KALA-AZAR AND ITS ELIMINATION PROGRAM IN

NEPAL, INDIA AND BANGLADESH

Bikram ChandMPH 2nd year

HISTORY Kala-azar ( kala- black , azar – fever ).

Colour of the skin of the patient become a strange earthy-

gray.

It was first noted in India in 1880.

Epidemics of the diseases have occurred every 15-20 years.

WHAT IS KALA AZAR? Kala azar (Visceral

Leishmaniasis ) is a deadly disease caused by parasitic protozoa  Leishmania donovani,  transmitted to humans by the bite of infected female sandfly, Phlebotomus argentipes.

Incubation period10 days to 9 years

CLINICAL SYMPTOMS Can have a fatality rate as

high as 100% if untreated. Fever is the first symptom

with irregular 2-3 peaks in a day often accompanied by chills and sweating.

Weight loss. Anemia. Hepatomegaly.

KALA-AZAR SITUATIONGlobal situation Leishmaniasis threatens 350 million people in 88 countries

of which 72 are developing and 13 of then are among the least developed countries.

Burden: Estimated cases: 2.5 million, Incidence 500,000/year, 59,000 deaths/year.

Over 90% of cases occur in Indian sub-continent (Bangladesh, India and Nepal).

Kala-azar affects largely the socially marginalized and the poorest communities.

KALA-AZAR SITUATION

KALA-AZAR SITUATION Endemic in three countries

of SEA Region viz, India, Bangladesh and Nepal

Population at risk :  200 million in this region

Estimated Cases  :   100,000  / annum

DALYS                :  400,000 / annum

Disease is now being reported in 45 districts in Bangladesh, 52 in India and 13 in Nepal

KALA-AZAR IN NEPAL

(Emerged in 1980)

KALA AZAR AFFECTED DISTRICTS OF NEPAL

KALA‐AZAR CASES AND INCIDENCE: FY 2070/71

Districts Total Foreign Native Incidence/10,000

Jhapa 12 0 12 0.14Morang 84 0 84 0.84Sunari 14 0 14 0.17Saptari 46 2 44 0.67

Udayapur 1 0 1 0.03Siraha 45 3 42 0.60

Dhanusha 31 2 29 0.37Mahottari 36 10 26 0.40

Sarlahi 48 10 38 0.47Rautahat 5 1 4 0.05

Bara 1 0 1 0.013Parsa 0 0 0 0Other

districts(18)46 0 44 0

Total 367 28 339 0.34

KALA-AZAR ELIMINATION IN NEPAL

The GoN has committed to the regional strategy to eliminate Kala‐azar and with India and Bangladesh is signatory of the memorandum of understanding that was formalized during the World Health Assembly held in May 2005 on Kala‐azar elimination, with the target of achieving the disease elimination by 2015.

In 2005, Epidemiology and Disease Control Division (EDCD) of Department of Health Services formulated a National Plan for the Elimination of Kala‐azar which is divided into three phases:

1. Preparatory Phase: 2005‐2008; 2. Attack Phase: 2008‐2015 and 3. Consolidation Phase: 2015 onwards.

KALA-AZAR ELIMINATION IN NEPAL

Goal of the plan“To contribute to improving the health status of vulnerable groups and at risk populations living in Kala‐azar endemic areas of Nepal through the elimination of Kala‐azar so that it is no longer a public health problem”.

Target of the plan: “To reduce the annual incidence of Kala-azar to less than 1 per 10,000 populations at the district level by 2015.”

STRATEGIES Early diagnosis, prompt and complete treatment (EDPCT) of

Kala azar cases through strengthening of referral at the peripheral health institutions.

Early detection and timely containment of kala azar epidemics.

Establishment of appropriate laboratory diagnostic facilities. Protection of at risk population with Indoor Residual Spraying

(IRS). Promotion of health education of community awareness of kala

azar, so that early diagnosis is made and timely treatment is given.

Training of HP In- charges, PHOs, DHOs and Medical officer on kala azar control and management.

An important strategy in the control of malaria and kala-azar is prevention through indoor residual spraying and use of long-lasting insecticide-treated bed-nets (LLINs).

This strategy has been implemented through the promotion of personal protection measures, including the use of simple mosquito nets or LLINs.

The MOHP has been distributing nets through various channels in affected areas, and it set a target of 80 percent of people in high-risk areas sleeping under LLINs by 2011.

(Nepal Demographic and Health Survey, 2011)

STRATEGIES

KALA-AZAR IN INDIA(Kala-azar control Programme was launched in 1990-91)

MILESTONES1953, 1958 Insecticide Residual spraying with DDT under National Malaria Eradication

Programme resulting in marked decline in disease incidence.1970s Resurgence of Kala-azar subsequent to withdrawal of IRS. Initially reported in four districts of Bihar and then from other parts.1992 High incidence at 77102 cases and 1049 deaths. Launched centrally sponsored Kala-azar Control Programme.2000 Recommendation for elimination of Kala-azar by Expert Committee.2002 National Health Policy set the goal for Elimination of KA by 2010.2005 Tripartite Memorandum of Understanding signed between India, Bangladesh and

Nepal for elimination of Kala-azar by 2015.

