FIELD PROJECT REPORTS
By Sagolsem lbungochouba Singh (MAE-FETP Scholar 2006-2007)
Submitted in partial fulfillment of the requirements for the degree of
MASTER OF APPLIED EPIDEMIOLOGY (M.A.E.)
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala - 695 011.
This work has been done as part of the two years Field Epidemiology Training
Programme (FETP) conducted at
National Institute of Epidemiology (Indian Council of Medical Research), R -127, Third avenue, Tamil Nadu Housing Board, Ayapakkam, Chennai, Tamil Nadu. Pin- 600 077
JANUARY 2008 CERTIFICATION
This is to certify that all the field projects submitted in this Bound Volume are original work carried out by Sagolsem lbungochouba Singh during the two field postings of six months each under the guidance of faculty of National Institute of
Epidemiology (ICMR), Chennai and the local supervisor specially nominated for this purpose. This is in partial fulfillment of the requirements for the degree of Master of
Applied Epidemiology (M.A.E.) and has not been submitted earlier by him in part or whole for any other (Publication or Degree) purpose.
Director ACKNOWLEDGEMENT
Several dignitaries have extended their valuable time, advice and assistance to me during preparation of this report. I extend with gratitude my sincere thanks to:
Prof. M.D.Gupte, Director, National Institute of Epidemiology (NIE), Chennai for his valuable guidance amidst his busy schedule.
Dr Murhekar Manoj Vasant, Deputy Director, NIE and MAE-FETP ,course coordinator and supervisor, for his close guidance and encouragement inspite of his busy schedule.
Dr Th~ Biren Singh, Additional Director (Public health), Medical & Health Services Department, Govt. of Manipur, Imphal, for his valuable guidance.and advice.
Dr Yvan Hutin, resident advisor WHO to NIE, Chennai, for his valuable guidance, comments, suggestions and advice.
Dr Sougaijam Sukumar Singh, Chief Medical Officer, Imphal districts for his valuable guidance and help during my field posting. Dr Wahengbam Gulapi Singh, Chief Medical Officer, Bishnupur district and Dr Puran Kumar Sharma, Superintendent, Kurseong sub-divisional hospital, Darjeling, West Bengal for their kind and help during my outbreak investigation.
Dr R Ramakrishnan, Dr (Mrs) Vidya Ramachandran, Deputy Directors, Dr P Manickam, Research Officer, Dr (Mrs) Vasna Joshua and Dr Sundaramoorthy, Technical officers, NIE, for their constant support and guidance. ·
Mr. S. Satish, librarian, Mrs. Uma Manoharan, secretary to the FETP and other office staff at NIE for their support and assistance.
My father S. Manihar Singh and mother S. Muktamani Devi, my wife Ranjeeta (Leima) and my sons Puthoiba and Tonton, my brother, sisters, friends, for bearing with me in this endeavor of hard work with patience support.
Last but not the least all the respondents who very graciously spared me their valuable time and information in addition to extending their cooperation, which rendered the entire research endeavor a very novel experience.
Date: The 28th January 2008 Sagolsem Ibungochouba Singh Table of Contents
Page No. Section 1: First Field Posting
1.1 Health situation analysis of Imphal East district, Manipur 1-19 state, India, 2006 1.2 Secondary data analysis of malaria surveillance in Imp hal 20-32 East district, Manipur state, India, 2006
Section 2: Second Field Posting
2.1 Description and evaluation of National antimalarial 33-46 programme in Imphal East district, Manipur state, India, 2007
2.2 Description and evaluation of STI Surveillance system in 47-62 Imphal East district, Manipur state, India, 2007
Section 3: Outbreak investigation 63-79
Section 4: Scientific Study Critique 80-84 Section 1
First Field Posting HEALTH SITUATION ANALYSIS OF IMPHAL EAST DISTRICT, MANIPUR STATE, INDIA, 2006
1. INTRODUCTION
In India, about 75% of health infrastructure, medical man power and other health resources are concentrated in urban areas where 27% of the populations live1. The leading causes of death are senility (23.5%), circulatory diseases (10.8%), causes peculiar to infancy (9.6%), and fevers (7.7%),2 priority diseases are mainly communicable diseases and non- communicable diseases3. The problem of safe water supply also facing. USAID National Integrated Child Survival and Maternal Health Program (NCMH)-"NIP" focusing on vulnerable populations and work with both public and private sector4. In India as of now, there are 5.7 million people with mv out of which 40% belongs to female sex. Anti Retroviral Therapy (ART) is in progress5.
In Manipur, IDV/AIDS, TB, Malaria, acute diarrhoeal diseases are common. The IDVI AIDS scenario in Manipur as well as to other parts of the country is very alarming. Manipur is one of the six states identified by National AIDS Control Organisation ( NACO) as having the highest IDV prevalence rate in India. Now, Manipur is under the National AIDS Control Programme Phase-II and Global fund for
AIDS, TB, and Malaria (GFATM) 6• In Manipur state, IDV positivity among the STI patients was 4.8%, VDRL reactivity among STI was 1.4%. In Imphal east district, IDV positivity among the STI patients was 2.8%, VDRL reactivity among STI was 0.8 %. 7 In the year 2006 that birth rate (13.9), death rate (4.3), natural growth rate
(9.6) and infant mortality rate (14)8•
I joined the MAE-FETP India course at National Institute of Epidemiology, I.C.M.R., Chetpet, Chennai on 23rd January 2006. Since my field placement site is Imphal east district of Manipur State, I will therefore describing the existing situation of this district in terms of health determinants, indices, inputs, facilities, strengths, challenges, weaknesses and services of the health system. This will enable the planning of interventions, health services and evaluation of health programme, implementation services and assignments. 2. METHODS
While discussing the situation analysis, various data sources were used. Data was collected from different sources by personnel visit, reviewing of various records and reports in the concern Departments and discussions with various District Officials of the Health and Family Welfare Services like Planning section, Manpower section, Public Health authority, State and District Programme Officers, Hospital Superintendent, Chief Medical Officer, Vital Statistics authority, various Head of Department of Regional Institute of Medical Sciences, Regional Health & Family Welfare Office, Food and Civil Supply Department, Public Health and Engineering Department, Sub-Divisional_Officers, Block Development Officers. Data was also collected from state web site, Imphal District web site and health website.
3. RESULTS
3.1. General presentation
3.1.1. Location
Manipur is one of the backward and hills gird state of the North-Eastern India. Now, Manipur has nine districts. Altitude varies from 790 meters above mean sea level, sub-tropical climate range from 0° to 36°C, average rainfall 1468 mm and humidity varies 40-100%. Population is 22, 93,896. Rural population is 1,717,928, female population is 842,657, Literacy rate is 68.87% out of this 59.70% constitutes female. The area of Manipur is 22,327 sq. kms out of these 20089 sq. kms is covered by hills and remaining one-tenth 2,238 sq. kms is valley area. The main occupation of Manipur ·is agriculture, horticulture, handloom & handicrafts and other cottage & household industries'.
3.1.2. Population
Imphal east district is divided into four sub-divisions. Imphal east district has three blocks but no block level medical officers. As per 2001 census the total population of the district is 394,876. After projection on 2005 is 431,719 of which 50.25% are male. 15-49 years constitutes 54.38%. Literacy rate is 76.38% out of this 66.30% constitute female. 72.58% of population lives in rural area, out of this 61.16% in municipality. Tribal constitutes about 6.26% of the general population and 2.64% belongs to Schedule Caste. A proportion of 40.65% population lives below poverty line.
3.2. LABORATORY RESOURCES
Laboratory support is essential for any programme implementation and surveillance. Therefore, there is need to update and strengthening the facilities at different levels in this district. As the existing facilities available at the peripheral level is very poor. ·
3.2.1. First level (P~H.C. level)
Laboratory facility at the Primary Health Centers is negligible due to lack of financial assistance and infrastructure. Investigation of hemoglobin, total leucocyte count, differential leucocyte count, erythrocyte sedimentation rate, urine for albumin and sugar, sputum microscopy for acid fast bacilli and peripheral blood smears for ·inalarial parasite, optimal tests of malaria are done in some centers. No other investigation was usually carried out.
3.2.2. Second level (District level)
Laboratory facility at the district level is better than first level in some centers. But the tests are almost the same. There was no culture facility at any of the second level. Serological tests are carried out occasionally.
3.3.3. State Level Laboratory and referral level
There are two main institutions; they are Jawaharlal Nehru Hospital, Porompat, Imphal east which is a state level hospital and Regional Institute of Medical Sciences, Lamphelpat, ·Imphal west. Jawaharlal Nehru Hospital, Porompat, Imphal east will function as state level laboratory as it has all facilities for Microbiology (culture, serology including lllV), Pathology (biopsy, cytology, haematology, clinical pathology), Biochemistry and Blood Bank, which are manned by qualified specialists
in each respective field. Referral is done outside this state10• List of the tests are given below (Table: 2). \
3.4. MAJOR PUBLIC HEALTH PRIORITIES
3.4.1. IDV, AIDS and other STis
In Manipur, the IDUs prevalence is 24.1 %. Young peoples below 30 years constitute about 59.71% and 15-24 years of age constitutes 2% in whole Imphal. Sentinel surveillance pregnant mother prevalence is 1.3% and below 10 years constitutes 5.9%. In lmphal east district, IllV positivity among the, STI patients was 2.8%, VDRL reactivity among STI was 0.8 %.7 No record of orphans. Regarding Imphal east districts, no proper separation of data is maintained. Sexually transmitted infections problem could not identified. GFA TM helps this programme.
3.4.2 Tuberculosis
In general sputum positivity rate has suddenly increased from 7% in 2001 to 25% in 2003 and 70% in 2005. New smear positive cases detection rate and death rate may be due to co-infection with mv as an opportunistic infection. This could be attributed to the better consideration after the introduction of· Revised National Tuberculosis Control Programme (RNTCP) in 2000. GFATM helps this programme.
3.4.3. Malaria
Malaria has been a public health problem mainly in Jiribam sub-division of the lmphal East district. This sub-division which accounts for 10% of the population of the district accounted for 60% P. falciparum cases in the district in 2005. The API in rest of the district is lower. We analysed the malaria surveillance data in the district to compare various malariometric indices in the Jiribam sub-division with the rest of the district. In 2005, under the GFATM, the Intensified Malaria Control Project (IMCP) has been implemented with the objective of 30% reduction in morbidity and 50% reduction in mortality.
3.5. ORGANIZATION OF THE HEALTH SYSTEM
At the beginning, the state health organization was under Central Health Service. Now, Manipur Health Service was formed and amended. The health system of the state is based on the concept of primary Health care approached and National !,~~--········ Health Policy 1983. The department gives special impetus to the needs of the underserved and vulnerable population groups particularly women, children and I people living in the tribal, hill and rural areas of the state.11. II 3.5.1 Secretariat Health Department
Major policy decisions are made at this level and implemented through the directorates.
3.5.2 Directorate
In Manipur, two separate health care delivery systems are available; they are Health and Family welfare Service and headed by the Directors.
3.5.3 District level Health Administration
The district level health administration is organized through the Chief Medical Officer (C.M.O) and assisted by district level programme officers. Imphal east district has two Community Health Centers, 11 Primary Health Centers, 45 Primary Health Sub-centers and 2 dispensaries. The District Health Organization is responsible for implementation of the various health programmes. Being posted at the village level of Imphal East District, I work in close association with them. The Organizational set up structures of the health system is given below as Figure 2.
3.6 INDICATORS TOWARDS THE MILLENNIUM DEVELOPMENT GOALS
3.6.1. Goal1
In relation to this goal, the state and district has malnourished form the source. This could be due to inadequate food or under reporting that can be attributed to their poor economy. High percentage detection may be due to unemployment and non productivity of the state. But district condition was better than state level. The percentage of children receiving vitamin A solution was 22% in Imphal East district, which was lower than state average of 40% and also higher than the country average of 29.3%. Lower value of the district could be due to low coverage or inadequate supply or lackof awareness. Exclusive breast-feeding record of Imphal east was not yet available but state level was available.
3.6.2. Goal 4
Under five mortality rate and infant mortality rats are not available. Manipur is one of the poorest state in this country. There are several factors that can be attributed to this like poor literacy, inadequate health facilities and lack of awareness in the rural areas, lack of telecommunication etc. Measles immunization indicators are more or less same & motivation is going on.
3.6.3. Goal 5
At present district records are not maintained except some. Related programme are also needs to improved.
