Neglecgted tropical disease: in context to Nepal

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  • The responsible pathogens are a biologically disparate group,including (1) vector-borne protozoa (such as Trypanosomacruzi), bacteria(ocular serovars of Chlamydia trachomatis) and filarial worms(such as Onchocercavolvulus); (2) soil-transmitted helminths (STHs);and (3) the two species of non-tuberculosis mycobacteria that produceBuruli ulcer and leprosy,-Following its second meeting in Berlin in 2005, WHO proposed that thevaguely defined term “other communicable diseases” be changed to the moresharply focused “neglected tropical diseases”-Grouping several diseases together under a new conceptual frameworkpresents an opportunity to recalculate the collective burden associated with thisset of diverse afflictions as well as their cumulative public-health relevance. Theframework has also enabled WHO to raise the profile of NTDs and to mobilizeresources for scaling up implementation of activities for their global control andelimination.“Forthe first time, we have a head start on these ancient companions of poverty. Forthe first time, more than 1 billion people left behind by socioeconomic progresshave a chance to catch up. I believe this is our shared ambition”.
  • -these diseases predominate in the tropics, but their predilection for hot places results principally from the fact that poverty is found ingreatest concentration in the remote rural communities, urban slumsand displaced populations near to the equator-Rather than being tropical diseases, then, we should consider the NTDs as being primarily diseases of the ‘bottom billion’—the poorest one-sixth of the world’s population
  • -Neglected tropical diseases have an enormous impact on individuals, families and communities in developing countries in terms of disease burden, quality of life, loss of productivity and the aggravation of poverty as well as the high cost of long-term care. They constitute a serious obstacle to socioeconomic development and quality of life at all levels.-This group of diseases largely affects low-income and politically marginalized people living in rural and urban areas. Such people cannot readily influence administrative and governmental decisions that affect their health, and often seem to have no constituency that speaks on their behalf. Diseases associated with rural poverty may have little impact on decision-makers in capital cities and their expanding populations.-Unlike influenza, HIV/AIDS and malaria and, to a lesser extent, tuberculosis, most NTDs generally do not spread widely, and so present little threat to the inhabitants of high-income countries. Rather,their distribution is restricted by climate and its effect on the distribution of vectors and reservoir hosts; in most cases, there appears to be a low risk of transmission beyond the tropics.- Many NTDs cause disfigurement and disability, leading to stigma and social discrimination. In some cases, their impact disproportionately affects girls and women, whose marriage prospects may diminish or who may be left vulnerable to abuse and abandonment. Some NTDs contribute toadverse pregnancy outcomes
  • - The once-widespread assumptions held by the international community that people at risk of NTDs experience relatively little morbidity, and that these diseases have low rates of mortality, have been comprehensively refuted. A large body of evidence, published in peer-reviewed medical andscientific journals, has demonstrated the nature and extent of the adverse effects of NTDs.Research is needed to develop new diagnostics and medicines, and to make accessible interventions to prevent, cure and manage the complications of all NTDs.- The five strategic interventions recommended by WHO (preventive chemotherapy; intensified casemanagement; vector control; the provision of safe water, sanitation and hygiene; and veterinary public health) make feasible control, prevention and even elimination of several NTDs. Costs arerelatively low
  • -One of the first internationally coordinated initiatives addressing a neglected tropical disease was the Onchocerciasis Control Programme (OCP), which was conceived as early as in 1968, and launched in 1974, with co-sponsorship by WHO, the World Bank, UNDP, and the Food and Agriculture Organization. emphasising both the public health and economic dimension—to eliminate the blinding disease and by doing so opening up large areas of prime agricultural land for settlement- But in the late 1970s and 1980s, resources and the political momentum for control of tropical diseases dwindled, partly because of the failure ofthe malaria eradication programme and a shift of focus to the social and equitable dimensions of health in the form of primary health care.17 By the late 1980s, another public health issue gained prominence, which increasingly dominated and continues to dominate the discourse inpopular culture, academia, and even the security and intelligence community—the HIV/AIDS pandemic2003, the World Health Organization (WHO) initiated a paradigm shift in the control and elimination of a group of neglected tropical diseases (NTDs). led by the former Director-General, the late Dr JW Lee – involved an important strategic change from a traditional approach centred on diseases to one responding to the health needs of marginalized communities. From a public-health perspective, this change translated into the provision of care and the delivery of treatment to underserved populations. The shift ensures a more efficient use of limited resources and the alleviation of poverty and accompanying illness for millions of people living in rural and urban areas.
