Guidelines for diagnosis, treatment and prevention of visceral leishmaniasis in South Sudan

Transcription

1 Guidelines for diagnosis, treatment and prevention of visceral leishmaniasis in South Sudan

2 Acromyns DAT FDA IM IV KA ME ORS PKDL RBC RDT RR SSG TFC TOC VL WBC WHO Direct agglutination test Freeze dried antigen Intramuscular Intravenous Kala azar Mercaptoethanol Oral rehydration salt Post kala azar dermal leishmaniasis Red blood cells Rapid diagnostic test Respiratory rate Sodium stibogluconate Therapeutic feeding centre Test of cure Visceral leishmaniasis White blood cells World Health Organization

3 Table of contents Acronyms... 2 Acknowledgements... 4 Foreword Introduction Background information Lifecycle and transmission patterns Human infection and disease Diagnosis Clinical diagnosis Laboratory diagnosis Diagnosis of primary kala azar Diagnosis of relapse Diagnosis of PKDL Treatment Treatment of primary kala azar (new cases) Treatment of relapse of kala azar Treatment of PKDL Other treatment related issues and special situations Treatment of concurrent infection and malnutrition Information system Prevention and control Annexes Annex 1. rk39 rapid diagnostic test procedure Annex 2. Direct agglutination test procedure Annex 3. Lymph node aspirate procedure Annex 4. Bone marrow aspiration procedures Annex 5. Procedures for splenic aspiration Annex 6. Preparation and examination of aspirates. grading of parasites Annex 7. Kala azar laboratory register book Annex 8. Kala azar treatment register book Annex 9. Kala azar patient treatment card Annex 10. Kala azar patient discharge card Annex 11. Dosage and precautions for the use of sodium stibogluconate (SSG) Annex 12. Dosage and precautions for the use of paromomycin (aminosidine) Annex 13. Dosage, administration and precautions for meglumine antimoniate Annex 14. Anthropometry and nutrition therapy look up tables Annex 15. Overview of treatment for concurrent illnesses in kala azar Annex 16. Medicine guidelines for kala azar Annex 17. Kala azar monthly reporting forms Annex 18. Kala azar weekly reporting forms... 82

4 Acknowledgements The Visceral Leishmaniasis (VL) guideline for South Sudan has been updated through a highly participatory process involving officials from endemic kala-azar states, World Health Organization representatives from Geneva-HQ, Cairo-EMRO, Sudan, Ethiopia, Somalia, UNICEF South Sudan, UN-OCHA, international (MSF s, CMA, DoT) and national partners. I sincerely appreciate and commend the role of the World Health Organization in supporting the Ministry of Health financially, technically and logistically; without which this document would have not been materialized. I would like to thank health workers in twenty four kala-azar treatment facilities; in particular nurses, laboratory technicians and community health workers. Without their continuous daily efforts in diagnosing, treating and monitoring patients, no progress on kala-azar guidelines would have been possible. A special thank you is extended to Dr Jose Postigo for valuable comments, guidance and effective assistance during the guidelines preparation and printing process. The guidance provided in this document has been drawn from vast experience and lessons learnt from global, regional and local level. We hope the guideline will unify kala-azar management in endemic foci and will be able to significantly reduce the high burden of kala-azar in the endemic states. Dr. Lul Riek, Director General for Community and Public Health, Ministry of Health, South Sudan-Juba 4

5 Foreword Visceral Leishmaniasis (VL) is the third most important vector-borne disease after malaria and lymphatic filariasis. It was responsible for an estimated 10,000 new cases in 2010, and a 4% case fatality rate in twenty four kala-azar treatment facilities in Jonglei, Upper Nile, Unity and Eastern Equatoria States of South Sudan. Efficient case management is the key to limit morbidity and to prevent mortality, and is also a measure to control the reservoir and transmission of the disease. South Sudan has upgraded from a first line regime of mono-therapy, sodium stibogluconate (SSG) for 30 days, to combination therapy of sodium stibogluconate (SSG) and paromomycin injections for 17 days; this is more effective than SSG monotherapy. In addition it offers the advantage of halving the patient s required hospital stay, thus reducing overcrowding and the risk of nosocomial outbreaks of infectious diseases associated with overcrowding. Based on the guidelines, the WHO South Sudan office is willing to support the National Ministry of Health in providing training on VL diagnosis, treatment and prevention to the health workers in the twenty four kala-azar treatment facilities. The guidance provided in this document has been drawn upon vast experience and lessons learnt from global, regional, government, and national partners. It is the Ministry s hope that the document will be a source of renewed motivation for a more unified, directional and concerted effort in further improving the diagnosis and management of kala-azar patients. Let us now, and in years ahead, join our efforts and ensure that the plan translates into concrete, focused and sustained actions. We hope this document will guide the Ministry s efforts towards controlling kala-azar in South Sudan. We are looking forward to the cooperation and harmonization of the treatment regime in South Sudan. Dr. Makur Mathur Koriom, Undersecretary, Ministry of Health, South Sudan-Juba. 5

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7 1. Introduction 1.1 Background information Leishmaniases is caused by over 20 species of parasitic protozoa of the genus Leishmania. The disease, transmitted to humans by sandflies (Phlebotomus and Lutzomyia species), is endemic in 98 countries or territories, affecting around two million people each year. Depending on the species of the parasite and the immune response of the host, the disease spectrum of leishmaniasis ranges from self healing skin lesions to a fatal systemic disease called visceral leishmaniasis (VL) which is also known as kala azar (KA), a Hindi term meaning black fever. Human leishmanial infections can result in 3 main forms of disease: Cutaneous leishmaniasis Muco cutaneous leishmaniasis Visceral leishmaniasis (kala azar) Visceral leishmaniasis (kala azar) is a deadly disease caused by the protozoan Leishmania parasite, transmitted through the bite of Phlebotomus sand flies. The World Health Organization (WHO) estimates that globally about 500,000 new cases and over 50,000 deaths of kala azar occur every year. Over 90% of these cases are from seven countries: Bangladesh, Brazil, Ethiopia, India, Nepal, Sudan and South Sudan. In Africa, there are six countries endemic for VL, namely Ethiopia, Kenya, Somalia, Uganda, South Sudan and Sudan. Kala azar generally affects poor and neglected populations living in remote rural areas. If not treated, more than 95% of kala azar cases will eventually result in death. Eastern Africa is one of the world s main kala azar endemic areas, with the majority of the burden being concentrated in focal areas in the east and south east of Sudan. In South Sudan, kala azar occurs in two separate foci in four states and is caused by Leishmania donovani. Phlebotomus orientalis is the vector in the northern kala azar focus of Upper Nile, Jonglei and Unity States, while Phlebotomus martini is responsible for transmission in the southern focus in parts of Eastern Equatoria State. Studies have found domestic animals infected with the parasite, but whether these play a role as disease reservoirs has not yet been proven, and transmission is believed to be anthroponotic. The disease was first reported from South Sudan in 1904 and the first epidemic was documented in 1940, with a death rate of 80%. In 1988 it emerged that an epidemic had been devastating the Western Upper Nile since 1984, ultimately causing an estimated 100,000 deaths in a population of over a ten year period. 1.2 Lifecycle and transmission patterns Kala azar is transmitted to humans through the inoculation during a blood meal of the promastigotes by an infected female Phlebotomus sandfly. The form of the parasite that infects man is called a promastigote. The promastigotes are injected into the skin of a healthy person through the bite of an infected female sandfly. Following inoculation, the promastigotes are taken up by the phagocytic cells and develop into amastigotes. The amastigotes spread in the

8 blood and multiply in the macrophages of the spleen, liver, bone marrow, lymph nodes, and the mucosa of the small intestines. Intracellular and free forms of amastigotes are ingested by a female sandfly while feeding on blood. After about 72 hours, the amastigotes become flagellated promastigotes in the mid gut of the sand fly. The promastigotes continue to multiply and fill up the sandfly gut. Subsequent migration to the mouth follows in 4 to 6 days time making promastigotes ready for inoculation when the vector takes the next meal (Figure 1). Different species of sandflies need different habitats to survive and have different biting patterns (in and outdoors, forest or village, day or night preferences). This has important implications for the transmission and possible control measures. The sandfly is found in specific habitats, in Greater Upper Nile (Upper Nile, Jonglei and Unity States) it is found in forests with Acacia seyal, or Balanites aegyptica which grow on the cracked grey clay soil (black cotton soil). In Equatoria the sandfly is found in old/abandoned termite hills. In Greater Upper Nile the sandfly is present in the second part of the dry season (March to July, mainly from April to June) while in Equatoria the sandfly is active throughout the dry season. The sandfly bites at night (from dusk to dawn) with peak biting activity from 6:30 to 9:30 pm. 1.3 Human infection and disease Most individuals infected by Leishmania donovani will not develop the disease (90% of asymptomatic or sub clinical infections). When the host immune system is not able to suppress the parasite, VL will develop. After an incubation period of 2 to 6 months, sometimes longer, patients will present with fever, anorexia, headache, sometimes with cough, abdominal pain, diarrhoea, vomiting, epistaxis (nose bleeding) and symptoms of anaemia. After several weeks of illness, splenomegaly develops and weight loss becomes prominent, sometimes leading to severe malnutrition. If left untreated, the disease leads to death in more than 95% of cases, often from superimposed bacterial infection, severe anaemia or bleeding. 8 Figure 1. Life cycle of the leishmania parasite.

9 2. Diagnosis 2.1 Clinical diagnosis A patient will be considered as a clinical suspect of VL if she/he presents with a history of prolonged fever (2 weeks or more) associated with clinical splenomegaly or wasting (weight loss). Case definition of a clinical suspicion of VL History of prolonged fever (more than 2 weeks) AND splenomegaly or wasting (weight loss) NO ONE SHOULD BE TESTED FOR KALA AZAR UNLESS THEY HAVE A FEVER. CHECK THE TEMPERATURE you may need to check in the afternoon. EXCEPTION: Occasionally you will clinically diagnose a severely malnourished patient with kala azar without finding a fever because they are too sick. As only 50 60% of patients meeting this clinical case definition have kala azar, the diagnosis needs to be confirmed serologically or parasitologically. The main differential diagnoses for KA patients are: Malaria Hyperreactive malarial splenomegaly (HMS): formerly called Tropical Splenomegaly Syndrome (TSS). This condition results from multiple partially treated malaria episodes Schistosomiasis: the splenomegaly is caused by portal hypertension and the fever is usually caused by another condition (e.g. pneumonia) Brucellosis: the splenomegaly is usually not massive; hepatomegaly; joint, bone and occasionally neurological involvement Typhoid fever: high grade fever, bradycardia, duration of illness less than one month, impaired mental status, constipation Tuberculosis: usually no splenomegaly, but possible in case of miliary tuberculosis; respiratory symptoms Splenic abscess Myeloproliferative diseases Malignancies of lymphoid origin (leukemias and lymphomas) Chronic haemolytic anaemia A kala azar patient can have either primary kala azar relapse or PKDL. The definitions for each are as follows: Primary kala azar: This refers to a patient who is diagnosed with KA for the first time. The patient had not been treated for KA before. Relapse: This refers to a patient who has completed a full treatment course and then returns with proven kala azar. If a patient was treated for at least 15 days with an appropriate amount of antimonial as single therapy more than one month ago, and then returns with proven KA she/he is also considered as a relapse. Relapses are diagnosed parasitologically and are mainly observed within 6 months after treatment. 9

