Contents

• Introduction

• Definition & Problem statement

• Epidemiological determinants

• Clinical features

• Diagnosis

• Treatment

• Prevention & Control

LEISHMANIASIS

• Leishmaniasis are group of protozoal diseases caused by parasite of genune Leishmania, and transmitted to humans by the bite of female phlebotomine sandfly.

• VL (Kala azar)

• CL

• MCL

• ACL

• ZCL

• PKDL

Problem statementWorld

• Visceral Leishmaniasis : Occurs widely through out the world, viz south America south Africa the mediterian countries India Bangladesh and china.

9 out of 10 cases occur in bangladesh,brazil india and sudan.

• Cutanious Leishmaniasis : Occurs in dry, semi desert rural areas of central asia, middle east north and west Africa, esp in Ethopia and Kenya.

9 out of ten cases occur in Afghanistan Brazil Iran peru and Saudi Arabia.

• Muco cutanious Leishmaniasis : Found in Brazil Bolivia and Peru, rarely found outside the world.

India• Has been known to occur epidemically endemically

in well defined areas in the eastern sector of the country viz Assam West bengal Bihar Eastern dist of Utter Pradesh Sikkim and to very lesser extent in Tamil nadu & Orissa.

• Kala Azar is endemic in 52 dist Bihar, Jharkhand, Westbengal, UP

• About 130million pop at risk of the disease

• Zoonotic cutaneous leishmaniasis : has been discovered in Rajasthan area in 1971, total 828 cases were reported.

• Cases of ACL have bee reported from Bhikanercity.

• Both cutaneous (ZCL,ACL) and VL found in india, KALA AZAR is by far so importatntdisease in india.

Kala-azar

• Kala-azar is a slow progressing indigenous disease caused by a protozoan parasite of genus Leishmania.

• Leishmania donovani

is the only parasite

causing this disease

in india.

• PKDL

(Post Kala-azar Dermal Leishmaniasis )

caused by Leishmania Donovani

P.argentipes:

Epidemiological determinants

Agent factors

• Leishmanis donovani Kala Azar & PKDL

• Leishmania tropica CL

• Leishmania brazileinsis MCL

Reservoirs of infection

• Zoonotic

• Non Zoonotic

Host Factor

• Age

• Sex

• Population movement

• Socio economic status

• Occupation

Environmental Factor

• Altitude

• Season

• Rural areas

• Vectors

• Development projects

Mode of transmission

• In india Kala Azar is transmitted from person to person by the bite of the female Phlebotomine Sandfly.

• Transmission may also take place by contamination of the bite wound or by contact when the insect is crushed during the contact act of feeding

• Blood transfussion

• Contaminted syringes and needles.

Signs and Symptoms

• Recurrent fever

• loss of appetite, pallor and weight loss with

progressive emaciation,

• weakness.

• Skin - dry, thin and scaly and hair may be lost.

• persons show grayish discolouration of the skin of

hands, feet,abdomen and face which gives the

Indian name Kala azar meaning "Black fever"

• Splenomegaly.

• Hepatomegaly.

• Lymphadenopathy.

• Anaemia - develops rapidly.

• Anaemia with emaciation

& gross splenomegaly produces

a typical appearance of the patients.

• PKDL Occurs several years after the apperantcure of kala azar, signs symptom includes lesion consists of multiple nodular infiltrations of the skin usually without ulceration, parasites are numerous in this lesion.

• CL,ACL,ZCL, etc here agent is

restricted to skin, painful ulcer

in the parts of body exposed to

sand fly bites, reducing the

victims ability to work

Diagnosis

Clinical• fever of more than 2 weeks duration not

responding to antimalarials and antibiotics.

Lab invest• Haematological findings viz Anaemia, leucopenia,

thrombocytopenia & hypergammaglobulinemia.• WBC : RBC ratio is 1:1500 or even 1:2000• Raised ESR

.

• Serology tests: Direct Agglutination Test (DAT), rk39 dipstick and ELISA. However all these tests detect IgG antibodies that are relatively long lasting. Aldehyde Test is commonly used but it is a non-specific test. IgM detecting tests are under development and not available for field use.

• Parasitological diagnosis

The demonstration of the parasite in the aspirates of bonemarrow/spleen/lymphnode/liver or in the skin (in case of CL) is the only way to confirm VL or CL. However, sensitivity varies with the organ selected for aspiration. Though spleen aspiration has the highest sensitivity and specificity (considered gold standard)

Sl. No.

