- Visceral leishmaniasis, commonly known as Kala azar, is a parasitic disease caused by Leishmania protozoan and transmitted by sandflies.
- The disease classically occurs in rural agricultural villages where houses are frequently constructed with mud walls and earthen floors, and cattle and other livestock are kept close to human dwellings.
- An estimated 200,000 to 400,000 new cases of Kala Azar occur worldwide each year. Over 90% of those new cases occur in 6 countries: Bangladesh, Brazil, Ethiopia, India, South Sudan and Sudan.
- Kala azar is one of the few neglected tropical diseases which, if left untreated, can be fatal.
- Symptoms include: prolonged fever, weight loss, swelling of liver and spleen and anaemia.
- New tools for diagnosis and treatment of Kala azar include rapid tests and single dose treatment using Liposomal Amphotericin B (Ambisome). The most widely used is the rk39 rapid test which is easy to perform, quick (results in 10‐20 minutes), and cheap.
- Control strategies include: Integrated Vector Management, surveillance, diagnosis and treatment of primary Kala Azar patients, diagnosis and treatment of PKDL and asymptomatic carriers including co-infected patients such as HIV-VL patients.
- India aims at eliminating Kala azar by the year 2017.
- Post Kala azar dermal leishmaniasis (PKDL) is a skin condition that develops within 6 months to 1 year (or more) after the completion of the Kala azar treatment. 5-10% patients may develop PKDL. PKDL’s treatment must be prioritized to achieve complete elimination of this disease.
- India bears the highest burden of Kala azar cases, with Bihar contributing 80‐90% of the reported case
- More than 90% cases occur in just six countries: Bangladesh, India, Nepal, Sudan, Ethiopia and Brazil
- Bangladesh, Nepal and India are the three most affected countries in South East Asia, spread over 109 districts.
- An estimated 1.3 million new cases and 20 000 to 30 000 deaths occur annually
- Found in more than 60 countries with a total of 200 million people at risk.
- Population at risk: 34.65 million, in 11,500 villages (approx.) spread over 429 PHCs.
- Off the 38 districts in Bihar, 33 are officially recognized as affected.
- Off these 33 districts, 11 districts contribute to about 70% cases. These districts include: Araria, Darbhanga, East Champaran, Madhepura, Muzaffarpur, Purnia, Saharsa, Samastipur, Saran, Sitamarhi and Vaishali.
- Most reported cases belong to northern Bihar constituting the flood plains of major districts.
MSF’s role in effective control of Kala azar in Bihar:
- MSF is an international humanitarian organization working in India since 1999.
- In Bihar’s Hajipur Sadar hospital MSF has been providing diagnosis and treatment to people suffering from Kala azar.
- MSF supported a Kala azar ward inside the Sadar District hospital in Hajipur as well as five primary health centres (PHCs) in Goraul, Vaishali, Mahua, Mahnar and Paghapour.
- In September 2014, the first-line treatment for kala azar in India was changed to a single dose of Liposomal Amphotericin B (LAmB). The policy was changed following crucial safety evidence from an MSF- Drugs for Neglected Diseases initiative (DNDi) pilot study. The change to single dose LAmB set a milestone towards achieving the elimination of kala azar in line with the national 2015 elimination goal.
- Since the roll-out of the newly available treatement by the national government as per the new treatment protocol, MSF has been extending its support to the Ministry of Health and Family Welfare (MoHFW), the National Vector Borne Disease Control Programme (NVBDCP), and the Rajendra Memorial Research Institute (RMRI) thereby contributing to improving the health status of at-risk populations in India.
- MSF calls for increased awareness, active case detection and the implementation of an effective, patient-friendly treatment protocol for PKDL. PKDL patients are reservoirs of infection that poses a major challenge to Kala azar elimination efforts
- In 2013, MSF decided to start focusing on HIV/KA co-infection providing support to screen and counsel kala azar patients for HIV in Sadar Hospital. If patients tested HIV positive then MSF worked with the ART centre of Hajipur to immediately start antiretroviral therapy.
Future role of MSF in Bihar
- Kala Azar is considered to be an opportunistic infection and therefore, HIV-infected patients are more likely to develop symptomatic VL or Kala Azar. Co-infected patients are at a higher risk of relapse and death because VL adversely affects the response to antiretroviral treatment.
- Currently, there are no evidence-based treatment recommendations for co-infected patients in India or Asia. Therefore, MSF in collaboration with Rajendra Memorial Research Institute of Medical Sciences (Patna) will test the most effective treatment regimen for the HIV-VL coinfected cohort of patients at the Sadar Hospital in Hajipur, Bihar.
- MSF will continue to work in Sadar Hospital, Hajipur, but it will limit its focus on the diagnosis and treatment of HIV-VL patients.
- Although Bihar has a relatively low prevalence of HIV (between 0.22 – 0.33%), its high population density means that in absolute numbers an estimated 300,000 people in the state live with HIV/AIDS.
- Evidence on the prevalence of HIV-VL co-infection in India is scarce, although estimates range from 2-5.6%. HIV-VL co-infection therefore appears to be an emerging public health issue in India.
MSF’s project has achieved the following since July 2007:
o Number of people screened : 38880 Using rk-39 test (rapid diagnostic test)
o Number of people admitted : 12480
o Number of people treated: Over 11,000 patients