INTRODUCTION

• India is experiencing a rapid health transition with a rising burden of NCD

causing a significant morbidity and mortality both in urban and rural

population with considerable loss in potentially productive year of life.

 DEFINITION

• “The study of distribution and determinants of health related

states or events in specified populations, and the application of
this study to the control of health problems”

…………John M .Last
 AIM OF EPIDEMIOLOGY

• To describe the distribution and magnitude of health and disease

problems in human populations
• To identify etiological factors (risk factors) in the pathogenesis of
disease; and
• To provide the data essential to the planning, implementation and
evaluation of services for the prevention, control and treatment of
disease and to the setting up of priorities among those services.
 NON-COMMUNICABLE DISEASE

• Non communicable diseases (NCDs), also known as chronic

diseases, tend to be of long duration and are the result of a
combination of genetic, physiological, environmental and
behaviors' factors.
• NCDs disproportionately affect people in low- and middle-income
countries where more than three quarters of global NCD deaths –
32million – occur
 DIFFERENCES BETWEEN COMMUNICABLE
AND NON-COMMUNICABLE DISEASE
Communicable disease Non communicable Disease

Causative agent Single specific infectious agent can be No single specific agent can be identified
identified as causative agent.

Epidemiological model of Epidemiological triad theory; interaction The web or multifactorial causation
between agent, host, environment. theory of interaction between various
causation risk factors

Pre pathogenic period Generally short Very long

Types of epidemics Common vehicle or propagated curve Very slowly evolving secular trends type;
type; occurrence of epidemic is easily occurrence of epidemic not easily
appreciated by lay public appreciated.
 BURDEN
GLOBAL LEVEL
• Non-communicable diseases (NCDs) kill 41 million people each year,
equivalent to 71% of all deaths Globally.

• Often associated with older age groups, but evidence shows that 15 million of
all deaths attributed to NCDs occur between the ages of 30 and 69 years.

• Of these 85% are estimated to occur in low- and middle-income countries.

CONT….
• These 4 groups of diseases account for over 80% of all
premature NCD deaths.

• Tobacco use, physical inactivity, the harmful use of alcohol and

unhealthy diets all increase the risk of dying from a NCD.

• Detection, screening and treatment of NCDs, as well as

palliative care, are key components of the response to NCDs.
NATIONAL LEVEL
 Who all are at risk?
• People of all age groups, regions and countries are affected by NCDs.

• These conditions are often associated with older age groups, but evidence shows that

15 million of all deaths attributed to NCDs occur between the ages of 30 and 69 years.

• Of these "premature" deaths, over 85% are estimated to occur in low- and middle-

income countries.

• Children, adults and the elderly are all vulnerable to the risk factors contributing to

NCDs, whether from unhealthy diets, physical inactivity, and exposure to tobacco

smoke or the harmful use of alcohol.

• These diseases are driven by forces that include rapid unplanned
urbanization, globalization of unhealthy lifestyles and population
ageing.
• Unhealthy diets and a lack of physical activity may show up in
people as raised blood pressure, increased blood glucose, elevated
blood lipids and obesity.
• These are called metabolic risk factors that can lead to cardiovascular
disease, the leading NCD in terms of premature deaths.
 RISK FACTORS
NON MODIFIABLE RISK FACTOR : MODIFIABLE BEHAVIOURAL RISK
FACTOR:

•Age: According to AHA most of the people die with

•Tobacco use,
CVD are above 65 years.
•Gender: Man are considered more prone for NCD as •Alcohol Consumption,
compared to women. Most heart disease is considered •physical inactivity, and
are primarily to be man disease
•unhealthy diet.
•Family history: Most NCD runs in family history
hence it become necessary for individual to know three
family history
•Ethnicity: Some races like African Americans are
more prone for CVD
1. Alcohol consumption: known to cause heart diseases,
cancers, liver diseases, a range of mental and behavioural
disorders, other non-communicable conditions, and
communicable diseases.
• Both total consumption of alcohol and drinking patterns, such
as heavy episodic drinking, contribute to alcohol-related harm.
• Insufficiently physically active have an increased risk of all-
cause mortality, compared with those who engage in at least 30
minutes of moderate-intensity physical activity most days of the
week .Additionally, physical activity lowers the risk of stroke,
hypertension and depression.
• Recognizing these strong links between physical activity and
physical and mental health, a global target of a 10% reduction in
levels of physical inactivity by 2025 was adopted by Member
States at the Sixty-sixth World Health Assembly in 2013.
• Insufficiently physically active – defined as not meeting the
WHO recommendation to perform at least 150 minutes of
moderate-intensity physical activity per week, or the equivalent .
• More than one third of the population was insufficiently
physically active in one third of countries (55 of 168 countries).
Women were less active than men, with 32% of women and 23%
of men not achieving the recommended levels for physical
activity.
• Salt/sodium intake
• Consuming a diet high in salt contributes to raised blood pressure
and increases the risk of heart disease and stroke .
• To reduce the risk, the recommended daily intake of sodium is
less than 2 grams of sodium or 5 grams of salt.
• The global NCD targets include a sodium reduction target of a
30% relative reduction in mean population salt intake by 2025.
• Tobacco use: Smoking is estimated to cause lung cancer,
chronic respiratory disease and cardiovascular disease. The
highest incidence of smoking among men is in lower-middle
income countries; for total population, smoking prevalence is
highest among upper-middle-income countries.
METABOLIC RISK FACTORS

