INDIA COUNTRY OFFICE | US CENTERS FOR DISEASE CONTROL AND PREVENTION ANNUAL REPORT 2015–2016 “We must work together to strengthen surveillance to detect emerging diseases, respond to outbreaks, and prevent future pandemics. Through our work together, both nations will benefit as we learn from one another.” —Richard Verma, US Ambassador to India CDC India staff gathered at US Embassy New Delhi FAST FACTS ESTABLISHED STAFF FUNDING OFFICES 2001 13 US Assignees FY2016 Delhi 37 Locally Employed Staff $30,600,000 Hyderabad PROGRAMS Division of Global HIV and Tuberculosis Division of Global Health Protection, Global Disease Detection Regional Center Influenza Division, including secondee to WHO SEARO Global Immunization Division, including secondee to WHO SEARO ii U.S. Centers for Disease Control and Prevention | India Country Office TABLE OF CONTENTS A Letter from the Director ..............................2 Key Partners .....................................................3 Glossary of Acronyms .....................................4 CDC Projects in India ......................................5 Global Health Security Agenda ......................6 Core 4 ................................................................7 Division of Global Health Protection/Global Disease Detection Regional Center ...............9 Surveillance .............................................10 Lab strengthening ..................................14 Workforce Development ........................15 Emergency Preparedness ......................17 Division of Global HIV and Tuberculosis ....20 Influenza Division .........................................28 Noncommunicable Diseases ........................31 Immunization ................................................33 Meet Our Staff ................................................34 Publications/Presentations ...........................36 2015–2016 Annual Report 1 LETTER FROM THE DIRECTOR The CDC India office has made great progress in 2016! This year our work in all areas—Global Health Security, HIV and tuberculosis, influenza, and immunization—has expanded and activities have been scaled to include work across more Indian states than ever before, with more intense efforts at the district level. Our office is collectively managing more than 30 projects, in 24 states, in collaboration with more than 32 Indian government agencies, local health organizations, hospitals, and universities. In DGHP, the Global Health Security activities have been focused on the “Core 4,” that is, expanding surveillance, strengthening laboratory capacity and biorisk management, building the public health workforce, and intensifying emergency management and response. In an essential demonstration of Government of India (GoI) commitment to GHSA, a GHSA “cell” was opened within the Ministry of Health and Family Welfare (MoHFW) and all GHSA activities are now coordinated and overseen through this cell by the Director General of Health Services and the Director General of the Indian Council of Medical Research. Major achievements this year include testing more than 24,000 in-patients with acute fever illness or acute encephalitis syndrome, or both, for a multitude of pathogens. Ultimately, across 14 states of India, only seven pathogens: influenza, malaria, dengue, scrub typhus, leptospira, Japanese encephalitis and Kyasanur Forest Disease comprise more than 85% of patients with a diagnosis. Furthermore, DGHP closely partnered with the government to support a national lab strengthening initiative which will scale up across all states, covering biochemistry, pathology, and microbiology laboratories of district hospital labs and medical college reference labs, and the state public health reference labs. Finally, in collaboration with the government, a robust strategic plan for Workforce Development has been designed, which includes initiating EIS with the WHO Country Office polio transition workforce, initiating EIS and the three-month Frontline Epidemiology training in additional institutions, and with GoI health ministry staff. Our influenza team has conducted vaccination camps as part of a cllinical trial comparing live attenuated influenza vaccine to inactivated influenza vaccine, and is now collecting follow-up data. These results will help estimate the burden of influenza in the community and effectiveness of available vaccines. The team has generated overall morbidity and mortality burden due to influenza which is crucial not only for informing policy in India but also for estimating the global burden due to influenza. The team is also embarking upon surveillance of a wider range of respiratory pathogens, and studies of influenza in pregnant women and in the elderly, two critically important and vulnerable populations. 