Kala Azar

2. Contents
• Introduction
• Definition & Problem statement
• Epidemiological determinants
• Clinical features
• Diagnosis
• Treatment
• Prevention & Control

4. LEISHMANIASIS
• Leishmaniasis are group of protozoal diseases caused
by parasite of genune Leishmania, and transmitted to
humans by the bite of female phlebotomine sandfly.
• VL (Kala azar)
• CL
• MCL
• ACL
• ZCL
• PKDL

5. Problem statement
 World
• Visceral Leishmaniasis : Occurs widely through out
the world, viz south America south Africa the
mediterian countries India Bangladesh and china.
9 out of 10 cases occur in bangladesh,brazil india and
sudan.
• Cutanious Leishmaniasis : Occurs in dry, semi desert
rural areas of central asia, middle east north and
west Africa, esp in Ethopia and Kenya.
9 out of ten cases occur in Afghanistan Brazil Iran
peru and Saudi Arabia.
• Muco cutanious Leishmaniasis : Found in Brazil
Bolivia and Peru, rarely found outside the world.

6. India
• Has been known to occur epidemically endemically
in well defined areas in the eastern sector of the
country viz Assam West bengal Bihar Eastern dist of
Utter Pradesh Sikkim and to very lesser extent in
Tamil nadu & Orissa.
• Kala Azar is endemic in 52 dist Bihar, Jharkhand,
Westbengal, UP
• About 130million pop at risk of the disease

7. • Zoonotic cutaneous leishmaniasis : has been
discovered in Rajasthan area in 1971, total
828 cases were reported.
• Cases of ACL have bee reported from Bhikaner
city.
• Both cutaneous (ZCL,ACL) and VL found in
india, KALA AZAR is by far so importatnt
disease in india.

8. Kala-azar
• Kala-azar is a slow progressing indigenous disease
caused by a protozoan parasite of genus Leishmania.
• Leishmania donovani
is the only parasite
causing this disease
in india.
• PKDL
(Post Kala-azar Dermal Leishmaniasis )
caused by Leishmania Donovani

9. P.argentipes:

10. Epidemiological determinants
Agent factors
• Leishmanis donovani Kala Azar & PKDL
• Leishmania tropica CL
• Leishmania brazileinsis MCL

11. Reservoirs of infection
• Zoonotic
• Non Zoonotic

12. Host Factor
• Age
• Sex
• Population movement
• Socio economic status
• Occupation

13. Environmental Factor
• Altitude
• Season
• Rural areas
• Vectors
• Development projects

14. Mode of transmission
• In india Kala Azar is transmitted from person
to person by the bite of the female
Phlebotomine Sandfly.
• Transmission may also take place by
contamination of the bite wound or by
contact when the insect is crushed during the
contact act of feeding
• Blood transfussion
• Contaminted syringes and needles.

15. Signs and Symptoms
• Recurrent fever
• loss of appetite, pallor and weight loss with
progressive emaciation,
• weakness.
• Skin - dry, thin and scaly and hair may be lost.
• persons show grayish discolouration of the skin of
hands, feet,abdomen and face which gives the
Indian name Kala azar meaning "Black fever"

16. • Splenomegaly.
• Hepatomegaly.
• Lymphadenopathy.
• Anaemia - develops rapidly.
• Anaemia with emaciation
& gross splenomegaly produces
a typical appearance of the patients.

17. • PKDL Occurs several years after the apperant
cure of kala azar, signs symptom includes
lesion consists of multiple nodular infiltrations
of the skin usually without ulceration,
parasites are numerous in this lesion.
• CL,ACL,ZCL, etc here agent is
restricted to skin, painful ulcer
in the parts of body exposed to
sand fly bites, reducing the
victims ability to work

18. Diagnosis
Clinical
• fever of more than 2 weeks duration not
responding to antimalarials and antibiotics.
Lab invest
• Haematological findings viz Anaemia, leucopenia,
thrombocytopenia & hypergammaglobulinemia.
• WBC : RBC ratio is 1:1500 or even 1:2000
• Raised ESR
.

19. • Serology tests: Direct Agglutination Test (DAT),
rk39 dipstick and ELISA. However all these
tests detect IgG antibodies that are relatively
long lasting. Aldehyde Test is commonly used
but it is a non-specific test. IgM detecting tests
are under development and not available for
field use.

