Barriers to cutaneous leishmaniasis care faced by indigenous communities of rural areas in Colombia: a qualitative study

Strengthening molecular testing capacity in Colombia: Challenges and opportunities

The COVID-19 pandemic has accelerated efforts to enhance pathogen detection using molecular biology techniques. This study examines the expansion of molecular testing capacity in Colombia, identifying strengths and areas for improvement in the existing infrastructure. The study began with the creation of a database inventorying laboratories based on publicly available data from government entities and active web searches. Ten laboratories were selected for detailed characterization. Structured surveys assessed their testing capacity and progress in implementing molecular-based diagnostic tests for various infectious diseases. The strategy for identifying laboratories showed a total of 311 laboratories. Of these, 65 % (n = 202) are private and 21 % (n = 65) are state-owned, mainly public health laboratories, and the remaining 14 % (n = 44) are affiliated with academic institutions. The highest concentration of these labs is in Bogotá, Antioquia, and Valle del Cauca, primarily in urban areas. Key limitations affecting testing laboratories in Colombia include: i) infrastructure (26.2 %), highlighting the need for standardized facility guidelines; ii) quality and documentation (16.7 %), requiring stronger quality management systems; iii) biosafety (14.3 %), emphasizing the need for continuous waste management, especially in public labs; and iv) human talent (10.7 %), needing better policies for staff retention, particularly in government institutions. Strengthening laboratories can establish a comprehensive national molecular testing system. Integrating molecular tests into health system diagnostic algorithms and implementing sustainable laboratory strategies will address human health challenges and support the "One Health" approach for animal and environmental health.

Effectiveness of Antileishmanial Treatments in Three Endemic Areas of Colombia: A Community-Based Cohort Study

The effectiveness of treatment of cutaneous leishmaniasis (CL) in rural settings remains underexplored. This study assessed the effectiveness of standard antileishmanial treatments using a community-based approach supported by mobile health (mHealth) in three rural areas of Colombia. From January 2018 to September 2021, we assessed treatment outcomes, adherence, and adverse drug reactions in CL patients, with the support of the Guaral+ST app. Treatment decisions were made by providers at health facilities at each site in accordance with national guidelines, whereas treatment follow-up and presumptive case identification were made by trained community leaders and health agents at the community level. In total, 231 participants received antileishmanial treatment (63 received miltefosine, 110 meglumine antimoniate, and 58 pentamidine). Disease presentation was mild (median number of lesions = 1, interquartile range [IQR]: 1-2) and of short duration (1.5 months, IQR: 1-3). The strategy yielded information on the therapeutic outcomes in 81% of study participants. Effectiveness, measured as the proportion of cure at 90 to 180 days, was 86.3% (95% CI: 73.3-93.48) for miltefosine; 77.6% (67.5-85.3) for meglumine antimoniate, and 73.1% (59.0-83.6) for pentamidine. The effectiveness of pentamidine in children ≤10 years old was 79.4% (61.6-90.3). This is one of the few reports of effectiveness of pentamidine in children with prospective data collection in the Americas. Adverse drug reactions occurred in 32% of patients, most frequently with meglumine antimoniate. Our findings demonstrate that standard antileishmanial treatments are effective in rural areas where the disease is endemic and that mHealth has a pivotal role in improving patient follow-up and data collection on therapeutic outcomes.

The role of economic factors in shaping and constituting the household burden of neglected tropical diseases of the skin: Qualitative findings from Ghana and Ethiopia

