Category Archives: India

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Scaling up NTD treatment and prevention: India’s experience scaling up mass drug administration for lymphatic filariasis

India, lymphatic filariasis, NTDs

by Dr. P.K. Srivastava is the Joint Director – Nodal officer of Elimination of Lymphatic Filariasis Programme, Government of India

Of the more than a billion people in the world affected by NTDs, 34% live in India. This is in large part due to the number of people living in India at risk of being infected with lymphatic filariasis (LF).  India alone is responsible for 42% of the global burden of LF and 16 states and 5 union territories are endemic for the disease. Many factors make LF a challenge to tackle in India.  First, there is the wide geographic spread of endemic areas in a country with one of the largest populations in the world — from the tip of the subcontinent in Kerala to the reaches of the Sundarban mangrove forests in West Bengal. The demographic and climactic diversity is also a challenge — progress in rural areas may be offset by changes in the way urban populations respond to mass drug administration (MDA), MDA schedules may be interrupted by annual cyclones or floods, and subtle changes in the monsoon rains may change vector patterns.

India has a long history of addressing LF, beginning with a pilot project in 1949 that shaped global standards for elimination.  India started administering diethylcarbamazine (DEC) in highly endemic areas in 1955. The lessons from these early years informed the launch of a revised strategy in 1997 when India signed the World Health Assembly resolution to eliminate LF.  Three years later, the then health secretary Mr. Javid Chowdhary was appointed the chairperson of the Global Program to Eliminate LF (GPELF).  Mr. Chowdhary committed to launching a program that covered 40 million people at risk of contracting LF, beginning with 20 million people that year. In 2002, India set 2015 as a target for LF elimination in the National Health Policy.

The current strategy to eliminate LF was launched in 2004. Between 2004 and 2007, the program scaled up to reach 421 million people, achieving 100% geographic coverage, all 250 endemic districts[1]. Coverage rates started out high, at 73% on average across the country, and continued to increase, reaching 83% in 2007 and 88.8% in 2014. India has benefited from drug donations of albendazole, provided for all annual MDAs against LF.

This increase in national average coverage may not seem like much over the course of a decade, but consider the challenges faced: as annual MDAs continue, LF infections become less common, serious complications related to LF, lymphedema and hydrocele, become less visible in the community and young people may be less motivated to participate in the annual MDA.  Rigorous pre-testing prior to undertaking transmission assessment surveys also requires technical human and laboratory resources at the regional and state level- something that can be challenging in the mostly rural areas where the disease has traditionally taken hold.  33 districts have been identified as “hotspot” districts, where microfilaria rates remain high and programs have not been as effective at tackling LF. Still, the scale the program has achieved is remarkable.  This rapid scale would not have been possible without the lessons from earlier pilots, the strong political will demonstrated on national and global platforms, local technical expertise, and the existence of an integrated, multi-level health system.

India’s efforts to scale MDAs and tackle LF have proven successful.  Of the 255 endemic districts, 222 have microfilaria rates below 1%, qualifying them for transmission assessment surveys (TAS).  72 districts have already passed the first round.  Although the 2015 deadline for elimination has passed, it is estimated that a first round of TAS will be underway in all 255 endemic districts by 2017. The fight will not end there. There is more to be done to scale up community based and facility based morbidity management, and surgical options have to be made accessible and affordable for those who can benefit from them.  We will need to continuously monitor the situation to not only ensure success against LF, but also sustain deworming efforts once MDAs for LF end. Fortunately, India’s National Deworming Day initiative will scale up school and community based deworming for children as LF MDAs start to scale down.

Just as getting to this point has been as result of a coordinated effort of technical, political, and community based partners, the road ahead will depend on coordinated monitoring and surveillance, community-based support from civil society, NGOs, and village health workers, accommodations in the health system and political support to see LF elimination to the end.  India’s success impacts the global progress on NTDs and will be a model for other nations, and so we encourage you to check back with us at the end of 2017.

Dr. P.K. Srivastava is the Joint Director – Nodal officer of Elimination of Lymphatic Filariasis Programme, Government of India

[1] The number of endemic districts in now 255, due to geo-political realignment of state and district boundaries.

