Combating visceral leishmaniasis: access to care for the most neglected

In the shadows of Eastern Africa, lurks a silent enemy – visceral leishmaniasis (VL), or Kala-azar as it is commonly known – a neglected tropical disease (NTD) caused by parasites transmitted through the bite of a sand fly. Kitui County in Kenya has emerged as a frontline battleground, where healthcare workers are spearheading a comprehensive strategy to combat VL and bring hope to communities.

Kitui County's leadership is combating VL; orchestrating a symphony of efforts through a steadfast commitment to the well-being of their community and urging the world to stand with them in the fight against VL and other neglected tropical diseases.

Visceral leishmaniasis often appears in children under two years old. It is manifested by a severe and continuous high fever and abdominal swelling, leading to death in 3–18 months. The disease may be worsened by HIV or opportunistic infections. A proportion of VL infected people do not present any symptoms, yet they still drive transmission in the community.

Kenya is among the top high-burden countries where poor, rural communities are the most affected. More than 5 million Kenyans live at risk, with 600-1,200 cases reported annually, likely an underestimation due to inadequate access to diagnosis. The diagnosis of VL in Kenya currently needs a complex combination of tests. Doctors first look for a series of non-specific symptoms such as fever, abdominal swelling, weight loss and test to rule out malaria.

Patients are then tested using a rapid diagnostic test (RDT), and if negative, tested using a Direct Agglutination Test (DAT). In some cases, microscopic examination of tissue from the spleen, bone marrow or lymph node is needed. The DAT, in contrast to RDTs, requires well-equipped laboratories and trained personnel. Those who test negative by RDT and still suspected to have VL are referred to facilities where DAT can be performed leading to delayed diagnosis and treatment, at significant costs to patients and the health system. Diagnosis is further hampered by a limited number of health facilities in endemic areas with access to RDTs and even fewer that can perform DAT. Controlling VL also poses significant challenges of periodic outbreaks, malnutrition, and co-infection with HIV. Left untreated VL is almost always fatal. With the WHO 2030 target for VL elimination, access to diagnosis and treatment is crucial for effective patient care.

Kitui County’s Journey: Identified as one of the 11 VL endemic counties in Kenya, Kitui County has the disease focused in Mwingi North and Mwingi Central sub-counties which have been at the forefront of control efforts since 2019. Growing expansion of the disease within the county has been recorded with cases in Kitui East as well. A total number of 6,798 VL positive cases have been reported in the period between 2019 – 2023 in a population of approximately 356,876. Expansion of the disease in previously non-endemic areas such as Kitui East is suspected. Fortunately, no deaths have been reported in the last few years with a decline in cases indicating potential for elimination in the region.

Partnering with the Kitui county government, the Foundation for Innovative and New Diagnostics (FIND) with support from the END Fund has played a pivotal role in equipping health facilities for VL diagnosis. Mwingi Level IV Hospital and Tseikuru Sub County Hospital are strategic centers for VL diagnosis and treatment. In partnership with the World Health Organization (WHO) and the National Ministry of Health, crucial tests, treatments, and nutritional supplements have been distributed to frontline healthcare facilities to provide timely screening and care to affected individuals.

In 2023, FIND facilitated a discussion with Kitui county health leadership and the National Ministry of Health Department for Vector-Borne and Neglected Tropical Diseases that culminated in the county including VL, in the county integrated development plan (CIDP). The purchase of key medical equipment and engagement of 2,470 paid community health promoters (CHPs) are a step forward to serving all communities. Engagement of CHPs for VL active case searches has been successful with a recent search recording a positivity rate of 16%, emphasizing pivotal roles of healthcare promoters in detection and referral of patients. Routine training of CHPs on VL signs and symptoms is equally important to raise awareness about the disease.

Lynn Kitwan, Chief Officer of Public Health and Sanitation, Kitui County,
Helen Bokea, Director, NTD Program, FIND,
Dawn Maranga, Lead Scientist, VL, NTD Program, FIND.

This op-ed was published in The EastAfrican, 30 January 2024