Neglected tropical diseases - India.

1. Neglected Tropical
Diseases
Moderator:
Dr. Meenakshi Kalhan
Professor
Dept. of Community Medicine
Presented By:
Dr. Annpurna
JR-2
Dept. of Community Medicine

2. Content
• Definition
• Introduction
• Diseases in NTDs
• NTDs in India
• Health programme related to NTDs in India
• NTDs Target for 2030
• SDGs related to NTDs
• World NTDs Day

3. Definition
• Neglected tropical diseases (NTDs) are ancient diseases of poverty
that impose a devastating human, social and economic burden on more
than 1 billion people worldwide, predominantly in tropical and
subtropical areas among the most vulnerable, marginalized
populations and receive little funding to address them.
• Control: Reduction of disease incidence, prevalence, morbidity and/or
mortality to a locally acceptable level as a result of deliberate efforts;
continued interventions are required to maintain the reduction. Control
may or may not be related to global targets set by WHO.

4. Definition
• Elimination (interruption of transmission): Reduction to zero of the
incidence of infection caused by a specific pathogen in a defined
geographical area, with minimal risk of reintroduction, as a result of
deliberate efforts; continued action to prevent re-establishment of
transmission may be required.
• Elimination as a public health problem: A term related to both
infection and disease, defined by achievement of measurable targets
set by WHO in relation to a specific disease.
• Eradication: Permanent reduction to zero of the worldwide incidence
of infection caused by a specific pathogen, as a result of deliberate
efforts, with no risk of reintroduction.

5. Introduction
• Since WHO’s first road map for the prevention and control of NTDs was published in
2012, substantial progress has been made.
• Today, 600 million fewer people require interventions against several NTDs than in
2010, and 42 countries, territories and areas have eliminated at least one disease.
• Dracunculiasis is on the verge of eradication, with 54 human cases reported in four
countries in 2019.
• Lymphatic filariasis and trachoma have been eliminated as public health problems in 17
and 10 countries.
• Onchocerciasis has been eliminated in four countries in the Region of the Americas
• The annual number of cases of human African trypanosomiasis has fallen from more
than 7000 in 2012 to fewer than 1000 in 2019, halving the original target of 2000 cases
by 2020
• The number of new leprosy cases reported globally has continued to decline since 2010
at an average of 1% per year after most endemic countries achieved elimination as a
public health problem, defined as less than one case on treatment per 10 000
population.

6. NTDs

7. • Neglected tropical diseases in India are a group of bacterial, parasitic, viral, and
fungal infections that are common in low income countries but receive little funding to
address them.
• Neglected tropical diseases are common in India.
• India’s population is about 1.3 billion as of 2018, which is the second largest in the
world.
• However, high population does not explain the greater frequently of neglected tropical
diseases in India than in other countries.
• Neglected tropical diseases in India occur in areas of both urban and rural poverty.
• The neglected tropical diseases which especially affect India include ascariasis,
hookworm infection, trichiasis, dengue fever, lymphatic filariasis, trachoma,
melioidosis, cysticercosis, leprosy, echinococcosis, visceral leishmaniasis and rabies.
Neglected tropical diseases in India

8. New cases of neglected tropical diseases in 2016
neglected tropical
disease
Cases in India Total cases globally
India's percent
of global total
India's incidence rank
Ascariasis 222 million 799 million 28% 1
Hookworm infection 102 million 451 million 23% 1
Trichuriasis 68 million 435 million 16% 1
Dengue fever* 53 million 101 million 53% 1
Lymphatic filariasis 8.7 million 29.4 million 29% 1
Trachoma† 1.8 million 3.3 million 53% 1
Cysticercosis 819,538 2.7 million 31% 1
Leprosy 187,730 523,245 36% 1
Echinococcosis 119,320 973,662 12% 1
Visceral leishmaniasis 13,530 30,067 45% 1
Rabies* 4,370 13,340 33% 1
* – only new cases
† – only cases causing visual impairment
New cases of neglected tropical diseases in 2016

9. The World Health Organization recognizes 20 neglected tropical diseases, of
which 12 are present in India.
• Protozoan infections
• Leishmaniasis
• Helminth infection
• Taeniasis/Cysticercosis
• Echinococcosis
• Lymphatic filariasis
• Soil-transmitted helminthiases
• Viral infections
• Dengue
• Rabies

10. • Bacterial infections
• Leprosy
• Trachoma
• Fungal infections
• Mycetoma, chromoblastomycosis and other deep mycoses
• Ectoparasitic infections
• Scabies and other ectoparasites
• Others
• Snakebite envenoming