10 Post kala azar dermal leishmaniasis (PKDL): PKDL is a recognized complication, occurring in a very mild form in about 50% of kala azar cases, and in severe forms in few cases. Usually, skin lesions develop months after the clinical cure of kala azar, but sometimes PKDL occurs during treatment or even before kala azar. In most of these cases however, a previous infection occurred subclinically. In some cases no history of previous KA is known. The lesions of PKDL start on the face as small scattered hyper pigmented macules and papules. The rash can become nodular and spread to the trunk and limbs. It is symmetrical and non itching. A grading system is used to describe the spread of the skin lesions: Grade 1: Scattered macular, rash on the face around the mouth with some lesions on the upper chest and upper arms. Grade 2: Dense macular, or nodular rash covering most of the face and extending to the chest, back and upper arms and legs. If extensive or black nodules, it is severe grade 2. Grade 3: Dense macular, rash, covering most of the body, including hands and feet. In grade 3 crusting ulcers, scaling and spreading to the mucosa of the lips and the palate occurs. PKDL might persist for years (up to 10 years have been reported). It is speculated that PKDL patients could form a reservoir of the parasite in the community. Bed nets should be given to PKDL patients to prevent transmission. Majority of PKDL cases are self limiting so treatment is not needed, only severe grade 2 and grade 3 are treated with specific medicines. PKDL is diagnosed clinically therefore none of the kala azar laboratory tests (rapid tests, DAT and aspirates) should be done. 2.2 Laboratory diagnosis Before proceeding to any blood testing for primary visceral leishmaniasis (DAT or rapid diagnostic test) first exclude malaria by doing a blood test and treating if positive, or if no testing is possible simply treat and evaluate after 4 days. If the patient still has a clinical diagnosis of kala azar, a blood test should be done. A patient who is severely ill can be tested for kala azar while at the same time getting treatment for malaria. If the patient has been treated for kala azar before with sodium stibogluconate (SSG) for 15 days or more and is sick again they do NOT need a DAT test. They may have a relapse. Diagnostic techniques involve serological and parasitological tests: Serological tests: - Rapid diagnostic test (RDT) (rk39 dipsticks Inbios and DiaMed IT LEISH also known as Opti Leish - Direct agglutination test (DAT) Parasitological tests: - Lymph node aspirate 10

11 - Splenic aspirate - Bone marrow aspirate Serological tests Several tests have been developed to detect antibodies against Leishmania in the blood or serum of VL patients. The most common serological tests used in the diagnosis of kala azar are the DAT and the rk39 dipstick tests. These tests indicate the presence of antibodies against Leishmania, therefore confirming the parasite (antigen) is, or was, present in the body. Inbios and DiaMed IT LEISH test are the commonly used and recommended rapid diagnostic tests in a dipstick format. The rapid tests allow diagnostic confirmation of kala azar at the peripheral health facilities, leading to early treatment and better prognosis. DAT is a robust and well validated test that requires more material and training. The procedure is a bit complex, thus requires health facilities with a laboratory, cold chain and well trained staff. Serological tests can only be used for the diagnosis of primary kala azar (patients with no prior history of kala azar, the ones who had not previously been treated for kala azar). For patients with a prior history of KA who present with a suspicion of relapse one cannot rely on a serological test for diagnostic confirmation, as specific anti leishmania antibodies can persist for several years. Rapid diagnostic (rk39 antigen based) tests The rapid diagnostic rk39 based tests (RDT) are easy to perform, quick, cheap and give reproducible results. They can therefore be used for early diagnosis of visceral leishmaniasis at both peripheral and central levels. The RDTs detect specific antibodies against the kinesin related antigen that is present in Leishmania donovani. The procedure of the rk39 dipstick is simple with results available within minutes (Annex 1). They do not require extra material and results are stable over time, allowing for quality control. The rk39 rapid tests are therefore the recommended tests for use in South Sudan for confirmation of the diagnosis of kala azar among clinical suspects with no prior history of the disease. Interpretation of dipstick results Positive: This patient needs admission (if they were never treated before) and treatment. Negative: This patient must await the result of the DAT test. Do not let that person leave. Treat for all other illnesses while they wait. Give ferrous and folic acid while waiting. Direct agglutination test The DAT can be performed using either blood (dried blood on filter paper) or serum. The DAT antigen is prepared from formalin killed promastigote stages of L. donovani cultures and stained 11

12 blue for visibility. The test is semi quantitative and gives antibody titres ranging from 1:100 up to 1: It is a highly sensitive (>95 %) and specific (>85 %) test when performed according to standardized procedures (Annex 2). It requires a well trained laboratory technician to undertake the process over a period of 2 to 3 days to obtain results. The DAT should be performed in a health facility with a laboratory, cold chain and well trained staff. The DAT cut off points vary between the type of antigen used either freeze dried antigen (FDA) or liquid antigen. The freeze dried antigen is more preferred in the field due to its stability during transportation and is therefore recommended for South Sudan. The positive cut off titre for freeze dried antigen is 1:3200 (well 7). Other cut off points for FDA are as follows: DAT negative (< 1: 400): VL is very unlikely. Alternative diagnoses (e.g. malaria, disseminated tuberculosis, brucellosis, typhoid fever, etc.) should be looked for and treated. If there is no response to treatment for a proven or suspected alternative diagnosis and if clinical suspicion of kala azar is high (i.e. much enlarged spleen), the tests can be repeated within a month or a parasitological test (lymph node/bone marrow/spleen aspiration) is performed to search for the Leishmania parasites. If the DAT is positive ( 1:3200): Kala azar is very likely and specific treatment should be initiated. If the DAT is borderline (1: 400, 1:800 and 1:1600), the test should be repeated within one month or alternatively a parasitological test (lymph node/bone marrow/spleen aspiration) should be performed in the absence of contraindication. Parasitological diagnosis Visceral leishmaniasis can be confirmed by microscopical examination of stained slides of lymph node, bone marrow, or spleen aspirates (Annexes 3 6). Specificity of these tests is near 100 % provided that slide staining is done properly, and that the laboratory technicians are well trained. Spleen aspirate is more sensitive (96%) than bone marrow (70%) or lymph node (58%) aspirates. Bone marrow aspirate is a very painful and invasive medical procedure that needs expertise and optimal sterilization of the puncture material. The procedure of lymph node aspiration is also quite painful. Spleen aspiration should be limited to hospital settings or health facilities where there is adequate equipment and trained staff to manage complications appropriately. Transfusion facilities should be present. Provided that the test is performed properly, the rate of life threatening bleeding after a spleen puncture is very low. The patient must strictly rest in bed for at least eight hours after the procedure and remain under close nursing observation. Spleen aspiration is contra indicated in the following situations: Spleen barely or not palpable Jaundice (a sign of possible liver dysfunction) Signs of active bleeding (nose, skin, digestive, etc). A history of recent nose bleeding without active bleeding is not a contra indication for spleen aspiration Severe anaemia (Haemoglobin < 5.5 mg/dl) Pregnancy 12

13 Patient in very poor general condition Low blood pressure Uncooperative patient or caretaker Lack of informed consent from patient or caretaker In patients with contra indication(s) to spleen puncture, bone marrow or lymph node aspirates can be done, provided that enlarged lymph nodes are present. 2.3 Diagnosis of primary kala azar The clinical indications for parasitological diagnosis (spleen, bone marrow or lymph node aspiration) are the following: Clinical suspect with a prior history of kala azar (suspicion of relapse) VL patient not responding to anti Leishmania treatment (test of cure) Clinical suspect with a borderline DAT result (1:400 1:1600) Clinical suspect with a negative rk39 dipstick or DAT results but with strong clinical suspicion of kala azar AND absence of alternative diagnosis or no response to treatment of alternative diagnosis. Figure 2 shows the diagnostic algorithm to guide you when to use each of the tests mentioned above and how to interpret the result in terms of treatment decisions. All diagnostic tests must be properly recorded on the laboratory register book (Annex 7). KA testing is administered to clinically VL suspect patients since most people infected by Leishmania do not develop the disease (KA). It is crucial to enquire about any previous treatment for KA because serological tests will test positive even after a successful treatment after several years. The first test to be used in a clinically VL suspect, who has not been previously treated, is the RDT. Treatment should start when the RDT is positive. In case of a negative RDT result, then blood should be tested for DAT. If the DAT result is positive the patient should be treated. If the DAT result is borderline, the test should be repeated not earlier than one week later, or a parasitological test must be performed. If the DAT result is negative another disease has to be considered. If a person shows a borderline DAT result and the parasitological test is positive the person has to be treated for KA. If the parasitological test is negative then re test for DAT or search for another diagnosis. In health facilities where either RDTs or DAT is not available the following is recommended: RDT not available: Take a blood sample using filter paper to perform DAT either in your health facility or at the referral laboratory. At the same time you can do a parasitological test. If the parasitological test shows Leishmania parasites then treatment can be started. If parasites are not observed wait for the DAT results. DAT not available and RDT is negative or not available: Take a blood sample using filter paper to perform DAT at the referral laboratory. 13

14 At the same time you can do a parasitological test. If the parasitological test shows Leishmania parasites then treatment can be started. If parasites are not observed wait for the DAT results. 2.4 Diagnosis of relapse A relapse of kala azar means that a person has kala azar but has already been treated before. Relapses usually occur within 6 months after treatment. If a patient presents with fever for more than 2 weeks, and has a palpable spleen, ask if they have been treated for kala azar before. A serological test cannot diagnose a relapse because it can still be positive for months to 2 3 years after treatment even if a person is feeling well. If the serological test was done and was negative, there is usually no relapse! 2.5 Diagnosis of PKDL Post kala azar dermal leishmaniasis is usually known as PKDL. This is a rash that starts on the face. This rash may sometimes spread to the whole body but it always starts on the face. This rash usually starts within 6 months of having kala azar. Sometimes it starts at the end of kala azar treatment. Rarely was the person not previously treated for kala azar. PKDL usually heals by itself. Sometimes it comes and goes for years. Sometimes it gets worse and worse. Sometimes it affects the mucous membranes. The diagnosis of PKDL is easier if you study the pictures. Note that people can die with severe PKDL and that PKDL itself may be a reservoir for kala azar infection. 3. Treatment The treatment regimens should follow these national guidelines in all treatment centers in South Sudan. All patients treated for KA must be registered in the designated KA treatment register book (Annex 8). On admission the KA treatment card will be also filled in so the data can be entered in the national data base of the Ministry of Health (Annex 9). At discharge the patient will be given a card which will be useful for his/her reference, especially when the person visits another health facility or health personnel (Annex 10). Patients must be encouraged to return for a follow up visit six months after discharge to make sure the treatment was successful. The date of that post treatment visit is the final cure date to be recorded in the KA treatment card. 3.1 Treatment of primary kala azar (new cases) Treatment should normally be given only after confirmation of disease based on the clinical examination and the laboratory tests. At the same time, the presence and extent of concomitant 14

15 Figure 2. Diaignostic algorithm of primary visceral leishmaniasis (VL) in South Sudan LN: lymph node aspirate BM: Bone marrow aspirate SP: spleen aspirate (1) Rarely DAT negative patients would need LN/SP/BM Clinical VL suspect Rapid diagnostic test Negative Positive Send blood for DAT DAT RESULT Positive Borderline VL treatment DAT Freeze Dried Positive: 1:3200 Borderline (BL): 1:1600; 1:800; 1:400 Negative: 1:200 Re test in 1 week or perform LN/BM/SP aspirate VL treatment Negative Lymph node, bone marrow or spleen aspirates Fever > 2 weeks with splenomegaly or wasting (malaria and previous VL ruled out). Search for other diagnosis and treat OR refer (1) Negative Positive Search for other diagnosis and treat OR refer OR Re test DAT in 1 week VL treatment Guidelines for diagnosis, treatment and prevention of visceral leishmaniasis in South Sudan 15

16 infection should be ascertained, as this may influence the choice of therapy or supportive treatment. In many cases, supportive treatment, for example rehydration or nutritional supplementation, may be required before the start of therapy. Treatment should be given under the supervision of medical personnel. The objectives of kala azar treatment are: to reduce parasites to below the level of detection support the patient s nutrition and hydration to treat complications to prevent resistance development to reduce or interrupt transmission of infection in the community Hence, daily monitoring of each VL patient s signs and symptoms is necessary. Obtaining important baseline information such as spleen size, haemoglobin, and body weight is also crucial. Weight should be taken weekly and medicine dosage adjusted accordingly. Treatment on the spot is important since some patients need treatment for other illnesses. Treat all the illnesses while waiting for the DAT result. Give ferrous and folic acid tablets while waiting for the results Treatment regimens (options) for primary kala azar First line regimens for primary kala azar 1. Sodium stibogluconate (SSG) and paromomycin (combination therapy) In this combination therapy, sodium stibogluconate, 20mg/kg body weight /day, and paromomycin injection, 15mg/kg body weight /day are given intramuscularly for 17 days (Annex 11 12). This combination treatment is the first choice and line of therapy as the safety and efficacy is similar to the pentavalent antimonials monotherapy, and considerably shortens the treatment duration. 2. Sodium stibogluconate (monotherapy) SSG in monotherapy is administered as intramuscular injections 20 mg/ kg/day for 30 days. In the absence or stock ruptures of paramomycin the pentavalent antimonials sodium stibogluconate (SSG) and meglumine antimoniate can be used in monotherapy (Annex 13). Remember that: 16 There is no upper limit for SSG, but doses above 10 ml should be given in 2 separate injections. The smallest dose is 2 ml for everyone over 5 kg in weight. For severe vomiting the SSG should be stopped for 2 to 5 days until the vomiting stops.

