India: Treating Kala Azar—a Complex and Deadly Disease

July 7, 2014

Bihar State, in northeastern India, is a major epicenter of the parasitic disease visceral leishmaniasis—also known as kala azar. Doctors Without Borders/Médecins Sans Frontières (MSF) works in Bihar’s Vaishali district to treat this complicated and deadly disease.

Photos by Anna Surinyach/MSF

Bihar State is one of the poorest and least developed areas of India. Agriculture is the main economic engine, but most people don't own land and must work long hours for little money.

India 2011 © Anna Surinyach/MSF

Bihar is an epicenter for kala azar - a parasitic disease that is nearly always fatal when left untreated.

India 2011 © Anna Surinyach/MSF

MSF opened a kala azar project in Vaishali district, in central Bihar, in July 2007. Hajipur, the district capital, where the project is based, has a population of about 700,000. Over four years, around 8,000 people have been successfully treated.

India 2011 © Anna Surinyach/MSF

MSF runs the the kala azar diagnostic and treatment unit on the second floor of Sadar Hospital, the district's main referral facility. At any given time, most of the unit's 40 beds are occupied.

India 2011 © Anna Surinyach/MSF

This 27-year-old patient, a woman named Baby, had a fever for several weeks. When she came to Sadar Hospital, she was referred to the second floor for a rapid kala azar diagnostic test.

India 2011 © Anna Surinyach/MSF

Symptoms of kala azar include fever, loss of appetite, enlarged spleen and liver, and anemia. Infection occurs when the kala azar parasite is transmitted through the bite of a sand fly. Symptoms usually appear around two weeks after the bite.

India 2011 © Anna Surinyach/MSF

The rapid test known as rK39 shows within 15 minutes whether or not the patient has been infected. Doctors use the test results and clinical symptoms to diagnose the patient.

India 2011 © Anna Surinyach/MSF

Taking symptoms into account is important because the rapid test can sometimes show a false negative. This is particularly common in HIV patients who have also contracted kala azar. In such cases, doctors must remove and examine fluid from the spleen and examine in order to confirm whether or not the patient has kala azar.

India 2011 © Anna Surinyach/MSF

Most people affected by the disease are poor, and there is not much research being done to find more effective and simple diagnostic methods and treatment.

India 2011 © Anna Surinyach/MSF

Complicated kala azar cases are treated at the hospital, including patients suffering from severe anemia, HIV, and severe acute malnutrition, as well as pregnant women, infants, and the elderly. Simple cases are treated on an outpatient basis. Patients receive four intravenous doses of the drug liposomal amphotericin B (LAmB).

India 2011 © Anna Surinyach/MSF

Previously, kala azar patients were given the drug SSG, which required a long and toxic treatment. Many people in India and Bangladesh developed resistance to SSG. The current drug used to treat the disease is effective, requires a short course of treatment, and has fewer side effects. The initial cure rate at MSF's project in Sadar Hospital is 98 percent.

India 2011 © Anna Surinyach/MSF

After 50-year-old Kamli Devi received her second course of treatment, she began to walk again. Devi is treated as an outpatient at one of the five health centers MSF supports in the district.

India 2011 © Anna Surinyach/MSF

A 30-year-old patient receives treatment for post-kala azar dermal leishmanisasis (PKDL), an infection some patients contract after being treated for kala azar, mainly in India and Bangladesh. Although PKDL is relatively painless, it is a reservoir for the kala azar parasite and it must be treated to prevent the disease from spreading.

India 2011 © Anna Surinyach/MSF

PKDL patients can develop skin lesions that can have an impact on their quality of life. Patients must be admitted to the hospital and are given three courses of treatment over 20 days.

India 2011 © Anna Surinyach/MSF

When kala azar patients also have HIV, the two diseases form a vicious circle that is difficult to break. HIV-positive patients have fewer defenses to fight the kala azar parasite, so treatment failure is more common. At the same time, kala azar further weakens the defenses of HIV patients, increasing their risk of contracting opportunistic infections.

India 2011 © Anna Surinyach/MSF

Mukesh, 18, smiled when the doctor told him he would be discharged tomorrow. “If someone I know has kala azar in the future," he said, "I will advise him to come and get treatment at Sadar Hospital. It is the best treatment one can find and totally free of charge.” Mukesh said he plans to rest for a few weeks and then return to Delhi to work as he used to before he became sick.

India 2011 © Anna Surinyach/MSF