Bill & Melinda Gates Foundation

Kala Azar elimination – within our reach

March 16, 2016

Today is Kala Azar Day and it is a good time for us to reflect on where we stand as we work toward the elimination of this disease. A potentially fatal parasitic disease, Kala Azar has been affecting thousands of lives in Bihar. The state alone accounts for around 76% of the 8,240 recorded cases in India in 2015 (data sourced from the National Vector Borne Disease Control Programme), and cases are found in 33 of its 38 districts. Transmitted by the bite of a female sand-fly -- which is one-third the size of a mosquito – the disease is affecting the poorest of the poor, partly due to the propensity of sandflies to inhabit kutcha houses and thrive in damp conditions with readily available organic matter. Female sandflies seek animal or human blood to help nourish their eggs, and incidentally transmit the disease-causing parasites from one patient to another.

Bihar recognizes Kala Azar as a public health problem and is committed towards its elimination – the state has developed a roadmap with targets and goals to track progress. Through strong planning, earmarking and disbursing funds, and most importantly through timely spray coverage and treatment, the government has made significant progress in the activities that will lead the state to elimination. These focused efforts by the Government of Bihar seem to be working - both the number of cases and number of deaths due to Kala Azar are coming down steadily. According to the currently available data sourced from the National Vector Borne Disease Control Programme, from as many as 23,084 cases in 2010, this number has dropped to 6,280 in 2015 while the number of reported deaths have come down from 95 to 5 during the same period.

The good news is that success is within our reach and there is high probability that current approaches using available solutions will help bring down the incidence of the disease to very low levels, and virtually eliminate deaths from the disease. However, certain challenges remain that might slow down success unless vigorously addressed. Firstly, early diagnosis and treatment is critical - Kala Azar starts with a low-grade fever, weakness, loss of appetite and eventually leads over many weeks to persistent high fever, anemia and enlargement of the spleen and liver with darkening of skin and protrusion of the belly, progressive emaciation and death unless treated. A majority of patients incur high medical costs as they undergo routine antibiotic or anti-malarial treatment, which do not work if the fever is due to kala azar. The specific drugs that work for Kala Azar treatment are limited in number and are too expensive for most patients to afford. Since late 2014, the Government of India, with the help of WHO, has made available a single-dose treatment in most of the highly affected districts in Bihar, an effective and safe regime. Early diagnosis and treatment with such effective drugs ensures that patients stop transmitting the disease to sandflies around them, and thus quickly stop spreading the disease.

Conversely, incorrect diagnosis often leads to delay in detection and treatment of Kala Azar, resulting in these patients transmitting the disease further into the community they live in.

Secondly, Kala Azar is a vector borne disease that spreads through the bite of the sand-fly and is not contagious. For protecting those living in kutcha houses, especially in villages that have

been affected by a case in the previous three years, the program currently offers free-of-cost spraying of the walls of all the rooms with a Synthetic Pyrethroid or SP (currently, alpha-cypermethrin) twice a year. So that the sandflies might not become immune to SP soon, faster than they did to DDT over the last few decades, the Bihar government is planning to quickly scale up its use replacement of DDT in all 33 Kala Azar affected districts in June 2016. Further, additional responsive spraying in and around the home of the affected case is also being explored.

Thirdly, very simple solutions from people can help prevent contacting Kala Azar – such as wearing clothes that cover the body, especially the lower half, particularly in the evening, can reduce the probability of getting bitten by the sand-fly. Breaking some old and entrenched habits is critical, for instance, sleeping on the ground and near domestic animals like cows and goats increases chances of being bitten and should ideally be avoided.

The government’s commitment towards this effort is commendable - efforts in coordinating the delivery of supplies, mobilizing community healthcare workers, and ensuring timely identification and treatment of active Kala Azar cases spread over large populations under challenging conditions, must be applauded. We have seen in the case of polio elimination that major accomplishments are feasible with relentless determination. As Bihar takes strides towards eliminating this disease, it is all of our duty to renew the focus and commitment to protect many whose lives are at the risk of infection.

This article was originally published in  'Prabhat Khabar' on the occasion of Kala Azar day.

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