Kala azar

Kala Azar

1. VECTOR BORNE DISEASES BY DR PRAVEEN AIVALLI 1 ST MPH JNMC KLE BELGAUM

2. Contents Introduction Definition & Problem statement Epidemiological determinants Clinical features Diagnosis Treatment Prevention & Control

3. KALA AZAR, DENGUE, JAPANESE ENCEPHALITIS & cHIKUNGUNYA

4. LEISHMANIASIS Leishmaniasis are group of protozoal diseases caused by parasite of genune Leishmania , and transmitted to humans by the bite of female phlebotomine sandfly . VL (Kala azar ) CL MCL ACL ZCL PKDL

5. Problem statement World Visceral Leishmaniasis : Occurs widely through out the world, viz south America south Africa the mediterian countries India Bangladesh and china. 9 out of 10 cases occur in bangladesh,brazil india and sudan . Cutanious Leishmaniasis : Occurs in dry, semi desert rural areas of central asia , middle east north and west Africa, esp in Ethopia and Kenya. 9 out of ten cases occur in Afghanistan Brazil Iran peru and Saudi Arabia. Muco cutanious Leishmaniasis : Found in Brazil Bolivia and Peru, rarely found outside the world.

6. India Has been known to occur epidemically endemically in well defined areas in the eastern sector of the country viz Assam West bengal Bihar Eastern dist of Utter Pradesh Sikkim and to very lesser extent in Tamil nadu & Orissa. Kala Azar is endemic in 52 dist Bihar, Jharkhand, Westbengal , UP About 130million pop at risk of the disease

7. Zoonotic cutaneous leishmaniasis : has been discovered in Rajasthan area in 1971, total 828 cases were reported. Cases of ACL have bee reported from Bhikaner city. Both cutaneous (ZCL,ACL) and VL found in india , KALA AZAR is by far so importatnt disease in india .

8. Kala- azar Kala- azar is a slow progressing indigenous disease caused by a protozoan parasite of genus Leishmania . Leishmania donovani is the only parasite causing this disease in india . PKDL (Post Kala- azar Dermal Leishmaniasis ) caused by Leishmania Donovani

9. P.argentipes :

10. Epidemiological determinants Agent factors Leishmanis donovani Kala Azar & PKDL Leishmania tropica CL Leishmania brazileinsis MCL

11. Reservoirs of infection Zoonotic Non Zoonotic

12. Host Factor Age Sex Population movement Socio economic status Occupation

13. Environmental Factor Altitude Season Rural areas Vectors Development projects

14. Mode of transmission In india Kala Azar is transmitted from person to person by the bite of the female Phlebotomine Sandfly . Transmission may also take place by contamination of the bite wound or by contact when the insect is crushed during the contact act of feeding Blood transfussion Contaminted syringes and needles .

15. Signs and Symptoms Recurrent fever loss of appetite, pallor and weight loss with progressive emaciation, weakness. Skin - dry, thin and scaly and hair may be lost. persons show grayish discolouration of the skin of hands, feet,abdomen and face which gives the Indian name Kala azar meaning "Black fever"

16. Splenomegaly . Hepatomegaly . Lymphadenopathy . Anaemia - develops rapidly. Anaemia with emaciation & gross splenomegaly produces a typical appearance of the patients.

17. PKDL Occurs several years after the apperant cure of kala azar , signs symptom includes lesion consists of multiple nodular infiltrations of the skin usually without ulceration, parasites are numerous in this lesion. CL,ACL,ZCL, etc here agent is restricted to skin, painful ulcer in the parts of body exposed to sand fly bites, reducing the victims ability to work

18. Diagnosis Clinical fever of more than 2 weeks duration not responding to antimalarials and antibiotics . Lab invest Haematological findings viz Anaemia , leucopenia, thrombocytopenia & hypergammaglobulinemia . WBC : RBC ratio is 1:1500 or even 1:2000 Raised ESR .

19. Serology tests: Direct Agglutination Test (DAT), rk39 dipstick and ELISA. However all these tests detect IgG antibodies that are relatively long lasting. Aldehyde Test is commonly used but it is a non-specific test. IgM detecting tests are under development and not available for field use.

