Visceral

Leishmaniasis

(Kalaazar)

Dr. Natalia Oli

(MD, MPH, PhD )

Department of Community Medicine

Leishmaniasis. Epidemiology

• 14 million people are currently infected with Leishmania

• 700,000 to 1 million new cases occurring annually

• Every year Leishmaniasis causes 26,000 to 65,000

deaths

• An estimated 50 000 to 90 000 new cases of Visceral

Leishmaniasis occur worldwide each year (only 25-45%

reported to WHO)

• An estimated 600 000 to 1 million new cases of

cutaneouse leishmaniasis occur worldwide annually.

Leishmaniasis. Epidemiology

• Was an endemic in 88 countries on every continent

(except Australia and Antarctica)

• In 2015, more than 90% of new cases of Kalaazar

reported to WHO occurred in 7 countries: Brazil, Ethiopia,

India, Kenya, Somalia, South Sudan and Sudan.

• >2/3 of new cutaneous leishmaniasis cases occur in 6

countries: Afghanistan, Algeria, Brazil, Colombia, Iran

and the Syria

• Over 90% of mucocutaneous leishmaniasis cases

occur in Bolivia (the Plurinational State), Brazil, Ethiopia

and Peru

•

Status of endemicity of Visceral Leishmaniasis

worldwide, 2016

Agent - Leishmania

• 20 species of Leishmania

cause Leishmaniasis

• L. donovani is the causative

agent of Kalaazar

• L. tropica – cutaneous leishmaniasis (oriental sore)

• L. braziliensis – muco-cutaneous leishmaniasis

• But visceral forms may produce cutaneous lesions and

cutaneous form may visceralize

• There is no cross immunity of one against the other

species of Leishmania

Vector - the Phlebotomine sandfly

500 known phlebotomine species

(30 vectors of the disease)

• A protozoa transmitted by the bite

of a tiny 2 to 3 mm female sandfly

P. argentipes – Kalaazar

P. papatasi and P. sergenti –

Cutaneous leishmaniasis

Sand fly bite

• large, red itchy bumps

• may turn into a rash

• several times as itchy as mosquito bites, last longer

Vector - the Phlebotomine sandfly

• Breeds in small cracks and holes

in the ground, animal burrows,

cracks in mud walls and masonry,

and among tree roots

• Do not breed in water

• Overcrowding, bad ventilation,

accumulation of organic matter

• Usually bites in the evening

and at night

Way of transmission of VL

• Zoonotic disease (dogs, rodents, wolves, foxes, jackals)

• Zoonotic VL (animal - vector - human)

found in areas of L. infantum transmission

• Anthroponotic VL (human- vector – human) found in

areas of L. donovani transmission

Major risk factors for Leishmaniasis

• Socioeconomic conditions

• Malnutrition

• Population mobility

• Environmental changes

• Climate change

Risk for increased human exposure

to the sandfly worldwide:

man-made environmental changes

- mining

- building dams

- widening areas under cultivation

- new irrigation schemes

- road construction

- fast urbanization

Social determinants of risk

Gender

• Clinical disease M > F:

- more frequent exposure of males than females

- under detection of disease in women in traditionally

male-dominated societies

• Case fatality rate F > M:

- higher rates of malnutrition

- anemia in women

- longer delays in seeking care

Morphology of Parasite

• intracellular parasite (within macrophages)

• dimorphic parasite

• It exists in two entirely different morphological

structures, parasitizing in two different hosts:

promastigotes stage in sandfly

amastigotes stage in vertebrate host

Promastigotes stage

• Promastigotes stage of Leishmania exists in

sandfly.

Amastigote stage

in macrophages of reticuloendothelial system of

vertebrates

(spleen, liver, bone-marrow and lymph node)

Leishmaniasis - four main clinical

syndromes :

• Visceral Leishmaniasis (VL) (Kala-azar)

• Post-kala-azar dermal Leishmaniasis (PKDL)

• Cutaneous Leishmaniasis (CL)

• Muco-cutaneous Leishmaniasis (MCL) (espundia)

Visceral Leishmaniasis (VL)

• by two leishmanial species, L. donovani or L. infantum

Depending on the geographical area:

L. donovani (infects all age groups)

- India, Nepal and Bangladesh (more than 2/3 of all cases

of VL in the world)

- The East African (second largest focus of visceral

leishmaniasis - Ethiopia and Sudan)

L. Infantum (infects mostly children and immunosuppressed

individuals)

- the Middle East and western Asia , predominantly in Brazil

Visceral Leishmaniasis

• It is the most severe among leishmaniasis

• VL estimated incidence of 500,000 new cases and

60,000 deaths each year

• "Kala-Azar" (Kala - Black & Azar - Fever)

hyperpigmention with fever

• Always fatal if untreated

• Even with treatment, case-fatality rates often exceed

10% in VL-endemic areas of Asia and Africa

VL (Kalaazar). Clinical features

• Fever (more than 2 weeks)

• Splenomegaly

• Hepatomegaly

• Anemia

• Weight loss

• Darkening of the skin of face,

hands, feet and abdomen

Marked enlargement of the spleen typical of

visceral leishmaniasis in a patient in Nepal.

