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Year : 2012  |  Volume : 1  |  Issue : 4  |  Page : 396-403

A study on delay in treatment of kala-azar patients in Bangladesh

1 Medicine Department, Dhaka Medical College Hospital, Dhaka, Bangladesh
2 Surya Kanta Kala Azar Research Centre, Mymensingh, Bangladesh
3 Medicine Department, Shahid Sarwardi Medical College Hospital, Dhaka, Bangladesh
4 Director General of Health Services; Dev Care Foundation, Dhaka, Bangladesh

Date of Web Publication25-May-2017

Correspondence Address:
Ariful Basher
Surya Kanta Kala Azar Research Centre, Mymensingh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2224-3151.207041

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Visceral leishmaniasis (kala-azar) continues to be a major rural public health problem in Bangladesh. A cross-sectional study was carried out in two subdistricts of Mymensingh district from January 2006 to June 2007 to evaluate the delay kala-azar treatment. Suspected patients who attended to out patient department (OPD) were subjected to a dipstick test (RK39) for kala-azar. Sixty five from Bhaluka and 60 positive patients from Gafargaon subdistrict were enrolled. Most of the patients (80%) first visited nonqualified private practitioners, while only 15.2% consulted registered doctors. Fifty per cent were referred to the Upazilla health complex (UZHC) by the family members or relatives. About 49% and 43% patients required third and second health-care providers for kala-azar treatment, respectively. Patient delay ranged from 2 to 30 days; median 4 (IQR 3 to 7 days), the system delay ranged from 0 days to 225 days; median 54 (IQR 40–66 days). Residential status (p value <0.05) had impact on patient delay. Educational status and number of treatment providers had impact on system delay (p<0.05). System delay rather than patient delay is the important weakness of the kala-azar control programme in Bangladesh. Residence in rural areas, low educational background and treatment providers are associated with these delays. A proper educational programme may reduce the delay.

Keywords: Visceral leishmaniasis, sand fly bite, health-seeking behaviour

How to cite this article:
Arif SM, Basher A, Rahman MR, Faiz MA. A study on delay in treatment of kala-azar patients in Bangladesh. WHO South-East Asia J Public Health 2012;1:396-403

How to cite this URL:
Arif SM, Basher A, Rahman MR, Faiz MA. A study on delay in treatment of kala-azar patients in Bangladesh. WHO South-East Asia J Public Health [serial online] 2012 [cited 2022 Aug 14];1:396-403. Available from: http://www.who-seajph.org/text.asp?2012/1/4/396/207041

  Introduction Top

The Indian subcontinent has experienced a major resurgence of kala-azar (KA) which accounts for 60% of all reported cases of kala azar in the world.[1],[2] Kala-azar is caused by infection in the retículo endothelial system by the protozoan Leishmania donovani acquired through sand fly bites.[3],[4],[5] It carries a high mortality ranging from 80% to 100% in untreated cases.[6] Even with treatment, case–fatality rates in excess of 10% are not uncommon.[7] It is associated with about 2.4 million disability–adjusted life years and around 70 000 deaths per year.[8]

Kala-azar is one of the major public health problems in Bangladesh, and the disease has been endemic for many decades. In the late 1970s kala-azar emerged sporadically in Bangladesh. During 1981–1985 only 8 upazilas (subdistrict) reported kala-azar cases, which was increased to 105 upazilas in 2004.[9] In the past few years, the kala-azar situation had assumed epidemic proportions with the number of reported cases increasing from 3978 in 1993 to 8505 in 2005.[9] But, in 2010, the number of cases reported was less than 4000 and there was only 1 death.[10] The actual number of cases might be a little higher due to incomplete reporting systems and late detection of PKDL cases. The hyperendemic zones in Bangladesh for kala-azar are mostly in Mymensingh district.

Social behaviour and economic consequences of kala-azar patients are still not well known, despite long standing occurrence of the disease and the implementation of various control programmes. This is due to inadequate information and the delay in diagnosis, social and community factors that influence care-seeking behaviour and the ability to control the disease etc. Delay in diagnosis and treatment of kala-azar leads to progression of disease, increase in the risk of complications and also augments the reservoir for further transmission.[7] Factors associated with delay are not well addressed. The objectives of this study were to understand patient and system factors responsible for delay in seeking treatment and suggest intervention tools towards improving the kala-azar control programme.

  Methods Top

The study was designed as hospital-based cross-sectional study; carried out at Gafforgaon and Bhaluka Upazilla Health Complex (UZHC); two Upazilla (subdistrict; lowest administrative unit and government 50 bed hospital) of Mymensingh district (highest(?) prevalence of kala-azar by Upazilla in the country).[8] Areas were selected purposively due to expediency of the investigators. Delay in receiving treatment for kala azar could be divided into “patient delay” (time from symptoms recognition to initial medical consultation) and “system delay” (time from first medical consultation to final treatment).[11]

We approached 125 new patients of kala azar attending at the UZHC during the study period. The sample size was determined with a single population proportion formula by assuming that 50% of the patients will come early for kala azar treatment at a UZHC (to obtain minimum sample size) with 95% confidence interval.

