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Amber Deveridge

on 13 November 2012

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Transcript of Leishmaniasis

Case Studies Introduction Epidemiology Treatment & control Leishmaniasis Outline Country Comparison Bolivia Conclusion Definition Distribution Lifecycle Burden of disease http://www.who.int/tdr/publications/documents/leishmaniasis-life-cycle.swf types, parasite, vectors Nepal Afghanistan Kabul: largest centre of cutaneous leishmaniasis in the world

Kabul has an estimated 67,500 cases (1/3 of all Afghanistan's cases)
probably an underestimate

Previously: good control measures existed

Relatively new disease to Kabul Overview Distribution Received external funds: HNTPO/WHO

Drug treatment
Distribution of 16 000 insecticide-treated nets: aim to protect ~ 30,000 people (previous trials showed improvement)

Plan to implement a national leishmaniasis control programme

If successful then rolled out to other areas of Aghanistan Control Program Recommendations Vectors & hosts Leishmaniasis refers to several different illnesses caused by parasitic protozoa of the genus Leishmania

More than 30 species of the protozoa infect humans

A poverty-related disease

Like many other neglected tropical diseases, leishmaniasis has a focal distribution and occurs in remote locations Secondary lesions appear in mouth & nose

Particularly destructive & painful

Appears in the tropics of South America Protozoa infect liver, spleen, lymph nodes & bone marrow

Fever, fatigue, weight loss & diarrhoea common

Appears in Asia, Africa, Russia & the Mediterranean Can be diffuse or localized

Localized: ulcer at bite site

Diffuse: parasite spread through body

Appears in central America & Asia visceral
(Kala Azar) mucocutaneous cutaneous Three types of Leishmaniasis Humans are infected via the bite of female phlebotomine sandflies

30 species of sandfly vectors

Found throughout inter-tropical and temperate regions

Breed in forest areas, caves and adobe brick houses

Most transmission to humans takes place indoors Leishmaniasis is zoonotic

Reservoirs include:

Also anthroponotic – the sandfly can transmit from human to human and human to animal Old World cutaneous leishmaniasis due to L. major Old World cutaneous leishmaniasis due to L. tropica & related species and L. aethiopica cutaneous & mucocutaneous leishmaniasis in the New World global distribution of visceral leishmaniasis
Present on four continents
Endemic in 88 countries, 72 of which are developing countries:
90% of all visceral leishmaniasis cases occur in Bangladesh, Brazil, India, Nepal and Sudan;
90% of mucocutaneous leishmaniasis occurs in Bolivia, Brazil and Peru;
90% of cutaneous leishmaniasis cases occur in Afghanistan, Brazil, Iran, Peru, Saudi Arabia and Syria. Worldwide prevalence: approximately 12 million cases

Annual mortality: about 60,000

2.4 million DALYs

350 million people at risk & Concomitant HIV infection multiplies the risk of developing active VL by 100 - 2320 times

In southern Europe, up to 70% of VL in adults is associated with HIV infection Visceral Leishmaniasis & HIV Treatment WHO control More than six month duration

Antimonial SSG (sodium stibogluconate)/Meglumin antimonat (IV/IM)
Side effects: cardiotoxicity
drug resistance

Miltefosine (oral)
Side effects: GI, kidney, liver toxicity, teratogenic
drug resistance

Other anti-protozoals: (oral)
amphotericin B, pentamidine, flagyl & allopurinol 1. Facilitation of early diagnosis and prompt treatment

2. Support for control of sandfly populations through residual insecticide spraying of houses and use of insecticide-impregnated bednets

3. Provision of health education and production of training materials

4. Detection and containment of epidemics in the early stages

5. Early diagnosis and effective management of leishmania/HIV co-infections WHO Control Program 1. The Programme for Elimination of Kala-azar in the South-East Asia Region
agreed by the Ministers of Health of Bangladesh, India and Nepal in 2005
Case study: Nepal

2. American region program to strengthen leishmaniasis control and surveillance
mapping of the disease in 14 countries
work to control the progression of visceral leishmaniasis in Argentina, Brazil and Paraguay
Case study: Bolivia

