India will miss its goal of eliminating kala azar by the end of this year. A national advisory committee on kala azar that has surveyed the four states in India where the disease is endemic has found that there are still many new cases of infection, according to a senior officer of National Vector Borne Disease Control Programme.

Kala azar, also known as visceral leishmaniasis is a chronic and potentially fatal infectious disease caused by the protozoan parasite Leishmania donovani. The parasite is transmitted to humans by the bite of female sand flies. The disease is characterised by bouts of fever, weight loss, anaemia, and an enlargement of the spleen and liver that shows up as a pot belly.

Kala azar is largely a disease of the poor. It has been endemic to four states in India – Bihar, Jharkhand, West Bengal, and Uttar Pradesh.

India has been trying to eliminate kala azar for decades but with little success. In 2014, the government launched the Kala Azar Elimination Programme with support from international agencies like the London School of Hygiene and Tropical Medicine, the Drugs for Neglected Diseases initiative. The programme focusses on the four endemic states and has been on the verge of eliminating the disease but has been struggling to cross the finish line.

In his budget speech this year, Finance Minister Arun Jaitley announced action plans to eliminate kala azar by the end of 2017. Following his speech, officials of the Ministry of Health and Family Welfare also reiterated these goals and appointed a national advisory committee to evaluate the kala azar elimination programme.

Eliminating kala azar in India is defined as achieving an annual incidence of less than one case per 10,000 people at the sub-district level. Bihar has the more than 70% of the disease burden, with kala azar endemic in 33 of its 38 districts.

(Data for 2017 is till October.)

In 2016, 94 blocks across the four endemic states had more than one case per 10,000 population. By the end of 2017, that number will fall to 80, according to the National Vector Borne Disease Control Programme. The programme official said India has achieved about 95% of its goal but will not be able to eliminate the disease by the end of 2017. The official also said that India will miss deadline to eliminate lymphatic filariasis, which was also at the end of this year.

Three missed elimination deadlines

India first set itself a target to eliminate kala azar in 2010, then in 2015 and then in 2017. For decades, the disease continued to linger and spread in endemic areas for lack of a good effective treatment and lack of political will. However, in recent years eliminating the disease has been within reach. The development and use of a liposomal amphotericin drug in 2014 became what many kala azar experts call a “game changer”. When administered intravenously, the drug can cure the disease in a day.

The elimination programme got another fillip when state governments started providing incentives to people getting treated for kala azar. Both Bihar and Jharkhand give Rs 6,600 to anyone completing a full course of treatment.

However, an outbreak of at least 50 new cases in Sheikhpura district of Bihar this June set the elimination programme back. Officials monitoring the kala azar programme told at the time that it might miss the elimination target.

Infection circulating within affected communities

The national advisory committee appointed to evaluate the kala azar elimination programme conducted a rigorous survey in April and May this year. The committee was headed by Dr NS Dharmashaktu, special director-general at the health ministry. Other members include Dr Saurabh Jain who is the technical officer for vector borne diseases and neglected tropical diseases with the World Health Organisation, Dr Suman Rijal who is the executive director of the Drugs for Neglected Tropical Diseases Initiative and Dr PC Bhatnagar from the non-profit organisation Voluntary Health Association of India.

Committee members travelled to affected areas and found out that while the number of blocks that had more than one case of kala azar was decreasing, there were still too many new cases being detected for the team to conclude that the disease was being eliminated.

Besides, cases of a skin presentation of kala azar called post-dermal kala azar leishmaniasis or PDKL have been increasing.

(Data for 2017 is till October.)

PDKL is first characterised by discolouration of the skin and later manifests as lesions. These lesions are reservoirs for the parasite. A person with lesions can therefore become infectious if bitten by a sand fly, leaving a source of infection within the community.

The National Vector Borne Disease Control Programme attributes the rise in PDKL cases to better surveillance and reporting. But, the larger number of PDKL cases also indicates that the infection is circulating within affected communities, said a committee member.

Gaps in the system

Kala azar experts say that while outbreaks, such as the one that took place in Sheikhpura, are to be expected, they need to be controlled quickly. For this, there needs to be a good surveillance system to detect new cases and effective, accessible treatment for the infected people.

India’s kala azar surveillance system is shaky.

In high endemic blocks – blocks with more than one case per 10,000 population – health authorities conduct active case finding exercises in which they go from house to house looking for people who might have kala azar and get them tested. However, in low endemic blocks – blocks that have less than one case of kala azar per 10,000 population – are not on the surveillance system radar, said a WHO official working in Bihar. In these blocks, a person is tested for kala azar only if he or she goes to a hospital with symptoms of the disease. Sometimes, a patient suffers for months before going to a health facility to be tested and treated.

The kala azar elimination programme also expects Accredited Social Health Activists or ASHAs to send people who have had fever for more than two weeks to a hospital. ASHAs are health workers in rural areas who help people in their communities to access public health services and help with providing antenatal care, bringing women to health facilities for institutional deliveries, and implementing immunisation programmes. ASHAs are often overburdened being the only healthcare workers for a clusters of villages and are underpaid for their work. For instance, an ASHA gets an incentive of only Rs 100 per person referred to a hospital for kala azar.

“The ASHA has a lot of work in the community,” said the WHO official. “This incentive is not good enough for her to concentrate her efforts.”

Another factor that has kept kala azar elimination just out of reach is the uneven implementation of sand fly control measures like indoor residual spraying in houses in endemic areas.

The state governments in Jharkhand and Bihar have pushed to eliminate kala azar. For example, Jharkhand’s kala azar endemic blocks are in areas that are hard to access but the government has deployed additional multipurpose health workers in these areas to support kala azar elimination activities. Health authorities have also organised communication and awareness programmes through churches.

“The motivation seems to be at the highest level,” said a member of the committee. “But at the ground level not much has changed. We found leadership lacking at the local levels, especially at the district level.”

In Uttar Pradesh, where there have been only 107 new cases of kala azar this year, committee members found that public health staffers were untrained to handle the disease, leaving questions over what might happen if a fresh outbreak should occur.

While the drug liposomal amphotericin has made a big difference in controlling infection, social conditions like poverty and neglect that help the disease spread still remain.

“We had all the ingredients to eliminate the disease this year,” said an expert from an international organisation working towards kala azar elimination.