MSF Holland Ten years Visceral Leishmaniasis INTERVENTION

1997-2007

IBRAHIM ABDELLA(MD)

Out line

• Introduction and VL burden• MSF H and VL programme in Ethiopia• Components of MSF H VL programme• VL programme out comes and success• Operational research• Lesson learned and challenges ahead

Introduction

• Leishmaniasis is a group of disease caused by parasite Leishmania species

• Over 20 species of Leishmania parasite cause the disease

• Three clinical forms Leishmaniasis are: 1.Cutaneous Leishmaniasis 2.Mucocutaneous Leishmaniasis 3.Visceral Leishmaniasis

Introduction

• VL is a systemic illness affecting the spleen, liver, bone marrow, LNs, GIT and RT

• IP - 2-6 months• Caused by L.Donovoani and ?L.Infantum in Ethiopia• Transmitted by P. Orientalis, P. Martini and

P.Celiae• Mode of transmission is athroponotic in

Ethiopia

Introduction

• C/F :Fever >2 weeks, Splenomegaly, Anemia, Weakness, Weight loss, Epistaxis, Lower Abdominal Pain

• 100% fatal, if left untreated• Globally ~500,000 cases/annually and

- 60,000 death /year• Ethiopia ~ 5,000 cases/Year

Endemic foci of Leishmaniasis in Ethiopia

The vector:

Phlebotomus orientalis

Breeding sites for sand flies

Introduction

• Factors that are attributable for increase in transmission and possible occurrence of VL out break are:

1. Mass population movement to endemic areas2. Urbanization, Agricultural development 3. Decrease in the immunity of the population

MSF and VL programmes in Ethiopia

• 1997 G.C an increased cases of VL was reported and the VL out break confirmed by the joint assessment of FMOH,MSF and WHO

• Large scale agriculture development and the restettlemnt programme resulted in huge influx of non-immune population in the area

• MSF established VL project in Kassay Abera Hospital in 1997 G.C

• HIV programme with ART in 2004

MSF Hand VL programmes in Ethiopia

• MSF has treated 10,748 VL patients with over all cure rate of 88.7% in three regions

Tigray Region• Humera – 1997 up to date• Mycadra - 2003-2005Amhara Region • Abdurafi - 2004 up to date• Metema – Dec 2005-Feb.06SNNPR• Konso - 1999- 2001

Components of VL programme1.IEC/HE

– Targets the community– Prevention method- use ITNs Sign and symptoms of KalaAzar/VL EARLY TO SEEK TREATMENT Where to get the treatment

METHODS - IEC Materials - Health educators - Radio broadcasting in 2006 and in 2010

2.OUT REACH ACTIVITIES– Health education– Active case finding and surveillance– Training of BOH Health workers

Components of VL programme

3.Laboratory -DAT -R k39 - Aspirate – Spleen, LNS - Para check/BF - Hematologic tests - Organ function tests

Components of VL programme

4.VL treatment and care A. Clinical Assessment- Grading of severity - Co-morbidities - Nutritional assessment - PIHCT Decided where to admit - ICU - IPD/VL Ward - Shelter – stable patients

KalaAzar Shelter

Component of VL programme

B. Treatment of VL First line drug – PKASSG 20mg/kg/d for 30 days Sever S/E – chemical pancreatitis, sudden death, nephrotoxicity , hepatotoxicitySecond line drug- HIV/VL Co –infected - Relapse cases - Pregnant - Severe SSG toxicityAmbisome 5mg/kg/ dose, a total of 6 doses is given

with in 12 days (every other day)

Components VL programme

5.Nutritional support Severely malnourished provided therapeutic

feeding 6.Emotional and physical stimulation

VL programme out comes and Success1997-2007

Tigray Amhara SNNPR

TotalHumera1997-

Mycadra2003-05

Abdurafi2004-

MetemaDec.05-Feb06

Konso1999-2001

Admission 7424 1304 1744 88 188 10748

PKA 7015 1251 1694 86 188 10234

Cure Rate 86.8% 94.4% 91.6% 89.5% 91% 88.7%

Death Rate 12.1% 3.97% 7.1% 9.3% 3.2% 10.0%

Defaulter Rate 1.1% 1.2% 1.0% 1.2% 5.6% 1.2%

Relapse Rate 4.14% 3.3% 1.6% 2.3% 0 3.5%

VL programme out comes• Humera VL admission pattern over ten years intervention

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Total

Total Adm. 112 506 565 476 561 581 140

6 913 1207 657 440 742

4

PKA 112 506 565 476 561 581 1339 824 112

4 542 385 7015

PKDL 0 0 0 0 0 0 19 10 6 18 6 59

Relapse 0 0 0 0 0 0 48 79 77 97 49 350

Cure rate(%)

75.0

76.9

82.5

84.7

92.0

81.0

88.3

88.7

90.3

90.4

91.8

86.8

Death rate(%)

25.0

23.1

17.5

15.3 8.0 19.

