Trends in spatio-temporal dynamics of visceral leishmaniasis cases in a highly-endemic focus of Bihar, India: an investigation based on GIS tools

Modelling spatiotemporal patterns of visceral leishmaniasis incidence in two endemic states in India using environment, bioclimatic and demographic data, 2013-2022

BACKGROUND

As of 2021, the National Kala-azar Elimination Programme (NKAEP) in India has achieved visceral leishmaniasis (VL) elimination (<1 case / 10,000 population/year per block) in 625 of the 633 endemic blocks (subdistricts) in four states. The programme needs to sustain this achievement and target interventions in the remaining blocks to achieve the WHO 2030 target of VL elimination as a public health problem. An effective tool to analyse programme data and predict/ forecast the spatial and temporal trends of VL incidence, elimination threshold, and risk of resurgence will be of use to the programme management at this juncture.

METHODOLOGY/PRINCIPAL FINDINGS

We employed spatiotemporal models incorporating environment, climatic and demographic factors as covariates to describe monthly VL cases for 8-years (2013-2020) in 491 and 27 endemic and non-endemic blocks of Bihar and Jharkhand states. We fitted 37 models of spatial, temporal, and spatiotemporal interaction random effects with covariates to monthly VL cases for 6-years (2013-2018, training data) using Bayesian inference via Integrated Nested Laplace Approximation (INLA) approach. The best-fitting model was selected based on deviance information criterion (DIC) and Watanabe-Akaike Information Criterion (WAIC) and was validated with monthly cases for 2019-2020 (test data). The model could describe observed spatial and temporal patterns of VL incidence in the two states having widely differing incidence trajectories, with >93% and 99% coverage probability (proportion of observations falling inside 95% Bayesian credible interval for the predicted number of VL cases per month) during the training and testing periods. PIT (probability integral transform) histograms confirmed consistency between prediction and observation for the test period. Forecasting for 2021-2023 showed that the annual VL incidence is likely to exceed elimination threshold in 16-18 blocks in 4 districts of Jharkhand and 33-38 blocks in 10 districts of Bihar. The risk of VL in non-endemic neighbouring blocks of both Bihar and Jharkhand are less than 0.5 during the training and test periods, and for 2021-2023, the probability that the risk greater than 1 is negligible (P<0.1). Fitted model showed that VL occurrence was positively associated with mean temperature, minimum temperature, enhanced vegetation index, precipitation, and isothermality, and negatively with maximum temperature, land surface temperature, soil moisture and population density.

CONCLUSIONS/SIGNIFICANCE

The spatiotemporal model incorporating environmental, bioclimatic, and demographic factors demonstrated that the KAMIS database of the national programmme can be used for block level predictions of long-term spatial and temporal trends in VL incidence and risk of outbreak / resurgence in endemic and non-endemic settings. The database integrated with the modelling framework and a dashboard facility can facilitate such analysis and predictions. This could aid the programme to monitor progress of VL elimination at least one-year ahead, assess risk of resurgence or outbreak in post-elimination settings, and implement timely and targeted interventions or preventive measures so that the NKAEP meet the target of achieving elimination by 2030.

Epidemiological, clinical and hematological profiles of visceral leishmaniasis among patients visiting Tefera Hailu Memorial Hospital, Northeast Ethiopia: a 4 year retrospective study

Visceral leishmaniasis is a major, life-threatening parasitic disease that still remains a serious public health problem in Ethiopia. Understanding the epidemiological, clinical, and hematological profiles of visceral leishmaniasis patients is important for implementing evidence-based control strategies. It is also important for early treatment and to decrease the mortality rate from the disease. Therefore, this study was aimed at assessing the epidemiological, clinical, and hematological profiles of visceral leishmaniasis among patients visiting Tefera Hailu Memorial Hospital, Northeast Ethiopia. A retrospective study was conducted at Tefera Hailu Memorial Hospital from September 2017 to August 2021. Data were collected from the medical records of suspected patients who were tested by the rK39 rapid diagnostic by strictly following standard operating procedures. The data was summarized using Microsoft Excel and analyzed using SPSS 26 version software. Descriptive statistics were used to describe the epidemiological, clinical, and hematological profiles of visceral leishmaniasis patients. A p-value < 0.05 was considered statistically significant. The overall positivity rate for visceral leishmaniasis was 23.4% (132/564). The result of this study indicated a fluctuating yet declining trend in VL over the past 4 years. From a total of 132 VL confirmed cases, the numbers of cases were highest among males (78.0%), those 15-29 years of age (37.1%), and urban residents (89.4%). Furthermore, Abergele (11.0%), Sehala (6.0%), and Ziquala (5.0%) districts had the highest number of VL cases. The major clinical presentations of patients were fever (96.2%), splenomegaly (94.7%), and general weakness (80.3%). With regard to hematological profiles, the most common findings were anemia (86.4%), thrombocytopenia (81.8%), leucopenia (78.8%), neutropenia (74.2%), and pancytopenia (71.2%). In the study area, the VL positivity rate was high. Our findings also concluded that VL causes significant alterations in clinical and hematological parameters. Therefore, the zone health office and other concerned stakeholders should strengthen evidence-based control programs for VL.

