KALA-AZAR ELIMINATION

PROGRAMME IN INDIA
(AN OVERVIEW)

DR. S.N.SHARMA
NODAL OFFICER, KALA-AZAR
NATIONAL VECTOR BORNE DISEASE CONTROL PROGRAMME
(MINISTRY OF HEALTH AND FAMILY WELFARE)
GOVT. OF INDIA

MILESTONES

1953, 1958

1970s

Insecticide Residual spraying with DDT under National Malaria

Eradication Programme resulting in marked decline in disease
incidence

Resurgence of Kala-azar subsequent to withdrawal of IRS

Initially reported in four districts of Bihar and then from other parts

1992

High incidence at 77102 cases and 1049 deaths

Launched centrally sponsored Kala-azar Control Programme

MILESTONES

2000

2002

Recommendation for elimination of Kala-azar by Expert Committee

National Health Policy set the goal for Elimination of KA by 2010

2005

Tripartite Memorandum of Understanding signed between India,

Bangladesh and Nepal for elimination of Kala-azar by 2015

KALA-AZAR ENDEMIC AREAS (52 Districts))

4 districts
Pop. 11.0 million
4 districts
Pop. 6.7 million
11 districts
Pop. 50.0 million

33 districts,
Pop. 62.3 million

 More than 90% of VL cases occur in five countries

(Bangladesh, Brazil, India, Nepal and Sudan).

In SEA Region, VL is reported from 96 contiguous

districts bordering Bangladesh, India and Nepal.

Approx. 147 million people at risk in these three

countries with an estimated 100 000 new cases each

year.
This is 20% of the global incidence.

 During 1970s, four districts in Bihar reported Kala-

azar.
Presently, 33 districts endemic in Bihar, 11 districts

in West Bengal, 4 districts each in Jharkhand & UP.

About 80 % disease burden in country contributed

by Bihar.
9 districts out of 33 districts in Bihar contributes 65-

70% of Kala-azar cases.

STRATEGY: THREE-PRONGED

VECTOR

CONTROL

9 Indoor Residual Spraying with DDT up to 6 feet height

from the ground twice annually.
9 Hygiene and environmental
sanitation

Advocacy / Promotion for use of Insecticide

treated bed nets.

Contd/-

STRATEGY: THREE-PRONGED

PARASITE ELIMINATION

9 Early case detection and complete treatment

Contd/-

STRATEGY: THREE-PRONGED

PARASITE ELIMINATION
9Introduction of Kala-azar rapid test - rk39 for use at
peripheral level
9Introduction of oral drug Miltefosine on pilot
basis as first line treatment
9Strengthening of referral services

Contd/-

Contd/-

SUPPORTING INTERVENTIONS:
Communication for Behaviour Impact
Inter-sectoral collaboration
Capacity Building
Operational research
Close monitoring and supervision
with periodic reviews/evaluations
Expert Committee on Kala-azar under the Chairpersonship of the DGHS,
Govt. of India, reviews Programme policy and strategies

TREATMENT GUIDELINES
Drug

Dosages

Injection SSG

Ist line drug

for treatment

20 mg. per kg. body weight

daily for 20 days
Maximum 8.5 ml per day

Injection Amphotericin-B

IInd line drug

1 mg. per kg. body weight

alternate days (15
injections)

Capsule Miltefosine

50 mg. below 12 years

100 mg. above 1 2 years 2.5
mg. 1kg body weight
(56 tablets) for 28 days
(adult Dose)

Trend of Kala-azar in India

61670
57742

48000

2800

45459
39173
35629
32803

1419
27049

25652
22625

2006

2007*

Year

2003

300
255 226 297
150 213 168 210 155 157 187 157

277

2002

1994

1993

1992

1991

1990

8000

2001

384

2000

606

1300
800

18214
17429
14753
12886
12239
687 13627
12140

710

1999

18000

1998

838

1800

24479

2004

28000

2005

38000

-2000

3300

2300

1997

58000

Cases
Deaths

1996

68000

Deaths

77102

1995

78000

Cases

-200

*2007 (up to Sept.)

