India

India remains the main focus of visceral leishmaniasis (VL) disease burden in the South Asia. The States of Bihar and Jharkhand remain the most endemic for VL infection.

India has made good progress towards VL elimination. In 2013, 13,869 cases were reported, representing a drop of over 50% from 2010. Since 2013, absolute case-load has decreased (6,245 cases were reported in 2016) owing to significant control efforts. A number of factors are likely to have contributed to this fall in numbers, however, one of which is the natural epidemiological trend of VL.

The department overseeing India’s VL strategy is the National Vector Borne Disease Control Programme (NVBDCP). Major components of the stretegy have been the introduction of single day AmBisome treatment and the change of insecticides. KalaCORE was responsible for rolling out of the first component. In early 2017, the NVBDCP published a new roadmap for the elimination of VL in India as a public health problem in the ‘Accelerated Plan for Kala-Azar Elimination’).

As the 2017 elimination target approaches, there is an increasing sense of political urgency for this goal to be met. It has become clear was that there also needs to be a focus on sustaining elimination targets so that a resurgence does not occur in the mid-long term; or if it does, that cases are detected early and managed appropriately.

Challenges

Quality of Indoor Residual Spraying.
Capacity gaps. Our baseline survey suggested limited awareness of VL and a limited capacity to provide quality care at Public Health Centre (PHC) level. Lack of behaviour change communication (BCC) with community health workers and community members has also contributed to a limited awareness of VL and what to do when people have symptoms.
Knowledge gaps around post kala azar dermal leishmaniasis (PKDL). PKDL remains an unknown entity from a multitude of perspectives. Its importance as a reservoir is unknown and the impact of the newer treatment regimens on prevalence and incidence of PKDL is unclear.
Under-reporting and parallel private healthcare systems. The high level of dependence on private healthcare providers in India means they play an important role and need to be fully engaged in the national VL response. This will ensure that practitioners are adequately trained, are able to treat or refer appropriately and that VL cases are reported correctly.
Inadequate surveillance systems. Surveillance has relayed heavily on passive case detection. KalaCORE aims to increase active case detection in order to detect cases earlier and reduce transmission times, and strengthening passive surveillance at the same time.
Poor coordination.

Building on opportunities

High level joint planning. The original and then accelerated roadmap for VL elimination detailed all the components of the programme that would be required to achieve sustainable elimination and allocated responsibility to specific stakeholders with clear timelines. KalaCORE were major contributors into the development of these roadmaps, while various, Memorandums of Understanding (MoUs) was signed between the NVBDCP, states and KalaCORE.
Responding to national priorities. The focus of KalaCORE's approach in India is to ensure better treatment, primarily by building capacity into the system
Working with key partners.

India

Activities

Validating and implementing active case detection strategies for post-kala azar dermal leishmaniasis and visceral leishmaniasis across highly endemic districts in Bihar and Jharkand.

Case management
Improving surveillance

Summary

Objectives

Validate and upscale index case detection and camp approaches for Active Case Detection of post-kala azar dermal leishmaniasis and VL.
Increase awareness of established incentives for Community Health Workers (Accredited Social Health Activist) and patients.
Training of Indoor Residual Spraying technicians to conduct active case detection for post-kala azar dermal leishmaniasis and VL.

Outputs

The active-case detection programme has begun its phase 1 roll-out in Bihar. Preparations (village mapping, approvals from government, liaising with district and block officials and training of front line workers) have been completed and field work has begun. In 3 days of "real" field operations 10 field teams (one person from IPE Global: India and one government staff member) covered 2760 households, equivalent to approximately 14,000 people. Most of the households were situated in very poor communities. We found 122 suspect cases of VL and PKDL.

We also introduced active-case searching through the Behaviour change communication (BCC) teams of New Concepts. Under this component the team from NC, after the Information Education Communication/BCC session (community group session), searched for any suspected VL or PKDL cases. This was done mainly through asking questions to the communities they interacted with, or by asking community health workers or other key people in the community. The teams have been able to identify more than 1,800 suspected cases of VL or PKDL, of which 211 were confirmed as VL and 35 as PKDL. These confirmed cases were then referred to PHC (via a referral slip). However, only 50% of these individuals went to the PHC for confirmatory diagnosis. We are looking at ways to increase this proportion.