International Journal of Noncommunicable Diseases

: 2018  |  Volume : 3  |  Issue : 4  |  Page : 111--114

Noncommunicable diseases surveillance in India: Moving toward a more comprehensive approach

Jai Prakash Narain1, KR Thankappan2,  
1 School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
2 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Correspondence Address:
Dr. Jai Prakash Narain
F-20A, Hauz Khas Enclave, New Delhi - 110 016

How to cite this article:
Narain JP, Thankappan K R. Noncommunicable diseases surveillance in India: Moving toward a more comprehensive approach.Int J Non-Commun Dis 2018;3:111-114

How to cite this URL:
Narain JP, Thankappan K R. Noncommunicable diseases surveillance in India: Moving toward a more comprehensive approach. Int J Non-Commun Dis [serial online] 2018 [cited 2019 Jan 16 ];3:111-114
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Full Text

Surveillance is often defined as an ongoing and systematic process of collecting and analyzing data for public health action[1] or put simply as “information for action.” It provides evidence that can be used for program planning, policy, and strategy development, and for evaluating the impact of interventions put in place. Surveillance, therefore, is a critical component of any disease prevention and control program.

In addition, surveillance data also provide a tool for advocacy essential for political mobilization. Based on the years of experience, it is increasingly clear that the programs which have a strong surveillance and monitoring and evaluation component are also those more likely to succeed.[2]

Monitoring noncommunicable diseases: Present status

In the context of noncommunicable diseases (NCDs), surveillance is at present primarily restricted to collecting data on the risk factors, in particular, behavioral, clinical/physical, and biochemical risk factors. The World Health Organization (WHO) STEPS survey deals with various risk factors, the Global Tobacco Surveys (i.e., Global Adult Tobacco Survey [GATS] and Global Youth Tobacco Survey [GYTS]) on the other hand deal almost exclusively on obtaining data on tobacco use.[3],[4]

The WHO STEPS survey is a step-wise approach to NCD risk factor surveillance. It gathers key information on risk factors on a representative sample of the study population, followed by simple physical measurements and collection of blood samples for biochemical analysis[5] (WHO STEPS manual). Data are collected on tobacco use, alcohol consumption, intake of fruit and vegetable, and on physical activity. While physical measurements include weight, height, waist circumference, and blood pressure, the biochemical measurements include fasting blood sugar, and total cholesterol. The WHO STEPs also has the provision for core, expanded and optional variables to be included in data collection depending on the resource availability and capacity of each country/state.

The GATS, according to the WHO, is a global standard for systematically monitoring adult tobacco use (smoking and smokeless) and tracking key tobacco control indicators, using a standard protocol across countries.

The first GATS survey in India was carried out in 2009–2010 followed by second round during 2015–2016.[6] The data so obtained assist countries for planning purposes and to fulfill their obligations under the WHO Framework Convention on Tobacco Control, allowing thereby for comparisons within and across countries. Similarly, GYTS, a school-based survey is carried out among students between 13 and 15 years of age.[7] The purpose is to collect data on the prevalence of smoking and smokeless tobacco use as well as information on to access/availability, exposure to secondhand smoke, cessation, media, and advertising, and school curriculum. So far, at least three rounds of GYTS have been conducted in India.

A word of caution however while these surveys have undoubtedly provided extremely useful data on tobacco use; they are rather time-consuming and expensive to undertake. Moreover, while surveys can be a one-off exercise, surveillance involves commitment to data collection on an ongoing, repeated basis. Repeat surveys are essential to identify trends in the prevalence of risk factors.

Keeping this in mind and to try to ensure availability of such data on an ongoing basis to guide implementation of the national NCD prevention and control program, there is a need to combine GATS with WHO STEPS surveys so that there is one comprehensive survey covering all relevant risk factors. In addition, the methodology also requires simplification. Such an approach will make surveys operationally feasible and sustainable on a long-term basis for low- and middle-income countries.

More importantly, there is an urgent need to align NCD surveillance activities with Sustainable Development Goals and WHO Global NCD Monitoring Framework indicators/targets.[8],[9],[10] Both the SDG three indicators and the Global monitoring framework on NCDs call for data not only on risk factors but also on diseases to monitor the trends of NCD morbidity/mortality; in fact, the first indicator deals specifically relating to reduction in premature NCD mortality by 25%, and target# 6 and 7 on reducing the prevalence of hypertension and diabetes, respectively. The fact that more than 60% of all deaths today are attributed to NCDs is such a powerful data for advocacy and to highlight the need for urgent action to address NCDs.[11]

Key aspects of a comprehensive noncommunicable diseases surveillance

The NCD surveillance, therefore, should have three key components: (1) monitoring exposure (risk factors and determinants), (2) outcome (morbidity and disease-specific mortality), and (3) health system response and capacity. While monitoring risk factors and mortality requires special surveys as described above, outcome measures in terms of morbidity can be included in the routine reporting system. The national programs have identified a set of standardized core indicators which could be measured on an ongoing basis as a part of the program. Assessing the capacity and response of the health system including policy changes is also a key aspect of surveillance and program monitoring.

