INDIA COUNTRY OFFICE | U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION ANNUAL REPORT 2014–2015 CDC India Staff with CDC Director Tom Frieden “It is health that is real wealth and not pieces of gold and silver.” —Mahatma Gandhi ii U.S. Centers for Disease Control and Prevention | India Country Office TABLE OF CONTENTS A Letter from the Director . . . . . . . . . . . . . . 2 Global Health Security Agenda . . . . . . . . . . 4 Division of Global HIV and Tuberculosis . . . . . . . . . . . . . . . . . . . . . . 6 Global Disease Detection Regional Center . . . . . . . . . . . . . . . . . . . . . . 10 Influenza Division . . . . . . . . . . . . . . . . . . . 14 Noncommunicable Disease . . . . . . . . . . . 16 Ebola Response . . . . . . . . . . . . . . . . . . . . . . 18 Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 CDC India Key Partners . . . . . . . . . . . . . . . 21 Meet Our Staff . . . . . . . . . . . . . . . . . . . . . . . 22 Publications . . . . . . . . . . . . . . . . . . . . . . . . 24 2014–2015 Annual Report 1 LETTER FROM THE DIRECTOR The U.S. Centers for Disease Control and Prevention (CDC) opened its office in Delhi in 2001. Working closely with local partners and health agencies, CDC India has spent the last 15 years addressing a widening range of infectious and noncommunicable diseases through the Global Disease Detection Regional Center (GDD), the Division of Global HIV and Tuberculosis (DGHT), the Influenza Division, and the Global Immunization Division. Our office and focus have expanded over the years, but 2014–2015 marked a significant period of growth and accomplishment. Our country teams collectively managed more than 23 projects, including 12 new launches. We partnered with more than 32 Indian government agencies, local health organizations, hospitals, and universities, and facilitated new collaborations in 23 states across India. GDD was busy nurturing the fledgling India Epidemic Intelligence Service (EIS), which graduated its first cohort in September of 2014 and the second in 2015. These graduates and other officers were often on the front lines of outbreak response across India, serving as invaluable resources to the government of India and GDD’s various project teams. GDD has also been collaborating on the design and implementation of the Global Health Security Agenda (GHSA) in India, and 2016 will see this work expand significantly. Great strides were made by our influenza team, which worked with local partners to help identify the spring seasonality of the influenza virus in India. The Influenza Program also collaborated with the All India Institute of Medical Sciences (AIIMS) to launch a vaccine trial comparing live attenuated influenza vaccine to inactivated influenza vaccine—one of the very few such trials being conducted in the tropics. DGHT continued a productive partnership with India’s National AIDS Control Organization (NACO), providing technical assistance to strengthen both local and national HIV monitoring, care, and treatment mechanisms. Over the past year the team supported planning for the largest Integrated Bio-Behavioral Survey of key populations and migrants in India’s history, as well as supported the first-ever assessment of ART clinics across the country. The team’s 2015 PEPFAR pivot will focus on epidemic control in high burden districts across five states and will introduce a broad tuberculosis initiative under the GHSA. Perhaps one of the most significant accomplishments happened in March of 2014: India was officially certified polio-free, marking a historic moment for one of CDC India’s very first collaborations. But with these milestones come reminders of all the work that lies ahead: curbing the growing tuberculosis (TB) epidemic, improving traffic safety measures, and building a local framework for global health security. The challenges will be many but I am confident in our tireless staff and ever thankful for our enduring partnership with India. Together we will continue to grow, work hard, and help give the people of this beautiful country healthier, safer, longer, and more productive lives. Sincerely, Dr. Kayla Laserson FAST FACTS ESTABLISHED STAFF PROGRAMS 2001 12 U.S. Assignees Division of Global HIV and Tuberculosis 26 Locally Employed Staff Division of Global Health Protection, Global Disease Detection Regional Center Influenza Division, including secondee to BUDGET OFFICES WHO SEARO FY2014: $16,671,296 Delhi Global Immunization Division, seconded to WHO SEARO FY2015: $40,401,705 Hyderabad 2 U.S. Centers for Disease Control and Prevention | India Country Office CDC PROJECTS IN INDIA KEY 2014–2015 Annual Report 3 GLOBAL HEALTH In 2014, the U.S. government announced its intent to invest more than $1 billion in resources to expand the GHSA—an initiative designed to make sure the SECURITY AGENDA world is ready to prevent, detect, and respond to future infectious disease outbreaks. (GHSA) The GHSA builds on the International Health Regulations (IHR), which provide guidance for countries to assess and manage serious health Working toward a world safe and secure threats that have the potential to spread beyond from infectious disease threats. borders. The GHSA expands on the IHR guidance by providing specific and measurable targets in 11 areas. CDC’s Division of Global Health Protection is focusing their efforts on four of those targets, including strengthening laboratory systems, increasing real-time surveillance of potential public health threats, ensuring health workers are well-trained, and establishing Emergency Operations Centers (EOCs) with rapid response teams capable of activating a coordinated emergency response. India is the largest of the initial 17 target countries, and also sits on the 10-country GHSA Steering Group, which puts India and our CDC team in a unique position to be true leaders in the initial stages of GHSA implementation. Drawing on extensive experience with