Health Systems & Control of Neglected Diseases in Asia
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- Title
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Health Systems & Control of
Neglected Diseases in Asia - extracted text
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COLLOQUIUM
Health Systems
&
Control of
Neglected Diseases in Asia
ITM 3rd International
Colloquium
20 - 23 November 201 3
Bangalore, India
ABSTRACT BOOK
'ipk
THE BELGIAN
DEVELOPMENT COOPERATION •
ISO
Health Systems
&
Control of
Neglected Diseases in Asia
ITM 3rd International Colloquium
20 - 23 November 201 3
Bangalore, India
ABSTRACT BOOK
Conference Location:
Hotel Park Plaza, Bangalore, India
1: BOULANGERIE HALL (Satellite Network Meeting on 20 Nov)
2: BOULANGERIE HALL (Colloquium 2013 Inauguration on 20 Nov)
3: GRAND VICTORIA HALL (Colloquium Oral Sessions; 21 to 23 Nov)
4: GRAND VICTORIA (Registration and information desk; 20 - 23 Nov)
5: GRAND VICTORIA (IT corner; 21 to 23 Nov)
6: GRAND VICTORIA (Poster Exhibition Area; 21 to 23 Nov)
7: GRAND VICTORIA (Lunch, coffee breaks; 21 to 23 Nov)
8: BOULANGERIE (Welcome reception on 20 Nov)
9: ITM Alumni social event. (Participation on invitation only; Lawn area on 21 Nov)
1 0: GRAND VICTORIA (Gala dinner for all colloquium participants on 22 Nov)
Accommodation
Hotel Park Plaza
Hotel IBIS
Local Taxi Services
MERU
1
Table of Contents
Rationale,
3
Organising committee.
4
Scientific committee.
4
Supporting Agency.
4
Conference programme
5
Poster presentations.
10
Oral Sessions.
13
Oral Sessions.
21
Oral Sessions.
25
Oral Sessions.
35
Poster Exhibition
44
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Rationale
2013 Colloquium: a unique event in Bangalore
Together with our institutional partner the Institute of Public Health (IPH) in
Bangalore, ITM's Public Health department has been working hard to getthe 2013
Colloquium Health systems and control of neglected diseases in Asia (20-23
November, Bangalore) on track. Building on the shared expertise in health systems
research that the IPH-ITM partnership is known for, the Colloquium emerges as
another highlight in a strong track record. It promises to be a great event, for two
main reasons.
First, linking health systems and disease control is a deliberate choice of utmost
importance based on "the recognition that stronger health systems can enhance
the effectiveness of disease control programmes, and vice versa". The Colloquium
takes the systems-programmes tandem a step further, "investigat(ing) pragmatic
ways to maximise the mutual benefits". It thus offers researchers, policymakers and
programme officers a platform to debate common challenges, to update on the
state of the art of neglected diseases in terms of knowledge and practice, and to
optimise the interface between disease control programmes and national health
systems.
Second, the 2013 Colloquium is also unique in applying the widest possible but
well grounded scope to neglected diseases: infectious diseases of poverty. These
include the big three (HIV, TB, malaria), plus the 23 neglected tropical diseases,
plus (re)emerging diseases. Indeed, there is today enough evidence to state that
"infectious diseases are a proxy for poverty and disadvantage, affect populations
with low visibility and little political voice, cause stigma and discrimination, impose
a heavy health and economic burden, are low on many research funders' agendas,
have greater impact where health systems are weak, and burden caregivers and
families". There will also be contributions on non-communicable diseases of
poverty.
With sessions on the state of the art of neglected diseases in Asia, design and
evaluation of disease control programmes, the role of the private sector in disease
control, disease control and health systems strengthening, and disease control and
social determinants of health, the Colloquium is a firm step towards effective
disease control, strengthened health systems and hopefully health for all in a better
world. We are looking forward to it and will keep you informed!
3
Organising committee
• Narayan Devadasan
• Jitendra Panda
• Severine Thys
• Jan Boeynaems
Scientific committee
• Marleen Boelaert
• Narayan Devadasan
•
Bart Criel
• Werner Soars
•
Patrick Van der Stuyft
•
Upendra Bhojani
•
Prashanth NS
• Tine Verdonck
• Sahibi Hamid
• Suman Rijal
Supporting Agency
• The Belgian Development Cooperation
Website
• Colloq201 3.in
4
Conference Programme
Wednesday, 20th November 2013
10:30 - 1 6:30 Satellite workshop of the FAS Strategic Network on Neglected
Diseases and Zoonoses (on invitation only)
Session 1 - Inauguration
16:00-18:00 Registration
18:00-19:00 Inauguration
- Shri U T Khader - Hon'ble Minister of Health &
Family Welfare (Bangalore, India)
- Dr L S Chauhan, Director of the National Centre for Disease
Control (New Delhi, India)
- Prof Marleen Boelaert, Head of Department of Public Health,
Institute of Tropical Medicine (Antwerp, Belgium)
- Dr N Devadasan, Director of the Institute of Public Health
(Bangalore, India)
19:00 - 20:30 Welcome Reception
Thursday, 21st November 2013
8:30 - 12:45
Session 2 - State of the art of the control of neglected diseases
in Asia, part 1
Chair
Dr A C Dhariwal (NVBDCC, MoHFW, Govt, of India)
Co- Chair
Dr Ravi Kumar, (Central Health Services, India)
Key note speakers:
- Prof T Jacob John
(Christian Medical College, Vellore, India)
- Prof Suman Rijal
(B P Koirala Institute of Health Sciences, Dharan, Nepal)
Oral presentations:
Outbreak of Kyasanur Forest Disease in Karnataka, India. 2012
Kasabi Gudadappa
Diagnosis and referral practices related persistent fever
syndrome in Nepal
Surendra Uranw
5
Zoonotic TB in a resource poor African community:
A perceived or real risk?
Anita Michel
Long term Efficacy of Liposomal Amphotericin B the
treatment of VL in Bihar
Raman Mahajan
Added value of insecticide treated curtains to control dengue
in Cuba
Toledo Maria Eugenia
Progress in Lymphatic Filariasis elimination in India
Pradeep K Srivastava
12:45 - 13:45 Lunch & Networking
13:45 - 1 7:00 Session 3: Planning and evaluation in disease control Chair
Dr Subash Salunke (Indian Institute of Public Health,
Bhubaneshwar, India)
Co - Chair
Dr Katja Polman (ITM, Antwerp)
Key note speakers:
Dr Freddie Ssengooba (Makerere School of Public Health,
Kampala, Uganda)
Prof Guy Kegels (Institute of Tropical Medicine, Antwerp,
Belgium)
Prof Venkat Raman (University of Delhi, India)
Prof. Melissa Parker (Brunel University, UK)
Oral presentations:
Barriers in equitable control Schistosomiasis, China
Julie Balen
Added value of anthropological studies in
Neglected Zoonotic Disease control
Severine Thys
19:00 - 21:30 ITM Alumni social event (on invitation only)
6
Friday, 22nd November 2013
8:30 -11:15
Session 4: State of the art of the control of neglected diseases
in Asia, part 2
Chair:
Prof. Shyam Sundar (Banaras Hindu University, Varanasi, India)
Co-Chair:
Prof. Hamid Sahibi (IAV, Morocco)
Oral Presentations:
Latent infection with Leishmania donovani, Bihar, India
Ankita Chourasia
High parasite burden in Healthy individuals contribute to
progression of VL
Abhishek Kumar Singh
Replacement of indoor residual spraying to control Visceral
Leishmaniasis, Nepal
Murari Lal Das
Effectiveness of long lasting insecticidal bed nets in reducing
domestic sandfly density.
Adithya Pradyumna
Miltefosine in India and Nepal
Bart Ostyn
In vitro susceptibility of Leishmania donovani to Miltefosine:
promastigote assay
Vijay Kumar Prajapati
Prevalence of HIV-VI co-infections and long term outcomes of
co-infection patients with Liposomal Amphotericin B, Bihar,
India.
Deepak Kumar
Reemergence of El Tor variant Vibrio cholerae O1 causing
cholera epidemic during 2010 in the tribal areas of Odisha,
India.
Bibhuti Bhushan Pal
11:30 -12:45 Posters Presentations
12:45 -13:30 Lunch and Networking
7
13:30 - 1 7:30 Session 6: Control of neglected diseases and social
determinants of health
Chair:
Dr Sunil Nandraj (Public Health Foundation of India)
Co-Chair:
Dr Werner Soors (ITM, Antwerp)
Panel Discussion
Expert panel:
Prof Fran Baum (Flinders University, Adelaide, Australia)
Dr May Wejebe-Shanahan (Autonomous University of Yucatan,
Merida, Mexico)
Dr Devaki NambiarjResearch Scientist, Public
Health Foundation of India,New Delhi)
Dr Upendra Bhojani (Institute of Public Health, Bangalore)
1 9:00 - 21:30 Colloquium dinner - all Colloquium participants
Saturday, 23rd November 2013
8:30 - 12:45
Session 7: Control of neglected diseases and health systems
strengthening (HSS) in Asia
Chair:
Dr Krishna D Rao
(Public Health Foundation of India)
Co-Chair:
Prof Bart Criel (ITM, Antwerp)
Key note speakers:
- Prof Vi rasa kdi Chongsuvivatwong (Prince of Songkla
University, Hat Yai, Thailand)
- Dr Bruno Marchal (Institute of Tropical Medicine, Antwerp)
Oral presentations
Role of Village health workers in control of Visceral
Leishmaniasis, Bihar
Paritosh Malaviya
Active case finding strategy for TB case detection in urban
slum
Muralidhara Prasad
8
Vertical, horizontal, diagonal: the policy debate continues, but
where is the evidence?
Julie Balen
Integrating and adapting human resources at service delivery
level with national disease control programmes
Preetha Menon
Community level morbidity control of lymphedema using self
care and integrative treatment
AM Guruprasad
Unmet needs of health system for tackling Neglected Tropical
Diseases in Bangladesh
SS Rahman
Experience of Sputum collection and transportation in TB care
and control.
Muralidhara Prasad
13:00 - 14:00 Lunch & Networking
14:00 - 15:00 Session 8 - Closing session
Interactive feedback from the participants Concluding remarks
Prof Bruno Gryseels (Institute of Tropical Medicine, Antwerp)
Dr N Devadasan (Institute of Public Health, Bangalore)
9
21 st, 22nd & 23rd November 201 3
Poster presentations
Scrub typhus: a re-emerging and neglected disease of Rajasthan
J Rathore Singh
Where do PLHIV (People Living with HIV/AIDS) go and what do they prefer?
Engaging private providers in HIV/AIDS service provision in Tamil Nadu, India
Asirvatham Edwin Sam
Assessing maternal and neonatal tetanus risk in a tribal district of Odisha
Raveesha R Mugali
From clinics to community? Detection of ESBL producing Enterobacteriaceae
from community water samples in Cochin, Kerala
Sushma Krishna
Challenge of melioidosis in Cambodia
Ellen Maling
An Epidemiological investigation of Cholera outbreak in Poonamallee
Municipal area, Tamil Nadu, India, December^Ol 1 -January'201 2
Dhruba Mahajan
Is cash transfer program a viable option to support children affected and
infected with HIV?: Evidences from Tamil Nadu State, India
Asirvatham Edwin Sam
Molecular identification of Hookworm species in a Multi-Centric efficacy trial
across seven soil transmitted helminths endemic countries
Santosh George
An epidemiological study of drugs availability related to three infectious
childhood diseases: Where does the compass point?
