World Report
India makes good progress in combating kala-azar India’s efforts to tackle visceral leishmaniasis are producing positive results but will the country reach its target of elimination by the end of 2015? Sophie Cousins reports from Bihar.
Sophie Cousins
Banana plantations and palm trees line the gravel, pot-holed narrow road to Narayanpur village in Vaishali district, Bihar, India’s poorest state. It’s a couple of hours from Patna, Bihar’s grimy capital city. In Narayanpur, like other villages in Bihar, huts are made from mud; the floors are earthen and people sleep on the floor in close proximity to their livestock. Such conditions are ideal for sandflies to breed. Transmitted by the bite of a sandfly, visceral leishmaniasis, also know as kala-azar is a neglected tropical disease that affects the poorest of the poor and if left untreated will ultimately be fatal. India has 50% of the world’s cases and 70% of those are in Bihar. “The most malnourished people with weak immune systems are affected”, said Abhishek Mishra, district programme officer at CARE India who is working on the disease. “It has been an uphill task to bring kala-azar to the table; to shift focus from other diseases to it.” But that uphill battle has been worth it, say health-care workers who’ve been working to eliminate visceral leishmaniasis in India. According to India’s National Health Policy, the country aims to eliminate it by the end of 2015. Elimination is defined by having less than one case per 10 000 people at a district level. India’s goal is in line with the WHO Regional Strategic Framework for elimination of the disease from the southeast Asia region (2011–15). Rita Kuwar, an Accredited Social Health Activist (ASHA) in Narayanpur village, contracted visceral leishmaniasis in 1993 and at the same time, four other family members also had the disease. The closest primary health-care centre (PHC) had no treatment, so she went to the nearest government hospital where she was admitted for 3 months. “Things have changed”, Kuwar said. “There used 1716
to be such a stigma around the disease but now we don’t find stigma even among the lower castes.” Kumar’s role, along with her colleagues, is to educate the community about the risks, symptoms, and treatment of visceral leishmaniasis. “5 years ago we used to find patients in villages—now people come to us or their nearest PHC or hospital”, Kirar Devi, another ASHA worker, said. “People’s behaviour has changed—they use mosquito nets, keep neat and clean, and they know the cause of the disease.”
“‘The progress made in India is evidence of good coordination and cooperation among all actors…but it needs to be maintained’...” What has also changed is the treatment protocol. From 2005 until late last year, the preferred treatment in India was a 28-day oral treatment protocol of miltefosine but because of the distance to reach hospitals and for economic reasons, the number of people unable to follow the treatment was high. Concerns also existed about its efficacy and the need for women of child-bearing age to take contraception for up to 3 months after the treatment. “It was difficult to monitor whether people took the tablets or not. Often patients would take them for 15 days— until their fever went—and then they would relapse”, Kuwar said. But since the introduction of a singledose of liposomal amphotericin B (AmBisome; Gilead Sciences), which only requires one intravenous infusion taking 2 hours, treating the disease has been made substantially easier. However, initially policy makers were hesitant of the drug because of its high cost and the need to maintain a cold-chain, said Temmy Sunyoto,
medical coordinator at Médecins Sans Frontières (MSF). But WHO, through an agreement with Gilead Sciences committed to provide supplies to cover the predicted caseloads until the end of 2016, and as required until 2021. In February this year, Dharmendra Kumar contracted visceral leishmaniasis. For 2 months he’d had a persistent fever that he’d treated with over-the-counter medication. “I’d heard of kala-azar but I wasn’t sure of the symptoms”, he said. “When I had a fever I thought it was a general fever but now I’m aware. I went to the closest PHC and was tested, diagnosed, and treated by a single dose. Since being treated I’ve put more emphasis on better hygiene and have been trying to mobilise the community to do so too.” The single-dose treatment is available across 28 districts in Bihar at the district hospital level, and at a few PHCs supported by MSF, but Sunyoto hopes it will be available in most PHCs soon. Despite the substantial progress that has been made on elimination— in 2011 there were 25 222 cases of visceral leishmaniasis and 76 deaths in Bihar compared with 7615 cases in 2014 and ten deaths, according to the National Vector Borne Disease Control Programme—international experts doubt that the government’s target will be reached this year. Co-infection with HIV is a growing concern and so too is post-kala-azar dermal leishmaniasis. “I doubt kala-azar can be eliminated by the end of this year”, Sunyoto said. “[But] the impact of kala-azar elimination for patients will change their lives.” Nines Lima, an MSF Tropical Medicine Adviser, agreed. “The progress made in India is evidence of good coordination and cooperation among all actors… but it needs to be maintained”, she said.
