Non Communicable Non Communicable Disease SurveillanceDisease Surveillance

A Pilot Project in the District of A Pilot Project in the District of PolonnaruwaPolonnaruwa

Dr Shaluka Jayamanne MD MRCP

Consultant Physician

GH Polonnaruwa

OBJECTIVE OF THE OBJECTIVE OF THE PRESENTATIONPRESENTATION

To present a newly established To present a newly established surveillance system on priority surveillance system on priority chronic NCD in Polonnaruwachronic NCD in Polonnaruwa

To present a community based To present a community based screening programme for a major screening programme for a major health problem in NCP - CRFhealth problem in NCP - CRF

Epidemiology of non Epidemiology of non communicable diseases in communicable diseases in the district of Polonnaruwathe district of Polonnaruwa

Situation of NCDSituation of NCD

Increasing trend with an aging populationIncreasing trend with an aging population

Increasing trend with change in life styleIncreasing trend with change in life style

TransportTransport

AgricultureAgriculture

DiateDiate

Alcohol and tobaccoAlcohol and tobacco

Control of infectionsControl of infections

Epidemiology of NCDEpidemiology of NCD

We do not have a district data baseWe do not have a district data base No Outpatient care statisticsNo Outpatient care statistics Inpatient statistics also have not Inpatient statistics also have not

been audited- Repetitionbeen audited- Repetition

Inadequate documentation Inadequate documentation There is no notification system for There is no notification system for

NCDNCD

Epidemiology NCDEpidemiology NCD

The top three causes of mortality are The top three causes of mortality are related to NCDrelated to NCD

Although NCD are not the leading Although NCD are not the leading causes for hospital admissions they causes for hospital admissions they take up a larger proportion of bed take up a larger proportion of bed occupancyoccupancy

More than 90% of medical clinic More than 90% of medical clinic attendance are related to NCDattendance are related to NCD

Top ten causes of hospitalization

01000

2000300040005000

60007000

Diseases

No. o

f pat

ient

s

Top ten causes of death

0

10

20

30

40

50

60

70

80

Diseases

No. o

f pat

ient

s

Mortality FiguresMortality Figures 200320031. Slow foetal growth and LBW 1. Slow foetal growth and LBW -75-752. Cerebro-vascular Disease 2. Cerebro-vascular Disease -57-573. Renal Failure 3. Renal Failure -56-56

200420041. Renal Failure 1. Renal Failure -89-892. Cerebro-vascular Disease 2. Cerebro-vascular Disease -55-553 Slow foetal growth and LBW 3 Slow foetal growth and LBW -43-43

200520051. Cerebro-vascular Disease 1. Cerebro-vascular Disease -35-352. Renal Failure 2. Renal Failure -28-28

Renal Failure

0

50

100

150

200

250

300

2001 2002 2003 2004 2005

Year

No. o

f pat

ient

s

M(A)

F(A)

M(D)

F(D)

CVA

020406080

100120140160

2001 2002 2003 2004 2005

Year

No. o

f pat

ient

s

M(A)

F(A)

M(D)

F(D)

DM

0

100

200

300

400

500

2001 2002 2003 2004 2005

Year

No. o

f pat

ient

s

M(A)

F(A)

M(D)

F(D)

MI

0

50

100

150200

250

300

350

2001 2002 2003 2004 2005

Year

No. o

f pat

ient

s

M(A)

F(A)

M(D)

F(D)

IHD

0

100

200

300

400

500

2001 2002 2003 2004 2005

Year

No. o

f pat

ient

s

M(A)

F(A)

M(D)

F(D)

Renal Failure Admissions and Renal Failure Admissions and DeathsDeaths

YEARYEAR M (A)M (A) M (D)M (D) F(A)F(A) F(D)F(D)

20052005 222222 5151 4848 1010

20042004 238238 6969 5656 2121

20032003 222222 ** 3232 *55*55

20022002 158158 ** 6767 *49*49

20012001 ## ** #253#253 *36*36

Cerebroavascular Disease Cerebroavascular Disease Admissions and DeathsAdmissions and Deaths

YEARYEAR M (A)M (A) M (D)M (D) F(A)F(A) F(D)F(D)

20052005 145145 3939 6969 2828

20042004 118118 3131 6868 2525

20032003 106106 ** 138138 *63*63

20022002 112112 ** 7272 *59*59

20012001 ** ## *145*145 #35#35

NCD EpidemiologyNCD Epidemiology

Overall we see an increasing trend in Overall we see an increasing trend in NCDsNCDs

Proportionately death rates have Proportionately death rates have come down marginallycome down marginally

Mortality data has not been assessed Mortality data has not been assessed comprehensivelycomprehensively

Disease burden has Disease burden has changed towards chronic changed towards chronic conditions in Polonnarwa conditions in Polonnarwa

world wide.world wide.