Nayan Chakravarty
Morbidity and mortality of meningococcal diseases in Gaza Strip during 2012
Nedal Ghuneim
Syndromic approach to neglected infectious diseases (NID) at primary health
care level: an international collaboration on integrated diagnosis-treatment
platforms
Marleen Boelaert
Outcome of MDR-TB treatment at DOTS Plus site: A retrospective study from
Maharashtra
Shriram Vitthal Gosavi
10
Single and Multiple Species Helminth Infections and Associated Morbidity in
Hunan Province, China: Lessons Learnt and Implications for Integrated Control
Julie Balen
The effect of increasing private sector representation in a dengue fever
surveillance network on incidence rates
Melo F'urtado Kheya
Burden of diarrhea, hospitalization and mortality due to cryptosporidial
infections in Indian children
Rajiv Sarkar
Epidemiology and risk factors of cryptosporidial infections among children in a
semi-urban slum in southern India
Rajiv Sarkar
A ten year experience of PPTCT clinic: Can we strengthen our health care
system
Ravishekar N Hiremath
Vertical programs and health systems strengthening in India: Lessons from three
programs
Sudha Ramani
Prevalence and risk factors for soil transmitted helminth infection among school
children in south India
Deepthi Kattula
Patients' perception on available public health facilities and services for
lymphatic filariasis: a qualitative study in Odisha, India
Gupteswar Patel
Comparison of the effectiveness of two different health education strategies on
the utilization of Long Lasting Insecticide Treated bed Nets among the tribal
population of Chhattisgarh - A community based intervention study
Mehul Chourasia
Public Health Standards and Filaria Control in India: A Review
Pratap Kumar Jena
Water Supply, Sanitation and Hygiene
Practices in Hunan Province, China: Implications for the Control of Neglected
Diseases and Health System Strengthening
Julie Balen
Neglected Brucellosis: A community based explorative study in Odisha, India
Sarthak Sarathi Pattanaik
Clinico-epidemiological profile and management practices for snakebites in
Himachal Pradesh, India, 2008-2012
Anadi Gupt
11
An assessment of knowledge of prevention and management of Rabies in
interns and final year students of Shri M.P Shah Government Medical College,
Jamnagar, Gujarat
Amrita Sarkar
Role of NGOs and public health partnership to improve accessibility to health
entitlements in rural India
Ashley Mary Thomas
Lessons learnt from Kaladrug-R: New tools for monitoring drug resistance and
treatment response in Visceral Leishmaniasis in the Indian subcontinent
Marleen Boelaert
Comparative Evaluation Of Three PCR-Based Assays For The Diagnosis and
Genotyping Of Cutaneous Leishmaniasis
Hamid Sahibi
Role of private health providers in Tuberculosis control: Preliminary findings
from a qualitative research.
Vijayashree Holalkere Yellappa
12
" ^COLLOQUIUM
2013
State of the art
of the control of
Neglected diseases
in Asia.
PART 1
Oral Sessions
13
Outbreak of Kyasanur Forest Disease (KFD) in Bandipura national park,
Chamarajnagara district, Karnataka, India, 2012
Gudadappa S Kasabi, Manoj VMurhekar, Shivanna Reddy
Background: Kyasanur forest disease (KFD), a tick-borne hemorrhagic fever has
unique existence in five districts of Karnataka. In November 2012, we received
information from Bandipura National park, a tiger reserve forest in
Chamarajanagara district, about unusual death of monkeys and suspected cases
of KFD among forest-watchers. The district is not endemic for KFD.
Methods: We defined suspected case of KFD as sudden onset of fever, headache,
and myalgia among the staff of Bandipura National park since November 201 2.
We searched actively for suspected cases among forest-workers (n=400) working
in all 38 anti-poaching camps. Blood specimens from the suspected patients,
viscera from dead monkeys and tick specimens from forest were tested for the
presence of virus using RT-PCR. We collected and analyzed the data to describe the
disease by time, place and person.
Results: We identified six suspected case-patients (attack rate: 1 9/1000), four of
which were laboratory confirmed. All case-patients had conjunctival congestion
while two had vomiting, pain in abdomen and facial swelling. A total of nine
monkey deaths were reported from the park prior to the outbreak in humans. All
case-patients handled carcasses of dead monkeys with bare hands prior to their
illness. One out of three monkey
nkey viscera sent for laboratory test were found positive
for KFD virus by RT- PCR.
Conclusions: This was the first report of KFD outside the five endemic districts. The
cluster was associated with handling of dead monkeys. We vaccinated all the
forest-watchers with KFD vaccine and advised them to use tick repellents before
going to forest.
Keywords: Kyasanur forest disease, India, outbreak
15
Exploratory qualitative study on healthcare provider diagnosis and referral
practices in regard to neglected infectious diseases related to the persistent
fever syndrome in eastern Nepal
Uranw S, Hendrickx D, Thapa B, Chappuis Fz RijaI S, Boelaert M
Introduction: Febrile illness is one of the most common reasons for seeking
medical attention in Nepal. Both healthcare providers and patients face significant
challenges regarding the diagnosis and management of infectious diseases. We
set out to document current diagnosis and referral practices of healthcare
providers in relation to persistent fever syndrome (PFS).
Methods: We conducted a qualitative study consisting of observations, in-depth
interviews and focus group discussions with healthcare providers. This study was
implemented in primary healthcare centers and reference hospitals. Interviews and
focus group discussions were recorded and transcribed. Data was analyzed using
N/Vivo.
Results: Healthcare providers were not overly familiar with the term PFS, although
knowledge about associated symptoms and infectious diseases was good.
Symptomatic treatment was mostly practiced at primary healthcare level, while
reference hospitals employed a diagnostics-based approach. Limited diagnostic
facilities and high volume of patients were some of the factors underlying limited
diagnostic-based practices. No specific protocols were available for the diagnosis
and management of PFS. Only few PFS patients seem to be referred to a higherlevel for further diagnostic work-up and clinical management. Financial concerns,
community beliefs and folklore and delays in seeking care were an important
barrier to referral.
Conclusion: An improved understanding of the current diagnosis and referral
practices of healthcare providers is an important first step in developing and
introducing new clinical algorithms. There is a perceived need for a clinical
algorithm that would enable a systematic approach in diagnosis and case
management of PFS cases at the primary healthcare level.
16
Zoonotic tuberculosis in a resource-poor African community: A perceived
or real risk?
Musoke, J., Molefe, C.K., Michel, A.L.
Introduction: Both humans and cattle can be infected with either Mycobacterium
bovis or Mycobacterium tuberculosis For a comprehensive assessment of zoonotic
tuberculosis (TB) it is important to include all causative agents of tuberculosis
transmitted between humans and animals.
We implemented a study to assess the risk factors of bovine tuberculosis (BTB) in
cattle and zoonotic TB in a resource poor rural community in South Africa. The
study methods in phase 1 included a questionnaire survey among cattle owners
and non-cattie owners as well as a prevalence study of bovine tuberculosis in the
community's cattle population.
Preliminary findings include the first confirmation of Mycobacterium bovis infection
in 2 out of 1 5 communal dip tanks whereby the prevalence at animal level was very
low (0.34%). The proximity to the Greater Kruger National Park Complex, where
BTB is endemic in African buffaloes, was identified as a likely driver for the
presence of BTB. Our results further revealed that 95% of cattle in the study area
were of indigenous or mixed breeds; 93% of the livestock owners interviewed did
not introduce new animals from outside the community within the past year. The
relative stability of the communal cattle herd managed by small scale farmers in an
extensive farming system is considered an important contributor to the limited
spread of BTB in this area. Among the predominant risk factors for zoonotic TB
were the consumption of unpasteurised milk and the sale of milk to the community
by 36% of farmers.
17
5-Year Programme Summary And Long Term Efficacy Of A 20 Mg/Kg
Liposomal Amphotericin-B
Regimen
For The Treatment Of Visceral
Leishmaniasis (VI) In Bihar, India
Burza, S. Mahajan R, Mitra G, Lima MA
Introduction: Since 2007 with support from the Rajindra Memorial Research
Institute, Medecins Sans Frontieres has implemented a VL treatment project in a
highly endemic area for Leishmania Donovani in Bihar, India using 20mg/Kg
Liposomal amphotericin-B (L-AmB) as first line treatment. Crucially, existing
infrastructure and HR has been used in the PHCsto provide high quality care at the
community level.
Methods: Intravenous L-AmB was administered in four 5 mg/kg doses to a total
20 mg/kg to all patients with laboratory confirmed primary VL. Treatment was
administered at primary health center (PHC), district, or tertiary hospital over 4-1 0
days, depending on disease severity. Initial clinical cure was defined as
improvement of symptoms, cessation of fever, and recession of spleen immediately
following the last dose. An Excel-based database of the project was then analysed
forthe5-year period from September 2007 to August 201 2.
Results: A total of 8749 patients with laboratory confirmed primary VL was treated
over 5 years. 1 396 were treated at PHC, 6875 at district hospital, 31 4 at tertiary
hospital, and 164 at community camps. Initial clinical cure was achieved in 99.3%
(n = 8692), with 0.3% (n = 26) defaulting after initiation of treatment, and 0.4%
(n = 31) dying. 138 (1.6%) oatients represented with parasite confirmed relapse.
The mean (SD) time to relapse following completion of treatment was, 1.1 (0.8)
years. No significant difference in the initial cure and tolerance was 'observed
under different administration schedules.
Conclusions: This is the largest cohort worldwide of VL patients treated with 20
mg/kg L-AmB. It has very high initial and long-term efficacy and very low rate of
adverse reactions when administered under field conditions in Bihar, India. Its use
in the rural PHC setting has demonstrated that this is not necessarily a barrier to its
use. The timing of relapse suggests that 1 -year follow up may be appropriate in
future studies.
18
Added value of insecticide treated curtains to control dengue in a setting
with low Aedes infestation levels and an intensive vector control
programme.
Toledo ME, VanlerbergheV, Lambertl, Popa JC, BalyA, Abad Y, Van derStuyft P
Introduction: No evidence exists on the effectiveness of Insecticide Treated
Curtains (ITC) for reducing dengue vector dentistry in contexts of intensive
larviciding and adulticiding campaigns.
Methods: We set-up a cluster randomized controlled trial in urban Guantanamo,
Cuba. Twelve clusters (about 500 houses each) were randomly allocated to
intervention and control areas. In March 2009 under field routine conditions, we
distributed long lastin ITC (PermaNet®) in the intervention cluster. The routine
control programme continued its actions (regular house inspection, temephos
application and indoor and spatial cypermethrine spraying) in the whole study
area. We containers/1 00 houses) and evaluated the effect of ITC coverage on HI.
Results: At distribution, the ITC coverage (%of houses using e"l ITC) was 99.1 % in
the intervention areas (95%CI 97.7-100.0), with a median of 3 ITC/household.
After 1 8 month, the coverage remained 97.4%. The local Aedes species stayed
susceptible to deltamethrin (mortality rate of 99.7%) and the deltamethrin in the
ITC remained active (mortality rate of 73.1 %) after one year of use. Over one year
after distribution, the infestation in the control area was 1 1% higher than in the
intervention area (incidence rate ratio of 1.11 (95% Cl 0.70-1.76)), but this
difference was not statistically significant. The annual cost per household of ITC
implementation was 7.1 USD against 79.7USD for all routine control
interventions.
Conclusion: In an environment with intensive routine Aedes control actions, the
additional implementation of ITC did not achieve a significant reduction in Aedes
infestation levels.
19
Progress in Lymphatic Filariasis Elimination in India
SrivastavO'RK., Dhariwal, A.C. And Bhattacharjee, J.
Goal of elimination of Lymphatic Filariasis (LF) by 2015 was set in the National
Health Policy - 2002 document of India. The initiative taken so far towards
elimination programme through Annual Mass Drug Administration (MDA) has
started paying dividends. The improved MDA coverage from 72% in 2004 to 88%
in 2012 had led to reduction in overall microfilaria prevalence from 1.24% to
0.33% during the same period. As a result, out of 250 LF endemic districts, 1 86
have reported microfilaria prevalence of < 1 % during 201 2. However, suboptimal
drugs compliance has caused continuation of >1% microfilaria prevalence in
certain areas. Stepping further towards elimination, Indian Programme has
initiated conduction of Transmission Assessment Survey (TAS) as per WHO
guidelines-2009. Core trainers of the country were trained by WHO at VCRC,
Puducherry, India in July 201 1. The success achieved so far in India through MDA
is being validated through TAS in phased manner. So far TAS has been successfully
conducted in 2 districts of Goa, one each of Puducherry and Tamil Nadu. During
2013-14, process has been initiated for conducting TAS in 50 districts under the
programme.
Towards disability alleviation, the strategy of home based morbidity management
for Lymphoedema cases and surgical operation of Hydrocele cases were initiated
and progressively augmented. A total of 8, 77,594 lymphoedema and 4,07,307
hydrocele cases have been line listed from LF endemic districts. Surgical
intervention for Hydrocele is regularly done in endemic districts. Between 2004
and 201 2, a total of 1,1 0,679 hydrocele cases have been operated.
20
-I
COLLOQUIUM
2013
Planning
and
Evaluation
in disease
control
Oral Sessions
21
Control of Schistosomiasis in Hunan Province, China
Balen, J., Liu, Z.C., McManus, D.R, Paso, G., Utzinger, J., Li, Y.S.
