Exposure Factors Associated with Visceral Leishmaniasis (kala-azar) in Loima Sub-County of Turkana County, Kenya

Background: Visceral Leishmaniasis (Kala-azar) is a serious disease caused by species of the parasitic protists Leishmania. It can affect humans living in parts of the tropics and sub-tropics and is transmitted by Phlebotomus sandflies. It is classified as a neglected disease yet it is a public health problem, a debilitating disease causing an estimated 500,000 new cases each year, and a tenth of these patients will die in the predisposed areas. Objective: To assess the exposure factors associated with kala-azar in Loima sub-county of Turkana County, Kenya. Methods: Descriptive crosssectional research design was employed and the study was conducted between October, 2015 and June, 2016. Cluster random sampling technique was used to identify study subjects in the purposively selected Loima Sub-county. A sample size of 341 respondents who were household heads or adult members and health facility workers were randomly sampled. Data collection was done using pretested structured questionaires, interviews, focus group discussions and observations; entered into Statistical Package for Social Sciences (SPSS) version 17.0 for analysis. Presentation of data was done using both quantitative and qualitative approaches. Results: The key exposure factors to the disease in the community include: Age, gender, educational level, socio-economic status, housing, presence of large amount of termite mounds all over the area 60.1%(n=205),inaccessibility to health services, varying health-seeking behaviour and lack of proper knowledge on transmission of disease. Also, human activities such as deforestation and hunting 52%(n=32), resting or sitting near termite mounds 70%(n=191) and dancing at night (Edong’a 64.8%(n=167), when the sand flies are active. There was a significant association between age ((OR=0.7; 95%CI= (0.4-1.1), p=0.135) and exposure to kala-azar, gender (OR=0.6; 95%CI= (0.4-0.9), p=0.012),education level (OR=1.2; 95%CI= (0.1-1.4), p=0.0501)), housing (OR=1.8; 95%CI= (1.0-3.1), p=0.029 ),presence of large amount of termite mounds (OR=0.6; 95%CI= (0.2-2.0), p=0.0045) and resting or sitting near termite-mounds (OR=0.6; 95%CI= (0.1-2.1), p=0.0043)).Conclusion: The study concludes that kala-azar is prevalent in the area and though the community is aware of its existence, the residents have different beliefs about transmission. The study recommends the need for enhanced general health education and awareness on the transmission cycle of kala-azar. Community empowerment and participation should be emphasized as well as structural development plans that include sand fly management strategies and control methods that would ensure the removal of breeding and resting sites of the vectors within human habitation. In addition, integrated disease surveillance and response to be implemented to avert the disease situation.


Background Information
Visceral leishmaniasis has been among the most important health problems since early 1900s, in the world and Sub-Saharan Africa especially Kenya and Sudan where major upsurges in the number of cases were and still are noted in the endemic areas. Though a forgotten tropical parasitic disease, it causes an estimated 500000 new cases yearly and a tenth of these patients will die; and that it is almost always fatal with a mortality rate of almost 100%, if the cause is not identified and if left untreated [1]. The actual toll death of the disease may be higher than this estimate, considering the existence of its unidentified foci. Current estimates suggest an overall prevalence of 12 million people infected with Kala-azar in an at -risk population of 350 million, suggesting more than 2 million new infections each year with the figures including only cases with the overt disease [2]. In terms of Disability -Adjusted Life Years, the disease is responsible for a loss of 34 DALYS [3]. The geographical distribution of the disease in the predisposed areas is limited by the distribution of the sand fly, its susceptibility to cold climates, its tendency to take blood from humans or animals only and its capacity to support the internal development of specific species of Leishmania [4].
In Kenya, the disease has been reported in Baringo, Kitui, Machakos, West Pokot and Turkana where the prevalence is high especially in Loima Sub-county. More recently Kalaazar has been reported in Kerio Valley, North Baringo East Pokot, Wajir and Mandera Districts in North Eastern Province [5]. In Pokot and Turkana areas, Kala-azar has existed for at least 40 years. WHO 1991 report on the epidemiology of kala-azar, mentioned a survey done in 1959 where a high prevalence of the disease was confirmed in the area(s). Two annual reports of Amudat Hospital, Uganda (1983,1985) that borders West Pokot and Turkana, mentioned kala-azar as frequently being predisposed to the people in Kenya and Uganda. Loima one of the six Subcounties of Turkana County, has a high kala-azar prevalence against a population of 50000 people [6].
The geographical distribution of kala-azar in Africa including Kenya is due to factors related to development including poverty due to low socio-economic status and socio cultural practices, inaccessibility to health services, vector dynamics, massive rural-urban migration and agro-industrial projects that bring non-immune urban dwellers into endemic rural areas. Man-made projects with environmental impact like dams, irrigation systems and wells as well as deforestation, also contribute to the spread of leishmaniasis [7].

