Figure 1: Integrated Disease Surveillance Programme – Monitoring and reporting of diseases in communities
Table of Contents
1. Introduction to Disease Surveillance
Disease surveillance is a cornerstone of public health practice, providing essential information for monitoring health events and planning appropriate responses. It involves the systematic collection, analysis, interpretation, and dissemination of health data to inform public health action. Effective disease surveillance systems enable the early detection of outbreaks, monitoring of disease trends, evaluation of prevention and control measures, and identification of emerging health threats.
In developing countries like India, disease surveillance plays a crucial role in addressing the high burden of communicable diseases. The Integrated Disease Surveillance Programme (IDSP) was established to strengthen surveillance activities by creating a decentralized, responsive system capable of detecting and responding to disease outbreaks promptly.
Did you know? Before the implementation of IDSP, India’s disease surveillance systems operated in isolation, leading to fragmented data collection, delayed responses, and inefficient use of resources.
Community health nurses are frontline workers who play a vital role in disease surveillance, particularly at the grassroots level. Their proximity to communities enables them to detect unusual health events early, collect surveillance data, implement control measures, and educate the public about disease prevention.
2. Overview of IDSP
The Integrated Disease Surveillance Programme (IDSP) was launched in India in November 2004 with World Bank assistance. The program was initially planned for a period up to March 2010 but was subsequently restructured and extended. It continues under the National Health Mission with domestic budget allocation.
2.1 Objectives and Components
The primary objective of IDSP is to strengthen/maintain a decentralized laboratory-based IT-enabled disease surveillance system for epidemic-prone diseases to monitor disease trends and detect and respond to outbreaks in their early rising phase through trained Rapid Response Teams (RRTs).
IDSP Core Components Mnemonic: “SOLID”
S – Surveillance Units at Multiple Levels
O – Outbreak Detection and Response
L – Laboratory Network Strengthening
I – Information Technology Integration
D – Data-driven Decision Making
Key program components include:
- Integration and decentralization of surveillance activities
- Human resource development through training of surveillance personnel
- Use of information communication technology for data management
- Strengthening of public health laboratories
- Intersectoral coordination for zoonotic diseases
2.2 Administrative Structure
IDSP operates through a three-tiered structure:
Figure 2: Administrative Structure of IDSP
- Central Surveillance Unit (CSU): Located at the National Centre for Disease Control in Delhi, oversees the entire program.
- State Surveillance Units (SSUs): Established at all State/UT headquarters, coordinate state-level activities.
- District Surveillance Units (DSUs): Located at all districts in the country, implement surveillance activities at the district level.
Each unit is staffed with trained epidemiologists, microbiologists, and data managers who work together to collect, analyze, and respond to disease surveillance data.
2.3 Disease Reporting Mechanism
Under IDSP, data is collected on epidemic-prone diseases on a weekly basis (Monday–Sunday). Information is collected using three specified reporting formats:
| Form | Name | Completed By | Description |
|---|---|---|---|
| “S” Form | Suspected Cases | Health Workers | Reports suspected cases based on syndromic surveillance without laboratory confirmation |
| “P” Form | Presumptive Cases | Clinicians | Reports probable cases based on clinical assessment by medical officers |
| “L” Form | Laboratory Confirmed Cases | Laboratory Staff | Reports cases confirmed through laboratory testing |
The weekly data provides information on disease trends and seasonality. When a rising trend of illness is observed in any area, it is investigated by Rapid Response Teams (RRTs) to diagnose and control potential outbreaks.
2.4 Data Collection and Flow
The flow of information within the IDSP structure follows a systematic process:
Figure 3: Data Flow in IDSP
- Health workers, clinicians, and laboratory staff at various health facilities collect data using S, P, and L forms.
- Data is reported to the District Surveillance Unit, where it is compiled and analyzed.
- District data is forwarded to the State Surveillance Unit for further analysis and action.
- State units report to the Central Surveillance Unit, which provides national-level surveillance data.
- Feedback and necessary actions flow back through the same channels.
The IDSP portal (www.idsp.nic.in) serves as a one-stop portal for data entry, report viewing, outbreak reporting, data analysis, and access to training modules and resources related to disease surveillance.
Note: About 94% of districts in India report weekly disease surveillance data through the IDSP portal. The Media Scanning and Verification Cell (MSVC) established under IDSP in July 2008 monitors media for unusual health events as an additional surveillance mechanism.
3. Enteric Fever Surveillance
Enteric fever, commonly known as typhoid fever, is a systemic bacterial infection caused by Salmonella enterica serotype Typhi or Paratyphi. It remains a significant public health concern in developing countries like India, where it contributes substantially to morbidity and healthcare costs. Disease surveillance plays a crucial role in monitoring its incidence, detecting outbreaks, and evaluating control measures.
3.1 Epidemiology
Enteric fever is endemic in many parts of India, with an estimated incidence of 214-2219 cases per 100,000 population annually. The disease primarily affects children and young adults, with higher rates in urban slums and areas with poor sanitation and inadequate access to safe drinking water.
