Disease Surveillance Disease Surveillance in Indiain India

Dr Sampath K KrishnanDr Sampath K Krishnan

National Professional Officer National Professional Officer (Communicable Diseases Surveillance)(Communicable Diseases Surveillance)

PresentationPresentation

Disease surveillanceDisease surveillance NSPCDNSPCD IDSPIDSP Lessons Learnt/IssuesLessons Learnt/Issues

Disease surveillanceDisease surveillance Disease surveillance in India has always Disease surveillance in India has always

been practiced by the states (health been practiced by the states (health being a state subject) being a state subject)

Many gaps, differed in degree and quality Many gaps, differed in degree and quality of surveillance, different priorities in of surveillance, different priorities in diseases diseases

Rapid Response Teams (RRTs) Rapid Response Teams (RRTs) (depending on the epidemic potential of (depending on the epidemic potential of these diseases) were called : - these diseases) were called : - • Malaria Response Teams Malaria Response Teams • Cholera Combat TeamsCholera Combat Teams• Other disease specific Response Teams Other disease specific Response Teams

Little / no information was made Little / no information was made available at National levelavailable at National level

National Health ProgrammesNational Health Programmes

Significant surveillance componentSignificant surveillance componentDisease specificDisease specificToo vertical in approach Too vertical in approach

Response at the district level is often delayedResponse at the district level is often delayed MalariaMalaria FilariasisFilariasis Kala azarKala azar Leprosy Leprosy TBTB PolioPolio HIV/AIDSHIV/AIDS VPDsVPDs

RCHRCH Cancer controlCancer control BlindnessBlindness Mental HealthMental Health Iodine deficiencyIodine deficiency Water supplyWater supply Total SanitationTotal Sanitation

Need for SurveillanceNeed for Surveillance

The Government of India realized the The Government of India realized the importance of Disease surveillance importance of Disease surveillance after the Cholera outbreak in Delhi after the Cholera outbreak in Delhi and the Plague outbreak in Surat, and the Plague outbreak in Surat, which not only had significant which not only had significant mortality and morbidity but also mortality and morbidity but also significant significant economic consequenceseconomic consequences..

National Surveillance National Surveillance Programme for Communicable Programme for Communicable

Diseases (NSPCD)Diseases (NSPCD)

NSPCD was therefore launched by the NSPCD was therefore launched by the Centre in 1997-98 in five pilot districts Centre in 1997-98 in five pilot districts of the country (centrally sponsored of the country (centrally sponsored scheme) and over the years extended to scheme) and over the years extended to cover 101 Districts in the country in all cover 101 Districts in the country in all 35 states and UTs in the country. 35 states and UTs in the country.

NSPCDNSPCD In this programme the states are the In this programme the states are the

implementing agencies and NICD implementing agencies and NICD Delhi is the Nodal agency for Delhi is the Nodal agency for coordinating the activities. coordinating the activities.

This programme is based on This programme is based on outbreak outbreak reportingreporting (as and when outbreaks (as and when outbreaks occur) with occur) with weekly reporting of weekly reporting of epidemic prone diseasesepidemic prone diseases directly from directly from Districts (including nil reporting) to Districts (including nil reporting) to the Centre.the Centre.

Main strategyMain strategyTo establish To establish Early Warning System (EWS)Early Warning System (EWS) so as to so as to institute appropriate and timely response for institute appropriate and timely response for prevention & control of outbreaksprevention & control of outbreaks

Every state/UT and all the 101 districts has a Every state/UT and all the 101 districts has a trained multi-disciplinary trained multi-disciplinary Rapid Response Team Rapid Response Team

Rapid communicationsRapid communications (through e-mails & fax) (through e-mails & fax)

Strengthening of state and district Strengthening of state and district laboratorieslaboratories for rapid confirmation of diagnosisfor rapid confirmation of diagnosis

Capacity developmentCapacity development of health staff in the of health staff in the

districtsdistricts

IECIEC (information, education and communication) (information, education and communication)

Districts covered under NSPCDDistricts 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

Diseases/pathogens coveredDiseases/pathogens covered

Epidemic prone communicable Epidemic prone communicable diseases- acute diarrhoeal diseases diseases- acute diarrhoeal diseases including cholera, viral hepatitis, including cholera, viral hepatitis, dengue, Japanese encephalitis, dengue, Japanese encephalitis, meningitis, measles, viral meningitis, measles, viral haemorrhagic fevers, leptospirosis etc.haemorrhagic fevers, leptospirosis etc.

