 Ik zal de chair van de eerste sessie introduceren en de chair is Dr. Rohit Sarin en hij is de directeur van de Nationale Instituut van TB en Respiratorie Diseases en die is een autonomische instituut functioneren onder de ministerie van Health en Family Welfare. Hij is ook chair van WHO's Regional Green Light Committee voor MDRTB in South East Asia. Dr. Sarin is een van de volledige technische experten van TB in Indië vandaag en hij heeft duurzame TB-preventie en controleren in de landen geïnteresseerd. Dr. Sarin, welkom. Dank u, Martin, voor de kind woorden van de introductie. Welvrienden, een heel goede morgen voor alle van jullie en voor onze collega's en partners over de wereld. Op wat tijd van de dag is het een goede dag. Ik zou zeggen dat het een historische moment is. Het is een historische moment voor alle van ons hier in Indië. En het is een historische moment voor de Indië-office. Omdat vandaag we de scientifiek dag van de MSF in dit land bezoeken. En we doen het voor het eerst. En ik ben zeker dat wanneer we terug naar de scientifiek dag zijn, vandaag, 8 maart, 2015, zal het altijd behoorlijk zijn. Dus ik wil beginnen met de MSF en de team onder de leadership van Martin, die dit gebeurt. En ik ben zeker dat dit een event is waarin we over de jaren gaan komen. Welvrienden, de morning session is een heel interessant session. Want het is focussing op iets wat we allemaal geïnteresseerd zijn. En dat is neglect. Neglect voor diseases, neglect voor cohorten, neglect voor populaties. En we hebben vier presentaties in deze particular session. En ieder van deze vier gaat op wat of de andere aspecten. Voordat ik voor de subsequentie gesproken ben, zal ik zeggen dat mijn eerste speaker is Chénéry Anne Lim. Ze is een pediatrie, een kwalificatie. En ze is in de MSF gedeelte van drie jaar terug. Zijn meeste plek van werk, of zou ik zeggen, onderzoek is primair in Sierra Leone en Pakistan. En ze heeft veel missies gedaan op een emergency exploratie basis ook. Ze is van Manila, St. Luke's College. En ik ben zeker dat we allemaal een feest hebben over wat ze moet proberen. Dat is een neglect geïnteresseerd disease, kutenis, beniasis. Dit is op haar experiences in Balochistan en Pakistan. Dus het is over voor Chéné, voor de volgende 10 minuten of 12 minuten. Wat vind je comfortabel? Dank je wel. Goedemorgen, iedereen, vrouwen en vrouwen van onze volgende speaker, panelist en alle mensen die op de wereld streamen. Vandaag gaan we een bescherming op de neglect geïnteresseerd disease, kutenis, beniasis en Pakistan. Als iedereen weet, in Balochistan is de grootste provincie van Pakistan met een volatiel en onpredictable security context. Er is een prinsen van veel volnerable, marginaliseerd en gesproken populaties met de centraliseerde ministerie van Health. Ze hebben een hoge morbiditeit en mortaaliteit in de ruralen, zonder de vrouwen, mensen en jonge kinderen. MSF OCA werkt in de kapitale stad van Balochistan, Quetta. We rinden twee uitpatiënte kliniek voor kutenis- en lachmaniasis in Kuslak en één in Marjabat. Deze kliniek serveert een verschillende targetpopulatie. Kuslak serveert de NOMADS en Afgan-communities die geen accesse heeft om health care te helpen, maar Marjabat serveert de verantwoordigde populatie van de Hazaras-community, die de mobiliteit, limiteren en de persicuutie van de landen, omdat ze het sectarie zijn. Kutenis- en lachmaniasis is een parasitieke lachmaniasis, die is vergeten door een zoonotische kast, die een lachmaniasis is, of een ondromameteren kast, die een lachmaniasis is. Het is een bektor, de plevotomus, de zandvlees en de animalreservoirs. De lachmaniasis kan bebelokt worden, op de lach en de extreemdies, en kan vergeten door extreemdieke lachmaniasis en deformities, die kan vergeten door behalve en psychologische ondromes. Kutenis- en lachmaniasis is een makkelijk vergeten disease. Het is een self-limiting, en alleen 2% van de ontwikkelde lachmaniasis is vergeten. De meest ondromende lachmaniasis zijn de kinderen, omdat ze onder de lachmaniasis vergeten zijn. We doen niet alle patiënten met lachmaniasis, we hebben alleen lachmaniasis in de lachmaniasis, en ze zijn over de lachmaniasis vergeten, en ze groeien groter, en de lachmaniasis is meer dan vijf tot zes maanden. De lachmaniasis analisert de routinely collectieve data, opgevoerd door de MSF Ethics Review Committee. De laboratorische diagnosis is gemaakt van microscopic smear of skin lesions, aspiratie, en vergeten met glucon-time injectie, die een ondromende lachmaniasis is gegeven, both intralationally or intramascularily, depending on the location and quantity of the lesions. MSF OCA recently added a new Seattle Clinic last June 2014 in Marjabat, de Menaceer-Bouteau Hospital. The data from 2013 to 2014 showed a markedly increase in the number of patients seen from 125 to 1,492 patients. The number of confirmed diagnosis is based on the laboratory, is also increased from 36.9% to 42.6%. The percentage of the confirmed diagnosis is a bit low, that is because cutaneous lachmaniasis is mostly a clinical diagnosis. That is why also in 2014 we also started 671 patients on treatment. The cure rate is 97% with very little default rate of under 3% and with very low relapse rate of 4.2%. All relapse cases were restarted on treatment and discharged as cured. For relapse cases we either extend the number of treatment or change the manner of injection. The type of lesions the clinic sees are usually ulcerative and nodular lesions with a lot of multiple popular lesions. A lot of the lesions have a duration of more than six months. The chances are this patient had already sick