Initially, KalaCORE procured the VL treatment drugs, sodium stibogluconate (SSG) and paromomycin, as well as rapid diagnostic tests and donated these to the Ethiopian Government. Supplies were then transferred to the Ethiopian Government’s Pharmaceutical Fund and Supply Agency (PFSA) who distribute them via established channels. KalaCORE has been providing technical assistance to forecasting supply needs.
Procurement of drugs and diagnostics and forecasting were gradually handed over to WHO from 2017. KalaCORE continued following up in the field with the clinical mentoring teams to ensure stock ruptures were averted.
Treatment: access and advocacy
In 2017, partly as a result of lobbying by KalaCORE, the Regional Health Bureaus of Amhara and Oromia committed to the provision of completely free hospital services and treatment of VL and co-morbidities for all VL patients. In 2018 this was also implemented by the Afar region.
- Assessment of facility capacity of all endemic districts in Bihar
- Support the training of health workers, upgrading and monitoring of health facilities to provide Single Dose AmBisome to up to 40 district hospitals and up to 100 Public Health Centres across 3 states
- Support the establishment of appropriate "cold chain" for use of Single Dose AmBisome
The roll-out of AmBisome in India was completed in 2015 and led to an increase in the proportion of VL cases treated to 67% in the same year. Within the first 2 months of 2016, increases in cases treated with AmBisome were already observed - at 67% of VL cases treated with AmBisome in Bihar and 98% treated in West Bengal. By April 2017, 100% of all reported cases were treated with AmBisome.
There are currently 169 AmBisome treatment centres in the four VL endemic states – Bihar, Jharkand, Uttar Pradesh and West Bengal. Centres have been upgraded through the provision of ice-lined refrigerators and appropriate training and re-training, or they have been relocated according to needs.
To allow sustainable storage and distribution capacity at the state level a walk-in cooler, able to store 25,000 vials of AmBisome was installed at the state VBD office. It has been working since the end of 2015 distributing AmBisome vials onwards to the districts.
Training Health workers
KalaCORE exceeded its target number of healthcare providers trained from early onto the programme. By the end of 2018, over 41,000 health workers have been trained in total and through a series of KalaCORE-supported trainings in the four VL endemic states of India.
Training sessions have had different formats and have addressed different needs. Over the years, trainings have taken place in conjunction with upgrades or initiation of new treatment centres. They have taken the format of classroom or hands-on training for medical officers, doctors, nurses and laboratory technicians, pharmacists and district Vector Born Disease consultants or others on the detection and management methods of KA, PDKL and VL-HIV. KalaCORE has also led “Training of Trainers” workshops for key doctors from the 4 endemic states to ensure continuity of training and sustainability.
Other training activities have aimed at boosting surveillance in the health system, by training Multi-Purpose Workers (MPWs) and district officials or by sensitising frontline health workers (e.g ASHAs and Anganwari Workers) on the identification of suspected Kala-azar/PKDL.
- Validate and upscale index case detection and camp approaches for Active Case Detection (ACD) of VL and post-kala azar dermal leishmaniasis (PKDL).
- Increase awareness of established monetary incentives for community health workers and patients, upon diagnosis of VL.
- Training of Indoor Residual Spraying technicians to conduct active case detection for post-kala azar dermal leishmaniasis and VL.
The ACD programme during KalaCORE was rolled out in three phases running over three years, respectively. Before field work began for the first phase roll-out in Bihar, necessary preparations were undertaken, such as village mapping, approvals from the government, liaison with district and block officials and training of front-line workers. During the first phase of ACD in 2016, and over the span of 3 days of field operations, 10 field teams (one person from IPE Global: India and one government staff member) covered 2760 households, equivalent to approximately 14,000 people. Most of the households were situated in very poor communities. 122 suspect cases of VL and PKDL were identified.
ACD activities have provided useful interim data on the duration of illness, PKDL, gender access to services and access of marginalised population. Lessons learnt from the first phase were used to shape the second phase of ACD which took place in 2017 (started in April 2017), and in turn lessons from the second phase were applied to the third ACD phase in 2018.