Pathogens with bioterrorism potentialPathogens with bioterrorism potential

Drug resistant pathogensDrug resistant pathogens

Central responsibilities (NICD)Central responsibilities (NICD)

Development of RRT guidelines, laboratory & Development of RRT guidelines, laboratory &

computer manuals, and training materialscomputer manuals, and training materials

Training of State Rapid Response Teams Training of State Rapid Response Teams

Strengthening & networking of National and Strengthening & networking of National and

Regional laboratories Regional laboratories

Establishing rapid communication networkEstablishing rapid communication network

Technical review, co-ordination, monitoring Technical review, co-ordination, monitoring

and evaluationand evaluation

State responsibilitiesState responsibilities Strengthening of epidemiological Strengthening of epidemiological

capabilities at state and district level by capabilities at state and district level by

training of district RRT and health personnel training of district RRT and health personnel

at the peripheryat the periphery

Modernization and computerization of state Modernization and computerization of state

& district Epidemiology cell& district Epidemiology cell

Strengthening of state / district laboratories Strengthening of state / district laboratories

Improving sub-district mobility and Improving sub-district mobility and

communicationcommunication

IECIEC

Expected outcomeExpected outcome

Early detection of outbreaksEarly detection of outbreaks Early institution of containment Early institution of containment

measuresmeasures

Reduction in morbidity & Reduction in morbidity &

mortalitymortality

Minimize economic lossMinimize economic loss

Weekly reports received from NSPCD Weekly reports received from NSPCD districts districts

during 2001, 2002 & 2003 during 2001, 2002 & 2003 Jan - JuneJan - June

0

10

20

30

40

50

60

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Week No. 2001 2002 2003

Weekly reports received from NSPCD Weekly reports received from NSPCD districts during 2001,2002 & 2003 districts during 2001,2002 & 2003

July-DecJuly-Dec

0

10

20

30

40

50

60

27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52

Week No.

No.o

f rep

orts

rece

ived

2001 2002 2003

Monthly reports received during Monthly reports received during 2001, 2002 & 2003 from NSPCD districts2001, 2002 & 2003 from NSPCD districts

43 4240 39 39

34 35

30 3027

32 31

4138 39

4542 41

44

3537

39

31

3938 39 38 39

45

32 32

28

2326

18

46

0

5

10

15

20

25

30

35

40

45

50

Jan

Feb

Mar Ap

r

May Ju

n Jul

Aug

Sep

Oct

Nov

Dec

Month

No.

of R

epor

ts re

ceiv

ed

2001 2002 2003

Month-wise outbreaks 2001, Month-wise outbreaks 2001, 2002 & 20032002 & 2003

0

10

20

30

40

50

60

70

J an Feb Mar Apr May J un J ul Aug Sep Oct Nov Dec

Month

No.o

f out

brea

ks re

porte

d

2001 2002 2003

Profile of outbreaks Profile of outbreaks investigated by NSPCD investigated by NSPCD

districtsdistricts

57

3 5 60

101 1 5 2 0 0

85

147 8 5 7 6 3 1 1 0 0

105

80

6 3 7 91 2 5 2 2

0

20

40

60

80

100

120

AD

D

(GE

,Dia

rrho

ea,

Dys

entr

y)

Mal

aria JE

Mea

sles

Foo

d P

oiso

ning

Chi

cken

pox

Type of outbreak

No

. o

f o

utb

reak

s

2001 2002 2003

Laboratory strengthening Laboratory strengthening District laboratoriesDistrict laboratories

WATER + STOOL C/S

WATER ONLY

NO WATER; NO STOOL C/S

NO INFORMATION

NON NSPCD DISTRICTS

Investigations performed at Investigations performed at NSPCD district laboratoriesNSPCD district laboratories

Microscopy:Microscopy:• Wet mount for cholera, T/S for diphtheria, AFB Wet mount for cholera, T/S for diphtheria, AFB

smear, smear for plague bacilli, P/S for MP, P/S for smear, smear for plague bacilli, P/S for MP, P/S for Mf, BMA for LD bodies, CSF for Pyogenic meningitis.Mf, BMA for LD bodies, CSF for Pyogenic meningitis.