11. Health Programme Related To NTDs In India
• National Vector Borne Disease Control Programme
• Elimination Of Lymphatic Filariasis
• National Kala-azar elimination Programme
• Prevention and Control of Dengue
• Prevention and Control of Chikungunya
• National Leprosy Eradication Programme
• National Programme for Control of Blindness
• National Rabies Control Programme
• National Snakebite Control Programme

12. Protozoan
Leishmaniasis
Leishmaniasis is caused by the protozoan Leishmania spp parasites which are
transmitted by the bite of infected female phlebotomine sandflies.
• Infective stage – Promastigote
• Kala-azar cases in India declined by 98.7% between 2007 and 2022, from 44,533 to
834 and 632 endemic blocks (less than one case per 10,000).
• In 2020, out of 633 endemic blocks (99.8%) spread across Bihar, Uttar Pradesh,
Jharkhand, and West Bengal have received elimination status , only 16 blocks
reported above elimination threshold(<1/10,000 population).

13. • There are 3 main forms of leishmaniasis: visceral (also known as kala-azar, which is
and the most serious form of the disease), cutaneous (the most common), and
mucocutaneous.
• Visceral leishmaniasis (VL):
• Fatal without treatment in over 95% of cases.
• Symptoms/signs: fever, weight loss, Hepatosplenomegaly and anemia.
• An estimated 50 000 to 90 000 new cases of VL occur worldwide annually, with
only between 25 to 45% reported to WHO.
• Cutaneous leishmaniasis (CL):
• most common form of leishmaniasis and causes skin lesions, mainly ulcers, on
exposed parts of the body, leaving life-long scars and serious disability or
stigma.
• Mucocutaneous leishmaniasis leads to partial or total destruction of mucous
membranes of the nose, mouth and throat.
DOC : LAMB (Liposomal Amphotericin B)

14. Soil-transmitted Helminthiases
• Soil-transmitted helminths refer to the intestinal worms infecting humans that are
transmitted through contaminated soil: Ascaris (Ascaris lumbricoides ), whipworm
(Trichuris trichiura), and hookworm (Anclostoma duodenale and Necator americanus).
• According to the World Health Organization (WHO), soil-transmitted helminths affect
around 24% of the world's population.
• As a result, about 241 million children in India between the ages of one and fourteen are
at high risk of parasitic intestinal worms, known as soil-transmitted helminths.
• India accounts for 65% of parasitic worm cases in Southeast Asia and 27% of all
parasitic worm cases worldwide.
• National Deworming Day (NDD) was established by the Indian government's Ministry
of Health and Family Welfare in February 2015 to address the worm infection problem
within the nation to deworm all children aged 1 to 19.

15. • Most people infected with hookworms have no symptoms.
• Most serious effects: blood loss (anemia), protein loss
• Heavy infections can cause intestinal blockage and impair growth in children.
• Cough are due to migration of the worms through the body (lungs).
• Treatment : Tab Albendazole 1 Tablet (400mg) - 2 to 19yrs
• Tab Albendazole 1/2 Tablet (200mg) - 1 to 2yrs

16. Lymphatic filariasis
• Lymphatic filariasis (LF) is a mosquito borne infectious disease caused by nematode
parasites of the order Filaridea.
• LF in man is caused by three species of filarial parasites – Wuchereria bancrofti, Brugia
malayi and Brugia timori.
• Several species of Culex, Anopheles, Aedes and Mansonia mosquitoes are involved in
transmission of LF.
• The disease is prevalent in 73 tropical and sub-tropical countries in South-east Asia,
Africa, Mediterranean, South Pacific and South America regions.
• LF is wide spread in India.
• Ministry of Health & Family Welfare launches nationwide Sarva Dawa Sevan or Mass
Drug Administration (MDA) campaign to Eliminate Lymphatic Filariasis (LF).
• Aim to eliminate Lymphatic Filariasis by 2027, three years ahead of the global target.

