Elimination of Lymphatic Filariasis
Country Scenario - India
Directorate of National Vector Borne Disease Control Programme
Directorate General of Health Services
Ministry of Health & Family Welfare, Delhi (India)
Elimination of Lymphatic Filariasis in India
India – Population at Risk of LF
JAMMU & KASHMIR
HIMACHAL PRADESH
PUNJAB
UTTARAKHAND
HARYANA
DELHI
ARUNACHAL PR.
SIKKIM
RAJASTHAN
UTTAR PRADESH
BIHAR
GUJARAT
MADHYA PRADESH
ASSAM
NAGALAND
MEGHALAYA
MANIPUR
WEST BENGAL
JHARKHAND
TRIPURA
MIZORAM
CHHATTISGARH
ORISSA
DAMAN & DIU
D&N HAVELI
MAHARASHTRA
ANDHRA PRADESH
Endemic Districts
Non-Endemic Districts
GOA
KARNATAKA
A&N ISLANDS
PONDICHERRY
TAMIL NADU
KERALA
LAKSHADWEEP
N
W
E
S
Endemic districts – 254
(in 21 States/UTs)
Population at risk:600 million
ELIMINATION OF LYMPHATIC FILARIASIS
Elimination of LF : LF ceases to be a public
health problem, when the number of
microfilaria carriers is less than 1% and the
children born after initiation of ELF are free
from circulating antigenaemia
Goal:
The National Health Policy (2002) has set
the goal of Elimination of Lymphatic
Filariasis in India by 2015.
Global goal to eliminate Lymphatic Filariasis (LF)
as public health problem by 2020 through World
Health Assembly resolution WHA 50.29.
3
GPELF overall framework
Mapping
MDA
Post-MDA
surveillance
TAS
M&E
Situation
2. MMDP analysis
Plan
Minimum
package of
MMDP care
Verification
1. MDA
Dossier development
VC/IVM
MMDP and
rehabilitation
integrated into
health services
Lymphatic Filariasis
Strategies for Elimination & Impact
2.00
90.00
86.69 87.92
86.42
86.07
1.50
84.50
83.09
8
2.91
81.86
80.00
Mf Rate (%)
100.00
Covg.%
1. Interruption of transmission
by Annual MDA with DEC +
Albendazole for 5 years or
more to the population
except:
 children below 2 years
 pregnant women
 seriously ill persons
2. Home based management of
lymphoedema cases and upscaling of hydrocele
operations in the identified
CHCs / District hospitals/
medical colleges.
1.2
76.23
72.42 1.0 1.0
1.00
70.00
60.00
0.7
0.6
0.5
0.50
0.4 0.4 0.4
0.3
50.00
0.00
2004200520062007200820092010201120122013
Coverage%
Impact of MDA
250
203
Number of Districts
200
142
150
100
76
50
30
19
6
1
0
2004
<1%
21
2013
1-5%
>5%
Not Done
Scaling Down MDA
• MDA to be stopped after minimum 5 rounds of MDA
with >65% compliance against total population at
risk and districts reporting less than 1% mf
prevalence
• WHO – 2011 guidelines simplified and capacity
building initiated
• 4 core trainers at Puducherry during July’12
• 139 state/district trainers during June-Oct’13
• 59 from 14 districts of UP trained in June’14
• 90 proposed in 2014-15
• 28 districts cleared TAS
• 50 out of 62 completed Pre-TAS activity.
TAS Plan for MDA Stoppage
Number of Distt
150
102
100
90
50
40
14
4
0
2012-13
Achievement
4
2013-14
14
2014-15
2015-16
2016-17
10
Anticipated to stop MDA after Nov-Dec 2015 and finish TAS by June 2016
Lymphoedema Management demonstration- Andhra Pradesh
Washing Demonstration
Providing Morbidity management Kits
Lymphoedema Management demonstration- Odisha
Washing Demonstration
Foot Exercise
Lymphoedema Management demonstration- Tamil Nadu
Training & Providing Kits of Soap, Mug, Towel
1 – 100 Cases
101 – 500 Cases
501 – 1000 Cases
1001 – 2000 Cases
2000 & above Cases
Lymphoedema Management demonstration - Madhya Pradesh
Training & Providing Kits of Soap, Mug, Towel
Lymphoedema Management demonstration – Daman & Diu
Providing Kits of Soap, Mug, Towel
Hydrocelectomy
• Hydrocelectomy is usually done in CHCs, district
hospitals or medical colleges free of cost.
• Programme emphasises to intensify the hydrocele
operations in camp mode for more operations
• The incentives to promote such activities are provided
@ Rs.750 per case (US$ 12)
• Rs. 250 to Surgeon,
• Rs.50 to staff Nurse,
• Rs.50 to Ward Boy/Attendant,
• Rs.300 for medicine/dressing
• Rs.100 to the patient towards travel expenses.
