Expert Consultation on Kala-azar Vector Control

Expert Consultation on Kala-azar Vector Control

CHENNAI, INDIA, 19-20 AUGUST 2016

CONSULTATION

REPORT

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Acronyms Page

1. Background 5............................................................................................................................................................................ 2. Objectives 5 ............................................................................................................................................................................ 3. Opening session 5 ............................................................................................................................................................................ 4. Proceedings of the meeting 6 ............................................................................................................................................................................ 4.1. Kala-azar vector control in General 6 4.2. Kala-azar vector control in Bangladesh 7 4.3. Kala-azar vector control in India 9 4.4. Kala-azar vector control in Nepal 11 4.5. Recommendations of the Vector Control Advisory Group 12 4.6. IRS for sandfly control: number of rounds, frequency, type of insecticide, spray pumps, geographic coverage etc 13 4.7. Rotation policy of insecticides: frequency, insecticide groups 14 4.8. When to stop IRS 15 4.9. Use of insecticide treated materials including bed nets and other materials 16 4.10. Other innovative vector control tools and / or approaches including IVM and / or environmental management 16 4.11. Other innovative vector control tools and / or approaches including IVM and / or environmental management Part II (Dr Pradeep Das) 19 4.12. Monitoring & evaluation of IRS quality and operations including insecticide resistance monitoring 19

............................................................................................................................................................................ 5. Recommendations 20

Annexure 1. Agenda 232. List of participants 243. In the Press 28 5. MoU Signed 306. Mission & Vision 31

CONTENTS

ACRONYMSATSBs Attractive Sugar Baits

CUTN Central University of Tamil Nadu

EVM Environmental Vector Management

DDT Dichlorodiphenyltrichloroethane

DWL Durable Wall Lining

IQK Insecticide Quantification Kits

IRS Insecticidal Residual Spray

IVM Integrated Vector Management

KA Kala –azar

LLIN Long Lasting Insecticidal Nets

NVBDCP National Vector Borne Disease Control Programme

RO Regional Office

RTAG Regional Technical Advisory Group

SEA South East Asia

SEARO South East Asia Regional Office

SP Synthetic Pyrethroids

VCAG Vector Control Advisory Group

VL Visceral Leishmaniasis

WHA World Health Assembly

051. Background

Kala-azar (KA) or visceral leishmaniasis (VL) is caused by Leishmania donovani parasite and is transmitted by sandfly Phlebotomus argentipes.

Worldwide, roughly 0.3 million VL cases occur each year in India, Bangladesh, Sudan, South Sudan, Brazil and Ethiopia. Since 2005, Bangladesh, India and Nepal embarked on elimination of the disease as a public health problem, and their Ministers of Health signed a memorandum of understanding (MoU) to collaborate towards elimination of VL from the region. The MoU was renewed, with the inclusion of Bhutan and Thailand, during the WHO’s South-East Asia Region (SEARO) meeting held in Dhaka, Bangladesh on 9–11 September 2014. Vector control helps to interrupt transmission of disease by controlling sand-flies, and methods include in-door residual spraying (IRS), environmental man-agement and personal protection.

Realising the importance of vector control in the VL elimination programme, the Regional Technical Advisory Group (RTAG) of SEARO recommended an expert consultation on KA vector control during its last meeting held in September 2015. WHO-SEARO assigned CUTN to organise this expert consultation.

2. Objectives

Dr Jayalakshmi Krishnan (Central University of Tamil Nadu) presented the main objectives/points for discussion as follows.

l Indoor residual spraying (IRS) for sand-fly control: number of rounds, frequency, type of in-secticide, spray pumps, geographic coverage, etc.l Rotation policy for insecticide: frequency, insec-ticide group, etc.l When to stop IRSl Use of insecticide treated materials including bed netsl Other innovative vector control tools and/or ap-proaches including IVM or other environmental management approachesl Recommendations on monitoring and evaluation (M&E) of IRS quality and operations including in-secticide resistance monitoring.

3. Opening session

The opening session was moderated by Prof A.P. Dash, Vice-Chancellor, Central University of Tamil Nadu, Thiruvarur, Tamil Nadu, India.

Dr Ahmed Jamsheed Mohamed (WHO-SEA-RO) delivered the opening remarks and stressed the following points:l Progress has been made across the region to bring down the number of VL cases in endemic areas.l The Regional Director of SEARO has placed elimi-nation of VL as a top item on SEARO’s agenda.l Since the renewed MoU in 2014, to reach elimina-tion targets by the end of 2017, rapid progress has been made to reduce the number of new cases to 8,000 (the lowest recorded in the region) in 2015.l Despite the strong political commitment and advances made, challenges remain relating to vector control.l Therefore, RTAG recommended to convene the expert meeting on vec tor control with the aim to harmonise and streamline practices and to make recommendations to address the specific objectives outlined above.

He concluded his address by thanking Prof A.P. Dash and the Central University of Tamil Nadu for hosting the meeting and also thanked Prof A.P. Dash for his past and continued support to WHO.

Dr Daniel Argaw Dagne (WHO) made the follow-ing remarks:l The region has made great progress in reaching targets in 80% of blocks but issues remain.l For example, new cases are being reported in mountainous regions of Nepal and in new areas of India and Bangladesh.l There remains a need for sustainable vector con-trol measures to prevent VL resurgence.l How long to continue IRS is the most important question to answer during the present consulta-tion and is the main purpose of this meeting.l Exploring the use of Long Lasting Insecti-cide-treated Nets (LLINs) is of secondary impor-tance.Dr Dagne also concluded his address by thanking Prof A.P. Dash for his support to WHO and for his commitment to VL elimination.

EXPERT CONSULTATION ON KALA-AZAR VECTOR CONTROL

3.1. Introduction of participants

All participants briefly introduced themselves – a full list of those attending is included at Annexure 2.

3.2. Nomination of the Chairperson and RapporteurDr Pradeep Das and Prof Mary Cameron were unanimously nominated as chairperson and rap-porteur, respectively.

4. Proceedings of the meeting

4.1. Kala-azar vector control in General (Prof A.P. Dash)

The number of VL cases, and the number of deaths from VL, in the Indian Subcontinent (ISC) has steadily declined in recent years

from around 37,000 cases and 94 deaths, in 2011, to 9,000 cases and 9 deaths in 2014.

Vector populations are influenced by their envi-ronment and host availability. The larvae of sand-flies, family Psychodidae, are adapted to live in moist soil. In this regard, they can be classed as a hydrophilic, and their dependency on moisture leads to their clustered distribution.

Although little is known about their breeding sites, they are found close to hosts (e.g. houses and animal shelters), but this distribution is uneven. Their development period is related to ambient conditions such as temperature.

One key element of the elimination strategy is integrated vector management (IVM), and good sur-veillance is crucial. The current mainstay for vector control across the region is IRS, although environ-mental vector management (EVM) and LLINS play a supplementary role to a greater or lesser extent in different countries.

The goal for IRS is to achieve >80% coverage, and spray indoors up to a height of 6 feet from the ground. Spray teams need to be well-supervised to ensure spraying protocols are correctly followed so that the correct dose is applied evenly.

Some insecticides may elicit an excito-repellency effect in sandflies which may push populations from their indoor resting sites to rest outdoors. If alterna-tive outdoor resting sites are hospitable, then sandfly populations will survive, and it is possible that this

06

effect has led to the selection of exophily and exoph-agy in P. argentipes.