Raised blood pressure: Raised blood pressure is a major risk factor for non
communicable disease. Mainly it leads to cardiovascular disease.

Overweight/obesity: obese people are at greater risk heart disease, stroke

and diabetes, increase steadily with increase BMI.

Hyperlipidemia (high levels of fat in the blood) : High cholesterol level

increasing risk of heart disease and stroke. Raised cholesterol is highest in high
income countries.
 GAPS IN NATURAL HISTORY

• There are many gaps in our knowledge about the natural history
of chronic diseases. These gaps cause difficulties in aetiological
investigations and research . These are:
Absence of a known agent.

Multi-factorial Causation.

Long latent period.

Indefinite Host
 1. ABSENCE OF A KNOWN AGENT:

• There is much to learn about the cause of chronic diseases.

Whereas in some chronic diseases the cause is known (e.g.,
silica in silicosis, asbestos in mesothelioma), for many chronic
diseases the causative agent is not known. The absence of a
known agent makes both diagnosis and specific prevention
difficult.
 2. MULTIFACTORIAL CAUSATION:

• Most chronic diseases are the result of multiple causes rarely is there a simple one-to-
one cause-effect relationship.

• In the absence of a known agent, the term "risk factor(s)" is used to describe certain
factors in a person's background or life-style that make, the likelihood of the chronic
condition more probable.

• These factors may be both environmental and behavioural, or constitutional.

Epidemiology has contributed massively in the identification of risk factors of chronic
diseases. Many more are yet to be identified and evaluated.
 3. LONG LATENT PERIOD

• A further obstacle to our understanding of the natural history of chronic disease is

the long latent (or incubation) period between the first exposure to "suspected

cause" and the eventual development of disease (e.g., cervical cancer).

• This makes it difficult to link suspected causes (antecedent events) with outcomes,

e.g., the possible relation between oral contraceptives and the occurrence of

cervical cancer.
CONT..
• In an attempt to overcome this problem, a search has been made for precursor lesions

in, for example, cancer cervix, oral cancer and gastric cancer. But this is not possible

in all chronic diseases.

• However, it has now become increasingly evident that the factors favouring the

development of chronic disease are often present early in life, preceding the

appearance of chronic disease by many years. Examples include hypertension,

diabetes, stroke, etc.

 4. INDEFINITE ONSET
• Most chronic diseases are slow in onset and development, and the

distinction between diseased and non-diseased states may be difficult to

establish (e.g., diabetes and hypertension).

• In many chronic diseases (e.g., cancer) the underlying pathological

processes are well established long before the disease manifests itself.

• By the time the patient seeks medical advice, the damage already caused

may be irreversible or difficult to treatment.

 WEB OF CAUSATION:
• This model of disease causation was suggested by Mac Mahon and Pugh .

• This model is ideally suited in the study of chronic disease, where the disease
agent is often not known, but is the outcome of interaction of multiple factors.
• The "web of causation" considers all the predisposing factors of any type and their
complex interrelationship with each other.
• The basic tenet of epidemiology is to study the clusters of causes and
combinations of effects and how they relate to each other . It can be visualized that
the causal web) provides a model which shows a variety of possible interventions
that could be taken which might reduce the occurrence of myocardial infarction. ".
 NCD CAUSATION PATHWAY