17 If a child weighs 5 kg or less she/he is usually severely ill. Give 1 ml daily and follow closely. Patients with severe ascites may need a lower dose. If the patient has severe ascites: - Subtract 5 kg from the weight of an adult - Subtract 2 kg from the weight of a patient weighing between kg - Subtract 1 kg from the weight of a patient weighting between kg Then calculate the dose of SSG. Weigh the patient weekly and recalculate the dose accordingly. Conditions for withdrawal of SSG: Acute pancreatitis Aberrations of creatinine Jaundice developing during treatment Excessively high LFT values, i.e. > 5x normal values of SGPT/SGOT Any evidence of cardiotoxicity (prolonged QT interval, cardiac arrhythmia) Declining haematological measurements (HCT, total WBT counts) Uninterrupted vomiting Failure to respond favorably during the first 2 weeks of treatment If SSG needs to be withdrawn, then ambisome can be used as a second line option. Contraindications: Patients with known cardiac diseases. Coadministration of quinine or any other medicine known to cause cardiac toxicity. HOW TO CALCULATE THE DOSE OF SSG SSG vials contain 100 mg / ml so it is calculated as follows: Dose in ml = Body Weight in kg x 0.2 EXAMPLES: If your patient weighs 40 kg 40 x 0.2 = 8 so give 8 ml If your patient weighs 32 kg 32 x 0.2 = 6.4 so give 6.4 ml If your patient weighs 8 kg 8 x 0.2 = 1.6 but give 2 ml (the lowest dose) Remember that: To administer paromomycin: You must have 1 ml and 2 ml syringes to give this medicine. The recommended dose is 15 mg/kg sulfate (equivalent to 11 mg/kg base); no maximum dose; monotherapy should not be used. Patients must remain well hydrated because paromomycin can affect the kidneys. Tell patients to drink enough that they pass urine 4 times a day. 17

18 If patients have severe vomiting and diarrhoea, do not give the injections. Patients over 60 years may have problems with their kidneys so should not be given this medicine. This medicine may NOT be given intravenously Weigh the patient weekly and recalculate the dose. Do not give during pregnancy unless there is no choice HOW TO CALCULATE THE DOSE OF PAROMOMYCIN Paromomycin is 500 mg/ml in a 2 ml vial so it is calculated as follows:. Dose of paromomycin in ml = (weight in kg x 15) divided by 500 EXAMPLES: If your patient is 8 kg: (8 x 15) / 500 = 120 / 500 = 0.24 ml If your patient is 15 kg: (15 x 15) / 500 = 225 / 500 = 0.45 ml If your patient is 45 kg (45 x 15) / 500 = 675 / 500 = 1.35 ml Liposomal amphotericin B (Ambisome ) Liposomal amphotericin B is the safest anti leishmanial medicine and needs to be available at the referral sites. It is presented as 50 mg per vial. Liposomal amphotericin B: 3 5 mg/kg per day intravenous by infusion over 6 10 days up to a total dose of 30 mg/kg. Ambisome requires cold chain. Ambisome in VL is the first line treatment for pregnancy, severe patients and HIV coinfected patients Treatment of relapse of kala azar First relapse A definitive or final cure is defined as an absence of signs and symptoms 6 months after initial cure (which was at the time of discharge). Therefore, to establish a definite cure, active follow up should be done as part of the treatment centre activities. For a definitive cure one looks at the clinical picture. No aspirate is necessary at follow up, unless relapse is clinically suspected. Patients should be instructed to return for a follow up 6 months after discharge or earlier in case they feel sick. If a person returns with a clinical suspicion of kala azar, after having received full treatment and was discharged with a negative test of cure (TOC), the patient has a relapse. It is impossible to differentiate a relapse from a new infection. Therefore, all are considered relapses and treated as such under this scenario. Relapses can occur in up to 5% of the patients treated. In HIV+ patients the relapse rate can be up to 50%. Most relapses occur within 6 months of initial discharge and these are called first 18

19 relapses. A patient who had a first relapse, was re treated and cured, can get a second relapse. Relapses tend to have a higher parasite load (but not necessarily so) and are difficult to treat. There must be two negative TOC s before discharging relapsed patients, because any further relapses will be more difficult to cure. The likelihood for a positive TOC after treating a relapse is higher than 10%. So, in every relapse case TOC s have to be done. To ensure that there is at least a week of treatment after the first negative TOC, two consecutive TOC s are performed one week apart. Relapse cases need close monitoring. Longer SSG therapy is associated with more side effects: kidney toxicity, pancreatitis, and arrhythmias are known complications. Inpatient treatment (if feasible) is always preferred for relapse treatments. Usually, it is better to refer a relapsed patient for treatment in a hospital. The clinician should check each week or even more frequently whether the relapsed patient is clinically responding. Good signs of response are the clearance of fever, wellbeing of the patient (e.g. able to walk, appetite improving), spleen size reducing, haemoglobin increasing, weight stable or increasing. First line regimens for first relapse In case of first relapses, a new treatment schedule is started, and the following are acceptable: First line regimens for relapses SSG 20 mg/kg/day IM plus paromomycin 15 mg/kg/day IM for days If parasitology is available, end of treatment should be guided by clinical assessment and test of cure aspirates. TOC aspirates can start on day 17 for two medicine (SSG plus paromomycin) combination therapy. TOC aspirates should be done weekly. When TOC is available, the minimum days of SSG is 30 for combination therapy. Paromomycin is given for only 17 days (more than 21 days may be toxic). Sodium stibogluconate 20 mg/kg/day IM for 40 to 60 days If parasitology is available, end of treatment should be guided by clinical assessment and test of cure aspirates. TOC aspirates can start on day 30 for single medicine (SSG) therapy. Then TOC aspirates should be done weekly. When TOC is available, the minimum number of days of SSG is 40 for monotherapy. After 60 days of SSG, it is clear that the parasite is unresponsive to SSG and second line treatment should be instituted as stated below. Second line regimens for first relapse Liposomal amphotericin B (Ambisome ) Liposomal amphotericin B is the safest anti leishmanial medicine and needs to be available at the referral sites. It is presented as 50 mg per vial. Liposomal amphotericin B: 3 5 mg/kg per day intravenously by infusion over 6 10 days up to a total dose of 30 mg/kg. Ambisome requires cold chain. Ambisome in VL is mainly used for relapses, pregnancy, severe patients, HIV coinfected patients and when SSG toxicity is not tolerated by the patient. 19

20 20 Amphotericin B deoxycholate Dose: mg/kg/d intravenously for 30 alternate days (15 mg/kg total dose) infused with 1 litre of 5% dextrose over 2 12 hrs. Before the full treatment course, the patient is given an initial test dose, which is the first 1 mg of the first dose to be infused over 20 to 30 minutes; and the patient observed for 1 hour. The remaining doses are given as 1 mg/kg body weight IV once per day every other day for 30 days (total of 15 treatment doses). Administration Amphotericin B is infused in 1 liter of dextrose 5% infusion running over 2 12 hours. The slower infusions decrease infusion related side effects (chills, fever). Before starting therapy, hydrate the patient and maintain hydration with ORS and, if needed, IV fluids. This is important to decrease the risk of renal toxicity. Give potassium supplementation (1 tablet 3x/day for adults); if potassium tablets are not available, give one banana every eight hours (1 banana = 8 mmol KCl = 1 tablet KCl). Management of fever: administer paracetamol before infusion or at the onset of symptoms. Avoid gentamicin, streptomycin, paromomycin or other medicines that can cause renal toxicity. Second relapses Second relapses are not very common but occur especially in immune suppressed patients. The treatment option for those cases is to administer amphotericin formulations at the highest dose Treatment of PKDL When to treat PKDL The rash shows blackening, especially around the nose. The rash is dense the skin is almost covered with bumps that are almost touching. The rash includes mucous membranes especially the nose, eyes or mouth. The rash is peeling or scaling. The patient with this rash is also ill with fever (after treatment for possible concurrent illnesses) and has a big spleen. The patient who develops PKDL during kala azar treatment. This patient should be continued on treatment until the PKDL is cured. The rare patient who has a new decrease in vision and eye pain with the rash. Iritis is rarely part of PKDL. End of treatment of PKDL It is when the rash is no longer palpable. Feel the rash with your finger. If the skin is smooth you can stop treatment even if you can still see the rash. Everyone must have at least 30 days of SSG.

21 The treatment regimen consists of SSG 20 mg/kg/day IM for days OR SSG 20 mg/kg/ day IM for 30 to 60 days plus paromomycin 15 mg/kg/day IM for 17 days Other treatment related issues and special situations Interruption of SSG treatment Interruption during treatment can occur under two conditions: medically initiated interruption or severe vomiting and defaulting by the patient: If the interruption is less than 5 days, continue the treatment from where the patient stopped taking the treatment, and continue until the full course of treatment is given. If the interruption is 5 14 days, the patient should continue from where they stopped but must have an adequate test of cure parasitology at the end of treatment. If the interruption is 15 days or more, irrespective of the number of days of previous treatment, the patient needs readmission for parasitology testing; if positive, restart treatment as day one and do a test of cure before discharge. If negative, follow up is necessary and parasitological tests done if need be. Evaluating cure At the end of treatment with combination or monotherapy, the patient should be re assessed. This usually includes clinical and laboratory examinations as described below: Clinical response Many patients get worse during the first few days of treatment. Patients, at the extremes of age, with severe anaemia, severely malnourished, in a state of collapse, and presenting with vomiting, pneumonia, or bleeding are at high risk during the first 10 days of treatment. After 7 to 10 days the patients become afebrile, and begin to look stronger, become more mobile, with increased alertness and appetite. By day 14 the spleen size regresses, haemoglobin rises and there is weight gain (note: loss of oedema may mask weight gain during treatment). By the end of successful treatment, patients are afebrile, usually have a smaller spleen than on admission, and have an increased hemoglobin level (although most remain anaemic). All of the patient s conditions have improved. Initial parasitological cure the role of TOC Splenic aspirate is more sensitive for diagnosis and for TOC. Lymph node aspirate (LNA) has been used for TOC when splenic aspirate is not possible. There is no clinical sign that correlates with a positive test of cure aspirate (TOC) or that predicts increased risk of relapse. The exceptions are signs of co existing TB or HIV, both of which will increase the risk of treatment failure. TOC is done for assurance that discharge is appropriate for patients who may have difficulty returning for care/follow up. When done systematically it is also a way to monitor the emergence of medicine resistance. 21

22 Non response is defined as no decrease in the grade of parasitology from before treatment to after adequate treatment. For those patients who are not aspirated on admission, use 4+ at TOC as defining primary unresponsiveness. Anyone with any TOC of 4+ (or a TOC that does not become negative by 60 days of SSG) should get second line treatment. Clinical judgment will always play the final role in any decision making process given the variability of individual VL cases. Kala azar treatment in pregnancy Kala azar treatment during pregnancy cannot be deferred as untreated VL during pregnancy may lead to severe disease, characterized by high grade anaemia, spontaneous loss of the foetus, and congenital VL because of transplacental transfer of parasites, even in apparently low symptomatic cases. Unfortunately, no medicine of VL is proven to be safe in pregnancy however, none are known to be harmful. Pregnant women should therefore be treated with the safest available anti leishmanial medicines. Amphotericin B deoxycholate or its liposomal formulation is safe and effective for pregnant women and their foetuses, and is therefore recommended as first line treatment for these patients. The dosage and administration is the same as other patients. Pentavalent antimonials are less safe in pregnancy, as they can result in spontaneous abortion, preterm deliveries and hepatic encephalopathy in the mother, and vertical transmission. Paromomycin: Ototoxicity in the foetus is the main concern and hence should be avoided as much as possible. Leishmania HIV co infection Visceral leishmaniasis is an AIDS defining condition and a valid entry point for starting antiretroviral treatment, irrespective of CD4+ count. The baseline CD4+ count is lower in visceral leishmaniasis HIV co infected patients, as visceral leishmaniasis itself causes a reduction in CD4+ cells. The impact of antiretroviral treatment on visceral leishmaniasis in co infected patients includes reduction of incidence of VL, higher survival rates, a reduction in relapse rate and possible immune reconstitution inflammatory syndrome. HIV and Leishmania infection reinforce each other. HIV patients are more likely to develop visceral leishmaniasis (due to reactivation of a dormant infection or clinical manifestation after primary infection). Patients characteristically have high disseminated parasite loads. Visceral leishmaniasis negatively affects the response to antiretroviral treatment and is difficult to cure in co infected patients. The prognosis of co infected patients is characterized by a high mortality rate during the first episode, increased anti leishmanial medicine toxicity (predominantly with antimonials), poor long term clinical response, parasitological cure and a high relapse rate over a lifetime. The risk factors for relapse are: no antiretroviral treatment, low CD4+ cell count, previous visceral leishmaniasis episode, failure to achieve clinical or parasitological cure during the first episode and no secondary prophylaxis. Antimonials are more toxic in HIV patients, necessitating careful monitoring for pancreatitis and cardiotoxicity. 22