Sophie Cousins www.thelancet.com Vol 385 May 2, 2015
India makes good progress in combating kala-azar India’s efforts to tackle visceral leishmaniasis are producing positive results but will the country reach its target of elimination by the end of 2015? Sophie Cousins reports from Bihar.
Sophie Cousins
Banana plantations and palm trees line the gravel, pot-holed narrow road to Narayanpur village in Vaishali district, Bihar, India’s poorest state. It’s a couple of hours from Patna, Bihar’s grimy capital city. In Narayanpur, like other villages in Bihar, huts are made from mud; the floors are earthen and people sleep on the floor in close proximity to their livestock. Such conditions are ideal for sandflies to breed. Transmitted by the bite of a sandfly, visceral leishmaniasis, also know as kala-azar is a neglected tropical disease that affects the poorest of the poor and if left untreated will ultimately be fatal. India has 50% of the world’s cases and 70% of those are in Bihar. “The most malnourished people with weak immune systems are affected”, said Abhishek Mishra, district programme officer at CARE India who is working on the disease. “It has been an uphill task to bring kala-azar to the table; to shift focus from other diseases to it.” But that uphill battle has been worth it, say health-care workers who’ve been working to eliminate visceral leishmaniasis in India. According to India’s National Health Policy, the country aims to eliminate it by the end of 2015. Elimination is defined by having less than one case per 10 000 people at a district level. India’s goal is in line with the WHO Regional Strategic Framework for elimination of the disease from the southeast Asia region (2011–15). Rita Kuwar, an Accredited Social Health Activist (ASHA) in Narayanpur village, contracted visceral leishmaniasis in 1993 and at the same time, four other family members also had the disease. The closest primary health-care centre (PHC) had no treatment, so she went to the nearest government hospital where she was admitted for 3 months. “Things have changed”, Kuwar said. “There used 1716
to be such a stigma around the disease but now we don’t find stigma even among the lower castes.” Kumar’s role, along with her colleagues, is to educate the community about the risks, symptoms, and treatment of visceral leishmaniasis. “5 years ago we used to find patients in villages—now people come to us or their nearest PHC or hospital”, Kirar Devi, another ASHA worker, said. “People’s behaviour has changed—they use mosquito nets, keep neat and clean, and they know the cause of the disease.”
“‘The progress made in India is evidence of good coordination and cooperation among all actors…but it needs to be maintained’...” What has also changed is the treatment protocol. From 2005 until late last year, the preferred treatment in India was a 28-day oral treatment protocol of miltefosine but because of the distance to reach hospitals and for economic reasons, the number of people unable to follow the treatment was high. Concerns also existed about its efficacy and the need for women of child-bearing age to take contraception for up to 3 months after the treatment. “It was difficult to monitor whether people took the tablets or not. Often patients would take them for 15 days— until their fever went—and then they would relapse”, Kuwar said. But since the introduction of a singledose of liposomal amphotericin B (AmBisome; Gilead Sciences), which only requires one intravenous infusion taking 2 hours, treating the disease has been made substantially easier. However, initially policy makers were hesitant of the drug because of its high cost and the need to maintain a cold-chain, said Temmy Sunyoto,
medical coordinator at Médecins Sans Frontières (MSF). But WHO, through an agreement with Gilead Sciences committed to provide supplies to cover the predicted caseloads until the end of 2016, and as required until 2021. In February this year, Dharmendra Kumar contracted visceral leishmaniasis. For 2 months he’d had a persistent fever that he’d treated with over-the-counter medication. “I’d heard of kala-azar but I wasn’t sure of the symptoms”, he said. “When I had a fever I thought it was a general fever but now I’m aware. I went to the closest PHC and was tested, diagnosed, and treated by a single dose. Since being treated I’ve put more emphasis on better hygiene and have been trying to mobilise the community to do so too.” The single-dose treatment is available across 28 districts in Bihar at the district hospital level, and at a few PHCs supported by MSF, but Sunyoto hopes it will be available in most PHCs soon. Despite the substantial progress that has been made on elimination— in 2011 there were 25 222 cases of visceral leishmaniasis and 76 deaths in Bihar compared with 7615 cases in 2014 and ten deaths, according to the National Vector Borne Disease Control Programme—international experts doubt that the government’s target will be reached this year. Co-infection with HIV is a growing concern and so too is post-kala-azar dermal leishmaniasis. “I doubt kala-azar can be eliminated by the end of this year”, Sunyoto said. “[But] the impact of kala-azar elimination for patients will change their lives.” Nines Lima, an MSF Tropical Medicine Adviser, agreed. “The progress made in India is evidence of good coordination and cooperation among all actors… but it needs to be maintained”, she said.
Sophie Cousins www.thelancet.com Vol 385 May 2, 2015
