NATIONAL GUIDELINES ON KALA-AZAR ELIMINATION PROGRAMME.pptx

department of health services national guidelines of kalazar elimination

1. NATIONAL GUIDELINES ON KALA-AZAR ELIMINATION PROGRAMME DEPARTMENT OF HEALTH SERVICES EPIDEMIOLOGY AND DISEASE CONTROL DIVISION

2. INTRODUCTION TO KALA-AZAR Leishmaniasis is group of vector borne disease caused by Leishmaniasis protozoan parasite transmitted to humans by bite of infected female phlebotomine sandflies 4 forms are: Visceral Leishmaniasis(VL) Post Kalaazar Dermal Leishmaniasis(PKDL) Cutaneous Leishmaniasis(CL) Mucocutaneous Leishmaniasis(MCL)

3. South East Asis Region(SEARO) regional strategic plan outlined 4 phases of kala azar elimination initiative in the region: 1. Preparatory phase : devt . Of new national policies, strategies, advocacy and operational plans 2. Attack phase : implementation of activities such as early diagnosis and complete treatment, vector control activities in form of IRS 3. Consolidation phase : at the end of attack phase. During this active surveillance continues with focal indoor residual sprays. Ends after 3 years of active surveillance 4. Maintainence phase : the case incidence at the district/ sub district level should be less than 1 per 10000 population

4. Epidemiology of Leishmaniasis First case reported in Nepal as early as 1960s Globally estimated 700000 to 1000000 cases occur annually and 20000 deaths occur annually In the countries of south east asia region Kala azar occurs mainly in India, Bangladesh and Nepal Kala azar cases have been reported from 50(out of 77)districts in the country. The highest numbers of Kala azar cases has been reported in 2003 and since then the cases are in decreasing trends In 2017 only 271 cases were reported.

5. KA Cases and Deaths 2000-2017

6. VL Districts reporting : 2017 Program Districts :18 (17) Other Districts : 31 Highest incidence : 1.47 (Dolpa) Highest incidence in program district: 0.67 ( Palpa) Highest No. of cases: 24 (Sarlahi) CFR: 3.69

7. DOLPA MUGU JUMLA KAILALI BARDIYA HUMLA DOTI SURKHET NAWALPARASI RUPANDEHI DANG BANKE ACHHAM KALIKOT JHAPA MORANG SIRAHA SAPTARI DARCHULA BAJHANG BAITADI DADELDHURAA KANCHANPUR BAJURA PARSA BARA RAUT-AHAT DHANUSHA MAHOTTARI SUNSARI SARLAHI DHADING MAKAWANPUR CHITWAN KASKI TANAHU PALPA SYANGJA PARBAT ARGHAKHANCHI GULMI UDAYAPUR SINDHULI ILLAM BHOJPUR DHANKUTA TAPLEJUNG OKHALDHUNGA TERHATHUM KHOTANG SOLUKHUMBHU DOLAKHA SANKHUWASABA NUWAKOT SINDHUPALCHOWK KAVRE RASUWA LAMJUNG GORKHA - PYUTHAN ROLPA SALYAN MYAGDI DAILEKH JAJARKOT RUKUM MUSTANG MANANG BAGLUNG KAPILVASTU PANCHTHAR RAMECHHAP Program districts-12 Non program districts-63 KA program/non program districts

8. DOLPA MUGU JUMLA KAILALI BARDIYA HUMLA DOTI SURKHET NAWALPARASI RUPANDEHI DANG BANKE ACHHAM KALIKOT JHAPA MORANG SIRAHA SAPTARI DARCHULA BAJHANG BAITADI DADELDHURAA KANCHANPUR BAJURA PARSA BARA RAUT-AHAT DHANUSHA MAHOTTARI SUNSARI SARLAHI DHADING MAKAWANPUR CHITWAN KASKI TANAHU PALPA SYANGJA PARBAT ARGHAKHANCHI GULMI UDAYAPUR SINDHULI ILLAM BHOJPUR DHANKUTA TAPLEJUNG OKHALDHUNGA TERHATHUM KHOTANG SOLUKHUMBHU DOLAKHA SANKHUWASABA NUWAKOT SINDHUPALCHOWK KAVRE RASUWA LAMJUNG GORKHA - PYUTHAN ROLPA SALYAN MYAGDI DAILEKH JAJARKOT RUKUM MUSTANG MANANG BAGLUNG KAPILVASTU PANCHTHAR RAMECHHAP Program districts-18 Non program districts-57 KA program/non program districts Program districts expanded to 18 districts

