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A child receiving medication for Visceral leishmaniasis through a drip whilst family members sit by his bed

Taking the fight to visceral leishmaniasis

Visceral leishmaniasis (VL), also known as kala-azar, is second only to malaria in terms of potentially fatal parasitic diseases. The leishmania parasite is transmitted through the bites of female infected sandflies and attacks the internal organs of carriers - hence visceral. It is almost always fatal if left untreated. For too long, VL was one of the world’s most neglected tropical diseases (NTDs).

Along with other NTDs like guinea worm, sleeping sickness and river blindness, VL has risen up the agenda in recent years. Mott MacDonald managed the first major donor-sponsored initiative to tackle the disease. With support from UK aid, KalaCORE aimed to reduce the economic and health impact of VL in three countries in South Asia (India, Bangladesh, Nepal) and three countries in East Africa (Ethiopia, Sudan, South Sudan), by providing technical and financial assistance to their national VL programmes. In Africa, KalaCORE worked closely with local partners to improve access to prompt diagnosis and effective treatment. In South Asia, the goal was to help the region to eliminate VL as a public health problem.

Fast facts

  • VL is fatal if left untreated in over 95% of cases.
  • An estimated 50,000 to 90,000 new cases of VL occur worldwide each year.
  • In South-East Asia, VL is most common in agricultural villages with mud-walled houses and earthen floors.
  • In East Africa, VL is most common in Acacia–Balanites woodlands and black cotton soil, and where herdsmen sleep outdoors with their livestock.

Challenge

In both South Asia and East Africa, sandflies are endemic to rural areas that are commonly populated by the poorest of the poor in society. These communities lack access to diagnosis and treatment, as well as the means to cover the associated costs of healthcare. The disease’s non-specific symptoms and lack of awareness around VL can cause misdiagnosis with fatal consequences. The economic burden of the VL illness on households has proved catastrophic. Whole families have lost their limited funds paying for ineffective treatments. In over 12% of affected households in the six countries, the costs of seeking treatment accounted for over 40% of total annual household expenditure. The majority were forced to use their savings to borrow money to pay for care.

Approach

The programme “Tackling Visceral Leishmaniasis in South Asia and East Africa” – known as KalaCORE - helped in the fight against VL by improving access to prompt diagnosis and effective treatment, training health workers, equipping health centres, raising community awareness, and bolstering national surveillance systems and vector control methods for protection against sandflies. As management agent, we worked in partnership with the WHO, the Drugs for Neglected Diseases Initiative, London School of Hygiene and Tropical Medicine, and Médecins Sans Frontières, provided assistance for active organisations on the ground.

VL can be eliminated from the Indian sub-continent as a public health problem due to its unique epidemiology, in that humans are the sole reservoir for the disease. Health workers can now accurately diagnose patients with a rapid test and then administer an effective single-dose injectable drug for treatment (AmBisome), which results in a clinical and parasitological cure in the majority of cases, in just a matter of days. The programme also helped to broadcast the availability of free, effective treatment in the public sector, which is even incentivised in some Indian states.

East Africa faces different challenges, including the fact that the disease here is caused by a different strain of the parasite that is less responsive to AmBisome. Moreover, there are also animal reservoirs for VL, which means that elimination is all but impossible with the current tools. All the same, better access to diagnosis and a new combination treatment (SSG and Paromomycin) is reducing the financial burden and discomfort of sufferers. KalaCORE also provided online resources to help practitioners in the fight against VL, while the London School of Hygiene and Tropical Medicine launched a MOOC (massive open online course) with the aim of helping physicians and health workers to better understand the spread of VL, and gain practical tools to control and combat it in different settings.

Progress

Within just a few years, breakthrough advances in diagnosis and treatment have helped Nepal reduce the incidence of VL to the point where (subject to verification from the World Health Organisation) it will no longer be considered a public health problem. Bangladesh is approaching a similar stage. The WHO is optimistic that India, VL’s traditional stronghold in South Asia, could reach this classification by 2020.

Through the work of KalaCORE, 4.5 million people in South Asia and East Africa have gained awareness, prevention or treatment for VL. Over 80,000 health workers were trained in recognising and treating the disease. Advocacy is another big part of the KalaCORE story, with members in regular policy dialogue with health departments on strategies to reduce the economic burden for patients. For example, in Ethiopia, the Oromia region committed to free hospital services for all VL patients. By improving the cold chain for storage in India – in a climate that regularly exceeds 40 degrees – India’s health system is now better equipped to bring AmBisome to the poorer, remote communities where it’s needed the most. Meanwhile in East Africa, despite civil war and mass people displacement, IMA World Health mobile teams, supported by KalaCORE, demonstrated admirable commitment in reaching, responding to and containing disease outbreaks in remote communities, often covering huge distances in difficult circumstances.

Good news stories

Community mobilisation and equitable access to healthcare were at the heart of the KalaCORE mission. For example, in Bangladesh, health workers adapted the popular folk song Gazi Gaan, using storytelling and pictures to reach and educate marginalised women about VL in indigenous communities.

Adapting to conflict

Following unrest and fighting in an area of South Sudan in April 2017, the local health activities were badly affected, including ongoing treatment for VL patients. When the IMA, a partner of KalaCORE, established emergency health services in an IDP camp, its outreach team included a tent to act as a makeshift VL treatment centre. The IMA provided drugs and rapid diagnosis tests, as well as experienced staff. In total, 11 primary VL cases were diagnosed and treated that would have otherwise gone untreated.

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