Visceral leishmaniasis (VL), a protozoan disease transmitted by sandflies, is the second-biggest parasitic killer worldwide (after malaria). In Ethiopia, the host country for the ICASA 2011 conference, VL and especially HIV/VL co-infection are major public health problems: more than one in three Ethiopian patients with VL is also HIV-positive, the world’s highest co-infection rate.

Treatment of HIV/VL patients presents serious challenges. The two diseases create a vicious spiral: HIV infection increases susceptibility to VL more than 2000-fold, and infection with VL accelerates progression to AIDS. VL is much more difficult to treat in patients with HIV, and even when initial treatment succeeds, patients usually relapse. While there are various drugs available for treating VL, all have drawbacks—for example, sodium stibogluconate (SSG) is highly toxic, particularly in HIV/VL patients (16-33% mortality during treatment) [1,2]; miltefosine is teratogenic; and resistance to drugs is a growing problem, especially when using monotherapy. Liposomal amphotericin B (L-AmB, currently registered as AmBisome®) is safe but must be given intravenously, and is prohibitively expensive for many settings. All these drugs show lower efficacy in HIV/VL patients.

As a physician with Médecins Sans Frontières (MSF) I spent two years living and working in Ethiopia, first in Humera, a hot, dusty border town, where MSF teams treated thousands of people with VL and HIV over the program’s 11 years.

Migrant workers in Humera, working and sleeping unprotected from the sandflies.

Here and elsewhere we worked towards better treatment for HIV/VL patients, and in a late-breaker oral presentation at ICASA I presented new data on outcomes of an alternative drug combination regimen and gave an overview of MSF’s experience managing HIV/VL patients in Ethiopia.

A combination treatment that improves on monotherapy
The main news was hopeful. In 2010 MSF introduced a new combination treatment, after evaluation of high dose L-AmB monotherapy in HIV/VL patients showed disappointingly limited effectiveness in HIV co-infected patients (32% parasitological failure) [3] and unacceptable mortality (16%) during “rescue” treatment of these patients with SSG. But in 50 patients treated with L-AmB (30 mg/kg) plus miltefosine (28 days), results were significantly better: initial cure rates of HIV/VL relapse, which is notoriously difficult to treat, were 87%, compared to 38% with L-AmB monotherapy (p<0.001). In 2012, MSF and several partners [4] will launch a randomized trial of the 2-drug combination, as well as higher-dose (40 mg/kg) L-AmB monotherapy, in co-infected patients.

Impact of ART on outcomes
Cellular immunity is vital for suppressing remaining parasites after VL treatment. While I was in Ethiopia, we demonstrated that ART in HIV/VL patients improves CD4 cell reconstitution only partially. Patients who had a VL relapse fared worst [5]: their CD4 levels never increased above 100 and VL relapses kept coming. Based on these findings, MSF now starts HIV/VL patients on ART as soon as possible after (first) VL treatment, regardless of CD4 count. Because ART alone is not adequate to prevent VL relapse, MSF and partners will soon begin a prospective study of secondary prophylaxis using monthly pentamidine injections.

Implications for HIV programs
MSF’s experience with VL and HIV/VL patients has important implications for HIV programs in VL-endemic countries. Donors and national HIV programs in these regions should include interventions that scale up VL prevention (e.g., impregnated bednets), diagnosis and optimal treatment. Access to early ART for those most vulnerable to VL, including rural migrant laborers and migrated populations, should be improved. In HIV-positive patients infected with the VL parasite but still asymptomatic, early use of ART may be the best way to prevent re-activation of latent VL. SSG should be avoided (due to its extreme toxicity) and high-dose L-AmB-based combination treatments given until parasitological cure is achieved, with ART added as soon as possible. And VL-endemic countries should add VL as in indication for ART initiation, irrespective of CD4 count.

Access to treatment
Access to L-AmB is a major challenge, mainly due to its high price. The recent AmBisome® donation agreement is significant in that it helps advance immediate treatment for one of the world’s most neglected diseases in four least-developed countries. But much more is needed to ensure long-term affordability and widespread availability, including more competition from similar products (for example, to reduce price) and registration of miltefosine and other VL drugs in more East African endemic countries, which otherwise cannot import them.

Rachel ter Horst is a Dutch physician who has worked for Médecins sans Frontières since 2003. She is currently serving as medical advocacy advisor, based in Amsterdam.