Statement of the Problem
The increasing number of people infected with kala-azar in Kenya and other countries poses a major public health problem, mostly in arid and semi-arid areas like Loima District of Turkana county, where many people are exposed and is endemic with a higher prevalence against a population of 50,000 people. This trend risks causing a health crisis as the disease is becoming a lethal cocktail, hence efforts need to be taken to avert the situation. The disease is fatal such that if not detected early, can result into deaths within a short period and that its mortality rate is almost 100% and it can result into epidemic outbreaks. The case fatality rate associated with the disease range from 0-50% of treated cases to 85-99% of untreated cases. The disease is a silent killer, invariably killing almost all untreated patients [8].
Kala-azar often exists in areas that are either remote or not easily accessible areas where health facilities are barely available or inadequate. Those most likely to be infected are people who are poor, living in villages far from roads and health care centres. Patients from such remote communities often die in the villages without seeking treatment. Some may attempt to report to distant health care centres, but in many cases it is simply too late. Even if they can make the journey to a hospital, they would still succumb to the illness because of the absence of anti-leishmanial drugs. Thus many decide to stay at home until they die. But in doing so, they act as a reservoir of infection, passing on the parasite to the family and neighbors through the bite of sand flies, hence the prevalence and incidence increase [1,9].
Kala -azar affects not only the Weakest in the community such as children and those weakened by other diseases such as HIV and tuberculosis, but also healthy adults and economically productive social groups [10] Most Kala-azar infections occur in remote geographical areas where say health facilities are not well established and where the infections often co-exist with malaria and other debilitating parasitic infections. Under this circumstance the disease usually presents a diagnostic dilemma, hence the need to determine the real cause of exposure in an area. Untreated Kala-azar is usually fatal in that even after recovery; patients may develop the chronic form that requires prolonged and expensive therapy [11].

Study Area and Study Population
The study was conducted in Loima Sub-county of Turkana county, Kenya from October 2015 to June, 2016. Loima (shown in figure 1 below) is part of Turkana County of the Rift Valley Province of Kenya, and which is suspected to have more people being predisposed to Kala-azar [8]. Turkana county occupies the northwestern part of Kenya sharing international borders with Ethiopia to the North, Sudan to the northwest and Uganda to the West, which are areas where also kala-azar is endemic. Turkana county is an arid and semi-arid land with warm and hot climates, unreliable rainfall where it receives annual rainfall of between 120mm and 500mm in the lowlands and highlands respectively and, with temperatures ranging between 24-380C. The main economic activities include livestock farming and trade, fishing, weaving and tourism. Natural resources are gemstone and saltlicks, oil,gold that is dormant, wildlife,Lake Turkana and Turkwell dam. Agricultural products are sorghum and maize. Despite all these, the poverty level is that 95% of the population live below the poverty line, 89.4 being the age dependence ratio.
Loima Sub-county covers an area of approximately 4,250km 2 comprising of two geographically distinct regions, Lorengippi region (2,050Km 2 ) and Loima hills plateau (2,200Km 2 ). Landforms in the district include mountains, hills, uplands, foot slopes, dissected erosional plains, sedimentary plains and riverine (flood) plains. The vegetation comprises of evergreen woodlands, deciduous bush land, deciduous bush annual 34 grassland, and wooded grassland and it is within 10Km of permanent water. It receives a median annual rainfall of 200-400mm. Loima Sub-county has three divisions with an estimated human population of 50,000 people in 6,000 households [12]. It is in the Western part of the county, sharing borders with West Pokot District to the South and Uganda to the West. Majority (55%) of the houses in the study area had mud-plastered walls with a tiled or thatched roof. The remainder were brick, made with either cement plaster or without cement plaster. Majority of the houses had a mud floor. The floors and walls are usually smeared with mud and cow excrements. The majority of the population were indigenous inhabitants with some inmigrants from near-by districts, such as Turkana South, West and Turkana Central. The population was of different socioeconomic strata, with the unemployed being 50.5% (n=172) as compared to employed 49.5% (n=169) that comprised mainly of cattle keepers, casual, skilled, and laborers engaged in business and some subsistence farming. The overall literacy level was low; males had higher levels than females.
The health in the sub-county is such that there are seventeen (17) health facilities, four (4) with diagnostic services and only one health facility-Pentecostal Assemblies of God (PAG) faith based health centre is equipped for kalaazar diagnosis. The infant and under five mortality rates are 60/1000 and 12/1000 respectively. The prevalent diseases include malaria, malnutrition, pneumonia or respiratory infections, diarrhea and neglected diseases like Kala-azar.  [12]. Loima Sub-County of Turkana County, Kenya