• Some states pay more out of state resources but it
varies from state to state
Incentivized morbidity management
1. Incentives for Morbidity Management
• Rs 750 per hydrocelectomy (camp
approach)
• Rs. 150 per Ly. Management Kit
• Rs.200/- one time for line listing of
lymphoedema and hydrocele cases
2. Financial Resources increased from Rs
250 cr (XI Plan) to Rs 400 Cr (XII
Plan) for total ELF including MDA, MM,
TAS.
Hydrocelectomy Camp in Satna Distt of Madhya Pradesh
Patient being operated
Two patients being operated
GUIDELINES
Experiences
• Tamil Nadu Model:
• Tamil Nadu initiated by providing morbidity management kit from
state resources.
• Recently, Tamil Nadu has also approved to provide a monthly
pension of Rs. 400 to grade-IV of lymphoedema patients.
• CASA model in Odisha:
• In Khurda district of Odisha, CASA – a NGO has taken 3 blocks
and linelisted all the lymphoedema cases.
• Engaged volunteers named as Task Force (1 per 20 patients).
CASA engaged 15 health workers (1 per 20 Task
Force/Volunteers) at the rate of Rs.3000 per month.
• To monitor these health workers, four supervisors and one
coordinator were engaged.
• Provided the morbidity management services to each and every
lymphoedema patients and maintained a card to monitor the
improvement in their suffering.
• CASA also helped during MDA programme of the district
especially in IEC/BCC activities.
Experiences
• Madhya Pradesh Model:
• The state provided morbidity management kit out of their own
resources to the Lymphoedema patients.
• They also organised hydrocele camps in district hospitals with
lot of social mobilization and awareness generation.
• Gujarat Model:
• Gujarat has very strictly observed the activity of updating
linelisting the lymphoedema and hydrocele cases for 15-30 days
in preceding months of MDA in each district.
• Mapped the prevalence of these cases village-wise.
The
morbidity management are provided to these patients and
resources are mobilized according to the number of patients.
Experiences
• Kerala Model:
• Kerala is known for presence of both W.bancrofti and B.malayi.
• Prof. Shenoy group has been providing home based morbidity
management services to the patients and keeping their records
for regular monitoring and assessing the impact.
• Dr.Narhari’s group at Institute of Applied Dermatology,
Kasargode, Kerala is using Ayurvedic medicines combined with
Yoga and getting the impact as per their reports.
• In addition, state is following the national guidelines of
morbidity management but its monitoring needs strengthening
at ground level.
Experiences
• There are some groups working on surgical repair, sculpturing etc.
in Tamil Nadu which includes:
• Dr. Manoharan’s group at Chennai
• Dr. Sivasubramaniyan’s group at
Tamil Nadu, India.
Settiarpatti,
Rajapalayam,
• Lepra India: working on Lymphoedema Management
- In two districts of Andhra Pradesh and Bihar each.
- After Line listing of Lymphoedema cases, they are
classified and the Morbidity Management training are
provided.
- Shoes are also providing from their project.
Major Achievements
 877,594 Lymphoedema cases line listed.
 407,307 Hydrocele cases line listed
 110,842 Hydrocele operated
 350 non endemic districts line listing initiated
 Involvement of CASA is appreciated and being expanded.
Priority actions
• Social Mobilization for improved drug compliance
and morbidity management.
• Supporting MDA and management of adverse
reactions.
• Involvement of faculties from medical colleges,
Research Institutions and Regional Directors (GoI)
for monitoring and independent assessment
• Morbidity surveys and morbidity management for
all patients individually and also at community
level.
• Motivating people suffering from Hydrocele to go
for surgical intervention.
• Involvement of NGOs/Voluntary organizations
Partnership
• State Governments
• Other Government Departments
• NGOs like CASA, Lepra India, IADKasargod
• Medical Colleges
• ICMR-VCRC Puducherry; RMRC
Bhubneswar; RMRC Dibrugarh; CRME,
Madurai
• NCDC
• Drug donors
• WHO
Joint Monitoring Mission
Action Points (1)
a)
b)
c)
d)
The Impact of last decade massive
intervention is clearly visible in 2012
as follows:
Coverage generally improved (73%
in 2004, 86% in 2012),
Microfilaria (mf) rate overall declined
(1.24% in 2004, 0.45% in 2012),
The program is on right track except
in few districts with sub-optimal
coverage,
Phasing out MDA has started in 50
districts, 7 districts has cleared and
43 are in pre-TAS phase in 2014.