20. • Parasitological diagnosis
The demonstration of the parasite in the
aspirates of
bonemarrow/spleen/lymphnode/liver or in
the skin (in case of CL) is the only way to
confirm VL or CL. However, sensitivity
varies with the organ selected for
aspiration. Though spleen aspiration has
the highest sensitivity and specificity
(considered gold standard)

21. Sl. No.
Affected
States/
UTs
2007 2008 2009 2010(P) 2011(P)
Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths
1 Assam 0 0 98 0 26 0 12 0 5 0
2 Bihar 37819 172 28489 142 20519 80 23084 95 18519 56
3 Delhi 19 0 34 0 12 0 33 0 0 0
4 Gujarat 4 1 0 0 0 0 0 0 0 0
5
Himacha
Pradesh
0 0 0 0 0 0 6 1 1 0
6
Jharkha
nd
4803 20 3690 5 2875 12 4305 5 4264 3
7
Madhya
Pradesh
0 0 1 0 0 0 0 0 0 0
8 Punjab 0 0 0 0 0 0 1 0 0 0
9 Sikkim 0 0 4 1 5 0 3 0 3 0
10
Uttrakha
nd
2 0 0 0 2 0 1 0 0 0
11
Uttar
Pradesh
69 1 26 0 17 1 14 0 8 1
12
West
Bengal
1817 9 1256 3 756 0 1482 4 1431 0
Total 44533 203 33598 151 24212 93 28941 105 24231 60

23. Control measures
• Control the reservoir
• Treatment of the cases
• Sand fly control
• Personal prohylaxis
Active and passive detection of the cases and
treatment of those who found to be infected.
House to house visit.
Mass serevys in endemic areas for early detection
of the cases.

24. • Treatment
Pentavalent antimony---- Sodium stibogluconate
10mg/kg body wt for 20 days in adults.
20mg/kg body w in childrens.
Pentamidine isethionate 3mg/kg body wt for 10 days.
Amphotericin B 1mg/kg body wt IV 15 to 20 Injections
alt dys
Miltefosine, 2.5 mg/kg body wt in two divided doses for
4 week

25. • Sandfly controle
DDT
Insecticide spraying at human dwellinngs and
all animal shelter and other resting places up
to the height of 6 feets from floor level
• Sanitation measures
• Personal prophylaxis

26. Kala azar control programme
The strategy of kala azar contorl broadly
includes three major activities
• Interruption of transmission for reducing
vector population by undertaking indoor
insecticidal spry twice annual major activities
• Early diagnosis and treatment of the kala azar
cases
• Health education for the community
awareness

27. cont
In view of the success achieved so far,
National health policy envisages kala azar
elimination by the year 2010.
The tenth five year plan targets are
• prevention of death by kala azar by 2004 by
annual reduction of least25%
• zero level incidence by 2007 with atleast 20%
annual reduction using 2001 as a base year,
• Elimination of kala azara by 2010. To achieve
this government of india has provided 100%
central support from the year 2003 2004

28. • Kala-azar Control Efforts in India
• An organized centrally sponsored Control
Programme launched in endemic areas in
1990-91.
• Government of India provided kala-azar
medicines, insecticides and technical support.
• State governments implemented the
programme through primary health care
system and district/zonal and State malaria
control organizations and provided other costs
involved in strategy implementation.

29. • Programme strategy
• Vector control through IRS with DDT up to 6 feet height from
the ground twice annually.
• Early Diagnosis and Complete treatment of the cases.
• Information Education Communication
• Programme intensified in 1991-92 which led to improved case
registration through primary health care system.
• Within 3 years of intensification (1995 as compared to 1992)
70.66% decline in annual incidence
80.48% decline in deaths
• By 2003 as compared to 1992
76.38% decline in incidence
85.20% decline in deaths.

30. • KALA-AZAR ELIMINATION INITIATIVE
• In addition to kala-azar medicines and insecticides,
cash assistance is being provided to endemic states
since December 2003 to facilitate effective strategy
implementation by states.
• State/District Action Plan for Kala-azar Elimination.
• Template for developing District Action Plan (Kala-
azar).
• Draft Communication & Media Plan for Kala-azar
Elimination.
• Patient Coding Scheme.
• Kala-azar Treatment Card.
• Monthly Kala-azar Reporting Formats.

33. Dengue
• Dengue is a viral disease.
• Caused by 4 antigenically related but distinct
dengue virus serotype(DEN 1,2,3 & 4)
• It is transmitted by the infective bite of Aedes
Aegypti mosquito
• The infection may be asymptomatic or may lead to
 Classical dengue fever or
 Dengue fever without shock or
 Dengue hemorrhagic fever with shock
• Dengue Haemorrhagic Fever (DHF) with shock is a
more severe form of disease, which may cause
death

34. The most common epidemic vector of dengue in the world is
the Aedes aegypti mosquito. It can be identified by the
white bands or scale patterns on its legs and thorax.