Study Design
A descriptive cross-sectional design that entails adoption of both the quantitative and qualitative data collection methods (mixed methods), was employed to determine the epidemiological, the social demographic characteristics, economic or socio-medical factors, health seeking behavior, disease transmission dynamics, local people's attitude, perception, knowledge and behavior towards the existence of kala-azar in the area, as the selected variables to be measured, among other factors [13]. The people at risk of disease were considered in relation to their sociodemographic characteristics, housing conditions, income level, socio-cultural practices or behaviour predisposing them to the disease as well as being a resident in the kala-azar endemic area for more than six (6) months.

Sampling Procedures
The county was purposely selected because it contained the population of interest. The Su-county was also purposively selected because according to MSF survey of 2004, the area has the highest prevalence of Kala-azar in comparison with other sub-counties, meaning that more people in the District are predisposed to the disease. Cluster random sampling was used to randomly select the divisions, locations, villages and the households that were sampled in order to obtain the required sample size. The standard formula as used by Bartlett et al;(2002 [14] and Lwanga and Lemeshow (1991), lead to arriving at 341 respondents and the sampling method was determined using probability sampling [13] and the study area clusters. The population in the clusters or locations and villages vary and to maintain an equal representation, a proportion commensurate to the number of household in the clusters was calculated (13]. The target population was stratified into units of households and only one member of the household (head or adult member) was interviewed. A list of the households was obtained from the area chief and the community health worker in charge of the location and the simple random sampling was used in enrolling an household for an interview.

Data Collection
Pretested structured questionnaires adopted from different literatures were employed to collect the quantitative data in this study from the randomly selected household heads or adult members. The questionnaires were constructed according to each objective and hypothesis of the study. Focus group discussions, key informat interviews and observations were used to collect qualitative data. Key informant interviews was conducted with elders, provincial administrators, other opinion leaders and the selected health facilities workers such as the doctors, nurses clinical officers, medical laboratory technologists and public health officers, all who are directly involved in the diagnosis, management, prevention and control of kala-azar. The selected community workers, opinion leaders and other stakeholders were also involved in the focus group discussions. Qualitative data collected was conceptualized, coded, categorized and summarized based on the themes and according to each objective of the study. The data collection instruments were first prepared in English and then translated in to Turkana language and back translated to English by principal investigator and language experts to check for its consistency.

Quality Assurance
A pilot study was done in the Turkwell locations and sublocations not chosen but had similar characteristics with the chosen ones, in order to ascertain the validity, reliability and suitability of the data collection instruments. Research assistants (4), were trained for one day on the use of interview schedules, making respondents understand questions, objectives and the significance of the study as well as explaining to them that participation is voluntary. They also helped in the interpretation of the local Turkana language for those who may not have understood Kiswahili/English, filling answers in the interview schedules and also assisted in locating the randomly selected respondents. Data collection from the households was done from the homes following prior appointments. The interviews were conducted in the local language Turkana, English and Kiswahili. A structured questionaire was used for data compilation. Filled questionnaires were checked for completeness on daily basis and the principal investigator ensured during the whole period of data collection that the questionnaires were reviewed and checked for completeness and consistency. Data entry was made by EpiData statistical software to ensure double entry verification so as to minimize error.