Under IDSP, enteric fever surveillance data has shown:
- Seasonal patterns with peaks during monsoon months
- Geographic clustering in specific hotspots within states
- Association with contaminated water sources and food handlers
- Emergence of multidrug-resistant strains
3.2 Clinical Features
The clinical presentation of enteric fever includes:
| Stage | Week | Clinical Features |
|---|---|---|
| Early | Week 1 | Gradually increasing fever, headache, malaise, anorexia, dry cough, relative bradycardia |
| Intermediate | Week 2 | Sustained high fever, abdominal pain, hepatosplenomegaly, rose spots on abdomen, diarrhea or constipation |
| Late | Week 3-4 | Complications like intestinal perforation, gastrointestinal bleeding, encephalopathy if untreated |
| Recovery | Week 4+ | Gradual resolution of symptoms, potential for carrier state |
TYPHOID Mnemonic for Clinical Features
T – Temperature (sustained high fever)
Y – Yield (decreased productivity, malaise)
P – Pulse (relative bradycardia)
H – Headache (often severe)
O – Organomegaly (hepatosplenomegaly)
I – Intestinal symptoms (abdominal pain, constipation or diarrhea)
D – Delirium (in severe cases)
3.3 Diagnosis and Reporting
Accurate diagnosis and prompt reporting are essential components of enteric fever surveillance under IDSP:
Diagnostic Methods:
- Blood Culture: Gold standard for diagnosis, highest sensitivity in first week
- Bone Marrow Culture: Higher sensitivity but more invasive
- Widal Test: Serological test, widely used but less specific
- Rapid Diagnostic Tests: Typhidot, Tubex TF for field-based diagnosis
- PCR-based Methods: Higher sensitivity and specificity
IDSP Reporting Process:
- Health workers report suspected cases using S forms based on clinical symptoms
- Medical officers report presumptive cases on P forms based on clinical assessment
- Laboratory-confirmed cases are reported on L forms with test results
- Cases should be reported within 24 hours of diagnosis
- Clusters or unusual increases in cases trigger outbreak investigations
Important: Delays in reporting can lead to missed opportunities for early outbreak detection and control. Community health nurses should ensure timely collection and submission of surveillance data.
3.4 Nursing Management
Community health nurses play a vital role in the management of enteric fever cases and their surveillance. The nursing management includes:
Assessment:
- Comprehensive assessment of fever pattern, duration, and associated symptoms
- Monitoring of vital signs, particularly temperature and pulse
- Assessment of hydration status and nutritional intake
- Evaluation of potential complications (abdominal tenderness, mental status changes)
- Identification of high-risk household contacts for screening
Nursing Interventions:
- Fever Management: Administration of antipyretics, tepid sponging, monitoring temperature patterns
- Fluid Management: Encouraging oral fluids, monitoring intake/output, administering IV fluids if needed
- Nutrition Support: Providing small, frequent, easily digestible meals
- Medication Administration: Ensuring adherence to prescribed antibiotics
- Comfort Measures: Alleviating headache, abdominal pain, and general discomfort
- Monitoring for Complications: Regular assessments for signs of intestinal perforation or hemorrhage
- Infection Control: Proper hand hygiene and safe disposal of excreta
Surveillance Activities:
- Identifying and reporting suspected cases in the community
- Contact tracing and screening of household members
- Collection of specimens for laboratory confirmation
- Documentation and reporting through appropriate IDSP formats
- Monitoring of treatment outcomes and complications
- Identifying potential sources of infection (water sources, food handlers)
Nursing Tip: While managing enteric fever cases, maintain a high index of suspicion for complications like intestinal perforation, which may present as sudden abdominal pain, rigidity, or distension. Prompt recognition and referral are crucial for preventing mortality.
3.5 Prevention and Control
Community health nurses are instrumental in implementing preventive measures for enteric fever:
Primary Prevention:
- Health Education: Teaching about safe water, food hygiene, and handwashing
- Environmental Improvements: Advocating for safe water supply and sanitation
- Vaccination: Promoting typhoid vaccines in endemic areas
- Food Handler Education: Training on safe food handling practices
Secondary Prevention:
- Early Case Detection: Through active and passive surveillance
- Prompt Treatment: Ensuring timely and appropriate antibiotic therapy
- Contact Screening: Identifying additional cases in households
Outbreak Response:
- Participating in rapid response teams for outbreak investigation
- Collecting environmental samples for testing
- Implementing control measures (water chlorination, food inspections)
- Conducting mass education campaigns
- Assisting in mass vaccination if indicated
Figure 4: Multi-barrier Approach to Enteric Fever Prevention
4. Diarrheal Disease Surveillance
Diarrheal diseases remain a leading cause of morbidity and mortality in developing countries, particularly affecting children under five years of age. Under IDSP, acute diarrheal disease (ADD) surveillance is a priority due to its epidemic potential and significant public health impact. Community health nurses are critical in the early detection and management of diarrheal outbreaks.
