NATIONAL KALA AZAR(VECTOR BORNE ‐DISEASE) CONTROL PROGRAM

Presented byMamata Manandhar

M Sc NursingBatch 2011.

Content

• History of Kala-azar in Nepal• Background• Goal• Objectives• Strategies• Major Activities• Analysis of Achievement• Problems/Constraints• Targets for 2068/69

History of Kala-azar in Nepal

• Kala-azar was originally reported in India in 1824 from where it spread to Bangladesh and Nepal.

• The DDT used in India in 1940s ravaged the sand fly population and interrupted the transmission of kala-azar.

• However, when the national malaria campaign was interrupted, kala-azar reappeared in 1970 in the Indian village of Vaishali, Bihar State.

History contd…

• In the late 1970s, the disease crossed the river and appeared in Bangladesh; shortly thereafter it entered Terai, the agricultural area in Nepal that borders Bihar State.

• In Nepal it was first reported in 1980. Since then, 21,612 people have been affected.

• Kala-azar is now endemic in 13 Nepalese districts in this border area.

• Kala-azar affects those of low socioeconomic levels in households where hygiene and sanitation are poor, favors the spreading and multiplication of the sand fly vector of the disease.

• Migrants are particularly vulnerable, as their movements entail the risks of propagating communicable diseases and infections such as HIV/AIDS, tuberculosis, malaria, and kala-azar. Nepal, and Bangladesh are the examples.

Background

• The government of Nepal 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.

Background contd…

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

• Preparatory Phase: 2005 2008; ‐• Attack Phase: 2008 2015 and ‐• Consolidation Phase: 2015 onwards.

Preparatory Phase

• The preparatory phase begins after the plan has been prepared and approved by the three countries and includes preparations for operations (including a pilot total coverage spraying operation and establishment of diagnosis and treatment facilities) in selected districts in endemic countries and monitoring (including passive and active case detection and vector monitoring).

• This will be useful in identifying constraints and operational difficulties.

• The lessons learnt during this phase can be useful in the attack phase of elimination.

Attack Phase This phase will include implementation and monitoring.The main activities proposed during this phase include the following:

• Indoor residual spraying in all the affected areas for five consecutive years in collaboration with the vector-borne disease control programme (Member States).

• Integrated vector management .

• Access to early diagnosis and complete treatment.

• Passive case detection, active case detection and vector surveillance, case-based diagnosis and monthly feedback.

• Community mobilization for vector control and for seeking early treatment.

Attack Phase contd…

• Monitoring of treatment completion and analysis of treatment failure.

• Intercountry task force meeting to review progress and exchange information (Member States and WHO).

• Quarterly monitoring, annual review to be carried out by Member States. Annual reporting to WHO on an agreed reporting format.

• Household and health facility survey once every 2-3 years (Member States with support from WHO).

Attack Phase contd…

• External country evaluation (Member States with support from WHO).

• Increasing research capacity and networking among research institutions through a research coordination mechanism (WHO and partners with Member States).

• Active case search at least once a year in rural and urban areas (Member States).

Consolidation Phase The consolidation phase will begin when total coverage by spraying has concluded i.e. at the end of the attack phase.

This phase will end after the period of three years of active surveillance has shown no increase in the incidence rate at district and subdistrict levels in endemic countries.

The main activities to be carried out during this phase include the following:

• Limited indoor residual spraying based on geographical location of cases, and in areas with high vector density (Member States).

• Intensified active case detection.

Consolidation Phase

• Early diagnosis and complete treatment to be sustained with focus on co-infections.

• Treatment adherence.• Continued activities of the attack phase such as

monitoring, research, review meetings and periodic evaluation.

Maintenance Phase (At least 2 to 3 years)• During this phase, surveillance against re-introduction of kala-azar will be

the responsibility of the disease control programme in the country until kala-azar is no longer a public health problem.

• During this phase, the case incidence at district/sub-district or should be less than 1 per 10 000 population.

• An international review commission should verify the achievements of the programme.

• Countries or affected districts in the countries where elimination targets have not been reached would require corrective measures.

• The maintenance phase will be followed by certification of the elimination status.

• The partners will decide the duration of this phase.

Background contd…

• The overall goal of the plan is “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”.

• The target is: “To reduce the annual incidence of Kalaazar to less than 1 per 10,000 populations at the district level by 2015”.

Background contd…

• Expected outputs of the Plan are six related to the different components of the system that need to be strengthened in order to achieve the elimination goal.

• One of the outputs is to develop a functional network that provides diagnosis and case management with special outreach to the poorest.

Background contd…

• EDCD has revised the recommendations for the diagnosis and treatment of Kala azar in Nepal. ‐

• The rK39 test kit has been accepted and introduced as a diagnostic test and Miltefosine as a first line treatment in Kala azar except in some situations. ‐

• This strategy is being pilot tested in Saptari district that will in turn serve as a demonstration district for all the other endemic areas to be trained.

Background contd…

• Kala azar is an vector borne disease caused by ‐ ‐parasite Leishmania donovani, transmitted by the sand fly, Phlebotomus argentipes.

• The disease characterized by fever for more than two weeks with splenomegaly, anemia, progressive weight loss and sometimes darkening of the skin. In the endemic areas, children and young adults are its principal victims.

• The disease is fatal if it is not timely treated. Kala‐azar and HIV co infections have emerged as a health ‐problem in recent years.