  • two workshops in Berlin, co-hosted by the German Agency for Technical cooperation and WHOIn the first workshop, participants called for an integrated approach towards these diseases both for efficiency and advocacy reasons.21 The second workshop concluded that the burden of disease shared by all the neglected tropical diseases justified an increased share of resources, that low-cost and cost-effective interventions were widely available, and that some integration or co-implementation was possible.This emerging vision was sharpened at a meeting held in Berlin, Germany, in December 2003 that convened experts from diverse sectors, including public health, economics, human rights, research, nongovernmental organizations (NGOs) and the pharmaceutical industry. The meeting set the scene for WHO to translate the new approach into a strategic policy and formulate ways of providing poor populations with an effective and comprehensive solution to some of their health problems. From 2003 to 2007, bold steps were taken to develop a framework for tackling NTDs in a coordinated and integrated way. Details of the framework are set out in section 4 of this report and in WHO’s Global plan to combat neglected tropical diseases 2008–2015.In April 2007, WHO convened its first meeting of Global Partners on NTDs,which was attended by more than 200 participants
  • because they share some common featuresFor instance, insect vectors spread Chagas disease, dengue, leishmaniasis, lymphatic filariasis and onchocerciasis.Schistosomiasis, soil-transmitted helminthiasis, yaws and trachoma are closely associated with poor environmental hygiene and sanitation
  • the remote rural communities, urban slums and displaced populationsMany of the neglected tropical diseases can be cured with drugs that cost as little as US$ 0.02–1.50. This figure is cheap for OECD countries with an average GDP per capita of US$ 28 500 but unaffordable for people earning less than US$ 1 per day.according to 2010 GNI per capita, low income, $1,005 or less; lower middle income, $1,006 - $3,975; upper middle income, $3,976 - $12,275; and high income, $12,276 or more. Low-income and middle-income economies are sometimes referred to as developing economies.An estimated 1.1 billion people live on less than US$ 1 a day and more than 2.7 billion live on less than US$ 2 a day: they are at higher risk of neglected tropical diseases.Furthermore, most countries are affected by more than one disease at the same time.International support is essential for scaling up control programmes against neglected tropical diseases.
  • , especially those living in remote areas with restricted access to services,In general, women are more exposed to communicable diseases than are men – and suffer more in terms of both illness and death. The consequences of stigma attached to many neglected tropical diseases are often more severe for women within their families and wider society.
  • as reaching a prevalence of less than 1 leprosy case per 10,000 population
  • Kala‐azar is a major problem in 12 districts of eastern and central Terai. Incidence of Kala‐azar hasdecreased from 1.71 per 10,000 areas at risk population in 2065/66 to 1.33 in 2066/67 and to 0.94 in2067/68 (excluding foreign cases). Out of the 12 districts five districts have an incidence of morethan 1, while 7 districts have an incidence of less than 1 case per 10,000 areas at‐risk population
  • Leprosy is in declining phase, however, this decline is not enough to reach the goal of elimination.The new case detection rate has declined from 1.99/10,000 population in 2065/66 to 1.15/10,000 in2066/67 and to 1.12/10,000 population in 2067/68.
  • Better diagnosis of neglected infectious diseaseAim: to develop an improved system for delivering primary health care in resource-poor settings. The major objectives:To develop and validate an integrated syndromic approach based on diagnosis treatment algorithms for three clinical syndromes (persistent fever syndrome, the neurological syndrome, and the intestinal syndrome.)To develop novel diagnostic platforms/assays tailored to specific epidemiological contexts at primary care level in NID-endemic settingsTo document the cost-savings and increased efficacy of this integrated syndromic approach for the clinical management of NID, and produce recommendations to policy makers for its broad implementatio
  • : In 1999, deworming of pre-school age children (PSAC) ages 1-5 years old was integrated with the national semi-annual Vitamin A distribution: Since 2004, the National Nutrition Policy and Strategy has included the objective to reduce STH infections among children to less than 10% by the year 2017. In 2006, the National School Health and Nutrition Strategy (SHNP) was developed jointly by the MoHP and Ministry of Education and Sports (MoES: In 2001, the MOHP initiated deworming of pregnant women after the first trimester during antenatal care visits
  • . A National Plan of Action (PoA) for integrated control of the three diseases was drafted in 2009 with support of WHO, introduced at a national stakeholders meeting held by the MOHP in December 2009, and endorsed by the MOHP in April 2010
  • The LF mapping completed in2005 by using ICT (Immunochromatography) card test revealed 60 out of 75 districts as endemic forlymphatic filariasis in the country.