Affected

States/

UTs

2007 2008 2009 2010(P) 2011(P)

Cases Deaths Cases Deaths Cases Deaths Cases Deaths Cases Deaths

1 Assam 0 0 98 0 26 0 12 0 5 0

2 Bihar 37819 172 28489 142 20519 80 23084 95 18519 56

3 Delhi 19 0 34 0 12 0 33 0 0 0

4 Gujarat 4 1 0 0 0 0 0 0 0 0

5Himacha

Pradesh0 0 0 0 0 0 6 1 1 0

6Jharkha

nd4803 20 3690 5 2875 12 4305 5 4264 3

7Madhya

Pradesh0 0 1 0 0 0 0 0 0 0

8 Punjab 0 0 0 0 0 0 1 0 0 0

9 Sikkim 0 0 4 1 5 0 3 0 3 0

10Uttrakha

nd2 0 0 0 2 0 1 0 0 0

11Uttar

Pradesh69 1 26 0 17 1 14 0 8 1

12West

Bengal1817 9 1256 3 756 0 1482 4 1431 0

Total 44533 203 33598 151 24212 93 28941 105 24231 60

Control measures

• Control the reservoir

• Treatment of the cases

• Sand fly control

• Personal prohylaxis

Active and passive detection of the cases and treatment of those who found to be infected.

House to house visit.

Mass serevys in endemic areas for early detection of the cases.

• TreatmentPentavalent antimony---- Sodium stibogluconate10mg/kg body wt for 20 days in adults.

20mg/kg body w in childrens.

Pentamidine isethionate 3mg/kg body wt for 10 days.

Amphotericin B 1mg/kg body wt IV 15 to 20 Injections alt dys

Miltefosine, 2.5 mg/kg body wt in two divided doses for 4 week

• Sandfly controle

DDT

Insecticide spraying at human dwellinngs and all animal shelter and other resting places up to the height of 6 feets from floor level

• Sanitation measures

• Personal prophylaxis

Kala azar control programme

The strategy of kala azar contorl broadly includes three major activities

• Interruption of transmission for reducing vector population by undertaking indoor insecticidal spry twice annual major activities

• Early diagnosis and treatment of the kala azarcases

• Health education for the community awareness

cont

In view of the success achieved so far, National health policy envisages kala azarelimination by the year 2010.

The tenth five year plan targets are

• prevention of death by kala azar by 2004 by annual reduction of least25%

• zero level incidence by 2007 with atleast 20% annual reduction using 2001 as a base year,

• Elimination of kala azara by 2010. To achieve this government of india has provided 100% central support from the year 2003 2004

• Kala-azar Control Efforts in India

• An organized centrally sponsored Control Programme launched in endemic areas in 1990-91.

• Government of India provided kala-azarmedicines, insecticides and technical support.

• State governments implemented the programme through primary health care system and district/zonal and State malaria control organizations and provided other costs involved in strategy implementation.

• Programme strategy

• Vector control through IRS with DDT up to 6 feet height from the ground twice annually.

• Early Diagnosis and Complete treatment of the cases.• Information Education Communication• Programme intensified in 1991-92 which led to improved case

registration through primary health care system.

• Within 3 years of intensification (1995 as compared to 1992)70.66% decline in annual incidence80.48% decline in deaths

• By 2003 as compared to 199276.38% decline in incidence85.20% decline in deaths.

• KALA-AZAR ELIMINATION INITIATIVE

• In addition to kala-azar medicines and insecticides, cash assistance is being provided to endemic states since December 2003 to facilitate effective strategy implementation by states.

• State/District Action Plan for Kala-azar Elimination.

• Template for developing District Action Plan (Kala-azar).

• Draft Communication & Media Plan for Kala-azarElimination.

• Patient Coding Scheme.

• Kala-azar Treatment Card.

• Monthly Kala-azar Reporting Formats.

Dengue• Dengue is a viral disease.

• Caused by 4 antigenically related but distinct dengue virus serotype(DEN 1,2,3 & 4)

• It is transmitted by the infective bite of AedesAegypti mosquito

• The infection may be asymptomatic or may lead to

Classical dengue fever or

Dengue fever without shock or

Dengue hemorrhagic fever with shock

• Dengue Haemorrhagic Fever (DHF) with shock is a more severe form of disease, which may cause death

The most common epidemic vector of dengue in the world is the Aedes aegypti mosquito. It can be identified by the white bands or scale patterns on its legs and thorax.

