Directorate of National Vector Borne Disease Control Programme Directorate General of Health Services Ministry of Health & Family Welfare, Delhi (India)

Directorate of National Vector Borne Disease Control Programme

Directorate General of Health ServicesMinistry of Health & Family Welfare, Delhi (India)

Elimination of Lymphatic FilariasisCountry Scenario - India

India – Population at Risk of LF

RAJASTHAN

ORISSA

GUJARAT

MAHARASHTRA

MADHYA PRADESH

BIHAR

UTTAR PRADESH

KARNATAKA

ANDHRA PRADESH

JAMMU & KASHMIR

ASSAM

TAMIL NADU

CHHATTISGARH

PUNJAB

JHARKHANDWEST BENGAL

ARUNACHAL PR.HARYANA

KERALA

UTTARAKHAND

HIMACHAL PRADESH

MANIPUR

MIZORAM

MEGHALAYANAGALAND

TRIPURA

SIKKIM

GOA

A&N ISLANDS

DELHI

D&N HAVELIDAMAN & DIU

PONDICHERRY

LAKSHADWEEPN

EW

S

Endemic Districts Non-Endemic Districts

Endemic districts – 254(in 21 States/UTs)

Population at risk:600 million

Elimination of Lymphatic Filariasis in India

3

ELIMINATION OF LYMPHATIC FILARIASIS

Elimination of LF : LF ceases to be a public health problem, when the number of microfilaria carriers is less than 1% and the children born after initiation of ELF are free from circulating antigenaemia Goal:The National Health Policy (2002) has set the goal of Elimination of Lymphatic Filariasis in India by 2015.Global goal to eliminate Lymphatic Filariasis (LF) as public health problem by 2020 through World Health Assembly resolution WHA 50.29.

GPELF overall framework

Mapping MDAPost-MDA

surveillance1. MDA

2. MMDP

VC/IVM

Situationanalysis

Plan Minimum package of MMDP care

Situationanalysis

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MMDP and rehabilitation

integrated into health services

M&ETAS

Strategies for Elimination & Impact

1. Interruption of transmission by Annual MDA with DEC + Albendazole for 5 years or more to the population except: children below 2 yearspregnant women seriously ill persons

2. Home based management of lymphoedema cases and up-scaling of hydrocele operations in the identified CHCs / District hospitals/ medical colleges.

Lymphatic Filariasis

Impact of MDA

Scaling Down MDA• MDA to be stopped after minimum 5 rounds of MDA

with >65% compliance against total population at risk and districts reporting less than 1% mf prevalence

• WHO – 2011 guidelines simplified and capacity building initiated

• 4 core trainers at Puducherry during July’12• 139 state/district trainers during June-Oct’13• 59 from 14 districts of UP trained in June’14• 90 proposed in 2014-15 • 28 districts cleared TAS• 50 out of 62 completed Pre-TAS activity.

Anticipated to stop MDA after Nov-Dec 2015 and finish TAS by June 2016

Lymphoedema Management demonstration- Andhra Pradesh

Providing Morbidity management Kits

Washing Demonstration

Foot Exercise

Washing Demonstration

Lymphoedema Management demonstration- Odisha

1 – 100 Cases

101 – 500 Cases

501 – 1000 Cases

1001 – 2000 Cases

2000 & above Cases

Training & Providing Kits of Soap, Mug, Towel

Lymphoedema Management demonstration- Tamil Nadu

Lymphoedema Management demonstration - Madhya Pradesh

Training & Providing Kits of Soap, Mug, Towel

Providing Kits of Soap, Mug, Towel

Lymphoedema Management demonstration – Daman & Diu

Hydrocelectomy• Hydrocelectomy is usually done in CHCs, district

hospitals or medical colleges free of cost.

• Programme emphasises to intensify the hydrocele operations in camp mode for more operations

• The incentives to promote such activities are provided @ Rs.750 per case (US$ 12)

• Rs. 250 to Surgeon,

• Rs.50 to staff Nurse,

• Rs.50 to Ward Boy/Attendant,

• Rs.300 for medicine/dressing

• Rs.100 to the patient towards travel expenses.

• Some states pay more out of state resources but it varies from state to state

Incentivized morbidity management

1. Incentives for Morbidity Management• Rs 750 per hydrocelectomy (camp

approach)• Rs. 150 per Ly. Management Kit• Rs.200/- one time for line listing of

lymphoedema and hydrocele cases2. Financial Resources increased from

Rs 250 cr (XI Plan) to Rs 400 Cr (XII Plan) for total ELF including MDA, MM, TAS.

