Government of Kerala Dr BIPIN GOPAL STATE NODAL OFFICER NCD KERALA Hypertension is a Silent Killer Hypertension high blood pressure can cause Brain Stroke Dementia Arteries Artery damage and narrowing ID: 934123
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Slide1
India Hypertension Management InitiativeGovernment of Kerala
Dr BIPIN GOPAL
STATE NODAL OFFICER NCD ,KERALA
Slide2Hypertension is a Silent Killer
Hypertension (high blood pressure) can cause:
Brain
Stroke
Dementia
Arteries
Artery damage and narrowing
Aneurysm
Leg amputation
Heart
Coronary artery disease
Heart attack
Congestive heart failure
Kidneys
Kidney failure
Kidney artery aneurysm
Slide3Burden of CVDs & HypertensionGlobal | India | Kerala
Slide4NCDs are major cause of death in India 2016
Source: India: Health of the Nation’s States The India State-Level Disease Burden Initiative
India, 2016:
Total deaths: 98 lakhs
NCD deaths: 60.5 lakhs
Slide5High Blood Pressure is the World’s Leading Killer
World Health Organization
High blood pressure kills nearly as many people worldwide
each year as all infectious diseases
combined
World Health Organization, 2010
Slide6Most with Hypertension in India are NOT controlled
Roy A et al. BMJ Open. 2017;7:e015639. Data for Delhi National Capital Region weighted and applied nationally.
<11%
218M
74M
60M
24M
Barely 1 in 10 of the 218 million adults with hypertension
in India have it under control
34%
27%
Slide7National targets for CVDs
National
action plan includes specific targets to be achieved by 2025:
25% relative reduction in overall mortality from CVD
30% relative reduction in mean population intake of salt/sodium
25% relative reduction in prevalence of raised blood
pressure
THE SDG GOAL FOR KERALA IS TARGETING TO ACHIEVE THIS BY 2020
Slide8Prevalence of HTN in various Indian states
Source: DLHS- 4 survey 2012-13
Slide9KERALA PROFILEParticulars
Numbers(Millions)
Population
33.39
Men
16.02
Women17.37
Population density
859Literacy
93.
IMR
10
MMR
46
Life expectancy
74
Slide10Heart Attack Mortality 6 -M 5.3- WAR
Stroke deathMen 2.5
Women-1.8ASR
High prevalence of Renal diseases
PURE
STUDY/million death study
Highest epidemiological transition zone
Rampant urbanisation
Changing lifestyles
High prevalence of Hypertension
High prevalence of Diabetes
Over
weght
obesity
Men 24%
Women 34%
High incidence of cancer
KERALA- THE WHEEL OF CHANGE
Slide11NCD control program- wheel of motion
NCD CLINICS IN ALL PHC, CHC, SUB CENTRES.
NCD CLINIC IN ALL DH/SDH
SPECIAL CLINCS 6/7 IN FHC
COE IN GH ERANAKULAM
MEDICINES UP TO PHC LEVEL
13300000 PEOPLE SCREENED
NHM-DHS JOINT PROGRAM
SPECIAL PROGRAMS FOR SCHOOLS & WORK PLACESTOBACCO CESSATION CENTRES IN ALL DISTRICTS
Hba1c analysis in all FHCs
Slide12State NCD Cell
COPD clinics in DH & H&WC
44 functional Dialysis units
20 chemo units
CCU/
Cath
lab in DH
Diabetic foot clinics
Retinopathy
clinics
Stroke units in DH
Slide13DHS- AMCHSS- NCD Survey
One out of Three have hypertension
One out of Five have Diabetes
13 % control rates
16 % control rates
Slide14Problem Non compliance to protocol by doctorsNon compliance to treatment by patientsNon adherence to lifestyle modificationHospital and medical systems hopping Quality of medicinesAnd the solution……..3 programs adopted by state health departmentIHMI, QS and PBS
Slide15IHMIProgram StatusKerala State
INDIA HYPERTENSION MANAGEMENT INITIATIVE
In association withWHO,ICMR, RESOLVE TO SAVE LIVES
Slide16In sync with WHO global HEARTS initiative
Launched by WHO & partners in Sept 2016 to reduce heart attacks and stroke
Slide17What is IHMI4 districts pilotedDevelopment of Standard protocol for management
Appointing CVHOs and STS for IHMI Districts
Trainings and capacity building
Documentation
Screening of all persons above 18 yrs of age &Protocol based management
Regular individual follow up and retrieval of defaulters
Half yearly and yearly evaluation
Slide18Timeline of Major Events – 1
Slide19Timeline of Major Events – 2
Slide20Protocol workshopchaired by ACS kerala, National and state level experts participated trivandrum
Slide21Field visitsvisit to institutions and houses lead by resolve team
Slide22Appraisal visitsto assess the preparedness of the districts lead by WHO and ICMR
Slide23The official launchby Health minister in presence of ACS, DHS, Dr Tom Frieden
Slide24Protocols
Community-Based Treatment
Medication Supply
Patient-
Centered
Care
Information
Systems
14.5% increase
Five Components of WHO HEARTS Technical Package
Slide25Hypertension Treatment Protocol(Kerala)
Slide26Advice Life Style Modifications (LSM) & Assess for complicationsStart T. Metformin 500mg OD or
BD
Monitor FPG/PPPG monthly
Review in
1 month, if FPG,PPBG values are
high,
Intensify T. Metformin 1000mg
BD
Along with LSM
Review
in
1 month,
if
FPG,PPBG values are
high
Add
T
. Glimepiride 1 mg OD(½ hour before breakfast and reduce to 0.5 mg/day depending if there is hypoglycemia.)