Lymphatic Filariasis: Why mainstream media must take note

India, MDA, NTDs, , , , ,

by Navneet Anand and Anuradha Singh, GreyMatters Communications

_M6A7431Recently Global Network for Neglected Tropical Diseases (GNNTD) partnered with us at GreyMatters Communications to run a media awareness program on Lymphatic Filariasis (LF) in India. We took a group of journalists to two affected villages in Odisha to provide them exposure about the problem as well as help them evaluate challenges towards its complete elimination.

The Global Network for Neglected Tropical Diseases, an initiative of the Sabin Vaccine Institute, works to raise the awareness, political will and funds necessary to control and eliminate neglected tropical diseases (NTDs).

Often falling beyond the purview of mainstream media, like many other compelling problems in the country, LF has severe enormity and has persisted in India as well as other countries of the world for many years.

Not many would be aware that LF is the world’s second leading cause of long-term disability. Although filariasis does not kill, it causes debility and imposes severe social and economic burden to the affected individuals, their families and the endemic communities. According to one estimate at one point in time 120 million people in 83 countries of the world were infected with lymphatic filarial parasites, and it was estimated that more than 1.1 billion (20% of the world’s population) are at risk of acquiring infection. Over 40 million people are severely disfigured and disabled by filariasis and 76 million are apparently normal but have hidden internal damage to lymphatic and renal systems. According to the World Health Organization, India, Indonesia, Nigeria and Bangladesh alone contribute about 70% of the infection worldwide.

Indigenous lymphatic filariasis cases have been reported from 20 States/UTs across 250 districts which were identified as endemic for filariasis with a population of about 600 million at risk. In India, a special program to eliminate lymphatic filariasis was launched in 2004 covering 202 endemic districts in 20 States/Union Territories and subsequently scaled up to cover all the 250 (now 255) endemic districts targeting a population of about 600 million.The population coverage during MDA has improved from 73% in 2004 to 83% in 2013, according to a document on National Roadmap for Elimination of LF by Ministry of Health.

It is rather heartening to note that the overall microfilaria rate has reduced from 1.24% in 2004 to 0.29% in 2013 (Prov.) at national level. Out of 250 districts 203 districts have reported overall microfilaria rate to less than 1%. Out of remaining 52 districts, 31 need high priority for focussed intervention as these districts have been persistently reporting microfilaria rate above 1%. Ganjam and Puri in Odisha, where we travelled, are also among the high-incidence districts in the country.

It was rather painful to come across two cases of Lakhender Swain and Kointa Swain in Kapileshwarpur village in Puri. Afflicted with this distressing disease, the two have wasted their most productive years attending to deal with this disabling disease. “I had a dream for my life but the tyranny of this disease was such that I was rendered helpless. For over 20 years now, I have lived with this heaviness in the leg and associated problems including social taboos and boycotts,” rued Lakhender, who is 45 only. Kointa, in her 60s, recalls how at one point she was extremely active and used to work “effectively” till destiny willed otherwise.

“NTDs like lymphatic filariasis hold people back not just physically, but also socially. Misunderstandings about what causes the disease, how it is transmitted and what its effects are can lead to stigma and social exclusion. This lack of understanding can cause communities to push LF patients to the margins, excluding them from employment or educational opportunities, from community festivals or celebrations and making it difficult to marry. The impact can go beyond the LF patient to also affect family members of LF patients. Self-stigma is also a problem and can impact a patient’s mental health. Social isolation compounds the impact of the infection, keeping people from trying to achieve their aspirations or have hope for the future. Although LF tends to be visible in rural and poor communities, LF is spread through mosquitos, like dengue and malaria, so anyone can be infected,” said Nandini Pillai, Programs and Operations Officer, GNNTD.

However, thanks to some serious and sustained intervention by the government as well as work by agencies like GNNTD as well as NGOs like CASA (Church’s Auxiliary for Social Action), the problem is well contained and India may well be on the verge of soon eliminating the disease altogether.

One of the key programs of the Government is Mass Drug Administration where all those at risk are administered medicine free of cost.

