Surveillance of NCD Dr Chaisri Supornsilaphachai Bureau of

Surveillance of NCD Dr. Chaisri Supornsilaphachai Bureau of Non-communicable Diseases; Department of Diseases Control In “Introductory Curse on Field Epidemiology” 8 June 2006

Main issues • Growing burden of NCDs, Mental Ds and Injury • Impact of globalisation, urbanisation • Greater emphasis on prevention • Need for standard, comparable data • Greater focus on trends in major risk factors • WHO framework for surveillance (STEPS) WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Health Risk Factors Health Poor Diet Low P. A. Chronic Condition High Blood Pressure Chronic Disease Stroke Death Non-communicable Disease Continuum

Definition of Surveillance In 1968 the 21 st World Health Assembly described surveillance as the “systematic collection and use of epidemiologic information for the planning, implementation, and assessment of disease control”; in this sense, surveillance implies “information for action”. STEPS page 9 WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Surveillance as a core component of NCD prevention We miss the mark if data are collected and are not linked to NCD prevention efforts, OR. . . if programmes and policies are developed without data, failing to show progress or outcomes.

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Surveillance as an integrated component of NCD prevention An essential “evidence” foundation for effective NCD programme and policy planning

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Difficult to link evidence in uneven, nonintegrated vertical programming

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; WHO Global Strategy on Prevention and Control of NCDs n n n Prevention: in the first place reduce major risk factors through population strategy and targeted high risk strategies Case Management: cost-effective and affordable interventions; health system reform Surveillance: assess the pattern and trends of major risk factors (and major NCDs); link with evaluation of preventive programs World Health Assembly, 2000

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; NCD and CD Surveillance Different Objectives, Different Data, Different Programme monitoring Health Status Monitoring Methods HP/DP Programme indicators HP/NCD Control activities Epidemic response Early warning information (CD) Epidemic Intelligence Health indicators Health Policy Resource allocation Administrative data Health System Monitoring

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Levels of causation and corresponding types of intervention SOCIAL STRUCTURE • Social class (social position) • Age HEALTHY PUBLIC POLICY • Ethnicity ENVIRONMENTAL • Geographic location INFLUENCES • Housing Conditions (places) • Occupational risks ORGANISATION AND COMMUNITY INTERVENTION • Access to services LIFESTYLE • Smoking INFLUENCES • Nutrition (individual behaviours) • Physical activity PRIMARY AND SECONDARY PREVENTION • Psychosocial factors PHYSIOLOGICAL • Blood pressure INFLUENCES • Cholesterol (the body) • Obesity PRIMARY AND SECONDARY PREVENTION • Blood glucose Health care services (the system) Noncommunicable Diseases Tertiary Prevention

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Chronic Disease Surveillance § § § § Behavioral trend Occupational Environmental risk factors Health condition Disability Disease Services Utilization Death

Risk factors occupy a central place because of the lag time between exposure disease • Public health strategies have to be driven by risk factor exposure • Intervention at all risk factor levels • Countries need to know the distribution of risk in the population • Better data lead to better decisions WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Uses of surveillance data · Provide prevalence of health risk behaviors · Track trends over time · Develop targeted programs, policy and legislation • Demonstrate progress in meeting global/national health objectives · Evaluate program and policy progress/ success (some part)

Leading 10 selected risk factors as causes of disease burden (WHR 2002) = Major NCD risk factor Developing countries High Mortality Low Mortality Developed countries 1 Underweight Alcohol Tobacco 2 Unsafe sex Underweight Blood pressure 3 4 5 Unsafe water Indoor smoke Zinc deficiency Blood pressure Tobacco Body mass index Alcohol Cholesterol Body mass index 6 Iron deficiency Cholesterol Low fruit & vegetable intake 7 Vitamin A deficiency Iron deficiency Physical inactivity 8 Blood pressure Low fruit & vegetable intake Illicit drugs Indoor smoke from solid fuels Unsafe water Underweight Iron deficiency 9 Tobacco 10 Cholesterol WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Figure 2: Characteristics of a surveillance system influence Research Health policies and programmes Surveillance evaluate Information WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

กระบวนการทำงานเพอการปองกนโรคไมต ดตอ THAILAND Developm ent and Research Surveillance Health Policy, Plan and program (Evidence based) Information for Action Evaluation

WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Information Sources for Surveillance Purposes WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

The STEPs Framework in NCD surveillance NCD Step 1 Step 2 Risk factors (the future) Questionnaire- Questionnaires plus based report physical measures on key risk factors Step 3 Questionnaires plus physical measures plus bio-chemical measurements Diseases Hospital or (the clinical present) admissions, by age and sex Rates and principal Cause-specific condition in 3 groups: disease incidence communicable diseases, or prevalence NCDs and injury Deaths Death rates by (the past) age and sex Death rates by age, sex and cause (verbal autopsy) Death rates (age/ sex/cause) by death certificate WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Some challenges • Many countries do not have adequate baseline data • Need trend data on major RF to map coming disease burden and effect of interventions • Continuous (for CD) vs periodic (for NCDs) surveillance • Risk factors vs R markers: balance between behaviours vs more – objective measures • Funding mechanisms and resource mobilisation • Making surveillance loop work WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Risk Factors Common to Major Noncommunicable Conditions * Including heart disease, stroke, hypertension STEPS Document p 18 WHO STEPwise Approach to Surveillance of NCD Risk Factors

Rationale Why Certain Risk Factors Have Been Selected © They have the greatest impact on NCD mortality and morbidity; © There is evidence that their modification is possible and effective in primary prevention; © The measurement has been validated; © The measurement can be applied in both developed and developing countries, and comparison across countries will be meaningful; and © The measurement can be obtained following appropriate technical and ethical standards. STEPS Document p 17 WHO STEPwise Approach to Surveillance of NCD Risk Factors

Why Standard Definition and Methods? Valid comparisons between states (populations, or countries) or years simply cannot be made without standard definition of terms and compatibility between public health recommendations and the collection and analyses of surveillance data. Brownson et al 2000 Surveillance, NMH

STEPS Framework The framework is the distinction between the different levels of risk-factor assessment: l health behaviours (SR) l physical measurements l blood samples and the three modules involved in describing each risk factor: l core l expanded and l optional WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

WHO STEPS a tool for NCD risk factor assessment Step 3: Blood samples • Blood glucose/diabetes • Cholesterol Step 2: Physical measures • Height /Weight/Waist • Blood Pressure Step 1: Behaviours • Tobacco Use • Physical Inactivity • Intake fruit/veg • Alcohol Use WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Key Premises for implementing STEPS: Global focus • STEPS-basic surveillance sites • Modular approach -‘appropriate’ STEPS according to country needs and resources – Focus on essential information – Ensure power to detect trends – Contribute to comparable data Implementation in countries through WHO Regional Offices and linked to Regional NCD Networks WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Key Premises for implementing STEPS: Local Focus – Building local capacity for surveillance – Understanding of ‘surveillance’ as: information for public health policy – Strengthening baseline systems with plans for continuity – Link to existing systems where feasible WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

WHO STEPS partnership WHO - HQ Co-ordination WHO - CC Countries Training Technical Support Centre WHO Regions Technical assistance Donor Support WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

WHO STEPS Technical Support Activity • Quality control • Streamline STEPS implementation process • Templates for Summary reports and transfer of aggregate data Outcome • Comparability of data • Efficiency, capacity for planning, data management and analyses • Accessibility in reports and WHO NCD Info. Base WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Table 1. Communicable and NCD Surveillance COMMON CHARACTERISTICS DIFFERENCES CD SURVEILLANCE NCD SURVEILLANCE PURPOSE Describe problem Monitor trends Emphasis on weekly or monthly Emphasis on trends over years variations to detect outbreaks Estimate health burden Focus is on identifying individuals Focus is on population Evaluate programmes for Prevention and control Short time frame between exposure and disease Rapid response Longer time frame between exposure and disease Planned response Source: Berkelman et al. (2001. (

Table 1. Communicable and NCD Surveillance (cont’) COMMON CHARACTERISTICS DATA Regular DATA ANALYSIS Descriptive statistics for time, Place, person DIFFERENCES CD SURVEILLANCE NCD SURVEILLANCE Reliance on notification by health-care providers and/or laboratories Greater use of existing databases )eg vital statistics, hospital discharges); population surveys Emphasis often on case counts Emphasis usually on rates, population means DATA DISSEMINATION Regular; frequency reflects data More frequent Collection and audience targeted Less frequent Source: Berkelman et al. (2001. (