- Amphotericin B: A drug of choice for Visceral Leishmaniasis

Visceral leishmaniasis or Kala-azar is a vector-borne disease caused by an intracellular parasite of the genus leishmania. In India, Amphotericin B (AmB) is a first-line medication for treating leishmaniasis. After a large-scale resistance to pentavalent antimony therapy developed in Bihar state, it was rediscovered as an effective treatment for Leishmania donovani infection. AmB which binds to the ergosterol of protozoan cells causes a change in membrane integrity resulting in ions leakage, and ultimately leading to cell death. The treatment effect of liposomal AmB can be seen more quickly than deoxycholate AmB because, it has some toxic effects, but liposomal AmB is significantly less toxic. Evidence from studies suggested that ABLC (Abelcet) and ABCD (Amphotec) are as effective as L-AmB but Liposomal form (Ambisome) is a more widely accepted treatment option than conventional ones. Nevertheless, the world needs some way more efficient antileishmanial drugs that are less toxic and less expensive for people living with parasitic infections caused by Leishmania. So, academics, researchers, and sponsors need to focus on finding such drugs. This review provides a summary of the chemical, pharmacokinetic, drug-target interactions, stability, dose efficacy, and many other characteristics of the AmB and their various formulations. We have also highlighted the clinically significant aspects of PKDL and VL co-infection with HIV/TB.

Application of BASNEF model in students training regarding cutaneous leishmaniasis prevention behaviors: a school-based quasi experimental study

BACKGROUND

Cutaneous leishmaniasis (CL) is endemic in 98 countries, and 350 million people are at risk of the disease worldwide. In endemic areas, conducting educational interventions is necessary to change preventive behaviors of CL. This study aimed to investigate the effect of an educational intervention based on the BASNEF model on CL preventive behavior in students.

METHODS

The present quasi-experimental study examined 80 students living in endemic areas of leishmaniasis in Isfahan province, Iran based on the BASNEF model. The required data were collected twice before and two months after the educational intervention based on a questionnaire whose validity and reliability had been already proven in other studies. The intervention was performed in three educational sessions for the students in the intervention group and 1 educational session for teachers and parents. Data were analyzed by SPSS (VER26) using the chi-square test, independent t-test, analysis of covariance (ANCOVA), and Paired t-test.

RESULTS

After intervention, the mean scores of Knowledge (P < 0.001), attitude (P = 0.02), subjective norms (P = 0.04), behavioral intention (P < 0.001), and behavior (P = 0.02) indicated significant differences between the intervention and control groups, but an increase in mean scores of enabling factors was not significant (P = 0. 93).

CONCLUSIONS

Providing students with the educational intervention based on the BASNEF model improve their ability to the extent that they transmit these educations to their family members, which would be effective in preventing and controlling CL in leishmaniasis-prone areas.

TRIAL REGISTRATION

Name: Iranian Registry of Clinical Trials. Registration number: IRCT20201024049131N1. Registration date: 2020-11-20. Registration timing: prospective.

Critical Antileishmanial in vitro Effects of Highly Examined Gold Nanoparticles

Introduction

The current therapeutic armory for visceral leishmaniasis (VL) caused by Leishmania donovani complex is inadequate, coupled with serious limitations. Combination therapy has proved ineffective due to mounting resistance; however, the search for safe and effective drugs is desirable, in the absence of any vaccine. There is a growing interest in the application of nanoparticles for the therapeutic effectiveness of leishmaniasis. Aimed in this direction, we assessed the antileishmanial effect of gold nanoparticles (GNP) against L. donovani in vitro.