20. Parasitological diagnosis The demonstration of the parasite in the aspirates of bonemarrow /spleen/ lymphnode /liver or in the skin (in case of CL) is the only way to confirm VL or CL. However, sensitivity varies with the organ selected for aspiration. Though spleen aspiration has the highest sensitivity and specificity (considered gold standard)

21. Sl. No. Affected States/UTs 2007 2008 2009 2010(P) 2011(P) Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths 1 Assam 98 26 12 5 2 Bihar 37819 172 28489 142 20519 80 23084 95 18519 56 3 Delhi 19 34 12 33 4 Gujarat 4 1 5 Himacha Pradesh 6 1 1 6 Jharkhand 4803 20 3690 5 2875 12 4305 5 4264 3 7 Madhya Pradesh 1 8 Punjab 1 9 Sikkim 4 1 5 3 3 10 Uttrakhand 2 2 1 11 Uttar Pradesh 69 1 26 17 1 14 8 1 12 West Bengal 1817 9 1256 3 756 1482 4 1431 Total 44533 203 33598 151 24212 93 28941 105 24231 60

22. Control measures Control the reservoir Treatment of the cases Sand fly control Personal prohylaxis Active and passive detection of the cases and treatment of those who found to be infected. House to house visit. Mass serevys in endemic areas for early detection of the cases.

23. Treatment Pentavalent antimony---- Sodium stibogluconate 10mg/kg body wt for 20 days in adults. 20mg/kg body w in childrens . Pentamidine isethionate 3mg/kg body wt for 10 days. Amphotericin B 1mg/kg body wt IV 15 to 20 Injections alt dys Miltefosine , 2.5 mg/kg body wt in two divided doses for 4 week

24. Sandfly controle DDT Insecticide spraying at human dwellinngs and all animal shelter and other resting places up to the height of 6 feets from floor level Sanitation measures Personal prophylaxis

25. Kala azar control programme The strategy of kala azar contorl broadly includes three major activities Interruption of transmission for reducing vector population by undertaking indoor insecticidal spry twice annual major activities Early diagnosis and treatment of the kala azar cases Health education for the community awareness  

26. cont In view of the success achieved so far, National health policy envisages kala azar elimination by the year 2010. The tenth five year plan targets are prevention of death by kala azar by 2004 by annual reduction of least25% zero level incidence by 2007 with atleast 20% annual reduction using 2001 as a base year, Elimination of kala azara by 2010. To achieve this government of india has provided 100% central support from the year 2003 2004

27. Kala- azar Control Efforts in India An organized centrally sponsored Control Programme launched in endemic areas in 1990-91. Government of India provided kala-azar medicines, insecticides and technical support. State governments implemented the programme through primary health care system and district/zonal and State malaria control organizations and provided other costs involved in strategy implementation.

28. Programme strategy Vector control through IRS with DDT up to 6 feet height from the ground twice annually. Early Diagnosis and Complete treatment of the cases. Information Education Communication Programme intensified in 1991-92 which led to improved case registration through primary health care system. Within 3 years of intensification (1995 as compared to 1992) 70.66% decline in annual incidence 80.48% decline in deaths By 2003 as compared to 1992 76.38% decline in incidence 85.20% decline in deaths. 

29. KALA-AZAR ELIMINATION INITIATIVE   In addition to kala-azar medicines and insecticides, cash assistance is being provided to endemic states since December 2003 to facilitate effective strategy implementation by states. State/District Action Plan for Kala- azar Elimination . Template for developing District Action Plan (Kala- azar ) . Draft Communication & Media Plan for Kala- azar Elimination . Patient Coding Scheme . Kala- azar Treatment Card . Monthly Kala- azar Reporting Formats .

30. Dengue Dengue is a viral disease. Caused by 4 antigenically related but distinct dengue virus serotype(DEN 1,2,3 & 4) It is transmitted by the infective bite of Aedes Aegypti  mosquito The infection may be asymptomatic or may lead to Classical dengue fever or Dengue fever without shock or Dengue hemorrhagic fever with shock Dengue Haemorrhagic Fever (DHF) with shock is a more severe form of disease, which may cause death

31. The most common epidemic vector of dengue in the world is the Aedes aegypti mosquito. It can be identified by the white bands or scale patterns on its legs and thorax .