23 Treatment of VL in HIV co infected patient Amphotericin B deoxycholate or lipid formulations should be considered first and pentavalent antimonials only in areas of no significant resistance and when lipid formulations of amphotericin B are unavailable. Lipid formulations (e.g., Liposomal Amphotericin B, Ambisome) infused at a dose of 3 5 mg/kg daily or intermittently for 10 doses (days 1 5, 10, 17, 24, 31 and 38) up to a total dose of 40 mg/ kg are recommended. 3.5 Treatment of concurrent infection and malnutrition General kala azar patient management Because infection with Leishmania depresses the immune system, patients with kala azar are at increased risk for other infections. Additionally, the severity of such infections in kala azar patients may be greater than in patients without kala azar. All concurrent illnesses should be treated immediately and aggressively. Many kala azar patients are severely malnourished. Because of this and their immune depression, these guidelines include routine treatments similar to those given in therapeutic feeding centers. Kala azar patients can die during treatment. Those at most risk are those who are very young (< 3 years), those who are old, those severely malnourished, those severely anaemic, those with prolonged disease (more than 2 month history), and those with vomiting. Please give special care to these patients! All kala azar patients should be screened for malaria and managed promptly following the national treatment guidelines: If treated with Amodiaquine plus Artesunate in the previous 7 days no more treatment is needed. If not treated in the last 7 days and lab test is negative, give Fansidar prophylaxis once on admission. If not treated and not tested, the patient must be tested for malaria or treated. - If the test is negative, give Fansidar. - If the test is positive or no testing is available give Amodiaquine plus Artesunate. NB: Remember not to use Fansidar in the first 2 months of life or for a woman in the last month of pregnancy. On admission give Vitamin A to all VL patients except pregnant women: Vitamin A 200,000 IU if 6 months to 1 year use 100,000 IU if < 6 months, use 50,000 IU do not give to pregnant women until after delivery 23

24 Amoxicillin for 5 days Tinidazole for 3 days or metronidazole 7 days Send children for measles vaccination if not previously vaccinated. Daily tablets Vit C and multivitamins not needed if there is good food available Ferrous plus folic acid If severely malnourished, give folic acid alone for the first 7 days. * Remember to also treat all other illnesses and complaints on admission Discharge tablets If the patient is pregnant give 2 ferrous each day Ferrous plus folic acid 30 tablets for daily use Fansidar* to all patients with a palpable or visible pregnancy that is less than 9 months. Mebendazole* for non pregnant patients if your area has round worms. Note that most severely malnourished patients have iron stored in their body, but kala azar patients may have none. For this reason we add the ferrous to the folic acid on day 7 rather than waiting for day 14 as in many therapeutic feeding centre (TFC) protocols. Treatment of malnutrition Promoting good nutritional status of patients is key in the management of kala azar. Experience has shown that 70 75% of the diagnosed cases are severely or moderately malnourished and in desperate need of nutritional supplements. According to the Sudan Household Health Survey 2010, one in five children are acutely malnourished with Jonglei, Warrap, NbeG, Unity, Upper Nile and EEQ, recording Global Acute Malnutrition levels above the emergency threshold of 15%. Kala azar is endemic in four of these states and affects all age groups. Therefore, these guidelines include the treatment of acute malnutrition in line with the National guidelines for integrated management of acute malnutrition (IM SAM). 24

25 Admission criteria for moderately and severely malnourished Kala Azar cases. Target group Admissions criteria 0 5 months Presence of bilateral pitting oedema Visible wasting Infant unable to suckle effectively (e.g., too weak) 6 59 months SAM: Bilateral pitting oedema + and ++ MUAC <115mm or WFH < 3 z score MAM: MUAC 115mm and <125mm, or WFH 3 and < 2 z score 5 9 years SAM: Bilateral pitting oedema BMI for age < 3 z score MAM: BMI for age < 2 z score years (adolescents) SAM: Bilateral pitting oedema BMI for age < 3 z score MAM: BMI for age < 2 z score Pregnant and lactating women Adults SAM: MUAC <210mm MAM: 210mm <230mm SAM Bilateral pitting oedema BMI < 16.0 kg/m 2 MAM BMI 16 to < 17 kg/m 2 SAM Severe Acute Malnutrition; MAM Moderate Acute Malnutrition See Annex 14 for Anthropometry look up tables Nutritional treatment for severely malnourished Kala Azar cases Infants 0 5 months with SAM who are not breastfed are particularly at risk and require protection and support to reduce the risks of artificial feeding. For these infants and their caregivers, the potential for restoring or establishing breastfeeding should always be explored to the maximum. Further, it is not appropriate to provide infants 0 5 months with RUTF because the reflex of swallowing semi solid foods is not yet present. 25

26 Age group With Oedema Without Oedema Infants 0 5 months breastfed Provide F75 for infants with bilateral pitting oedema. (See Look up Table 17 Maintenance of F 110 diluted in IM SAM Guidelines pg. 52) Change to F100 Diluted when the oedema is resolved. F100 Diluted is given at 130 ml/kg bodyweight/day, distributed across eight feeds per day. Infants 0 5 months not breastfed F75 until the oedema has resolved and then F100 Diluted. Amount given should be calculated based on 130 kcal/kg bodyweight/day. (See Look up Table 19 Stabilization Phase in Annex 14) F100 Diluted in the stabilisation phase fed with cup and saucer. Never provide F100 full strength or RUTF. Amount given should be calculated based on 130 kcal/kg bodyweight/ day. (See Look up Table 19 Stabilization Phase in Annex 14) Children 6 59 months Children 6 59 months (Transition Phase) Give 130 ml of F75 (100 kcal) per kg bodyweight per day, six or eight feeds per day (every three or four hours) Use the look up tables for the volume of F75 to give to individual child per feed according to the child s bodyweight (see Tables 10 and 11 Stabilization Phase in Annex 14) Give 130 ml of F75 (100 kcal) per kg bodyweight per day, six or eight feeds per day (every three or four hours) Use the look up tables for the volume of F75 to give to individual child per feed according to the child s bodyweight (see Tables 10 and 11) Conduct appetite test before withdrawal of F 75 (See Box 5 Appetite Test in Annex 14) Provide RUTF to the caregiver to feed the child. Give RUTF to Child per day or week based on a Dose of 200 kcal/kg Bodyweight/Day, using 92 g Packets Containing 500 kcal. (See Look up Table 8 in Annex 14) RUTF is offered at every feed and complemented by F100 if needed. If both F100 and RUTF are being given, they can be substituted on the basis that about 100 ml of F100 equals 20 g of RUTF. (See Look Up Table 12 for amounts of RUTF in Annex 14) Above 5 years (older children 5 9 yrs, adolescents 10 18yrs and Adults) See Look up Table 22 Dietary Requirements in Annex 14 Provide 3 sachets of RUTF Nutritional treatment for Moderate Malnourished Kala Azar cases Target Group Children 6 59 months Above 5 years (older children 5 9 yrs, adolescents 10 18yrs and adults) Treatment Provide 3 sachets of RUTF for the duration of the treatment Provide 2 sachets of RUTF for the duration of the treatment 26

27 Basic food rations Food rations should be provided to all kala azar patients for the duration of treatment. Beneficiary category Daily food ration (per person/grams) Eligible beneficiaries) Cereal Pulses Oil Salt Sugar CSB Total Duration 1) IFP inpatient HIV, TB, Kalazar, Leprosis inpatient During hospitalization 2) IFP outpatient 3) IFP Caretaker HIV, TB, Kalazar, Leprosis outpatient One caretaker for one HIV, TB, Kalazar, Leprosis inpatient During ambulatory treatment period (ARV, DOTS) When accompanying inpatients for treatment in hospitals 4) IFP Family ration Two family members for one HIV, TB, Kalazar, Leprosis outpatient During ambulatory treatment period (ARV, DOTS) 5) TFP Caretaker One caretaker for one SAM child 6 59 months During therapeutic treatment at TF center Routine Medication Protocols (IM SAM Guidelines) Medicine/supplement When to give Age/weight Prescription Dose ANTIBIOTIC On admission All beneficiaries Amoxicillin mg/kg bodyweight/ day 3 times a day for 5 days ANTIMALARIAL (artemisinin based combination therapy [ACT]) Test on admission; Repeat test later if initial test negative and malaria suspected. If no test, rely on symptoms. All beneficiaries Artesunate (AS) 50 mg and Amodiaquine (AQ) 153 mg: ½ AS and ½ AQ 1 AS and 1 AQ Once a day for 3 days ANTIHELMINTHIC MEDICINE* After 1 week < 12 months DO NOT GIVE NONE Albendazole 200 mg or <10 kg 10 kg Mebendazole 250 mg Albendazole 400 mg or Mebendazole 500 mg Single dose MEASLES VACCINA- TION** Inpatient care: On admission and discharge Outpatient care: On week 4 (or upon discharge) From 6 months Standard Single dose, or repeated dose** VITAMIN A*** SUPPLE- On week 4 (or upon discharge) MENTATION 6 months 12 months IU IU Single dose 27

28 Treatment of diarrhoea This protocol is for use with kala azar patients only. Viruses are the cause of most diarrhoea, and there is no medicine other than oral rehydration salt (ORS). Kala azar patients are different; they are prone to dysentery and are very weak. Any diarrhea: ORS, made with boiled water, left to cool, or with borehole water. Tinidazole for 3 days, then continue tablets to 5 days if diarrhea continues (no more than 10 days total) Ask if they have nausea or vomiting and treat if they do Diarrhea 4 times or more in 24 hours OR any diarrhea with blood OR any diarrhea with fever: ORS, made with boiled water, left to cool or with borehole water. Ciprofloxacin AND Tinidazole for 3 days to 5 days if diarrhea persists.. (Tindazole for persistent diarrhea may be given for a total of 10 days.) Ask if they have nausea or vomiting and treat if they do Second line treatment: substitute tinidazole for 7 10days with metronidazole Unresponsive diarrhoea Consider schistosomiasis: it is common, can give diarrhoea, bloody diarrhoea and malnutrition. The treatment is praziquantel. Consider sending a stool specimen to the laboratory. Consider potassium supplement (slow K) for patients with severe diarrhoea and vomiting. People do not usually die of the germ causing diarrhoea, they die because they lost too much water or they are starving. Anyone with diarrhoea must eat and drink more than normal or they may die. ORS, locally made with extra water, and high energy biscuits are good choices. Laboratory based diagnosis Syndromic diagnosis (diagnosis based on history and physical) is good. The syndromic diagnosis is based on evidence from well equipped hospitals and on knowing what diseases are in your area. Sometimes there are confusing cases. If you have a lab this can sometimes help sort out these confusions. Remember though, one stool specimen is not sensitive it is simply a help. You may need multiple specimens. Remember too that patients can have more than one germ. Treatment of vomiting SSG can cause nausea and vomiting. Vomiting is associated with death in kala azar patients. Please pay close attention to these patients. Remember that malaria and meningitis also cause vomiting; check your patients carefully! 28