3. Eastern Mediterranean regional plan
based on three pillars: harmonization of surveillance systems, capacity building (for epidemiology, use of geographical information systems, and case management), and sharing of information.
Case study: Afghanistan Three WHO Regional Programs 60% of world cases of VL: border districts of Bangladesh, India and Nepal
Occurs in 13 districts in Nepal: eastern and central Terai (plains) Nepal May 2005 –
regional efforts: Elimination Initiative formalised at the World Health Assembly to reduce incidence VL at district level to <one case per 10,000 2015 (Mondal, et al., 2009) (World Health Organisation, 2006)

Access to early diagnosis and complete treatment
Diagnosis: free of charge in public hospitals (rK39 test kit)

Integrated vector management
Indoor residual spraying
Insecticide treated bed nets

effective disease and vector surveillance

Social mobilisation and partnerships

clinical implementation and operational research

(DHS 2010/2011) Current VL elimination strategies in Nepal Challenges to elimination: access Approach based on “passive case detection”

Treatment on presenting to a health care provider

Rural, poor labourers, lower educational level:
Low use of available services
Delayed care seeking (nearly 60%)
Risk for further spread of VL

Peripheral primary health centres lack medication stock & skilled staff
Incorrect prescribing = risk for resistance

Lack of medications at public hospitals
patients turn to private system
cost burden and risk of interrupting treatment Bed nets:
Poor implementation

Awareness: Only 11-88% of at-risk aware that sandfly is the vector

Limited evidence of effect for:
Indoor residual spraying (DDT / pyrethroids)
Environmental management (mud or lime plastering of hut walls) Challenges to elimination: vector control Active case detection

Community based treatment strategies
Quality control

Vector control

Disease and vector surveillance

Partnership and Research Future strategies 2 decades of conflict:
weak health infrastructure
environmental damage + poor sanitation: proliferation of sand flies’ breeding sites
Influx of large # displaced people (little immunity)
Poor local knowledge of disease
Cases occurring in foreign solders working in Afghanistan

Cost effectiveness:
USD 27 to treat each individual
Lower than other places: generic meds, therapy protocol, outpatient care
Regime found not to be cost effective
c/t DALYs and GDP Challenges to control Along with Peru & Brazil, Boliviacomprises 90% of all ML cases
1984 – 2006: 4,619 cases in Bolivia Bolivia – mucosal leishmaniasis Responsible body: National Program of Leishmaniasis Control (NPLC)

No effective control

For the species L. braziliensis, WHO recommends: active detection and says IRS and repellents MAY be useful. No effective control is currently available for intermediate hosts

Problems throughout the program: surveillance, case management, education, control & research

The NPLC control initiatives reportedly occur only after media publishes information on an outbreak

Bed nets, repellents & protective clothing are recommended but their provision and education on proper use is unmet & sporadic Control program The WHO regional program appears to have a focus on VL, which is not (yet) a real problem in Bolivia

Even though it is a notifable disease, there are estimates of wide underreporting, misclassification

Passive case finding

Growing concern of drug resistance

Treatment delays

Poor knowledge of disease by health care workers

Poor health seeking behavior Challenges to control Needs to be research into what control methods are going to be effective

Currently there is little information on the epidemiology of the vector, inhibiting control plans

One study showed that IRS of bed nets, curtains and clothes and bed sheets is the most effective control. Yet previous studies indicate that sandfly behavior in Bolivia appears mostly exophylic thus IRS will not be effective Further research needed Diagnosis Diagnosis Cutaneous leishmaniasis: scraping of skin ulcer or small biopsy
antigen skin test

Mucocutaneous leishmaniasis: biopsy of mucosal tissue

Visceral leishmaniasis:
blood sample and/or biopsy from bone marrow

Microscopic examination or culture for parasite

Culture can take 2-4 weeks Treatment Prevention Prevention Protect against sandfly bites:
insect repellent
protective clothing

Reduce vector population:
clear the land of trees and brush for at least 300m around villages
Insecticide spraying

Reservoir control:
control rodent population
get dogs tested (skin test)

no vaccine exists Poverty – poor health infrastructure & inability to seek treatment

Lack of awareness among at-risk

Neglected = lack funding & awareness

Behavioural changes needed

Poor control of reservoirs

No one highly effective control measure Common factors affecting control in all case studies Key messages Research into most effective control measures for each region

Needs more global attention/publicity/advocacy
More funding

Greater emphasis on education of at-risk populations:
Behavioural changes – bed nets, clearing vegetation, debris

Improved sanitation, infrastructure, housing

Greater understanding of vector – behaviour

Upskill health workers – better diagnostic abilities

Destigmiatisation Nepal:
1.Joshi, A. B., Das, M. L., Akhter, S., Chowdhury, R., Mondal, D., Kumar, V., et al. (2009). Chemical and environmental vector control as a contribution to the elimination of visceral leishmaniasis on the Indian subcontinent: cluster randomized controlled trials in Bangladesh, India and Nepal. BMC Medicine , 7, 54.

