- Continuous event monitoring and monitoring outcomes of treatment regimens during long-term follow up of patients.
- Monitor drug resistance in Leishmaniasis by establishing standardised techniques and sentinel surveillance.
To develop capacity of public health system to integrate VL surveillance mechanisms and early response to outbreak, KalaCORE is developing an integrated coordination project between IDSP (Integrated Disease Surveillance Programme) and NVBDCP at national level and four endemic states. This comprehensive project will be implemented by Public Health Foundation of India and will develop the capacity of health systems down to the block level to address early warning signs and facilitate an early and effective outbreak response.
During the reporting period, the ToRs of theM&E consultants within the national and the state programmes in India was finalised with the NVBDCP. We have now signed the contract with Public Health Foundation of India for the placement of 7 M&E consultants, one at NVBDCP and others at the state level. The mechanism for training state and district level epidemiologists and surveillance officers has been finalised.
The pharmacovigilance system is subject to a delay, and will be undertaken by WHO using a system that is integrated into the national pharmaco-vigilance system (PVPI). Overall, we expect that the completion time-scale of the project will not be affected.
Progress on the Continuous Event Monitoring (‘active’ pharmacovigilance) has been through comprehensive site assessments of seven candidate sentinel sites. These assessments will serve as the foundation for the implementation of the CEM project, and sites for which capacity building in weak areas, such as diagnosis of relapse cases, has been identified and solutions proposed.
The objective of this activity was to address the need for monitoring outcomes of treatment regimens by supporting the integration of pharmacovigilance into the national VL elimination programme in keeping with India's current overall pharmacovigilance system. By April 2017, KalaCORE handed over this activity to WHO India and the WHO Pharmacovigilance project that is solely dedicated to Pharmacovigilence.
In 2015, KalaCORE developed a study protocol to create “Continuous Event Monitoring” of treatment regimens (‘active’ pharmacovigilance) and undertook comprehensive site assessments of seven candidate sentinel sites (district hospitals of Saran, Samastipur, Godda, Vaishali, Motihari and Saharsa and Purnea). These assessments revealed weak areas for capacity-building, such as the diagnosis of relapse cases. Outputs of these site assessments fed to WHO India’s WHO Pharmacovigilance funded project at handover.
- 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.
To address gaps in knowledge about the epidemiology of VL in Ethiopia KalaCORE, together with the Armauer Hansen Research Institute (AHRI) conducted a ‘mapping of mapping’ exercise in 2015. This was published on the open access journal, Parasites and Vectors:
- Gadisa, E., Tsegaw, T., Abera, A., Elnaiem, D., Boer, M, Aseffa. A., Alvar, J. (2015). Eco-epidemiology of visceral leishmaniasis in Ethiopia. Parasites & Vectors, 381. https://doi.org/10.1186/s13071-015-0987-y
KalaCORE has also supported the retrospective data collection over the period from 2005 to 2016 to improve understanding on VL cases and mortality rates in the country and to guide needs for improved reporting and access to diagnosis and treatment of VL.
From 2016 two KalaCORE surveillance officers have been operating in Amhara and Tigray Regional Health Bureaus to strengthen surveillance supervision and outbreak response capacity. Joint assessments of hotspot areas for VL in these regions have been carried out in collaboration with VL focal persons within the Regional Health Bureaus (RHBs). Reporting has largely improved in Ethiopia, with all facilities in Amhara and Tigray region, which have the highest VL caseload, reporting within 3 months, at the end of the programme.
KalaCORE has also supported the identification and response to VL outbreaks or suspected cases by facilitating coordination and communication amongst partners. In collaboration with teams from the Ministry of Health and the WHO, KalaCORE has participated in outbreak assessments in endemic and non-endemic areas from the start and been involved in responses to potential outbreaks such as referring suspected VL patients and facilitating training to health workers at health 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.
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Strengthening of VL surveillance in Bangladesh started with input of national level experts closely reviewing the existent national HMIS surveillance system. The VL web-based system (linked to the national HMIS system) was updated integrating new VL surveillance forms. By April 2017, 91.3% of cases were reported from 84.2% of treatment centres via the VL web-based surveillance system. During this time, zero case reporting was also introduced in the VL web-based surveillance system, which is particularly important during the elimination phase of disease surveillance and for monitoring VL post-elimination. In collaboration and consultation with the communicable disease control (CDC), DGHS and the WHO, VL surveillance was migrated to the DHIS2 system and in 2018 all data were captured electronically (via DHIS2) on a real time basis. Before the end of the programme, tertiary care centres were also included within the DHIS2 system for Kala-azar reporting.
A training plan and specific guidelines for use of web-based VL surveillance were also developed. Training covered central level NKEP team members surveillance staff from upazila health complex (UHC) and also included "Training of Trainers" sessions with district level statistical assistants/statisticians.
