India gears-up to overcome last-mile challenge of eliminating visceral leishmaniasis

INDIA – India is redoubling efforts to resolve remaining challenges in the elimination of visceral leishmaniasis, also known as kala-azar, as a public health problem.

After years of steady progress, several measures and cross-sectoral interventions are being envisaged, with 4 centres of excellence to become operational in disease endemic areas, in order to provide improved access to specialized care for complicated cases of kala-azar.

India has also expanded vector control interventions. In endemic villages that have reported cases of kala-azar over the past 3 years, 2 rounds of indoor residual spraying are being applied.

About Visceral leishmaniasis

Visceral leishmaniasis is commonly known as kala-azar (KA), a word coined in the late nineteenth century in India, which literally means “black disease”, referring to the greyish or blackish discolouration of the skin during infection, from the Hindi word for black (kala) and the Persian word for disease (azar).

The disease is caused by the parasite L. donovani and it remains one of the major eco-epidemiological hotspots of the world.

Earliest cases of KA in India can be traced back to 1824–1825, when an outbreak of fever in Jessore (now in Bangladesh), known as jwar-vikar (“fever disease”), that caused approximately 750 000 deaths over 3 years, has since ascribed to KA.

Situation in Pakistan

The disease is common across the Asian continent and in the neighbouring Pakistan state, progress of eradicating it has been futile as a result of the COVID-19 pandemic.

This is because soon after the first cases of COVID-19 were detected in Pakistan, in March, 2020, the government shut down all non-essential services, including outpatient care for an array of diseases not requiring emergency treatment.

As a result, Médecins Sans Frontières (MSF) was forced to close its clinics for people with visceral leishmaniasis.

Many patients, unaware of the extent of the shutdown and desperate for care, showed up to clinics anyway.

But MSF, the only organization providing care for the disease in the country, had no choice but to turn them away, with nowhere else to go.

Even hospitals would not accept patients for supportive treatment, since the disease is not considered life-threatening.

Suzette Kämink, a medical researcher focused on cutaneous leishmaniasis with MSF in Peshawar, Pakistan, witnessed the confusion and worry among patients in the early stages of the pandemic.

Some travelled hundreds of kilometres for treatment only to find clinics shuttered for reasons they struggled to understand, with little information about COVID reaching poorer, rural communities.

Pre-pandemic, in early 2020, MSF clinics in Pakistan were receiving over 250 new patients each week to start treatment for visceral leishmaniasis.

Despite the huge turn out of patients pre-pandemic era, the disease was still a neglected epidemic that was looming in Pakistan and was the cause of suffering among Pakistani residents.

Researchers have express concern that stalled progress over the last year has further set back much-needed advancements to treatments.

With the pandemic in its second year, doctors and researchers around the world are seeing the alarming effects of stalled health care and clinical trials on diseases affecting the world’s most vulnerable populations.

Pakistan’s reported 50,000+ cases of cutaneous leishmaniasis in 2019 is likely an undercount, given Pakistan’s limited diagnostic capacity.

The few treatment facilities are unevenly distributed throughout the country, rendering them tougher for more remote communities to reach.

Traveling long distances every day for a 3-week course of treatment means a significant loss of income, in addition to transportation costs.

Many who cannot afford the costs end up delaying treatment or skipping doses, which increases the likelihood that the lesion will leave a lifelong scar.

Some patients were unable to find any form of transportation to reach treatment centers once they reopened in September of 2020, after 6 months of closure.

The pandemic not only exacerbated the obstacles to care and it also set back efforts to develop better treatments.

Currently, the only treatment available with the standard symptoms reliever for over 70 years consisting of a series of painful injections administered daily for 3 weeks.

Kämink and other neglected disease advocates believe new drugs are essential for reducing the burden of leishmaniasis, and MSF had long planned a clinical trial to improve treatments and potentially spare patients’ long journeys to clinics to cure their wounds.

MSF plans to study 2 potential therapies in its clinical trial. One, an oral drug, would entail a 1- month course of treatment—but it could be taken from the comfort of home rather than requiring patients to travel to the treatment facility each day.

The other, in the form of thermotherapy, utilizes heat to treat the parasitic infections, and would only require patients to travel to the clinic once. If either of these therapies is found to be effective, Kämink says, it could significantly improve treatment access.

While MSF is the only organization focusing on leishmaniasis in Pakistan, other NGOs such as the Drugs for Neglected Diseases initiative are working on similar clinical trials for leishmaniasis treatments in different regions of the world.

Not surprisingly, though, studies on neglected diseases have taken a back seat to COVID-19 in the pandemic era.

With the unpredictability of COVID-19, the timeline for approving new treatments is anything but certain. Still, those working on neglected diseases believe in the work they are doing.

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