Hydrocelectomy Camp in Satna Distt of Madhya Pradesh

Two patients being operatedPatient being operated

GUIDELINES

Experiences• Tamil Nadu Model:

• Tamil Nadu initiated by providing morbidity management kit from state resources.

• Recently, Tamil Nadu has also approved to provide a monthly pension of Rs. 400 to grade-IV of lymphoedema patients.

• CASA model in Odisha: • In Khurda district of Odisha, CASA – a NGO has taken 3 blocks

and linelisted all the lymphoedema cases. • Engaged volunteers named as Task Force (1 per 20 patients).

CASA engaged 15 health workers (1 per 20 Task Force/Volunteers) at the rate of Rs.3000 per month.

• To monitor these health workers, four supervisors and one coordinator were engaged.

• Provided the morbidity management services to each and every lymphoedema patients and maintained a card to monitor the improvement in their suffering.

• CASA also helped during MDA programme of the district especially in IEC/BCC activities.

Experiences• Madhya Pradesh Model:

• The state provided morbidity management kit out of their own resources to the Lymphoedema patients.

• They also organised hydrocele camps in district hospitals with lot of social mobilization and awareness generation.

• Gujarat Model:

• Gujarat has very strictly observed the activity of updating linelisting the lymphoedema and hydrocele cases for 15-30 days in preceding months of MDA in each district.

• Mapped the prevalence of these cases village-wise. The morbidity management are provided to these patients and resources are mobilized according to the number of patients.

Experiences• Kerala Model:

• Kerala is known for presence of both W.bancrofti and B.malayi.

• Prof. Shenoy group has been providing home based morbidity management services to the patients and keeping their records for regular monitoring and assessing the impact.

• Dr.Narhari’s group at Institute of Applied Dermatology, Kasargode, Kerala is using Ayurvedic medicines combined with Yoga and getting the impact as per their reports.

• In addition, state is following the national guidelines of morbidity management but its monitoring needs strengthening at ground level.

Experiences

• There are some groups working on surgical repair, sculpturing etc. in Tamil Nadu which includes:

• Dr. Manoharan’s group at Chennai

• Dr. Sivasubramaniyan’s group at Settiarpatti, Rajapalayam, Tamil Nadu, India.

• Lepra India: working on Lymphoedema Management

- In two districts of Andhra Pradesh and Bihar each.

- After Line listing of Lymphoedema cases, they are classified and the Morbidity Management training are provided.

- Shoes are also providing from their project.

877,594 Lymphoedema cases line listed.

407,307 Hydrocele cases line listed

110,842 Hydrocele operated

350 non endemic districts line listing initiated

Involvement of CASA is appreciated and being expanded.

Major AchievementsMajor Achievements

• Social Mobilization for improved drug compliance and morbidity management.

• Supporting MDA and management of adverse reactions.

• Involvement of faculties from medical colleges, Research Institutions and Regional Directors (GoI) for monitoring and independent assessment

• Morbidity surveys and morbidity management for all patients individually and also at community level.

• Motivating people suffering from Hydrocele to go for surgical intervention.

• Involvement of NGOs/Voluntary organizations

Priority actions

• State Governments• Other Government Departments• NGOs like CASA, Lepra India, IAD-

Kasargod• Medical Colleges• ICMR-VCRC Puducherry; RMRC

Bhubneswar; RMRC Dibrugarh; CRME, Madurai

• NCDC• Drug donors• WHO

Partnership

Joint Monitoring MissionAction Points (1)

The Impact of last decade massive intervention is clearly visible in 2012 as follows:

a) Coverage generally improved (73% in 2004, 86% in 2012),

b) Microfilaria (mf) rate overall declined (1.24% in 2004, 0.45% in 2012),

c) The program is on right track except in few districts with sub-optimal coverage,

d) Phasing out MDA has started in 50 districts, 7 districts has cleared and 43 are in pre-TAS phase in 2014.