17. • Health workers will go door-to-door to administer anti-filaria medicine in 10 filaria
affected States Focus on High-burden districts in Bihar, Chhattisgarh, Jharkhand,
Maharashtra, Uttar Pradesh, West Bengal, Karnataka, Odisha, Madhya Pradesh, and
Andhra Pradesh.
• Mass treatment: to reduce the microfilaremia
• regimen consisting of ivermectin, diethylcarbamazine, and albendazole is
used

18. Echinococcosis
• Human echinococcosis is a zoonotic disease caused by tapeworms of the genus
Echinococcus.
• Infective form : Eggs
• Echinococcosis occurs in 4 forms
• Cystic echinococcosis (CE), also known as hydatid disease or hydatidosis:
infection with Echinococcus granulosus;
• Alveolar echinococcosis (AE): infection with E. multilocularis;
• Two forms of neotropical echinococcosis: polycystic caused
by infection with E. vogeli and unicystic caused by E. oligarthrus.
• The two most important forms (medical and public health relevance) are CE and AE.

19. Echinococcosis
• CE is worldwide distributed. AE is usually located in the north, specially in China
and Russian Federation
• CE in endemic regions can reach human incidence rates around 50 per 100,000
person-year
• Human prevalence: 5%–10% may occur in areas of Argentina, Peru, East Africa, Central Asia and
China.
• Livestock prevalence: can be around 20%-95% in hyperendemic areas of South America,
specially in rural areas.
• When livestock is affected, also compromise the economical revenue of this rural
communities

20. Echinococcosis
• Treatment:
• Initial Phase: Albendazole
Albendazole + PAIR therapy
• Definitive Treatment: Surgical Removal

21. Taeniasis/Cysticercosis
• Cysticercosis is a parasitic tissue infection caused by larval cysts of the tapeworm Taenia
solium.
• Can affect brain, muscle, or other tissue
• major cause of adult onset seizures in most LMICs
• A person gets cysticercosis by swallowing eggs found in the feces of a person who has
an intestinal tapeworm.

22. Taeniasis/Cysticercosis
• Treatment:
• Managing elevated intracranial pressure
• Antiseizure drug therapy
• Antiparasitic therapy: albendazole and praziquantel (+corticosteroids)
• Control
• treatment of human taeniasis
• intervention in pigs
• community health education, including hygiene and food safety
• improved sanitation - ending open defecation
• no free-roaming pigs
• improved meat inspection and processing of meat products

23. Leprosy
• Leprosy, also known as Hansen’s disease, is a chronic infectious disease caused by
Mycobacterium leprae.
• The disease mainly affects the skin, the peripheral nerves, mucosal surfaces of the
upper respiratory tract and the eyes.
• Leprosy is likely transmitted via droplets, from the nose and mouth, during close and
frequent contact with untreated cases.
• Leprosy is a neglected tropical disease (NTD) which still occurs in more than 120
countries, with more than 200 000 new cases reported every year.
• Elimination of leprosy as a public health problem globally was achieved in 2000.
• As per data of 2019, Brazil, India and Indonesia reported more than 10 000 new cases,
while 13 other countries each reported 1000–10 000 new cases. Forty-five countries
reported 0 cases.

24. • India has achieved the elimination of leprosy as a public health problem as per
WHO criteria of less than 1 case per 10,000 population at the National level in
2005.
• The Government of India has launched National Strategic Plan (NSP) & Roadmap
for Leprosy (2023-27) on 30th January, 2023, to achieve zero transmission of
leprosy by 2027 i.e. three years ahead of the Sustainable Development Goal
(SDG) 3.3.
• With various intervention introduced under NLEP in the last few years, number of
new leprosy cases detected have come down to 75,394 in 2021-22 from 1,25,785
in 2014-15, accounting for 53.6% of global new leprosy cases.
• Vision of NLEP : Leprosy free India with zero infection and disease, zero
disability, zero stigma and discrimination.
• Goal of NLEP : Accelerate towards achieving Interruption of Leprosy
Transmission in India.

25. • Revised Classification of Leprosy in India:
• Revised Treatment Regimen of Leprosy in India:
S.
No.
Type Skin lesions Nerve(s) involvement Bacilli in laboratory-
based test (Slit Skin
Smear)
1 Pauci-Bacillary(PB) 1-5 No nerve(0) Absent(Negative)
2 Multi-Bacillary(MB) More than 5 (>5) One or more nerve
involved(>1)
Present(Positive)
S.
No.
Type Duration of
Treatment
Dapsone Clofazimine Rifampicin
1 Pauci-
Bacillary
(PB)
Adult 6 months 100mg Daily 300mg once a month and 50 mg
daily
600mg once a
month
Child
(9-14 yrs)
6 months 50mg Daily 150mg once a month and 50 mg
alternate day
450mg once a
month
2 Multi-
Bacillary
(MB)
Adult 12 months 100mg Daily 300mg once a month and 50 mg
daily
600mg once a
month
Child
(9-14 yrs)
12 months 50mg Daily 150mg once a month and 50 mg
alternate day
450mg once a
month

