Directorate of National Vector Borne Disease Control Programme Directorate General of Health Services Ministry of Health & Family Welfare, Delhi (India) Elimination of Lymphatic Filariasis Country Scenario - India

India – Population at Risk of LF Endemic districts – 254 (in 21 States/UTs) Population at risk:600 million Elimination of Lymphatic Filariasis in India

3 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 Global goal to eliminate Lymphatic Filariasis (LF) as public health problem by 2020 through World Health Assembly resolution WHA

GPELF overall framework Mapping MDA Post-MDA surveillance 1. MDA 2. MMDP VC/IVM Situation analysis Plan Minimum package of MMDP care Situation analysis Dossier development Verification MMDP and rehabilitation integrated into health services M&E TAS

Strategies for Elimination & Impact 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 up- scaling of hydrocele operations in the identified CHCs / District hospitals/ medical colleges. Lymphatic Filariasis

Impact of MDA

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’ state/district trainers during June-Oct’13 59 from 14 districts of UP trained in June’14 90 proposed in districts cleared TAS 50 out of 62 completed Pre-TAS activity.

Number of Distt Anticipated to stop MDA after Nov-Dec 2015 and finish TAS by June 2016

Lymphoedema Management demonstration- Andhra Pradesh Providing Morbidity management Kits Washing Demonstration

Foot Exercise Washing Demonstration Lymphoedema Management demonstration- Odisha

1 – 100 Cases 101 – 500 Cases 501 – 1000 Cases 1001 – 2000 Cases 2000 & above Cases Training & Providing Kits of Soap, Mug, Towel Lymphoedema Management demonstration- Tamil Nadu

Lymphoedema Management demonstration - Madhya Pradesh Training & Providing Kits of Soap, Mug, Towel

Providing Kits of Soap, Mug, Towel Lymphoedema Management demonstration – Daman & Diu

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 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 Two patients being operated Patient 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 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 Settiarpatti, Rajapalayam, Tamil Nadu, India. 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.

 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. Major Achievements

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 Priority actions

State Governments Other Government Departments NGOs like CASA, Lepra India, IAD- Kasargod Medical Colleges ICMR-VCRC Puducherry; RMRC Bhubneswar; RMRC Dibrugarh; CRME, Madurai NCDC Drug donors WHO Partnership

Joint Monitoring Mission Action Points (1) The Impact of last decade massive intervention is clearly visible in 2012 as follows: a)Coverage generally improved (73% in 2004, 86% in 2012), b)Microfilaria (mf) rate overall declined (1.24% in 2004, 0.45% in 2012), c)The program is on right track except in few districts with sub-optimal coverage, d)Phasing out MDA has started in 50 districts, 7 districts has cleared and 43 are in pre-TAS phase in 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 poor- performing areas IVM is already in vogue and providing co-lateral benefits 96 districts are planned for TAS in 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) 1 st briefing meeting on 20 th June, st phase field visit for secondary data from 1-3 July, nd Phase field visit for primary data from July, 2014 S.No.Name of stateName of District 1BiharMuzaffarpur, Khagria 2GujaratValsad, Surat 3Madhya PradeshDamoh, Panna 4OdishaGanjam, Khurda 5TelanganaKarim Nagar, Nalgonda 6West BengalWest 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 4/22/2015ELF - PKS30

4/22/2015ELF - PKS31 StateDistrictNo. AssamDibrugarh, Sibsagar2 Bihar Begusarai, Buxar, Jahanabad, Khagaria, Munger, Muzaffarpur, Saharsha, Shekhpura, Sheohar, Sitamarhi, Vaishali 11 GujaratSurat1 JharkhandDumka, Goda, Lohardaga3 KarnatakaGulbarga1 MaharashtraGadchiroli, Nagpur2 TelanganaNalgonda1 OrissaGanjam1 Uttar Pradesh Banda, Barabanki, Faizabad, Gorakhpur, Kheri, Sohanbadra 6 West BengalBankura, Burdwan, Purulia3 Total31 Hard core Districts

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

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