infectious disease surveillance, emergency response, and lab strengthening, CDC India began working with India’s Ministry of Health (MOH) to support GHSA goals in 2014. In September of 2015, CDC India received over $15 million in new funding for the Indian government and local partner organizations to establish or expand on existing GHSA projects and to begin implementing GHSA activities. CDC India Director Kayla Laserson, US Ambassador Richard Verma GHSA partners at the first interagency and officials from India’s first Ministry of Health light a lamp GHSA stakeholder meeting in 2015 at the opening of the GHSA Stakeholder meeting 4 U.S. Centers for Disease Control and Prevention | India Country Office CDC India is working to strengthen India’s global health security by focusing on the three pillars of the GHSA Prevent Avoidable Detect Threats Respond Rapidly Epidemics Early and Effectively ◆ Supporting sentinel surveillance ◆ Strengthening national epidemiologic ◆ Providing training for disaster sites in at least five epidemiologic capacity through the India EIS response and mass casualty events zones across India program, three month epidemiology ◆ Supporting the Indian Strategic trainings, and rapid response team ◆ Enhancing the quality and capacity Health Operations Center (SHOC) training, including for veterinarians of public health laboratories with emergency response training through projects like the Labs for ◆ Conducting high impact public health and facilitating development of Life partnership surveillance of disease syndromes SHOCs at state level such as Acute Febrille Illness and ◆ Supporting surveillance of ◆ Training laboratory staff in safe Acute Encephalitis Syndrome healthcare associated infections handling and rapid transportation and antimicrobial resistance ◆ Working with national and regional of clinical specimens and of partners on One Health to track, potentially infectious waste during ◆ Working with the government detect and prevent pathogens from public health emergencies of India to increase routine spreading from animals to humans immunization coverage ◆ Expanding laboratory-based diarrheal ◆ Training hospital and laboratory disease surveillance and enhancing staff on antimicrobial resistance foodborne outbreak response laboratory techniques, infection control practices, and antimicrobial ◆ Enhancing influenza virus, respiratory resistance and healthcare- disease, and viral hemorrhagic fever associated infection surveillance surveillance ◆ Enhancing current surveillance to detect vaccine-preventable bacterial disease in young children ◆ Developing rapid diagnostic capabilities and DNA sequencing for drug resistant TB 2014–2015 Annual Report 5 DIVISION OF CDC India has been working on HIV/AIDS prevention and control since 2001, and currently provides technical assistance and support to the Indian GLOBAL HIV AND Ministry of Health and Family Welfare’s National AIDS Control Organization (NACO) and the Central TB TUBERCULOSIS Division. With staff in Delhi and Hyderabad, along with indigenous and international implementing partners, DGHT supports activities and initiatives across the Over 2.1 million Indians are infected with country designed to help prevent new infections, HIV—constituting the third largest HIV increase access to services and service quality for persons living with HIV and/or TB, and accelerate epidemic in the world. these efforts in areas with high HIV burden and large unmet need. Supporting TB Control in India India has an estimated 2.6 million TB cases and 240,000 TB deaths annually, and accounts for a substantial portion of all multi-drug resistant (MDR) TB cases globally. CDC India has provided technical assistance for TB control efforts here since 1997 through a secondment agreement with WHO. In 2015 CDC India received direct funding for a medical officer dedicated to a broad initiative aimed at supporting the Central TB Division within the Ministry of Health and Family Welfare, GHSA goals, enhancing HIV-TB coordination, and reducing the importation of TB into the United States. In particular, under the GHSA, DGHT staff will collaborate with the National Institute of Research in Tuberculosis (NIRT) in Chennai, and will support the prevention, diagnosis and treatment of MDR TB in Mumbai, where the team aims to support the government of India in establishing a model center for addressing MDR TB. India Care and Treatment and DGHT Director Pauline Harvey signs the TB Call To Action HIV-TB Project In 2014 only 61% of TB patients were screened for HIV and knew their HIV status. Mortality among HIV- infected TB patients continues to be unacceptably high, primarily due to a late or missed diagnosis of either disease. In 2015 DGHT began providing technical support to NACO and strengthening key institutions to help address gaps in the coverage and quality of HIV-TB and HIV treatment services. By working to strengthen airborne infection control, increase ART treatment coverage and cross referrals, support efforts to improve treatment adherence and other strategies, DGHT hopes to help NACO increase the number of TB patients who know their HIV status to 90%, as well as link and retain 90% of HIV-TB co-infected patients in care. DGHT team members Archana Beri, Sunita Upadhyaya, and Sanjeev Verma 6 U.S. Centers for Disease Control and Prevention | India Country Office Quality Management Systems in Local Capacity Initiative (LCI) Blood Banks NACO has scaled up the HIV/AIDS response throughout the country. While declining HIV trends Charged with reducing the rate of transfusion are reported in southern states, some low prevalence transmitted HIV infections to below 0.5 percent and states in the northern region are showing rising ensuring that safe blood is available to all health trends. NACO was concerned with the rising number facilities, NACO and its Blood Transfusion Service of new HIV infections in some northern