Kala azar is a strange disease

Since January 2010, MSF has been running a kala azar treatment centre in the state of Al-Gedaref in eastern Sudan. We talk to the doctor in charge of the project.

Dr Dagemlidet WORKU has extensive experience of working with kala azar (visceral leishmaniasis), a disease that is neglected by pharmaceutical companies yet affects half a million people every year, primarily in Asia and Africa. The Ethiopian doctor has previously treated patients in Uganda and Kenya and, in January 2010, he was involved in opening a treatment centre in Al-Gedaref State, 500 kilometres east of the capital, Khartoum. Al-Gedaref is traditionally one of the regions most affected by kala azar, although southern Sudan is also currently facing an unprecedented epidemic. Dr Dagemlidet Worku, just back from Al-Gedaref, talks about treating the disease

What struck you most when you arrived in eastern Sudan?
In Kenya, I was used to treating 60 or 70 cases a month. In Al-Gedaref, when we started work at the kala azar treatment centre in Tabarak Allah, we were receiving as many as 150 patients a day in January. Today, we have an average of 100 patients per month. Some had travelled up to 130 kilometres to get treatment. There wasn’t enough space in the building and we were forced to treat people under a tree. The patients were then transferred to temporary shelters, and eventually we built a new ward. I was very surprised by this influx; my Sudanese colleagues weren’t quite so surprised.

Al-Gedaref is one of the regions in Sudan hardest hit by kala azar. In some villages, all the inhabitants are infected. Eighty-five percent of the cases recorded in northern Sudan come from this state.

Why is this region so severely affected?
Al-Gedaref’s climate and topography are particularly favourable for the sandflies that transmit kala azar. These insects take refuge in the cracks that form in the ground after the rainy season and in tree trunks.

As there are ten health centres specialising in the treatment of kala azar, patients come from other states to be treated. Al-Gedaref is also the place where the progress of the disease is most closely monitored. I’m sure that if the same attention were paid to it elsewhere in north Sudan, the percentage of cases recorded in Al-Gedaref would fall.

Despite these efforts, the disease isn’t yet under control
A lot more financial resources are needed. Al-Gedaref has become an important region for research on kala azar, but not enough research is being focused on improving diagnosis and treatment. For example, sodium stibogluconate (SSG), the first-line drug against kala azar, was developed in the 1930s. Also, the treatment centre managed by MSF is the only one that uses a rapid screening test. This test is very easy to use, as it simply involves taking a drop of blood from the patient’s finger.

Kala azar is a strange disease. Some of the symptoms vary, depending on whether the sufferer is in Kenya or Sudan. The effectiveness of the screening tests and treatment also differs, depending on the country. For example, in India, patients can be cured by a single session of intravenous liposomal amphotericine B, the second-line drug. In Africa, single doses don’t work. Without operational research, all these differences remain a mystery.

Why are children more affected by kala azar?
Because they have lower immunity to fight the infection. Not everyone who comes into contact with kala azar develops the disease. What’s more, patients who have been treated before are immune to it. It’s no coincidence that HIV/AIDS sufferers are more vulnerable, because their immune systems are already weakened.

How can this disease be eradicated?
As a medical organisation, MSF is trying to treat as many sufferers as possible. In 2010, we screened some 7,000 people and treated around 1,200 cases. The cure rate has reached 96 percent and, once cured, people are immune to the disease. That’s the best way of reducing the stock of infection.

To eradicate kala azar, living conditions need to be improved. In Sudan, as elsewhere, kala azar hits the poorest. It attacks those weakened by malnutrition. As the dried mud walls of the houses are an ideal refuge for the sandflies that carry kala azar, putting up plastic sheeting inside would be a simple measure; but the communities concerned often can’t even afford to do that. There is doubt about the effectiveness of mosquito nets in preventing kala azar. As with all parasitic diseases, MSF simply encourages people to protect themselves by keeping their skin covered.