|The Vector-borne diseases (VBDs) are a group of communicable diseases transmitted by mosquitoes and other vectors. People suffer from a significant disease burden from these diseases in local and focal areas of India, which is reflected in the form of morbidity and mortality from Malaria, Dengue, Chikungunya, Japanese Encephalitis (JE), Kala-azar and Lymphatic filariasis. The epidemiology of these vector borne diseases varies considerably on account of ecology, vector bionomics, economic, socio-cultural and behavioral factors. Generally, the high risk areas for VBDs are rural and tribal areas and urban slums inhabited by the poor, marginalized and vulnerable groups with limited access to quality health care, communication and other basic amenities in those focal areas.|
Dr. A.C. Dhariwal
The National Vector Borne Disease Control Programme (NVBDCP) is the programme for prevention & control of these vector borne diseases as an integral part of the National Rural Health Mission (NRHM) of India. The NVBDCP envisages a self-sustained and well informed, healthy India free from vector borne diseases with equitable access to quality health care services nearest to their residences. The Programme activities are directed in a way to meet with the Millennium Development Goal of halting and reversing the incidence of malaria and other vector borne diseases by the year 2015 towards reduction of poverty.
The programme aims to make the investments sustainable by developing robust systems and supporting the local capacity. It is planned to ensure that the right diagnostics and treatment are available to all people – especially the poor and disadvantaged living in tribal and rural areas. The GoI has provided cash assistance for engaging Multi-Purpose health Workers (MPW) on contractual basis in high endemic districts for strengthening surveillance, treatment, prevention and control of malaria and other vector borne diseases. Accredited Social Health Activists (ASHA), Anganwadi Workers and MPWs are trained on the use of RDTs and ACT for malaria diagnosis and treatment at community level. Incentives are given to ASHAs for providing these services.
Significant progress has been made in some states but the progress in a few other states has been uneven, although tender shoots of success are visible. Though the malaria situation has leveled to around 1.5 million cases per year in the past few years, there is immense confidence for future in spite of logistic challenges. The window of opportunity is wide open with availability of effective interventions and increased resource allocations.
Monitoring and evaluation are integral to every aspect of the programme and critical to its success. A new cadre of Malaria Technical Supervisors has been inducted in high endemic areas at sub-district level to strengthen supportive supervision and micro-level monitoring of diagnosis, treatment, prevention and control activities.
In The National Malaria Drug Policy (2010), it has been recommended that the first line of treatment of all P. falciparum cases in the entire country will be Artemisinin-based combination Therapy (ACT). Studies are conducted regularly to monitor therapeutic efficacy through teams at the Regional Offices of Health and Family Welfare and National Institute of Malaria Research. It is very important that the treatment guidelines as given in the article in the present issue of the journal are followed by everyone involved in the treatment of malaria cases so that the development of resistance to the effective drugs are delayed.
Indoor Residual Spray (IRS) and Insecticide Treated bed Nets (ITN) / Long Lasting Insecticidal Nets (LLIN) are used for vector control in rural areas and anti-larval measures in urban areas. LLINs were introduced in 2009 with supply of 2.57 million nets to people living in high malaria endemic areas and 6.5 million LLINs supplied during 2011. The insecticide policy in different areas is revised based on results of vector susceptibility studies and epidemiological impact of IRS. The use of larvivorous fish for larval control is expanded as an eco-friendly and effective vector control measure.
Sentinel surveillance has been initiated for obtaining information on severe malaria cases and deaths due to malaria, by designating 1 - 2 hospitals in each high endemic district. Detailed investigation on deaths is done with the aim of improving referral and treatment services in problem areas. Provision exists for transfer of severe malaria cases to referral centers with the expenditure borne out of untied funds of the National Rural Health Mission. Early and timely reference of severe cases even by the private providers to the referral centers where such cases are managed will help in reducing the deaths due to malaria.
There is an upsurge noted in the number of cases of some of the arboviral diseases like Dengue and Chikungunya especially in the urban areas of the country. This has happened due to favourable environment available in these areas to the vector Aedes mosquitoes. Effective control of the vector mosquitoes with the help of community support and increased awareness is very important to control the transmission of these diseases. The role of both private and public sector healthcare providers in these areas is very important to increase the awareness in the community and motivating the people for reducing the breeding sources of the vector. A network of 311 Sentinel surveillance hospitals and 14 Apex Referral Laboratories with advanced facilities located in 35 States/UTs for diagnosis of Dengue and Chikungunya has been established in the country where antigen and both antibody-based case detection kits are available.
Japanese Encephalitis (JE) outbreaks have been reported from different parts of the country periodically. These outbreaks are usually circumscribed and do not cover large areas. They usually do not last more than a couple of months. The involvement of private providers in motivating the community for vaccination in the specific areas against JE and in preventive actions will help to reduce its transmission.