Consecutive confirmed 65 patients from Bhaluka and 60patients from Gafargaon upazilla were enrolled in this study. Patients attending to the out patient department (OPD) or in-patient facility with history of fever (Temp ≥38 °C) for at least for 2 weeks with one or more of the followings criteria: (a) anaemia (5<Hb<10 g/dl); (b) loss of weight; (c) splenomegaly were eligible to a RK 39 test for kala-azar. The patients were subjected to be a detailed clinical evaluation by one of the investigators. Historical points as outlined in the CRF (case record form) were recorded through a face-to-face interview. Few of the physical examination findings (e.g. anaemia, hepato-splenomegaly) were also recorded.

The data were checked with logical explanations to ensure accuracy. Standard definitions of the different types of delays were followed. Both descriptive and inferential statistics were determined using SPSS-16. Frequencies and proportions were used for the descriptive analysis. The ANOVA test, 2 sample Student’s-t test, chi2 test were used to assess differences considering each group is approximately normal. Cross-tabulations and multiple logistic regression analysis was done to identify the most important predictors for kala-azar treatment delay.

Ethical clearance was obtained from the ethical committee of Bangladesh Medical Research Council (National Ethics Committee). Prior to study enrollment, written informed consent was obtained from each participating patient. Detailed study-related information was read out and explained in local language. Research assistants supplied a copy of the handout to the patient/his/her guardian. Signed written informed consent was obtained from the patient/guardian. Finger impressions were obtained from participants, who could not sign. For subjects below 18 years, consent was taken from the eligible guardian. All patients were ensured treatment with Miltefosine tablets.

  Results Top

General characteristics of patients

About 60% study subjects were less then 20 years of age with only of the 15.1% above 45 years (range 4–60 years). A majority 64% (80) were male and almost all (98.4%) were from the Muslim community. Most patients were from rural areas (80.8%) and half (42.2%) were married; 34.4% were farmers and 32.8% students. About half had monthly income < US$ 50, while 8% had income >US$ 100.00. Twenty four per cent had no formal education. Those educated up to the fifth grade were 52.8%, and only 23.2% were graduates. Splenomegaly was present in 87.2% patients, 8.8% patients were moderately anaemic while the rest were mildly anaemic [Table 1].
Table 1: General characteristics of the study population

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Knowledge about the disease

Only 15.2 % had no idea about the disease [Table 2]. Almost all the respondents (84.8%) had heard the name kala-azar, and most (92.8%) knew that the disease was completely curable but only one person knew that it is an infectious disease transmitted by the bite of a sandfly. About 30.0% had family history of kala-azar. Most patients (85.6%) heard about the disease from hospital. According to the interviewees, about 60.8% always used mosquito nets at bedtime and 1.6% never used one. Approximately 96.8% fell asleep on a bed rather than the floor, and 56% slept during daytime [Table 2].
Table 2: Knowledge of respondents about kala-azar in Baluka and Gafargaon

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Type of facility first visited

One hundred and twenty five patients consulted with various types of health-care providers as the first place for seeking help with most visiting private health-care providers. About half (49.6%) went to village doctors, 27.2% to pharmacy personnel, 3.25% to the ‘Kabiraj’ (traditional health provider) and 2.4% to a medical assistant. Only 15.2% visited registered doctors and 2.4% directly reported to the Upazilla Health Complex (UZHC). Majority (85.6%) attended at UZHC as their third or fourth order treatment location. Many patients were referred to the UZHC by immediate family members or relatives (49.6%) for definite treatment. MBBS (registered) doctors referred 21% of patients to UZHC.

Determinants of pattern of delay

Patient delay ranged from 2 to 30 days with a median of 4 (IQR 3 to 7) days. The system delay ranged from 0 to 225 days, with a median duration of delay 54 (IQR 40 to 66) days. The median total delay was 55 (IQR 35 to 68) days. Seventy three per cent of cases had patient delay below 7 days (73%). System delay over 2 months were experienced by 28% of patients (Table 5). Residential status had significant statistical association with patient delay. Educational status, number of treatment providers and first healthcare provider had statistical association with System delay (p<0.05).[Table 3]
Table 3: Relationship between sociodemographic factors and patient delay and system delay (multiple linear regression analysis)

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  Discussion Top

Understanding the treatment-seeking behaviour of communities regarding kala-azar can be the key to the success of an elimination programme launched by the Government as Bangladesh along with India and Nepal have set the target of reducing the cases below 1 per 10 000 by the year 2015.[1]

Our data showed that most patients were below 40 years (82.2%) which is consistent with the studies.[12],[13] Awareness about the signs and symptoms of a disease can prompt patients to seek early treatment. However, in our study population, knowledge about the signs and symptoms of the disease was very poor despite the fact that the disease has been endemic for such a long time. Fever and splenomegaly were present in almost every kala-azar patient in Bangladesh. The majority of subjects lacked knowledge about the involvement of humans in the transmissibility and the infectious nature of the disease. There was an almost complete lack of knowledge about the transmitting vector (99.2%), which is a matter of concern for adaptation of preventive measures against the disease. Although most people were aware of the protective role of mosquito nets [Table 2], and many of households used bednets during sleeping, their acceptability and efficacy against kala-azar need more study.