Methods

GNP were synthesized and characterized for particle size by dynamic light scattering (DLS) and atomic force microscopy (AFM) and for optical properties by UV-visible spectroscopy. Cytotoxicity of GNP was measured by the MTT proliferation assay. The antileishmanial activity of the nanoparticles was evaluated against L. donovani promastigotes and macrophage-infected amastigotes in vitro.

Results

GNP showed a strong SPR peak at 520 nm and mean particle size, polydispersity index (PDI), and zeta potential of 56.0 ± 10 nm, 0.3 ± 0.1 and −27.0 ± 3 mV, respectively. The GNPs were smooth and spherical with a mean particle diameter of 20 ± 5 nm. Nanoparticles [1.2–100 µM] did not reveal any cytotoxicity on RAW 264.7 murine macrophage cell line, but exerted significant activity against both promastigotes and amastigote stages of L. donovani with 50% inhibitory concentrations (IC₅₀) of 18.4 ± 0.4 µM and 5.0 ± 0.3 µM, respectively. GNP showed significant antileishmanial activity with deformed morphology of parasites and the least number of surviving promastigotes after growth reversibility analysis.

Conclusion

GNP may provide a platform to conjugate antileishmanial drugs onto the surface of nanoparticles to enhance their therapeutic effectiveness against VL. Further work is warranted, involving more in-depth mechanistic studies and in vivo investigations.

GIS-based risk mapping of cutaneous leishmaniasis: a survey in an endemic area of Central Iran

Cutaneous leishmaniasis (CL) is a vector-borne infectious disease that is affected by various environmental agents. The main objective of this study was to determine the spatial distribution of CL incidence by using Geographical Information System (GIS). This is a cross-sectional study that was conducted during 5 years from 2014 to 2018 in Isfahan, Iran. We used the required data on each leishmaniasis patient that were recorded from 44 counties of Isfahan in the databases and archive of the Provincial Health Centre. We used GIS for determining the incidence of CL in the high-risk foci. Moran index was used to identify high risk points (clustering in similar values) compared to the values of neighborhood points. Hot spot analysis was conducted by Getis-Ord-Gi. The highest incidence of the disease occurred in the age group of 18-64 years and 61.6% of patients were male. According to seasonal distribution, autumn (58.6%) had the highest frequency. Time trend of incidence showed that it had both decreasing and increasing, and there was a sudden upward trend of disease in 2018 except only two counties. The hot spots were involved the central areas of the Isfahan province slightly toward to the north and southeast of the province. Moran index showed that the differences for all points were not significant (p-value>0.05). Varzaneh (placed in southeast of Isfahan) was the hottest spot and had the worst position for leishmaniasis compared to all years and all cities.

Environmental influence on <em>Triatoma vitticeps</em> occurrence and <em>Trypanosoma cruzi</em> infection in the Atlantic Forest of south-eastern Brazil

Trypanosoma cruzi requires a triatomine insect vector for its life cycle, which can be complex in different enzootic scenarios, one of which is the unique transmission network in the Atlantic Forest of south-eastern Brazil. In Espírito Santo (ES) State, highly infected Triatoma vitticeps are frequently reported invading domiciles. However, triatomines were not found colonizing residences and mammals in the surrounding areas did not present T. cruzi infection. To date, the biotic and abiotic variables that modulate T. vitticeps occurrence and T. cruzi infection in ES State are still unknown. The aim of this study was to identify the environmental variables that modulate their occurrence. Local thematic maps were generated for two response variables: T. vitticeps occurrence and T. cruzi infection. The following explanatory variables were tested: climate (temperature, relative air humidity and rainfall), altitude elevation, mammalian species richness as well as soil and vegetation types. Spatiotemporal distribution patterns and correlation levels between response and explanatory variables were assessed through spatial statistics and map algebra modelling. The central and southern mesoregions presented higher T. vitticeps and T. cruzi distributions and can be considered transmission hotspots. The explanatory variables that can explain these phenomena were relative air humidity, average temperature, soil type, altitude elevation and mammalian species richness. Algebra map modelling demonstrated that central and southern mesoregions presented the environmental conditions needed for T. vitticeps occurrence and T. cruzi infection. The consideration of environmental variables is essential for understanding the T. cruzi transmission cycle. Cartographic and statistical methodologies used in parasitology have been demonstrated to be reliable and enlightening tools that should be incorporated routinely to expand the understanding of vector-borne parasite transmission.