• The Western Pacific Regional Action Plan for Non-

communicable Diseases is aligned with the global NCD action
plan and emphasizes the need for a ‘whole-of-government’
approach to addressing NCD risk factors.
 True/false
• a) NCD are degenerative and incurable
• b) they are diseases of the elderly; c) they are diseases of the
rich.
• about NCD preventive programs are: a) difficult to implement,
b) expensive, and c) ineffective.
• NCDs affect high-income (developed) countries only/ low/
middle-income countries do not need to worry about NCDs.
• Fact: NCDs affect all countries. High-income countries used to
account for a disproportionately large number of cases and
deaths due to NCDs in the past. Currently, nearly 80% of NCD
deaths occur in low and middle income countries (except
Africa).
• Even in Africa, they are projected to be the leading cause of
death by 2030.
• NCDs can be prevented- they run in families.
• Fact: NCDs can be prevented through a variety of measures at
the community/ population and individual levels.
• Preventing NCDs is complicated and expensive.
• Many NCDs can be prevented by following simple, inexpensive measures.
• NCD Prevention: The BIG FOUR (Controlling these risk factors will substantially reduce the risk of
developing NCDs regardless of location)
• The BIG FOUR :
• Tobacco: Accounts for 10% of all deaths. The highest incidence of smoking among men is in lower-
middle income countries.
• Insufficient Physical Activity: Those who are insufficiently physically active have 20-30% higher risk
of death (from any cause)
• Harmful use of alcohol: Accounts for 3.8% of all deaths.
• Unhealthy diet: Adequate consumption of fruits and vegetables reduces the risk for cardiovascular
disease, stomach and colon cancers. High salt intake (5 grams per person per day or more)
increases the risk for developing hypertension and cardiovascular disease. High consumption of
saturated fats and trans-fatty acids is linked to heart disease.
• NCDs are diseases of affluence
• In reality, NCDs are drivers of, and result from poverty. Around
80% of global deaths from NCDs occur in the 
worlds’ poorest nations. While these are also the most
populous countries in the world, NCDs selectively burden
lower-socioeconomic groups, even in high-income nations,
such as Australia.
• NCDs mainly affect older people
• More than 50% of the global burden of NCDs falls on people 
younger than 70 years. So, while the diseases are associated
with ageing, the global burden is not simply an outcome of
ageing populations
• NCDs are diseases of laziness and are self-inflicted
Many argue that NCDs occur as a result of poor choices by
individuals and parents, and should therefore not be the
responsibility of government or society.
• This ignores the fact that states have a responsibility to make 
being healthy easy through education, initiating societal
change and providing incentives to make good health choices.
• NCDs represent a health crisis for future generations, not our
own
• NCDs are often seen as a problem society will face in coming
decades, when, in fact, the global community is already in the
midst of a chronic disease epidemic, and their mitigation is
something we cannot afford to postpone.
 STEPWISE APPROACH TO NON-COMMUNICABLE DISEASE RISK FACTOR SURVEILLANCE (STEPS)

• Introduction: The STEPS approach focuses on obtaining core

data on the established risk factors that determine the major
disease burden. It is sufficiently flexible to allow each country to
expand on the core variables and risk factors, and to incorporate
optional modules related to local or regional interests.

• Purpose: The WHO STEPwise approach to noncommunicable

disease (NCD) risk factor surveillance is designed to help
countries build and strengthen their surveillance capacity.
Cont..
• Design: The STEPS Instrument covers three different levels of
"steps" of risk factor assessment.

• These steps are:

• Questionnaire
• Physical measurements
• Biochemical measurements
Cont…
WHO Global Action Plan for the Prevention and Control of
NCDs (2013-2020)
• The Global Action Plan provides member states with a road map and menu of
policy options which, when implemented collectively between 2013 and 2020,
will contribute to progress on 9 global NCD targets including that of 25 per cent
relative reduction in premature mortality from cardiovascular diseases, cancer,
diabetes and chronic respiratory diseases by 2025.
• These four diseases make the largest contribution to mortality and morbidity due
to NCDs.
• It will target four behavioural risk factors - tobacco use, unhealthy diet, physical
inactivity and harmful use of alcohol
 CONT..
A 25 per cent relative reduction in risk of premature mortality from cardiovascular diseases, cancer, diabetes and chronic
respiratory disease.

At least 10 per cent relative reduction in the harmful use of alcohol as appropriate within national context.

A 10 per cent relative reduction in prevalence of insufficient physical activity.

A 10 per cent relative reduction in mean population intake of salt/sodium.

A 30 per cent relative reduction in prevalence of current tobacco use in persons aged 15+ years
Cont…
A 25 per cent relative reduction in prevalence of raised blood pressure. ·

Halt the rise of diabetes and obesity.

At least 50 per cent of eligible people receive drug therapy and counselling (including glycaemia control) to prevent
heart attacks and strokes.