Data Management and Analysis
Data from the questionnaires was coded and entered into a spreadsheet and the database. The data was double entered in Access, cleaned in Epinfo and quantitative data analysed using the regression and correlation, multi-variate analysis with the use of Software statistical Package for Social Sciences (SPSS) [13]. Qualitative data was analysed thematically. Analytical techniques were used depending on the type of data and the variables to be analyzed. Independent and the dependent variables were compared using Chisquare, where a probability value of p< 0.005 at 95% confidence interval, were considered significant [13]. Descriptive statistics such as frequencies, line graphs, pie charts and bar graphs, were used to describe, organize and summarize the data.

Ethical Considerations
Clearance for the study was obtained from Scientific and Ethical Review Unit (SERU) in KEMRI, Jomo Kenyatta University, Ministry of Health and Ministry of Education.
Further permission was sought from the Provincial administration Turkana county and Loima sub-county, household heads and the community leaders. The purpose of the study was clearly explained to the participants while requesting them to sign informed consent forms as a sign of willingness.

Social Demographic Characteristics and Socio-Economic Factors of the Study Subjects
The results of the study have shown that 171 (50.1%) of the subjects interviewed were in the age category 18-35, 129 (37.8%) were in the age category 36-49, 38 (11.1%) were in the category of 50-70 years, while only 3 (0.9%) were in the age category of above years (Table 1). Slightly over 181 (53.1%) of those interviewed were females while 160 (46.9%) were males.
A high proportion of 294 (86.2%) of the respondents were married while 47 (13.8%) were single, widowed or divorced.
The results revealed that the practice of cultural activities of dancing at night (Edong'a) and deforestation 64.8%(n=167 OR=2.0; 95%CI= (0.3-13.7), p=0.481) could be more an exposure to kala-azar than polygamy 30.8%(n=4) early marriages 8.3%(n=1) or drinking of animal blood during dry season 20%(n=24) which had no statistical significance in the association with being predisposed to Kala-azar.
The respondents time of sleep beyond 11.30pm 60%(n=25),9.30-11.30pm 51%(n=40) exposed them to the disease as compared to sleeping between 9.30pm-10.30pm 48.3%(n=35) and time between 8pm-9pm 42.5%(n=60). The sand flies ( Kala-azar vector) are active during all these times, hence the people are at risk daily, thus the need to always use insecticide treated bed nets and other preventive measures.
The behaviour or practice of resting,playing or sitting near termite mounds oftenly (70%(n=191), resting or sleeping near the animal homesteads 48%(n=17) OR=0.6; 95%CI= (0.1-2.1), p=0.0043) exposed the respondents more to kala-azar as compared to sleeping close to goatherds 39%(n=13) OR=0.7; 95%CI= (1.6-2.9), p=0.0023). There was a significant statistical association between these behaviours or practices and being predisposed to kala-azar. The results also revealed that the respondents' or community members practice of making of incision to the affected area (spleen) or stomach and drawing out blood as a form of treatment 73%(n=24) OR=0.6; 95%CI= (2.2-3.4), p=0.0040),Use of traditional herbs around or given by traditional healers 71%(n=99) OR=1.1; 95%CI= (0.1-3.3), p=0.0042), exposes more to the disease as compared to smear of cow-dung to the affected area 53%(n=27) and going straight to the hospital when sick of kala-azar without first going through the traditional healers 24%(n=30) OR=0.6; 95%CI= (1.1-2.3), p=0.0563). The difference in proportions were statistically significant as compared to the sick being taken to hospital without first going through traditional healers; and that the results on treatment given to somebody when sick of kala-azar, showed that preference for alternative treatments influences the health seeking behavior in the community and thus more exposure to the disease. The main factors that were used to determine the prevalence of Kala-azar in Loima sub-county were classified as exposure factors. These included the mostly affected groups and those groups that were considered to be at risk. Table 4 shows the association between those exposure factors and being predisposed to Kala-azar. The results showed that the males 52.8%(n=28) are the mostly affected gender and that young boys 56.6%(n=142) as compared to other groups due to their behaviour, practices, daily activities or occupation. The results showed that among the top priority and prevalent diseases in the area as indicated, Kala-azar is the 2 nd prevalent parasitic disease 17.6%(n=60) after malaria 37.0%(n=126). Kala-azar according to the medical records and key informant interviews, is the most neglected tropical disease in the area and more people are predisposed 73.7%(n=44) OR=1.2; 95%CI=(1.1-2.6), p=0.0025).
The results revealed that majority of the respondents that mentioned that kala-azar is not a common disease in the area were likely to be exposed to it 54%(n=42) OR=0.6; 95%CI= (2.0--3.0), p=0.0456), as compared to those who said the disease is common in the area 46%(n=121). The respondents member of family who had not suffered kala-azar according to the results, were more likely to be exposed by 65%(n=40) as compared to those who had suffered 62%(n=174). The results also indicated that the respondents who ever suffered kala-azar, were more at risk of its exposure 49%(n=74) as compared to those who had not suffered 42%(n=80) OR=0.5; 95%CI= (0.1--2.1), p=0.642).
The results also indicated that among the respondents that could identify kala-azar vector in a photo,22.9%(n=43) were less likely to be predisposed to the disease as compared to those who could not 65.4%(n=85) or even did not have any knowledge on the identification58.4%(n=14) OR=1.1; 95%CI= (0.4--5.0), p=0.076). The results further indicated that the TB/HIV/AIDS 60% (n=86) or even other opportunistic infections combination could be the diseases that mostly encourage the spread of the dreadful disease kalaazar in the area. The results are supported by key informant interviews, focus group discussions and medical records that indicate kala-azar is now becoming an AIDS defining disease.