Access to health care is a major requirement in improving health and fostering
socioeconomic development. In the People's Republic of China (PR. China),
considerable changes have occurred in the social, economic, and health systems
with a shift from a centrally planned to a socialist market economy. This brought
about great benefits and new challenges, particularly for vertical disease control
programs, including schistosomiasis. We explored systemic barriers in access to
equitable and effective control of schistosomiasis. Between August 2002 and
February 2003, 66 interviews with staff from anti-schistosomiasis control stations
and six focus group discussions with health personnel were conducted in Hunan
Province. Additionally, 79 patients with advanced schistosomiasis japonica were
interviewed. The health access livelihood frameworx was utilized to examine
availability, accessibility, affordability, adequacy, and acceptability of
schistosomiasis-related health care. We found sufficient availability of
infrastructure and human resources at most control stations. Many patients with
advanced schistosomiasis resided in non-endemic or moderately endemic areas,
however, with poor accessibility to disease-specific knowledge and specialized
health services. Moreover, none of the patients interviewed had any form of health
insurance, resulting in high out-of-pocket expenditure or unaffordable care.
Reports on the adequacy and acceptability of care were mixed. There is a need to
strengthen health awareness and schistosomiasis surveillance in post-transmission
control settings, as well as to reduce diagnostic and treatment costs. This study
contributes towards a growing multi-layered, in-depth understanding of barriers to
equitable and effective control, so that the ultimate goal of schistosomiasis
elimination in PR. China can be reached.
23
Added Value of anthropological studies in neglected zoonotic disease
control: Reports of three case studies
Thys S', Sahibi H2, Mwape EK3, Knobel D4, Rahali T2, Gabriel S5, Phiri A3, Van
Rooyen J4, Simpson G6, Lefevre P1, Boelaert M', Rhalem A2, Dorny P5 and
Marcotty T5
Forcalling attention to their effect on poor, marginalised communities, widespread
under-reporting and low prioritisation by national and international agencies, a
number of endemic zoonoses in developing countries (anthrax, bovine
tuberculosis, brucellosis, cysticercosis, echinococcosis, leishmaniasis, rabies,
zoonotic trypanosomiasis and foodborne trematode infections) have recently been
termed 'neglected zoonotic diseases' (NZDs). Although sharing characteristics
with the neglected tropical diseases (NTDs), many NZDs present unique control
challenges as they involve issues at the animal-human-ecosystem interface where
they inflict a dual burden on communities, compromising livestock health while
causing human morbidity and mortality.
To face these complex control issues, the "One Health" perspective emphasises the
need for inter-sectoral collaborations between actors in agriculture, medicine,
animal health, conservation and others in the social sciences, including
anthropologists, sociologists and economists. While the 'One Health' paradigm
recognises the importance of social and cultural factors in disease transmission
dynamics and the planning of control interventions, the significance and potential
role of applied anthropology for NZD control remains unclear.
Through three anthropological case studies, respectively assessing local
knowledge and perception of rabies in the Mnisi community (Mpumulanga, South
Africa), echinococcosis in the Amazigh population (High Atlas, Morocco) and
cysticercosis - taeniasis in the Nsenga ethnic group (East Province, Zambia), the
author attempts to reveal the complex relationships between different aspects of
the social and biological world at the transmission dynamics level and therefore
the potential contribution of applied anthropology for a more adapted and
effective control of NZDs.
24
^COLLOQUIUM
State of the art
of the control of
neglected diseases
in Asia.
Part 2
Oral Sessions
25
Latent infection with Leishmania donovani in highly endemic villages in
Bihar, India.
Chourasia A,Masker E, Kansal S, Malaviya P, Gidwani K, Picado A, Singh RP, Singh
AK, Shankar R, Menten J, Wilson ME, BoelaertM, SundarS.
Introduction: Asymptomatic persons infected with the parasites causing visceral
leishmaniasis (VL) usually outnumber clinically apparent cases bya ratio of 4-1 Oto
1. We describe patterns of markers of Leishmania donovani infection and clinical
VL in relation to age in Bihar, India.
Methods: We selected eleven villages highly endemic for Leishmania donovani.
During a 1 -year interval we conducted two house to house surveys during which we
collected blood samples on filter paper from all consenting individuals aged 2
years and above. Samples were tested for anti-leishmania serology by Direct
Agglutination Test (DAT) and rK39 ELISA. Data collected during the surveys
included information on episodes of clinical VL among study participants.
Results: We enrolled 13,163 persons; 6.2% were reactive to DAT and 5.9% to
rK39. Agreement between the tests was weak (kappa=0.30). Among those who
were negative on both tests at baseline, 3.6% had converted to sero-positive on
either of the two tests one year later. Proportions of sero-positives and seroconverters increased steadily with age. Clinical VL occurred mainly among
children and young adults (median age 1 9 years).
Discussion: Although infection with L. donovani is assumed to be permanent,
serological markers revert to negative. Most VL cases occur at younger ages, yet
we observed a steady increase with age in the frequency of sero-positivity and
sero-conversion. Our findings can be explained by a boosting effect upon
repeated exposure to the parasite or by intermittent release of parasites in infected
subjects from safe target cells
27
Higher Parasite Burden in Healthy (Asymptomatic) Individuals Contribute
In Progression of Visceral Leishmaniasis.
Singh AK; Sudarshan M; Chourasia A; Chakravathy J; Rai M; SundarS
Abhishek Singh Kumar, Department of Medicine, Institute of Medical Sciences,
Banaras Hindu University, Varanasi, Uttar Pradesh, India
In an area endemic for Visceral Leishmaniasis (VL), subclinical or asymptomatic
infections play a crucial role in progression of disease. We determined the parasite
load by quantitative PCR (qPCR) in healthy infected population living in an area
endemic for Visceral Leishmaniasis. We enrolled 13366 persons from 1 1 villages
of highly endemic region of Bihar, India. We conducted two sero- surveys with 1
yeartime interval for identification of incident infected healthy individuals. Parasite
load using TaqMan based qPCR were done on these sero-converted individuals
and its matched control populations. Individuals having parasite load greaterthan
1 genome/ml of blood was considered as positive by qPCR. Follow-up visit to the
homes of each individual were made to monitor the disease conversion in this
cohort. Agreements between seroconversion and qPCR were accessed by kappa
value. Total 235 persons had converted their serology within 1 2 month intervals.
Of these 235 sero-converters 1 05 (44.6%) individuals were also positive by qPCR.
However, similar number of control groups (87/ 237, 37%) also showed positivity
by qPCR. The agreement between sero-converter and qPCR was moderate.
Among all individuals only one had converted into disease that has parasite load
of 146 parasite genome/ ml of blood. These findings suggest the usefulness of
parasite load in healthy individuals living in an endemic area of Bihar and
contribute as a good tool for VL elimination programme.
28
Replacement of indoor residual spraying to control Visceral leishmaniasis
Das M L1, KumarV, Mondal D3
Introduction: Visceral leishmaniasis is a neglected disease transmitted by
Phlebotomus argentipes in 109 districts of India, Bangladesh and Nepal. In 2005
the three countries agreed to reduce annual VL incidence to 1/ 10,000 for its
elimination. Toward this set target, vector control will play a significant role.
Objectives:
• To compare the effectiveness of three different types of alternative of IRS.
• To measure the community acceptance of interventions.
Materials and Methods:
Study design: This study was a multi-centre cluster randomized trial with three
methods to control vector. The methods were Indoor Durable Wall Lining (IDWL)
containing deltamethrin, Indoor Wall and Floor Plastering with Lime (IWFPL) and
Impregnation of existing bed-nets (ITN) with slow release insecticide tablet
containing deltamethrin.
Entomological activity: 2 weeks before intervention and 4 weeks after intervention
sand-flies were collected for two consecutive nights by CDC light traps.
Results: Altogether 1 297 houses inhabited by 2858 male and 2830 female were
covered under this study. 1362 slept on floor but 4813 slept under bed net. In
comparison to base line data, IDWL, IWFPL and ITN reduced the vector density by
68%, 18% and 16% respectively. However in the control arms there was a
reduction of 12% without any intervention. Though, about 20 persons in each of
the group IDWL and ITN had suffered from headache, itching, burning sensation
efface and bad smell only 1 1 persons did not like the interventions.
Conclusion: Highest decrease in the density of Rargentipes was noticed by IDWL.
29
Effectiveness of community-level distribution of long-lasting insecticidal
bed nets in reducing domestic sand-fly density in the Indian subcontinent A systematic review.
Pradyumna A.
Visceral leishmaniasis (VL)Z with a prevalence of 2.5 million cases, is a major
vector-borne disease in the adjoining regions of north-eastern India, Bangladesh
and Nepal. As indoor residual spraying (IRS) showed limited success, newer
approaches such as long lasting insecticidal bed nets (LLIN) are being tested. This
systematic review on the effectiveness of LLIN in reducing domestic vector (sandfly)
density identified four relevant community-level intervention studies from the
Indian subcontinent, all of which were published in 2009-2010, and were of
acceptable quality. A narrative synthesis was performed (meta-analysis was
unfeasible), with simple transformations of results to facilitate inter-study
comparison. All four studies reported a relative reduction in sand-fly density on an
average between 31.9% and 59.7% in LLIN houses when compared with controls,
though reduction levels were not consistent. Reductions were reported as early as
one month and as late as 1 8 months post intervention. Two of the included studies
also compared LLINs with IRS (which showed relatively greater reduction in vector
density (63.6-72.4%)), and environmental measures (liming of walls) (which
showed relatively lower reduction (26.8-42%)). No peri-domestic increase in
sandfly density was reported following LLIN use, ruling out vector displacement. It
was perceived as useful by over 50% of the community even six months post
distribution. This review established that use of LLINs reduced domestic sand-fly
density when implemented at community level, but its usefulness in reducing VL
incidence needs further regional research as one follow-up study reported no
reduction in VL incidence despite reduced vector density with LLINs.
30
Risk factors for relapse of visceral leishmaniasis after initial cure with
miltefosine in India and Nepal.
Ostyn B, Masker E, Dorio TPC, Rijal S, SundarS, Dujardin JC, BoelaertM.
Background: High incidence of relapse in miltefosine-treated patients in India
and Nepal followed up fortwelve months.
Methods: in a prospective study in seven health care structures in India and
Nepal, we collected data from 1 01 6 VL patients treated with miltefosine according
to the standard treatment guidelines and recorded early and late treatment
outcomes up to 12 months after the end of treatment. We investigated patient and
treatment characteristics associated with VL relapse.
Results: Clinical records from 78 relapse patients were compared with those of
775 patients who had no record of subsequent relapse. Relapse was 2 times more
common amongst men compared to women (IRR 2.1 4, 95% Cl 1.27-3.61), and 2
to 3 times more frequent in the 2 age groups below 1 5 compared to the over 25
year olds (Age 1 0 to 14: IRR 2.53; 95% Cl 1.37-4.65 and Age 2 to 9: IRR 3.1 9 ;
95% Cl 1.77-5.77). Previous VL history, or clinical presentation at time of
diagnosis such as duration of symptoms or spleen size were no predictors of
relapse.
Conclusions: Age and gender were associated with increased risk of VL relapse
after miltefosine, suggesting that the mechanism of relapse at the current stage is
mainly immunological and that the observed increase of relapse may be partly
explained by the inclusion of younger patients compared to the earlier clinical
trials, ratherthan a decrease in efficacy of miltefosine.
31
In vitro susceptibility of leishmania donovani to miltefosine in Indian
visceral leishmaniasis: Promastigote assay
Prajapati VK, Sharma S, Rai M, Ostyn B, Salotra P, Vanaerschot Mz Dujardin JC and
SundarS
Promastigote miltefosine (MIL) susceptibility was performed on Leishmania
donovani isolates from Indian patients with visceral leishmaniasis (VL) treated with
MIL. Isolates that were obtained before the onset of MIL treatment, after
completion of treatment (29th day), or at the time of fail were screened using in
vitro promastigote assay. The MIL susceptibility of the pre-treatment isolates
(n=24, mean IC50±SEM = 3.74±0.38/jM) was significantly higher than that of
the post-treatment group (n = 26, mean IC50±SEM = 6.15±0.52pM;p =
0.0006) but was found to be similar between the cure (n= 22, mean IC50±SEM
= 5.58±0.56^M) and treatment failure group of isolates (n= 28, mean
IC50±SEM = 4.53±0.47/jM). The pre/post-treatment results thus showed a
hardly 2-fold difference while cure Vs fail samples showed a similar susceptibility,
suggesting that this higher tolerance is not responsible for MIL-treatment failure.