An 80 per cent availability of the affordable basic ·technology and essential medicines including generics, required to
treat major NCDs in both public and private facilities.
 PREVENTION AND CONTROL OF NCD

a) Population strategy
• prevention in whole populations

• primordial prevention in whole populations

b) High risk strategy

c) Secondary prevention
 PRIMORDIAL PREVENTION

Primordial prevention, a new concept, is receiving special

attention in the prevention of chronic diseases. This is primary
prevention in its purest sense, that is, prevention of the
emergence or development of risk factors in countries or
population groups in which they have not yet appeared.
 2. PRIMARY PREVENTION
– Primary prevention can be defined as "action taken prior to the onset of disease, which

removes the possibility that a disease will ever occur".

– It signifies intervention in the pre-pathogenesis phase of a disease or health problem

(e.g., low birth weight) or other departure from health.

– Primary prevention is far more than averting the occurrence of a disease and

prolonging life. It includes the concept of "positive health", a concept that encourages

achievement and maintenance of "an acceptable level of health that will enable every

individual to lead a socially and economically productive life".

Cont…
– It concerns an individual's attitude towards life and health and the initiative he
takes about positive and responsible measures for himself, his family and his
community.
– The concept of primary prevention is now being applied to the prevention of
chronic diseases such as coronary heart disease, hypertension and cancer based
on elimination or modification of "risk-factors" of disease.
– The WHO has recommended the following approaches for the primary
prevention of chronic diseases where the risk factors are established
 POPULATION STRATEGY
• The strategy should therefore be based on mass approach focusing mainly on the
control of underlying causes (risk factors) in whole populations, not merely in
individuals.
• This approach is based on the principle that small changes in risk factor levels in
total populations can achieve the biggest reduction in mortality.
• That is, the aim should be to shift the whole risk-factor distribution in the direction
of "biological normality". This cannot obviously be done by medical means alone;
it requires the mobilization and involvement of the whole community.
 POPULATION STRATEGY
(I) IDENTIFYING RISK: (II) SPECIFIC ADVICE:
• High-risk intervention can only start once • Having identified those at high risk, the
those at high risk have been identified. By next step will be to bring them under
means of simple tests such as blood preventive care and motivate them to take
pressure and serum cholesterol positive action against all the identified
measurement it is possible to identify risk factors,
individuals at special risk. • From a methodological point of view,
however, high-risk approach suffers from
the disadvantage that the intervention (e.g.,
treatment) may be effective in reducing the
disease in a high-risk group.
 SECONDARY TREATMENT
• Secondary prevention can be defined as "action which halts the progress of a
disease at its incipient stage and prevents complications". The specific
interventions are early diagnosis {e.g., screening tests, case finding programmes)
and adequate treatment.

• By early diagnosis and adequate treatment, secondary prevention attempts to

arrest the disease process;

• It may also protect others in the community from acquiring the infection and thus
provide, at once, secondary prevention for the infected individuals and primary
prevention for their potential contacts.
 CONT..

• Secondary prevention is largely the domain of clinical medicine.

The health programmes initiated by governments are usually at
the level of secondary prevention. Secondary prevention is an
imperfect tool in the control of transmission of disease. It is often
more expensive and less effective than primary prevention.
 Need for a program
• Disease tree
• Control rate
• Alteplase for Stroke – 126
• Patient flow directly to doctors by passing nurses – need of
pathway
• COPD and Asthma
• TB and DM
 National programme for prevention and control of cancer,
diabetes, cardiovascular diseases and stroke

• The Programme focuses on health promotion , capacity

building including human resource development , early
diagnosis and management of these disease with integration
with primary health care system.
• The various approaches including such as mass media,
community education and interpersonal communication will
be used for behavioural change focusing on following
message :
 Objectives of NPCDCS

 
• Health promotion through behavior change with involvement of
community, civil society, community based organizations, media etc.
• Opportunistic screening at all levels in the health care delivery system
from sub- centre and above for early detection of diabetes,
hypertension and common cancers. Outreach camps are also envisaged.
• To prevent and control chronic Non-Communicable diseases, especially
Cancer, Diabetes, CVDs and Stroke.
 