treatment in the facility and only was given partial treatment. Or so some they don't know where to seek proper treatment before. Now we are noticing that a lot of people come in with a lesion of less than three months. The reason for this is about the CL treatment that the center is now being giving and it is for free. We would rather prefer that the patient come to us earlier so that the improvement will be better. So what is MSL treatment in all this? The drug importation in Pakistan is a long administrative process with a six months lead time and a lot of further delays due to custom regulation, importation requirements and frequent personal changes. MSF is the only organization that is giving free CL treatment in all over the country. En because of the population that we targeted, access also by the patient not limited to the target population is also limited due to the security constraint which can include sectarian violence. What is the Ministry of Health challenges? Currently there is no cutaneous lesion in IC surveillance reporting system in place. The World Health Organization disease early warning system must stop due to funding constraint. There is low priority station for the disease because of the low mortality rate. The low available in the market is expensive. In purchase in the black market, their quality assurance is also questionable. There are still a lot of places in the country with low awareness of the disease. So what is MSF doing right now? Currently we're still continuing to analyze the program data and sharing our achievement, the Ministry of Health. The cutaneous lesion in IC's clinic is still integrated in the outpatient department as what we have been doing in Benazir Bouta Hospital. We are working closely with the Ministry of Health in Benazir Bouta Hospital in Marjaba to showcase CL treatment in the region. We have a very good collaboration with the Ministry of Health. The available treatment is still effective in the region. Hence we will push to lobby to increase the priority and budget allocations for the disease en we will improve public awareness of the cutaneous lesion in the community. In achieving this study, we would like to extend our acknowledgement to Benazir Bouta Hospital, their medical superintendent and staff, the district health office assistant, the MSF staff in Quetta, fortairlessly working in the clinic and cooperating closely with the government. I will finish with this pictures which depicts some of the happy faces of the people we were able to treat in the outpatient department. We are serving in Quetta. The picture on the right is of the tree lady which fell over her body and with a parasite test of more than 1,000. At first, she doesn't want to be seen because of the lesions on her body. A lot of people doesn't want to talk to her or even touch her because they are scared that they will get what she has. She was misdiagnosed to have leprosy even. But after treatment in our clinic, she has acquired her confidence back and is now working and smiling to everyone. We have brought back dignity to life on this patient. Thank you and Mabuhay. Thank you, Chen. I would say that we, being the first session here, are grateful to you for having kept to the time because that's the most critical thing when you are online and having a direct cast. We can take one or two clarifications at the outset en then of course the discussions will happen at the end of the session. So if there are any points, anyone wants to clarify at this point of time. Yes, we have some caller from outside. Yes, could I ask Chen to respond please? So PA-KDL is more of a post-ketanus one and it's caused by legemaniasis del navani. So for ketanus legemaniasis, the reason why it affects only children is because of their immunity status. The immune system is not yet well developed so they are more prone to the disease. Okay, are there any other clarification points, I would say, rather than discussion points? Yes, Dr. Deewan. You said that the patient is the only one which is providing free treatment for this facility. That means the Pakistan's or the hospitals do not provide. That's one question and second, what is the usual cost? So thank you for the question. Currently in the whole of Pakistan there is no CL treatment program by the government. Before NGO that has been giving free treatment but they already moved out of the country. So currently in the whole of Pakistan it's only MSF that is giving free treatment for ketanus legemaniasis. And for the second question. The ketanus legemaniasis treatment in Pakistan costs around 70 US dollars per injection. And for a CL treatment for intralitional you have to go to the clinic at least a minimum of eight. And for intramuscular, go to the clinic at least a minimum of 20 sessions. So that means for a very minimal wage person they wouldn't be able to afford such a lucrative treatment for the disease. So that is why a lot of the people in the country is not being given treatment. Or is not being treated for the disease. All right, that's the last one and then we move on, right? All right, thanks Chen for a nice talk. I was just wondering what is an alternative prosodium antimonyglucid which you would use. There are many patients who would not like to take the injections or they may not be in a position to take the injection. Is there an alternative that you have used in these CL patients in Balochistan? Okay, thank you for that question. So as of now, there's still no other alternative for gluconeem injection for treatment of ketanus legemaniasis. There has been proposal on using some