4.1 Epidemiology
In India, diarrheal diseases are a major public health concern:
- Approximately 10 million cases and over 1,000 deaths reported annually
- Children under five years account for 40% of hospitalizations
- Seasonal patterns with higher incidence during monsoon season
- According to IDSP data, diarrheal diseases account for approximately 26% of reported outbreaks
Common causative agents include:
- Bacteria: Vibrio cholerae, Escherichia coli (ETEC, EHEC, EIEC), Shigella, Salmonella
- Viruses: Rotavirus, Norovirus, Adenovirus
- Parasites: Giardia lamblia, Entamoeba histolytica, Cryptosporidium
Surveillance Note: IDSP data shows that most diarrheal outbreaks are related to contaminated water sources (65%), followed by contaminated food (25%), with the remaining attributed to person-to-person transmission and other sources.
4.2 Clinical Features
Diarrheal diseases present with various clinical manifestations based on the causative agent and host factors:
| Type | Clinical Features | Common Causative Agents |
|---|---|---|
| Acute Watery Diarrhea | Sudden onset, watery stools, vomiting, rapid dehydration, no blood in stool | Cholera, ETEC, Rotavirus, Norovirus |
| Dysentery | Blood and mucus in stool, abdominal cramps, tenesmus, fever | Shigella, EIEC, Entamoeba histolytica |
| Persistent Diarrhea | Diarrhea lasting >14 days, weight loss, malnutrition | Giardia, Cryptosporidium, malabsorption syndromes |
Dehydration Assessment:
A critical aspect of clinical assessment is determining the degree of dehydration:
| Parameter | Mild Dehydration (3-5%) | Moderate Dehydration (6-9%) | Severe Dehydration (≥10%) |
|---|---|---|---|
| Mental Status | Alert, restless | Irritable, lethargic | Lethargic, unconscious |
| Eyes | Normal | Sunken | Deeply sunken |
| Tears | Present | Decreased | Absent |
| Mouth/Tongue | Slightly dry | Dry | Very dry |
| Thirst | Drinks normally | Thirsty, drinks eagerly | Unable to drink |
| Skin Pinch | Returns quickly | Returns slowly | Returns very slowly (>2 sec) |
| Capillary Refill | Normal | Prolonged | Very prolonged |
4.3 Diagnosis and Reporting
Accurate diagnosis and prompt reporting are essential for effective diarrheal disease surveillance:
Diagnostic Methods:
- Clinical Assessment: History, physical examination, dehydration evaluation
- Stool Examination: Macroscopic (consistency, presence of blood/mucus) and microscopic
- Microbiological Tests: Stool culture, rapid diagnostic tests (RDTs)
- Molecular Methods: PCR for specific pathogens
- Environmental Sampling: Water quality testing during outbreaks
IDSP Reporting Process:
- Community health workers report cases using S form based on the syndromic definition
- Medical officers report presumptive cases on P form
- Laboratory-confirmed cases reported on L form
- Unusual increase in cases or clustering triggers outbreak investigation
- Weekly reporting through IDSP portal
- Immediate reporting required for suspected cholera cases and outbreaks
Alert Threshold: An increase of diarrheal cases by 2-3 times the usual number in a defined geographical area within a short period should trigger an outbreak investigation. Community health nurses should report such increases immediately to the District Surveillance Unit.
4.4 Nursing Management
Community health nurses are central to the management of diarrheal diseases, particularly in resource-limited settings:
Assessment:
- Comprehensive assessment of diarrhea characteristics (frequency, volume, consistency)
- Evaluation of dehydration status using standard criteria
- Monitoring of vital signs, particularly for signs of shock
- Assessment of nutritional status, especially in children
- Identification of risk factors and potential sources of infection
WASH Mnemonic for Diarrhea Assessment
W – Water intake and losses (dehydration)
A – Appearance of stools (watery, bloody, mucoid)
S – Severity (frequency, volume, associated symptoms)
H – History (duration, exposure, previous episodes)
Nursing Interventions:
- Rehydration: Oral rehydration therapy (ORT) as first-line treatment
- ORS Preparation: Teaching correct preparation of ORS solution
- IV Therapy: Assisting with intravenous rehydration for severe cases
- Zinc Supplementation: Administering zinc supplements, especially in children
- Nutrition Support: Encouraging continued feeding during and after diarrhea
- Medication Administration: Antibiotics when indicated (dysentery, cholera)
- Infection Control: Proper disposal of feces, hand hygiene education
- Monitoring: Ongoing assessment of hydration status and response to treatment
Surveillance Activities:
- Active case finding in communities, especially during outbreaks
- Collection of stool specimens for laboratory testing
- Documentation and reporting through IDSP formats
- Contact tracing and source identification
- Monitoring of treatment outcomes
- Environmental assessment (water sources, sanitation)
Clinical Pearl: The “pinch test” for skin turgor is less reliable in elderly patients and those with malnutrition. In these populations, assess other signs of dehydration such as dry mucous membranes, decreased urine output, and altered mental status.
