notified by WHO) • Bio-terrorism (34 agents + others) • Disasters (19 disasters + others) • Centre would have powers to direct states • Declare area of PHE for 3 months duration at a time Need for a draft (model) PHE Act for countries to adapt World Health Organization Country Office - Vertical policy coordination and coherence Current strategy • National Rural Health Mission, NHPs • All India Services – Bureaucrats (IAS, IPS), Central Government Health Scheme, etc • Regional Offices of Health & Family Welfare (cover all states/UTs) monitor implementation of central health schemes • Communications is entirely under Centre Dispute resolution • Central Council for Health & Family Welfare World Health Organization Country Office - Fiscal and budgetary issues Adequate resources to fulfill the basic obligations of IHR implementation Funds would be required for capacity building at • Centre • State & districts • Public Health Laboratories • Border crossings • Port and airport health authorities • Hospitals for admitting large numbers of patients under isolation World Health Organization Country Office - IHR and non-governmental actors Municipal Corporations especially large Metros Defence Airlines Railways Shipping Travel & Tourism Exporters Hospitals Media NGOs World Health Organization Country Office - Media Freedom of press a major factor in frequent reporting of outbreaks Often report ‘mysterious illness/unknown disease’ which does alert international health networks. All disease outbreaks would fall in this category until lab confirmed. 24 hr news channels (repeat the news, does create apprehension and also significant economic impact) Health authorities use it to convey the status report Play a positive role in IEC World Health Organization Country Office - Public health surveillance and response infrastructure National Surveillance Programme for Communicable Diseases Integrated Disease Surveillance Project (WB supported) for 5 years Budgetary support planned under XI Five-year Plan Laboratory strengthening under IDSP as well as additional funds for Pandemic Flu preparedness Training of Health staff on-going World Health Organization Country Office - Disease surveillance Disease surveillance in India has always been practiced by the states (health being a state subject) Many gaps, differed in degree and quality of surveillance, different priorities in diseases, lack of uniformity Rapid Response Teams (RRTs) functioning but weak Information was made available at National level only at monthly intervals World Health Organization Country Office - National Surveillance Programme for Communicable Diseases (NSPCD) NSPCD was therefore launched by the Centre in 1997-98 in five pilot districts of the country (centrally sponsored scheme) and over the years extended to cover 101 Districts in all 35 states and UTs in the country. In this programme the states were the implementing agencies and NICD Delhi was the Nodal agency for coordinating the activities. This programme was based on outbreak reporting (as and when outbreaks occur) with weekly reporting of epidemic prone diseases directly from Districts (including nil reporting) to the Centre.World Health Organization Country Office - Main components To establish Early Warning System (EWS) so as to institute appropriate and timely response for prevention & control of outbreaks Every state/UT and all the 101 districts had a trained multi-disciplinary Rapid Response Team Rapid communications (through e-mails & fax) Strengthening of state and district laboratories for rapid confirmation of diagnosis Capacity development of health staff in the districts IEC (information, education and communication) World Health Organization Country Office - Districts covered under NSPCD 1997-98 (25 districts) 1998-99 (20 districts) 2000-01(35 districts) 2001- 02 (20+1 districts*) * The district of Shimla taken as a special case during 2002-03 World Health Organization Country Office - Diseases/pathogens covered Epidemic prone communicable diseasesacute diarrhoeal diseases including cholera, viral hepatitis, dengue, Japanese encephalitis, meningitis, measles, viral haemorrhagic fevers, leptospirosis, others Pathogens with bioterrorism potential Drug resistant pathogens World Health Organization Country Office - Expected outcome Early detection of outbreaks Early institution of containment measures Reduction in morbidity & mortality Minimize economic loss World Health Organization Country Office - Profile of outbreaks investigated by NSPCD districts 100 105 85 80 60 57 40 14 8 3 20 57 0 6 86 0 53 10 7 7 1 69 13 1 5 12 21 5 0 02 00 2 Chickenpox Food Poisoning Measles JE Malaria 0 ADD (GE,Diarrhoea, Dysentry) No. of outbreaks 120 Type of outbreak 2001 2002 2003 World Health Organization Country Office - NSPCD NSPCD has significantly improved the capacity of these districts and states to detect investigate and respond to outbreaks, yet It was not case based reporting