Active case detection in national visceral leishmaniasis elimination programs in Bangladesh, India, and Nepal: feasibility, performance and costs

M Mamun Huda,Sangeeta Kansal,Axel Kroeger,Siddhivinayak Hirve,Niyamat Ali Siddiqui,Chitra Kumar Gurung,Dinesh Mondal,Paritosh Malaviya,Suman Rijal,Byron Arana,Eva Naznin,Pradeep Das,Megha Raj Banjara

doi:10.1186/1471-2458-12-1001

Abstract

BackgroundActive case detection (ACD) significantly contributes to early detection and treatment of visceral leishmaniasis (VL) and post kala-azar dermal leishmaniasis (PKDL) cases and is cost effective. This paper evaluates the performance and feasibility of adapting ACD strategies into national programs for VL elimination in Bangladesh, India and Nepal.MethodsThe camp search and index case search strategies were piloted in 2010-11 by national programs in high and moderate endemic districts / sub-districts respectively. Researchers independently assessed the performance and feasibility of these strategies through direct observation of activities and review of records. Program costs were estimated using an ingredients costing method.ResultsAltogether 48 camps (Bangladesh-27, India-19, Nepal-2) and 81 index case searches (India-36, Nepal-45) were conducted by the health services across 50 health center areas (Bangladesh-4 Upazillas, India-9 PHCs, Nepal-37 VDCs). The mean number of new case detected per camp was 1.3 and it varied from 0.32 in India to 2.0 in Bangladesh. The cost (excluding training costs) of detecting one new VL case per camp varied from USD 22 in Bangladesh, USD 199 in Nepal to USD 320 in India. The camp search strategy detected a substantive number of new PKDL cases. The major challenges faced by the programs were inadequate preparation, time and resources spent on promoting camp awareness through IEC activities in the community. Incorrectly diagnosed splenic enlargement at camps probably due to poor clinical examination skills resulted in a high proportion of patients being subjected to rK39 testing.ConclusionNational programs can adapt ACD strategies for detection of new VL/PKDL cases. However adequate time and resources are required for training, planning and strengthening referral services to overcome challenges faced by the programs in conducting ACD.

Highlights

Active case detection (ACD) significantly contributes to early detection and treatment of visceral leishmaniasis (VL) and post kala-azar dermal leishmaniasis (PKDL) cases and is cost effective
Sensitivity of the camp in Bangladesh was calculated as the percentage of new VL cases identified by the camp out of the total of new cases identified by the camp and the additional new cases identified in the house to house search
In Bangladesh, 14 new PKDL cases were identified in the camps compared to one in India and none in Nepal

Summary

Introduction

Active case detection (ACD) significantly contributes to early detection and treatment of visceral leishmaniasis (VL) and post kala-azar dermal leishmaniasis (PKDL) cases and is cost effective. With an estimated 200 million people at risk, India, Nepal and Bangladesh harbour an estimated 67% of the global VL disease burden [2] In this region, Leishmania donovani is the only species causing VL, the female sand fly Phlebotomas argentipes is the only vector and humans are the only known reservoir [3,4,5]. A comparison of cost-effectiveness of four different strategies for ACD including Camp strategy (fever camps with spleen examination and rapid diagnostic test (rK39)), Index case (focal) strategy (house to house screening in the neighborhood of recent VL cases), Incentive based strategy (case detection through village health workers who receive an incentive for every new case) and house to house screening strategy (as reference approach) shows 80% sensitivity for the camp approach with high cost-effectiveness. NKEPs need the right combination of different ACD strategies based on the epidemiological profile, affordability and organizational feasibility

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Conclusion