Kala Azar- Reason to ResurgeHISTORY:Kala Azar, which means Black Fever in Urdu, has been reported in India since 1824when an outbreak was recorded in Jessore (now in Bangladesh). There was disagreementabout which epidemics were Kala Azar and which Malaria at first. One epidemic resultedin 750,000 people dying over three years. Kala azar spread to Assam in 1869 and to Biharas well. Leishman and Donovan identified the parasite in Calcutta and Madras in 1903.Kala Azar also came to be called visceral leishmaniasis. Dr UN Brahmachari discoveredthe medicine Urea Stibamine. Sinton published maps in 1925 showing that the sandflyand Kala Azar had a similar geographic distribution. But it was only in 1940 that it wasrecognized that the sandfly carried this disease. Epidemics recurred up to 1946.As a result of National Malaria Programme spraying of DDT from 1953 Kala Azar washardly seen between the 1955 and 1974. Residual spraying with DDT was stopped in1964. Parasites of Kala Azar probably remained in the community in the form of skinlesions called PKDL (post Kala Azar Dermal Leishmaniasis) during these years. ThesePKDL cases were seen by the Leprosy Mission Hospital at Muzaffarpur. Kala Azaraffected children were also seen by the Paediatrics Department of Patna Medical College.There was an increase in cases seen at School of Tropical Medicine Calcutta in 1971. 40cases of Kala Azar were reported from Bihar in 1974. In 1977 a survey done by NationalInstitute of Communicable Disease estimated 70,000 cases in Bihar. Cases also increasedin Bangladesh after 1973. A factor that may have had a role was the large scaledisplacement during the liberation struggle of 1971. Sirajganj district in the Pabna regionhad a large outbreak in 1980.RECENT TRENDS:The disease spread from the districts around Muzaffarpur(Bihar) to the eastern districtsaround Purnea. In 1984 some patients were reported south of the Ganges by a Catholichealth project in Sahebganj (which is now in Jharkhand). A survey by an enterprisinggovernment doctor in 1987 uncovered 56 patients were from a single villageMungra(total population 100). There were 3100 patients in the hill block of Borio.Sahebganj district as a whole had 5887 cases and it now became the Kala Azar capital ofthe world. According to Mansons Textbook of Tropical Disease Kala Azar spreadsslowly- it travels 10 miles a year. In 1994 a Kala Azar camp in the sleepy market town ofLitipara (50km south of Mungra) drew 300 people, mostly Santals and Maltos (two tribesof these districts). 65 of those tested were proved to have the disease. A survey by theSchool of Tropical Medicine around Satia village of Litipara in 1994 showed that 16% ofthe population had been affected by Kala Azar while as many as 45% of those tested hadmalaria parasites in their blood. This was the first study of coexistence of malaria andKala Azar.In 2000 a study by R Patil showed that the Annual Rate of Infection in villages near Satiawas around 4% among those less than forty years old. Above this age the ARI was 0.8%.There was already 19% Cumulative Incidence among children up to ten years, around64% between eleven and forty years, and 36% among those above forty. The datasuggested that the epidemic might continue among the younger children.
INCREASE IN THE TWENTY FIRST CENTURY:There was an increase in reported cases in Jharkhand from 469 in 2000 to over 2159 in2003 when drugs were available. 5960 cases are reported in 2011. In 2003 there was anincrease in cases reported from Bihar too- from 9684 in 2002 to 25215 in 2011.Cases from Pathna Block increased from 94 in 2000 to 206 in 2001 and 327 up toSeptember 2002 at Holy Cross dispensary in Sahebganj District. The entire districtreported only 370 cases in 2000 while this dispensary alone recorded 223 cases fromdifferent blocks.Data from Sundarpahari block of Godda shows that patients increased in governmentPHC facilities from 85 in 2001 to 129 in 2002 and 251 in 2003(up to September). Incontrast there were 283 patients in 2001,177 in 2002 and 163 in 2003(up to September) inNGO Dispensaries in the same block (compilation by Somik Banerjee, PRADANSundarpahari). Though there is a list of 364 patients belonging to this block up toSeptember 2003, the District Malaria Office gave a report for just 373 cases in December2003. Possibly some of the NGO data did not get counted. In 2011 Godda reported 1725cases."We have missed the 2010 target. According to a tripartite treaty among Bangladesh,Nepal and India, the new elimination target date is 2015. Elimination means reducingnumber of cases to one per 10,000 people," a Union health ministry official said. (TOIMarch 3 2012) • Kala-azar drugs not available in Bihar hospitals, says health minister TNN Mar 7, 2012, 02.23AMPATNA: The state government on Tuesday admitted that kala-azar drugs are notavailable in state hospitals for the last six months. Health minister Ashwini KumarChaubey said the state government is not empowered to buy kala-azar drugs on its own.Replying to a question of Nawal Kishore Yadav of the RJD in the legislative council, theminister said: "We have made repeated requests to the Centre to allow us to buy kala-azardrugs. Even the principal secretary had gone to Delhi to discuss the issue but no progresscould be made in this regard till date."WHAT CAN A PHC DO IN AN EPIDEMIC OF THIS SIZE?There were 87,536 people in Litipara Block in 2001. About 24,000 of them were childrenunder ten years old. If 1% of them are infected every year one expects 875 patients. If 4%of these children (960) and 1% of others (635) are infected every year one expects 1595patients. This means 40 to 80 patients for injection every day. The PHC has a capacity tomaintain only 6 beds.There would also be 15 to 30 positive tests every week. An extra laboratory technicianand at least one day a week of doctors time would be needed to do the bone marrow testsin Litipara. It is more practical to make a diagnosis based on clinical examination andcomplete it by Aldehyde or K39 strip or DAT testing for those who are not admitted tohospital. A number of staff and their relatives have died of Kala Azar in the HiranpurMission Hospital which treats many of the patients from Litipara. This includes BenjaminTudu who died in the first half of 2005 and the daughter of Dr Cornelius.