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 through funding from the President’s Emergency Plan for AIDS Relief (PEPFAR). This year was particularly noteworthy for the HIV prevention activities conducted on behalf of People Who Inject Drugs (PWID) in the Northeastern states of Mizoram, Manipur and Nagaland. This collaboration has had great success in building the effectiveness of NGOs who work with PWIDs and in improving the accessibility of services such as opioid substitution therapy. This year DGHT also accelerated treatment scale up, HIV prevention, and HIV/TB efforts in rigorously selected “cluster districts,” six districts in the states of Maharashtra and Andhra Pradesh identified as having high HIV burden and large unmet need. Finally, intense efforts by CDC India and partners were made in Mumbai, and with the Central TB Division, to improve and expand airborne infection control, and expand accessibility to comprehensive diagnosis and programmatic management of drug-resistant TB. In immunization, CDC India is providing support to scale up measles-rubella vaccination, and is also supporting WHO in strengthening both in-country and cross-border surveillance and disease detection and response. Our collaboration with WHO on training the polio transition staff in EIS will ensure these officers can transition from polio-specific activities to greater public health strengthening. These achievements are only a beginning, and much remains to be done. I remain grateful for our collaborations with, and trust from, our partners, and inspired by the CDC India team. Despite the challenges we will no doubt encounter, I am confident our dedicated staff and partners will work together to overcome them, and together, we will continue to ensure better public health for India. Sincerely, Dr. Kayla Laserson 2 U.S. Centers for Disease Control and Prevention | India Country Office KEY PARTNERS All India Institute of Medical Sciences (AIIMS) American Society for Microbiology (ASM) Association of Public Health Laboratories (APHL) Christian Medical Association of India (CMAI) FHI360 Health Information Systems Program (HISP) Indian Council of Medical Research (ICMR) India HIV/AIDS Alliance Kalawati Saran Children’s Hospital, New Delhi Integrated Quality Laboratory Service (IQLS) Manipal University Ministry of Health and Family Welfare—Central Tuberculosis Division Ministry of Health and Family Welfare—International Health Division Ministry of Health and Family Welfare—National AIDS Control Organization National Centre for Disease Control (NCDC) National Disaster Management Authority (NDMA) National Institute of Epidemiology (NIE) National Institute of Health and Family Welfare (NIHFW) National Institute of Mental Health and Neurosciences (NIMHANS) National Institute for Medical Statistics (NIMS) National Institute for Research in Tuberculosis (NIRT) National Institute of Tuberculosis and Respiratory Diseases (NITRD) National Institute of Veterinary Epidemiology and Disease Informatics (NIVEDI) National Institute of Virology, Pune (NIV) National Tuberculosis Institute (NTI) Public Health Institute (PHI) SHARE India Sher-i-Kashmir Institute of Medical Sciences, Srinagar UNAIDS University of Washington—I-TECH Voluntary Health Services World Health Organization—India Office World Health Organization—Southeast Asia Regional Office 2015–2016 Annual Report 3 GLOSSARY OF ACRONYMS ADD Acute Diarrheal Diseases NACO National AIDS Control Organization AES Acute Encephalitis Syndrome NACP National AIDS Control Programme AFI Acute Febrile Illness NCDC India National Centre for Disease Control AIC Airborne Infection Control NGO Nongovernmental Organization AICU Airborne Infection Control Unit NGS Next Generation Sequencing AIDS Acquired Immune Deficiency Syndrome NIE National Institute of Epidemiology AIIMS All India Institute of Medical Sciences NIHFW N ational Institute of Health and Family AMR Antimicrobial Resistance Welfare ARI Acute Respiratory Infection NIMHANS National Institute of Mental Health and ART