Adaptation of a malaria surveillance system for use in a visceral leishmaniasis elimination programme.

Background: Successful public practice relies on generation and use of high-quality data. A data surveillance system (the Disease Data Management System [DDMS]) in use for malaria was adapted for use in the Indian visceral leishmaniasis elimination programme. Methods: A situational analysis identified the data flows in current use. Taxonomic trees for the vector of visceral leishmaniasis in India, Phlebotomus argentipes, were incorporated into the DDMS to allow entry of quality assurance and insecticide susceptibility data. A new quality assurance module was created to collate the concentration of DDT that was applied to walls during the indoor residual spraying (IRS) vector control programme. Results: The DDMS was implemented in Bihar State and used to collate and manage data from sentinel sites in eight districts. Quality assurance data showed that DDT was under-applied to walls during IRS; this, combined with insecticide susceptibility data showing widespread vector resistance to DDT prompted a national policy change to using compression pumps and alpha-cypermethrin insecticide for IRS. Conclusions: The adapted DDMS centralises programmatic data and enhances evidence-based decision making and active policy change. Moving forward, further modules of the system will be implemented, allowing extended data capture and streamlined transmission of key information to decision makers.

Pharmacovigilance of Miltefosine in Treatment of Visceral Leishmaniasis in Endemic Areas of Bihar, India.

Miltefosine, the only oral drug for visceral leishmaniasis (VL), is being used as the first-line drug under the VL elimination program in the Indian subcontinent. Miltefosine is an oral drug which was used as a topical application for skin metastasis of breast cancer. It was found to be effective against Leishmania donovani The main adverse events (AE) reported previously with miltefosine use includes diarrhea, vomiting, and dehydration. Other AEs include, raised serum alanine transaminase/aspartate aminotransferase and renal parameters such as creatinine. In this study, we report AEs in a large patient cohort of VL treated with miltefosine. The purpose of this pharmacovigilance study was to assess adverse drug reactions (ADRs)/AE of miltefosine treatment under unrestricted condition in the field setup. Patients were followed up to 6 months for therapeutic effectiveness. Outcomes of a larger data set of patients treated with this regimen from April 2012 to March 2015 were recorded. In the present study, 646 patients of VL were given miltefosine. Majority of the study subjects (58%) were male. Relapse occurred in 7% during follow-up period. Main causes of death were VL-pulmonary tuberculosis coinfection, extreme diarrhea, and acute pancreatitis which were reported in 1.7% subjects. Of 553 (85.6%) patients completing full course of treatment, 463 (83.7%) showed ADR with miltefosine during the study period. About 2.3% were suffering severe ADR, 51% from moderate, and the rest had mild ADR. The initial and final cure rate was 97.4% and 85.6%, respectively.

Community perceptions on malaria and care-seeking practices in endemic Indian settings: policy implications for the malaria control programme.

BACKGROUND: The focus of India's National Malaria Programme witnessed a paradigm shift recently from health facility to community-based approaches. The current thrust is on diagnosing and treating malaria by community health workers and prevention through free provision of long-lasting insecticidal nets. However, appropriate community awareness and practice are inevitable for the effectiveness of such efforts. In this context, the study assessed community perceptions and practice on malaria and similar febrile illnesses. This evidence base is intended to direct the roll-out of the new strategies and improve community acceptance and utilization of services. METHODS: A qualitative study involving 26 focus group discussions and 40 key informant interviews was conducted in two districts of Odisha State in India. The key points of discussion were centred on community perceptions and practice regarding malaria prevention and treatment. Thematic analysis of data was performed. RESULTS: The 272 respondents consisted of 50% females, three-quarter scheduled tribe community and 30% students. A half of them were literates. Malaria was reported to be the most common disease in their settings with multiple modes of transmission by the FGD participants. Adoption of prevention methods was seasonal with perceived mosquito density. The reported use of bed nets was low and the utilization was determined by seasonality, affordability, intoxication and alternate uses of nets. Although respondents were aware of malaria-related symptoms, care-seeking from traditional healers and unqualified providers was prevalent. The respondents expressed lack of trust in the community health workers due to frequent drug stock-outs. The major determinants of health care seeking were socio-cultural beliefs, age, gender, faith in the service provider, proximity, poverty, and perceived effectiveness of available services. CONCLUSION: Apart from the socio-cultural and behavioural factors, the availability of acceptable care can modulate the community perceptions and practices on malaria management. The current community awareness on symptoms of malaria and prevention is fair, yet the prevention and treatment practices are not optimal. Promoting active community involvement and ownership in malaria control and management through strengthening community based organizations would be relevant. Further, timely availability of drugs and commodities at the community level can improve their confidence in the public health system.