and did not give a complete picture of disease burden in the country especially in respect of epidemic prone diseases GoI not convinced to expand this programme to all 600 districts in the country World Health Organization Country Office - Integrated Disease Surveillance Project (IDSP) Integrated Disease Surveillance Project (IDSP) was conceptualized and the Govt of India approached the World Bank for the necessary funding (US $ 68 M over five yrs) Objectives: • To establish a decentralized system of disease surveillance for timely and effective public health action • To improve the efficiency of disease surveillance for use in health planning, management and evaluating control strategies World Health Organization Country Office - Target diseases in IDSP Sentinel Surveillance Regular Weekly Surveillance Malaria ADD (Cholera) Typhoid Tuberculosis Measles Polio Plague Unusual Syndromes State Specific Diseases HIV, HBV, HCV Accidents Water Quality Outdoor Air Quality Community-based Surveys NCD Risk factors World Health Organization Country Office - Phasing of Integrated Disease Surveillance Project Phase-I (04-05) Phase II (05-06) Phase III (06-07) World Health Organization Country Office - Organizational structure National Surveillance Committee Central Surveillance Unit State Surveillance Committee State Surveillance Unit District Surveillance Committee District Surveillance Unit World Health Organization Country Office - Information flow Weekly Surveillance System Sub-Centres Programme Officers S.S.U. P.H.C.s C.H.C.s Dist.Hosp. D.S.U. P.H.Lab. Country Office - Pvt. Practitioners Nursing Homes Private Hospitals Med.Col. World Health Organization C.S.U. Private Labs. Other Hospitals: ESI, Municipal Rly., Army etc. Corporate Hospitals Linkages at Central level W.H.O. Outbreak Investigation & Rapid Response MIS & Report NCD Surveillance CSU NICD ICMR NVBDCP E.M.R. RNTCP National Programs CBHI RCH Programme Monitoring NACO World Health Organization Country Office - Network of Reference Laboratories for Surveillance of in India Kasauli Delhi New Delhi Lucknow Dibrugarh Ahmedabad Kolkata Mumbai Pune Proposed BSL-3 under ICMR Bangalore Chennai L5 labs Pondicherry World Health Organization Country Office - Activities planned under National Rural Health Mission Accredited Social Health Activist (ASHA) to be the community based informant for Disease Surveillance Computerization up to PHC level, establishing connectivity with District Surveillance Unit Setting up Distance Learning Communication Channel using EduSat Strengthen Laboratory Services at PHC level World Health Organization Country Office - Use of EDUSAT in Distance Learning & Communication for IDSP/NRHM EDUSAT REMOTE CLASSROOMS TEACHING END ROT TV/Monitor Teacher /Board Touch Screen TEACHERS/STUDENTS DVD Player PC/ Web-Camera PTZ Camera SIT World Health Organization Country Office - RETURN LINK (Live Voice/ Voice Mail/Text Message) WLL Strengths of IDSP Functional integration of surveillance components of vertical programmes Reporting of suspect, probable and confirmed cases –syndromic reporting from periphery Strong IT component for data analysis Trigger levels for gradated response Action component in the reporting formats Streamlined flow of funds to the districts World Health Organization Country Office - Jammu & Kashmir WHO collaborative network Himachal Pradesh Punjab Uttaranchal Haryana Delhi Uttar Pradesh Rajasthan Assam Bihar Madhya Pradesh Gujarat sh rade lP acha Arun Sikkim isgarh Chatt Nagaland Mizoram Manipur Tripura West Bengal Jharkhand Mizoram Orissa Daman & Diu Dadra & Nagar Haveli Filariasis Malaria HIV/AIDS Kar na taka Kala Azar Andhra Pradesh Routine Immunization la Plague Surveillance land Tamil Nadu Is obar Hep B & Nic Lakshadweep Kera nce man Anda ation Polio Leprosy ance Goa Tuberculosis Disease Surveillance Maharashtra Legend Plan of Action World Health Organization Country Office - National Workshop of all Stakeholders for effective implementation of Revised IHR (2005), 20-21 April 2006 To prepare a plan of action and list out the activities for establishing/ strengthening of core capacities for surveillance and response (as per annex – 1A of IHR document) at National/State and District level To prepare a plan of action and list out the activities for establishing/ strengthening of core capacities (as per annex – 1B of IHR document) at Designated airports, Ports, and Ground crossings To suggest a mechanism for: • • Collaboration between different stakeholders at National / State/ District level and at designated Airports/ Ports/ Ground crossings Addressing the administrative and legal issues related to implementation of IHR 2005 World Health Organization Country Office - Planning for Strengthening of core capacities for surveillance and response S. NO. ACTIVITIES TIME LINE RESPONSIBLE AGENCIES 1 Strong linkages between IHR & IDSP June 2006 IDSP, NFP 2 Strong component of IHR in all IDSP trg December 