Kala azar

Kala Azar elimination programme 2015

1. Dr.S.Preethi
Guide: Dr.Poonam R Naik

2. Kala azar, black fever, sandfly disease,
Dum-Dum fever

3. •1756;Russell:The first clinical description
•1898;Borovsky noted the protozoal nature of the organism
•1901;Leishman identified the parasite (Dum-Dum)
•1903;Donovan described identical organisms in a splenic
puncture (Madras)
•Ronald Ross – Leishman-Donovan bodies

5. 76.38% decline in incidence
85.20% decline in deaths

6. TYPES OF LEISMANIASIS
•VISCERAL LEISHMANIASIS (Bangladesh, Brazil, India, Nepal and
Sudan).
•CUTANEOUS LEISHMANIASIS (Afghanistan, Brazil, Iran, Peru,
Saudi Arabia and Syria,
•DIFFUSE CUTANEOUS LEISHMANIASIS
•MUCO CUTANEOUS LEISHMANIASIS (Bolivia, Brazil and Peru).
• Post kala azar dermal leishmaniasis(Endemic to India and the
Sudan)

7. •A ‘suspect’ case: history of fever of more than 2 weeks with Splenomegaly &
Hepatomegaly not responding to anti malarial and antibiotics in a patient from an
endemic area.
•Or a patient with above symptoms clinically examined by doctor and found
positive on screening with rapid diagnostic test.
•Or in cases with past history of Kala-azar or in those with high suspicion of Kala-
azar but with negative RDT test result but found (+) by examination of bone
marrow/spleen aspirate for LD bodies at appropriate level (district hospital).

8. VISCERAL LEISHMANIASIS
•Double- quotidian type of fever
•Splenomegaly
•Hepatomegaly
•Anemia
•Weight loss
•Weakness
•Skin over forehead, face, hands, feet
and abdomen is black

10. CUTANEOUS LEISHMANIASIS
•Skin ulcers on the exposed parts of the body, such as the face,
arms and legs,

11. MUCOCUTANEOUS LEISHMANIASIS
•Mucous membranes of the nose
• Mouth
•And throat cavities

12. SAND FLY
•Class : Insecta
•Order : Diptera
•Family : psychodidae
•Genus : Phelobotomus
•Small insect, dark brown in color, hairy insect, painful& irritating
bite
•Size : 1.5 to 2.5 mm in length
•30 species in India
•Kala azar : P. Argentipes
•It bites during night, lower extremities
•Blocked sand fly ( epidemiologically danger)
•Flight range : hopping movement( not more than 3 feet) , it can fly
for shorter distance

13. Bionomics
•Distribution: Eastern cost (WB – Kanyakumari)
•Seasonal prevalence: August/ September
•Feeding habits: Zoophilic
•Flight range: fly usually covers a distance less than ½ meter.
•Resting sites:soil cracks and crevices, burrows (rodent
burrows), tree holes, termite hills, caves, bird tunnel, in
earthern mounds, under stone and foliage, etc.
•Longevity: 23-27 days

14. •Phlebotomus argentipes -Visceral Leishmaniasis.
•Phlebotomus papatasi -urban Cutaneous leishmaniasis.
•Phlebotomus salehi - rural (zoonotic) Cutaneous leishmaniasis.
•Life cycle in four stages, egg, four instars of larva, pupa and adults
• Total time taken from egg to adult reported to be 20-36 days
with average 26.75 days in laboratory.
•Sampling Techniques include (i) Hand collection, (ii) light trap
collection and (iii) sticky traps.

15. EPIDEMIOLOGY
•Agent : L. Donovani
•Host : All ages , peak in children 5- 9 years
•Vector :Sand fly
•Transmission : Female sand fly
•Six hundred meter above sea level kala azar is free
•It is disease of rural area
•Low socio economic status, bad housing, habit of sleeping with
cattle inside the house
•Incubation period 2-6 months
•The disease is more common during and after rainy season

18. PROMASTIGOTES
AMASTIGOTES

19. GOAL OF NATIONAL HEALTH POLICY 2002
ELIMINATION OF KALA AZAR 2010
Later got extended to 2015 in 12th Financial Plan Document
OPERATIONAL GUIDELINES ON KALA-AZAR (VISCERAL
LEISHMANIASIS) ELIMINATION IN INDIA - 2015

20. •Goal: The national goal is to achieve elimination of KA by 2015
• Target : Less than 1 case per 10,000 population at the
Block PHC level
4 objectives and 5 strategies

21. Four Objectives
•Reducing the incidence of Kala-azar
•Reducing case fatality rate due to Kala-azar
•Treatment of (PKDL) to reduce the parasite reservoir
•Prevention and treatment of Kala-azar-HIV, TB co-infections

22. Five strategies
•Early diagnosis & complete treatment (EDCT)
•IVM and IRS
•IEC and Inter- sectoral convergence
•Capacity Building
•Supervision, Monitoring and Evaluation

