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      Burden of Visceral Leishmaniasis in Villages of Eastern Gedaref State, Sudan: An Exhaustive Cross-Sectional Survey

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          Abstract

          Background

          Since December 2009, Médecins Sans Frontières has diagnosed and treated patients with visceral leishmaniasis (VL) in Tabarak Allah Hospital, eastern Gedaref State, one of the main endemic foci of VL in Sudan. A survey was conducted to estimate the VL incidence in villages around Tabarak Allah.

          Methods

          Between the 5 th of May and the 17 th of June 2011, we conducted an exhaustive door-to-door survey in 45 villages of Al-Gureisha locality. Deaths were investigated by verbal autopsies. All individuals with (i) fever of at least two weeks, (ii) VL diagnosed and treated in the previous year, and (iii) clinical suspicion of post-kala-azar dermal leishmaniasis (PKDL) were referred to medical teams for case ascertainment. A new case of VL was a clinical suspect with a positive rk39 rapid test or direct agglutination test (DAT).

          Results

          In the 45 villages screened, 17,702 households were interviewed, for a population of 94,369 inhabitants. The crude mortality rate over the mean recall period of 409 days was 0.13/10'000 people per day. VL was a possible or probable cause for 19% of all deaths. The VL-specific mortality rate was estimated at 0.9/1000 per year.

          The medical teams examined 551 individuals referred for a history of fever of at least two weeks. Out of these, 16 were diagnosed with primary VL. The overall incidence of VL over the past year was 7.0/1000 persons per year, or 7.9/1000 per year when deaths possibly or probably due to VL were included. Overall, 12.5% (11,943/95,609) of the population reported a past VL treatment episode.

          Discussion and Conclusion

          VL represents a significant health burden in eastern Gedaref State. Active VL case detection had a very low yield in this specific setting with adequate access to care and may not be the priority intervention to enhance control in similar contexts.

          Author Summary

          Visceral leishmaniasis (VL) is a life-threatening parasitic disease, transmitted by a sandfly. A survey was conducted to estimate the VL incidence in 45 villages located in the eastern part of Gedaref State, the main endemic focus of VL in Sudan. Between the 5 th of May and the 17 th of June 2011, we interviewed 17,702 households for a population of 94,369.

          Sixteen individuals were diagnosed with primary VL through active case-detection, and 725 reported VL treatment over the past year. The overall incidence rate of VL over the past year was 7.0/1000 persons per year. The crude mortality rate over the mean recall period of 409 days was 0.13/10'000 persons per day. VL was a possible or probable cause for 19% of all deaths. Taking also into account the VL-specific mortality of 0.9/1000 per year, the incidence was estimated at 7.9/1000 per year. Overall, 12.5% of the population reported having been treated for VL in the past.

          VL is a major public health issue in Gedaref. Active VL case detection had a very low yield in a context of adequate access to care. Such strategy seems redundant if patients already have access to care.

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          Most cited references1

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          A meta-analysis of the diagnostic performance of the direct agglutination test and rK39 dipstick for visceral leishmaniasis.

          To compare the performance of the direct agglutination test and rK39 dipstick for the diagnosis of visceral leishmaniasis. Medline, citation tracking, January 1986 to December 2004. Selection criteria Original studies evaluating the direct agglutination test or the rK39 dipstick with clinical visceral leishmaniasis as target condition; adequate reference classification; and absolute numbers of true positive, true negative, false positive, and false negative observations available or derivable from the data presented. 30 studies evaluating the direct agglutination test and 13 studies evaluating the rK39 dipstick met the inclusion criteria. The combined sensitivity estimates of the direct agglutination test and the rK39 dipstick were 94.8% (95% confidence interval 92.7% to 96.4%) and 93.9% (87.7% to 97.1%), respectively. Sensitivity seemed higher and more homogenous in the studies carried out in South Asia. Specificity estimates were influenced by the type of controls. In phase III studies carried out on patients with clinically suspected disease, the estimated specificity of the direct agglutination test was 85.9% (72.3% to 93.4%) and of the rK39 dipstick was 90.6% (66.8% to 97.9%). The diagnostic performance of the direct agglutination test and the rK39 dipstick for visceral leishmaniasis is good to excellent and seem comparable.
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            Author and article information

            Contributors
            Role: Editor
            Journal
            PLoS Negl Trop Dis
            PLoS Negl Trop Dis
            plos
            plosntds
            PLoS Neglected Tropical Diseases
            Public Library of Science (San Francisco, USA )
            1935-2727
            1935-2735
            November 2012
            1 November 2012
            : 6
            : 11
            : e1872
            Affiliations
            [1 ]Epicentre, Paris, France
            [2 ]Médecins Sans Frontières - Operational Centre Geneva, Geneva, Switzerland
            [3 ]Institute of Tropical Medicine, Antwerp, Belgium
            [4 ]Federal Ministry of Health, Khartoum, Sudan
            [5 ]Community Medicine Department, University of Gedaref, Gedaref, Sudan
            [6 ]Médecins Sans Frontières - Operational Centre Amsterdam, Amsterdam, Holland
            [7 ]Institut de Recherche pour le Développement (IRD), Montpellier, France
            [8 ]Geneva University Hospitals and University of Geneva, Geneva, Switzerland
            Institut Pasteur de Tunis, Tunisia
            Author notes

            The authors have declared that no competing interests exist.

            Conceived and designed the experiments: YKM FN KAA MB JCD RE HAG KR DW JFE FC. Performed the experiments: YKM FN OH NS. Analyzed the data: YKM. Wrote the paper: YKM.

            Article
            PNTD-D-12-00663
            10.1371/journal.pntd.0001872
            3487394
            23133683
            2fb21587-d09c-46e5-9ec5-c63347e87204
            Copyright @ 2012

            This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

            History
            : 10 May 2012
            : 6 September 2012
            Page count
            Pages: 6
            Funding
            This work was funded by Médecins Sans Frontières. MSF gave technical input in preparation and implementation of the survey. MSF co-authors reviewed this manuscript and agreed for its publication. However, final decisions were the responsibility of the principal investigator who certifies the absence of interests that could have affected the reliability of these results.
            Categories
            Research Article
            Medicine
            Epidemiology
            Disease Mapping
            Infectious Disease Epidemiology
            Survey Methods
            Infectious Diseases
            Parasitic Diseases
            Leishmaniasis

            Infectious disease & Microbiology
            Infectious disease & Microbiology

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