2 Leishmaniasis A group of diseases, caused by the Leishmania parasites and transmitted by the sandfly

3 Types of LeishmaniasisVisceral Leishmaniasis (VL)/ Kala-azar It is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia. It is fatal if left untreated. Cutaneous/ mucocutaneous Leishmaniasis It is the most common form of leishmaniasis and causes skin lesions, mainly ulcers, on exposed parts of the body, leaving life-long scars and serious disability. 

4 Post Kala-azar Dermal Leishmaniasis (PKDL)PKDL is a sequel of visceral leishmaniasis that appears as macular, papular or nodular rash usually on face, upper arms, trunks and other parts of the body. People with PKDL are considered to be a potential source of kala-azar infection.

5 Global disease burden Leishmaniasis (visceral leishmaniasis & cutaneous leishmaniasis) is the third most important vector-born diseases in the world with an estimated 1.0 to 1.6 million cases per year According to WHO estimates: Incidence of visceral leishmaniasis (VL) is 0.2 to 0.4 million cases/year VL affects 98 countries worldwide and 90% of all VL cases occurs in only 6 countries VL kills about 20,000 to 40,000 people per year Source: WHO (most endemic counties are highlighted in red)

6 VL burden in the Indian subcontinent200 millions population are at risk Annually 25,000 to 40,000 cases are reported deaths occur per year Source: Joshi et.al (2008)

7 VL situation in BangladeshTotal Population million population (approx.) Population at risk - around 31 million (approx.) Kala-azar reduced more than 91% Endemic Districts- 26 Endemic Upazilas- 100 Hyper endemic upazila-02 Moderate endemic upazila – 06 Low endemic upazila – 92 Sources: CDC, DGHS, 2014

9 VL Elimination Program in the Indian subcontinentThe Government of Bangladesh, India and Nepal committed to eliminate VL from the Indian sub-continent by 2015. The elimination target is to reduce VL case less than one per 10,000 people at sub-district level in Bangladesh Recently the elimination target time is extended up to 2017 and two new countries (Bhutan and Thailand) joined in this initiative

10 Strategy of National Kala-azar Elimination Program in BangladeshEarly diagnosis and complete treatment Integrated vector management (IVM) Effective disease surveillance Social mobilization and building partnerships Operational research

11 Strategy -1: Early diagnosis and complete treatment

12 Diagnosis of Visceral Leishmaniasis (VL)New Kala-azar Kala-azar Treatment Failure Kala-azar Relapse Fever more than two weeks Residing/Traveling in Kala-azar endemic areas No improvement of initial treatment within six months or reappearance of symptoms and sign of Kala-azar Reappearance of symptoms and sign of Kala-azar six months after treatment Splenomegaly rk 39 strip test positive Parasitological confirmation through splenic smear or bone marrow exination or PCR

16 Lab Test for Kala-azar rk39 strip test is the most effective laboratory tool for diagnosing VL Other methods are the splenic aspiration cytology, different molecular tests (PCR, ELISA), DAT etc Slit-skin smear or skin biopsy is used in patients with skin involvement

17 Treatment of VL New Kala-azar: - Liposomal Amphotericin B (AmBisome); [10 mg/kg single dose] Treatment Failure / Relapse: Liposomal Amphotericin B (AmBisome) [Day 1] + Inj. Paromomycin [Day 2 – day 11] Cap. Miltefosine [For 10 days] + Inj. Paromomycin [For 10 days] + Cap. Miltefosine [Day 2 – day 8]

18 Treatment of PKDL First line treatment: MiltefosineAdult dose: 100 mg daily for 12 weeks in two divided doses. Children: 2.5 mg/kg body weight/ day in two divided doses, not exceeding 50mg/day for 12 weeks. Second line treatment: Amphotericin B deoxycholate : Dose: 4 courses of 20 injections IV over 5-6 months in every alternate day dose. LAmB : 5mg/kg/day total 20mg/kg in 4 divided dose once in a week Sodium Stibogluconate (SSG) : 20-mg/kg/day in intramuscular route. Total 6 cycles and each cycle consists of 20 days of treatment and 10 days in between two cycles.

19

20 Active VL and PKDL Case DetectionCamp Approach Focal Approach Incentive based approach House to house survey Active Surveillance: ACD House to house visit for Kala-azar case detection (2013 &2014) Camp: Union (2015) & Village (2012) based No Kala-azar Transmission Activity (2014)

21 Strategy-2: Integrated vector management (IVM)

22 Vector Control Tool Indoor residual spraying with insecticide (IRS)Long-lasting insecticide treated bed-net Impregnation of existing bed-net with long-lasting insecticide tablet Insecticide treated wall lining Environmental management

23 Integrated Vector Management (IVM)Indoor Residual Spraying Larvicide Spraying

24 WALL LINING Bed-net Impregnation

25 Risk Factor for VL Socioeconomic condition MalnutritionPopulation mobility Environmental changes Climate changes Source: WHO (http://www.who.int/mediacentre/factsheets/fs375/en/)

26 Strategy -3: Effective Disease Surveillance

27 Kala-azar Surveillance in BangladeshKala-azar surveillance is a part of web-based national disease surveillance system centrally managed by Kala-azar Elimination Programme, Disease control Unit, DGHS. Kala-azar elimination program-specific indicators is incorporated in the reporting format. In order to strengthen Kala-azar surveillance, KA surveillance units is set up at upazila and district level. KEP has access to surveillance data in real time

28 Kala-azar Surveillance in Bangladesh: A Modern SurveillanceNational Kala-azar Elimination Program is using both: Passive Surveillance & Active Surveillance

29 Kala-azar Surveillance in Bangladesh (Cont.)Passive Surveillance Self reported cases identified at health facilities Active Surveillance

30 Screenshot of the SystemMain page web link for DHIS 2 Patients Registration Treatment history and Follow-up

31 Reporting Event Report Bar Diagram Patient’s list Mapping

32 Strategy-4: Social mobilization and building partnerships

34 Some Newly Introduced IEC / BCC Materials by NKEPFlipchart Poster

35 Pen-Holder Sticker

36 Strategy -5: Operational research

37 Clinical and operational researchClinical trials with miltefosine , combination drug therapy, and feasibility studies for single-dose AmBisome at the sub-district level Trials have also been conducted with different vector control methods and studies for better diagnostic tools for VL and PKDL. Another major success of the program is the establishment of a Kala-azar research center at the Surja Kanta (SK) Hospital The research center at the SK Hospital is open to all researchers who are interested in conducting studies on VL and PKDL.

38 Achievement of NKEP 98% of the Upazila already achieved elimination target. ONELY TWO UPAZILAS are now above the target

39 Challenges of Kala-azar Elimination ProgramEstablishing an effective surveillance system Health seeking behavior Effective community mobilization Ignorance on PKDL Drug resistance Proper vector management Cross border collaboration Sporadic cases are reported from both non-endemic and from eliminated Upazilas

40 Information on Kala-azar available

41 Acknowledgement

42 THANK YOU