26. Trachoma
• Trachoma is a disease of the eye caused by infection with the bacterium Chlamydia
trachomatis.
• It is a public health problem in 44 countries, and is responsible for the blindness or
visual impairment of about 1.9 million people.
• It causes about 1.4% of all blindness worldwide.
• Blindness from trachoma is irreversible.
• Infection spreads through personal contact (via hands, clothes or bedding) and by flies
that have been in contact with discharge from the eyes or nose of an infected person.
• With repeated episodes of infection over many years, the eyelashes may be drawn in so
that they rub on the surface of the eye, with pain and discomfort and permanent
damage to the cornea.

27. Trachoma
• Elimination programmes in endemic countries are being implemented using the WHO-
recommended SAFE strategy. This consists of:
• Surgery to treat the blinding stage (trachomatous trichiasis);
• Antibiotics to clear infection, particularly mass drug administration of the
antibiotic azithromycin
• Facial cleanliness
• Environmental improvement, particularly improving access to water and
sanitation.
• In December 2017 the health minister of India announced that India was free
of trachoma. This announcement included a statement that there were no children in
India who had an active case of trachoma

28. Viruses
• Dengue fever and chikungunya fever
• The WHO groups dengue and chikungunya fever together, but these are separate
conditions.
• Chikungunya fever
• Chikungunya fever is a viral disease transmitted to human beings by infected Aedes
aegypti mosquitoes.
• Chikungunya virus belongs to genus Alphavirus and family Togaviridae.
• India had chikungunya cases before 1973 when the disease was nearly eliminated.
• In 2005 India got another case of chikungunya.
• In January 2006, the outbreak was confirmed as Chikungunya with laboratory findings
with 13.9 million clinically suspected and 2001 laboratory-confirmed cases.
• Subsequently, World Health Organization confirmed the re-occurrence of
Chikungunya fever in India.

29. • The disease showed an upward trend in 2018 (57,813 clinically suspected cases),
2019 (81,914 clinically suspected cases), 2020 (43,424 clinically suspected cases),
2021 (1,19,070 clinically suspected cases) and 2022 (1,48,587 clinically suspected
cases).
• Presently, Chikungunya is endemic in 34 States/ UTs in the country.
• To date, no report of mortality directly attributable to Chikungunya has been received
from any part of the country.
• National Center for Vector Borne Diseases Control (NCVBDC), Government of India
(GoI) has identified a network of laboratories for surveillance of Chikungunya fever
cases across the country since 2007.
• Numbers are increasing yearly to augment the free diagnostic facilities in all endemic
areas, which were 110 in 2007 and 783 in 2022.

30. • Dengue fever
• Dengue fever is an acute febrile disease transmitted by the bite of an Aedes mosquito
infected with any one of the four dengue viruses (DEN1, DEN2, DEN3, DEN4).
• Before 1970, only 9 countries had experienced severe dengue epidemics.
• The disease is now endemic in more than 128 countries.
• The number of cases reported increased from 2.4 million in 2010 to 5.2 million in 2019.
• Deaths have increased from 1050 in 2011 to 1684 in 2019.
• In 2020, the number of dengue cases and deaths in seven SEAR member states dropped
to 0.26 million and 928, respectively.
• Dengue virus was isolated in India during 1945 for the first time.
• During 1996, one of the most severe outbreaks of dengue fever occurred in Delhi, with
10252 cases and 423 deaths being reported (country total being 16517 cases and 545
deaths).

31. • During 2018, a total of 1,24,493 cases were reported; 2,05,243 in 2019; 44,585 in
2020; 1,93,752 in 2021 and 2,33,251 in 2022.
• The case fatality rate (CFR- deaths per 100 cases) has declined from 3.3% in 1996 to
0.3% in 2014 and sustained at 0.2% in 2015 to 2018, and 0.1% in 2019, which has
been maintained at this level since then.
• The disease has a seasonal pattern i.e., the cases peak after monsoon and it is not
uniformly distributed throughout the year.
• The seasonal trends for 2018- 2022.
• There are no specific antiviral medicines for dengue or chikungunya.
• Management: Hydration
• Not use of aspirin or NSAIDs in dengue
• Chikungunya usually presents (besides fever and rash) persistent joint pain.
Convalescence can be prolonged, and requires sometimes long-term anti-
inflammatory therapy
• Nevertheless widespread occurrence of diseases causes substantial morbidity and
economic loss