32. Infective period : day before onset to the 5 th day of illness Extrinsic incubation period : 8-10 days Sex : both male & female Incubation period : 3- 10 days

33. Problem statement Most important emerging disease: Tropical & sub tropical regions Affecting urban & per urban areas The cases has increased dramatically in the past 30yrs A pandemic(56 countries) : 1998 (1.2 million cases ) WHO –50 million infections/yr - 5,00,000 cases of dengue hemorrhagic fever/yr - At least 12000 deaths/yr

34. Cont.. Currently dengue is endemic in Bangladesh India Indonesia, Maldives Mayanmar , Srilanka and Thailand. Bhutan and Nepal reported their first case in 2004 and 2006 resp. Aproximately 2.5 to 3 bilion are living in areas where dengue virus can transmitted. Over the past 10 15 years, next to diarrheal disease and acute respiratory infection dengue has become a leading cause of hospitalization and death among children in the south east asia region. During 2006 SEAR reported about 190000 cases with 1600 deaths.

35. Burden of the disease Important disease of tropics & is one of the important disease affecting nearly ½ of worlds population. There are about 50 to 100 million cases of dengue fever & about 500,000 cases of dengue hemorrhagic fever that require hospitalization each yr World health assembly passed a resolution in 1993 which urged members states to strengthen their national & international program for control of DF/DHF

36. Countries in South East Asia Region have been divided in 4 categories Category A: Indonesia, Myanmar & Thailand Major Public Health problem Increased hospitalization death among children Multiple virus type circulating; Ades aegypti (Principal vector)

37. Category B: India, Bangladesh, Maldives & Srilanka DHE an emerging disease Cyclic epidemic becoming more frequent Multiple virus serotype circulating expanding geographicallywithin country, Aedes albopictus principal vector

38. Category C: Bhutan & Nepal No reported cases & endemicity uncertain Category D: Korea Non endemic

39. Affected States/UTs 2008 2009 2010 2011(P) Cases Deaths Cases Deaths Cases Deaths Cases Deaths Andhra Pradesh 313 2 1190 11 776 3 235 3 Assam 237 2 1 Bihar 1 1 510 2 Chattisgarh 26 7 4 Goa 43 277 5 242 7 Gujarat 1065 2 2461 2 2568 1 493 Haryana 1137 9 125 1 866 20 39 1 Himachal Pd. 3 J & K 2 1 Jharkhand 27 12 Karnataka 339 3 1764 8 2285 7 263 3 Kerala 733 3 1425 6 2597 17 847 8

40. Kerala 733 3 1425 6 2597 17 847 8 Madhya Pd. 3 1467 5 175 1 14 Meghalaya 1 Maharashtra 743 22 2255 20 1489 5 223 2 Manipur 7 Nagaland 25 Orissa 29 5 1697 25 Punjab 4349 21 245 1 4012 15 609 Tamil Nadu 530 3 1072 7 2051 8 1091 4 Rajasthan 682 4 1389 18 1823 9 81

41. States. 2008 2009 2010 2011(P) Cases Deaths Cases Deaths Cases Deaths Cases Deaths Uttar Pradesh 51 2 168 2 960 8 50 1 Uttrakhand 20 178 4 West Bengal 1038 7 399 805 1 149 A& N Island 25 Chandigarh 167 25 221 1 Delhi 1312 2 1153 3 6259 8 245 3 D&N Haveli 46 Puduchery 35 66 96 34 Total 12561 80 15535 96 28292 110 6098 50

42. Magnitude of the problem

43. Transmission Resvr of infection is both man and mosquito Aedes albopictus become infective by feeding on a paitent from the day before onset to 5 th day of illness. After an extrinsic incubation period of 8 to 10 days the mosquito become infective and able transmit the disease.

