Dr. Samarjeet Kaur Lecturer, Deptt of Community Medicine GSVM Medical College Kanpur

1. Dr Samarjeet Kaur
Lecturer
Department of Community Medicine
GSVM Medical College, Kanpur

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

3.  Leishmaniasis are group of protozoal diseases
caused by parasite of genus Leishmania, and
transmitted to humans by the bite of female
phlebotomine sandfly.
 They are responsible for various syndromes in
humans-
i. Visceral Leishmaniasis (Kala azar)
ii. Cutaneous Leishmaniasis
iii. Muco-Cutaneous Leishmaniasis
iv. Anthroponotic Cutaneous Leishmaniasis
v. Zoonotic Cutaneous Leishmaniasis
vi. Post Kala-azar Dermal Leishmaniasis

4. World
Visceral Leishmaniasis :
◦ 500,000 cases of kala-azar are reported
annually worldwide.
◦ India, Bangladesh, Brazil, Nepal and Sudan
accounts for 90% of the global incidence.
◦ Within the countries kala-azar occurs
among poorest communities.

5.  Cutaneous Leishmaniasis :
 Occurs in dry, semi desert rural areas of
central asia, middle east north and west
Africa, esp in Ethopia and Kenya.
 90% of cases occurs in Afghanistan,
Brazil, Iran, Peru and Saudi Arabia.
 Muco-cutaneous Leishmaniasis :
 More than 90% of cases occur in Brazil, Bolivia and
Peru

6. India

7.  About 130 million population is at risk of the
disease
 Kala-azar is endemic in 52 districts in Bihar
(31), Jharkhand (4), West Bengal (11) and UP
(6).
 In India both cutaneous (ZCL and ACL) and
visceral disease occur but visceral is by far the
most important leishmaniasis.
 There is an increasing trend of this disease in
India

8.  Zoonotic cutaneous leishmaniasis : has been
discovered in Rajasthan area in 1971, total 828
cases were reported.
 Cases of ACL have bee reported from Bikaner city.

10.  Leishmania are intracellular parasites.
 They infect and divide within macrophages.
 About 20 different leishmania parasites have been
associated with human infection.
 They don’t offer cross immunity of one against the
other.
 Leishmanis donovani Kala Azar & PKDL
 Leishmania tropica CL
 Leishmania brazileinsis MCL
 Distinction is not absolute.

11.  The life cycle is completed in two different hosts-
 Vertebrate host – Amastigote form (LB)
 Insect host – Promastigote form (flagellate)
 Reservoir of infection : There are variety of animal
reservoir (dogs, jackals, foxes, rodents and other
mammals).
 Indian Kala-azar is considered to be non – zoonotic
infection with man as the sole reservoir.

12.  Age – all age group including infants, peak age in
India is 5 to 9 years.
 Sex – Males are affected twice as often as females.
 Population movement – movement of population
between endemic and non-endemic areas can result
in spread of infection.
 Socio economic status – usually strikes the poorest
of the poor.
 Occupation – people working in farming practices,
forestry, mining and fishing have a great risk of
being bitten by sandflies.

13.  Immunity- recovery from kala-azar and oriental
sore give a lasting immunity.
 During active phase of disease there is impairment
of cell-mediated immunity, this is reflected in the
negative skin reaction to leishmanin test.

14.  Altitude – the disease is mostly confined to the
plains, it does not occur over 2000 ft.
 Season- the prevalance of disease is high during and
after rainfalls.
 Rural areas – more common in rural areas as
favorable conditions for breeding of sandflies exists.
 Vectors
 Development projects

15.  In India,
 P. argentipes is a proven vector of kala-azar.
 P.papatasi and P. sergenti – cutaneous leishmaniasis.
 Sandflies breed in cracks and crevices in the soil and
buildings, tree-holes, caves etc.
 Overcrowding, ill-ventilation and organic matter in
the environment facilitate transmission .
 The habits of flies is mostly nocturnal and only
females bite.

16.  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.

18.  Indian Kala-azar has a unique epidemiological
feature of being Anthroponotic; human is the only
known reservoir of infection
 Female sandflies pick up parasite (Amastigote or LD
bodies)while feeding on an infected human host.
 Parasite undergo morphological change to become
flagellate (Promastigote or Leptomonad),
development and multiplication in the gut of
sandflies and move to mouthparts.
 Healthy human hosts get infection when an infective
sandfly vector bites them

19.  Visceral leishmaniasis (VL), also known as kala-
azar is fatal if left untreated in over 95% of cases.
 It is characterized by irregular bouts of fever, weight
loss, enlargement of the spleen and liver, and
anaemia.
 Darkening of the skin of face, hands, feet and
abdomen is common in India (kala-azar=black
sickness)
 Lymphadenopathy may also occur.

