An Integrated Disease Surveillance Project Concern for Kala-azar: Does the Framework in Nonendemic Regions Need an Overhaul?

Sir,

Integrated Disease Surveillance Project (IDSP) is expected to provide essential data to monitor the progress of ongoing disease control programs and detect the early warning signals of impending outbreaks so as to initiate an effective response in a timely manner.[1] Leishmaniasis in India exists mainly in two forms, namely, Kala-azar (KA) or visceral leishmaniasis (VL) and post-KA dermal leishmaniasis. Fifty-four districts (33 in Bihar, 11 in West Bengal, 4 in Jharkhand, and 6 in Uttar Pradesh) are endemic for KA. Sporadic cases have been reported from Assam, Himachal Pradesh, Jammu and Kashmir, Kerala, and Uttarakhand. The notification of VL is mandatory.[2] Case reporting is based on passive surveillance. Despite significant progress toward the targets of the KA Elimination Program, some challenges remain.[3] A changing epidemiological pattern has been observed, with new foci being reported in Uttarakhand district.[45] Nepal, also, has lately observed a wider geographical distribution, with new cases reported from hilly areas. Other challenges include ensuring an uninterrupted supply of diagnostics; vector control interventions (coverage, monitoring, and insecticide resistance); cross-border surveillance and information-sharing; and capacity for verification of elimination.[3]

A case study of a patient from Champawat district of Uttarakhand is presented here which raises few questions that need to be answered in the context of the National Roadmap for Elimination of KA in India. A 10-year-old female patient reported to a “Charitable Hospital” (a 30 bedded primary level hospital) with long-standing fever of 4 months associated with chills/rigors and abdominal pain. Physical examination revealed pallor and hepatosplenomegaly, and laboratory testing showed hemoglobin of 6 g%. Antimalarial treatment did not result in symptom resolution. The patient was then diagnosed as a case of KA on the basis of clinical picture of chronic fever, hepatosplenomegaly, and anemia along with a positive ELISA test for KA. KA medication was not available in public hospitals as well as private medicine shops of Champawat or Haridwar.rk39 kit, or anti-KA medicines were not available there as the district is supposed to be nonendemic for KA. The case was rather recommended to be treated as Pyrexia of unknown origin. Finally, Amphotericin B was procured following extensive efforts and support from Patna Medical College as well as “Medicine Sans Frontier”. With a resolution of symptoms, and regression of hepatosplenomegaly [Figure 1], the patient stopped coming and was lost to follow-up.

Figure 1

Photograph with markings on the abdomen showing initial extent of splenomegaly (black solid arrow) which improved (white solid arrow, after ten injections) with amphotericin B treatment

Kumar et al. from Government Medical College, Haldwani, reported ten cases of VL from their hospital during December 2005–September 2011. None of them had been out of the state or district during the 3 years preceding the onset of symptoms. They suggested need for epidemiological work for documentation of zoonotic reservoir in this area.[4] A more recent study by Chufal et al. in a tertiary care hospital in Kumaun, Uttarakhand, from 2010 to 2014 revealed twenty LD (Leishman Donovan) positive and five LD negative, rk 39 positive cases of VL in the study. They emphasized emerging need for proper epidemiological work up in this region to find out the reason for increasing incidence over the last few years.[5] Coincidentally, the first published case of VL-HIV from India in 1999 was reported from the Sub-Himalayan state of Uttarakhand.[6]

Currently, KA is included in IDSP as Disease of State priority and does not have a portal except in the endemic states. Cases and death data for VL from nonendemic states are reported from the concerned states to NVBDCP through Health Management Information System. 12 KA cases and 1 death have been reported from Uttarakhand through NVBDCP (http://nvbdcp.gov.in/ka-cd.htm) between 2010 and 2014. However, 25 cases have been reported by Chufal et al. in their retrospective study from a tertiary care hospital in the Kumaon region of Uttarakhand in the same period.[5] This clearly indicates under reporting/diagnosis of cases.[7]

In this context, if India is to eliminate VL in the near future, pertinent concerns that arise are:

The patient in our case study fulfilled the standard diagnostic criteria of Fever more than 2 weeks, splenomegaly, no response to antimalarial, positive ELISA for VL (considering unavailability of rk-39 kit in the area), and therapeutic response to amphotericin B. This evidence is enough to label the case as VL. This case raises the possibility of a sizeable number of missed cases in nonendemic areas like Uttarakhand

Sporadic incidence of VL is reported from Uttarakhand – local availability of diagnostic and treatment facilities and proper reporting mechanism needs to be considered

The index case had no connection with VL endemic states/districts of India, as also in Haldwani study[4] and sandfly breeding seems highly unusual in the environmental characteristics of Uttarakhand. Thus, zoonotic transmission may be considered and investigated.

Above all, is it time for IDSP to intensify the reporting for more cases (trigger level) in the area to help NVBDCP get the early warning signal of impending outbreak and initiate a proper epidemiological outbreak response and lay down necessary guidelines to achieve and sustain VL elimination from the country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.