other type of treatment modalities. This is also something that we are looking in now. But as of the moment, gluconeem injection is the only one that is available. Of course, as you said, there are also a lot of sample for age for people with certain kinds of diseases, but since mostly we are treating a lot of children, so they're more susceptible to the treatment. Okay, thank you. So if there are any further, I would say discussion points, we'll take it at the end of the session. You'll have an opportunity once again. I'd now like to invite our second speaker, Janet Ausle. She is a field epidemiologist working for the MSF in Myanmar, and she took her master's in public health at Emmerich University. Her main focus is on infectious disease epidemiology. And in fact, I worked with MSF, she's also been with the CDC for quite some time, and she's worked in different countries, primarily in the African subcontinent and in all parts of the world. And the area which she's going to talk on, the thing which has an area of neglect, this is the immunocompromised individuals, adolescents, having HIV positive. So there is an increased risk of treatment failure in HIV infected adolescent cohort in southern Myanmar. So go to you. Hello everyone, or can you hear me? Minglaaba, as we would say in Myanmar, as we said, I want to talk to you about adolescents today, and I'm guessing that of what country you're coming from or your generation, you remember adolescents as a somewhat turbulent time. Adolescents can be a bit tough. It's a time when every system of the body is going through dramatic developments, especially adolescent brains. And for adolescents who are living with illness, particularly those who are HIV infected, it can be a really difficult time and those normal hormonal and physical changes that are part of the teenage years can seem really overwhelming and can manifest in unpredictable ways and be different. So adolescents are kind of a special cohort generally, but I'd like to speak to you specifically today about a cohort of adolescents in Myanmar, where MSF has been active in HIV and TB care, MSF Switzerland, I should say, for over a decade. We're in the far south of the country in that little tale of Myanmar over by Thailand. It's a region that's very coastal, interesting subpopulations that depend on fishing industries. In Myanmar, HIV is not a generalized epidemic. It is more fueled by high-risk populations, so men who have sex with men, commercial sex workers, drug users, and in this region actually, fishermen are also considered high-risk. The analysis I'll talk to you about today is part of an initiative that the MSF Switzerland mission has started in the last few years, really integrating operational research and using and capitalizing on the medical data that we have after almost a decade of working in the region. And that's our sort of clever name for our operational research unit. I'd like to know more about that. We have a poster in the hall and online, a little shameless self-promotion. But what we were trying to do exactly was take some of our medical data that we had and really look at the 10- to 19-year-old cohort among those. We know that our doctors and our nurses and our counselors had certain suspicions about things that were happening, but we had really never, before this point, systematically disaggregated that data to look at what was happening. And so what we did was a cross-sectional analysis of those adolescents, routinely collected data that was available to us easily in the Fuchsia database. And for those of you who aren't the follow-up and care for HIV and AIDS database developed by Episant, we found that we had 248 patients between the ages of 10 and 19 who'd ever been admitted in the 10 years of the clinic. Now, not all of these patients will still be on treatment. Some of them will have died. Some of them perhaps never started these reasons. Others may have started and were lost to follow-up. And frankly, others may have started treatment and grew up with us at the MSF Clinic and are now no longer adolescents. But we wanted to describe this cohort and again, really dig a little deeper into what was happening, but do it in a scientific and a systematic way. And that's a picture of our clinic in the southern Myanmar. We had a few limitations as all studies and all data sets have. We are dependent on that Fuchsia data, so it's really medicalized data. So things like treatment adherence, a lot of information about vex of the adolescents, psychosocial information or information about their environments, which is really important to understanding their experience. We don't have and we're actually trying to improve upon that in the future, since our counselors do have a lot of that information. We also know that a 10-year program is a really long. Perhaps the adolescents we were seeing in the project changed because of things like politics or even economics or frankly even evolving HIV carats. And it could have had subtle effects on our data. And then finally, a real limitation that we felt was the fact that we can't currently decide between those adolescents who had a perinatal infection or acquired their disease from their mother and those who acquired their disease sexually or through transfusion. And we think that these groups might be quite different. And so again, in trying to better information and analyze for that. So our results, the interesting part. When we started this cohort, what did we find out? Well, first I can say interesting because the adolescents seem like a pretty good group of patients, at least