  • The adult worms reside in the lymphatics of the human host.Microfilariae are ingested by the vector female mosquito during a blood meal. They exsheath in the mosquito stomach, becoming first-stage larvae which penetrate the stomach wall of the mosquito and migrate to the thorax muscles. There they develop through two moults to the infective third-stage larvae (1500 × 20 μm).The development in the mosquito takes a minimum of 10–12 days. Mature infective larvae then migrate to the mouthparts of the mosquito from where they enter the skin of the human host, probably through the puncture site made by the proboscis of the vector when it takes its blood meal.The larvae migrate to the lymphatics and develop to adult worms. Microfilariae appear in the blood after a minimum of 8 months in W. bancrofti and 3 months in B. malayiWuchereriabancrofti is the only recorded parasite in Nepal. The mosquito, Culexquinquefasciatus,an efficient vector of the disease has been recorded in all the endemic areas of the country
  • )(but when tested demonstrate some degree of parasite-associated immunosuppression, and many show evidence
  • Owing to the risk of inducing severe adverse reactions in individuals with onchocerciasis, DEC should not be used on a mass scale for control of lymphatic filariasis in areas co-endemic for O.volvulus infection. For these areas, ivermectin is the drug of choice. When distributed in a dose of 150 μg/kg body weight it effectively reduces microfilaraemias. Side-effects are few and comparable to those of DEC. Adult worms are not affected by the ivermectin treatment, and regularly repeated treatments (half-yearly or yearly)The combination of albendazole with either ivermectin or DEC appeared in recent studies to give a considerably more effective and sustained reduction in lymphatic filariasismicrofilaraemia than ivermectin or DEC alone.75 Macrofilaricidal properties of albendazole apparently prolonged and reinforced the microfilaricidal suppression produced by the other two drugs. Following these promising findings it was recommended that DEC and ivermectin should be given in combination with albendazole in programmes for lymphatic filariasis control. The effect of albendazole on intestinal helminth infections would be an additional benefi t of the combination treatments. Other recent studies have failed to provide clear evidence for the superiority of these combinations in the clearing of microfilaraemias
  • management by self‐help and with support using intensive but simple, effective and local hygenic techniques
  • -Blinding trachoma is hyperendemic in many of the poorest and most remote rural areas in 57 countries of Africa, Asia, Central and South America, Australia and the Middle-East
  • NTP NATIONAL TRACHOMA PROGRAM has implemented the SAFE program activities in 7 trachoma endemic districts of Nepal in theyear 2011. Antibiotics distribution was supposed to be completed in 4 districts out of this 7 districtsin the year 2010Achham, Doti, Rolpa, Dailekh, Rukum Rautahat and SarlahiNTP/NNJS NEPAL NETRA JYOTI SANGH along with SAFE partners nowable to complete disease burden mapping in 67 out of 75 districts in Nepal. As a result of the entireSAFE implemented program, NTP is able to eliminate blinding trachoma from twelve (Kailali,Kanchanpur, Chitawan, Nawalparasi, Surkhet, Banke, Bardiya, Dang, Kapilvastu, Bara, Parsa andRasuwa) districts so far in Nepal.An estimated six million Nepalese are currently at risk of trachoma infection, with more than 32,000 already blinded by the disease. Another 245,000 suffer from active trachoma, and active trachoma prevalence rates among children aged 1-9 are as high as 32.7% in some parts of the western region of Nepal.prevalence of trachoma at 6.9% and identified trachoma as responsible for 2.4% of all blindness.Based on the finding 10 districts Banke, Bardia, Kailali, Kanchanpur, Chitawan, Nawalparasi, Kapilbastu, Rupendehi, Dang and Surkhet are identified as Trachoma endemic area and undergoing Trachoma eliminating intervention: the SAFE strategy in these area.
  • Trachoma is a recurrent, chronic eye infection. The infecting organism is Chlamydia trachomatis – one of a group of organismsEye infection begins in early childhood. Recurrent episodes of inflammation, together with secondary bacterial infection, may lead to scarring of the tarsal conjunctiva. Typically, the upper eyelid turns inwards (entropion), and distortion of the eyelashes occurs. These rub on the eyeball (trichiasis), leading to disturbance of the corneal surface, inflammation, corneal scarring and BlindnessOne can summarize the risk factors for trachoma by the sixDs:• Dry• Dusty• Dirty, unwashed faces• Dung- attraction for flies and predispose for the trachoma• Discharge• Density (overcrowding in the home).The modes of transmission are summarized by the three Fs:• Flies• Fingers• Fomites (contaminated material or objects such as clothing ortowels).
