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Low Castes Have Poor Access to Visceral Leishmaniasis Treatment in Bihar, India

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Low Castes Have Poor Access to Visceral Leishmaniasis Treatment in Bihar, India View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by MSF Field Research Tropical Medicine and International Health doi:10.1111/j.1365-3156.2012.02960.x volume 00 no 00 Low castes have poor access to visceral leishmaniasis treatment in Bihar, India F. Pascual Martı´nez1, A. Picado2,3, P. Roddy1 and P. Palma1 1 Me´decins Sans Frontie`res – Operational Center Barcelona-Athens, Barcelona, Spain 2 Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium 3 Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK Abstract objectives Bihar, the poorest state in India, concentrates most of the visceral leishmaniasis (VL) cases in the country. A large proportion of the poor rural communities where VL is endemic are marginalized by their socio-economic status, intrinsically related to the caste system. In this study, we evaluated whether people from low socio-economic strata had difficulties accessing VL treatment in Bihar. As a secondary outcome, we evaluated whether people delaying their VL treatment had poorer clinical indicators at admission. methods Data on 2187 patients with VL treated by Me´decins Sans Frontie`res (MSF) in Vaishali district from July 2007 to December 2008 were analysed. Patients who reported having onset of symptoms ‡8 weeks before admission were defined as ‘late presenters’. Logistic regression models were used to evaluate whether low castes had higher risk to be ‘late presenters’ compared to the rest of castes and whether ‘late presenters’ had poorer indicators at admission (i.e. haemoglobin level, spleen size). results After adjusting for age, gender and distance to VL treatment facility, Mushars (the lowest caste in Bihar) had twice the odds to be ‘late presenters’ compared to the rest of castes (OR 2.05, 95% CI: 1.24–2.38). Subjects that had VL symptoms for ‡8 weeks had a larger spleen and lower haemoglobin level than those that were treated earlier. conclusion Low castes have poor access to VL treatment in Bihar, and late presenters have poorer clinical indicators at admission. These findings have implications at individual and community levels and should stimulate targeted VL control programmes to ensure that marginalized communities in Bihar are properly treated. keywords Kala azar, visceral leishmaniasis, caste, Bihar, Mushar In India, VL is caused by Leishmania donovani trans- Introduction mitted by Phlebotomus argentipes (Dedet 2008) in an Visceral leishmaniasis (VL; kala azar) is a disease caused by a anthroponotic cycle (Desjeux 2004). Current VL control systemic infection of parasites of the genus Leishmania measures are based mainly on indoor residual spraying transmitted to humans via phlebotomine sandflies (Hey- (IRS) of households with dichlorodiphenyltrichloroethane mann 2008). The annual burden of VL is estimated to be (DDT) and early diagnosis and treatment for those 500 000 new cases and 51 000 deaths (WHO, 2004). infected. To date, these measures have been insufficient to Approximately half of VL cases globally occur in India, control the disease (Ostyn et al. 2008). A series of available where 165 million people residing in 52 VL-endemic districts new tools, namely rapid diagnostic tests and therapeutics are at risk of infection (Desjeux 2004) (India., such as liposomal amphotericin B, should facilitate the M.o.H.a.F.W.G.o, 2009). Bihar is the most affected state implementation of a more effective control strategy for accounting for more than 90% of India’s cases (Ranjan et al. high VL risk communities. The active detection of and 2005) with an annual incidence rate of 22.3 cases per 10 000 treatment for VL cases should be an indispensable control people (Mondal et al. 2009). Bihar’s Vaishali district is programme component (Mondal et al. 2009). However, endemic for VL with an estimated incidence of 29.8 cases per this strategy requires accessing VL-affected communities, 10 000 per year (S. J. Seena, J. F. Saint Sauveur, P. K. Sinha, which tend to be marginalized, extremely poor (Boelaert M. C. Vin˜ oles, R. K. Topno, P. Das, P. Roddy, L. Flevaud, et al. 2009) and lack access to both diagnosis and M. A. Lima, P. P. Palma, unpublished data). treatment. In India, marginalized communities typically ª 2012 Blackwell Publishing Ltd 1 Tropical Medicine and International Health volume 00 no 00 F. P. Martı´nez et al. Poor access to visceral leishmaniasis treatment comprise the lower castes (Van de Poel & Speybroeck identified at MSF mobile clinics, thus by active case 2009). detection campaigns, were not included in the analyses. No Caste, as a proxy for socio-economic status (Van de Poel transportation fees were paid for the first visit. Patients & Speybroeck 2009), is an important determinant of with VL who completed their VL treatment received an social position and affects numerous aspects of daily life, insecticide-treated net. including access to public health services (Babu et al. Visceral leishmaniasis-suspected patients were confirmed 2001). The lower strata in the caste system