3.6.4. Goal 6
Manipur was one of the high prevalence rates of HIV in this country and 13th round of sentinel surveillance had completed. Prevalence in antenatal is more than one and 15-24 years women are 2% in the district. HIV infection is now spreading through sexual route. Prevention of Parents to Child HIV Transmission (PPTCT) Programme is going on in this state. District wise stratified data and other data are not documented till now.
In Imphal East district, malaria is not common except in one sub-division where API is 2.03, SPR is 0.96% in 2005 and district API is 0.42 and SPR is 1.68%. Falciparum rate is 1.48%, state rate is 0.58 and 3 deaths in 2005. The entire 9 districts are under IMCP since 2005. Insecticide treatment on bed distribution is going on.
Regarding tuberculosis, the overall indicators of Imphal east and Manipur state was worse than the national figures. New smear positive cases detection rate and death rate may be due to co-infection with HIV as an opportunistic infection. Now in
6 this state RNTCP has been implemented in the year 2000. This will improve the coverage and cure rate of tuberculosis. HIV- TV co-ordination programme also implemented. Goal 8 is now under GFATM Project.
3.6.5. Goal 7 and 8
No record was available.
4. DISCUSSION
4.1. STRENGTHS
Health system of this district is having adequate policy making manpower and health manpower with institutions. It has own mission with sufficient institutions. It has a tertiary hospital with core specialist and specialized laboratory. Health staffs are dedicated in the interest of the public with full satisfaction. Transport and communications are very good. Several programmes and funded projects are assisting the health systems.
4.2. CHALLENGES
Today world is fighting for Millennium Development Goals. So, political commitment is very much necessary on priority basis for the improvement of the health care delivery system. Plan budget needs to improve with sincerity for the better improvement of the health system. Community participation or involvement is very much required without any external disturbances. Secondary care level hospital needs appropriate technology with core-specialist.
4.3 WEAKNESSES
Plan budget for the health is very much inadequate. State has no proper flying squad service. No proper health and health related policy with decentralization of working. Lack of intersectorial & intrasectorial collaboration with community participation is very much lacking and needs to improve. Infrastructures in the peripheral health centers as well as tertiary hospital are inadequate. Trained personnel
-- J!!'!L_ and appropriate technology are also · inadequate. Information, Education, Communication, Surveillance, Feedback, Epidemic Preparedness and Response Team are not helping the peoples.
5. CONCLUSIONS AND RECOMMENDATIONS
5.1. CONCLUSIONS
The health situation of Imphal east district as well as Manipur is far behind the national averages and proper data are not maintained yet. A lot needs to be done to improve the indicators, proper data storages, co-operation as well as feed back system. In view of the proportion of population, the infrastructures of all the health centres are very far behind. Up-to-date equipments were not installed and need to be update. However, improvement of existing facilities will be needed. Govt. of India and Govt. of Manipur had signed two Memorandums of Understanding (MOU) to provide services to the people of Manipur; they are National Rural Health Mission (NRHM) and Integrated Disease Surveillance Project (IDSP). This will be very beneficial to the villagers and those people who live below poverty line as well as other levels of population. Before implementation of these projects we need to improve accordingly. Government of Manipur has been taken up several centrally sponsored programme. This will help in the health care system. Health and health related Non-Governmental Organizations (N.G.O.s); Voluntary Organizations are also helping the state health programmes. Other departments of this state also helping for health.
After MAE-FETP India experiences, I will be able to give more of my experience to the Sate Govt. I will render my service in this field to make up the gap in our health facility. The experience from this course will strengthened the health care system by assisting the programme officers. I will try to improve these problems best level. This training will immensely help in improving the quality of the work that we c;rre doing now. Since my field placement site in Imphal East District, I will therefore to carry out my field project in this district.
0 5.2 RECOMMENDATIONS
1. Surveillance system should be strengthened
2. Records are to be maintained properly. In time feed back are to be given for further action including maintenances of the data.
3. Programmes and surveillances are to be evaluated regularly.
4. Prompt outbreak investigation to be done.
5. Health problems should keep in the first priority. REFERENCES
1. Patil AV, Somasundaram KV, Goyal RC. Current health scenario in rural India, Aust J Rural Health. 2002 Apr; 10(2): 129-35.
2. Ali A. The present health· scenario of India, Health Millions. 2000 Mar-Apr; 26(2):4-5.
3. National Commission on Macroeconomics and Health.
4. USAID National Integrated Child Survival and Maternal Health Program (NCMH) "NIP"- Dr. Rajiv Tandon, MCHUHIPHNIUSAID India Jan. 2006, New Delhi.
5. National AIDS Control Organization, Govt. of India.
6. Project Implementation Plan, IDSP, Health department, Govt. ofManipur.
7. National AIDS Control Program, State summary report on Sentinel surveillance for HIV infection and VDRL reactivity, Manipur State AIDS Control Society, Govt. of Manipur, 2006.
8. Registrar General, SRS, Govt. of India: 2006;
9. Census of India, 2001.
10. Superintendent, Jawaharlal Nehru Hospital, Porompat, Govt. of Manipur. \ ll.Annual Administrative Report 2005-2006, Health Department, Manipur.
lQ ~ ~- 0 z
.., Director.. Additional DirectorsiCoMwtantsl State Nodm. Otlkeas
Joint Dhecton/... CM01 /Semor Spedati•tsiStM:e Prognunme Officers • t Chie£ Medical Oilicer, lmphal east (National)/ State :Epidflfmiologist/ Me.die:.g,.legtl Oftkerl Stattt AIDS Control Socie1y I Dep~ Directo:rs/Semor.. Medical Offiieers/ Deputy Directors/Senior Medical Off'tem:sl Diltrict Proarauune OITic,erc(Natio:ruil}! District Progranune omeerc(Nati.onal)l SpKiwts/ District Jpidemiologinl Specialictsi.Di.s:triri ':EpidemiolBgist/ Distrkt District Sunreilluce Officer/ Surveill.a.ftce Ofticer/ Dnt~ D&addittion Drq D&-additti~u• Centercl Ce.nterc/ District Medico..legal Officer/ District Hospitals Diltrict.. Hospital~ .. Medical Otfkm:s!PHCs/ CHCs Medical Otlb':eriiPHC's /CHCs PHECs• PHSCs• Community.. Community•
12 •, Table 1: Characteristics of the population of lmphal East district, Manipur state, India, 2005.
Population group Population size Proportion of the total
Age 0-4 yean of age 41,056 10 5-14 years of age 98,777 23
15-29 years of age 128,739 30 30-44 years of age 86,430 20
44-59 years of age 46,367 11 60 + years of age 30,350 7
Sex Male 216,939 50 Female 214,780 50
Socio-economic status Above poverty level 256,225 59
Below poverty level 175,494 50
Caste General caste NA NA Schedule caste 11,379 3 Schedule tribe 27,026 6
Other backward caste NA NA
Total 431,719
13 Table 2 : List of the names of the tests done at Jawaharlal Nehru Hospital, Porompat, Imphal East, Manipur state, India, 2005
Disease(s )llnvestigation(s) Test(s) done Availability of test(s) .;
1. Bacterial Culture and sensitivity Yes 2. Parasitology a). Demonstrati'!n of MP Yes b). Demonstration of Ova & cyst Yes 3. Serology Widal test Yes 4. Viroogy & Immunology a). Hepatitis B & C Yes b). HIV-Rapid, Elisa,FACS Counter Yes
c). Syphilis-VDRL Yes
5. Mycobacteriology AFB staining Yes a). T.B. Yes
b). Leprae Yes 6. Staining Gram Yes 7. Biochemistry General tests Yes Urinalalysis, routine haematology, ASO titre, 8. Others C-reactive protein, Rh factor, etc Yes
9. Specified Dengue, Plague, Measles etc No 10. Serotyping No
14 Table 3: Key public health priorities in lmphal east district, Manipur state, India, 2005
Public health Key elements Ongoing prevention and control programmes .J. priority 1. HIV, AIDS and 1. By decreasing the prevalence among 1. Preventions amongst the high risk and other STis pregnant women. Present status is more amongst the vulnerable groups. than one in this state. 2. Care and support of the People Living 2. By decreasing the number of positives withlllV/AIDS (PLWHA) and treatment below 10 years. e.g. A.R.T. 3. Intersectional collaboration and institutional strengthening e.g. Training.Behavioral Change Communication Programme. 2. T.B. 1. High Sputum positivity and co- 1. RNTCP started and DOTS implemented. infection amongst mv positive 2. IDV & T.B. co-ordination programme individuals and leads to smear also implemented. negative T.B. patient's no. is increased 3. Behavioral change communication & its incidence is becoming higher. programme. 2. Case detection rate was 70% and cure rate was 85% in new smear Eositives. 3. Malaria 1. Annual parasite incidence was more 1. GFATM funded intensified Malaria Control than 2 in one sub-division. Programme (IMCP). 2 . Plasmodium falciparum contributes 2. Bed net distribution and insecticide treatment 60% to the district. on community bed nets. 3. Early Diagnosis and Prompt Treatment.
15 Table 4: Indicators of progress for the health related millennium development goals, Imphal East district, Manipur state, India, 2005
Value ofth~ indicator Indicator In Imphal east In Manipur state, In India, 2006 Goal district, 2006 2006 Goall Prevalence of underweight children < 5 years of age 14 t 10 (DSW, ICDS 47 * 2006) Proportion of population below minimum level of dietary energy 41 § 41 (FCS, 2006) 30 (NCAER, 2001) consumption Percentage of children 6-59 month of age who received one dose of 22% ** 40% tt 30% ** vitamin A in the past six months Proportion of infants under six months who are exclusively breastfed Not available 93 §§ 55 (1999) Goal4 Under-five mortality rate Not available 56% 17
Infant mortality rate Not available 14 (SRS-2006) 58 (SRS-2006)) Measles immunization among children under one 76ttt 69 67 (DFWS-2006) (SRS-2003)
t Directorate of Social Welfare, Integrated Child Development Scheme((DSW, ICDS), 2006 *National Family Health Survey, II, 1998 §Directorate of Food & Civil Supply(FCS), Govt. ofManipur, 2006 **Achievement for the year 2005-2006, District Family Welfare Office(DFWS), Imphal East. tt Immunization Target and Achievement, 2005-2006 in respect of Manipur State, Department of Family Welfare, Govt. of Manipur ** Statistical Abstract Manipur 2005, Directorate of Economics & Statistics, Govt. of Manipur.
§§Directorate of Family Welfare Services 2006(DFWS), Govt. ofManipur. *** Sample Registration System Statistical Report 2004, Register General Of India. ttt Achievement for the year 2005-2006, District Family Welfare Office(DFWS), Imphal East.
16 Table 4 (contd): Indicators of progress for the health related millennium development goals, Imphal East district, Manipur state, India, 2005.
Value of the indicator Goal Indicator In Imphal east In Manipur state, district, 2006 2006 In India, 2006 GoalS Maternal modality ratio Not available 374 (2001) 168 (2003) Proportion of births attended by skilled health personnel 52 (DFWS-2006) 64 (DFWS-2006) 60% (SRS, 2004) Contraceptive prevalence rate 47(DFWS-2006) 39 (NFHS-2) 47 (2001) Percentage of women receiving antenatal care Not available 80% 41%(2001)
Goal6 HIV prevalence among 15-24 years old pregnant women 1 (MACS-2006) 1 (2003) (HIV) 2*** Condom use rate of the contraceptive prevalence rate Not available 78 (MACS-2006) 32 (2004) Number of children orphaned by HIVIAIDS Not available Not available 1.2 million 1 Percentage of people using a condom during most recent higher risk Not available 67 (MACS-2006) 59 (2001) sexual encounter Percentage of STI clients who are diagnosed and treated according to Not available 5 (MACS-2006) 89 (2003) guidelines Percentage of HIV-positive women receiving anti-retroviral treatment Not available 21 (MACS 2006) 85 (2003) during pregnancy to prevent mother to child transmission of HIV Goal6 Malaria death rate 0 *"'**' 0.002 (SM0-2006) 0.003 (2000) (Malaria) Proportion of people with uncomplicated malaria getting correct 100 (SM0-2006) 100 (SM0-2006) Not available treatment at the health facility and community levels, according to the national guidelines, within 24 hours of the onset of symptoms Percentage of pregnant women who have taken chemoprophylaxis or Not available Not available Not available drug treatment for malaria The proportion of households having at least one insecticide treated bed Not available Not available Not available nets
*** Manipur State AIDS Control Society(MACS), Govt. of Manipur, 2006 §§§ Estimates USAIDS, India, 2005 **** Annual Report, Manipur State Malaria Office(SMO) - 2006
17 Table 4 ·( contd): Indicators of progress for the health related millennium development goals, lmphal east district, Manipur state, India, 2005
Value of the indicator Goal Indicator In Imphal east In Manipur state, In India, 2006 ·I district, 2006 2006 Goal6 Prevalence and death rate associated with tuberculosis Prevalence=O.l% Prevalence=O.l% Prevalence=O.l% (TB) Death rate=4% Death rate=3% Death rate=O.Ol% (STB-2006tttt) (STB-2006) (RNTCP-2004****)
Proportion of tuberculosis cases detected and cured under DOTS 0.2 (STB-2006) 0.2 (STB-2006) 0.1 (RNTCP-2004) Percentage of estimated new smear-positive tuberculosis cases 28 (STB-2006) 27 (STB-2006) 72 (RNTCP-2004) registered under the DOTS approach Goal7 Proportion of population with sustainable access to an improved water Not available 50% & 24.7% 86% source, urban and rural (NFHS,OS-06) (WHO, 2002§§§§) Proportion of urban population with access to improved sanitation Not available 25% (98-99) 30% (WH0,2002) GoalS Proportion of population with access to affordable essential drugs on a Not available Not available Not available sustainable basis
tttt State T.B. Cell, Manipur(STB), 2006 ****Revised National Tuberculosis Control Prograrnme(RNTCP), 2004 §§§§World Health Organization, 2002 18 Tablet': Potential topics for the v~rious field MAE-FETP assignments.