Bacterial cultures & sensitivity testing:Bacterial cultures & sensitivity testing:• Stool C/S for enteric pathogens (Salmonella, Stool C/S for enteric pathogens (Salmonella,

Shigella, Vibrio cholerae); Blood C/SShigella, Vibrio cholerae); Blood C/S Bacteriological water testingBacteriological water testing Basic serology:Basic serology:

• Widal, HBV & HCV, VDRL, HIV, dengueWidal, HBV & HCV, VDRL, HIV, dengue Referral of specialized serology.Referral of specialized serology.

Format for weekly reportsFormat for weekly reports

• Week Starting

Week ending• Outbreak

– Number– Nature

• News Paper cutting• Report of epidemiological investigation• Name & Signature of Nodal Officer of District

Involvement of Medical CollegesInvolvement of Medical Colleges

In State RRTs- Gauhati Medical College, In State RRTs- Gauhati Medical College, Trivandrum Medical College, SCB Medical Trivandrum Medical College, SCB Medical College Cuttack, etcCollege Cuttack, etc

In District RRTs-Medical Colleges Kottayam, In District RRTs-Medical Colleges Kottayam, Khozikode, Calicut, Alappuzha, Dibrugarh, Khozikode, Calicut, Alappuzha, Dibrugarh, Silchar, etcSilchar, etc

As Regional/District Labs- Medical Colleges As Regional/District Labs- Medical Colleges Gwalior, Kolar, Bellary, Shimla, Ahmedabad, Gwalior, Kolar, Bellary, Shimla, Ahmedabad, Kakinada, Silchar, Dibrugarh, etcKakinada, Silchar, Dibrugarh, etc

Monitoring of the programmeMonitoring of the programme

Review meetings- regional Review meetings- regional meetings half yearly in 2001, meetings half yearly in 2001, 2002, 20032002, 2003

Field visits by experts Field visits by experts throughout the yearthroughout the year

Independent Appraisals carried Independent Appraisals carried out in 2001 and December 2003out in 2001 and December 2003

AchievementsAchievements

1.1. Improved quality of detection, Improved quality of detection,

investigation and response to investigation and response to

outbreaksoutbreaks

2.2. Rapid Response Teams with requisite Rapid Response Teams with requisite

knowledge and skills in placeknowledge and skills in place

3.3. Technical material on outbreaks Technical material on outbreaks

investigation, manual on laboratory investigation, manual on laboratory

procedures and computer usage procedures and computer usage

developed and made available in field developed and made available in field

AchievementsAchievements4.4. Training in computer application for Training in computer application for

data processing and communicationdata processing and communication

5.5. Feedback mechanism in the form of Feedback mechanism in the form of

“Outbreak News” & “CD Alert” and by “Outbreak News” & “CD Alert” and by

frequent letters through e-mail/postfrequent letters through e-mail/post

6.6. Improved capability of laboratories for Improved capability of laboratories for

etiological diagnosis etiological diagnosis

7.7. Rapid transmission of informationRapid transmission of information

8.8. NICD Website www.nicd.org (includes NICD Website www.nicd.org (includes

NSPCD networking)NSPCD networking)

NSPCDNSPCDNSPCD has significantly improved the NSPCD has significantly improved the capacity of these districts and states to capacity of these districts and states to detect investigate and respond to detect investigate and respond to outbreaks, yet outbreaks, yet

It was not case based reporting and did It was not case based reporting and did not give a complete picture of disease not give a complete picture of disease burden in the country especially in burden in the country especially in respect of epidemic prone diseasesrespect of epidemic prone diseases

GoI not convinced to expand this GoI not convinced to expand this programme to all districts in the programme to all districts in the countrycountry

Integrated Disease Surveillance Integrated Disease Surveillance Project (IDSP)Project (IDSP)

Integrated Disease Surveillance Integrated Disease Surveillance Project (IDSP) was conceptualized Project (IDSP) was conceptualized and proposed and the GoI and proposed and the GoI approached the World Bank for the approached the World Bank for the necessary fundingnecessary funding

Objectives of IDSPObjectives of IDSP

Establish a decentralized system of Establish a decentralized system of

disease surveillance for timely and disease surveillance for timely and effective public health action effective public health action

Improve the efficiency of disease Improve the efficiency of disease surveillance for use in health surveillance for use in health planning, management and planning, management and evaluating control strategies evaluating control strategies

IDSPIDSPBased on Based on case based reportingcase based reporting

Syndromic surveillanceSyndromic surveillance (suspect (suspect

case reporting at PHC and below)case reporting at PHC and below) Confirmed case reportingConfirmed case reporting of of

selected priority diseases (at selected priority diseases (at district level) district level)

Passive reportingPassive reporting of Road Traffic of Road Traffic Accidents and Air Pollution.Accidents and Air Pollution.