2006 IDSP, NFP 3 All RRTs should be aware of the information needed to be reported December 2006 IDSP, NFP 4 Increase awareness about IHR among administrators and politicians at national / state/ district levels December 2006 IDSP, NRHM, IH 5 Electronic transmission of data including GIS from phase I districts December 2006 IDSP 6 Electronic transmission of data from districts under phase II of IDSP June 2007 IDSP 7 Electronic transmission of data from districts under phase III of IDSP December 2007 IDSP 8 Designation of surveillance officers of state & district surveillance units as state/ district IHR focal points December 2006 IDSP 9 Mechanism for rumor verification to be strengthened at district/ state/ national level June 2007 IDSP World Health Organization Country Office - Planning for Strengthening of core capacities for surveillance and response (cont’d 2) 10 Evaluation of laboratory capacities at state and district levels and their strengthening December 2006 IDSP & State Governments 11 At least one laboratory (L4 level of IDSP) in each state (more in bigger states) to be identified / strengthened December 2007 State Governments & IDSP 12 At least one BSL4 laboratory under the Ministry of Health, GOI – which should be linked to IDSP and NFP December 2008 MOHFW 13 Preparation for state / district health contingency plans and their periodical updating December 2007 State Governments 14 Evaluation of isolation facilities and hospital infection practices in all districts/ states December 2007 State Governments 15 Involvement of private sectors for disease surveillance by sensitization, persuasion, training, legislation and also through professional organizations like IMA December 2007 State Governments & IDSP 16 GOI may expedite approval of Public Health Emergency Act 2005 December 2006 MOHFW 17 All surveillance officers to have the list of big and small international airports, ports and ground crossings and invite them in surveillance meetings December 2006 IDSP & State Governments World Health Organization Country Office - Planning for Strengthening of core capacities for surveillance and response (cont’d 3) 18 APHOs/ PHOs to be included in the state surveillance committees December 2006 IDSP, Min of Shipping, Civil Aviation, DGHS 19 Assessment of disease surveillance and response capacity as mentioned under the IHRidentification of responsible agency, preparation of assessment instrument & methodology and provision of resources June 2007 IDSP, MOHFW 20 Establishment of a mechanism for periodic independent evaluation of IDSP June 2007 IDSP 21 National RRT must be involved for investigation of events if more than one state is involved December 2006 IDSP & State Governments 22 State RRT must be involved for investigation of events if more than one district is involved December 2006 IDSP, MOHFW 23 A copy of the investigation report should be given to the district collector or Municipal commissioner December 2006 IDSP, MOHFW, State govts MHA 24 Findings of investigations of central RRT should be urgently conveyed to states and the findings of state RRT should be urgently conveyed to district December 2006 MOHFW, State Governments 25 All major laboratories in the country testing clinical samples should start reporting to IDSP December 2006 IDSP World Health Organization Country Office - Planning for Strengthening of core capacities for surveillance and response (cont’d 4) 26 Identification of high-risk areas near the international borders and establish/activate the programme for cross border control of diseases June 2007 IDSP, State Govts., MOHFW, MEA 27 Strengthening of capacity including trained manpower for disease surveillance and response at central level (e.g., NICD, Emergency Medical Response division of Dte. GHS), to provide support to the states during PHEIC December 2007 MOHFW 28 The proposal for conversion of NICD to National Centres for Disease Control (NCDC) may be put on fast track December 2007 NICD, MOHFW 29 Strengthening of capacity for disease surveillance and response at state and district level December 2007 State Govts 30 Involvement of major institutions and National Health Programmes like ICMR, NVBDCP in assessment and investigation of public health events December 2006 MOHFW World Health Organization Country Office - Planning for Strengthening of core capacities for surveillance and response (cont’d 5) 31 Existing disease control guidelines to be updated and widely circulated, issue new guidelines for emerging diseases, and their periodic updating June 2007 NICD & IDSP 32 National IHR focal point (NICD) should have the linkages with international reference labs and should have the authority to directly send the biological material to them December 2006 NICD, MOHFW 33 Satellite linkages of IDSP and national IHR focal point with all state and district HQs June 2007 IDSP 34 Establishment of mechanism for collaboration and coordination between different