1. Ritmeijer K, Veeken H, Melaku et al. Ethiopian visceral leishmaniasis: generic and proprietary sodium stibogluconate are equivalent; HIV co-infected patients have a poor outcome. Trans R Soc Trop Med, 2001, 95;668-72.

2. Ritmeijer K, Dejenie A, Assefa Y, et al. A comparison of Miltefosine and Sodium Stibogluconate for treatment of Visceral Leishmaniasis in an Ethiopian population with high HIV-prevalence. Clin Infec Dis, 2006, 43 (3): 357-64.

3. Ritmeijer K, ter Horst R, Chane S, et al. Limited effectiveness of high-dose liposomal amphotericin B (AmBisome®) for treatment of visceral leishmaniasis in an Ethiopian population with high HIV prevalence. Clin Infect Dis 2011: Dec;53(12):e152-8. Epub 2011 Oct 19.

4. Drugs for Neglected Diseases initiative (DNDi), Gondar University, Ethiopia, and the Institute of Tropical Medicine (ITM) in Antwerp, Belgium.

5. Ter Horst R, Collin S, Ritmeijer K, et al. Concordant HIV infection and visceral leishmaniasis in Ethiopia: the influence of antiretroviral treatment and other factors on outcome. Clin Infect Dis 2008:46;1702-9.

On the menu: progress towards elimination of one of the world’s most neglected tropical diseases, sleeping sickness (human African trypanosomiasis [HAT]). Sleeping sickness is a parasitic disease transmitted by the bite of an infected tsetse fly. The disease affects mostly poor populations living in remote rural areas of Africa. If left untreated, HAT is usually fatal.

Elimination of the disease implies a reduction in incidence to zero in a defined area (as opposed to eradication, which is a permanent reduction to zero of worldwide incidence, after which intervention measures are no longer needed). Continued intervention measures are required to prevent re-establishment of transmission.

Over the past 10 years, considerable progress has been made in the control of sleeping sickness. In several countries, no cases have been diagnosed for over a decade. In others, especially the Democratic Republic of Congo (with nearly 7200 reported cases in 2009 and over 5600 in 2010; 80% of all reported HAT cases), the Central African Republic, South Sudan, Uganda and Chad, the annual reported incidence is considerable. However, the real incidence in these countries is not actually known, because some HAT endemic areas are too insecure to access, lack health care and surveillance, or both.

Médecins Sans Frontières (MSF) has been involved in sleeping sickness treatment since 1986. The organisation tends to go where the disease burden is highest, and national control programme teams or other non-governmental organisations do not go because of war, insecurity, or lack of capacity. While implementing extensive active case-finding and providing life-saving treatment, MSF advocates enhanced coordinated efforts and research and development into better diagnostic tests and treatments. The current diagnostic test (card agglutination test for trypanosomiasis followed by cerebrospinal fluid microscopy for confirmation and staging) and treatment tools (pentamidine intramuscular injections for stage 1, NECT [nifurtimox-eflornithine combination therapy; includes twice daily eflornithine intravenously for a week] for stage 2) require trained medical and laboratory staff, and are difficult to integrate into primary health care (where available).

The new MSF international mobile HAT team was introduced at the conference. Operating in countries with highest burden of HAT, the teams will facilitate diagnosis and treatment for neglected populations that are difficult to access, investigate suspected transmission areas, strengthen surveillance capacity, raise awareness and action at national and international levels, and assess and integrate new approaches.

Good news on sleeping sickness diagnostics came from the Foundation for Innovative New Diagnostics (FIND), who presented their diagnostic pipeline. If all goes well, by late 2012 there could be a rapid diagnostic test for sleeping sickness. A lumbar puncture will still be needed to establish the disease stage of a patient since this determines the choice of current treatments. Research is ongoing into developing a biomarker (neopterin) test that can be performed on blood. If that becomes successful, it would greatly improve feasibility of scale-up and integration of HAT care into the health system.

On the treatment front, a hopeful compound in the pipeline of the Drugs for Neglected Diseases initiative (DNDi), named fexinidazole, was discussed. Clinical trials with patients are planned for early next year. Fexinidazole, a once-daily tablet, will hopefully work for both stages of the disease. Another drug candidate is an oxaborole currently named SCYX7158. The outlook is encouraging, but it is still early days.