32. Rabies
• Rabies, also known as hydrophobia is an acute, highly fatal viral disease of
central nervous system, caused by Lyssavirus type 1, family Rhabdoviridae.
• It is primarily a zoonotic disease of warm blooded animals, particularly
carnivorous such as dogs, cats, jackals and wolves.
• It is transmitted to man usually by bites or licks of rabid animals.
• It is a 100% fatal but preventable viral zoonotic disease.
• Rabies occurs in more than 150 countries and territories.
• Although a number of carnivorous and bat species serve as natural reservoir,
rabies in dogs is the source of 99% of human infection and posses a potential
threat to more than 3.3 billion people.
• 55,000 deaths caused by rabies each year in rural areas of Africa and Asia.

33. • In India alone, 20,000 deaths are estimated to occur annually.
• In India, Union Territory of Lakshadweep and Andman and Nicobar
islands are free of the disease.
• Management:
• Primary prevention: pre-exposure immunization
• Secondary prevention: wound care and post-exposure prophylaxis (rabies
immunoglobulin and vaccination)

34. Mycetoma, Chromoblastomycoses
and other deep fungal infection
• Mycetoma is a chronic, progressively destructive morbid inflammatory disease usually
of the foot but any part of the body can be affected.
• Infection is most probably acquired by traumatic inoculation of certain fungi or bacteria
into the subcutaneous tissue.
• Mycetoma commonly affects young adults, particularly males aged between 20 and
40 years, mostly in developing countries.
• As mycetoma is a badly neglected disease, accurate data on its incidence and
prevalence are not available.
• The treatment is unsatisfactory, has many side effects, is expensive and not available in
most endemic areas.

35. Scabies and other ectoparasites
• Human scabies is a parasitic infestation caused by Sarcoptes scabiei var hominis.
• Scabies is one of the commonest dermatological conditions
• ↑ % of skin disease in developing countries
• Scabies is endemic in many resource-poor tropical settings, with an estimated
average prevalence of 5
– 10% in children. Recurrent infestations are common.
• Incidence of scabies in India ranges from 13 to 59%
• Treatment: topical scabicide (such as 5% permethrin, 0,5% malathion in aqueous
base, 10– 25% benzyl benzoate emulsion or 5–10% sulphur ointment). Also
oral ivermectin is also highly effective
• Other ectoparasites are: Tungiasis or jiggers, head lice and cutaneous larva
migrans.

36. Snakebite Envenoming
• Snakebite envenoming is a potentially life-threatening disease caused by toxins in the
bite of a venomous snake.
•The four snakes in India which account for most bites are the Indian cobra, common
krait, Russell's viper, and saw-scaled viper. Besides these four there are various other
snakes which bite enough to require an organized medical response
• Big limitation: Inaccurate epidemiological data.
• High-risk groups include rural population and low income settings
• Snake antivenoms are effective treatments to prevent or reverse most of the harmful
effects of snakebite envenoming and are included in the WHO list of essential medicines.

37. Overarching targets
Top−line targets for NTDs, in line with the Sustainable Development Goals and
WHO’s 13th General Programme of Work
90%
75%
100
2
Countries having eliminated at least one NTD
NTDs eradicated (dracunculiasis and yaws)
Fewer NTD-related DALYs
Fewer people requiring interventions against NTDs
NTD targets for 2030

38. Cross-cutting targets for 2030

39. Cross-cutting targets for 2030

40. From MDGs to SDGs: new challenges
and opportunities for NTDs
• NTDs were not specifically mentioned in the Millennium Development Goals
(MDGs)
• Successful scaling up of ‘medical’ NTD interventions was very much in line with
progress achieved for HIV/AIDS, TB and malaria.
• Sustained implementation and pivotal combination with interventions impacting
transmission, as already strongly recommended by WHO in 2005, have highlighted
the potential for large scale elimination of NTDs.
• Sustainable Development Goals (SDGs) focused on equity (leaving no one behind),
• New opportunities for NTDs to promote cross-sectoral activities
•SDG Target 3.3 : End the epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases and combat hepatitis, water-borne diseases and other communicable
diseases

41. World Neglected Tropical Diseases Day 2024
(30th Jan 2024)
• Theme for World NTD Day 2023: Unite. Act. Eliminate
Unite : Together we can improve the health and wellbeing of 1.62
billion people worldwide.
Act : Your voice, your action, can change lives.
Eliminate : Neglected tropical diseases are preventable and
treatable.