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 If you read this newspaper, chances are you’ve never heard of kala azar even though it is the second largest parasitic killer in the world after malaria. And, if you know kala azar, you’ve probably never read a newspaper.

Kala azar is found in 88 countries, but 90 per cent of the cases are in India, Bangladesh, Nepal, Sudan and Brazil. According to the WHO, 350 million people are at risk of kala azar globally, with 200 million in India, Bangladesh and Nepal. Yet, even with about one-fifth of India’s population at risk, it’s still definitely a ‘most neglected disease’.

Medicins Sans Frontieres, winner of the Nobel Peace Prize in 1999, defines neglected diseases as those where most patients are very poor, live in remote or unstable areas, have limited access to healthcare and have limited or no political influence. It is tragic that diseases are neglected not because they are rare, but because their patients are at the bottom of the socio-economic heap. This is certainly true of victims of kala azar in the districts of Bihar, Jharkhand, UP and West Bengal where kala azar is endemic.

Also known as visceral leishmaniasis, kala azar presents itself as a persistent fever, lowers immunity, and causes anaemia and liver and spleen enlargement. It kills if not treated. It is transmitted when a female sandfly bites and picks up the parasite from an infected person and then transmits the parasite by biting another person.

In 2002, the government of India declared that it would eradicate kala azar by 2010. Despite the stated resolve, high-level political commitment, infrastructure, manpower and funding to implement the elimination programme, we have seen a rise in the number of cases since 2002.

In south Asia, where kala azar is believed to be prevalent in only 96 districts, WHO says the disease can definitely be eradicated if we make sure there are no infected humans and no sandfly carriers. This would require early diagnosis, an effective cure and successful vector control.

The sandfly which is the vector for kala azar, breeds in and around homes, in thatched roofs, cracks and crevices of mud used to plaster walls, in cow dung, and in the shrubs and low greenery around homes. With the WHO having re-endorsed indoor residual spraying of DDT by application on walls and roofs of houses in September 2006, it will help the vector control programme.

We need to keep in mind, however, that the vector control programme for malaria in India, with heavy reliance on indoor residual spraying and inadequate use of other interventions, led to an increase in cases of malaria and an increase in resistance to DDT. In the case of kala azar too, development of tolerance by the sandfly to DDT has been reported from several districts. Thus, operational coverage with accurate spraying techniques and the correct insecticide will be key to a successful vector control programme.

Currently used drugs for kala azar show variable efficacy and are toxic. They also involve a treatment course of about four to six weeks, which creates its own problems. We need shorter therapies as four week treatments are difficult to support given the high incidence of the disease and the overstretched health infrastructure in the regions where the disease is endemic. Long treatments specially lead to low compliance and consequent drug resistance.

Two new drugs have been introduced in India at the initiative of multilateral agencies, but while they have some advantages, there are issues with both of them, not least of all drug resistance.

The WHO gives the highest therapeutic index of existing drugs for kala azar to liposomal amphotericin B. Not only is it the safest and most effective drug for kala azar, it is a ten-day treatment. The problem is that it is very expensive. At retail price in India, treatment would cost Rs 1.5 to 3 lakh at US$ 280 per vial. The manufacturer offers the price of US$20 per vial for public sector agencies of developing countries. But even with the preferential price, it remains unaffordable for most patients.

And so, there is a quest to find a short course cure that is safe and effective. There is much research being done in labs inside and outside India, funded by international donor agencies and by the government of India. There are even combination therapy trials underway to overcome the shortfalls of the current drugs available in India for kala azar.

An amphotericin B emulsion, researched, developed and internationally patented by an Indian company, has been in the market since 2003. Recent studies have shown that it achieved a 100 per cent cure rate with a single dose of the medication. Studies also show it is at least as effective and safe as the liposomal amphotericin B. Priced at half the concessional rate of liposomal amphotericin B, it is affordable. So it appears that we have a promising cure for kala azar that is effective, safe, affordable, and which can even be an out-patient treatment.

The tragedy, or opportunity — depending on how you choose to look at it — is that if kala azar is a neglected disease, for some reason, this is a ‘neglected drug’. Who pays the price for the health system ignoring this drug?

The writer is a lawyer and Mumbai-based management consultant kavitakhanna108@gmail.com