Progress related to CKDu/CKD

programme – Health sector

May 2015

oshjeähdj yd wê reêr mSvkh ksid'''

PRDPU - NCP 12/18/2012

ld,sl jl=.vq wlrKh Chronic Kidney Disease

PRDPU - NCP 12/18/2012

Causative factors of Chronic Kidney Diseases of Uncertain Aetiology (CKDu)

• Prevalent in certain parts of the dry zone • Evidence shows;

– high level of Arsenic, Cadmium in humans in these areas – Low levels of Selenium in humans (Malnutrition) – High levels of Calcium and fluoride in the water – Presence of Agrochemicals residues in humans – Dehydration due to inadequate drinking of water & heat – Alcohol and tobacco consumption – Excessive and indiscriminate use of agrochemicals

• Need further research while primary and secondary preventive measures are being taken

Uncertainties

• Causative agents • Method of screening • Use of drugs • Other preventive measures

– Water – Agrochemicals

CKD/CKDu Prevalent DS Divisions in Sri Lanka

New Renal Units CKD Clinic Centers

Live Discharges(LD) and Deaths due to renal failure IMMR) No.

RDHS Division

2005 2006 2007 2008 2009 2010 2012

LD D LD D LD D LD D LD D LD D LD D 1 Ampara 14 4 40 9 322 8 1010 43 1194 44 1168 46 683 38 2 Anuradhapura 1479 104 1895 194 2061 199 2288 166 1570 332 2083 308 3340 270

3 Badulla 270 76 161 56 199 61 679 125 611 121 636 135 734 157

4 Batticaloa 76 0 6 0 16 0 13 0 2 0 49 17 887 24 5 Colombo 1984 363 2754 390 2964 477 4410 420 4977 474 5707 535 3056 463 6 Galle 422 59 154 41 140 86 188 91 517 83 84 90 474 67

7 Gampaha 1583 61 392 89 476 114 551 105 562 107 639 104 907 123 8 Hambanthota 79 1 55 11 109 7 150 10 195 9 281 15 251 24 9 Jaffna 794 84 1003 72 423 62 394 52 459 52 500 72 478 88 10 Kalmunai 43 3 41 8 54 6 71 6 103 4 103 11 123 13 11 Kaluthara 138 7 186 15 193 34 261 13 316 37 287 37 450 42 12 Kandy 940 57 1593 134 1694 161 2053 156 2483 161 2687 151 2615 141 13 Kegalle 80 13 133 19 183 32 249 52 196 30 189 33 170 24 14 Killinochchi 4 0 112 0 0 0 0 0 0 0 0 0 52 5

15 Kurunegala 739 89 1108 163 1103 173 1070 177 1343 154 1691 176 2089 170 16 Mannar 28 0 8 4 37 3 23 2 10 1 35 5 40 6 17 Matale 138 18 179 10 277 11 295 20 381 32 489 46 313 29 18 Matara 138 22 114 14 129 20 133 24 96 17 181 22 252 24 19 Monaragala 163 20 145 25 196 38 201 31 204 32 179 29 328 60 20 Mullativu 17 0 8 1 24 4 26 4 0 0 0 0 77 2 21 Nuwara Eliya 93 19 83 11 81 15 64 18 85 17 124 25 140 14 22 Polonnaruwa 221 33 532 102 443 92 699 79 868 91 1334 94 553 153 23 Puttalam 89 10 106 19 99 15 145 11 240 18 241 31 355 28 24 Rathnapura 226 20 186 10 185 25 145 28 270 37 218 35 289 42 25 Trincomalee 165 16 116 13 171 16 268 14 273 20 512 19 851 40 26 Vavuniya 475 29 331 38 492 31 402 54 325 70 549 48 823 62

Total 10398 1108 11441 1448 12071 1690 15788 1701 17280 1943 19966 2084 20330 2109

CKDu estimates Province

District DS Division EEmated CKD/u pts.

