By Henry Owino
Kacheliba, West Pokot: In the interior remote villages of Katuperot and Sook in Kacheliba, West Pokot County, a rare and little-known neglected Kala-azar disease infests the community. Scientifically known as Visceral Leishmaniasis (LV), it is a disease caused by sandfly bites.
Therefore, Kala-azar or Visceral Leishmaniasis (VL) is protozoan parasite transmitted to humans by the bite of an infected female phlebotomine sandfly (Phlebotomus species), a tiny 1.5 to 3.5 millimetres long insect vector.
Sandflies are much smaller than mosquitoes almost invisible to the naked eye, they are hairy and their wings stand up. They look the same to the naked eye.
Sandflies are most active at dawn and dusk, but may bite throughout the night and on overcast days. They are also more likely to bite when the weather is calm, and are attracted to darker clothing.
Sandfly species generally thrives in semi-arid and arid areas, preferably a relatively dry, warm, and dark environment, with 21°C –28 °C is believed to be a favorable temperature range. Residents of West Pokot are exactly residing in such advantageous weather conditions and shelters for the parasitic protozoa that causes kala-azar.
In Kenya, kala-azar is common in arid and semi-arid regions of North Eastern and Rift valley, especially the Loima Sub- County of Turkana County, Marigat in Baringo East areas, Machakos, Mandera, Garissa, Wajir, and West Pokot counties.
The vector thrives in cracks, crevices of mud plastered houses, heaps of cow-dung, ant-hills (Termes in Pokot local dialect) that dots these areas and acacia trees which leak sap that attracts sand flies as feedstuffs.
In Kenya, kala-azar is common in arid and semi-arid regions of North Eastern and Rift valley, especially the Loima Sub- County of Turkana County, West Pokot, Machakos, Mandera, Garissa, Wajir counties, Marigat and Baringo East areas.
Situational Experience
At Kacheliba Sub-County hospital, a female patient has just arrived from Kasu village approximately 100 kilometres away from the health facility for diagnosis and treatment. Evelyne Lokoriese, aged 30, is accompanied by her husband who will be taking care of her during 3 weeks of treatment at the hospital.
Clinician Leakey Koringura receives Lokoriese and takes her personal details as first things first to examine general health status. Lokoriese is a second timer kala-azar patient, so she has to go through a splenic aspirate diagnostic procedure that involves extracting a sample from the spleen to test for kala-azar parasites.
Extracted sample is taken to the laboratory for testing and results expected out within 20-30 minutes which finds Lokoriese positive for kala-azar. In the meantime, as laboratory detection goes on, clinician Koringura does other mandatory testing to confirm if patient Lokoriese is in good general health status conducive for kala-azar treatment.
So, Koringura does tests on; pregnancy, blood pressure and heart rate which must be standard and normal body weight to commence kala-azar treatment. All these procedures are done simultaneously through a process known as rK39, thus random diagnosis test mostly for any first line kala-azar patient.
Again, the clinician monitors the patient for 12 hours to ensure all vital organs; heart, lungs, kidneys, and liver are functioning normally. The other cautions the clinician pays attention to is any major underlying medical conditions such as HIV, diabetes, cancer, obesity, chronic heart, lung, kidney, and liver disease.
Koringura the clinician confirms patient Lokoriese’s health status and condition as fit for kala-azar medication. He admits her at the female ward scheduling her first injection for kala-azar the next day very early in the morning.
“Our Kala-azar patient, Lokoriese, is now officially admitted to commence her treatment for kala-azar tomorrow Saturday, 14th December 2024. She will stay in the ward for at least 3 weeks in order to receive a full dose of kala-azar medication on time,” Koringura, the clinician explains.
“Patient Lokoriese will receive a 17 -day double injection (34 injections) of Stibogluconate and Paromomycin (SSG & PM) usually administered very early in the morning between 7:00 am to 7:30 am or before sunrise,” Clinician, further clarifies.
Kala-azar treatment requires a patient to be admitted in hospital because of the nature of treatment, need for closer monitoring and distance most patients cover to arrive at the health facility. The patients are usually accompanied by their relatives as care-givers while in most cases patients are children.
