Health

India’s mysterious diseases: What is NCDC doing?

There is enough evidence to show that National Centre for Disease Control on diseases is not equipped to deal with the country’s disease burden

 
By Vibha Varshney
Published: Friday 24 July 2020
There is enough evidence to show that India’s premier institute on diseases is not equipped to deal with the country’s disease burden. Photo: Manoj Singh

India’s premier organisation mandated to collect data about diseases from each village of the country is failing in its task even as the spread of novel coronavirus disease (COVID-19) continues unabated.  

The National Centre for Disease Control (NCDC) carries out disease surveillance through its Integrated Disease Surveillance Programme (IDSP). This programme has been present in the country in different avatars since 1997, when the National Surveillance Programme for Communicable Diseases was set up.

This was upscaled to Integrated Disease Surveillance Project in 2004, with the assistance from the World Bank, to address the demands of the World Health Organization (WHO)’s International Health Regulations, 2005, under which, each country had to assess public health emergencies of international concern within 48 hours and report them to WHO within the next 24 hours. It was then included in the 12th Plan (2012-17) under the Union Ministry of Health and Family Welfare (MoHFW) and renamed Integrated Disease Surveillance Programme.

However, there is enough evidence that IDSP is not equipped to deal with the monitoring of India’s disease burden and fails to perform even the basic reporting well. Here are a few examples.

IDSP’s manual says weekly and monthly updates are mandatory for each of the 36 state and Union Territories (UT) even if no outbreaks are reported. Down To Earth found an unusual trend when it looked at the weekly reports for 2019.

In 12 of the 52 weeks, the report does not mention how many states uploaded the information even though the information is right there. In another 36 weeks, a higher number of states and UTs are mentioned in the total tally than mentioned in the outbreak description list.

For example, the update for the first week of April reads that 35 states and UTs shared their records and 25 of them had outbreaks. The report however has detailed outbreak descriptions from only 15 states and UTs.

The last weekly update on the website till July 22 was for March 2020 and it was based on information received from just 17 states and UTs.

On July 9, 2019, Ashwini Kumar Choubey, Union Minister of State in the MoHFW, admitted in Parliament that only 380 of the 739 districts in the country had surveillance committees though the reports were sent from 95 per cent of the districts in 2019.

The lack of interest is also visible through the fact that the budget allocated under the scheme is seldom spent. In 11 of the 13 years between 2004-05 and 2016-17, expenditure was lower than the allocated budget. The last expenditure information available on the IDSP site is till October 2017. 

A joint monitoring mission (JMM) set up by WHO and the MoHFW in 2015 raised concerns over the fact that IDSP looked at only 22 diseases and had suggested that the programme should expand the list and include other high priority diseases.

The JMM also indicated that there was an overlap between the diseases being followed by IDSP and other agencies like the National Vector Borne Disease Control Programme (both NCDC and NVBDCP are vertical programmes under Directorate General of Health Services).

The fact that IDSP does not collect mortality data was also a concern. They also pointed out that IDSP was not investigating zoonotic diseases despite the fact that it was just a matter of time that one of the emerging / re-emerging diseases became virulent and resulted in a major pandemic.

Capacity-building was one of the major recommendations made by the JMM set up by WHO and the MoHFW in 2015. It had found that the government had only 407 epidemiologists (who study the transmission and control of epidemic diseases) as against the sanctioned posts of 703. There was a 33 per cent shortage of microbiologists and a nearly 80 per cent shortfall in veterinary doctors. The situation is equally dismal now.

To handle the current COVID-19 pandemic, states are scrambling to hire 227 epidemiologists, according to media reports. The scramble started after a letter dated April 7, 2020 by Preeti Sudan, secretary, MoHFW, asked state governments to immediately hire epidemiologists for 216 districts that have vacancies. The letter indicated that IDSP had 382 vacancies at present.

Lack of trained human resources could explain why infectious disease investigations are so poor in India. To aid the process of an investigation, NCDC has put down 10 steps that need to be followed for each outbreak: 

  • Determine existence of an outbreak
  • Confirm the diagnosis
  • Define a case 
  • Search for cases
  • Generate hypothesis using descriptive findings
  • Test hypothesis with analytical study 
  • Draw conclusions
  • Compare hypothesis with established facts
  • Communication of findings 
  • Execute preventive measures  

But few researchers — from IDSP, public health institutions like medical colleges and public-private health agencies — seem to be following the procedure. A study published on April 13, 2019, in Clinical Epidemiology and Global Health screened 10,657 articles published between 2008-20016 in various electronic databases. Out of these 136 articles were included for the review.

The completion of the 10 steps in the outbreak investigations was seen in only 16 per cent of reports. The highest level of completion was for drawing conclusions in outbreak investigation (98 per cent) and the lowest completion (29 per cent) was for developing a case definition by time, place and person followed by conducting an analytic study (24 per cent).

IDSP’s failure at so many fronts could also be the reason why the Indian Council of Medical Research has been put on the helm during the current COVID-19 epidemic even though this should have been handled by NCDC, say experts on conditions of anonymity. Repeated requests for information and interview with the director of IDSP remains unanswered to date. 

It is not that India cannot do good work. “We have excellent examples of promptly recognising a serious outbreak and quickly getting the act together to control an epidemic which could have been disastrous,” George M Varghese, professor at the Department of Infectious Diseases, Christian Medical College, Vellore, said.

In Kerala, an unusual infectious disease was noted by an astute clinician. The sample was sent to a reference laboratory who quickly identified it as Nipah virus in 2018. “In all  my years of work, I have not seen an outbreak handled as well in India as that of Nipah in Kerala. Education has paid dividends and people are aware,” Varghese said.

Public health infrastructure too is much better in the state. The lesson from this success is that we need to work on public health infrastructure, he said.

This is missing to a great extent in India where people succumb even to easily treatable diseases like diarrhoea and tuberculosis. Rajib Dasgupta, professor at Centre of Social Medicine and Community Health, JNU, is optimistic:

Public health systems are built brick by brick. The experience of COVID-19 shall also contribute to the strengthening of the surveillance system.

Milind M Gore, who was the former incharge of National Institute of Virology’s lab in Gorakhpur, puts down an easy litmus test for India’s surveillance system. “If we can solve the Gorakhpur problem, we would be able to solve the problem of infectious diseases in the country,” he says.

This is the third article of a 3-part series. The second can be read here

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