Leishmaniasis is a parasitic disease caused by the Leishmania protozoa, presenting mainly as cutaneous, mucocutaneous, and visceral forms, with kala-azar being the most severe. The disease is primarily transmitted by the sandfly and is endemic in various regions including India, where significant control measures have been implemented since the 1990s, resulting in a notable decline in cases. The Indian government aims to eliminate kala-azar by reducing its incidence to less than one case per 10,000 population through various public health strategies and collaborations with neighboring countries.

1. LEISHMANIASIS
Dr Adhya Dubey
JR-2 (Dept Of Community Medicine)
PGIMS, Rohtak

3. Outline of presentation
• Introduction
• Infectious agent
• Occurrence
• Reservoir
• Mode of transmission
• Incubation period
• Susceptibility
• Methods of control

4. Leishmaniasis is a parasitic disease caused by the protozoa belonging to the
genus, Leishmania .
Human leishmaniasis is not a disease, but a group of diseases.
While several ways to classify leishmaniasis (eg, by geography or taxonomy) are
available, clinically, it can present itself in various ways, and is more easily classified as
cutaneous, mucocutaneous, and visceral leishmaniasis.

5.  Kala-azar (KA) or Visceral Leishmaniasis (VL) is caused by Leishmania donovani and
transmitted by Phlebotomus argentipes (Sandy fly).
 Maximum number of 44533 Kala-azar (KA) cases reported in 2007 and minimum
9241 cases reported in 2014 in India.
 Incubation period in KA varies from 10 days to > 2 years in general but from four
months to one year in India. Disease found across all age groups.
 Males are more afflicted than females.

6. Classification
Eukaryota (organisms with nucleated
cells),
◦ Kingdom Protista,
◦ Phylum Protozoa,
◦ Class Flagellates,
◦ Genus Leishmania.

7. Leishmania donovani Visceral Leishmaniasis/ Kala – Azar / Post
Kala – azar Dermal Leishmaniasis (PKDL)
Leishmania infantum Infantile Visceral Leishmaniasis
Leishmania tropica Cutaneous Leishmanisis;
urban/anthroponotic.
Leishmania major Cutaneous Leishmanisis; rural/zoonotic
Leishmania aethiopica Cutaneous Leishmanisis/ Diffuse Cutaneous
Leishmanisis
Infectious Agents

8. ◦ Kala-azar endemic areas.
◦ 54 districts in 4 states
(2021)

9. Sl.
No.
Affected States/UTs 2020 2021 2022 2023 (P) 2024(P)
C D C D C D C D C D
1 Assam
2 Bihar 1427 0 893 2 550 0 329 3 19 0
3 Delhi*
4 Jharkhand 424 0 275 2 188 1 154 0 5 0
5 Kerela 1 0 3 0
6 Punjab*
7 Sikkim 3 0 1 0 2 0 4 0 1 0
8 Uttrakhand
9 Uttar Pradesh 55 3 49 2 23 2 16 1 0 0
10 West Bengal 57 3 58 2 52 0 17 0 1 0
Total 1967 6 1276 8 818 3 520 4 26 0
Kala-azarTrendinIndia

10. 🞂 Man:
◦ No zoonotic reservoir detected so far in Indian Sub-
continent
◦ it’s Anthroponotic in India.
🞂 Rodent:
◦ African kala-azar
🞂 Canine
Reservoir

11. Visceral Leishmaniasis
(Kala-azar)
Etiology
The L. donovani species complex
includes several species:
L. infantum and L. chagasi

12. 1. The amastigote is the intracellular,
non-motile form in the vertebrate
host.
2. The amastigote is also called the
Leishman-Donovan (LD) body.
1. These forms are found in culture
medium as well as digestive tract of
sand fly.

13. Epidemiology
◦ The species of visceral leishmaniasis are endemic in areas
of India, China, Central and South America, East and West
Africa, and the countries surrounding the Mediterranean.
◦ In India, no extrahuman reservoirs are known, but in other
regions, infection may involve several mammalian species,
including dogs, foxes, and wild rodents.
◦ Sandflies of the genus Phlebotomus are the insect vectors
that spread L. donovani.

14. Vector
 Visceral Leishmaniasis or Kala-azar is transmitted by the bite of infected sandflies.
 Phlebotomus argentipes is the only known vector of Kala-azar in India.
 Disease transmission is highest in the rainy season.
 The vector breeds in humid soil rich in organic matter and near cattle sheds and mud- houses.
 It rests most commonly in cracks & crevices of thatched mud-houses.
 The peak biting time of the vector is around midnight.

16. ◦ During blood meal, infected sandflies inject the infective stage, the so-called
promastigote parasite, into the human host.
◦ Injected promastigotes are first phagocytized by macrophages and transform into
so-called amastigote parasites.
◦ Released amastigotes disseminate hematogenously and invade reticuloendothelial
cells in the spleen, liver, lymph nodes, bone marrow, and skin.
Pathogenesis

17. ◦ When sandflies take blood meals from an infected host, they take up parasitized
macrophages.
◦ In the vector fly's midgut, these parasites differentiate into the so-called promastigote
form, which multiplies and finally migrates to the fly's proboscis.