4.5 Prevention and Control
Community health nurses implement various preventive strategies to reduce the burden of diarrheal diseases:
Primary Prevention:
- WASH Interventions: Promoting safe Water, Sanitation, and Hygiene practices
- Health Education: Teaching handwashing with soap at critical times
- Food Safety: Promoting safe food handling and preparation
- Breastfeeding: Encouraging exclusive breastfeeding for infants up to 6 months
- Vaccination: Promoting rotavirus vaccination for infants
Secondary Prevention:
- Early Case Detection: Through active and passive surveillance
- Prompt Treatment: Early initiation of ORT and appropriate medications
- Case Management: Following standard treatment protocols
Outbreak Response:
- Participating in rapid response teams for outbreak investigation
- Setting up oral rehydration corners/units in affected communities
- Conducting health education campaigns
- Water quality testing and chlorination
- Promoting household water treatment methods
- Proper disposal of excreta and waste
Figure 5: F-Diagram of Diarrheal Disease Transmission and Prevention Barriers
5. Respiratory Infection Surveillance
Respiratory infections represent a significant burden of disease globally, affecting all age groups and contributing substantially to morbidity and mortality. Under IDSP, surveillance of respiratory infections is crucial for early detection of outbreaks, monitoring seasonal trends, and implementing timely control measures. Disease surveillance of respiratory infections has gained even more importance following the COVID-19 pandemic.
5.1 Epidemiology
Respiratory infections in India show distinct epidemiological patterns:
- Acute respiratory infections (ARIs) account for approximately 20-40% of outpatient attendance and 12-35% of hospital admissions
- Pneumonia remains a leading cause of death in children under five years
- Seasonal influenza shows peaks during monsoon (June-July) in southern states and winter (December-February) in northern states
- Tuberculosis remains endemic with an incidence of approximately 193 per 100,000 population
Common pathogens responsible for respiratory infections include:
| Category | Common Pathogens | Typical Presentations |
|---|---|---|
| Viral | Influenza viruses, RSV, Adenovirus, Rhinovirus, SARS-CoV-2 | Common cold, influenza-like illness, viral pneumonia |
| Bacterial | Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Mycobacterium tuberculosis | Pneumonia, tuberculosis, streptococcal pharyngitis |
| Fungal | Aspergillus, Mucormycosis | Invasive fungal infections, especially in immunocompromised |
Surveillance Insight: IDSP data indicates that respiratory infections show clear seasonal patterns with influenza-like illness (ILI) typically increasing during monsoon and winter months. This seasonal information is crucial for planning preventive interventions and healthcare resource allocation.
5.2 Clinical Features
Respiratory infections present with a spectrum of clinical manifestations depending on the pathogen, site of infection, and host factors:
Upper Respiratory Tract Infections (URTIs):
- Common Cold: Rhinorrhea, nasal congestion, sore throat, cough, mild fever
- Pharyngitis: Sore throat, painful swallowing, tonsillar exudates, cervical lymphadenopathy
- Sinusitis: Facial pain/pressure, nasal discharge, congestion, headache
- Otitis Media: Ear pain, decreased hearing, tympanic membrane abnormalities
Lower Respiratory Tract Infections (LRTIs):
- Bronchitis: Productive cough, chest discomfort, mild fever
- Pneumonia: Fever, cough, sputum production, dyspnea, chest pain, tachypnea
- Tuberculosis: Chronic cough (>2 weeks), hemoptysis, weight loss, night sweats, fever
- COVID-19: Fever, dry cough, fatigue, loss of taste/smell, dyspnea, variable presentations
RESPIRATORY Mnemonic for Pneumonia Assessment
R – Rate of breathing (tachypnea)
E – Effort (increased work of breathing)
S – Sound (crackles, wheezes, decreased breath sounds)
P – Percussion (dullness over affected areas)
I – Infection parameters (fever, elevated WBC)
R – Radiography findings (infiltrates, consolidation)
A – Arterial blood gases (hypoxemia)
T – Tachycardia (increased heart rate)
O – Oxygen saturation (decreased)
R – Respiratory secretions (purulent sputum)
Y – Yield to treatment (clinical response)
5.3 Diagnosis and Reporting
Accurate diagnosis and timely reporting are essential for effective respiratory infection surveillance:
Diagnostic Methods:
- Clinical Assessment: History, physical examination including vital signs and respiratory parameters
- Laboratory Tests:
- Complete blood count (CBC)
- C-reactive protein (CRP), procalcitonin
- Sputum Gram stain and culture
- Rapid antigen tests for influenza, COVID-19
- Molecular tests (RT-PCR) for viral pathogens
- Tuberculosis testing (smear microscopy, GeneXpert, culture)
- Imaging: Chest X-ray, CT scan when indicated
- Pulmonary Function Tests: In selected cases
IDSP Reporting Process:
- Syndromic surveillance (S form) for Influenza-like Illness (ILI) and Severe Acute Respiratory Infection (SARI)
- Presumptive cases (P form) based on clinical assessment
- Laboratory-confirmed cases (L form) with test results
- Immediate reporting of clusters or unusual increases in respiratory cases
- Weekly reporting through IDSP portal
- Special surveillance protocols for TB, COVID-19, and other priority respiratory pathogens
Case Definitions for Surveillance:
| Condition | Case Definition |
|---|---|
| Influenza-like Illness (ILI) | Acute respiratory infection with fever ≥38°C and cough with onset within the last 10 days |
| Severe Acute Respiratory Infection (SARI) | Acute respiratory infection with fever ≥38°C and cough with onset within the last 10 days requiring hospitalization |
| Suspected Tuberculosis | Cough for more than 2 weeks, with or without fever, weight loss, night sweats, or hemoptysis |
| Pneumonia in Children | Cough or difficulty breathing plus fast breathing or chest indrawing |
Reporting Triggers: Any unusual increase in respiratory cases, particularly with severe presentations or clustering in specific areas or institutions, should be reported immediately to the District Surveillance Unit for prompt investigation.