29 Pathogen Fever common Stool exam Other symptoms Treatment ORS for all! Viral No Normal ORS Giardia No Giardia Nausea, vomiting, burping, bloating, abdominal cramp, may or may not have diarrhoea Tinidazole or Metronidazole Ameba No RBC <5 WBC Ameba Trophs Bacterial Yes WBC RBC Abdominal pain, tenesmus, sometimes with blood mixed with mucus Many times a day diarrhoea, may be bloody, may be very ill Tinidazole or Metronidazole Ciprofloxin or co trimoxazole Patients who vomit only with a cough do not need medication for vomiting. Administer paracetamol if they have a fever Give promethazine tablets for 2 days, but if patient has difficulty taking orally, give it IM. Tell the patient to take the tablet and then wait 1 hour before taking any other tablets or eating. Tell the caretaker that the patient will get a little sleepy from promethazine, but they should be awakened to drink. Give ORS and asses hydration status frequently. Consider stopping the SSG for 2 to 5 days. Any patient who has nausea or vomiting should continue eating and drinking but in small amounts 5 to 7 or more times a day. Any patient taking tinidazole or metronidazole should be asked about vomiting. Both these medicines are common causes of vomiting. You may treat with promethazine. Severe vomiting Be careful of these patients who cannot stop vomiting, patients who vomit too much to keep down water, ORS or milk. Stop the SSG for 2 to 5 days until the vomiting is gone. If the vomiting stops within 5 days, continue the SSG from the dose you stopped. Give a promethazine injection. Always start promethazine tablets following the injection. Start the promethazine tablet 1/2 hour after the injection so they do not vomit it; the effect of the injection will stop in 1 or 2 hours. The effect of the tablets lasts 3 to 6 hours. Always give ORS, give small amounts every 15 minutes. They may need an IV of Saline or Ringers Lactate if they are dehydrated. Please refer them to help! 29

30 Special notes for children < 12kg who are vomiting Take the temperature and make sure the child has no other disease such as malaria or meningitis. Try giving small amounts of ORS every 5 10 minutes. Give paracetamol if needed. You may give promethazine syrup after you have checked for other illnesses. Patients who vomit only when coughing do not need promethazine. Treatment of malaria After the first 7 days of kala azar treatment, patients with documented fever which has no obvious source, should get a blood film or RDT for malaria if possible. Consider malaria treatment if there is no other source of fever and no laboratory test is available. Treat with Amodiaquine plus Artesunate and paracetamol if more than 2 weeks after the last malaria treatment. Treat with quinine for severe malaria severe vomiting, a seizure in an adult, repeated seizures in a child, talking crazy, hypoglycemia, jaundice, pulmonary edema, Hb < 5, or any altered mental status Treat with quinine if the blood film is positive within 2 weeks of previous treatment. Remember that pregnant mothers and young children get malaria easily. SSG should not be used with quinine (due to prolonged QT interval and cardio toxicity). Use Fansidar in uncomplicated falciparum cases or Artemether Intra Muscular (IM) in severe malaria cases (follow the national malaria treatment guidelines). If treatment with quinine is inevitable, stop SSG for VL while quinine is being given. After quinine treatment is finished, resume SSG injections, starting 24hrs after the last dose of quinine. Consider shortening quinine usage for 3 5 days and finish with other antimalaria medicines. This helps to resume SSG within a short period. Treatment of pneumonia The diagnosis follows the health worker guidelines so check the last version of the integrated management childhood illness (IMCI) guidelines in use in South Sudan: kala azar patients can get a dry cough that does not need antibiotics kala azar patients commonly get pneumonia that does need antibiotics adults as well as children get pneumonia fever, productive cough, chest pain with breathing, and fast breathing are all part of a diagnosis of pneumonia. WHO IMCI guidelines for diagnosing pneumonia in children based on respiratory rate (RR): Diagnose pneumonia if a child 2 12 mo has RR > 50; 12mo 5 yr has a RR > 40 NOTE normal RR is up to 60 for 0 2mo, 40 for infants, 30 for 12mo 5 yr 30

31 Treatment of mild to moderate pneumonia amoxicillin for 7 days. Amoxicillin is preferred over cotrimoxazole. Amoxicillin but not cotrimoxazole will treat most pneumonia from aspiration that occurs with vomiting or seizures or a concurrent ginigivitis. Erythromycin is a reasonable first line medicine for older children and adults who do not have the aspiration risks. Erythromycin can cause vomiting which is already a problem for kala azar patients. Patients treated successfully for pneumonia will usually have their fever subside in 3 days and their cough and crepitations usually subside in 8 days. Treatment of pneumonia not improving by day 3 or 4: ceftriaxone injection, chloramphenicol capsules Initial treatment of all serious pneumonia: ceftriaxone once, daily injection second line treatment, chloramphenicol orally or by injection 3 or 4 times a day Signs of serious pneumonia: infants breathing too fast to breastfeed pneumonia patients with significant vomiting, unable to keep down medicines patients with respiratory distress (retractions, flaring nose, grunting) unexplained abnormal mental status Please refer these seriously ill patients to the senior medical staff. They may be acidotic from dehydration or sepsis, they may have severe malaria or meningitis with the pneumonia. Patients who have pneumonia all through their kala azar treatment who are unresponsive to antibiotics may have TB. Document if there is a fever. Take the temperature in the evening. The adults may need a sputum test. Ask the children with the continuing pneumonia if there is a family history of pulmonary TB. Treatment of tooth or gum pain with or without bleeding Clean teeth twice a day Procain penicillin or amoxicillin for 5 days Paracetamol as needed (never aspirin) Treatment of bleeding Nose bleeding: Pinch the nose at the end of the bony part for 10 minutes. Put petroleum jelly on the nasal mucosa to prevent cracks in the mucosa that bleed. 31

32 If the nose bleed will not stop with pinching: pack the nose with petroleum jelly on gauze and leave the pack in for at least 2 days. If you pack the nose, treat with amoxicillin (for prevention of sinusitis). Gum bleeding: Treat with penicillin or amoxicillin for 5 days Give vitamin C Occasionally you will need epinephrine on gauze compresses to stop the bleeding If the patient has jaundice: give vitamin K IM for 5 days Treatment of conjunctivitis Tetracycline eye ointment is used for red conjunctiva especially if there is drainage. Any sign of trachoma should be treated with tetracycline eye ointment. Gentamicin or chloramphenicol eye drops for abundant pus discharge or for failure of tetracycline ointment. Use until 2 days after pus discharge is gone. Make sure this patient receives vitamin A on admission! Patients who are severely malnourished can have a second dose of vitamin A. Iritis is a rare disease that can accompany PKDL. There is eye pain and the vision is blurry like looking through a cloud. There is usually little or no pus. Please notify a doctor. The patient needs to continue the SSG. They may also need steroid eye drops. Treatment of infected wounds Clean and treat with penicillin for 5 days, they may need gentian violet. If the wound is not improving consider cloxacillin. If they have an injection abscess it may need draining and cloxacillin. Treatment of herpes zoster This is an extremely painful rash that can occur at the end of, or just after kala azar treatment. It is only on one side of the body and usually covers only a small area. The skin is red and develops blisters. This is NOT associated with HIV when it occurs at the end or after kala azar treatment (or if it occurs in the elderly). Treat with 5 to 10 days with paracetamol or ibuprophen (ibuprophen is OK to use ONLY at the end of kala azar treatment). If the wounds are open you can use gentian violet Treatment of pain Treat with paracetamol (for severe pain consider tramadol). Never use aspirin for kala azar patients, this can cause bleeding Ibuprophen and indometacin may cause bleeding so should be avoided 32

33 See treatment and medicines for concomitant diseases in Annexes Information system This is a crucial aspect to allow data collection and analysis for monitoring and evaluation of the activities. In addition to the register books and patient s forms, data should be summarized in the monthly report forms and then submitted to the MOH. When an outbreak is declared a weekly report form is also to be filled in (Annex 17 18). 5. Prevention and control Leishmaniasis control in general is primarily based on finding and treating cases, combined where feasible with vector control and, in some zoonotic foci, control of animal reservoirs. In practice, providing access to sensitive diagnostics and quality treatment, and prevention of sandfly bites are currently the only feasible options in South Sudan. Active case finding may be opted for as it becomes essential if patients have difficulties and delays in reaching treatment. Prevention should aim at reducing the number of bites by wearing appropriate clothes (long sleeved) and repellents (ash, neem oil, commercial) during the evenings, especially during the dry season when kala azar is transmitted. The use of long lasting insecticide treated nets (LLINs) provides personal protection in areas of transmission. Fine mesh (jersey fabric) bed nets with or without impregnation will also protect, but are hot. Impregnated bed nets should be distributed to all Kala azar patients at the treatment centre. Health education should focus on: Appropriate usage of LLINs, including the mode of transmission of kala azar The danger of sleeping outside without being protected by a mosquito net The signs and symptoms of kala azar, and the availability and location of treatment centres, aiming at improving early reporting of symptomatic cases. Operational research is required to establish whether the combination of scaling up LLINs coverage and health has the desired effect of reducing VL transmission and prevalence, and whether it could be complemented by other methods, such as insecticide treated sheets which are sometimes used as nets (dhamuria) 33

34 6. Annexes Annex 1. rk39 rapid diagnostic test procedure The utility of a rapid diagnostic test for visceral leishmaniasis lies in its simplicity. Several brands of tests with rk39 antigen are available. Operators should always read the package insert carefully, and follow the manufacturer s instructions. This is especially important with regard to the type of specimen used: serum or whole blood. Some brands can be used only with serum, while others can be used with whole blood collected by a finger prick. Test procedure In general, the test procedure is as follows (Figure 3): 1. Remove the test strip from the pouch and place it on a flat surface. 2. Place a specified amount of patient specimen (serum or finger prick blood) on the absorbent pad on the bottom of the strip. 3. Add the specified amount of buffer provided. 4. Read the result after min, according to the manufacturer s instructions. Some brands require a slightly different procedure, for example: 1. Take a test tube or a U bottom microtitre plate. 2. Add a specified amount of buffer to the tube or well. 3. Add a specified amount of specimen (blood or serum) to the tube or well and mix. 4. Immerse the test strip into the buffer specimen mixture. 5. Read the result after min, according to the manufacturer s instructions. Points to consider for optimizing use of rapid diagnostic tests: Have a clear management plan to deal with positive and negative results. Follow biosafety standards and precautions for handling blood and other body fluids. Ensure proper storage conditions. Do not use damaged or expired tests. Adhere strictly to the manufacturer s instructions. Use test kits within 1 hour of removal from pouch. Read the results within the time specified by the manufacturer. Do not reuse a test. 34

35 Interpretation of the test Positive result: When both control and test lines appear, the sample tested has antibodies against recombinant K39 antigen of Leishmania. Even a faint line should be considered positive. Negative result: When only the control line appears, there are no antibodies against recombinant K39 antigen of Leishmania present in the patient s sample. Invalid result: When no control line appears, a fresh patient sample should be tested with a new strip. Advantages and disadvantages of the rk39 test Advantages Simple to perform with minimal training. Does not require a laboratory. Can be performed with finger prick whole blood, serum or plasma. Kits can be transported and stored at ambient temperature (up to 30 C). Results are available within minutes. Disadvantages Cannot distinguish between active cases and relapse in previously treated cases. Therefore, interpretation must always be accompanied by clinical case definition. In patients with advanced HIV infection, a negative result does not rule out a diagnosis of visceral leishmaniasis. Figure 3. Procedures for the DiaMed IT LEISH test. 35

36 A. DiaMed IT LEISH This is a ready made kit, so strictly follow the instructions provided by the manufacturers. The test can be used either on finger prick blood or plasma/serum. The kit is provided with a device containing 2 wells: that of conjugate well (red line) and wash well. The device should be used within 15 minutes of opening the packet. Test procedure Take out the device from its package and place it horizontally on a flat surface. Write the name and an identifying number of the patient on the space provided. Tear open the ampoule of buffer, add 1 drop to the conjugate well and 4 drops to the wash well, and allow to stand for 1 minute. Add 8 12 l blood/serum/plasma to the conjugate well by squeezing the pipette gently. Stir gently with the upper end of the pipette and allow to stand for 1 minute Pull the device apart by holding the device with wells between thumb and forefinger, and with the other hand pulling out the dipstick holder (with label). Then place the wells on a flat surface, and insert the legs of the dipstick holder into the holes beside the conjugate well (with red line) so that the dipstick end reaches the bottom of the conjugate well. Allow to stand 10 minutes (5 10 minutes for serum/plasma). Transfer the dipstick to the second well (wash well) and allow to stand 10 minutes (5 minutes for serum/plasma). N.B. the reaction field should then be completely cleared of blood or serum/ plasma, and the control band should be clearly visible. Remove the dipstick from the wash well and click it back into the clear plastic piece. Close the wells with the well cover, break them off, and break the two legs off from the clear plastic piece (to be discarded). Read the reaction and interpret the results. Keep the dipstick slide for future reference. The appearance of dark purple bands on the dipstick demonstrates a positive reaction in the presence of a control band. The test is invalid if the control band is not visible. A very faint line/band must be considered as positive reaction. DiaMed IT LEISH Set. B. Inbios kalazar detect test This is also a ready made kit, so strictly follow the instructions provided by the manufacturers. The test can 36

