MSF Holland Ten years Visceral Leishmaniasis INTERVENTION 1997-2007

IBRAHIM ABDELLA(MD)

Out line
Introduction and VL burden MSF H and VL programme in Ethiopia Components of MSF H VL programme VL programme out comes and success Operational research Lesson learned and challenges ahead

Introduction
Leishmaniasis is a group of disease caused by parasite Leishmania species Over 20 species of Leishmania parasite cause the disease Three clinical forms Leishmaniasis are: 1.Cutaneous Leishmaniasis 2.Mucocutaneous Leishmaniasis 3.Visceral Leishmaniasis

Introduction
VL is a systemic illness affecting the spleen, liver, bone marrow, LNs, GIT and RT IP - 2-6 months Caused by L.Donovoani and ?L.Infantum in Ethiopia Transmitted by P. Orientalis, P. Martini and P.Celiae Mode of transmission is athroponotic in Ethiopia

Introduction
C/F :Fever >2 weeks, Splenomegaly, Anemia, Weakness, Weight loss, Epistaxis, Lower Abdominal Pain 100% fatal, if left untreated Globally ~500,000 cases/annually and - 60,000 death /year Ethiopia ~ 5,000 cases/Year

Endemic foci of Leishmaniasis in Ethiopia

The vector:

Phlebotomus orientalis

Breeding sites for sand flies

Introduction
Factors that are attributable for increase in transmission and possible occurrence of VL out break are:
1. Mass population movement to endemic areas 2. Urbanization, Agricultural development 3. Decrease in the immunity of the population

MSF and VL programmes in Ethiopia

1997 G.C an increased cases of VL was reported and the VL out break confirmed by the joint assessment of FMOH,MSF and WHO Large scale agriculture development and the restettlemnt programme resulted in huge influx of non-immune population in the area MSF established VL project in Kassay Abera Hospital in 1997 G.C HIV programme with ART in 2004

MSF Hand VL programmes in Ethiopia

MSF has treated 10,748 VL patients with over all cure rate of 88.7% in three regions Tigray Region Humera 1997 up to date Mycadra - 2003-2005 Amhara Region Abdurafi - 2004 up to date Metema Dec 2005-Feb.06 SNNPR Konso - 1999- 2001

Components of VL programme
1.IEC/HE

Targets the community

Prevention method- use ITNs Sign and symptoms of KalaAzar/VL EARLY TO SEEK TREATMENT Where to get the treatment

METHODS

- IEC Materials
- Health educators - Radio broadcasting in 2006 and in 2010

2.OUT REACH ACTIVITIES

Health education Active case finding and surveillance Training of BOH Health workers

Components of VL programme
3.Laboratory -DAT -R k39 - Aspirate Spleen, LNS - Para check/BF - Hematologic tests - Organ function tests

Components of VL programme
4.VL treatment and care A. Clinical Assessment- Grading of severity - Co-morbidities - Nutritional assessment - PIHCT Decided where to admit - ICU - IPD/VL Ward - Shelter stable patients

KalaAzar Shelter

Component of VL programme
B. Treatment of VL First line drug PKA SSG 20mg/kg/d for 30 days Sever S/E chemical pancreatitis, sudden death, nephrotoxicity , hepatotoxicity Second line drug- HIV/VL Co infected - Relapse cases - Pregnant - Severe SSG toxicity

Ambisome 5mg/kg/ dose, a total of 6 doses is given with in 12 days (every other day)

Components VL programme
5.Nutritional support Severely malnourished provided therapeutic feeding 6.Emotional and physical stimulation

VL programme out comes and Success

1997-2007
Admission

Tigray
Humera 1997Mycadra 2003-05

Amhara
Abdurafi 2004Metema Dec.05Feb06

SNNPR
Konso 1999-2001

Total
10748

7424

1304

1744

88

188

PKA
Cure Rate

7015
86.8%

1251
94.4%

1694
91.6%

86
89.5%

188
91%

10234
88.7%

Death Rate
Defaulter Rate Relapse Rate

12.1%
1.1% 4.14%

3.97%
1.2% 3.3%

7.1%
1.0% 1.6%

9.3%
1.2% 2.3%

3.2%
5.6% 0

10.0%
1.2% 3.5%

VL programme out comes

Humera VL admission pattern over ten years intervention
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Total
Total Adm. PKA PKDL Relapse Cure rate(%) Death rate(%) Default rate(%) Relapse rate(%)

