Kala-azar (Visceral Leishmaniasis) Elimination in Bangladesh: Successes and Challenges
Visceral leishmaniasis (VL) also known as kala-azar is a major public health problem in Bangladesh. A national VL elimination program was initiated in 2008 in Bangladesh after the signing of a memorandum of understanding between the Government of Bangladesh, India, and Nepal in 2005 for the elimination of VL from these three countries by 2015. Following the strategic plan of the VL elimination program of the three countries, the national program in Bangladesh was established in 2008. Based on information in the directorate general of health services, expert opinions in a recently held advocacy meeting in Dhaka and on available scientific literature, we report here the successes and challenges of the national VL elimination program in Bangladesh. The program prepared the national kala-azar elimination guidelines and strategic plan for VL elimination in consultation with the technical working group for VL elimination and VL experts in Bangladesh and abroad, including the World Health Organization-The Special Programme for Research and Training in Tropical Diseases (TDR). The program trained health staff from all VL endemic hospitals in proper diagnosis and treatment, stratified the country according to VL burden, and introduced the rapid diagnostic test and oral treatment with miltefosine at no cost for patients. Integrated vector control management with indoor residual spraying and the distribution of commercial, long-lasting, insecticide-treated bed-nets were also studied and then implemented. VL burden has declined, but is still far from the target of VL elimination. Thus, the program must continue to maintain these activities and also introduce new activities to involve community participation in the program. The program is facing challenges regarding the shortage of human resources and logistics because of a scarcity of resources. To maintain the success of the program, support from national and international donor agencies and policy makers will be necessary. Other options for the treatment of VL patients as well as for vector control must also be considered.
KeywordsVisceral leishmaniasis National program Bangladesh VL Protozoa Leishmnaniasis
Visceral leishmaniasis (VL) also known as kala-azar is a public health problem in 90 countries of the world . The estimated annual VL incidence in the world is 0.2–0.4 million with a 10 % fatality rate . Ninety percent of all VL cases occur in India, Bangladesh, Nepal, Sudan, South Sudan, and Brazil . VL in the Indian sub-continent has unique epidemiologic and etiologic features as follows: VL is localized to the bordering districts of Nepal, India, and Bangladesh; VL is only caused by the Leishmania donovani parasite; there is only one vector, Phlebotomus argentipes; there is a high treatment response to anti-leishmania drugs such as miltefosine, liposomal amphotericin B, paromomycin, and amphotericin B deoxycholate; and VL can be diagnosed with the rK39 rapid test in the field [2, 3]. These features specific to the Indian sub-continent inspired the policy makers from Bangladesh, India, and Nepal to initiate a national VL elimination program, and a Memorandum of Understanding was signed by the governments of these three countries in 2005 to eliminate VL by 2015 . The elimination target is to reduce VL burden to less than 1 per 10,000 people at the district level in Nepal and at sub-district (upazila) level in India and Bangladesh . The strategic objectives of the elimination program are: (1) early diagnosis and complete case management; (2) integrated vector management (IVM); (3) effective disease surveillance through passive and active case detection; (4) social mobilization and building partnerships; and (5) clinical and operational research .
Almost 7 years have passed since the initiation of the VL elimination program in the Indian sub-continent and although the MoU was signed in 2005, the VL elimination program was started in Bangladesh in 2008. Here, we report the successes and challenges of the program in Bangladesh following the strategic framework for elimination of VL from the South-East Asia region.
The method for this review included VL surveillance data of the Disease Control Unit of the Directorate General of Health Services, the Government of Bangladesh, national and international expert opinion on VL control in Bangladesh from a recently held advocacy meeting on VL in November 2012 in Dhaka (organized by the Disease Control Unit of the Directorate General of Health Services, Bangladesh and Program For Appropriate Technology in Health (PATH)), and information from the published literature.
Early Diagnosis and Complete Case Management
Integrated Vector Management
IRS activity of the visceral leishmaniasis elimination program of Bangladesh in 2011–2012
HH Target for IRS
Achievement of Pre-monsoon IRS
Achievement of Post-monsoon IRS
Long-lasting insecticide-treated bed-nets for integrated vector management in Bangladesh
Total KA and PKDL cases(2008)
No. of LLINs distributed
Future plan for integrated vector management in Bangladesh for visceral leishmaniasis control
Pre- and post-monsoon IRS/year
During April to May and September to October for 3 consecutive years
LLIN distribution: in first round, last 5 year, patients and routine distribution to the current patients
First round: during September to October 2012 and routine distribution to the patients up to 2015
Camp followed by focal spray (selected village)
IRS (blanket spray to all HH of the selected villages)
May to June and November to December for 3 consecutive years
LLIN distribution: same as hyper-endemic Upazilla
Same as hyper-endemic Upazilla
Camp followed by focal spray (selected Village)
Same as moderate-endemic Upazilla
Thus, the IVM of the Bangladesh VL elimination program comprises IRS and the distribution of LLINs. Despite significant achievement for the implementation of IVM, the program also has weaknesses and challenges. Weaknesses include: lack of regular vector surveillance, a weak reporting system, lack of external quality control of insecticide, dependence of IRS only on deltamethrin, lack of back-up regulatory authority-approved insecticides for VL vector control, weak participation of other stakeholders, and inadequate BCC intervention for VL vector control. Challenges of IVM include: insufficient funds, insufficient number of entomologists, knowledge gap about VL vector bionomics, and knowledge gaps about the efficacy of other insecticides and the most cost-effective strategy for distribution of the LLINs to endemic areas. The program requires support from the national and international policy makers and donors to overcome these challenges.
