RSSDI Diabetes Update–2019 Banshi Saboo, Hardik Chandarana
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1Epidemiology

Opportunistic Screening: How Feasible it is in Rural Setting?CHAPTER 1

Chakrapani M,
Nitish Mathur,
Unnikrishnan B
 
INTRODUCTION
Screening is defined by the World Health Organization (WHO) as “services for the presumptive identification of unrecognized disease in an apparently healthy, asymptomatic population by means of tests, examinations or other procedures that can be applied rapidly and easily…..”1 Screening is important for diseases where metabolic and organ complications develop much before symptoms manifest. Screening not only involves early diagnosis, but also a comprehensive plan for a full evaluation, education and management plan.1 It can either be population screening or opportunistic screening. While population screening is ideal, it involves a huge expenditure and may not be cost effective. Opportunistic screening is the process wherein screening of the individual for a disease is done whenever the person comes in contact with the healthcare system. Growing epidemic of diabetes and other noncommunicable diseases (NCDs) in India can be controlled by a systematic opportunistic screening.2 National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) is an ambitious program of the Government of India which involves opportunistic screening for diabetes, hypertension and common cancers,2 by providing promotive, preventive, curative, and supportive services in an integrated manner. Implementing this program in rural India is quite a challenge.
 
NEED FOR OPPORTUNISTIC SCREENING
Opportunistic screening for diabetes is extremely crucial because there is a long period of time before the clinical presentation and target-organ damages are seen at the time of diagnosis itself. Large proportions of diabetic patients have complications at diagnosis since they were asymptomatic for a long period of time.3 Average hemoglobin A1c (HbA1c) at the time of diagnosis was 9.2, even in newly diagnosed young diabetic patients.4 Diabetic retinopathy, neuropathy, nephropathy, and ischemic heart disease were noted in 5.1%, 13.2%, 0.9%, and 0.7% of these newly diagnosed young diabetic patients.4 Interventions done at the earliest stage of the disease are much more cost-effective than interventions done later. In United Kingdom Prospective Diabetes Study (UKPDS), lower blood sugar at diagnosis was associated with lesser long-term micro- and macrovascular complications.5 Overall cost is less with opportunistic screening for sugar, blood pressure (BP) and lipids done together as a package.6 In India, half of those identified with diabetes were not aware of their disease.7 In a recent large observational study, it was noted that 40% of the mortalities are due to cardiovascular causes and modifiable risk factors accounted for 70% cardiovascular deaths.8,9 Modifying a few simple risk factors in the population can have huge overall gains.10 Hence, opportunistic screening is required.
Diabetes is a very common condition and the prevalence is rising. Prevalence of diabetes in India was 7.3% and the prevalence of prediabetes was 10.3%.7 Diabetes is no more considered a mild-chronic disease, because 60% of mortality in India are due to NCDs, overtaking deaths due to trauma and infectious diseases.2
 
IMPORTANCE OF SCREENING IN RURAL POPULATION
Diabetes management and prevention programs traditionally did not focus on rural areas since it was that burden of diabetes is less in rural areas. In a recent large study, prevalence in urban areas was 11.2% and in rural areas it was 5.2%. However, since 70% of Indian population is in rural areas, burden of diabetes in rural areas is at least equal to the burden of diabetes in urban areas.7 Interestingly, the prevalence of prediabetes was 10.3% and was similar among rural and urban population.7 There is an increasing trend of diabetes among economically weaker sections of India. Studies done with opportunistic screening have shown that about 40% of the individuals above the age of 30 years have a random glucose of more than 140 mg% even in rural areas.11 Higher cardiovascular deaths (40%) are observed in low-income countries compared to lower cardiovascular deaths (23%) in high-income countries in spite of having lesser number of risk factors.9 These complications are compounded in rural areas where ignorance of the disease, socio-political, cultural, and economic factors affect their lifestyle behaviors12 and a prolonged asymptomatic phase leads to a significant cardiovascular burden among rural population.
 
