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Background While three countries in South-Asia decided to eliminate visceral
leishmaniasis (VL) by 2015, its control in other regions seems fraught with difficulties. Is
there a scope for more effective VL control in the Americas? We reviewed the evidence
on the effectiveness of VL control strategies in Latin America – diagnosis, treatment,
veterinary interventions, vector control - with respect to entomological and clinical
outcomes.
Methodology/Principal findings We searched the electronic databases of MEDLINE,
LILACS, the Cochrane Central Register of Controlled Trials, from 1960 to November
2008 and references of selected articles, restricted to English, Portuguese and Spanishlanguage
publications. Intervention trials as well as observational studies that evaluated
control strategies of VL in the Americas were included. Evidence suggests that improved
VL control in the Americas is possible if interventions with known effectiveness would
be applied in a more structured approach but the impact of the existing control strategies
on transmission still needs to be demonstrated. Elimination of VL does not seem a
realistic goal at this point in the Americas.
Conclusion: A substantial number of descriptive observational studies have been carried
on VL in the Americas, but few controlled intervention studies. Research priorities and
current strategies should be reviewed with the aim of achieving better VL control.
VL REVIEW VERSION May 28th, 2009
Visceral leishmaniasis (VL) in Latin America is a zoonosis and is caused by an
intracellular protozoon, Leishmania infantum (syn. L. chagasi). The domestic dog is the
main animal reservoir [1–4]. Other domestic animals such as cats have been found
naturally infected with L. chagasi [5]. Foxes and other wild animals might play a role in
sylvatic transmission [6–16]. VL is a vector-born disease, and knowledge of the
characteristics of the vector population and its behavior is crucial for defining potential
control measures. The parasite is transmitted from one mammalian host to another by a
night-biting sandfly, Lutzomyia longipalpis, a 2 to 3mm long insect that is well adapted to
the peri-domestic and intra-domiciliary environment [17–21]. The distribution of Lu.
longipalpis is wide-ranging throughout Latin America -from Mexico to Argentina- [22–
34]. Other vector species have been incriminated in L. infantum transmission: Lu. cruzi
in Brazil [35] and Lu. evansi in Colombia , Venezuela and Mexico [36–39].
The disease burden of VL in Latin America is not easy to assess because most
countries lack effective surveillance systems. The number of exposed individuals is also
hard to estimate due to the focal and sparse geographical distribution of the disease [40–
42].
Control of VL in the Americas has proved challenging so far. Early diagnosis and
treatment of human cases is essential to improve the prognosis of the individual patient,
but will have limited impact on transmission if the animal reservoir is not tackled,
considering that the efficiency of man as a reservoir for L. infantum is poor [43].
Mathematical modeling suggests that vector control and vaccination of dogs would be
more efficacious than interventions targeting infected dogs such as dog culling [44].
Some experimental studies showed a decreased incidence of VL in both dogs and
children following serological screening and culling of seropositive dogs [45–47], but this
control strategy is increasingly debated [48]. Despite intensive application of this strategy
in Brazil in recent years, human VL incidence remained high [49]. The lack of
effectiveness of this culling strategy has been attributed to the low sensitivity of the
screening test, the long delays between diagnosis and culling and the rejection to this
intervention by the dog owners. Treatment of infected dogs is not an effective control
strategy as relapses are frequent, and dogs quickly become infectious again despite
VL REVIEW VERSION May 28th, 2009
clinical cure [50–52]. A controlled trial in Iran showed how the use of deltamethrine
treated dog collars reduced the risk of infection in dogs (by 54%) and in children (by
43%)[53]. Another controlled trial in Brazil showed only a modest effect on canine
seroconversion rates [54] in spite of the proven effect of deltamethrin impregnated dog
collars on vector density in the same country [55]. Vaccination of dogs would be the best
strategy, if an efficacious vaccine can be developed. At present, two canine vaccines are
registered in Brazil, but none has proven to be a tool for controlling transmission. Finally,
the sandfly vector population can be directly targeted through a variety of insecticide
delivery tools or other interventions.
Recently, an ambitious VL elimination initiative was launched by the
governments of India, Bangladesh and Nepal, aiming to reduce the annual incidence of
VL to less than one per 10,000 population at the district or sub district level by 2015 [56].
This strategy exploits recent technological developments of easy-to-use diagnostic tests,
new drugs and some evidence on the efficacy of integrated vector control. The epidemic
is thought amenable to elimination in that region because of the anthroponotic nature of
the disease, the relative confinement to 96 districts in 3 countries and because of the
historic evidence that intensive DDT spraying for malaria eradication almost eliminated
VL [57–59]. Contrastingly, in Latin America the zoonotic transmission pattern constitutes
a major constraint for such endeavor, and moreover, the efficacy of diagnostics and drugs
for VL as demonstrated in Asia cannot be readily extrapolated to Latin-America because
VL could be heterogeneous across the regions regarding clinical presentation and
prognosis.
