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.