Takshashila

Discussion Document: A National Epidemic Intelligence Service (NEIS) for

India

Ruturaj Gowaikar & Shambhavi Naik

TAKSHASHILA DISCUSSION DOCUMENT 2021-22

V1.0 19th August 2021

Executive Summary
The COVID-19 outbreak has demonstrated the need for India to develop its
own capacity to assess emerging biological threats. Reliance on foreign inputs
led to delayed actions such as airport closures or screening/quarantine of
incoming travelers.

We propose the formation of an Indian National Epidemic Intelligence Service

to monitor emerging outbreaks of novel or existing diseases, assess the threat
in an Indian context, and alert public health agencies to take actions to protect
Indian citizens. This service builds on India’s already existing intelligence and
surveillance units, to create a network of trained personnel who can analyse
incoming data, identify threats, secure biological samples and characterise
pathogens.

© The Takshashila Institution, 2021

©
This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
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Introduction
The need for an Indian service that could provide intelligence regarding the type and
magnitude of a biological event became apparent during the COVID-19 pandemic. India
relied on information from multi-national agencies like World Health Organisation
(WHO) to take decisions regarding closure of airports and testing protocols. But reliance
on data and analysis provided by such organisations have an inherent drawback, as they
rely on the information submitted by host countries. During the COVID-19 pandemic,
suppressed data on the extent of COVID-19 spread and nature of asymptomatic
transmission led to uninformed decision-making such as late closures of international
travel. Early, precise information and understanding of the COVID-19 threat in the India
context may have led to a more tailored public health response. Hence, it would be
advantageous for India to develop its own intelligence agency to make an assessment of
emerging threats and inform public health organizations.

We propose the formation of an Indian National Epidemic Intelligence (NEI) agency,

under the Ministry of Health and Family Welfare (MoHFW) staffed with individuals
trained in epidemiology and intelligence gathering. The main function of this agency
would be to collect and analyse comprehensive information on emerging pathogens,
existing health threats, hygiene practices, and public health systems across the world.
These data can feed into making informed decisions when a new health threat emerges.

This document covers existing agencies that monitor public health threats and
recommends a roadmap for India’s NEI agency.

Existing agencies involved in gathering intelligence

regarding epidemic outbreaks
Co-ordinated by the WHO, a consortium of national and international agencies gathers
and collates data on emerging biological threats. These data are analysed and, if a public

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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health threat is identified, follow up action is initiated. Control measures can be put in
place, alerts can be disseminated through partner organisations and further investigations
of the threat can be set up as required. Figure 1 provides an overview of this intelligence
flow.

Figure 1: An overview of a global epidemic intelligence framework. Figure adapted from

Global infectious disease surveillance and detection: Assessing the challenges—finding
solutions.i EWRS = Early Warning Response System; MS = messaging system; DSN =
disease surveillance network; EWGLI = European Working Group for Legionella
Infections; EISS = European Influenza Surveillance Scheme; BSN = Basic Surveillance
Network; EMEA = European Agency for the Evaluation of Medicinal Products; EFSA =
European Food and Safety Authority; WHO-OVL = Outbreak Verification List; OIE =
Office International des Epizooties (World Organization for Animal Health); FAO = Food
and Agriculture Organization; EU = European Union. Enternet is an established and
thriving EU-wide network for the laboratory-based surveillance of human Salmonella and
Verocytotoxin-producing Escherichia coli (VTEC) infections.

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Below we discuss the structure and functions of select existing agencies involved in
epidemic intelligence.

1. WHO; International Health Regulations (IHR)

The IHR treaty is the legal instrument which empowers WHO to be an international
monitoring and advisory body for public health across the 196 signatory countries. The IHR
Global Health Security Index (GSI) is a comprehensive assessment and benchmarking of
health security and related capabilities across these countries. Data gathered from active
surveillance efforts in host countries, information about past outbreaks, as well as the Joint
External Evaluation (JEE) scores of countries part of the Global Health Security Agenda
(GHSA) helps develop a medical intelligence profile for a country. JEE is a collaborative
exercise by a country’s public health experts and external evaluators from the Centers for
Disease Control (CDC) of United States. The JEE examines capacities across 19 technical
areas in the field of human health and prepares a report. This report is useful for the
participant country to identify weaknesses in its public health machinery.ii

Figure 2: The Joint External Evaluation Process. Image sourced from The Joint External
Evaluation (JEE) Process: A Project to Assess and Build Global Health Security, CDC
website.iii

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
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In 2012, WHO, along with its member states and partner organisations, created the ECO-
NET, a global network of emergency operations and centres. The Strategic Health
Operations Centre (SHOC) coordinates operations of the ECO-NET by providing a
platform for information exchange and response coordination during public health crises
of international proportions.

