India

Activities

Vector Control and IEC/BCC interventions
  • Health education
Summary

One of the barriers to effective vector control is the acceptance of IRS in the communities. In order to improve the uptake of IRS in India, KalaCORE decided to support the sensitisation of the community pre-IRS by delivering IEC/BCC interventions together with New Concept Information Systems.

Outputs

Large scale Information-Education-Communication and Behaviour-Change-Communication campaigns started in 2015 in 7 districts in Bihar to support IRS in districts where synthetic pyrethroid insecticide was being newly introduced. These were coordinated with the IRS micro-plan to raise public awareness prior to IRS delivery in the village. By 2016 more IEC/BCC interventions were developed and delivered in Jharkhand and West Bengal.

 

Such interventions have consisted of group communication sessions using films on Kala-azar developed especially for this purpose, information sessions with communities using flip books and leaflets, orientations of ASHAs and other community-level influencers and the display of KA posters at PHCs and in endemic villages. Also screening the kala-azar film in schools, using SMS Alerts and using public announcements and displaying information through mobile vans during IRS campaigns. More innovative approaches have been adopted to deliver IEC/BCC messages for VL in India, including engagement with Self Help Groups and training of female community members as sahelis to help educate, and refer suspected VL cases to diagnostic/treatment providers.

 

Data on IRS coverage and refusal rates at block and village level were not initially available.  KalaCORE together with NCIS collected this coverage data together with information on reasons for refusal, which then informed Behaviour Change Communication messages. Preliminary data suggests that the presence of IEC/BCC messages had a positive impact, with a reduction in IRS refusal rates and a general increase in IRS uptake by the whole community.

Monitoring anti-leishmanial drug sensitivity
  • Operational research
Summary

In parallel to pharmacovigilance, monitoring the susceptibility of Leishmania strains to anti-leishmanial drugs is key importance to achieving sustainable control.

 

In India, KalaCORE has worked with RMRI to set-up a national reference laboratory for drug susceptibility monitoring, assessing the susceptibility of Leishmania donovani clinical isolates to the standard anti-leishmanial drugs in current use. To ensure quality assurance of testing, cross-validation is currently underway. 

Studies to understand barriers and improve access to VL care and diagnosis by vulnerable groups
  • Operational research
Summary

Together with partners at the Foundation for Research in Health Systems, Epicentre and Mekelle University, KalaCORE conducted research in India and Ethiopia to understand how to improve access to VL diagnostics and treatment for vulnerable groups. As a first step the research aimed to describe real or perceived barriers of access to VL diagnostic services and treatment by vulnerable groups, from the perspective of community and health care providers; followed by investigating the reasons that create such barriers. Outcomes of this research aim at providing recommendations to improve access, with an emphasis on migrants and displaced populations in Ethiopia and female patients in India. 

Outputs
  • The study looking at gender barriers to care-seeking for visceral leishmaniasis in highly endemic districts in India is awaiting publication in spring 2019.
  • The study in Ethiopia has been published and can be accessed as following:

Coulborn RM, Gebrehiwot TG, Schneider M, Gerstl S, Adera C, et al. (2018) Barriers to access to visceral leishmaniasis diagnosis and care among seasonal mobile workers in Western Tigray, Northern Ethiopia: A qualitative study. PLOS Neglected Tropical Diseases 12(11): e0006778. https://doi.org/10.1371/journal.pntd.0006778

 

Research into insecticide resistance and insecticide rotation
  • Operational research
Summary

KalaCORE researchers teamed up with the Liverpool School of Tropical Medicine and Rajendra Memorial Research Institute of Medical Sciences to understand insecticide resistance mechanisms and methods of best practice to avoid the development of resistance. The researchers have looked specifically at different insecticides and the utility of an insecticide rotation strategy as a sustainable method of effective vector control.

 

Findings from this work (expected to be published after the end of KalaCORE) will provide an evidence base that guides the future use of insecticides deployed within India’s Integrated Vector Management efforts.

Enabling the uptake of liposomal amphotericin B across endemic areas – upgrading treatment centres and training for capacity building.
  • Case management
  • Training health workers
Summary

Objectives

  • 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
Outputs

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. 

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

Strengthening VL pharmacovigilance within the national VL programme
  • Improving surveillance
Outputs

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.

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

To improve access to care for women and vulnerable groups with VL in Bihar, it is first important to understand access. Objectives for this activity are:

  • 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 to central and state government facilities to build capacity, strengthen programme monitoring and build skills in epidemiology
  • Training health workers
Summary

To develop capacity of the public health system and integrate VL surveillance mechanisms and early response to outbreak, KalaCORE has been working towards integrated coordination between IDSP (Integrated Disease Surveillance Programme), the NVBDCP at the national level and the four VL endemic states of India.

Outputs

KalaCORE provided Monitoring & Evaluation and skilled Human Resources support into central and state government facilities for capacity building, middle management strengthening and programme monitoring.

 

  • By October 2016, seven M&E experts were seconded: one into the National Vector Borne Disease Control Programme nodal office in New Delhi, one M&E expert under the Jharkhand State Programme and five M&E experts under the Bihar State Programme.

Capacity and skills building of epidemiologists and surveillance officers, project management, monitoring and evaluation and data for decision making within the state level programme were also addressed via:

 

  • The development of training modules for state level epidemiologists and district surveillance officers
  • The delivery of in-state trainings to establish robust network of disease surveillance human resources within each endemic state, to ensure elimination.

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