23. Passive surveillance
•Cases diagnosed by ‘Rapid
Diagnostic test’
•Cases diagnosed by
parasitological method
•Cases currently on
treatment categorized
according to Kala-azar drug
regimen
•Cases completed treatment
•Cases who did not respond
to treatment, categorized
according to drug regimen
•Cases admitted to hospital
•Cases died in hospital
•Cases died at home

24. Active surveillance
•Quarterly basis
•Health workers and volunteers visit screen fever of more
than 2 weeks
•‘Rapid Diagnostic test’.
•The health worker / volunteer may have to search about 300-
400 households to detect a single case of Kala-azar.
•Active case search should be started at village level (start with
those villages with high number of KA cases) to trace the
suspected KA patients.

25. PKDL surveillance
•PKDL patients have only skin manifestations and therefore often
consult skin specialists.
• PKDL may be confused with leprosy and other skin diseases.
•Since PKDL patients do not have other manifestations or any
discomfort, they do not seek treatment readily.
•Treatment of PKDL is prolonged and usually associated with side
effects.
•Therefore, patient requires strong motivation to complete
treatment.

27. VECTOR CONTROL
•50% DDT – 1 kg in 10 lit of water
•Up to 6 feet from ground level
•The average requirement of DDT is 150 grams per house in the
rural areas and the
•average surface area for spray per house is 75 square meters.
•If it is resistant , Alphacypermethrin 5%
The droplets may be seen on the wooden structures in the rooms/
cattle sheds where insecticide has been sprayed or by flashing torch
light on sprayed surface which will exhibit star like twinkling/shining.

28. EARLY DIAGNOSIS
•L.D BODIES (Spleen, bone marrow, lymph node) ,culture in NNN
( Novy Mac neal Nicolle) Medium
•ALDEHYDE TEST using 40% formalin
• Dot ELISA (using antigen from amastigote)
•Polymerize chain reaction (PCR)
•Leismanin intra dermal test
•Splenic aspirates are more sensitive (96%) than are aspirates of
bone marrow (70%) or lymph nodes (58%)

29. RDK > 90% specificity and sensitivity

30. Case definitions for PKDL
•Probable PKDL: a patient from a KA-endemic area with
multiple hypopigmented macules, papules, plaques or
nodules, who are RDT positive.
•Confirmed PKDL: a patient from a KA-endemic area with
multiple hypopigmented macules, papules, plaques or
nodules, who is parasite positive in slit-skin smear (SSS) or
biopsy.

31. Kala-azar Drugs available in India
•Sodium Stibogluconate
•Single dose of Liposomal Amphotericin- B (LAMB)
•Pentamidine Isethionate
•Amphotericin B
•Liposomal Amphotericin B
•Miltefosine

32. •Single dose Liposomal Amphotericin B 10 mg/kg b.w. IV
infusion for 2 hrs.
•Adults > 12 years, weight > 25 kgs 100 mg daily in two doses
of 50 mg each after meals for 28 days
•adult >12, year weight < 25 kg, only one capsule of 50 mg
daily X 28 days.
•Children 2-11 years milteforsine to be given at 2.5 mg/kg once
daily after meals x 28 days.
•Amphotericin B deoxycholate injection intravenously at a
dose of 1 mg/kg b.w. on alternate days x 15 doses.

33. •HIV/VL co-infected patients ” LAMB 40 mg/kg b.w as total
dose of 3-5 mg/kg bw daily or intermittently for 10 doses,
days 1-5,10,17,24, 31 and 38
•PKDL ” In order of preference: First drug of choice, miltefosine
100 mg orally per day x 12 weeks
•Amphotericin ‘B’ deoxycholate injection 1 mg/kg bw over 4
months in 60-80 doses

34. Vaccine
•Phase III Trials with a first-generation vaccine (killed Leishmania
organism mixed with a low concentration of BCG as an
adjuvant) have also yielded promising results
• Leishmania major mixed with BCG have been successful in
preventing infection with Leishmania donovani.

37. Training
•Re-orientation training to all the levels of staff like ASHAs, Village
Volunteers, AWWs, spray workers etc. so that the knowledge
acquired remains intact.

38. Wage compensation for Kala-azar patients:
•Rupees 500/- for completion of treatment irrespective of any
drug regimen.
Wage compensation for PKDL Patients:
•Rupees 2000/- after complete treatment irrespective of drug
regimen.
ASHA
•1. Rupees 300/-for reffering and ensuring full treatment of
Kala-azar patients.
•2. Rupees 100/- per IRS round for community motivation (Rs.
200/- for two rounds).

40. THANK YOU
Operational guidelines on kala-azar (visceral Leishmaniasis)
elimination in India. GoI Oct 2015. Available from
www.nvbdcp.gov.in. Last accessed on 10
th
Dec, 2016.