Kala-azar elimination project is being implemented in four endemic States namely Bihar, Jharkhand, Uttar Pradesh and West Bengal with introduction of Rapid Diagnostic Test for diagnosis and oral drug Miltefosin for treatment. The private providers can use this facility to diagnose their cases through the nearest PHCs and help in ensuring treatment compliance by getting involved through various partnership schemes and thus contributing in achieving the elimination of Kala-azar.
The strategy for achieving the goal of elimination of filariasis is by annual Mass Drug Administration of anti-filarial drugs (DEC+Albendazole) for 5 years or more to the population excluding children below two years, pregnant women and seriously ill persons in affected areas to interrupt transmission of disease. Home based management of cases of lymphoedema (elephantiasis) is encouraged under this. Hydrocelectomy operations in identified CHCs and hospitals are also done under the programme. The private providers can play an important role in this endeavour by referring the cases to avail those services and also motivate the community during MDA.
Malaria control activities are intensified in high endemic states with special projects. The strategies include early diagnosis and complete treatment, integrated vector management and other supportive interventions including training, and behavior change communication. The use of Rapid diagnostic tests (RDT) for diagnosis of cases has been scaled up in the country for early diagnosis of P. falciparum malaria in difficult-to-reach areas where microscopy results cannot be made available within 24 hours of taking blood smears. About 10 million RDTs are used annually by the programme.
I am happy to see that there is a renewed commitment for collaboration to improve the lives of those we are privileged to serve. The programme is constantly promoting partnership with NGOs, private sector including industry, Faith Based Organizations, Community Based Organizations and Panchayat / Village Councils / Tribal Councils. Necessary information is being shared with all partners to facilitate system strengthening and quality enhancement. Through these efforts, access to services and support can be provided to people in isolated and vulnerable areas. We also look forward to the participation of Medical Colleges to function as sentinel sites as well as in operational research activities for which NVBDCP has supported NIHFW to organize training of faculty of medical colleges (community medicine, pediatrics, medicine and microbiology) during 2011.
There is a constant threat of malaria and other vector borne diseases for spread into new areas as a result of climate change and environmental factors. In these days, with inter-state travel as common as travel between adjacent villages was, a generation ago, dispersal of the malarial parasites from endemic areas to non-endemic areas, particularly to cities and towns has become common. Now is the time to focus on what has to be achieved – to scale up and produce results; to roll back malaria, its threats and suffering. We are now more determined than ever to achieve the ultimate goal of eliminating malaria and other VBDs from India.
The focus of India’s malaria control strategies is not only on techno-managerial aspects but also on the socio-economic-cultural context. Behvaiour Change Communication (BCC) activities are aimed at generating awareness that would enable and empower the people to access and utilize available services and actively participate in the decision making processes. Anti Malaria Month is observed in the month of June every year with enhanced campaigning prior to the peak malaria transmission season.
Improving health outcomes is a shared responsibility. It is intended to pursue VBD control strategies through actions which involve all sections of society and all sectors. By doing so, we could serve as engines of change that would demonstrate what is possible when the right ideas, policies and resources come together. This requires an alignment of people and forces that share a mutual commitment.
It is estimated that the private sector account for around 80% share of all health care delivered in India and this share is increasing rapidly. We urge the private practitioners to join as strongly as possible in the government’s fight against malaria. We request the practitioners to adopt diagnostic and treatment practices which are consistent with the national guidelines. Incorrect schedules based on patient’s demands and sub-therapeutic regimens can lead to emergence and spread of drug resistant strains of malarial parasites. We also appeal to the practitioners to educate the community on methods of preventing malaria and protecting oneself from mosquito bites. Together as partners we have an opportunity to contribute to effective programme implementation and impact. The programme conducts training not only for government personnel but also for private practitioners to sensitize them about the policy and strategies for VBD control.
In spite of some spectacular successes against malaria, we are still far from attaining freedom from malaria. It is not acceptable to consider that malaria is part of the misery of being poor. Our control strategies have the potential to substantially reduce the malaria burden, breaking the cycle of infection, disease and lost opportunities that keep people in poverty. Much more remains to be done, and the road ahead may not be easier than the one already traveled.
The Global Fund (GFATM) and the World Bank are the major partners supporting the NVBDCP for its specific activities in focal areas for malaria control and kala- azar elimination in the most endemic districts affecting the poorest of the poor residing in inadequate and unhygienic housing. WHO is another important partner providing technical support and assistance to the programme in various forms.
The website of NVBDCP is an effort to meet those challenges. It is an effort to communicate the learned readers of this site about the activities undertaken by the NVBDCP and current status and issues related the VBDs. I hope that it will be useful to the readers in the provision of their healthcare services. It is requested to the healthcare providers in the private sector to adopt the current drug policy for the treatment of the malaria cases treated by them. Various Public –private partnership schemes are also there to involve the private providers, the information of which can be available from the State/district authorities. The combined efforts of all will help us to achieve our goals for controlling VBDs.