  • A new strategy, with the acronym SAFE, provides an appropriate and focused approach in control measures which involve tertiary prevention (surgery), secondary prevention (antibiotic treatment) and primary prevention (facial hygiene and environmental change
  • These worms have similar lifecycles in that adults infect thegastro-intestinal tract, reproduce sexually and release eggs which arepassed in faeces into the environment. Hookworms differ from Ascarisand Trichuris in that, rather than being acquired through ingestion ofeggs larvae develop to the infective stage in the soil then penetrateintact skin to initiate the parasitic phaseinfections are acquired from an environment contaminated by the worms’ infective stages, and so the species are often considered collectively as ifthey are a single entityPeople infected with soil-transmitted helminths pass parasite eggs in theirFaecesIn areas where there is no latrine system, the soil and water around thevillage or community becomes contaminated with faeces containing these eggsThe symptoms of soil-transmitted helminthinfections are nonspecific and become evident only when the infection isparticularly severe. Symptoms include nausea, tiredness, abdominal pain and lossof appetite. These infections aggravate malnutrition and amplify rates of anaemia.They impede children’s physical growth and cognitive development, contributingsignificantly to school absenteeism
  • Americas, SEA and Sub-SaharanAfrica.
  • The prevalence and intensity of infection with Ascaris and Trichuris typicallyreach a peak among children aged 5–14 years and subsequently decline amongadults. However, although heavy hookworm infections may occur in children, thepeak of their prevalence and intensity is commonly reported among those aged30–44 years or even among people who are older than 50 (1). Soil-transmittedhelminthiases (especially hookworm) are particularly detrimental to the healthof childbearing women and on pregnancy outcomes owing to their impact onnutrition, since they cause iron deficiency and anaemia.
  • The main form of morbidity caused by STH is the negative effect on nutritionalstatus (3). In addition the disease may cause cognitive impairment in children,and complications requiring surgical intervention, such as intestinal and biliaryobstructions.
  • Lack of access to safe water and proper sanitation are the main factors in thepersistence and prevalence of the disease.Control programmes in endemic countries have demonstrated that thebenefits of regular deworming are not limited to reducing direct morbidity.School attendance, school results and productivity improve. An efficient wayto reach preschool-aged children for deworming treatment is to integrate thistreatment into vaccination campaigns organized for this age groupAn equally efficient way to reach children of school age is through the schoolsystem.
  • due to poor awareness and sensitization of both the health staff and mothers on the correct use of ALB during pregnancy
  • Working to overcome individual NTDs or a group of these diseases should rely on a combination of the five strategic approachesPreventive chemotherapy is the main intervention for controlling lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiases. This intervention contributes to the control of trachoma and, depending on the choice of medicine, relieves strongyloidiasis,scabies and liceWHO recommends these medicines be used not only because of their ease of administration and efficacy but also because of their excellent safety profiles and minimal side-effectsThe frequency of administration ranges from once to twice yearly, according to the prevailing epidemiology of the targeted infectionsIntensified case-management involves caring for infected individuals and those at risk of infection. The key processes are (i) making the diagnosis as early as possible, (ii) providing treatment to reduce infection and morbidity, and (iii) managing complications.This intervention is justified as a principal strategy for controlling and preventing those NTDs for which there are no medicines availableThe medicines for treatment of the six target diseases include nifurtimox and benznidazole for Chagas disease; pentamidine, suramin, melarsoprol, eflornithine and nifurtimox for human African trypanosomiasis; pentavalentantimonials (sodium stibogluconate and meglumineantimoniate), amphotericin B, paromomycin and miltefosine for visceral leishmaniasis; multidrug therapyfor leprosy using a combination of rifampicin, clofazimine and dapsone for multibacillary leprosy, and rifampicin and dapsone for paucibacillary leprosy; a combination of rifampicin and streptomycin or amikacin for Buruli ulcer; and benzathine penicillin for yaws. Most of these medicines are donated to WHO, facilitating the delivery of high-quality treatment free of charge to targeted populations in endemic areas.Most NTDs involve vector transmission: insects transmit the infectious agents of dengue and other virus-induced diseases, Chagasdisease, human African trypanosomiasis, leishmaniasis, lymphatic filariasis and onchocerciasis; snails are essential in transmitting the agents of foodbornetrematodiasis and schistosomiasis; crustaceans are essential for transmission of the agents of dracunculiasis and foodborneparagonimiasis.integrated vector management (IVM) is a rational decision-making process for the optimal use of resources in the management of vector populations, so as to reduce or interrupt transmission of vector-borne diseasesselection of proven vector control methods based on knowledge of local vector biology and ecology, disease transmission and morbidity;utilization of a range of interventions, separately or in combination and often synergistically;collaboration within the health sector and with other public and private sectors that impact on vector breeding;engagement with local communities and other stakeholders;a public health regulatory and legislative framework;rational use of insecticides;good management practices. Statistics compiled by the United Nations reveal that 900 million people lack access to safe drinking-water, and 2 500 million lack access to appropriate sanitation (8). Despite the obvious health benefits that accrue from improved sanitation, the targets set under MDG 7 (Annex 2) are far from being met, especially in the African and South-East Asia regions. Until this situation improves, many NTDs and other communicable diseases will not be eliminated, and certainly not eradicatedNTDs with a zoonotic component – including brucellosis cysticercosis, echinococcosis, foodbornetrematodiasis, human African trypanosomiasis, leishmaniasis and rabies as priority negletedzoonosesControl of these diseases in livestock requires interventions that do not threaten the economic security of populations whose livelihoods are dependent on animals. There is a crucial role for veterinarians in the public-health arena.