112 112 0 0 75.0 25.0 0.0

506 506 0 0 76.9 23.1 0.0

565 565 0 0 82.5 17.5 0.0

476 476 0 0 84.7 15.3 0.0

561 561 0 0 92.0 8.0 0.0

581 581 0 0 81.0 19.0 0.0

1406 1339 19 48 88.3 8.9 2.7

913 824 10 79 88.7 9.4 1.9

1207 1124 6 77 90.3 7.9 1.8

657 542 18 97 90.4 8.3 0.8

440 385 6 49 91.8 6.7 1.3

7424 7015 59 350 86.8 12.0 1.4

0.0

0.0

0.0

0.0

0.0

0.0

3.4

8.7

6.4

14.6

1.4

4.1

VL programme out comes

Humera VL Programme admission pattern over ten years

1600 1400 1200 1000 800 600 400 200 0 Primary kala-azar PKDL relapses total admissions

19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07

VL programme out comes

Primary Kala-azar Admissions N.W. Ethiopia, 1997-2006
400 350 300 250 200 150 100 50 0 Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006

VL programme out comes

Humera VL programme Death rate pattern over ten years

30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Series1

VL programme out comes

Abdurafi VL admission pattern over four years intervention
2004
Total Adm. PKA PKDL Relapse Cure rate(%) Death rate(%) Defaulter Rate (%) Relapse Rate (%)

2005 522 504 9 9 92.3 6.5 1.2 1.7

2006 430 420 6 4 89.4 8.7 1.2 0.9

2007 302 297 3 2 92.9 6.2 0.3 0.7

Total 1744 1674 22 28 91.6 7.1 0.9 1.6

490 473 4 13 91.9 7.0 1.1 2.6

Operational Research
Comparative study of Pentostam Vs SSG -1998/1999 Cure rate 70.2%(Pentostam) and 81.1%(SSG) High mortality rate among HIV co-infected patients was seen (33.3%vs3.6%) Comparative study of SSG Vs oral Miltefosine -2003/4 Initial Cure rate 88% Mortality rate 10%( on SSG) vs. 2%(on Miltefosine) during treatment Parasitological treatment failure was 8%(Miltefosine) and 1%(SSG) Parasitological failure of Miltefosine 18% in HIV patients and 5% in HIV Negatives Miltefosine is equally effective as SSG for HIV negative VL patients and lesser effective but safer among HIV positives.

Operational Research
Field Evaluation of DiaMed IT-Leish rk39 (RDT) for VL-2006 *Sensitivity 84.3%(in parasitological confirmed cases)
and Specificity 91.5%(in DAT Neg. clinical Suspects) *Sensitivity of rk39 in parasitological confirmed HIV positives was 77.3% *Specificity in DAT negative endemic control was 99.0% *Reasonable for screening and very good for diagnosis

Operational Research
VL/HIV co-infection in Ethiopia -2003-2006
365 HIV/VL co-infected patients followed Among 195 patients on HAART 31.3% had one or more VL episodes and Baseline CD4 strongly influence the risk of relapse Relapsed patients showed poor CD4 recovery in spite of being on ART HAART reduces the risk of relapse significantly,but doesnt prevent it

VL is causing considerable morbidity and mortality

in Ethiopia Migrant workers &Re-settlers are most vulnerable in North-Western part of Ethiopia Seasonal workers in endemic areas are likely to be misdiagnosed when they go back home Knowledge and diagnostic skill among health professionals is limited Early diagnosis and referral is possible at remote areas using RDT and can reduce mortality significantly

Blood transfusion is needed at VL treatment centers HIV co-infection rate among VL patients ranges 30-35% PHICT, HIV care and treatment needs to be available at VL treatment centers HIV/VL co-infection is a great challenge, multiple relapse is inevitable among co-infected patients SSG is not enough for VL treatment , combination therapy and/or alternative treatment needs to be available Nutritional support and hydration is equally important

I.

IMPLEMENTAION OF NATIONAL KALAAZAR ROLL OUT PLAN

 Rapid diagnostic method needed Drug with less side effect, shorter duration of treatment and with easy administration is needed

Challenges Ahead
III.HIV/VL

Co-infection

THANK YOU !!!!!