Supplementary tools are available. For example, EVM (e.g. plastering walls) can reduce sandfly popu-lations by 30% and LLINs may be used indoors if the sandflies bite indoors and when people are sleeping under a net. However, the cost of EVM is prohibitive compared with LLINs or IRS.

VL is impacted by the climate so there is season-ality in transmission. Historically, Bihar and Assam were endemic foci for VL. More recently, there was a resurgence of VL in Bihar but not Assam. It is possible that Bihar remains the major focus of VL due to its ecological stability.

IVM involves the community and is an evi-dence-based approach to vector control. It aims to reduce: adult longevity, breeding, contact of sand-flies with humans and vector density. Therefore, be-havioural aspects of the sandfly, breeding sites and transmission ecology need to be considered.

Recent findings suggest that P. argentipes are re-sistant to DDT, indoor resting of sandflies has signifi-cantly decreased and only Bangladesh has demon-strated a clinical impact on VL as a result of using LLINs. Therefore, in order to maintain elimination, we need to monitor insecticide susceptibility of sandflies, determine the sites and time of transmis-sion, understand risk factors, map breeding sites and study the excito-repellency effect of insecticides on sandflies. In conclusion, IRS is effective at reducing sandfly densities providing it is implemented in ac-cordance to the toolkit.

However, IRS was suboptimal in 2005-2015, and it is important to demonstrate whether IRS results in a clinical impact. An IVM approach is recommended but LLINs are not evidence-based and EVM can only be used at a micro-level.

Discussion and comments

l Question: Why recommending IVM when EVM is difficult to implement, is expensive and requires a huge effort? Answer: EVM may be used in specific environments. Once more is known regarding the bionomics of P. argentipes, the approach may be more clearly di-rected thus reducing effort and cost.l Question: Why do you not consider IRS as evi-dence-based when the vector is indoor resting and indoor biting and there is evidence of reduced vec-tor densities following spraying?Answer: It is possible that there are subpopulations

of P. argentipes that are outdoor biters and these are not affected by IRS.l Question: Why is there resurgence of cases and PKDL patients arising in the same previous endemic villages? Answer: Unknown – further research is required.l Comment: Lack of impact of LLINs on VL in the Kalanet project may be due low coverage.l Comment: Funders do not invest sufficient fund-ing for studies on vector bionomics.l Comment: Active involvement of the community in the VL elimination project needs to be strength-ened (as in Dengue control projects) by involving social scientists in the National Programme.l Comment: Combining IRS with LLINs results in better control than using either single measure alone.l Comment: Need to estimate the human exposure to sandflies that results in transmission of VL (sug-gestion that there is no disease transmission when P. argentipes density is <8 sandflies/man-hour).

4.2. Kala-azar vector control in Bangladesh (Dr Rajaul Karim)

Between 1981 to 2004, the number of endemic areas in Bangladesh increased from 8 to 105. As a result of the National Programme to con-

trol VL, the number of cases of VL decreased mark-edly from 12-14,000 in 2012 to 862 in 2015. In 2010, 8 areas were considered to be hyper-endemic and 16 meso-endemic (moderate endemicity).

In 2015, no areas were classed as hyper-endemic and only 5 areas were considered meso-endemic.

07EXPERT CONSULTATION ON KALA-AZAR VECTOR CONTROL

The reduction in cases was paralleled by a reduc-tion in PKDL patients.

The National Programme uses an IVM approach involving deltamethrin-IRS implemented as blan-ket or focal spraying according to the situation. Spray teams are given training on spraying and sandfly sampling and are told to spray households (HH), cowsheds (CS), chicken coops. After spraying, chalk is used to mark the house and notify that the house has been sprayed.

Sandflies are highly susceptible to synthetic py-rethroids (SPs). As a consequence of IRS, the num-ber of VL cases was reduced by 64% in 2013. Some areas have now received 6 or 7 rounds of IRS.

Bioassays have been conducted to determine whether efficacy of IRS is affected by the type of wall materials being sprayed (e.g. mud, tin, wood or brick). The effect of IRS has been determined by comparing the numbers of female sandflies (unfed, blood-fed, and gravid) collected in HH and CS in sprayed and unsprayed villages. In two areas (Dau-latpur and Panchbibi) sandfly densities were higher in sprayed villages than unsprayed villages).

In 2012-13, 19,550 LLINs were distributed in 8 hyper-endemic areas and, between 2013-14, 30,450 LLINs were distributed in meso-endemic area ar-eas. The government policy is to provide two LLINs to each patient treated for VL (and not to provide LLINs for the whole family or whole village). Ac-ceptance of the intervention is facilitated by social

mobilization.An innovative study used temephos to spray the

floors of CSs with the aim to reduce breeding sites. An area of 16,244 square metres (4,207 HH) was treated in two districts and the reported number of cases was 70.


l Question: You mention 6 rounds of spraying, is this per year? Answer: No, this is over a period of 3 years (2 rounds per year), and some areas have now received 7 rounds of IRS.l Comment: It is not good practice to mark houses with chalk, because this is not sufficiently durable?l Comment: What is the rationale for targeting breeding sites and why did you use temephos, which has side-effects, where is temephos being sprayed? l Comment: A challenge is monitoring the suscep-tibility of sandflies to insecticides.l Comment: Another challenge is underreporting of VL cases (although significant progress in active case search has been made across the ISC and cur-rent estimates of underreporting are as low as <10% in Bangladesh and <5% in India). One reason for the reduction in underreporting is the recent incentive scheme introduced in India (the incentive approach

08 CONSULTATION REPORT

was introduced in Feb 2016: the chief minister’s relief fund and the government of India give 6,600 and 500 rupees, respectively, to each case following treatment - a cheaper approach than door-to-door or camp surveillance).

4.3. Kala-azar vector control in India (Dr R.K. DasGupta)

Kala azar is endemic in 6 districts of Uttar Pradesh, 34 districts of Bihar, 4 in Jharkhand and 11 in West Bengal. However, the number

of KA cases and deaths has decreased since 2007

from 44,533 and 203, respectively, to 3,603 cases and zero deaths in 2016.

This success can be attributed to the national programmes implementation of the VL elimination road map that has clearly defined roles for the task forces at state, district and block level. It is expected that the programme will come close to elimination targets by the end of 2016.

The number of blocks with >1 case/10,000 peo-ple was 149 during July 2014- June 2015, but this has been reduced to 111 blocks, mostly in Bihar, between July 2015-June 2016. However, there has been an increase in the number of patients with PKDL, particularly in Bihar, to 850 in 2016. HIV/VL coinfections are also more common in Bihar.

The IVM strategy consists of two rounds of IRS per year and construction of Pucca (concrete hous-es) in certain areas. The switch from DDT-IRS to SP-IRS has increased acceptance rates by villagers. Villagers also get a subsidy if they construct Pucca houses, cement floors and plaster walls.

Historically, a decline in KA was observed that coincided with the use of DDT-IRS in the 1950-60s. So much so, that drug manufacturers reduced pro-duction of VL drugs. However, withdrawal of DDT-IRS in 1962 allowed sand fly populations to increase and a resurgence of VL soon followed leading to 4,500 deaths due to VL in 1977.

In 2017, all districts will use SP-IRS delivered using hand compression pumps and independent


monitoring will be carried out in parallel by part-ners such as the WHO, RMRI, and CARE in addition to NVBDCP. Bi-annual spraying is conducted in any village where a new case has been reported and fo-cal spraying is conducted off-season.