Tracers of health system equity, neglected tropical diseases (NTDs) disproportionately affect marginalized populations. NTDs that manifest on the skin - "skin NTDs" - are associated with scarring, disfigurement, physical disability, social exclusion, psychological distress, and economic hardship. To support development and evaluation of appropriate intervention strategies, we aimed to improve understanding of the role of economic factors in shaping and constituting the burden that skin NTDs place on households. We collected data in 2021 in two predominantly rural districts: Atwima Mponua in Ghana (where Buruli ulcer, yaws, and leprosy are endemic) and Kalu in Ethiopia (where cutaneous leishmaniasis and leprosy are endemic). We conducted interviews (n = 50) and focus group discussions (n = 14) that explored economic themes with affected individuals, caregivers, and community members and analysed the data thematically using a pre-defined framework. We found remarkable commonalities across countries and diseases. We developed a conceptual framework which illustrates skin NTDs' negative economic impact, including financial costs of care-seeking and reductions in work and schooling; categorises coping strategies by their degree of risk-pooling; and clarifies the mechanisms through which skin NTDs disproportionately affect the poorest. Despite health insurance schemes in both countries, wide-ranging, often harmful coping strategies were reported. Traditional healers were often described as more accessible, affordable and offering more flexible payment terms than formal health services, except for Ethiopia's well-established leprosy programme. Our findings are important in informing strategies to mitigate the skin NTD burden and identifying key drivers of household costs to measure in future evaluations. To reduce skin NTDs' impact on households' physical, mental, and economic wellbeing, intervention strategies should address economic constraints to prompt and effective care-seeking. While financial support and incentives for referrals and promotion of insurance enrolment may mitigate some constraints, structural interventions that decentralise care may offer more equitable and sustainable access to skin NTD care.

Involving patients in drug development for Neglected Tropical Diseases (NTDs): A qualitative study exploring and incorporating preferences of patients with cutaneous leishmaniasis into Target Product Profile development

BACKGROUND

Target Product Profiles (TPPs) are instrumental to help optimise the design and development of therapeutics, vaccines, and diagnostics - these products, in order to achieve the intended impact, should be aligned with users' preferences and needs. However, patients are rarely involved as key stakeholders in building a TPP.

METHODOLOGY

Thirty-three cutaneous leishmaniasis (CL) patients from Brazil, Colombia, and Austria, infected with New-World Leishmania species, were recruited using a maximum variation approach along geographic, sociodemographic and clinical criteria. Semi-structured interviews were conducted in the respective patient's mother tongue. Transcripts, translated into English, were analysed using a framework approach. We matched disease experiences, preferences, and expectations of CL patients to a TPP developed by DNDi (Drug for Neglected Diseases initiative) for CL treatment.

PRINCIPAL FINDINGS

Patients' preferences regarding treatments ranged from specific efficacy and safety endpoints to direct and significant indirect costs. Respondents expressed views about trade-offs between efficacy and experienced discomfort/adverse events caused by treatment. Reasons for non-compliance, such as adverse events or geographical and availability barriers, were discussed. Considerations related to accessibility and affordability were relevant from the patients' perspective.

CONCLUSIONS/SIGNIFICANCE

NTDs affect disadvantaged populations, often with little access to health systems. Engaging patients in designing adapted therapies could significantly contribute to the suitability of an intervention to a specific context and to compliance, by tailoring the product to the end-users' needs. This exploratory study identified preferences in a broad international patient spectrum. It provides methodological guidance on how patients can be meaningfully involved as stakeholders in the construction of a TPP of therapeutics for NTDs. CL is used as an exemplar, but the approach can be adapted for other NTDs.

Ensuring access to essential health products: Lessons from Colombia's leishmaniasis control and elimination initiative

BACKGROUND

This paper identifies opportunities and challenges for leishmaniasis control and elimination in Colombia, emphasizing the role of pooled procurement of essential medicines and supplies. Colombia is among the countries most affected by leishmaniasis globally, and also faces the dual challenge of procuring critically needed medicines in the context of limited national resources. It recently renewed its commitment to the control and elimination of leishmaniasis under its 2022-2031 Public Health Plan (PDSP) through a comprehensive public health approach.

METHODOLOGY/PRINCIPAL FINDINGS

The methodology comprises a comprehensive literature review and key informant interviews with leishmaniasis experts from the Colombian national control program and PAHO/WHO, focusing on cutaneous, mucocutaneous, and visceral leishmaniasis. Leishmaniasis is endemic throughout Colombia, with over 11 million people at risk, many of whom live in poverty-stricken, remote and isolated rural areas with limited access to health services. Leishmaniasis care, including medicines, is provided free of charge, but many barriers were nonetheless identified at environmental, population, and health system levels, including the supply of quality-assured medicines. Opportunities to alleviate these barriers were identified, including the support of the PAHO Strategic Fund. Within the context of the sustainable development goals and international leishmaniasis control and elimination targets, Colombian officials have established their own priorities, the highest of which is the reduction of deaths from visceral leishmaniasis.

