INTERVENTION

These preliminary results of the review stated above initiated the launching of a “National Program for the Prevention and Control of Hepatitis” in August 2005. The program was approved at the highest forum of country to have following interventions / components for implementation;

Hepatitis B Vaccination for High Risk Groups	Safety of blood and blood products against hepatitis
Safety of injection delivery, invasive medical devises & proper hospital waste management	Capacity building of health care providers for the prevention and control of hepatitis
Behavior Change Communication	Surveillance and Diagnostic Lab services for Viral Hepatitis and Epidemic Response
Establishment of Water Purification Plants	Operational Research Including M&E
Treatment Interventions at teaching and district headquarter hospitals	Formation of Program Implementation Units at Federal and provincial level with aims of technical assistance at all tiers of health sector.

 

Consequent upon launching of the program at national level, a provincial implementation unit was set up in five months’ time.

The program’s design in field had an overall emphasis on;

Passive laboratory (sentinel) based surveillance system of chronic Hepatitis B and C.

Vaccination of Hepatitis B to high-risk groups

Treatment Interventions at teaching and district headquarter hospitals

Installation of autoclaves, water purification plants and hospital waste incinerators.

At district level the portal of entry was the District Headquarter Hospital (DHQ) declared as sentinel site having all the above facilities under one roof.

 

COMPONENT WISE PERFORMANCE OF PROGRAM IN SINDH

The component wise performance of the Program is as follows;

HEPATITIS B VACCINATION:

PM’s Program on Hepatitis envisaged the interruption of Hepatitis B virus transmission by enhanced vaccination in the high-risk groups. The high-risk groups identified in the project PC-1 are as under;

High-Risk Groups identified in the Program

  

COMPARATIVE STATEMENT OF HEPATITIS B VACCINATION IN SINDH

The distribution, consumption and vaccination of high-risk groups against Hepatitis B during 2005-2008 is as under:

Hepatitis B Vaccine Coverage of Various High-Risk Groups from 2006-2008

District	Health Care Workers	Prison Inmates	Hepatitis C Pts.	Hemophiliacs / Thallasemics / Dialysis Pts.	Injection Drug Users	Others	Total Vaccinated	Vaccine Vials Supplied
Larkana	1224	1281	684	0	0	7557	10746	32238
Nawabshah	537	208	500	118	0	1050	2413	7239
Shikarpur	150	758	300	56	0	1300	2564	7692
Jacobabad	222	460	200	0	0	533	1415	4245
Mirpurkhas	500	292	300	10	0	300	1402	4206
Umerkot	366	0	150	0	0	8750	9266	27798
Thatta	550	0	161	0	0	0	711	7500
Badin	110	315	250	237	0	2088	3000	9000
Kamber	1836	35	0	0	0	6119	7990	23970
Mithi	80	0	340	0	0	150	570	1710
Hyderabad	96	3439	0	251	0	291	4077	12231
Jamshoro	150	0	810	5	0	1140	2105	6315
Karachi	874	9218	650	1331	0	0	12073	36219
Sanghar	73	359	75	0	0	2050	2557	7671
N.feroze	0	0	110	0	0	1000	1110	3330
Khairpur	10	904	259	0	0	150	1323	5969
Ghotki	25	0	50	0	0	120	1110	3330
Sukkur	10	2542	250	250	0	100	1323	3969
Tando Allahyar	100	0	294	0	0	500	195	585
T.M.Khan	275	0	0	0	0	0	3152	9456
Dadu	91	512	350	0	0	1200	2153	6459
TOTAL	7279	20323	5733	2258	0	34398	69932	209796

  

VACCINATION OF PRIMARY SCHOOL GOING CHILDREN:

In addition to the numbers vaccinated above; some special initiatives were undertaken to vaccinate the primary school going children against Hepatitis B. The activity was implemented by the respective District Governments, vaccine and syringes were being provided by the Expanded Program on Immunization. Prime Minister’s Program for Prevention and Control of Hepatitis Sindh took a natural role of leading the initiative and coordinating the activity. The details of the drive are as under:

  Hepatitis B Vaccine Coverage of Primary School Going Children

 

 HEPATITIS DELTA AT KAMBER AND LARKANA:

Due to the ongoing spread of Hepatitis Delta at district Kamber and Larkana, a special initiative of vaccinating the general population near to their doorsteps was launched. Ring Vaccination methodology was adopted and from September 2007 onwards in which the adult Hepatitis B Vaccine is made available at all EPI centers in the district and vaccine was administered to general population. The impact of initiative was never fully evaluated. However it is assumed that vaccination of large number of people may have slowed down the virus transmission if not interrupted it. 

