Disease surveillance — collection, analysis and interpretation of disease-related data — is key to public health. Depending on the disease being tracked, its impact and infectiousness – public health departments regularly collect information such as demographics, symptoms, exposure, contact history, progress made, care received and other epidemiological characteristics. This information is then used to design appropriate interventions and implement them at scale.
A strategic mix of active, passive and sentinel surveillance is the backbone of the health information system of any country. The ongoing pandemic has shown how accurate and real-time disease surveillance can act as early warning systems, and play a foundational role in preventing transmission and administering timely care.
However, while both governments and leaders understand the importance of disease surveillance, the implementation of it leaves much to be desired.
Today, much of the disease surveillance in India relies heavily on human resources, performed by Accredited Social Health Activists (ASHA). ASHA workers bear an overwhelming amount of the workload. To get an idea, we only need to look at the 24 registers or logbooks for various programs, in addition to the field visits and citizen interaction they regularly carry out.
This clerical and administrative workload leaves room for errors like unreported/missed incidents, delayed reporting or even data manipulation. For instance, Kumar et.al. in 2014 found 93% of workers at the health centers were unaware of the both, the concept and practice of zero reporting — the process of recording the absence of cases under surveillance to ensure that they have not simply forgotten to report. The researchers also found that none of the centers they surveyed was practicing zero reporting.
Moreover, the program-based approach to surveillance creates vertical silos, exacerbating the workload. For example, the National TB Elimination Program and National AIDS Control Program run in parallel. There is no doubt that both the programs are necessary and have demonstrated their value in reducing disease transmission. However, both these programs command individual infrastructure to function, even though patients tracked largely overlap since HIV-positive patients are more susceptible to TB.
In addition, there are way too many organizations involved in surveillance such as the Indian Council of Medical Research’s (ICMR) Virus Research and Diagnostic Laboratory (VRDL) Network, the National Vector Borne Disease Control Programme (NVBDCP) and the Integrated Disease Surveillance Programme (IDSP). All three of these organizations collect similar data but do not have a mechanism of data sharing.
These challenges can be effectively addressed with technology solutions that sustainably support active, passive and sentinel surveillance.
Active surveillance requires the officials/community health workers (CHWs) to actively search for information. It is a resource-intensive activity and frequently involves field visits. Applications like DHIS2, CommCare, Avni have made a significant impact by reducing the work involved in data collection and reporting.
These applications can be run on mobile phones and tablets. Health workers can carry these apps to the field and collect data on the go. These apps can collect and save data even in areas with no connectivity and sync seamlessly when the connectivity is resumed. This cuts down the lag in reporting as well as the margin of human error.
Passive surveillance requires health professionals to report to the authorities when they encounter patients with symptoms related to the 34 notifiable diseases, 12 L-form and 22 P-form diseases. Electronic health records (EHRs) can be the backbone of such a passive surveillance system.
With the roll-out of the National Digital Health Mission (NDHM), EHR adoption is likely to increase, with more health facilities participating as nodes for sentinel surveillance. Linking it with Geographic Information System (GIS) and visualization systems will enable the researchers and decision-makers to identify correlations that are not apparent in tabular formats.
As the pandemic continues and national-level public health initiatives become more critical, technology solutions are fundamental to building robust disease surveillance. Various digital health applications collecting data for specific purposes can come together to offer clear and real-time visibility into the public health posture of a country.
With the National Digital Health Mission rolling out soon in India, we have a significant opportunity to develop a comprehensive and unified system for active, passive and sentinel surveillance that can be leveraged by the government to build a better-informed and responsive public health system.
A version of this blog appeared in Economic Times.
Disclaimer: The statements and opinions expressed in this article are those of the author(s) and do not necessarily reflect the positions of Thoughtworks.
