Visceral Leishmaniasis Outbreaks in Bihar: Community-level Investigations in the Context of Elimination of Kala-azar as a Public Health Problem

Priyamvada, Khushbu; Bindroo, Joy; Sharma, Madan Prashad; Chapman, Lloyd A. C.; Dubey, Pushkar; Mahapatra, Tanmay; Hightower, Allen W.; Bern, Caryn; Srikant, Sridhar

doi:10.21203/rs.3.rs-90830/v1

Cited by 5 publications

(5 citation statements)

References 27 publications

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“…Given the many small and large outbreaks in the eight-year time window of KAMIS data, an appropriate threshold could be empirically derived and then prospectively tested. To date, initiation of outbreak investigations has required reporting of case clusters by astute local staff ( Priyamvada et al., 2021 ).…”

Section: Discussionmentioning

confidence: 99%

“…The well-documented clustering of VL cases at the village and sub-village levels provides the basis for developing ACD targeting strategies ( Bulstra et al., 2018 ; Chapman et al., 2020 ; Priyamvada et al., 2021 ). It is not possible to cover all villages in the affected districts of the affected states using any ACD method, particularly the more intensive ones such as house-to-house searches, since Bihar alone has more than 43,000 villages in 33 endemic districts.…”

Section: Introductionmentioning

confidence: 99%

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Optimizing Village-Level Targeting of Active Case Detection to Support Visceral Leishmaniasis Elimination in India

Bindroo¹,

Priyamvada²,

Chapman

et al. 2021

Front. Cell. Infect. Microbiol.

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BackgroundIndia has made major progress in improving control of visceral leishmaniasis (VL) in recent years, in part through shortening the time infectious patients remain untreated. Active case detection decreases the time from VL onset to diagnosis and treatment, but requires substantial human resources. Targeting approaches are therefore essential to feasibility.MethodsWe analyzed data from the Kala-azar Management Information System (KAMIS), using village-level VL cases over specific time intervals to predict risk in subsequent years. We also graphed the time between cases in villages and examined how these patterns track with village-level risk of additional cases across the range of cumulative village case-loads. Finally, we assessed the trade-off between ACD effort and yield.ResultsIn 2013, only 9.3% of all villages reported VL cases; this proportion shrank to 3.9% in 2019. Newly affected villages as a percentage of all affected villages decreased from 54.3% in 2014 to 23.5% in 2019, as more surveillance data accumulated and overall VL incidence declined. The risk of additional cases in a village increased with increasing cumulative incidence, reaching approximately 90% in villages with 12 cases and 100% in villages with 45 cases, but the vast majority of villages had small cumulative case numbers. The time-to-next-case decreased with increasing case-load. Using a 3-year window (2016–2018), a threshold of seven VL cases at the village level selects 329 villages and yields 23% of cases reported in 2019, while a threshold of three cases selects 1,241 villages and yields 46% of cases reported in 2019. Using a 6-year window increases both effort and yield.ConclusionDecisions on targeting must consider the trade-off between number of villages targeted and yield and will depend upon the operational efficiencies of existing programs and the feasibility of specific ACD approaches. The maintenance of a sensitive, comprehensive VL surveillance system will be crucial to preventing future VL resurgence.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Optimizing Village-Level Targeting of Active Case Detection to Support Visceral Leishmaniasis Elimination in India

Bindroo¹,

Priyamvada²,

Chapman

et al. 2021

Front. Cell. Infect. Microbiol.

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“…Another behavioral habit that may be relevant to vector-transmission of L. donovani by Ph. argentipes in India is open defecation, which was associated with significantly elevated risk of VL in a recent investigation in Bihar ( Priyamvada et al., 2021 ). Despite government campaigns to change it, open defecation is still common in India, and represents one of the highest rates in the world.…”

Section: Knowledge Gaps Underpinning Failures In Vector Control Efformentioning

confidence: 99%

Towards a Sustainable Vector-Control Strategy in the Post Kala-Azar Elimination Era

Garlapati

Iniguez

Serafim

et al. 2021

Front. Cell. Infect. Microbiol.

