Management of Visceral Leishmaniasis in Muzaffarpur, Bihar, India

Visceral leishmaniasis (VL) is a chronic infectious disease and transmitted by female Phlebotomus argentipes sand fly. The disease is a public health problem in the Indian subcontinent, East Africa and South America with an estimation of 200,000 to 400,000 new cases worldwide in 2012. In the Indian subcontinent the VL elimination strategy builds on early case detection and management as well as vector control with the aim of reducing the VL incidence rate to less than one new case per 10,000 populations per year at sub-district level. We conducted our studies in Muzaffarpur, India to address the issues related to the general epidemiology of VL, the control strategy and the health information system. We retrospectively analysed the district VL incidence data and their association with meteorological parameters. We also investigated risk factors for sand fly abundance in houses. Under control strategies, we studied the willingness of grassroots community health workers to contribute to active case detection for VL. Lastly, on the health information system part, we tried to develop new tools for the monitoring of clinical outcomes of VL patients, adapted from tuberculosis control program, and field tested it. We assessed the cost and operational feasibility of periodic surveys among a random sample of patients treated by the primary health centres in respect to the routine surveillance system. Our data showed geographic spreading over time into new areas, and a clear link with meteorological parameters. The housing and environmental conditions of the rural villages provide a natural habitat for the sand flies. Housing improvement is recommended. Under the control strategies and information system research, our register-based tool for monitoring clinical outcomes of VL treatment was user-friendly, but required the involvement of ASHAs and ANMs to obtain information on late treatment outcomes. These community health workers are well organized and are ready to get involved in the VL control initiatives. Operational research of this kind can help the VL elimination program address some of its current weaknesses, but for addressing more fundamental research questions on VL transmission and control, we established a research platform in the form of Muzaffarpur-TMRC-HDSS.