India recently carried out a high-level independent mission to assess and evaluate its national visceral leishmaniasis (kala-azar) strategy.
The aim of the independent assessment mission is to identify existing gaps and measure the country’s performance in implementing programmes to achieve the elimination of the disease as a public health problem1
“Challenges need to be identified as we resolutely move towards eliminating kala-azar,” said Dr Henk Bekedam, WHO Representative to India. “The importance of an inclusive, pro-poor strategy cannot be underscored as the disease affects marginalized communities. We are confident that this independent assessment by experts will guide the national programme to address remaining bottlenecks.”
“There are around 130 million people at risk of Kala-azar in the 54 districts of four endemic States” said Dr Neeraj Dhingra, Director, National Vector Borne Disease Control Programme, Ministry of Health and Family Welfare, Government of India. “We have made substantial progress in reducing the endemicity of kala-azar by ensuring house to house search, treatment and follow up of cases. We are determined to eliminate the disease soon and counter the challenges of continued transmission in the country.”
In addition, 94% of implemntation units are below the elimination threshold, which means they are reporting less than one kala-azar case per ten thousand of population.
Challenges
But despite this significant decline, challenges remain in several implementation units, including persistent pockets with high endemicity.
The WHO Country Office and WHO headquarters technically supported the development and roll out of the surveillance system and the guidelines. Medical doctors and medical recorders from kala-azar treatment centres also benefitted from practical training on the web tracking system, which will be phased out and expanded to all districts.
“What we find today is almost 6% of blocks are still above the elimination threshold and have high case fatality” said Dr Jorge Alvar, head of the mission who, in the past, led the global leishmaniasis elimination programme at WHO. “Compounded to this we’ve had weak reporting of relapsed cases, increased cases of post Kala-azar dermal leishmaniasis and inadequate tools for vector surveillance. All these need to be addressed along with a reinforcement of the national task force to harmonize efforts by stakeholders and the ministry of health.”
Independent assessment
In December 2019, the national programme organized its first independent assessment mission, with assistance from the WHO Country Office in India. Eight teams, comprising 61 independent and national global experts in visceral leishmaniasis, vector control and other areas of expertise, investigated nineteen districts in the states of Bihar, Jharkhand, Sikkim and Uttar Pradesh.
The experts were accompanied by officials of the Ministry of Health and Family Welfare, the National Vector Borne Disease Control Programme, representatives from the Indian Council of Medical Research, the Bill & Melinda Gates Foundation and several other organizations.
In addition to endemic states, sporadic cases are reported from other states - Assam, Delhi, Himachal Pradesh, Kerala, Madhya Pradesh, Punjab, Sikkim and Uttarakhand.
Kala-azar is a highly focal vector borne disease, transmitted by sandflies. It is fatal if left untreated in over 95% of cases.
The disease is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anemia. Major risk factors include socio-economic conditions of populations.
Poor housing and domestic sanitary conditions (such as a lack of waste management or open sewerage) may increase sand-fly breeding and resting sites, as well as their access to humans.
Sandflies are attracted to crowded housing as these provide a good source of blood-meals. Human behavior, such as sleeping outside or on the ground, may increase risk. Malnutrition and diets lacking protein-energy, iron, vitamin A and zinc increase the risk co-infection will progress to a full-blown disease.
Furthermore, epidemics of both cutaneous and visceral leishmaniasis are often associated with migration and the movement of non-immune people into areas with existing transmission cycles. Occupational exposure as well as widespread deforestation remain important factors.
1Elimination of kala-azar means reducing the cases to a level where it is no longer a public health problem. The target is to achieve less than one kala-azar case per 10 000 population annually, at the district or sub-district level.
2In 2014, this MoU was extended to include Bhutan and Thailand through which the countries agreed to collaborate to eliminate VL. At that time 147 million people in WHO’s South-East Asia Region were at risk. Areas of collaboration include mutually agreed mechanisms of resource mobilization; exchange of information; inter-sectoral collaboration; research; capacity building and technical support.