·I Assignment Potential topic
STI Surveillance System in Imphal east district Surveillance system description and evaluation Malaria Surveillance data of the Imphal east Secondary data analysis district Anti Malaria Programme of the Imphal east Programme evaluation district Syndromic approach in STis and treatment Dissertation seeking behaviour in Imphal east district
19 SECONDARY DATA ANALYSIS OF MALARIA SURVEILLANCE, IMPHAL EAST DISTRICT, MANIPUR STATE, INDIA, 2006
1. INTRODUCTION
Malaria is a vector borne disease caused by protozoan infection and the causative organism belongs to Plasmodium group, namely, Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae and Plasmodium ovale. The genus plasmodium is transmitted to man by infected female anopheles mosquito. 1 More than 40 female anopheles mosquito species transmit malaria worldwide. The disease is preventable, treatable and curable. Both vector and parasite had the propensity to develop resistance, to insecticide and to anti-malarial drugs respectively. 2
World scenario
Malaria is endemic in 101 countries worldwide. Globally 300-500 million clinical cases of malaria occur every year resulting in 2.7 million deaths, 90% of which are from Sub- Saharan Africa.3 Malaria accounts for 10% of disease burden, 40% public health expenditure and 30-50% hospital admission in Africa.4 In 1960, only 10% of world population was at risk of malaria, but in 2001, about 40 % of world population is at risk (WHO 2001). Malaria is the leading cause of under-five mortality in Africa and accounting for 20% of all cause mortality.
WHO Southeast region
In South-East Asia, 80% of population lives in areas with moderate to high risk of malaria and 90% of this population lives in India, Myanmar and Thailand. In 2000, India reported a total 2.1 million cases of malaria including 946 deaths.5 Plasmodiumfalciparum contributed to the majority of these deaths.
Malaria in India
Malaria has been a public health problem in India for centuries. Before 1953, every year there were about 75 million cases and 0.8 million deaths due to malaria annually. After significant decline in the 1960's malaria re-emerged as a major communicable disease in the country with an increasing trend of 2 to 2.5 million malaria cases annually. Epidemiological data on malaria indicate that the dynamics vary from place to place6 and there is a sharp increase in the malaria related morbidity and mortality in India in the last decade. Sharma et ae in 1998 reported that a total of 2.15 million cases of malaria occurred in India. Plasmodiumfalciparum being the main cause of severe malaria which accounts for 30 to 40 % of malarial deaths in India. The strategy of Modified plan of Operation (MPO) was changed as Malaria Action Programme (MAP) in the year 1995 (Expert Committee on Malaria).8 The Government of India has signed a grant agreement in July 2005 with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) for launch of Intensified Malaria Control Project (IMCP). The IMCP has been implemented with the objective to reduce malaria morbidity in 100 million population in 10 states by 30% in 5 years from 461,083 cases to 322,758 cases and deaths by 50% from 464 to 232. The project was introduced in India with World Bank assistance. The main components of the IMCP are early case detection and prompt treatment, selective vector control like indoor residual spray, insecticide treated nets, use of larvivorous fishes, information, education and communication with community non-governmental organization (NGO), private sector involvement for malaria control activities and monitoring and evaluation.9 Now malaria control programme is under National Vector Borne Diseases Control Programme (NVBDCP).
Malaria in Manipur
Since large parts of Manipur are hilly, forested and inaccessible with poor communication facilities, control of malaria is logistically difficult and outbreaks are frequently recorded. Entomological studies conducted in Manipur state revealed the presence of An. dirus and An. nivipes from the state. An. dirus is the major malaria vector. 10 About one third of malaria cases in the states are due to P. falciparum. During 1994, a large number of malaria cases were reported from the state. A survey conducted by health authorities revealed that the death rate due suspected malaria deaths was 63 per thousand population whereas rates for confirmed malarial deaths was 10 per thousand. Except during this year, the annual parasite incidence (API) for Manipur was below two. IMCP was implemented in the state since 2005.
21 Malaria in Imphal east district
In the year 1997, Imphal district was divided into two districts, namely Imphal east and Imphal west. Separate data about the malaria control programme was available since 2001. Malaria has been a public health problem mainly in Jiribam sub-division of the Imphal East district. This sub-division which accounts for 10% of the population of the district accounted for 60% P. falciparum cases in the district in 2005. The API in rest of the district is lower. We analysed the malaria surveillance data in the district to compare various malariometric indices in the Jiribam sub division with the rest of the district. The objectives of our analysis were to study (1) Study the trend of malaria between 1985 to 2005 in Imphal east district and Manipur state and (2) Study the incidence of malaria in lmphal east by time, place, person and agent characteristics during 2001-2005.
2. METHODS
2.1. DATA COLLECTION AND SOURCES OF DATA
We included the available secondary data from 2001 to 2005 from the District Malaria Office of Imphal east, from the two Community health Centres and 11 Primary Health Centres. This abstracted information pertaining to the demographic characteristics and malaria epidemiological data (e.g. blood smear examined, total malaria cases, total P. falciparum cases, death due to malaria) from the available records. We used census data available from District Malaria Office as well as from census 2001 for the calculation of various indices. 11 We used the available data at the State Malaria Office from 1985-2005, to compare the trend of malaria in Imphal and the state.
2.2. DATA ANALYSIS
We calculated annual parasite incidence of malaria in Imphal east from 1985 to 2005. We calculated the following programme related indicators for Jiribam sub division and rest of Imphal east. 2.2.1. Annual Blood Examination Rate (ABER)
We divided total number of blood smears examined for malarial parasite in a year by total population to calculate ABBR. Epidemiologically, this parameter reflects the efficiency and adequacy of case detection mechanism. In the Modified Plan of Operation, the minimum prescribed is 10% of the population in a year.
2.2.2. Annual Parasite Incidence (API)
We divided total number of blood smears positive for malaria parasite in a year by total population to calculate API. Epidemiologically, this parameter depends upon the adequacy of case detection mechanism i.e. ABBR. If ABER is adequate, this parameter is the most important criterion to assess the progress of malaria control programme. Under NAMP, API of more than 2 in any area is considered to be public health problem. As per Modified Plan of Operation, areas more than two API brought under spray operation.
2.2.3. Slide Positivity Rate (SPR)
Slide Positivity Rate is calculated by dividing total number of blood smears found positive for malaria parasite by total number of blood smears per 100. It gives the information of parasite load in the community. It is more reliable than API even for areas where ABER fluctuates from year to year.
2.4.4. Plasmodium falciparum Percentage (Pf %)
Plasmodium falciparum Percentage is calculated by dividing the total number of blood smears found positive for P. falciparum by total number of blood smears positive for malaria parasite per 100. Epidemiologically, this parameter gives the relative proportion of P. falciparum infection and identifies trends of P. falciparum incidence in relation to total caseload of malaria in the community. 3. RESULTS
3.1. TREND OF API IN MANIPUR AND IMPHAL EAST
Figure 1 shows the API of Imphal and Manipur state during 1985-2005. The trend of API for Manipur state and Imphal over the last 20 years indicated that the API for Imphal was lower than that of the state (Figure 1). API for the state and district were below 2 for last twenty years, except during 1994 in the state and 1995 in the district.
3.2. MALARIA SITUATION IN IMPHAL EAST DISTRICT
3.2.1. API in Jiribam Sub-division and Rest of Imphal East district
The average API during 2001-2005 was more than 2 per 1000 (range: 2-8) in CHC Jiribam and PHC Borobekra (Fig 2). The API in rest of the PHC/CHC areas were lower than 2 during last five years (range: 0.01-0.02) (Fig.3).
3.2.2 Annual Blood Examination Rate (ABER) •
During 2001-05, ABER of Jiribam sub-division ranged between 6% to 11% whereas the rate in rest of the Imphal east ranged between 1% to 4% (Fig. 5). ABER in Jiribam sub-division was 11% during 2001. ABER in the remaining years in this sub-division and rest of the district was less than 10%.
3.2.3. Slide Positivity Rate (SPR)
During 2001-05, SPR of Jiribam sub-division and rest of the Imphal East district ranged between 1.7% to 8.7% and 0 to 2% respectively.
3.2.4. Plasmodium falciparum (Pf )Percentage
The Pf percentage in Jiribam sub-division ranged between 46% to 100% during 2001-2005, whereas in the rest of Imphal east it was 8% to 56%. (Figure: 4). 3.2.5. Incidence according age and sex
Data regarding age and sex distribution of malaria positive cases were available for the district since 2003. In Jiribam sub-division, incidence rates were higher among individuals aged five years or more and males (Table-1). No death was reported during these periods.
4. DISCUSSION
Analysis of the secondary data indicated that (1) Annual parasite incidence of malaria was lower in Imphal east district than the state average over last two decades and (2) malaria is an important health problem in Jiribam sub-division in Imphal east district.
As per Modified Plan of Operation, areas with API of two or more considered as high risk areas . Such areas are brought under spray operati.on. Except for two years, API in the district as well as state, was lower than 2. API however, depends on adequacy of blood slides examined. ABER in the state showed a declining trend. In Imphal east district, ABER was much below the recommended target of 10% indicating poor surveillance. Thus, the lower API reported in the state as well as in the district might not be true reflection of malaria situation.
In spite of low overall ABER in Imphal district, the API in Jiribam sub division was higher than rest of the district. API was 2 or more over last five years. More than 50% of malaria cases in the district were due to P. falciparum. These findings indicate a need to intensify malaria control activities in Jiribam sub-division including strengthening fever surveillance.
Based on these findings, we propose the following recommendations. First, evaluate NAMP in Jiribam sub-division to identify weaknesses in the programme. Second, strengthen malaria surveillance activities in the district as well as state.
25 REFERENCES
1. Parks textbook of Preventive and Social Medicine, sixteen edition, 2000.
2. David A Warrell, Herbert M Gilles. Essential Malariology. Fourth Edition. 2002
3. WHO : World Health Report 2000, World Health Organization, Geneva, Switzerland, 2000
4. RBM News, Issue 4 September 2001
5. WHO : World Health Report 2002, World Health Organization, South East Asia region, New Delhi, 2002
6. Pattanayak, S., Sharma, V.P., Kalra, N.L., Orlov, V.S. and Sharma, R.S. Malaria paradigms in India and control strategies. Indian J Malariol 31: 141, 1994.
7. Sharma, V.P. Reemergence of malaria in India. Indian J Med Res 103: 26, 1996.
8. Operational Manual For Malaria Action Programme (MAP) 1995, Government of India, National Malaria Eradication Programme.
9. National Vector Borne Diseases Control Programme, Intensified Malaria Control Project, Financial Management Guidelines for State and District Societies, www.nvbdcp.gov.in/Doc/Financial Management Guidelines
10. Dutta P, Khan SA, Khan AM, Sharma CK, Mahanta J. Biodiversity of mosquitoes in Manipur State and their medical significance. J Environ Biol. 2005 Jul; 26(3):531-8.