Accuracy and Precision Part of Treatment
According to Koringura who handles most of kala-azar patients and drugs, SSG & PM, are usually administered very early in the morning because it is highly reactive to sunlight. So, treatment requires accuracy in timing and correct medication to avoid any medication errors that can significantly harm patients.
“Remember combination of the two drugs thus; SSG &PM for 17 days thus making a total of 34 injections is specifically for patients in the age bracket of 3 to 45 years. Because of its sensitivity to sunlight, it is administered very early in the morning to avoid any reactivation to sunlight,” Koringura further clarifies.
The Clinician however, says special groups for kala-azar patients are those below ages 3 years or above 45 years, pregnant mothers and patients with pre-existing medical conditions are treated with AmBisome (amphotericin B). This medication is usually given to a patient through intravenous infusion for 6-10 days.
Koringura, who was the nurse on duty during the Talk Africa, Science Journalist visit at Kacheliba hospital, says apart from rK39 random diagnosis test, there is Direct Agglutination Test (DAT). So, DAT is used when rK39 fails to give accurate results yet patients continue complaining and show persistence symptoms of kala-azar.
Generally, DAT diagnosis is a simple, accurate, and efficient test that can be used in remote settings.
Remember, a health professional may perform a microscopic examination of tissue aspirate from the spleen, bone marrow, or lymph node, a process known as splenic aspirate. Again, patients may also be advised to come back to hospital after 3-6 months for clinical re-examination.
Female Ward
Inside the 20-bed female ward there are 14 kala-azar patients both young and old. A 68-year-old, Rutono Cheplege lies on bed, emaciated with sunken eyes and protruding cheekbones due to weight loss.
Cheplege could easily pass off as another case of malnutrition which is also common in West Pokot. Fortunately, doctors at the health facility diagnosed her with Kala-azar. It is a prevalent disease in the area with signs and symptoms of substantial weight loss, prolonged fever, progressive anemia(pancytopenia), enlargement of spleen(splenomegaly) and liver (hepatomegaly).
Kala-azar is the most severe form of the disease and, if left untreated, is usually fatal. The World Health Organization (WHO) ranks kala-azar as the second killer of parasitic diseases after malaria.
To get treatment, Cheplege and her granddaughter Tabitha Chebet aged 23, had to make a 130-kilometre journey from Chepareria, in Pokot South to Kacheliba Level 4 hospital. The grandmother had been bedridden for weeks with pain, fever that would not go away and was frail from not eating due to lack of appetite (Anorexia).
The first few days the old mother arrived at the health facility, nurses had to put her on nutritional medical treatment (MNT) to restore normal body weight, a requirement if diagnosed positive for kala-azar.
Stabilizing Kala-azar Patients is Crucial
Jackline Chepengat, a nurse at the female ward, clarifies that malnutrition treatment depends on the type of malnutrition, severity of the condition, and the patient’s age. For instance, at Kacheliba hospital, we have oral nutritional supplements (ONS), enteral tube feeds, which are administered directly into the gastrointestinal tract and parenteral nutrition, which is used intravenously.
“Cheplege is an elderly mother and for her condition, we put her on ONS with macronutrients and micronutrients designed to be consumed orally, thus taste and format are important considerations to hasten her stability,” Chepengat explains.
Cheplege, the elderly lady was first treated for malnourishment for close to two weeks. She is currently on AmBisome drugs for kala-azar treatment owing to her age but she doesn’t have any pre-existing health condition.
Medics at Sigor Sub-County hospital where the old woman had first sought medical attention after herbs from traditional healer failed to cure her, advised Chebet, the grand-daughter to rush her to Kacheliba Level 4 hospital. It was not easy for the care-giver and patient to take the advice owing to the patient’s age, health condition, distance to Kacheliba and unexpected urgent referral.
“Sigor Sub-County hospital was close to home and comfortable for me to stay as a care-giver. Additionally, we had heard of better treatment at Kacheliba sub-county hospital but were discouraged by its physical location from our home in Chepareria,” Chebet reveals.
“A relative who was treated by kala-azar had told us that West Pokot County Government was in collaboration with the Drugs for Neglected Diseases initiative (DNDi) thereby commissioning several crucial healthcare projects than ever before,” she affirms. Adding, Sigor health facility has not been picked as Kacheliba.” Chebet compares.