DISTRIBUTION OF VACCINE IN FY 2009-2010

Sindh PIU received 2^nd consignment of its share in vaccine in July 2009. It is still in process of being distributed and reports are being collected. The distribution details of the vaccine received during financial year 2009-2010 is as under:

 Distribution of Hepatitis B Vaccine in 2009-10

  SAFETY OF INJECTIONS AND MEDICAL DEVICES

The category wise targets and achievements are as follows:

Targets and Achievements in Safety of Injections and Medical Devices

Category	Targets	Recipient Hospital DHQ Hospital	Achievements
Safe Injection Delivery	Provision of needle cutters and injections to sentinel sites as per demand	All sentinel sites in Sindh	40 needle cutters and 200000 syringes distributed to sentinel sites.
Autoclaves	08 sentinel sites to be equipped with autoclaves	Badin, Dadu, Tharparker, PMC Nawabshah, Khairpur, GMCH Sukkur, THQH Kotri, Tando Allahyar	08 are installed and functional

 

During project life Sindh PIU provided 2.0 Million Auto Disable Syringes to various hospitals for non-immunization use. These were distributed to various sentinel sites as per following demand

Table 17: Supply details of Auto-Disable Syringes to various institutes in province

 

 

 HOSPITAL WASTE MANAGEMENT SYSTEM

This component may be called as the Achilles’ heel of the program. The program envisaged installing a 50 Liters / hour capacity, double burner incinerator with scrubber. The technical specifications of the equipment are given as annexure. The equipment was planned to be installed all District Headquarter Hospitals and those teaching hospitals, where there is no incinerator. These centers were to be linked with clusters of geographically surrounding health facilities where infectious hospital waste is generated. The hospital waste vehicles would transport the waste from clustering hospitals to the main site of burning. To aid in the incineration consumable items like (1) Long Rubber Boots (2) Yellow Polythene Bags (3) Wheel Barrows (4) Three Colored Baskets were supplied. Government of Sindh nominated (08) hospitals as recipients of system at the outset. The details are as under;

 Status of Incinerators and supplies made to hospitals

 

ESTABLISHMENT OF WATER PURIFICATION PLANT

09 water purification plants are established at the DHQ level hospitals as under:

                                    Table 19: List of Hospitals where plants are installed

 

ADVOCACY AND SOCIAL MOBILIZATION

Advocacy and social mobilization was a neglected component in the project life, it would have been the otherwise. The lacunas were addressed as a stronger provincial  project in 2009.

Capacity Building of Health Care Providers:

The training guidelines of the program were finalized in January 2009. A training of provincial master trainers was conducted at Islamabad where 10 master trainers from the province were trained. The first formal training of the health care providers in Sindh province was undertaken in May 2009 by the Chief Minister’s Initiative for Hepatitis Free Sindh. In October 2009 World Health Organization supported the training of 60 Medical Officers and Senior Medical Officers from 10 districts of North Sindh at Sukkur. 

SURVEILLANCE AND LABORATORY DIAGNOSTIC SERVICES:

By supplying the laboratory equipments for Viral Hepatitis diagnostics, program has not only enhanced the district headquarter hospitals’ capacity but also upgraded these facilities for the registration with Sindh Blood Transfusion Authority. One of the major impediments in the registration was availability of ELISA Micro plate Reader. A standard set of equipments provided by the program in this component is given in table below;

                 Table 21: Standard Set of equipments supplied to sentinel sites in Sindh

 

Distribution Details of Hepatitis ELISA Kits in 2008-2009

Name of Recipient Institute	Distributed
EDO(Health) Kamber	10
Civil Hospital Karachi	65
Civil Hospital Dadu	15
Civil Hospital Thatta	10
Civil Hospital Tando Allahyar	10
Taluka Hospital Kotri	20
Civil Hospital Mirpurkhas	10
Civil Hospital Mithi	15
Civil Hospital Sanghar	10
DHQH Tando Mohd. Khan	10
DHQ Hospital Umerkot	10
SGH Shah Bhitai Hyderabad	05
SGH Qasimabad Hyderabad	07
SGH Saudabad Karachi	15
Abbasi Shaheed Hospital	10
SGH New Karachi	08
Liaquat University Hospital	05

