India: Fighting Kala Azar in Bihar State

It is 10 in the morning and several people are already standing at the lab doors, waiting to be tested. The lab is part of the kala azar diagnostic and treatment unit in Sadar Hospital, the referral facility in Bihar State’s Vaishali district, which is home to about three million people.

Inside the unit, a woman named Baby, a 27-year-old mother of two, is lying in a hospital bed. For several weeks, she’d had a fever and no appetite – two of the most common symptoms of the disease. She was referred by the outpatient department and, earlier this morning, tested positive for kala azar. After a medical examination, she was 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 said from her hospital bed.

Kala azar, a disease transmitted by certain types of sand flies, is endemic in much of Bihar. It causes enlargement of the spleen and, if left untreated, is fatal for virtually all patients. MSF has been running a kala azar diagnostic and treatment project in Vaishali since July 2007. In the four years the project has been open, about 8,000 patients have been treated at Sadar Hospital and in five MSF-supported health centers. The initial cure rate of kala azar cases is 98 percent.

“The treatment we are using in Vaishali is very safe and effective,” said Dr. Gaurab Mitra, coordinator of the medical activities in the MSF project. “It usually consists of four intravenous doses of liposomal amphotericin B, [also know as] LAmB. From the second dose patients can show signs of improvement.”

“Right now, we are giving patients 20 mg/kg of liposomal amphotericin B and we know it is effective,” said Marta González, an MSF doctor in Vaishali. “But we are also looking into potential alternatives for the future, such as 10 mg/kg of LAmB in a single dose, or combined therapies with proven efficacy.”

The World Health Organization’s latest kala azar treatment guidelines also recommend these treatments. MSF hopes the national program will follow the recommendations.

Treating PKDL and HIV co-infection

Chandeshwar, 30, was admitted to Sadar Hospital. He has something known as post-kala azar dermal leishmaniasis, or PKDL, a complication that can affect patients who have already been treated for kala azar. Chandeshwar was treated three years ago with a medicine called SSG, which up until recently was the main medicine used to treat visceral leishmaniasis. SSG is no longer effective in India, however, because 65 percent of patients have developed resistance. The country's Ministry of Health has indicated that it will stop using the drug.

PKDL does not pose any health risks for patients, but it causes skin rashes or lesions that may affect quality of life. Treatment of PKDL is long, and patients such as Chandeshwar need to be kept as an inpatient during treatment, which involves three 20-day periods. Despite these difficulties, treating the affected patients is essential to curbing the spread of the disease. “Skin lesions are a reservoir for the parasite,” said Dr. Deepak Kumar. “If untreated, the sand fly that transmits the disease may continue to infect other people more easily.”

Treating HIV co-infected patients is not easy either. The two diseases impact each other: kala azar lowers the immunity of HIV-positive patients, increasing their risk of contracting opportunistic infections; while HIV-positive patients are more prone to contracting kala azar and less likely to then respond to treatment. “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,” said Dr. Kumar.

Receiving liposomal amphotericin B at OPD level

Bilanpur is a village inhabited by 10,000 people. Vinod, 15, lives here with his parents and seven brothers and sisters. He started feeling ill a few weeks ago, and now he is receiving treatment for kala azar as an outpatient at the Lalgang health center. For him and his family, going to the health center every two days to receive the required dose of LAmB is easier than being admitted to Sadar Hospital, which is further away.

Just like Vinod, Kamli, 50, is 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,” Kamli said of her search for treatment from private doctors. “I am a sick person, yet we do not have enough food to eat.” In Vaishali, MSF is working to change this situation and to provide people with access to lifesaving diagnosis and treatment free of charge.