2. Global Health Security Agenda (GHSA)

GHSA is a multi-national body of 70 countries, international and non-government
organisations, and private sector companies focussing on global infectious diseases. It has
an event-based monitoring system/package in development. GHSA is supported by
countries such as Georgia, Norway, Finland, Indonesia, Israel, Italy, Kenya, Mexico, United
Kingdom, United States, and Yemen and international organisations like Food and
Agriculture Organisation of the United Nations (FAO) and World Organisation for
Animal Health (OIE). WHO is also part of this event-based monitoring package of
GHSA.iv

3. Global Health Security Strategy (GHSS), USA

The USA’s National Security Strategy (NSS) originally did not include biological threats.
Initial work to develop a framework related to public health was done by the US Office of
International Health and Biodefense (IHB), which comes under the Department of
Homeland Security. In 2018, a National Biodefense Strategy (NBS) was formulated,
expanding the NSS to encompass a comprehensive and integrated approach to address
natural, accidental, and intentional biological threats domestically and internationally.v
The vision for NBS was expanded to the global arena in May 2019 when the White House
released the GHSS, which outlines the United States’ government’s approach to
strengthen global health security, including improving the capacity of foreign countries to
prevent, detect, and respond to infectious disease outbreaks. IHB engages the U.S.
interagency and diverse stakeholders to implement these strategies.

The Centers for Disease Control and Prevention (CDC) is tasked with studying national
and international public health threats. The agency runs the Epidemic Intelligence Service
programme in epidemiology, creating a workforce of fellows that respond to health threats
locally and globally.vi Since the inception of the programme in 1951, fellows have

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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India



investigated numerous health threats, including biological warfare during the Korean war,
responding to Anthrax, SARS, and flu outbreaks, and providing on-ground response to
Ebola and Zika virus outbreaks.vii

4. Global Outbreak Alert and Response Network (GOARN)

GOARN leverages the WHO network of over 250 several technical and public health
institutions, laboratories, and NGOs, to observe and respond to threatening epidemics. It is
not funded directly by the WHO, but derives funding from fundraising for each new
incident it chooses to respond to.

5. Global Public Health Intelligence Network (GPHIN)

This is one of the most active and effective health monitoring systems in operation
currently. It is a Canadian system that feeds into WHO. It has been the first to detect
multiple Ebola outbreaks and other medical events around the world. GPHIN is an
electronic monitoring system that uses news feeds from multiple languages to monitor any
health related event in the world. It uses Natural Language Processing (NLP), weighted
search words, automated translations etc. to analyse real time news feeds. Public health
analysts and intelligence analysts perform a second level of analysis on the electronically
collated data. GPHIN reports are forwarded by Canadian authorities to WHO. By some
estimates, GPHIN reports form 20% of the health monitoring inputs to WHO.viii

6. Force Health Protection Agency (formerly, DHSC) for NATOix

The Force Health Protection Agency was formed to monitor disease outbreaks in areas
where NATO armed forces have been deployed to rule out biological warfare and provide
an early warning system in the event of a local outbreak of a communicable disease.

7. MediSys
The medical surveillance system of the EU is similar to GPHIN but only accessible to EU
members.

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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India



8. Blue dotx
Blue dot is one of the leading private entities in the realm of digital health monitoring
systems in the world. Blue dot started as a private start-up relying on technology similar to
GPHIN that makes use of NLP, auto-translations, etc. of global news feeds.

Limitations of current monitoring systems

The current surveillance systems, be they multi-national or national organizations have
certain limitations made apparent by the emergence of COVID-19. The main problem with
multi-national organisations like WHO is that they depend on the generosity of a ‘host’
country to access ground level as well as collated data from that country. The limitation of
national systems is that domestic situations or budgetary constraints can influence the
efficiency of monitoring systems. For example, GPHIN, arguably the best monitoring
system, didn’t detect COVID-19 outbreak due to Canadian government’s priority to focus
on domestic health issues.xi India has been relying on analysed data, warnings, advisories
mainly from multi-national organisations. Additionally, it is important to assess these
threats in the Indian context, taking into account India’s geographical location,
geostrategic ties, trade routes and capacity of health systems to respond to threats. It is
therefore in India’s national interest to create an Indian system capable of global
monitoring and threat assessment.