There are also other opportunities for IVM in Bangladesh. VL is highly endemic in a few districts of Bangladesh and this will favor implementation of IVM in a cost-effective way. Except for deltamethrin, no other pyrethroids have been used for vector control in the country. The elimination program should have additional World Health Organization-approved insecticides in hand if sand flies eventually become resistant to deltamethrin. Another opportunity is that the bed-net impregnation program with slow-release insecticide tablets was shown to be effective for the reduction of sand fly density for a comparatively long period . Thus, the program could compliment the IRS program with a mass bed-net impregnation program.
Effective Disease Surveillance Through Passive and Active Case Detection and Vector Surveillance
Like disease surveillance, vector surveillance also needs improvement. Repeated entomological surveys have been performed during the piloting of IRS in the Fulbaria sub-district and this can be taken as a sentinel site for vector surveillance. More areas now must be included for vector surveillance. The challenges for successful vector surveillance are constraints with human resources, insufficient number of entomologists, and lack of funds and logistics. There is a need for capacity building for vector surveillance and entomological research, particularly for sand fly insectariums, laboratories for testing insecticide susceptibility, and periodic internal quality control of insecticides.
Social Mobilization and Building Partnerships
Success of the national VL elimination program is not possible without the active participation of the community. Among the three countries, community knowledge and attitude was poorest in Bangladesh . Current health education and social mobilization through billboard and leaflets are not sufficient to increase community awareness about VL. It is unknown what the most appropriate tools for health education are, especially for BCC. The program should pay more attention to the selection of BCC tools and to conducting periodic BCC intervention. BCC is a process that motivates people to adopt and sustain healthy behaviors and lifestyles. Sustaining healthy behavior usually requires a continuing investment in BCC as a part of an overall health program, which is a major challenge for the national program. Building partnerships with national NGOs, and national and international donor agencies is crucial. Currently, partnerships do exist for pilot interventions with MSF Holland, Institute For Epidemiology, Diseases Control and Research (IEDCR), International Centre for Diarrhoeal Disease Research, Bangladesh, Shaheed Suhrawardy Medical College (SSMC), World Health Organization-The Special Programme for Research and Training in Tropical Diseases (TDR), Institute for One World Health (iOWH), Drugs for Neglected Diseases initiatives (DNDi), and Program for Appropriate Technology in Health (PATH). Despite these partnerships, the national VL elimination program is totally financed by the Ministry of Health and Family Welfare, Bangladesh and does not receive sufficient support from the international donor organizations. Strong advocacy for the sustainability of existing activities of the program as well as for the start of new activities such as BCC is required.
Clinical and Operational Research
This is one of the most successful areas of the national VL elimination program in Bangladesh and includes the clinical trials with miltefosine , combination drug therapy, and feasibility studies for single-dose AmBisome at the sub-district level. Trials have also been conducted with different vector control methods and studies for better diagnostic tools for VL and PKDL. Additional research activities on PKDL are planned. However, the program should consider additional research activities such as a follow-up epidemiological survey of VL and PKDL burden compared with the baseline survey performed in 2009. Research to identify cost-effective larvicidal methods, efficacy trial with new insecticides, and other vector control methods, and treatment trials for PKDL is also required.
Another major success of the program is the establishment of a Kala-azar research center at the Surja Kanta (SK) Hospital in collaboration with Japan International Cooperation Agency (JICA), Japan, Drugs for Neglected Diseases initiatives (DNDi), and the International Centre for Diarrhoeal Disease Research, Bangladesh. This hospital will treat VL relapse cases, VL cases with complications, and patients with PKDL. The research center at the SK Hospital is open to all researchers who are interested in conducting studies on VL and PKDL.
The national VL elimination program has experienced considerable success as a result of its operational research activities in early case detection and complete treatment, IVM, and clinical research. However, the program needs to strengthen its activities for effective surveillance, BCC, monitoring, and evaluation. The main constraints for the program moving forward are insufficient human resources, funds, and logistics. These constraints may be overcome through building a partnership with national and international donor agencies and advocacy institutions, and by working closely with policy makers to ensure this successful program is sustainable.
The authors acknowledge our gratitude to the District Civil Surgeons of the VL endemic districts of Bangladesh, Heads of the Upazila Health Complex, and Statistical Technician at Upazila Hospitals for their contribution in data collection and data compiling. We also wish to thank Greg Matlashewski for his valuable input in preparing this article.
Compliance with Ethics Guidelines
Conflict of Interest
Be-Nazir Ahmed, Shah Golam Nabi, Mizanur Rahman, Shahjada Selim, Ariful Bashar, Md. Mahbubur Rashid, Fahima Yeasmin Lira, Tanveer Ahmed Chowdhury, and Dinesh Mondal declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
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