5.4 Nursing Management
Community health nurses play a vital role in the management of respiratory infections and their surveillance:
Assessment:
- Comprehensive assessment of respiratory symptoms (onset, duration, progression)
- Evaluation of respiratory status (rate, depth, pattern, work of breathing)
- Monitoring of vital signs, particularly respiratory rate and oxygen saturation
- Assessment of risk factors (age, comorbidities, exposure history)
- Identification of complications and warning signs
Nursing Interventions:
- Respiratory Support:
- Positioning for optimal ventilation (high Fowler’s position)
- Oxygen administration when indicated
- Airway clearance techniques
- Breathing exercises and deep breathing encouragement
- Medication Administration:
- Antibiotics for bacterial infections
- Antivirals when indicated
- Bronchodilators and other respiratory medications
- Antipyretics for fever management
- Supportive Care:
- Adequate hydration
- Nutritional support
- Rest and energy conservation
- Comfort measures for symptoms (sore throat, cough)
- Infection Control:
- Respiratory hygiene/cough etiquette education
- Mask-wearing when appropriate
- Hand hygiene promotion
- Isolation precautions as needed
- Monitoring: Ongoing assessment of respiratory status and response to treatment
Surveillance Activities:
- Active case finding for respiratory symptoms in communities
- Collection of specimens (nasal/throat swabs, sputum) for testing
- Documentation and reporting through IDSP formats
- Contact tracing and screening of household members
- Identifying clusters of respiratory illness
- Monitoring seasonal trends in respiratory infections
Clinical Tip: For patients with respiratory infections in the community, teach them the “SMACC” rule for when to seek immediate medical attention: Shortness of breath at rest or with minimal activity, Mental confusion or lethargy, Ability to eat or drink decreased, Color change (bluish lips or face), Chest pain that is severe or persistent.
5.5 Prevention and Control
Community health nurses implement various strategies to prevent and control respiratory infections:
Primary Prevention:
- Immunization:
- Influenza vaccination annually
- Pneumococcal vaccination for high-risk groups
- COVID-19 vaccination
- BCG vaccination for TB prevention
- Health Education:
- Respiratory hygiene/cough etiquette
- Hand hygiene practices
- Avoiding crowded places during outbreaks
- Proper ventilation of living spaces
- Environmental Measures:
- Improved indoor air quality
- Reduced exposure to air pollutants
- Avoidance of tobacco smoke
Secondary Prevention:
- Early Case Detection: Through active and passive surveillance
- Prompt Treatment: Early initiation of appropriate therapy
- Isolation: Of infectious cases to prevent transmission
Outbreak Response:
- Participating in rapid response teams for outbreak investigation
- Contact tracing and screening
- Implementing enhanced infection control measures
- Mass education campaigns
- Promoting appropriate use of masks and other personal protective equipment
- Supporting vaccination campaigns if indicated
Figure 6: Comprehensive Approach to Respiratory Infection Prevention
6. Scabies Surveillance
Scabies is a highly contagious skin infestation caused by the mite Sarcoptes scabiei var. hominis. It affects people of all ages, races, and socioeconomic levels, but is particularly prevalent in resource-limited settings with overcrowding and limited access to water. Under IDSP, surveillance of scabies is important due to its potential for outbreaks in institutional settings and communities. Disease surveillance helps in early detection and management of scabies to prevent widespread transmission.
6.1 Epidemiology
Scabies has distinct epidemiological patterns in India:
- Estimated prevalence of 5-10% in the general population, with higher rates in crowded communities
- Children and young adults are most commonly affected
- Outbreaks frequently reported in institutional settings (schools, nursing homes, prisons)
- Secondary bacterial infections are common complications, particularly in tropical regions
- Seasonal variation with higher incidence during winter months in some regions
Risk factors for scabies include:
- Overcrowded living conditions
- Poor hygiene and limited access to water
- Close physical contact with infected individuals
- Poverty and resource-limited settings
- Immunocompromised status
Transmission Note: Scabies mites can survive for 24-36 hours off the human body, enabling indirect transmission through shared items such as clothing and bedding. However, prolonged skin-to-skin contact remains the primary mode of transmission.