Existing structures in India

India has few organisations involved in general monitoring, biosafety and biosecurity, but
not systems involved in global, real-time data gathering pertaining to health. They are as
follows:

1. National Centre for Disease Control (NCDC)

The National Centre for Disease Control is an institute under the Indian Directorate
General of Health Services (DGHS), Ministry of Health and Family Welfare (MoHFW).

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
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NCDC is the nodal agency for the Integrated Disease Surveillance Programme (IDSP) and
is the leading agency for implementation of the International Health Regulations (IHR) in
India.

NCDC runs a program for doctors called Indian Epidemic Intelligence Service (EIS). It is a
two-year programme in applied epidemiology in which trainee officers develop skills while
working in Indian public health agencies and programs. Officers then return to their
respective states or organisations. Since its conception in 2017, 33 Indians officers have been
trained. They have investigated 121 outbreaks and evaluated 46 surveillance systems.
xii,xiii
Thus, the EIS is a training service and not an intelligence service.

2. Integrated Disease Surveillance Programme (IDSP)

The aim of IDSP is to develop human resources for domestic disease surveillance and
integrate data gathered from decentralised surveillance and analysis. IDSP was set up in
two phases using funding provided by the World Bank. NCDC is the reporting agency for
IDSP.
IDSP has a media surveillance wing that was established in 2008. The Media Scanning and
Verification Cell (MSVC) receives around 2-3 media alerts of unusual health events daily.
A total of 2,925 health alerts have been detected till September 2014 since its establishment
in July 2008.xiv

Additionally, 97% of Indian districts have mechanisms in place that provide data from
government medical facilities including government laboratories to IDSP.xv However, not
all laboratories are covered by IDSP due to budgetary constraints. Private medical
establishments are not covered. Reporting centres are present at the Union, state, and
district level. IDSP also runs the EIS programme for medical doctors wanting to pursue a
career in field epidemiology and public health.

The data collected by IDSP is geotagged (GIS), has meteorological inputs and is in the ‘S’,
syndromic; ‘P’, probable; & ‘L’, laboratory format. But currently IDSP data is not analysed
using big-data tools.

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
India



3. DRDO laboratories
DRDO operates six laboratories under its life science cluster. These include Defence
Bioengineering and Electromedical Laboratory (DEBEL), Bengaluru; Defence Institute of
Bio-Energy Research (DIBER), Haldwani; Defence Food Research Laboratory (DFRL),
Mysore; Defence Institute of Physiology and Allied Sciences (DIPAS), Delhi; Defence
Institute of High Altitude Research (DIHAR); and Defence Institute of Psychological
Research (DIPR), Delhi.xvi

These laboratories do not work in the area of monitoring but are geared towards solving
technical problems related to life science that may or may not have applications in medical
intelligence, biowarfare defence etc.

4. Medical Corps of Armed Forces

The medical corps has capabilities to identify a biowarfare attack and provide treatment but
does not have monitoring/surveillance systems on a national/global level.

Lacunae in existing Indian monitoring systems

India’s current epidemic monitoring systems need further strengthening to prepare for
further disease outbreaks. Key areas that need to be included are:

1) Global, real-time news monitoring of biological events as the primary step.

2) Medical intelligence data of other countries
3) Medical data from private medical facilities under the IDSP format
4) Medical data from Medical Corps of Armed Forces under IDSP format
5) Include all government labs under IDSP format
6) Need for analysis of IDSP data using big-data tools
7) Need to include analysts versed in strategic studies at the Central office of IDSP

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
India



The proposed NEI

Data Gathering Data Analysis (NEI) Decision making (NEI)

Surveillance of Create a country Commission sample

domestic samples specific assessment collection and
(IDSP) matrix to be used further
for assessing characterisation of
emerging threats. disease, if necessary
Real-time Screening identify emerging
of local and global threats

!
news and social Alert DGHS/ICAR
media Check in-coming of possible threat to
(MSCV) data to flag any issue public health
emerging threats measures
Medical
intelligence, JEE
scores
(WHO, other
Assess threats on
basis of country of
origin and disease
! Alert MHA of
possible threat

countries)

Figure 3: Data flow/decision making structure in proposed NEI system.

We propose a National Epidemic Intelligence (NEI) service for the primary function of
assessing biological threats to India. For threats within India, the IDSP needs to be
strengthened to ensure complete coverage of public and private hospitals in India. The
sentinel centres need to be well-equipped to identify new diseases and characterise novel
pathogens.