37 be used either on finger prick blood or plasma/serum. The kit is provided in pouches containing strips and appropriate buffers. Test procedure Take out the test strips from its package and allow to reach room temperature. Add ml blood/serum/plasma to the area beneath the arrows shown in the strips. Place the test strip into a test tube or well of a 96 well tissue culture plate so that the end of the strip is facing downward. Add two to three drops (150 ml) of the chase buffer provided with the test kit Read the results in 10 minutes. 37

38 Annex 2. Direct agglutination test procedure Principle of DAT Infection with L. donovani results in production of antibodies against the parasite. These antibodies can be demonstrated in blood or serum by an agglutination test. The DAT antigen is a whole, killed promastigote from cultures of L. donovani which have been stained blue for visibility. These are suspended in solution, and when left in a V shaped well, will slowly fall to the tip of the V, giving a dense blue dot. If anti Leishmania antibodies are present from the blood or serum, the blue stained parasites (DAT antigen), will become cross linked by the antibodies (directly agglutinated) and will settle to the bottom of the well as a hazy blue mat or a cloud, NOT a dot. By diluting the serum 2 fold in each well starting at 100 x dilution, the titer (quantity of antibody) can be measured. These procedures are for freeze dried presentation of DAT. Collection of blood specimen for DAT Collect capillary blood from the finger or the toe or heel in infants. Method Requirements: DAT request form DAT registration book Whatman No.3 filter paper Sterile lancet Disinfectant e.g. iodine, alcohol etc. Cotton wool Scissors Plastic bag Pen (ball point) Paper clips Procedure Cut the circular filter paper into 8 16 segments depending on the size. Each segment can be used for one patient s test only. 38

39 Draw a circle of approximately 1cm in radius on the segment of the filter paper. Record the patient s details in the laboratory registration book (Annex 7). Write the DAT number on the patient s request form and also write this number on the segment. Soak a piece cotton wool in iodine or alcohol and disinfect finger, toe or heel thoroughly. Allow the skin to dry. Using the sterile lancet, prick the finger firmly so that blood flows freely without excessive squeezing. Wipe the first drop of blood with a plug of dry cotton wool. The first drop of blood is normally contaminated with dirt and tissue fluid. Squeeze the finger gently and collect the next drop of blood into the circle on the segment of the filter paper. Check the DAT number on the filter paper before collecting the blood. Make sure the blood soaks through both sides of the filter paper and fills the circle Allow the filter paper to dry. Apply pressure to the finger prick with dry cotton wool. Discard the used cotton wool into the waste bucket and the lancet into the sharps container. When dry, very dry, clip the filter paper with the request form and put into a plastic bag. Store in a fridge or cooler box until ready to send for testing or until ready for performing the test. Elution of samples Day 1 Requirements Laboratory register Microtitre plates (V shaped) Sample (dry in filter paper) Micropipette to measure 125 µl Normal saline Paper punch (5mm) Scissors Marker (permanent) Forceps Refrigerator 39

40 Procedure Write the number of the samples in order in the laboratory register. The list should be labeled to show which row of which microtitre plate corresponds to which sample. e.g. The list can be labeled A, B, C, D, E, F, G, and H in order. The samples need to be grouped by 8 samples in each group or less. Group one is called Plate I, group two is called Plate II and so on. Label the microtitre plates to correspond with the laboratory register. i.e. Get out the microtiter plates and write the plate number on the plate itself. The first one is plate I. Using the paper punch, punch out a sample of filter paper blood. Using the forceps, put the punched sample of filter paper blood into the well of the first column of the microtitre plates corresponding to the position recorded on the patient laboratory register. Ensure that the punched filter paper blood is properly inserted in the well. e.g. The sample listed as A should go in the first row labeled A. The sample listed as B should go in the second row labeled B, and so on. Take the micropipette and adjust it to measure 125ul, fix the pipette tip firmly and pipette 125ul of normal saline. Add the 125ul of normal saline to each well with a sample paper. Make sure that the punched filter paper blood is completely immersed in the saline. Cover the plates with another microtitre plate incubate in the fridge (at 40C) overnight for at least 8 hours. Dilution and titration Day 2 Requirements Measuring cylinder 50ml container (plastic or glass bottle or conical tubes) Research (Repetitive) pipette l, adjustable; brand Handy Step or Eppendorf with volume display, Combitip ejection. Multipipette μl Eppendorf or Handy Step adjustable with Volume display and tip ejection. Multichannel pipette, 8 channels, 5 50 l Eppendorf, adjustable volume and tip ejection. Micropipette tips (yellow tips for 100ul Multipette and the Multichannel pipette, blue tips for up to 1000ul Research pipette, combitips standard 1.25ml and combitips plus 2.5 ml) 5 10 ml syringe 2 mercaptoethanol (2 ME) Normal saline DAT antigen (Freeze dried antigen OR Liquid antigen) Freeze dried control sera 40

41 Preparation of diluent 1. To be used with Freeze dried antigen (FDA) Measure 50ml of normal saline and place in the container Adjust the multipipette to measure 390ul, pipette 390ul of 2 ME and add to the normal saline then mix gently. Reconstitution of the Freeze dried antigen (FDA) Add 5ml of fresh normal saline to the vial of the antigen Mix gently by rotating and tilting the vial. Do not shake Let it stand for about 10 minutes before use. Freeze dried antigen is kept at room temperature. Reconstitution of the freeze dried control Use a new set of control sera with every new batch of DAT antigen. Make sure all the freeze dried powder is on the bottom of the vial. (The control kits made in Amsterdam contain 2ul of serum each) Strictly follow the manufacturers instructions on the procedure for reconstitution especially the amount of normal saline or diluent to be added to the vial. Either add 100ul or 200ul of normal saline or diluent to the vial of the control sera depending on the manufacturers instructions. Mix gently by rotating. Let it stand for at least 10 minutes before use. Dilution of samples Filter paper blood Take the microtitre plates with the eluted blood out of the fridge and allow it to reach room temperature (Serum dilution in column 1 is 1:50). Reconstituted control sera Fill the control well(s) in column 1 with 100ul of reconstituted control serum. This is a 1:50 dilution Adjust the pipette to measure 50ul. Fill the wells from columns 2 to 12 with 50ul diluent. Adjust the multichannel pipette to measure 50ul. 41

42 Place 8 standard tips (yellow tips) on the multichannel pipette, making sure they are firmly fixed to avoid pipetting errors. If the multichannel pipette is not available, you may use a single channel pipette and pipette each row separately. Mix the contents in column 1 by pipetting in and out at least 5 times. Avoid forming bubbles by expelling air prior to inserting the pipette tips into the wells and using a slow action. Pipette 50ul from column 1 and transfer to column 2. Continue this mixing and transferring until column 11. Discard the last 50ul from column 11. Do not add to column 12. (Serial dilution). Column 12 is the negative control. Adding antigen Gently rotate the antigen bottle to mix it. Do not shake the bottle as this may destroy the antigen Adjust the pipette to measure 50ul and fit the pipette tips. Add 50ul antigen to every well except wells in column 1. It is advisable that, to avoid contamination, start with wells in column 12 (negative control) and add row by row, and also change the pipette tip every time the antigen is taken out of the bottle. Rotate the plates gently, both clockwise and anticlockwise. Cover the plates with a spare microtitre plate, leave them on a level surface at room temperature for about 12 to 18 hours. Reading the DAT results Day 3 Put the plates against a white background. Estimate the titre by comparing the dots in column 12 (negative control) to those of the samples in the other columns. The titre is expressed as the last dilution that shows a difference compared to the negative control. A dark blue dot indicates that the result is negative and no reaction took place whereas a hazy blue mat or cloudy appearance indicates that reaction took place. The highest titre will be last dilution that still shows a hazy blue mat or cloud. 42

43 Record the result in the lab book by titer and meaning. For example record well 9, positive. If you are not sure of the meaning (positive, negative or borderline) simply record the titre. Currently the positive titre is well 7 or 3200 with the FD antigen. Report the results in the patients request form. The titres are as follows: Fig 7 here Column: Dilution: 1:50 1:100 1:200 1:400 1:800 1:1600 1:3200 1:6400 1: : :51200 See below an example of positive result: Sample E: well 11, titre 1:51200, positive 43

44 Annex 3. Lymph node aspirate procedure Collection of lymph node aspirate The most common site for collection of the lymph node aspirate for diagnosis of kala azar is the inguinal glands. Infected glands will be swollen. Method: Items required: Sterile needle (21G ) Syringe (10ml) Clean glass slide Iodine (disinfectant) or sterile cotton swabs Cotton wool Procedure Allow the patient to lie comfortably. Prepare the syringe by pulling the piston back as far as possible. Feel both sides of the inguinal area to locate a swollen gland. Disinfect the located gland using a piece of cotton wool soaked in iodine or suitable disinfectant. Take the gland between the thumb and index finger of the left hand. Hold it steady, at the same time making it stand out. Introduce the needle at a right angle into the centre of the gland in two stages: a) First: pierce the skin b) Second: penetrate the gland With your left hand, gently knead the gland. With your right hand, revolve the needle in both directions. The glandular fluid will ooze into the needle. Withdraw the needle in one rapid movement, holding the thumb over the hub. Then apply a swab dipped in iodine to the point of entry. Attach the syringe (piston pulled back) to the needle. Place the needle on the slide. Push the piston gently down the barrel to discharge the glandular fluid contained in the needle onto the slide Make a thin film using the fluid on the slide. The fluid can be discharged on more than one slide. 44

45 Annex 4.Bone marrow aspiration procedures Materials needed Sterile BM needle 10 ml syringe Clean microscope slides NNN or any other suitable culture medium Wooden applicator or tooth picks Spirit lamp with sufficient flame Drapes Sterile gloves Sterile cotton and gauze Plaster Labels Pen and pencil/marker Biopsy aspiration needles (recommended sizes): Regular/Adults: Adults: Orthopaedic: Paediatric: Infant: 4 inch, 11 gauge 4 inch, 8 gauge 6 inch, 10/11 gauge 3 ½ inch, 13 gauge 2 inch, 13 gauge Pre operative procedures No specific procedures are needed. Aspiration procedures 1. Place the patient in a right or left lateral decubitus position with the back comfortably flexed and the top knee drawn toward the chest. 2. Locate the posterior iliac spine and mark with ink or thumb nail pressure. 3. Using the sterile technique, prepare the skin with antiseptics and drape. 4. Using a sterile syringe, apply/infiltrate the marked area with local anaesthetic especially the periosteum. 5. Make a 3 mm skin incision with a scalpel blade over the marked area. 45

46 6. Hold the needle with the proximal end in the palm, and the index finger against the shaft near the tip. 7. With the stylet locked in place, introduce the needle through the incision pointing toward the anterior superior iliac spine and bring it into contact with the posterior iliac spine. 8. Using gentle but firm pressure, advance the needle to bore through the iliac spine. 9. Rotate the needle in an alternating clock wise and counter clockwise motion. Entrance into the marrow cavity is generally detected by decreased resistance. 10. Remove the stylet, and check for presence/absence of marrow material. If not, proceed to bore until marrow is found in the tips of the stylet. 11. With a syringe locked into the proximal portion, apply a negative pressure. 12. The material can then be expelled on to clean slides and also inoculated into appropriate culture medium (preferably NNN medium) N.B. For cultures, insert needle into a tube containing culture medium and push the plunger into the barrel to expel contents of the needle on to the side walls of the tube or directly into the liquid phase of the medium. You may repeat this once or twice until the LN material is visible in the tube. For safety purposes, inoculate 2 culture tubes. For smears, expel any remaining material gently on clean glass slides holding tip of needle on the surface of slide, and spread evenly into a smear immediately using a linear motion. More material can be obtained at the end of the plunger or the needle (or tip of syringe) after removing the plunger and needle. Tooth picks or wooden applicators may be used for this purpose. It is important that culture tubes are not over loaded by large amounts of inoculum, which is not uncommon with BM aspirates. 13. Slides can be stained with Leishman, Giemsa or Wright s stain (See Annex 4). NNN cultures should be incubated at 25 0 C for up to 2 weeks. Post operative procedures No specific procedures are needed. 46