6.2 Clinical Features
Scabies presents with characteristic clinical features that aid in diagnosis:
Typical Manifestations:
- Intense Pruritus: Particularly at night, often the earliest and most prominent symptom
- Skin Lesions: Papules, vesicles, excoriations, and burrows
- Distribution Pattern: Predilection for specific sites:
- Finger webs
- Flexor surfaces of wrists
- Anterior axillary folds
- Periumbilical area
- Genitalia in males
- Periareolar region in females
- Burrows: Pathognomonic serpiginous or S-shaped lines (3-10 mm)
- Secondary Lesions: Excoriations, eczematization, and impetiginization
Special Clinical Forms:
| Form | Features | Population Affected |
|---|---|---|
| Crusted (Norwegian) Scabies | Hyperkeratotic, crusted lesions; minimal pruritus; highly contagious | Immunocompromised, elderly, institutionalized |
| Nodular Scabies | Persistent pruritic nodules, often on genitalia and groin | Can occur in any age group |
| Infantile Scabies | Vesicles, pustules, and papules; involves face, scalp, palms, and soles | Infants and young children |
| Hidden Scabies | Atypical presentation with minimal signs; persistent pruritus | Individuals with good hygiene or treated inadequately |
SCABIES Mnemonic for Clinical Assessment
S – Severe itching, especially at night
C – Characteristic distribution (finger webs, wrists, axillae)
A – Appearance of burrows, papules, vesicles
B – Burrows (pathognomonic sign)
I – Infestation history and contacts
E – Excoriations and secondary infection
S – Skin scraping for confirmation
6.3 Diagnosis and Reporting
Accurate diagnosis and timely reporting are essential for effective scabies surveillance:
Diagnostic Methods:
- Clinical Diagnosis: Based on history and characteristic clinical features
- Microscopic Examination: Skin scrapings from burrows examined for mites, eggs, or feces
- Dermoscopy: Non-invasive visualization of mites and burrows
- Burrow Ink Test: Application of ink over suspected burrows
- Adhesive Tape Test: For collecting superficial mites
The 2020 International Alliance for the Control of Scabies (IACS) Diagnostic Criteria categorizes diagnosis at three levels:
| Category | Criteria |
|---|---|
| Confirmed Scabies | Visualization of mites, eggs, or feces on microscopy of skin samples; or visualization of mites using high-powered imaging devices |
| Clinical Scabies | Presence of burrows; or typical lesions in a typical distribution with two history features (pruritus, close contact with someone with itchy skin rash) |
| Suspected Scabies | Typical lesions in a typical distribution with one history feature; or atypical lesions or atypical distribution with two history features |
IDSP Reporting Process:
- Individual cases are reported using S form (suspected cases) by health workers
- Clinical diagnosis is reported on P form by medical officers
- Confirmed cases (if microscopy is done) are reported on L form
- Clusters or outbreaks in communities or institutions require immediate reporting
- Weekly reporting through IDSP portal as part of routine surveillance
Reporting Considerations: While individual cases of scabies may not require immediate notification, clusters of cases in institutional settings (schools, nursing homes, healthcare facilities) should be promptly reported to initiate outbreak investigation and control measures.
6.4 Nursing Management
Community health nurses play a critical role in the management of scabies cases and outbreaks:
Assessment:
- Comprehensive skin assessment focusing on typical distribution sites
- Evaluation of pruritus intensity, pattern, and impact on quality of life
- Assessment of secondary infections and complications
- Identification of household contacts and potential sources
- Evaluation of living conditions and hygiene practices
Nursing Interventions:
- Medication Administration:
- Teaching proper application of scabicides (permethrin, benzyl benzoate)
- Ensuring whole-body application from neck down (including under nails)
- Administering oral medications (ivermectin) when prescribed
- Providing antibiotics for secondary infections if needed
- Pruritus Management:
- Administering antihistamines for symptom relief
- Applying soothing lotions for skin comfort
- Advising cool compresses for temporary relief
- Environmental Management:
- Teaching proper decontamination of clothing and bedding
- Advising on washing items in hot water (60°C) and drying in hot cycle
- Educating about items that cannot be washed (sealing in plastic bags for 72 hours)
- Infection Control:
- Implementing contact precautions as needed
- Educating about avoiding close contact until treatment completion
- Teaching proper hand hygiene practices
- Follow-up Care:
- Scheduling follow-up assessment 1-2 weeks after treatment
- Evaluating treatment effectiveness and compliance
- Addressing persistent or recurrent symptoms
Surveillance Activities:
- Case finding in communities and institutions
- Contact tracing of household members and close contacts
- Documentation and reporting through IDSP formats
- Monitoring for outbreaks in high-risk settings
- Coordinating simultaneous treatment of identified cases and contacts
Implementation Tip: Post-scabicide pruritus can persist for 2-4 weeks after successful treatment. Educate patients about this expected course to prevent unnecessary retreatment, which can lead to irritant dermatitis.