• Infective period: day before onset to the 5th

day of illness

• Extrinsic incubation period : 8-10 days

• Sex : both male & female

• Incubation period: 3- 10 days

Problem statement• Most important emerging disease:

– Tropical & sub tropical regions

– Affecting urban & per urban areas

• The cases has increased dramatically in the past 30yrs

• A pandemic(56 countries) : 1998 (1.2 million cases )

• WHO –50 million infections/yr

- 5,00,000 cases of dengue hemorrhagic fever/yr

- At least 12000 deaths/yr

Cont..

• Currently dengue is endemic in Bangladesh India Indonesia, Maldives Mayanmar, Srilanka and Thailand.

• Bhutan and Nepal reported their first case in 2004 and 2006 resp.

• Aproximately 2.5 to 3 bilion are living in areas where dengue virus can transmitted.

• Over the past 10 15 years, next to diarrheal disease and acute respiratory infection dengue has become a leading cause of hospitalization and death among children in the south east asia region.

• During 2006 SEAR reported about 190000 cases with 1600 deaths.

Burden of the disease

• Important disease of tropics & is one of the important disease affecting nearly ½ of worlds population.

• There are about 50 to 100 million cases of dengue fever & about 500,000 cases of dengue hemorrhagic fever that require hospitalization each yr

• World health assembly passed a resolution in 1993 which urged members states to strengthen their national & international program for control of DF/DHF

Countries in South East Asia Region have been divided in 4 categories

Category A:

Indonesia, Myanmar & Thailand

Major Public Health problem

Increased hospitalization death among children

Multiple virus type circulating; Ades aegypti

(Principal vector)

Category B:India, Bangladesh, Maldives & Srilanka

» DHE an emerging disease

» Cyclic epidemic becoming more frequent

» Multiple virus serotype circulating expanding geographicallywithin country,

Aedes albopictus principal vector

• Category C:

Bhutan & Nepal

No reported cases & endemicity uncertain

• Category D:

Korea

Non endemic

Affected

States/UTs

2008 2009 2010 2011(P)

Cases Deaths Cases Deaths Cases Deaths Cases Deaths

Andhra

Pradesh313 2 1190 11 776 3 235 3

Assam 0 0 0 0 237 2 1 0

Bihar 1 0 1 0 510 0 2 0

Chattisgarh 0 0 26 7 4 0 0 0

Goa 43 0 277 5 242 0 7 0

Gujarat 1065 2 2461 2 2568 1 493 0

Haryana 1137 9 125 1 866 20 39 1

Himachal Pd. 0 0 0 0 3 0 0 0

J & K 0 0 2 0 0 0 1 0

Jharkhand 0 0 0 0 27 0 12 0

Karnataka 339 3 1764 8 2285 7 263 3

Kerala 733 3 1425 6 2597 17 847 8

Kerala 733 3 1425 6 2597 17 847 8

Madhya

Pd.3 0 1467 5 175 1 14 0

Meghala

ya0 0 0 0 1 0 0 0

Maharas

htra743 22 2255 20 1489 5 223 2

Manipur 0 0 0 0 7 0 0 0

Nagalan

d0 0 25 0 0 0 0 0

Orissa 0 0 0 0 29 5 1697 25

Punjab 4349 21 245 1 4012 15 609 0

Tamil

Nadu530 3 1072 7 2051 8 1091 4

Rajastha

n682 4 1389 18 1823 9 81 0

States.2008 2009 2010 2011(P)

Cases Deaths Cases Deaths Cases Deaths Cases Deaths

Uttar

Pradesh51 2 168 2 960 8 50 1

Uttrakha

nd20 0 0 0 178 0 4 0

West

Bengal1038 7 399 0 805 1 149 0

A& N

Island0 0 0 0 25 0 0 0

Chandiga

rh167 0 25 0 221 0 1 0

Delhi 1312 2 1153 3 6259 8 245 3

D&N

Haveli0 0 0 0 46 0 0 0

Puducher

y35 0 66 0 96 0 34 0

Total 12561 80 15535 96 28292 110 6098 50

Magnitude of the problem

Transmission

• Resvr of infection is both man and mosquito

• Aedes albopictus become infective by feeding on a paitent from the day before onset to 5th

day of illness.

• After an extrinsic incubation period of 8 to 10 days the mosquito become infective and able transmit the disease.

