Management of Visceral Leishmaniasis in Muzaffarpur, Bihar, India “What we are seeking so frantically elsewhere may turn out to be the horse we have been riding all along.” Harvey Cox ISBN: 9789057284830 Legal deposit number: D/2015/12.293/12 The digital copy of this thesis can be downloaded from www.itg.be/thesis/paritosh Cover design by Natacha Hoevenaegel - Nieuwe Media Dienst, UA Description of cover photo: The cover page depicts a banner of a kala-azar camp sponsored by World Health Organization and organized by our research group at Banaras Hindu University, Varanasi and Kala-azar Medical Reasearch Centre, Muzaffarpur. The banner says in Hindi ‘Free Kala-azar diagnosis health camp’. Free diagnosis and treatment is one of the main strategies of Kala-azar Elimination Program in India. Management of Visceral Leishmaniasis in Muzaffarpur, Bihar, India Dissertation submitted for the degree of Doctor in Medical Sciences at the University of Antwerp Paritosh Malaviya Promoters: Mentors: Prof. Dr. Marleen Boelaert Prof. Dr. Shyam Sundar Department of Public Health, Institute of Medical Sciences, Institute of Tropical Medicine, Banaras Hindu Univesity, Antwerp, Belgium Varanasi, India Prof. Dr. Jean-Pierre Van geertruyden Dr. Epco Hasker Faculty of Medicine and Health Sciences Department of Public Health, University of Antwerp, Institute of Tropical Medicine, Antwerp, Belgium Antwerp, Belgium Antwerp, April 2015 In the sacred memory of my father Late Padmakar Malaviya (1945-2002) Doctoral Committee Promoters: Prof. Dr. Marleen Boelaert Department of Public Health Institute of Tropical Medicine Antwerp, Belgium Prof. Dr. Jean-Pierre Van geertruyden Faculty of Medicine and Health Sciences University of Antwerp Antwerp, Belgium Mentors: Prof. Dr. Shyam Sundar Institute of Medical Sciences Banaras Hindu Univesity Varanasi, India Dr. Epco Hasker Department of Public Health Institute of Tropical Medicine Antwerp, Belgium External Jury Members: Dr. Koert Ritmeijer Lead Neglected Tropical Diseases Public Health Department Médecins Sans Frontières Dr. Philippe Desjeux Leishmaniasis expert Internal Jury Members: Prof. Dr. Joost Weyler (Chair) Faculty of Medicine and Health Sciences University of Antwerp Antwerp, Belgium Prof. Dr. Surbhi Malhotra Faculty of Medicine and Health Sciences University of Antwerp Antwerp, Belgium Table of Contents SUMMARY ............................................................................................................................................13 SAMENVATTING .................................................................................................................................... 19 CHAPTER I. INTRODUCTION .................................................................................................................. 25 Leishmaniasis in the world .................................................................................................................... 25 The VL disease burden in India ............................................................................................................. 26 Transmission ..................................................................................................................................... 28 History of VL in India ......................................................................................................................... 29 Diagnosis ........................................................................................................................................... 31 Treatment ......................................................................................................................................... 31 Control .............................................................................................................................................. 32 Vector control ............................................................................................................................... 32 Social mobilisation ........................................................................................................................ 33 Active case detection .................................................................................................................... 34 The VL elimination initiative ......................................................................................................... 35 CHAPTER II. Background ....................................................................................................................... 37 Study setting ..................................................................................................................................... 37 India’s public health system .............................................................................................................. 38 Access to health care in the public sector in India ............................................................................ 42 Community health services in India .................................................................................................. 43 The study area: Muzaffarpur district ................................................................................................ 48 CHAPTER III. Rationale and objectives of the doctoral study ............................................................... 51 CHAPTER IV. Results .............................................................................................................................. 55 Section 1. Epidemiology of Visceral Leishmaniasis in Bihar .................................................................. 55 1.1 Incidence ..................................................................................................................................... 55 1.2 Risk factors .................................................................................................................................. 77 Section 2. VL Control strategies: on active case detection at community level ................................... 93 Section 3. Information system: on strategies for monitoring clinical outcomes of treatment and on a health research information platform .............................................. 107 3.1 Surveys ...................................................................................................................................... 107 3.2 Register-based quarterly monitoring of treatment outcomes ................................................. 125 3.3 A health research information platform ................................................................................... 145 CHAPTER V. Discussion ....................................................................................................................... 163 REFERENCES ........................................................................................................................................ 171 ACKNOWLEDGEMENT Abbreviations ACD Active Case Detection ANM Auxiliary Nurse Midwife ASHA Accredited Social Health Activist AWW Aangan Wadi Workers BPL Below Poverty Line CHC Community Health Centre IMR Infant Mortality Rate IPHS Indian Public Health Standards KA Kala-azar MMPW Male Multi-Purpose Worker MoHFW Ministry of Health and Family Welfare MOIC Medical officer in-charge NRHM National Rural Health Mission NVBDCP National Vector Borne Disease Control Programme PHC Primary Health Centre RNTCP Revised National Tuberculosis Control Programme SC Sub-centre U5MR Under Five Mortality Rate VL Visceral Leishmaniasis WHO World Health Organization SUMMARY Background and rationale Visceral leishmaniasis (VL) or kala-azar is a chronic infectious disease which poses a public health problem in the Indian subcontinent, East Africa and South America. In 2012, the estimated worldwide number of new cases of VL was between 200,000 and 400,000. Bangladesh, India and Nepal have entered into a joint commitment to eliminate VL as a public health problem from this region by the year 2015. The aim is to reduce the incidence rate of VL to less than one new case per 10,000 populations per year at sub-district level in these countries. In the Indian subcontinent VL is caused by the parasite Leishmania donovani and transmitted by a sand fly of the species Phlebotomus argentipes in the peridomestic environment. The sand fly breeds in moist soil littered with organic debris and rests inside houses in cracks and crevices of walls. There is no known animal reservoir. Prolonged fever of more than two weeks’ duration with enlarged spleen are the main signs and symptoms of VL, a syndrome that develops progressively into extreme wasting, anaemia and ultimately death if not treated – usually by secondary infections. Cure can be achieved in over 90% of cases with a full course of four weeks of the oral drug Miltefosine, amongst other regimens. The VL elimination strategy therefore builds on early case detection and management as well as vector control. In the Bihar state of India, VL is endemic in 33 out of 38 districts. The disease affects the rural areas, where the poorest families are most at risk. VL has catastrophic effects on the household economy of families of poor patients. Though the elimination program in this region was launched with much enthusiasm in 2005; several weaknesses in its set-up were identified in program reviews and research reports. Firstly, several basic facts about disease transmission and risk factors needed better understanding: the role of asymptomatic carriers, the role of