47 Annex 5. Procedures for splenic aspiration Splenic aspiration should be performed only if the following conditions are met: absence of clinical contraindication(s): signs of active bleeding (e.g. epistaxis, rectal bleeding, skin bruises) jaundice (a potential marker of liver dysfunction) pregnancy spleen barely palpable bad general condition (e.g. cardiovascular shock, altered consciousness) absence of biological contraindication(s): severe anaemia (haemoglobin count 5 g/l) difference in prothrombin time between patient and control > 5 s platelet count < /ml rapid access to blood transfusion in case of bleeding The two important prerequisites for the safety of the procedure are rapidity, so that the needle remains within the spleen for less than l s; and precision, so that the entry and exit axes of the aspirating needle are identical to avoid tearing the splenic capsule. The procedure is as follows: 1. Clean three glass slides and label them with patient s name, date and the words splenic aspirate. Have culture medium ready (if available) and labelled in the same way as the slides. Attach a 1 1/4 inch 21 gauge ( mm) needle to a 5 ml syringe. Place all items on a table at the bedside. 2. Inform the patient about the procedure. Check all clinical and biological contraindications again. Palpate the spleen and outline its margins on the patient s abdomen with a pen. For safety, the spleen should be palpable at least 3 cm below the costal margin on expiration. Use an alcohol swab to clean the skin at the site of aspiration, and allow the skin to dry. 3. With the 21 gauge (0.8 mm) needle attached to the 5 ml syringe, just penetrate the skin, midway between the edges of the spleen, 2 4 cm below the costal margin. Aim the needle cranially at an angle of 45 to the abdominal wall. The actual aspiration is done as follows: pull the syringe plunger back to approximately the 1 ml mark to apply suction, and with a quick in and out movement push the needle into the spleen to the full needle depth and then withdraw it completely, maintaining suction throughout. 4. For young, restless children, have two assistants hold the child (arms folded across the chest, with shirt raised to obstruct the line of vision, and pelvis held firmly). Carry out the aspiration as a single stage procedure, using the same landmarks, angles and suction as in step 3, all in one quick motion. The insertion should be timed with the patient s breathing so that the diaphragm is not moving; this should be done during fixed expiration if the child is crying. Only a minute amount of splenic material is obtained, but this is sufficient for culture and smear. 47

48 5. If a culture is available: slowly pull the plunger back to the 2 3 ml mark, and, using sterile techniques, insert the needle into a tube containing culture medium and briskly push the plunger into the barrel to expel the contents of the needle onto the side walls of the tube. If necessary, repeat once or twice until splenic material is visible in the tube. Replace the cap on the tube and invert to wash splenic material on the side of the tube. Repeat the procedure for the second tube of culture medium. Sterile techniques are essential throughout. 6. Expel material (or additional material if culture is available) gently onto glass slides, holding the needle tip on the surface of the slide. Immediately spread evenly with the needle, using a linear (not circular) motion. The smear should be slightly thinner than a thick blood film for malaria. Remove the needle, and use the end of it to obtain additional material from the tip of the syringe and spread it on slides. Further material found on the end of the plunger may be dabbed directly onto a slide and spread. Allow the slides to dry. 7. Write the time of aspiration on the patient s chart, with the instructions: "Record pulse and blood pressure every half hour for 4 hours, then every hour for 6 hours. Patient must remain in bed for 12 hours." Ensure that the patient understands the instructions. Enter the procedure in the notes, and sign. 8. Take the slides (and medium) to the laboratory for preparation and microscopic examination. 48

49 Annex 6. Preparation and examination of aspirates. grading of parasites. Preparation of the aspirates Prepare thin films of the splenic aspirate material or lymph gland fluid. Spread the films on a clean glass slide immediately after collection, before the material clots. Slides are stained with Giemsa as for thin malaria film, and examined under oil immersion Items required: Methanol Glass slide Slide rack Giemsa Buffer solution ph 7.2 Microscope Thin films Collect a drop of the aspirate/fluid on one end of the slide; about 1 2 cm from one end. Place the slide horizontally on a flat surface. Hold the sides of the second slide (spreader) or coverslip on to the center of the specimen slide and move it backwards until it touches the drop of the fluid. Let the fluid spread along its base. At an angle of between , move the spreader firmly and steadily across the specimen slide to make a film. A good film should have a conical tail and should cover about two thirds of the slide. Let the film dry. Fix the dried smear by dipping in absolute methanol for a few seconds and allow to air dry on a drying/draining rack. Fixation: Place the slides horizontally on the slides rack and leave to air dry. Fix the slides by dipping them in 100% methanol for 1 minute. The methanol must be stored in a tightly closed bottle to prevent absorption of water. Staining: Stain the slides with Giemsa stain 1: 10 concentration; 1ml of stock Giemsa stain to 9ml buffer solution ph 7.2. The slides can either be stained in a staining trough or on a staining rack. 49

50 Staining in trough Place the slides in a staining trough Pour the stain gently into the trough until the slides are totally covered. Avoid pouring the stain directly onto the film Leave the slides to stain for minutes. Pour clean water into the trough to float off the scum on the surface of the stain. The water should be poured into the end of the trough. Gently pour off the stain and rinse again in clean water. Then pour off the water. Remove the slides one by one and place them in vertical position on a slides rack to dry Staining on a rack Use a test tube or a small container to hold the prepared stain Gently pour the stain onto the slide or use a pipette to drop the stain on to the slide Leave the slides to stain for minutes Gently flush the stain off the slide by adding drops of clean water. Never pour the stain off the slides, otherwise the surface scum will stick to the film and spoil if for microscopic examination Place the slides in vertical position on a slides rack to dry Microscopic examination of stained aspirates Method Place the microscope on a firm bench, free from vibration. Switch on the light source. If there is no inbuilt light source, adjust the flat side of the mirror to reflect the light up through the condenser. Adjust the eyepieces by sliding them horizontally until they fit both eyes comfortably and the two fields merge. Centre the condenser if applicable. Prepare the slide for examination by putting a drop of oil immersion on the smear. Clean and dry underneath of the slide by wiping with cotton gauze/wool or tissue paper. Rotate the nosepiece until the low power objective is in position ( 10). A slight resistance and a click are felt as the objective moves to the correct position. Place the slide carefully on the stage. Never place the slide on the stage when the 40 or 100 (oil immersion) objectives are in position as this may scratch the lenses. Adjust the illumination. 50

51 Focus the specimen by racking the stage up to the top and then while observing through the eyepiece, rack the stage down slowly using the coarse adjustment knob, until the image comes into view. Use the fine adjustment knob to focus the image sharply. Scan the film and select a part that is well stained, free of staining debris and well populated with white blood cells. Swing the required objective into position i.e. oil immersion ( 100) objective. Focus using the fine adjustment knob. Never use the coarse adjustment knob because the objectives are parfocal. Adjust the illumination by opening the iris diaphragm as required, for oil immersion objective open the iris diaphragm fully. Examine the specimen systematically, moving from field to field using the knobs that control the mechanical stage. For example, start at the selected site and move horizontally to the top right hand corner. Move the slide down by one field and then horizontally in the other direction to the end of the smear. Continue until the whole specimen has been examined. After examination, lower the stage or swing the lowest power objective into position before removing the slide from the stage. Never remove the slide from the stage when 40 or 100 objectives are in position, as this may scratch the lenses. Wipe the oil immersion objective using lens cleaning tissue. Switch the microscope off. Identification of the Leishmania parasite Leishmania amastigotes are oval or round and are usually seen in the cytoplasm of monocytes. Free parasites may be seen if the host cells are ruptured during preparation of the film. In stained preparations, Leishmania amastigotes contain two visible structures: Nucleus Kinetoplast The nucleus and kinetoplast stain dark reddish. The cytoplasm stains pale pink. The nucleus of the host cell may be pushed to one side by the multiplying parasites. Leishmania amastigotes are sometimes referred to as L.D. bodies. Free amastigotes Intra cellular amastigotes 51

52 If Leishmania amastigotes are seen, report the slide as: Lymph node or splenic aspirate: Leishmania amastigotes seen and indicate the grade. Examine at least 1000 fields before declaring a film to be negative. Grading of slides Parasite grading has several uses. It increases the sensitivity of parasite detection, provides an objective measure of the speed of response to treatment, distinguishes quickly between slow responders and non responders, and provides an indication of parasite load that is useful in research. The average amastigote density is graded as follows 1 : 6+: > 100 parasites per field (viewed with a 10 eyepiece and 100 oil immersion lens) 5+: parasites per field 4+: 1 10 parasites per field 3+: 1 10 parasites per 10 fields 2+: 1 10 parasites per 100 fields 1+: 1 10 parasites per 1000 fields 0: 0 parasite per 1000 fields Parasite grading has several uses. It increases the sensitivity of parasite detection, provides an objective measure of the speed of response to treatment, distinguishes quickly between slow responders and non responders, and provides an indication of parasite load that is useful in research. 1 Adapted from Chulay JD, Bryceson AD. Quantitation of amastigotes of Leishmania donovani in smears of splenic aspirates from patients with visceral leishmaniasis. American Journal of Tropical Medicine and Hygiene, 1983; 32:

53 Date Name Age Sex County Payam Village Dipstick DAT Aspirate Date DAT Annex 7. Kala azar laboratory register book Serial No. Laboratory results Reference laboratory results samples sent to Ref. Laboratory Date DAT results received from Ref. Laboratory Ref. Laborator y DAT results Comment 53

54 Annex 8. Kala azar treatment register book Name of organization/partner: Location: State: (Left hand) Admission Number Date Name Age Sex County Payam Village/Town Rx: treatment Category of patient: Primary KA, Relapse or PKDL NA: Not applicable RDT: Rapid diagnostic test DAT: Direct agglutination test Treatment Outcome: Discharged, default, referred or died 54

55 Right hand Continuation of the above Laboratory tests No. of months (RDT/DAT/ Aspirate) sick before Rx Date Result Rx start date Category of patient Treatment Pregnancy Medicines(s) (yes/no/na) Adverse side effects Treatment outcome Rx: treatment Category of patient: Primary KA, Relapse or PKDL NA: Not applicable RDT: Rapid diagnostic test DAT: Direct agglutination test Treatment Outcome: Discharged, default, referred or died 55

56 Annex 9. Kala azar patient treatment card PATIENT No. TREATMENT SITE: NAMES: AGE: Sex VILLAGE PAYAM COUNTY PREGNANCY (Y/N) HOW MANY MONTHS SICK: PREVIOUSLY TREATED FOR KA (Y/N) When Where Treatment General condition: Edema (Y/N) Jaundice (Y/N) Lymphadenopathy (Y/N) _ WEIGHT : kg HEIGHT: cm BMI: WFH (z score) SPLEEN SIZE: cm LIVER size: cm General condition: able to walk unable to walk Presence of concomitant infection(s): No Yes If yes, specify: Tuberculosis Malaria Diarrhoea Pneumonia HIV If yes for HIV, on ART? HAEMOGLOBIN (g/dl)..: DIPSTICK KA: DATE: RESULTS DAT: DATE: TITRE (well result) DATE: TITRE (well result) ASPIRATE: (LN/BM/SP) DATE: RESULTS DATE: RESULTS Medicine: Combination ANTIMONIAL (SSG or Glucantime) + PAROMOMYCIN DOSE: DOSE: AMBISOME DOSE: ANTIMONIAL (SSG or Glucantime) DOSE: Other Medicines: : Dose 56

57 Patient category: Primary KA PKDL Relapse Date Dose SSG (in ml) Dose PM Dose Amb. No T o DI DI wb Vo Co RD BL Other medicines given including ORS Others specify Condition on discharge: Date: Weight: Spleen: cm TOC result: date: Outcome: Discharged clinically cured died default transferred No: = Day number RD = Respiratory distress T o = Temperature BL = Bleeding DI = Diarrhoea (how many times) Co = Coughing DI wb = Diarrhoea with blood (how many times) Vo= Vomiting (how many times) Other = Any other sign (e.g. Abdominal discomfort, pain/abscess at injection site etc) 57