Our work highlights the need for careful monitoring of MIL susceptibility for
implementation in national VLelimination program.
Dr Vijay Kumar Prajapati, Department of Biochemistry, School of Life Sciences,
Hemwati Nandan Bahuguna Garhwal University, Srinagar-Garhwal, 246174,
Uttarakhand, India
32
Prevalence Of HIV-VI And Long Term Outcomes Of Co-Infected Patients
Treated With 20mg/Kg Liposomal Amphotericin B In Bihar, India.
Burza, S. Mahajan R, Mitra G, Lima MA
Introduction: MSF has treated over 10000 VL patients using 20mg/Kg L-AmB in
Bihar since 2007, a state estimated to have an adult HIV prevalence of <0.28%.
Although MSF does not provide ART, HIV-VL co-infections have been recognized as
a high-risk group for both relapse and mortality afterVL treatment. This abstract
presents the field condition outcome of all co-infected patients treated from Jul
2007 until Aug 2012, and provides evidence of HIV prevalence in patients
presenting with VL in Bihar.
Method: This was a retrospective database analysis using routine program data.
MSF follow up is both passive (e.g. relapsing patients who self-present) and active.
The range of time since completion of initial treatment ranged from 3 months to 5
years.
Results: From Jul 2007 to Aug 2012, 161 patients had been diagnosed with HIVVL co-infection. 83.2% of who were male, with a mean age of 36.5 yrs (SD 10.4).
41% (n=66) patients presented with a history of VL relapse. No patients had initial
treatment failure after receiving 20mg/kg L-AmB. Of 1 61 patients followed up at
the end of 2012, 25 (15%) were not traced. Of these 25, only 7 had no record of
any passive or active follow up following discharge. Mortality at 0.5, 1,2, 3, 4 and
5 years afterVL treatment was estimated as 1 4.4, 1 9, 22.5,28.5, 28.5 and 59.1 %
respectively. Probability of relapse was 4.6, 16.6, 28.5, 28.5, 37.2 and 52.9%
overthe same time periods respectively.
From Mar 201 1 to Dec 2012, MSF offered VCT to all patients e"l 4 yrs diagnosed
with VL and unknown HIV status. 1 535 patients were eligible for VCT, of whom
1519 were offered VCT. Of these >99% accepted VCT. 3.4% of these tested
positive for HIV.
Conclusion: This is the biggest cohort of HIV-VL co-infected patients treated in the
Indian subcontinent. Both national HIV and VL programs are yet to acknowledge
the importance of co-infection or to develop appropriate guidelines and VCT is not
currently recommended for all VL patients. The 1 1 times higher prevalence of HIV
infection in patients presenting with VL, together with the high mortality and relapse
rate compared to immune-competent patients suggests this is an emerging issue
that needs to be addressed.
33
Re-emergence of El Tor variant Vibrio cholerae O1 causing cholera
epidemic during2010in the tribal areas of Odisha, India.
Pal B.B., KarS.K., Khuntia H.K., Achary K.G., and Khuntia.C .R
Background: The epidemics of cholera were reported in the Kashipur, K.singhpur,
B cuttack blocks of Rayagada district and Mohana block of Gajapati district of
Odisha during 2010. The present study was carried out to isolate the bacterial
pathogen, its drug sensitivity pattern and to describe the spread of the disease in
those areas.
Methods-A total of 68 rectal swabs collected from severe diarrhoea cases
admitted to different health centers and diarrhoea affected villages were
bacteriologically analyzed. Similarly 22 water samples collected from different
villages from nala, chua, etc were tested for the presence of V cholerae.
Results- Out of 68 rectal swabs tested 35 (71.4%) were V cholerae O1 Ogawa
and 14(28.6%) were E coll; whereas all water samples were negative for V
cholerae. All V cholerae strains were sensitive to gentamicin, norfloxacin,
ciprofloxacin, azithromycin and ofloxacin; but were resistant to ampicillin,
tetracycline, nalidixic acid, furazolidone, streptomycin, erythromycin, cotrimoxazole, neomycin and chloramphenicol.
Discussion: All V cholerae strains were 100% resistant to tetracycline and they
were El Tor variants harboring ctxB gene of classical strain which is the first report
from this state. The date wise spread of the disease is described in the worst cholera
affected villages of Kashipur, K.singhpur and B.cuttack blocks of Rayagada
district. Conclusions- The present study indicated the reemergence of El Tor
variants of V cholerae strains in the same tribal areas with altered antibiogram after
a gap of three years;, and its spread in the tribal areas which needs close
monitoring.
34
<
^COLLOQUIUM
W 013
Control of neglected diseases
and health systems
Strengthening (HSS)
in Asia
Oral Sessions
35
Role of village health workers in control of visceral Leishmaniasis, Bihar"
Paritosh Malaviya; Epco Masker; Rudra Pratap Singh; Jean-Pierre Van
Geertruyden; Marleen Boelaert; Shyam Sundar
Introduction: In India visceral leishmaniasis (VL) elimination initiative faces some
major shortcomings in monitoring of treatment and treatment outcomes which
could be addressed by involving village health workers (VHWs). We reviewed the
random periodic surveys for recording treatment outcomes and assessed the
willingness and preparedness of VHWs in relation to VL for their involvement in VL.
Methods: Records of 1 50 randomly sampled patients from PHCs of Muzaffarpur
district were examined. Both patients and physicians were interviewed using two
specific questionnaires. Costs of this survey were properly documented and vehicle
log books were maintained. Randomly sampled 200 7HWs were interviewed to
explore their knowledge on signs and symptoms, transmission, diagnosis and
treatment of VL and TB and willingness to become further involved in VL control.
Results: After all efforts 1 1 patients were untraceable due to erroneous recording
of patients' characteristics and addresses at the PHCs. Per patient follow-up cost
was USS 15.51. Total human resource involvement costs 75% whereas
involvement of physician costs 51 %.
VHWs know the symptoms and diagnosis of VL and TB but not the recommended
first-line treatment and treatment administration. They are involved in TB control
but not in VL control. They are organized, linked to the PHCs and ready to get more
involved in VL control. They require proper training and demand monetary
incentive to compensate forthe additional workload.
Conclusion: A random survey to document clinical outcomes is costly and labor
intensive. A health service based retrospective quarterly cohort monitoring
developed by tuberculosis program could be a better alternative.
37
Active case finding strategy for tuberculosis case detection in urban slum
Banuru Muralidhara Prasad, Srinath Satyanarayana, Sarabjit Singh Chadha,
SubaratMohanty, Anand Das, Mohammed Ubaid.
Background: Active Case Finding (ACF) strategy is a cross sectional house-tohouse survey among high risk community groups to identify TB symptomatics and
provide treatment. ACF in Tuberculosis is an emerging strategy and The Union
with its partner conducted an ACF survey in Agra slum population by engaging
volunteers to inform communities about TB care and control. During the survey,
person with TB symptomatics were referred to nearest designated microscopic
centres (DMCs). Volunteers were entrusted to follow-up on referrals made.
Results: In the survey population 91% had heard about TB, and among the
households reached, about 1 7 households had one of their family members who
had TB. Through ACF, 400 TB symptomatics were referred from 3940 households
and 7 were found to be positive for sputum examination (3 male, 4 female).
Conclusion: Stigma about TB is still prevalent in the community though awareness
levels were high. Low positivity rate in study, reflected on systems acceptability to
strategies like ACF when the programme target of respective DMC was achieved.
Health system staff expressed the limitation in availability of reagents, manpower,
medicines, etc for such activities. The experiences highlight need for system
strengthening to conduct ACF - within the framework of Universal Healthcare
approach in areas particularly for marginalized and vulnerable populations.
'Sekandi JN, Neushause D, Smyth K and Whalen CC (2009) Active case finding of undetected
tuberculosis among chronic coughers in a slum setting in Kampala, Uganda, International Journal of
Tuberculosis and Lung Disease, Vol 13 . No 4: PP 508-513
38
Vertical, horizontal, diagonal: the policy debate continues, but where is the
evidence?
Balen, J., Jasseh, M., Conteh, L, Smith, R, Demba, A., d'Alessandro, U.
A longstanding debate within the health research field relates to the integration of
'international' disease control programmes into national health systems, with
disagreements regarding the purpose, level, extent, timing, relative merits and
outcomes of such integration. This debate is of particular importance in light of
substantial increases in externally funded control programmes and global efforts
aimed at health system strengthening. Indeed, increased attention from the global
health community is being directed towards potential synergies among disease
control programmes and health systems, with recent calls for coordination and
integration of cross-cutting action aimed at reaching all of the Millennium
Development Goals (MDGs), particularly the three health-related MDGs of
reducing child mortality, improving maternal health and combating HIV/AIDS,
malaria and other diseases. The aim of such integration is to "bring together
different threads into one fabric" (Jeffry Sturchio, Former President and CEO of
Global Health Council, 2010), and thereby limit the negative consequences of
working within disease-specific silos, whilst harnessing complementary strengths
that have been established throughout decades of vertically-driven programmes.
Our work presented here addresses key knowledge gaps by examining the nature
and extent of cross-programme and programme-system integration in selected
case-study countries from West Africa and Southeast Asia, namely: (1) The
Gambia; and (2) Cambodia, respectively, bringing concrete evidence to the
global policy debate. An improved understanding of the nature, extent and
outcomes of interactions between disease control programmes and national
health systems will enable more informed policy-making and implementation,
increased effectiveness in the scale-up of programmes, and sustained success.
39
Integrating and Adapting Human Resources at Service Delivery Level
within National Disease Control Programs- A Case Study
Menon PK., Singh A., Kansakar B.z Hira S.K., Balasubramaniam P
Background: This paper is part of a larger on-going research study on "Identifying
Operational Pathways for Accommodating and Integrating National Disease
Control Programs within the Framework of Universal Health Coverage".
India currently has 15 disease control programs, traditionally designed at the
Centre that exclusively engage allied health professionals at block level to work for
individual programs. This replication of human resources across programs is a
typical example of duplication of services that occurs in vertical programs resulting
in fragmentation compounding health system inefficiencies.
Objectives: While the broader study aims to assess and identify potential
operational pathways of integration of various disease control programs, this
'case-study' examines how some States have managed to work around rigid
national policy and program design at service delivery level for efficient utilization
of central resources.
Methods: The case-study is developed on emerging evidence from the original
study which incorporates mixed methods. Data collection involves structured and
semi-structured, interviews of key informants in six states selected on low,
moderate, and high health indicators. Field data was supplemented by extensive
literature review on national disease programs. Data is transcribed and analysed
using Atlas Ti and SPSS software.
Observations: In attempting to identify operational pathways in integrating
program components of vertical programs, this case-study focuses on State-led
program implementation around human resource utilization. We demonstrate
State driven multi-skilling and multi-tasking efforts as efficient ways to deliver
related program services while effectively containing costs.
40
■
Community level morbidity control of lymphoedema using self care and
integrative treatment
Aggithaya MG, Narahari SR, Bose KS
Background: There is no nationwide public health programme of proven
effectiveness, in any endemic country to manage lymphatic filariasis (LF). Narahari
et al developed a treatment protocol for LF integrating ayurveda, biomedicine and
yoga to address the morbidity in rural communities. This presentation is on efficacy
of the integrative treatment protocol when applied in a resource poor community
village setting of South Indian states.
Methods: The study was conducted as a before-and-after interventional non
randomized trial. Two LF endemic districts of south India, Gulbarga in Karnataka
(GK) and
Alleppey in Kerala (AK), were selected. All known patients on
governmental records or specialist registers were invited to a training camp.
Patients with grade two late or three lymphoedema with a family member for
assistance were enrolled.
All patients received initial two weeks of supervised treatment as outpatients in the
treatment centers. The outcome measures were, quality of life assessment using LFspecific QoL questionnaire, limb volume by water displacement method, girth
measurement, and LF morbidity. This was carried out at baseline and at monthly
follow ups, forthree months.
Results: 730 patients (851 limbs) completed the three and half month follow up.
The quality of life of patients improved significantly P<0 01. There was a
statistically significant reduction up to mid thigh level volume measurement for
both small (0.7-1.1 liters) and large (1.8-5.0 liters) limbs, P<0 01. Patient had
fewer filarial fever episodes, and reduced bacterial entry points.
Conclusions: Self-care and integrative treatment is possible in resource poor
Indian village settings.
41
Unmet needs of health system fortackling NTDs in Bangladesh
Shawon MSRZ Bulbul MMI, Adhikary G.