• To build capacity at various levels of health care for prevention,
early diagnosis, treatment, IEC/BCC, operational research and
rehabilitation.
• To support for diagnosis and cost effective treatment at
primary, secondary and tertiary levels of health care.
• To support for development of database of NCDs through
Surveillance System and to monitor NCD morbidity and
mortality and risk factors.
 Strategy

 
• Health promotion, awareness generation and promotion of
healthy lifestyle Screening and early detection
• Timely and accurate diagnosis
• Access to affordable treatment,
• Rehabilitation
• During the 12th FYP, while the coverage is proposed to be pan
India, the focus of the programme is on health promotion,
prevention, detection, treatment and rehabilitative services at
decentralized level up to district hospital under the overall
umbrella of National Health Mission for primary and secondary
level health care services.
• The programme division at the national level will develop
broad guidelines and strategy for implementation of different
components of the programme. The States may adopt and
modify these guidelines as per their need and circumstances
for implementation of the programme. Involvement of
community, civil society and private sector partnership would
be vital, and suitable guidelines would be made for the same.
 Health Promotion

 
• Given that the major determinants to hypertension, obesity, high blood
glucose and high blood lipid levels are unhealthy diet, physical
inactivity and stress, awareness will be generated in the community to
promote healthy life style habits. For such awareness generation and
community education, various strategies will be devised /formulated
for behavior change and communication by inter personal
communication (IPC), involvement of various categories of mass media,
civil society, community based organization, panchayats/local bodies,
other government departments and private sector.
 The focus of health promotion activities will be on:

 
• intake of healthy foods
• Increased physical activity
• Avoidance of tobacco and alcohol
• Reduction of obesity
• Stress management
• Awareness about warning signs of cancer
• Regular health check-up
  
MODE OF OPERATION

• Screening, diagnosis and treatment

• Screening and early detection of non-communicable diseases
especially diabetes, high blood pressure and common cancers
would be an important component. The suspected cases will
be referred to higher health facilities for further diagnosis and
treatment
• Common cancers (breast, cervical and oral ), diabetes and high
blood pressure screening of target population (age 30 years
and above,) will be conducted either through opportunistic
and/or camp approach at different levels of health facilities
and also in urban slums of large cities.
Establishment/Strengthening of Health infrastructure
 
• Community health centers and district hospitals would be
supported for prevention, early detection and management of
Cancer, Diabetes, Cardiovascular Diseases and Stroke. Support
would be provided for establishing NCD clinics and
strengthening laboratory at Community health centers and
district hospitals.
• In order to provide cardiac care and cancer care at district level, the
districts not having Medical College hospitals and not covered under
Scheme for Upgradation of District Hospitals to Medical College
hospitals, would be provided financial assistance for establishing at
least 4 bedded cardiac care unit. This includes provision for renovation
and purchase of equipments such as ventilators, monitors,
defibrillator, CCU beds, portable ECG machine and pulse oxymeter etc.
for cardiac care and chemotherapy beds for . Financial support for the
essential contractual staff such as doctors and nurses at these units
would also be provided under the programme.
 Human Resource development

• Under NPCDCS, health professionals and health care providers at

various levels of health care would be trained for health promotion,
NCD prevention, early detection and management of Cancer, Diabetes,
CVDs and Stroke. For imparting training both for the programme
management and for specialized training for diagnosis, treatment of
cancer, diabetes, CVDs and strokes, the nodal agency/agencies will be
identified to develop the training material, organize training of health
care providers at different levels and for monitoring the quality of the
training. Structures Training programmes will be developed to provide
quality training with appropriate curriculum to various category of staff.
Miscellaneous services:

• Financial support would be provided to district and

CHC/FRU/PHC for procurement of screening devices , essential
drugs, consumables, transport of referral cases as per the
details annexed for treatment of Cancer, Diabetes, CVDs and
Stroke.
 Outreach services

• These services are proposed to be provided periodically in the

programme districts in collaboration with tertiary care
hospitals / institutes for early detection of common cancers,
diabetes, CVDs and stroke.
Integration with AYUSH:
 
• AYUSH doctors can play an important role in prevention and control of NCDs
through primary health care network. They can be involved in health promotion
activities through behavior change, counseling of patients and their relatives on
healthy lifestyle (healthy diet, physical activity, salt reduction, avoidance of
alcohol and tobacco) meditation, Yoga, opportunistic screening for early
detection of non- communicable diseases and their risk factors, and treatment
using Indigenous System of Medicines. The AYUSH practitioner can supplement
the efforts to operationalizing these activities and thus need to be integrated
with the National NCD prevention and control programs especially NPCDCS
Public private partnership
• It is proposed to involve NGOs, civil society and private sector
in health promotion, early diagnosis and treatment of common
NCDs through appropriate guidelines as per the need at
Central, State, District levels and below.
Research and surveillance

• Support would be given to States and Institutes for surveillance

& research on NCDs. Emphasis would be given on creating
database, applied and operational research related to the
programme. Survey for risk factors for NCDs would be
conducted at frequency and by methods decided by experts.
Monitoring & evaluation