“Concerning referral, I was a bit skeptical, thinking the medics were politely raising a red flag for us to give up with treatment of my grandmother. Before making up my mind on what to do as the only care-giver at that moment, I further consulted for help back at home,” she recalls vividly.
Chebet says parents at home informed her to heed to medics’ suggestion but her grandmother resisted. Seeing the granddaughter’s tears flowing with pain, the elderly woman confessed and changed her mind, accepting a referral to Kacheliba hospital.
Up to the time of going to press, Cheplege was much stable and stronger than the previous two weeks since admission. Nurses confirmed to the media that the patient was increasingly improving and responding well to treatment.
“Our patient is doing well and much better than when she came. Chances of her survival are high as she gets better day after day. Grand-daughter who is also the care-giver, at least nowadays looks joyful, confident and she sees light at the end of the tunnel,” Chepengat the female nurse observes.
The elderly patient was scheduled for discharge in just a few days according to the nurse Chepengat in charge of the female patients.
Male Ward
In the wing of male ward, there were 8 kala-azar patients together with their care-givers. Majority were teenagers meant to be in high school and colleges from the look of their appearances.
John Lokoel, is 19 years old, a form 3 who hails from Nabeiye village, Kalem Ngorok in Turkana South Sub-County. He had no choice but to travel approximately 270 kilometres from Turkana to Kacheliba Sub-County hospital for kala-azar treatment.
Lokoel initially preferred Kapenguria County Referral hospital for his treatment on Kala-azar but was told the facility had no drugs for it. After 3 days of bed-rest, he proceeded to Kacheliba Kala-azar hospital on a transfer mission.
“Medics at Kapenguria referral hospital informed me of my illness and they were sorry that my health condition could only be treated at Kacheliba kala-azar hospital. I was shocked, almost fainted but managed to calm down through counselling,” Lokoel narrates.
The fact that kala-azar disease is curable gave Lokoel hope. The only problem is that it doesn’t respond to antibiotics or malarial drugs. The WHO ranks kala-azar as the second largest parasitic killer in the world after malaria, and of the most dangerous neglected tropical diseases (NTDs).
“At Kapenguria County Referral hospital, I was admitted for 3 days of bed-rest to regain energy before proceeding to Kacheliba kala-azar health facility about 20 kilometres away. The journey and distance may add more suffering to already sick patients due to tedious and costly transport though treatment is absolutely free,” Lokoel grumbles.
At Kacheliba Sub-County hospital, Lokoel disclosed his admission was welcoming and medics assured him of quick recovery. He only complains of daily painful injections going for almost 3 weeks which for him is just too much to withstand.
“Injections are very painful. It makes some of us contemplate sneaking out of the hospital. We need better and simpler treatment, not necessarily injections. Sitting upright is becoming uneasy, forcing me to be always on my sideways,” Lokoel agitates for alternative medication.
Death Rate of Kala-azar Patients
According to Bruno Shimenga the hospital records keeper, the death rate as a result of kala-azar disease is very low, almost nil among patients undergoing treatment. But during an outbreak, fatalities may shoot up by very minimal percentage.
Bruno says there are only two kala-azar health facilities in the North Rift region (Sigor and Kacheliba), which is made up of eight counties including West Pokot. This forces patients to travel long distances over rough terrain in search of medication costing them more on transport.
Considering most patients are always accompanied by their relatives as care-givers, makes the journey much more expensive. He discloses Kacheliba kala-azar wards receives at least 5 patients daily thus about 140 kala-azar patients in a month.
Kala-azar outbreaks are usually in the months of June to August and again between January – March which are very dry seasons in the region.
“We thank our partners especially DNDi for support in equipment provision which are used across the board regardless of the patients’ ailments. Be it malaria, pneumonia, typhoid, cholera, name it. Otherwise, the hospital could not be in a position to deal with kala-azar prevalent on its own for lack of resources,” Bruno admits.
Bruno says DNDi has really upscale the health facility in terms of laboratory equipment, drugs, beds, and modern kitchen. The hospital has been upgraded to Level Four though with a few challenges that are being sorted out progressively.
