Transcript Kala-azar Web based Surveillance System

Training on Outbreak Management for Kala-azar in
Bangladesh
Kala-azar Situation in Bangladesh
Presenter:
Dr. Mohammad Sohel Shomik
Deputy Project Coordinator
icddr,b
Leishmaniasis
A group of diseases, caused by the Leishmania
parasites and transmitted by the sandfly
Types of Leishmaniasis
 Visceral 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.
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.
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)
VL burden in the Indian subcontinent
 200 millions population are
at risk
 Annually 25,000 to 40,000
cases are reported
 200-300 deaths occur per
year
Source: Joshi et.al (2008)
VL situation in Bangladesh
 Total Population- 160
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
Unique epidemiological features of VL
in the Indian subcontinent
 Human are the only
reservoir/host
 Female Phlebotomas
argentipes sand fly is the
only vector
 Leishmania donovani is the
only species responsible for
VL
 The disease is highly
clustered
Visceral leishmaniasis
VL patient/host
Sand fly Vector
Case fatality rate is 100% if VL is not treated properly
VL Elimination Program in the Indian
subcontinent
 The 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
Strategy of National Kala-azar Elimination
Program in Bangladesh
1.
2.
3.
4.
Early diagnosis and complete treatment
Integrated vector management (IVM)
Effective disease surveillance
Social mobilization and building
partnerships
5. Operational research
Strategy -1: Early diagnosis and
complete treatment
Diagnosis of Visceral Leishmaniasis (VL)
New Kala-azar
Kala-azar Treatment Failure
Kala-azar Relapse
Fever more than two weeks
Fever more than two weeks
Fever more than two weeks
Residing/Traveling in Kalaazar endemic areas
No improvement of initial
Reappearance of symptoms
treatment within six months or and sign of Kala-azar six
reappearance of symptoms and months after treatment
sign of Kala-azar
Splenomegaly
Splenomegaly
Splenomegaly
rk 39 strip test positive
rk 39 strip test positive
rk 39 strip test positive
Parasitological confirmation
through splenic smear or bone
marrow exination or PCR
Parasitological confirmation
through splenic smear or bone
marrow exination or PCR
Picture (VL)
Diagnosis of Post Kala-azar Dermal
Leishmaniasis (PKDL)
 Residing / travelling in the endemic areas
 History of treatment for Kala-azar any time in the past.
 Suggestive skin lesion without loss of sensation, which may be hypomelanotic,
macular, papular, nodular or mixed.
 Exclusion of other causes of skin disease like Leprosy, Vitiligo, Pityriasis, Ring
worm, Arsenicosis etc.
 rk39 positive/ Slit skin smear positive/ PCR positive.
Cutaneous Leishmaniasis (CL)
 CL should be suspected in a person or a case of single or multiple
skin ulcer (granulomatous, eschar like) who travelled in an endemic
areas of CL (Middle East, South America, Africa etc.).
 CL should always be confirmed by demonstration of parasite from
the lesion by slit skin smear, skin biopsy or parasite DNA in tissue
specimen.
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
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]
- Liposomal Amphotericin B (AmBisome) [Day 1]
+ Cap. Miltefosine [Day 2 – day 8]
Treatment of PKDL
First line treatment:
Miltefosine
• Adult 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:
a.
Amphotericin B deoxycholate : Dose: 4 courses of 20 injections IV over 5-6 months in
every alternate day dose.
b.
LAmB : 5mg/kg/day total 20mg/kg in 4 divided dose once in a week
c.
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.
Active VL and PKDL Case Detection




Camp 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)
Strategy-2: Integrated vector
management (IVM)
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
Integrated Vector Management (IVM)
Indoor Residual Spraying
Larvicide Spraying
WALL LINING
Bed-net Impregnation
Risk Factor for VL
 Socioeconomic condition
 Malnutrition
 Population mobility
 Environmental changes
 Climate changes
Source: WHO (http://www.who.int/mediacentre/factsheets/fs375/en/)
Strategy -3: Effective Disease
Surveillance
Kala-azar Surveillance in Bangladesh
 Kala-azar surveillance is a part of web-based national
disease surveillance system centrally managed by Kalaazar 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
Kala-azar Surveillance in Bangladesh:
A Modern Surveillance
National Kala-azar Elimination Program is
using both:
1. Passive Surveillance &
2. Active Surveillance
Kala-azar Surveillance in Bangladesh
(Cont.)
 Passive Surveillance
Self reported cases identified at health facilities
 Active Surveillance
Screenshot of the System
Main page web link for DHIS 2
http://103.247.238.75:8080/mishealth/
Patients Registration
Treatment history and Follow-up
Reporting
Event Report
Patient’s list
Bar Diagram
Mapping
Strategy-4: Social mobilization and
building partnerships
Social Mobilization and Partnership
Folk song on Kala-azar sung
at market places
Folk song on Kala-azar sung at
school premises
Kala-azar
Billboard
Some Newly Introduced IEC / BCC Materials by
NKEP
Flipchart
Poster
Pen-Holder
Sticker
Strategy -5: Operational research
Clinical and operational research
Clinical 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.
Achievement of NKEP
 98% of the Upazila already achieved elimination target.
ONELY TWO UPAZILAS are now above the target
Challenges of Kala-azar Elimination Program
 Establishing 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
Information on Kala-azar available
www.kalacorebd.com
Acknowledgement
THANK YOU