6.5 Prevention and Control
Community health nurses implement various strategies to prevent and control scabies:
Primary Prevention:
- Health Education:
- Personal hygiene practices
- Recognition of early symptoms
- Avoidance of close contact with infected individuals
- Environmental Measures:
- Reducing overcrowding in institutional settings
- Promoting access to water for personal hygiene
- Improving housing conditions
Secondary Prevention:
- Early Case Detection: Through active and passive surveillance
- Prompt Treatment: Of cases and contacts
- Contact Management: Simultaneous treatment of all household members
Outbreak Control in Institutional Settings:
| Step | Actions |
|---|---|
| 1. Case Identification | Promptly identify and isolate index case(s); implement contact precautions |
| 2. Contact Tracing | Identify all contacts including residents, staff, and visitors who had physical contact |
| 3. Mass Treatment | Implement simultaneous treatment of all cases and contacts; consider prophylactic treatment for entire facility in severe outbreaks |
| 4. Environmental Decontamination | Wash all bedding, clothing, and linens in hot water; vacuum upholstered furniture; seal non-washable items in plastic bags for 72 hours |
| 5. Surveillance | Implement enhanced surveillance for new cases for at least 6 weeks after the last case |
| 6. Education | Provide education to staff, residents, and families about recognition and prevention |
Community-Based Interventions:
- Mass Drug Administration (MDA): In high-endemic communities
- Community Engagement: Involving local leaders and community members
- Integration with Other Programs: Combining with skin NTD initiatives
- WASH Interventions: Improving water access and hygiene facilities
Figure 7: Comprehensive Approach to Scabies Control
7. Role of Community Health Nursing in Disease Surveillance
Community health nurses are integral to the success of disease surveillance systems, serving as frontline workers who bridge the gap between communities and the healthcare system. Their proximity to communities positions them uniquely to detect, report, and respond to disease occurrences promptly.
7.1 Key Responsibilities
Community health nurses fulfill several critical roles in the IDSP framework:
Case Detection and Reporting:
- Active case finding during community visits and outreach activities
- Recognition of syndromic presentations of priority diseases
- Timely completion and submission of S forms (syndromic surveillance)
- Alert notification for unusual disease patterns or clusters
- Collection of appropriate specimens when indicated
Data Collection and Analysis:
- Maintaining accurate records of cases and outbreaks
- Conducting simple data analysis at the local level
- Interpreting surveillance data to identify trends
- Mapping cases to identify geographic clustering
- Contributing to community health assessment
Outbreak Response:
- Participating in Rapid Response Teams (RRTs)
- Conducting initial outbreak investigation
- Implementing immediate control measures
- Contact tracing and follow-up
- Conducting targeted health education during outbreaks
Prevention and Control Activities:
- Implementing routine preventive measures
- Promoting immunization for vaccine-preventable diseases
- Conducting health education on disease prevention
- Supporting environmental health interventions
- Facilitating community engagement in disease control
Role Enhancement: Community health nurses also serve as cultural brokers, helping public health authorities understand local beliefs, practices, and barriers related to disease reporting and control measures. This bidirectional communication is essential for effective surveillance and response.
| Level of Prevention | Nursing Interventions in Disease Surveillance |
|---|---|
| Primary Prevention |
|
| Secondary Prevention |
|
| Tertiary Prevention |
|
7.2 Challenges and Solutions
Community health nurses face several challenges in implementing effective disease surveillance, along with potential solutions:
| Challenge | Impact on Surveillance | Potential Solutions |
|---|---|---|
| Heavy Workload | Delayed reporting, incomplete data collection, reduced case finding |
|
| Limited Training | Inadequate case recognition, improper specimen collection, poor data quality |
|
| Inadequate Resources | Limited specimen collection, inadequate response capacity, poor follow-up |
|
| Community Resistance | Under-reporting, concealment of cases, delayed treatment-seeking |
|
| Poor Feedback Mechanisms | Reduced motivation, lack of data utilization, missed opportunities for improvement |
|
Advocacy Role: Community health nurses should advocate for adequate resources, training, and support for surveillance activities. Effective advocacy requires documentation of surveillance gaps, their impact on public health, and potential cost-effective solutions.
8. Global Best Practices
Around the world, various innovative approaches have been developed to strengthen disease surveillance for enteric fever, diarrhea, respiratory infections, and scabies. These best practices can be adapted to enhance surveillance activities within the IDSP framework in India.
Innovative Surveillance Approaches:
Enteric Fever Surveillance:
- Typhoid Conjugate Vaccine (TCV) Implementation: Countries like Pakistan and Zimbabwe have integrated TCV campaigns with enhanced surveillance to monitor impact.
- Laboratory Networks: The Coalition against Typhoid has established regional laboratory networks for standardized diagnostics and antimicrobial resistance monitoring.
- Environmental Surveillance: Nepal and Bangladesh have implemented environmental sampling from sewage to detect Salmonella Typhi circulation in communities.
Diarrheal Disease Surveillance:
- Rotavirus Surveillance Networks: The WHO-coordinated Global Rotavirus Surveillance Network provides a model for pathogen-specific surveillance.
- WASH Integration: Ethiopia’s integrated WASH and diarrheal disease surveillance program links environmental factors with disease occurrence.
- Digital Health Records: Rwanda has implemented electronic reporting systems for diarrheal diseases that trigger automated alerts when thresholds are exceeded.
Respiratory Infection Surveillance:
- Sentinel Surveillance: The Global Influenza Surveillance and Response System (GISRS) provides a model for respiratory pathogen surveillance through strategically placed sentinel sites.
- Community-Based Surveillance: Thailand’s Village Health Volunteer system detects respiratory disease clusters in remote communities.
- Integrated Platforms: South Africa’s Severe Acute Respiratory Illness (SARI) surveillance program integrates multiple respiratory pathogens in a single platform.
Scabies Surveillance:
- Integrated Skin NTD Programs: Fiji and Solomon Islands have integrated scabies surveillance with other skin NTD programs for efficiency.