However, between 1991-2010, irregular spraying, due to a lack of supervision, led to an increase in the number of VL cases. This problem was resolved by the national programme with its partners delivering two complete and supervised rounds of IRS. Thus, il-lustrating the need to ensure that spraying is of good quality and is well-supervised. The inclusion of good partners provided the necessary extra man power to enhance supervision and monitoring leading to >90% coverage. In addition, the prime minister re-views the KA elimination programme every month to ensure that the programme is on track.

Of course, resistance monitoring of P. argentipes is also very important. DDT resistance is now wide-spread. In 2016, 18 districts in Bihar still use DDT-IRS but 15 districts use SP-IRS. In 2017, all districts

will use SP-IRS. Replacing stirrup pumps with hand compression pumps has also helped to improve ap-plication and reduce the time required for a team to spray each house. Compliance has been improved by using ashas to prepare households prior to spraying, and by providing stickers to those house-holders who have allowed spray teams to spray.


l Question: Were biannual rounds of blanket IRS conducted in all endemic districts? Answer: Yes, in India districts are considered soley as endemic and are not differentiated in to “hy-per-endemic”or meso-endemic” as in Bangladesh (where 1-10 cases per 10,000 people = hypo-en-demic, 5-500 cases = meso-endemic and >500 cas-es = hyper-endemic).l Comment: Suggest RTAG discusses the usefulness of standardising endemicity levels across ISC.


l Question: Are any specific strategies aimed to control PKDL? Answer: The programme does active search for PKDL patients four times per year but it is difficult to focus on PKDL patients due to the time con-straints of rolling out two rounds of IRS each year.l Question: What is the focal spraying strategy?

Answer: Even if elimination thresholds are achieved in 2017, focal spraying will be conducted for at least 3 years to sustain elimination. Activities are required to address residual transmission after blanket spraying is stopped. The states need to take ownership of this. The national programme has sufficient funding to continue the programme but partners are required for extra manpower. Social mobilization is needed to manage expectations of communities post blanket spraying. It was suggest-ed that the area of focal spraying around houses of confirmed VL cases needs to be increased to 1 Km to take in to account the flight distance of P. argen-tipes and observations that clustering of cases can be 500m in diameter in Vaishali.l Comment: Role of PKDL? In India, PKDL devel-ops after either AmBisome or mitefosine treatment. Whether PKDL patients serve as reservoirs of VL is debatable. A study in India (soon to be published) suggests that macular PKDL patients are not in-volved in VL transmission. However, the experience is different in Bangladesh. In India, PKDL is evident 10 years after VL, but appears 6 months after VL in Bangladesh. Perhaps the genomics of different Leishmania donovani strains plays a role?

4.4. Kala-azar vector control in Nepal (Mr Shishir Pant)

In the 2011 census, the total population of Ne-pal was 28 million. Malaria control efforts, per-formed in the 1960s, reduced the number of VL

cases in the country but a resurgence was observed in the 1980s are as result of their cessation. The elimination programme established in 2005 includ-ed treatment of cases, treatment of PKDL and IVM. As a result, the number of cases and deaths was re-duced from 2090 and 50, respectively, in 2000, to 207 cases and zero deaths in 2015.

Diagnosis of cases is performed by Public Health Centres (PHCs) as well as tertiary facilities. Vector control consists of SP-IRS and EVM. IRS is conducted twice a year (May to June and September-October) for 3 years follow-ing case detection.

Despite progress, there are challenges. For example, new VL cases have been observed in mountainous areas of Nepal, there are new cases of PKDL, monitoring of in-secticide resistance is not always conducted and drug resistance may be developing.


l Q: Are three different SPs used for IRS? Answer: Yes, Lambda-cyhalothrin, alpha-cyperme-thrin and deltamethrin are used but are rotated ev-ery three years.l Comment: Your slide suggests that the appli-cation of insecticides that you are using does not comply with WHO guidelines and, if you are not monitoring for insecticide resistance, there is po-tential for resistance to develop.l Comment: You mention that you are switching from using alpha-cypermethrin to deltamethrin for SP-IRS but this may also lead to insecticide resis-tance if LLINs for malaria control are being used in the same areas as SP-IRS.l Question: Please can you give more information on the number cases observed in hill regions? Yes, these regions are routes for transport via donkeys and are difficult areas to access for vector control activities. No largescale vector control activities are being conducted at present.l Comment: These areas border other countries and cross-border agreements may be necessary to pre-vent apportioning blame for potential immigration of cases to any one country. Cross-border agree-ments present complex issues requiring governmen-tal agreements and are outside the scope of WHO. Nevertheless, WHO may play a role in facilitating regular dialogue between different members and integrate malaria as well as VL control programmes.


4.5. Recommendations of the Vector Control Advisory Group (Dr Raman Velayudhan)

The Vector Control Advisory Group (VCAG) was established in 2013. Any institute or organization that wishes to register a new vector control tool needs to submit a letter of intent. VCAG provides guidance on the type of data that need to be col-lected to firstly demonstrate an impact on vector populations, and then later advice on operational requirements for deployment.

So far, VCAG have received 20 submissions. Ap-proval is beneficial to applicants because it helps to attract funding from funding agencies for further development. The types of tools that have received approval include: LLINs with added synergists, microbial control (Wolbachia), spatial repellents, traps, systemic insecticides, genetic manipulation, lethal lures/attractive toxic sugar baits (ATSBs) and

insecticide-treated clothing.VCAG generally meet twice a year, but an emergen-

cy VGAG meeting was held in March 2016 in response to the Zika outbreak. For Zika, in addition to IRS, space spraying and larval control for Aedes, Wolbachia and sterile insect techniques were recommended.

Discussion and commentsl Comment: The NVBDCP were pleased to hear that Dr Jambulingam (Director of VCRC, Pondicherry) has VCAG approval for testing new tools.l Comment: A proposal to treat cattle with fipronil (a systemic insecticide) in India has not yet been conducted because it has been difficult to obtain the necessary approvals from either the Central Animal Health Organization Scientific Advisory Committee or the Bihar Veterinary Association. The ethical committee are concerned that fipronil may be present in milk and cause harmful effects in hu-mans, particularly in infants.l Comment: What is the difference between VCAG and


WHOPES? A: WHOPES deals with established products and does not look at epidemiological impacts.

4.6. IRS for sand fly control: number of rounds, frequen-cy, type of insecticide, spray pumps, geographic coverage (Dr Pradeep Das)

In 1933-37, North Bihar was highly endemic for VL. Following the cessation of IRS in 1966, an ep-idemic of more than 100,000 cases was observed

in 1971. In contrast, Madras stopped spraying in 1954 and no resurgence was observed and Assam never stopped spraying, there was no resurgence Assam either. So why is resurgence found in some areas but not in others?

The RMRI have conducted several trials to examine different interventions against P. argentipes. For exam-ple, in 2006 a phase 1 trial was performed to compare DDT-IRS with EVM and EVM was shown to be less cost-ef-fective.

Currently, a study comparing DDT-IRS with SP-IRS, in collaboration with the Liverpool School of Tropical Medicine, suggests that there may be 3, rather than 2 seasonal peaks of P. argentipes abun-dance, and, as DDT was active for more than 6 months but alpha-cypermethrin may only be active for 4 months, 3 rather than 2 rounds of IRS may be necessary for SP-IRS.

A “good” insecticide needs to be: highly toxic to the target organism, long-lasting on a given surface, not repellent, stable (during storage and transport), safe to humans, acceptable to house owners and cost-effective.

Factors affecting whether spraying is effective include: insect resting behaviour, susceptibility, suitability of the wall or roof-surface and co-opera-tion of house owners.