Rapid diagnosis of Leishmania infection with a portable loop-mediated isothermal amplification device

L. donovani is an intracellular protozoan parasite, that causes visceral leishmaniasis (VL), and consequently, post-kala azar dermal leishmaniasis (PKDL). Diagnosis and treatment of leishmaniasis is crucial for decreasing its transmission. Various diagnostic techniques like microscopy, enzyme-linked immunosorbent assays (ELISA) and PCR-based methods are used to detect leishmaniasis infection. More recently, loop-mediated isothermal amplification (LAMP) assay has emerged as an ideal diagnostic measure for leishmaniasis, primarily due to its accuracy, speed and simplicity. However, point-of-care diagnosis is still not been tested with the LAMP assay. We have developed a portable LAMP device for the monitoring of Leishmania infection. The LAMP assay performed using our device can detect and amplify as little as 100 femtograms of L. donovani DNA. In a preliminary study, we have shown that the device can also amplify L. donovani DNA present in VL and PKDL patient samples with high sensitivity (100%), specificity (98%) and accuracy (99%), and can be used both for diagnostic and prognostic analysis. To our knowledge, this is the first report to describe the development and application of a portable LAMP device which has the potential to evolve as a point-of-care diagnostic and prognostic tool for Leishmania infections in future.

Spatiotemporal distribution of cutaneous leishmaniasis in Sri Lanka and future case burden estimates

BACKGROUND

Leishmaniasis is a neglected tropical vector-borne disease, which is on the rise in Sri Lanka. Spatiotemporal and risk factor analyses are useful for understanding transmission dynamics, spatial clustering and predicting future disease distribution and trends to facilitate effective infection control.

METHODS

The nationwide clinically confirmed cutaneous leishmaniasis and climatic data were collected from 2001 to 2019. Hierarchical clustering and spatiotemporal cross-correlation analysis were used to measure the region-wide and local (between neighboring districts) synchrony of transmission. A mixed spatiotemporal regression-autoregression model was built to study the effects of climatic, neighboring-district dispersal, and infection carryover variables on leishmaniasis dynamics and spatial distribution. Same model without climatic variables was used to predict the future distribution and trends of leishmaniasis cases in Sri Lanka.

RESULTS

A total of 19,361 clinically confirmed leishmaniasis cases have been reported in Sri Lanka from 2001-2019. There were three phases identified: low-transmission phase (2001-2010), parasite population buildup phase (2011-2017), and outbreak phase (2018-2019). Spatially, the districts were divided into three groups based on similarity in temporal dynamics. The global mean correlation among district incidence dynamics was 0.30 (95% CI 0.25-0.35), and the localized mean correlation between neighboring districts was 0.58 (95% CI 0.42-0.73). Risk analysis for the seven districts with the highest incidence rates indicated that precipitation, neighboring-district effect, and infection carryover effect exhibited significant correlation with district-level incidence dynamics. Model-predicted incidence dynamics and case distribution matched well with observed results, except for the outbreak in 2018. The model-predicted 2020 case number is about 5,400 cases, with intensified transmission and expansion of high-transmission area. The predicted case number will be 9115 in 2022 and 19212 in 2025.

CONCLUSIONS

The drastic upsurge in leishmaniasis cases in Sri Lanka in the last few year was unprecedented and it was strongly linked to precipitation, high burden of localized infections and inter-district dispersal. Targeted interventions are urgently needed to arrest an uncontrollable disease spread.

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

Background

India 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.

Methods

We 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.

Results

In 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.

Conclusion

Decisions 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.

Impact of Changes in Detection Effort on Control of Visceral Leishmaniasis in the Indian Subcontinent

Background

Control of visceral leishmaniasis (VL) on the Indian subcontinent relies on prompt detection and treatment of symptomatic cases. Detection efforts influence the observed VL incidence and how well it reflects the underlying true incidence. As control targets are defined in terms of observed cases, there is an urgent need to understand how changes in detection delay and population coverage of improved detection affect VL control.

