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Surveillance of the risk factors for non-communicable diseases (NCDs) IDSP training module for state Surveillance of the risk factors for non-communicable diseases (NCDs) IDSP training module for state and district surveillance officers Module 14

Learning objectives (1/2) • Describe the importance and the need for surveillance of risk Learning objectives (1/2) • Describe the importance and the need for surveillance of risk factors for non communicable diseases • Enumerate the differences between surveillance for communicable diseases and risk factors for non communicable diseases • List non communicable disease risk factors under surveillance

Learning objectives (1/2) • List steps involved in organization and conduct of surveillance of Learning objectives (1/2) • List steps involved in organization and conduct of surveillance of risk factors for non communicable diseases • Describe the role of the district surveillance officer in surveillance of risk factors for non communicable diseases

Communicable versus non-communicable diseases • • Communicable diseases Sudden onset Single cause Short natural Communicable versus non-communicable diseases • • Communicable diseases Sudden onset Single cause Short natural history Short treatment schedule Cure is achieved Single discipline Short follow up Back to normalcy • • Non-communicable diseases Gradual onset Multiple causes Long natural history Prolonged treatment Care predominates Multidisciplinary Prolonged follow up Quality of life after treatment

Projected proportional increase in population > 65 years age, 2000 -2030 Italy Japan UK Projected proportional increase in population > 65 years age, 2000 -2030 Italy Japan UK USA China India Chile Mexico 0% 50% 100% 150% 200% Proportion (%) Social Determinants of Health Inequalities, Marmot M, Lancet 2005 250%

Projected population pyramid of India Projected population pyramid of India

Proportion (%) Estimated and projected proportion of deaths due to non-communicable diseases, India, 1990 Proportion (%) Estimated and projected proportion of deaths due to non-communicable diseases, India, 1990 -2010 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Injuries Communicable diseases Non communicable diseases 1990 2000 Year 2010

Estimated and projected specific mortality rate per 100, 000, by sex, India 1985 All Estimated and projected specific mortality rate per 100, 000, by sex, India 1985 All causes Infectious Neoplasms Circulatory Pregnancy Perinatal Injury Other M 1158 478 43 145 0 168 85 239 2000 F 1165 476 51 126 22 132 65 293 M 879 215 88 253 0 60 82 280 2015 F 790 239 74 204 12 48 28 285 M 846 152 108 295 0 40 84 167 F 745 175 91 239 10 30 29 171 Epidemiological transition: The concept of evolution from a communicable diseases burden of disease profile to a predominance of non communicable disease Source : World Bank Health Sectorial Priorities Review

Burden of major non-communicable diseases, India, 2004 Stroke Ischemic heart diseases Diabetes Burden of major non-communicable diseases, India, 2004 Stroke Ischemic heart diseases Diabetes

Non communicable disease programmes in India A. B. C. D. E. F. G. H. Non communicable disease programmes in India A. B. C. D. E. F. G. H. National cancer control programme National mental health programme National blindness control programme Cardiovascular diseases, stroke and diabetes programme Trauma and accident programme Oral health programme Rehabilitation programme Geriatric care programme

Existing reporting systems for non communicable diseases in India • Sentinel surveillance systems § Existing reporting systems for non communicable diseases in India • Sentinel surveillance systems § National Cancer Registry Programme • Periodic surveys/studies § § § Census of India Sample registration systems National sample surveys National family health survey National nutrition monitoring programme

Sources of data collection for non communicable diseases in India • Mortality data § Sources of data collection for non communicable diseases in India • Mortality data § Medical certificates for death § Cause of death surveys § Hospital records • Morbidity data § Registry (Cancer) § Special surveys § Hospital reports • Risk factors § Special surveys • Registries § Cancer (Shift from hospital to community based) § RF/RHD (Jai Vigyan Mission) § Thalasemia (Jai Vigyan Mission)

Implementation of non communicable diseases programmes in countries of the WHO South East Asia Implementation of non communicable diseases programmes in countries of the WHO South East Asia region Countries Tobacco control Cardio vascular diseases Diabetes 1982 Bangladesh Cancer Integrated control 1978 Bhutan DPR Korea India 2000 Indonesia 2000 1975 1989 1995 Maldives Myanmar 2001 1982 Sri Lanka 1988 1999 Thailand 1996 1999 Nepal 1982 1993 2000 1988 1993 Source: Non-Communicable Diseases in South-East Asia Region, A Profile, WHO, 2002

Prioritizing surveillance for non communicable diseases ? Mortality? ? Morbidity? ? Disability? ü Risk Prioritizing surveillance for non communicable diseases ? Mortality? ? Morbidity? ? Disability? ü Risk factors § The risk factors of today are the diseases of tomorrow

Development of non communicable diseases Life course approach for the prevention of non communicable Development of non communicable diseases Life course approach for the prevention of non communicable diseases Foetal life • SES • Maternal nutritional status & obesity, • Fetal growth Infancy and Adolescence childhood • SES • Nutrition • Diseases • Linear growth • Obesity • Lack of activity • Diet • Alcohol, • Smoking • SE potential Adult Life • Established adult risk factors (behavioural/biological) Range of individual risk Accumulated risk Age