NCP Anuradhapura All Divisions 856,232 34249

Polonnaruwa All Divisions 403,335 16133

Uva Badulla Giranduru Kotte 41811 1672

Moneragala Wellawaya, Ridimaliyadda Under investigation

EP Ampara Dehiatta Kandiya 59628 2385

Trincomalee Padavi Sripura, Gomarankadawala 58499 2339

NWP Kurunegala Polpithigama, Galgamuwa, Mahawa, Giribawa, Nikawaratiya

258537 10341

Central Matale Wilgamuwa 29550 1182

NP Mulathiv Weli oya 6949 277

Vaunya Vaunya South 17,000 680

SP Hambathota Thissamaharamaya Angunakola Palassa

Under investigation

Total 1,731,451 69,258

Newly diagnosed CKDu/CKD patients in CKDu prevalent areas

Anuradhap

ura Polonnar

uwa Kuruneg

ala Batticalo

a Trincoma

lee Ampara Badlula Total 2000 377 377 2001 431 431 2002 521 521 2003

6639

581

13628

2004 789 2005 825 2006

1175 869 137

2007 1070 255 2008 1138 150 2009 1143 365 1141 1104 271 266 4290 2010 1451 380 1457 1236 439 2333 7296 2011 1424 854 1232 325 1518 231 172 5756 2012 555 183 679 177 148 1742 2013 1203 929 1596 679 241 275 4923 Total 12415 3886 12706 325 4537 1359 3736 38964

District CKD registered - 2014 Source of Information 01

Ampara 403 RDHS Ampara

02 Anuradhapura 13764 CKD Prevention Unit NCP

03 Badulla 3214 NCD Unit

04 Batticaloa 154 MO(NCD)

05 Kurunegala 1200 GH Kurunegala

06 Mannar 220 MO (NCD) Dr. Sisil

07 Matale 648 RDHS Matale

08 Monaragala 263 MO (NCD)

09 Mullaitivu 114 Mullative hospital

10 Polonnaruwa 5435 CKD Prevention Unit NCP

11 Trincomalee 332 MO(NCD)

12 Vavuniya 196 MO(NCD)

TOTAL 25 943

Targets – 2014,2015 2014 2015

01 Mass screening of high risk population 500,000 1,000,000 02 Make available basic drugs to PHC hospitals 80% 100% 03 Education of school children on prevention of CKD 100% 100% 04 Education of other stakeholders and CBOs 40% 100% 05 Media campaign on prevention Media Ministry 06 Systematic collection of information of all CKD/CKDu

patients through hospital surveillance system 40% 100%

07 Development of e surveillance registers of CKD/CKDu patients

30% 100%

08 Locating CKD/CKDu patients in using GPS in DS Divisions 08 15

09 Strengthening of laboratory facilities in hospitals in high risk areas

80% 100%

10 Strengthening of dialysis facilities including establishing Renal Units in TH Karapitiya, TH Batticaloa, PGH Trincomalee,

Long term

PRDPU - NCP 12/18/2012

Screening – 2014 November Districts Total

Screened Ampara 44,412 Anuradhapura 96,521 Badulla 30,706 Kurunegala 98,073 Mannar 4,756 Matale 63,019 Monaragala 69,138 Mullaitivu 2,889 Polonnaruwa 83,224 Trincomalee 12,301 Vavuniya 5,277 TOTAL 510,316

CKD clinic centres - 2015 Building Allocation-2014 Responsibility Progress

1. Mdawachchiya 2. Hingurakgoda 3. Padaviya 4. Aralaganvila 5. Bakamuna 6. Hettipola 7. Padavi Sri pura 8. Dehiattakandiya 9. Wallawaya 10.Thissamararamaya 11.Mamaduwa 12.Sampath Nuwara 13. BH Kabithigollawa 14. GH Mallawi 15. BH Cheddikulum Total

30 30 25 25 25 25 25 25 25 25 25 25 25 25 360

PDHS NCP MoH

60% 60% 10% Work started Work started Bid doc app Work started Work started Bid doc app Bid doc app Work started Work started Bid doc app Bid doc app Work started

Equipment needed for the CKD Clinic Centres & Renal Units

Equipments Nephrology

Units

Hospitals

with

dialysis

facilities

Nephro

logists

Visiting

Centers

Primary

Care

Units

Centrifuge (12-24 buckets) 1 1 1 1 Phase contrast Microscope 1 Electrolyte analyser (K, Na, Ca,) 1 1 1 1 Electronic weighing scale (3 decimal) 1 1 1 1 Haematology analyser (3 part) 1 1 1 1 PH Meter 1 Refrigerator (2 door) with glass front 1 1 1 1 Osmometer 1 HbA1c (HPLC machine) 1 1 1 Fully automated biochemistry analyser 1 1 1 Dissecting Microscopes 1 Immunological analyser 1

Equipment needed for the CKD Clinic Centres & Renal Units

Equipments Nephrology

Units

Hospitals with

dialysis facilities

Nephrologists

Visiting

Centers

Primary

Care

Units Blood gas analyser 1 1 Renal biopsy gun 1 Portable us scanners 1 Digital weighing scales 1 1 1 1 Digital BP apparatus 1 1 1 1