37. • Infective period: day before onset to the 5th
day of illness
• Extrinsic incubation period : 8-10 days
• Sex : both male & female
• Incubation period: 3- 10 days

38. Problem statement
• Most important emerging disease:
– Tropical & sub tropical regions
– Affecting urban & per urban areas
• The cases has increased dramatically in the past 30yrs
• A pandemic(56 countries) : 1998 (1.2 million cases )
• WHO –50 million infections/yr
- 5,00,000 cases of dengue hemorrhagic fever/yr
- At least 12000 deaths/yr

39. Cont..
• Currently dengue is endemic in Bangladesh India
Indonesia, Maldives Mayanmar, Srilanka and Thailand.
• Bhutan and Nepal reported their first case in 2004 and
2006 resp.
• Aproximately 2.5 to 3 bilion are living in areas where
dengue virus can transmitted.
• Over the past 10 15 years, next to diarrheal disease
and acute respiratory infection dengue has become a
leading cause of hospitalization and death among
children in the south east asia region.
• During 2006 SEAR reported about 190000 cases with
1600 deaths.

40. Burden of the disease
• Important disease of tropics & is one of the
important disease affecting nearly ½ of worlds
population.
• There are about 50 to 100 million cases of
dengue fever & about 500,000 cases of dengue
hemorrhagic fever that require hospitalization
each yr
• World health assembly passed a resolution in
1993 which urged members states to strengthen
their national & international program for control
of DF/DHF

41. Countries in South East Asia Region have been divided in 4
categories
Category A:
Indonesia, Myanmar & Thailand
Major Public Health problem
Increased hospitalization death among
children
Multiple virus type circulating; Ades aegypti
(Principal vector)

42. Category B:
India, Bangladesh, Maldives & Srilanka
» DHE an emerging disease
» Cyclic epidemic becoming more frequent
» Multiple virus serotype circulating expanding
geographicallywithin country,
Aedes albopictus principal vector

43. • Category C:
Bhutan & Nepal
No reported cases & endemicity uncertain
• Category D:
Korea
Non endemic

45. Affected
States/UTs
2008 2009 2010 2011(P)
Cases Deaths Cases Deaths Cases Deaths Cases Deaths
Andhra
Pradesh
313 2 1190 11 776 3 235 3
Assam 0 0 0 0 237 2 1 0
Bihar 1 0 1 0 510 0 2 0
Chattisgarh 0 0 26 7 4 0 0 0
Goa 43 0 277 5 242 0 7 0
Gujarat 1065 2 2461 2 2568 1 493 0
Haryana 1137 9 125 1 866 20 39 1
Himachal Pd. 0 0 0 0 3 0 0 0
J & K 0 0 2 0 0 0 1 0
Jharkhand 0 0 0 0 27 0 12 0
Karnataka 339 3 1764 8 2285 7 263 3
Kerala 733 3 1425 6 2597 17 847 8

46. Kerala 733 3 1425 6 2597 17 847 8
Madhya
Pd.
3 0 1467 5 175 1 14 0
Meghala
ya
0 0 0 0 1 0 0 0
Maharas
htra
743 22 2255 20 1489 5 223 2
Manipur 0 0 0 0 7 0 0 0
Nagalan
d
0 0 25 0 0 0 0 0
Orissa 0 0 0 0 29 5 1697 25
Punjab 4349 21 245 1 4012 15 609 0
Tamil
Nadu
530 3 1072 7 2051 8 1091 4
Rajastha
n
682 4 1389 18 1823 9 81 0

47. States.
2008 2009 2010 2011(P)
Cases Deaths Cases Deaths Cases Deaths Cases Deaths
Uttar
Pradesh
51 2 168 2 960 8 50 1
Uttrakha
nd
20 0 0 0 178 0 4 0
West
Bengal
1038 7 399 0 805 1 149 0
A& N
Island
0 0 0 0 25 0 0 0
Chandiga
rh
167 0 25 0 221 0 1 0
Delhi 1312 2 1153 3 6259 8 245 3
D&N
Haveli
0 0 0 0 46 0 0 0
Puducher
y
35 0 66 0 96 0 34 0
Total 12561 80 15535 96 28292 110 6098 50

48. Magnitude of the problem

49. Transmission
• Resvr of infection is both man and mosquito
• Aedes albopictus become infective by feeding
on a paitent from the day before onset to 5th
day of illness.
• After an extrinsic incubation period of 8 to 10
days the mosquito become infective and able
transmit the disease.