Trend of Kala-azar
Bihar

Jharkhand
29711

Cases
Deaths

30000

23383

Cases

25000
20000
15000
10000

30541

17324
204
10327
9684160

13960
187

162
107

129

124

5000
0
2001

2002

2003

2004

2005

2006

500
450
400
350
300
250
200
150
100
50
0

8000

7509

7000

14

5000

2000
1000

758

0
2001

0
2002

2003

2004

15

36

34

22

10
5

1
0
0
2001 2002 2003 2004 2005 2006 2007*
Year

*2007 up to May

3500

2500
2000
1500

2007*

1238

25
2706

20
18
15

15 1750

1592 1487

10

1000
500

3015
23

Cases
Deaths

3000

73

2006

West Bengal

Deaths

Cases

Cases
Deaths

2005

20
18
16
14
12
10
8
6
4
2
0

Year

83

3685

5
589

2007*

20

34

11

2607

3000

Uttar Pradesh

32

12

4028

4000

Year

100
90
80
70
60
50
40
30
20
10
0

18

6578

Cases
Deaths

6000
Deaths

35000

1350

10

7
4

0
2001 2002 2003 2004 2005 2006
Year

2007

Proportion of Kala-azar cases in four

endemic States

2006
2005
2004
Bihar
Jharkhand
WB
UP

2003
2002
2001
2000
0%

20%

40%

60%

80%

100%

Kala Azar Endemic Districts in Bihar

W.Champaran

Sitamarhi
E.Champaran

Sheohar

Gopalganj

Madhubani
Supaul

Siwan

Muzaffarpur

Kishanganj

Araria

Darbhanga
Purnea
Saharsa

Saran

Vaishali

Samastipur

Madhepura
Katihar

Buxar

Begusarai Khagaria
Bhojpur

Patna
Munger

Nalanda
Arwal

Kaimur

Jehanabad

Rohtas

Sheikhpura

Nawada
Aurangabad

Gaya

Bhagalpur

Lakhisarai

Jamui Banka

> 1400 cases (5)

1000-1400 cases (2)
600 - 1000cases (3)
200- 600 cases (10)
< 200 cases (11)
Nil report (7)

KALA-AZAR ENDEMIC DISTRICTS IN BIHAR SHOWING KALA-AZAR

CASES

4000
3500
3000
2500
2000
1500
1000
500
0
2003
Araria
E.Champaran
Saran

2004
Madhepura
Saharsa
Katihar

2005
Purnea
Vaishali

2006
Muzaffarpur
Madubani

Kala-azar affected villages

2005

2006

Pilot districts for use of miltefosine & rK 39

Bihar
9
9
9
9
9
9

West Bengal
9
9

Muzzafarpur
Vaishali
East Champaran
Saran
Samastipur
Darbhanga

Murshidabad
24 Parganas (South)

Jharkhand
9
9

Godda
Pakur

Financial Assistance from GOI

Year

Approved B.E.
(Rs. in crores)

Expenditure (Rs.
in crores)

2003-04

37.00

30.79

2004-05

50.00

40.48

2005-06

58.86

26.50

2006-07

20.00

22.59

2007-08

20.86

Support from Govt. of India to States

Infra-structure Strengthening
Appointment of National / State / Regional Coordinators
from WHO support.
Appointment of data entry operators.
Appointment of Kala-azar technical supervisors at
district level from world bank support
(under consideration)
Identification of kala-azar activist / Sainanies

Technical
Guidelines

Diagnosis & Treatment

Vector Control
Kala-azar Fortnight
Road-Map
Use of rK39
Use of Miltefosine
IEC Tool Kit / Prototypes
Patient Coding Scheme

Training Modules

For ASHA / Kala-azar Activist/ Health Worker / Medical Officer /

Private Practitioner / AWW / NGOs / CBOs /FBOs

Logistics

rK39 diagnostic for kala-azar for

10 pilot districts
Miltefosine capsule for 10 pilot districts
SSG
Amphotericine B
Stirrup pumps
DDT 50 % wdp

Financial
Cash assistance
Release of Operation cost on spray men
wages
Incentive to patient and attendant
Incentive to Kala-azar activist / ASHA

Capacity Building
Medical Officers
Para-medical staff
Spray men
Private Practitioners

Supervision and Monitoring

Central Monitoring Teams

State Mobile Teams
District monitoring teams
Block level monitoring supervision

Kala-azar Elimination Programme

(Strengths)

New Tools i.e. rK39 - diagnostic kit & oral

drug miltefosine introduced.
Arrears of spray wages given.
Free diet to patient and one attendant.
Incentive to patient @Rs. 50/- per day
towards loss of wages during treatment.
Incentive to kala-azar activist for referring a
case and ensuring complete treatment.
Construction of pucca houses for mushar
community in collaboration with Ministry of
Rural Development.

Strength

Patient Coding Scheme

Guidelines on Diagnosis and treatment, vector

control, roadmap, kala-azar fortnight, use of
rK39 and Miltefosine

GIS mapping for focused interventions.

Identification of Kala-azar activist for

involvement in cases detection and IRS.

Kala-azar Elimination Programme

(Weakness)

Lack of supervision and monitoring at all levels

of implementation.
Delay in release in funds at State to Districts /
PHCs level.
Delay in submission of SOEs & UCs by States.
Very Poor Advocacy for community awareness.
Delayed Spray Schedules.
Route chart not followed up.
Active case search not done on regular basis.
Proper case management is needed.

Preparation of spray suspension

Spray man operating stirrup pump

Stenciling of house & spray team moving

to other village

Publicity vans for advance intimation

Inaccessible area of Raghopur PHC approachable

by temporary bridge over Ganga and
kucha (muddy) house of Musahar community

KALA-AZAR WARD OPENED AT DEEN DAYAL

UPPADHAYA HOSPITAL, VARANASI

VISIT TO KALA-AZAR AFFECTED VILLAGE TEWAR

BICHLAPUR

Constraints
Inadequate dedicated staff
Lack of interest by PHC Medical Officers
Prolonged treatment schedules
Non-compliance by the patients
Development of resistance
Inadequate information on vector bionomics
Asymptomatic carriers