Visceral Leishmaniasis Relapse in Southern Sudan (1999–2007): A Retrospective Study of Risk Factors and Trends

Visceral leishmaniasis (kala-azar) caused by Leishmania donovani is spread from person to person by Phlebotomus sandflies. Major epidemics of visceral leishmaniasis have occurred in Southern Sudan during the 20th century. The worst of these killed 100,000 people in the western Upper Nile area of Southern Sudan from 1984–1994, a loss of one-third of the population. Médecins Sans Frontières has treated 40,000 kala-azar patients in Southern Sudan since the late 1980's. In this study we used routinely collected clinical data to investigate why some patients relapse after treatment. We found that patients with severely enlarged spleens (splenomegaly) are more likely to relapse. Patients treated for 17 days with a combination of two drugs (sodium stibogluconate and paromomycin) were more likely to relapse (but less likely to die) than patients treated for 30 days with a single drug (sodium stibogluconate). However, the transition from sodium stibogluconate to the sodium stibogluconate/paromomycin combination as standard treatment between 2001–2003 has not led to a significant increase in visceral leishmaniasis relapse

Conflict and kala-azar: determinants of adverse outcomes of kala-azar among patients in southern Sudan.

We analyzed data obtained from 3365 patients with kala-azar (KA) or post-KA dermal leishmaniasis (PKDL) treated by Medecins Sans Frontieres-Holland in south Sudan from October 1998-May 2002. Patients were malnourished (median body mass index [BMI], 15.5; median weight for height [WFH], 75.5%) and anemic (median hemoglobin (Hb) level, 8.5 g/dL). The proportion of patients with primary KA who were children 850 mg per day did not decrease the chances of survival. Risk factors for death among adults were age > or =45 years (odds ratio [OR], 4.6), malnutrition (BMI, or =5 months; OR, 2.3). Risk factors for death among children and adolescents were age <2 years (OR, 5.4,), malnutrition (WFH, <60%; OR, 5.0), anemia (Hb level, <6 g/dL; OR, 3.7), and splenomegaly (OR, 2.9). A higher risk of death was associated with episodes of diarrhea (OR, 1.4), vomiting (OR, 2.7), and bleeding (OR, 2.9). Relapse and PKDL occurred in 3.9% and 10.0% of cases, respectively

What it takes to get it right: A qualitative study exploring optimal handover of health programmes in Tonkolili District, Sierra Leone

Since 2015 Médecins Sans Frontières (MSF) has been supporting the Ministry of Health (MoH) in Tonkolili district, Sierra Leone, with an integrated health care approach at the community, primary health centre (PHC), and hospital level. This programme is planned to be handed over to MoH. To prepare for this handover, a qualitative study exploring elements of a successful handover was undertaken in 2019. Focus group discussions (FGD) with the community members (n-48) and in-depth interviews (IDI) with MSF staff, community leaders, and MoH staff in Sierra Leone (n-15) were conducted. Data were audio-recorded, transcribed verbatim from English, Creole, and Themne, coded, and thematically analysed. Participants expressed that an optimal project handover and exit strategy should be a continuous, long-term, the staggered process included from the inception of the programme design. It requires clear communication and relationship building by all relevant stakeholders and demands efficient resources and management capacity. Associated policy implications are applicable across humanitarian settings on the handover of programmes where the government is functional and willing to accept responsibilities

Multivariable model of risk factors for relapse after treatment for primary VL.

<p>*adjusted for age, sex, year, treatment centre and all variables in table.</p><p>**excluding patients who had spleen size ‘0’ on admission (adjusted for age, sex and all variables in table).</p><p>***Wald test-for-trend across spleen size as linear variable.</p

Characteristics on admission of primary VL patients who did or did not have record of subsequent relapse.

<p>*<b>Student's t-test for difference between mean values, Chi-squared test for differences in proportions.</b></p

Trends in VL relapse and related factors in Southern Sudan (1999–2007).

<p>Trends in VL relapse and related factors in Southern Sudan (1999–2007).</p

Trends in primary and relapse VL in Southern Sudan (1999–2007).

a<p>from MSF summary statistics (expressed as proportion of patients treated for primary VL, N = 11,319).</p>b<p>from MSF treatment records (proportion of primary VL patients receiving this treatment, N = 8,521).</p>c<p>from MSF summary statistics (expressed as proportion of all patients treated, N = 12,924).</p>d<p>from MSF treatment records (duration of illness self-reported by VL relapse patients, N = 589).</p>e<p>from MSF treatment records (duration of illness self-reported by primary VL patients, N = 7,841).</p>f<p>from MSF treatment records (spleen size measured in primary VL patients, N = 8,494).</p>g<p>from MSF treatment records (interval between discharge and re-admission, N = 166).</p>h<p>Annual Percentage Change (95% confidence interval) estimated from join-point regression.</p

Primary VL, relapse VL and PKDL treatment data from Médecins Sans Frontières - Holland clinics in Southern Sudan (1999–2007).

a<p>from MSF summary statistics.</p>b<p>low proportion in 2004 due to looting of Lankien and consequent loss of patient medical record.</p

Characteristics of relapse VL patients (N = 621) who did or did not have a record of previous treatment for primary VL.

<p>*<b>Student's t-test for difference between mean values, Chi-squared test for differences in proportions.</b></p