  • post elimination strategy- integration of NTDs control into the primary health services,Surveillance after the elimination of the disease in previous endemic area to minimize the effect of re-emergence.
  • Neglecgted tropical disease: in context to Nepal

    1. 1. Dr Dipesh Tamrakar 1st Yrs JR SPH & CM
    2. 2. Content  Introduction  Problem Statement  Important NTD in context to Nepal  Impact  Challenges  Recent Advances
    3. 3. Introduction  Neglected tropical disease is an umbrella term for a large group of diseases.  there is still ambiguity about the term neglected tropical diseases
    4. 4. Definition  WHO “...Chronically endemic and epidemic-prone tropical diseases, which have a very significant negative impact on the lives of poor populations [and] remain critically neglected in the global public health agenda.”
    5. 5.  Protozoan Infections  Leishmaniasis  Human African trypanosomiasis (sleeping sickness)  Chagas disease  Viral Infections  Dengue & dengue haemorrhagic fever  Rabies  Bacterial Infections  Leprosy  Trachoma  Buruli ulcer  Endemic Trepanomatoses(Yaws, Pinta, Bejel  Helminth Infections  Soil-transmitted       helminth infections (Ascariasis, Trichuriasis, Hookworm) Lymphatic filariasis (elephantiasis) Onchocerciasis (river blindness) Schistosomiasis Dracunculiasis (guineaworm disease) Cysticercosis and other zoonotic helminthiasis Food borne Nematodes(clonorchias is, opisthorchiasis, fasciolasis
    6. 6. Definition contd..  Global Network for Neglected Tropical Diseases “The neglected tropical diseases are a group of 13 parasitic and bacterial infections that affect over 1·4 billion people, most of whom live on less than $1·25 per day.  Diseases: Aascariasis, Buruliulcer, dracunculiasis, human Africantrypanosomiasis, hookworm, leishmaniasis, leprosy,lymphaticfilariasis, onchoceriasis, schistosomiasis, trachoma, trichuriasis
    7. 7. Defination contd…  Neglected Tropical Disease Program (USAID) “These diseases disproportionately impact the poor and rural populations, who lack access to safe water, sanitation, and essential medicines. They cause sickness and disability, compromise children’s mental and physical development, and result in blindness and severe disfigurement.”  Targeted diseases: Lymphaticfilariasis, schistosomiasis, trachoma onchocerciasis, soiltransmitted helminthiasis
    8. 8. WHY They are called “neglected Tropical Disease”  two important shared characteristics - First, these diseases predominate in the tropics - Second, they have all to a greater or lesser extent been neglected by funders, researchers and policy-makers
    9. 9. Why neglected?  Do not travel easily not a threat to Western society  New tools and interventions not attractive-not a significant market -<1% of approx. 1400 new drugs, -< 0.001% of 60 –70 billion on new drugs  Hidden from health facilities and politician –affect marginalized population with little political voice
    10. 10. Why neglected?  Feared and source of strong social stigma and prejudice  Severe pain and life long disabilities generally not major killers  High mortality diseases prioritized -resource
    11. 11. Common features of NTD  A proxy for poverty and disadvantage  Affect populations with low visibility and little political voice  Do not travel widely  Cause stigma and discrimination, especially of girls and women
    12. 12. Contd…  Have an important impact on morbidity and mortality  Are relatively neglected by research  Can be controlled, prevented and possibly eliminated using effective and feasible solutions
    13. 13. History  Onchocerciasis Control Programm(OCP)- First     internationally coordinated initiatives( 1974) Late 1970s and 1980- resources and the political momentum for control of tropical diseases dwindled Late 1980- HIV Pandemics 2000- MDG6 “ others disease” 2003- WHO initiated paradigm shift in the control and elimination of NTDs
    14. 14. Contd…  This emerging vision was sharpened at a meeting held in Berlin, Germany, in December 2003 , co-hosted by the German Agency for Technical cooperation and WHO  In April 2007, WHO convened its first meeting of Global Partners on NTDs- . Details of the framework are set out in WHO’s Global plan to combat neglected tropical diseases 2008–2015.