The NCD in top ranks THAILAND DALYs - Stroke - CA liver - Diabetes - COPD - IHD (male) - Depression (Female) - LBW (Female) Deaths - Stroke CA liver IHD LBW CA Lung (male) DM (Female)

Evolution of Thai NCDs Surveillance : Can’t answer for prevention action efficiently and effectively ÖInformation reliability and validity !!! Ö

Source Introduction to Modern Epidemiology by Ahlbom A, Norell S. p. 36 34

Data set considered in Thai Community for NCDs Epidemic THAILAND v Mortality/Morbidity Patterns since 1975 v Prevalence data v Demographic Patterns v Change of Related Behavioral & socioeconomic risk and tentative determinants v Change of Related Biological Risk

Source of Data set for extent of problems THAILAND v Existing Vital Statistics v Related epidemiological and pilot studies v Population data from Office of the National Economic and Social Development Board (NESDB (

Source of Data set for risk determinants THAILAND v Related epidemiological and pilot studies v National Nutritional Survey since 1964 v National Health Interview Survey since 1976 v. Other data sources such as economic data , consumption data etc.

Create New Specifie Surveillance and Information Source for High Priority NCDs THAILAND • Cancer surveillance ……. . . initiated in 1987 • National Health Examination Survey …. . . initiated in 1990 • Injury surveillance ……. . . initiated in 1994

Source of Data set for extent of problems THAILAND v Existing Vital Statistics v Related epidemiological and pilot studies v Population data from Office of the National Economic and Social Development Board (NESDB (

Source of Data set for risk determinants THAILAND v Related epidemiological and pilot studies v National Nutritional Survey since 1964 v National Health Interview Survey since 1976 v. Other data sources such as economic data , consumption data etc.

Create New Specifie Surveillance and Information Source for High Priority NCDs THAILAND • Cancer surveillance ……. . . initiated in 1987 • National Health Examination Survey …. . . initiated in 1990 • Injury surveillance ……. . . initiated in 1994

Collaborative in Burden of Disease Study • Aim at comparative risk assessment THAILAND ( integrated risks) • Identify the burden attributable to the important risk and behavioral factors • The burden is measured in unit of DALYs, YLL (Year life lost), Number &rate of deaths and illness

Correction Process Experiences for Information reliability and validity !!! THAILAND • Make sense of data with considerable for source of information • Analysis with comprehensive picture on ongoing epidemiological course and critical approach comparable with other population’s epidemiological course as possible • Systemically reanalysis with more other information sources • Validity unaccurate information resources. . Existing Vital Statistics ………. Verbal autopsy (1997(

THAILAND Multiple sources of data needed for composing of systematic and comprehensive picture correlated with long natural courses of diseases considerably identified. The data has to be concerned about comparing overtime and with other population’s epidemiological data as possible while using systemic and comprehensive approach with integration based for identifying minimum data set

Outline of National database for comprehensive NCD surveillance system NCD After 2001 Basic Core Expanded Core THAILAND Deaths Death rates by age, sex and cause of death (death certificate)…quality improvment Death rates by age, sex and cause of death (verbal autopsy) will be done as necessity Diseases Hospital or clinic number of visit or admissions, rates by age and sex and principal cause-specific disease and specific condition in 3 groups: communicable diseases, NCDs and injury …. . coverage improvement -Cause-specific disease incidence or prevalence - Cause-specific burden of disease Risk factors Questionnaire-based report on key risk factors, plus physical measurements plus bio-chemical measurements …standardized and comparable between regional and internationally. Questionnaire-based report on key risk factors (: . . Other health-related behaviours, mental health, plus physical measurements (: …) plus bio -chemical measurements (. HDLcholesterol, triglycerides( Ongoing collection, analysis and use of health data -Aggregation consumption data (: . sugar, salt, …etc) -Economic activity data -Administrative data (: … service -Administrative data (: ……insurance claims etc. )

THAILAND Thai National NCD Surveillance Networks agreed to improve quality of the network be the important part of program development and evaluation and also concerning linked with policy maker for reinforcing and enabling process for prevention and control )RESOLUTION OF POLICY DEVELOPMENT FOR SUSTAINABLE THAI SURVEILLANCE NETWORKS OF MAJOR NCD AND THEIR RISK FACTORS(

