Kala-azar

Background
Kala-azar is a vector-borne disease caused by the parasite Leishmania donovani, which is
transmitted by the sandfly Phlebotomus argentipes. The disease is characterized by fever for
more than two weeks with spleenomegaly, anaemia, and progressive weight loss and sometimes
darkening of the skin. In endemic areas, children and young adults are the principal victims. The
disease is fatal if not treated on time. Kala-azar and HIV/TB co-infections have emerged in
recent years.
The government of Nepal is committed to the regional strategy to eliminate Kala-azar and signed
the memorandum of understanding that was formalized at the World Health Assembly in 2005,
with the target of achieving elimination by 2015. In 2005, the EDCD formulated a National Plan
for Eliminating Kala-azar across preparatory (2005-2008), attack (2008–2015) and consolidation
(2015 onwards) phases for the plan’s goals, target, objectives and strategies. The expected
outputs of the plan are related to the components of the system that need strengthening. One is to
develop a functional network that provides diagnosis and case management with special outreach
to the economically back warded people.
Goal, objectives and strategies
The national plan was revised in 2010 as the National Strategic Guideline on Kala-Azar
Elimination in Nepal that recommended rK39 as a rapid diagnostic test kit and Miltefosine as the
first line of treatment in Kala-azar in most situations. The updated national guideline on KA
Elimination Program (2019) has also recommended Liposomal Amphotericin B and a
combination regimen for Kala-azar and PKDL treatment in Nepal. The Liposomal Amphotericin
B has been rolled out in all treatment centers since 2016.
Major activities in 2074/75
Case detection and treatment
 Early case detection and complete and timely treatment is the mainstay of eliminating
Kala-azar.
 Kala-azar related diagnostic and treatment services are provided at PHCC and above
levels of health facilities while awareness, health education, follow-up for treatment
compliance, identification and referral of suspected cases are also offered at health posts.
Indoor residual spraying in priority affected areas
 In 2074/75 two rounds of selective indoor residual spraying were carried out in
prioritized Kala-azar affected areas of endemic districts based on the national IRS
guideline.
 IRS is carried out only in villages where kala-azar cases were recorded in the previous
year or in areas with an outbreak in the recent past.
 The kala-azar programme also benefits from IRS for the prevention of malaria.
Use of liposomal amphotericin-B as first line treatment regimen
 The WHO Expert Committee on Leishmaniasis in 2010 and the Regional Technical
Advisory Group (RTAG) for the kala-azar elimination programme in 2011 recommended
Liposomal Amphotericin B (L-AmB) as the first line regimen during the attack phase in
the Indian subcontinent.
 Taking into consideration its high efficacy, safety, ease of use and assured compliance,
the results of a phase 3 trial evaluating three regimens for combination therapy showed
excellent efficacy and safety across all three regimens.
 The combination regimens has been recommended as second line regimens for the Indian
sub-continent in the attack phase.
 In the long term, combination regimens are the best way to protect individual drugs from
developing resistance.
 Monotherapy with Miltefosine or Paromomycin is a fourth choice (after Amphotericin B)
in the expert committee’s recommendations.
 L-AmB was introduced in Nepal in December 2015 after training about 60 doctors and
nurses from endemic districts.
 The therapy should be directly observed and patients should be hospitalized for the full
duration of the therapy.
  L-AmB needs a cold chain (<25°Celsius) for storage; and therefore should be made
available only in hospitals where proper storage is ensured.