    15. 15. Problem Statement
    16. 16. Disease of poverty with high Burden DALYs Mortality 24 20 46 30 51 29 Neglected tropical disease Other infectious disease Neglected tropical disease TB/HIV/Malaria Other infectious disease TB/HIV/Malaria
    17. 17. Overlapping threats to neglected populations  NTDs tend to cluster geographically and overlap  149 countries and territories are affected by at least one neglected tropical disease.  More than 70% of them are affected by two or more diseases.  28 countries are afflicted by more than six diseases simultaneously; most of them are low-income economies experiencing humanitarian emergencies 4th July 2010 17
    18. 18. 4th July 2010 18
    19. 19. victims of neglected tropical diseases 4th July 2010 19
    20. 20. Women and children are more vulnerable  Women, children and ethnic minorities are most at risk of infection.  Women also face additional barriers to seeking, and often to receiving, treatment.  Nearly 70% of all deaths and 75% of all disabilityadjusted life years (DALYs) from communicable diseases globally occur in children under 14 years of age.  This also applies to neglected tropical diseases as children are much more exposed to infections. 4th July 2010 20
    21. 21. 4th July 2010 21
    22. 22. SEARO  an estimated 0.5 billion (about 50%) of the one billion people living in poverty are in this Region  SEA Region is the second among WHO Regions with largest burden of NTDs.  Among the six WHO regions, the South-East Asia Region has the highest burden of leprosy, lymphatic filariasis and kala-azar
    23. 23. 4th July 2010 24
    24. 24.  Nepal is endemic to three of the five targeted neglected tropical diseases  Trachoma (TRA)  Lymphatic Filariasis(LF)  Soil Transmitted Helminthes (STH)  -ascariasis  -hookworm  -trichuristrichuria  Leishmaniasis  leprosy –elimination phase  Dengue( emerging disease)  Rabies  Cystecercosis and Echinococcus 4th July 2010 25
    25. 25. Programs for control of NTDs in Nepal  National Plan for the Elimination of Kala-zar - Goal : “To reduce the annual incidence of Kala-zar to less than 1 per 10,000 populations at the district level by 2015” -Objectives • Reducing the incidence of Kala‐azar in the endemic communities including the poor, vulnerableand unreached population; • Reducing case fatality rates from Kala‐azar; • Treatment of PKDL to reduce the parasite reservoir; and • Prevention and treatment of Kala‐azar HIV–TB Co infections.
    26. 26. Leprosy control program  Goal - Reduce further the burden of leprosy and to break channel of transmission of leprosy from person to persons by providing quality service to all affected community.  Objectives • To eliminate leprosy (Prevalence Rate below 1 per 10,000 population) and further reduce disease burden at district level; • To reduce disability due to leprosy; • To reduce stigma in the community against leprosy; and • Provide high quality service for all persons affected by leprosy.
    27. 27. Dengue control:  Goal  • • • • To reduce the morbidity due to Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS) Objectives To develop an integrated vector control approach for prevention and control. To develop capacity on diagnosis and case management of DF/DHF/DSS To intensify health education/IEC activities and To strengthen the surveillance system for predication, early detection, preparedness and earlyresponse to out ‐break of dengue.