Tentative Conceptual Model HSRI for Thai NCD Surveillance Network. Hlth Status and Trend Health Promoti onon Fund Review Sampling frame THAILAND -Increase capacity of analyzing information for actions Increase collaborative and communication activities by mail, small meetings etc -Standardized data Increase capacity of analyzing and synthesizing information for actions N. B. : . - Establish a focal point for major NCDs and their risk factors surveillance at MOPH level -. Each information center has a complete process of data collection, data analysis and data dissemination NCD Information Center Refined Objective

The goal achievement for Thai NCDs prevention and control THAILAND • Reduce premature death both in number and rate • Reduce the disease burden( morbidity, disability, cost) from NCDs • Increase years of quality of life

List of the tentative name and organization in National NCD Surveillance Networks Health Information Center, Bureau of Health Policy and Planning, MOPH Epidemiology Division, Office of the Permanent Secretary, MOPH Health System Research Institute, MOPH National Cancer Institute, Department of Medical Services Social Statistics Division, National Statistics Office Mental Health Department, MOPH Nutrition Division, Department of Health, MOPH Nutrition Institute, Mahidol University Thai Health Research Institute, Thai Public Health Foundation Social and Behavioral Medicine Division, Department of Medical Services, MOPH

The Focal Points • The comprehensive NCD information center was established in the Bureau of NCD control, Department of Disease Control. • The center is most likely to act as a focal point of NCD surveillance in Thailand will work closely with Division of Epidemiology, Department of Disease Control. • National Interagency Coordinating Committee for Surveillance will be proposed to MOPH.

In “Health Management for ASEAN Health Executives” Thailand; 9. 00 -12. 00; 3 -21 -March 2003 ; Trend of Future Burden NCDs • Rapidly economic and social development in this area into more western-lifestyle since at least ten years ago • Size of ASEAN Population and change of population structure • All of these countries are low and middle economic countries • The present Infrastructure of Health service system inappropriately and inadequately of coming burden problems

Prior Important Problems to be answered • What main objectives of surveillance ? Are the same ? ? …. different in the stage of diseases …. different in the existing information system …. different in each stakeholders concern …. different stage of prevention program • Is population attributed risk of NCDs alike among countries? • limit resources……Initiative budget…. . by whom? how ? • Focal Point and Capacity of resource persons • …………etc.

Suggestive Surveillance Information Characterestics Needed for Actions • Multiple sources of data • Systemic and comprehensive picture correlated with long natural courses of diseases with considerably information sources and comparable with other population’s epidemiological course as possible Past risk - current disease : Current risk - future disease • Reinforce links with policy makers

Suggestive Surveillance Information Characterestics Needed for Actions • Population based • Ongoing/ repeated measures • Practical, relevant, Timely

Including Which minimum set of NCDs determinants has to be focused both risk factors & determinants and positive factors that are preventable and exist in our communities.

• National NCD control program since 1987 • NCD strategic plan 1997 -2006 • Medium term plan 2002 -2006 • Different approach: 2 focal points – NCD surveillance – Health Survey

The Focal Points • The comprehensive NCD information center was established in the Bureau of NCD control, Department of Disease Control. • The center is most likely to act as a focal point of NCD surveillance in Thailand will work closely with Division of Epidemiology, Department of Disease Control. • National Interagency Coordinating Committee for Surveillance be proposed to MOPH.

Health Survey • The survey will be carried out by newly founded center “Health Survey Center” under Health System Research Institute. • Thailand already adopts STEPS approach to risk factor surveillance. • Expanded core module of questionnaire, physical measurement, blood samples for biochemical analyses will be included in the Third national health exam survey.

Thai 3 rd National Health Examination Survey • Executive committee and working group of the third NHES has been appointed since June 2002. • Expanded Core module of STEP approach was introduced to the committee and working group

• Working plan is established. • Activities – Sampling Frame & Sampling Method – Sampling size is more than 10, 000 (depend on government budget and other sources) – Test the questionnaire – Launch the national survey in June 2002 – Report by the end of 2003

Public Health Approach for Disease Control Implementation: (How do you do it? ) Intervention & Evaluation: (What works? ) Surveillance: (What is the problem? ) Problem Risk Factor Identification: (What is the cause? ) Response

“Because behaviours can be modified, promoting positive health behaviour choices, through education and through community policies and practices, is essential to reducing the overall NCD burden. ”