The causal chain explains the risk factor approach for surveillance of non communicable diseases The causal chain explains the risk factor approach for surveillance of non communicable diseases Behavioral risk factors • • Tobacco Alcohol Physical inactivity Nutrition Physiological risk factors • • Body mass index Blood pressure Blood glucose Cholesterol Disease outcomes • Heart disease • Stroke • Diabetes • Cancer • Respiratory diseases

Rationale of the risk factor approach for non communicable diseases • Non communicable diseases Rationale of the risk factor approach for non communicable diseases • Non communicable diseases are slowly evolving § Early recognition difficult • A number of risk factors influence one or more non communicable diseases • Risk factors have the greatest impact on non communicable diseases mortality and morbidity • Effective modification of risk factors is possible through primary prevention • Projections may be used to estimate burden • Simple surveillance systems can be used • Measurements standardized and validated and obtainable within ethical limits

The WHO STEPwise approach to surveillance of non-communicable disease risk factors Complexity Step 3 The WHO STEPwise approach to surveillance of non-communicable disease risk factors Complexity Step 3 (Biological) Step 2 (Physical) At each step Core Step 1 (Verbal) ess n e siv n e eh pr m Co Sequential approach, step by step Expanded Optional

Heterogeneity of non-communicable risk factors in India Kerala Different dietary patterns Delhi Different body Heterogeneity of non-communicable risk factors in India Kerala Different dietary patterns Delhi Different body composition Jammu & Kashmir Different habits Nagaland Bihar High literacy rate, developed Metropolitan city, highly urbanized, heterogeneous population Nested population Terrain, relatively underdeveloped Nested population Underdeveloped, Tribes and Terrain Illiterate, Poor population Rural, Agricultural, Tribals

Risk factors under surveillance • Tobacco use • Alcohol consumption • Raised blood pressure Risk factors under surveillance • Tobacco use • Alcohol consumption • Raised blood pressure § Systolic and diastolic • Obesity § Height, weight, body mass index, waist circumference • Diet § Low fruit, high fat, added salt to served food • Physical inactivity • Diabetes mellitus § Fasting plasma glucose • High serum cholesterol

How surveillance for non-communicable diseases differs • Surveillance methods: § Estimating the prevalence of How surveillance for non-communicable diseases differs • Surveillance methods: § Estimating the prevalence of risk factors § Periodic sample surveys in each state every five years • Data generated: § § Prevalence of risk factors and unhealthy life style Time trends Geographical distribution Distribution among various populations

Type and frequency of surveys • Periodic sample surveys conducted in states once in Type and frequency of surveys • Periodic sample surveys conducted in states once in five years • 20% of districts surveyed each year • Whole population covered in 5 years • Survey conducted every year in randomly selected districts in a five-year cycle

Organization of the surveys • Practical implementation § Institution with sufficient epidemiological capacity § Organization of the surveys • Practical implementation § Institution with sufficient epidemiological capacity § Best bidders • Coordination and supervision § State directorate of public health § State surveillance unit § District surveillance unit

Target population for survey • Population of 15 years to 64 years. • 10 Target population for survey • Population of 15 years to 64 years. • 10 -year age groups § § § 15 -24 25 -34 35 -44 45 -54 55 -64 • Sampling technique § National Family Health Survey • Cluster sample survey

Sample size • 2500 persons across the 15 -64 years age range § 250 Sample size • 2500 persons across the 15 -64 years age range § 250 participants in each 10 -years age group • Two strata § 2500 individuals in urban area § 2500 individuals from rural area

Proposed survey design • Primary sampling unit § Village in case of rural area Proposed survey design • Primary sampling unit § Village in case of rural area § Ward (Census Enumeration Block) in case of urban area • Stratification of primary sampling units based on selected variables • House-listing in primary sampling units • Within each selected household, all male and female members aged between 15 -64 years are surveyed

Survey instrument • • A pre-tested simple questionnaire Developed on the basis of the Survey instrument • • A pre-tested simple questionnaire Developed on the basis of the WHO (STEPS) Modified for the Indian context Already in use for sentinel surveillance for cardiovascular risk factors in 10 selected industrial populations all over India

Information collection • Questionnaire • Measurement § Height § Weight § Blood pressure • Information collection • Questionnaire • Measurement § Height § Weight § Blood pressure • Biochemical results § Fasting blood glucose § Serum cholesterol

Step 1: Individual questionnaire (1/2) • Baseline demography § Identification, age, sex, education, occupation Step 1: Individual questionnaire (1/2) • Baseline demography § Identification, age, sex, education, occupation • Alcohol consumption § Current drinkers, frequency, quantity • Tobacco (Smoking and smokeless) § Age at initiation, usage, cessation

Step 1: Individual questionnaire (2/2) • Diet, fruits and vegetables § In a typical Step 1: Individual questionnaire (2/2) • Diet, fruits and vegetables § In a typical week, frequency and quantity • Physical activity § At work, transportation and leisure • History of diagnosis and treatment § Hypertension and diabetes