- Community-Led Surveillance: Australia’s remote Aboriginal communities have developed community-led models for scabies surveillance.
- Mass Drug Administration Monitoring: Ethiopia’s scabies MDA program includes pre- and post-intervention surveillance to measure impact.
Digital Innovations in Disease Surveillance:
- Mobile Health Applications: Mobile apps for case reporting, data collection, and outbreak alerts being used in multiple countries
- Geographic Information Systems (GIS): Spatial mapping of cases for visualizing disease patterns and identifying hotspots
- Electronic Integrated Disease Surveillance Systems: Web-based platforms integrating multiple diseases and data sources
- Participatory Surveillance: Community-based reporting through mobile phones and social media
- Artificial Intelligence: Predictive analytics for early outbreak detection and trend analysis
Community Engagement Strategies:
- Community Health Committees: Local committees involved in surveillance planning and implementation
- Community Health Workers: Extension of the surveillance network into remote communities
- Incentive Systems: Recognition and reward mechanisms for timely reporting
- Feedback Mechanisms: Regular sharing of surveillance findings with communities
- Cultural Adaptation: Tailoring surveillance approaches to local cultural contexts
Adaptability Note: When adapting global best practices to the Indian context, it’s important to consider local health system capacity, cultural factors, and existing IDSP infrastructure. Pilot testing of new approaches in selected districts before scaling up can help identify implementation challenges and solutions.
9. Conclusion
Disease surveillance is an essential function of public health systems, providing the data needed for evidence-based decision-making and timely response to health threats. The Integrated Disease Surveillance Programme (IDSP) in India has established a comprehensive framework for monitoring and responding to various diseases, including enteric fever, diarrheal diseases, respiratory infections, and scabies.
Community health nurses are critical stakeholders in the IDSP, serving as the eyes and ears of the surveillance system at the grassroots level. Their unique position at the interface between communities and the healthcare system enables them to detect unusual health events early, report through established channels, and implement initial control measures.
Key takeaways from this educational resource include:
- IDSP provides a structured approach to disease surveillance through its three-tiered system and standardized reporting formats (S, P, and L forms).
- Each of the four diseases discussed—enteric fever, diarrhea, respiratory infections, and scabies—requires specific surveillance approaches tailored to their epidemiology, clinical features, and control strategies.
- Effective nursing management of these diseases involves comprehensive assessment, targeted interventions, and ongoing monitoring within the surveillance framework.
- Prevention and control strategies span primary, secondary, and tertiary levels, with community health nurses playing roles across this spectrum.
- Global best practices offer innovative approaches that can be adapted to strengthen surveillance activities within the Indian context.
As emerging infectious diseases, antimicrobial resistance, and shifting patterns of endemic diseases continue to challenge public health systems, the role of community health nurses in disease surveillance becomes increasingly important. By strengthening their knowledge and skills in surveillance methodologies, case detection, reporting procedures, and response strategies, nurses can contribute significantly to building resilient health systems capable of protecting population health.
The integration of digital technologies, community engagement strategies, and innovative surveillance approaches offers opportunities to enhance the effectiveness and efficiency of surveillance activities. However, the fundamental principles of vigilance, systematic data collection, timely reporting, and prompt response remain at the core of successful disease surveillance systems.
By applying the knowledge and skills outlined in this resource, community health nurses can fulfill their critical role in disease surveillance, ultimately contributing to reduced morbidity and mortality from preventable communicable diseases in the communities they serve.
10. References
- National Centre for Disease Control. Integrated Disease Surveillance Programme (IDSP). https://ncdc.mohfw.gov.in/integrated-disease-surveillance-programme/
- Ministry of Health and Family Welfare, Government of India. Integrated Disease Surveillance Programme (IDSP). https://idsp.mohfw.gov.in/
- John, J., Bavdekar, A., Rongsen-Chandola, T., Dutta, S., & NSSEFI Collaborators. (2018). Estimating the incidence of enteric fever in children in India: A multi-site, active fever surveillance of pediatric cohorts. BMC Public Health, 18(1), 594.
- Luby, S. P., Saha, S., & Andrews, J. R. (2015). Towards sustainable public health surveillance for enteric fever. Vaccine, 33, C3-C7.
- World Health Organization. (2022). Diarrhoeal disease fact sheet. https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease
- Zwane, A. P., & Kremer, M. (2007). What works in fighting diarrheal diseases in developing countries? A critical review. The World Bank Research Observer, 22(1), 1-24.
- Centers for Disease Control and Prevention. (2023). Respiratory infections. https://www.cdc.gov/respiratory-infections/
- Ugbomoiko, U. S., Oyedeji, S. A., Babamale, O. A., & Heukelbach, J. (2018). Scabies in resource-poor communities in Nasarawa State, Nigeria: Epidemiology, clinical features and factors associated with infestation. Tropical Medicine and Infectious Disease, 3(2), 59.
- World Health Organization. (2023). Scabies fact sheet. https://www.who.int/news-room/fact-sheets/detail/scabies
- Engelman, D., Steer, A. C., Bratton, H., Cantey, P. T., et al. (2019). The public health control of scabies: priorities for research and action. The Lancet, 394(10192), 81-92.