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Visceral leishmaniasis (VL) is a potentially deadly parasitic disease. In the Indian sub-continent, VL is caused by Leishmania donovani and transmitted via the bite of an infected Phlebotomus argentipes female sand fly, the only competent vector species in the region. The highest disease burden is in the northern part of the Indian sub-continent, especially in the state of Bihar. India, Bangladesh, and Nepal embarked on an initiative, coordinated by World Health Organization, to eliminate VL as a public health problem by the year 2020. The main goal is to reduce VL incidence below one case per 10,000 people through early case-detection, prompt diagnosis and treatment, and reduction of transmission using vector control measures. Indoor residual spraying, a major pillar of the elimination program, is the only vector control strategy used by the government of India. Though India is close to its VL elimination target, important aspects of vector bionomics and sand fly transmission dynamics are yet to be determined. To achieve sustained elimination and to prevent a resurgence of VL, knowledge gaps in vector biology and behavior, and the constraints they may pose to current vector control methods, need to be addressed. Herein, we discuss the successes and failures of previous and current vector-control strategies implemented to combat kala-azar in Bihar, India, and identify gaps in our understanding of vector transmission towards development of innovative tools to ensure sustained vector control in the post-elimination period.

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“…Prevalence is associated with malnutrition, population displacement, poor housing, a weak immune system, and poverty [3]. In a previous study in Bihar, residence in highly marginalized communities was found to be the greatest risk factor for being affected by VL [12].…”

Section: Introductionmentioning

confidence: 99%

Patient insights research exploring disease awareness, patient life experience, and current management of visceral leishmaniasis in Bihar, India

Sundar,

Alves,

Ritmeijer

et al. 2024

Preprint

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BackgroundVisceral leishmaniasis (VL) is a vector-borne disease caused byLeishmaniaparasites and transmitted by sand fly bites, targeted for elimination in India. VL primarily affects rural, low-income populations with limited health care access. In South Asia, few studies have explored patients’ perspectives, diagnoses, and treatment experiences, and how these experiences influence their expectations about treatment.Methodology/principal findingsA qualitative study was conducted in Bihar, India, using moderator-facilitated, protocol-defined discussion. Eighteen adult patients and 12 caregivers of children diagnosed with and treated for VL within the last 12 months were identified by self-report. Mean time from symptom onset to diagnosis was 13.8 days. Challenges of the patient life experience included lack of urgency by health care professionals, delayed diagnosis, and unavailability of current standard-of-care therapy where a patient receives their diagnosis (63% switched to a different center for treatment, at times delaying treatment). Key barriers include out-of-pocket financial burden, absence from work/home duties, and long-distance travel to hospitals. Patients expressed a preference (29/30) for a potential oral treatment that could be taken close to home over the current standard of care (infusions/injections in clinics).Conclusions/significanceThis study reveals new insights and confirms previous research showing access to care for patients with VL in the Bihar area remains a challenge. Although most patients with VL seek care early, diagnosis often requires multiple visits to a health care facility. Despite access to therapy in public hospitals, a substantial number of patients prefer private clinics. Even in public locations, many patients need to move from the diagnostic center to another center to receive therapy, creating an additional burden for patients. As a potential alternative to current parenteral treatment, oral therapy would be preferred by adult patients and caregivers of pediatric patients and may reduce barriers to access to care.AUTHOR SUMMARYThis is an interview-based investigation of patient awareness, experience, and individual challenges for adults and caregivers of children seeking diagnosis and effective care for visceral leishmaniasis (VL) in rural districts of Bihar, India. Patients’ descriptions of their health experiences revealed obstacles at every stage, including limited information about the illness at the community level, financial burdens associated with loss of work, and cost of travel to seek diagnosis. Although our study was subject to recall bias, it elicited insights from the patients’ own experiences and revealed deterrents and burdens that may not have been visible otherwise. Our study also found that most patients would prefer a potential oral treatment for VL over the current parenteral–based standard of care. This patient-driven approach of identifying unmet needs and potential gaps in public health access can be useful in furthering the aims of the National Elimination Program for VL in India and in other areas with endemic VL, particularly those planning to introduce elimination programs.

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Visceral Leishmaniasis Outbreaks in Bihar: Community-level Investigations in the Context of Elimination of Kala-azar as a Public Health Problem

Cited by 5 publications

References 27 publications

Optimizing Village-Level Targeting of Active Case Detection to Support Visceral Leishmaniasis Elimination in India

Optimizing Village-Level Targeting of Active Case Detection to Support Visceral Leishmaniasis Elimination in India

Towards a Sustainable Vector-Control Strategy in the Post Kala-Azar Elimination Era

Patient insights research exploring disease awareness, patient life experience, and current management of visceral leishmaniasis in Bihar, India

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