Methods

Using a mathematical model for transmission and control of VL, we predict the impact of reduced detection delays and/or increased population coverage of the detection programs on observed and true VL incidence and mortality.

Results

Improved case detection, either by higher coverage or reduced detection delay, causes an initial rise in observed VL incidence before a reduction. Relaxation of improved detection may lead to an apparent temporary (1 year) reduction in VL incidence, but comes with a high risk of resurging infection levels. Duration of symptoms in detected cases shows an unequivocal association with detection effort.

Conclusions

VL incidence on its own is not a reliable indicator of the performance of case detection programs. Duration of symptoms in detected cases can be used as an additional marker of the performance of case detection programs.

Costs and outcomes of active and passive case detection for visceral leishmaniasis (Kala-Azar) to inform elimination strategies in Bihar, India

BACKGROUND

Effective case identification strategies are fundamental to capturing the remaining visceral leishmaniasis (VL) cases in India. To inform government strategies to reach and sustain elimination benchmarks, this study presents costs of active- and passive- case detection (ACD and PCD) strategies used in India's most VL-endemic state, Bihar, with a focus on programme outcomes stratified by district-level incidence.

METHODS

Expenditure analysis was complemented by onsite micro-costing to compare the cost of PCD in hospitals alongside index case-based ACD and a combination of blanket (house-to-house) and camp ACD from January to December 2018. From the provider's perspective, a cost analysis evaluated the overall programme cost of each activity, the cost per case detected, and the cost of scaling up ACD.

RESULTS

During 2018, index case-based ACD, blanket and camp ACD, and PCD reported 1,497, 131, and 1,983 VL-positive cases at a unit cost of $522.81, $4,186.81, and $246.79, respectively. In high endemic districts, more VL cases were identified through PCD while in meso- and low-endemic districts more cases were identified through ACD. The cost of scaling up ACD to identify 3,000 additional cases ranged from $1.6-4 million, depending on the extent to which blanket and camp ACD was relied upon.

CONCLUSION

Cost per VL test conducted (rather than VL-positive case identified) may be a better metric estimating unit costs to scale up ACD in Bihar. As more VL cases were identified in meso-and low-endemic districts through ACD than PCD, health authorities in India should consider bolstering ACD in these areas. Blanket and camp ACD identified fewer cases at a higher unit cost than index case-based ACD. However, the value of detecting additional VL cases early outweighs long-term costs for reaching and sustaining VL elimination benchmarks in India.

A spatio-temporal approach to short-term prediction of visceral leishmaniasis diagnoses in India

BACKGROUND

The elimination programme for visceral leishmaniasis (VL) in India has seen great progress, with total cases decreasing by over 80% since 2010 and many blocks now reporting zero cases from year to year. Prompt diagnosis and treatment is critical to continue progress and avoid epidemics in the increasingly susceptible population. Short-term forecasts could be used to highlight anomalies in incidence and support health service logistics. The model which best fits the data is not necessarily most useful for prediction, yet little empirical work has been done to investigate the balance between fit and predictive performance.

METHODOLOGY/PRINCIPAL FINDINGS

We developed statistical models of monthly VL case counts at block level. By evaluating a set of randomly-generated models, we found that fit and one-month-ahead prediction were strongly correlated and that rolling updates to model parameters as data accrued were not crucial for accurate prediction. The final model incorporated auto-regression over four months, spatial correlation between neighbouring blocks, and seasonality. Ninety-four percent of 10-90% prediction intervals from this model captured the observed count during a 24-month test period. Comparison of one-, three- and four-month-ahead predictions from the final model fit demonstrated that a longer time horizon yielded only a small sacrifice in predictive power for the vast majority of blocks.

CONCLUSIONS/SIGNIFICANCE

The model developed is informed by routinely-collected surveillance data as it accumulates, and predictions are sufficiently accurate and precise to be useful. Such forecasts could, for example, be used to guide stock requirements for rapid diagnostic tests and drugs. More comprehensive data on factors thought to influence geographic variation in VL burden could be incorporated, and might better explain the heterogeneity between blocks and improve uniformity of predictive performance. Integration of the approach in the management of the VL programme would be an important step to ensuring continued successful control.