Name of Recipient Institute	Distributed
Civil Hospital Sukkur	40
Civil Hospital Khairpur	35
Civil Hospital Naushahroferoze	15
Civil Hospital Mirpur Mathelo	10
RBUT Hospital Shikarpur	30
CMC Hospital Larkano	20
DHQ Hospital Kamber	10
Civil Hospital Jacobabad	35
DHQ Hospital Kandhkot	10
PMCH Benazirabad	20
EDO(H) Shikarpur	30
SGH Paretabad Hyderabad	08
EDO (H) Karachi	35
EDO (H) Thatta	20
Lyari General Hospital Karachi	10
SGH Qatar Hospital	05
Taluka Hospital Hala	35

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  A summary of screening statistics from September 2006 to June 2007 are as follows;

 

 

Screening of Prison Inmates

During the project life Supreme Court of Pakistan ordered for the screening of prison inmates and providing treatment to patients. Almost 8000 prison inmates were screened, which to date remains the largest Hepatitis C seroprevalence survey amongst the prison inmates population. The results subsequently were published in an indexed journal in 2010. Copy of the paper is attached.

PCR Test

The program when designed at the Federal level could not envisage the provisions of PCR test. Contracting methodology was adopted for the services. The research and teaching institutes were having the PCR machines which were not used for the general public. The project engaged the academia in a manner where PCR services were opened for the general public on a no profit no loss basis and it was outsourced. At that time this mechanism was an innovation hitherto unheard of in Health Department. Before that all the patients were bearing the expenditure out of pocket.

TREATMENT FACILITIES AT DISTRICT AND TEACHING HOSPITALS:

Program envisaged provision of treatment to deserving and poor patients, however this component over shadowed all other interventions. The latent demand for Hepatitis C and B in the community became evident after the initial supply of Injection Interferon in June 2006. The demand supply mismatch was enormous. The treatment component of the program was actualized through the Viral Hepatitis Control Committees notified at each hospital.

Table 26: Distribution Details of Treatment during 2006-2007

S. No	Name of Sentinel Site	Injection Interferon	Capsule Ribavirin	Tablet Lamividine
1	C.M.C Hospital Larkana	46686	349920	20075
2	Civil Hospital Sukkur	16632	124740	20075
3	PMC Hospital Benazirabad	23400	175500	18250
4	J.P.M.C Karachi	3600	27000	0
5	Civil Hospital Jacobabad	23760	178200	3980
6	Civil Hospital Shikarpur	3600	27000	7300
7	Civil Hospital Dadu	19872	149040	10950
8	Civil Hospital Mirpur Mathelo	3600	27000	0
9	Civil Hospital Khairpur	18648	139860	29050
10	Civil Hospital Naushahroferoze	3600	27000	5420
11	Civil Hospital Sanghar	3600	27000	5400
12	Civil Hospital Mirpurkhas	19800	148500	10220
13	Taluka Hospital Kotri, District Jamshoro	30600	229500	14600
14	Civil Hospital Thatta	3600	27000	3650
15	Civil Hospital Badin	13320	99900	5425
16	Civil Hospital Mithi	15528	116100	1795
17	Civil Hospital Tando Allahyar	17424	115020	1825
18	S.G.H Qasimabad Hyderabad	0	0	1095
19	District Headquarter Hospital Umerkot	3600	27000	0

 

Distribution Details of Treatment during 2008-2009

S. No	Name of Sentinel Site / Recipient	Injection Interferon	Ribavirin
1	Civil Hospital Sanghar	1440	10800
2	SGH Qasimabad Hyderabad	1800	13500
3	Civil Hospital Badin	1440	10800
4	Civil Hospital Thatta	1440	10800
5	Civil Hospital Naushahroferoze	2520	18900
6	GMC Hospital Sukkur	1440	10800
7	Civil Hospital Jacobabad	1080	8100
8	Balochistan PIU	1440	10800
9	SGH Paretabad Hyderabad	528	3942

 

Distribution Details of Treatment during 2009-2010

S. No	Name of Sentinel Site / Recipient	Injection Interferon	Ribavirin
1	PMCH Shaheed Benazirabad	21800	163500
2	Executive District Officer (Health) Kamber	20000	150000
3	Chandka Medical College Hospital Larkana	8136	61020
4	Civil Surgeon Civil Hospital Naushahroferoze	10800	81000
5	Medical Superintendent RBUT Shikarpur	6656	49920
6	Civil Surgeon Civil Hospital Mir Mathelo	10800	81000
7	Medical Superintendent Shah Bhitai Hospital Hyderabad	10800	81000
8	Executive District Officer (Health) Matiari	7200	54000
9	Medical Superintendent DHQH Tando Mohammed Khan	7200	54000
10	Sindh Government Hospital Paretabad	5040	37800
11	Medical Superintendent Khairpur	14400	108000
12	Civil Hospital Tando Allahyar	1440	10800
13	Sindh Government Hospital Qasimabad Hyderabad	1440	10800