“The treatment is a weight-based dose of diethylcarbamizne (DEC), and a single pill of albendazole, to everyone over the age of 2 years and not ill or pregnant. Both drugs are anti-parasitic medications which prevent and expel parasites. These medicines also protect from intestinal worm infections. The treatment is safe and free and delivered to communities through ASHA workers and other community-based drug distributors. The drugs are donations from major pharmaceutical companies, like GlaxoSmithKline (GSK), or procured in India from WHO approved companies. They are completely safe,” informed Shaliesh Vaite, National NTD Advisor, GNNTD.

The 2015 MDA is underway nationwide from December 14-20.

The medical approach to defeating NTDs is through a set of medications donated by major pharmaceutical companies for free distribution to communities in need. “In India, state governments locally procure some medications and submit their requests for donated drugs to the central government, which then works with WHO to order and deliver the drugs. Community drug distributers are responsible for going door to door to hand out the drugs and ensure that people take them properly. This grassroots method for treating and protecting against NTDs takes the partnership of the whole community working in tandem, and ensures that nobody is left behind,” added Kelly Toves, Communications Officer, GNNTD.

Along with this, if media also undertakes to write more often and inform people about the ways to deal with this scourge, the process of elimination will be faster.

This post was originally published on Communicate, Connect.

Eliminating Lymphatic Filariasis in Odisha

elephantiasis, India, lymphatic filariasis, NTDs, , ,
ASHAs in Ganjam District, Odisha, India

ASHAs in Ganjam District, Odisha, India. Photo: Naveen Pun / Sabin Vaccine Institute

by Dr. Madan Mohan Pradhan

During the late 1990s, I was infected with lymphatic filariasis (LF), or elephantiasis, a neglected tropical disease (NTD) that can cause extreme pain, crippling disability and disfigurement. LF is one of 17 NTDs recognized by the World Health Organization (WHO) as a group of parasitic and bacterial infections, which primarily affect people living in extreme poverty.

The incident occurred after I completed my medical degree. I was eager to work in Odisha and help some of its most vulnerable and under-served communities. It was during this time that I began working on an LF project, making nightly visits to endemic villages to collect blood samples from fevered patients. I knew how LF was transmitted, but had limited knowledge on the preventive aspect. As is typical in most cases, I didn’t present symptoms until years later. When I saw my right foot swelling with redness and pain four years later, I immediately diagnosed the disease and took the full course of diethylcarbamazine (DEC) tablets. I was cured and never had a recurrence again. Though I was fortunate enough to stop the disease at an early stage, many are not as lucky.

During my tenure as a medical officer in rural Odisha, I saw a number of patients with LF. Many of them lived in the poorest communities, with limited resources and support from their families. Social stigma and discrimination, along with misconceptions about transmission of the disease, often made matters worse.

As we observe National Filaria Week from December 14 to 20, it is important to raise greater awareness about this disease, which threatens nearly 352 million people in India. It is particularly important to know the source of transmission of LF. It is not caused by a curse or deeds from a past life. And it is not hereditary.

Lymphatic filariasis is caused by a tiny parasite, which is transmitted by Culex mosquitoes. Globally, more than 120 million people are affected by this disease. People living in poor environmental and unhygienic conditions are vulnerable to the infection as the Culex mosquito breeds in these places. Most LF infected people may not have any symptoms and are found apparently healthy. But the LF parasite can be transmitted from these asymptomatic people to healthy people through mosquitoes. LF affects the lymphatic channels of the body due to which there occurs swelling of breast, lymph nodes, genital organs, and at later stage these swellings can result in disfiguration.

Although LF isn’t fatal, it can lead to disfigurement, disability and chronic pain. As a result, many people with LF are unable to make a living for themselves and their families. Social stigma and discrimination also limit the quality of life for those affected by LF. It is not uncommon for parents to be unable to marry off children with LF.

To facilitate greater progress in combating the disease, the WHO launched a global program to eliminate LF by 2020. They adopted the intervention known as mass drug administrations (MDA), in which two drugs — DEC and albendazole tablets — are co-administered in a single dose. These drugs are cost-effective and safe, and can be administered by trained community volunteers.

If more than 85 percent of the eligible population of at-risk communities consume the drugs once annually for five to seven years, the risk of LF infection will be minimal to zero. That is why the Indian government has prioritized efforts to eliminate LF through the National Vector Borne Disease Control Programme.