Background & objectives: Neglected tropical diseases are a cluster of chronic
disabling infections affecting under-privileged population (residing in rural area,
urban slums & conflict zones) of low income countries. These infections contribute
to poverty cycle, disruption in social stability and economic progress in developing
tropical countries like Bangladesh. Health system strengthening is crucial to
elimination of NTDs. Our objective is to contextualize the health system of
Bangladesh to combat NTDs according to WHO suggested six building blocks of
health system.
Findings: In Bangladesh, primary health service does not integrate NTD control
program and community sensitization & mobilization is inadequate. Interrupted
provision of priority drugs and lack of pharmacovigilance & data on adverse
reaction have worsened the scenario. Capacity building of health workforce on
NTD is limited and often faces nepotism. Absence of financial risk pooling
mechanism marks inequitable access to healthcare by the destitute and make
them more vulnerable to NTDs. Ineffective surveillance system and poor data
generation, documentation and management system fail to guide the policy
makers for developing adaptive strategies. There is no operational plan for NTDs
in the latest sector wide approach, HPNSDP (201 1 -201 6) of Ministry of Health &
Family Welfare.
Conclusion:
People-centered
comprehensive
primary
care
along
with
rationalizing and bringing coherence to fragmented elimination programs and
strong and sustained political commitment and integration of NTD control
program within national health policy strategy and plan are crucial to tackle NTDs
in Bangladesh.
42
Experience of Sputum collection and transportation in TB care and control
Banuru Muralidhara Prasad Mryutyunjaya Nayak
Introduction: Public health facilities in India are established based on population
norms. Implementation of this norm had limitations resulting in non-uniform
distribution of facilities affecting the universal access to health services and also for
tuberculosis services. Tuberculosis services are available within these public health
facilities for those with chest symptomatics. These units are labeled as DMCs at
identified facilities. DMCs accessibility to chest symptomatic varies, as a result
symptomatics reaching these facilities for examination is delayed.
Method: Project Axshya developed and implemented strategy to train volunteers
in remote, rural part of villages in Meghalaya and Mizoram to sensitize
communities about TB care and control; visit households who present with chest
symptomatics. The volunteer inform household members about TB services and
collects sputum of symptomatics (two samples) and transports to nearest DMC.
Result: Volunteers, transported sputum from 692 TB symptomatics to nearest
DMCs (October'l 2-March'l 3). Laboratory technicians examined and diagnosed
sputum samples of 68 symptomatics as positive. Volunteers communicated results
and informed about DOTS providers. Four volunteers are actingas DOTS
providers in areas where there are no ANMs/ASHAs/AWWs.
Conclusion: Burdened with poor public transportation and household
economies, commutation of TB symptomatics to DMCs for seeking care/service is
challenging. Through this mechanism of sputum collection and transportation a
nexus of volunteers - local taxi drivers; communities unreached were reached and
educated about TB care and control. Project was able to identify 68 TB patients
who would otherwise not have got examined or would have reached DMCs in later
stages of disease infecting healthy individuals.
c
s
43
Poster Exhibition
Scrub typhus: a re-emerging and neglected disease of Rajasthan
Dr Rathore Jalam Singh
Introduction: Scrub typhus is re-emerging and neglected infectious disease in
Alwar and Rajasthan. Though some studies had reported presence of disease in
decade of 70s, but after that till 201 1 this disease was not considered in diagnosis.
In 201 1 during investigation of an outbreak of acute febrile illness in Alwar, NCDC
documented scrub typhus as one of the causes of outbreak. In year 201 2, total 82
cases including 3 deaths were found positive for scrub typhus in district.
Observations: Almost all blocks of the district have presence of disease and its
more prevalent among adults especially females. Majority of the cases were
reported in late or post monsoon season (Aug-Sep-Oct).
Lack of guidelines for prevention and control of disease is a hurdle to ensure
curative and preventive services. Consideration of disease in diagnosis and
initiation of empirical therapy by health professionals is another impediment.
Conclusion & Recommendations: Scrub typhus has been found as re-emerged
and neglected cause of the Acute Febrile Illness in the region. There is a need for
research to understand epidemiological situation, challenges and opportunities
for preventive and curative services in Rajasthan and local strategy to halt the
infection.
Scrub typhus should be included in vector borne program so that preventive and
curative measures can be performed to halt transmission. Training of health
professionals and involvement of ASHAs in identifying febrile cases can help
screening of cases early and thus mortality can be prevented with start of early
initiation of empirical therapy.
44
Where do PLHIV (people living with HIV/AIDS) go and what do they prefer?
Engaging private providers in HIV/AIDS service provision in Tamil Nadu,
India
Asirvatham Edwin Sam
Introduction: In India 75% of health care is provided by private providers. The
percentage of HIV care by private providers is not known; they operate largely
outside the National AIDS Control Program. This study aimed at understanding the
utilization of services and provider preferences of PLHIV as these are prerequisites
to change behavior and improve health practices among PLHIVs.
Methodology: This was a cross sectional study, carried out in twelve districts of
Tamil Nadu. A sample of 667 PLHIV was selected using simple random sampling
of registered PLHIVs; district sample size was in proportion to the number of PLHIVs
registered. A pre-tested interviewer administered schedule was used to collect
data.
Results: During last illness, 46.5% of PLHIV approached private facilities, 43.8%
public, 5.2% pharmacists, 4% opted for self-medication and 0.4% traditional
practitioners. Public facilities were accessed for HIV counseling/testing(HCT),
advanced lab investigations, antiretroviral therapy, delivery, surgery and STI
management. Private facilities were accessed for specialist consultation and
management of opportunistic infections. PLHIVs with higher income and
education were more likely to seek private facilities; however, for HCT, these were
not factors. Given an opportunity, majority(64%) preferred private facilities;
Education and income were the factors associated with the preference of private
facilities.
Conclusion: The higher preference for private facilities emphasizes the need to
engage private providers in the provision of HIV/AIDS care and treatment services.
The study provides valid insights on the need to subsidize the cost at private
facilities. Cost sharing approaches could be used through public-private
partnership initiatives.
45
Assessing maternal and neonatal tetanus risk in a tribal district of Odisha
Dr. Raveesha RMugali.
Introduction:
Maternal and Neonatal Tetanus (MNT) has been a major public
health concern in India. As is known, MNT can be prevented by immunizing
pregnant women with tetanus toxoid, ensuring clean delivery and post-natal
safecordcare. Through sustained immunization efforts and ensuring institutional
safe deliveries, some states have successfully eliminated neonatal tetanus while
some others are still reeling under it. The status of elimination is validated through
using the WHO methodology-lot quality assurance with cluster sampling (LQACS). A pre-validation exercise precedes the LQA-CS survey to assess the MNT risk.
This paper draws on evidence from one such pre-validation exercise in a remote
tribal district of Odisha.
Methodology: The pre-validation exercise methodology included:
• Ranking of district for MNT risk in the state: this was done by tabulating primary
and surrogate indicators of MNT from the last 3 years data and ranking with
appropriate weightings.
• Assessment of health systems delivery in the district: With semi structured
questionnaire, ANC, Immunization institutional deliveries.
• Assessment outreach services including cord care practices: A Field survey of 30
mothers in randomly selected villages.
Results: The pre-validation exercise shows that the district reported only 42%Institutional deliveries. 48%-of deliveries were attended by SBA. 30%-of villages
received periodic outreach health services due to security reasons (the district has
been a hub of Maoist movement). The immunization coverage shows 46%-DPT3,
89%-TT coverage. 50 %-of mothers (n=30) used various materials to apply on
cord stump like Blackened mud from the clay oven, goat-dung, snails-shelIpowder and leaves-paste from trees. Barely 48 doctors were in place against
sanctioned 87 (55%) while 14 % of health-worker posts were vacant.
Conclusion: The pre-validation-survey shows that the district is still under high risk
of MNT. Behavioural-change -communication strategies for mothers & community
towards MNT and safe-cord practices are critical. Improving access, effective
utilization of health-services particularly institutional deliveries with-SBA is needed.
Strategies to reach the health services in security compromised areas through local
community involvement are imminent to reduce the risk of MNT in this remote
district.
46
9
From clinics to community? - Detection of ESBL producing
Enterobacteriaceae from community water samples in Cochin, Kerala
Krishna S, Aswathy S’, Dinesh K, Viswanath V', Panicker KN;, Karim S1
Introduction: Antimicrobial resistance is now a worrying global public health
issue as infections caused by multi-drug resistant bacteria are associated with
higher morbidity and mortality. Bacteria carrying resistance genes are moving
beyond the hospitals into the community, infecting healthy people, and posing
therapeutic challenges leading to fatal infections. Enterobacteriaceae that
produce Extended Spectrum a-lactamases (ESBLs) confer resistance to commonly
used antibiotics, are no longer limited to hospitals (70-90% Indian prevalence) but
have emerged within the community settings.
Methodology: A total of 1 05 Enterobacteriaceae isolates obtained from 1 00 (46
well water, 45 tap and 9 river water) samples in and around Kochi were
investigated for their production of ESBLs for better understanding of transmission
of antibiotic resistance links and the public health risks involved. Coliform
contamination rate in water samples and antimicrobial resistance pattern of
obtained isolates were assessed.
Results & conclusion: Coliform contamination rate was 76%. Contrary to the
belief of community water as an important source of dissemination and
transmission of Multi-Drug resistant bacteria linking the clinics and community, our
study results showed negligible prevalence of MDR(<1%) and 2 ESBL producing
Enterobacter Spp (1.9%), confirmed by molecular methods. The city water does
not currently pose a threat for ESBL hospital-community transmission of infections.
The results may be regarded as a benchmark to monitor an impending problem at
an early stage. Further epidemiological and environmental studies with plasmid
analysis, phage studies, and frequency of the transfer of resistant elements may be
undertaken to explore the dissemination pathophysiology and the unexplained
links of transmission.
47
Challenge of melioidosis in Cambodia
Ellen Mating PheT. ; Kruy L. ;Thai S1"; Veng C.1"; Vlieghe E.,?; De Smet B.
Melioidosis
is
a
life-threatening
community-acquired
disease
caused
by
Burkholderia pseudomallei, having its reservoir in soil. It is endemic in South-East
Asia and Northern Australia, causing high mortality rates among infected
individuals (20-50%). Invasive blood-borne dissemination into organs is the
hallmark of the disease, with pneumonia being the most frequent presentation.
Diagnosis relies on culture of the bacterium, which causes an important diagnostic
delay and requires a microbiology laboratory. Its treatment is difficult and long,
due to high level of intrinsic resistance and ability to survive in macrophages.
Ceftazidime or meropenem are required for the initial intensive therapy but both
permanent access and affordability are difficult to ensure in Cambodia, especially
in public hospitals.
In 2007, the Sihanouk Hospital Centre of HOPE, a tertiary hospital in Phnom Penh,
Cambodia, implemented a blood culture based, passive surveillance. So far, 1 53
cases of melioidosis have been laboratory confirmed.
We observed a learning curve on melioidosis at several levels in the hospital.
Although melioidosis is well known in the region, it was unfamiliar to most
clinicians and laboratory staff at the start of the study. Our findings from this
surveillance project, raising awareness at the local level, can be translated to a
national level. Accordingly a national workshop for Cambodian health care
workers was organized to share this experience, especially regarding the early
diagnosis and appropriate treatment.
The public health impact of this disease warrants further research and actions. An
immanent problem of melioidosis in Cambodia remains access to effective drugs
and
further
development
microbiology capacity.
48
of
quality-assured
and
affordable
diagnostic
An Epidemiological investigation of Cholera outbreak in Poonamallee
Municipal area, Tamil Nadu, India
Mahajan Dhruba1, RamakrishnanR-, MurhekarM-, Mehendale Sanjay M;.
Background: Cholera causes frequent diarrheal outbreaks in India including
Tamil Nadu. On 9th December, 2011 we investigated an outbreak (detected on
8th December) in Poonamallee (population 56,685) municipality to identify
agents, source of infection, control and recommend preventive measures.
Methods: We reviewed records in hospitals and searched for cases with
occurrence of e"3 loose stools with or without vomiting, within 24 hours between
December, 201 1 and January, 2012. We examined drinking water for chlorine
level, microbiological content; collected rectal swabs for confirmation. We
described outbreak in terms of time, place and person; we conducted a case
control study with 95 patients and 1 95 controls in selected five wards with higher
attack rates and performed univariate and multivariate analysis.