3. Conduct surveillance rather than surveys We need a systematic approach to: · Maintain infrastructure visibility and support for data collection over time · Increase efficiencies for sustaining surveillance efforts · Provide routinely-collected trend data that are consistent and comparable · Incorporate emerging health issues into the system quickly, as they arise

Bridging the gap

Surveys Research driven Theory based Surveillance Public health driven Atheoretical--helps develop theory Focuses on categorical health issues Focuses on multiple health issues Goes into depth within categorical health issue Looks at broad trends and patterns across health issues

Surveys Shows relationships between behaviours within single health issue One point in time Subpopulation-based Results point to the way things were Surveillance Shows actual changes in behaviour across multiple health issues Continuous Population-based Results point to the way things are

Surveys Surveillance Less efficient: re-starting & retraining are required; does not generate capacity building Ongoing system generates efficiencies with start-up, training, and capacity building A separate survey is developed to address an emerging health issue Emerging health issues are integrated into the system fairly quickly

(Indonesia) (Mexico)

Definition of Surveillance/Monitoring · Public health surveillance is the ongoing collection and timely analysis, interpretation, and communication of health information for public health action · Public health surveillance provides an important “evidence-based” foundation for programme and policy development Ultimate goal is to strengthen country infrastructure for establishing and maintaining surveillance

Close-up on surveillance Data Interpretation Data Analysis Data Collection Program Evaluation Information Dissemination Program Implementation Program Planning Kathy Douglas, Ph. D; Department of NCDs Prevention and Health Promotion; WHO

Public health surveillance loop Data Interpretation Data Analysis Data Collection Program Evaluation Information Dissemination Program Implementation Program Planning Kathy Douglas, Ph. D; Department of NCDs Prevention and Health Promotion; WHO

INTEGRATED DISEASE SURVEILLANCE Definition • Integration of various surveillance activities with similar functions, nature and common public service in one system

ADVANTAGE OF IDS • Cost saving and cost-effective • Sustainable • Comprehensive information on health status • Easy to access and to use for policy decisions

LIMITATIONS OF IDS • Different nature of diseases (acute, chronic) and diagnosis methodology require different approaches • Reliability of surveillance information • Different purpose of using surveillance information

Causal Pathway of Disease • Environment, Hazard/agent in environment (pre-exposure) • Behavior/risk factor • Exposure • Pre-symptomatic phase • Apparent disease • Disability or Death

LEVEL OF INTEGRATION • No integration (vertical surveillance) • Partial integration (separate from HIS) – Integrated CD surveillance – Integrated NCD surveillance • Full integration (within national health information system)

SURVEILLANCE: NO INTEGRATION Communicable Diseases (CD) Activity Reports Morbidity, Mortality Noncommunicable Diseases (NC D) Morbidity, Mortality Activity Reports

PARTIAL INTEGRATION OF SURVEILLANE Communicable Diseases (CD) Activity Reports Noncommunicable Diseases (NC D) Morbidity, Mortality Activity Reports

INTEGRATED HEALTH INFORMATION SYSTEM Others Disease morbidity, mortality Activity reports (immunization, ORT, IUD, etc. ) Admin. / finance Risk factors

Definition of Advocacy is a combination of individual and social actions designed to gain political and community support for a particular health goal or program. Action may be taken by/or on behalf of individuals and groups to create living conditions which promote health and healthy lifestyles. Health Promotion Glossary, WHO, Geneva. 1998: 5 WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Why advocacy? NCD prevention depends on action beyond the health sector, and requires appropriate policies and investments from government, industry, and community organisations. WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Making the Burden of NCD understood Ø Provide key messages that the general public, opinion leaders, and the health and medical communities can easily interpret and understand. Ø Focus on topics that affect the peoples health in important ways. Ø Highlight problems that can be changed and will have a substantial impact on the health of the population. Ø Chose key messages that can be used in directing public policies and programs. WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO

Keeping a Population-wide Focus with choosing Risk Factors • Focus on the mean or median, not % at high risk • “Abnormal” is arbitrary • Potential impact of screening is inevitably limited: – Screening is expensive and difficult – Treatment is imperfect – Most cases derive from the “normal” range • Primary prevention is cheap, safe, universally applicable and potentially more effective WHO STEPwise Approach to Surveillance of NCD Risk Factors WHO