    28. 28. NIDIAG Better diagnosis of neglected infectious disease)  Aim: to develop an improved system for delivering     primary health care in resource-poor settings. The major objectives: To develop and validate an integrated syndromic approach based on diagnosis treatment algorithms for three clinical syndromes. To develop novel diagnostic platforms/assays tailored to specific epidemiological contexts at primary care level in NID-endemic settings To document the cost-savings and increased efficacy of this integrated syndromic approach for the clinical management of NID, and produce recommendations to policy makers for its broad implementation
    29. 29. National Plan for integrated NTDs control Program( USAID/MoHP)  A National Plan of Action for integrated control of the three diseases( STH, TRA, LF) was drafted in 2009 with support of WHO,  National stakeholders meeting held by the MOHP in December 2009, and endorsed by the MOHP in April 2010
    30. 30. Partners and Stakeholders for NTD Control Program             Department of Education (DoE) Department of Water Supply and Sewerage Glaxo Smith Kline (GSK) Japanese International Cooperation (JICA) International Trachoma Initiative (ITI) Helen Keller International (HKI) Nepal Netra Jyoti Sangh (NNJS) Nepal Technical Assistance Group (NTAG) Save the Children UNICEF World Health Organization (WHO) Research Triangle Institute (RTI) International
    31. 31. National Plan for Integrated NTDs Control Programme (2010 –2014) 32
    32. 32. NTDs distribution & co-endemicity STH 33
    33. 33. Status 34
    34. 34. Lymphaytics Filariasis  More than a billion people in more than 80 countries are at risk!!!  Over 120 million have already been affected!!!  over 40 million of them are seriously incapacitated and disfigured  Approximately 65% of those infected live in the WHO South-East Asia Region  40% are in India alone
    35. 35. 36
    36. 36. endemicity in Nepal 37
    37. 37. Epidemiology
    38. 38. Life Cycle
    39. 39. Cilincal Spectrum 1. Asymptomatic infection (sub-clinical lymphatic damage with high risk of developing disease at a later stageof renal dysfunction 2. Acute adenolymphangitis(ADL) 3. Progressive lymphoedemaleading to elephantiasis 4. Hydrocele, swelling arms,breast,externalgenitalia 5. Tropical Pulmonary Eosinophilia(TPE) 6. Renal damage resulting in haematuria 7. Endomyocardialfibosis 8. Arhritisand others
    40. 40. Control  Preventive chemotherapy: DEC / Ivermectin( anti filarial) Albendazole( anti helminthsm anti filarial)  Vector Control
    41. 41. National PoA for elimination of filariasis National Target : To eliminate the disease from Nepal by the year 2020 Objectives • To interrupt the transmission of lymphatic filariasis; • To reduce and prevent morbidity; • To provide de‐worming benefit through use of Albendazole to endemic community especially to the children; and • To reduce mosquito vectors through application of suitable and available vector control measures (Integrated Vector Control Management). Strategy • Interruption of transmission by yearly Mass Drug Administration using two drug regimens (Diethylcarbamazine and Albendazole) for six years. • Morbidity management by self‐help and with support using intensive but simple, effective and local hygienic techniques.
    42. 42. Both Drugs are administered at the same time under direct supervision.Drugs should be taken after food. Contraindication : -Children below 2 years of age -Pregnant women -Very sick people : (Patient who can not take medicine orally. Patient who is Jaundice. Patient with chronic heart disease Patient with Chronic liver disease Patient with chronic kidney disease Epileptic patient.) Don’t give drugs to anybody taking medicines for any severe disease
    43. 43. Morbidity Management
    44. 44. Trachoma  Trachoma affects about 84 million people of whom about 8 million are visually impaired  It is responsible, at present, for more than 3% of the world’s blindness  Blinding trachoma is hyperendemic in many of the poorest and most remote rural areas in 57 countries of Africa, Asia, Central and South America, Australia and the Middle-East
    45. 45. Nepal Prospective  Trachoma control is managed by the National Trachoma Program (NTP)  Nepal Blindness Survey (1981), prevalence of trachoma at 6.9% and identified trachoma as responsible for 2.4% of all blindness.  Prevalent in western part of nepal  15 districts are identified as Trachoma endemic area
    46. 46. Epidemiology  Caused by Chlamydia trachomatis  Modes of transmission 3 Fs: - Flies( Musca spp, Hippelatus - Fingers - Fomites (contaminated material or objects such as clothing or towels).  Risk factors 6 Ds: - Dry - Dusty - Dirty - Dung - Discharge - Density (overcrowding in the home).
    47. 47. Pathogenesis  Eye infection in early childhood.  Recurrent episodes of inflammation, together with secondary bacterial infection, may lead to scarring of the tarsal conjunctiva.  Typically, the upper eyelid turns inwards (entropion), and distortion of the eyelashes occurs.  These rub on the eyeball (trichiasis), leading to disturbance of the corneal surface, inflammation, corneal scarring and Blindness
    48. 48. Control(SAFE strategies)
    49. 49. Soil Transmitted Helminths  includes - Ascaris lumbricoides( round worm) - Trichuris trichiura( whip worm) - Anchylostoma dudenale and Necotar americanus ( Hook worm)  More than 1 billion people are infected with the species of nematode that cause soil-transmitted helminthiases (STH).
