Friday, November 20, 2015

Are Kala Azar cases increasing in Uganda?

By Esther Nakkazi

This week, on 19th and 20th November, representatives from the Ugandan Ministry of Health, key stakeholders in the field of the Drugs for Neglected Diseases initiative (DNDi) and the World Health Organisation (WHO) met in Kampala to discuss current treatments for Visceral Leishmaniasis, commonly known as kala azar.

I was invited to the meeting and just understood why not many people are interested in kala azar.

First of all, the disease affects mainly the world’s poorest populations who live in arid or semi-arid regions of the world. In Africa, Eastern Africa is the most affected region with an estimated annual incidence rate of 29,000 to 56,000 cases.

Although Uganda’s national diagnosis and treatment Visceral Leishmaniasis or kala azar guidelines were drafted in 2007, they are yet to be revised. Other countries, which have the disease prevalent like Kenya, Ethiopia and Sudan have already done so.

Guidelines are important as new drugs come to the market, because policies will change and access to treatment will be improved.

No one knows the burden of disease in Uganda for Kala azar. All the scientists know is that it is endemic to Amudat district in Uganda and increasingly people from other districts like Kotido, Moroto, Katakwi, Napak and Nakapiripirit all in the Karamajong region are presenting with it.

So maybe there are increasing cases but no one knows or they are not concerned! Indeed Kala azar is a neglected disease.

“We have not mapped so we do not know the extent of the disease in the country but more people from other districts are presenting with it,” said Dr. Thomson Lakwo, assistant commissioner, the national Entomologist for Onchocerciasis Control programme, NTD progarmme, Ministry of Health.

Scientists working on neglected tropical diseases at the ministry of health in Uganda said the increased cases could be de to increased awareness because many cases were not reported previously.

At Amudat Hospital, the only place where kala azar is treated in Uganda, they register 12-15 cases per month. Kala azar patients present with symptoms of irregular bouts of high fever, weight loss, swelling of the spleen and liver, a swollen abdomen and anaemia.

Prof Joseph Olobo a lecturer at the Immunology Department, College of Health Sciences, Makerere University, said they are training more health workers to treat the disease. He said kala azar is treatable but fatal if left untreated. Amudat has first class facilities.

70 percent of patients sick of kala azar are children and it affects more men than women because they spend more time outside looking after animals.

It is spread by the female sand flies that bite an infected person and spread the disease. So it can be easily eliminated with treatment if all the affected population is treated because the female sand flies will not be able to spread it. The vector will remain but with nothing to inject to its hosts around.

Unlike malaria, which cannot be eliminated with drug prophylaxis, because the vector has many species and the malaria parasite survives in many conditions, scientists think because the sand fly is confined to arid and semi arid areas, the people in that region can be given treatment and it can be eliminated. They also think a vaccine can be developed.

But alas, private pharmaceutical companies lack interest in producing new drugs for patients suffering from neglected diseases since they cannot recuperate their investments in drug development.

Costs of treating an adult patient is about 60 Euros and half of that for children and fortunately, patients once treated do not relapse. The drugs provided for free by the International Dispensing Association (IDA) and through the Drugs for Neglected Diseases initiative (DNDi).

Being a neglected disease there is hardly research for new treatments or they are not prioritized, so they are unavailable, inaccessible, and unaffordable. Currently, the treatment is only by injections and toxic.

But Dr. Monique Wasunna, the director, Drugs for Neglected Diseases initiative (DNDi) Africa regional office says they are hoping for less invasive tests for kala azar and the use of oral medication.

Action has been taken and in 2013, Ethiopia, Kenya, Sudan and Uganda partnered to create the Leishmaniasis East Africa Platform (LEAP), with a mandate to research new treatment options for kala azar and support their access.

In 2010, in its first landmark study, LEAP together with DNDi delivered sodium stibogluconate and paromomycin combination therapy for Eastern Africa, which was over 91 percent effective in treating the disease.

The therapy is recommended by the WHO as a first-line treatment for kala azar in Eastern Africa.

“The most significant achievement from the study is that the therapy is cheaper and has nearly halved the length of treatment from the previous 30 days to 17 days,” said Dr. Wasunna.

She said the development of the new therapy was a milestone since it came after 70 years of little or no improvement and change in kala azar treatment in Africa.

I hope the Uganda national guidelines for kala azar are developed after this meeting.

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