Although the national programme has switched to using alpha-cypermethrin-IRS, malathion is pro-viding good results in laboratory studies (but note that India does not produce IRS).

Resistance levels of field populations of P. argen-tipes to DDT are around 55%, but there is 100% sus-ceptibility to deltamethrin. Resistance is likely to occur if there is poor quality assurance.

Currently, alpha-cypermethrin-IRS is applied using 25mg of active ingredient (0.025 g) per metre squared of surface and compression pumps increase coverage by 30%, compared to stirrup pumps, and produce less wastage. This means that one squad can treat more houses each day using compression pumps compared with stirrup pumps. Compression pumps maintain pressure, coverage and quality and squads find them easier to operate.

The quality of spraying needs to be checked us-ing insecticide quantification kits (IQKs). These co-lourmetric tests provide results on the quality of spraying in as little as 30 mins and the results are comparable with HPLC.

Although improvements have been made, gaps remain concerning the following: effective moni-toring and supervision, effective tools for IRS qual-ity, identification of hot spots for transmission, year-round monitoring of P. argentipes densities, monitoring of insecticide resistance, intersectorial co-ordination, public awareness of VL, bioassays to be conducted at regular intervals post-IRS, check for changing behaviour of sandflies and developing a strategy to target breeding sites.

Recommendations are required to avoid develop-ment of insecticide resistance. For example, different classes of insecticides should be used when target-ing adults and larvae, and a rotational policy of in-secticides should be developed. The use of integrat-ing non-chemical tools should also be considered.


l Question: Do PHCs monitor cases? Answer: PHCs are the starting point for IRS activi-ties. Once cases have been confirmed, spraying con-tinues for 3 years.l Question: Why is there resurgence is some areas but not in others? Answer: It could be linked to the stability of the en-


vironment and availability of sugar meals. For ex-ample, sand flies have been found in the roots of banana trees.l Question: If it is possible to map the distribution of sand flies in relation to environmental condi-tions, it should be possible to predict disease out-breaks. Answer: Perhaps.l Question: Although compressor pumps can help with coverage, how can monitoring be improved? Answer: Compression pumps help with coverage, but coverage depends on state involvement and can never be 100%. This is because partial coverage is only possible for a variety of reasons. For exam-ple, although house owners prefer SP-IRS some are still reluctant to allow spray teams to treat kitch-en areas and worship rooms. For monitoring, the programme needs to stick to the WHO toolkit. IQKs are being developed for SPs, so quality control can be assessed. In some areas, e.g. West Bengal, spray teams will not spray until the asha is present. For sustainability, IRS needs to be performed through the public system rather than providing incentives to ashas.l Question: Is your recommendation 2 or 3 rounds of IRS per years? Answer: Practically, only 2 rounds can be imple-mented.

4.7. Rotation policy of insecticides: frequency, insecticide groups (Dr Murari Lal Das)

Currently, countries in the ISC are performing 2 rounds of IRS with or without supplementary control measures. Nepal is using alpha-cyper-

methrin for IRS but switches the active ingredient every 3-5 years and will next use deltamethrin. Nepal, India and Bangladesh are also testing dura-ble wall lining in field trails. Insecticide resistance occurs when an insect survives exposure to an in-secticide at a dose that would normally prove le-thal. Insecticide resistance to SPs is widespread in Anopheles mosquitoes and is compromising malar-ia control programmes. DDT resistance in P. argen-tipes is widespread in Indian and to some extent in Nepal. Resistance rates tend to double every 6 years. In addition to public health programmes, resistance can develop in human vectors as a result of their use in agriculture and urban pest control. There are

different types of resistance: metabolic resistance, behavioural resistance and penetration resistance.

Although there are several classes of insecticide only four of them are used for vector control. Only SPs can be used for LLINs. Resistance tends to de-velop within 4-20 years of introduction of a new insecticide. Multiple- resistance can be detected using genetic studies and one paper examining bio-chemical markers of resistance in P. argentipes has been published.

New insect control strategies aim to break the life-cycle of the insect, by using season-long control methods, and to tackle the most vulnerable stage. An insecticide rotation policy should also be devel-oped as part of an IVM strategy. Pesticides should be used strategically to reduce the likelihood of re-sistance development. The IVCC recommends the use of mixtures of SPs with synergists (such as in-sect growth regulators, IGRs) for improving LLINs. Third generation of LLINs have been developed hav-ing one insecticide on the four sides but synergist on the roof.

Such policies need to be introduced pre-emp-tively, rather as a response reaction, because they will be less effective once resistance has reached a tipping point. Recommendations include: judicious use of insecticides, improving operational quali-ty, using a combination of interventions, mosaic spraying, using mixtures (two or more insecticide classes – one formulation is currently under trial for KA control) and insecticide rotation. The latter should be the primary strategy. Rotation assumes that multiple- resistance will be extremely rare. The timeframe for rotation needs to be short to prevent resistance to one class being too widespread (to re-duce any selection pressure). Note that it is not suf-ficient to switch from one SP to another. Different


classes of insecticide must be used for rotation. As borders of India, Bangladesh and Nepal are open it is important to rotate same insecticide class in the three countries simultaneously.

Other studies suggest that resistance develops in insects within 14 years for organophosphates, 7 years for DDT, 5 years for carbamates and 4 years for SPs. Problems between national programmes in the ISC include inconsistent resistance monitoring and a reluctance to share resistance data. Indicators are required to measure the effectiveness of IVM.

In conclusion, it would be good to establish a central data repository for countries to share their experiences and agree a fixed period for rotation (as adopted by the Insecticide Resistance Management Technical Working Group in Zambia).


l Question: How do we check the quality of insecti-cides developed by different manufacturers? Answer: Such testing is very expensive but the WHO toolkit states that it is each national pro-gramme’s responsibility to check quality prior to procurement. A pre-dispatch quality check needs to be performed followed by a post-quality check.l Question: The NVBDCP suggested switching from SP to DDT every 3 years, but there are few classes of insecticides suitable for IRS available and DDT is no longer an option.

Answer: Any other class of insecticide may be rotated. It is true that all other insecticides are ex-pensive than DDT.

4.8. When to stop IRS? (Dr R.K. DasGupta)

The revised elimination target is to reduce the number of cases to be <1/10,000 people per block by the end of 2017. Once this elimination

target is reached, IRS will be continued for period of 3 years in order to obtain WHO validation.

After validation it will be necessary to have a strategy to prevent resurgence such as reactive focal spraying in combination with improved sur-veillance and diagnosis for case detection. Improve-ments have been made to reduce the time between case detection and treatment but further improve-ments are required.

A proposal was put forward to continue with routine, blanket spraying until 2017 but to stop

blanket spraying once VL was no longer considered to be a public health problem. At this point, the pro-gramme will switch to reactive focal spraying (opti-mised for effectiveness and efficiency) and improve case detection and reporting.

