India

Activities

Vector Control
  • Health education
Summary

Indoor Residual Spraying

DDT remains the primary vector control agent in India, and stirrup pumps are used for spraying inside homes.

 

stirrup pump

The 3-year reactive spray cycle remains the government’s current policy, with indoor DDT spraying being carried out in all villages reporting cases of VL within the previous three years. Logistical issues such as lack of available protective gear, eroded spraying nozzles and patchy spraying of rooms have resulted in variable quality of IRS.  There are not enough Kala azar Technical Supervisors to monitor sprayer actvity and data on quality assessment and vector surveillance is not being shared among programme implementors. The Bill & Melinda Gates Foundation is now providing substantial funds to CARE India to work with state authorities to overcome these challenges.

 

The question of DDT ground penetration is also not yet being addressed by any research institution and remains a politically sensitive issue. There does appear to be an increasing openness to discussing alternative insecticides (as evidenced by the forthcoming pilot study of Synthetic Pyrethroid in Muzaffarpur, to be carried out by the Rajendra Memorial Research Institute (RMRI), Patna). 

Outputs

Large scale Information-Education-Communication campaigns have been conducted in 7 districts to support insecticide use and reduce the refusal rate by 10%. The data collected so far has not lead to any conclusive results. There was 73% coverage of Indoor Residual Spraying at the sub-district level but many confounding factors contribute to the difficulty of accessing the data, for example block and village level data is not available.

 

Because of the difficulty in accessing the data needed, there is now a plan to collect such data together with data on reasons for refusal, which can then inform future Behaviour Change Communication messages.

 

We are planning a small scale evaluation to assess the impact of KalaCORE supported behaviour change communication (BCC) interventions on treatment seeking behaviour and acceptance of indoor residual spraying (IRS) for visceral leishmaniasis (VL), in selected areas of West Bengal, Bihar and Jharkhand. The evaluation will measure the impact of NCIS’s behaviour change communication programme on refusal rates of IRS in order to assess progress against this indicator.

Supporting training of health workers, upgrading and implementation of liposomal amphotericin B across 33 districts in Bihar, 4 districts in Jharkand and 1 in West Bengal.
  • Case management
  • Training health workers
Summary

Objectives

  • Assessment of current 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
Outputs

The AmBisome roll-out was completed in 2015 and the proportion of VL cases treated increased to 67% in 2015.  The first 2 months of 2016 saw 67% of VL cases treated in Bihar and 98% treated in West Bengal. By the end of February 2016, 7517 patients have been treated with AmBisome.

 

There are currently 135 AmBisome treatment centres in four endemic states: 87 in Bihar, 15 in Jharkand, 3 in Uttar Pradesh and 30 in West Bengal. Of these, 85 centres in Bihar and Jharkand have been upgraded through the provision of ice-lined refrigerators and appropriate training. Re-training on cold-chain management has also been conducted.

 

To allow sustainable storage and distribution capacity at the state level a walk-in cooler, with secondary electricity back-up, has been installed at the state VBD office.  It has been working since the end of 2015 and has distributed 9820 vials onwards to the districts. The cooler is able to store 25,000 vials of AmBisome and has so far received 11,500.

 

Training of 1500 health workers (estimated 50% of targeted workforce).

 

KalaCORE has exceeded its target of training healthcare providers. 76 training sessions in Bihar and Jharkhand were conducted to train 2,223 healthcare providers (including 469 doctors, 897 nurses, and 857 pharmacists/ district Vector Born Disease consultants/others) on the management of KA, PDKL and VL-HIV.

 

In addition, KalaCORE provided training to health care providers in Uttar Pradesh (UP) and West Bengal. Training in UP was delivered in response to reports of an increasing number of VL cases in this otherwise low-endemic area. Follow up visits were made to all facilities within 2 months of training to assess retention and compliance with best practice.

 

Up to the end of the reporting period, over 6500 frontline health workers (ASHAs and Anganwari Workers (AWW)) were sensitised on identification of suspected Kala-azar/PKDL. 

 

Specific material was also shared with CARE for distribution within their established network of private doctors in preparation for the KalaCORE private practitioner training project.