CONCLUSIONS/SIGNIFICANCE

The elimination of leishmaniasis as a public health problem presents significant challenges, given its biological complexity and diversity, physical and clinical manifestations, social and economic impacts, frequently burdensome treatment regimens, and insufficient supply of necessary medicines. However, rigorous prevention and control efforts through strong political commitment and a highly motivated workforce can dramatically reduce its burden. Colombia's new PDSP, which highlights leishmaniasis control, is an opportunity for a revitalized health system response through committed leadership, intersectoral actions, and partnerships with international organizations that share a common vision.

Cutaneous leishmaniasis treatment and therapeutic outcomes in special populations: A collaborative retrospective study

BACKGROUND

Treatment guidance for children and older adult patients affected by cutaneous leishmaniasis (CL) is unclear due to limited representation of these groups in clinical trials.

METHODS

We conducted a collaborative retrospective study to describe the effectiveness and safety of antileishmanial treatments in children ≤ 10 and adults ≥ 60 years of age, treated between 2014 and 2018 in ten CL referral centers in Latin America.

RESULTS

2,037 clinical records were assessed for eligibility. Of them, the main reason for non-inclusion was lack of data on treatment follow-up and therapeutic response (182/242, 75% of children and 179/468, 38% of adults). Data on 1,325 eligible CL patients (736 children and 589 older adults) were analyzed. In both age groups, disease presentation was mild, with a median number of lesions of one (IQR: 1-2) and median lesion diameter of less than 3 cm. Less than 50% of the patients had data for two or more follow-up visits post-treatment (being only 28% in pediatric patients). Systemic antimonials were the most common monotherapy regimen in both age groups (590/736, 80.2% of children and 308/589, 52.3% of older adults) with overall cure rates of 54.6% (95% CI: 50.5-58.6%) and 68.2% (95% CI: 62.6-73.4%), respectively. Other treatments used include miltefosine, amphotericin B, intralesional antimonials, and pentamidine. Adverse reactions related to the main treatment were experienced in 11.9% (86/722) of children versus 38.4% (206/537) of older adults. Most adverse reactions were of mild intensity.

CONCLUSION

Our findings support the need for greater availability and use of alternatives to systemic antimonials, particularly local therapies, and development of strategies to improve patient follow-up across the region, with special attention to pediatric populations.

Knowledge, attitude, and practice of the rural community about cutaneous leishmaniasis in Wolaita zone, southern Ethiopia

BACKGROUND

Cutaneous leishmaniasis (CL) is a neglected tropical disease that is caused by a Leishmania parasite and transmitted by the bite of infected female sandflies. Community awareness is an essential component of disease control and prevention. Therefore, this study aimed to assess the community's knowledge, attitude, and practice toward CL in Wolaita zone, southern Ethiopia.

METHODS

A community-based cross-sectional study design was employed to include 422 study subjects selected using a systematic sampling technique from two districts, Kindo Didaye and Sodo Zuria. A pretested structured questionnaire was used to collect data from the household heads. Bivariate and multivariate logistic regression analyses were performed to determine the relationship between the participants' knowledge about CL and socio-demographic characteristics.

RESULTS

Out of the 422 study participants, only 19% had good knowledge of CL in general. Most (67.1%) of the respondents knew CL by its local name ("bolbo" or "moora") though this knowledge varied highly over the study districts. The majority (86.3%) of respondents did not know how CL is acquired, though they considered CL a health problem. Most (62.8%) respondents believed that CL was an untreatable disease. Most (77%) participants responded that CL patients preferred to go to traditional healers for treatment. Herbal treatment was the most (50.2%) used to treat CL. Knowledge about CL was significantly associated with sex, age, and study districts.

CONCLUSION

The overall knowledge, attitude, and practice about CL and its prevention in the study area were low. This emphasizes the need to implement health education and awareness campaign to reduce the risk of CL infection. Policymakers and stakeholders should also give due attention to the prevention and treatment of CL in the study area.