11. Census of India, 2001
26 .rf
Figure 1: Distribution of Annual Parasite Incidence in both Manipur state & Imphal district (1985-2005), India, 2005
4.5
4.0
3.5
3.0
2.5 a: c( 2.0
1.5
1.0
0.5
0.0 ~~~~~~~~~~~~~~~~~~~~~ ~~~~~~~~-~~~~~~~~~~~~~ Year I...,_Manipur ..,._lmphal East I
27 Figure 2: Average distribution API in different health centres of Imphal east district (2001-2005), India
I JIRIBAM & BORO~EKM t
2 .. AliO"\\E
J.'fooo;OZ
...... 111.,1
AT ZERO
28 Figure 3: Annual parasite incidence of rest of the Imphal east district and Jiribam sub-division of Imphal east district (2001-2005), Manipur state, India, 2005
9
8
7
6
5 ..._Jiribam -Resto! the l.'flphal _Elast 4 :J
3
2
1
0 2001 2002 2003 2004 2005
29 Figure 4: Comparison of plasmodium falciparum percentage in Manipur state, rest of the Imphal east district and Jiribam sub-division, India, 2005
, I
120%
100%
80%
~ -Rest of lmphal lt- 60% D. -Q-Jiribam sub-division
40%
20%
Oo/o +------,------,------,------,------~ 2001 2002 2003 2004 2005
30 Figure 5: Comparative annual blood examination rate of Jiribam sub-division and rest of the district (2001-2005), Manipur state, India, 2005
12
10
8
~Jiribam
6 -Rest of the lmphal east
4
2
0+------~------T------~------r------~
2001 2002 2003 2004 2005 /
31 Table 1: Number of cases and attack rates by age and sex, Jiribam sub-division and rest of the district, Manipur state, India, 2003-2005
Age and sex Demographic Total malaria cases specific incidence characteristics during 2003-2005 Average population rate per 1000 Rest of the Rest of the Rest of the Jiribam district Jiribam district Jiribam district Age (years)* 1-4years 7 0 3796 35826 2 0 5-14years 44 10 9132 86193 5 0.1 15+ yrs. 107 47 26984 254699 4 0.2 Sex Male 108 40 20056 189301 5 0.2 Female 50 17 19856 187417 3 0.1 Total 158 57 39912 376718 4 0.2
*Monthly report of malaria programme of Primary Health Centre, appendix-IV(E), MF-4.
32 Section 2·
Second Field Posting EVALUATION OF THE NATIONAL ANTI MALARIA PROGRAMME IN IMPHAL EAST DISTRICT, MANIPUR STATE, INDIA, 2006
1. INTRODUCTION
Analysis of the malaria surveillance data from Imphal east district indicated that malaria is an important health problem mainly in Jiribam sub-division. Annual parasite incidence in the sub-division was more than 211000 over last five years and more than half· of the malaria cases were due to Plasmodium falciparum. Annual blood examination rate of the district was much below the recommended target of 10%.1
We evaluated the activities of the national anti malaria programme (NAMP) and compared its performance in Jiribam sub-division and rest of the district. The objectives of this evaluation were to (1) describe the performances of different components of the national anti malaria programme in terms of input, process, outcome and impact in Jiribam sub-division & rest of the district and (2) formulate recommendations on leading issues that the programme is facing.
2. METHODS
Description of the programme
We reviewed in detail the operational manual for malaria action programme (MAP) 1995 of the national anti malaria programme (Government of India). Stakeholders were District Malaria Officer (DMO), medical officer, laboratory technicians, health supervisors and workers. We interviewed the stakeholders involved in the NAMP of the Imphal east district. We reviewed the available records of the programme at the DMO office and health centres. We also discussed about different operational issues of the programme in Imphal east district with DMO of Imphal east, medical officers of the health centres and laboratory technicians microscopic centers.
______33 __..__ Evaluation of the programme
Indicators used
We considered the health centres of Imphal east district to evaluate the NAMP in terms of input, process, output and outcome indicators. These indicators are described in the logic model (Table: 1).
Input indicators
Our input indicators included the proportion of medical officers, laboratory technicians and health workers trained and in position, proportion of passive case detection (PCD) agencies having facility for examining blood smears, proportion of health centres with microscopes and laboratory reagents, proportion of health centres with adequate stock of anti-malarial drugs, proportion of health centres with indoor facility.
Process indicator
Our process indicators included the proportion of health workers visiting households fortnightly, proportion of passive case detection agencies collecting blood smears, proportion of negative slides found positive in the cross checking_by the laboratory in Regional Directorate (Govt. of India), proportion of positive slides found negative in the cross checking by the laboratory in Regional Directorate (Govt. of India), proportion of drug distribution centres (DDC) treating fever cases, proportion of complicated Plasmod~umfalciparum (Pf) cases treated.
Output indicator
Our output indicators included the percentage of fever cases screened for malaria by passive case detection (PCD) agencies, percentage of blood slides collected from new patients attending out patients department (OPD), time lag between blood smears receipt in the laboratory, examination of smears, dissemination of results and treatment, proportion of fever cases receiving presumptive treatment after smear positive for malaria, proportion of malaria positives receiving radical treatment within seven days of blood slide collection or after results.
34 r J_ Outcome indicator
Our outcome indicators included the case fatality ratio at health centres, annual blood slide examination rate, annual parasite index (number of blood smear positive for malaria per 1000 population), slide positivity rate (number of blood smear positive for malaria per 100 examined smear), percentage of the Plasmodium falciparum.
3. RESULTS
Description of the programme
The basic strategy of national anti malaria programme is to (1) ensure community access to early diagnosis and prompt treatment, (2) conduct selective vector control, (3) promote community use of bed net (especially insecticide treated), and (4) ensure community participation in prevention and control through capacity building with a network of community health services. From operational point of view, the aim is to identify high-risk areas in the district. The criteria for high risk area were (1) recorded deaths due to malaria (on clinical diagnosis or microscopic confirmation) with plasmodium falciparum infection during the transmission peri
The infrastructure of the anti-malaria programme in the Imphal east district comprises of two Community Health Centres (CHC), 11 Primary Health Centres (PHC), 45 Primary Health Sub-centres (PHSC), 73 fever treatment depots (FTD) and 227 drug distribution centres (DDC) and manpower in position are also given in Table 2. The components early case detection and prompt treatment (EDPT) are described below. Active case detection (ACD)
Male health workers (MHW) conduct house to house visits in the assigned villages of the Imphal east on fortnightly basis and collect both thick and thin peripheral blood smears from the fever cases. The collected blood smear is marked with an identification number and the particulars of the person with the slide number including name of the village are recorded in the malaria form (MF) number two (I register. Stencil is put on the wall of each household with date and signature during the visit of the worker. The collected blood slides are sent to the laboratory on the same day.
During antenatal and postnatal domiciliary visit of the female health workers and collect both thick and thin peripheral blood smears from the fever cases from the mothers. The records are entered in MF-2 register and mark as described above. After the blood slide collection, presumptive treatment is administered to these fever cases with chloroquine in presence of the health workers. Seriously ill fever cases is referred to Primary health centre after peripheral smear collection. Chloroquine is given in a pregnant women second trimester of pregnancy.
The laboratory technician of the health centre after receiving the slides records them in MF-8 register and examines the submitted slides within 24-48 hours. If any of the slides is found positive, then it is recorded in MF-7 register. The laboratory technician returns the report of positive individuals to the concerned health worker/supervisor. The health worker traces the person and administers the radical treatment with chloroquine and primaquine. Radical treatment is not given in pregnant women, post partum period of 45 days and infants below one year of age. In case of active case detection, radical treatment for malaria positive cases is completed within seven days.
Passive case detection
Both thick and thin blood smears are collected from the fever cases attending the health centres. The collected blood smear is marked with an identification number and the particulars of the person with the slide number including name of the village are recorded in the MF-2 register. Presumptive treatment is administered to the fever
36 cases. The laboratory technician examines the slide and gives the result. Positive cases are given radical treatment and negative cases are referred back to medical officer for further medical advice. In case of passive case detection, radical treatment for malaria positive cases is initiated within 24 hours. The details of the positive slides from active and passive case detections are recorded in the MF-7 register. Complicated cases are hospitalized if the health facility is having indoor facility or if the health facility is not having indoor facility, the cases are referred to the nearest centre/hospital where indoor facility is available for further management. All the positive slides and 10% of the negative slides are sent to Regional Health and Family Welfare Office (Govt. of India), Uripok, Imphal west for cross checking. The village wise epidemiological report is entered in MF-9 register. All the reports (MF-2) from the health sub-centres are aggregated in MF-4 register at PHC/CHC and sent to district malaria officer of the Imphal east. In the district, the reports (MF-4) from the reporting units are aggregated in MF-5 register and sent to state head quarter. Fever treatment depots collect peripheral blood smears from the fever cases and administer presumptive treatment, whereas drug distribution centers give only presumptive treatment to the fever cases. The records of fever treatment depots and drug distribution centres are entered in MF-10 register. The laboratory technician of the / health centre maintains these registers. The flow chart of the EDPT is shown in Figure 1.
Evaluation of the programme
We conducted the evaluation in eight of the 13 health centres (CHCs-2, PHCs- 6). We included both the health centres from Jiribam sub-division for evaluation. We calculated various indicators of the National Anti-Malaria Programme from Jiribam sub-division and rest of the district.
Input indicator
In Jiribam sub-division, 5 of 9 (56%) medical officers, both the laboratory technicians and 10 of 18 (56%) health workers were in position compared to sanctioned post. Of the personnel in position, 3 of 5 (60%) medical officers, both the laboratory technician and 6 of 10 (60%) health workers were trained in malaria. Both health centres had microscope in working condition and one centre had indoor facility: In the rest of the district, 12 of 19 (63%) medical officers, all the laboratory
37 technicians and 24 of 32 (75%) health workers were in position compared to sanctioned post. Of the personnel in position 8 of 12 (67%) medical officers, all the laboratory technicians and 15 of 24 (67%) health workers were trained in malaria, all the microscopes are working. One of the .six health centres having indoor facility (17%).
Process indicator
In Jiribam sub-division, both the passive case detection agencies were working with laboratory facility. 12 of 20 (60%) fever treatment depots (FfDs) were collecting peripheral blood smear and treating fever cases, 31 of 45 (69%) drug distribution centres (DDCs) treating fever cases. None of the 38 Pf malaria cases detected in the two health facilities in the sub-division passively during 2006 was admitted in the indoor health facility. Six of the ten (60%) health workers visited the household fortnight! y.
In the rest of the district, 6 of 6 (100%) passive case detection agencies were working with laboratory facility. 20 of 37 (54%) fever treatment depots (FfDs) were collecting peripheral blood smear and treating fever cases, 38 of 86 (44%) drug distribution centres (DDCs) treating fever cases. 12 of 24 (50%) health workers visited the household fortnightly. None of the 14 Pf malaria cases detected in the health facilities in rest of the district passively during 2006 was admitted in the indoor health facility.
We obtained the information regarding cross checking of the blood slides. No blood slide was sent to Regional Health and Family Welfare Office (Govt. of India), Uripok, Imphal west for cross-checking.
Output indicator
In Imphal East district, the interval between peripheral blood smear collection and examination ranged from 1 to 3 days (median 1 day) for passive case detection in health centres and from 7 to 12 days (median 8 days) for active case detection. The interval between peripheral blood smear collection and radical treatment ranged from 10 to 19 days (median 12 days).
38 A total of 689 fever cases attended the OPD in two health centres in Jiribam in 2006. Blood smears were collected from 531 (77%) of the fever cases. 385 (73%) of the fever cases received presumptive treatment. 28 of the 51 slide positive malaria cases 55% received full course of radical treatment. None of the health officials of the Imphal east district paid supervisory visits to any health centres in the sub-division.
A total of 742 fever cases attended the OPD in the rest of the district in 2006. Blood smears were collected from 328 (44%) of the fever cases. 263 (80%) of the fever cases received presumptive treatment. 44 of the 50 slide positive malaria cases 88% received full course of radical treatment. None of the health officials of the Imphal east district paid supervisory visits to any health centres in the sub-division.
Outcome indicator
In Jiribam, during 2006, annual blood examination rate was 7.2%, annual parasite index (API) was 2/1000 and Plasmodium falciparum percentage (Pf%) was 38. The corresponding figures for the rest of the district was 4.2%, 0.2/1000 and 29 respectively.
4. DISCUSSION
Our evaluation identified several weaknesses with respect to case detection, laboratory diagnosis and their treatment in the NAMP in Jiribam sub-division and rest of the Imphal east district. These included inadequate staff position, lack of training and supervision. The findings .of the evaluation could be used for improving the performance of the programme.
