National Vector Borne Diseases Control Programme (NVBDCP)

Overview

Diseases Covered (6 Vector Borne Diseases)

Historical Milestones

Objectives (11th Five Year Plan, 2007-12)

1. Prevent mortality due to Malaria, Kala-azar, Dengue/DHF, and Japanese Encephalitis
2. Reduce morbidity due to Malaria, Dengue/DHF, Chikungunya, and JE
3. Eliminate Kala-azar and Lymphatic Filariasis

Long-term Goals

• Malaria elimination (zero indigenous cases) throughout India by 2030
• Eliminate Filariasis by 2027
• Maintain malaria-free status in areas where transmission has been interrupted

Three-Pronged Strategy (as per Park's Textbook)

1. Disease Management

• Early Case Detection and Complete Treatment (EDCT)
• Rapid Diagnostic Tests (RDT) for Pf malaria in high-endemic areas
• Strengthening of referral services
• Epidemic preparedness and rapid response

2. Integrated Vector Management (IVM)

• Indoor Residual Spraying (IRS) in selected high-risk areas
• Insecticide Treated Bed-Nets (ITBNs)
• Larvivorous fish (e.g., Gambusia, Lebistes) in water bodies
• Anti-larval measures in urban areas
• Source reduction and minor environmental engineering

3. Supportive Interventions

• Behaviour Change Communication (BCC) and IEC
• Public-private partnership and inter-sectoral convergence
• Human resource development through capacity building
• Operational research (drug resistance, insecticide susceptibility)
• Monitoring and evaluation through web-based MIS
• Vaccination against Japanese Encephalitis
• Annual Mass Drug Administration (MDA) against lymphatic filariasis

Personal Prophylactic Measures

• Mosquito repellents (creams, coils, mats, liquids)
• Wearing long-sleeved clothing
• Use of bednets (especially during day for children - Aedes bites during day)

Organizational Structure

• Drug Distribution Centres (DDCs) and Fever Treatment Depots (FTDs) are established at the community level for early treatment
• Regional offices of the Directorate exist in 19 states
• Each state has a State Vector Borne Disease Control Society (now merged with State Health & Family Welfare Society under NRHM)

Malaria Elimination Classification of States

Key Sub-Programmes

Funding

• Central Government supplies: DDT, larvicides, some drugs
• State Governments procure: insecticides for IRS, spray equipment, some anti-malarials
• External support: World Bank (malaria in tribal districts), WHO, Global Fund

Source: Park's Textbook of Preventive and Social Medicine - Chapter on National Health Programmes and NVBDCP

Low Birth Weight (LBW) - Definition, Classification & Prevention

Definition

Birth weight of less than 2.5 kg (up to and including 2499 g), the measurement being taken preferably within the first hour of life, before significant postnatal weight loss has occurred.

• Birth weight is the single most important determinant of an infant's chances of survival, healthy growth, and development
• LBW is an indicator of a multifactorial public health problem - reflecting long-term maternal malnutrition, ill-health, and inadequate health care in pregnancy
• Globally, 15-20% of all births are LBW, representing more than 20 million births annually
• In India, approximately 18.6% of babies are born LBW (RSOC 2014), compared to ~4% in developed countries

Classification

A. By Birth Weight

Note: These three levels reflect diagnostic certainty, not necessarily different grades of clinical severity.

B. By Gestational Age

• Extremely preterm: < 28 weeks
• Very preterm: 28 to < 32 weeks
• Moderate to late preterm: 32 to 37 weeks

C. By Growth Status - The Two Main Groups of LBW Babies

• Born alive before 37 completed weeks
• Intrauterine growth may be normal (appropriate for gestational age)
• Their weight, length, and development may be within normal limits for gestation duration
• With good neonatal care, can catch up growth by 2-3 years
• Predominant cause of LBW in developed/low-prevalence countries

• Weigh less than the 10th percentile for their gestational age and sex
• May be born at term or preterm
• Result from Intrauterine Growth Restriction (IUGR)
• Represent foetal growth retardation
• Predominant cause of LBW in developing countries (including India)
• These babies miss out on critical growth period in the womb and face long-term consequences

Risk Factors / Causes

Maternal Factors

• Malnutrition and anaemia (most significant in India)
• Short maternal stature
• Very young maternal age (adolescent pregnancy) or advanced maternal age
• High parity and short inter-pregnancy intervals
• Heavy physical labour during pregnancy
• Smoking, excess alcohol, recreational drug use
• Maternal psychological issues (depression, domestic violence)
• Cervical incompetence