2.Mondal, D., Singh, S. P., Kumar, N., Joshi, A., Sundar, S., Das, P., et al. (2009). Visceral leishmaniasis elimination programme in India, Bangladesh, and Nepal: reshaping the case finding/case management strategy. PLoS Neglected Tropical Diseases , 3 (1), e355.

3.Ostyn, B., Vanlerberghe, V., Picado, A., Dinesh, D. S., Sundar, S., Chappuis, F., et al. (2008). Vector Control by insecticide-treated nets in the fight against visceral leishmaniasis in the Indian subcontinent, what is the evidence? Tropical Medicine and International Health , 13 (8), 1073-1085.

4.Rijal, S., Chappuis, F., Singh, R., Bovier, P., Acharya, P., Karki, B., et al. (2003). Treatment of visceral leishmaniasis in south-eastern Nepal: decreasing efficacy of sodium stibogluconate and need for a policy to limit further decline. Transactions of the Royal Society of Tropical Medicine and Hygiene , 97, 350-354.

5.Sundar, S., Mondal, D., Rijal, S., Bhattacharya, S., Ghalib, H., Kroeger, A., et al. (2008). Implementation research to support the initiative on the elimination of kala azar from Bangladesh, India and Nepal-the challenges for diagnosis and treatment. Tropical Medicine and International Health , 13 (1), 2-5.

6.Vanlerberghe, V., Singh, S., Paudel, I., Ostyn, B., Picado, A., Sanchez, A., et al. (2010). Determinants of bednet ownership and use in visceral leishmaniasis-endemic areas of the Indian subcontinent. Tropical Medicine and International Health , 15 (1), 60-67.

7.García ALA, Parrado RR, Rojas EE, Delgado RR, Dujardin J-CJ, Reithinger RR. Leishmaniases in Bolivia: comprehensive review and current status. CORD Conference Proceedings. 2009Apr.30;80(5):704–11.

8.RAMOS-E-SILVA M, DE MOURA CASTRO JACQUES C. Leishmaniasis and other dermatozoonoses in Brazil. Clinics in dermatology. Elsevier; 2002;20(2):122–34.

9.González U, Pinart M, Rengifo-Pardo M, Macaya A, Alvar J, Tweed JA. Interventions for American cutaneous and mucocutaneous leishmaniasis. Cochrane Database Syst Rev. 2009;(2):CD004834.

10.Coleman, R.R.a.P., Treating cutaneous leishmaniasis patients in Kabul, Afghanistan: cost-effectiveness of an operational program in a complex emergency setting. BMC Infectious Diseases, 2007. 7(3): p. 1-9.

11.Richard Reithinger, J.-C.D., Hechmi Louzir, Claude Pirmez, Bruch Alexander, Simon Brooker, Cutaneous leishmaniasis. Lancet Infectious Diseases, 2007. 7: p. 581-96.

12.Richard Reithinger, K.A., Jan Kolaczinski, Mohammad Mohsen, Samad Haml, Social Impact of Leishmaniasis, Afghanistan. Emerging Infectious Diseases, 2005. 11(4): p. 634-636.

13.Control of the leishmaniases: report of a meeting of the WHO Expert Committee on the Control of Leishmanises, Geneva 22-26 March 2010 (World Health Organization Technical Series). [Internet]. The World Health Organization. Available from: www.who.int/leishmaniasis/burden/en Accessed on: 6/10/2012

14.World Health Organization [Internet]. World Health Organization -Leishmaniasis (home, burden of disease, surveillance & control, epidemics, access to medicines). Available from: http://www.who.int/leishmaniasis/en/ Accessed on 6/10/2012 References A disease of the poor

Disfiguring with high DALYs, but relatively low mortality (except VL) = less recognition

No perfect control programs in place

Main control is protection from vectors & vector reduction

Like many public health problems, needs behavioural change = awareness & education
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