Kala-azar elimination in a highly-endemic district of Bihar, India: A success story

Background

Visceral leishmaniasis (VL) or Kala-azar has been a major public health problem in Bihar, India, for several decades. A few VL infected districts including Vaishali have reported >600 cases annually. Hence, in 2015, the Government of India entrusted ICMR-Rajendra Memorial Research Institute of Medical Sciences, Patna, to implement an integrated control strategy for achieving the VL elimination target (<1 case per 10,000 people at the block level) in the Vaishali District of Bihar.

Methodology

This study was conducted between January 2015 and December 2016. An integrated control strategy including the spatio-temporal mapping of VL-case distribution, active case detection, chemical-based vector control using indoor residual spraying (IRS), community awareness campaigns, the training of IRS members, the training of medical doctors for effective treatment, daily monitoring and the supervision of IRS activities, logistic management, post-IRS quality assurance, epidemiological surveillance, and entomological monitoring was performed. An insecticide quantification test was performed for evaluating the IRS quality on sprayed walls. A modern compression pump was used to maintain spray quality on different wall surfaces. The impact of IRS was assessed through sand fly collection in human dwellings and cattle sheds in pre- and post-IRS. The insecticide susceptibility of local P. argentipes was performed before each IRS round (in February and June) during 2015–2016. Statistical analysis such as the mean, percentage, and 95% CI were used to summarize the results.

Findings

All 16 blocks of the Vaishali District achieved the VL elimination target in 2016. The integrated VL control strategy helped reduce the number of VL cases from 664 in 2014 to 163 in 2016 and the number of endemic villages from 282 in 2014 to 142 in 2016. The case reduction rate was increased from 22.6% in 2014 to 58.8% in 2016. On average, 74 VL infected villages became Kala-azar free each year from 2015 to 2016.

Conclusions

The results of this study suggest that the elimination of VL is possible from all endemic blocks of Bihar if the integrated Vaishali VL control strategy is applied under strong monitoring and supervision.

The World Health Organization (WHO) has set a target to eliminate visceral leishmaniasis (VL), commonly known as “Kala-azar,” as a public health problem in India by 2020. The elimination target is defined as achieving less than 1 case per 10,000 people at the block level. Although India has made substantial progress in the elimination of the disease since 2012, VL remains a stable public health problem in four middle-eastern states including Bihar. Bihar contributes >61% of the total Indian cases annually, and a few districts of the state have reported more than 600 cases annually. In this study, the results indicate that an intensive integrated VL control strategy including epidemiological analysis based on a geographical information system (GIS), hot-spot mapping, active case detection, vector control using the indoor residual spraying (IRS) of chemical insecticides, awareness campaigns, human resource development, the close monitoring of control activities, and active epidemiological surveillance and entomological monitoring can achieve the elimination target in the highly endemic region of Bihar. The elimination of VL from highly endemic zones is urgently required to control any new outbreak. Therefore, the implementation of the Vaishali VL control strategy is strongly recommended in all highly endemic districts of Bihar, India.

Retrospect and Risk Analysis of Foot-and-Mouth Disease in China Based on Integrated Surveillance and Spatial Analysis Tools

Foot-and-mouth disease (FMD) is a highly contagious disease of livestock and seriously affects the development of animal husbandry. It is necessary to defend the spread of FMD. To explore the distribution characteristics and transmission of FMD between 2010 and 2017 in China, Global Moran's I test and Getis-Ord Gi index were used to analyze the spatial cluster. A space-time permutation scan statistic was applied to analyze the spatio-temporal pattern. GIS-based method was employed to create a map representing the distribution pattern, directional trend, and hotspots for each outbreak. The number of cases was defined as the number of animals with FMD for the above analysis. We also constructed a phylogenetic tree to compare the homology and variation of FMD virus (FMDV) to provide a clue for the potential development of an effective vaccine. The results indicated that the FMD outbreaks in China had obvious time patterns and clusters in space and space-time, with the outbreaks concentrated in the first half of each year. The outbreaks of FMD decreased each year from 2010 with an obvious downward trend of hotspots. Spatial analysis revealed that the distribution of FMD outbreaks in 2010, 2015, and 2017 exhibited a clustered pattern. Space-time scanning revealed that the spatio-temporal clusters were centered in Guangdong, Tibet and the junction of Wuhan, Jiangxi, Anhui. Comparison of the spatial analysis and space-time analysis of FMD outbreaks revealed that Guangdong was the same cluster of the two in 2010. In addition, the directional trend analysis indicated that the FMD transmission was oriented northwest-southeast. The findings demonstrated that FMDV in China can be divided into three pedigrees and the homology of these strains is very high while comparing the first FMDV strain with the others. The data provide a basis for the effective monitoring and prevention of FMD, and for the development of an FMD vaccine in China.

