June, 1949J KALA-AZAR IN UNITED PROVINCES : PRASAD 269

Public Health Section

INCIDENCE AND CONTROL OF KALA -

AZAR IN THE EASTERN DISTRICTS OF UNITED PROVINCES

By B. G. PRASAD, m.d. (Luck.), d-p.h. (Cal.), D.T.M. (Cal.)

Assisla)it Epidemiologist, United Provinces, Luc-know

Kala-azar as a distinct clinical entity has been recognized in this country for about a century. A number of epidemics occurred in Bengal, and though it was in early stages con- fused with malaria, failure to respond to specific treatment led to the establishment of its separate entity. This was confirmed in 1903 by the discovery of Leishman-Donovan bodies? the causative organism, by W. B. Leishman in the spleen of a soldier who died in England from kala-azar which he had contracted at Dum Dum and by C. Donovan in Madras in material from spleen puncture carried out on patients believed to be suffering from malarial cachexia (Scott, 1942). It invaded Assam in 1875, and swept up the Brahmaputra valley in three different epidemics between this date and 1917 (Napier, 1946). In Bihar, there was an epidemic of kala-azar in 1939-41 and the province suffered heavily from its ravages (Sen Gupta, 1947). It now seems to have slowly infiltrated the eastern districts of United Provinces during the last 25 years. According to Napier (loc. cit.) the disease is endemic in this province as far west as Lucknow, where the infiltration gradually tails off, its westerly extension being checked by the dry areas. Sporadic cases have even been reported from the Punjab, Delhi, Jaipur and Mussoorie (Heiiig and Sachdev, 1947; Amir Chand et al, 1948). The heavily infected districts in the United

Provinces, so far known at present, are Gorakh- pur, Deoria, Basti and Banaras. In Baharas City, the Municipal Board opened a kala-azar dispensary in the year 1932-33. In Gorakhpur district, first survey of kala-azar was done in 1938. Two rural development travelling dispensaries in this district and one in the district of Banaras at Sakaldiha were opened in 1942 for the heavily infected areas. In 1944, some survey work was done in Basti district as well. With the increasing movement of labour and army personnel in the last Great War to Assam, Bengal, North Bihar and back, the disease, as shown (table I), started showing signs of rapid increase in the eastern districts and measures for its control had to be rapidly intensified and widely organized, covering nearly the whole of eastern part of the province.

It is seen that since 1941-42 the disease has shown a rapid rise in the districts of Banaras (specially municipality), Gorakhpur and Deoria.

Table I

Number of kala-azar cases treated in certain eastern districts of the United Provinces

Gorakhpur Year J and Deoria

i districts

1935 1936

270 224

1937 240 1938 i 208 1939 ! 191 1940 1941 1942 1943 1944 1945 194G 1947

247 202 559

1,263 3,030 3,904 5,200 8,455

Banaras district

201 242 287 115 266 306 597 536 827 930 905

1,332 1,355

Banaras muni-

cipality

152 287 429 398 690 945 878

1.222

1,232

Basti district

30 42 35 100 243 281 880

The rise in Basti was recorded a little later. (Increased facilities provided for diagnosis and treatment in the districts may be, at least in part, responsible for the considerable rise in the figures in 1946 and 1947.) The reasons for this' rise may be :?

1. Movements of labour and army personnel from the eastern districts of United Provinces to

Assam, Bengal and Bihar during the last Great War and their returning with the infection. In January 1946 it was reported by the Assistant Director of Medical and Health Services, IV Range, Gorakhpur, that as many as 1,000 labourers were daily coming from Assam to Gorakhpur and he proposed that they might be examined for kala-azar in the labour camps and arrangements be made for treatment of those found positive.

2. The endemic and in some areas epidemic prevalence of kala-azar in the adjacent province of Bihar and its slow infiltration to the eastern districts of this province.

3. High density of population in the eastern districts as a whole and abnormal congestion of Banaras City in particular.

4. The prevailing climatic and socio- economic conditions in the eastern districts favourable for the propagation of the trans- mitting vector, the sand-fly P. argentipes, such as comparatively high humidity and low mean diurnal range of temperature, alluvial soil with large tracts under wet cultivation, ill-ventilated houses built out of mud, and poor economic condition.