when you compared them to adults. We found that they were less sick at presentation to the clinic, at least if you looked at their CD4 counts, which is a measure obviously of immune health. They remained on treatment for longer than adults and they responded better immunologically over time. But we weren't necessarily really surprised by this. We could at least explain why this might be. A higher CD4 count at presentation might be because we knew their average age at diagnosis was about seven years. And it's possible that much sicker children had already died at that point, leaving the sample of people we were looking at somewhat biased. Or frankly, perhaps just because they have caregivers, they were accessing treatment sooner. Adolescents stayed on ART longer than adults on average. But again, they have caregivers and that's really important in this situation. They were less lost to follow up than adults. But many or most of these adolescents don't necessarily have jobs like adults do. And in a region that is really affected by economic migration, especially to the fishing communities, that matters. They did better over time compared to adults immunologically, but they also have younger immune systems so perhaps could bounce back a little easier. It was interesting to describe the cohort this way and use the adult cohort as a comparison group. But we weren't necessarily shocked by what we were finding. When things got really interesting then was when we dug a little bit deeper and started to look at potential treatment failure. And this is where we saw that the adolescent cohort about a quarter of them were on second line treatments, meaning that they could not take the drugs of first choice that are sometimes easier to take and certainly cheaper because of various reasons. We know that adolescents sometimes have reasons besides treatment failure to take second line treatment regimens, perhaps a treatment when they were really young and develop toxicities or side effects over time. But then when we looked at another indicator of treatment failure which was viral load testing, we saw that adolescents were over three and a half times as likely as adults to have a detectable viral test, meaning they had enough virus in their blood that the test could see it and therefore we know that the treatment is not suppressing their virus, confirming that they're failing their treatment. So again it was a consistent pattern of treatment failure and this is kind of contradictory. They seem like great patients when you look at them as a cohort, but then when we look at a really important indicator which is how they respond to treatment, they were failing. So what does this mean for MSF in Myanmar? We feel like we have a lot of questions still to answer. We suspect that there is large scale adherence problems for our adolescents that despite being good patients and coming to the clinic, that they're not taking their medicines and we don't know if this is because support networks, we know many are orphaned though we don't know the exact proportion. We don't know if this is because there's some sort of shame or stigma surrounding take their medicines. Frankly, as teenagers we don't know if this is a manifestation of depression and some sort of self-harm by not taking their treatment and or we don't know if none of these are true and if we're wrong and these adolescents are very adherent, really we need to look deeper and see what's happening. So what we're going to do is take this cross sectional analysis we did and we've written a research in the next year, we hope because we're currently under ethical review, we want to prospective study that will have both a clinical and quantitative component and a qualitative component that will look at psychosocial factors and the adolescents environment to really better understand the HIV experience for adolescents in Myanmar. There's been a lot of research in the last decade on HIV in adolescents and even in Southeast Asia there has been but Myanmar is really evolving right now and adolescents haven't really been a part of that conversation. So we think that MSF could really use our voice to add to that conversation. And that's a picture of one of our peer support groups that the MSF clinic runs. And so just to sum up and I hope we over time but if you take away three messages from this presentation today, I'd like them to be this. First of all, adolescents are as a colleague of mine at the MSF clinics, beautifully complex, meaning that they're a really unique group. They're not a pediatric cohort and they're not adults and we need to respond to them in unique ways because they have special needs. And then to use a term, what gets measured gets done. So a good first step is looking at their data uniquely not just aggregating them in with other cohorts but really taking that data stratifying by age and seeing what's happening. And if you haven't done that, I guess we at the MSF Myanmar mission really encourage you to because you might be surprised as we were. And then finally, simple solutions can be powerful. We've really redoubled our efforts with this group of adolescents in Southern Myanmar as a result of this cross sectional analysis doing more peer support and really letting the apps what they need and have some agency to use that sort of newfound autonomy and independence to tell us what they need and we don't have data yet but we've had some really feedback from that. So a final thank you to the Myanmar team who I kind of don't know if they can listen to this presentation because of very slow internet but they