We report a systematic review of the literature on the effectiveness of VL control
strategies in Latin-America aiming to identify key questions for better control and
research in this area. Our review is based on an evidence report that was requested by the
Pan American Health Organization to support cooperative action for neglected infectious
diseases in Latin America.
#
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No ethical approval was required for this review.
Firstly, we reviewed the epidemiological issues related to VL occurrence in Latin
America to be able to contextualize the systematic review of control interventions. We
screened titles and abstracts of 573 papers retrieved by PubMed using the key-words and
MeSH terms without limits: (visceral leishmaniasis OR Leishmania chagasi OR L
chagasi OR Kala-azar OR Leishmania infantum) AND “Americas” [MeSH], and
selected those found relevant for full reading.
The systematic literature review on VL control interventions was structured
around the following themes: 1. Diagnosis of human VL, 2. Treatment of human VL, 3.
Diagnosis of canine VL, 4. Control of the animal reservoir and arthropod vector.
We searched for English, Portuguese and Spanish–language articles in
MEDLINE, LILACS, as well as the Cochrane Central Register of Controlled Trials from
1960 to November 2008. We considered only original research, mainly but not
exclusively intervention trials, diagnostic accuracy studies and observational studies, with
scope targeted to American VL. Additional articles were obtained through citation
tracking of review articles and original articles.
We used the following Medical Subject Heading (MeSH) terms and keywords;
i. for diagnosis of human VL: For the PubMed search: (visceral leishmaniasis OR
kala-azar OR L.infantum OR L. chagasi OR L.donovani OR Leishmania infantum
OR Leishmania chagasi OR Leishmania donovani) AND (diagnostic accuracy OR
diagnostic performance OR sensitivity OR specificity OR validation) AND
“Americas” [MeSH] . For the LILACS search the key-words: leishmaniasis AND
visceral AND (diagnosis OR DAT OR dipstick) were used.
ii. for treatment of human VL: For the PubMed search the following key-words were
used: (visceral leishmaniasis OR kala azar OR L. chagasi OR L donovani) AND
(amphotericin b OR glucantime OR sodium stibogluconate OR miltefosine OR
sitamaquine OR pentavalent antimonials OR paromomycin) AND “Americas”
[MeSH]. For the LILACS search the key-words: leishmaniasis AND visceral AND
treatment were used. For the Cochrane Central Register of Controlled Trials we used
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the term visceral leishmaniasis because the search with the key-words and MeSH terms
used for the PubMed searching failed to retrieved any paper.
ii. for diagnosis of canine VL: For the PubMed search: (canine visceral leishmaniasis
OR L.infantum OR L.chagasi OR L.donovani OR Leishmania infantum OR
Leishmania chagasi OR Leishmania donovani) AND (diagnostic accuracy OR
diagnostic performance OR sensitivity OR specificity OR validation) AND
“Americas” [MeSH]. For the LILACS search the key-words: canine AND
leishmaniasis AND visceral AND diagnosis were used.
iii. Control of the animal reservoir and arthropod vector: for the PubMed search:
(visceral leishmaniasis OR Leishmania chagasi OR L chagasi OR Kala-azar OR
Leishmania infantum) AND “Americas” [MeSH] AND control.
In a next step, the titles, abstracts and if necessary the full text of the studies was
examined to identify relevant papers for the review. The inclusion criteria are listed
below.
The inclusion criteria for the papers on diagnostics were as follows: original studies
evaluating the DAT or the rK39 immunochromatographic test; clinical visceral
leishmaniasis diseases in humans as target condition; adequate reference classification;
absolute numbers of true-positive, true-negative, false-positive and false-negative
observations available or derivable from the data presented.
The inclusion criteria for treatment papers were as follows: clinical trials including
uncontrolled and retrospective studies; description of the intervention; description of case
definition; description of follow-up schedule; description of therapeutic endpoints;
description of the control group; and efficacy measure.
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The inclusion criteria for the papers were as follows: original studies evaluating any
diagnostic test for canine leishmaniasis; Leishmania infection and/or VL disease in
domestic dogs as target condition; adequate reference classification; absolute numbers of
true-positive, true-negative, false-positive and false-negative observations available or
derivable from the data presented.
The inclusion criteria for efficacy/effectiveness studies of control measures (canine
culling, impregnated dog collars, canine vaccination, insecticide spraying, insecticide
treated bed nets, environmental management) were: field trials only; main objective
directed to evaluate at least one control measure (even if there was no control group);
clear definition of the intervention under analysis; description of the period of
intervention and follow-up; description of target population; description of sampling
procedure if any; description of the randomization process if any; adequate case
definitions for asymptomatic infection or VL; definition of outcomes related to effects on
humans or dogs or sand flies; at least one effect measure; and at least one point
estimation for the magnitude of the expected effect.