Present position and control Thus kala-azar became a major public health

problem in the United Provinces, and demanded much more vigorous measures by the State to

270 THE INDIAN MEDICAL GAZETTE [June, 1949

eradicate the disease than the detailing of a couple of travelling dispensaries here and there. Early detection and treatment of cases being the primary control measure, the first step was to gauge its intensity in different districts in order to get an idea of the magnitude of the problem. Control of sand-fly in rual areas is rather a difficult problem and cannot be much of a success without improving the housing condition and surroundings. Early treatment campaign is effective and is the cheapest method of eradicating the disease. In November 1945, some stock of urea

stibamine was supplied to branch and mill dis- pensaries in Gorakhpur, Deoria, Banaras and Basti districts, the medical officers having been trained earlier in the technique of diagnosis and treatment of kala-azar at district hospitals. One wholetime medical officer was also posted in 1945 for survey work in the district of Basti. More outdoor dispensaries were opened in Banaras municipality. District-wise data were collected in 1945-46 and a comprehensive scheme was drawn up early in 1947 for an organized anti-kala-azar campaign in the eastern districts. Government realizing the urgency of the problem had sanctioned in 1946 the starting of twenty non-mechanized travelling dispensaries to cover remote rural areas and also the equipping and providing of free facilities for diagnosis and treatment in the existing branch and mill dispensaries of the eastern dis- tricts. Liberal supply of urea stibamine was placed at their disposal. Ninety-nine fixed dispensaries were equipped by 1947. Eleven of the non-mechanized travelling dispensaries also started functioning by September 1947 in these districts. These dispensaries have been put in the charge of medical graduates and their scale of pay is Rs. 300?25?400?30?700?50?850

p.m. A peon and a coolie are allowed to each

travelling dispensary. Tents have been provided for camping in rural areas. A non-recurring expenditure of Rs. 2,000 was incurred to provide tents and furniture and a recurring expenditure of Rs. 5,500 per annum is provided on pay, allowances and contingencies for each travelling dispensary. Besides this, a sum of Rs. 50,000 is annually provided in the provincial budget for the purchase of urea stibamine, distilled water, kala-azar outfits and medicines of common ailments for supply to the various treatment centres from the Epidemic Stores Depot, U.P., Lucknow. The medical officer in charge of travel- ling dispensary visits villages for survey in the morning and treats cases in the afternoon at his camp headquarter. The unit is usually stationed for three months in one area. Portable kala-azar

diagnostic and treatment outfits which can easily be carried by a coolie (size 16 inches by 11 inches by 10 inches) have been provided to all the treating centres. The outfit contains some 33 items of equipment and is self-sufficient for diagnosis by serum tests (formol-gel and urea stibamine tests) and treatment. Prescribed

forms for collecting and reporting of the monthly data and printed instructions on treatment and diagnosis were distributed to all the treating centres. An elaborate case card has also been introduced. To get a rough idea, village-wise information of cases is also collected in each district through vaccinators and patwaris. A kala-azar sketch map (1 inch = 4 miles) has been prepared for most of the districts and the area has been divided into convenient circles for being assigned to the fixed and travelling dispensaries. The anti-kala-azar campaign, thus, was put on a firm footing and an organized start made in 1947 in the affected districts. Work done during 1947 is shown in table II and district-wise intensity of infec- tion based on the number of cases diagnosed in 1947 is shown in the map. This map will need to be revised when figures for next ten years or so become available.

Monthly reports from all the treating centres are received by the District Medical Officer of Health on the prescribed forms giving informa- tion about each case. The district figures are reported monthly to the Assistant Director of Medical and Health Services of the Range and the Assistant Director of Epidemiology. Regular monthly spraying with D.D.T. in the infected localities as an anti-sand-fly measure is also being carried out. Besides, a permanent sanitary gang of a jamadar, two coolies and two sweepers provided in each tahsil, temporary coolies are

Map

map or

UNITED PROVINCES. SHOWING

The cndamUtfy of Kala-ozar

infection, in. eastern Districts. Number of Cct&es diagnosed in )M7 per 100,000'populatum. Less than i E-3 Between. I_ 10 m 10-25 ann

25-50 S .? 50-100..