The three components are detailed below:

Monitoring Exposure or Risk Factor Surveillance. Periodical community-based surveys at national and state or even district levels covering both rural and urban areas can help ascertain the prevalence of risk factors such as tobacco use (smoking or smokeless); physical activity; use of alcohol; diet including consumption of fruits and vegetable, salt, sugar, and trans fats; overweight or obesity; and hypertension or blood glucose levels

The National Centre for Disease Control (NCDC) conducted the first-ever NCD risk factor survey in the country in 2007 with a sample of 5000 households sampled across seven Indian states – Andhra Pradesh, Kerala, Madhya Pradesh, Maharashtra, Mizoram, Tamil Nadu, and Uttarakhand, using the WHO STEP methodology.[12] This was to be expanded to further 13 states the following year, but the idea was abandoned due to lack of resources.

More recently, however, state-level surveys have been carried out in Kerala, Haryana, and Punjab. In Kerala, the survey was carried out in 2016 using a representative sample of over 12000 adults. It showed that nearly one of five (20.3%) and one of three (28.9%) male participants reported the current use of tobacco and alcohol, respectively. Hypertension was prevalent in nearly one of three adults (34.6% in males and 28% in females) and diabetes in nearly one of five adults (19.8% in males and 18.8% in females).[13] In Punjab, tobacco use, alcohol consumption, and levels of physical activity observed were 11.3%, 15%, and 31% of the population respectively. The prevalence of hypertension was 40.1% and of diabetes 14.3%.[14] These findings highlighted an urgent need to implement population, individual and program-wide prevention and control interventions on NCDs in the state. The Punjab model was based on empowering the states by involving state medical colleges and funding under the National Health Mission to ensure sustainability.

A nationwide NCD monitoring survey is presently underway spearheaded by ICMR in collaboration with ten technical institutes across the country. The results are expected to be released in October 2018. The results of this first-ever national survey can help shape NCD policy and strategy, assess the prevalence of risk factors and health system capacity to respond, and in advocacy. Surveys using similar methodology are expected to be carried out at periodic intervals to discern the trends over time.

Such a nationwide surveys are clearly a massive undertaking and can be repeated only once in 4–5 years. Moreover, many states as indicated above often prefer data for their own states, for planning purposes because health is a state subject in India.

Monitoring outcome. The NCD outcome measured through disease surveillance includes:

Routine reporting of various NCD cases by health facilities such as NCD clinics in public as well private sectors. While routine reporting of communicable diseases is the responsibility of NCDC's Integrated Disease Surveillance Program (IDSP), the reporting of NCDs could be integrated into IDSP as the name itself indicates.[15] The IDSP infrastructure in all states can be put to good use for NCD reporting from the states and other partners. Although private sector remains a huge challenge, both for communicable as well as NCD reporting, bringing them on board is critically important[16]Sentinel surveillance to monitor trends by choosing selected district hospitals, private physicians, private hospitals, and employee state insurance hospitals for reporting of NCDs such as diabetes and cancer. This type of surveillance has been used effectively in communicable disease surveillance in particular to monitor disease trends over time and evaluate the effectiveness of health interventionsMajor sources of vital statistics such as Sample Registration System, Civil Registration Systems, and National Family Health Survey. In addition, disease registries on specific diseases are available such as the Indian Council of Medical Research or ICMR cancer registry program, national stroke registry and they need to be brought under surveillance.[17],[18] While surveillance through the use of population-based registries is critical for monitoring disease trends and evaluating NCD control programs, these need to be evaluated to assess quality parameters such as data validity, timeliness, and representativeness[19]Other data available from research studies, existing monitoring, and evaluation systems can be used along with other sources of data to estimate the burden of disease.

The health system response and capacity. Global monitoring framework also calls for reporting by countries on health system capacity to respond to NCDs through the availability of essential medicines, counseling, affordable, and basic/appropriate technologies/equipment such as glucometers. It might be useful from program point of view to include this component also in the surveillance guidelines. Conventionally, such data are not included as a part of surveillance, but we believe we should be guided by program needs and this will be useful from program point of view

The Political Declaration of the recent UN High-Level Meeting on NCDs (2011)[20] urges each country to integrate NCD surveillance with existing surveillance and monitoring systems, as well as into existing national health information systems.

It is thus expected that surveillance be recognised as a critical component of NCD program and adequate funding be set aside for this purpose, that all available data from various sources will be collected and analyzed to estimate the burden of disease, and that surveillance data be made available widely including on the program website and used for program planning and monitoring and evaluation.

Finally, good surveillance data can play a critical role in good decision-making and ultimately for better delivery of NCD services. Experience shows that intuitively the programs which have had a better surveillance program or more reliable data, have had more success or had better program performance. It is also imperative to periodically evaluate surveillance system and assess it is quality and usefulness. The evaluation data so obtained can then be used to further improve the system.


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