0 8.9 9.4 7.9 8.3 6.7 12.0

Defaultrate(%) 0.0 0.0 0.0 0.0 0.0 0.0 2.7 1.9 1.8 0.8 1.3 1.4

Relapserate(%) 0.0 0.0 0.0 0.0 0.0 0.0 3.4 8.7 6.4 14.

6 1.4 4.1

VL programme out comes

• Humera VL Programme admission pattern over ten years

0

200

400

600

800

1000

1200

1400

1600

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Primary kala-azar

PKDL

relapses

total admissions

VL programme out comes

Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun0

50

100

150

200

250

300

350

400

Primary Kala-azar Admissions N.W. Ethiopia, 1997-2006

1997-19981998-19991999-20002000-20012001-20022002-20032003-20042004-20052005-2006

VL programme out comes

• Humera VL programme Death rate pattern over ten years

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Series1

VL programme out comes• Abdurafi VL admission pattern over four years intervention

2004 2005 2006 2007 Total

Total Adm. 490 522 430 302 1744

PKA 473 504 420 297 1674

PKDL 4 9 6 3 22

Relapse 13 9 4 2 28

Cure rate(%) 91.9 92.3 89.4 92.9 91.6

Death rate(%) 7.0 6.5 8.7 6.2 7.1

DefaulterRate (%) 1.1 1.2 1.2 0.3 0.9

Relapse Rate (%) 2.6 1.7 0.9 0.7 1.6

Operational ResearchComparative study of Pentostam Vs SSG -

1998/1999• Cure rate 70.2%(Pentostam) and 81.1%(SSG)• High mortality rate among HIV co-infected patients

was seen (33.3%vs3.6%)

Comparative study of SSG Vs oral Miltefosine -2003/4

• Initial Cure rate 88%• Mortality rate 10%( on SSG) vs. 2%(on Miltefosine)

during treatment• Parasitological treatment failure was 8%(Miltefosine)

and 1%(SSG)• Parasitological failure of Miltefosine 18% in HIV

patients and 5% in HIV Negatives• Miltefosine is equally effective as SSG for HIV

negative VL patients and lesser effective but safer among HIV positives.

Operational Research• Field Evaluation of DiaMed –IT-Leish rk39 (RDT) for

VL-2006 *Sensitivity 84.3%(in parasitological confirmed cases) and Specificity 91.5%(in DAT Neg. clinical Suspects) *Sensitivity of rk39 in parasitological confirmed HIV positives was 77.3% *Specificity in DAT negative endemic control was 99.0% *Reasonable for screening and very good for diagnosis

Operational Research

• VL/HIV co-infection in Ethiopia -2003-2006365 HIV/VL co-infected patients followedAmong 195 patients on HAART 31.3% had one or

more VL episodes and Baseline CD4 strongly influence the risk of relapseRelapsed patients showed poor CD4 recovery in spite

of being on ARTHAART reduces the risk of relapse significantly,but

doesn’t prevent it

LESSON LEARNED VL is causing considerable morbidity and mortality in Ethiopia Migrant workers &Re-settlers are most vulnerable in North-Western part of Ethiopia Seasonal workers in endemic areas are likely to be misdiagnosed when they go back home Knowledge and diagnostic skill among health professionals is limited Early diagnosis and referral is possible at remote areas using RDT and can reduce mortality significantly

LESSON LEARNED....Blood transfusion is needed at VL treatment centers HIV co-infection rate among VL patients ranges 30-35% PHICT, HIV care and treatment needs to be available at VL treatment centersHIV/VL co-infection is a great challenge, multiple relapse is inevitable among co-infected patients SSG is not enough for VL treatment , combination therapy and/or alternative treatment needs to be availableNutritional support and hydration is equally important

Challenges Ahead

I. IMPLEMENTAION OF NATIONAL KALAAZAR ROLL OUT PLAN

II.Decentralization of KA diagnosis and treatment Rapid diagnostic method needed Drug with less side effect, shorter duration of treatment and with easy administration is needed

Challenges Ahead

III.HIV/VL Co-infection

THANK YOU !!!!!