Kala Azar- Reason to Resurge

HISTORY:
Kala Azar, which means Black Fever in Urdu, has been reported in India since 182
4 when an outbreak was recorded in Jessore (now in Bangladesh). There was disagr
eement about which epidemics were Kala Azar and which Malaria at first. One epid
emic resulted in 750,000 people dying over three years. Kala azar spread to Assa
m 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 leishmani
asis. Dr UN Brahmachari discovered the medicine Urea Stibamine. Sinton published
maps in 1925 showing that the sandfly and Kala Azar had a similar geographic di
stribution. But it was only in 1940 that it was recognized that the sandfly carr
ied this disease. Epidemics recurred up to 1946.
As a result of National Malaria Programme spraying of DDT from 1953 Kala Azar wa
s 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 o
f skin lesions called PKDL 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 increa
se in cases seen at School of Tropical Medicine Calcutta in 1971. 40 cases of Ka
la Azar were reported from Bihar in 1974. In 1977 a survey done by National Ins
titute of Communicable Disease estimated 70,000 cases in Bihar. Cases also incre
ased in Bangladesh after 1973. A factor that may have had a role was the large s
cale 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 d
istricts 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 s
ingle 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 D
isease 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 peop
le, mostly Santals and Maltos. 65 of them were proved to have the disease. A sur
vey 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 a
s 45% of those tested had malaria parasites in their blood. This was the first s
tudy 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 under forty years old. Above this age the A
RI 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 for
ty. The data suggested that the epidemic might continue among the younger childr
en.
INCREASE IN THE TWENTY FIRST CENTURY:
There was an increase in reported cases in Jharkhand from 469 in 2000 to over 21
59 in 2003 when drugs were available. In 2003 there was an increase in cases rep
orted from Bihar too- from 9684 in 2002 to 13960 in 2003.
Cases from Pathna Block increased from 94 in 2000 to 206 in 2001 and 327 up to S
eptember 2002 at Holy Cross dispensary in Sahebganj District. The entire distric
t 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 governmen
t 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 3
73 cases in December 2003. Possibly some of the NGO data did not get counted.
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 are chi
ldren 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 eve
ry year one expects 1595 patients. This means 40 to 80 patients for injection ev
ery 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 tech
nician and at least one day a week of doctor's time would be needed to do the bo
ne marrow tests in Litipara. It is more practical to make a diagnosis based on c
linical 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 ha
ve died of Kala Azar in the Hiranpur Mission Hospital which treats many of the p
atients from Litipara. The last was Benjamin Tudu who died in the first half of
2005.
TREATMENT:
A large supply of SAG (Sodium Antimony Gluconate) was available in undivided Bih
ar between 1991 and 1993 as a result of Kala Azar Control Programme (KACP), a go
vernment effort.
In 1994, the government became reluctant to supply SAG to NGOs in Sahebganj. The
y 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 i
t was not available in the newly formed state of Jharkhand, though Bihar did hav
e some stocks through the Modified Kala Azar Control Programme (mKACP). It becam
e 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 pri
ce 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 case
s. A new oral drug is now available- Miltefosine. However it costs Rs 3000 for a
28 day course and is not yet part of the National Programme. Research supported
by WHO is in process to see whether Paromomycin (an injectable and cheaper drug
) could be used (personal communication to author by Dr. Suranjan Prasad, Ranchi
).
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 Xa
vier's and Kodma in Sahebganj: Debpur, Satia (Herbal) and Sohorghati of Pakur; a
s well as Damruhat, Manikbathan, Sundar Mohr and Chandana of Godda is worth repo
rting. There has been active support from Bishops Julius Marandi of Dumka (himse
lf 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 Chan
dragoda(Sahebganj) is actively involved in treatment among the Malto community.
SOME DATA:
India (Government of India quoted by Park)
1986 17806 # before KACP
1992 77102 * during KACP
1998 13542 @ between KACP and mKACP
Bihar (data from Chief Malaria Officer, Health and Family Welfare Department, Go
vernment of Bihar, Patna)
1999 11151
2000 13076
2001 10387
2002 9684
2003 13960
Jharkhand 1999, 2000 data from GOI
District Sahebganj
1999 200
2000 370
2003 263 (uptil August from Regional Directorate, Health and Family Welfare, Pa
tna)
District Pakur (District Malaria Officer supplied data from 2003)
1999 38
2000 0
2003 644
2004 650
2005 209 (uptil May)
District Godda (District Malaria Officer supplied data from 2001)
1999 238
2000 99
2001 445
2002 893
2003 1497
2004 2298 - 6 deaths
2005 1021 uptil June- 6 deaths
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 c
ollecting and entering the dispensary data. The District Health authorities, Abh
isek 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 t
he first study and Rajan Patil in the second one.
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