18. Incubation and Clinical Symptoms
◦ Incubation period is 6-8 months.
Symptoms:
◦ weakness, dizziness, weight loss, diarrhea, and constipation.
◦ Fever, may spike twice daily;
◦ chills and sweating.
◦ hepatosplenomegaly
◦ anemia and leukopenia.
◦ bleeding from the gingivae, nose, or GI tract,
◦ ecchymoses and petechiae on the skin.

19. Clinical forms
VISCERAL
MUCOCUTANEOUS
CUTANEOUS

20. Immunity
◦ In visceral leishmaniasis (Kala-Azar) cellular immunity is responsible for resolving
mild disease. High levels of antibodies are found.
◦ In cutaneous and mucocutaneous leishmaniasis host defense relies on cell-mediated
immunity; antibody titers are low. The response ranges from a local granuloma with
few parasites to a histiocytoma with many parasites.

21. Laboratory Diagnostics of visceral leishmaniasis
◦ Demonstration of the organism in host tissues cultured on a Novy-MacNeal-Nicolle (NNN) or
other medium or detection of Leishman-Donovan bodies (amastigotes) in stained tissue
samples.
◦ PCR can be performed using genus- or species-specific oligonucleotides.
◦ Established by examining bone marrow aspirates.
◦ Splenic aspirates have the highest yields but may be risky.
◦ Liver biopsy or aspiration of enlarged lymph nodes can also provide diagnostic material.

22. Laboratory Diagnostics of cutaneous and mucocutaneous
leishmaniasis
◦ Demonstrating amastigotes on stained smears of a biopsy or
of scrapings from the border of an ulcer.
◦ Culturing amastigotes on NNN medium inoculated with lesion
material.
◦ PCR targeting parasite kinetoplast DNA has allowed detection
of organisms that might be missed on histologic section or
culturing.

23. Laboratory Diagnostics of cutaneous and mucocutaneous
leishmaniasis
◦ Except in diffuse cutaneous leishmaniasis
(which heals spontaneously), the leishmanin
skin test is usually positive.

25. Prevention:
◦ Preventing sandfly bites is the most immediate form
of protection. Insect repellent, appropriate clothing,
screening of windows, and fine mesh netting around
the bed (in endemic areas) will reduce exposure.
◦ Public health measures to reduce the sandfly
population and animal reservoirs are important. There
are no preventive vaccines or drugs for leishmaniasis.

26. National Kala Azar Elimination Program
◦ Concerned with the increasing problem of Kala-azar in the country, the Government of India
(GOI) launched a centrally sponsored Kala-azar Control Programme in the endemic states in
1990-91.
◦ The GoI provided drugs, insecticides and technical support and state governments provided
costs involved in implementation.
◦ The program was implemented through State/District Malaria Control Offices and the primary
health care system. The programme brought a significant decline in Kala-azar morbidity, but
could not sustain the pace of decline for long.

27. ABOUT NFEP
◦ The National Health Policy-2002 set the goal of Kala-azar elimination in India by the year 2010 which
was revised to 2015. Continuing focused activities with high political commitment, India signed a
Tripartite Memorandum of Understanding (MoU) with Bangladesh and Nepal to achieve Kala-azar
elimination from the South-East Asia Region (SEAR). Elimination is defined as reducing the annual
incidence of Kala-azar to less than 1 case per 10,000 population at the sub-district (block PHCs) level
in Bangladesh and India and at the district level in Nepal.
◦
Presently all programmatic activities are being implemented through the National Vector Borne
Disease Control Programme (NVBDCP) which is an umbrella programme for prevention & control of
vector borne diseases and is subsumed under National Health Mission (NHM).

28. Goal
To improve the health status of vulnerable groups and at-risk population living in Kala-azar endemic
areas by the elimination of Kala-azar so that it no longer remains a public health problem.
Target
To reduce the annual incidence of Kala-azar to less than one per 10,000 populations at block PHC
level.

29. Objective
• To reduce the annual incidence of Kala-azar to less than one per 10 000 population at
block PHC level by the end of 2015 by:
• To reducing Kala-azar in the vulnerable, poor and unreached populations in endemic
areas;
• To reducing case-fatality rates from Kala-azar to negligible level;
• To reducing cases of PKDL to interrupt transmission of Kala-azar; and
• To preventing the emergence of Kala-azar and HIV/TB co-infections in endemic areas.

30. The Elimination strategy
◦ The national strategy for elimination of Kala-azar is a multipronged approach which is in line with
WHO Regional Strategic Framework for elimination of Kala-azar from the South-East Asia Region
(2011-2015) and includes:
◦ Early diagnosis & complete case management
◦ Integrated Vector Management and Vector Surveillance
◦ Supervision, monitoring, surveillance and evaluation
◦ Strengthening capacity of human resource in health
◦ Advocacy, communication and social mobilization for behavioral impact and inter-sectoral
convergence.

31. Much progress has occurred in the country in the past decades.
Kala-azar cases have decreased by 98% (1 275 cases in 2021)
since the start of intensified activities in 1992 (77 102
cases).(WHO)