New perspectives of malaria control in India under World Bank Project.

The World Bank has been assisting Government of India (GoI) for a number of years with development of effective health services for the control of vector borne diseases (VBDs). An Enhanced Malaria Control Project (EMCP) under financial assistance from Bank was implemented in selected tribal states and districts from 1997 to 2005. While most of the project districts did report a decline in malaria incidence, the Implementation Completion Report (ICR) highlighted the need for major reform. Plasmodium falciparum (Pf) malaria, which accounts for almost all malaria related mortality, has been increasing in India and there is widespread resistance to chloroquine. The needed reform would require, first and foremost, updating of policy on malaria case management in public and private sectors. Also needed are innovative approaches for promoting the use of insecticide treated nets (ITNs) and strengthening institutions at the district and state levels for effective implementation of new policies. Several important changes in the policy on diagnosis and treatment of malaria are being implemented in this new project. The most important of these are: Use of artesunate combination therapy (ACT) as the first line treatment for all confirmed Pf malaria cases, introduction of rapid diagnostic kits for quick diagnosis of Pf cases, promotion of long lasting insecticide treated bed nets (LLINs) in vulnerable population. Supervision and monitoring will be strengthened by deployment of Malarial/Kala azar Technical Supervisors (MTS/KTS) and VBD consultants at district level. The project has also envisaged two important components like Environment Management Plan (EMP) for safe use of insecticides and materials and Vulnerable Community Plan (VCP) for the benefit of underprivileged population.

Japanese Encephalitis epidemic in Anantapur district, Andhra Pradesh (October-November, 1999).

Epidemic of Japanese Encephalitis has occurred in Andhra Pradesh during October-November, 1999 affecting 15 out of 23 districts. In total, 873 cases with 178 deaths have been recorded up to the day 29.11.99. The epidemiological investigation has been done in Anantapur district in western Andhra Pradesh, where the outbreak has started in the third week of October. In the district 47 PHC have been affected. On an average 4.5 per cent of 3175 villages have been affected. Average number of cases per affected village have been 1.5. Rural population has been primarily affected. Age groups 1-14 years including infants have been affected but nearly 86.8% of cases have been among 1-9 year age group. The overall case fatality rate has been 18.4 per cent. Clinical features have been high fever, headache, altered sensorium, convulsions and coma. A marked seasonal onset of a few cases per village and 93.75 per cent of human serum samples collected from hospitalised cases showed the evidence of J.E. virus infection indicating that the present outbreak was due to JE virus. High density of Culex vishnui complex mosquitoes has been observed in the area. All the environmental and ecological conditions, temperature, rainfall and relative humidity have been in favour of JE transmission. Analysis of the data for the last 10 years showed that the human JE cases occurred in Anantapur in September-October months, which shifted to October-November, 99. Prolonged draught conditions were observed till October. Possibly the delayed monsoon and congenial atmospheric conditions after monsoon were favourable to the vector species for extra-human cycle of transmission in 1999. Low level transmission leading to small number of cases continued during the succeeding years every September-October till the present epidemic. In all 24 PHCs and urban towns were identified with 212 cases and 39 deaths till 29.11.99.