• Monitoring and evaluation of the programme would be carried out at

different levels through NCD cells, reports, regular visits to the field and
periodic review meetings. National, State and District NCD Cell would be
established/strengthened to monitor and supervise the programme by
providing the support for contractual manpower, establishment of
physical infrastructure and for field visits, contingencies etc.
Management Information System (MIS) would be developed for
capturing and analysis of data.
• Health Facility Packages of services 
Sub centre
• Health promotion for behavior change and counseling
• ‘Opportunistic’ Screening of Diabetes using glucometer kits and Blood Pressure measurement.
• Awareness generation of early warning signals of common cancer Referral of suspected cases to CHC/ nearby health
facility 
PHC
• Health promotion for behavior change and counseling
• ‘Opportunistic’ Screening of Diabetes using glucometer kits and Blood Pressure measurement.
• Clinical diagnosis and treatment of common CVDs including Hypertension and Diabetes
• Identification of early warning signals of common cancer Referral of suspected cases to CHC
 
• Mentoring of District Hospital and outreach activities Comprehensive cancer care including prevention, early detection,
diagnosis, treatment, palliative care and rehabilitation
• Training of health personnel Operational Research
CHC/FRU
• Prevention and health promotion including counseling
• Early diagnosis through clinical and laboratory investigations Management of common CVDs, diabetes and stroke cases
• Lab. investigations and Diagnostics: Blood sugar, Total Cholesterol
• ,Lipid Profile, Blood Urea, XR, ECG,USG (To be outsourced, if not available)
• ‘Opportunistic’ Screening of common cancers (Oral, Breast and Cervix) Referral of complicated cases to District Hospital/higher health
care facility
 
District Hospital
• Diagnosis and management of cases of CVDs, Diabetes, Stroke and Cancer (outpatient, inpatient and intensive Care ) including
emergency services particularly for Myocardial Infarction & Stroke.
• Lab. investigations and Diagnostics: Blood sugar, Lipid Profile, KFT, XR, ECG,USG ECHO, CT Scan, MRI etc (To be outsourced, if not
available)
• Referral of complicated cases to higher health care facility Health promotion for behavior change and counseling
• ‘Opportunistic’ Screening of NCDs including common cancers(Oral, Breast and Cervix)
• Follow up chemotherapy in cancer cases
• Rehabilitation and physiotherapy services
Medical College
• Mentoring of District Hospitals
• Early diagnosis and management of Cancer, Diabetes, CVDs
and other associated illnesses
• Training of health personnel
• Operational Research
Tertiary Cancer Centre
• Mentoring of District Hospital and outreach activities
Comprehensive cancer care including prevention, early
detection, diagnosis, treatment, palliative care and
rehabilitation
• Training of health personnel
• Operational Research
 Expected Outcomes

 
• The programmes and interventions would establish a comprehensive sustainable system for
reducing rapid rise of NCDs, disability as well as deaths due to NCDs.
• Broadly, following outcomes are expected at the end of the 12th Plan: 
• Early detection and timely treatment leading to increase in cure rate and survival Reduction
in exposure to risk factors, life style changes leading to reduction in NCDs
• Improved quality of life
• Reduction in prevalence of physical disabilities including blindness and deafness Providing
user friendly health services to the elderly population of the country Reduction in deaths
and disability due to trauma, burns and disasters
• Reduction in out-of-pocket expenditure on management of NCDs and thereby preventing
catastrophic implication on affected individual
Institutional framework for the implementation of NPCDCS activities

• Activities permissible under NCD flexi-pool:

 
• NCD control at the primary and secondary levels upto the district hospitals.
• Prevention and promotion activities for NCDs.
• Proposal for screening, case detection and follow up.
• Proposal which provide synergies between NCD control and already existing activities
under the mission such as screening of pregnant women for diabetes and
hypertension.
• Innovations for NCD control.
• IEC and BCC activities.
• Any other NCD related initiatives proposed by the states as per their felt needs.
• Program Structure-Integration with NHM:

• Financial management group (FMG) of Programme

Management support units at state and district level, which is
established under NHM, will be responsible for financial
management (maintenance of accounts, release of funds,
expenditure reports, utilization certificates and audit
arrangements).
• State Health Society (SHS):