Over 100 W0

Map

MAP OF

UNITED PROVINCES. 3H0WIN4

The endamicUy of Kala-azar

infcctloti in. eastern Dutricfs Number of Cases diagrujsad in )M7 per 100,000 population. Less than. i E-3 Between. I "10 liiiaJ

?? 10-25 CUED 25-50 S

.? 50-100 m Over 100 W0

June, 1949] IvALA-AZAR IN UNITED PROVINCES : PRASAD 271

trained and engaged, whenever necessary for syraying work. Propaganda is done by the district health staff and by the Health Publicity Bureau, which has prepared a talkie film and a pamphlet on the disease. Regulations under the Epidemic Diseases Act, 1897 (III of 1897), making it compulsory for a person suffering from kala-azar to take the treatment, have not been enforced, as the experience of this measure in Bihar has rather been disappointing.

District-wise progress

The anti-kala-azar scheme is functioning at present in the districts of Gorakhpur, Deoria, Banaras, Basti, Jaunpur, Azamgarh, Ballia, Ghazipur, Allahabad, Faizabad and Mirzapur (table II).

Table II

Showing kala-cizar work in eastern districts of United Provinces in 1947

Name of the district

Total i 109 j 22 11 13.665

?- a

o g

V) % o o i 2

r*?to o^.S

in 1-1 13

272 THE INDIAN MEDICAL GAZETTE [June, 1949

situated on the edge of a big marshy Tal (2^ miles by 1 mile). At the time of the visit the area surrounding the village was dry but during rains it gets flooded. The subsoil water level was at 15 feet and during rains it rises to 10 feet. Crops grown in the surrounding area are mustard, sugarcane, wheat and barley. The village has a population of 987 (884 Hindus and 103 Mohammedans). Twenty-two kala-azar cases were diagnosed by serum tests at the time of the visit. One bed-ridden female, aged 30 years, very strongly positive by serum tests, with history of eight months' fever, liver four fingers and spleen two fingers, very much emaciated and having diarrhoea, also showed Leishman-Donovan bodies in the peripheral blood. One case of fever, negative l3y serum tests, was positive for malaria parasites. Enquiry into socio-economic status showed

that with the exception of some two dozen houses of Thakurs, the village is inhabited by Chamars, Kumhars and Julahas. Nearly all arc cultivators. Out of the 182 families living, 177 (97.2 per cent) are poor (monthly income less than Rs. 100) and five (all Thakurs) arc middle class (monthly income between Rs. 100 and Rs. 500). The houses of the latter group were inspected in detail by the writer and were found to be kutcha, insanitary, ill-ventilated, dark, in bad state of repairs and had cattlesheds adjoining them. There had occurred twenty-five deaths from suspected kala- azar in these five families of Thakurs. Three cases were present at the time of the visit. One of these families of 33 members (present strength), the richest in the village, had as many as 14 deaths and had one case under treatment in the district hospital. This shows that all are equally liable to infection when living under insanitary conditions. 75 per cent of the houses in the village have thatched and 25 per cent tiled roofs. All houses except three are single storeyed. Even in them, the upper storey is not used for living. Except two houses all were ill-ventilated and badly lighted. Torch had to be used for entering most of the living rooms visited during the day time. Except half a dozen houses all were in damaged condition and needed renewal of mud plaster badly. Twenty-two houses (12.1 per cent) had kala-azar cases at the time of visit and more than 50 per cent of the houses gave history of deaths from suspected kala-azar in the past. There was 512 head of cattle accommodated in 196 cattlesheds attached to 135 houses (74.2 per cent) in the village. All the cattlesheds were insanitary and in bad state of repairs. The cowdung is allowed to accumulate for some days before it is removed from the cattlesheds. The village presented insanitary appearance and as many as 95 rubbish heaps were counted in the village. The sanitation was good only in 21 houses (11.5 per cent). Out of 163 children examined, 14 (8.6 per