Trypanosomiasis not only affects humans, but also livestock such as cattle. Animal trypanosomiasis is called Nagana, a Zulu word meaning “to be depressed”. Since the disease affects livestock, economic implications and the attention of many more actors is coming to the fore. Land cleared of the tsetse fly can be turned into agricultural or grazing land. Tourists in national parks should not be infected. Huge investments are being made into preventing animal trypanosomiasis, such as cattle spraying, cattle foot baths, insecticide-treated fencing, and vector control such as aerial spraying and releasing sterile male tsetse flies.

My mind drifts back to the human disease, with its human implications, and an inspiring message that has started shining through the darkness. Numbers of sleeping sickness cases are steadily decreasing through
coordinated efforts. Elimination of this scourge from even the hardest-to-reach places could become feasible. A good rapid test, effective treatment in tablet form, commitment, action (including surveillance), and investment are the ingredients needed to push sleeping sickness down and keep it down.

This is a guest blog written by Rachel ter Horst, the Medical Advocacy Adviser at Médecins Sans Frontières (MSF)

Also posted on the BMJ blog: http://blogs.bmj.com/bmj/2011/09/29/rachel-ter-horst-inspiring-progress-in-the-fight-against-sleeping-sickness/

If you asked the average American if they’ve ever heard of sleeping sickness, river blindness, or elephantiasis, you’d likely get a puzzled look. But ask a Congolese, Sudanese, or Bangladeshi about these parasitic diseases, and you might get a nod of the head or perhaps even a point in the direction of someone behaving erratically and slipping into a coma due to sleeping sickness, being led by stick by a child because of river blindness, or barely able to walk due to grossly swollen legs or genitalia caused by elephantiasis.

This weekend in Boston, health workers, researchers, donors, and social innovators from around the world will convene to discuss current efforts to treat patients and develop new drugs and vaccines for neglected tropical diseases (NTDs) such as these. Most of us have never heard of these diseases, although they are the most common infections of the world’s poor, debilitating or killing more than 1 billion people in the developing world.

This first-ever NTD meeting of the International Society for Infectious Diseases offers an opportunity for U.S. policy-makers and the public to better understand the devastating toll these illnesses exact on the world’s poorest and most vulnerable people. It may also shine light on the commendable achievements — as well as some limitations — of the current approach the U.S. government is taking to tackling NTDs.

The elimination of certain NTDs has been set as a goal by the U.S. Global Health Initiative (GHI) and World Health Organization (WHO). Great progress in reaching these elimination targets is being achieved through a program of mass treatment. To date, more than 100 million people have received access to essential medicines for NTDs thorough funding from the U.S. Agency for International Development (USAID).

However, for many NTDs, elimination will not be possible using existing drugs because they are limited in effectiveness and safety, are difficult to use, or come with serious concerns about resistance. Therefore, while continuing to provide existing medicines for NTDs, there is an urgent need to implement a parallel program of development, manufacture, and clinical testing of new drugs, diagnostics, and vaccines.

While basic research and early-stage product development is supported by the National Institutes of Health and should continue to be funded at ever-increasing levels, late-stage product development, including for drugs, diagnostics, and vaccines, is urgently needed to bring new health technologies through the “pipeline” to patients. This would help bridge the gap between innovation and access and would align NTDs with other USAID programs in malaria, HIV/AIDS, and tuberculosis, which currently allocate a percentage of their funding for late-stage product development.

Neglected disease researchers are trying to do their part. At the ISID-NTD meeting in Boston, the Drugs for Neglected Diseases initiative (DNDi), a non-profit R&D organization focused on sleeping sickness, Chagas disease, and leishmaniases, will announce the start of a new project testing the drug flubendazole in people suffering from either river blindness or elephantiasis. If effective, this drug could dramatically improve case management and simplify mass drug treatment of patients throughout Africa and Asia. The Sabin Vaccine Institute will describe new vaccines in development for hookworm, schistosomiasis, and Chagas disease, one of which will soon enter clinical trials.

Up to 600 million people are infected with hookworm and schistosomiasis, and 120 million with elephantiasis throughout the low- and middle-income countries of Africa, Asia, and Latin America, Another 26 million have river blindness, while up to 10 million people have Chagas disease, a leading cause of heart disease in Latin America.