Discussions
The results showed that age is a factor with regard to exposure and susceptibility to Kala-azar, with age groups between 5-29 years being hardly hit, but especially 15 years being the most at risk (by 60%). It has been demonstrated that males are more at risk due to their occupation or their daily activities which often bring them into contact with termite mounds, that are kala-azar habitat. This observation concurs with other studies [10,15], which have noted that males are three times more susceptible to kala-azar than females. An epidemiological systematic review and metaanalysis done in America to assess factors associated with Visceral Leishmaniasis (VL) also revealed that the male sex was significantly associated with the infection, with the ORs of 1.30 and 2.38 [4]. A similar study on factors associated with Visceral leishmaniasis infection in North Gondar zone, Amhara region, North West Ethiopia by Kindie Bantie et al;2014 [2], revealed that age and gender were significantly associated with increased risk of Visceral leishmaniasis (VL) infection; such that children less than 15 years were 3.3 times more likely to be infected with VL than adults who were aged 15 years and above (AOR=3.26;95%CI=1.54,56.92); and that males were about 4.6 times more likely to be infected with kala-azar than females (AOR=4.64; 95%CI=2.39,9.39). The male gender predominance of the infection could be due to the reason that males are mostly engaged in outdoor activities and stay outdoor from dawn to dusk that might increase their contact with sand fly and in most rural parts of our country like Loima, men are mostly forced to sleep outside to keep their cattle and other valuables from theft. A study done in Trishal Upazila, Bangladesh demonstrated a significant association between VL and different age groups [16]. Another study done in Nepal also indicated that age is associated with increased risk of infection [17]. A study done in South Sudan also indicated Loima Sub-County of Turkana County, Kenya that the peak age group for VL infection was under the age of three years old [18]. The possible justification for this age based predominance could be due to the reason that children whose age is below 15 years are less developed immune system and most of them would not have previous attack with VL which could make them partially immune after getting infected with the disease commonly observed in areas with sustained transmission of the disease [2].
Education, level, occupation, housing and the level of income also have a significant contribution to exposure since those with higher education( college/ university) seem to have better occupation hence high level of income and better housing in the community. Apparently, results show majority of the community members have either primary, secondary or no formal education-90.4%. It is shown that few of these are salaried, many live in either grass thatched or semipermanent houses and low income levels with a higher number of children and fewer number of cattle despite the main economic activity in the area being livestock keeping. This situation increases vulnerability as most people are not economically able to protect themselves from the disease that is reported to hit the poorest among the poor in the communities [1,3]. Consistent with this finding, the study by S. P. Singh et al, 2010 [19] reported that low socio-economic status was found to be associated with Visceral leishmaniasis [19]. Another study done in India also showed that higher socio economic status was associated with reduced risk of VL infection compared to lower ones [20]. Similarly, a study done in Kenya and Uganda demonstrated that highest socio economic status was protective to VL infection [21]. A report from systematic review and meta-analysis that assessed subjects' income directly showed that an increase in income was associated with a decrease in the occurrence of the disease [4]. The probable justification for this could be that low income can affect over all status of household and individuals in many aspects. Low income can be associated with poor housing conditions, poor environmental hygienic conditions, poor nutritional status and increased risk of infections [1,2]. The housing condition like type of floor, wall,roofing were associated with increase in kala-azar infection, according to this study. This finding is consistent with findings from other studies which indicated that housing condition is one of the most important factors for VL. A case control study done in India demonstrated that thatched wall of housing condition is high risk for the disease [19]. Similar study from India also showed that house made of mud wall was statistically significantly associated with VL infection [22]. The possible reason for this could be due to the fact that thatched and mud walls are most likely to be cracked and favorable for entrance and breeding of the sand fly, the kalaazar vector.
The results also showed that sleeping time for the members of the community at night ranges from 8 p.m. to beyond 11.30 p.m, with majority -44% sleeping between 9.30 p.m-10.30 p.m, 22.9% between 8 p.m-9 p.m, 21.1% between 10.30 p.m-11.30 p.m with only 12% sleeping beyond 11.30 p.m.The biting times of sand flies lie between 6.30 p.m-6.30 a.m. at dawn according to the study at Uganda, Sudan and Bangladesh [23,24]. Clearly, most people especially are perpetually exposed and prone to frequent infections [25,26].