KALA-AZAR ENDEMIC AREAS (52 Districts)

SCENARIO During 1970s, four districts in Bihar reported Kala-azar.

Presently, 33 districts endemic in Bihar, 11 districts in West

Bengal, 4 districts each in Jharkhand & UP.

About 80 % disease burden in country contributed by Bihar.

9 districts out of 33 districts in Bihar contributes 65-70% of

Kala-azar cases.

SCENARIO

KALA-AZAR CONTROL PROGRAM

Objective:

The Eleventh Five Year Plan for achievement by the year 2012 is reduction on mortality rate of kala-azar by 100 per cent by 2010 and sustaining elimination until 2012.

NVBDCPNational Vector Borne Disease Control Programme (NVBDCP) Under World Bank supported project, 46 Kala-Azar endemic

districts in 3 states namely Bihar, Jharkhand and West Bengal were continued under the project.

The World Bank supported project is with outlay of Rs.1000 Crores from 2008-09 to 2012-13.

However World Bank Supported Project on Kala-azar Elimination has been closed on 31.12.2013.

Now, all the project activities are being carried out with the Domestic Budgetary Support i.e. upto March 31st 2017.

MAJOR ACHIEVEMENTS 320 out of 543 Kala Azar endemic blocks have achieved elimination

(<1 case/10,000 population at block level).

Important recent initiatives taken to control Kala-azar include case

detection through rapid diagnostic kits and improved treatment

compliance by using oral drug Miltefosine.

Compensation to the patients for loss of wages and performance

based incentive to ASHAs/volunteers in endemic areas for case

detection and ensuring complete treatment have also been provided.

SITUATION IN INDIA

STRATEGY FOR KALA-AZAR ELIMINATION:

1. Parasite Elimination and disease management: Early case detection and complete treatment. Strengthening of referral.

2. Integrated vector control: Indoor Residual Spraying (IRS). Environmental management by maintenance of sanitation and hygiene.

3. Supportive interventions: Behaviour Change Communication for social mobilization. Inter-sectoral coordination. Capacity building by Training and Monitoring and Evaluation.

To realize the goal of elimination of Kala-azar, the Govt. of India provides 100% operational costs on:

1) Free diet support to patient.2) Rs. 500/- as incentive to Patient for loss of wages

irrespective of drug regimen and Rs. 2,000/- to Post Kala-azar Dermal Leishmaniasis (PKDL) cases.

3) Strengthening of human resource component by positioning State Consultants, District VBD consultants and Kala-azar Technical Supervisor for effective monitoring and supervision with vehicle and motorcycles.

STRATEGY FOR KALA-AZAR ELIMINATION:

KALA-AZAR IN BANGLADESH

(Emerged in 1970)

KA IN BANGLADESHIn late 1970s Kala-azar re-emerged sporadically.

During 1981-85 only 8 upazilas reported Kala-azar, which increased to 105 upazilas in 2004.

Number of reported cases increased from 3978 in 1993 to 8505 in 2005 and 3376 in 2011.

In 2013 : 1428 cases and 02 deaths were reported.

DISTRICT EFFECTED IN BANGLADESH

Pabna

Sirajgonj

Dinajpur

Rajsahi

Mymensingh

Natore

Tangail

Gazipur

Jamalpur

Thakurgaon

Naogaon

2013 REPORTING Hyperendemic

Upazilas: Trishal

Fulbaria Muktagachha

Moderately endemic upazillas:

Madhupur, Sokhipur Chouhali,Faridpur,

Vangura, Terokhada, Valuka,

Gafargaon

ENDEMIC AREAS OF BANGLADESH

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TREND OF KA CASES AND DEATH (2000-2013)

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TARGET: The impact objective is to reduce the incidence of Kala-azar

to less than 1 case of Kala-azar and Post Kala-azar Dermal Leishmaniasis per 10,000 population upazila level by:

Reducing the incidence of Kala-azar in the endemic communities

including the poor, vulnerable and un-reached populations.

Reducing case fatality rates from Kala-azar.

Treatment of Post Kala-azar Dermal Leishmaniasis (PKDL) to

reduce the parasite reservoir.

Prevention and treatment of Kala-azar-HIV-TB co-infections.

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ELIMINATION STRATEGY

Early diagnosis and complete treatment

Integrated vector management

Effective disease surveillance

Social mobilization and partnerships

Operational research32

References Annual Report: National Programmes under

NHM, 2014-15 Annual Report to the People on Health, 2011