The U.S. has led the way in ensuring the poorest people receive urgently needed treatments for NTDs, while simultaneously supporting programs of basic research. This commitment has spanned several presidential administrations, receiving widespread support from both Democrats and Republicans in the U.S. Congress. This weekend, we will join with other leading NTD experts in Boston to call for the expansion of the U.S. government’s approach to NTDs so that it includes new investments in R&D to develop and test new products for a wider range of neglected diseases. Only then will we be able to eliminate the neglect of millions of poor people in need and at risk.

Bernard Pecoul, MD, MPH is Executive Director of the Drugs for Neglected Diseases initiative, and Peter Hotez, MD, PhD is President of Sabin Vaccine Institute at Texas Children’s Hospital and Baylor College of Medicine, and Editor-in-Chief of PLoS Neglected Tropical Diseases

Source: Map created by Jessica Schwartz, The George Washington University doi:10.1371/journal.pntd.0000843.g001

Outside of the US, Washington, D.C. and the Gulf Coast are, respectively, more likely to be thought of as the seat of global power or as the home of endless sunshine. By contrast, Hotez argues that “Hurricanes Katrina and Rita and the BP oil disaster have shed light on a tragic level of poverty in the northern Gulf of Mexico” and that “Washington, D.C., rivals Louisiana, Mississippi, and Alabama as among the worst in terms of life expectancy and health index”. His list of the diseases common in these communities is stark, and shaming -Trichomoniasis, Toxocariasis, congential toxoplasmosis and cytomegalovirus – even leaving aside the “astonishing” prevalence of HIV- 6.5% of African American males in Washington, D.C..

His conclusion is hard to disagree with: “The fact that we know so little about the neglected infections of poverty in America’s most distressed areas is representative of just how glaring these conditions are as health disparities.”

“It never ceases to amaze me how much Medsinners [members of Medsin] accomplish while studying full time, and with such limited resources; giving up weekends and evening to work for the cause,” says Elly Pilavachi, the current national co-ordinator of Medsin , a student led UK charity. And the cause? Medsin’s mission: “to create a network of students, empowered to effect tangible, social, and political change in health on a local, national and global level through education, advocacy, and community action.”

I wholeheartedly agree with her words and share her amazement. Medsinners are awesome as I witnessed last weekend while at Medsin’s national global health conference based in Cambridge. In addition to the logistical triumph of the Cambridge student team in organising such a huge conference (there were 4 plenary sessions with 3 speakers in each and up to 60 workshops), over 300 students (the majority of which were medical students) from around the UK, gave their time, energy, and scare financial resources to learn more about the conference theme: “The mad and the bad: the diseases that nobody talks about.”

Many diseases and conditions could fall into this area but the conference focused particularly on the neglected tropical diseases and mental illness. At first glance, these two areas may not appear linked but there are many overlapping issues. For example, people with neglected tropical diseases, such as leprosy, and people with mental health problems are stigmatised by society. One of my most memorable memories of the conference is the talk given by Peter Byrne, a consultant liaison psychiatrist and Director of Education for the Royal College of Psychiatrists, who eloquently demonstrated how people with mental illness continue to be stigmatised in the way in which they are portrayed in film and the media.

Plenary sessions and workshops discussed the particular issues of neglected tropical diseases, such as the lack of affordable treatments and diagnostic tests, mostly due to the lack of pharmaceutical company involvement in the Research and Development of this unprofitable market area. But there are many possible solutions to help move forward, including public private partnerships and publications such as PLoS Neglected Tropical diseases. Others looked at WHO’s Global Burden of Diseases and how in 2030, there will be no infectious diseases in the top 15 conditions — chronic non communicable diseases and road traffic accidents will lead the way. Articulate student advocates for Pharmaware, Universities Allied for Essential Medicines and minds for health enlivened many sessions.

At the end of an exhausting weekend, I felt that the conference and its passionate participants had not only exemplified Medsin’s mission but also its Vision—a fair and just world, in which equity and health is a reality for all. If doctors of the future are anything like these marvellous Medsinners, there is hope for the world, a realistic opportunity to improve global health and the chance to make a lasting difference.

As I began with the words of Elly Pilavachi, I will also finish with them: “On these occasions when we are left feeling bereft of energy, when our work appears to go unrecognised, and we struggle to grasp the results, there is nothing more invigorating than knowing that there are thousands of young people in the UK who are still striving for the same outcome.” Amen to that!

