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VL elimination and post-elimination management in Bangladesh

Dr Mondal talks about the National Kala-azar Elimination Programme in Bangladesh and how best proceed once the elimination target has been reached.
DR DINESH MONDAL: For elimination of kala-azar as a public health programme, it means that to bring down the number of the cases less than one per 10,000 population, in Bangladesh at sub-district level, in India in block level, and in Nepal, at district level. So fortunately, Nepal already achieved its target. They bring down the number of kala-azar cases at district level, less than one per 10,000 population. Bangladesh last year achieved 98 percent of its target. We are very hopeful that by this year, Bangladesh will achieve their target, that in 100 sub-districts, the number of cases of kala-azar will be less than one per 10,000 of the population. The Indian programme and that is also very much inspiring, very impressive.
They are very close, also very close to achieving elimination target very soon. So sustainability is now a challenge, because what they achieved, they have to sustain it for the next three subsequent years. Then the WHO certified that yes, kala-azar is eliminated from Bangladesh, from Nepal, or from India, wherever it is. And I think during this consolidation and maintenance phases, programmes should develop new strategy such as, is if there is a new case of kala-azar. So how they should respond? If there is a case from non-endemic area, how programmes should respond? And also getting the vector control, it is a very tough job, because it needs huge infrastructure, human resources, and logistics.
And right now, you can divide the kala-azar, I mean endemic areas, where the programme activity is going on. So let’s say these programme areas, but there are some other areas from where the kala-azar cases, are you know, emerging. So in those places, there is no, I mean, control activities by the national programme. So how programmes should respond to those areas? To new cases of VL, if there is a new case of VL, how programmes should implement their activities? So when you are getting all these issues, programmes should develop some new strategies for the maintenance – and for the consolidation and mentoring phases of the elimination programme.
In Bangladesh, we have national guidelines for kala-azar and post-kala-azar dermal leishmaniasis case management, case detection. We have guidelines for vector control. And recently, we also, the programme, thanks to the KalaCORE activities, now have a guideline for the outbreak investigations. So another guideline is under preperation that is monitoring and evaluation. So all the necessary documents are there in the Bangladesh programme. In addition to guidelines, training is very important. Training is becoming more important, because when the caseload is going down, people start to forget.
This is why the programme should emphasise training of doctors, nurses, lab technicians, and people who are doing the high risk vector control activities, et cetera. So that training is also important, and activities regarding community– to build up a community awareness, through BCC/IEC activities, these activities must be continued, with high priority during the consolidation and the maintenance phase of the elimination programme. Otherwise, people will forget about kala-azar and it will be neglected and the disease will come back again.

The film in this step shows Dr Mondal, a Senior Scientist at Bangladesh’s International Centre for Diarrhoeal Disease Research, talking about the National Kala-azar Elimination Programme and how best proceed once the elimination target has been reached.

Among the endemic regions for VL globally, countries in the Indian Sub-continent (ISC) have made phenomenal progress in approaching elimination of the disease. Since the early 2000s, several ongoing efforts to control VL in the region have contributed to this achievement. In 2005, the governments of Bangladesh, India and Nepal signed a Memorandum of Understanding (MoU) to eliminate VL by 2015[1]. In 2014, the elimination target was extended to 2017 at a regional meeting in Dhaka, where a new MoU was signed by the health ministers of Bangladesh, India, Nepal and also Bhutan and Thailand[2].

Meanwhile, global commitment for NTD elimination has also increased. In 2012, the WHO NTDs Roadmap set out the target to eliminate a range of different NTDs including VL by 2020s[3]. This together with the 2012 London Declaration[4] have encouraged NTD elimination activities, not only by providing technical guidance but also by securing funds and resources and supporting key partnerships.

At present (2018), the goal of elimination of VL or kala-azar as a public health problem in the ISC is defined as less than 1 cases per 10,000 per year – at the sub-district in India and Bangladesh and at the district level in Nepal. Nepal has achieved this goal unofficially; despite a significant decrease VL cases, India has yet to achieve the target, and Bangladesh officially achieved the target at the end of 2017.

Bangladesh first launched its National Kala-azar Elimination Programme (NKEP) in 2008. The VL elimination programme consists of three separate phases[5]:

  1. attack (achieving the target by 2017)
  2. consolidation (sustain target for three years i.e. from 2017–2019)
  3. maintenance (sustain target beyond 2020)

Dr Dinesh Mondal, Senior Scientist at the icddr,b a research and implementation institute in Bangladesh working closely on VL control and elimination, spoke to us in the spring of 2017, just before elimination was announced. Some of the (national) guidelines, on case management, outbreak response and monitoring and evaluation that Dr. Mondal refers to can be found in the references section below[6].

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Control and Elimination of Visceral Leishmaniasis

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