Study population
Kerala State in south western India has a population of approximately 34.7 million people and 11/14 districts are know to be endemic for lymphatic filariasis (all districts except Pathanamthitta, Idukki & Wyanad). Although GPELF was officially launched by WHO in 2000, MDA was first started in Alappuzha, Kozhikkode and Kannur districts in 1997. Subsequently the MDA activities were extended to all 11 endemic districts with diethylcarbamazine and albendazole being given in a total of eight annual rounds of MDA, the last being carried out in 2012. Currently MDA is continuing only in certain areas of one district (Malappuram) where the infection has persisted.
Goals
The Kerala LF Elimination program is the part of SDG activities of the State, with the specific SDG targets for LF established for Kerala State being:
1. Interruption of transmission by reducing microfilarial (Mf) prevalence below 1% in all endemic districts.
2. Ensuring availability of the “recommended essential package of care (EPC) ” in all areas with known patients.
SDG 3.3 refers to a reduction in number of persons requiring NTD interventions, with SDG 3.8 / Universal Health Coverage (UHC) concerning access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all. In case of LF the recommended essential package of care (lymphedema management, ADL treatment and hydrocelectomy) should be provided under the framework of Universal Health Coverage through the primary health care system with the aim of “leaving no one behind” [8]. To attain this, the LF MMDP services should be included in the essential package of services of UHC.
The fundamental strategy ultimately followed in Kerala, in keeping with WHO recommendations, involves the following major steps :
1. Knowing the patient burden: An estimate of the number of lymphedema and hydrocele cases is important for planning, and for determining the number and location of LF care-providing facilities to be established, the allocation of funding, and the subsequent assessment of success of these actions, including the overall integration of long-term LF patient care into the public health system.
2. Making MMDP services available: The aim is to have 100% geographic coverage of MMDP where each IU has at least one facility providing the EPC for lymphoedema patients and there is availability of surgical treatment for all those suffering from hydrocoele.
3. Ensuring the quality of these services: The provided services for LF patients should be of good quality; an assessment of quality should be carried out in at least 10% of the designated medical facilities using the WHO Direct Inspection protocol.
Training procedures
The Director of Health Services for Kerala State selected specific health facilities in every district (i.e. 14 districts), which included the three non-endemic districts as patients with LF clinical disease have been reported to reside in these districts; doctors and nurses from these health facilities were then selected for the training. The training on MMDP was inaugurated by the Additional Chief Secretary Shri. Rajeev Sadanandan on 5th June 2017 at Govt. TD Medical College, Alappuzha. The training was given to a total of 184 health care providers, in 6 sessions of 3 days each, by the staff of the Filariasis Research Unit, Govt. TD Medical College, Alappuzha. The number of these health care providers that were trained and the dates of the training events are given in Table 1.
The training content followed the WHO Certified Training Module which encompasses components detailing the general background, as well as clinical and programmatic, aspects of LF. The learning objectives of the training sessions for the attendees were to: 1) to understand the background, the requirements and current status of global program to eliminate LF (GPELF); 2) to understand LF clinical disease focusing on lymphoedema, hydrocele, and acute attacks (ADL); also to be aware of the recommended essential package of care; and to 3) learn details concerning the implementation of GPELF including situation analysis, selection and development of health facility to impart MMDP services, the documentation and reporting of services provided, and assessment of quality of services given by the health facility.
The longstanding WHO Filariasis Center in the Government TD Medical College of Alappuzha [6, 8], worked with Kerala’s medical Administration to develop a solid, state wide, system of specialised care for LF lymphoedema patients. The training of the medical staff occurred through organized, structured sessions over six months included information, hands-on demonstrations and the development of specific LF lymphoedema care plans for the trainees’ hospitals (Figure 1).
Assessment of activities and outcome
Each training session included interactive sessions, photo quizzes, as well as direct interaction with lymphoedema patients. Participants were instructed in taking clinical history, carrying out a physical examination, as well aa being given hands-on-training on limb hygiene and other details of lymphedema management. The participants were divided into groups according to their institutions and each group given the task of developing a proposal for initiating MMDP services at their own hospitals. The institutional plans that each group of participants developed during the training sessions were assessed for quality and content. At the beginning of each of the six training sessions every attendee carried out a twenty item questionnaire with questions covering both programmatic and clinical elements. The same questions were asked again at the conclusion of each training session. A few attendees (an overall total of 8 across all sessions) did not carry out both tests. Throughout the training period regular conversations were held with the participants to obtain their opinions of the training and on any challenges they might have had in implementing the instructions and advice they received.
The number of medical facilities that instigated a lymphoedema care system as result of attending the training sessions was assessed one year after the training sessions ended. The number of patients who received instruction in the package of self-care from these clinics at 6 months after the trading session was also determined by survey of all participating institutions.