Peoples relationship with dogs according to the results do not predispose the community people to the disease and this is confirmed by WHO, 2005 and MSF, 2006 report on the study at Uganda and along the Kenyan border that the type of Kala-azar found in the area is anthroponotic where the transmission is directly from human to human and not zoonotic that is supposed to be from animals to man; hence dogs are not reservoir hosts of Kala-azar in Loima, except rodents such as rats, squirrels that are seen and even indicated by the medical records, key informant interviews and focus group discussions [27,28]. A study on factors associated with kala-azar infection in North Gondar zone, Amhara region, North West Ethiopia and a similar study in Addis Zemen, Ethiopia had their results to the contrary that dog ownership was associated with Visceral leishmaniasis and that the finding of epidemiological survey and metaanalysis in the combined data also demonstrated pattern of increasing likelihood of infection for subjects with dogs in the household; with the possible justification being that dogs are reservoir hosts for canine VL and they attract sand flies for search of blood meal [2,29].
According to this study, majority of the respondents (80.2%) revealed that the behaviour or practice of resting, playing or sitting near the termite mounts, predisposes the community to the disease a great deal, as well as also sleeping near the animal homesteads and close to goatherds as alluded by 19.8% of the respondents.
Majority of the respondents (72.8%) stated that the cultural festivities, particularly dancing at night (Edong, a) and overgrazing predispose the community to Kala-azar. The rest (27.2%) also mentioned that marriage ceremonies due while polygamy, drinking animal blood during the dry season as exposure factors. A high proportion-239 (70%) of the respondents were exposed to Kala-azar as compared to 102 (30%) not. There was an association between the cultural practices and being predisposed to Kala-azar (x²=63.236, df=6,p= 0.002). This is supported by focus group discussions, key informat interviews and other studies [1,3].
The study showed that the human activity of livestock keeping as mentioned by (55%) of the respondents, is an exposure to kala-azar in the area with deforestation, peasant farming, gold extraction and military service and hunting activities. encourages the presence of the disease The results further showed that preference for alternative treatments influences the health seeking behavior in the community and thus more exposure to the disease. The study revealed that few of the community members seek treatment from the health facilities as mentioned by 41.1% of the respondents while majority-58.9% resort to traditional healers, apply cow-dung or do incision to the affected area. A study on awareness about kala-azar disease and related preventive attitudes and practices in India showed that government hospitals and health centres were the first choice of treatment by 73.6% of respondents if a suspected case of kala-azar occurred in the household [30]. The study showed that majority of the respondents (80.4%) have the distance from their houses to animal shed is between 1-200 meters while a small proportion (19.6%) having theirs between 201-500 meters. This is an exposure to the bites of sand fly due to proximity to the animals.
The results have indicated that the disease is endemic in the area, is among the top priority diseases and the most deadly disease after malaria even according to medical records and the key informant interviews [1]. More than 77% of the respondents have mentioned that kala-azar is a common disease in the area, another 82% stated that at least a member of their family has once suffered from the disease with a good percentage of 44.3% also agreeing that they have themselves had an episode of kala-azar.; and this is in consistency of other studies [30,31]. The results revealed that among the prevalent diseases in the area, Kala-azar is the 2 nd parasitic disease (17.6%) after malaria (39.6%). Kala-azar according to the medical records and key informant interview, is the most neglected tropical disease in the area followed by trachoma. A similar study in India showed that 98% of the respondents were aware that kala-azar is an endemic,2 nd parasitic after malaria and the most neglected tropical disease in the area [30,32].
A high proportion of 82%) of the respondents indicated that a family member had once suffered Kala-azar., with only 18% reported that this had not happened. It is supported by medical records and other studies, indicating that the disease is prevalent in the area, hence the need for health education and medical intervention for control strategies [30,33]. Despite that more than a half of the respondents (55.7%) mentioned that they have never suffered kala-azar, a good number (44.3%) also said that they have once suffered from the disease thus indicating endemicity and prevalence of this disease kala-azar in the area as supported by other studies [2,4]. A considerable proportion of respondents 205 (60%) correctly mentioned that presence of anti-hills in large numbers makes the disease to spread due to the human encroachment of the vector habitat. Other factors mentioned also by 40% of the repondents that encourage spread included livestock or cattle keeping, lack of medical facilities or medical intervention and drought and the study is consistent with other studies [2,31]. Majority of the respondents (54.8%) mentioned that they can be able to identify kala-azar in a photo or picture because of the way it is common while (45.2%) said either no or they do not know how to identify the disease in a photo or picture. This indicated lack of proper awareness on the disease, is in itself a risk factor [4,30].
Majority of the respondents (88%) mentioned that HIV/AIDS and it's opportunistic infection like TB do support the spread of kala-azar. Another small number (7%) mentioned malaria only to be encouraging the spread of the disease while (5%) mentioned that all the above encourage spread of this dreadful disease. The results are supported by key informant interviews, focus group discussions and medical records that indicate kala-azar is now becoming an AIDS defining disease [2,4].