58 Annex 10. Kala azar patient discharge card Name: No: Age: Sex: M F Village: PAYAM 1 o KA RELAPSE KA PKDL SSG/Glucantime PAROMO AMBISOME Other medicines (specify) ADMISSION DATE: DISCHARGE DATE: Weight: Spleen: Liver: TOC: 58

59 Annex 11. Dosage and precautions for the use of sodium stibogluconatessg) Presentation: Solution for injection, vials 30ml. Contains 33% (= 9.9g/30ml) SSG corresponding to 10% Sb 5+ which is 100mg Sb 5+ /1ml or 3000mg Sb 5+ /30ml. Table of SSG volume per body weight (20mg Sb 5+ /kg/day) Weight in kg SSG dose in ml Weight in kg SSG dose in ml Weight in kg SSG dose in ml No upper limit for SSG! If the patient s weight is more than 75kg then calculate accordingly. Contraindications 59

60 There are no absolute contraindications to its use but under ideal circumstances patients with underlying renal, hepatic or cardiac disease should be well monitored. Elderly patients may have age related decreased kidney function so may be at risk of increased toxicity. Toxicity and side effects Prevention of SSG toxicity: The most important way to prevent SSG accumulation between doses is to ensure adequate hydration. SSG is cleared in the urine. Patients should repeatedly be told to drink enough fluids so they pass urine at least 4 times a day. Babies should pass urine every hour or so while awake. Minor side effects: Symptoms: nausea, anorexia, arthralgias, myalagias, injection site pain, fatigue, and abdominal pain. Laboratory toxicity: elevated amylase (biochemical pancreatitis), elevated liver enzymes (biochemical hepatitis), leukopenia / anaemia / thrombocytopenia. Occasionally, renal failure occurs. Electrocardiograph changes (ST segment and T wave). Nausea and anorexia are substantial problems where patients are already malnourished and dehydrated. The nausea and anorexia subside somewhat in the later weeks of treatment. Serious toxicity: Severe vomiting and abdominal pain (pancreatitis?): Vomiting is relatively common and should be treated aggressively. Treat with anti emetic medications, and push sips of fluids. When anti emetic treatment fails the SSG should be withheld for 2 to 5 days as needed. If vomiting is associated with other risk factors especially extremes of age, low haemoglobin, severe malnutrition, withholding of SSG is even more imperative. In hospitals with chemistry available, patients vomiting from known pancreatitis should also have SSG withheld. Note that when the pancreatic enzymes return to normal and the patient is re challenged with SSG, the amylase may remain normal. Electrocardiograph abnormalities (QT prolongation), and sudden death (rare): Sudden death occurs rarely possible explanations are cardiac arrhythmias or intra cerebral bleeds. ECG changes are common. Sudden death is associated with high doses of SSG (over 30mg/kg/day). However, cardiotoxicity and sudden deaths are not seen in PKDL patients, so toxicity may be a combination of SSG and a weak individual. Other points of interest: 60

61 Blindness is NOT a toxicity of SSG if a patient complains of loss of vision after treatment then it could be iritis (which can occur in isolation or with PKDL) and this iritis requires further treatment with SSG. Apparently retinal haemorrhages occur with KA (not associated with SSG) as well. Injection abscesses from the IM route have been uncommon but when present need aggressive treatment (antibiotics, drainage of pus). Neurological toxicity: not reported elsewhere as a toxic effect of SSG. Before or during treatment some patients have ataxia and severe tremors with or without a headache. Neuropathy, psychosis and epilepsy are other occasional neurological features. It is unclear whether any of these are an effect of SSG in patients with KA (it never occurs in patients undergoing treatment for PKDL), if it is KA itself, or if it represents bleeding into areas of the brain. The ataxia, tremor and neuropathy may all remain for months after cure. 61

62 Annex 12. Dosage and precautions for the use of paromomycin (aminosidine). Presentation Solution for injection vials of 375 mg/ml, 2 ml (750 gr). Table of paromomycin (PM) volume per body weight (15mg/kg/day) Weight in kg PM dose in ml Weight in kg PM dose in ml Weight in kg PM dose in ml

63 Toxicity and side effects PM is an aminoglycoside and as such has renal and ototoxicity. The toxic effects of SSG and PM do not overlap. Ototoxicity: All aminoglycosides can cause damage to hearing and balance. PM is probably less toxic than streptomycin, amikacin or gentamicin. PM should be avoided in patients who complain of deafness before treatment this occasionally occurs in KA. Renal toxicity: Renal toxicity is increased in patients who are dehydrated, hypokalemic [low serum potassium e.g. patients with vomiting or profuse diarrhea], or who have underlying renal impairment. All patients should be encouraged to remain orally well hydrated when on PM or SSG. Patients should be told to drink until they have passed urine at least 4 times a day; babies should pass urine about each hour. Old patients are more vulnerable to renal toxicity. Pregnancy: Like streptomycin, PM could theoretically affect the hearing of the newborn. The survival benefits of PM in pregnant women in South Sudan are thought to out weigh this theoretical risk. 63

64 Annex 13. Dosage, administration and precautions for meglumine antimoniate. Dosage Meglumine antimoniate and sodium stibogluconate are the pentavalent antimony (Sb 5+ ) compounds used to treat leishmaniasis; Meglumine antimoniate is commercialized by SANOFI AVENTIS as a solution for injection in 5ml ampoules (Glucantime ) containing 405mg of pentavalent antimony (Sb 5+ ), which is 81mg of Sb 5+ /1 ml. The dose of meglumine antimoniate is based on the amount of pentavalent antimony the presentation contains and is 20mg/kg/day. Table of Meglumine antimoniate volume of injection to give 20mg/kg/day Route of administration Intravenous (IV) or intramuscular (IM) Sb 5+ pharmacokinetics are almost identical by either IM or IV routes. The choice of IV or IM depends on the setting. IM administration is most logical in the bush. The medicine may be given by deep intramuscular injection. Consider also the high volume that should be injected (if the volume of injection exceeds 10 ml, it should be divided in 2 doses: one in each buttock or thigh). During a polio outbreak consider giving all the children less than 3 years of age IV injections (IM injections increase the rate of paralytic disease in those incubating with polio). IV is much less painful. It should be given slowly, over 5 10 minutes or longer, using small butterfly style needles. Another possibility is to dilute the medicine in 5% glucose solution, 500 ml in adults and administer it slowly (30min 1hour). In children weighing between kg body weight use 100 ml, and if less than 10 kg use 50 ml. Contra indications Severe cardiac, liver and kidney disorders and breastfeeding. Precautions The risk of serious, even fatal, toxicity of pentavalent antimonials is increased in patients who concomitantly present with: cardiac disease, in particular arrhythmia; renal failure, liver disease, severe malnutrition/severely impaired general condition; advanced HIV infection; pregnancy. If one of these conditions are present, provide a protein rich diet and good hydration throughout treatment. If possible, correct iron and other nutritional deficiencies; renal and hepatic impairment; monitor cardiac, renal and hepatic function; treat concomitant infection (for example pneumonia), and check the patient regularly (ECG and renal, liver, pancreatic function). And if possible an alternative medicine should be used. 64

65 The minimum dose is 2ml (162mg) for children weighing less than 10 kg. Weight in kg Meglumine antimoniate dose in ml Weight in kg Meglumine antimoniate dose in ml Weight in kg Meglumine antimoniate dose in ml < < < < < < < < < < < < < < < < < < < < < < < < <

66 Annex 14. Anthropometry and nutrition therapy look up tables. Table 17. Look up table for maintenance amounts of F100 diluted (severe wasting) or F75 (bilateral pitting oedema until the oedema is resolved) for breastfed infants Child s weight (kg) F100 Diluted or F75 in case of oedema (ml per feed if 12 feeds per day) F100 Diluted or F75 in case of oedema (ml per feed if 8 feeds per day) Table 19. Stabilisation phase look up table for volume of F100 diluted (severe wasting) or F75 (bilateral pitting oedema) for non breastfed infants under 6 months Child s weight (kg) F100 diluted or F75 in case of oedema (ml per feed if 12 feeds per day) F100 diluted or F75 in case of oedema (ml per feed if 8 feeds per day)

67 Table 8. Look up table for amounts of RUTF to give to a child per day or week based on a dose of 200 kcal/kg bodyweight/day using 92 g packets containing 500 kcal Child s weight (kg) Packets per day Packets per week 4.0* ³ * Infants < 4 kg are referred to inpatient care Table 10. Stabilisation phase volume of F75 for persons with severe wasting Weight (kg) F75 (ml per feed if 12 feeds per day) F75 (ml per feed if 8 feeds per day) F75 (ml per feed if 6 feeds per day) F75 (ml per feed if 5 feeds per day)

68 Table 11. Stabilisation phase volume of F75 for persons with severe (+++) bilateral pitting oedema Weight (kg) F75 (ml per feed if 12 feeds per day) F75 (ml per feed if 8 feeds per day) F75 (ml per feed if 6 feeds per day) F75 (ml per feed if 5 feeds per day)

69 Box 5. Appetite test For children meeting the anthropometric criteria for admission for treatment of SAM, the appetite test, in addition to the presence or absence of severe medical complications, forms one of the most important criteria for deciding whether to treat a child with SAM in outpatient care or inpatient care. The pathophysiological responses to nutrient depletion in children with SAM are such that liver and metabolic functions are disturbed and dysfunctional, leading to poor appetite. In addition, children with a significant infection also lose appetite, especially in the acute phase. This puts children with SAM with poor appetite at higher risk of death. The appetite is tested upon admission and is repeated at each follow up visit to the health facility. Points to consider when conducting an appetite test: Conduct the appetite test in a quiet separate area. Provide an explanation regarding the purpose of the test to the caregiver and describe the procedure. Observe the child eating the RUTF during 30 minutes, and decide if the child passes or fails the test. Advise the caregiver to: o Wash hands before giving the RUTF o Sit with the child in lap and gently offer the RUTF o Encourage the child to eat the RUTF without force feeding o Offer plenty of clean water to drink from a cup when child is eating the RUTF Appetite Test: Pass appetite test The child eats at least one third of a packet of RUTF (92 g) or three teaspoons from a pot. Fail appetite test The child does NOT eat one third of a packet of RUTF (92g) of three teaspoons from a pot Note: If necessary, arrange a quiet corner where the child and caregiver can take their time to get accustomed to eat the RUTF. Usually the child eats the RUTF in 30 minutes. A child who fails the appetite test should be admitted to inpatient care. Table 12. Transition phase look up table for amounts of RUTF to give to a child per day based on a dose of 150 kcal/kg bodyweight/day using 92 g packets containing 500 kcal Child s weight (kg) Packets per day Table 22. Dietary requirements of adolescents and adults in the stabilisation phase Age Daily energy requirement* Volume of diet required In years In kcal/kg bodyweight F75 (ml/kg bodyweight/ hour) F75 (ml/kg bodyweight if 8 feeds a day) F100 (ml/kg bodyweight/ hour) F100 (ml/kg bodyweight if 8 feeds a day) > * Individual needs may vary by up to 30 percent from these figures. 69

70 Anthropometry look up tables Weight for length look up table, children 6 23 months, WHO 2006 child growth standards-+ Boys' Weight (kg) Length a Girls weight (kg) 3 SD 2 SD 1 SD Median (cm) Median 1 SD 2 SD 3 SD a Length is measured for children under 2 years or less than 87 cm height. For children 2 years or older or 87 cm height or greater, height is measured. Recumbent length is, on average, 0.7 cm greater than standing height; although the difference is of no importance to individual children, a correction may be made by subtracting 0.7 cm from all lengths above 86.9 cm if standing height cannot be measured.

71 Weight for height look up table, children months, WHO 2006 child growth standards Boys' weight (kg) Height a Gitls weight (kg) 3 SD 2 SD 1 SD Median (cm) Median 1 SD 2 SD 3 SD a Length is measured for children under 2 years or less than 87 cm height. For children 2 years or older or 87 cm height or more, height is measured. Recumbent length is, on average, 0.7 cm greater than standing height; although the difference is of no importance to individual children, a correction may be made by subtracting 0.7 cm from all lengths greater than 86.9 cm if standing height cannot be measured. 71

72 Guidelines for diagnosis, treatment and prevention of visceral leishmaniasis in South Sudan BMI Look up tables 72

73 Look up tables (continued) 73