Competing interest: RM is a Trustee of Medsin

The findings, from 218 funders, from 2009, are intriguing, coming as they do at the beginning of the global financial crisis. Perhaps unexpectedly the report sees a shift from philanthropic funding to public funding (though as pointed out by Joe Cerrell from the Gates Foundation at the launch this may have been an effect of some unusually large outlays in 2008). The effect of more public funding is important as public funders traditionally fund more basic research and less product development – and as the report argues overall this may be problematic since for a number of these diseases  basic research is not the bottleneck: many of these diseases are well understood – what’s needed is products targeted to these populations.

As the report also points out however the magnitude of funding does not necessarily have to correlate with disease burden. For some diseases what is really needed is quite a small amount of money, appropriately targeted.

For example – “investment of a few million dollars to create a successful diagnostic may be all that is needed to dramatically improve patient outcomes.”  That this is not happening is often a reflection of a lack of strategic oversight of required funding. This is coupled with lack of coordination between funders. As the authors say “ This is particularly the case for the most neglected diseases, which are seeing a highly scattered approach with multiple small funders disbursing grants that, although considerable for them, are not appropriately sized or targeted to the products needed for that disease (such as for leprosy, rheumatic fever and Buruli ulcer) – although collectively they could have a significant impact.”

And of course there is the even bigger issue of what investment is needed into implementation and health systems in order to finally get the products to the communities that need them;  this is outside of the scope of this report, though clearly important.

The camera pans across a parched landscape—the state of Eastern Equatoria, in Southern Sudan—where goats are being herded and water is collected by hand.  In this opening scene of the new film, Foul Water Fiery Serpent, we are immediately transported to a harsh, impoverished environment, one that has been destroyed by civil war.

Now we see a woman and her daughter, both of whom have declined treatment for their festering wounds, which were caused by Guinea worm.  A Biblical quotation appears onscreen, perhaps the first historical description of this debilitating and stigmatizing condition:

“And the Lord sent fiery serpents among the people, and they bit the people” (Numbers 21:4-9).

Foul Water Fiery Serpent examines the global campaign to eradicate Guinea worm spearheaded by the Carter Center (Jimmy Carter himself has invested a huge amount of his political capital in the campaign).  Part science documentary, with terrific animations showing the life cycle of the worm, and part advocacy tool, the film mostly shows the day-to-day work of the expat and local technical advisers employed by the Carter Center, interspersed with gruesome scenes of patients writhing in pain.

The work is unglamorous and uses basic tools—no vaccines or drugs, just low-tech interventions such as working with rural communities to distribute water filters, treat ponds with chemical larvicide, manually remove worms from those infected, and teach infected people to stay out of water sources.

The campaign is surely one of the great public health success stories of our time.  The disease is on course to become the second in history, after smallpox, to be eradicated.  Ghana, for example, has seen a dramatic decline in reported cases, from 180,000 in 1989 to only 8 in 2010.   The biggest challenge remains Southern Sudan—2,900 cases were recorded in 2009—and the greatest threat to achieving eradication would be the return of civil war to this country.

Carter himself appears in the film.  He discusses the Carter Center’s early work “to survey the world” for Guinea worm, finding it in twenty countries in 1986. “We quickly eradicated it in Yemen, India, Pakistan,” he says.  He gives a fascinating account of his role in the 1995 Guinea worm ceasefire in Sudan, in which Carter amazingly persuaded the disputing parties in the civil war to put down their weapons for 4 months to allow eradication activities.

I was lucky enough to see the film at a screening at the University of California Berkeley that was followed by a Q&A with Donald Hopkins, the Vice-President for Health Programs at the Carter Center.  The campaign’s success to date, he argued, has lessons for other health problems: “It shows the power of community mobilization and health education.”

Foul Water Fiery Serpent is a powerful film, telling an important story, although there was one aspect I found a little grating.  There’s a very big focus on the young American technical advisers, which has the effect of portraying them—rather than the local participating communities or local technical advisers—as the “heroes” of the story, a portrayal that seems at odds with Hopkins’ inspiring message.

Gavin Yamey leads the Evidence-to-Policy initiative (E2Pi) in the Global Health Group at the University of California San Francisco; E2Pi receives core funding from the Bill & Melinda Gates Foundation, which supports the Carter Center’s Guinea Worm Eradication Programs.

A recent report by Médecins Sans Frontières (MSF) of an outbreak of visceral leishmaniasis (VL) in southern Sudan¹ comes at a time when an increasing focus is being put on the control and elimination of neglected diseases. However, this outbreak raises the question of how far along we really are in reaching such targets.

