CHERINET ADERA: When I was practicing as a clinician, I was noticing different challenges related to management of visceral leishmaniasis. Most of the patients are migrants, seasonal migrant workers, who travel to low-lands for harvesting season and weeding season. And at that moment, they acquire the illness and they start to develop the symptoms after a few months when they go back to the high-lands, or some of them develop the illness– start to develop the symptoms while they are in the field. And most of them cannot afford the cost of treatment. Actually, the drugs and diagnostics are given for free, both in MSF projects and government hospitals. But there are some indirect costs.
For example, until the diagnosis is settled, they need to pay for the investigations. And after admission, they need to pay for the cost of the bed, food, and other indirect costs, which is very challenging. And there are some other challenges, like HIV-VL co-infection in Ethiopia, in Tigray and Amhara region especially, in northwest part of Ethiopia, HIV-VL co-infection is high. And some patients have frequent relapse. I remember a patient who relapsed 12 times. And he received treatment in different hospitals. When he was relapsing, you can imagine how a patient could suffer being admitted for more than 2 weeks in a hospital, and 12 times - it will be very challenging. He was frequently coming back every few months.
So he was losing hope. It was a very challenging issue. The other issue is malnutrition. In visceral leishmaniasis, malnutrition is so common. Around 50% of the cases are malnourished, according to retrospective data we collected from different hospitals. And there is no additional supplemental nutritional therapy for those patients. Now, since KalaCORE started implementation, this supplement is being given. But it needs to be sustained. There are also other challenges, like drug supply and diagnostic supply shortage, sometimes interruption. These are the main challenges. In Ethiopia, there are several differential diagnoses for a patient presenting with clinical manifestations similar to visceral leishmaniasis. And these include malaria, typhoid fever, tuberculosis, HIV, and other illnesses.
So for a clinician, it is better to consider different diagnosis before concluding a patient as a case of visceral leishmaniasis. For that, we need to stick with the clinical case definition if possible. If the patient has fever for more than two weeks and/or lymphadenopathy or splenomegaly or leukopenia, anaemia and weakness, with travel history to visceral leishmaniasis endemic area, or living in a visceral leishmaniasis endemic area, it is better to consider visceral leishmaniasis. The available diagnostic modalities for visceral leishmaniasis in Ethiopia are rK39 test kits. If the rK39 test is positive and if the patient fulfils the clinical case definition and if other differential diagnoses are ruled out, we can go for treatment.
But if rK39 is negative, we can go for Direct Agglutination Test (DAT), which is also a serological test, but this test is not available in Ethiopia. So the next option could be performing parasitologic tests, like splenic and bone marrow aspiration. Those tests are considered as confirmatory tests. The sample can be taken and confirmed. If the patient is confirmed, we can treat. In Ethiopia, according to 2013 Ethiopian National Guideline, the first-line drug is SSG with paromomycin combination therapy, which is given for 17 days. It has been rolled out in different health facilities since 2016. And the other first-line for immunocompetent individuals is SSG, or sodium stibogluconate, with a dose of 20-milligramme per kg for 30 days.
If there are immune-suppressed individuals, like HIV co-infected and other special groups, AmBisome comes to the picture. And it can be given as first-line, but in immunocompetent individuals, AmBisome is a second-line treatment option.