In conjunction to ACD, KalaCORE has tested and implemented other methods to increase VL case-detection in the communities affected and ensure sustainability of VL awareness in the communities:
- Case searching has also been conducted through the Behaviour Change Communication (BCC) teams of New Concept Information Systemsvia “lay surveillance”. Under this component BCC teams searched for suspected VL or PKDL cases, after health education group session in communities. This was done mainly via asking questions to the communities they interacted with, or by asking community health workers or other key people in the community. The teams were able to identify suspected cases of VL or PKDL and referred them to a Public Health clinic (PHC) for confirmatory diagnosis.
- KalaCORE piloted the “Kala Azar Mitra” (KAM) scheme, where former VL patients or individuals whose family members have been affected by VL, become dedicated champions known as Kala Azar Mitras. They engage in house to house searches for suspected cases of VL or PKDL and encourage diagnostic/treatment seeking. In the beginning of 2017, KAMs were active in 150 highly endemic villages in Bihar and Jharkhand.
- In 2018, KalaCORE initiated a new pilot programme with Community Based Resource Persons (CBRPs). CBRPs are women from villages in marginalized communities, also known as ‘Sahelis’ (friends) of the community, who are trained to be able to identify suspected cases (VL/PKDL) and facilitate access to diagnostic and treatment services.
KalaCORE coordinates with WHO and Epidemiology & Disease Control Division (EDCD) to assist with the training of health workers in the use of AmBisome, which arrived in Nepal in October 2015. These training sessions were delivered successfully, and as a result, treatment with AmBisome in Nepal has been well underway.
The AmBisome roll-out also resulted in an expansion in access to treatment by marginalised communities residing in difficult-to-reach VL endemic areas. Results of a recent analysis indicate that, within 90 highly endemic blocks in Bihar, all but 3 blocks were situated within 30km of the nearest upgraded treatment centre.
In the first instance, KalaCORE conducted Health Facility Assessments in 17 health facilities where the vast majority of VL patients are diagnosed and treated (Amhara, Tigray, Oromia and SNNPR). Results showed that some of the facilities needed support for improving the standard of care in the following critical areas:
- Stock management
- Strengthening laboratory and diagnostic capacity
- Upgrading services for high numbers of VL patients during the peak season
- Minor infrastructure work and provision of equipment to ensure quality care while MoH finishes upgrading health facilities.
Mid-term health facility assessment were also carried out half-way into the programme to further guide health facility strengthening.
Following assessments, KalaCORE has been undertaking rehabilitation or refurbishment of treatment centres and supported health facilities to meet quality criteria in a number of ways: from overseeing the roll-out and respective supply of drug treatments (SSG, PM, AmBisome) and diagnostics (e.g. DAT) and making basic equipment available in wards and laboratories, to ensuring the training of at least one member of medical and laboratory staff in the national standardized VL guidelines and SOPs, among others.
In 2017 KalaCORE started the instalment of two new VL wards in order to increase bed capacity and provision of VL treatment at the endemic states of Amhara and Tigray. The wards at the St Mary hospital in Axum and Addis Zemen hospital were launched in 2018.
At programmatic closure, KalaCORE has been supporting 22 VL treatment centres and 13 facilities diagnosis only centres. Coordination with the Ethiopian government and the World Health Organization (WHO) to form and execute plans has been instrumental to service provision in new and/or improved facilities.
To increase treatment compliance, KalaCORE first seconded clinical and laboratory staff to the Surya Kanta Kala-azar Research Centre (SKKRC) hospital. Soon after a Logistics and Supply Chain Management Officer was seconded to the NKEP to maintain a central database of drugs, diagnostic kits and associated logistics at UHCs. By April 2017, five Kala-azar Coordinators were seconded at the upazila health centre level to help improve the Kala-azar surveillance system via the improvement of patient reporting and outbreak investigation. A Data Management Officer also started functioning at the CDC, assisting the elimination programme by strengthening the existing surveillance system for reporting and patient follow up. In addition, an M&E manager was also appointed to support monitoring and evaluation who developed a complete M&E system of NKEP including a comprehensive M&E guideline for NKEP.
At end of the 2018, central level KalaCORE seconded staff (including a medical officer, a M&E manager and one supply chain manager were taken over by the national programme, while all KalaCORE supported staff at the SKKRC including nurse and laboratory technician by icddrb’d.