Syndromic surveillanceSyndromic surveillance

Fever<7 days (alone, with rash, with altered Fever<7 days (alone, with rash, with altered sensorium/convulsions, bleeding skin/gumssensorium/convulsions, bleeding skin/gums

Fever>7 daysFever>7 days Cough>3 weeksCough>3 weeks AFPAFP DiarrheaDiarrhea JaundiceJaundice Unusual events causing Unusual events causing

death/hospitalizationdeath/hospitalization

Target diseasesTarget diseases

MalariaMalaria ADD(Cholera)ADD(Cholera) TyphoidTyphoid TuberculosisTuberculosis MeaslesMeasles PolioPolio Plague Plague HIV, HBV, HCVHIV, HBV, HCV

Unusual Unusual SyndromesSyndromes

AccidentsAccidents Water QualityWater Quality Outdoor Air QualityOutdoor Air Quality NCD Risk factorsNCD Risk factors State Specific State Specific

DiseasesDiseases

Project componentsProject components

• Integrating & decentralizing disease Integrating & decentralizing disease surveillance & response mechanismssurveillance & response mechanisms

• Strengthening Public Health Strengthening Public Health LaboratoriesLaboratories

• Using Information Technology and Using Information Technology and Networking in disease surveillanceNetworking in disease surveillance

• Human Resource DevelopmentHuman Resource Development

Level of responsesLevel of responses

Trigger-1 : Response Health WorkersTrigger-1 : Response Health Workers

Trigger-2 : Outbreak Inv. & Response Trigger-2 : Outbreak Inv. & Response (PHCs/ CHCs)(PHCs/ CHCs)

Trigger-3 : Outbreak Inv. & Resp. (DSU)Trigger-3 : Outbreak Inv. & Resp. (DSU)

Trigger-4 : Epidemic Response (SSU)Trigger-4 : Epidemic Response (SSU)

Trigger-5 : Disaster Response (CSU)Trigger-5 : Disaster Response (CSU)

Project phasingProject phasing

Phase – IPhase – I (2004-05): Tamil Nadu, Kerala, (2004-05): Tamil Nadu, Kerala, Karnataka, Andhra Pradesh, Maharashtra, Karnataka, Andhra Pradesh, Maharashtra, Madhya Pradesh, Uttaranchal, Himachal Madhya Pradesh, Uttaranchal, Himachal Pradesh & Mizoram (nine states)Pradesh & Mizoram (nine states)

Phase – II (2005-06)Phase – II (2005-06): Chattisgarh, Goa, Gujarat, : Chattisgarh, Goa, Gujarat, Haryana, Rajasthan, West Bengal, Manipur, Haryana, Rajasthan, West Bengal, Manipur, Meghalaya, Tripura, Chandigarh, Pondicherry, Meghalaya, Tripura, Chandigarh, Pondicherry, Delhi;Delhi;

Phase – III (2006-07)Phase – III (2006-07): Uttar Pradesh, Bihar, : Uttar Pradesh, Bihar, Jammu & Kashmir, Jharkhand, Punjab, Jammu & Kashmir, Jharkhand, Punjab, Arunachal Pradesh, Assam, Nagaland, Sikkim, A Arunachal Pradesh, Assam, Nagaland, Sikkim, A & N Island, D & N Haveli, Daman & Diu, & N Island, D & N Haveli, Daman & Diu, Lakshwadeep.Lakshwadeep.

