Visceral Leishmaniasis (VL; also known as kala-azar) is an ultimately fatal disease endemic in the Indian state of Bihar, while HIV/AIDS is an emerging disease in this region. Dr. Shahwar Kazmi, Field Coordinator, VL/HIV project, Bihar, Doctors Without Borders/Médecins Sans Frontièresb (MSF), provides an in-depth analysis of how Kala azar cannot be eliminated from India unless the HIV/VL cohort is not taken into consideration.
Kala azar or Visceral Leishmaniasis (VL) is a deadly parasitic disease which spreads by the bite of infected sandflies. An infected patient experiences high-grade fever, anaemia, hepatosplenomegaly and weight-loss. Unless treated promptly, Kala azar could be fatal in a majority of cases. The disease is still endemic in the Indian sub-continent and some parts of Africa.
As per the National Vector Borne Disease Control Program (NVBDCP), a total of 6,221 cases of Kala azar were reported in India in 2016. This marks an 80 percent reduction in the number of cases in the last five years.
In the light of these achievements, Government of India (GoI) has pledged to eliminate Kala azar from India by the year 2017. The World Health Organization (WHO) defines elimination of Kala azar as annual incidence of less than 1 case per 10,000 population at the district or sub-district level.(1) In India, the elimination criterion applies to sub-district or block level.
Although, India stands poised to achieve the elimination goal, the challenge to achieve it is immense and daunting. Bihar, for example, contributes more than 75% of country’s VL burden with 33 out of 38 districts still endemic to this dreadful disease.(2)
MSF has been a strategic partner in the battle against Kala azar in India. MSF set up a project in 2007 in Vaishali, Bihar to develop a comprehensive program to combat Kala azar by integrating its approach with the state government. MSF strengthened the district hospital of Vaishali and upgraded 5 block primary healthcare centres (PHCs) to effectively use latest drugs for Kala azar treatment. This was done by extensive information, education and communication (IEC) activities, to create awareness about Kala azar symptoms, and the importance of early diagnosis and treatment at an appropriate centre. At district level hospital in Vaishali, MSF provided the technical human resource needed to run a VL treatment ward while adequate trainings were imparted to government health staff at PHC level. Further, diagnostic kits and drugs needed for VL treatment in these wards were provided and maintained by MSF. All of this was conducted in collaboration with State Health Society, Bihar.
In August 2015, the project on VL treatment was handed over to the government of Bihar. In a span of 8 years, since MSF entered Bihar, it treated more than 12,000 Kala azar patients and made a significant impact on national treatment protocol for VL in India. In September 2014, a MSF/Drug for Neglected Diseases initiative (DNDi) pilot study research demonstrated the critical safety profile of a single dose ambisome (LAmB) as the means to curb the menace of Kala azar in India. These findings were unanimously adopted by both the WHO and GoI.(2) The fact that now patients can take one drug as against a cocktail to cure Kala azar is path breaking. This not only improved treatment compliance but is also instrumental in saving numerous lives, thus making elimination of Kala azar so much more achievable in near future.
MSF is now focusing on treating people who are suffering from VL/HIV co-infection, a niche cohort of patients who may be Kala azar (VL)/HIV co-infection. A co-infected patient acts as a reservoir for perpetual transmission of L.donovani, the parasite responsible for Kala azar.(3) Additionally, Bihar is one of the few states in India where there is an upward trend in newly diagnosed people living with HIV. Although the current prevalence of HIV ranges between 0.22 % to 0.33%, this translates into around 300,000 people in absolute numbers.(4) Moreover, a HIV infected patient is 100-2300 times more prone to acquire VL.(5) All this, makes HIV-VL co-infection a significant and crucial cohort to treat before India achieves Kala azar elimination.
MSF in collaboration with Rajendra Medical Research Institute (RMRI) is conducting an operational research to decide the best treatment options for co-infected patients. MSF has now expanded its surveillance activities by hiring HIV-VL facilitators who go to different districts of Bihar and educate health staff to screen for co-infection in all HIV and VL cases and refer them for better management at MSF ward in RMRI. NVBDCP is also a vital contributor to MSF’s VL/HIV program, as it provides free of cost drugs and facilitates referrals to MSF ward. In 2016, with such a strong support base MSF treated 79 out of 96 Kala azar (VL)/HIV co-infected patients from Bihar.
There is an urgent need to effectively prevent and treat Kala azar in India. Strong political will, a seamless partnership of different stakeholders, and active community participation hold the key to reach the finishing line Further, concerted efforts from all endemic countries in the region, is key to achieve and sustain elimination of Kala azar. With active collaboration in areas of resource mobilization, capacity-building, research, innovation and information sharing along with good technical support, it is hoped that India will soon achieve the goal of Kala Azar elimination.
1. World Health Organization. Regional Office for South-East Asia. Indicators for monitoring and evaluation of the kala-azar elimination programme [Internet]. WHO-TDR. 2010. Available from: http://www.who.int/tdr/publications/documents/kala_azar_indicators.pdf
2. MOHFW. Operational Guidelines on Kala Azar Elimination in India-2015 [Internet]. Operational Guidelines on Kala Azar. New Delhi; 2015. Available from: www.nvbdcp.gov.in
3. WHO. Kala-azar elimination programme. World Heal Organ 978 92 4 150949 7. 2015;(February):Report of a WHO consultation of partners Geneva, S.
4. Pandey A, Sahu D, Bakkali T, Reddy D, Venkatesh S et al. Estimate of HIV prevalence and number of people living with HIV in india. BMJ Open. 2012;2(10).
5. Burza S, Mahajan R, Sinha PK, van Griensven J, Pandey K, Lima MA, et al. Visceral Leishmaniasis and HIV Co-infection in Bihar, India: Long-term Effectiveness and Treatment Outcomes with Liposomal Amphotericin B (AmBisome). PLoS Negl Trop Dis. 2014;8(8):1–12.