Data collection instrument and analysis • • Computer friendly data collection instrument Easy data Data collection instrument and analysis • • Computer friendly data collection instrument Easy data entry Automated data analysis through programme Generation of information on trends and patterns of non communicable disease risk factors

Findings and their uses • Information generated on non communicable disease risk factors: § Findings and their uses • Information generated on non communicable disease risk factors: § Trends § Prevalence in various areas § Distribution in the populations • Uses: § Document the need for prevention and control programmes in the community § Influence policy makers § Guide financial allocation

Ensuring validity • • • Maximize response fraction Use valid and reliable instruments Calibrate Ensuring validity • • • Maximize response fraction Use valid and reliable instruments Calibrate instruments Train staff Ensure participation of individuals selected § Reduces the probability that those who do attend are unrepresentative of the sample • Engage district surveillance officer and other health personnel • Use existing local public health infrastructure

Role of the district public health laboratories • Conduct tests: § Blood sugar § Role of the district public health laboratories • Conduct tests: § Blood sugar § Cholesterol • Co-ordinate collection, transport and receipt of the samples from the periphery • Plan capacity to carry out analyses quickly • Ensure quality control of biochemical assays § Key factor to ensure useful results

Quality assurance • • Common protocol Standardized training Standardized survey methods Monitoring and coordinating Quality assurance • • Common protocol Standardized training Standardized survey methods Monitoring and coordinating set ups Advisory group and resources Site visits Common data management mechanisms Critical appraisal

Ethical considerations • Questionnaires dealing with lifestyle issues and simple non-invasive measurements § Verbal Ethical considerations • Questionnaires dealing with lifestyle issues and simple non-invasive measurements § Verbal consent • Blood pressure § Need to clarify whether persons with elevated readings would be followed up and treatment provided § Written consent needed • Collection of blood § Requires prior ethical clearance § Built-in plans for treatment of those with raised levels • Built-in consent form in the questionnaire

Promise to care • Referral, diagnostic and treatment support to persons identified with non Promise to care • Referral, diagnostic and treatment support to persons identified with non communicable disease risk factor will be built into the system • Patients identified with hypertension, diabetes will be referred to the next level for treatment

Timing of the survey • Physiological and cultural considerations • Overnight fasting needed § Timing of the survey • Physiological and cultural considerations • Overnight fasting needed § Start early in the morning (6: 00 am) § Finish early in the afternoon (1: 00 pm) • Rest of the day § Coding forms § Dealing with the laboratory specimens and other documentation § Preparations for the next day

Follow up action • Coordinated approach for community level interventions • Partnerships § Medical Follow up action • Coordinated approach for community level interventions • Partnerships § Medical colleges, state health departments, primary health care services and nongovernmental organisations • Dissemination of health education material on causes, prevention and incentives to enhance public awareness

High risk and population approaches to prevention Truncate high risk end of exposure distribution High risk and population approaches to prevention Truncate high risk end of exposure distribution (e. g. , organize an obesity clinic). Clinical approach to disease prevention Reduce a small amount of risk in a large number of people (e. g. , reduce fat a little in fast-food outlets). Lifestyle change plus environmental approach More burden from a large proportion of the population exposed to moderate risk factors than from a small segment exposed to a high risk factor

Intervention strategies • Population based strategy § Prevent non-communicable diseases in the whole population Intervention strategies • Population based strategy § Prevent non-communicable diseases in the whole population • High-risk strategy § Target people with identified risk factors

Public health interventions Policy interventions Educational interventions Enabling environment (Financial, Social, Physical) Health beliefs Public health interventions Policy interventions Educational interventions Enabling environment (Financial, Social, Physical) Health beliefs and behaviours (Community; Individual) Desired change

Challenges and opportunities • • • Challenges Huge population Many programmes Rural population Emerging Challenges and opportunities • • • Challenges Huge population Many programmes Rural population Emerging epidemics Unemployed youth Burden of non communicable diseases • • • Opportunity Good sample size Different strategies Complex exposures Interventions Trained workforce Feasible intervention

Points to remember (1/3) • • • The burden of diseases due to non Points to remember (1/3) • • • The burden of diseases due to non communicable diseases in India became almost equal to that due to communicable diseases in 1990 The burden of non communicable diseases is increasing while it is declining in developed countries because of surveillance and interventions The life style related modifiable risk factors for non communicable diseases have been identified and the magnitude of their impact is documented

Points to remember (2/3) • The major non communicable diseases share common, preventable life Points to remember (2/3) • The major non communicable diseases share common, preventable life style risk factors • There is sound evidence that non communicable diseases can be reduced through a package of simple, effective and feasible life style changes • The treatment of non communicable diseases is expensive and therefore the key to control is in its primary prevention

Points to remember (3/3) • Non communicable diseases surveillance is therefore considered an important Points to remember (3/3) • Non communicable diseases surveillance is therefore considered an important component of the integrated disease surveillance project • Non communicable diseases surveillance will be done by periodic surveys of selected risk factors and will be independent of regular surveillance for other conditions • The Non communicable disease risk factors to be measured in include: tobacco use, alcohol consumption, high blood pressure, obesity, diet, physical inactivity, fasting plasma glucose and serum cholesterol