MSF doctor Caroline Forwood on kala azar in India

Caroline ForwoodThe music is loud tonight, layers of competing sounds, horns and wind instruments, a screeching female voice on a tannoy system then a man with a better trained voice, car horns and shouting.  The 11pm train from Patna must be able to sense the competition and is blasting a longer than usual announcement of its presence. Standing on the fenced-in and mosquito net shrouded balcony gazing out I feel like a little female anopheles mosquito unable to get to her prey, the bright lights of the town, Eid celebrations beckon but security rules prevent us from going out to partake in the events.

Re-reading this I think I should have compared myself to a sand fly rather than a mosquito! The genus Phlebotomus – a great name for a little fly that transmits a disease that causes so much misery to the poorest of the poor.  So some facts and figures of what I am doing here.

I came to Bihar in October, to join the Médecins Sans Frontières programme that has treated 4,500 cases of visceral leishmaniasis – or kala azar – since it started working here in 2007. Kala azar, which means “black fever” in Hindi, is caused by the intracellular parasite Leishmania Donovani and transmitted from person to person by the bite of that little infected Phlebotamus.
There are around 500,000 cases of kala azar annually, and 200,000 related deaths. India has the largest burden for this disease in the world, and Bihar state has the highest disease burden in the country (around 20,000 new cases every year). The vector thrives in poor rural communities where the heat and humidity, deficient living conditions (mud houses with cracks in the walls and animals in close proximity) and the absence of preventive vector control measures fuel infection.

The national treatment programme here recommends the utilization of Sodium Stibogluconate (SSG) but in some areas of Bihar the parasite’s resistance to this drug is up to 60%, and SSG is nasty stuff causing lots of side effects including cardiotoxicity.  So we use the wonder drug AmBisome (Liposomal amphotericin B) which is a much more expensive treatment than SSG, costing around 250 USD per patient, but has very few side effects and a cure rate of over 98%.  We are using a 4 dose iv regime of 5mg/kg at days 0, 1, 4 and 9, making a total dose of 20 mg/kg.  It is amazing to see patients coming in looking so toxic, pale and unwell and by the third day their fever has usually resolved and they are so much better.

We treat most of patients on our 55 bed (stretching to 60) bed ward at the hospital here in Hajipur.  Kala azar is one of the several diseases causing febrile hepatosplenomegaly (in kala-azar the spleen gets particularly enlarged – the largest I have seen so far was 18cm!) The disease tends to be insidious with prolonged fever, body weakness, weight loss and pallor accompanying pancytopenia and hepatosplenomegaly.

We refer complicated patients – those with suspected kala-azar relapses, children under two, pregnant women, PKDL (post-kala azar dermal leishmaniasis) and patients co-infected with HIV to the research institute RMRI (Rajendra Memorial Research Institute) in Patna where we have 10 beds looked after by one of our very experienced doctors.  We are lucky to have such experienced national doctors in this project from whom I have learnt so much in the last few weeks – and still so much to learn!  The expatriate doctor I took over from was an HIV specialist so it has been hard to fill her shoes, but then again my GP experience and the experiences of my last mission in Bangladesh bring another dimension.  I don´t think they had received teaching on antenatal care on the ward round before last week: we were treating an 8 year old boy for primary kala azar when we noticed that his pregnant mother had the hypopigmented rash typical of PKDL. She was referred to RMRI for assessment and diagnostic skin snip testing.

Caroline Forwood is a general practitioner from London who’s currently working for MSF in India.