Infections

• Urinary tract infections (UTI)
• Malaria
• HIV, syphilis
• Bacterial vaginosis
• TORCH infections (cytomegalovirus, toxoplasmosis, rubella, syphilis)

Medical Conditions

• Hypertension / pre-eclampsia / toxaemia
• Diabetes
• Anaemia, asthma, thyroid disease

Other Factors

• Multiple pregnancy (twins, higher order)
• Genetic risk / family history
• Poor socio-economic conditions
• Inadequate antenatal care

Importance / Public Health Significance

• Infant Mortality Rate (IMR) is 20 times greater for LBW babies than for normal weight babies
• Half of all perinatal deaths and one-third of all infant deaths are due to LBW
• Prematurity is the 2nd leading cause of death in children under 5 years
• LBW is the single most important cause of death in the critical first month of life

Complications of Preterm / LBW Babies

Prevention

I. DIRECT (Primary) Interventions

1. Increasing Food Intake

• Even a small dietary improvement in a malnourished pregnant mother (even in the last trimester) can significantly improve birth weight
• Supplementary feeding programs
• Distribution of iron and folic acid (IFA) tablets - standard antenatal supplement
• Food fortification and enrichment
• Treatment of anaemia in pregnant mothers

2. Controlling Infections

• Diagnose and treat maternal infections promptly:
  • Malaria (ITBNs, antimalarials, IPTp)
  • UTIs
  • Syphilis, HIV (PMTCT)
  • TORCH infections
• Vaccination (e.g., rubella immunization before pregnancy)

3. Early Detection and Treatment of Medical Disorders

• Hypertension / pre-eclampsia management
• Gestational diabetes management
• Thyroid disorders

II. INDIRECT Interventions

• Family planning - birth spacing, avoidance of too frequent pregnancies
• Avoidance of excessive smoking and alcohol
• Improved sanitation and environmental conditions
• Improving health and nutrition of young girls (addressing intergenerational malnutrition)
• Maternity leave with full wages (government policy support)
• Child benefits and social support programs
• Improving socio-economic conditions

III. Antenatal Care (ANC) Package

• 4-visit focused ANC (minimum standard)
• IPTp (Intermittent Preventive Treatment in pregnancy) for malaria with bednets
• Prevention and management of STIs and HIV
• Calcium supplementation (prevents pre-eclampsia)
• Nutritional counselling
• Diagnosis and treatment of chronic conditions

IV. Intrapartum Measures

• Antenatal corticosteroids for women at risk of preterm birth (lung maturity)
• Antibiotics for preterm premature rupture of membranes (pPROM)
• Skilled birth attendance

V. Postnatal / Neonatal Care

• Kangaroo Mother Care (KMC) - skin-to-skin contact for preterm/LBW babies; reduces mortality and hypothermia
• Exclusive breastfeeding support
• CPAP and surfactant therapy for RDS
• Warmth provision (radiant warmers, incubators)
• Emergency newborn care

Treatment of LBW Babies (Two Groups)

Global Targets

• WHO Global Nutrition Target 2025: 30% reduction in LBW by 2025 (3% relative reduction per year from 2012)
• Translates to a reduction from ~20 million to ~14 million LBW infants

Source: Park's Textbook of Preventive and Social Medicine - Chapters on Maternal and Child Health and Nutrition; WHO Global Nutrition Monitoring Framework

Perinatal Mortality Rate (PMR)

Definition

• ICD-8 defined the perinatal period as from the 28th week of gestation to the 7th day after birth
• ICD-10 (1993) refined criteria for inclusion in perinatal statistics

Formulae

1. Standard WHO Formula (for countries with well-established vital records):

2. WHO Formula (for countries with less well-established records):

The difference lies in the denominator - developed nations use total births (live + late foetal deaths) while developing nations often use only live births. This makes international comparisons difficult.