Majority of Majority of Health systems Health systems haven’thaven’t

Prioritizing Prevention & Control Prioritizing Prevention & Control EffortsEfforts

Leading Causes of DeathLeading Causes of Death Years of Potential Life LostYears of Potential Life Lost Economic Cost to SocietyEconomic Cost to Society

Noncommunicable Disease Noncommunicable Disease ModelModel

Your geneticYour geneticendowmentendowment

Personality

Personality

Beliefs

Beliefs

BehavioralBehavioralchoiceschoices

Noncommunicable Disease Noncommunicable Disease ModelModel

Your geneticYour geneticendowmentendowment

Personality

Personality

Beliefs

Beliefs

BehavioralBehavioralchoiceschoices

EnvironmentEnvironment Health C

are

Health C

are

System

System

Wat

er Q

ualit

y

Wat

er Q

ualit

y

AirAirPollutionPollution

Eco

nom

ics

Eco

nom

ics

Importance of a Surveillance Importance of a Surveillance System for Chronic NCDSystem for Chronic NCD

Surveillance provides health information in a timely Surveillance provides health information in a timely manner to fight epidemics now or plan for the future.manner to fight epidemics now or plan for the future.

A SURVEILLANCE SYSTEM: NOT ENTIRELY A NEW A SURVEILLANCE SYSTEM: NOT ENTIRELY A NEW FIELDFIELD• Notification of Communicable DiseasesNotification of Communicable Diseases• Pilot of a Surveillance System in Colombo District Pilot of a Surveillance System in Colombo District

(XXX)(XXX)

The present information systemThe present information system• Xxxxx (status… strengths and weaknesses vis-à-vis Xxxxx (status… strengths and weaknesses vis-à-vis

chronic NCD)chronic NCD)

Transforming the District Transforming the District Information SystemInformation System

POLONNARUWA - AN IDEAL PARTNERPOLONNARUWA - AN IDEAL PARTNER• The success of earlier pilot testing of The success of earlier pilot testing of

information systemsinformation systems Hospital Information systemHospital Information system Drugs management InformationDrugs management Information Public Health Information SystemPublic Health Information System

• Positive Previous experiences Positive Previous experiences Cooperation of the staff in innovative Cooperation of the staff in innovative

projects – Easy to work withprojects – Easy to work with Good motivated team with positive Good motivated team with positive

attitudesattitudes

The Surveillance SystemThe Surveillance System Phase 1:Phase 1:

• CVDCVD HypertensionHypertension Ischaemic Heart DiseasesIschaemic Heart Diseases Cerebrovascular DiseasesCerebrovascular Diseases Congenital Heart Congenital Heart

DiseasesDiseases• DiabetesDiabetes

Phase 2:Phase 2:• Renal diseasesRenal diseases• CancerCancer• Mental healthMental health• OthersOthers

Phase 1Phase 1• GH PolonnaruwaGH Polonnaruwa• BH MedirigiriyaBH Medirigiriya• DH HingurakgodaDH Hingurakgoda• MOH (all 7) AreasMOH (all 7) Areas

Phase 2Phase 2• All Hospitals in All Hospitals in

Polonnaruwa Polonnaruwa • All MOH areasAll MOH areas

Using the NCD NC, enters informationin the MOH NCD registerGenerates NCD Basic Surveillance FormGenerates NCD Special Surveillance Form

- Facilitate continuityof care (e.g. follow up,treatment)- Health promotion

- Risks analysis- Health promotion

PROPOSED CHRONIC NCD PROPOSED CHRONIC NCD SURVEILLANCE SYSTEMSURVEILLANCE SYSTEM

GeneratesNCD NotificationCard (NCD NC)