Results: Total 1 72 residents suffered from diarrhea with an attack rate of 3 per
1000 population. Two case-patients died (CFR=1.16%). Laboratory isolated
Vibrio Cholerae 01 from 1 2 of 43 rectal swabs; 50% of water sample collected
from various sources showed fecal contamination; Drinking municipal pipe water
was 2.31 (95% Cll .02-5.41) times more among cholera case-patients, on the
other hand drinking bottled water and boiled water were 3.03 (95% Cl 1.081 0.53) and 2.98 (95%CI 1.62-5.71) times more respectively among controls.
Conclusions: Fecal contamination at the source of drinking water probably
contributed to this outbreak. Pipe water supply was stopped with arrangement of
alternate water supply. Pipes were repaired and water was chlorinated prior to the
supply. The outbreak was controlled and we recommended regular cleaning,
chlorination and adopting household safe water usage to prevent outbreak.
49
Is cash transfer program a viable option to support children affected and
infected with HIV? Evidences from Tamil Nadu State, India
Asirvatham Edwin Sam
Background: Children affected and infected with HIV are primarily from the poor
households and they are deprived of basic needs. The Government of Tamil Nadu
implemented a cash transfer program to address the children's education,
nutrition, health-care and socioeconomic needs through a trust with a corpus fund
of $1 million. The objective of the study was to assess the effectiveness of this
program in achieving its intended purposes.
Methods: The study was undertaken in 1 0 districts from four clusters of districts in
the state of Tamil Nadu. A sample of 153 beneficiaries was selected using the
probability to proportionate size method from each district. In addition to the
secondary data, interviews were conducted using a semi-structured interview
schedule. The caretakers were interviewed for children below 15 years.
Results: Among study participants, 37% were double orphans, 53% were paternal
and 10% were maternal orphans. Around 63.4% were from rural areas; 30%
were under the care of grandparents. Food expenditure was the primary
household expenditure. The cash transfer programs disbursed an average amount
of INR261 7. The respondents reported improvements in school attendance (98%)
and performance (94%). Around 42% reported an improvement in the food
consumption. Among children on ART (81), both mean hemoglobin level (10.04
mg to 10.76 mg; p<.001) and mean CD4 level (738.75 to 1014.34; p<0.01)
increased significantly.
Conclusion: This program was found to be effective especially in supporting the
education of children. It is imperative to scale up the program as it reached only a
low proportion of eligible beneficiaries.
50
Molecular identification of hookworm species in a multi-centric efficacy
trial across seven soil transmitted helminths endemic countries
Santosh George, Bruno Levecke, Gagandeep Kang, Peter Geldhof, Jozef
Vercruysse
Soil transmitted helminths (STH, Ascaris, Trichuris and hookworms-Ancylostoma
duodenale and Necator americanus) are the most prevalent parasitic infections
worldwide, including countries like India. The accurate diagnosis of hookworm
infection in humans is central to effective control and the detection of the parasite.
Therefore, in this study molecular identification of two important species of
hookworm namely, A.duodenale and N.americanus was done using a semi
nested standardized polymerase chain reaction (PCR).
The study was carried out from samples collected in a multi-centric drug efficacy
trial, which looked at the efficacy of a single-oral dose of mebendazole (500mg)
against STH. From six developing contries, namely Brazil, Cambodia, Cameroon,
Ethiopia, Tanzania and Vietnam, 5,830 children were assessed for anthelminthic
efficacy. From each of the six countries, approximately 200 random stool samples,
positive for STH, either at baseline or both at baseline and follow-up, were
preserved in 70% ethanol and sent to the Laboratory of Parasitology, Ghent
University. 20 subjects who were excreting eggs only at baseline and 20 subjects
who were excreting STH both at baseline and at follow-up were selected at
random. The sampling strategy resulted in aprox 60 stool samples per country. The
study was carried out to help understand the role of zoonosis and anthroponotic
mode of infection for STH and to verify to which extent treatment has an impact on
STH species originating from animals.
The study found N.americanus mainly in countries of Asia and South America;
whereas for samples from Africa both hookworm species were found prevalent.
Sequence analysis revealed 99% homology with sequences available in NCBI
database. On analysis, 54% of samples tested were positive for hookworm by
microscopy and PCR, whereas 30% of samples positive microscopically for
hookworm were missed out in PCRs. This can be due to the presence of PCRs
inhibitors coupled with degraded template DNA.
KO I a
pH - \ 30
\5v5\
n 9 a J., Vo/Z
51
An epidemiological study of drugs availability related to three infectious
childhood diseases: Where does the compass point?
Nayan Chakravanty
Globally more than 6.9 million children die under the age of five every year, of
which many are attributed to preventable infections. Three most infectious
diseases, contributes to about 10 percent of all childhood deaths are due to
diarrhea, 7 percent to malaria and 9 percent to ARI. Access to affordable and
timely availability of essential drugs can play a vital role in reducing morbidity and
mortality. The study provides an insight into the availability of common drugs with
respect to infectious disease load of ARI, diarrhea and malaria. A mixed-method
approach using both qualitative and quantitative study techniques were used.
Hospital level data from randomly selected PHCs and CHCs were collected. The
data collected were both on disease load and availability of drugs during the study
period (2009-2012), using a retrospective cohort. Results represented that the
month of September having highest morbidity. ARI is most prevalent, with total case
loads of 1,539 cases. Howeverthe Vital and Essential drugs availability for ARI was
found to be 7 percent, 57 per cent for malaria and 98 per cent for diarrhea against
requirements. Drug supply was found to be erratic, having weak correlation with
the pattern of disease morbidity. The study adds to the existing body of literature by
demonstrating the system level gap that exists in availability of vital drugs. In
addition, it provides a useful guide to policy makers by establishing drugs
requirement based on disease load, not just in the state of Odisha, India but also
across other LMIC.
52
Morbidity and mortality of meningococcal diseases in Gaza Strip during
2012
Nedal Ghuneim, Majdi Dheir, Fouad Issaw
Background: Meningococcal disease (MD) is a serious life-threatening infection
with a high case-fatality rate especially in infants. In Gaza Strip, MD remains one of
the most challenging infections.
Methods: Cross-sectional study carried out involving all confirmed reported cases
from 1 st January 201 2 to 31 st December 201 2 were studied.
Findings: A total of 2049 cases with clinically diagnosed meningitis patients were
reported during the year 201 2. 103 cases (5%) of them were positive for Neisseria
meningitidis with an incidence rate of 6.3 per 100.000 population. The
majority of reported cases 63 (61.2%) were meningococcal septicemia (incidence
rate was 3.8 per 1 00.000) and 40 cases (38.8%) were meningococcal meningitis
(incidence rate was 2.4 per 1 00.000).
There was a male predominance 56 cases (54.4%) than female. The mean age
of cases was 4.7 years while the median age was 3 years and age distribution
showed that it occurred mainly in underfive children where 75.7% (78 cases) were
reported. The highest reported incidence was in Rafah governorate (9.4/100000)
followed by Gaza and Mid-Zone governorates (6.7/1 00000). Serogrouping was
done for 20 cases (1 9.4%) and showed only serogroup B. The case fatality rate
(CFR) among all cases was 23.3% (36.5% among meningococcal septicemia and
2.5% among meningococcal meningitis with a p-value of 0.000). Results show
that 58.3% of deaths were among females (p-value was 0.1 1 7).
Interpretation: Gaza strip still highly endemic with MD with high CFR mainly from
septicemia possess a challenge for continuous monitoring of surveillance of MDI
53
Syndromic approach to neglected infectious diseases (NID) at primary
health care level: an international collaboration on integrated diagnosis
treatment platforms
M. Boelaert, F. Chappuis, S. El Safi, K. Lim, R Lutumba, Y. Mahendradhata, F.
Meheus, R Mertens, M. Miles, R. Peeling, S. Rijal, M. Sacko, S. Sundar, M. Traore,
J. Utzinger, J. Weinbach
Neglected Infectious Diseases (NID) such as trypanosomiasis, leishmaniasis,
schistosomiasis and soil-transmitted helminthiasis receive less than 5% of global
investment for tropical diseases research. Clinical praxis in disease-endemic
countries (DEC) is rarely evidence based and does not make use of latest
innovations in diagnostic technology. NID-related research on diagnostics is
particularly underfunded, and diagnostic tools are lacking for a number of NID.
The aim of this proposal is to bridge the gap between existing technological
innovation in diagnostics and clinical care practice for NID in resource-poor
settings. The specific objectives are to develop simple, cost-effective diagnosis
treatment algorithms for three NID-related clinical syndromes: persistent fever,
neurological and digestive syndromes. Evidence-based algorithms for the primary
care level will be designed with a patient-centred approach, following guidance
from DEC stakeholders and making the best possible use of existing assays and
treatments. Relevant diagnostic technology and diagnostic platforms will be
introduced according to the specific epidemiological contexts in Africa and SouthAsia. The research consortium brings together a network of clinical
epidemiologists, a diagnostics development group, several
partners from
academia and SMEs. The consortium further includes work packages on reference
laboratory, economic evaluation, quality assurance and translation to policy. By
developing accurate and affordable diagnostic platforms and by optimizing
diagnostic-treatment algorithms, this project will rationalise treatment use,
circumvent progression to severe presentations and thereby reduce NID
morbidity/mortality and hinderthe emergence of resistances. The project will result
in two main deliverables: policy recommendation for health authorities in DEC,
and a series of innovative diagnostic platforms.
54
Outcome of MDR-TB treatment at DOTS Plus site: A retrospective study
from Maharashtra
Gosavi SV, Kulkarni G, Dugad SR, Patil MS
Introduction: As per Global TB report, 2012, out of the estimated 73,000
estimated MDR TB patients living in India, only 1,660 cases were notified and
1,136 cases were put on treatment. However no study so far has reported outcome
of Cat- 4 treatment in India. Therefore, this study was conducted with an objective
to determine the outcome of treatment of MDR-TB & associated factors such as age
& sex.
Methodology: The present study included the retrospective analysis of diagnosed
cases of multidrug resistant TB patient admitted in DOTS Plus site at Medical
College for Category 4 treatment. The study was conducted during the period from
July 201 3 to August 2013. Data were collected from register maintained at DOTS
Plus site with prior permission from Medical Director of hospital.
0
Result: Total 231 patients of MDR-TB enrolled for Category 4 treatment between
January 201 2 and June 201 3. Among the study subjects, 67 (29%) were in the age
group of 1 5-24 years followed by 62 (26.8%) in 25-34 years and 56 (24.2%) were
in the age group of 35-44 year. 151 (65.3%) were males and 80 (34.6%) were
females. Out of 231 patient 1 77 (76.6%) were still on Cat 4 while 1 0.3%, 8.6%,
3.9% & 0.4% patient were found to be defaulted, died, transfer out & switch to Cat
5, respectively.
Conclusion: MDR-TB is mainly affects the young and male population. Some
patients were defaulter & died before treatment. Appropriate supervision and
monitoring of the DOTS Plus activities will play an important role in shaping future
policies and recommendations.
55
Single and Multiple Species Helminth Infections and Associated Morbidity
in Hunan Province, China: Lessons Learnt and Implications for Integrated
Control
Balen, J., Raso, G., Li, Y.S., Zhao, Z.Y., Yuan, L.P, Utzinger, J., McManus, D.R
The World Health Organisation (WHO) launched an innovative action plan forthe
integrated control of neglected tropical diseases involving individual programmes
joining to concurrently deliver a combined "package" of low-cost, safe and
effective drugs. The People's Republic of China (PR China) has made great strides
toward reducing the burden of schistosomiasis and soil-transmitted helminthiasis,
facilitated by sustained political commitment and a multi-faceted control strategy.
However, very few studies have been reported on the distribution and interaction of
multiple species helminth infections. We carried out a comparative study of
households in rural and a peri-urban settings of Hunan province in Novemberand
December 2006 to determine the extent of single and multiple species infections,
the underlying risk factors, and the relationships with clinical manifestations and
self-reported morbidity. Complete parasitological, clinical and questionnaire data
were obtained for 1,298 inhabitants. The overall prevalences of S. japonicum, A.
lumbricoides, hookworm and T. trichiura were 6.5%, 5.5%, 3.0% and 0.8%,
respectively; the majority of the infections were of light intensity. We found
significant negative associations between wealth and infections with S. japonicum
and A. lumbricoides. Clinical manifestations of splenomegaly, hepatomegaly and
anaemia were prevalent (9.0%, 3.7% and 10.9%, respectively), the latter two
being significantly (P < 0.05) associated with schistosomiasis. Self-reported
symptoms were more common among females but there was considerable under
reporting in both sexes when relying only on spontaneous recall. Our findings may
guide the design and targeting of a more equitable, comprehensive and
integrated parasitic disease control programme in Hunan province, China and
elsewhere.
