A decade and 4 deadlines later, India set to eliminate kala azar this year

“With the elimination target just a year away, the team started working rigorously after the pandemic. And, we started to see the results. We haven’t seen more than one case per 10,000 population in any of the blocks since January this year,” said Rajiv Manjhi, the Joint Secretary overseeing kala azar and other vector-borne infection programmes.

Kala azar is a parasitic infection transmitted by sandflies. It causes fever, weight loss, and spleen and liver enlargement. Left untreated, it can be fatal in 95% of cases.

India recorded 530 cases and four deaths due to the infection till October this year, compared to 891 cases and three deaths in 2022. There were 1,357 cases and eight deaths recorded in 2021. There were also 286 reported cases of post-kala azar dermal leishmaniasis (PKDL) till October 2023. Completely curing the skin condition is essential as it can act as a reservoir for the parasite.

In December last year, Prime Minister Narendra Modi said in a ‘Mann ki Baat’ radio broadcast that India was on the brink of eliminating kala azar after diseases such as smallpox, polio and guinea worm. From more than 50 districts across four states, the disease was found to be higher than elimination levels in just four districts in Bihar and Jharkhand. “I am sure the strength and awareness of the people of Bihar and Jharkhand will help the government’s efforts to eliminate kala azar from these four districts as well,” he had said.

India’s first target year for kala azar elimination was 2010. This was later pushed to 2015, 2017 and 2020. There were three key interventions that helped India achieve the elimination targets this year, Manjhi said.

The first was ensuring effective indoor residual spraying. The sandflies that transmit the infection usually breed in the crevices of mud walls. Effective spraying can prevent breeding and reduce the spread of the disease. “Initially, when central teams checked houses, where indoor residual spraying had already been done, we still kept finding sandflies. This meant there was some deficiency in the mixing of chemicals or spraying. With Central teams as well as senior district officials monitoring the process, effective spraying was ensured,” he said.

The second was reducing crevices in ‘kuccha’ walls to reduce breeding areas. “We started using Gerrard soil that is found in Jharkhand and neighbouring areas to plaster the walls and crevices. The soil does not come off easily and ensures that breeding doesn’t happen,” he said.

Under the third intervention, the ASHA (About Accredited Social Health Activist) network was tasked with ensuring that people with PKDL complete their treatment. While one intravenous dose of the antimicrobial drug amphotericin B is effective in curing kala azar, those with PKDL need to take the medicine Miltefosine for 12 weeks.

Dr Kavita Singh, South Asia Director at the not-for-profit research organisation Drugs for Neglected Diseases initiative (DNDi), explained that compliance is poor because the treatment is long and many a times the patients are asymptomatic. She added that Miltefosine is also teratogenic — meaning it results in abnormal development of the foetus during pregnancy. The drug cannot be given to children and pregnant women. In fact, women shouldn’t conceive while on the treatment and for three months after, she said.

One of the key challenges now would be to ensure strong surveillance to pick up even the few cases that come up. In addition, said Manjhi, there would be a need to monitor new areas.

“While most of the kala azar cases in the country were reported from four states — Uttar Pradesh, Bihar, Jharkhand and West Bengal — sporadic cases from other states are also reported. We have to monitor states such as Uttarakhand that have a potential to become hotspots,” he said.

Dr Singh said there was also a need to ensure availability of drugs such as paromomycin, used to treat those with HIV and kala azar. Kala azar has a tendency to relapse in HIV patients, she said, adding that second-line treatment, such as paromomycin along with amphotericin, is important.

Dr Singh said: “Although it is mentioned in the programme, the medicine is not really available in India. It can be procured from the WHO. But the effort needs to be made.”