Overall, there was shortage of trained doctors and health workers in the district. Active and passive case detection components in the programme were weak resulting in lower number of blood slides collected from fever cases. Facilities for laboratory diagnosis of malaria are adequate in the district. However, no slides were sent for cross-checking. It is therefore necessary to ensure that cross-checking is increased by encouraging supervision and emphasizing the importance of sending I blood slides for cross-checking. As per NAMP guidelines, all fever cases are assumed to be due to malaria and presumptive treatment is administered with the aim of relieving symptoms possibly due to malaria and to reduce mortality and morbidity. Radical treatment is administered to fever cases positive for malarial parasites. One of the rationale for giving the radical treatment is make the patient non-infective to mosquitoes and thereby reducing the transmission of the disease. In Jiribam, about one forth of the suspected cases did not receive presumptive treatment and about half of the slide positive malaria cases did not receive radical treatment. Besides, there was a long delay in administering the radical treatment.
Rest of the Imphal east, about majority of the suspected cases received presumptive treatment and about majority of the slide positive malaria cases received radical treatment. Besides, there was a long delay in administering the radical treatment.
We cannot comment on vector control measures. Based on the findings of the evaluation, we propose the following recommendations for improving the performance of NAMP in Jiribam sub-division where malaria is an important health problem.
(1) It is necessary to strengthen malaria surveillance in the district especially the Jiribam sub-division. This could be achieved by filling the vacant posts, training health workers in malaria surveillance and proper supervision of peripheral health workers.
(2) Educate health professionals about the need for appropriate management of malaria cases.
(3) Ensure cross-checking of positive and negative slides from all the health facilities
/
.All ------·----·-·--·--- -~--- REFERENCE
1. Ibungochouba Sagolsem. Secondary data analysis of malaria surveillance in Imphal
East district, Manipur state, India:2006.
41 Table 1: Descriptions of the National Anti Malaria Programme by a logic model, Impluil East, Manipur state, India, 2006
Key Elements INPUT PROCESS OUTPUT OUTCOME IMPACT Case detection • Health Supervisors • Fever cases screening by Fortnightly House • Fever cases screened and • ABER • Multipurpose Health Worker (Male) Visit: Active Case Detection (ACD) blood slides collected • Multipurpose Health Worker (Females) • Fever cases screening in the health centers, • FfD volunteers fever treatment depot: Passive Case Detection • Capacity building (PCD) • Special screening in case of epidemics: Mass & Contact Survey Laboratory • Lab Technician, • Receipt of blood slides • Number of blood slides • SPR, SfR Investigation • Microscopy and staining materials etc • Staining of blood smears received, stained and >-3 • Capacity building • Examination of blood smear and reporting examined ~ • Training at all levels > Cross checking z • (ll Case Management • Doctors • Presumptive treatment • Fever cases treated • CFR (Treatment) • Health Supervisors • Radical Treatment • Malaria positives treated ....== • Multipurpose Health Worker (Male) • Treatment to complicated cases of Pf malaria • Complicated Pf cases (ll Multipurpose Health Worker (Females) .... • treated 0 • Capacity building z • Antimalarial stock • Facilities available at the Health centers e.g. Beds, Vector control • Insecticides • Spray technique • Human Dwellings sprayed • Reduction in malaria (":) measures Spray Squads Low vector density morbidity & mortality c:: • • ~ • Spray pumps >-3 • Spray schedule > Training & Supervision .... • ~ • Reports & returns t:r.l • Operational costs l:j
Personal • Manpower • Impregnation technique • Bed nets impregnated or • Reduction in malaria Protection • Training & Supervision • Participation ofNGOs distributed morbidity & mortality • Bed nets • Propaganda • People adopting Personal • Lower human - vector • Insecticides • Community participation protection measures contact • Impregnation • BCC technique • Use of bet nets • BCC
------~------~
43 I f t Figure 1: Flow chart of the early case detection and prompt treatment in Imphal East district, Manipur state, India, 2006
COMMUNITY DDC
Passive Case~ Detection Active Case Detection (PHC/CHC/F/D) (Male and female 1 health workers t of the PHSC) I Laboratory technician .. of the health centre --+ Complicated & severe cases referred I Health worker/ Positives ~ hospitalised Health sup'~ Negatives Active Passive -- ! Medical officer
44 - ~-·----~---·----·---· ------
Table -2: Selected indicators at district level of the national anti malaria programme evaluation, Imphal East district, Manipur state, India, 2006
Com~onent Indicators N/n % Input Medical officer in position 27/39 69 Laboratory technician in position 19/19 100 Medical officer trained in malaria 18/27 67 Laboratory technician trained in malaria 19/19 100 Health workers in position 58/93 62 Health workers trained in malaria 39/58 67 Microscopes in position 13/14 93 Health centres having indoor facilit~ 2/13 15 Process Health workers visiting the household fortnightly 32/58 55 Sub center visited by district official once in a year 0/42 0 Sub center visited by medical officer once in a quarter 0/42 0 Working Passive Case Detection agencies 14/14 100 FTDs treating fever cases 47173 64 DDCs treating fever cases 122/227 54 Outcome Pf cases admitted in the health centre and treated for complication 0/52 0 Health facilities fulfilling the target of annual blood examination rate 0/13 0 Health facilities having stock-out of anti malarial drug for more than 13/13 100 one week Impact Annual Blood Examination Rate 242921431719 5.6 Annual parasite incidence 147/431719 0.3
45 Table -3: Selected indicators at Jiribam sub-division and rest of the district of the national anti malaria programme evaluation, lmphal east district, Manipur state, India, 2006.
Rest of the district Jiribam sub-division Com:eonent Indicators N/n % N/n % Input Medical officer in position 12/19 63 519 56 Laboratory technician in position 6/6 100 2/2 100 Medical officer trained in malaria 8/12 67 3/5 60 Laboratory technician trained in malaria 6/6 100 2/2 100 Health workers in position 24/32 75 10/18 56 Health workers trained in malaria 15/24 67 6/10 60 Microscopes in position 6/6 100 2/2 100 Health centres having indoor facilit~ 116 17 112 50 Process Health workers visiting the household fortnightly 12/24 50 6/10 60 Working Passive Case Detection agencies 6/6 100 2/2 100 Number of fever cases collected peripheral blood smears from the OPD 328/742 44 531/689 77 FfDs treating fever cases 20/37 54 12/20 60 DDCs treating fever cases 38/86 44 31/45 69 Outcome Number of fever cases received presumptive treatment from OPD 263/328 80 385/531 77 Number of slide positive cases received radical treatment from OPD 44/50 88 28/51 55 Health centres fulfilling the target of annual blood examination rate 0/6 0 012 0 P.f. cases admitted in the health centre and treated for comElication 0114 0 0/38 0 Impact Annual Blood Examination Rate 9847/233037 4.2 3372/4698 7.2
46 DESCRIPTION AND EVALUATION OF THE STI SURVEILLANCE SYSTEM IN IMPHAL EAST DISTRICT, MANIPUR STATE, INDIA, 2007
1. INTRODUCTION
Public health surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of data regarding a health-related event for use in public health action to reduce morbidity and mortality. Data disseminated by a public health surveillance system can be used for immediate public health action, program planning and evaluation, and formulating research hypotheses. The purpose of evaluating public health surveillance systems is to ensure that problems of public health importance are being monitored efficiently and effectively. 1 One of the most essential, high-priority public health activities is surveillance, because it is intended to guide action that will reduce morbidity and mortality in populations?
Sexually transmitted infections (STis) are a major public health problem now compounded by the advent of acquired immuno-deficiency syndrome (AIDS) and human immuno-deficiency virus ( HIV) infection. The size of the problem represented by STis and HIV is unknown. 3 The older terminology of "venereal diseases" (VDs) largely has been superseded in the past 50 years by "sexually transmitted diseases" (STDs), and more recently by "sexually transmitted infections" (STis).4 As per World Health Organization (WHO) during 1999, about 340 million people aged 15 - 49 years suffered from sexually transmitted infection (STI) like syphilis, gonorrhea, Chlamydia and Trichomoniasis etc. world over and 151 million STI cases (44.4%) were from South and Southeast Asia.5 Burden of STis excluding HIV in DALYs estimates in 2001 in both sexes was 0.85%, female estimate was 1.1 %. Burden of HIV estimates in 2001 in both sexes was 6.0%, female estimate was 5.9%.6 Sexually transmitted infections (STis) constitute a huge health and economic burden for developing countries: 75-85% of the estimated 340 million annual new cases of curable STis occur in these countries, and STis account for 17% economic losses because of ill health? STI is ranked as one of the top five categories of diseases in adults for seeking health-care services.8 As per National AIDS Control Organisation (NACO) estimates, In India, STis occur at an estimated rate of more than 40 million every year. The annual incidence of STis in India is 5%.9 During 2005, the prevalence of HIV among the STI population was 5.66%. 10 Nearly 40% of all HIV infections in India are among women. 11 The control of sexually transmitted diseases is one of the important strategies under the National AIDS Control Programme. In Manipur state, HIV positivity and Venereal .disease research laboratory (VDRL) reactivity among STI patients in 2006 was 4.8% and 1.4% respectively. And, HIV positivity and VDRL reactivity from the pregnant women was 1.4% and 1% respectively. In Imphal east district, HIV positivity and VDRL reactivity among STI patients in 2006 was 3% and 1% respectively. And, HIV positivity and VDRL reactivity from the pregnant women was 1% and 0.4%.12
Sexually transmitted infections surveillance is on-going in Imphal east district. The surveillance of sexually transmitted diseases provides valuable information on prevalence of various STis as an input for prevention and control programmes. We evaluated the STI surveillance system with the following objectives: (1) describe the existing surveillance system of STI (2) estimate the proportion of different type of STis among clinic attendees, (3) evaluate the STI surveillance system in terms of sensitivity, acceptability, positive predictive value, simplicity, and flexibility and (4) suggest recommendations.
2. METHODS
2.1 DESCRIPTION OF THE SURVEILLANCE SYSTEM
STD surveillance has been under the Manipur State AIDS . Control Society (MACS). We obtained written permission from the MACS authority. We interviewed the stakeholders involved in surveillance system of STI in the Imphal east district including the staff of the Manipur State AIDS Control Society (MACS), doctors and paramedical staffs of the STI clinic. We reviewed the available records of the surveillance at the MACS and STI Clinic. We reviewed the operational manual, records, routine procedures followed in routine STI surveillance including population under surveillance, use of case definition, type of system, data transmission, data management and analysis, feedback and action. 2.2 EVALUATION OF THE STI SURVEILLANCE SYSTEM
We evaluated the STI surveillance system of Imphal east district. We reviewed surveillance records and reports during the period 2002-2006 available at the STI clinic and at MACS level for evaluation of timeliness, simplicity. To evaluate acceptability and flexibility we visited to the clinic. We also conducted a community survey for the sensitivity attribute.
We used CDC guideline for STI evaluation. We assessed different attributes of STI surveillance system with the following indicators (Table-1):
2.2.1 Simplicity
Proportion of staff nurses or health workers, who knew the case definition for syndromic STI. We reviewed the surveillance flow chart to detect opportunities for simplifications.
2.2.2 Flexibility
Proportion of staff nurses or health workers, medical record officer and laboratory technicians willing to handle other diseases in same surveillance system.
2.2.3 Acceptability
Proportion of medical officers of the reporting unit submitting reports regularly and completely every month to the MACS.
2.2.4 Sensitivity
Proportion of STI cases captured by surveillance system among cases in community and proportion of cases reported to the STI clinic among those captured in the public sector.
2.2.5 Positive predictive value (PPV)
Proportion of STI cases that were laboratory confirmed. 2.2.6 Cost
The cost incurred for the STI surveillance activities and the flow and utilisation of funds and logistics were reviewed to identify any obstacle compromising surveillance activities.
2.3 SURVEY TO ESTIMATE THE SENSITIVITY OF STI SURVEILLANCE SYSTEM
2.3.1 Study population and study design
We conducted a cross-sectional study. We considered all the villages in Imphal east district. The population of the district in this age group was 1,70,745 and 50% females. We excluded men and women with severe and chronic disease and mentally ill patients.
2.3.2 Operational defmitions
We used syndromic approach to identify women with symptoms of RTI/STI in the community and used the case definition given by the Indian National AIDS Control Organization (NACO). 13 We defined a case of RTI/STI as one who had one or more of the following symptoms at the time of the interview: (1) abnormal vaginal I discharge, (2) dysuria, (3) lower abdominal pain, (4) ulcer in genital area, (5) swelling in the groin and (6) other related syndromes.
