India: Fighting kala azar in Bihar

Visceral leishmaniasis is known worldwide as kala azar. Since 2007 Médecins Sans Frontières(MSF) is implementing a kala azar diagnostic and treatment project in Bihar state, northern India.

It is ten in the morning and several people are already waiting at the lab doors to be tested for kala azar. The lab is located at the kala azar diagnostic and treatment unit in Sadar Hospital, which is the referral facility in the Vaishali district, home to about three million people. Baby is 27 and has two children; she lives close to the hospital and for several weeks she has had fever and no appetite – two of the most common symptoms for the disease. She is referred by the outpatients department to the kala azar department. The test reads positive, and after a medical examination, she is admitted to hospital for treatment. “Until this morning I had never heard about kala azar but, if I am going to improve, I don’t mind spending a few days in hospital,” she explains from her hospital bed.

Kala azar is a disease endemic to Vaishali, in the centre of the Indian state of Bihar. Transmitted by the sand fly, the disease causes enlargement of the spleen and, if left untreated, is fatal for virtually all patients. “The treatment we are using in Vaishali is very safe and effective. It usually consists of four IV doses of liposomal amphotericin B - LAmB.  From the second dose patients can show signs of improvement,” states Dr. GAURAB, coordinator of the medical activities in the MSF project.

Since July 2007, MSF has been running a kala azar diagnostic and treatment project in Vaishali. In the four years the project has been open, about 8,000 patients have been treated at the Sadar Hospital, and in five MSF-supported health centres. The initial cure rate of kala azar cases is at 98 per cent. “Right now, we are giving patients 20 mg of liposomal amphotericin B and we know it is effective. But we are also looking into potential alternatives for the future, such as 10 mg of LamB in a single dose, or combined therapies with proven efficacy,” explains Dr. Marta GONZÁLEZ, MSF doctor in Vaishali.

The World Health Organization is also recommending all these treatments in its latest book on control of the leishmaniasis and MSF hope the national program will follow-up the recommendations.

The difficulties to treat PKDL and HIV co-infection
Chandeshwar, 30, is admitted to Sadar hospital. He has post kala azar dermal leishmaniasis (PKDL), a complication that can affect patients who have already been treated for kala azar. Chandeshwar was treated three years ago with a medicine traditionally used to treat visceral leishmaniasis, known as sodium stibogluconate (SSG). It is no longer effective in India because 65 per cent of patients have developed resistance and just recently have there been signals from the Ministry of Health that they will take it out of use.

PKDL does not pose any health risks for patients, but causes skin rashes that may affect quality of life. Treatment of PKDL is very long, and patients such as Chandeshwar need to be kept as an inpatient while the treatment regime, which involves three courses of 20 days each, is carried out. Despite these difficulties, treating the affected patients is very important, in order to curb the spread of the disease. “Skin lesions are a reservoir for the parasite. If untreated, the sand fly that transmits the disease may continue to infect other people more easily,” explains Dr. DEEPAK.

Treating HIV co-infected patients is not easy either. The two diseases impact against each other: kala azar lowers the defences of HIV positive patients, increasing the risk of contracting opportunistic infections, and HIV positive patients are more prone to contracting kala azar, and treatment is less effective. “When we treat HIV-Kala azar co-infected patients with LAmB, we know that the risk of a relapse is higher than in patients who just have kala azar,” concludes Dr. Deepak.

Receiving liposomal amphotericin B at OPD level
Bilanpur is a village inhabited by 10,000 people, surrounded by paddy fields. Vinod, 15, lives here, with his seven brothers and sisters, and their parents. Vinod started feeling unwell a few weeks ago, and now he is receiving treatment for kala azar as an outpatient at the Lalgang health centre. For him and his family, going to the health centre every two days to receive the required dose of LAmB is easier than being admitted to the Sadar hospital, which is further away.

Just like Vinod, Kamli, 50, is also being treated as an outpatient. It took Kamli six months before she was diagnosed with kala azar and received treatment free of charge. Until then, she had visited several private doctors and borrowed money to pay for her treatment. Most people infected with kala azar are poor and do not have means to fight the disease. “I couldn’t pay it back so I had to mortgage my two pieces of land. I am a sick person, yet we do not have enough food to eat,” says Kamli. In Vaishali, MSF is working to change this situation and to provide people with access to life-saving diagnosis and treatment free of charge.