56
The effect of increasing private sector representation in a dengue fever
surveillance network on incidence rates
Melo Furtado K, Kar A
Background: The under-representation of the private sector in dengue fever (DF)
surveillance has been stated to be one of the causes for under-estimation of DF,
thereby affecting disease control. Our objective was to establish whether increasing
private sector health facilities in a surveillance network (CODREN) would improve
case detection for dengue fever.
Method: We mapped and set up a network of all private sector medical
practitioners in a single administrative ward of Pune city, Maharashtra. Participants
were requested to report suspected and confirmed cases of DF. Data generated by
this network was compared to that collected by the local unit of the National Vector
Borne Disease Control Programme (NVBDCP).
Results: The total number of cases detected by CODREN was 262 (annual
incidence rate 12.4 cases per 10 000 population) as compared to 162 cases
(annual incidence rate 7.7 per 1 0 000) detected by the NVBDCR Discrepancy in the
data arose from the recording of cases diagnosed using the NS1 antigen.
CODREN detected 1 44 cases while only 23 cases were recorded by the NVBDCP,
even though the case data was obtained from the same reporting centres.
Conclusion: The discrepancy in the recorded data was due to under-recording of
cases by the public health sector, possibly due to issues of case definition. Sentinel
sites identified under the NVBDCP were responsible for providing data on all cases.
Adding other private sector facilities to the surveillance did not contribute to
increased case reporting.
Burden of diarrhea, hospitalization and mortality due to
CRYPTOSPORIDIAL INFECTIONS IN INDIAN CHILDREN
Cryptosporidium spp. is a common, but under-reported cause of childhood
diarrhea throughout the world, especially in resource-poor settings. Children under
the age of 2 years are at the highest risk. A comprehensive national estimate of the
burden of cryptosporidiosis in developing countries is, however, not available.
We used a combination of published and unpublished studies as well as national
statistics to determine the rates of cryptosporidial diarrhea, hospitalization and
mortality among children <2 years of age in India.
Ourestimatessuggestthat annually, one in every 6-1 1 children <2 years of age will
have an episode of cryptosporidial diarrhea, 1 in every 169-631 children will be
hospitalized and 1 in every 2894-7246 children will die due to cryptosporidiosis.
57
Since there ore approximately 45 million children <2 years of age in India, these
estimates suggest that Cryptosporidium results in 4.2-7.7 million diarrheal
episodes, 71.9-268.6 thousand hospitalizations, and 6.3-15.7 thousand deaths
each year in children <2 years of age in India.
These estimates provide a useful assessment of the under-recognized burden of
cryptosporidiosis among Indian children and makes a compelling case for further
research on transmission and prevention modalities of Cryptosporidium spp. in
India and other endemic countries.
Epidemiology and risk factors of cryptosporidial infections
AMONG CHILDREN IN A SEMI-URBAN SLUM IN SOUTHERN INDIA
Cryptosporidium spp. is a common cause of parasitic diarrhea throughout the
world and causes significant endemic disease and morbidity in developing
countries.
However, the mechanisms of transmission and
risk factors of
cryptosporidiosis in such settings are not completely understood.
Between September 2008 and April 201 1, 176 children residing in semi-urban
slums of Vellore, southern India were enrolled, pre-weaning, in a quasiexperimental study on the effect of bottled drinking water on cryptosporidiosis and
followed until the age of 2 years; 1 60 children (90.9%) completed the follow-up.
Diarrheal and monthly surveillance stools were collected and tested for presence
of Cryptosporidium spp. by PCR.
One
hundred
and
seventy-seven
episodes
of
parasitologically-confirmed
cryptosporidiosis were observed in 105 (59.7%) children at a rate of 0.56
episodes/child-year of observation. Majority of infections were asymptomatic.
Thirteen children whose stool samples were negative by PCR were positive by
serology.
In a nested case-control study among those who completed the follow-up,
presence of one or more older siblings in the house (OR=4.39, P—0.005),
stunting at 6 months (OR=5.89, P=0.008) and presence of cow in the house or
handling of cow-dung by the primary caregiver (OR=2.70, P=0.032) were
associated with increased risk of multiple cryptosporidiosis, whereas maternal age
of >24 years was protective (OR=0.38, P=0.051). Drinking bottled water did not
confer additional protection.
The results suggest sustained transmission of cryptosporidiosis among Indian slum
children, possibly through multiple pathways. Effective disease control strategies
will require a multi-faceted approach that takes into accountthe complex nature of
the host-parasite interaction.
58
A ten year experience of pptct clinic: can we strengthen our health - care
system
Hiremath RN, Ghodke S, Vidhya G, Bhalla S, Sinha S
Introduction: The PPTCT programme aims to prevent the perinatal transmission
of HIV from an HIV infected pregnant mother to her new born baby. The
programme entails counselling and testing of pregnant women in the ICTCs.
Objectives: To find out the coverage of PPTCT service, dropouts, intervention
efficacy with other determinants and to make necessary recommendations to
strengthen our health care system based on the findings of the study
Material and methods: The 1 0 year data of PPTCT program at large tertiary care
centre in Pune was collected and analyzed.
Results and discussion: Out of 27683 pregnant women who availed PPTCT
services, 1 08 tested positive. The prevalence rate was found to be 0.39%. Of 1 08
HIV positive women, 55.6% delivered in the hospital, 1 7.6% had undergone MTP/
Abortion, 2.7% were referred to other Government hospital and 24.1 % were loss
to follow up. In respect to PPTCT intervention 73.3% had ARV and 26.7% had ART.
There were total of 60 child births. Just like ANCs, drop-out in service utilization
was observed among exposed children also. Only 18 of the exposed children
could be traced till the age of 06 months and 1 8 upto 1 8 months while 02 are
under HIV follow up and 22 were loss to follow up. No child was tested reactive for
HIV antibodies.
CONCLUSION:
There is an urgent need to induce faith, confidence and motivation among the
women and make her acceptthe verdictand avail the facilities. In orderto improve
access and reduce various gaps, PPTCT services should be made available to all
ANCs with necessary awareness campaigns and health care system strengthening
should be carried out to prevent and proper monitoring of dropouts cases.
Vertical programs and health systems strengthening in India: Lessons from
three programs
Vertical programs have had a long history and an important place in the public
health system of India. This study focuses on the interaction between local health
systems and three vertical programs in India—National AIDS Control Program
(NACP) (HIV/AIDS), Revised National Tuberculosis Control Program (RNTCP) (TB)
and National Vector Borne Disease Control Program (NVBDCP) (Malaria). It also
examines factors that create an enabling environment for vertical programs to
strengthen health systems.
59
A total of 1 03 in-depth interviews were conducted in 2009 and 201 0 in six states of
India. Key informants included managers of disease control programs and health
systems, both at state level and national level, and staff from peripheral health
facilities. Key themes were analyzed using the World Health Organization (WHO)
building block and the Systems Rapid Assessment framework.
We found that vertical programs contribute to strengthening some components of
the health system: by sharing human and infrastructural resources, increasing
demand for health services, by improving public perceptions of service quality,
encouraging involvement of civil society in health services and sharing disease
specific information with local health system managers. These synergies were
observed more frequently in the RNTCP and NVBDCP compared with the NACP
The study findings suggest that certain conditions enable vertical programs to have
a positive influence on health systems—one, the program needs to have an explicit
policy to strengthen local health systems, and two, it should be embedded within
the health system administration.
*This study was funded by the Maximizing Positive Synergies project of the World Health Organization
(WHO) and The Global Fund to Fight AIDS, Tuberculosis and Malaria.
60
Prevalence and risk factors for soil transmitted helminth infection among
school children in south India
Kattula D, SarkarR, AjjampurSSR, MinzS, LeveckeB, MuliyilJ and Kang G
Soil-transmitted helminths (STH) are a major public health problem in tropical and
sub-tropical countries, affecting the physical growth and cognitive development in
school-age children. This study aimed to assess the prevalence and risk factors of
STH infection among school children aged 6 -14 years in Vellore and
Thiruvanamalai districts in south India. Children aged 6-14 years, going to
government and government aided schools (n = 33) in Vellore and Thiruvanamalai
districts were screened to estimate the prevalence of STH and a case control study
was done on a subset to assess the risk factors for the infection. The prevalence of
STH was 7.8%, varying widely by school from 0 to 20.4%, in 3706 screened
children. Hookworm (8.4%) rates were high in rural areas, while Ascaris (3.3%)
and Trichuris (2.2%) were more prevalent among urban children. Consumption of
de-worming tablets (OR=0.25, P<0.01) offered protection, while residing in a
field hut (OR=6.73, P=0.02) and unhygienic practices like open air defecation
(OR=5.37, P<0.01), keeping untrimmed nails (OR=2.53, P= 0.01) or eating
food fallen on the ground (OR=2.52, P =0.01) were important risk factors for STH
infection. The epidemiology of STH is changing in India. Identifying risk factors and
dynamics of transmission in vulnerable groups can help to plan for effective
prevention strategies.
61
Patients' perception on available public health facilities and services for
lymphatic filariasis: a qualitative study in Odisha, India
Gupteswar Patel, Dr.Swapnil More, Rojalin Swain, Dr.Ambarish Dutta, Dr. Krushna
Chandra Sahoo.
Background: Globally, 40 million people live with the long-term effects of
lymphatic filariasis (LF), which is the second leading cause of disability and, still
considered as a neglected disease. The LF in India is more endemic in coastal
regions but there are few studies with regards to community awareness of the
disease and LF-related services available to the community through the public
health system in this region. Therefore, this study aims to explore the patients'
perception on the disease and available LF-related public health services to
rationalize the current strategy.
Methods: A qualitative in-depth interview study was conducted among ten LF
patients in coastal district of Odisha. A semi-structured interview guide was
developed based on the objective of the study. The data were analyzed using
contentanalysis.
Findings: Patients perceived that, due to filariasis they are suffering from long
term physical and psychosocial problems such as social stigma and
underemployment. They conceptualized from the existing inadequate awareness
generated by the public health system that long-term effects of filariasis are
incurable. They opined that, if any supportive assistance can be provided, it will be
useful fortheir daily sustenance.
Conclusion: The findings suggest that, there is need for awareness and special
services to support filariasis patients especially with regarding the curability of LF
complications. They recommended that government should include filariasis
patients as physically disabled persons for subsidizing their livelihoods that can
lead to maintenance of healthy and participatory life instead of dependency in
them.
62
Comparison of the effectiveness of two different health education
strategies on the utilization of Long Lasting Insecticide Treated bed Nets
among the tribal population of Chhattisgarh - A community based
intervention study
Chourasia M K, Abraham Vz John J
Purpose- Malaria is endemic in India, especially in tribal populated states since
the last 5 decades. Effective use of long lasting insecticide treated bed nets (LLITNs)
can reduce the burden of malaria. Health education plays a major role in
improving the utilization by changing the practice and behavior of the community.
This study assessed the knowledge and behavior of the tribal community regarding
malaria and compared two methods of health education for effective utilization of
bed nets among tribal people.
Method-A community based intervention study was carried out. A total of 218
households were selected and two different health educations were given in
respective villages. A follow up was done after a period of two months. Data was
entered in Epidata 3.1 and analysis was performed using SPSS 1 6 software.
Results-The findings of the study show that proportion of utilization of bed nets was
significantly higher among villages with household training as compared to the
villages with mass education((28.2%,95% Cl- 15.8-40.6). Use of bed nets was
significantly associated with knowledge of disease symptoms, transmission, and
prevention. Mean increase in knowledge score from baseline to two month follow
up was significantly higher in the household intervention as compared to mass
campaign (0.547,95%CI- 0.18-0.91 ,p value-0.004).
Conclusion- Overall findings suggest that household training is a more effective
form of health education for improving knowledge and promoting practices of
daily personal protective measures such as using LLITNs as compared to the
routine mass education.
63
Public Health Standards and Filaria Control in India: A Review
Jena PK, Kishore J
Filariasis is a neglected and endemic communicable disease affecting 250 districts
and around 553 million Indians, contributing to 80% of disease burden in South
East Asia region. Filariasis control is a part of integrated National Vector Borne
Disease Control programme. The standard of service delivery of Filariasis control
programme at Sub-Center(SC), Primary Health Center(PHC), Community Health
Center(CHC) etc. is guided by Indian Public Health Standards (IPHS). This review
of IPHSs for filarial control focuses on systemic approach to disease control. IPHS
sets norms for service delivery and job responsibilities of health human resources.
