1. Kala Azar- Reason to Resurge
HISTORY:
Kala Azar, which means Black Fever in Urdu, has been reported in India since 1824
when an outbreak was recorded in Jessore (now in Bangladesh). There was disagreement
about which epidemics were Kala Azar and which Malaria at first. One epidemic resulted
in 750,000 people dying over three years. Kala azar spread to Assam in 1869 and to Bihar
as 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 discovered
the medicine Urea Stibamine. Sinton published maps in 1925 showing that the sandfly
and Kala Azar had a similar geographic distribution. But it was only in 1940 that it was
recognized 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 was
hardly seen between the 1955 and 1974. Residual spraying with DDT was stopped in
1964. Parasites of Kala Azar probably remained in the community in the form of skin
lesions called PKDL (post Kala Azar Dermal Leishmaniasis) during these years. These
PKDL cases were seen by the Leprosy Mission Hospital at Muzaffarpur. Kala Azar
affected 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. 40
cases of Kala Azar were reported from Bihar in 1974. In 1977 a survey done by National
Institute of Communicable Disease estimated 70,000 cases in Bihar. Cases also increased
in Bangladesh after 1973. A factor that may have had a role was the large scale
displacement during the liberation struggle of 1971. Sirajganj district in the Pabna region
had a large outbreak in 1980.
RECENT TRENDS:
The disease spread from the districts around Muzaffarpur(Bihar) to the eastern districts
around Purnea. In 1984 some patients were reported south of the Ganges by a Catholic
health project in Sahebganj (which is now in Jharkhand). A survey by an enterprising
government doctor in 1987 uncovered 56 patients were from a single village
Mungra(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 of
the world. According to Manson's Textbook of Tropical Disease Kala Azar spreads
slowly- it travels 10 miles a year. In 1994 a Kala Azar camp in the sleepy market town of
Litipara (50km south of Mungra) drew 300 people, mostly Santals and Maltos (two tribes
of these districts). 65 of those tested were proved to have the disease. A survey by the
School of Tropical Medicine around Satia village of Litipara in 1994 showed that 16% of
the population had been affected by Kala Azar while as many as 45% of those tested had
malaria parasites in their blood. This was the first study of coexistence of malaria and
Kala Azar.
In 2000 a study by R Patil showed that the Annual Rate of Infection in villages near Satia
was 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, around
64% between eleven and forty years, and 36% among those above forty. The data
suggested that the epidemic might continue among the younger children.

2. INCREASE IN THE TWENTY FIRST CENTURY:
There was an increase in reported cases in Jharkhand from 469 in 2000 to over 2159 in
2003 when drugs were available. 5960 cases are reported in 2011. In 2003 there was an
increase 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 to
September 2002 at Holy Cross dispensary in Sahebganj District. The entire district
reported only 370 cases in 2000 while this dispensary alone recorded 223 cases from
different blocks.
Data from Sundarpahari block of Godda shows that patients increased in government
PHC facilities from 85 in 2001 to 129 in 2002 and 251 in 2003(up to September). In
contrast there were 283 patients in 2001,177 in 2002 and 163 in 2003(up to September) in
NGO Dispensaries in the same block (compilation by Somik Banerjee, PRADAN
Sundarpahari). Though there is a list of 364 patients belonging to this block up to
September 2003, the District Malaria Office gave a report for just 373 cases in December
2003. Possibly some of the NGO data did not get counted. In 2011 Godda reported 1725
cases.
"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 reducing
number of cases to one per 10,000 people," a Union health ministry official said. (TOI
March 3 2012)
• Kala-azar drugs not available in Bihar hospitals, says health minister TNN Mar 7, 2012, 02.23AM
PATNA: The state government on Tuesday admitted that kala-azar drugs are not
available in state hospitals for the last six months. Health minister Ashwini Kumar
Chaubey 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, the
minister said: "We have made repeated requests to the Centre to allow us to buy kala-azar
drugs. Even the principal secretary had gone to Delhi to discuss the issue but no progress
could 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 children
under 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 1595
patients. This means 40 to 80 patients for injection every day. The PHC has a capacity to
maintain only 6 beds.
There would also be 15 to 30 positive tests every week. An extra laboratory technician
and at least one day a week of doctor's time would be needed to do the bone marrow tests
in Litipara. It is more practical to make a diagnosis based on clinical examination and
complete it by Aldehyde or K39 strip or DAT testing for those who are not admitted to
hospital. A number of staff and their relatives have died of Kala Azar in the Hiranpur
Mission Hospital which treats many of the patients from Litipara. This includes Benjamin
Tudu who died in the first half of 2005 and the daughter of Dr Cornelius.