COMPREHENSIVE NONCOMMUNICABLE DISEASE SCREENING AND PREVENTION PROGRAM OF THE GOVERNMENT
Government of India has rolled out an ambitious project to contain the damages of NCDs by reinforcing the concept of early detection and effective and affordable management. All individuals above the age of 30 years are to be screened for diabetes by glucometer with opportunistic screening at all the levels of health care including subcenters, by trained paramedical staff.2 As per the program, anyone with glucometer general random blood sugar (GRBS) of 140 or above with a glucometer testing will be given a referral card for a formal venous blood examination in a fasting state to confirm diabetes mellitus at a suitable healthcare level which is generally community health center or district laboratory. All such patients diagnosed with diabetes are to be evaluated thoroughly and treated according to the protocol. It is unethical to screen the population of individuals for a particular disease unless there is a detailed plan of action for subsequent management of the condition. This program is a comprehensive one wherein protocols for diagnosis, follow-up treatment and management of complications are built in. But there are a lot of logistical challenges that need to be addressed in rural settings.
A major challenge is the high dropout rate after the initial glucometer screening. In the rural areas, dropouts are higher because of various logistical reasons including the need for traveling to distant higher center and the need for fasting blood sample. It has been seen that in the rural areas only about 60% of the individuals referred for the next level complete the process even when the government is providing it free of cost.11 But innovative approaches involving technology can solve this issue. When reminders using mobile phones were used, conversion rate significantly went up to nearly about 80% and this led to a significantly more number of subjects being diagnosed with diabetes and prediabetes.11 Involvement of private institutions and nongovernmental organizations (NGOs) and innovative use of technology can improve the yield of this program.
The HOPE 4 study showed that community-based interventions are highly effective in reducing the burden of NCDs, especially in rural areas.13 However, in India, non-physician health workers were not as effective as their counterparts in other third world countries in community level interventions for NCD. Compared to 90% concordance of their assessment with physicians, Indian health workers could reach up to 30% concordance only. Outsourcing specific tasks to private players like educating the paramedical staff in the rural areas can be a viable option. Previous experience in NCD prevention has confirmed that packaged and bundled intervention consisting of paramedical workers doing screening and risk assessment, innovative use of information technology (IT), lifestyle counseling at or near their home, free supply of medicines and overall supervision by physicians was very effective at the community level.14
 
OUR EXPERIENCE AT DAKSHINA KANNADA DISTRICT, KARNATAKA
Involvement of the private institutions is also important in the implementation of the program. Our institution was involved in one such activity and experience in this program confirmed the potential of the public–private initiatives. The project consisted of two components: (1) Training healthcare workers in integrated preventive activities and (2) Second level laboratory screening of high-risk individuals of 30 years and above and GRBS >140. The project lasted for about 6 months and was implemented in 2015 in the district of Dakshina Kannada, Karnataka. Department of Community Medicine took up the initiative of training 1,690 healthcare workers across 3the district which involved structured and comprehensive modular training.
Following the training program, laboratory workup for opportunistic screening was undertaken. About 6,060 individuals underwent confirmatory test after the initial screening test. Instead of a patient coming to the district laboratory which generally is far away from the remote rural areas in the villages, arrangements were made for sample collection from the Public Health Center (PHC) itself. The success of the program was mainly because of the active participation of the coordinator, whose involvement and commitment was crucial. Seventy percent of the initially screened individuals were diagnosed with newly detected diabetes mellitus.
 
SOME OF THE CHALLENGES THAT WE ENCOUNTERED
Transporting the blood samples without centrifugation often leads to hemolysis. Centrifuge was installed at the site of blood collection to separate the serum. But erratic power supply and unscheduled power failures in the villages lead to failure of the centrifugation resulting in difficulty in proper processing of the sample. This challenge was overcome by using gel vacutainers. Paramedical personnel in the villages were not accustomed to drawing blood with vacutainers. They were drawing blood samples with syringes only.
The fasting sample was not truly fasting. For many villagers, fasting would imply not eating solid breakfast. Having a liquid diet was still fasting in their belief. Proper education of the public would improve the situation.
Poor network connectivity with the remote areas results in slower and delayed reporting from the central laboratory back to the individuals.
Another interesting challenge was name. Unique identification numbers have to be generated to avoid the common problem of name similarities.
The samples were supposed to be transported through public transport system and received at the central laboratory for processing. Poor transport network, cancellation of the scheduled trips and diversion from the scheduled routes were other issues that had to be tackled.
Previous studies have also observed such logistic issues. Installing centrifuge at primary level, point-of-care HbA1c measurement with random samples and outsourcing venous blood testing to private contractors at PHC were some of the recommendations.11
Overall experience was very gratifying because good number of asymptomatic lean diabetics were identified who otherwise would have continued with their abnormal lifestyle behaviors before being diagnosed. General awareness regarding this NCD was generated by this program. Moreover, training large number of healthcare workers resulted in capacity building for scaling up of the activities.
Opportunistic screening should not be seen as one-off event. It has to be part of comprehensive screening, diagnosis, follow-up and treatment plan including all NCDs since most of them are interrelated. Public–private partnership is a crucial element in implementing this program. Instead of organizing isolated, one-time events, public institutions and private partners should integrate their activities with the existing framework of comprehensive plan.
 
CONCLUSION
Opportunistic screening for diabetes is extremely important for rural India. It is very much feasible if the existing program of the government of India is implemented with the help of private partners, voluntary organizations and NGOs. Technology and improved logistics will be required for the successful implementation.
REFERENCES
  1. World Health Organization. (2017). Screening. [online]. Available from www.who.int/cancer/prevention/diagnosis-screening/screening/en/. [Last accessed on September, 2019].
  1. Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), Operational Guidelines (Revised: 2013-17). [online]. Available from mohfw.gov.in/sites/default/files/OperationalGuidelinesofNPCDCS%28Revised-2013-17%29.pdf. [Last accessed on September, 2019].
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