3. For International Comparisons (WHO Expert Committee, 1970):

ICD-10 Criteria for Inclusion in Perinatal Statistics

1. Birth weight ≥ 1000 g (equivalent to ~28 weeks gestation) - preferred criterion
2. If birth weight unavailable: gestational age ≥ 28 weeks
3. If neither available: crown-to-heel body length ≥ 35 cm

Components of PMR

Why Use PMR? (Significance)

1. Factors are common to both components - the causes of stillbirths and early neonatal deaths are often the same (operating before and around birth), so combining them is logical
2. Avoids registration error - A proportion of deaths shortly after birth are incorrectly registered as stillbirths. PMR, being a combination of both, is not influenced by this error because it removes the dividing line between a stillbirth and a live birth with death shortly after
3. Sensitive quality indicator - PMR gives a good indication of the extent of pregnancy wastage and the quality and quantity of health care available to mother and newborn; it reflects maternity care more clearly than neonatal death rate alone
4. High mortality concentration - Although the perinatal period occupies less than 0.5% (<168 hours) of the average lifespan, there are more deaths within this period than during the next 30-40 years of life in many developing countries
5. Benchmark in developed countries - With declining IMR in developed countries, PMR has assumed greater significance as a yardstick of obstetric and paediatric care before and around birth

Incidence

• Perinatal mortality now accounts for about 90% of all foetal and infant mortality in developed countries
• In India, stillbirths are seldom registered, so most studies are hospital-based
• About two-thirds of all perinatal deaths occur among infants with birth weight < 2500 g (LBW)

Social and Biological Risk Factors

1. Low socio-economic status
2. High maternal age (35 years or more)
3. Low maternal age (under 16 years)
4. High parity (5th and subsequent pregnancies, especially with short inter-pregnancy intervals)
5. Heavy smoking (10 or more cigarettes daily)
6. Short maternal stature (compared to average for locality)
7. Poor past obstetric history (previous stillbirths, neonatal deaths, premature live-borns)
8. Malnutrition and severe anaemia
9. Multiple pregnancy

Causes of Perinatal Mortality

(a) Antenatal Causes

1. Maternal diseases - hypertension, cardiovascular disease, diabetes, tuberculosis, anaemia
2. Pelvic diseases - uterine myomas, endometriosis, ovarian tumours
3. Anatomical defects - uterine anomalies, incompetent cervix
4. Endocrine imbalance and inadequate uterine preparation
5. Blood incompatibilities (e.g., Rh incompatibility)
6. Malnutrition
7. Toxaemias of pregnancy (pre-eclampsia, eclampsia)
8. Antepartum haemorrhages (placenta praevia, abruptio placentae)
9. Congenital defects
10. Advanced maternal age

(b) Intranatal Causes

1. Birth injuries
2. Asphyxia (intrapartum hypoxia)
3. Prolonged effort / obstructed labour
4. Obstetric complications

(c) Postnatal Causes (Early Neonatal)

1. Prematurity / LBW
2. Respiratory Distress Syndrome (RDS / hyaline membrane disease)
3. Respiratory and alimentary infections
4. Congenital anomalies

(d) Unknown Causes

• In some cases, causes are not clinically ascertainable

Prevention of Perinatal Mortality

Antenatal Measures

• Early and regular Antenatal Care (ANC) - minimum 4 focused visits
• Identification and management of high-risk pregnancies
• Treatment of anaemia (iron and folic acid supplementation)
• Nutrition supplementation for malnourished mothers
• Management of hypertension, diabetes, infections (UTI, malaria, syphilis)
• Tetanus toxoid immunization
• Rh incompatibility detection and management (Anti-D prophylaxis)
• Treating antepartum haemorrhage promptly
• Antenatal corticosteroids for women at risk of preterm delivery

Intranatal Measures

• Skilled birth attendance at every delivery
• Institutional deliveries (avoidance of home deliveries by unskilled persons)
• Proper management of prolonged/obstructed labour
• Caesarean section when indicated (not elective/unnecessary)
• Aseptic delivery practices to prevent infection

Postnatal / Neonatal Measures

• Immediate newborn resuscitation and airway clearance
• Kangaroo Mother Care (KMC) for LBW/preterm babies
• Early and exclusive breastfeeding
• Thermal care - prevention of hypothermia
• CPAP and surfactant therapy for RDS
• Neonatal intensive care for high-risk newborns
• Prevention and prompt treatment of neonatal sepsis
• Prevention of neonatal tetanus (clean cord care)

Indirect / Social Measures

• Improving socio-economic status and education of women
• Family planning - birth spacing, reducing high parity
• Improving maternal nutrition before and during pregnancy
• Reducing adolescent pregnancies
• Maternity benefits and social support policies

International Certificate of Perinatal Death

• ICD-9 (1975) recommended a special certificate of cause of perinatal death for international comparability
• ICD also has a list of 100 tabulation of perinatal morbidity and mortality

Related Mortality Rates (Contextual Framework)

Source: Park's Textbook of Preventive and Social Medicine - Chapter on Maternal and Child Health (Perinatal Mortality Rate section, pp. 657-658)