3. TREATMENT:
A large supply of SAG (Sodium Antimony Gluconate) was available in undivided Bihar
between 1991 and 1993 as a result of Kala Azar Control Programme (KACP), a
government effort.
In 1994, the government became reluctant to supply SAG to NGOs in Sahebganj. They
insisted on Bone Marrow testing. Thousands of vials of SAG expired in January 1996 in
Sahebganj District Store. There was an acute shortage of Sodium Antimony Gluconate
between July 1996 and 1998 in Sahebganj. Again from to 2000 to 2002 it was not
available in the newly formed state of Jharkhand, though Bihar did have some stocks
through the Modified Kala Azar Control Programme (mKACP). It became available in
2003 in Godda, Jharkhand. From 2004 SAG became a scarce commodity everywhere in
the country due to problems in the manufacturing company. The price has already
doubled in the last decade and twenty injections for an adult now cost about Rs 1000 (the
course is even longer in Bihar).
Pentamidine and Amphotericin B are supplied by the government for resistant cases. A
new oral drug is now available- Miltefosine. However it costs Rs 3000 for a 28 day
course. 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 injectable
and 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 of
the health staff at various dispensaries in Jharkhand: Sitapahar, St Xavier's and Kodma in
Sahebganj: Debpur, Satia (Herbal) and Sohorghati of Pakur; as well as Damruhat,
Manikbathan, Sundar Mohr and Chandana of Godda is worth reporting. There has been
active support from Bishops Julius Marandi of Dumka (himself a Santal) and Thomas
Kozhimala of Bhagalpur (who contracted cerebral malaria in a Santal village and died in
June 2005). Prem Jyoti Hospital of EHA at Chandragoda (Sahebganj) is actively involved
in treatment among the Malto community.
At the research level the LEISH-F3 + GLA-SE vaccine is being tested on healthy adults
in Washington. (TOI March 3 2012)
From Report of the Working Group for Communicable Diseases in the 12th Plan (WG-3.1
Communicable Diseases Report) May 2011.

4. SOME DATA:
India (Government of India quoted by Park)
1986 17806 # before KACP
1992 77102 * during KACP
1998 13542 @ between KACP and mKACP
1999 12286
2000 14753
2001 12239
2002 12140
2003 18214
2004 24479
2005 32803
2006 39173 (Dr SN Sharma)
2007 44453 (http://nvbdcp.gov.in/ka-cd.html)
2008 33598 NVBDCP
2009 24212 NVBDCP
2010 29000 NVBDCP provisional
2011 33133 NVBDCP provisional
Bihar (up to 2000 data from Chief Malaria Officer, Health and Family Welfare Department,
Government of Bihar, Patna)
1999 11151
2000 13076
2001 10327
2002 9684
2003 13960
2004 17324
2005 23383
2006 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)
Jharkhand
2001 589
2002 758
2003 2607
2004 4028
2005 5989
2006 7508
2007 4803
2008 3689
2009 2875
2010 4305
2011 5960

5. District Pakur (District Malaria Officer supplied data from 2003)
1999 38
2000 0
2003 644
2004 650
2005 1042
2006 1418
2007 764
2008 669
2009 501
2010 611
2011 1244
350
2005
2011 306 349 2011 307
300
250
2005
243 2011 197
2011 192
200
2011 174
2005
180
150
2005
109
100 2005
72 2011 68
2005
85
50
0
Pakur Hiranpur Maheshpur Pakuria Amrapara Litipara
Annual KA reported block wise between 2005 and 2011 (source: CS Office Pakur)
District Godda (District Malaria Officer supplied data from 2001-5)
1999 238
2000 99
2001 445
2002 893
2003 1497
2004 2298 - 6 deaths
2005 2155
2006 2903
2007 1725
2008 1505
2009 1049
2010 1646
2011 1878

6. District Sahebganj 1999, 2000 data from GOI
(State Malaria Office from 2006)
1999 200
2000 370
2005 1403
2006 1977
2007 1509
2008 908
2009 762
2010 803
2011 1098
District Dumka
2005 1389
2006 1210
2007 805
2008 607
2009 563
2010 1245
2011 1740
West Bengal
2001 1238
2002 1592
2003 1487
2004 3015
2005 2706
2006 1750
2007 1817
2008 1256
2009 756 NVBDCP
2010 1482 NVBDCP provisional
2011 1962 NVBDCP provisional
Acknowledgements:
Both studies at Satia were done with the assistance of Dr A Nandy and his team. Md
Anish Ansari in Pakur and Sahebganj, and Somik Banerjee in Godda spent time
collecting and entering data. The District Health authorities, Abhisek Dutta and Sanjeev
Singh were extremely helpful. SM Reuben of Navjeevan Seva Mandal and Rural Unit for
Health and Social Action (Vellore) were involved in the first study and Rajan Patil in the
second 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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the Flood Action Plan. Annals Trop Med Parasitol 1993; 87 (4): 319-334
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kala azar and newer trends in its diagnosis in:
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Control jointly organized by Action Aid India, RUHSA and Navjeevan Seva
Mandal New Delhi 25-26 April 1995 Development Support division Action Aid
India Bangalore 1995
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Health and Family Welfare 1998 quoted by Park Textbook of Preventive and
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leishmaniasis. Ind J Pediatr 2004; 71: 143-144
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• Kala-Azar Since 1977 Chatterjee, P MFC Bulletin 248-9 November-December
1997
• Status of kala-azar in Bangladesh, Bhutan, India and Nepal: A regional review
update Kala Azar Status 2008 webpage WHo/SEARO Feb 2009
• 5_1b_Kala Azar elimination programme in India.pdf Dr S N Sharma Deputy
Director National Vector Borne Disease Control Programme New Delhi Email:
drsnsharma@sify.com 12/3/2007
• Updates on the status of Visceral leishmaniasis (Kala azar) in SEA region,
Communicable Diseases, www.searo.who.int/en/section10
• http://www.ndtv.com/article/india/bihar-battles-kala-azar-over-6000-cases-
reported-116252 accessed on 18/03/2012
• http://articles.timesofindia.indiatimes.com/2012-03-15/patna/31196369_1_kala-
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8. • http://articles.timesofindia.indiatimes.com/2012-03-03/india/31119358_1_kala-
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