• States preparing for next round of MDA

• Completed 4 TAS workshops with WHO support

• Planned 6 more TAS workshops for district level officials

• 14 districts (IUs) and 21 IUs have successfully completed TAS

JMM Action Points (2)

• Districts >1% mf: MDA compliance should focus on poor-performing PHCs within the district for improvement and supplement vector control on IVM strategy with MDA

• Districts <1% mf: TAS to be performed to stop MDA with technical support by ICMR / WHO

• Efforts are on to improve compliance especially in poor-performing areas

• IVM is already in vogue and providing co-lateral benefits

• 96 districts are planned for TAS in 2014-15 out of which 55 have validated mf prevalence <1%

JMM Action Points (3)

• Provision of Lymphoedema management services at PHCs

• expansion of hydrocele operations at CHCs/ District Hospitals to be established under NHM.

• IEC/BCC to be strengthened to raise awareness

• Morbidity management to continue even after stoppage MDA – continued support is required

• Already emphasized in PIP guidelines

• Hydrocele operation at District Hospitals is regular phenomenon. Incentives are provided for camp approach.

• To strengthen IEC/BCC, flexibility for use of funds is provided.

• Yes it will continue

JMM Action Points(4)• Post MDA surveillance to be

performed as per guidelines – at least two TAS after every 2-3 years.

• Support to assess new (ICT) /additional (i.e. antifilarial antibody) diagnostic tools for surveillance and alternative surveillance strategies (i.e. xenomonitoring) to ensure the interruption of transmission.

• The “hot-spots” (with persistent high case burden) to be under intensive surveillance for treatment and interventions

• Post MDA surveillance draft National guidelines circulated Second TAS as per guidelines will be followed

• Still under multi-centric trial phase.

• The “hot-spots” are being covered under treatment and interventions. However, Independent Appraisal of ELF programme is also going on in 12 districts of 6 states and detail recommendations will be available in August.

Independent Appraisal• Independent Appraisal through ICMR (VCRC)• 1st briefing meeting on 20th June,2014• 1st phase field visit for secondary data from 1-3 July, 2014• 2nd Phase field visit for primary data from 14-26 July, 2014

S.No. Name of state Name of District

1 Bihar Muzaffarpur, Khagria

2 Gujarat Valsad, Surat

3 Madhya Pradesh Damoh, Panna

4 Odisha Ganjam, Khurda

5 Telangana Karim Nagar, Nalgonda

6 West Bengal West Medinipur, Bankura

Update on Independent Appraisal• Bihar :Governance at state/distt level is crucial but grass

root workers are aware and can improve• Gujarat : showing impact but coordination in corporation

and state Directorate needs attention for monitoring to tackle migratory population

• MP : Mf rate in certain blocks is high due to suboptimal performance

• Odisha : Priority affects performance in some areas (malaria is main priority)

• Telangana : high Mf rate in certain blocks reflects suboptimal performance

• West Bengal : Progressed well video conferencing from Director NVBDCP & MD to DC followed by letters has given priority in districts

04/18/23 ELF - PKS 30

04/18/23 ELF - PKS 31

State District No.Assam Dibrugarh, Sibsagar 2Bihar Begusarai, Buxar, Jahanabad,

Khagaria, Munger, Muzaffarpur, Saharsha, Shekhpura, Sheohar, Sitamarhi, Vaishali

11

Gujarat Surat 1Jharkhand Dumka, Goda, Lohardaga 3Karnataka Gulbarga 1Maharashtra Gadchiroli, Nagpur 2Telangana Nalgonda 1Orissa Ganjam 1Uttar Pradesh Banda, Barabanki, Faizabad,

Gorakhpur, Kheri, Sohanbadra6

West Bengal Bankura, Burdwan, Purulia 3Total 31

Hard core Districts

Hot Spot Areas identified for focused attention

• Assam –Tinsukhia, Karbi Anglong, Naugaon, Sonitpur (Tea estates & patchy population)

• Odisha – Sambalpur, Bolangir, Bargarh, Keonjhar, Kandhamal

• Madhya Pradesh – Narsinghpur, Shivpuri, Panna

• Gujarat – Surat migratory poulation

Way Forward1. Tackling Hard core Distt, Hot spot Areas &

Migratory Population ( Expert Panel)2. National TAS & Post TAS Guidelines draft

ready and to be printed for circulation 3. Phasing out MDA

• Transmission Assessment Survey using ICT in all districts (WHO to be requested for facilitating ICT supply)

4. Morbidity Management - Intensification5. Programme Appraisal 6. Sustaining Achievement through Post MDA

Surveillance7. Validation of Achievement 8. Elimination Certification

Thank YouThank You