44. SIGNS & SYMPTOMS OF DF high fever with chills 39 to 40 degree cel Severe frontal headache Retro orbital pain, which worsens with eye movement Photophobia Muscle and joint pains Loss of sense of taste and appetite Measles-like rash over chest and upper limbs Nausea and vomiting

45. SIGNS & SYMPTOMS OF DHF Symptoms similar to dengue fever Severe continuous stomach pains Skin becomes pale, cold or clammy Bleeding from nose, mouth & gums and skin rashes Frequent vomiting with or without blood Sleepiness and restlessness Patient feels thirsty and mouth becomes dry Rapid weak pulse Difficulty in breathing

46. Based on the signs and symptoms the dengue illness is divided into 3 phases Febrile phase Critical phase Recovery phase

47. IgM / IgG

48. Diagnosis Clinical diagnosis Fever acute onset high continuous lasting 2-7 dys Hepatomegally Epitaxis Gum bleeding haematemesis DHM include + ve torniquet test

49. Lab investigation Thrombocytopenia (less 1 lack) Haematoconcentration ie increased haematocrit more than 20% of normal value

50. Acc to clinical manifestation pt may divide into 3 broad groups Group A pt with uncomplicated condi Group B pt in hospital management Group C pt require Emergency treatment

51. Treatment No drug or vaccine is available for the treatment of Dengue/DHF Symptomatic & supportive Bed rest – during acute febrile phase Antipyretics Sponging (to keep the body below 40 C ) Avoid – Aspirin (endemic areas) Causes: gastritis Bleeding Acidosis Oral fluid & electrolyte therapy : Pts with excessive sweating, Vomiting Diarrhea

52. Management of DHF Is similar to the DF during febrile phase Rise in haematocrit – parenteral fluid therapy In Grade I &II volume replacement for a period of 12-24 hrs Admission to hospital : Any signs of bleeding Persistently high haemetocrit values

53. Fluid replacement should be minimum Excessive replacement will cause Respiratory distress Pulmonary congestion Oedema The type of fluid use are: 5% dextrose in lactated Ringer’s solution 5% dextrose in ½ strength normal saline solution 5% dextrose in normal saline solution

54. Control measures Vector control measures Personal prophylactic measures Use of mosquito repellent creams, liquids, coils, mats etc. Wearing of full sleeve shirts and full pants with socks Use of bednets for sleeping infants and young children during day time to prevent mosquito bite Biological control Use of larvivorous fishes in ornamental tanks, fountains, etc. Use of biocides

55. Chemical control Use of chemical larvicides like abate in big breeding containers Aerosol space spray during day time Environmental management & source reduction methods Detection & elimination of mosquito breeding sources Management of roof tops, porticos and sunshades Proper covering of stored water Reliable water supply Observation of weekly dry day

56. Health education Impart knowledge to common people regarding the disease and vector through various media sources like T.v ., Radio, Cinema slides, etc. Community participation Sensitilizing and involving the community for detection of Aedes breeding places and their elimination

57. REF K Park: text book of preventive and social medicine; edt -18 & 21 Text of Public Health and Community Medicine: Armed Force Pune Davidson`s Principles and practice of medicine Sundarlal Adarsh Pankaj : text book of community medicine; edt-1 st www.whoindia.int/chi www.nvbdcp.com

58. Topley & Wilsons Text book of parasitology 9 th ( Edn ), 428-524 O P Ghai Text book of preventive and social medicine, 161-162 Harrisons Text book of Medicine, 15 th ( Edn ),1428-1430 Ananth Narayans Text book of Microbiology, 2 nd ( Edn ),209-211

59. Control measures Vector control measures Personal prophylactic measures Use of mosquito repellent creams, liquids, coils, mats etc. Wearing of full sleeve shirts and full pants with socks Use of bednets for sleeping infants and young children during day time to prevent mosquito bite Biological control Use of larvivorous fishes in ornamental tanks, fountains, etc. Use of biocides

60. Chemical control Use of chemical larvicides like abate in big breeding containers Aerosol space spray during day time Environmental management & source reduction methods Detection & elimination of mosquito breeding sources Management of roof tops, porticos and sunshades Proper covering of stored water Reliable water supply Observation of weekly dry day

61. Health education Impart knowledge to common people regarding the disease and vector through various media sources like T.v ., Radio, Cinema slides, etc. Community participation Sensitilizing and involving the community for detection of Aedes breeding places and their elimination

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