Map of Bihar showing district distribution of visceral leishmaniasis endemicity, antimonial resistance, and arsenic contamination of the groundwater.

<p>The map is based on published data <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001227#pntd.0001227-Croft1" target="_blank">[4]</a>, <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001227#pntd.0001227-Ravenscroft1" target="_blank">[6]</a>, <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001227#pntd.0001227-Thakur3" target="_blank">[44]</a>–<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001227#pntd.0001227-Central1" target="_blank">[46]</a> with additional data from <a href="http://www.indiawaterportal.org/node/10925" target="_blank">http://www.indiawaterportal.org/node/10925</a> and <a href="http://www.soesju.org/arsenic/groundwater_bihar.htm" target="_blank">http://www.soesju.org/arsenic/groundwater_bihar.htm</a>, both last accessed 12/20/2010. Data for Muzaffarpur are from personal correspondence with Dr. Ashok Ghosh, A.N. College, Patna.</p

Results of consecutive clinical studies of antimonials at 20 mg/kg dosing in Bihar, India.

<p>Graph drawn from data presented in tabular form in a systematic review of clinical trials done in India between 1980 and 2004 <a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0001227#pntd.0001227-Olliaro1" target="_blank">[2]</a>. Doses received are indicated in the figure key. Linear regression correlation coefficient  =  −0.831.</p

Bivariate logistic regression analysis of risk factors for SSG treatment failure.

<p>Note: *This number includes 10 deaths.</p><p>Bivariate logistic regression analysis of risk factors for SSG treatment failure.</p

Kaplan Meier curves for all-cause and VL mortality.

<p>Panels A and B are survival curves comparing arsenic exposed (dotted line, = > 10 μg/L As) and non-arsenic exposed (solid line, <10 μg/L As) patients in the outcomes of all-cause mortality (log rank p = 0.004) and VL mortality (log rank p = 0.044).</p

Flow chart of individuals identified as having received SSG treatment between 2006 and 2010.

<p>Additional outcomes: One patient had a still birth during antimonial treatment. One patient was identified with PKDL at the time of study.</p

Dot plots of arsenic exposure and SSG treatment outcome and mortality in antimonial treated cohort (n = 110).

<p>Panels A, B and C show the log of the mean arsenic level plotted against outcome: SSG failure (MWU p = 0.42), all-cause mortality (MWU p = 0.005) and VL mortality (MWU p = 0.048). MWU = Mann Whitney U.</p

Multivariate Cox regression analysis of effect elevated arsenic water levels (> = 10 μg/L) on risk of the outcomes of all-cause and VL related mortality in a cohort of SSG treated patients.

<p>HR = Hazard Ratio; CI = Confidence Interval</p><p>* Two time varying covariates were fitted in the model as the effect of arsenic exposure on mortality was found to vary with time</p><p>Multivariate Cox regression analysis of effect elevated arsenic water levels (> = 10 μg/L) on risk of the outcomes of all-cause and VL related mortality in a cohort of SSG treated patients.</p

Map of study area.

<p>A. The State of Bihar, India. B. District level map of Bihar with study area boxed. Districts with blue dots have had arsenic contamination previously identified and those with black dots have reported antimonial resistance in clinical isolates [<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003518#pntd.0003518.ref010" target="_blank">10</a>]. C. Mohiuddin Nagar block: study area showing the town boundary (dotted line). Each dot represents the mean arsenic level determined from 5 wells in each study subject’s local area.</p