In India, a concerted push to eliminate kala-azar

After treating more than 13,000 people afflicted with kala-azar, Médecins Sans Frontières looks toward closing shop by the end of August and passing the ropes to the government of Bihar, India’s poorest state.

Also known as black fever or visceral leishmaniasis, kala-azar is a neglected tropical disease transmitted by the bite of a sand fly. Kala-azar affects the poorest of the poor and, if left untreated, will ultimately be fatal. Symptoms include fever, enlargement of the spleen and liver, loss of appetite and weakness.

Kala-azar is also endemic in Bihar, an eastern Indian state on the south bank of the Ganges River with a population of 100 million. Bihar has made progress in combating poverty, but more than 30 percent of people there still live below the poverty line, well above the national average.

There, huts are made out of mud and bamboo. The ground is earthen and people live in close proximity to their livestock — conditions perfect for sand flies to breed. Sand flies also love the monsoon season, which hits in June and lasts until September.

So while India has 50 percent of the world’s cases of kala-azar, 70 percent of those are in Bihar alone.

Grass-roots education

“It has been an uphill task to bring kala-azar to the table,” explained Abhishek Mishra, district program officer at CARE India who is working on the disease, “to shift focus from other diseases to it.”

But that uphill battle has been worth it, health workers said, noting the significant progress they’ve made toward eliminating the disease.

According to India’s National Health Policy, the country aims to eliminate kala-azar by the end of 2015. Elimination is defined as having less than one case per 10,000 people at a district level. Its goal is in line with the World Health Organization’s 2011-2015 regional strategic framework to eliminate kala-azar in Southeast Asia.

There were 25,222 cases of kala-azar and 76 deaths in 2011, according to the National Vector Borne Disease Control Program. Last year there were 7,615 cases and 10 deaths.

Aside from educating local communities on what kala-azar is and how it is transmitted, female front-line health workers known as accredited social health activists, a change in treatment protocol, cooperation among all actors, and indoor residual spraying have been fundamental in combating the disease.

ASHAs act as an interface between the community and the public health system. In the context of kala-azar, they educate locals about the how the disease is transmitted, its symptoms and treatment options.

“Their behavior has changed — people use mosquito nets, keep neat and clean. They know poor hygiene causes disease. But we need more awareness programs and early diagnosis if we are going to eliminate kala-azar,” ASHA Kirar Devi said.

Treatment protocol change

From 2005 until late last year, the preferred treatment in India was a 28-day oral treatment protocol of miltefosine. Due to the distance to reach hospitals and for economic reasons, the number of people unable to complete the treatment was high.

There were also concerns about its efficacy and the need for women of childbearing age to take contraception for up to three months after completing the treatment.

“It was difficult to monitor whether people took the tablets of not. Often patients would take them for 15 days — until their fever went — and then they would relapse,” Rita Kuwar, another ASHA, said.

But since the introduction of liposomal amphotericin B, or AmBisome, which only requires one two-hour intravenous infusion, treating the disease has been made significantly easier and more accessible for locals, who largely work as daily wage laborers.

However, policymakers had initial concerns on the use of the drug. Not only was it more expensive than miltefosine, but it also requires a temperature-controlled supply chain, MSF medical coordinator Dr. Temmy Sunyoto told Devex.

But WHO, through an agreement with the producers of AmBisome, Gilead Sciences, committed to provide supplies to cover the predicted caseloads until the end of 2016 and as required until 2021. MSF worked hard to have the drug implemented as well, completing several different trials on its efficacy, Sunyoto added.

“Oral drugs make sense because they’re the easiest to give but that’s not the case in India,” Nines Lima, tropical diseases adviser at MSF, explained to Devex. “There were high levels of relapse, it wasn’t working well enough and there was resistance to the drug. The new drug is super safe and effective. Knowing that it affects the poorest people and they lose wages when they’re not at work … this is the most reasonable drug to help eliminate kala-azar.”

But will the disease be eliminated this year? Despite huge progress, experts believe 2017 is a more achievable timeframe given that there are still a considerable number of cases being reported.

“Yes there are less cases, but I doubt kala-azar can be eliminated by the end of this year,” Sunyoto said. “We [also] need to define what ‘elimination’ means. There are cases that are not reported and people who get private treatment.”

In addition, Limes warned of growing concerns on HIV co-infection, and post-kala-azar dermal leishmaniasis, a complication of the disease where patients develop skin lesions six months to one year of completing treatment. She stressed however that it is possible to eliminate kala-azar — given good political will.

“The progress made in India is evidence of good coordination and cooperation among all actors … but it needs to be maintained,” she concluded.

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