Using the NCD NC, enters information

in the Hospital NCD Register

Patient

WardDoctor

MOH

PHI

MO/PH

House-hold

RE

CHRONIC NCD SURVEILLANCE SYSTEM:CHRONIC NCD SURVEILLANCE SYSTEM: FORMS & REGISTERSFORMS & REGISTERS

1.1. NCD Notification CardNCD Notification Card

2.2. Hospital NCD RegisterHospital NCD Register

3.3. MOH NCD RegisterMOH NCD Register

4.4. NCD Basic Investigation FormNCD Basic Investigation Form

5.5. PHI NCD RegisterPHI NCD Register

6.6. NCD Monthly ReturnNCD Monthly Return

Programme TodayProgramme Today

CRF- Extent of the ProblemCRF- Extent of the Problem

Leading cause of death at Leading cause of death at GH GH PolonnaruwaPolonnaruwa in year 2004 in year 2004

Among three leading causes for Among three leading causes for hospital medical admissionshospital medical admissions

10% of clinic attendance is due to CRF10% of clinic attendance is due to CRF

Until recently there was no established Until recently there was no established community screening programme community screening programme

Therefore this is the tip of the ice bergTherefore this is the tip of the ice berg

CRFCRF

Main CharacteristicsMain Characteristics Male to Female ratio 5:2Male to Female ratio 5:2 Average age of Diagnosis 30-50 Average age of Diagnosis 30-50

yearsyears More than 95% are farmersMore than 95% are farmers Poor socio-economic classPoor socio-economic class

CRFCRF

Overall analysis shows that 8-10 deaths Overall analysis shows that 8-10 deaths per month is due to CRF or related causesper month is due to CRF or related causes

Average in hospital mortality with CRF is Average in hospital mortality with CRF is about 120/per yearabout 120/per year

Considering the fact that a substantial Considering the fact that a substantial number of deaths occur outside the number of deaths occur outside the hospital we can assume a figure around hospital we can assume a figure around 180180

CRFCRF

It is difficult to give a general figure It is difficult to give a general figure of prevalence with these results but of prevalence with these results but we can assume a 2%-3% prevalencewe can assume a 2%-3% prevalence

Protienurea seems to be a useful Protienurea seems to be a useful cheap markercheap marker

We need a screening programme We need a screening programme using the available infrastructureusing the available infrastructure

Renal Screening and ManagementRenal Screening and Management

Established Renal Clinics led by a VP Established Renal Clinics led by a VP and trained medical officers in renal and trained medical officers in renal medicine in regional hospitalsmedicine in regional hospitals

MedirigiriyaMedirigiriya

BakamunaBakamuna

WelikandaWelikanda

AralaganwilaAralaganwila

Renal ScreeningRenal Screening

Established a continues screening Established a continues screening programme in MOH divisions led by programme in MOH divisions led by community health staff and health community health staff and health volunteersvolunteers

Detection of protienurea and high BP Detection of protienurea and high BP are the main determinantsare the main determinants

Screened patients are referred to Screened patients are referred to clinics for further evaluationclinics for further evaluation

CRF NotificationCRF Notification

CRF patients are notified to the CRF patients are notified to the regional epidemeologistregional epidemeologist

The notification will be forwarded to The notification will be forwarded to the PHIthe PHI

We have submited a data collection We have submited a data collection form to the PHIform to the PHI

CRF Screening programme – PolonnaruwaMOH Area Populati

onNo of clinicHeld Since

Aug . 2006

No of screened

% No of U . alb Positive

No.of S.crPositive

No ofWaiting for

USS

No . OfCRF

Dimbulagala 53466 6 11500 21 482 151 114 14

Elahera 42734 5 6694 15.6 463 170 152 2

Hingurakgoda 64274 2 1639 2.5 60 10 10

Lankapura 36865 2 1352 3.6 65 12 12

Thamankaduwa 83809 4 2263 2.7 164 46 46

Welikanda 36215 5 2368 6.5 106 46 28 3

Medirigiriya Since 2004 Aug.

67860 11 17771 26 693 455

Total 385223 35 43587 11.3 20334.6%

362362 4711%

Establishing Epidemiological DataEstablishing Epidemiological Data

The collected data will be analysedThe collected data will be analysed We hope to screen about 50% of the We hope to screen about 50% of the

population by the middle of next yearpopulation by the middle of next year

Issues for discussionIssues for discussion

Whose responsibility to establish a Whose responsibility to establish a notification system for Chronic NCDs.notification system for Chronic NCDs.

If so when to start national system? If so when to start national system? Funds and human resources ? Funds and human resources ?

Are we going to incorporate it into Are we going to incorporate it into existing system.existing system.

Can PHI measure BP (Using Can PHI measure BP (Using Electronic Device)Electronic Device)