The main health-seeking behaviour with the onset of fever was to visit a local health-care provider. People in the study community generally consult traditional healers due to a hierarchical system in their households. The majority of patients seeked care at the village doctor or personnel at the pharmacy (76.8%) or private doctor (MBBS) (15.2%). This indicates that the traditional healers are considered important in the treatment of kala-azar. Only a small number preferred public health facilities for treatment because of their views of inadequacy of the health system. Only 2.4% rated public health facilities as their first choice. The care-seeking pattern for fever were more likely to be managed initially at low cost. Multiple care-seeking events and switching different types of providers were not uncommon. More than 50% patients required three or four health-care providers for their definitive treatment.

Sociodemographic factors have long been associated with delay in management of kala-azar patients. The results indicate the obvious existence of delay in diagnosis and treatment of kala-azar patients. System delay was the most frequent type of delay and the greatest contributor to total delay. Distance from patients’ home to a health facility is also important as it affects health-care seeking and follow-up of diagnostic procedures. As most patients were from rural areas, distance between their homes to the health-care service had contributed to the delay in the diagnosis. This is consistent with the studies done in TB patients in Uganda and Ethiopia.[18],[19] Patients who tried their first consultation at rural areas experienced a longer patient delay than those who first sought care in urban facilities. Our data suggested that the first health-care provider plays an important role in determining the duration of system delay. A major finding of this study was that about 50% of the study subjects who soughted final treatment at UZHC were referred by their immediate family members or relatives. Village doctors referred only 5.6% patient although they play a significant role as first-care providers. This exposes a very weak point in our health care system. Therefore, by raising awareness among health-care providers and field staff, we can strengthen the referral system and thus shorten system delay. Eighty per cent of patients soughted medical care from village doctors, pharmacies and ‘kabiraj’, so health campaigns at the community level should be conducted to raise awareness and to facilitate early referral. Educational status also had significant relationship with system delay (p<0.05). This may be due to fact that most of the patients of this study reside in rural areas (80.8%) [Table 1]. They were illiterate and had to travel a long distance to consult with a qualified doctor to seek medical care and most rural people had no easy access to Government facilities. However educational status had no effect on delay to initiation of treatment (patient delay) as established in other studies.[20],[21] Other factors such as age, sex, marital status, economic status and religion were not associated with patient delay and system delay [Table 3], although other studies had confirmed prolonged delays with initiation of treatment.[18],[19],[20],[21],[22],[23]

Further in this study, poor knowledge of the study subjects about symptoms, infectious nature, and mode of transmission emphasizes the need for health education campaigns.

A system delay in treatment of kala-azar appears to be the major determinant of a treatment delay in the selected highest kala-azar prevalent area of Bangladesh. The current National Kala-azar Elimination Programme should address this issue in attempts to improve patients’ access to early treatment. Residence in rural areas and treatment providers have contributed to both the patient delay and the system delay. The elimination programme should emphasize training and continued education program for the First level health-care providers, many of whom are private health-care providers, in addition to the general BCC (behaviour change communication) campaign, to effectively reduce the treatment delay in the early case management of kala-azar.

Although it is difficult to extrapolate these findings, the level of KAP (knowledge–attitude–practice) about Kala-azar is not likely to be substantially different in other parts, because the study area is the oldest focus of kala-azar in Bangladesh and the population is expected to have maximum awareness about the disease. Even after such a prolonged and incessant disease transmission in the area, this lack of knowledge, indifferent attitude, and incorrect practices are pointers about the poor commitment of health–policy planners for the disease. For optimal utilization, public health facilities should be fully equipped to deal with cases of kala-azar.

  References Top

Bangladesh, Ministry of Health and Family Welfare. Kala azar elimination programme, MIS: technical report Dhala: Disease Control Unit, DGHS, 2010.  Back to cited text no. 1
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Indu BA, Bern C, Costa C, Akter T, Chowdhury R, Ali M, et al. Visceral leishmaniasis: consequences of a neglected disease in a Bangladeshi community. Am J Trop Med Hyg. 2003; 69(6): 624-8.  Back to cited text no. 7
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Bangladesh, Ministry of Health and Family Welfare. Kala azar elimination programme. National guideline and training module for kala azar elimination in Bangladesh. 1st edn. Dhaka: Disease Control Unit, DGHS, 2008.  Back to cited text no. 9
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  [Table 1], [Table 2], [Table 3]

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