• Under the NHM framework different Societies of national

programmes such as Reproductive and Child Health Programme,
Malaria, TB, Leprosy, National Blindness Control Programme have
been merged into a common State Health Society is chaired by
Chief Secretary/Development Commissioner. Principal/Secretary
(Health & Family Welfare) is the vice chairperson and mission
director is the Member -Secretary of the State Health Society.
• District Health Society (DHS)
• At the district level all programme societies have been merged
into the District Health Society (DHS).The Governing Body of
the DHS is chaired by the Chairman of the Zila Parishad /
District Collector. The Executive Body is chaired by the District
Collector (subject to State specific variations).The CMHO is the
Member - Secretary of the District Health Society.
Technical Resource Groups
• To provide technical guidance, advice and review the progress
of the programme for enhancing the quality of implementation
of NPCDCS, national level committee and various other
committees would be set up to provide technical support for
the programme. States may also devise their own mechanisms
for State specific technical support for issues related to
NPCDCS.
Establishment/Strengthening of Health infrastructure

• 1. Primary Health Centers and Sub Centres(PHCs & SCs)

– Health promotion for behavior change and counseling

– ‘Opportunistic’ Screening of Diabetes using glucometer kits and Blood Pressure
measurement.
– Follow up of common CVDs including Hypertension and Diabetes
– Identification of early warning signals of common cancer
– Referral of suspected cases to CHC Referral of suspected cases to CHC
• Community Health Centers (CHCs)

• Under NPDCS, support will be provided to the CHC/FRU to establish a ‘NCD clinic’
(NCD here refers to Cancer, Diabetes, Hypertension, cardiovascular diseases and
stroke and associated illnesses) where comprehensive examination of patients
referred by the Health Worker as well as reporting directly will be conducted for
early diagnosis and treatment.
 
• Priority would be given to First Referral Units (FRUs) to be strengthened for
screening of common cancers,(oral, breast and cervix), NCD clinic, laboratory
investigations and referral services.
District Hospital

• District hospital would be strengthened /upgraded for

management of Cancer, Diabetes, Cardiovascular Disease and
Stroke (DCS). Support would be provided for non-recurring and
recurring costs, where non-recurring grants would be for
equipments, renovation and laboratory strengthening while
recurring grants would be towards the remuneration of staff,
drugs and IEC etc.
NCD clinic:

• All districts will have regular NCD clinic for screening, management, and
counseling and awareness generation etc. for non-communicable
diseases. (NCD, here refers to Cancer, Diabetes, Hypertension,
Cardiovascular diseases, COPD, CKD and Stroke and associated illnesses)
where comprehensive examination of patients referred by lower health
facility /Health Worker as well as of those reporting directly will be
conducted for ruling out complications or advanced stages of common
NCDs
Cardiac Care unit:

• 4 bedded Cardiac Care Unit (CCU) will be established /

strengthened in identified district hospitals, wherever it is
feasible
Support for cancer: 
• For diagnosis of common cancers, District hospitals will use
existing diagnostic facilities. In case any of the facility is not
available in the district hospital, the same may be outsourced,
as per state policy/practice. The suspected cases / diagnosed
cases may be referred
Laboratory strengthening:

• Laboratory services at district hospital will be supported to

provide necessary investigations for cancer, diabetes,
hypertension and cardiovascular diseases. District hospital may
outsource certain laboratory investigations that are not part of
IPHS standards and are not available at the facility. The District
Hospital shall display the list of Laboratories in which these
investigations would be outsourced.
Composition of National NCD Cell:
• National NCD Cell will be established in the Directorate General
of Health Services. The National NCD Cell will be responsible
for planning, providing overall guidance to States /UTs for
implementation, monitoring and evaluation of the different
activities, and achievement of physical and financial targets
planned under the programme.
 State NCD cell
 
• State NCD Cell will be established preferably in the Directorate
of Health Services or any other space provided by the State
Government. The NCD Cell will be responsible for overall
planning, implementation, monitoring and evaluation of the
different activities, and achievement of physical and financial
targets planned under the programme in the State
 District NCD Cell

• The District NCD Cell will be established preferably in the viscinity of

the District Hospital or any other space provided by District CMO.

• The NCD Cell will be responsible for overall planning,

implementation, monitoring and evaluation of the different
activities and achievement of physical and financial targets planned
under the programme in the District.
 Activities under NPCDCS at various levels

Sub Centre
• A. Health promotion:
 
• B. Opportunistic Screening
 
• Referral
•  

• ANM and (or) Male Health Worker will refer the suspected case of Diabetes and Hypertension to the CHC or higher
Health Facility for further diagnosis and management.
 
