Kala-azar: The neglected scourge threatening Kenya's arid regions
Despite efforts to control it, challenges like poor healthcare access, poverty, malnutrition, and displacement continue to fuel its spread.
As the world marks Rare Disease Day, attention turns to kala-azar (visceral leishmaniasis), a neglected tropical disease that, while rare in many regions, remains widespread in Marsabit County and other arid parts of Kenya.
Despite its endemic presence, kala-azar is often underreported and misdiagnosed due to limited healthcare access and awareness.
East Africa has the second-highest number of visceral leishmaniasis (VL) cases after India.
Also known as kala-azar, VL is a major neglected tropical disease (NTD) caused by Leishmania donovani.
Over 95 per cent of global cases occur in just 10 countries across South Asia, Africa, and South America. In Africa, the disease is most common in Sudan, South Sudan, Ethiopia, Kenya, and Somalia.
Despite efforts to control it, challenges like poor healthcare access, poverty, malnutrition, and displacement continue to fuel its spread.
Kala-azar is a slow-developing disease transmitted through the bite of an infected sandfly. The symptoms often appear weeks or even months after infection, gradually worsening over time.
Patients typically experience prolonged fever, severe weight loss despite having an appetite, and swelling of the spleen and liver, which causes noticeable abdominal distension. Anaemia sets in due to the destruction of blood cells, leading to extreme fatigue, weakness and pale skin.
Deadly
In some cases, especially in South Asia, the disease causes darkening of the skin, earning it the name “kala-azar,” meaning “black fever.” Swollen lymph nodes may also develop, adding to the patient’s discomfort.
Without timely medical intervention, kala-azar can be deadly.
The disease progressively weakens the immune system, making the body vulnerable to severe complications. Anaemia worsens, leading to malnutrition, and the risk of secondary infections, such as bacterial and fungal infections, increases significantly.
As the spleen and liver continue to enlarge, their function deteriorates, sometimes resulting in organ failure.
The reduction of platelets in the blood can also lead to internal bleeding, further endangering the patient’s life. If left untreated, VL has an almost 100 per cent fatality rate within two years.
Even when treatment is available, inadequate or improper medication can lead to complications. Patients who fail to complete their treatment may suffer a relapse, requiring additional, often more aggressive, therapy.
Misuse of drugs or inconsistent treatment can also result in drug resistance, making it harder to cure the disease.
Some individuals develop post-kala-azar dermal leishmaniasis (PKDL), a condition that causes skin lesions even after the disease appears to have been cured. These lesions not only pose cosmetic concerns but also serve as reservoirs for further transmission of the parasite.
Preventing complications
Early diagnosis and proper treatment with anti-leishmanial drugs are crucial to preventing these complications and saving lives. Strengthening healthcare access, ensuring the availability of effective medications, and raising awareness about the disease are vital steps in controlling kala-azar and reducing its devastating impact.
Many affected individuals face challenges in obtaining timely diagnosis and treatment, which requires specialised anti-parasitic drugs.
Deforestation and climate change have also expanded sandfly habitats, increasing the risk of infections.
According to the World Health Organisation (WHO), Kenya has experienced multiple outbreaks of VL over the years.
Since 2020, nine counties — Marsabit, Garissa, Kitui, Baringo, West Pokot, Mandera, Wajir, Tharaka Nithi and Isiolo — have reported a total of 2,037 confirmed and suspected cases, with 10 fatalities (a case fatality rate of 0.5 per cent). Currently, active outbreaks are ongoing in Kitui, West Pokot, Wajir and Isiolo.
Recurrent outbreaks
Kenya has seen recurrent VL outbreaks in Isiolo, Marsabit, Wajir and Baringo in 2008, 2011, 2013, 2014, 2017, and 2019. Marsabit, in particular, has shown a steady increase in cases. In 2014, 136 cases were reported with a case fatality rate (CFR) of 9.6 per cent. This number rose to 437 in 2017 and surged sharply to 2,338 in 2019.
Besides the rising case numbers and geographic spread, there has been an increase in infections among younger individuals.
The average age of patients dropped from 17.6 years in 2017 to 15.3 years in 2019, with more cases reported in women and children under ten. This increase may be linked to expanded testing availability.
Traditionally, VL was more common in the arid eastern and northern regions, while cutaneous leishmaniasis (CL) was prevalent in the semi-arid western and central areas. However, recent outbreaks have extended into western and southern counties.
Factors such as human migration for trade or survival, displacement of pastoral communities and refugees, increased human-animal interaction, environmental changes and social unrest may be contributing to this shift into previously non-endemic areas.
Despite efforts by the WHO and the Kenyan government to prevent VL through evidence-based policies, public-private collaborations and the provision of medical supplies from the WHO’s global emergency stockpile, VL remains a significant public health challenge.
Several critical areas require urgent attention.
Enhancing patient care, expanding diagnostic facilities and improving staff training are essential. Additionally, using shorter and more effective drug combinations can lead to better clinical outcomes. A swift response to outbreaks through early case detection, strengthened vector control, improved surveillance and robust monitoring and evaluation systems is crucial to managing the disease effectively.
Kala-azar remains a significant public health concern in Kenya, across Africa and globally.
Second-largest parasitic killer
WHO notes that VL is the second-largest parasitic killer worldwide, following malaria, with an estimated 20,000 to 40,000 deaths annually. However, this figure is likely underestimated, as many VL-related deaths go unrecognised or unreported.
In 2022, eastern Africa accounted for 73 per cent of global VL cases, with half of these occurring in children under 15 years of age.
The region reports at least 4,000 VL-related deaths annually, resulting in approximately 385,000 disability-adjusted life years lost.
Kenya is among the 10 countries that collectively report over 90 per cent of new VL cases annually worldwide. In 2019, Kenya reported 43 VL-related deaths, which decreased to 21 in 2020.
These statistics underscore the critical need for continued efforts in prevention, early diagnosis, and effective treatment to reduce the burden of VL in Kenya, Africa and globally.
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