Assistance in detection, control and reporting of Filarisis and Mass Drug
Administration are part of essential service package at SC and job responsibility of
male and female health worker. Filariasis diagnosis and treatment is a part of
essential service package at PHC and CHC in endemic areas only. At PHC level
Medical officers, health assistant (male) and lab-technicians are assigned
appropriate job responsibilities. However job assignment of female health worker
to detect hydrocele, exclusion of female health supervisor in filarial control will
create cultural barrier and supervisory issues during implementation. Filariasis
clinic, a part of filarial control programme is not covered in the existing IPHS.
Further exclusion of health service in non-endemic areas in the IPHS would hamper
disease surveillance. Revision of IPHS at par with other national programmes,
extending application of IPHS for non-endemic areas, and setting norms for
private practitioner and community involvement may aid in elimination of
lymphatic Filariasis.
64
Water Supply, Sanitation and Hygiene Practices in Hunan Province, China:
Implications for the Control of Neglected Diseases and Health System
Strengthening
Balen, J., Li, Y.S., McManus, D.R, Utzinger, J., Raso, G.
Clean water supply, sanitation and hygiene practices (WASH) have wide-ranging
health implications. Inadequate sanitary conditions and poor knowledge, attitudes
and practice of good personal hygiene, such as hand washing with soap, play a
major role in the high incidence of numerous communicable diseases, with
negative consequences for health and development across communities. Indeed,
a recent systematic review of the literature confirmed that good hygiene practices
reduce neonatal mortality and that hand washing with soap reduces the risk of
endemic diarrhoea, as well as respiratory and skin infections, while face washing
prevents trachoma and other eye infections. We conducted a pilot study on WASH
in a Schistosoma japonicum endemic area of Hunan province, China.
Questionnaires were used to obtain quantitative data on defecating behaviour
and hygienic practices in 2,000 inhabitants of rural and peri-urban villages.
Although both settings were well endowed with latrines, inhabitants still declared
that they sometimes defecated elsewhere, in particular near to streams where the
vegetation offers hideouts. China has not yet invested widely in public education
regarding personal hygiene and public health practices. The active involvement of
health professionals in hygiene, sanitation, and water supply is crucial to
accelerating and consolidating progress in disease control and health system
strengthening.
65
Neglected Brucellosis: A Community Based Explorative Study In Odisha,
India
Pattanaik sarthak
Introduction: Under the umbrella of Tuberculosis, Malaria & HIV/AIDS all other
infectious diseases are being neglected in India. Further zoonotic disease like
Brucellosis is in the state of playing its role in community like a silent killer, causing
a great economic loss to livestock sector as well as mankind. According to OIE
brucellosis is one of the slowly emerging diseases in the developing countries. In
Odisha this disease is greatly neglected as very few studies have been conducted.
Methodolgy: This study was conducted by questionnaire at community level & in-
depth interview at professional level, also literature reviews. Tribal livestock
keepers, dairy farmers/workers, farm-owners, vets, Medicos are the key
informants of this study.
Finding: The study found peoples in regular contact with dairy cows for long
duration have backpain, joint pain, unknown fever, headache and orchitis. There
is huge knowledge gap in diagnosis of clinical brucellosis, as diagnosis is purely
laboratory based. The state immunization status against brucella in livestock sector
is very poor.
Discussion: Brucellosis incidence among livestock in Odisha is highest found in
India. Study by mohanty et al (2000) reports 9% seropositive to the tube
agglutination test. Finding shows brucella may be underlying cause which is being
neglected.
Conclusion: As a preliminary study brucella infection can't be avoided. Regular
screening, efficient diagnostic technique, vaccination, awareness are the key
solution. The 'One Health' concept is relevant here which makes collaboration
and integration of medical and veterinary programmes to uproot the problem.
Further study is required for quantitative measurement.
9
66
Clinico-epidemiological profile and management practices for snakebites
in Himachal Pradesh, India, 2008-2012
GuptA, BhatnagarT, Murthy BN
Background: WHO classifies snakebite as a neglected tropical disease. In India
snakebites are managed as per standard guidelines although prevalence of
species of snakes may vary across different regions. We describe the clinicoepidemiological profile and management practices of snakebite cases in
Himachal Pradesh.
Methods: We extracted records of snakebite cases at Zonal Hospital, Solan, from
2008 to 201 2. We estimated time trends, age and sex distribution of cases, and
distribution of bites by colour of snake. We categorized the clinical manifestations
into syndromes. Cases with locally toxic, hemotoxic or neurotoxic manifestations
were classified as poisonous bites. Amongst the poisonous cases, we analyzed
trends in use of vials of anti-snake venom (ASV) and its clinical outcomes and
financial implications.
Results: Of the total 497 snakebites during five years, cases increased from 77
(2008) to 1 1 0 (201 2), 73% occurred in rainy season (July-September), and 63 %
among 30-39 year old females. Colour of snake was recorded in 1 59 (32%) of
which 1 22 (77%) were green. In all, 1 71 (34%) were poisonous out of which 96
(56%) were hemotoxic. Out of 25 referred envenomings, 2 (8%) were given ASV at
peripheral institutes. Use of ASV vials decreased from 747 (2008) to 71 (2012),
with a corresponding reduction of 266% in the expenditure on ASV per cured
patient. Cure rate remained above 70%. Five (3%) poisonous cases died.
Conclusions: The cost of effective treatment of snakebites can be substantially
reduced by rationalizing the management practices, and producing monovalent
antitoxin as per predominance of specific species of snakes.
67
An assessment of knowledge of prevention and management of Rabies in
interns and final year students of Shri M.P Shah Government Medical
College, Jamnagar, Gujarat
Sarkar A, Parmar D.V.
Introduction: Rabies is one of the most important zoonotic diseases in India. Dogs
are the main reservoir of rabies in India. In Southeast Asia, untreated, improperly
treated or neglected cases lead to thousands of deaths yearly. Rabies can be
completely prevented through proper management, but once contracted its
almost always fatal.
Objectives: To assess the knowledge regarding preventive measures, post
exposure prophylaxis, wound management and use of RIG among the interns and
final year medical students of Shri M.R Shah Government Medical College,
Jamnagar, Gujarat.
Materials and methods: It is a cross-sectional study conducted in July,201 3.
Data was collected using pre-tested questionnaire from 1 00 interns and final year
students of Shri M.R Shah Government Medical College, Jamnagar, Gujarat.
Results: It was seen that only 59% knew that vaccination of dogs was an essential
preventive measure, 80% and 68% agreed that pre-exposure vaccination and
educating the people regarding pre- and post-exposure prophylaxis were useful,
respectively. Also 89% and 59% were aware that wound should be washed
immediately and antiseptics should be applied, respectively. 50% and 29% were
not aware of the schedule and dose of the PER respectively. Only 35% knew about
both IM and ID route of administration of PER Only 66% were aware that the site of
administration of PEP is deltoid.
Conclusion: The study showed that there was no proper knowledge about the
prevention and management of rabies in the study population which needs to be
overcome immediately with proper training.
68
Role of NGOs and public health partnership to improve accessibility to
health entitlements in rural India
Thomas, A. M., Abraham, G., Lalthanmawia, R., John, R
Introduction: The National Rural Health Mission aims to provide equitable access
to health services in rural India. But low demand and poor accessibility to health
entitlements under NRHM challenges the government's efforts to improve health
and control disease among the marginalized populations. This study highlights the
role of public-private partnership between NGOs and public health functions
which aimed to bridge the gaps, increase demand for health services and hence
improve access to NHRM health entitlements.
Methods: 40 NGOs were trained using Participatory Communication methods
on community mobilization, participatory governanze and networking in 40
blocks of 7 states from 2009 to 2012. Based on stratified random sampling 8
NGOs were selected and 8 Focus Group Discussions held. The study conducted 4
KI Is and 1 FGDs with community members and 1 3 KI Is and 1 FGD with health care
professionals to understand how this partnership helped improve communities'
accessibility to public health services.
Results: The 40 NGOs increased awareness and advocated for the NRHM health
entitlements using the participatory communication strategy among 100,000
populations in each district respectively. This resulted in increased immunization,
regular Ante Natal Care and institutional deliveries among the target audience.
The NGOs helped enhance the capacity of the public health service providers,
local media, Panchayati Raj Institutions on their roles and responsibilities for the
NRHM commitments. The NGOs created forums and spaces for dialogue among
various stakeholders in the community to promote the exchange of experiences,
innovations, learning and challenges.
Discussion: The NGOs developed innovative communication strategies,
empowered the public health service providers, innovated spaces for equitable
participation of the community, health service providers and PRIs in decision
making and health planning. The part
nership hence empowered people of marginalized, rural populations to access
and utilize the NRHM health entitlements in rural India which in turn contributes to
the field of disease control.
69
Lessons learnt from Kaladrug-R: New tools for monitoring drug resistance
and treatment response in Visceral Leishmaniasis in the Indian
subcontinent
Ostyn B, Vanaerschot M, Roy S, Salotra P, Carter Cz Berriman M, Eichner M, Maes
L, Schoenian G, Rijal S, SundarS, BoelaertM, Dujardin JC.
Background: Kaladrug-R project
We present the most relevant findings of four years (2009-2012) of clinicalepidemiological and parasitological research on treatment response and drug
resistance in previously treated and new cases ofVL in India (Muzaffarpur district,
Bihar) and Nepal (Terai region).
Miltefosine (MIL):
• Up to 20% MIL-relapse observed when patients are followed up for 1 2 months,
early treatment failure of MIL is not observed.
•
Relapse is not due to re-infection, low-drug quality or under-exposure to the
drug.
• Age and gender were risk factors for MIL-relapse.
• Although MIL-resistance is inducible in vitro, true MIL-R strains have as yet not
been identified in clinical samples.
• An association between parasite infectivity and MIL-treatment outcome of the
patient was observed.
Paromomycin (PMM) and pentavalent antimonials (SSG):
•
PMM-R is easily induced in vitro, vigilance is required when implemented in
clinical practice
• SSG-R strains, which are still present in the Indian subcontinent, more efficiently
manipulate the host's immune system, causing higher parasite burdens: what is
their legacy for the efficacy of othertreatments?
VL-epidemiology
• L. donovani population in the Indian subcontinent is fairly homogeneous, but
highly divergent strains circulate in the hilly regions of Nepal.
• Asymptomatics significantly outnumber clinical cases. Mathematical modeling
shows that if these are able to transmit parasites to sandflies, this reservoir can be
most efficiently tackled through adequate vector control.
VL-control take home messages
•
Importance of late treatment outcome monitoring, up to 12 months after
treatment.
•
Tools for VL-treatment outcome monitoring at primary health care level
available.
• Importance of vector control
70
Role of private health providers in Tuberculosis control: Preliminary
findings from a qualitative research
Vijayashree Holalkere Yellappa, Pierre Lefe
Background: Private practitioners (PPs) are the first choice for seeking
Tuberculosis (TB) care in India. Since 2001, National TB Programme (NTP)
engages with PPs through Public Private Mix Schemes (PPMS) to ensure universal
access. We conducted this study to understand what barriers exist to engage PPs in
NTP
Methods: This study employed a qualitative approach. Field work consisted of in
depth interviews with TB patients(n = 24), PPs(54) and programme managers
(n= 1 0) and focus group discussions with RNTCP field staff in Tumkur district from
March to August 201 3
Results:
Providers: None of the PPs interviewed had formally signed-up for any PPMS.
Collaboration was largely understood as routine referrals of TB suspects to NTP
Interaction between the public and private sector was minimal and was mostly
informal. There was low awareness about the PPMS among PPs. Record
maintenance was perceived as a major barrierto collaborate
Patients: Analysis of patient's itineraries revealed that, it is indeed complex with
patients shopping for care in-between public and private providers. This had led to
delays in seeking care, getting timely diagnosis thus leading to delay in initiating
the treatment. Factors such as family support, economic condition, knowledge
about TB have influenced the pathway of patients seeking care.
Discussion: The findings suggest that there is an urgent need for promoting
integrated and constructive notions of collaboration between private and public
sector. Strategies may be aimed at enhancing interactions and providing regular
trainings to inform PPs about the availability of PPMs in order to seriously aim for
universal access to TB care in India.
71
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