Strengthening of the CKDu management at Primary Health care level CKDu screening

Strengthening of information system

Responsibility

Progress 2015 estimate

NCP NP EP Uva CP NWP SP Other areas

15 05 05 05 03 05 02 02

02 02 02 02 02 02

Respective PDHS/ RDHS

Funds allocated to Provinces Screening programmes started Procurement procedure in progress

60 (For screening programmes

NCP CKD unit

05

Nikawawa CKD centre

03

Total 40 20

Provision of 15 passenger vans Distributed

Delivered

Improvement of transport facilities (Providing transport facilities- 15 seater vans)

Province District Number Responsibility 2014 2015

NCP Anuradhapura 01 MoH 120 50

Polonnaruwa 01 TEC documents submitted to procurement division

NCP Unit 01

NWP Kurunegala 01

Uva Badulla 01

Moneragala 01

CP Matale 01

Sp Hambanthota 01

NP Vavuia South 01

Mulathivu 01

EP Trincomalee 01

Ampara 01

Epid Unit 02

CKD unit 01

Mobile lab

• NCP – 01 (On special request made by the Hon. Chief Minister NCP) – Provincial Authorities to purchase

Distribution of curative settings for CKD management District Primary Care Units Nephrologists Visiting

Centers

Dialysis Units

managed by VPs

Nephrology Units

Anuradhapura Galenbindunuwewa,

Horowpathana,

Kahatagasdigiliya,

Kakirawa,

Mahawilachchiya,

Nochchiyagama,

Rambawa, Thalawa,

Thambuthegama

Madawahchciya,

Kabathigollawa

Padaviya TH Anuradhapura

Polonnaruwa Walikanda,

Aralaganwila

Bakamuna,

Hingurakgoda

Madirigiriya DGH Polonnaruwa

Kurunegala Giribawa, Kobeigane,

Kotewehera

Nikawaratiya, Nikawawa,

Polpithigama

- TH Kurunegala

Matale - Wilgamuwa - -

Ampara - Dehiattakandiya DGH Ampara -

Distribution of curative settings for CKD management District Primary Care Units Nephrologists

Visiting Centers

Dialysis Units

managed by VPs

Nephrology

Units

Trincomalee Padavisripura,

Gomerankaradwala,

Wanela, Kanthalai

- - -

Badulla Girandurukotte,

Mahiyangane,

BH Mahiyanganaya PDG Badulla

Moneragala Bibile, Syabalanduwa,

Wellawaya, Buttala,

Madagama, Thanamalwila

- DGH Moneragla -

Hambanthota Thisamaharamaya,

Lunugamvehera,

Sooriyawawa

- - -

Vavuniya Vavuniya South,

Cheddikulum

DGH Vavuniya - -

Mullaitivu Sampathnuwara, Welioya,

Mallavi

- - -

Haemodialysis facilities Centre No. of

units Centre No. of units

TH Jaffna 11 NHSL 09

TH Batticaloa 03 CSTH 05

DH Ampara 06 Sri jayawardanapura TH 12

TH Anuradhapura 23 TH Karapitiya 07

DGH Polonnaruwa 16 CNTH 01

PGH Kurunegala 12 Police Hospital 03

PGH Rathnapura 01 NINDT Maligawatta 20

DGH Moneragala 03 Lady Ridgeway Hospital 03

PGH Badulla 04 BH Padaviya 06

TH Kandy 23 DGH Trincomalee 02

DGH Matara 02 BH Madirigiriya 02

DGH Vavuniya 04 BH Mahiyangana 05

DGH Mannar 04 25 Hospitals 186

Improvement of dialysis facilities- Renovations & upgrading

Responsibility Progress Allocation-2014 2015 estimate

BH Madirigiriya PDHS NCP Procument procedures are in progress

10

BH Vauniya PDHS NP 04

TH Jaffna Dir TH Jaffna 04

TH Batticaloa Dir TH Batti 04

BH Polpithigama PDHS NWP 46

BH Nikawaratiya PDHS NWP 46

BH Mahiyanganaya PDHS Uwa 20

Total 134 100

Target – Strengthen Haemo dialysis facilities in CKDu high Risk areas

Allocations for 2015 for improvement of dialysis facilities

Dialysis centers

Tentative allocations (Rs. Million)

Established New BH Padaviya 10 BH Kabethigollawa 12 DH Madawachchiya 12 BH Thambuththegama 12 DGH Polonnaruwa