SIGNS & SYMPTOMS OF DF• high fever with chills 39 to 40 degree cel

• Severe frontal headache

• Retro orbital pain, which worsens with eye movement

• Photophobia

• Muscle and joint pains

• Loss of sense of taste and appetite

• Measles-like rash over chest and upper limbs

• Nausea and vomiting

SIGNS & SYMPTOMS OF DHF

• Symptoms similar to dengue fever

• Severe continuous stomach pains

• Skin becomes pale, cold or clammy

• Bleeding from nose, mouth & gums and skin rashes

• Frequent vomiting with or without blood

• Sleepiness and restlessness

• Patient feels thirsty and mouth becomes dry

• Rapid weak pulse

• Difficulty in breathing

• Based on the signs and symptoms the dengue illness is divided into 3 phases

– Febrile phase

– Critical phase

– Recovery phase

IgM/IgG

Diagnosis

• Clinical diagnosis

– Fever acute onset high continuous lasting 2-7 dys

– Hepatomegally

– Epitaxis

– Gum bleeding

– haematemesis

– DHM include +ve torniquet test

• Lab investigation

– Thrombocytopenia (less 1 lack)

– Haematoconcentration ie increased haematocritmore than 20% of normal value

• Acc to clinical manifestation pt may divide into 3 broad groups

– Group A pt with uncomplicated condi

– Group B pt in hospital management

– Group C pt require Emergency treatment

Treatment• No drug or vaccine is available for the treatment of

Dengue/DHF • Symptomatic & supportive • Bed rest – during acute febrile phase• Antipyretics• Sponging (to keep the body below 40 0 C )• Avoid – Aspirin (endemic areas)

– Causes: • gastritis • Bleeding • Acidosis

• Oral fluid & electrolyte therapy :– Pts with excessive sweating,– Vomiting – Diarrhea

Management of DHF

• Is similar to the DF during febrile phase

• Rise in haematocrit – parenteral fluid therapy

• In Grade I &II volume replacement for a period of 12-24 hrs

• Admission to hospital :– Any signs of bleeding

– Persistently high haemetocrit values

• Fluid replacement should be minimum

• Excessive replacement will cause – Respiratory distress

– Pulmonary congestion

– Oedema

• The type of fluid use are:• 5% dextrose in lactated Ringer’s solution

• 5% dextrose in ½ strength normal saline solution

• 5% dextrose in normal saline solution

Control measuresVector control measures

• Personal prophylactic measures

– Use of mosquito repellent creams, liquids, coils, mats etc.

– Wearing of full sleeve shirts and full pants with socks

– Use of bednets for sleeping infants and young children during day time to prevent mosquito bite

• Biological control

– Use of larvivorous fishes in ornamental tanks, fountains, etc.

– Use of biocides

• Chemical control

Use of chemical larvicides like abate in big breeding containers Aerosol space spray during day time

• Environmental management & source reduction methods

• Detection & elimination of mosquito breeding sources • Management of roof tops, porticos and sunshades • Proper covering of stored water • Reliable water supply • Observation of weekly dry day

• Health education

Impart knowledge to common people regarding the disease and vector through various media sources like T.v., Radio, Cinema slides, etc.

• Community participation

Sensitilizing and involving the community for detection of Aedes breeding places and their elimination

REF

• K Park: text book of preventive and social medicine; edt -18 & 21

• Text of Public Health and Community Medicine: Armed Force Pune

• Davidson`s Principles and practice of medicine

• Sundarlal Adarsh Pankaj: text book of community medicine; edt-1st

• www.whoindia.int/chi

• www.nvbdcp.com

• Topley & Wilsons Text book of parasitology 9th

(Edn), 428-524

• O P Ghai Text book of preventive and social medicine, 161-162

• Harrisons Text book of Medicine, 15th (Edn),1428-1430

• Ananth Narayans Text book of Microbiology, 2nd

(Edn),209-211

Control measuresVector control measures

• Personal prophylactic measures

– Use of mosquito repellent creams, liquids, coils, mats etc.

– Wearing of full sleeve shirts and full pants with socks

– Use of bednets for sleeping infants and young children during day time to prevent mosquito bite

• Biological control

– Use of larvivorous fishes in ornamental tanks, fountains, etc.

– Use of biocides

• Chemical control

Use of chemical larvicides like abate in big breeding containers Aerosol space spray during day time

• Environmental management & source reduction methods

• Detection & elimination of mosquito breeding sources • Management of roof tops, porticos and sunshades • Proper covering of stored water • Reliable water supply • Observation of weekly dry day

• Health education

Impart knowledge to common people regarding the disease and vector through various media sources like T.v., Radio, Cinema slides, etc.

• Community participation

Sensitilizing and involving the community for detection of Aedes breeding places and their elimination

THANK YOU ALL