Along with LSM, T.Metformin 1000mg BID. Give hypoglycemia training.Intensify T.Glimepiride 1 mg BD up to 2mg BID
(½ hour before
meals)
Along with LSM, T.Metformin 1000 mg/day
BID.
If
plasma glucose not under control after second drug and
if
any complications
present,
Refer
to
District
hospital
If there is no complications, Continue LSM, Metformin 1
gm
BD,
Tab.
Glimepiride 2mg
BD,
Add
T
.
Pioglitazone 7.5 mg
OD
(to a maximum 15 mg
once
daily)
Avoid
in
cardiac failure, fluid overload
patients
If plasma glucose not under control
after
third
drug,
Start
Insulin
If plasma glucose not under
control
Refer
to
District
hospital
1
2
3
5
LIFE STYLE
MODIFICATIONS
Restrict
sugar
&
sweets
Restrict
fried and oily
foods
Increase
fiber in diet (green leafy vegetables, lentils or peas, whole grains, apple,
banana)
Regular consumption
of
seasonal vegetables
Brisk
walking
for
30
minutes
daily
5 minutes warm
up
5 minutes cool down
Avoid Tobacco and
Alcohol
Hypoglycemia
Symptoms
Cold
sweat, trembling
of
hands, hunger, palpitation, confusion
etc
Treatment
Ingestion
of
glucose or carbohydrate containing foods. Consume
15
gms
of
glucose i.e. 1 tablespoon sugar, fruits, next
meal &
recheck blood glucose
after
15
minutes, repeat
if
hypoglycemia
continues
If patient
is
under control by
any
of the above steps, continue
same
treatments
if
no complications
is
identified
and
follow up shall be done every month with FBG
and
2hour
PPBG
Give hypoglycemia
training.
4
Department
of
Health
&
Family
Welfare
TREATMENT PROTOCOL
FOR
TYPE
2
DIABETES
MELLITUS
Screen all individuals
above
30 years and
if
diagnosed
Diagnosed diabetes with symptoms
&
FPG ≥ 250
mg/dL
at
presentation.
Repeat testing once a
week
and start combination therapy with Tab. Metformin 500 mg BD & Tab Glimepiride 1mg daily , up titrate , monitor weekly and to start Insulin if not getting controlled. Refer if not controlled
If
any of the following complications are present, refer to higher centre.Uncontrolled plasma glucose with symptomsVisual symptomsFoot ulcerNephropathy/ frothing of
urinePainful neuropathy
Infections/sepsis.
6
7
STATE
NCD
DIVISION
Base Line
Lab
InvestigationsUrine Albumin Blood Urea Serum Creatinine
Target mg/dLFPG: 80-130PPPG: >180
Slide27Establishing NCD Pre-assessment AreaManaged by staff NurseBP measurement of all above 18 years of ageEnters the recordings in treatment cardBlood sugar estimation, HbA1c estimation, PFT in FHCsPatient send to physician after pre check.