9. Trend of KA cases reported from endemic and other districts 6 more districts included as program districts

10. Current interventions Early Diagnosis and Treatment KA Cases Surveillance IRS Social mobilization and partnership IEC/BCC Training /orientation /symposium

11. Goal and Elimination target: To contribute to mitigation of poverty in Kala azar endemic district of Nepal by reducing motbidity and mortality of the disease and assisting in the development of equitable health systems Target: Renewed MoU signed by Bangladesh, Bhutan, India, Nepal and Thailand during the regional committee meeting in 2014 has revised the elimination timeline by the end of 2017 Objectives: Reduce incidence of kala azar in endemic communities with special emphasis on poor Reduce case fatality rates from kala azar to zero Detect and treat post Kala azar dermal leishmaniasis to reduce parasite reservoir Prevent and manage Kala azar -HIV-TB co infections

12. Clinical descriptions and case definitions A typical patients presents with several of the following symptoms and signs Fever of 2 weeks or more Mod. To severe splenomegaly Weight loss Loss of appetite Hepatomegaly Early satiety Anaemia epistaxis Other uncommon manifestations: Oedema Jaundice Vomiting Abdominal pain Lymphadenopathy Cough Diarrhoea

13. Physical examination findings Fever Splenomegaly Moderate to severe pallor Malnutrition Hepatomegaly Lymphadenopathy Icterus Signs of secondary infections like respiratory, GI, etc.

14. Differential diagnosis If symptoms are of more than 2 to 4 weeks: Tuberculosis Chronic Hepatitis Brucellosis Liver Cirrhosis Malnutrition Lymphoma and leukemia AIDS If symptoms are of 2 weeks: Malaria Typhoid Leptospirosis

15. Case definitions: Visceral Leishmaniasis Probable KA case: A person living in or having travelled to kala azar endemic areas showing clinical signs and symptoms of kala azar( mainly irregular fever lasting more than 2 weeks and splenomegaly and /or weight loss after ruling out malaria in endemic areas Confirmed VL case Laboratory confirmed VL cases: A probable KA case with laboratory confirmation either serological(RDT, DAT, ELISA, IFAT) and/or parasitological(smear, culture) and/or positive by PCR or related techniques Clinically confirmed VL case: a probable case that has not been confirmed by any laboratory test, but is assessed by a clinician to be a confirmed KA case based on clinical grounds

16. PKDL operational case definitions Probable PKDL cases : a patient living on or having travelled to KA endemic areas presenting with a typically symmetrical multiple hypo pigmented macules, papules, plaques, nodules without loss of sensations Confirmed PKDL case : a probable PKDL case with leishmaniasis infection confirmed parasitological by PCR or a slit skin smear or biopsy

17. Cutaneous Leishmaniasis Probable CL case : a person living in/or having travelled to endemic areas showing typical skin lesion( macules, papule, nodule, ulcer) Confirmed CL case : Laboratory confirmed CL case: a probable CL case with parasitological confirmation, by positive smear, culture or PCR Clinical confirmed CL case:A probable CL case that has not been confirmed by any laboratory case but is assessed by a consultant physician to be a confirmed CL case based on clinical grounds CL due to L. tropica

18. Muco-cutaneous Leishmaniasis Probable MCL case: A person living in or having travelled to CL endemic areas showing mucosal/ mucocutaneous lesions( incl.nodules, infiltration, obstruction, mutilations) A confirmed MCL case : a probable case with parasitological confirmation of the diagnosis( positive smear or culture), PCR and/or , for mucocutaneous leishmaniasis only, serological diagnosis

19. Treatment: Objectives: Clinical cure of the patients Minimize drug toxicity and side effects, if any Prevent and/or identity and treat complication Support patients nutritional and hydration ststus Manage other medical conditions Reduce the risk of relapse and PKDL All Kala azar patients must be admitted for treatment with liposomal amphotericin B

20. Supportive management: Nutritional support Treatment of inter current infections Anaemia Other situations Drug treatment: Primary Kala azar: First line regimen- Liposomal Amphotericin B at the dose of 10 mg/kg single dose over 2 hour Single dose treatment ensures 100% treatment compliance Second line treatment : Combination regimes: L iposomal AMB plus Miltefosine Liposomal AMB plus paramomycin Miltefosine plus paramomycin