50. SIGNS & SYMPTOMS OF DF
• high fever with chills 39 to 40 degree cel
• Severe frontal headache
• Retro orbital pain, which worsens with eye
movement
• Photophobia
• Muscle and joint pains
• Loss of sense of taste and appetite
• Measles-like rash over chest and upper limbs
• Nausea and vomiting

51. SIGNS & SYMPTOMS OF DHF
• Symptoms similar to dengue fever
• Severe continuous stomach pains
• Skin becomes pale, cold or clammy
• Bleeding from nose, mouth & gums and skin
rashes
• Frequent vomiting with or without blood
• Sleepiness and restlessness
• Patient feels thirsty and mouth becomes dry
• Rapid weak pulse
• Difficulty in breathing

52. • Based on the signs and symptoms the dengue
illness is divided into 3 phases
– Febrile phase
– Critical phase
– Recovery phase

53. IgM/IgG

54. Diagnosis
• Clinical diagnosis
– Fever acute onset high continuous lasting 2-7 dys
– Hepatomegally
– Epitaxis
– Gum bleeding
– haematemesis
– DHM include +ve torniquet test

55. • Lab investigation
– Thrombocytopenia (less 1 lack)
– Haematoconcentration ie increased haematocrit
more than 20% of normal value

56. • Acc to clinical manifestation pt may divide into 3
broad groups
– Group A pt with uncomplicated condi
– Group B pt in hospital management
– Group C pt require Emergency treatment

57. Treatment
• No drug or vaccine is available for the treatment of
Dengue/DHF
• Symptomatic & supportive
• Bed rest – during acute febrile phase
• Antipyretics
• Sponging (to keep the body below 40 0 C )
• Avoid – Aspirin (endemic areas)
– Causes:
• gastritis
• Bleeding
• Acidosis
• Oral fluid & electrolyte therapy :
– Pts with excessive sweating,
– Vomiting
– Diarrhea

58. Management of DHF
• Is similar to the DF during febrile phase
• Rise in haematocrit – parenteral fluid therapy
• In Grade I &II volume replacement for a
period of 12-24 hrs
• Admission to hospital :
– Any signs of bleeding
– Persistently high haemetocrit values

59. • Fluid replacement should be minimum
• Excessive replacement will cause
– Respiratory distress
– Pulmonary congestion
– Oedema
• The type of fluid use are:
• 5% dextrose in lactated Ringer’s solution
• 5% dextrose in ½ strength normal saline solution
• 5% dextrose in normal saline solution

60. Control measures
Vector control measures
• Personal prophylactic measures
– Use of mosquito repellent creams, liquids, coils, mats
etc.
– Wearing of full sleeve shirts and full pants with socks
– Use of bednets for sleeping infants and young children
during day time to prevent mosquito bite
• Biological control
– Use of larvivorous fishes in ornamental tanks, fountains,
etc.
– Use of biocides

61. • Chemical control
Use of chemical larvicides like abate in big breeding
containers
Aerosol space spray during day time
• Environmental management & source reduction
methods
• Detection & elimination of mosquito breeding sources
• Management of roof tops, porticos and sunshades
• Proper covering of stored water
• Reliable water supply
• Observation of weekly dry day

62. • Health education
Impart knowledge to common people
regarding the disease and vector through
various media sources like T.v., Radio, Cinema
slides, etc.
• Community participation
Sensitilizing and involving the community for
detection of Aedes breeding places and their
elimination

63. REF
• K Park: text book of preventive and social
medicine; edt -18 & 21
• Text of Public Health and Community
Medicine: Armed Force Pune
• Davidson`s Principles and practice of medicine
• Sundarlal Adarsh Pankaj: text book of
community medicine; edt-1st
• www.whoindia.int/chi
• www.nvbdcp.com

64. • Topley & Wilsons Text book of parasitology 9th
(Edn), 428-524
• O P Ghai Text book of preventive and social
medicine, 161-162
• Harrisons Text book of Medicine, 15th (Edn),1428-
1430
• Ananth Narayans Text book of Microbiology, 2nd
(Edn),209-211

65. Control measures
Vector control measures
• Personal prophylactic measures
– Use of mosquito repellent creams, liquids, coils, mats
etc.
– Wearing of full sleeve shirts and full pants with socks
– Use of bednets for sleeping infants and young children
during day time to prevent mosquito bite
• Biological control
– Use of larvivorous fishes in ornamental tanks, fountains,
etc.
– Use of biocides

66. • Chemical control
Use of chemical larvicides like abate in big breeding
containers
Aerosol space spray during day time
• Environmental management & source reduction
methods
• Detection & elimination of mosquito breeding sources
• Management of roof tops, porticos and sunshades
• Proper covering of stored water
• Reliable water supply
• Observation of weekly dry day

67. • Health education
Impart knowledge to common people
regarding the disease and vector through
various media sources like T.v., Radio, Cinema
slides, etc.
• Community participation
Sensitilizing and involving the community for
detection of Aedes breeding places and their
elimination

68. THANK YOU ALL