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