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Tackling a Deadly Outbreak of Kala Azar in War-Torn South Sudan

The conflict that erupted in South Sudan little more than a year ago has left people more vulnerable to a deadly tropical disease known as kala azar (visceral leishmaniasis). The risk of infection increases as people are displaced by fighting into areas where the disease is prevalent, and malnutrition lowers their ability to fight the infection. With many health facilities not functioning in conflict areas, getting treatment is more difficult.

Last year, Doctors Without Borders/Médecins Sans Frontières (MSF) treated more than 6,700 cases of kala azar in South Sudan, more than double the number of cases it treated the year before (2,714 cases in 2013). The majority of people treated were in Lankien, a dusty settlement in the conflict-wracked state of Jonglei. Casey O’Connor, who oversees MSF’s activities in Lankien, reflects on a tough year.

“For nearly 20 years, MSF has been running a clinic and hospital in Lankien, providing primary health care services and treatment for tropical diseases such as kala azar," O'Connor says. "Early in 2014 it was evident that both the outpatient clinic and the hospital were overwhelmed by war-wounded patients, plus we were providing health care services to the growing number of people who had been displaced by the conflict."

In Jonglei state, people have been uprooted from their homes by fighting and insecurity. Many have moved into acacia forests, where sandflies, which are the vectors for kala azar, breed. Sleeping out in the open, often without a mosquito net, increases the risk of infection.

Most health facilities that were providing testing and treatment for kala azar before the conflict started are no longer functioning, or are struggling to get medical supplies, which makes it more difficult for sick people to get treated rapidly. This has lethal consequences, as without treatment the disease has a near 100 percent fatality rate in eastern Africa.

“Already busy, the outpatient clinic started overflowing with patients in June, with rising numbers testing positive for kala azar, much earlier in the season than anyone could remember and in numbers not seen before in Lankien,” says O'Connor. “What at first appeared as an anomaly was soon recognized as an unprecedented outbreak, with staff trying desperately to manage—hiring more paramedics, working long hours, [and] ordering more drugs for a rise in a disease that normally peaks in September.”

The disease attacks organs such as the liver, spleen, and bone marrow, and depletes the immune system, leaving those infected vulnerable to serious infections. It is complicated to treat. For most people, the treatment takes 17 days and requires two daily injections. In severe cases, or for pregnant women or people with HIV/AIDS, it requires admission to hospital and the administration of intravenous medications for five days.

“At some points, five injection teams were treating 800 patients per day, compared to 250 now," says O'Connor. "And no one likes the treatment—painful intra-muscular injections into the buttocks. Not just once, but for 17 painful days. All day you can hear the children crying from the pain of the injection,” said Casey.

In Lankien alone last year, MSF treated 4,611 Kala Azar patients, more than triple the amount treated in 2013 (1,346 patients). This means that from July to September 2014, nearly 2,000 patients were on treatment, which rivals the worst outbreak in Lankien since data started being recorded in 1999. Since then, the outbreak has slowed. Numbers went down in late October and started to level off—but concern remains.

“There is a critical shortage of drugs for treatment on a global level—some of them take six months to manufacture and the worldwide supply is under strain, as there is only one manufacturer," says O'Connor. "Any rupture in the supply of medications means treatment is interrupted and the patient must start all over again with painful injections. But getting early and sufficient treatment means the difference between certain death and recovery with the likelihood of lifelong immunity to this disease.”

In Jonglei, MSF provides treatment for Kala Azar in Lankien, Chuil, and Yuai. In neighboring Upper Nile, MSF teams are responding in Malakal and Melut.