Data Extraction: characteristics of interventions, study setting, study design, population
characteristics, and entomological or clinical outcomes were recorded.
$%&
VL in the Americas is characterized, as in other regions, by prolonged fever,
weight loss, hepatomegaly, splenomegaly, hypergammaglobulinemia and pancytopenia
and it is usually fatal if it is not adequately treated. However, not all leishmanial
infections lead to overt clinical disease: in Brazil ratios of 8-18 incident asymptomatic
infections to 1 incident clinical case were described [60–64]. Some studies suggest that
the susceptibility/resistance to VL disease in humans could be genetically determined
[65–70]. VL prognosis has been studied in Brazil and severe anemia, fever for more than
60 days, diarrhea and jaundice have been reported as poor prognostic factors [71]. A
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localized non-ulcerated form of leishmaniasis caused by L. infantum was reported from
Honduras in the same region where VL cases had been observed [72–74].
Canine VL is relevant both as the source of sandfly infection within the domestic
environment as well as relevant in itself because of the burden of animal disease.
Incidence and prevalence estimates of canine VL in the Americas have been reported
from several endemic foci [75–85]. However the magnitude and the specific relationship
between canine and human infections, and most importantly, the association with human
VL cases are not well understood. The maintenance of transmission in the dog population
is mainly due to infected sandfly bites but alternative transmission routes have been
described such as other vectors [86,87] and sexual transmission [86,88]. The latter routes
were invoked to explain the presence of Leishmania infection in dogs in environments
where no sandfly vectors were detected.
Brazil declared a total of 50,060 clinical VL cases between 1990 and 2006 and
this number accounts for 90% of all reported VL cases in the Americas [41,49].
However, substantial underreporting (42- 45%) of VL in the Brazilian surveillance
system has been recently documented [89]. In the past VL affected mainly the poor rural
areas in the northeast of the country, but since the 1980s, epidemics have occurred in
major cities of over 500,000 inhabitants such as Teresina, São Luis, Belo Horizonte,
Campo Grande, Natal, Araçatuba and others[90–94]. Some of these urban VL outbreaks
were attributed to the migration of families from the rural areas to the peri-urban slums
after periods of prolonged drought. Whereas the reported VL incidence in the 1980s
averaged at 1,500 cases per year, this figure increased to an average 3,362 per year
between 2000 and 2006 [49]. The disease has gradually spread south and east ward and
has been reported since 1999 from the states of São Paulo and Mato Grosso do Sul [95].
More recently, a few human cases have been reported in Brasilia, the federal capital
where the canine infection prevalence is around 18% affecting dogs in poor peripheral
settlements as well as high-income neighborhoods. Human VL outbreaks have also been
reported from Honduras [96], Venezuela [83], Colombia [78], Paraguay [97] and
Argentina [98]. Sporadic and/or import human or canine cases were described in Chile
[99], Ecuador [100], Bolivia[101], Mexico[102], Central-America and the
Caribbean[28,103], and French Guyana[104].
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While the increasing trend in VL in Latin-America has largely been attributed to
the rural exodus, the emergence of HIV could be another risk factor. So far the
contribution of the HIV-epidemic to the VL burden has been less than was feared
initially, as the number of reported cases of VL with AIDS stayed low. Brazil reported
176 HIV-coinfected VL cases [105] in spite of a significant number of asymptomatic coinfected
individuals [106]. Risk factors for the development of human disease are only
partially understood. In Latin-America, VL primarily affects children, and those with
malnutrition are at higher risk [107–109]. Being a young male and the presence of
animals in the neighborhood were identified as risk factors for VL in one case-control
study [110]. Dog ownership and socioeconomic factors could also be linked with a higher
risk of asymptomatic infection – measured by positive leishmanin skin test [111,110].
Poor urban services and sanitation have also been associated with higher VL risk. After
controlling for age, crowding, and the background incidence of VL in the area where the
subjects lived, the risk of acquiring the disease was found to be significantly higher for
those who lived in houses with an inadequate sewage system and those who had no
regular waste collection [112]. Associations between VL incidence and residence in an
urban slum or in areas with green vegetation have also been reported [113,114].
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VL is a fatal condition if not treated and the currently available drugs are quite
toxic. As its clinical manifestations are non-specific, diagnostic tests are needed that are
highly sensitive as well as very specific [115]. An effective control strategy requires
moreover a user-friendly and robust test that can easily be used in primary care settings.