inform every word of this in their fantastic team. So thank you for listening. Thank you, Janet. I would say that that was an excellent presentation and it has really stimulated the thinking. There's a paradoxical situation which she's pointed out, a group of children which one would see because their disease is less, their compliance is better, even logical response is better but still their failure rates are high. It's really very paradoxical and we need to really work more on this and I would say that you also spared us a minute or two for taking some clarifications. Thank you for that also. So we'll just have one clarification from anyone in the audience and then we move on to the next speaker. Yes, sir. Does Myanmar has a Sentinel surveillance mechanism in place to know the estimates of prevalence? If at all, what is the prevalence now? Latest prevalence, segregated or not? Got it, second one. Sure, if I understand your question correctly, there is a national AIDS program and they're really doing a lot, especially since recent political openings and there is, there's good monitoring and evaluation surveillance of HIV in the country. But what we have found in our project is that there's certain subpopulations that we feel could get more attention and that's why I think some of our analyses, the adolescence analyses and certainly the high-risk groups that we've displayed some information about on a poster could use a bit more of a spotlight, I can say. And so that's why we're talking about them today. In Myanmar, the prevalence in the general population is 0.5% but in high-risk groups it can be up to 17% in drug users. Ja, I believe it's 6.8 in sex workers. I actually, I encourage you to go out in the hall because in the high-risk groups. Yeah, in high-risk groups it's quite high, yeah. But only 0.5% in the general population. I don't have a prevalence estimate for just adolescents but I think that's kind of what we're trying to encourage is that the... Who's very active in HIV management in Myanmar and the National AIDS Program and all of the actors, including MSF, who engage with these patients that we start to look at them a little more closely. All right, thank you, Janet. I think we'll move on to the next. And I'll request if there are any other discussion points for Janet, we'll just park it till the end of the session and we'll again have an opportunity to discuss with you, ma'am. We'll take your support. And now I'd like to invite our third speaker and Sri Priya Pandurangan. She's working with the International Union against lung diseases in the Southeast Asia Regional Office here in Delhi. And she's done her bachelor's in statistics and master's in econometrics. She's more than a decade of experience in planning, monitoring and evaluation. And she has been part of the project which the union is running, dealing again with a marginalized group of population working towards universal access and that's called the Akshaya project. And I'll request her to give her presentation on novel interventions to enhance access to TV services for the vulnerable and marginalized populations. Thank you, Dr. Sarain, for the interaction. Good morning, everyone. I would like to thank you for giving me this opportunity to present one of the largest advocacy, communication, social mobilisation project which has been implemented by the union to enhance the access to TV services for vulnerable and marginalized populations. So why does it need for this project? The universal access to TV services is critical for timely diagnosis and treatment. However, low awareness about TV and poor health services results in delayed diagnosis with resultant morbidity and mortality. So this presentation will focus on interventions which has led to enhance the access to TV services. In line with the end TV strategy, the goal of the project is to improve access to quality TV care and control services through enhanced civil society initiative. Our main objective is to reach the unreached, build the capacity of the community, engage care and control services app. So I'm not going to talk about the project, has actually many activities. So I'll just brief you about the activities and then I'll move on to my presentation on the innovative activities app. So the project first, the project has identified, mapped and the vulnerable and marginalised population. So this is to achieve the goal of providing universal access to TV care app. And the project is also involved with the community, built to the capacity of the community and then we have built the existing village health communities app. To discuss about and include TV in the village health agenda. And thereby in the process we have also involved the health care providers, the rural health care providers, the non-qualified health care providers to talk about the TV symptoms in the community, identifying them, link them to TV services app. So adopting the strategy advocacy, communication, social mobilisation, the project has made advocacy efforts at all levels, sensitise de different stakeholders and ensure their commitment to TV control services app. So all this has led to increased TV case notification and decrease in the last two follow up cases and improved treatment success rates, thereby achieving the goal of universal access to TV quality TV care services app. So the way you can see the coverage of the project, so the project being is implemented in 300 districts across 21 states of India. This has been implemented by nine sub-recipient partners. So as I have told, this is the union implementing the project with nine