21. Third line treatment: Amphotericin B deoxycholate OR Paramomycin OR Miltefosine Treatment of PKDL: The WHO recommended dose: 1 . AMB deoxycholate1mg/kg/day by infusion upto 60-80 doses over 4 month. 2. Miltefosine orally for 12 weeks

22. Indoor Residual Spray (IRS) Prevention of KA through vector control is one of the major strategies in the elimination of the disease Vector control options for the elimination of KA in Nepal comprises of indoor residual spraying (IRS), personal protective measures and environmental modification/manipulation techniques

23. In Fiscal Year (FY) 2016/17, two rounds of selective indoor residual spraying were carried out using Deltamethrin in prioritized kala-azar affected areas of endemic districts based on the national IRS guideline. Since the cases are continuously reported from non program districts, EDCD has allocated some budget for IRS in selected local level of those district s as well in FY 2017/18.

24. Surveillance Active case detection activities in VL endemic districts and pockets; – Camp based approach – Index case based approach Collaboration with leprosy control program: Orientation and training to leprosy service providers on KA , PKDL, CL and MCL; Collaborative active case search in endemic districts (Combined search) Rapid diagnostic test kits provided to selected leprosy service centers/hospitals

25. Surveillance and Information System EDCD/VBDRTC(EWARS) Other Health Facilities MD-HMIS Monthly (Aggregate) Weekly/Immediately (Individual) EWARS Sentinel Sites(Hospitals) Provincial level/ PHD/DPHO Public Hospitals Monthly (Aggregate) Local level

26. IEC/BCC materials developed to support VL elimination programme ( Health Education ) A national IEC/BCC strategy has been developed with national stakeholders The IEC/BCC messages for VL control have been endorsed by govt. of Nepal Poster for general public Flipbook for FCHVs & HCPs at HFs

27. Leaflet for general public & healthcare providers Notebook for training /meeting participants

28. Early Warning and Reporting System Early Warning and Reporting System (EWARS) – weekly reporting system focusing on outbreak potential diseases Started in 1996 with development of guidelines and training Functional in 8 hospitals in 1997 Functional in 40 sites till 2009 Excel based reporting system initiated in 2010 Medical Recorders are the reporting focal point Expanded to 82 sentinel sites up to 2018 Functional Control Room for data analysis and feedback Information disseminated through EWARS weekly bulletin Surveillance section came into existence within EDCD as IHR core capacity in 2015

29. Diseases/Syndromes under EWARS Vector Borne Diseases Malaria Kala-azar Dengue Epidemic Potential Diseases/Syndromes Acute gastroenteritis (AGE) Cholera Severe Acute Respiratory Infection (SARI) Other outbreak potential diseases

30. Monitoring and Evaluation Monitoring and Evaluation is a process that helps improve performance and achieve results towards Kala azar elimination Its goal is to improve current and future management of outputs, outcomes and impact of the program

31. Key Areas of Monitoring and Evaluation Diagnostic tests Other laboratory tests, i.e. electrolytes, RFT, LFT, complete blood counts, ECG Treatment with first line and second line drug Follow up of treatment Management of adverse effects of drugs Referral of PKDL cases to special referral center Recording and reporting Line listing of patients

32. Key Areas of Monitoring and Evaluation.. Clinical training to improve diagnosis & treatment Supervision of health workers/HFs Improve supply of drugs & diagnostics tools Behaviour change communication (BCC) Strengthening surveillance Vector control

33. Recording and Reporting System

34. Recording Tools of Kala azar Specimen collection form laboratory registers Patients’ treatment register

35. Existing Information System SYSTEM SOFTWARE Features HMIS DHIS2 Currently in use Universal and national- wise EWARS Excel Individual data collected 35

36. Transmission of Reports Immediate Reports Consolidated immediate reports should be verified and signed by Medical Recorder and Medical Superintendent of the hospital and reported to EDCD email:[email protected] or [email protected] Weekly Reports Consolidated weekly reports should be prepared for the epidemiological week and sent to EDCD and VBDRTC by email on Tuesday noon, Late reporting on Friday noon of the following week

37. Challenges Lack of regular reporting/Unreported cases Private sectors ( Private Hospitals , Medical Colleges) Cross border issues Entomological surveillance Changing epidemiology