• States preparing for
next round of MDA
• Completed 4 TAS
workshops
with
WHO support
• Planned
6 more
TAS workshops for
district level officials
• 14 districts (IUs) and
21
IUs
have
successfully
completed TAS
JMM Action Points (2)
• Districts >1% mf: MDA
compliance should focus
on
poor-performing
PHCs within the district
for improvement and
supplement
vector
control on IVM strategy
with MDA
• Districts <1% mf: TAS to
be performed to stop
MDA
with
technical
support by ICMR / WHO
• Efforts are on to
improve
compliance
especially in poorperforming areas
• IVM is already in vogue
and providing co-lateral
benefits
• 96 districts are planned
for TAS in 2014-15 out
of which 55 have
validated
mf
prevalence <1%
JMM Action Points (3)
• Provision of Lymphoedema
management
services
at
PHCs
• expansion
of
hydrocele
operations at CHCs/ District
Hospitals to be established
under NHM.
• IEC/BCC to be strengthened
to raise awareness
• Morbidity management to
continue even after stoppage
MDA – continued support is
required
• Already emphasized in
PIP guidelines
• Hydrocele operation at
District
Hospitals
is
regular
phenomenon.
Incentives are provided
for camp approach.
• To strengthen IEC/BCC,
flexibility for use of funds
is provided.
• Yes it will continue
JMM Action Points(4)
• Post MDA surveillance to be
performed as per guidelines –
at least two TAS after every 2-3
years.
• Support to assess new (ICT)
/additional
(i.e.
antifilarial
antibody) diagnostic tools for
surveillance and alternative
surveillance strategies (i.e.
xenomonitoring) to ensure the
interruption of transmission.
• The “hot-spots” (with persistent
high case burden) to be under
intensive
surveillance
for
treatment and interventions
• Post MDA surveillance draft
National
guidelines
circulated Second TAS as
per guidelines will be
followed
• Still under multi-centric trial
phase.
• The “hot-spots” are being
covered under treatment
and
interventions.
However,
Independent
Appraisal
of
ELF
programme is also going
on in 12 districts of 6 states
and
detail
recommendations will be
available in August.
Independent Appraisal
•
•
•
•
Independent Appraisal through ICMR (VCRC)
1st briefing meeting on 20th June,2014
1st phase field visit for secondary data from 1-3 July, 2014
2nd Phase field visit for primary data from 14-26 July, 2014
S.No. Name of state
Name of District
1
Bihar
Muzaffarpur, Khagria
2
Gujarat
Valsad, Surat
3
Madhya Pradesh
Damoh, Panna
4
Odisha
Ganjam, Khurda
5
Telangana
Karim Nagar, Nalgonda
6
West Bengal
West Medinipur, Bankura
Update on Independent Appraisal
• Bihar :
Governance at state/distt level is crucial but
grass root workers are aware and can improve
• Gujarat : showing impact but coordination in corporation
and state Directorate needs attention for monitoring to
tackle migratory population
• MP :
Mf rate in certain blocks is high due to
suboptimal performance
• Odisha : Priority affects performance in some areas
(malaria is main priority)
• Telangana : high Mf rate in certain blocks reflects
suboptimal performance
• West Bengal : Progressed well video conferencing from
Director NVBDCP & MD to DC followed by letters has
given priority in districts
4/13/2015
ELF - PKS
30
Hard core Districts
State
District
Assam
Bihar
Dibrugarh, Sibsagar
Begusarai,
Buxar,
Jahanabad,
Khagaria,
Munger,
Muzaffarpur,
Saharsha,
Shekhpura,
Sheohar,
Sitamarhi, Vaishali
Surat
Dumka, Goda, Lohardaga
Gulbarga
Gadchiroli, Nagpur
Nalgonda
Ganjam
Banda,
Barabanki,
Faizabad,
Gorakhpur, Kheri, Sohanbadra
Bankura, Burdwan, Purulia
ELF - PKS
Total
Gujarat
Jharkhand
Karnataka
Maharashtra
Telangana
Orissa
Uttar Pradesh
West Bengal
4/13/2015
No.
2
11
1
3
1
2
1
1
6
3
31
31
Hot Spot Areas identified for focused
attention
• Assam –Tinsukhia, Karbi Anglong, Naugaon,
Sonitpur (Tea estates & patchy population)
• Odisha – Sambalpur, Bolangir, Bargarh,
Keonjhar, Kandhamal
• Madhya Pradesh – Narsinghpur, Shivpuri,
Panna
• Gujarat – Surat migratory poulation
Way Forward
1. Tackling Hard core Distt, Hot spot Areas &
Migratory Population ( Expert Panel)
2. National TAS & Post TAS Guidelines draft
ready and to be printed for circulation
3. Phasing out MDA
• Transmission Assessment Survey using
ICT in all districts (WHO to be requested
for facilitating ICT supply)
4. Morbidity Management - Intensification
5. Programme Appraisal
6. Sustaining Achievement through Post MDA
Surveillance
7. Validation of Achievement
8. Elimination Certification
Thank You