HEALTH MATTERS: Kala-azar – A serious public health threat

Image of an Phlebotomus Papatasi sandfly which is known to cause Black Fever.

Image of an Phlebotomus Papatasi sandfly which is known to cause Black Fever.

For decades, Visceral Leishmaniasis commonly known as Kala-azar, has been a major health risk across the country, especially in the eastern states. This vector borne disease has been one of the debilitating and fatal parasitic diseases, afflicting lacs of people, especially those families who live in remote regions, because it is one of the most neglected vector borne disease in the country.

Over the years, thousands of people have succumbed to this life-threatening disease, which is transmitted by sand flies, which carries a vector called phlebotomus aregentipes. These are small insects compared to mosquitoes but pose an equally high threat. The symptoms include fever, weight loss, fatigue and anaemia, swelling of the lever and spleen.

According to the National Vector Borne Disease Control Programme data, the most endemic states are Bihar, Jharkhand, West Bengal and Uttar Pradesh, which report the highest number of cases related to Kala-azar. Approximately 130 million people living in these endemic areas in these four states are at the risk of acquiring infection.

Of the four states, Bihar has the highest number of Kala-azar cases. About 35 million people have Kala-azar in the state.

In Jharkhand, the population at risk is 4.8 million, in approximately 1,507 villages spread over 30 blocks, a majority of them are tribals, who are the most marginalized.

In West Bengal, where Kala-azar was endemic much before other states, is still struggling with this infectious disease. The overall population at risk is 4.76 million, in approximately 731 villages spread over 119 blocks.

In Uttar Pradesh, Kala-azar cases have emerged in eastern districts, where sporadic cases of Kala-azar have been reported. The population at risk is 2.35 million in these areas.

The prime cause for this growing mortality due to Kalazar is because it has been a neglected tropical disease, and has remained unaddressed especially in rural areas.

It has been found that those living in villages and mountainous terrains are most vulnerable to Kala-azar. The environment where families live, sandflies are rampant. It begins to breed when the temperature is humid and moist. Mangroves are also where sandflies rest. Since a number of homes are not made insecticide proof, they are easily exposed to the vector, especially when the home is humid.

Sandflies generally bite at dusk and dawn but there is low awareness about how to prevent these bites, which put families at risk. Besides, there is no support from the government in terms of providing indoor residual spray and bed-nets (machhardaani) to cover bamboo thatch and mud plasters that these homes have where the sand flies breeds and rests. Indoor residual spray can prevent the sandflies from biting. But since they have no such support, families are prone to be bitten.

The other cause of death is poor availability and access to health care. Since the disease is so fatal, unless the infected person is diagnosed and treated on time, it can lead to death.

In rural settings, especially in villages, which are located far away from the mainstream, it has been found that thousands of people succumbed to this fatal disease, since a majority of those infected could not access to health care facilities. As a result, a number of severely infected people were not diagnosed on time, nor were they provided adequate treatment and care leading to death.

In Pakur district in Jharkhand, where Kala-azar is widespread, it was found that tribal families did not have access to diagnosis and treatment. At the health clinic, there were no diagnostic kits or medications available so doctors are unable to provide timely diagnosis or adequate treatment and care. As a result, thousands of Kala-azar patients have succumbed to this fatal and life-threatening disease because they were not diagnosed on time, nor did they get proper treatment.

Given the rising number of Kala-azar deaths and the negligence faced by the public, the government is now planning a programme to eliminate Kala-azar in the country.

The National Vector Borne Disease Control programme has worked out guidelines for all states so that Kala-azar can be addressed at the field, in appropriate manner.

Black-fever---Amastigotes-in-a-chorionic-villus

Amastigotes in a chorionic villus Image credit: WHO/TDR/El-Hassan/CC BY-SA 3.0

Although the department claims that Kala-azar has reduced over the years, it is unclear, since many areas still remain off the radar and it is unclear what the overall extent of the disease is.

It also remains unaddressed if many are also suffering post-kala-azar dermal leishmaniasis as well, which is also manifesting in many cases one of two years after getting Kala-azar.

Therefore, the concern still remains where the most marginalized communities who bear the brunt of multiple vector borne diseases like Malaria, Dengue, Chikungunya along with Kala-azar will benefit. Will Rapid diagnostic kits, drugs and adequate doctors reach these remote areas and will discrimination and indifference against these groups end so that they are able to access health care and get appropriate treatment. Or will the gaps remain.

To improve the health status of vulnerable groups and at-risk population living in Kala-azar endemic areas, elimination of Kala-azar is required so that it no longer remains a public health problem.

To achieve the final milestone, it is also imperative to reach the most unreachable groups who are the most ignored communities, where thousands of people living in these endemic areas continues to face the risk of acquiring infection and deaths. The magnitude of the disease burden is needed to be explored along with the treatment regimen that is suitable for them has to be identified. Unless these communities are given prime focus, the programme will fail to achieve its goal of ending Kala-azar in India.

In rural areas, special attention is required to control and end Kala-azar. Each household needs to be made aware about how to prevent themselves of getting infected by from vector borne diseases like Kala-azar and be also provided adequate protection in the form of indoor residual spray as well as provide appropriate treatment and care to the population so that Kala-azar is eliminated completely across all categories.

(Mohuya Chaudhuri is a journalist and researcher)