Intensely clustered outbreak of visceral leishmaniasis (kala-azar) in a setting of seasonal migration in a village of Bihar, India

Background

A visceral leishmaniasis outbreak was reported from a village in a low-endemic district of Bihar, India.

Methods

Outbreak investigation with house-to-house search and rapid test of kala-azar suspects and contacts was carried out. Sandfly collection and cone bio-assay was done as part of entomological study.

Results

A spatially and temporally clustered kala-azar outbreak was found at Kosra village in Sheikhpura district with 70 cases reported till December 2018. Delay of more than a year was found between diagnosis and treatment of the index case. The southern hamlet with socio-economically disadvantaged migrant population was several times more affected than rest of the village (attack rate of 19.0% vs 0.5% respectively, OR_MH = 39.2, 95% CI 18.2–84.4). The median durations between onset of fever to first contact with any health services, onset to kala-azar diagnosis, diagnosis to treatment were 10 days (IQR 4–18), 30 days (IQR 17–73) and 1 day (IQR 0.5 to 3), respectively, for 50 kala-azar cases assessed till June 2017. Three-fourths of these kala-azar cases had out-of-pocket medical expenditure for their condition. Known risk factors for kala-azar such as illiteracy, poverty, belonging to socially disadvantaged community, migration, residing in kutcha houses, sleeping in rooms with unplastered walls and non-use of mosquito nets were present in majority of these cases. Only half the dwellings of the kala-azar cases were fully sprayed. Fully gravid female P. argentipes collected post indoor residual spraying (IRS) and low sandfly mortality on cone-bioassay indicated poor effectiveness of vector control.

Conclusions

There is need to focus on low-endemic areas of kala-azar. The elimination programme should implement a routine framework for kala-azar outbreak response. Complete case-finding, use of quality-compliant insecticide and coverage of all sprayable surfaces in IRS could help interrupt transmission during outbreaks.

Insights from mathematical modelling and quantitative analysis on the proposed WHO 2030 targets for visceral leishmaniasis on the Indian subcontinent

Visceral leishmaniasis (VL) is a neglected tropical disease (NTD) caused by Leishmania protozoa that are transmitted by female sand flies. On the Indian subcontinent (ISC), VL is targeted by the World Health Organization (WHO) for elimination as a public health problem by 2020, which is defined as <1 VL case (new and relapse) per 10,000 population at district level in Nepal and sub-district level in Bangladesh and India. WHO is currently in the process of formulating 2030 targets, asking whether to maintain the 2020 target or to modify it, while adding a target of zero mortality among detected cases. The NTD Modelling Consortium has developed various mathematical VL transmission models to gain insight into the transmission dynamics of VL, identify the main knowledge gaps, and predict the feasibility of achieving and sustaining the targets by simulating the impact of varying intervention strategies. According to the models, the current target is feasible at the appropriate district/sub-district level in settings with medium VL endemicities (up to 5 reported VL cases per 10,000 population per year) prior to the start of the interventions. However, in settings with higher pre-control endemicities, additional efforts may be required. We also highlight the risk that those with post-kala-azar dermal leishmaniasis (PKDL) may pose to reaching and sustaining the VL targets, and therefore advocate adding control of PKDL cases to the new 2030 targets. Spatial analyses revealed that local hotspots with high VL incidence remain. We warn that the current target provides a perverse incentive to not detect/report cases as the target is approached, posing a risk for truly achieving elimination as a public health problem although this is taken into consideration by the WHO procedures for validation. Ongoing modelling work focuses on the risk of recrudescence when interventions are relaxed after the elimination target has been achieved.

