Monday May 5 2014

Pastoral communities pay high price for kala-azar disease


For two months, Nakor Nawate relied on traditional medicine to treat kala-azar, a disease she had been suffering from over a long period. By the time she was brought to Amudat Hospital by a community health worker, the blood in her body was too low that she had to get transfusion and was put on a healthy diet before embarking on medical treatment.
“I do not know what causes this disease that sucks nearly all your blood,” says Nawate.

Nawate, who does not know her age is married with three children and lives in Kosiroi Village in Katikekile Sub-county in Moroto District.
Benson Ruto is another survivor of kala-azar disease. He too cannot tell how old he is, nor can his father, Benson Lolingang. But he looks about eight or nine. For four months, Ruto’s parents treated their son using local herbs and coartem because they thought he had malaria. “When his condition did not improve, we called the community health worker who tested him at home. The results confirmed he had kala-azar. He was admitted here at Amudat Hospital,” Lolingang says of his son who is recovering from his hospital bed.
“I developed fever, a swollen stomach and general body weakness before I was admitted here. After the treatment, I now feel better. I can even run around the ward,” says Ruto.

Not all Lolingang’s seven children attend school. Ruta was one of those who were herding livestock instead of attending school.
“If I take all of my children to school, who will look after our animals? Ruto has been herding cattle but I have now decided to take him back to school because he falls sick frequently,” says Lolingang.
Ruto is excited about going to school. “I want to become a doctor and treat people in future,” he says with a wide smile.

Mobile communities
The Amudat District community mobilizer, Andrew Ochieng observes that because of their pastoral nature, the community in this region is mobile and difficult to mobilise.

“When I test them in their different locations and find some are suffering from kala-azar, they do not come to hospital immediately. I have to plead with them all the time. However, those who know the values of a hospital do not hesitate to seek treatment as soon as they can,” Ochieng says.
He adds that most young boys in the region have to look after the family livestock even when they are sick.

“Unless parents get replacements, the boys are not allowed to go tohospital, and only do so when they have become too weak,” explains Ochieng.
According to the World Health Organisation (WHO),kala-azar is the most serious form of the disease caused by leishmaniasis visceral. Others are cutaneous and mucocutaneous.

leishmaniasis is caused by a protozoa parasite from over 20 leishmania species and is transmitted to humans by the bite of infected female phlebotomine sandflies.

The disease is commonly associated with malnutrition, poor housing, climate change and a weak immune system. According to the Ministry of Health, the disease is common in remote villages of Uganda, Sudan, Ethiopia and Kenya.
Kala-azar is characterised by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and general body weakness.
Up to 90 per cent of people who are not treated against the disease die due to organ failure, anaemia and other secondary infections. It can also cause skin ulcers. People of all ages are at risk of infection if they live or travel in areas where the prevalence of kala-azar is high, although male teenager are said to be at a higher risk of infection because they engage more in animal herding.

The Leishmaniasis East Africa Platform (LEAP) clinical trial principle investigator in Uganda, Prof. Joseph Olobo observes: “At household level, the impact of kala-azar is disastrous. It is lethal if not treated. The disease is mainly found in children, so families will lose their loved ones if it is not treated on time.”

The Health ministry says the disease has predominantly been reported in Amudat District, which forms part of Karamoja sub-region.
Termite mounds are a dominant feature of the area and form the main breeding and resting site for the sand fly vectors which transmit the disease. However, two cases were recently reported in Moroto and Kotido districts, which are part of the Karamoja sub-region in north-eastern Uganda.
“We do not know the extent of the disease in Uganda. In the past, it was mainly in Amudat District, but now we are getting cases in neighbouring districts. Mapping is important to establish the extent of the disease, however, we need to know where the vector is more prevalent. We also need to have good diagnosis and treatment,” Prof. Olobo notes.

A poor health seeking behaviour and low literacy levels are some of the challenges that make it easy for kala-azar disease to thrive in Amudat.
“When people in these areas fall sick, they do not seek medical care from hospital immediately. Their first call is usually the traditional healers and when this fails, they come to hospital,” says Lawrence Okello, the medical officer in charge of the management of kala-azar patients at Amudat Hospital.
According to WHO, kala-azar is most prevalent in the Indian sub-continent and in East Africa. An estimated 200,000 to 400,000 new cases of kala-azar occur worldwide each year. Over 90 per cent of the new cases occur in six countries of Bangladesh, Brazil, Ethiopia, India, South Sudan, and Sudan.

Following a kala-azar disease assessment, Medecins Sans Frontiers (MSF), which has been offering technical assistance to Amudat Hospital, initiated a control programme in 2000, focusing on case detection and treatment.
Treatment of kala-azar usually involves the use of antimonial drugs such as sodium stibogluconate (SSB), which has also been included on the essential drugs list of Uganda.

Research has also been conducted in the past three years to see if drug combinations are effective.
The health ministry admits there is no established control programme for kala-azar, with current diagnosis and treatment largely supported by the Drugs for Neglected Disease initiative (DNDi).