Antiretroviral Treatment Neurosciences ATT Anti-TB Treatment NIRT National Institute of Research in Tuberculosis BRM Biorisk Management NIV National Institute of Virology CBNAAT C artridge based nucleic acid amplification test NIVEDI N ational Institute of Veterinary Epidemiology and Disease Informatics CDC U nited States Centers for Disease Control and Prevention NLSI National Laboratory Strengthening Initiative CLABSI C entral Line Associated Bloodstream NTF National Task Force Infection NTI National Tuberculosis Institute CMAI Christian Medical Association of India NVBDCP N ational Vector Borne Disease Control CTD Central TB Division Programme DGHP/GDD D ivision of Global Health Protection/Global OSC Opioid Substitution Center Disease Detection Regional Center OST Opioid Substitution Therapy DGHT Division of Global HIV and TB PATH A global health NGO DPH Directorate of Public and Preventive Medicine PEPFAR President’s Emergency Program For AIDS DRS Drug Resistance Survey Relief DR TB Drug-resistant Tuberculosis PHI Public Health Institute DST Drug Susceptibility Testing PI Principal Investigator EIS Epidemic Intelligence Services PLHIV People Living with HIV EOC Emergency Operations Center EQAS External Quality Assurance Scheme PMTCT P revention of Mother to Child Transmission of HIV FEMA United States Federal Emergency Management Agency POE Port of Entry GHSA Global Health Security Agenda PPTCT P revention of Parent to Child Transmission GLPGP Global LPG Partnership of HIV GoI Government of India PWID People Who Inject Drugs HAI Healthcare Associated Infection RNTCP Revised National TB Control Programme HIV Human Immunodeficiency Virus RRT Rapid Response Team HTC HIV Testing and Counselling RSV Respiratory Syncytial Virus IBBS Integrated Biological and Behavioral Survey SARI Severe Acute Respiratory Infection ICMR Indian Council of Medical Research SEARO Southeast Asia Regional Office IDSP Integrated Disease Surveillance Programme SEWA Self-Employed Women’s Association IHR International Health Regulations SHARE S ociety for Health Allied Research & IMS Incident Management System Education IPC Infection Prevention Control SHOC Strategic Health Operations Center IQLS Integrated Quality Laboratory Service SI Strategic Information ISO International Standards Organization SIMS Strategic Information Management System JE Japanese Encephalitis SOP Standard Operating Procedure KFD Kyasanur Forest Disease STI Sexually Transmitted Infection LAIV Live Attenuated Influenza Vaccine TEPHINET Training Programs in Epidemiology and Public LCI Local Capacity Initiative Health Interventions Network LPG Liquefied Petroleum Gas TPT Tuberculosis Preventive Therapy M&E Monitoring and Evaluation UAV Unmanned Aerial Vehicle MDR TB Multidrug-resistant Tuberculosis UNAIDS United Nations Programme on HIV/AIDS MoHFW India Ministry of Health and Family Welfare VHF Viral Hemorrhagic Fever MOU Memorandum of Understanding VHS Voluntary Health Services MR Measles-Rubella WHO World Health Organization MTA Mid-term Appraisal 4 U.S. Centers for Disease Control and Prevention | India Country Office CDC PROJECTS IN INDIA In addition to all state specific activities, CDC India provides technical assistance to national programs in such areas as development of guidelines, national policies, and training programs. These activities have countrywide reach. 2015–2016 Annual Report 5 GLOBAL HEALTH Recognizing that a health threat anywhere is a health threat everywhere SECURITY AGENDA In 2014, the United States government announced its intent to invest more than $1 billion in resources (GHSA) to expand GHSA–an initiative designed to make sure the world is ready to prevent, detect, and respond to future infectious disease outbreaks. “The world is more connected than in any GHSA in India continues to build on the International time in human history. Distance no longer Health Regulations (IHR), which provide guidance affords protection from disease, viruses, for countries to assess and manage serious health even epidemics.” threats that have the potential to spread beyond borders. CDC’s Division of Global Health Protection/ CDC Director Dr. Tom Frieden, Global Disease Detection (DGHP/GDD) in India is focusing efforts on four of the 11 GHSA action et al in A Path to Global Health Security packages (the “Core 4”), specifically increasing real- time surveillance of potential public health threats, strengthening