The elimination of a water pump’s handle was a water pump’s defining event in epidemiological history. This is a really remarkable tale. When a devastating epidemic of cholera struck London’s Soho neighborhood in 1854, a British doctor and epidemiologist John Snow (1813-1858) utilised data from the General Registrar Office (GRO) to display the distribution of cholera cases and deaths on a map of the region. He saw that the bulk of cases and fatalities were in the Broad Street neighbourhood, which was serviced by a public water pump, proving his hypothesis that cholera was a waterborne, infectious illness.
Because of the tireless work of another medical practitioner, William Farr (1807-1883), the GRO’s collection of health data and vital statistics had increased during the preceding decade and a half. Snow was able to persuade the local authorities in London, on September 7, 1854, to remove the handle of the water pump, which they grudgingly did, based on statistics on the time, place, and person distribution of cholera cases and fatalities, augmented by a map. In only a few weeks, the cholera epidemic was brought under control. In epidemiology, it marked the start of a new era. William Farr, the inventor of the modern disease surveillance system, is frequently referred to as the father of modern epidemiology.
In the years thereafter, epidemiology has grown in importance as a field for preventing and controlling infectious illnesses (and, more recently, non-communicable diseases). The use of epidemiological concepts is made feasible by the systematic collection, timely analysis, and distribution of illness data. Disease surveillance is the process of taking action to prevent or halt the spread of disease.
However, with the discovery of antibiotics and advancements in modern medicine in the late 19th century and early 20th century, the emphasis moved away from epidemiology. Disease monitoring systems were invested in by high-income nations, while medical treatment was restricted in low- and middle-income countries. Numerous nations recognised the significance of disease monitoring in the second half of the twentieth century, as part of worldwide efforts to eradicate smallpox and subsequently to combat many new and reemerging illnesses. With the advent of Avian flu in 1997 and the Severe Acute Respiratory Syndrome (SARS) epidemic in 2002-04, these efforts were given a further push.
India’s disease surveillance
The National Surveillance Programme for Communicable Diseases was established in 1997 after a large cholera epidemic in Delhi in 1988 and a plague breakout in Surat in 1994 prompted the Indian government to act. However, until 2004, when India established the Integrated Disease Surveillance Project in response to the SARS epidemic, this effort was primitive (IDSP). The IDSP aims to boost government financing for disease monitoring, improve laboratory capacity, educate health professionals, and ensure that every district in India has at least one qualified epidemiologist. As a result, almost every year between 2004 and 2019 saw an increase in the number of outbreaks identified and examined. When the COVID19 pandemic hit, India was able to quickly deploy teams of epidemiologists and public health professionals to react to and lead the response, organise contact tracing, and swiftly scale-up testing capacity thanks to the IDSP (which has now become a fully-fledged programme).
Disease surveillance systems and health data collection and reporting systems are important epidemiological tools, yet, as we can see from existing studies, such as seroprevalence survey results or the analysis of excess COVID19 fatalities, they have behaved differently in Indian states. According to data from the fourth round of serosurvey, Kerala and Maharashtra were able to detect one in every six and twelve infections, respectively; however, only one in every 100 COVID19 infections was detected in Madhya Pradesh, Uttar Pradesh, and Bihar, indicating a weak disease surveillance system. Excess fatalities are also predicted to be greater in states with ineffective disease monitoring and civil registration and vital statistics (CRVS) systems.
In a well-functioning disease monitoring system, an increase in cases of any sickness would be detected relatively quickly. Kerala, for example, has probably the finest disease surveillance system among India’s states, since it is selecting the most COVID19 cases; it may choose the first Nipah virus case in early September 2021. Dengue, malaria, leptospirosis, and scrub typhus infections, on the other hand, only got attention until more than three dozen fatalities were recorded and health institutions in various districts of Uttar Pradesh were overloaded. In states like Madhya Pradesh and Haryana, viral infections, most likely dengue fever, are causing hospitalisation but are not properly identified or recorded as mystery fever. This is worrisome since one would anticipate a better performance 18 months into the COVID19 pandemic and after many governmental pledges to improve disease monitoring and health systems. It begs the question: if the pandemic isn’t enough to convince countries to improve disease monitoring, what will? Is improving the illness monitoring system really so difficult?
What actions should be taken?
In 2015, a joint monitoring mission led by the Ministry of Health and Family Welfare, the Government of India, and the World Health Organization India reviewed the IDSP and offered many specific suggestions to improve disease surveillance systems. Increasing financial resources, providing a sufficient number of skilled human resources, improving labs, and monitoring for zoonosis, influenza, and vaccine-preventable illnesses were among them. All of these suggestions must clearly be reconsidered and implemented. The following should be taken into account by health policymakers on a more detailed level.
To begin, the Union and State governments must boost government resources dedicated to preventative and promotive health services, as well as illness monitoring. Second, both rural and urban primary healthcare workers need to be retrained in disease monitoring and public-health interventions. Surveillance staffing openings at all levels must be filled as soon as possible. Third, the COVID19 laboratory capacity that was built in the past 18 months has to be planned and repurposed to enhance the ability to test for additional public health problems and diseases. This should be connected in order to establish a system in which samples are gathered, transported, and analysed rapidly, with reports accessible in real-time.
Fourth, new zoonotic disease outbreaks, such as the Nipah virus in Kerala, avian flu in other states, and scrub typhus in Uttar Pradesh, serve as a reminder of how human and animal health are intertwined. The concept of “One Health” must be pushed beyond policy debates and put into practise on the ground. Fifth, a concentrated effort must be made to improve the civil registration and vital statistics (CRVS) systems, as well as medical certification of death causes (MCCD). These systems work in tandem with disease monitoring systems, and when one fails, the other frequently suffers as a result. Sixth, it is now time for the state government and local corporations to work together to create joint action plans and take responsibility for public health and disease monitoring. This procedure should be kicked off using funds provided by the 15th Finance Commission to companies for health.
The development and re-emergence of new and old illnesses, as well as a rise in the number of cases of endemic diseases, are inevitable. We won’t be able to stop every epidemic, but we may lessen their effect with a well-functioning disease monitoring system and the use of epidemiological concepts. The removal of a water pump handle may sometimes be all that is required to control a fatal illness. However, only coordinated activities between a disease monitoring system, a civil registration system, and medical statistics specialists, as well as the application of epidemiological principles, can determine which approach should be used. Indian states must do all possible to begin identifying illnesses so that the nation may be prepared for future breakouts, epidemics, and pandemics. This is one of the most important considerations for Indian health policymakers.