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PERSPECTIVE
Year : 2016  |  Volume : 144  |  Issue : 6  |  Page : 799-802

Is elimination of kala-azar feasible by 2017?


Emeritus Professor of Medicine, Patna Medical College & Chairman, Balaji Utthan Sansthan, Patna 800 001, Bihar, India

Date of Submission04-Mar-2016
Date of Web Publication28-Apr-2017

Correspondence Address:
C P Thakur
Emeritus Professor of Medicine, Patna Medical College & Chairman, Balaji Utthan Sansthan, Patna 800 001, Bihar
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmr.IJMR_335_16

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How to cite this article:
Thakur C P. Is elimination of kala-azar feasible by 2017?. Indian J Med Res 2016;144:799-802

How to cite this URL:
Thakur C P. Is elimination of kala-azar feasible by 2017?. Indian J Med Res [serial online] 2016 [cited 2017 May 22];144:799-802. Available from: http://www.ijmr.org.in/text.asp?2016/144/6/799/205342

Kala-azar (visceral leishmaniasis, VL) is a major public health problem in four States of India including Bihar, affecting the poor sections of the society. The disease has been targeted for elimination by 2017. In fact, the National Health Policy, 2002 had set the goal of kala-azar elimination by the year 2010 [1] which was revised to 2015 [2] . The target date has been further revised to 2017 [3] . Elimination is defined as reducing the annual incidence of kala-azar to less than 1 case per 10,000 population at the sub-district level. At present, all programmatic activities are being implemented through the National Vector Borne Disease Control Programme [4] . With a year to go for the target date, it is opportune time to review the situation and assess the current challenges and prospects of kala-azar elimination by the due date.

As one of the neglected tropical diseases, kala-azar is reported mainly from six countries namely Bangladesh, Brazil, Ethiopia, India, South Sudan and Sudan [5] . In 2005, the Government of India, Nepal and Bangladesh signed a tripartite memorandum of understanding for the elimination of kala-azar; later on Thailand and Bhutan also joined the group. Nepal is likely to achieve kala-azar elimination soon [5] .

Historically, dichlorodiphenyltrichloroethane (DDT) was used as an insecticide during the malaria eradication programme in India launched in 1953 [6] . As a result, kala-azar was brought down to near eradication during the early 1960s. However, due to emergence of insecticide resistance in malaria vector, the DDT spray was discontinued in 1964. Thereafter, kala-azar resurged with return of sandflies [7] , leading to a big epidemic during the late 1970s, with 100,000 cases [8] . The National Kala-azar Control Programme was initiated by the Government of India in 1990-1991 [9] with sodium antimony gluconate (SAG) as the main drug used for the treatment of cases and DDT for vector control. The strategy for the national programme for the elimination of kala-azar included early diagnosis and complete case management; integrated vector management and vector surveillance; supervision, monitoring, surveillance and evaluation; strengthening capacity of human resource in health; advocacy, communication and social mobilization for behavioural impact and inter-sectoral convergence; and finally programme management [4] . The doses and duration of treatment with SAG were standardized in a study conducted in Bihar [10] . During 1991-1992, there was an epidemic of VL in Bihar, India, with 250,000 cases [11] . In our clinic in Bihar, we started using amphotericin-B in 1991 for the treatment of SAG-resistant cases and also for fresh cases [12] .

Over time, kala-azar cases in India have shown a decline from 24,212 with 93 deaths in 2009 to 8223 cases with nine deaths in 2015. Kala-azar cases in Bihar were 20,519 with 80 deaths in 2009 which decreased to 6280 with five deaths in 2015. In Muzaffarpur which was a heavily affected district of Bihar, 2308 cases of kala-azar were reported with 11 deaths in 2009, which dropped to 711 with no death in 2015, in Jharkhand there were 20,875 cases of kala-azar with 12 deaths in 2009 which decreased to 1262 cases with no death in 2015. In West Bengal, 750 cases were reported with no death in 2009 which decreased to 556 cases with no death in 2015 (nvbdcp.gov.in/Doc/Annual-report-NVBDCP-2014-15.pdf; http://nvbdcp.gov.in/ka-cd.html ). The trend analysis confirmed the declining trend in India as well as in Bihar ([Figure 1] and [Figure 2]).
Figure 1: ( A & B ) Trend analysis of total deaths and cases in kala-azar in India from 2009 to 2015.
Source: http://nvbdcp.gov.in/ka-cd.html; nvbdcp.gov.in/Doc/Annual-report-NVBDCP-2014-15.pdf


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Figure 2. ( A & B ) Trend analysis plots for total deaths and total cases in kala-azar in Bihar (India) from 2009 to 2015.
Source: http://nvbdcp.gov.in/ka-cd.html, nvbdcp.gov.in/ Doc/Annual-report -NVBDLP-2014-15.pdf..