states and turned to the DGHT staff for technical assistance and looked to augment the capacity of these states to strategic guidance. Since 2013 DGHT has been an scale up the response. Through the LCI project, integral part of the assessment of blood banks and NACO requested CDC to strengthen the institutional training centres, delivery of in-service training modules, capacity of civil society organizations in the states and providing ongoing technical support for the project of Chattisgarh, Madhya Pradesh, and Odisha. NACO, as a whole. These ongoing efforts have helped reduce CDC, and our implementing partner, the India HIV/ HIV transmission and other transfusion-transmitted AIDS Alliance, conducted a detailed analysis of the infections, as well as supported well-coordinated epidemiology and the current program response national and state-level blood transfusion programs. in these states, and an implementation plan with innovative approaches has been developed to achieve Laboratory Systems Strengthening accelerated epidemic control in these areas. Previous phases of the National AIDS Control Program By working to enhance the skills of outreach workers (NACP) focused on scaling up HIV testing and related and health care providers, improving access to services. But in 2015 DGHT began working with government social benefit schemes, and piloting other NACO on Phase IV goals, which include ensuring innovative, cost effective strategies, NACO and DGHT higher quality diagnosis while also sustaining efforts have started to see improvement in the ability of Civil to scale up coverage. Efforts have been focused Society Organizations to advocate for improved access on a cost-effective and mandatory External Quality to HIV prevention, care and treatment services and Assessment Scheme and capacity building initiatives, ultimately reach underserved areas and populations. with the ultimate goal being International Standards Organization (ISO) accreditation. India’s National Blood Donation Day, 2014 2014–2015 Annual Report 7 Prevention of Mother to Child Transmission Strategic Assessment for Strategic Action of HIV (PMTCT) (SASA) With the global target of eliminating new HIV In an effort to help inform the Indian government’s infections among children in mind, DGHT partnered decisions on strategic investments, NACO with NACO to provide technical assistance and implemented the SASA project in 2014 under expert implementation support to Prevention of Mother to guidance from DGHT. The SASA project provides Child Transmission of HIV — referred to as Prevention cutting edge technical assistance to the Indian of Parent to Child Transmission of HIV, or PPTCT, government to collect data-based evidence for in India. improving strategic information, HIV prevention, and care and treatment interventions. Faced with limited counseling and testing for pregnant women and poor linkage of HIV-infected women and Since launching, the project team has guided an children to the appropriate postnatal care, the team assessment of linked antiretroviral therapy centers has been working to improve detection and increase and finalized critical district epidemiological profiles access to care. A new initiative to expand and of Andhra Pradesh, Karnataka, and the northeastern strengthen PMTCT coverage in Chattisgarh, Haryana, states. With continued progress, the team hopes to and Punjab involves mobilizing private healthcare foster the creation of a monitoring system that can institutions in these efforts, with an aim to integrate help identify best practice HIV models for India. PPTCT care with general health services in high burden districts. Technical Assistance to the National AIDS Since its launch, the project has helped implement Control Program (NACP) triple-drug, life-long antiretroviral therapy (ART) for HIV- India’s NACP is currently in its fourth phase, focused infected pregnant and breast feeding women (Option on reversing the HIV epidemic and sustaining that B+) across all states in India. National guidelines response level for five years. The Technical Assistance for PPTCT have been revised and implemented, to NACP Project provides needs-based technical and the team has also successfully assessed the assistance to NACO in support of NACP-IV. Partnering implementation of Option B and Option B+ rollout in with Voluntary Health Services, DGHT works to four states. maximize resources, address gaps in the HIV/AIDS prevention, care, and treatment program, and assist India People Who Inject Drugs (PWID) with scaling up high-impact practices in the areas of Collaborative Project prevention, care and treatment. Despite success with outreach services, HIV To date this project has helped increase PPTCT prevalence continues to be high among PWID in coverage in 80% of the target states; enhanced the the northeast region of India, due in large part to capacity of 189 District AIDS Prevention and Control the multiple barriers this population faces when Units; and increased the number of private maternity trying to access the comprehensive package of hospitals providing stigma-free PPTCT services. In services available. the coming year the team anticipates broadening technical assistance efforts to help support the To help address this growing epidemic, NACO and governments of Bangladesh and Sri Lanka in their DGHT launched the India PWID Collaborative Project HIV response. in April of 2015 to support NACO’s ongoing efforts to reach PWID with efficient and effective care, especially in high burden districts of Manipur, Mizoram, and Nagaland. By working to scale up and improve the quality of services for the PWID population in these areas, DGHT hopes to eventually see a 30%-40% reduction in new HIV cases, a significant increase in the use of opioid substitution therapy, and a majority of eligible HIV-positive PWID receiving ART. 8 U.S. Centers for Disease Control and Prevention | India Country Office