• Data recording and reporting 
• ANM and (or) Male Health Worker at Sub Centre will maintain in prescribed format
• Common Register of all the persons(>30 years) screened at sub centre / camps / VND / Health Melas or under any other
activity.
• Referral Card in duplicate one to be given to the patient (the suspected case >140 dl. /mg) and other to be retained at the
subcentre for future reference and follow up.
 Activities at Community Health Centre
• Opportunistic screening
• Prevention and health promotion
• Lab. investigations and Diagnostics
• Blood sugar, Total Cholesterol , Lipid Profile, Blood Urea, XR, ECG,USG (To be
outsourced, if not available)
• Referral 
• Complicated cases of diabetes, high blood pressure etc. shall be referred
from CHC to the District Hospital for further investigations and management.
• Data recording and reporting
 Activities at District Level

Day Care Chemotherapy Facility

Palliative Care
Referral & Transport facility to serious patients
Health promotion
Training
Data recording and reporting
 At the State level
• Community awareness
• Planning, Monitoring and Supervision
• Training of Human Resources
• CCU
• Cancer Care
 Activities at Central level
• Information, Education & Communication
• Tertiary Level Care
• Training
• Monitoring, Evaluation, Surveillance and Research
 District lab Facility

– Hb, TLC, DLC, Platelet count

– Bleeding Time, Clotting time
– Fasting /PP blood sugar
– Lipid profile
– Liver Function Test
– Kidney Function Test
– Urine routine & Urine Sugar
– X-ray
 CHALLANGES
• BORDER DISTRICTS OR PANCHAYAT
• DRUG CROSS OVER
• POPULATION BASED SCREENING
• TREATMENT PASS BOOK
• BUFFER STOCK INTIMATION
 THEORY APPLICATION

• The Self-Care or Self-Care Deficit Theory of Nursing is composed of three

interrelated theories: (1) the theory of self-care, (2) the self-care deficit
theory, and (3) the theory of nursing systems, which is further classified into
wholly compensatory, partial compensatory and supportive-educative.
 
• Theory of Self-Care
• This theory focuses on the performance or practice of activities that individuals
initiate and perform on their own behalf to maintain life, health and well-being.
 
• Theory of Self-Care Deficit
• This theory delineates when nursing is needed. Nursing is required when an adult (or
in the case of a dependent, the parent or guardian) is incapable of or limited in the
provision of continuous effective self-care. Orem identified 5 methods of helping:
• • Acting for and doing for others
• • Guiding others
• • Supporting another
• • Providing an environment promoting personal development in relation to meet
future demands
• • Teaching another
• Theory of Nursing System
• This theory is the product of a series of relations between the
persons: legitimate nurse and legitimate client. This system is
activated when the client’s therapeutic self-care demand
exceeds available self-care agency, leading to the need for
nursing.
• Journal reference
Indian Journal of cancer  Title:- Risk factors of female breast carcinoma: A case control study at
Puducherry  Investigators:-SM Balasubramaniam, SB Rotti, S Vivekanandam
• Objective: To identify and quantify various demographic, reproductive, socio-economic and
dietary risk factors among women with breast cancer. 
• Study Design: Case control study.  Study Period : February 2004 to May 2005.  Study Setting:
Departments of Surgery, Medicine and Radiotherapy of JIPMER
• Materials and Methods: Cases were women with pathologically confirmed breast cancer.
Controls were age-matched women from medicine and surgery wards without any current breast
problem or previous breast cancer. A total of 152 cases and 152 controls were enrolled. They
were interviewed for parity, breast feeding, past history of benign breast lesion, family history
and dietary history with a pre-tested interview schedule after obtaining informed written
consent.
• Results: The significant risk factors were previous history of
biopsy for benign breast lesion 10.4, nulliparity 2.4 (1.14-5.08),
consumption of fats more than 30 g/day 2.4 (1.14-5.45) and
consumption of oils containing more of saturated fat 2.0 (1.03-
4.52).
• Conclusions: Nulliparity, past history of benign breast lesion,
high fat diet and consumption of oils with more saturated fats
were the risk factors.
Summary
• Chronic non-communicable diseases are assuming increasing importance among the adult
population in both developed and developing countries. Cardiovascular diseases and cancer
are at present the leading causes of death in developed countries. The prevalence of chronic
disease is showing an upward trend in most countries, and for several reason this trend is
likely to increase. life-styles and behavioural patterns of people are changing rapidly, these
being favourable to the onset of chronic diseases. Modern medical care is now enabling
many with chronic diseases to survive. The impact of chronic diseases on the lives of people
is serious when measured in terms of loss of life, disablement, family hardship and poverty,
and economic loss to the country.India is experiencing a rapid health transition with a rising
burden of NCDs causing significant morbidity and mortality, both in urban and rural
population, with considerable loss in potentially productive years (age 35-64 years) of life.
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