2.3.3 Sampling procedure and sample size
We considered all the villages in Imphal East district as clusters (n=200). We selected 27 clusters following probability proportional to size. Within the selected clusters, we randomly selected 40 household and interviewed one eligible man from one household and woman from neighborhood house. Assuming a prevalence of syndromic STIIRTI of 50%, planning for a confidence coefficient of 95% and a confidence interval of± 5%, a cluster size of 20 and a rate of homogeneity of 0.02, we calculated the sample size as 540 each.
__ ,_'ill ------~ 2.3.4 Information collected
We surveyed men and women to identify those with symptoms of RTI/STI. We interviewed men and women with these symptoms to understand their treatment seeking behaviour. We used a structured questionnaire to collect information regarding socio-demographic details, current STIIRTI symptoms and STI/RTI symptoms during last six months. From men and women having STIIRTI symptoms at the time of interview, we collected information about treatment seeking behaviours.
2.3.5 Human subject protection
The ethical committee of the National Institute of Epidemiology, Chennai, approved the study. We obtained written informed consent from the study participants. We ensured privacy when the questionnaire was administered. We referred women with symptoms of suggestive of RTI/STI to the nearest government hospital for treatment.
2.3.6 Data collection procedure
We translated the questionnaire into Manipuri, the local language. We pilot tested the questionnaire before the survey. We trained five male and female health workers for data collection at the STI clinic, Imphal. The questionnaire were administered by trained male and female health worker. We interviewed each study subject for approximately 30 minutes.
2.3. 7 Data analysis
We analysed the data using Bpi Info 3.3.2. We divided the number of STI cases attended in the STI clinic by number of cases detected during survey. We also collected information about the number of cases of STI registered in STI clinic from the outpatient department (OPD) and number of cases reported to the MACS from the MACS data. 3. RESULTS
3.1 DESCRIPTION OF THE SURVEILLANCE SYSTEM
STI surveillance is earned out through one STI clinic attached to the dermatology department of Jawaharlal Nehru Hospital, Imphal east district. STI cases attending the clinic are examined by the dermatologist who makes the etiological diagnosis of various STis based on his clinical knowledge. A staff nurse posted to the clinic makes entry of all the STI cases in the register according to the etiological diagnosis. There are no medical record officer and counselor for the clinic. There were no minor operation theatre, side laboratory and laboratory technician of the clinic.
3.2 DATA STRUCTURE
Since 2002, STI clinic has been using NACO's reporting format. Data has five components, they are (1) the status of the availability of equipments and consumables, (2) Number of patients attending STI Clinics i.e. type of patients (3) Details of the cases detected i.e. type of diseases, (4) laboratory test results and (5) Details of condom distribution, partner notification, and counseling services. STI clinic collected the data daily, reported monthly to the MACS and aggregated at the MACS.
3.3 DATAANALYSIS
The data from the STI clinics is compiled and anlysed by the statisticians at MACS to calculate the following indicators: (1) distribution of STI patients by sex (2) proportion of STI cases due to specific diseases (3) Proportion of the STI cases confirmed by laboratory tests (4) Proportion of the STI cases who were given condoms, and counseled.
3.4 FEEDBACK
The feedback is in the form of correspondence or letter or paper or fax or electronics, periodic meetings, supervisory visits etc. The feedback comes from the NACO to MACS through Computerized Management Information System(CMIS). Feedback usually is about the completeness and timeliness of reporting (Figure 2). MACS does not give any feedback to clinic.
------·------·-- 3.5 EVALUATION OF THE SURVEILLANCE SYSTEM
3.5.1 Simplicity
This was a hospital based surveillance and a trained dermatologists examined the attending cases. Staff nurse on duty filled the columns of the NACO's format. Staff nurse expressed that the format is lengthy, complicated and time consuming. Filled reports are sent to MACS.
3.5.2 Flexibility
The reporting is based on ethological STI diagnosis which . is done by the trained doctor. There is no scope for including cases with syndromic STI.
3.5.3 Acceptability
Participation in this system was willing but they were facing the problem of the lack of manpower. They complete all the necessary report forms in time according to the availability of the logistics.
3.5.4 Sensitivity
Of the 540 males and 540 females surveyed, we identified Ill cases of STI among males and 321 cases of STI among females (Table-3). Of the 111 male case patients with syndromic STI, 29 (26%) attended STI clinic at Jawaharlal Nehru Hospital, Imphal east district while 21 (19%) attended other public health facilities. 48 (43%) of them received treatment from private practitioners. Of the 321 female case patients with syndromic STI, 64 (20%) attended STI clinic at Jawaharlal Nehru Hospital, Imphal east district while 55(17%) attended other public health facilities. 123 (38%) of them received treatment from private practitioners. During 2006, a total of 359 case-patients attended STI clinic. Of these, all the cases were reported to the MACS
3.5.5 Positive predictive value
The etiological diagnosis of STI is made by the trained dermatologists. However, the diagnosis was not supported by laboratory investigations. The microbiology laboratory conducts only VDRL test.
53 3.5.6 Cost
The estimated budget for clinic of the year 2006 was Rs. 250,000. The clinic did not get the. same, instead they got the logistics. The clinic did not get the required materials in time. The details obtained from the MACS are given below:
(1). Rs. llacs: STI drugs and others
(2). Rs. 1 lacs: Maintainance of infrastructures, consumables like reagents, gloves, glass slides, etc.
(3). Rs. 50 thousand: Computer and its accessories.
4. DISCUSSION
· The STI surveillance system evaluation of Imphal east district was conducted during 2007. We obtained low sensitivity both in males and females. The surveillance system was based on the STI clinic attached to the Jawaharlal Nehru Hospital, Porompat. Peripheral health centres of the district were not participating. Trained dermatologist examined the attending cases and treated on the basis of the etiological diagnosis. There was no laboratory confirmation of the attending STI cases.
Majority of the STI patients were not attending the present clinic. The magnitude of the different types of STis can not be determine. So, some of the cases attending to this clinic might not be from the study district. Many of the cases might have gone to the private sectors for the treatment. Many STI patients are not attending peripheral health centres. Peripheral health staffs including doctors are to be trained for STI syndromic management.
STI cases were examined by the dermatologist. The positive predictive value (PPV) are likely to be high inspite of not confrrming by laboratory test. There is need to do laboratory test for specific confirmation. Treatment based on laboratory result support should get the idea- of specific medication and control measures. Infrastructures and manpowers are to be improved and laboratory facility are to be provided at the clinic. There were several limitations in the study. First, we cannot analysed the data on the basis of the age and place. Second, we cannot comment on syndromic STI. Third, we cannot included unwilling participants during the survey. To reduce recall bias we interviewed the happenings in the last six months.
Based on the findings of the evaluation, we recommend to strengthened the surveillance system at the peripheral institutions. This clinic is one of the referral clinic in the district, so good laboratory facility should be provided for the public.
55 I I REFERENCES I
1. Centres for Disease Control and prevention: Updated Guidelines for Evaluating Public Health Surveillance Systems: Recommendations from the Guidelines Working Group. MMWR 2001; 50: RR-13.
2. Division of STD Prevention. Program operations guidelines for STD prevention: Surveillance and data management. Atlanta, GA: Centers for Disease Control and Prevention, 2002. Available at: http://www.cdc.gov/std/program/surveillancetrOC-PGsurveillance.htm. Accessed Sept 12, 2006.
3. Adler MW. Sexually transmitted diseases control in developing countries. Genitourin Med. 1996 Apr;72(2):83-8.Erratum in: Genitourin Med 1996 Jun;72(3):229.
4. Judson F. Introduction. In : Kumar B, Gupta S, editors. Sexually transmitted infections, 1st ed. Elsevier: New Delhi; 2005. p. 1-4.
5. World Health Organization, Global prevalence and incidence of selected curable sexually Transmitted Infections overview and estimates, WHOIHIV__AIDS/2001.02, WHO/CDS/CSR/EDC/2001.10, Geneva, 2001.
6. The WORLD HEALTH REPORT 2002, Reducing Risks, Promoting Healthy Life, 192-197, [email protected].
7. Mayaud P, Mabey D. Approaches to the control of sexually transmitted infections in developing countries: old problems and modem challenges. Sex Transm Infect. 2004 Jun;80(3):174-82.
8. Dallabetta G, Field M L, Laga M, Islam Q.M, STis: Global burden and challenges for control, in control of Sexually Transmitted Diseases: A handbook for the design and management of programmes. Dallabetta G et al. (eds.); AIDSCAP, Family Health International, 2101 Wilson Boulevard, Suite 700, Arlington, Virgina 22201. 9. Bhalla S., Lalchandani K., Singh s., Somasundaram c, Bhalla V. 3rd International AIDS Society Conference on HIV Pathogenesis and Treatment, Rio de Janeiro- July 24- 27, 2005, A Study of prevalence of STDs from a rural village in Gujarat, India among the reproductive age (15-49 years) subjects.
10. HIV/AIDS epidemiological Surveillance & Estimation report for the year 2005, April 2006, National AIDS Control Organization Ministry of Health & Family Welfare Government of India, Page 1 of 11, NACO, HSS- 2005.
11. Leaflets and banners ofNational AIDS Control Organization (NACO), India.
12. National AIDS Control Program, State summary report on Sentinel surveillance for HIV infection and VDRL reactivity, Manipur State AIDS Control Society, 2006.
13. National AIDS Control Organization(NACO), Ministry of health & family welfare, Govt. of India; Training module on the Surveillance of Sexually Transmitted Diseases. Figure 1: Yearly trend of STD patients attendance in Jawaharlal Nehru Hospital, Porompat, Imphal East district, Manipur state, India, 2006 •,
600
500
0+------~~------r------~------~------~2002 2003 2004 2005 2006 Year
58
j9 Figure 2: Flow chart of the surveillance system of lmphal East district, Manipur state, India, 2006
Case-patients fro~ the community
STI clinic, Jawaharlal Nehru Hospital, Porompat ~~ Manipur State AIDS Control Society (MACS)
CMIS c::=:::::::>
National AIDS Control Organisation
59 Table 1: Logical frame indicating surveillance attribute indicators of STI surveillance system, Imphal East district, Manipur State, India , 2006
Indicators Data needed Source of data • Simplicity • Review of the surveillance flow chart, reporting • Description of the actual system • Qualitative interviews with mechanism, laboratory confirmation before reporting to participants/health staffs detect opportunities for simplifications • Description of the theoretical • Guidelines, operation manuals
system and forms I • Flexibility • Proportion of health staffs willing to add other diseases • Number of health staffs willing • Interview with health staffs in STD surveillance • Proportion of health staffs willing to participate in STD • Total number of health staffs • Review of hospital records surveillance posted in the clinic • Acceptability • Proportion of Clinic willing to participate and submitting • Number of clinics reporting data • Manipur State AIDS Control monthly report regularly Society records • Total number of clinic participating the surveillance • Sensitivity • Proportion of STD cases captured by the clinic among • STD cases reported in • Community cases in the community community • Number who received treatment at STD clinic • Proportion of STD cases to the Manipur State AIDS • STD cases reported in MACS • Manipur State AIDS Control Control Society among those attending the STD clinic Society records • STD cases attended in two STD • STD Clinic register clinic • Positive predictive • Proportion of STD cases that are laboratory confrrmed • STD cases confirmed out of total • Manipur State AIDS Control value laboratory test Society records • Cost • Cost incurred for the STD surveillance activities • Cost of logistics and others • STD Clinic • Total sanction amount • Manipur State AIDS Control Societ~ records
60 .,..______.-1 ttrtr ,,.
\
Table 2 : Selected indicators for the evaluation of STD surveillance, Imphal districts, Manipur state, India, 2006.