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Considerable research has already been done in the country which provides insights on evolving situation of kala-azar in the country as well as on the treatment and prevention aspects. For example, there is evidence that DDT, used initially for malaria elimination and is manufactured in India has become less effective or ineffective [13],[14],[15],[16] . Therefore, the practice of using DDT needs to be discontinued. Instead, newer insecticides such as pyrethroids or malathion should be used.

A new oral drug miltefosine [17] which came in the market with a bang became less effective in a short span of time. Not only were there high number of relapse cases, but the cases of post kala-azar dermal leishmaniasis (PKDL) also increased after cure with miltefosine. In view of this, the drugs which need to be used in this last phase of epidemic are amBisome and amphotericin-B. Ambisome is given 10 mg/kg bodyweight on the first day, a gap of one day and another 10 mg/kg body weight of the drug on the third day. Administration of ambisome 15 mg/kg bodyweight in a single dose can be fatal, whereas divided doses have not caused any toxic effect [18],[19] . Amphotericin-B can be given at a dose of 1 mg/kg bodyweight for 20 days with precautions taken [20] . The drug should not be given if the haemoglobin is <5 g/dl. Serum levels of sodium, potassium and urea should be closely watched if toxicity appears; the drug has to be discontinued for some days and then started again.

PKDL cases require a longer time period for treatment and cure even with amBisome, two to three courses are required over 15-20 days [21] . Disappearance of all lesions should be the criteria of cure. Some cases of kala-azar complicated with HIV posed a difficult therapeutic problem; both the diseases have to be treated simultaneously [22] . Kala-azar cases with HIV infection require repeated treatment with both amBisome and antiretroviral drugs [22] .

In view of the changing scenario of kala-azar in the country, the Ministry of Health and Family Welfare, Government of India and the State Governments need to work not only for case finding but also for curing these patients with effective drugs. The omission of kala-azar in the priority list of diseases to be dealt by the government has raised a cause of concern [23] .

To achieve elimination in 2017, the Government should be ready to have a fortnightly review of kala-azar situation and the experts need to visit the affected districts in highly affected States such as Bihar, Jharkhand and West Bengal, besides keeping a close watch on all the affected States. The search of cases should be both active and passive. Supervisory support should be provided to local doctors and private practitioners alike. Any case of fever of more than two weeks duration should be tested for kala-azar.

In the severely affected areas, active search for the kala-azar cases could also be done. After due publicity patients with fever of more than two weeks duration should be asked to assemble at a common place. They should be examined for enlargement of spleen and liver, and tested for rk39 antibodies. Those found positive for anti-rk39 antibodies should be transferred to district hospitals or other secondary or tertiary care hospitals for further investigations for the confirmation of diagnosis. The idea behind this system is that patients being the only source of infection are transferred away from the area as they can be the source of infection to others through sandflies. This method was found to be effective for elimination of kala-azar in certain villages [23] . The local ecology, environmental factors and climatic conditions such as temperature and rainfall can also play an important role in disease transmission and persistence.

In conclusion, kala-azar may be eliminated by 2017 if we take up elimination programme with renewed vigour, effective drugs, better insecticides and strict supervision. Given the focal nature of the disease, availability of effective interventions including newer drugs and diagnostics, absence of animal reservoir in the Indian subcontinent, it should be possible to eliminate kala-azar from India within the time frame. This would, however, require close monitoring and evaluation of Programme activities, by reaching out to interested experts/individuals and institutions for technical support.


   Acknowledgmen Top


Author thanks Dr Arun Kumar Sinha, Former Vice-Chancellor and Head of Department of Statistics, Patna University, Patna for statistical analysis.

Conflicts of Interes: None.





 
   References Top

1.
National Health Policy-2002. Available from: http://www.mohfw.nic.in/npcb2002.htm , accessed on November 9, 2016.  Back to cited text no. 1
    
2.
National Health Policy 2015 Draft. Ministry of Health and Family Welfare; December, 2014. Available from: http://www.nhp.gov.in/sites/default/files/pdf/draft_national_health_policy_2015.pdf , accessed on November 9, 2016.  Back to cited text no. 2
    
3.
WHO. Health Ministers Commit to eliminating kala-azar. Available from: http://www.searo.who.int/mediacentre/releases/2014/pr1581/en/. accessed on November 9, 2016.  Back to cited text no. 3
    
4.
National Road Map for Kala-azar Elimination. Delhi: Directorate of National Vector Borne Disease Control Programme (NVBDCP), Directorate General of Health Services, Minister of Health & Family Welfare; August, 2014. Available from: http://www.nvbdcp.gov.in/Doc/Road-map-ka_2014.pdf , accessed on November 9, 2016.  Back to cited text no. 4
    
5.
Kala-azar Elimination Programme: Report of a WHO Consultation of Partners, Geneva, Switzerland; 10-11 February, 2015. Available from: http://www.apps.who.int/iris/bistream/10665/185042/1/9789241509497_eng.pdf , accessed on November 9, 2016.  Back to cited text no. 5
    