Besides the MDA, there are other components for LF elimination and morbidity management, including hydrocele operations. Government and non-profits are working to increase the knowledge and skill of LF-affected persons and family members on home care. For the success of both MDA and morbidity management, community involvement, participation from other government departments and active involvement of civil society organisations is essential. This requires high level political and administrative commitment and raising awareness through community participation

In Odisha, the MDA will be conducted on December 19, followed by two days of mop up rounds. Following 10 districts: Deogada, Boudh, Angul, Dhenkanal, Bhadrak, Jajpur, Jagatsinghpur, Nayagarh, Ganjam and Jharsuguda will be covered under 2015 MDA. During this time, drug administrators such as ASHA workers and other community volunteers, will make door-to-door household visits to administer the two drugs used in MDA. They will explain the safety and importance of taking the drugs and ensure that people consume drugs after eating; and monitor any adverse effects. If we continue our momentum and efforts in Odisha, we can eliminate LF within the next few years. Together, we can help create a filaria-free reality in Odisha and India.

Dr. Madan Mohan Pradhan is the joint director of health services for the National Vector Borne Disease Control Programme in Odisha, India.

This story originally appeared in the Orissa POST and the Political and Business Daily.

Eight Million Toilets and Counting

India, NTDs, WASH, , ,

By Alice Carter

world toilet day 2015Normally, we don’t like to talk about bathrooms. That is a private space that most of us would largely like to avoid thinking about. But on World Toilet Day, we give thanks for our sanitary facilities and celebrate the invention of the toilet, which has saved countless lives as a disease control mechanism, and gives us privacy to, you know, go.

There is a Sesame Street , a global “urgent run,” and an art show in New York. All of these types of events are celebrations for the often overlooked efficiency of the mundane technology that is a toilet, but also are opportunities to spread awareness of just how precious our access to toilets really is. One in three people around the globe don’t have access to adequate sanitary infrastructure, leaving them at increased risk for neglected tropical diseases (NTDs) that are spread through contact with fecally-contaminated soil. Half of the people who practice open defecation globally live in India, where 1.1 million liters of human excrement enter the Ganges River every minute. Recognizing the toll that open defecation takes on health, education and economic output, the government of India is trying to increase access to sanitation infrastructure and put an end to open defecation.

Prime Minister Modi has pledged that India will be open defecation free by 2019, and under his leadership the government has set up incentives for toilet construction and usage. Swachh Bharat Abhiyan — the Clean India Mission — is a sanitation campaign run by the Indian government, with the joint objectives of reducing open defecation and changing behavior to increase the use of sanitary facilities. Prime Minister Modi launched Swachh Bharat on Mahatma Gandhi’s birthday in 2014. The government also plans to raise Rs 3,800 crore (approximately 550 million USD) from the public to support this initiative, which gives subsidies for toilet construction and helps villages become certified as open defecation free. As of August 2015, 8 million toilets have been constructed as part of the campaign.

Unfortunately, it is tricky to measure the prevalence of open defecation and people’s toilet usage. Simply constructing a toilet in every home and school won’t make people start exclusively using toilets, especially if they don’t know the benefits of sanitation infrastructure and the risks of open defecation. For this, public awareness campaigns are also needed, and people need to be given plenty of reasons to use the toilet exclusively. One motivating factor for people to switch from open defecation to toilet use is awareness of the health risks of open defecation.

In communities that continue to practice open defecation, children playing outside or walking to school with no shoes can be exposed to contaminated soil, putting them at risk for infection by soil-transmitted helminths (STH). Similarly, clean drinking water sources and uncooked fruits and vegetables can be contaminated, increasing the risk of infection.

On the other hand, access to a household latrine has been found to reduce the risk of infection with STH by 40%. Nadia, a district in West Bengal, India, was the first district to be certified as open defecation free, and has since noted a decreased incidence of diarrhea and malnutrition. Reduced NTD infection is a strong indicator of the success of the Swachh Bharat campaign. Including an NTD indicator in Swachh Bharat would give the mission concrete targets to measure exclusive toilet use in communities where the campaign has built toilets, and it would help spread awareness of the negative health impacts of open defecation.

Perhaps on Gandhi’s 150th birthday, in 2019, India will have achieved its goal of ending open defecation. He would be proud, as he often stressed that a society’s approach to private and public sanitation reflects its commitment to true freedom and dignity.

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