sub-recipient partners, involving 20,000 community volunteers and 1,200 non-governmental organisation app. So it has reached nearly 16 million population in 300 districts. So now I'll move on to key innovative strategies, which the project has adapted. The first one is about Akshya Samvada. This is an intensive outreach activity, whereby we have trained the community volunteers to conduct visits, creating awareness about TV and identify those with the symptoms and the symptoms suggestive of TV app. So these persons, once we have identified them, we have given the choice of referrals to the nearby diagnostics facilities. And if they are unable to go to the diagnostics services, we have actually given them the option of sputum collection and transportation. So we have transported the diagnostics services and then we have actually gone back to the patients who are positive en then we ensured them to put on treatment. So nearly we have, we are reaching 1000 households every month in each district. So the results of this intervention, 5.1 million households were reached during this period, April 2013 to December 2014 and out of which we have identified nearly 4 lakh TV symptomatics of them 60 examined and 7% were diagnosed as TB patients and we were able to put 97% on treatment. The next innovative intervention I'm going to talk about is the rural health care providers. The unqualified rural health care providers who are the first point of the majority of rural and urban puwara are trained to identify those with symptoms of TB and refer them immediately for sputum examination to the nearest public health facility. They have also been trained to provide directly observed treatment short course for which they get incentives from the RNTCP programmer. So the results of this training, we have nearly trained 19,000 RSPs and out of them 13% are engaged with the project. We mean by engagement, they refer at least 3 patients in a quarter and then do a sputum collection and transportation of at least 1 patient in a month and provide dots for at least 1 patient. So this is called engagement in the project. As of engagement, the RSPs were able to identify nearly 50,000 TB symptomatics, 70% were examined at the DMCs and 12% were diagnosed as positive and 98% of them were put on treatment. So this advocacy social mobilization project has given an yielding of additional TB. So we have involved the community, we have tapped the local resources to enhance the access to TB services. Thereby we have also rural health care providers to provide TB services to the community. So though we are implementing in 300 districts, so in the next NFM Global Fund project, this is going to be replicated again in India in other districts as well. So thank you for this opportunity. So it's really beautiful. I mean, fortunate that my presenters are all time in fact, they are giving us some time for seeking clarifications and discussions. Thank you very much. A very interesting talk and universal access. Yes, all of us did the issue as a concept. We must reach and treat every TB patient till the patient gets cured. That's the part of the end TB strategy. Yes, sir, kindly introduce yourself before asking the question. My name is N.B. Nair. I edit a science journal called Indian Science Journal. Just want to know what is the burden of tuberculosis in India in comparison to the world tuberculosis burden. Second is what is the linkage of air pollution in India, mostly in Delhi and other city pollution is higher than what is normally should be. Linkage between air pollution and TB. Sripriya, would you like to take that or would you want me to respond? Well, I would encourage at this particular session clarifications from our presenter. But just to answer your question, yes, the burden of the disease in India is roughly about 2.7 million TB patients to be precise, which are prevalent and about 2 million are added every year. So that's the extent of the burden en globally, we have about, say, 25% of the incident cases. That's the comparison in the world. In relation to air pollution, yes, air pollution does have, to some extent, on that it has increased chances of an individual getting the disease. As you know, even though most of us present in this hall today would be infected, but there only a 10% lifetime risk until and unless we get immunocompromised. And airway pollution enhances this particular risk of getting, you know, that is to do mainly with the immunological factors which operate at the macrophage level in the lungs, because whenever there is air pollution, the ability of the lung macrophages to fight against infections reduces. That's the reason why you see we who land up with air pollution, also land up with other problems, other infections, other diseases, not just limited to TB, but definitely it'll also increase tuberculosis. Yes, sir, please introduce yourself. Thank you, Sripri, a very nice presentation. I just wanted to know, because this is a point of view of sustainability, what was the issue of a patient when you made the strategy of active case detection en training of these providers? What was the extra cost? What was the cost per detection? Cost per save, actually the project is being implemented by NGOs, sir. So the NGOs were paid for each household. We are paying a 10 rupee to go and reach about the messages to tuberculosis, sir. And for the rural healthcare providers, we are giving a training at the district level. This cost around, for the recipes, we pay them 6,000 per training. So, yes, I think that's a very important comeback to that, sir, again, because sustainability