    50. 50. Nepal Prespectives  mapping for STH has not occurred on a national scale  number of studies indicate that more than 50% of children and adolescents are suffering from intestinal worms  Estimated 27.5 m are at risk and endemics in all 75 districts
    51. 51. Epidemiology  Ascaris and Trichuris : The prevalence and intensity of infection reach a peak among children aged 5–14 years and subsequently decline among adults.  Hookworm : the peak of their prevalence and intensity is commonly reported among those aged 30– 44 years or even among people who are older than 50  Soil-transmitted helminthiases (especially hookworm) are particularly detrimental to the health of childbearing women and on pregnancy outcomes
    52. 52. Mobidity associated
    53. 53. Prevention and Control  Lack of access to safe water and proper sanitation are the main factors  Mass Drug Admnistration: Albendazole and Mebendazole  Health Education  Monitoring and survillence
    54. 54. National Program for deworming  Pre-School Age Children: In 1999, deworming of pre-school age children (PSAC) ages 1-5 years old was integrated with the national semi-annual Vitamin A distribution.The program managed by Child Health Division (CHD) of the MOHP reached national-scale in 2004  School-Age Children:. In 2006, the National School Health and Nutrition Strategy (SHNP) was developed jointly by the MoHP and Ministry of Education and Sports (MoES). In FY2010-2011 , it was targeted to reach Enrolled students in Grades 1-5 in government schools in all 75 districts  Pregnant Women: In 2001, the MOHP initiated deworming of pregnant women after the first trimester during antenatal care visits; however, coverage has remained low
    55. 55. IMPACT
    56. 56. NTDs and their Impact  Health—Can cause blindness, horrible swelling of the limbs, and even death.  Education—Children with NTDs are often too sick to attend or perform well in school.  Economic Development—NTDs are debilitating and prevent adults from working and caring for their families.  Hunger and Nutrition—Anemia and malnutrition are common side effects of several NTDs.  Women’s Empowerment—Most NTDs have more severe effects on women and girls
    57. 57. Control Strategies For NTDs  Preventive chemotherapy  Intensified case-management  Vector control  Safe water, sanitation and hygiene  Veterinary public health: zoonotic aspects of neglected tropical diseases
    58. 58. Challenges and opportunity  Sustaining the Political Commitment and providing the adequate resources  Preventing the stigma and discrimination, along with social displacement of people affected  Operation research to generate evidence in support of the post elimination strategy
    59. 59. Recent Advance
    60. 60. Vaccine  Echinococcus and Tenia solium - EG 95( recombinant vaccine)- sheep, on field trial - TSOL 18( recombinant vaccine)- pig, first field trail in Cameroon  Hookworm: - ASP 2- 1st phase clinical trial in brazil failed - NA-APR-1 and NA-gst-1 ( animal study)
    61. 61.  Schistosomiasis: - Sh 28-GST( s. haematobium)- on clinical trail -SM14(S. mansoni)- animal study promising  Vector Saliva based Vaccine(sand fly): - Vector saliva protiens( immunogenic & immunomodelating) - induce the antibody against itimpact on pathogens residing in the vicinity - PpSP15: rodent trail, P papatusi against Leishmaniasis
    62. 62. Thank you
    63. 63. References  G. C. Cook, Manson’s Tropical Diseases, 21st Edition, 2003  K. Park. Park’s Textbook of Preventive and Social Medicine, 21th Edition;2011  “Working to overcome the global impact of neglected tropical diseases”: First WHO report on neglected tropical diseases 2010  Jai P Narain et al.”Neglected tropical diseases in the WHO South-East Asia Region” Bull World Health Organ 2010;88:206–210  Bethony et al “Vaccines to combat the neglected tropical diseases” Immunological Reviews 2011 Vol. 239: 237–270
    64. 64. references  “Neglected tropical diseases, hidden successes, emerging      opportunities” WHO (2006) Annual report 2067/68, MoHP Annual report – nepal netra jyoti sangh national trachoma program(2011) Bernhard Liese, Mark Rosenberg, Alexander Schratz “Programmes, partnerships, and governance for elimination and control of neglected tropical diseases” Lancet 2010; 375: 67–76 http://www.who.int/mediacentre/factsheets/fs102/en RTI-Nepal Work Plan Year 5 (FY2010-2011) NTD Control Program
    65. 65.  Paul Emerson and Laura Frost “Implementing the SAFE Strategy for Trachoma Control” The Carter Center Web site: http://www.cartercenter.org.

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