Organizational StructureOrganizational Structure

Disease Surveillance Disease Surveillance CommitteeCommittee

Executive CommitteeExecutive Committee

Disease Surveillance UnitDisease Surveillance Unit

District Surveillance CommitteeDistrict Surveillance Committee

Chairperson* District Surveillance Committee

District Surveillance Officer (Member Secretary)

CMO(Co. Chair)

RepresentativeWater Board

Superintendent Of Police

IMA Representative

NGORepresentative

District PanchayatChairperson

Chief District PHLaboratory

Medical CollegeRepresentative

if any

RepresentativePollution Board

District Training Officer(IDSP)

District Data Manager(IDSP)

District Program ManagerPolio, Malaria, TB, HIV - AIDS

* District Collector or District Magistrate

STRUCTURAL FRAMEWORKSTRUCTURAL FRAMEWORK

C.S.U.C.S.U.

S.S.US.S.U

D.S.U.D.S.U.

P.S.UP.S.U

MED COL.

DIST HOS.

PVT. HOS.

OTHER HOS.

LABS

SUB CENTRES

PHCs/CHCs

RURAL PPs

Formats & manualsFormats & manuals

Standard Case DefinitionsStandard Case Definitions

Standard Formats for reportingStandard Formats for reporting

Operations manual for Health Workers, Operations manual for Health Workers, Medical Officers, Laboratory Medical Officers, Laboratory Technicians and District/State Technicians and District/State Surveillance TeamsSurveillance Teams

Standard user friendly training Standard user friendly training manuals manuals

NCD risk factor surveillanceNCD risk factor surveillance Monitor trends of important risk Monitor trends of important risk

factors of NCD in the community over factors of NCD in the community over a period of timea period of time

Evolve strategies for interventions of Evolve strategies for interventions of these risk factors so as to reduce the these risk factors so as to reduce the burden of diseases due to NCDsburden of diseases due to NCDs

Strengthen NCD surveillance at Strengthen NCD surveillance at District levelDistrict level

Integrate NCD risk factor surveillance Integrate NCD risk factor surveillance with IDSPwith IDSP

Strengths of IDSPStrengths of IDSP

Functional integration of surveillance Functional integration of surveillance components of vertical programmescomponents of vertical programmes

Reporting of suspect, probable and Reporting of suspect, probable and confirmed casesconfirmed cases

Strong IT component for data analysisStrong IT component for data analysis Trigger levels for gradated responseTrigger levels for gradated response Action component in the reporting Action component in the reporting

formatsformats Streamlined flow of funds to the Streamlined flow of funds to the

districtsdistricts

IntegrationIntegration

National programmesNational programmes NCDsNCDs Private sectorPrivate sector Police, PCBs, Water supplyPolice, PCBs, Water supply IEC activitiesIEC activities TrainingTraining Formation of committees to oversee Formation of committees to oversee

integrationintegration

Integration ?!Integration ?!

What exactly do we expect in What exactly do we expect in integrationintegration

Functional integration to what degreeFunctional integration to what degree Vertical programmes will continueVertical programmes will continue NCD component invariably stand NCD component invariably stand

alonealone IEC, Training, Formats- consultation IEC, Training, Formats- consultation

with these programmes with these programmes Fund sharing a daunting taskFund sharing a daunting task

Disease SurveillanceDisease Surveillance

Lessons learnt / Issues Lessons learnt / Issues

Lessons learntLessons learntNSPCDNSPCD No budget for NSPCD No budget for NSPCD

nodal cellnodal cell No integrationNo integration No budget for No budget for

retrainingretraining Feedback inadequateFeedback inadequate

Weak IT componentWeak IT component Weak state ownership Weak state ownership

(selected districts)(selected districts)

Slow financial flowSlow financial flow Weak M & E, Weak M & E,

supervisionsupervision Weak Advocacy Weak Advocacy

IDSPIDSP IDSP cell in Ministry IDSP cell in Ministry

with budgetwith budget IntegrationIntegration Budget for retrainingBudget for retraining

Adequate feedback Adequate feedback plannedplanned

Strong IT componentStrong IT component Strong state Strong state

ownership (all ownership (all districts)districts)

Fast financial flowFast financial flow Strong M & E, Strong M & E,

supervisionsupervision Advocacy at all levelsAdvocacy at all levels

National IssuesNational Issues Political considerations based on Political considerations based on

Centre-state relationsCentre-state relations Central assistance proportionate to Central assistance proportionate to

political affiliationspolitical affiliations Media attention an important Media attention an important

consideration for responseconsideration for response Time constraints-inadequate time Time constraints-inadequate time

given for outbreak investigation given for outbreak investigation Hesitancy for international assistance Hesitancy for international assistance

either in Outbreak Investigation or either in Outbreak Investigation or Lab supportLab support