 

For Hepatitis C the End Treatment response was a major indicator and for Hepatitis B sero-negative state was taken as an indicator. End Treatment Response rate is as follows:

                                End Treatment Response for the year 2006-2008

DESIGNING THE PROVINCIAL AND DISTRICT INITIATIVES FOR HEPATITIS IN SINDH:

The PC-1 of the Prime Minister’s Program for Prevention and Control of Hepatitis alluded to a separate Provincial Hepatitis Programs from the 3^rd year of the program implementation. Sindh took the lead in designing the provincial version of the National Hepatitis Program. It is pertinent to mention the factors affecting the design and launch of a provincial hepatitis program before any other province in country.

Political Will

The project was successful in generating a goodwill among the decision makers due to its performance from 2006-2009. Hence a public funded scheme was prepared and financed upto a scale which had no precedence in the province.

Demand and Supply Mismatch:

As described earlier a huge demand for hepatitis C treatment was lying latent in the community which surfaced itself after the launch of program. It was not possible for the program to cater to even 50% of the needs, e.g. in 2007, on an average more than 500 patients were booked for treatment at every one of 19 sentinel sites at some sites like Larkana and Karachi the figure rose up to thousands. This phenomenon put the Sindh PIU, Federal PIU and Government of Sindh in an obligation to deliver the public from this problem. Moreover Honorable High Court of Sindh gave a decision to screen all prisoners and provide treatment to the diseased. In this connection Provincial Coordinator appeared in the High Court of Sindh for 03 times along with Director General Health Services Sindh. The public discomfort was also voiced from time to time by the elected representatives in the National Assembly and Senate of Pakistan adding onto the pressure on Sindh PIU and Government of Sindh. All these factors demanded an innovative approach to the program.

Financing from District Government

Sindh floated the idea of district project of the Hepatitis Program and actively lobbied and pursued the idea with all District Nazims (Governors) from July 2007 onwards. Prototype letters describing the inputs of Prime Minister’s Program for Prevention and Control of Hepatitis in the district was sent to all Nazims. The effort was carried on for 02 years and by the end of 2^nd year 20 out of 23 districts had allocated a cumulative sum of 350 million Rs in program interventions. Districts like Dadu / Umerkot / Jacobabad were supported in developing their independent PC-1s. The allocations were mainly utilized for purchase of injection interferon while some of the districts also managed the diagnostic services mainly the ICT Kits and PCR.  

 In table below the financial allocations from the various District Governments in year 2007-2008 are given;

    Details of financial allocations from the District Governments

 

The initiative from these district governments created a sense of relief to patient population in these districts. The benefit incidence analysis of the effort has yet to be determined. However the provincial level institutes were lacking in this initiative which had to be dealt by a provincial scheme.

Provincial Hepatitis Control Program

In 2007 a small scheme of complimentary support to the Prime Minister’s Program for Prevention and Control of Hepatitis in Sindh was sent to Planning and Development Department at the cost of 5.0 Million Rupees. In a follow-up meeting it was decided by the P&D department that a complete and holistic scheme would be launched. Responsibility for developing a PC-1 was entrusted upon Sindh PIU. 

The idea of holistic scheme took shape because of following reasons;

1.      

High Court of Sindh was constantly pushing the health department for screening and providing treatment to diseased prisoners at all prisons. Responding to the decisions an amount of 150 million was allocated for the purpose in May 2008. The sum could not be utilized due to delayed release.

2.      

An obligation on part of provincial tier of government to allocate finances when compared with the fact that federal and district governments had allocated resources towards hepatitis.

3.      

Multiple organizations and districts were approaching Finance and Planning & Development Department with proposals for allocation towards Hepatitis. Government amalgamated all proposals under one ambit of provincial hepatitis control program.

From March 2008 to July 2008 Provincial PIU Sindh leading a core team of Hepatologists, Pathologists, Public Health Specialists and Planning & Development Department team, a PC-1 worth 2.35 Billion was prepared and it was approved in August 2008 for three years. The scheme was coined as “Chief Minister’s Initiative for Hepatitis Free Sindh”. In essence the project is an up scaled version and replica of interventions of Prime Minister’s Program on Hepatitis. The objectives are:

Preventing the acute infections

Addressing the chronic infections

Raising the public awareness

Changing the policy environment

Health System Strengthening

Under every objective a set of sub-objectives and activities are developed. The project has a detailed and elaborate logical framework for monitoring and evaluation. A copy of the project in winzip form is attached.