Please visit http://kalacorebd.com/component-1/ for more information.
Following a collaborative process of workshops and formation of a sub-committee, a guideline for Kala-azar outbreak management in Bangladesh was developed in 2016.
As per the guideline, an Outbreak Management Team (OMT) was formed at two levels: i) Central level team and ii) upazila level team. Training of the OMT quickly followed. Since 2016, the programme in Bangladesh has conducted a total of 34 training events involving central level CDC team for 121 upazilas/UHC level.
Since the formation of the OMT, a total of 11 outbreak investigations were conducted.
Please visit http://kalacorebd.com/component-3/ for more information.
By October 2018, KalaCORE has supported the training of a total of 10,263 health workers. A full review of available training materials was conducted at the beginning of programme implementation in Nepal, in order to identify and fill gaps in standard resources. Task-specific training has been provided to a range of health professionals – including frontline workers such as female community health volunteers, paramedics, clinicians and dermatologists working in both public and private health facilities in VL programme and non-programme districts.
Further training on active case detection has been provided to vector control and public health officers, including case-based surveillance strategies of VL & PKDL at district level.
In January 2015 KalaCORE together with IMA launched an emergency response for VL in South Sudan. Two mobile teams were formed and have since been conducting health facility visits to prove ad-hoc support to health facilities all over the country. Teams have travelled to inaccessible areas, often completing their journeys on foot.
KalaCORE has been supporting health facilities by procuring drugs and diagnostics, providing basic equipment and light refurbishment, and conducting clinical mentoring visits for health providers. Drugs capable for the treatment of VL patients have also been procured and distributed, with a buffer stock kept for rapid response.
As of October 2018, 46 facilities in VL endemic states have been actively supported by KalaCORE, including facilities re-activated and upgraded. In most facilities at least one person has been trained in the last year, rapid tests and first line drugs have been available with no stock ruptures in last 3 months and VL guidelines, SOP's have been present in treatment wards and laboratories operating at basic GLP standards in place.
Three clinical mentoring (CM) teams were formed in June 2017 for the provision of on-the-job training and mentoring on VL case management at health facilities, stock management and support for surveillance. CM teams have been instrumental to VL care delivery via supervisory visits. In addition to the training of health staff of multiple health cadres (e.g. medical, laboratory staff, pharmacists), reporting and checking drug stocks and supplies, CM teams have also actively encouraged community engagement through the training of health promoters and participation in activities like radio programmes on VL.
Comprehensive health facility assessments of 36 facilities in Sudan were conducted at the start of the programme in 2015 and results from these assessments were used to guide facility strengthening, provision of basic equipment, drugs and diagnostics and training plans.
By 2016, each of these facilities had received equipment and a key trained contact person was nominated. Meanwhile, 23 clinics began to provide decentralized VL services in camps for South Sudanese refugees and internally displaced persons (IDPs) in the White Nile, South Kurdufan, North Darfur and South Darfur states. Seven new treatment centres (4 in Red Sea state and 3 in Kassala state) were established by March 2018 and rehabilitation of 2 VL wards in Gedarif teaching hospital and in Gedarif paediatric hospital was also initiated.
By October 2018, each of the VL treatment centres supported by KalaCORE and WHO, had at least one person trained in the last year, rapid tests and first and second line drugs available with no stock ruptures in last 3 months, VL guidelines and SOP's present, wards and a laboratory with basic standards in place.
Health facility strengthening has been largely facilitated by the clinical mentoring (CM) teams and the creation of a “Kala-azar hotline”. The CM teams have been visiting facilities to give on-site training, bedside monitoring and help address drug and diagnostic kit supply gaps, while the “Kala-azar hotline”, accessible 24/7, provides advice via mobile phones and immediate support for health personnel managing patients under treatment to.
Also, of note was the establishment of the Kala-azar Research Centre (KRC) in 2016. It is the first such centre on VL research allowing for the formation of collaborations between the University of Gedarif (UoG)(Sudan) and the University of Gondar (Ethiopia). KalaCORE M&E activities and studies on understanding access to VL care have been conducted there.