In the long-term, sentinel VL case detection can be used to target reactive focal spraying and pre-vent re-emergence. Therefore, an improved case re-porting system needs to be developed. Challenges remain such as a vaccine not being available, diag-nostic tests need to be improved, new vector tools need to be developed and we need to have a better understanding of VL transmission.


l Comment: It is important to keep in mind that the elimination targets are milestones and not end-points. They provide temporary recognition of suc-cess, but appropriate measures need to be put in place to sustain elimination. Efforts and interven-tions need to be continued even though the mile-stone has been reached. The 3-year sustainability period is required for an application for validation to be made. The leprosy elimination programme had a similar milestone. However, resurgence of lepro-sy developed demonstrating that milestones need to be sustained. A similar situation was also shown in lymphatic filariasis (LF) elimination programmes where the number of cases increased 5 years after mass drug administration was stopped in some ar-eas. RTAG members need to consider appropriate indicators of “zero transmission”. For example, what is the critical density of (infected) sandflies that sug-gests VL is no longer a public health problem?l Comment: Mapping of cases at a village level may


be useful to identify villages most at risk of resur-gence and whether cases are imported. Increased surveillance can be directed at those villages that are most at risk.l Comment: The unit of measurement should be village-based rather than at the block level.l Question: Should national programmes imple-ment reactive IRS for PKDL? C: Reacting to PKDL may be useless. Firstly, there is no relationship be-tween PKDL cases and sand fly densities. Secondly, there is no evidence for xenodiagnostic studies to suggest that macular PKDL patients are a source of transmission.l Comment: Lessons can be learned from the WHO’s malaria policy advisory committee regard-ing scaling back vector control measures.l Comment: Once the elimination milestone is reached, the next target is zero transmission.

4.9. Use of insecticide treat-ed materials including bed nets and other materials (Mr Rajib Choudhury)

IVM relies on IRS and, to a lesser extent, LLINs and EVM. Only SPs can be used for LLINs, but there are improved slow-release formulations that can

last for up to 2 years. Durable wall liners (DWL) are a potential tool to add to IVM.

Although two studies demonstrated a reduc-tion of sandfly densities in Nepal and Bangladesh following LLIN treatment, the Kalanet project, con-ducted in Nepal and Bangladesh, did not detect an impact on VL (as measured by seroconversion) de-

spite lowering the densities of P. argentipes females by 25%. Since then, two papers have demonstrated a significant impact on VL and a reduction in sand-fly densities by 47% was achieved. It was suggested that LLINs could reduce incidence by 66.5% and pro-vide 87% protection.

The study sites in Bangladesh have a history of bednet use and acceptance: control villages had their own bednets, which were not impregnated, whereas the bednets in treated villagers were impregnated. Prior to treatment, villagers were asked to wash their bednets before dipping with KOTAB 123.

DWLs reduced sandfly densities by similar levels to LLINs in Bangladesh but they are not as cost-ef-fective. An advantage that they have over IRS is that supervision during implementation does not have to be so rigorous (the materials are pre-treated so uniformity of application is not a problem).

In conclusion, there is evidence to suggest that LLINs reduce P. argentipes populations more in Bangladesh than in India and Nepal. LLINs may be a suitable supplementary tool in IVM, but IRS should be continued. DWL are expensive, so their cost needs to be reduced before they can be incorporat-ed in national programmes.


l Question: Acceptibility of DWLs is low in Bihar. People complain of developing a rash after touch. Answer: It is important to inform and communi-cate with people when introducing a new interven-tion. DWLs proved very popular in Bangladesh and Nepal. So much so that when people removed the DWLs for re-plastering, they immediately rehung them.l Comment: The cost of DWLs may prove restric-tive for poor communities in Bihar.

4.10. Other innovative vector control tools and / or approaches including IVM and / or environmental man-agement – Part I (Prof Mary Cameron)

In 2004, the WHO set out the Global Strategic Framework for IVM. IVM is a comprehensive strategy that integrates available and effective

resources to reduce or interrupt transmission of


disease. A major challenge concerns the scaling up of vector control interventions.

Two recent systematic reviews, including a Co-chrane review examining studies using measures to prevent Leishmaniases, suggest that scant re-sources might be best directed toward prevention of human infections, rather than vector control, and that studies performed to assess the impact of vector control interventions are generally biased. Nevertheless, in the absence of a VL vaccine, vector control is crucial in the VL elimination programme.

Whether a vector control intervention is effec-tive has different meanings for a researcher or a na-tional programme manager. National programmes need clear evidence that the new intervention will be effective and that it is good value for money com-pared to existing alternatives. Trial data showing an impact on epidemiological outcomes is needed in addition to vector outcomes. It is also important to know where and when it will be effective.

The VCAG, established by the Global Malaria Programme and the Department of Control of Ne-glected Tropical Diseases, provides guidance on the evidence required for public health practitioners to adopt and implement a new intervention in public-ly funded disease control programmes.

When the number of VL cases and residual trans-mission declines, it will become more difficult to conduct field trials with sufficient power to detect significant differences between treatment groups, and refined predictive modelling may prove useful for providing an evidence base. There is a need to collect contemporary human and vector data to re-fine models and to understand transmission further.

Two independent reviews examining how to target P. argentipes, in order to improve the elim-ination programme, were published in 2016 and suggest that more studies are required to under-stand sandfly bionomics, particularly regarding: blood-feeding preferences, and how they vary spa-tially and temporally (diurnally and seasonally), dispersal, the relative importance of indoor and outdoor transmission, breeding sites and rates of emergence of insecticide resistance.

Tools/approaches available for tackling exophilic and exophagic sandflies include:i) Treating other main sources of bloodmeals with systemic insecticides (endectocides), such as fipronil and imidacloprid.

Endectocides kill medically-important insects feeding on the treated animals so, in theory, re-duce human exposure to potential pathogens (also effective against ectoparasites e.g. ticks). Poché et al. demonstrated significant mortality among sand-flies and mosquitoes within days and up to 1 month after feeding on cows orally-treated with 1 mg/Kg fipronil. The main question is when and where will the implementation of endectocides have maximal benefit as part of IVM. An ecological model look-ing at different scenarios of biting behaviours and the effect of combining endectocide-treated cattle and LLINs suggests that fipronil offers a potential-ly excellent complement to existing malaria con-trol programmes centred on LLIN distribution. The same may prove true for fipronil and IRS against P. argentipes in ISC.

i) Exploiting sugar-feeding behaviour of vectors to develop attractive toxic sugar baits (ATSBs)

In addition to blood-feeding, sandflies need sug-ar meals for survival (e.g. plant tissues, floral nectar and honeydew from aphids). Attempts have been made to exploit sugar-feeding behaviour using at-tractive toxic sugar baits (ATSBs). The adoption of ATSBs into vector control programs offers several advantages: they can alleviate insecticidal resis-tance by allowing the use of new classes of insec-ticides, which are not available as insecticides for IRS and LLINs. Also, since toxins are ingested, their concentrations are lower and more environmen-tally friendly. They may provide an additional tool for vector control for IVM. When sprayed on vege-tation or fences, ATSBs have been effective against


sand flies and mosquitoes where alternative natu-ral sugar sources are scarce or absent, although a model predicts that ATSBs can be effective even in resource rich environments.

i) Environmental Control

In Bangladesh, plastering houses with mud did not significantly reduce sandfly density, whereas plastering with a lime/mud mixture in India and Nepal reduced P. argentipes densities. Overall, plas-tering reduced the sand fly density by 42%. EVM is less cost-effective than IRS or LLINs.

i) Developing insecticide-impregnated or repel-lent-impregnated products to be used by specific communities.