6.
Sanyal RK. Some observations on epiderminology of current outbreak of kala-azar in Bihar. J Commun Dis 1979; 4 : 170-82.  Back to cited text no. 6
    
7.
Sen Gupta PC. Return of kala-azar. J Indian Med Assoc 1975; 65 : 89-90.  Back to cited text no. 7
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8.
Dutta M, Ghosh TK. Reviewed of current status of leishmaniasis epidemiology. In: Mahajan RC, editor. Proceeding of the Indo-UK, workshop on leishmaniasis. New Delhi: Indian Council of Medical Research; 1983. p. 97-102.  Back to cited text no. 8
    
9.
National Kala-azar Elimination Programme. National Vector Borne Disease Control Programme, Directorate of Health Services, Ministry of Health and Family Welfare, New Delhi, India. Available from: www.nvbdcp.gov.in/kal13.html, accessed on November 9, 2016.  Back to cited text no. 9
    
10.
Thakur CP. Epidemiological, clinical and therapeutic features of Bihar kala-azar (including post kala-azar dermal leishmaniasis). Trans R Soc Trop Med Hyg 1984; 78 : 391-8.  Back to cited text no. 10
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11.
Thakur CP. Socio-economics of visceral leishmaniasis in Bihar (India). Trans R Soc Trop Med Hyg 2000; 94 : 156-7.  Back to cited text no. 11
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12.
Thakur CP, Sinha GP, Sharma V, Pandey AK, Kumar M, Verma BB. Evaluation of amphotericin B as a first line drug in comparison to sodium stibogluconate in the treatment of fresh cases of kala-azar. Indian J Med Res 1993; 97 : 170-5.  Back to cited text no. 12
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13.
Pinder M, Jawara M, Jarju LBS, Salami K, Jeffries D, Adiamoh M, et al. Efficacy of indoor residual spraying with dichlorodiphenyltrichloroethane against malaria in Gambian communities with high usage of long-lasting insecticidal mosquito nets: A cluster-randomised controlled trial. Lancet 2015; 385 : 1436-46.  Back to cited text no. 13
    
14.
Coleman M, Foster GM, Deb R, Pratap Singh R, Ismail HM, Shivam P, et al. DDT-based indoor residual spraying suboptimal for visceral leishmaniasis elimination in India. Proc Natl Acad Sci U S A 2015; 112 : 8573-8.  Back to cited text no. 14
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15.
Lines J, Kleinschmidt I. Is malaria control better with both treated nets and spraying. Lancet 2015; 385 : 1375-7.  Back to cited text no. 15
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16.
Cousins S. India unlikely to meet goal of eliminating kala-azar by 2015, say experts. B M J 2015; 351 : h4117.  Back to cited text no. 16
    
17.
Bhattacharya SK, Sinha PK, Sundar S, Thakur CP, Jha TK, Pandey K, et al. Phase 4 trial of miltefosine for the treatment of Indian visceral leishmaniasis. J Infect Dis 2007; 196 : 591-8.  Back to cited text no. 17
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18.
Berman JD, Badaro R, Thakur CP, Wasunna KM, Behbehani K, Davidson R, et al. Efficacy and safety of liposomal amphotericin B (AmBisome) for visceral leishmaniasis in endemic developing countries. Bull World Health Organ 1998; 76 : 25-32.  Back to cited text no. 18
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19.
Thakur CP, Singh RK, Hassan SM, Kumar R, Narain S, Kumar A. Amphotericin B deoxycholate treatment of visceral leishmaniasis with newer modes of administration and precautions: A study of 938 cases. Trans R Soc Trop Med Hyg 1999; 93 : 319-23.  Back to cited text no. 19
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20.
Thakur CP, Narayan S, Ranjan A. Kala-azar (visceral leishmaniasis) and HIV coinfection in Bihar, India: Is this combination increasing? J Acquir Immune Defic Syndr 2003; 32 : 572-3.  Back to cited text no. 20
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21.
Desjeux P, Ghosh RS, Dhalaria P, Strub-Wourgaft N, Zijlstra EE. Report of the Post Kala-azar Dermal Leishmaniasis (PKDL) Consortium Meeting, New Delhi, India, 27-29 June 2012. Parasit Vectors 2013, 6 : 196.  Back to cited text no. 21
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22.
Burza S, Mahajan R, Sinha PK, van Griensven J, Pandey K, Lima MA, et al. Visceral leishmaniasis and HIV co-infection in Bihar, India: Long-term effectiveness and treatment outcomes with liposomal amphotericin B (AmBisome). PLoS Negl Trop Dis 2014; 8 : e3053.  Back to cited text no. 22
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23.
Thakur CP, Kumar A, Kumar A, Sinha K, Thakur S, Sinha AK. A new method of kala-azar elimination: Shifting the reservoir of infection from that village. Glob Adv Res J Med Med Sci 2013; 2 : 163-76.  Back to cited text no. 23
    


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