Assessing the combined effects of household type and insecticide effectiveness for kala-azar vector control using indoor residual spraying: a case study from North Bihar, India

BACKGROUND

Indoor residual spraying (IRS) is the mainstay for vector control intervention of visceral leishmaniasis (VL) in India. Little is known on the control effects of IRS on different household types. Here, we assessed if IRS with insecticides has an equal residual and interventional effect on all household types in a village. We also developed a combined spatial-risk map and a sand fly, Phlebotomus argentipes density analytical model based on household characteristics, insecticide susceptibility and IRS-status to explore the spatio-temporal distributions of the vector at a micro-scale level.

METHODS

This study was carried out in two villages of Mahnar block in Vaishali district, Bihar. IRS using two insecticides [dichlorodiphenyltrichloroethane (DDT 50%) and synthetic pyrethroid (SP 5%)] was evaluated for VL-vector (P. argentipes) control. Temporal residual efficacy of the insecticides on different wall-surface types was evaluated using the cone-bioassay technique according to WHO guidelines. Insecticide susceptibility of local P. argentipes was explored using the tube-bioassay method. Pre- and post-IRS sand fly densities were monitored in human dwellings and animal shelters using Centers for Disease Control light-traps installed between 18:00-6:00 h. A best-fit model for sand fly density analysis was developed using multiple logistic regression analysis. Geographical information system based spatial analysis techniques were employed to map the household type distribution of insecticide susceptibility of the vector, and IRS-status of the households to interpret the spatio-temporal distributions of P. argentipes.

RESULTS

Phlebotomus argentipes was highly susceptible to SP (100%) but showed high resistance to DDT with a 49.1% mortality rate. SP-IRS has been reported as having better community acceptance than DDT-IRS in all household types. Residual efficacies were varied between wall-surfaces; both insecticides failed to achieve the duration of IRS effectiveness recommended by the WHO. Reduction in P. argentipes counts due to SP-IRS was higher than DDT-IRS between household groups (i.e. sprayed and sentinel), in all intervals post-IRS. Combined spatial risk-maps revealed a better control effect of SP-IRS on sand flies than DDT-IRS in all household types risk-zones. The multilevel logistic regression analysis explored five risk-factors that were strongly associated with the density of P. argentipes.

CONCLUSIONS

The results contribute to furthering current understanding of IRS-practices for control of visceral leishmaniasis in endemic Bihar, which may help in future actions for improvements.

Visceral leishmaniasis: Spatiotemporal heterogeneity and drivers underlying the hotspots in Muzaffarpur, Bihar, India

BACKGROUND

Despite the overall decrease in visceral leishmaniasis (VL) incidence on the Indian subcontinent, there remain spatiotemporal clusters or 'hotspots' of new cases. The characteristics of these hotspots, underlying transmission dynamics, and their importance for shaping control strategies are not yet fully understood and are investigated in this study for a VL endemic area of ~100,000 inhabitants in Bihar, India between 2007-2015.

METHODOLOGY/PRINCIPAL FINDINGS

VL incidence (cases/10,000/year) dropped from 12.3 in 2007 to 0.9 in 2015, which is just below the World Health Organizations' threshold for elimination as a public health problem. Clustering of VL was assessed between subvillages (hamlets), using multiple geospatial and (spatio)temporal autocorrelation and hotspot analyses. One to three hotspots were identified each year, often persisting for 1-5 successive years with a modal radius of ~500m. The relative risk of having VL was 5-86 times higher for inhabitants of hotspots, compared to those living outside hotspots. Hotspots harbour significantly more households from the two lowest asset quintiles (as proxy for socio-economic status). Overall, children and young adelescents (5-14 years) have the highest risk for VL, but within hotspots and at the start of outbreaks, older age groups (35+ years) show a comparable high risk.

CONCLUSIONS/SIGNIFICANCE

This study demonstrates significant spatiotemporal heterogeneity in VL incidence at subdistrict level. The association between poverty and hotspots confirms that VL is a disease of 'the poorest of the poor' and age patterns suggest a potential role of waning immunity as underlying driver of hotspots. The recommended insecticide spraying radius of 500m around detected VL cases corresponds to the modal hotspot radius found in this study. Additional data on immunity and asymptomatic infection, and the development of spatiotemporally explicit transmission models that simulate hotspot dynamics and predict the impact of interventions at the smaller geographical scale will be crucial tools in sustaining elimination.