Background contd…

• Over the last decade, there have been some significant advances both in the diagnosis and treatment of Kala azar.‐

• The rK39 dipstick test kit, a rapid and easy applicable serological test has been demonstrated to have high sensitivity and specificity in validity studies conducted in the Indian subcontinent.

• For the first time, an oral drug Miltefosine has ‐proven to be efficacious in drug trials and has been registered for the use in Kala azar.‐

Goal

• Reduce incidence of Kala azar to less than 1 case per ‐10,000 populations at district level by 2015.

Objectives

• Reducing the incidence of Kala azar in the endemic ‐communities including the poor, vulnerable and unreached population;

• Reducing case fatality rates from Kala azar;‐

• Treatment of PKDL to reduce the parasite reservoir; and

• Prevention and treatment of Kala azar HIV–TB Co ‐infections.

Strategies

Based on the regional strategy, Government of Nepal, Ministry of Health and Population has adopted the following strategies in the implementation of the Kala azar elimination ‐program in Nepal.

• Improve program management• Early Diagnosis and Complete Treatment• Integrated Vector Management• Effective Disease Surveillance and Vector Surveillance• Social Mobilization and Partnerships• Clinical, Implementation and Operational Research

Major Activities

1. Case detection and Treatment:• Various training programs for health workers at

different health institutions were conducted so as to develop the desired competency in the prevention and control of Kala azar to achieve the Kala Azar ‐ ‐elimination by 2015.

• EDCD continued conducting training programs for the laboratory personnel from the district hospitals on rK 39 dipstick diagnosis of Kalaazar.‐

1. Case detection and Treatment contd…

• Currently health institutions in Kala azar endemic ‐districts are using this diagnostic technique.

• Peripheral level health workers were trained on appropriate skills required for prevention and control of vector borne diseases including Kala azar. ‐

1. Case detection and Treatment contd…

• Similarly, as in the previous year, Vector Borne Disease Research and Training Centre (VBDRTC) also conducted training on Kala azar and other Vector‐ ‐Borne Diseases (VBDs) for District Health Officers, Medical Officers, Public Health Officers and other health personnel.

• Kala azar elimination activities were carried out in ‐Saptari District as a pilot program.

2. Indoor Residual Spraying in Priority selected Kala‐ ‐azar Affected Areas

• Two rounds of selective Indoor Residual Spraying (IRS) was carried out in prioritised Kala azar affected areas of ‐11 districts based on the national guideline on IRS.

• IRS is carried out only in those villages where Kala azar ‐cases were recorded in previous year or in areas with an outbreak in the recent past.

• It is independent of the spray schedule, of the insecticide used (in our case, DDT in India, deltamethrin in Bangladesh; lambdacyhalotrin in Nepal)

Contd…

• Collateral benefit for the Kala azar elimination ‐program has been gained from the IRS used for the prevention and epidemic response for malaria in Kala azar endemic and Kala azar non endemic ‐ ‐districts too.

3. Continuation of Treatment through Miltefosine and Amphotericine B:

• As in the previous fiscal year, Miltefosine (oral drug) as first line drug and Amphotericin B as second line drug have been continually utilised for the treatment of Kala azar in endemic districts and Sukra Raj ‐Tropical Hospital in this fiscal year 2067/2068.

Analysis of Achievement

1. Vector Control• Indoor residual spraying in two cycles was conducted

in Kala azar affected areas of 11 endemic districts ‐with 100 percent achievements against the set targets.

• During this fiscal year a total of 1,359,085 people were protected with indoor residual insecticide spraying.

2. Case Detection and Treatment

• A total number of 806 cases were reported and treated in different health facilities in 2067/68.

• Out of the 806 cases 802 (99.5%) cases were improved after the treatment while 4 patients (0.5%) were died.

2. Case Detection and Treatment contd..

• Reported cases of Kala azar increased from 791 in ‐2066/67 to 806 in 2067/68.

• EDR reported more cases (373) in 6 endemic districts reflecting the incidence of 0.90 per 10,000 areas at risk population than the CDR (312) with incidence of 0.85.

• Highest number of cases was recorded in Morang, Mahottari, Sarlahi, Siraha, Saptari, Dhanusa and Sunsari in the chronological order.

2. Case Detection and Treatment contd..

• However, if we exclude the foreigner cases (Indian) Morang, Siraha and Saptari ranks in top in the Kala‐azar cases where there are more than 60 cases .

• The reported cases from referral hospitals like BPKIHS Dharan and Sukraraj Tropical and Communicable Disease Hospital, Teku, Kathmandu are not segregated as there is no detail about address of the patient.

2. Case Detection and Treatment contd..

• It is known that cases of Kala azar also cross the ‐border for treatment at the hospitals and private clinics from Nepal to India or vice versa.

• A total number of 173 foreigner patients of Kalazar were also treated during the reporting year.

3. Kala azar Incidence‐

• Kala azar incidence per 10,000 areas at risk populations ‐ ‐ranged from 1.95 in Morang to 0.01 in Parsa reflecting the national incidence of 0.95 per 10,000 areas at risk population ‐(excluding foreign cases).

• Out of the 12 districts 5 districts have an incidence of more than 1, while 7 districts have an incidence of less than 1case per 10,000 areas at risk population (including foreigner cases). ‐

• However, the incidence rate becomes more than 1 in only 3 districts (Morang, Saptari and Siraha), if we exclude the Indian cases of Kala azar.‐

Problems/Constraints

Targets for 2068/69

Thank you…