# Kala-azar Elimination Programme > Kala-azar elimination programme for MBBS Community Medicine: block-level threshold, rK39, single-dose liposomal amphotericin, IRS and the four endemic states. - Canonical URL: https://prepelephant.com/topics/mbbs/community-medicine/kala-azar-elimination-programme - Exam / course: MBBS · Subject: Community Medicine - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Kala-azar Elimination Programme", PrepElephant, https://prepelephant.com/topics/mbbs/community-medicine/kala-azar-elimination-programme ## Direct answer Kala-azar elimination is defined arithmetically: fewer than one case per 10,000 population per year at block primary health centre level, sustained — and India's programme, with a 2005 inter-country agreement with Bangladesh and Nepal, has driven cases from tens of thousands in the early 1990s to below a thousand annually in recent years. The strategy rests on four pillars: active and passive case detection with the rK39 rapid test for fever of two weeks or more with splenomegaly; single-dose liposomal amphotericin B (10 mg/kg infusion) as first-line treatment, supplied free through a WHO-mediated arrangement; indoor residual spraying with synthetic pyrethroids after DDT was withdrawn in the mid-2010s; and post-kala-azar dermal leishmaniasis (PKDL) search, since PKDL cases keep the parasite circulating. Bihar carries the bulk of the burden, with Jharkhand, West Bengal and Uttar Pradesh completing the endemic map; the vector is the sandfly Phlebotomus argentipes. ## What you must remember - **The threshold:** elimination means under 1 case per 10,000 per year at block (sub-district) level — not state or national averaging, a deliberate viva trap. - **Diagnosis:** fever of 2 weeks or more with splenomegaly in an endemic area; rK39 immunochromatographic strip as the programme's rapid test; spleen or bone-marrow aspiration for confirmation where needed. - **Treatment to quote:** single-dose liposomal amphotericin B 10 mg/kg intravenous infusion as first-line (adopted in national guidelines in the 2010s); alternatives include oral miltefosine (28 days) and paromomycin; untreated visceral leishmaniasis is nearly always fatal. - **PKDL:** post-kala-azar dermal leishmaniasis appears after treatment of visceral disease — hypopigmented patches, nodules — treated with miltefosine for weeks; PKDL patients are the recognised reservoir sustaining transmission. - **Vector control:** indoor residual spraying with synthetic pyrethroids (DDT discontinued from the mid-2010s), targeting walls and cattle sheds where Phlebotomus argentipes rests; sandflies are weak fliers, so bednets and plastered walls matter. - **Geography:** four endemic states — Bihar (the large majority), Jharkhand, West Bengal, Uttar Pradesh; village-level micro-stratification directs spraying. - **Trajectory:** targets set for 2010 were revised repeatedly (2015, 2017, 2020, 2023); India has met the block-level threshold recently and is moving toward WHO validation (per current programme reports). ## From outbreak numbers to elimination arithmetic — one village's story A villager in Bihar has two weeks of fever, weight loss and a dragging left upper abdomen; the ASHA flags him, the ANM performs an rK39 test, and the positive strip plus splenomegaly makes him a programme case. He receives single-day liposomal amphotericin B under observation — a transformation worth understanding: the older sodium antimony gluconate needed a month of painful injections amid rising resistance, and oral miltefosine demanded weeks of adherence; one infusion converted kala-azar from a hospital-month to an outpatient-day disease. His and neighbours' houses are line-listed for spraying; contacts are examined; and he is followed twelve months to catch PKDL, which can seed the next transmission cycle. The recent history is the classic elimination endgame: as cases fell below threshold, the problem shifted from treating crowds to finding the last few — active case search, incentivised voluntary reporting, PKDL camps — then validation paperwork, since WHO elimination status is certified, not self-declared. This endgame pattern (detect-treat-track-certify) is identical to polio, yaws and malaria frameworks and is the transferable lesson examiners reward. ## Where students slip Three slips recur. First, the threshold's denominator: candidates say "less than 1 per 10,000 population" without specifying block level, losing the point that averaging at state level hides endemic villages. Second, treatment drift: quoting antimonials as first-line dates the answer — single-dose liposomal amphotericin B at 10 mg/kg is the current national first line, with miltefosine as the oral alternative and the mainstay for PKDL. Third, vector confusion: the sandfly — silent, weak-flying, indoor-resting — transmits leishmania, which is why indoor residual spraying and bednets, not larval control, are the tools. A sharp differentiator for theory answers: kala-azar is often called the second-largest parasitic killer after malaria, and linking elimination to the 2005 India-Bangladesh-Nepal memorandum shows you know this is a regional, synchronised programme — the parasite does not respect the border. ## Frequently asked questions ### What is the elimination threshold for kala-azar? Fewer than one case per 10,000 population per year at block primary health centre level, sustained over time — the block, not the state, is the unit of assessment. ### What is first-line treatment under the programme? A single infusion of liposomal amphotericin B at 10 mg/kg, replacing older antimonial regimens; miltefosine orally and paromomycin are alternatives, and miltefosine is the standard for PKDL. ### Which test does the programme use for field diagnosis? The rK39 immunochromatographic rapid test on a patient with fever of two weeks or more and splenomegaly in an endemic district, with parasitological confirmation reserved for doubtful cases. ### Why does PKDL matter for elimination? Post-kala-azar dermal leishmaniasis patients harbour parasites in skin lesions long after cure of visceral disease, acting as the residual human reservoir that can reignite transmission. ### Which states and vector define Indian kala-azar? Bihar, Jharkhand, West Bengal and Uttar Pradesh are the endemic states, and Phlebotomus argentipes sandflies — indoor-resting, weak fliers — transmit Leishmania donovani.