Kala-azar Situation in Bangladesh
Training on Outbreak Management for Kala-azar in Bangladesh
Presenter: Dr. Mohammad Sohel ShomikDeputy Project Coordinatoricddr,b
Leishmaniasis
A group of diseases, caused by the Leishmania
parasites and transmitted by the sandfly
Types of Leishmaniasis
Visceral Leishmaniasis (VL)/ Kala-azar
It is characterized by irregular bouts of fever, weight loss,
enlargement of the spleen and liver, and anaemia. It is fatal if
left untreated.
Cutaneous/ mucocutaneous Leishmaniasis
It is the most common form of leishmaniasis and causes skin
lesions, mainly ulcers, on exposed parts of the body, leaving
life-long scars and serious disability.
Post Kala-azar Dermal Leishmaniasis (PKDL)
PKDL is a sequel of visceral leishmaniasis that appears as
macular, papular or nodular rash usually on face, upper arms,
trunks and other parts of the body. People with PKDL are
considered to be a potential source of kala-azar infection.
Global disease burden
Leishmaniasis (visceral leishmaniasis & cutaneousleishmaniasis) is the third most important vector-born diseases in the world with an estimated 1.0 to 1.6 million cases per year
According to WHO estimates:
― Incidence of visceral leishmaniasis (VL) is 0.2 to 0.4 million cases/year
― VL affects 98 countries worldwide and 90% of all VL cases occurs in only 6 countries
― VL kills about 20,000 to 40,000 people per year
Source: WHO (most endemic counties are highlighted in red)
VL burden in the Indian subcontinent
200 millions population are at risk
Annually 25,000 to 40,000 cases are reported
200-300 deaths occur per year
Source: Joshi et.al (2008)
VL situation in Bangladesh
Total Population- 160 million population (approx.)
Population at risk - around 31 million (approx.)
Kala-azar reduced more than 91%
Endemic Districts- 26
Endemic Upazilas- 100
Hyper endemic upazila-02
Moderate endemic upazila – 06
Low endemic upazila – 92
Sources: CDC, DGHS, 2014
Unique epidemiological features of VL in the Indian subcontinent
Sand fly Vector
VL patient/host
Visceral leishmaniasis
Case fatality rate is 100% if VL is not treated properly
Human are the only reservoir/host
Female Phlebotomasargentipes sand fly is the only vector
Leishmania donovani is the only species responsible for VL
The disease is highly clustered
VL Elimination Program in the Indian subcontinent
The Government of Bangladesh, India and Nepal committed to eliminate VL from the Indian sub-continent by 2015.
The elimination target is to
reduce VL case less than
one per 10,000 people at
sub-district level in Bangladesh
• Recently the elimination target time is extended up to 2017 and two new countries (Bhutan and Thailand) joined in this initiative
Strategy of National Kala-azar Elimination Program in Bangladesh
1. Early diagnosis and complete treatment
2. Integrated vector management (IVM)
3. Effective disease surveillance
4. Social mobilization and building partnerships
5. Operational research
Strategy -1: Early diagnosis and complete treatment
Diagnosis of Visceral Leishmaniasis (VL)
New Kala-azar Kala-azar Treatment Failure Kala-azar Relapse
Fever more than two weeks Fever more than two weeks Fever more than two weeks
Residing/Traveling in Kala-
azar endemic areas
No improvement of initial
treatment within six months or
reappearance of symptoms and
sign of Kala-azar
Reappearance of symptoms
and sign of Kala-azar six
months after treatment
Splenomegaly Splenomegaly Splenomegaly
rk 39 strip test positive rk 39 strip test positive rk 39 strip test positive
Parasitological confirmation
through splenic smear or bone
marrow exination or PCR
Parasitological confirmation
through splenic smear or bone
marrow exination or PCR
Picture (VL)
Diagnosis of Post Kala-azar Dermal Leishmaniasis (PKDL)
Residing / travelling in the endemic areas
History of treatment for Kala-azar any time in the past.
Suggestive skin lesion without loss of sensation, which may be hypomelanotic,
macular, papular, nodular or mixed.
Exclusion of other causes of skin disease like Leprosy, Vitiligo, Pityriasis, Ring
worm, Arsenicosis etc.
rk39 positive/ Slit skin smear positive/ PCR positive.
Cutaneous Leishmaniasis (CL)
CL should be suspected in a person or a case of single or multiple
skin ulcer (granulomatous, eschar like) who travelled in an endemic
areas of CL (Middle East, South America, Africa etc.).
CL should always be confirmed by demonstration of parasite from
the lesion by slit skin smear, skin biopsy or parasite DNA in tissue
specimen.