Insecticide-impregnated or repellent-impreg-nated products have been developed for outdoor use. One study showed that mosquito mortality from SP-impregnated blankets was comparable to LLIN sand offered significant protection against bit-ing. They have potential use for outdoor sleepers and travelling/transient populations. Another study showed that permethrin-treated clothing could provide protection to individuals from Aedes ae-gypti mosquitoes that show permethrin resistance.

i) PheromonesThe synthesised sex pheromone, (S)-9-ethylger-

macrene-B, released by male Lutzomyia longipalpis sandflies significantly increases captures in CDC light traps in Rio de Janeiro, Brazil. It also increases the effectiveness of LLINs in Minas Gerais, endem-ic for VL, in Brazil. Similar to L. longipalpis, male P. argentipes form lek-like aggregations on hosts and behavioural activity in females is elicited by solvent extracts of males. Further research in this area is re-quired.

i) Biological Control (e.g. Bti: Bacillus thuringiensis var. israelensis; Lsph: Lysinibacillus sphaericus)

This approach is inappropriate until we know more about sandfly breeding sites.

i) Genetic Control (e.g. SIT: sterile insect technique; dsRNA: double-stranded RNA; RIDL: rearing of in-sects carrying a dominant lethal allele; RNAi: RNA interference; HEGs: homing endonuclease genes)

This approach is also inappropriate, at this stage, as only limited work has been performed to exam-ine Wolbachia effects in sandflies.

In conclusion, despite recent progress that has

been made to develop tools and approaches to target outdoor transmission, there remains an ur-gent need to develop tools that have a high impact against disease vectors and that are suitable for up-scaling.

With the complementary tools currently in the pipeline, further research is required: a. to obtain clinical evidence before systemic treatment of hosts with endectocides can be rolled out for use against human diseases (Phase 3), b. to prevent ATSBs killing non target benefi-cial insects, and to increase their reach (Phase 1, 2 and 3),c. to identify whether and how breeding sites can be best targeted (Phase 1, 2 and 3),d. to increase compliance and increased lon-gevity of impregnated products (Phase 1, 2 and 3),e. to identify and synthesise a P. argentipes sex pheromone (Phase 1, 2 and 3)


• Question: You mention that the Co-chrane review highlighted the Kalanet ITN trial as one of the best designed vector control studies to prevent leishmaniasis, in that it was considered as moderately biased, but it did not detect a clinical impact. Is this because coverage was insufficient?

Answer: Given that most people in India sleep outdoors during the warm months when sandflies are at their peak, and the low acceptability of bed-net use in India compared with Bangladesh, usage was more likely an issue rather than coverage.

• Comment: The lack of demonstrat-ing a clinical impact with LLINs in the Kalanet trial has severely affected the uptake of this intervention in the programme, so it is very important to consid-er in more depth why this result was obtained and learn for this experience. It could be the case that LLINs could contribute to IVM in certain settings in India as well as Bangladesh.

• Comment: I agree that it is im-portant to collect contemporary human and vector data at the village level over time to gain important information concerning transmission and for VL modelling.

• Comment: If suitable ATSB proto-types are developed, they could play a useful role in the programme because they would not require regular maintenance.


4.11. Other innovative vector control tools and / or approaches including IVM and / or environmental manage-ment Part II (Dr Pradeep Das)

A recent field study suggests that combining LLINs with SP-IRS is the optimal strategy for IVM. The Permanet LLIN is more acceptable

than KOTAB 123.New tools that can help the programme include

the use of optimised SP-IRS: compression pumps, IQKs and the introduction of a disease data man-agement system (DDMS) for monitoring all vec-tor-borne diseases (such as malaria and dengue) in addition to VL. Rajender Memorial ResearchInsti-tute for Medical Sciences (RMRI) has recently con-ducted a field trial to compare DDT-IRS with SP-IRS. Spraying of DDT onto different substrates was com-pared (brick, plaster and mud walls) and bioassays were performed to examine alpha-cypermethrin degradation and efficiency. An IQK specifically for SPs was developed and cone tests and bottle assays were performed.

The susceptibilities of wild populations of P. ar-gentipes to deltamethrin and alpha-cypermethrin were examined and they were shown to be highly susceptible to both SPs in 6 districts.

GIS software and a remote sensing system was develop to predict sandfly densities in relation to different environmental parameters. The vector control strategy developed by RMRI and imple-mented in Vaishali district consists of the following: the whole district was mapped at the village level and a village undergoing SP-IRS was monitored for

the quality of IRS using the developed IQK. Clinical diagnoses were made using Rk39 tests. Ashas and spray squads were trained for SP-spraying with new compression pumps. Information, education and communication (IEC) and behaviour change com-munication (BCC) strategies were performed two days prior to spraying. Households were mapped using GIS.

Following examinations of the number of cases in villages over time, it was proposed that there is a need to spray peripheral villages within 500 me-tres of the house belonging to a case (diagnosed the previous year).

Note that case reduction figures provided by PHCs need to be viewed with caution because they may not have necessarily been given the correct addresses of patients. Verified case reduction was 53% in 2015, and between Jan-July 2016 this was increased to 62% (according to state government records). Currently, only three PHCs in Vaishali ex-ceed the elimination target.


l Question: Is there a need to increase capacity building for training in medical entomology?

Answer: RNRI provides training for Kala-azar technical supervisors in Vaishali, and NVBDCP pro-vides 3-months training for vector-borne disease consultants.

4.12. Monitoring and Evaluation of IRS quality and operations including insecticide resistance monitoring (Dr Raman Velayudhan)

There are broad issues regarding the quality of operation of IRS:l In order to maintain quality, there is a need

for certification of operators within the programme and the provision of refresher courses for spray personnel (e.g. provide badges or certificates with 2-year expiry dates). l Accuracy of spraying should be regularly mon-

itored using the filter paper technique for IRS (in ac-cordance with the toolkit).l Procurement sources of insecticides and

sprayers should be WHOPES approved.


l Squad leaders need appropriate training, and gender issues should be considered (some house-holders would be more compliant, and allow entry to their homes, if women personnel are used).l Feedback can be improved by using SMS mes-

saging, tablets and mobiles in addition to paper forms.l Personal protective equipment (PPE) of per-

sonnel should be improved (WHO website provides more guidance on PPE, which has been improved following the Zika outbreaks in Brazil).l Consumption of insecticides should be record-

ed rigorously (to prevent misuse). For example, the number of sachets allocated should be recorded, and personnel should return the outer envelopes of each sachet for monitoring.l Spray equipment should be examined fre-

quently, and dedicated staff for inspecting and re-pairing equipment, e.g. control flow valves, should be recruited.l Timing of IRS is very important and should re-

flect disease epidemiology, although some flexibili-ty may be necessary according to the environment.

It may be possible to share resources (staff, equipment etc) between malaria and VL pro-grammes. Note that coverage needs to be at least 70-80%. Operation issues include: community feed-back, disposal of leftover insecticides and coverage of cowsheds.

Challenges of the programme remain: capacity building, surveillance of IRS and vector, establishing sentinel sites, a plan for resistance monitoring and management and local decisions being made base on the evidence available.

Lessons can be learned from the insecticide re-sistance management plan used in malaria vector control. The resistance management plan uses sen-tinel sites for monitoring, examines mechanisms of insecticide resistance, uses either a rotational, mo-saic or combined intervention approach, and aims to manage resistance before it becomes a problem.


l Question: Is 70-80% coverage sufficient? The NVBDCP aims to achieve 90% coverage

Answer: This is a minimum for vector control, but it is agreed that 90% is better for P. argentipes.l Comment: Agree that the provision of refresh-

er courses is a good idea.l Comment: Are there longterm health risks for

spray teams? A: PPE has been improved, and should

be used by spray teams to reduce any risk.l Comment: Perhaps it will be possible in the fu-

ture to develop insecticide-exposure badges to wear on PPE (similar to radioactive exposure badges).