of such interventions should always be kept in mind. You see, we can't have this operating at a project level for decades and decades, because, you know, it's a one-time intervention is maybe simpler, but if we have to bring about an impact we'll definitely have to have it more often, yes, sir. And that's the last clarification from you and we move on to our last speaker. Thank you very much. My name is Suman Rajal, I'm from DNDI. I just want to ask, you had 62% of those who were tested. What happened to the others who were suspected, but who did not get tested? I mean, does it, there is a system that you, that to capture those patients or to look into that? Yeah, actually the project where, you know, we are doing a follow-up of actually who, and we go and do a follow-up and do collections, put them collection. And some of the, you know, we have seen many studies also in our project also, we see some of them, they are not willing to go to the government facilities. So they either land up in private health facilities or, you know, to any other quacks, who they feel that they are comfortable in revealing their diseases. All right, so with this, thank you so much, Sripriya. And we move on to our final batsman for the day. We have George Varghis here, who's from the Christian Medical Corps. And his interest in infectious diseases is well known. He's studied it, not only in country, he's also been to London School of Hygienentropical Medicine, wherein he's done his postdoctoral fellowship in infectious diseases. And Varghis has been doing a lot of work in many infectious diseases, but today he will be presenting mainly on typhus, scrub typhus in India, emerging insights and future challenges and opportunities. So Varghis, let's have what you have to say. Thank you, Dr. Saran, for those kind words. Good morning, ladies and gentlemen. Typhus claimed millions during the First and Second World War. The story in India is no different. It is very clearly documented. The typhus and the other rickettsial infections were major threats to the British army during those times. However, for several decades, it became a rarity. It was unknown disease. This was not even kept in the differential diagnosis of someone who comes with acute febrile illnesses for several years. We started noticing a group of patients, this is in the late 1990s, group of patients who come with acute febrile illnesses with multiple organ involvement, most of them with hepatitis, some of them with frank jaundice, with pneumonitis, which may even progress to ARDS, aseptic meningitis, and where you look for common causes like falciparamalaria, leptospirosis, et cetera, were all negative. Looking harder for an answer in these patients, we found that there were small S-cars considering the possibility of rickettsial infections. We, this is the time when we looked at it prospectively, we looked at 2001, 2002 period, we looked at somethings coming with these multiple organ involvement with alillness, with them having LFT abnormality. We clearly documented that this is due to scrub typhus, four major serotypes where the serology was positive for IgM scrub, where all the other workup was negative. This was published in Annals of New York Academy of Sciences in 2003. In the smaller group of cohort, the case fatality was around 11%. As you know, this is a mite-borne zonotic bacterial disease caused by Orientia sudsuga musi. The bacteria was earlier called as rickettsia sudsuga musi, which is transmitted by the chiggers, which is the laval trombicloid mite, leptotrombidium most commonly. And this is usually maintained in nature because of the reservoirs, the chiggers and the rats. There is trans ovarial transmission and therefore it's indefinitely kept in nature. And the humans are incidentally infected. So we started working on, whenever at that time, nowhere in the country was a diagnostic test to diagnose this particular infection. So we looked at what are the ways, when would you suspect scrub typhus, the pathognomonic eschar was found only in 10 or 15% of patients at that time. Primarily because it was very low, unless you search carefully in the axilla, in the groin, unless you search carefully, you wouldn't find the eschar. Even if you search carefully in 50% of them, you may not find the eschar. It may have been very poor, fallen off. I have also recognized that transaminase elevation with thrombocytopenia and leukocytosis could be indicators of multi-organ involvement in acute febrile illnesses with the appropriate epidemiology, with reasonable predictive value in these group of patients. But as you know, specific indicators. Now the issue is even today, in 10 of 15 years down the line, it's grossly underrecognized. The burden and the pattern of scrub typhus have not been documented in India. Therefore, this particular study was to describe the public health bread and severity of this, which can serve as the basis for formulating policy in our country. So what we did is to assess the disease burden, we reviewed the medical literature, and also the government of India's integrated disease surveillance programs and Rickettsil infection database at CMC Veloor. We also did a cross-sectional population-based survey in Veloor district to estimate the community zero prevalence using IgM and IgG serologies. Now, there was also a case control study done to assess the risk factors for acquiring the disease in the community. And the severity of disease and current management options were assessed among patients admitted to CMC. Now, when you really look at during this five-year period, there