Hepatosplenomegaly (Visceral Leishmaniasis)

Cutaneous Leishmaniasis

• Skin ulcers on the exposed parts of the body such

as the face, arms and legs

• Large number of lesions (up to 200 )

- serious disability

- permanently scarred

Typical cutaneous leishmaniasis

ulcer (Guatemala)

Mucocutaneous Leishmaniasis

• Lesions can lead to partial or total destruction of the

mucous membranes of the nose, mouth and throat

cavities and surrounding tissues

• Almost 90% of mucocutaneous leishmaniasis cases

occurs:

- Bolivia

- Brazil

- Peru

Post-kala-azar dermal leishmaniasis (PKDL)

• Macular, maculo-papular or nodular rash

(nodular lesions contain many parasites)

• Cause by L. donovani, complication of VL (common

in Sudan and rarely in the Indian sub-continent)

• However, there are cases without any previous

known history of VL

• Can also occur in immunosupressed individuals in

L. infantum endemic areas

Leishmania-HIV co-infection

• VL accelerates HIV replication and progression to AIDS

• Cause severe forms of visceral and cutaneous

leishmaniasis that are more difficult to manage

• Antiretroviral treatment reduces the development of the

disease, delays relapses and increases the survival of the

co-infected patients.

• High leishmania-HIV coinfection rates are reported from

Brazil, Ethiopia and the state of Bihar in India.

Global distribution of reported cases of

Leishmania/HIV co-infection,1990-1998 (WHO)

Visceral Leishmaniasis:

National situation and responds

Nepal

• 12 endemic districts, and 2 regions:

6 - Eastern Development Region (EDR)

6 - Central Development Region (CDR)

• Approximately 7.5-8 million populations at

risk

• There are few PKDL cases identified.

Elimination of Kalaazar. National response

• Nepal, India, Bangaldesh – elimination of Kalaazar by

2015 (memorandum of understanding World Health

Assembly 2005)

• In 2005, Epidemiology and Disease Control Division

(EDCD) of Department of Health Services - National

Plan for the Elimination of Kala-azar

• Three phases:

Preparatory Phase: 2005-2008

Attack Phase: 2008-2015

Consolidation Phase: 2015 onwards

National Plan for the Elimination of Kala-azar

Goal

• Reduce incidence of Kala-azar to less than 1 case per

10,000 populations at district level by 2015.

Objectives

• Reduce the incidence of Kala-azar in endemic

communities with special emphasis on poor, vulnerable

and unreached populations.

• Reduce case fatality rates from Kala-azar to ZERO.

• Detect and treat Post-Kala-azar dermal leishmaniasis

(PKDL) to reduce the parasite reservoir.

• Prevent and manage Kala-azar HIV–TB co-infections.

National Plan for the Elimination of Kala-azar

Strategies

• Improve Program Management

• Early Diagnosis and Complete Treatment

• Integrated Vector Management

• Effective Disease and Vector Surveillance

• Social Mobilization and Partnerships

• Clinical, Implementation and Operational Research

Elimination of Kalaazar. National response

• The national plan was revised in 2010 as National

Strategic Guideline on Kala-Azar Elimination in Nepal

• Recommended rK39 as a rapid diagnostic test kit:

- high sensitivity and specificity

- available up to PHC centre level

• Liposomal Amphotericin B (L-AmB) as the first line

regimen during the attack phase in the Indian subcontinent

(introduced in Nepal in December 2015)

• Miltefosine

The rK39 dipstick test

Major activities: Case Detection and Treatment

• Diagnostic and treatment services are provided at primary

health care centre (PHC)

• RDT scaling up

• Identification and referral of suspected cases are also

offered at HP

• Active case detection activity in 5 most endemic VDCs

each of Morang, Saptari and Sarlahi districts (camp)

• House to house search (by the FCHVs )

• Disease surveillance

Major activities: Reservoir and Vector Control

Indoor Residual Spraying

• Two rounds per year in prioritised Kala-azar affected

areas of 12 districts

• Repeated at regular interval to keep down the density of

sandflies

Combined with sanitation measures:

- elimination of breeding places

- location of cattle sheds at the distance from houses

Insecticide- impregnated materials

Trend of Kala-azar cases and deaths (Source: EDCD)

Trend of kala-azar cases

2015/16 2016/17

2017-18

Native Foreign Native Foreign Native Foreign

Programme

Districts

181 17 151 6 122 0

Other districts 69 0 74 0 117 0

Total 250 17 225 6 239 0

The incidence trend of Kala-azar (Nepal)

2007/08 2008/09 2009/10 2014/15 2015/16 2016/17

Incidence

per

10,000

1.71

1.33

0.95

0.25

0.12

0.11

Kala‐azar cases and incidence: 2016- 2018

Thank you