may have by a positive rK39 rapid diagnostic test (DiaMed-IT- difficulties accessing health facilities, not only for financial LeishÒ; DiaMed) or by demonstration of the parasite in the reasons but also because of social segregation (Alvar et al. spleen or bone marrow aspirates. All patients with VL were 2006). This may reduce awareness and expectations of treated with liposomal amphotericin B (AmbisomeÒ; treatment and discourage or delay presentation to a health Gilead Sciences), given according to the current World facility in the event of disease. Delayed treatment for VL Health Organization (WHO) recommendation (WHO, has consequences at community level as infectious cases 2005a): a total dose of 20 mg ⁄ kg administered intrave- help maintaining the transmission cycle of the disease. nously at 5-mg ⁄ kg doses on days 0, 1, 4 and 9. An Similarly, delayed treatment may be related to poor clinical extended schedule with liposomal amphotericin B was used parameters at admission (Collin et al. 2004), which may as second-line treatment. MSF provided free diagnosis and adversely affect the clinical outcome. treatment. Only VL-confirmed individuals living in Vais- In India, castes and sub-castes are categorized into three hali district and treated at Hajipur Hospital were included groups: (i) scheduled castes and tribes (SC ⁄ T), which include in this study (Figure 1). the former ‘untouchables’ (or ‘Dalit’), the lowest castes; (ii) other backward classes (OBC); and (iii) other castes (OC), Study variables which include those groups higher in the socio-economic scale. In rural communities in particular, the caste system has For each patient, demographics (i.e. age in years at a rigid hierarchical structure. Mushars are the lowest caste admission, gender, sub-district of residence and caste), among the SC ⁄ T in Bihar (A. Juan, P. Duch, unpublished clinical data (i.e. spleen size, nutritional status and report) with an average daily income of 50 Indian rupees (1.1 haemoglobin levels), date of onset of symptoms and USD) and poor literacy rates: 2% among males and 0.9% co-infections at admission were recorded. among females compared with 59.7% and 33.1%, respec- Castes were categorized following the 2001 census tively, for the entire state of Bihar (India., G.o, 2001). designation (India., G.o, 2001) as SC ⁄ T, OBC and OC in Moreover, Mushars report suffering from acts of violence ascending social order. Mushars, the lowest caste in Bihar (Watch 2007). In Bihar, Mushars comprise approximately included in the SC ⁄ T group, were also identified and 2.5% of the total population (India., G.o, 2001). compared to the rest of castes. The primary objective of this study was to determine The primary outcome was the number of weeks between whether low castes, and Mushars in particular, had poorer the onset of VL symptoms and presentation to the access to VL treatment in Vaishali district (Bihar) com- treatment site. This variable was divided into quintiles. pared to other castes. The secondary study objective was to Patients in the last quintile, that is, patients who reported determine whether patients with VL who delayed their onset of symptoms ‡8 weeks before admission, were treatment had poor clinical indicators at admission. defined as ‘late presenters’. Clinical variables were defined as follows. Patients’ spleen size and haemoglobin levels were divided into Materials and methods quintiles per age group: 6 months to 4 years, 5–18 years and older than 18 years for spleen size; and 6 months to Study population 5 years, 6–11 years, 12–14 years, pregnant women of Our study population included patients with VL treated by any age, non-pregnant women over 15 years and men Me´decins Sans Frontie`res (MSF) at Hajipur Hospital in over 15 years for haemoglobin levels. Patients whose Vaishali district (Bihar) from July 2007 to January 2009. spleen size was in the 5th quintile were considered to Patients with VL symptoms who self-presented to the have a very large spleen. Similarly, patients whose hospital’s outpatient department (OPD) or who were haemoglobin level was in the 1st quintile were consid- referred to the hospital from one of the Primary Health ered to have a very low haemoglobin level. Poor Centres (PHC) in the district or from the Rajendra nutritional status was defined according to WHO stan- Memorial Research Institute of Medical Sciences in Patna dards and included patients that were both severely acute (RMRI) were included in the study. Patients with VL (below )3z scores of the median WHO growth 2 ª 2012 Blackwell Publishing Ltd Tropical Medicine and International Health volume 00 no 00 F. P. Martı´nez et al. Poor access to visceral leishmaniasis treatment Visceral Leishmaniasis (VL) patients treated by Médecins Sans Frontières (MSF) in Vaishali district (Bihar) from July 2007 to January 2009: Rajendra Memorial Research Institute of Medical Sciences in Patna (RMRI) n = 343 Hajipur hospital & Primary Health Centres (PHC) n = 2436 Total = 2779 Excluded Duplicated records n = 102 Lost to follow up n = 21 Patients living outside Vaishali district n = 469 VL patients finally included in the study Figure 1 Schematic flow of study partici- pants.
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