Slide28BP apparatus used in pre check area
Slide29Ideal Patient Flow on all days
NCD Pre-assessment Area
All patients above 18 years screened for blood pressure irrespective of their purpose of visit
Slide30Patient flow in FHC
Slide31Recording & Reporting SystemTreatment Card | HT Facility Register | Patient Passbook
Slide32Treatment CardFor Hypertension and Diabetes
MellitusAll diagnosed patients will be given an unique id number and a treatment card which will be stored in the facility.
For individual patient monitoring: identifies when was the last visit; when is follow up due; if BP controlled; if patient irregular; what medications
Slide33Registration and issue of treatment card
Slide34Slide35Hypertension Facility RegisterOnly for Hypertension
Slide36Hypertension Facility Register
Each health facility maintains a HTN Register
It is line listing of all patients on treatment in that health facility
Entries are made from the patient treatment cards
Each health facility designates a staff who will be responsible for maintaining this register
Patient ID information can be filled at the time of starting the treatment card or soon after
After 2 quarters i.e. at the end of 6-9 months, and every year thereafter, update the Register to indicate if the patient’s BP is under control or not by writing Yes/No
36
Slide37F
illed immediately or soon after starting the treatment card
Filled later
Slide38Patient Pass BookFor Hypertension & Diabetes MellitusGiven to Patients
Slide39Slide40Slide41Integration with e health systemAll health workers provided tablet PC through ehealth systemNCD module integrated in the ehealth systemRegistration and referral could be done onlineBack referral from the doctor to the concerned health workerAlerts to health workers and field workers to track defaulters
Slide42Indicator based evaluationScreening – number screened out of total eligible population
Detection- number of cases detected out of number screened
Treatment-number put on treatment out of number detected
Outcome- number of people attaining control levels out of number treated
Slide43Implementation of Population Based Screening
The same four districts selected for an integrated synergistic activity
Helped in accessing the target population
Patient tracking and referral using ASHADefault retrieval using ASHA
Slide44QUALITY STANDARDS IN HYPERTENSION MANAGEMENTPILOTED IN 2 DISTRICTS – ALAPPUZHA & ERANAKULAMIN ASSOCIATION WITH IMPERIAL COLLEGE LONDONACTIVITIES SIMILAR TO IHMI
FOCUS ON SERVICE PROVIDERS THAN BENEFICIARIESTRAINING ON
IDEAL BP MEASUREMENT TECHNIQUES FOR ALL HEALTH STAFF
FOLLOW UP
Slide45IHMI Implementation StatusAs on 29/9/18
96% of institutions in 4 IHMI districts have implemented the program including screening, treatment and follow-up of Diabetes Mellitus
Slide46Registration StatusUpdated on 29/9/18
69460 patients registered for HT and DM till Sep 2018
HT
DM
Both
37643
9988
21829
Slide47Implementation & Registration – District wise status
District
Total No. of facilities
No. of facilities where IHMI implemented
HT
DM
Both
Total
Trivandrum
92
92
6860
3454
6617
16931
Thrissur
102
102
10352
3652
7760
21764
Kannur
97
9
6
15293
2882
7452
25627
Wayanad
36
23
5138
DM data not
avl
.
5138
Total
327
313
37643
9988
21829
69460
Updated on 10/10/18
Slide48Training 16 state level trainings ( TOT )64 district level trainings124 block level trainings240 institution level trainings32446 staff given training
91% of staff trained
Slide49Training Status (%)
District
MO
SN
HS & LHS
HI
& LHI
JPHN & JHI
Pharm.
District Avg.
Trivandrum
91
92
94
96
90
87
91
Thrissur
98
99
100
91
98
98
98
Kannur
88
77
-
81
90
88
85
Wayanad
87
93
98
85
91
State Avg.
91
90
93
90
91
Updated on 25/10/18
Slide50ChallengesAdherence to new treatment protocol by Medical officersAcceptance to protocol based management
Long waiting times during NCD clinics Coverage in urban areas
Protocols
Community-Based Treatment
Low participation of male population
Involvement of private sector
Medication
Supply
Drug forecasting for next financial year
Quality of drugs
Slide51Way forward
Expand IHMI to Urban PHCs
Involve JHI, JPHN and
ASHA workers in defaulter retrieval
Camps, workplace intervention and holiday/evening op to capture more male population
Coalition with professional organizations for more private participation
Complete digitization for decreasing paper work
Slide52Expected outcome decrease the rise in Prevalence of Hypertension increase control rates to above 50%
create a population based registry for Hypertension and diabetes
decrease OOPE by early detection and prevention of complications
Slide53You are under scanner, Once detected , you are booked – and we spare no one