5. Recommendations

1Vector Bionomics: Information on vector bionomics needs to be generated. In particu-lar, more information is required on breeding

sites and adult behaviour in order to determine how they can best be targeted. Also, further work is required to examine importance of exophily; and site of transmission to develop eclectic vector man-agement strategies.

2 Community involvement and behaviour change communication: Kala-azar vector con-trol should continue in the IVM approach. Contin-ued community involvement is essential for sus-taining elimination efforts. This can be facilitated by involving social scientists in the programme, and experts from Media & Mass Communication to develop appropriate behavioural change communi-cation strategies.

3 Indoor Residual Spray (IRS): It is well un-derstood that IRS remains as the main stay for Kala-azar vector control. The types of insecticides have to be decided based on insecticide resistance. Hand compression sprayers with CFV are recom-mended for IRS with proper PPE. The IRS should have more than 80% coverage with proper super-vision, appropriate training and refresher training. The discharge rates need to be frequently examined to ensure proper dose delivery of the insecticide. The number of rounds will depend upon the insec-ticide and transmission seasons.

It is essential that national programmes adhere to monitoring and evaluating IRS according to the WHO toolkit. Regular susceptibility tests need to be performed. IQK tests need to be used to assess qual-ity control for each type of insecticide used, after third party validation.

It is important to look at transmission dynamics in more detail to optimise timing of IRS.

4 Rotational Policy of IRS: A rotational poli-cy is required using different classes of insecticide for IRS to prevent insecticide resistance. The choice


of insecticide should take into account levels of resistance shown in vectors from previous studies for each class of insecticide. Efforts may be initiat-ed to harmonise the rotational policy in the Indian Sub-Continent (ISC).

5 When to stop IRS: Routine IRS should be con-tinued until there are no new cases for at least three consecutive years. This should be accompanied by a strong surveillance system, case management and capacity for vector control response.

6 Use of Insecticide treated materials and other innovative tools: To supplement IRS in or-der to achieve required levels of control, additional tools are recommended. India has obtained evi-dence to show that combining LLINs with IRS im-proves control levels, by lowering sandfly densities. Bangladesh studies clearly shows that LLINs reduce new VL cases significantly. Bangladesh experience on larval control needs to be explored further for use in the Region.

If both IRS and LLINs are used, an insecticide

from a different group is recommended.At present there is no evidence base to recom-

mend tools that tackle exophiIic behaviour in sand flies and research in this area is a priority.

7 Cross-border issues: There is a need for regu-lar review of progress and dialogue between VL en-demic countries in the Region, facilitated by WHO.

8 Role of PKDL Patients and asymptomat-ics: Further research is required to determine the role of PKDL patients and asymptomatic cases in VL transmission. If they are proved to play a role in VL transmission, then vector control activities need to be continued to ensure that elimination is sustained even if the milestone (<1 case/10,000) is achieved.

9 Strengthening surveillance and monitor-ing: As countries progress towards the elimination target, village level monitoring of vector control and epidemiological situation needs to be established. Countries are encouraged to develop such a moni-toring system with the help WHO or other partners.


Prof A.P. Dash thanked all of the participants for their excellent contributions during the meeting, and Dr Ahmed Jamsheed Mohamed (WHO-SEARO) thanked Prof. Dash for hosting a productive and enjoyable meeting. The meeting was closed after the above

recommendations were unanimously agreed by all the participants.


Annexure 1

Agenda

Friday, 19th August 2016:• Registration• Opening sessionTechnical Session-I• Kala-azar vector control in General• Kala-azar vector Control in Bangladesh• Kala-azar vector Control in India• Kala-azar vector Control in Nepal• Recommendations of the Vector Control Working Group, WHO, Geneva

Technical Session –II• Indoor Residual Spray (IRS) for sand fly control:• Number of rounds, frequency, type of insecticides, spray pumps, geographical coverage etc• Rotation policy of insecticides, frequency,Insecticide groups• When to stop IRSSaturday, 20th August 29016:

Technical Session – III• Use of Insecticide treated Materials including bed nets and other materials including IVM and / or environmental approaches• Other innovative vector control tools and / orapproaches including IVM, insecticide resistance monitoring and / or environmental approaches• Recommendations and closing


Annexure 2

List of participants

1.Prof. Shireen AkhterNational Institute of Preventive and Social Medicine Mohakhali, Dhaka -1212, Bangladesh, Ph: +880181923802, Email:shireen_nipsom@yahoo. com

2.Mr. Rajib ChoudhuryInternational Centre for Diarrhoeal Disease ResearchMohakhali, Dhaka -1212, Bangladesh,Ph: +8801912168475E: [email protected]

3.Dr. Rajaul Karim KhanDirectorate General of Health Services (DGHS),Mohakhali, Dhaka, BangladeshPh: +88 02 01715914640E: [email protected]

4.Dr. Dinesh MondalICDDRBGPO Box 128Dhaka 1000, BangladeshPh: +8801712027091Email: [email protected]

5. Mr. Shishir Kumar PantEntomologist Vector Borne Disease Research and Training CenterHetauda, Makwanpur, NepalPh: +977 9845027494E: [email protected]

6.Prof. Murari Lal Das Entomologist,Dept of MicrobiologyB.P.Koirala Institute of Health SciencesDharan- 56700, NepalPh:00977-9842052757Email: [email protected]

7.Dr. R.K. DasguptaNational Vector Borne Disease Control Programme (NVBDCP)DMRC Building, Block-III,Ground Floor, Delhi IT Park, Shastri Park, DELHI – 110053Ph: 91-9312214016Email: [email protected]

8.Dr. Ram SinghJoint DirectorNational Centre for Disease Control, Patna Branch16-Kitab Bhawan Lane, North S. K. Puri,Patna-800013Ph: 91-9430001486Email: [email protected]

9.Dr. P. JambulingamDirector,Vector Control Research CentrePuducherry-605006Email: [email protected]

10.Dr. Pradeep Das DirectorRajendra Memorial Research Institute of Medical SciencesAgam Kuan Flyover, Sadikpur, Patna, Bihar 800007Email: [email protected]

11. Dr Rashmi Arora, M.D ( Paed), MPH Scientist “G” & Head Division of Epidemiology and Communicable DiseasesIndian Council of Medical Research Ansari NagarNew Delhi 110029Tel No 91-11-26588296Fax No 91-11-26588896Email: [email protected]

12.Dr. Vijay Kumar, Deputy Director (Scientist-E) & Head Of Department, Vector Biology and Control Division, Rajendra Memorial Research Institute of Medical Sciences, Agam Kuan Flyover, Sadikpur, Patna, Bihar 800007Email: [email protected]


13.Dr Mary Cameron, FRESReader in Medical EntomologyMSc Medical Entomology for Disease Control Course DirectorMSc Medical Parasitology Course DirectorFaculty of Infectious & Tropical DiseasesLondon School of Hygiene & Tropical Medicine

Keppel Street, LondonPh: +44 7858 505461Email: [email protected]

14.Prof. A.P. Dash,Vice ChancellorCentral University of Tamil NaduThiruvarur 610101, INDIAPh: 9489054250Email: [email protected]@gmail.com

15.Dr. Jose Antonio Ruiz PostigoLeishmaniasis ControlInnovative & Intensified Disease Management (IDM)Department of Control of Neglected Tropical DiseasesHIV/AIDS, TB, Malaria & Neglected

Tropical DiseasesWorld Health Organization ,20, Avenue Appia, 1211 Geneva 27, SwitzerlandPh:+41795163882Email: [email protected]