For threats originating in foreign countries, the NEI could have, as its first level, a global
digital monitoring system on the lines of Canada’s Global Public Health Intelligence
Network and similar agencies. This monitoring system would involve expansion of the
IDSP’s current MSVC programme to include international events and active monitoring of
news and social media. The monitoring system would use automated translations of news
feeds from multiple languages, sentiment analysis, Natural Language Processing (NLP) etc.,
This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
India



to identify and locate an incident in the public health domain. Thess data can be analysed
by public health experts and intelligence officers of the NEI and the threat assessed for the
Indian context.

The second level of the proposed NEI could consist of personnel trained to analyse output
of the first level. A mixed team of officers trained in epidemiology under the Indian EIS
programme, statisticians and public health officials would be needed for informed analysis.
The data gathered by IDSP can be used in conjunction with global digital monitoring at
this level. Inclusion of analysts trained in strategic studies would also be required at this
second level. The quality of analysis at this stage would improve if India has access to JEE
scores from WHO as well as medical intelligence on countries. It will be critical for the NEI
to develop an assessment matrix to judge an emerging threat – such a matrix can take into
account the nature of the threat, distance from India, probability of the threat entering
India, and transparency with which information about the threat is being shared.

The third level should consist of personnel trained to collect samples from distant locations
and infrastructure consisting of laboratories capable of analysing these samples. The
samples refer not only to biological specimens from individuals but can include
environmental sampling of soil, water, sewage, construction material etc. Some of these
laboratories might have to be located on foreign soil, as transporting samples contaminated
with a pathogen or chemicals over long international distances is risky as well as governed
by laws that prevent transport of certain biological entities across national borders. These
personnel could be specially trained individuals from NEI or India’s intelligence services.
Once the samples are received, the NEI could work with existing governmental
organisations to characterise the threat and get better understanding of the pathogen. This
characterisation is important to take coherent public health measures - as seen in COVID-
19, the suppression of the knowledge of asymptomatic transmission led to initial
underestimation of the disease’s spread. This step only requires to be done if the emerging
threat is caused by a novel pathogen, such as SARS-CoV-2.

Once the assessment is done, concerned agencies can be notified about the emerging
threat. This would include the MoHFW for public health measures, the Ministry of Home
Affairs for internal security measures if required, and global organisations such as WHO.

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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Takshashila Discussion Document: A National Epidemic Intelligence Service (NEIS) for
India



Data to be collected by NEI
The NEI’s primary role will be to monitor for emerging threats by looking at real-time data
on outbreaks. However, for assessing the threat in the Indian context, the NEI would also
need to maintain data on various health parameters for all countries. The following
categories of data are key inclusions for the NEI:

Medical intelligence - The knowledge of physical infrastructure, medical systems, and

general health statistics of the target country/region. This category also includes data on
life expectancy, disease burden, extent of vaccination etc. in a population of a country.
This also includes cultural or societal norms that can feed into public health. For example,
through COVID-19, countries which practiced mask wearing in public following previous
SARS exposure fared better than others.

This intelligence can help form the basis for prediction models, in case there is an emerging
public health threat in the target country. This intelligence can be gathered through
publicly available data and on-site reconnaissance, but does not include near-real time
information regarding an ongoing medical emergency.

Health system preparedness – this includes both, health monitoring systems – systems
involved in gathering of information on the state of general medical status of a
region/country and health surveillance systems – systems involved in gathering of
information pertaining to a particular medical event.

Biosecurity measures – this includes procedures designed to protect the population against
intentional exposure of harmful biological or biochemical substances. Measures such as
regular monitoring for disease outbreaks, restricted access to pathogens, monitoring of
supply chain of biological products and ratification of key international agreements to
control bioweapon proliferation signal a country’s preparedness to improve biosecurity.

Biosafety measures - procedures designed to protect the population against accidental

exposure of harmful biological or biochemical substances. This includes laboratory safety

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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India



measures, training of laboratory personnel and mechanisms of disposal of biological
products. This can be assessed by reports of laboratory incidents, violations reported by
institutions, and how strictly the country enforces its biosafety policies.

Data transparency - One key parameter that will influence the prediction of a biological
threat is the transparent sharing of data amongst countries. China has been alleged to
suppress the early dissemination of information on COVID-19, resulting in delayed public
health response. Not only did they not share data openly, doctors who tried to raise alarm
were censured.xvii Thus, the freedom of speech or state of transparency of media across
various platforms in a country is a key determinant of its handling of a health threat.
Countries with a history of information suppression should be treated with more caution
than countries which openly share information. xviii

Functions of the NEI

International situations
Monitor emerging threats to human, animal or agriculture, originating outside India. The
NEI would be responsible for flagging any emerging threats to the responsible agency in
India. Functions would include monitoring for news updates, social media accounts and if
required, retrieval of samples for further analysis in India. The NEI in collaboration with
existing agencies can recommend steps to avoid the spread of the threat to India.