By January 2016, five upazila Kala-azar Coordinators (UKC) supported by KalaCORE, were also recruited and seconded to endemic sub-districts. Each UKC started providing support on early detection of VL/PKDL cases and appropriate treatment but also prompt case reporting. UKCs continuously worked with upazila level surveillance teams (comprised of a Medical Officer, Nurse and a Statistician) to ensure timely reporting into the web-based surveillance system. The government has been working towards the creation of permanent posts to sustain high quality patient management beyond the timeframe of KalaCORE’s support. Key clinical positions have been agreed during this reporting period for handover to national bodies to ensure that they are continued in the long term.
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KalaCORE has developed vector control guidelines and drafted VL outbreak response strategies which are relatively advanced and well defined. The programme will be supporting the sustainability and evaluation of the national vector control strategy, and is pushing to finalise broader outbreak response strategies so that the vector control components can be evaluated and enhanced.
VL Surveillance and M&E Officers are currently in place within the national programme, and plans for capacity building for an outbreak investigation team within the national programme have been finalised.
Study areas are being selected for intensive monitoring & evaluation of Vector Control effects at district level as part of entomological capacity strengthening.
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.
KalaCORE developed comprehensive VL outbreak response and management guideline that also include vector control guidelines and IEC/BCC strategies for Kala-azar elimination programme in Nepal. By October of 2018, the Kala Azar outbreak assessment guidelines were approved and endorsed by the national programme and were incorporated into the National Guideline on Kala-azar Elimination Programme in Nepal.
Early into the programme, VL Surveillance and M&E Officers were put in place within the national programmes. Since the development of the Outbreak assessment guidelines, KalaCORE has led sensitization meetings to orient district rapid response team/outbreak response team members on the guidelines and strengthen the capacity of the health system at the district level on vector surveillance. By Oct 2018, another 46 vector control officers and entomologists have also been trained on sand fly collection and preservation to strengthen capacity of health systems during outbreak response. Outbreak investigation and response activities have also been conducted. By April 2018 these have included investigation and assessment of cases from non-endemic districts.
VL surveillance strengthening has been supported by KalaCORE in collaboration with the WHO. Nepal is currently using multiple reporting systems for VL. KalaCORE is working to improve the use and uptake of the Early Warning, And Response System (EWARS) for outbreak reporting and the District Health Information System 2 (DHIS2) for routine disease surveillance.
The deteriorating security context, remoteness of health facilities and difficulties in communication have been major obstacles to timely reporting of VL in South Sudan. Since the start of KalaCORE mobile teams have been providing training, health education and pre-positioning diagnostics and drugs and when needed have also been investigating and responding to reports of suspected VL cases or outbreaks in new sites. suspected cases. From 2016 onwards, KalaCORE’s mobile teams also started collecting retrospective data address VL data gaps.
KalaCORE has been advocating with the Ministry of Health and other stakeholders for strengthened reporting of VL cases An incentive-based scheme that encourages health facilities to regularly submit VL data, was thus developed and by April 2016, MoUs were signed with 6 health facilities and county health departments to begin its implementation. By October 2018, another 10 facilities joined the incentive scheme thus allowing for improvement of reporting.
The South Sudan team has also worked on drug supply-chain strengthening and improving drug surveillance where possible and KalaCORE has also supported the Ministry of Health through the provision of laptop, printer, communication gadgets (e.g. modems) and office furniture to improve on data collection and surveillance.
KalaCORE introduced DAT testing in the National Public Health Laboratory (NPHL) in Juba in 2017 in the attempt to reduce the lead time for sample processing. Staff in the reference laboratory were trained inconducting DAT testing procedure. They were provided with DAT equipment and supplies which include refrigerator, automatic pipettes and microtiter plates. The reference laboratory was also provided with the first batch of reagents. The staff in the health facilities were also trained in collection, storage, preservation and transportation of DAT samples and provided with filter papers.
Tents for admission of patients and basic equipment such as weighing scales, stethoscopes, thermometers etc, have also been distributed to centres in South Sudan and training of performance of RDT Rk39 and the diagnostic algorithm to identify the cases that will require DAT test.
In order to improve data collection and documentation, KalaCORE, along with WHO and the Federal Ministry of Health, first focused on updating the standardised surveillance tool for VL (included in patient files). Though reporting of VL was being done in KalaCORE-supported facilities, the quality of reporting was low and data collected often incomplete. With the help of trained personnel allocated in each health facility and the clinical mentoring teams, timely reporting on case data on VL and PKDL and stock reports increased across all KalaCORE health facilities.
To improve surveillance, two VL surveillance officers, one working nationally in Khartoum and one in Gedarif, were seconded through WHO. KalaCORE has also been collaborating with the WHO for introduction of an improved health information system – the District Health Information Software (DHIS2) – in Sudan, with a dedicated interface for VL. Roll-out of DHIS2 started in 2018 together with staff training in the use of the software and supply of equipment needed.
The Kala Azar Hotline has also supported of monitoring VL and assisting in the referral of VL/suspected cases. In response to considerable influx of refugees from VL endemic areas of South Sudan, in March 2015 KalaCORE conducted VL training in 2 clinics in White Nile camps. Following this training, the Kala Azar Hotline received an increasing number of calls regarding patients diagnosed with VL, allowing for emergency intervention to transport patients to treatment centres.