National Issues cont’dNational Issues cont’d Reduced attendance in public health Reduced attendance in public health

system and increased in private sector system and increased in private sector almost 40:60 or morealmost 40:60 or more

Wide-spread quackery in the name of Wide-spread quackery in the name of alternate medicine (ayurveda, unani, alternate medicine (ayurveda, unani, homeopathy, etc)homeopathy, etc)

‘‘Overworked’ clinicians so poor Overworked’ clinicians so poor maintenance of medical records like case maintenance of medical records like case sheets/prescription slips/provisional sheets/prescription slips/provisional diagnosis/etcdiagnosis/etc

Lack of ownership by states of central Lack of ownership by states of central vertical programmesvertical programmes

State issuesState issues State RRT not utilized to full potentialState RRT not utilized to full potential Regional labs strengthened but lab Regional labs strengthened but lab

diagnosis not enhanced & increasing diagnosis not enhanced & increasing dependence on Centredependence on Centre

Insufficient epidemiological analysis Insufficient epidemiological analysis No clear IEC strategyNo clear IEC strategy Frequent transfer/retirements of trained Frequent transfer/retirements of trained

staff so programme invariably suffersstaff so programme invariably suffers Shortage of staff so multi-tasking for state Shortage of staff so multi-tasking for state

and district level functionaries. and district level functionaries. Fund issues and Utilization certificatesFund issues and Utilization certificates

State issues cont’dState issues cont’d

Lack of competent staff especially Lack of competent staff especially Public Health Professionals and Public Health Professionals and Microbiologists in majority of the Microbiologists in majority of the states. Short trainings not likely to states. Short trainings not likely to build the necessary capacity.build the necessary capacity.

Clear demarcation between the Clear demarcation between the Directorate of Health Services and Directorate of Health Services and Directorate of Medical Education so Directorate of Medical Education so difficulties in integrating Medical difficulties in integrating Medical collegescolleges

District issuesDistrict issues Programme is focused on district epidemic Programme is focused on district epidemic

preparedness and response but some preparedness and response but some districts yet to get their act togetherdistricts yet to get their act together

Reporting from periphery needs Reporting from periphery needs improvement. If media first reporting then improvement. If media first reporting then SURVEILLANCE FAILURESURVEILLANCE FAILURE

Weekly reports incomplete and irregular Weekly reports incomplete and irregular (and under reporting)(and under reporting)

Monthly reports also irregular (CBHI has Monthly reports also irregular (CBHI has to increase its role & responsibility)to increase its role & responsibility)

Communication ‘failure’Communication ‘failure’ CMO-CMS-DSO lack of co-ordinationCMO-CMS-DSO lack of co-ordination

District issues cont’dDistrict issues cont’d Overworked peripheral staff to whom all Overworked peripheral staff to whom all

programmes are dependent onprogrammes are dependent on Multiple formats for different programmesMultiple formats for different programmes Rapid Response Teams usually composed Rapid Response Teams usually composed

of specialists from District hospital/ of specialists from District hospital/ Medical college and problem in rapid Medical college and problem in rapid mobilization as from different agenciesmobilization as from different agencies

Concept of Nil reporting/routine reporting Concept of Nil reporting/routine reporting difficult for the peripheral staff to difficult for the peripheral staff to understand, compounded by lack of understand, compounded by lack of feedback from the higher levelsfeedback from the higher levels

District lab issuesDistrict lab issues District labs few established and District labs few established and

functioning satisfactorilyfunctioning satisfactorily Many labs in a district:Many labs in a district:

• Public health lab-testing water samplesPublic health lab-testing water samples• Hospital lab-testing for NCDs and clinical Hospital lab-testing for NCDs and clinical

requirementsrequirements• Medical College lab-testing for majority of Medical College lab-testing for majority of

the diseasesthe diseases• Surveillance lab-testing for few diseasesSurveillance lab-testing for few diseases• District blood bank –with ELISA readerDistrict blood bank –with ELISA reader• Peripheral labs-Microscopy onlyPeripheral labs-Microscopy only

Co-ordination between these labs so that Co-ordination between these labs so that overall overall district lab capacity enhanceddistrict lab capacity enhanced

Thank You