Domestic situations
The quality of public health infrastructure is vastly different across different states in India.
The presence of both private and public medical facilities, concentration of medical
facilities in urban areas, the poor quality of record keeping, and low rate of follow-up by
patients makes it difficult to generate a situational picture of the medical state of the
nation. NEI would play a role in monitoring for unusual disease outbreaks and
collaborating with local governments to contain their spread.

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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India



Non-biological events
Medical emergencies can arise due to chemical, radioactive, physical agents apart from
biological agents. A monitoring system that is being proposed in this paper can be easily
employed in such scenarios.

Conclusion
We propose the formation of a comprehensive National Epidemic Intelligence service for
India that can monitor and assess emerging biological threats. Such a service can monitor
both domestic and international situations to feed data to existing public health systems for
preparing against potential biological outbreaks. We envision this data-based service to use
digital data to identify potential hotspots of outbreak, and if required deploy field services
to obtain samples for testing. An assessment based on the complete health and medical
intelligence provided for the country of outbreak can help gauge the actual threat to India.
Public health agencies can then make informed decisions to suspend travel or increase
healthcare capacity in a timely manner to counter the emerging threat.

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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India




References: -
i
Institute of Medicine. 2007. Global infectious disease surveillance and detection:
Assessing the challenges—finding solutions. Workshop summary. Global public health
surveillance: the role of nontraditional surveillance tools. Page 117. Washington, DC: The
National Academies Press.

ii
Centers for Disease Control and Prevention Global Health Protection and Security.
https://www.cdc.gov/globalhealth/healthprotection/stories/global-jee-process.html

iii
Ibid

iv
Global Health Security Agenda – Members https://ghsagenda.org/ghsa-members/

v
US Department of Health and Human Services.
https://www.phe.gov/Preparedness/biodefense-strategy/Pages/goals-and-objectives.aspx

vi
Centers for Disease Control and Prevention. Epidemic Intelligence Service
https://www.cdc.gov/eis/about/index.html

vii
Centers for Disease Control and Prevention. Epidemic Intelligence Service
https://www.cdc.gov/eis/what-eis-officers-do/how-we-serve.html

viii
Grant Robertson. “Health Minister orders review of pandemic warning system, concerns
raised by scientists”. 7th September, 2020.
https://www.theglobeandmail.com/canada/article-health-minister-orders-review-of-
pandemic-warning-system-concerns/

ix
Medical Corps International Forum (4/2011) Published 31 January, 2019.
https://military-medicine.com/article/3650-development-of-a-multinational-deployment-
health-surveillance-capability-dhsc-for-nato.html

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

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x
Cory Steig. “How this Canadian start-up spotted coronavirus before everyone else knew
about it”. 3rd March, 2020.
https://www.cnbc.com/2020/03/03/bluedot-used-artificial-intelligence-to-predict-
coronavirus-spread.html

xi
Grant Roberston. “Without early warning you can’t have early response”: How Canada’s
world-class pandemic alert system failed. 25th July, 2020.
https://www.theglobeandmail.com/canada/article-without-early-warning-you-cant-have-
early-response-how-canadas/

xii
India Epidemic Intelligence Service (EIS) Programme: Compendium National Centre for
Disease Control. 2018
https://www.ncdc.gov.in/WriteReadData/l892s/59619306901530697655.pdf

xiii
Ibid

xiv
Integrated Disease Surveillance Programme, National Centre for Disease Control,
Directorate General of Health Services.
https://www.idsp.nic.in/index4.php?lang=1&level=0&linkid=411&lid=3694

xv
Integrated Disease Surveillance Programme, National Centre for Disease Control,
Directorate General of Health Services. Data management-
https://idsp.nic.in/index4.php?lang=1&level=0&linkid=412&lid=3695

xvi
Ajai Shukla. “Government exhorts DRDO to revive work on biological defence
initiative.” 11th May 2020. https://www.business-standard.com/article/defence/govt-
exhorts-drdo-to-revive-work-on-biological-defence-initiative-120051101502_1.html

xvii
Coronavirus: The information heroes China silenced. 6th May 2020.
https://rsf.org/en/news/coronavirus-information-heroes-china-silenced

This document is prepared for the purpose of discussion and debate and does not necessarily constitute
Takshashila’s policy recommendations. To contact us about the research, write to
[email protected].

16