Lab Test for Kala-azar
rk39 strip test is the most effective laboratory tool for diagnosing VL
Other methods are the splenic aspiration cytology, different
molecular tests (PCR, ELISA), DAT etc
Slit-skin smear or skin biopsy is used in patients with skin involvement
Treatment of VL
New Kala-azar:
- Liposomal Amphotericin B (AmBisome); [10 mg/kg single dose]
Treatment Failure / Relapse:
- Liposomal Amphotericin B (AmBisome) [Day 1]
+ Inj. Paromomycin [Day 2 – day 11]
- Cap. Miltefosine [For 10 days] + Inj. Paromomycin [For 10 days]
- Liposomal Amphotericin B (AmBisome) [Day 1]
+ Cap. Miltefosine [Day 2 – day 8]
Treatment of PKDL
First line treatment:
Miltefosine
• Adult dose: 100 mg daily for 12 weeks in two divided doses.
• Children: 2.5 mg/kg body weight/ day in two divided doses, not exceeding 50mg/day for 12weeks.
Second line treatment:
a. Amphotericin B deoxycholate : Dose: 4 courses of 20 injections IV over 5-6 months inevery alternate day dose.
b. LAmB : 5mg/kg/day total 20mg/kg in 4 divided dose once in a week
c. Sodium Stibogluconate (SSG) : 20-mg/kg/day in intramuscular route. Total 6 cycles andeach cycle consists of 20 days of treatment and 10 days in between two cycles.
Active VL and PKDL Case Detection
Camp Approach
Focal Approach
Incentive based approach
House to house survey
Active Surveillance: ACD ― House to house visit for Kala-azar case detection (2013
&2014)
― Camp: Union (2015) & Village (2012) based
― No Kala-azar Transmission Activity (2014)
Strategy-2: Integrated vector management (IVM)
Vector Control Tool
Indoor residual spraying with insecticide (IRS)
Long-lasting insecticide treated bed-net
Impregnation of existing bed-net with long-lasting
insecticide tablet
Insecticide treated wall lining
Environmental management
Integrated Vector Management (IVM)
Indoor Residual Spraying Larvicide Spraying
WALL LINING Bed-net Impregnation
Risk Factor for VL
Socioeconomic condition
Malnutrition
Population mobility
Environmental changes
Climate changes
Source: WHO (http://www.who.int/mediacentre/factsheets/fs375/en/)
Strategy -3: Effective Disease Surveillance
Kala-azar Surveillance in Bangladesh
Kala-azar surveillance is a part of web-based national disease surveillance system centrally managed by Kala-azar Elimination Programme, Disease control Unit, DGHS.
Kala-azar elimination program-specific indicators is incorporated in the reporting format.
In order to strengthen Kala-azar surveillance, KA surveillance units is set up at upazila and district level.
KEP has access to surveillance data in real time
Kala-azar Surveillance in Bangladesh: A Modern Surveillance
National Kala-azar Elimination Program is using both:
1. Passive Surveillance &
2. Active Surveillance
Kala-azar Surveillance in Bangladesh (Cont.)
Passive Surveillance Self reported cases identified at health facilities
Active Surveillance
Screenshot of the System
Patients Registration Treatment history and Follow-up
Main page web link for DHIS 2
http://103.247.238.75:8080/mishealth/
ReportingEvent Report
Patient’s list
Bar Diagram
Mapping
Strategy-4: Social mobilization and building partnerships
Social Mobilization and Partnership
Folk song on Kala-azar sung
at market places
Folk song on Kala-azar sung at
school premises
Kala-azar
Billboard
Some Newly Introduced IEC / BCC Materials by NKEP
PosterFlipchart
Pen-Holder
Sticker
Strategy -5: Operational research
Clinical and operational research
The research center at the SK Hospital is open to all researchers who are interested in conducting studies on VL and PKDL.
Another major success of the program is the establishment of a Kala-azarresearch center at the Surja Kanta (SK) Hospital
Trials have also been conducted with different vector control methods and studies for better diagnostic tools for VL and PKDL.
Clinical trials with miltefosine , combination drug therapy, and feasibility studies for single-dose AmBisome at the sub-district level
Achievement of NKEP
98% of the Upazila already achieved elimination target. ONELY TWO UPAZILAS are now above the target
Challenges of Kala-azar Elimination Program Establishing an effective surveillance system
Health seeking behavior
Effective community mobilization
Ignorance on PKDL
Drug resistance
Proper vector management
Cross border collaboration
Sporadic cases are reported from both non-endemic and from
eliminated Upazilas
Information on Kala-azar available
www.kalacorebd.com
Acknowledgement
THANK YOU