Attributes Indicator Number Total %
Number of STD cases who receive treatment at STD Clinics out of total number Males 29 111 26 of STD cases in the community after survey Sensitivity Females 64 321 20
Number of STD cases reported in th.e Manipur SACS out of total cases attended in the clinics 359 359 100
Acceptability Number of STD Clinic submitted monthly reports regularly 1 1 100
Simplicity Number of staff nurse who can fill up the reporting format 1 1 100
Flexibility Number of STD Clinics who can add new cases apart from STD in the format 0 1 0
61 Table-3 : Number of syndromic STI patients detected during survey in Imphal East district, Manipur state, India, 2006
Males Females
Symptoms* Total % Total % -- Genital ulcer 4 1 11 2
Vaginal discharge X X 236 44
Urethral discharge 89 17 126 23. Swelling in the groin 9 2 35 7
Lower abdominal pam X X 110 20
Others 17 3 10 2
Total STI symptoms 111 21 321 59
• Some had more than one symptoms
62 Section 3
. Outbreak Investigation AN OUTBREAK OF SCRUB TYPHUS IN BISHNUPUR
MUNICIPAL AREA OF THE BISHNUPUR DISTRICT, !9. MANIPUR STATE, INDIA, 2007
1. INTRODUCTION
Scrub typhus also known as tsutsugamushi disease was first described by the Chinese about 2000 years ago and causative organism was first isolated in 1930. The name tsutsugamushi is derived from two Japanese words: tsutsuga, meaning something small and dangerous, and mushi, meaning creature. 1 Scrub typhus - also known as mite-borne typhus or tsutsugamushi disease - is an acute, zoonotic, febrile illness of humans. 2
The etiological agent, Orientia tsutsugamushi (formerly, Rickettsia tsutsugamushi), is transmitted through the bite of infected, free-living, larval Lepotrombidium mites, or chiggers.2 The mites are parasitic only in the larval stage.
0. tsutsugamushi is maintained in the vector mites by transovarial transmission.3.4 The chiggers normally feed upon only a single vertebrate host and do not transmit infection from one host to the other.5 Rodents are critical to the maintenance of the disease as they harbour chiggers.4 Leptotrombidium mites are all primarily parasites on rats, field mice, shrews and rabbits, all of which have been found naturally infected with the agent.6 Thus, the chigger distribution often directly reflects the distribution of the rodent host. Foci of infection known as typhus or mite islands have been reported in some areas as sharply localized and irregularly scattered spots where transmission is common. 7 Rodents are the usual vertebrate host while humans are accidental hosts.8 Humans become infected when they accidentally encroach in an area where the chigger-rodent cycle is occurring, most often areas are low-lying transitional vegetation.9 Apart from the rodents, chigger mites (Acarina: Trombiculidae), ectoparasite during the larval stage, were found on both resident and migratory or wild birds, bats and reptiles. 10•11 •12
63 The infection begins by local multiplication at the site of the bite resembling a cigarette burn. This produces a papule that later ulcerates and forms a black crust, the 'eschar', which is pathognomonic of scrub typhus infection.13 The organisms enter and multiply in the endothelium of the capillaries and other small vessels. Capillary obstruction occurs from endothelial swelling or thrombosis, with resultant necrosis in heavily involved tissues. 14 Fever, rash and eschar are the most common symptoms of scrub typhus and are important in the clinical diagnosis of this disease. 15 Clinical manifestations of scrub typhus range from mild fever with few other symptoms to a fatal syndrome characterized by multiple-organ failure are the most life-threatening complications. 16•17 Fever typically begins from 6 - 21 days following the bite and is accompanied by a maculopapular rash, headache and lymphadenopathy.18 If the disease is unrecognized or untreated, case fatality up to 60% have been reported. 19 The treatment of choice is doxycycline.16
Scrub typhus is widespread extending from Japan in the North to tropical Queensland (Australia) in the South and from India in the West to Solomon Islands and Vanuatu in the East.20 It occurs in the Far East, Assam, Burma, Pakistan, Bangladesh, India, Indonesia, S Pacific Islands and Queensland.21 Scrub typhus was endemic in the Asia Pacific region during World War II and re-emerged as outbreaks and sporadic cases since the 1980s in various countries including Japan, Australia and in south Asia. 22•23•24•25 Rickettsia tsutsugamushi (now called Orientia tsutsugamushi) is a rural zoonosis endemic in the Asia Pacific region, Australia, Japan and India.26 The disease was reported from various ecosystems including seashores, mountainous regions, rain forests, semiarid deserts, riverbanks and terrain undergoing secondary vegetation growth.Z7 Although 25 - 50 % of scrub typhus cases occur in children, most cases occur through agricultural exposure, among paddy field workers of ' Thailand, Japan, or Korea and among oil palm and rubber plantation workers in Malaysia. 27 Factors that may have contributed to this decline include wide spread use of insecticide, effective antibiotics and changes in life style.28
In India, the presence of scrub typhus has been documented for several decades. 29 Epidemics were reported in West Bengal and Assam during the World War
II especially in the Eastern regions.28'30 Since 2000, there have been reports of scrub
64 typhus outbreaks from the Indian state of Tamilnadu in the South and the states of
Himachal Pradesh and Sikkim in the Northern Himalayan region.31.32'33 The incidence declined considerably due to the widespread use of insecticides, effective antibiotics and changes in life styles. 34 However, the disease has not disappeared from the Indian subcontinent. Recent reports from India and other neighbouring countries suggest that there is a resurgence of scrub typhus infection in these parts of the world. 35 The apparently low frequency of the disease in India is due to the fact that a large number of cases might not be diagnosed correctly given the low level of diagnostic suspicion that health functionaries have in respect of scrub typhus. 36
Seasonal, post-monsoon outbreaks of febrile illness with rash and high case fatality rates (>20%) have been reported in the municipal areas of Bishnupur district of Manipur since 2001. The disease mainly affected adult females. However, since the etiology of the disease was not established, the disease was known locally as Khullai laipha or Nung phuri. The disease was diagnosed as scrub typhus during the outbreak in 2006.
There was an outbreak of suspected scrub typhus in Municipal area of Bishnupur district in July 2007. We investigated this outbreak to (1) confirm its etiology (2) describe the outbreak in time, place and person (3) identify the risk factors associated with the disease and (3) propose recommendations for control and prevention.
2. METHODS
2.1. DESCRIPTIVE STUDY
There was a report of one death due to suspected scrub typhus from Ward No. one in Bishnupur district on 25th July 2007. Following this report, we collected information about suspected scrub typhus cases admitted in the district hospital, Bishnupur. We established a stimulated surveillance system to identify suspected cases by requesting (l}four community health workers (2) two private practitioners in the municipal area to report about -any suspected cases of scrub typhus. We defined the suspected case of scrub typhus as occurrence of fever with one or more skin
65 lesions among residents of Bishnupur district since July 2007 (World Health Organisation, Recommended Surveillance Standards. Second edition, WHO/CDS/CSR/ISR/99 .2. ).
We conducted clinical examination of all the suspected cases detected by the surveillance system. We collected information about demographic details, place of residence and date of occurrence of rash.
2.2 LABORATORY INVESTIGATIONS
We collected sera samples from eight suspected case-patients. We sent the sera samples to Kurseong sub-divisional hospital, Darjeeling district, West Bengal for Weil-Felix test.
2.3 ENVIRONMENTAL AND ENTOMOLOGICAL INVESTIGATIONS
We visited all the case-patients in their houses from ward no.1 and conducted environmental investigations. We used 18 traps to catch the rodents in the houses and kitchen gardens as well as nearby bushes in the Bishnupur municipal ward no. 1, 4, and 5 from where the cases had been reported. Rodents collected in these traps were combed over the white plain paper and examined for presence of mites.
2.4 ANALYTICAL STUDY
Based on the findings of the descriptive study, environmental investigations, entomological investigations and interview of few case-patients, we hypothesized that exposure to environment was associated with occurrence of scrub typhus. To test this hypothesis, we conducted case-control study. We included all the 38 suspected scrub typhus cases identified by the surveillance system. For each case, we selected four age, sex and neighborhood controls. We collected the information about the environmental exposure during the last 21 days from cases and controls. This included information about the living environment, occupational environmental exposure, hygienic and protective practices. We used structured, standardized, close ended, pre-tested questionnaires translated into Manipuri, the local language to collect the information. Two trained interviewers collected information for cases and controls.
66 2.5 DATA ANALYSIS
We described the outbreak in terms of time, place and person. We calculated the attack rates of suspected scrub typhus by age and sex using the population of municipal area of the Bishnupur as denominator. 37 We plotted the epidemic curve to understand the dynamics of the disease. Administratively, municipal area of Bishnupur is divided into twelve wards. We drew a map of the attack rates according to the municipal wards. We calculated matched odds ratios and their 95% confidence intervals to identify different forms of environmental exposure associated with occurrence of scrub typhus. We analysed the data with the help of Bpi Info 3.3.2 version.
3. RESULTS
3.1 DESCRIPTIVE EPIDEMIOLOGY
We identified 38 cases fulfilling the case definition with an attack rate of 3.4 per 1000. Five of eight sera samples were positive for Weil-Felix test. Five of eight sera samples were positive for Weil-Felix test. Besides high grade fever, common presenting features of the case-patients were eschar, generalized rash, headache, cough, chest pain, lymphadenopathy, restlessness, respiratory and abdominal discomfort. Thirty seven case-patients (97%) had single eschar while one had multiple small rash (3%). Twenty (53%) case-patients had eschar/rash on the perineal area, 14 (39%) on head, neck, shoulder and chest area and 3 (8%) had at thighs lower abdomen.
In the last six years, 10 female case-patients family members was suffered and three from ward no. one. First time suffered was 34 and 16 from ward no. one and deaths was suffered for the first time. Suffered twice and more than twice in the last six years are two respectively. ·
Attack rates were higher among females (3.9/1000) and those aged 15 years or more (4.2/1000) (Table-1). Two case-patients died with a case-fatality ratio of 5.3%. One (3%) died in the hospital whereas one (3%) died at home after getting treatment from the local traditional healers. The cases of scrub typhus started appearing from
67 2ih May 2007 and peaked in the last week of July 2007. The last case was reported in the 2ih September 2007 (Fig. I). Scrub typhus cases were reported from seven of the twelve wards. Sixteen (42%) of the cases were from ward no.l. Attack rates were highest in this ward (30/1000) followed by ward No. four (6/1000) and five (9/1000) (Fig.2).
3.2 TREATMENT
In this outbreak, 11(29%) case-patients were given doxycycline. One (3%) pregnant woman was given azithromycin and six (16%) childrens were given azithromycin. 20(53%) gets treatment from the local traditional healers. Six (16%) case-patients were hospitalized, 12 (32%) were treated by qualified private practitioners and 20 (53%) gets treatment from the local traditional healers. One (3%) pregnant woman delivered at term a live female baby in the hospital weighing 2.5 kg during this study. There was no postpartum complications and visible foetal abnormality.
3.3 ENVIRONMENTAL AND ENTOMOLOGICAL INVESTIGATIONS
Ward No. 1 is located at the foot-hills and is surrounded by steep hills in the north and west. The area has full of grown trees, bamboo plants, herbs and shrubs. Villagers practice terrace farming in the upper reaches of the hills. A small river, Thongjaorok, passes through the middle of the ward with gravels and heavy bushes along the banks. Ward no. 5 is located in the south of this river.
A total of 18 traps for collection of rodents were laid in the houses and kitchen gardens as well as nearby bushes in the Bishnupur Municipal ward no. 1, 4, and 5 from where the cases had been reported. Of those, one trap was found positive for rodent, giving the trap positivity as 5.5%. The species trapped was Rattus rattus. The rodent was combed over the white plain paper. State entomologist identified and one flea (Xenopsylla astia) and 4 mites (Laeplas jugalis) could be collected.
68 3.4 ANALYTICAL EPIDEMIOLOGY
On multiple logistic regression analysis, the odds of developing the disease were significantly higher among individuals who stored fire woods in and around the living houses (Odds Ratio= 32, 95% CI= 4-265), involved in vegetable plucking or farming (OR=56, 95% CI=5-673), slept or sat on the floor without mat (OR=l6, 95% CI=l.3-202) and those who defecated or urinated in jungle or bushy areas in squatting position (OR=20, 95% CI=2.3-174) (Table-2).
4. DISCUSSION
An outbreak of scrub typhus occurred in Bishnupur area during June 2007. Attack rates of scrub typhus were higher among older females and ward No.1. We identified several environmental exposures associated with development of disease. The findings of the investigation could be useful for control of scrub typhus in the district.
Several factors are important in transmission of scrub typhus. These include presence of infected mites, infestation of rodents or animals with the infected mites and exposure of human beings to the infected mites either through the exposure to the contaminated environment or animals. Unfed Leptotrombidium tend to aggregate closely in clusters on twigs and debris a few inches above the ground and await a host.38 The mites are closer to the ground and the eschars are more commonly found on the exposed part of the body of the case-patients. We identified several environmental exposures associated with development of scrub typhus. These included storing of firewood in and around the living house, involved in vegetable plucking or farming, slept or sat on the floor of the house/lawn without mat. These activities are likely to expose an individual to environment leading to bite by an infected mite.