were about 6,649 cases of scrub typhus documented from 24 different states. This is the last five years or so. And five states, the burden has been quite high. But Tamil Nadu, of course, Veloor has been instrumental in part of recognizing this reemergence. And all these five states, more than 300 cases were documented during this period. Now, if you look at the entire burden which is being reported, this is just the tip of the iceberg. I'll give you a comparison. When we looked at our database during this period, we confirmed scrub typhus of over 3,000 patients and what has been published in medical literature is only about 450 cases or so. So even that, you must remember that CMC is a tertiary care center and therefore more severe cases are only admitted into the hospital. So what you're really seeing is just a very tip of the iceberg. Now, when we did the community prevalence study, this was a, we have done a good clustered sample design, taking about 721 participants from Veloor district. About 61% from rural and 30% from the region. Majority were female, 62 and 37.4% were male and the mean age was 50.6 years. As you recognize, the mean age was higher because all these surveys were done during the daytime and most of the younger adults would have been out for work and there was a bit of bias in that. However, it still conveys the message very clearly. About 30% have had evidence of infection in the past. IGG is a good marker of the past infection in these, for this infection. When we looked at the case control study to see the risk requiring the disease, we took 128 confirmed cases and almost similar numbers. 132 agent sex matched controls from the same village. We tried to look at various factors, be a risk factor for acquiring the disease. We being agricultural laborers, there's an increase risk bushes or shrubs around home. So basically, either as part of occupation or as part of daily life, if they are around the same age, if they are around the bushes or the scrub, they are at higher risk of developing the disease. And of course, clothing again makes a difference. You can see the odds ratio. These are some of the ones which clearly stood out saying, this is where they are getting exposed and probably getting the disease from. And if you look at the seasonality, the cooler months of the year from September to January is when the maximum number of cases are occurring. So this is when the mites breed and the lava comes out and the disease is transmitted. This is over the years we have seen the same pattern of seasonality as well. When we looked at the severity and complications about one third of them will develop or developed a multi-organ dysfunction, almost the same number with adult respiratory distress syndrome. Many of them going on to require ventilatory support, but it's a dying disease to treat. If you recognize early and treat them, they come out beautifully unlike most of the other ARDS. So very gratifying disease to treat. The case fatality in the Sica group was still continued to be about 9%. Doxycycline is the choice, but IV doxycycline was not available in our country until now, which was a major problem. And the alternative was azithromycin IV. So what we used to do was give IV azithromycin along with oral doxycycline. Somebody who's on ventilator, the absorption, there is a problem there. The option was IV azithromycin, which probably may not have been the best. We don't know, but it was quite a reasonable therapy. So to conclude, scruptyphus is a significant public health threat in India, yet it is underrecognized and grossly underdiagnosed. Doxycycline is the drug of choice. Azithromycin is a good alternative. Unavailability of IV doxycycline to treat severe infection necessitates urgent advocacy. Dat is waar MSF comes in. When we discussed several months ago, we have been advocating this for quite some time. MSF is more than happy to help out, and that is when the whole initiative started. But I'm sure you will be happy to note that now the IV doxycycline, we've just got the first talk in the country. Maybe the MSF's willingness itself made a difference to help out. This is one of the major reason why we thought MSF, we should work with MSF in advocacy to get this IV doxycycline available in the country. It's a very cheap drug. Less is a day for the oral doxycycline for the entire course. But so most of the pharmaceutical industry, because the margin was very low, was not willing, but we are happy that it's available. Information and advocacy are still needed for investing in surveillance, prevention and detection, as well as appropriate management strategies. Thank you very much for your patient listening and also this opportunity to MSF. Thank you, George. As I would say that he's also followed the trend, we have time with us. En now also time for the discussions on any of the patients also. In fact, he's talked of a disease, which again is, as he rightly said, underdiagnosed, but a disease which has a definitive treatment, a disease where we should have a high index of suspicion. And a disease if left untreated could be very fatal. I would have this opportunity to thank all the four speakers on this panel. They have done an excellent job, both to their topic as well as to the time. And they have given us opportunity to interact, discuss and learn more about these neglected diseases, about these neglected populations. Thank you so much. And I'd also like to take this opportunity to personally thank the MSF India for giving me this chance to be with all of you and to chair this most important session. Thank you so much.