 

Training of Trainers workshop for 15 key doctors from the 4 endemic states. These have now started to conduct training (one in UP and one planned for Bihar in 2016) showing continuity and sustainability.

Improve access to diagnosis, treatment and cross-border sharing of information
  • Case management
  • Improving surveillance
Summary

Objectives

  • Improve the existing VL case management regarding diagnosis, treatment and follow up along the Indian-Nepalese border.
  • Establish baseline data on VL patients' cross border movements.
  • Understand health-seeking behaviour of migratory VL patients
  • Develop mechanisms for further and sustained active cross-border collaboration of health authorities in the affected areas.
Outputs

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 trainings were delivered successfully, and as a result, treatment with AmBisome in Nepal is now well underway.

The AmBisome roll-out has 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.

Develop and implement passive pharmacovigilance within the national programme
  • Improving surveillance
Summary

Objectives

  • Develop pharmacovigilance for the national VL elimination programme in keeping with India's current overall pharmacovigilance system
  • Design a mechanism to enable safety signal detection and a feedback loop which will feed into the national VL programe
  • Standardise pharmacovigilance practice between India, Nepal and Bangladesh to enable all to benefit from best practice
Generate regional pharmaco-epidemiological data on long-term drug tolerability, treatment outcomes and drug resistance patterns.
  • Improving surveillance
Summary

Objectives

  • 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.
Outputs

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.

Improving equitable access to treatment within Bihar state
  • Health education
Summary

Understanding and improving access to care for women and vulnerable groups with VL in Bihar.

 

Objectives

  • Establish reasons for lower reported number of female VL cases at village, household and individual level
  • Improve attitudes of Accredited Social Health Activists (community health workers) and health care providers in terms of identification and referral of female patients with suspected VL
  • Based on Operational Research findings, work with the National Programme on Information-Education-Communication/Behaviour Change Communication strategies to improve access to care for female VL patients
Support central and state government facilities to build capacity, strengthen middle management and programme monitoring, and build skills in epidemiology
  • Training health workers
Summary
  • Seconding Monitoring & Evaluation and skilled Human Resources support into central and state government facilities for capacity building, middle management strengthening and programme monitoring.
  • Capacity and skills building of epidemiologists and surveillance officers, project management, monitoring and evaluation and data for decision making within the state level programme.
Outputs

Objectives

  • Second 1 M&E expert into the National Vector Borne Disease Control Programme nodal office in New Delhi.
  • Second 5 M&E experts under Bihar State Programme Officer.
  • Second 1 M&E expert under Jharkand State Programme Officer.
  • Develop on-going training modules for up to 40 state level epidemiologists and district surveillance officers
  • Conduct in-state training to establish robust network of disease surveillance human resources within each endemic state, to ensure eliminiation.
Validating and implementing active case detection strategies for post-kala azar dermal leishmaniasis and visceral leishmaniasis across highly endemic districts in Bihar and Jharkand.
  • Case management
  • Improving surveillance
Summary

Objectives

  • Validate and upscale index case detection and camp approaches for Active Case Detection of post-kala azar dermal leishmaniasis and VL.
  • Increase awareness of established incentives for Community Health Workers (Accredited Social Health Activist) and patients.
  • Training of Indoor Residual Spraying technicians to conduct active case detection for post-kala azar dermal leishmaniasis and VL.
Outputs

The active-case detection programme has begun its phase 1 roll-out in Bihar. Preparations (village mapping, approvals from government, liaising with district and block officials and training of front line workers) have been completed and field work has begun. In 3 days of "real" 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. We found 122 suspect cases of VL and PKDL.

 

We also introduced active-case searching through the Behaviour change communication (BCC) teams of New Concepts. Under this component the team from NC, after the Information Education Communication/BCC session (community group session), searched for any suspected VL or PKDL cases. This was done mainly through asking questions to the communities they interacted with, or by asking community health workers or other key people in the community. The teams have been able to identify more than 1,800 suspected cases of VL or PKDL, of which 211 were confirmed as VL and 35 as PKDL. These confirmed cases were then referred to PHC (via a referral slip). However, only 50% of these individuals went to the PHC for confirmatory diagnosis.  We are looking at ways to increase this proportion.