Individuals who defecated or urinated in the jungle or bushy areas were also found to be at increased risk of scrub typhus. It is a common practice among women to pass urine in squatting position. Attack rates were higher among females. More
69 than half of the females had eschar on their perineal area. These findings indicate that I the practice of defecating or urinating in jungles or bushy areas is associated with exposure to infected mites. I Attack rates of scrub typhus were higher in ward No. 1 compared to other wards of the municipal area. This ward is located at the foot-hills and is surrounded by jungles. On the other hand, other wards are far away from jungles whereas ward No. 5 is located at the sides of the river gravels and heavy bushes are abundantly present along the banks.
Majority of the cases had typical eschar of scrub typhus resembling the cigarette bum whereas few had small rash. Cases may have been misdiagnosed if the unique symptoms of scrub typhus; eschar, fever and rash were not present. Absence of typical eschar resulting from a tick bite of Leptotrombium spp. Which transmits 0. tsutsugamushi, and rash were reported to be much more common in 10 to 15% of
cases.39.4° Cases without eschar (76.9%) may have been easily ·misdiagnosed as cases of common cold or other febrile illness. Such delay in diagnosis has sometimes resulted in death.41 Mortality was high in earlier outbreaks. During this year, majority of the cases were treated from the local traditional healers. In an endemic areas, in addition to increase awareness amongst the physicians, intensive health education on clinical symptoms such as eschar, fever and headache is also important in order to improve the rate of self recognition by local residence.42
Though we identified several environmental exposures associated with disease, however, we could not demonstrate the causative agent in mites. Further entomological studies are needed to demonstrate the organism in mites and habitat of the mites.
The main limitations are: First, the study was conducted in Bishnupur Municipal area and the findings may not be generalize to other places. Second, We cannot did laboratory test in the state health laboratory.
Based on our results, we can propose several recommendations for local health authorities and municipalities to control of scrub typhus in Bishnupur municipal area,
70 1. Health education: It is necessary to educate the community to (a) early and prompt treatment are to be encourage, (b) store fire woods away from the living house, (b) avoid defecation/urination in jungle/bushy areas (c) use mat or stool/local stool* while taking rest after activities or plucking vegetables (d) surroundings of the farming areas or kitchen garden areas are to be kept clean.
2. Establish surveillance of scrub typhus in the district.
3. Establish facilities for laboratory test for scrub typhus.
* Mora: made by bamboo & cane or phan: made by wood.
71 REFERENCES
1. http://www .emedicine.com/ped/topic271 O.htm#section-introduction, last updated: July 14, 2006, access on 12-08-07.
2. Bavaro, M.F et al. History of US Military to the study of Rickettsial diseases, Military medicine, Vol. 170. 4:49, 2005
3. Walker JS, Chan CT, Manikumaran C, Elisberg BL, 1975. Attempts to infect and demonstrate transovarial transmission of R. tsutsugamushi in three species of Leptotrombidium mites. Ann NY Acad Sci 266:80-90
4. Takahashi M, Murata M, Misumi H, Hori E, Kawamura A Jr, Tanaka H, 1994. Failed vertical transmission of Rickettsia tsutsugamushi (Rickettsiales: Rickettsiaceae) acquired from rickettsemic mice by Leptotrombidium pallidum (Acari: Trombiculidae). J Med Entomol31: 212-216
5. Traub R, Wisseman CJ. Jr, Jones MR, O'Keefe JJ, 1975. The acquisition of Rickettsia tsutsugamushi by chiggers (trombiculid mites) during the feeding process. Ann NY Acad Sci 266: 91-114
th 6. Chandler, Read, CP. Introduction to Parasitology. 10 edition. Pp 550-554
7. Frances SP, Watcharapichat P, Phulsuksombati D, Tanskul P, 2000. Transmission of Orientia tsutsugamushi, the aetiological agent for scrub typhus, to co-feeding mites. Parasitology 120: 601-607
8. Shah, Alfred J., Scrub typhus. Principles and Practice of Infectious diseases. Third Edition. Mandel, Douglas and Bennett (Editors). Churchill Livingstone, 1990
9. Lewislq M.D., et al, Scrub typhus Re-emergence in the Maldives. Emerging Infectious Diseases Vol. 9, No. 12, December 2003
72 10. Stekol'nikov AA, Litenik I, Capek M, Havlck M. Chigger mites (Acari: Trombiculidae) from wild birds in Costa Rica, with a description of three new species. Folia Parasitol (Praha). 2001 Mar;54(1):59-67.
11. Dietsch TV. Seasonal variation of infestation by ectoparasitic chigger mite larvae (Acarina: Trombiculidae) on resident and migratory birds in coffee agroecosystems of Chiapas, Mexico. J Parasitol. 2005 Dec;91(6):1294-303.
12. Daniel M, Stekol'nikov AA. Chigger mites (Acari: Trombiculidae) new to the fauna of Cuba, with the description of two new species. Folia Parasitol (Praha). 2003 Jun;50(2): 143-50.
13. Shah, Alfred J., Scrub typhus. Principles and Practice of Infectious diseases. Third Edition. Mandel, Douglas and Bennett (Editors). Churchill Livingstone, 1990.
14. J. R. Anderson: Types of infection, Rickettsial infections, Muir's Textbook of Pathology, Edward Arnold (publishers) limited, 12th edition, 1985, 9.33-9.43.
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19. Smadel JE, Elisberg BL; Scrub typhus Rickettsia. In: Viral and Rickettsial infections of man, Ed 4, pp 1130-43. Edited by Horsfall FL et al (1965)
73 20. Arthropod- and rodent -borne viral and Rickettsial diseases in the WHO South-East Asia and Western Pacific Regions: Memorandum from a WHO Meeting. Bulletin of World Health Organisation.61 (3).435-446(1983)
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25. Antony G Faa, et al, Scrub typhus in the Torres Strait Islands of North Queensland, Australia. Emerging Infectious Diseases. Vol. 9, No. 4, April 2003
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75 Figure 1: Distribution of suspected scrub typhus cases according to date of onset of the rash, Municipal area, Bishnupur district, Manipur state, India, 2007
76 Figure 2: Distribution of attack rates of scrub typhus cases in different wards of Bishnupur Municipal area of Bishnupur district, Manipur state, India, 2007
N t
D.I$TIUBTION OF.ATTACI( RATE$ IN DIFFERENT WARDS. ATTACK RATES 0
1 to 4.9
• 5to10
11 >10
77 ,I Table 1: Age and sex distribution of Scrub typhus cases, Bishnupur municipal area, Manipur state, India, 2007
Demographic No. of Attack rate Case Fatality Rate characteristics Populations No. of caSes deaths per 1000 per 1000 Age group 0-4 1122 1 0 0.9 0.0 5-9 1235 2 0 1.6 0.0 10-14 1235 3 0 2.4 0.0 15-44 5499 23 1 4.2 0.2 45+ 2132 9 1 4.2 0.5 Total 11223 38 2 3.4 0.2 Sex Male 5822 17 1 2.9 0.2 Female 5401 21 1 3.9 0.2 Total 11223 38 2 3.4 0.2
78 Table 2: Selected exposures for scrub typhus cases and controls, Bishnupur municipal area, Bishnupur district, Manipur state, India, 2007
95% Odds Confidence Exposurest Ratio Interval Living environment Storing of firewood in and around the house 32 3.9-265 Storing of rice in and around the living house 0.9 0.1-5.8 Personal activities and occupation Involved in vegetable plucking or farming* 56 4.7-673 Slept/sat on the floor of house/lawn without mat 16 1.3-202 Defecated or urinated in jungle or bushy areas in Hygienic and protective practices squatting position§ 20 2.3-174 Taking bath after the daily activities 1.0 0.1-7.3 Place of taking bath** 5.4 0.3-96 Drying of wet cloths tt 0.2 0.02-1.8 Changing of clothes after the daily activities 0.03 0.0-1.7
t Referent period of 21 days *Working in the farm for food /fodder for domestic animals §On the way to farming/daily activities/playing •• Inside the bathroom tt High up
79 Section 4
Scientific Study Critique SCIENTIFIC STUDY CRITIQUE
General information
Title of the paper: Cassia occidentalis poisoning as the probable cause of hepatomyoencephalopathy in children in western Uttar Pradesh
Authors: V. M. Vashishtha, Amod Kumar, T. Jacob John & N.C. Nayak
References: Indian J Med Res 125, June 2007, pp 756-762
Reviewer: Sagolsem Ibungochouba Singh
Date: 12-1-08
General narrative comments
This outbreak investigation is justified because of the recurrent outbreaks of acute encephalopathy illness affecting children in many districts of Uttar Pradesh. Moreover, definite cause is not known and it has high case fatality ratio. Introduction is not clear. Global, regional and Indian disease burden is not mentioned. Some elements of methods and results section are misplaced in the introduction. Outbreak investigation is not done systematically. Use of passive voice is common. Descriptive epidemiology as per time, place and person is missing. Numbers are not rounded up in the text. Good writing and systematic case building is present though not consistent all the time.
80 Grading from 1 (strongly Area Checklist items disagree) to 5 (strongly agree) Explanations 1 2 3 4 5 Overall assessment of The background provides a ..J The background does not provide global the paper description of the public issue at the burden of the public issue. Local disease global and local levels and logically burden described but not clear. introduces the need to answer a specific research question.
The methods section provides ..J The type of study and analytical study is sufficient information on the well described. Systematic outbreak methods used, including the type of investigation is missing including time study, the sampling strategy, the place and person analysis. case definitions, the data collection and the data analysis.
The results reports sound scientific ..J The results are tabulated with adequate results that meet the study's statistical information and meet the study objective and the research question. objective. They are presented with sufficient details and adequate statistical information (e.g., Confidence Intervals).
~------·-···------' ~
81 Grading from 1 (strongly I Area Checklist items disagree) to 5 (strongly agree) Explanations I 1 2 3 4 5 The discussion summarizes and ,; The results are well summarized and interprets the results, discusses the interpreted. The limitations of the study are findings in view of what is already not well defined. However, known, frames what the results of recommendations are generalized and not the study can support, defines the specific as per the findings. limitation of the work and suggests next steps in terms of (1) intervention and (2) research. Methods The study design is adequate to meet ,; Study design is appropriate. the objective. The study population is well defined ...; Study population is well defined. and relevant to the research question Definitions are specified, sound and ...; Case definition is mentioned but not based based upon standardized criteria on standardized criteria. when available. Sampling methods are statistically ...; The method adopted for taking the sample is sound and adapted. mentioned. The sample size was estimated ...; All 18 subjects taken for study are
I' beforehand appropriately. mentioned. I
The study is exempt from bias. ...; There may be recall bias. ! The data that were collected are well ...; Data were well described and relevant. described and relevant.
82 Grading from 1 (strongly Area Checklist items disagree) to 5 (strongly agree) Explanations 1 2 3 4 5 The data was collected was of v The data collected were not of sufficient ,/ sufficient quality. quality. Quality control measures in the generation of the data were not mentioned. The analysis is thought beforehand v The analysis was not done according to and appropriate. time, place and person distribution. The child who ate Cassia pods very recently may be a confounding factor rather than causal . The indicators generated are ...J The indicators are well calculated and appropriate and well calculated. appropriate . The statistical tests used are ...J The statistical tests are well computed. appropriate and well computed. Appropriate attention has been given ...J No mention has been made regarding to human subject protection issues. human subject protection. Writing The content is well distributed by ~ Yes ,the content is well distributed ' chapters and sections. The language is simple and clear. ~ Though the language is simple and clear, The word count is < 3000. some statistical word's are used. The word count is less than 3000 words. The writing is sequential, going from ~ The writing is not sequential. one point to the next. The active voice is used throughout. ~ Active voice has not been used throughout.
------,., ------
83 Grading from 1 (strongly Area Checklist items disagree) to 5 (strongly agree) Explanations 1 2 3 4 5 The vocabulary is precise, consistent ~ The vocabulary is not precise and and standardized. inconsistent Tables and figures There are no more than five tables --1 The number of tables and/or figures is less and or figures. All are needed. than five. All are needed. The choice of graph or table to ~ Choice of tables and figure are not display information is judicious. judicious. Table of person distribution is missing. The tables are clear, exact and the ~ Tables are exact and clear. But some zeros I totals add up. are not needed.
The graphs are effective, appropriate ~ Photo is appropriate. and understandable. ------
84