RDT scaling up (Rapid diagnostic tests)

 RDT is the simple test that can be used at all level of health care services.
 It does not need highly skilled laboratory staffs and test results expedite the initiation of
treatment provided standard case definitions are followed.
 They are currently the best available diagnostic tool for Kalaazar diagnosis and can be
used in any field setting.
 Therefore, in 2074/75 a diagnostic tool update of reporting tools at all PHCC level has
been conducted.
 Recently rK39 (RDT) is available at Kala-azar affected districts from level II and above
health institutions.
 There is provision of supply on demand to any health facility in high degree of clinical
suspicion.
Orientation on updated national guidelines on KA Elimination Program
 Medical officers, nursing staff, laboratory staffs and other paramedics will be offered
training in coming year on the revised national Kala-azar guidelines and treatment
protocols.
Kala-azar review meeting
 A review meeting was held with DHO and district hospital personnel and the focal
persons of all Kala-azar endemic and non-endemic districts focusing on data verification,
line listing update and the revised treatment protocols.
 National Kala-azar Technical Working Group Meeting: One event of national Kala-azar
Technical Working Group Meeting was conducted in Kathmandu where various issues
regarding Kala-azar were discussed.
Disease surveillance
 Kala-azar tends to be under reported as most data is obtained through passive case
detection especially from government hospitals.
 During 2074/75, active case detection was carried out in endemic and non-endemic
Rural/Municipalites.
 This was done through case based and camp based approach.
 The sites were selected based on the number of new cases reported in the previous and
running fiscal year.
 Community-based house to house searches were carried out by district team, local health
facility staffs and FCHVs for suspected kala-azar and PKDL cases.
  Suspected cases were then screened clinically by physicians and rapid diagnostic kits
(rK39) at health facilities by laboratory persons and other health workers. rK39 positive
cases were referred to district, zonal hospitals and center for further confirmation and
management.
Trend of kala-azar cases
 The number of Kala-azar cases has been decreasing significantly in recent years.
 In 2072/73 a total of 267 Kala-azar cases were reported out of which 250 cases were
native.
 Of all the native cases 181 (72.4%) were from the 18 program district.
 However, no cases were reported from Parsa although being one
 from program district. As well, 32 non-programme districts reported 69 cases in
2072/73.
 In 2073/74, 231 Kala-azar cases were reported from various parts of the country which is
slight decrease compared to previous year.
 In 2074/75, there has been slight increase in reported cases (239 Kala-azar cases)
compared to previous year.
 Out of all cases 122 Kala-azar cases were reported from 17 program districts where the
most cases reported are from Palpa (19), Sarlahi (17) and Morang (16) while the
programme district Parsa reported no cases this year.
 However, there has been rapid increase in Kala-azar cases compared to previous years
among non-programme districts.
 Similarly, out of 239 total cases, 5 cases of Post Kala-azar Leishmaniasis (PKDL) from-
Mahottari, Morang, Saptari and Siraha as well as, 12 cases of Cutaneous Leishmaniasis
(CL) has been reported from different districts in the year 2074/75 namely- Baitadi,
Kailali, Kalikot, Kanchanpur, Ramechhap, Rautahat, Rolpa, Syangja and Tanahun.
 This epidemiological shifting indicates that the programme should conduct a vector
survey to map the presence of the vector and the indigenous transmission of the disease.
Strengths, weakness, challenges and Recommendations of Kala-azar Elimination Program
Strengths
• Implementation of Health Management Information System (HMIS) and Early Warning and
Reporting System (EWARS) for surveillance of Kala-azar.
• Use of multi-disciplinary approach to overcome the challenges for elimination of Kala-azar.
• Use of different approaches of active case detection of Kala-azar like-camp based approach,
index case-based approach.
Weakness
• At present disease, surveillance is mostly passive and some of the cases of private sector is
missing which is merely covered by the surveillance system.
• Lack of trained staffs to monitor outbreak investigation and response efforts in non-endemic
districts.
• Inadequate awareness about disease among community population.

Challenges
• Networking with dermatologists for confirmation of PKDL cases since variable presentation of
these cases requires expertise on diagnosis.
• Contribution of varied factors like- local transmission and lack of epidemiological evidence
leading to Kala-azar infections.
Recommendations
• Dissemination of educational message to public, public health professionals and policy makers
related to Kala-azar.
• Improving investigation and management of outbreaks.
• Complete reporting of outbreak within one month of closing the outbreak investigation and
response.
• Verification of endemicity status of Kala-azar reporting in new case reported districts.
• Expand Kala-azar related strategies and activities to all districts in the country where cases are
seen or where there is probability of transmission.