Ministries/ Departments June 2007 MOHFW 35 Preparation of a National Public Health Emergency Response Plan December 2007 IHR focal point, MOHFW, MHA World Health Organization Country Office - Planning for Strengthening of core capacities of ports and ground crossings S.NO. ACTIVITIES TIME LINE RESPONSIBLE AGENCIES 1 Identification of airports, ports and ground crossings for implementation of IHR June 2006 MOHFW (ADG,IH) M/O Civil Aviation M/O Shipping MHA 2 Assessment of present capacities at the designated airports, ports and ground crossings June 2007 M/O Civil Aviation M/O Shipping MHA MOHFW (ADG,IH) 3 Taking a policy decision about who will provide the health services at the designated airports, ports and ground crossings (in context of privatization) December 2006 M/O Civil Aviation M/O Shipping MHA 4 Filling up of vacant posts for strengthening of medical services at the designated airports, ports and ground crossings December 2007 M/O Civil Aviation M/O Shipping MHA MOHFW 5 Establishing a referral system for medical services at the designated airports, ports and ground crossings December 2007 M/O Civil Aviation M/O Shipping MHA MOHFW World Health Organization Country Office - Planning for Strengthening of core capacities of ports and ground crossings (cont’d 2) 6 Creation of new public health units at designated ports, airports and ground crossings (at present there are 6 APHOs, 8 PHOs and one ground level Health organization) December 2007 MOHFW 7 Improvement of physical infrastructure of quarantine centers at designated airports, ports and ground crossings December 2007 MOHFW 8 Training of technical staff of designated airports, ports and ground crossings on IHR (2005) December 2007 MOHFW NFP IDSP 9 Provision of ambulance at all designated airports, ports and ground crossings December 2007 M/O Civil Aviation M/O Shipping MHA MOHFW 10 District IDSP laboratories be designated for each airport/ port/ ground crossing health organizations June 2007 MOHFW, IDSP State Govts. M/O Civil Aviation M/O Shipping MHA World Health Organization Country Office - Planning for Strengthening of core capacities of ports and ground crossings (cont’d 3) 11. Provision of entomologist at all the health units for vector surveillance and control activities December 2007 MOHFW 12. Linkages with IDSP: Link with website Networking with IDSP laboratories June 2007 MOHFW, IDSP State Govts. 13. Preparation of Public Health Emergency Contingency plan including: Preparation of panel of doctors/ paramedical staff for deputation during Public Health Emergency Identifying referral laboratories and medical facilities Coordination amongst: December 2007 MOHFW (ADG,IH) Designated hospitals, Department of Animal Husbandry, Designated laboratories, Immigration contact point, Airport/ ship management agencies, Customs contact point World Health Organization Country Office - Planning for Collaborative, administrative and legal issues S. NO ACTIVITIES TIME LINE RESPONSIBLE AGENCIES 1 Examination of IHR (2005) document for administrative and legal issues July 2006 MOHFW 2 Examination of health certificates/ documents and charges mentioned in IHR (2005) and to revise national certificates/ documents and charges, if necessary, and communicate to the WHO June 2007 MOHFW 3 Examination of National Aircraft/Port Health Act and Rules and to revise/amend them, if necessary, for effective implementation of IHR (2005) June 2007 MOHFW 4 Prepare/Update Health rules for designated Ground Crossings June 2007 MOHFW MHA World Health Organization Country Office - Planning for Collaborative, administrative and legal issues (cont’d 2) 5 Presently MHA provides emergency support services and coordination between different sectors during emergencies. The same mechanism should be used for the purpose of Public Health Emergencies of International Concern under the IHR. December 2006 MOHFW, MHA 6 Coordination committees: Mechanism for coordination and collaboration between different sectors at various levels (National, State and District) already exists under IDSP. These committees should be suitably expanded for the purpose of IHR. Nodal members to be identified from the following ministries/ organizations: December 2007 MOHFW, MHA MOHFW Designated hospitals, laboratories and various pest/ vector control agencies State Health Directorates, District Health Authorities Local municipality, cantonment board, any other relevant agency Ministries of Civil Aviation, Shipping, Surface transport, Agriculture (veterinary dept.), Home Affairs, Tourism, Railways Customs, Immigration, AAI Association of shipping agents World Health Organization Country Office - Obstacles to implementation Inter-sectoral coordination (Av Flu) Border crossings (large border and large number of migrants) Frequent large outbreaks (daily 3-5 important outbreaks-presently Chikungunya, Japanese encephalitis, Leptospirosis) World Health Organization Country Office - Thank You