20.  Post-kala-azar dermal leishmaniasis (PKDL)
◦ is a sequel of visceral leishmaniasis that appears as
macular, papular or nodular rash usually on face, upper
arms, trunks and other parts of the body.
◦ It occurs mainly in East Africa and on the Indian
subcontinent, where 5–10% of patients with kala-azar
develop the condition.
◦ It usually appears 6 months to 1 or more years after
kala-azar has apparently been cured, but can occur
earlier.
◦ People with PKDL are considered to be a potential
source of kala-azar infection.

21.  Cutaneous leishmaniasis (CL) causes skin lesions,
mainly ulcers, on exposed parts of the body, leaving
life-long scars and serious disability.
 Several forms have been described – ACL, ZCL, DCL
etc.
 The disease may be mistaken for leprosy.

22.  Mucocutaneous leishmaniasis leads to
partial or total destruction of mucous
membranes of the nose, mouth and throat.

23.  Leishmania-HIV co-infection
◦ Leishmania-HIV coinfected people have high
chance of developing the full-blown clinical
disease, and high relapse and mortality rates.
◦ Antiretroviral treatment reduces the
development of the disease, delays relapses and
increases the survival of the coinfected patients.
◦ High Leishmania-HIV coinfection rates are
reported from Brazil, Ethiopia and the state of
Bihar in India.

24.  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"

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

26.  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

27. Clinical
 Most infections are diagnosed clinically.
 The patient has an irregular fever, anemia, and
leukopenia; hepatosplenomegaly and bone marrow
suppression are characteristic.
Lab invest
 Haematological findings viz Anaemia, leucopenia,
thrombocytopenia & hypergammaglobulinemia.
 WBC : RBC ratio is 1:1500 or even 1:2000
 Raised ESR
.

28.  Parasitological
 Aldehyde (Napier) test
 Serological test
 Leishmanin (Montenegro) test
 Haematological findings

29.  Parasitological diagnosis
◦ The demonstration of the parasite LD bodies in
the aspirates of spleen, bone-marrow, lymph
nodes 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.
◦ Spleen aspiration has the highest sensitivity and
specificity (considered gold standard)

30.  1 to 2 ml of the serum from the case of kala-azar is
taken and a drop or two of 40% formalin is added.
 Jellification to milky white opacity (like the white of
hard boiled egg) so that in ordinary light newsprint
is invisible through it, is considered positive.
 This test is good for surveillance but not for
diagnosis.
 The test is non-specific as it becomes positive in
many other chronic infections in which albumin to
globulin ratio is reversed.

31.  Serology tests:
 Direct Agglutination Test (DAT), rk39 dipstick test,
ELISA and indirect fluorescent antibody test (IFAT)
are available.
 rk39 – rapid diagnostic test is based on the
recombinant k39 protein.
 It is an epitope apparently conserved on amastigote
of Leishmania species that cause visceral infection.

33. Sl. No.
Affected
States/
UTs
2007 2008 2009 2010(P) 2011(P)
Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
1 Assam 0 0 98 0 26 0 12 0 5 0
2 Bihar 37819 172 28489 142 20519 80 23084 95 18519 56
3 Delhi 19 0 34 0 12 0 33 0 0 0
4 Gujarat 4 1 0 0 0 0 0 0 0 0
5
Himacha
Pradesh
0 0 0 0 0 0 6 1 1 0
6
Jharkha
nd
4803 20 3690 5 2875 12 4305 5 4264 3
7
Madhya
Pradesh
0 0 1 0 0 0 0 0 0 0
8 Punjab 0 0 0 0 0 0 1 0 0 0
9 Sikkim 0 0 4 1 5 0 3 0 3 0
10
Uttrakha
nd
2 0 0 0 2 0 1 0 0 0
11
Uttar
Pradesh
69 1 26 0 17 1 14 0 8 1
12
West
Bengal
1817 9 1256 3 756 0 1482 4 1431 0
Total 44533 203 33598 151 24212 93 28941 105 24231 60

35.  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 surveys in endemic areas for early detection of
the cases.

46. 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

49.  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

50. 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

51. 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

52.  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.

53.  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.

54.  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.