cent) had enlarged spleen. Seventy-seven

children of the primary school in the village were also examined for clinical signs of deficiency diseases; two had angular stomatitis and six Bitot's spots. No definite history could be elicited as to how

the epidemic started in this village. Informa- tion was, however, obtained that at least four persons of this village had served in Calcutta and Howrah for a number of years and suffered from prolonged illness and fever. One of these aged 25 years, who died about 14 years ago, was employed in some Bengali family on cow feed- ing for ten years in Calcutta. He used to come to the village regularly every H to 2 years. When he last came about 15 years ago, he died after an illness for about 1^ years with fever and enlarged spleen. Another villager employed in Howrah returned ill, after some years' stay about ten years ago, with fever and enlarged spleen. Two other villagers working in Calcutta for a number of years returned ill last year with

history of prolonged fever and died after some days' stay in the village. The disease, it appears, first started in eastern part of the village inhabited mainly by Chamars and Kumhars. Some sixteen houses adjoining each other in this locality gave history of kala-azar cases and 32 deaths occurring in a population of 121 persons between 1944 and 1948. The disease then spread to the rest of the village and lately, Thakurs, who are economically better placed but have the largest number of cowsheds and are living in insanitary, though big, houses like others, suffered heavily. In three adjoining houses of Thakurs, as many as 33 persons out of 53 persons living, died from prolonged illness and fever between 1946 and 1948. In another

house, 14 persons died between 1946 and 1948 (see above). These houses were free before 1946. In nine years (1940 to 1948), some 129 persons had died from the disease in the village. Year-wise deaths from suspected kala-azar cases (based on house-to-house enquiry) were (deaths are shown in the bracket): 1940 (1), 1941 (3), 1942 (4), 1943 (4), 1944 (14), 1945 (20), 1946 (25), 1947 (38) and 1948 (20). It appears that the peak of the epidemic was reached in 1947 and now it is on the decline.

A hurried survey in the adjoining villages within a distance of one mile from village Pokhara gave 9 positive cases in 7 villages. One treatment centre has now been opened in this area and a systematic survey is being carried out.

Till July 1946, the district of Jaunpur was considered to be a relatively free district. With the co-operation of the medical officers of the fixed dispensaries and private practitioners, 102 cases were diagnosed and 67 treated from September to December 1946. Seventy-six cases were also detected in 152 villages surveyed in 1946-47. In the remaining districts so far only few cases of kala-azar have been reported.

.Tune, 1949] FIFTY YEARS AGO 273

Summary 1. Kala-azar at present is confined to eastern

parts of the United Provinces. An attempt has been made with the available data to show the distribution of kala-azar in these parts where lately it has been showing a rise in its incidence. The figures available for each district have been discussed to show the degree of its endemicity. Some of the districts have definite belts of heavy infection. Data of a village in district Basti, where an epidemic outbreak has occurred, are discussed in some detail.

2. Measures undertaken for control are dis- cussed. .Necessary machinery has been provided in eleven eastern districts through the agencies of 109 fixed and 22 kala-azar travelling dis- pensaries (of which 11 have started functioning). During 1947, out of 13,665 bloods examined by serum tests, 11,597 were found positive and 11,390 cases were treated. Seven hundred and forty-nine villages were surveyed by the medical officers in charge of kala-azar travelling dis- pensaries. Thus, a regular anti-kala-azar scheme has been strated in the affected districts and a good amount of work is noAV being done. The writer thanks Dr. A. C. Banerjea, Director, and

Dr. A. N. Das, Deputy Director of Medical and Health Services,_ United Provinces, for encouragement to write this article. His gratitude is also due to the latter for some very useful suggestions.

REFERENCES

Amir Chand, Gupta, Indian Med. Gaz., 83, 291. D.C., and Chhuttani, P. N. (1948).

Heilio, R., and Sachdev, Ibid., 82, 336. R. N. (1947).

Napier, L. E. (1946) .. The Principles and. Practice of Tropical Medicine. The Macmillan Companv, New York.

Scott, H. H. (1942) .. A History of Tropical Medicine. Edward Arnold and Co., London.

Sen Gupta, P. C. (1947). Indian Med. Gaz., 82, 281.