Dr Manica Balasegaram, DNDi

VL (also known as kala azar) is one of the deadliest parasitic diseases in the world, with an estimated half a million new cases each year. Spread by the bites of sandflies, VL severely affects the liver, spleen, and bone marrow, and if left untreated is almost always fatal. Yet the disease remains largely unknown in the developed world.

The control of VL, particularly in the anthroponotic areas of transmission (south Asia and east Africa), has focused on vector control and treatment. In terms of treatments, VL is fairly well served in comparison with other neglected diseases. There are several drugs available, including antimonials (eg, sodium stibogluconate or glucantime), amphotericin B, parmomomycin, and miltefosine (the only available oral drug against the disease). However, all these treatments have various problems, including cost, toxicity, long treatment courses, and low feasibility in the field setting. To achieve the objective of elimination, a tailor-made drug for the disease that only would require a few pills of a very cheap (a few dollars), safe, and effective treatment is needed.

Nonetheless, considerable efforts have recently been made to improve options for patients. On the development side, pivotal trials on combinations of drugs (such as sodium stibogluconate & paromomycin, AmBisome & paromomycin, AmBisome & miltefosine, miltefosine & paromomycin; data in publication) and on a single dose AmBisome have recently been completed in both Africa and Asia.² The results of these trials indicate good safety and efficacy and these treatments could be available for use next year. There is also ongoing research looking at promising potential candidates for clinical development. The goal of such research is to develop a safe, short course (7 day) oral treatment that can be used at the most basic healthcare level. These investments could pay off in the near future, since it is possible that a clinical candidate might be available for development within the next 1–2 years.

This all sounds very exciting, but there are a couple of major issues. Firstly, drug development does not equate to drug implementation. While resources are required and indeed have been invested in research, it is paramount that more resources are dedicated towards roll-out of treatment to ensure that patients get access to these life-saving drugs. This is particularly relevant in regions such as southern Sudan, where the recent outbreak has been reported. The fact that MSF are so actively involved in treating VL patients in several countries is an illustration in itself that insufficient resources are being invested by both governments and donors (both private and public) in control and implementation activities, including case detection, treatment, surveillance, and prevention. There have been some signs of improvement, particularly in south Asia, where a regional commitment has been made between India, Nepal, and Bangladesh to eliminate the disease. However, more efforts need to filter down into field level so that sufficient equipment, drugs, and trained personnel are made available to control the disease.

Another major issue is that VL, like so many neglected diseases, is very much a disease of neglected populations; specifically groups that are poor, marginalised, and living in rural, peri-conflict, or unstable environments.

The further impoverishing effect of VL is now also well documented. It is therefore questionable that we can ever truly eliminate neglected diseases without first making considerable improvements to the lives of the populations in endemic areas. A recent study I read looking at risk factors for VL in India concluded that “improving housing conditions for the poor has the potential to reduce VL incidence”.³ The implication is that the long-term solution to tackling these types of diseases perhaps lies beyond the scope of research and medicine, and that a serious effort needs to be made at a political, social, and economic level to tackle the eternal pandemics of poverty and inequity. In the meantime, the rest of us should continue our day jobs and try to find more mundane, and ‘less ambitious’ solutions.

1  MSF increases response to kala azar outbreak in South Sudan. http://www.msf.org.uk/kala_azar_south_sudan_20100824.news

http://www.doctorswithoutborders.com/news/article.cfm?id=4693&cat=field-news&ref=news-index (Aug 25, 2010)

2. Sundar S, Chakravarty J, Agarwal D, Rai M, Murray HW. Single-dose liposomal amphotericin B for visceral leishmaniasis in India. N Engl J Med 2010; 362: 504–12.

3  Singh SP, Hasker E, Picado A, et al. Risk factors for visceral leishmaniasis in India: further evidence on the role of domestic animals. Trop Med Int Health 2010; 15: 29–35.

But treatment works best in the context of better health, and before drug therapy those who are severly ill are treated for pneumonia, diarrhoea, and anaemia. Malnutrition predisposes to infection, as do environmental conditions favouring multiplication of the vector for VL, which is a sandfly. It seems that a perfect storm of food insecurity, failed crops, altered weather and reduced immunity owing to time elapsed since the last outbreak, has led to the current outbreak.