TREATMENT:A large supply of SAG (Sodium Antimony Gluconate) was available in undivided Biharbetween 1991 and 1993 as a result of Kala Azar Control Programme (KACP), agovernment effort.In 1994, the government became reluctant to supply SAG to NGOs in Sahebganj. Theyinsisted on Bone Marrow testing. Thousands of vials of SAG expired in January 1996 inSahebganj District Store. There was an acute shortage of Sodium Antimony Gluconatebetween July 1996 and 1998 in Sahebganj. Again from to 2000 to 2002 it was notavailable in the newly formed state of Jharkhand, though Bihar did have some stocksthrough the Modified Kala Azar Control Programme (mKACP). It became available in2003 in Godda, Jharkhand. From 2004 SAG became a scarce commodity everywhere inthe country due to problems in the manufacturing company. The price has alreadydoubled in the last decade and twenty injections for an adult now cost about Rs 1000 (thecourse is even longer in Bihar).Pentamidine and Amphotericin B are supplied by the government for resistant cases. Anew oral drug is now available- Miltefosine. However it costs Rs 3000 for a 28 daycourse. It is now part of the National Programme in some areas(http://whoindia.org/LinkFiles/Communicable_Diseases_Kala_Azar_May_07.pdf).Research supported by WHO is in process to see whether Paromomycin (an injectableand cheaper drug) could be used (www.oneworldhealth.org/kala-azar).STILL WE HOPE:There is a new international effort to eradicate Kala Azar under way. The silent work ofthe health staff at various dispensaries in Jharkhand: Sitapahar, St Xaviers and Kodma inSahebganj: Debpur, Satia (Herbal) and Sohorghati of Pakur; as well as Damruhat,Manikbathan, Sundar Mohr and Chandana of Godda is worth reporting. There has beenactive support from Bishops Julius Marandi of Dumka (himself a Santal) and ThomasKozhimala of Bhagalpur (who contracted cerebral malaria in a Santal village and died inJune 2005). Prem Jyoti Hospital of EHA at Chandragoda (Sahebganj) is actively involvedin treatment among the Malto community.At the research level the LEISH-F3 + GLA-SE vaccine is being tested on healthy adultsin Washington. (TOI March 3 2012)From Report of the Working Group for Communicable Diseases in the 12th Plan (WG-3.1Communicable Diseases Report) May 2011.
SOME DATA:India (Government of India quoted by Park)1986 17806 # before KACP1992 77102 * during KACP1998 13542 @ between KACP and mKACP1999 122862000 147532001 122392002 121402003 182142004 244792005 328032006 39173 (Dr SN Sharma)2007 44453 (http://nvbdcp.gov.in/ka-cd.html)2008 33598 NVBDCP2009 24212 NVBDCP2010 29000 NVBDCP provisional2011 33133 NVBDCP provisionalBihar (up to 2000 data from Chief Malaria Officer, Health and Family Welfare Department,Government of Bihar, Patna)1999 111512000 130762001 103272002 96842003 139602004 173242005 233832006 29711 (Source SHS Bihar)2007 37819 (NVBDCP)2008 29094 (Times of India ToI March 15 2012)2009 21318 (ndtv.com)2010, 23084 (ndtv.com)2011 25215 (Times of India ToI March 15 2012)Jharkhand2001 5892002 7582003 26072004 4028 2005 5989 2006 7508 2007 4803 2008 3689 2009 2875 2010 4305 2011 5960
District Sahebganj 1999, 2000 data from GOI(State Malaria Office from 2006)1999 2002000 370 2005 1403 2006 1977 2007 1509 2008 908 2009 762 2010 803 2011 1098District Dumka 2005 1389 2006 1210 2007 805 2008 607 2009 563 2010 1245 2011 1740West Bengal2001 12382002 15922003 14872004 30152005 27062006 17502007 18172008 12562009 756 NVBDCP2010 1482 NVBDCP provisional2011 1962 NVBDCP provisionalAcknowledgements:Both studies at Satia were done with the assistance of Dr A Nandy and his team. MdAnish Ansari in Pakur and Sahebganj, and Somik Banerjee in Godda spent timecollecting and entering data. The District Health authorities, Abhisek Dutta and SanjeevSingh were extremely helpful. SM Reuben of Navjeevan Seva Mandal and Rural Unit forHealth and Social Action (Vellore) were involved in the first study and Rajan Patil in thesecond one.Short Bibliography: • Sanyal RK et al. A longtitudinal review of kala azar in Bihar. J Comm Dis 1979; 11(4): 149-169 • Manson- Bahr, Apt ed. Tropical Diseases 18th Edition London 1982
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