16.Dr Raman VelayudhanCoordinatorVector Ecology and Management UnitDepartment of Control of Neglected Tropical Diseases (HTM/NTD), World Health Organization20 Avenue Appia, CH-1211 Geneva 27, SWITZERLAND, Tel: +41 22 791 1868, Mobile:- +41 79 484 3296Email: [email protected]

17.Dr Ahmed Jamsheed MohamedRegional Adviser (NTD)WHO Regional Office for South-East AsiaMarg, New Delhi, 110002Tel: +91-11-43040194 (GPN 26194)Mobile: + 91 9810788669Web: http://www.searo.who.intEmail: [email protected]


18.Dr. Daniel Argaw DagneCoordinatorLeishmaniasis ControlInnovative & Intensified Disease Management (IDM)Department of Control of Neglected Tropical Dis-easesHIV/AIDS, TB, Malaria & Neglected Tropical Diseas-esWorld Health Organization20, Avenue Appia, 1211 Geneva 27, SwitzerlandEmail: [email protected]

19.Dr. Vittal Babu Gudimetla,Assistant ProfessorCentral University of Tamil Nadu, Thiruvarur, Tamilnadu, INDIAPhone: 91-9489054280Email: [email protected]

20. Dr. Francis P Barclay,Assistant Professor,Central University of Tamil Nadu,Thiruvarur, Tamilnadu, INDIAPhone: 91-9894009264Email: [email protected]

21. Dr Jayalakshmi KrishnanAssistant ProfessorCentral University of Tamil Nadu, Thiruvarur, Tamil Nadu, INDIAPhone: 91-8939111470Email: [email protected]



In the PressReport published in the Asia Times on Aug. 26.

Killer kala-azar dropping below tipping pointBY ANUSHA VENKAT on AUGUST 26, 2016

Incidence of black fever (called ‘Kala-azar’) in the Indian subcontinent is declining fast — and dropping below the tipping point — thanks to

the interventions of World Health Organization (WHO) and the combined efforts of governments. However, fears of its resurgence are haunting the establishments.

From 33,187 cases in 2011, incidence of Kala-azar

in India has come down to 8,500 in 2015. But it is still prevalent in 54 districts in four states, Bihar, Jharkhand, West Bengal and UP, said Dr RK Das Gupta, joint director, National Vector Borne Disease Control Program, at a recent expert consultation meet held in the southern Indian city of Chennai

WHO organised this “Expert Consultation on Ka-la-azar Vector Control” to draw vector-control ex-perts from India, Nepal and Bangladesh and frame a set of recommendations to eliminate Kala-azar as a public health concern in these countries. Central University of Tamil Nadu coordinated this two-day event that was conducted from August 19.

Officials from the WHO offices in Geneva and New Delhi and experts from the London School of Hygiene and Tropical Medicine and Spain were in Chennai to take stock of the Kala-azar situation in Asia and frame control strategies. Black fever had killed thousands in the first half of last century but was curtailed during the anti-malarial blitzkrieg when each household was sprayed with insecticide.

Like malaria and dengue, it is a vector-borne dis-ease spread by sand flies affecting the victim’s liver, spleen and bone marrow, and is fatal if left untreat-ed. Its vector or carrier, sand flies need moisture to thrive and the poorest of poor people turn out to be


soft targets. During the malarial mission, sand flies got killed but the disease resurfaced in the 1980s. Now, it is the second-largest parasitic killer in the world after malaria, responsible for an estimated 200,000 to 400,000 infections each year world-wide. Annually, over 20,000 deaths occur world-wide. India accounts for about half of these figures.

Poonam Khetrapal Singh, regional director of WHO’s South-East Asia Region, had initiated an agreement in 2014 involving the governments of In-dia, Nepal and Bangladesh to eliminate this health menace. Through insecticide spray campaigns within households, identification of breeding areas and distribution of insecticide-treated bed nets to people with poor housing conditions, the incidence of this disease has been brought down to a consid-erable extent.

Prof Dr Shireen Akhter, former Director of the National Institute of Preventive and Social Medi-cine, Bangladesh, noted that in 2006 about 10,000 black fever cases were diagnosed in the country and an elimination drive was launched in 2008 in 100 endemic sub-districts (upazilas) to bring down the incidence levels to below one-per-ten thousand people at the upazila-level.

Dr. Dinesh Mondal, Senior Scientist at the Interna-tional Centre for Diarrhoeal Diseases and Research, said their national program achieved its target in 98 of the 100 upazilas where integrated vector-control measures were executed. Dr. Dinesh Mondal is con-fident that all those upazilas will reach the target by 2017-end. Dr Murari Lal Das, Professor at BP Koira-la Institute of Health Sciences, Dharan, Nepal, pre-sented the picture of Kala-azar in Nepal and said the

disease was endemic in 12 Nepalese districts, where vector-control measures were adopted.

Based on the presentations of the experts, a set of recommendations was submitted to the endemic countries to achieve the target of bringing down the incidence of black fever below the one-per-ten thou-sand people threshold. After reaching that target, the aim is to ensure zero transmission of the disease through targeted sprays to avoid its resurgence.

WHO recommends indoor spraysDarting out a list of recommendations to the af-fected countries, WHO observed that indoor resid-ual spray (IRS) of insecticide was the most-effec-tive method available to control black fever. It also suggested rotation of insecticides as sand flies are developing resistance to the insecticides used. It advocated collaborations among these countries to facilitate knowledge exchange and synchronize the choice of insecticides and spray frequencies.

Regional Adviser of WHO/SEARO Dr Ahmed Jamshed Mohamed reads out the WHO recommen-dations at the two-day “Expert Consultation on Ka-la-azar Vector Control” in Chennai, India, on August 20. India has started using synthetic pyrethroids to kill sand flies instead of DDT (dichlorodiphenyltri-chloroethane), which is still in use in other coun-tries as an insecticide.

WHO wants the countries to continue routine sprays of insecticide twice a year until there are no traces of the disease. This apart, it encourages countries to distribute insecticide-treated bed-nets to people without proper housing facilities.


MoU Signed

SIGNING of MoU ON KALA – AZAR (Dr Poonam Khetrapal Singh with the Health Ministers of Bangladesh, Bhutan India, Nepal and Thailand (Sept. 2014)


Vision & MissionDR POONAM KHETRAPAL SINGH

REGIONAL DIRECTOR OF WORLD HEALTH ORGANIZATION (WHO), SOUTH-EAST ASIA, REGION MESSAGE ON NTDS

The vision of controlling, eliminating and erad-icating neglected tropical diseases has gathered significant momentum over recent years. WHO rec-ommends five strategies for the prevention, con-trol, elimination and eradication of NTDs. These in-clude preventive chemotherapy, intensified disease management, vector and intermediate host control,

veterinary public health at the human-animal in-terface and provision of safe water, sanitation and hygiene. The WHO South-East Asia region bears the second highest burden of NTDs--though not all NTDs are prevalent in the region. Priority NTDs in this region include dengue fever, rabies, leprosy, lymphatic filariasis, Kala-azar, trachoma and yaws. Prevention and control of NTDs contributes signifi-cantly to achievement of the MDGs and improve so-cial and economic well-being. Substantial success has been achieved in eliminating some of NTDs of public health importance in the South-East Asia re-gion in recent past. WHO will continue to support countries with technical assistance, provision of free drugs, strengthening of health system and aug-menting national capacity to combat NTDs.


Documents

Expert Consultation on Kala-azar Vector Control