laboratory systems, ensuring more health workers are well trained in detect, respond, and prevent capacities, and establishing Emergency Operations Centers (EOCs)/Strategic Health Operations Centers (SHOCs) with rapid response teams capable of activating a coordinated emergency response. India is the largest of the Phase 1 GHSA countries, and also sits on the ten-country GHSA Steering Group, which has placed India and our CDC team in a unique position to lead and demonstrate successes of GHSA implementation. Drawing on extensive experience with infectious disease surveillance, emergency preparedness, public health workforce development, and laboratory strengthening, CDC India began working with India’s MoHFW and other partners to support GHSA goals. Since 2015, the Government of India and other partners have received over $25 million to establish or expand existing GHSA projects. Already in just over one year and a half, we have seen significant public health impact of these activities, such as establishing 28 acute febrile illness (AFI) sites, providing diagnosis to nearly 40% of acute encephalitis syndrome patients, assessing 388 laboratories to develop action plans for improvement, and establishing a state-level EOC in Tamil Nadu. CLABSI Surveillance staff meeting at AIIMS. 6 U.S. Centers for Disease Control and Prevention | India Country Office CDC India is working to strengthen global health in India and around the world by focusing on four of GHSA’s 11 Action Packages Surveillance ◆ Conducting high-impact public health surveillance of disease syndromes such as acute febrile illness and acute encephalitis syndrome. ◆ Strengthening viral hemorrhagic fever and respiratory disease surveillance. ◆ Enhancing surveillance platforms to detect vaccine-preventable bacterial disease in young children. ◆ Supporting surveillance of healthcare associated infections and antimicrobial resistance. Lab Strengthening ◆ Enhancing the quality and capacity of public health laboratories by supporting the National Laboratory Strengthening Initiative of the National Centre for Disease Control. ◆ This initiative strengthens the capacity of all district and state laboratories beginning in the states of Gujarat, Tamil Nadu, Jharkhand, and Madhya Pradesh. ◆ Implementing a district model of integrated lab services in the states of Rajasthan, Maharashtra, Telangana, Andhra Pradesh, West Bengal, and Assam through Labs for Life. ◆ Expanding laboratory-enhanced disease surveillance for improved outbreak response. ◆ Developing rapid diagnostic capabilities and whole genome sequencing methodology to be used for drug-resistant TB, and to diagnose known and unknown pathogens. Workforce Development ◆ Strengthening national epidemiologic capacity through the India EIS program, three- month Frontline Epidemiology trainings, and Rapid Response Team trainings, including for veterinarians. ◆ Evaluating laboratories on techniques including for antimicrobial resistance, and hospital staff on infection control practices and healthcare-associated infection surveillance. Emergency Preparedness ◆ Providing training for disaster response and mass casualty events. ◆ Supporting the national Indian Emergency Operations Centers (EOC)/Strategic Health Operations Centers (SHOC) with emergency response training and facilitating development of these centers at the state level. Training laboratory staff in safe handling and rapid transportation of clinical specimens and of potentially infectious waste during public health emergencies. GHSA 2015–2016 Annual Report 7 Projects by State and Partner PARTNERS WITH PROJECT IN STATES STATE/UNION TERRITORY Andhra Pradesh CMAI AIIMS, NCDC, NIMHANS, Assam NIV, CMAI, Manipal Goa Manipal NIV, NCDC, Gujarat CMAI, Manipal Jammu & Kashmir NIV Jharkhand Manipal, NCDC AIIMS, NIMHANS, Karnataka Manipal, NCDC Kerala Manipal Madhya Pradesh NIV, NCDC AIIMS, NIV, CMAI, NCDC, Maharashtra Manipal, SHARE Meghalaya NIV Odisha NIV, Manipal, NIVEDI Punjab NCDC AIIMS, NIHFW, Rajasthan NCDC, NIV, CMAI AIIMS, NCDC, NIE, NIRT, NIV, Tamil Nadu PHI, Manipal, MoHFW Telangana AIIMS, CMAI Tripura Manipal AIIMS, NIMHANS, Uttar Pradesh NCDC, NIV AIIMS, NIMHANS, West Bengal NIV, CMAI UNION TERRITORIES Andaman NIV and Nicobar Islands Chandigarh AIIMS AIIMS, NIV, NCDC, MoHFW, Delhi WHO-I, WHO-SEARO Puducherry NCDC 8 U.S. Centers for Disease Control and Prevention | India Country Office