8

BH Madirigiriya 12 DH Hingurakgoda 12 DGH Matale 12 BH Dambulla 12

Allocations for 2015 for improvement of dialysis facilities

Dialysis centers

Tentative allocations (Rs. Million)

Established New PGH Badulla 7.8 BH Mahiyangane 14

DH Girandurukotte 12 DGH Moneragala 4.2 DGH Trincomalee 1.9 BH Kanthale 7.1

BH Polpithigama 15 BH Nikawaratiya 15

Allocations for 2015 for improvement of dialysis facilities

Dialysis centers

Tentative allocations (Rs. Million)

Established New DGH Ampara 7.95

BH Dehiaththakandiya 20 DGH Vavuniya 8

DGH Kilinochchi 5.7 DGH Mullative 5 DGH Mannar 8

Distribution of 23 dialysis machine Institutions Provided in February 2015

TH Kandy 8

DGH Ampara 2

TH Anuradhapura 2

BH Padaviya 2

BH Madirigiriya 1

TH Jaffna 2

DGH Killinochchi 2

BH Mahiyangana 2

DGH Moneragala 2

Establishment of Renal Units Responsibility Progress Allocation-2014 2015

estimate

TH Karapitiya MOH Contract given to cecb

200 200

TH Batticaloa Submitted to treasury planning unit

100

TH Trincomalee Submitted to MOH planning unit

100

PH Badulla Under preparation

100

TH Jaffna Total 200 500

Hospital surveillance and Health Education Allocation-2014

Responsibility

Progress 2015 estimate

Strengthening of Hospital surveillance system

20 Epidemiology unit

Consultative meetings conducted, developing modules, ICNO training done, monthly returns receiving from sentinel sites Target – to develop 30 sentinel sites

20

Strengthening of Health education

10 Health education Bureau

FGD Done, Leaflet prepared, Training of master teachers will be started Target – To educate all school children in high risk areas

10

Research to identify better marker for early diagnosis -Peritonial dialysis -Identification of an early marker

7 0.4

TH Kandy TH Anuradhap

In progress 30

Hospital surveillance – submission of reports

No Name of the Hospital No Name of the Hospital 1 DH Padawiya 16 GH Polonnaruwa 2 DH Madawachchiya 17 TH Kandy 3 BH Kebithigolawa 18 GH Vavuniya 4 DH Kekirawa 19 BH Dehiaththakandiya 5 BH Madirigiriya 20 TH Jaffna 6 DH Higurakgoda 21 GH Mullaitvu 7 DH Bakamoona 22 GH Kilinochchi 8 DH Walikanda 23 TH Kurunegala 9 DH Dimbulagala 24 BH Thabuththegama 10 DH Nikawewa 25 DH Hettipola/Wilgamuwa 11 DH Padawi Siripura 26 DH Kahatagasdigiliya 12 DH Giradurukotte 27 DH Thanamalwila 13 BH Mahiyangana 28 DH Buttala 14 DH Galenbidunnuwewa 29 GH Mannar 15 TH Anuradhapura 30 DH Sampathnuwara

COMBI Programme

• Proposed plan • Leaflet developed by HEB • Intersectoral plans will be developed with

consultation of Provincial Authorities

MO CKDP appointed Already Existing • RDHS Anuradhapura • RDHS Polonnaruwa • RDHS Kurunegala • MOH Polpithigama • MOH Padaviya • MOH Giribawa • MOH Galgamuwa • MOH Madirigiriya • MOH Madawachchiya • MOH Giranduru kote • MOH Kabithigollawa • MOH Padavi sripura

Obtained from Post Intern list •MOH Gomerankadawala •MOH Vavuniyawa •MOH Welioya •MOH Padaviya •MOH Madirigiriya •MOH Elahara •MOH Dimbulagala •MOH Welikanda •RDHS Ampara •MOH Padiyathalawa

Financial Assistance

Recommendation of MoH • To be given to those in 21 high risk divisional

secretariat areas in 9 districts • 3000/= for CKDu stage III • 5000/= for those undergoing dialysis

Future

• Dedicated budget line for CKDu – 2015 estimate – Rs. 1500 mn.

• Develop a Strategic plan to strengthen the programme

• Development of guidelines • Web base monitoring system with GIS/ GPS ? • Regular follow at the field • Continuous community based screening • Regular monitoring and reviews

Sectoral collaboration

Provincial Authorities

Public Administration

Other sectors

• Own the programme • Liaise with the centre

• Collaboration at all levels • Organising community

based clinics

• Close collaboration • Liaison

Thank You