Monitoring and Evaluation issues related to Preventive Chemotherapy

(LF and STH)

Dr. S. K. JainJoint Director & Head Department of Parasitic Diseases

National Centre for Disease ControlMinistry of Health & FW

India

NTDs in India

India has made considerable progress in the control/ elimination and eradication of the NTDs.• Guinea worm has been eradicated from the country

February, 2000. • Leprosy eliminated at National level (2005)• Yaws eliminated in September, 2006.• Moving towards LF and Kala Azar elimination

India- Population at Risk of LF

Endemic districts: 255 (in 21 States/UTs)Population at risk: 600 million

Population eligible for MDA – 509 Million

Indian Scenario• 54 million infected (45% of global)

• 30.9 million mf carriers and 23.4 million diseased

• 16 states and 5 Union Territories

• 255 endemic districts

• About 800,000 lymphoedema and 400,000 hydrocele cases line listed

5

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.

ELF Programme Programme initiated on a pilot basis

in 13 districts during 1996– 97 Gradually scaled up to reach all the

endemic districts DEC + Albendazole since 2008.

Strategies -

Interruption of transmission of filariasis by Annual MDA for 5 years or more using (DEC + Albendazole )

Morbidity Management Home based management of

lymphoedema cases

up-scaling of hydrocele operations

MDA Coverage vs Microfilaria Rate

Impact of MDA

2004 20130

50

100

150

200

250

76

203

142

3019

16

21

<1% 1-5% >5% Not Done

Nu

mb

er o

f D

istr

icts

Brief Roadmap200 Districts with <1% mf

rate

55 districts to reduce Mf Rate <1%

2012-13: 4 District cleared2013-14: 9 districts cleared2014-15: 15 Districts cleared & 40 in process2015-16: 100 Proposed subject to availability of 200,000 ICT Cards

Data analysis & Validation + surveillance

MDA and Data analysis

Validation through additional Mf survey

Antegenemia Test in Phased manner

2015-16 onwards:10% of distt may require MDA due to poor compliance & Remaining to undergo Post MDA surveillance for 5-6 years

TAS in India

• TAS successful in 28 EUs in Goa, Pondicherry, Daman & Diu, Tamil Nadu, Karnataka, Maharashtra, West Bengal and Assam

• Training of Trainers (TOTs) - National level and at four regional level at Maharashtra, Odisha, Tamil Nadu, and Karnataka (139 officers trained)

• Most of the endemic states are in the process of preparing plans for TAS after fulfilling pre- TAS criteria i.e. where MDA has been undertaken more that 5- 6 rounds, mf rates < 1% in the sentinel & spot check sites as well as population coverage > 65%.

Initiatives of the Programme related to M&E

Programme has taken necessary steps towards elimination • Development of National Roadmap towards LF elimination• Focussed approach in hot spots and districts still endemic for LF

Nationwide uniform campaign launched in 3rd week of Dec 2014 in twelve states

90 million DEC tablets received from WHO facilitating MDA in high endemic districts

Involvement of partners (GNNTD) in advocacy & media campaign

• Focussed approach in districts eligible for TAS 74000 ICT tests received from WHO 5-6 regional TAS capacity building workshops planned- Feb 2015 National roadmap Considering vast area in Preparatory

activities- In majority these were carried out, but the timelines have not been followed.

Initiatives of the Programme related to M&E

• National Vector Borne Directorate has undertaken joint monitoring mission (JMM-2014) through National & International experts

• Independent appraisal of ELF programme completed through WHO collaborating centre (VCRC) year July-Aug 2014

Lymphatic FilariasisJoint Monitoring Mission revealed :

• Overall performance in filarial elimination is satisfactory except Bihar where regular observance of MDA and commitment towards elimination are serious concern.

• Assam, Odisha and West Bengal are on right track • Tamil Nadu and Karnataka have almost achieved the

prevalence of Mf rate of less than 1%. • Uttar Pradesh has management problem like providing

70% of required DEC • Filaria officers and District malaria officers are doing the

job without coordination.

Lymphatic Filariasis -Recommendations

• Districts reporting more than 1% mf to Improve compliance

• Districts reporting less than 1% mf to do TAS• Post MDA surveillance as per guidelines with 3 TAS • Vector surveillance (i.e. xenomonitoring)• The hot-spots to be under intensive surveillance for

treatment and interventions• Provision of Lymphoedema management services at PHCs

and hydrocele operations at CHCs/ District Hospitals to be established under NHM

• Morbidity management to continue even after stoppage of MDA

Independent Appraisal-2014 in 6 states revealed:

• 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 after video conferencing between Director NVBDCP & senior state/ district officers followed by letters

Soil Transmitted Helminths (STH) in India

• Within SEARO, 64% of the children who require deworming in this region are from India, 15% from Indonesia and 13% from Bangladesh

• In absolute numbers, 157,498,685 school age children require PC in India

Lack of National Database on STH Prevalence

• India is endemic for STH • Vast country with diverse ecological zones and varying STH transmission dynamics • Limited STH data throughout the country (Few States like Bihar, Delhi and

Rajasthan have conducted independent surveys)• None of the current National or Sub-national surveys like NFHS, DLHS, AHS, NNMB

captures information on worm load. • Need to understand prevalence and intensity of STH infections to:

Guide treatment strategies. (annual / bi-annual / no )Assess impact of program.

• There are no national guidelines to ensure technically appropriate and standardized strategies for mapping STH in India.

………..there is an urgent need for a National database for mapping of prevalence of worm

infestation loads in India across all States/ UTs

STH prevalence survey (1972-1996)

STH prevalence survey 1999-2003

Deworming activities In India• 11 States providing Albendazole bundled in Vitamin A to <5 children bi-

annual rounds

• Albendazole under Lymphatic Filariasis programme – Annual Mass Drug Administration (MDA) of single dose of

Albendazole with DEC – For 5 years or more to the eligible population (except pregnant

women, children below 2 years of age and seriously ill persons)

• WIFS: Along with Weekly Iron Folic Acid Supplementation– Operational since 2012– Bi-annual deworming – to all 11- 19 yr school going adolescents girls

& boys and out-of-school adolescent girls

• Revised strategy under National Iron Plus Initiative, 2013- Children 1-19 years, women in Reproductive Age 20 – 49 years

• National Deworming Day 10th Feb 2015

Deworming

Recent survey

• In Jan 2015 among school children in a district Delhi

• Overall prevalence 30.96%. • The prevalence of single infection: 26.72%

(Ascaris), 1.9%(H.nana) & 0.76% (Trichuris) • None of the sample was found positive for

Ankylostoma. • All Ascaris positive samples had epg values

within the category of “light infection” (<5000 epg)

Monitoring Systems

• MDA programmes implemented to control soil-transmitted helminths (STH), are currently poorly monitored, and one of the main reasons for this lack of monitoring systems is the absence of a Plan of Action

• Work for National plan of action is currently underway• The is no National Programme for STH

– No sentinel sites– No data monitoring

• Whatever coverage data is available is through LF programme where Albendazole is being given along DEC

• As per last round of Deworming in Under-five children, the national coverage was 68.06 percent (data from LF programme for LF endemic districts)

Current update

• Series of meetings have been undertaken to address the STH related issues– Recently on 22nd Dec 2014

• Child Health Division, MoH is leading the deworming campaign

• Systematic coverage data & monitoring mechanisms to be laid down with National Plan of Action– Planned to be captured after introduction of National

Deworming Day 2015 (10th Feb 2015)

Thank you