Conclusions
Kala-azar is endemic in Loima sub-county of Turkana County, Kenya, for it is among the top priority diseases in the area and it is second parasitic disease in prevalence ( 17.6%) in the area after malaria hence a public health problem that needs Integrated Disease Surveillance Response (IDSR). This concurs with MSF 2010; WHO 2014 reports. Social demographic and socio-economic factors that have significance and seem to expose people in the area to kalaazar include; age, where the age groups between 5-29 years are mostly at risk due to their daily activities or occupation; gender, where males who at most sleep outside their houses at night, the biting times for the sand fly. Education level, occupation, housing and the level of income are also a factor since those with higher education( college/ university) seem to have better occupation hence high level of income and better housing in the community. Apparently, results show majority of the community members have either primary, secondary or no formal education. The termite hills associated with Visceral leishmaniasis transmission in Kenya that are common throughout or all over the area, need control strategies such as insecticidal applications to resting habitats such as termite mounds and insecticide barrier spraying and not termite mounds destruction as suggested by some people in the community; since this is a difficult measure for the reason that anthills harbour termites that comprise the locals diet. The feeding propensity of Phlebotomus martini on livestock and the efficacy of zoo-prophylaxis could be enhanced by using the livestock not only to divert the vector from humans to animals but to attract them to contact with insecticide-treated livestock.