Definite diagnosis of VL is classically established by the microscopic demonstration of
the amastigote form of the parasite, in aspirates from spleen, bone marrow or lymph
nodes. The diagnostic sensitivity and specificity of splenic aspirates is excellent (93–
99%), but the technique carries a risk of potentially fatal internal bleeding in
approximately 1/1000 procedures, which prevents its large-scale use in primary care
settings. Bone marrow and lymph node aspiration are safer but less sensitive - 53–86%
and 53–65% respectively- and equally require technical expertise for aspiration and
Key questions for control
1. How to establish or improve the current VL reporting systems?
2. How to establish the cross-border veterinary surveillance of the dog
populations?
3. How to better document vector distribution and vector behaviour?
4. How to improve the health system capacity for the detection of Leishmania coinfection
in HIV/AIDS patients?
Questions for research
1. What are the risk factors of VL infection and disease at individual and at
community level in the current epidemic context?
2. What is the minimal protocol to assess risk factors in each transmission
scenario and how to make the results from different scenarios comparable?
3. How to document the frequency of asymptomatically infected humans and dogs
individuals in endemic areas and what is their role in transmission?
4. What is the role of sylvatic animals for maintenance of transmission and
spreading to new areas?
5. What is the role of transmission routes such as blood transfusion, organ
transplantation and hemodialysis in humans or sexual transmission in dogs?
6. How to assess hot spots of high transmission focus in space and time so to be
useful for the prioritization of control interventions?
7. What is the role of permissive vectors in transmission?
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reading which is usually not available in primary care settings [115]. Several
immunological tests have been developed for the diagnosis of VL, but all suffer from two
major drawbacks. Firstly, antibodies remain detectable up to several years after
successful treatment, precluding the diagnosis of relapse. Secondly, a significant
proportion of healthy people living in endemic areas are positive for anti-leishmanial
antibodies because of asymptomatic infections. Therefore, antibody tests must always be
used in combination with a standardized clinical case definition for VL diagnosis.
Several antibody detection assays are used in current practice. The
Immunofluorescent Antibody Test (IFAT) uses whole promastigote forms of L. donovani
or L. infantum. The Enzyme Linked Immunosorbent Assay (ELISA) uses a crude soluble
extract of these parasites, or recombinant antigens (a.o. rK39). However, the relevance of
IFAT or ELISA as a test for human VL is limited in the primary care setting, because
they require a well equipped laboratory and skilled personnel. Two antibody detection
tests are considered as appropriate for the diagnosis of VL in field conditions: the Direct
Agglutination Test (DAT) based on whole promastigotes of L. donovani or L. infantum
and the rK39 immunochromatographic test (ICT)[116]. The DAT is a semi-quantitative
test performed in microtitre plates in which increasing dilutions of patient’s serum or
blood is mixed with stained killed promastigotes of L. donovani or L. infantum.
Agglutination results have to be read visually after 18 hours of incubation at ambient
temperature. The test has been extensively validated in most endemic areas. The DAT is
simpler than many other serological tests but requires cool storage (2-8°C), some
equipment, well-trained laboratory technicians and regular quality control. Freeze-dried
DAT antigen is more robust than liquid antigen [117]. rK39 is a 39-amino acid repeat that
is part of a kinesin-related protein of L. chagasi that is highly conserved amongst
viscerotropic Leishmania species. rK39-based ELISA showed excellent sensitivity (93 -
100%) and specificity (97-98%) in numerous VL endemic countries. An ICT or ‘dipstick’
format was later developed to make the test more suitable for field use. rK39 ICTs are
easy-to-perform, reproducible, rapid (10-20 minutes) and affordable (approx. US$1-
2/test). The VL Elimination Initiative in the Indian subcontinent has selected the rK39
ICT in combination with a clinical case definition as the basis for treatment. Although
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performance of both tests is similar in terms of sensitivity and specificity, rK39 is more
suitable as a diagnostic test in the primary care setting.
A recently developed latex agglutination test which detects the Leishmania
antigen in the urine of infected patients, is easy to perform, gives rapid results and has a
high specificity [118]. Because of its variable sensitivity, lack of objectivity in
interpretation, requirement of refrigeration of the reagents and need to boil the urine,
application of this test in the field is difficult [119]. The detection of parasites in the blood
or organs by culture or molecular techniques (PCR) is more sensitive but these
techniques remain restricted to referral hospitals and research centres, despite current
efforts for simplification. PCR seems to be a valuable marker for infection [120].
We concentrated our systematic review of diagnostics for human VL in Latin-
America on the two diagnostic tests that are considered suitable for use in the primary
care level. A Medline search generated 77 papers, and LILACS 167. After screening the
titles and abstracts of those papers for evaluations of the DAT or rK39 in human VL (see
inclusion criteria), we retrieved eight original papers (See Table 1). We discuss them in
comparison with results of a meta-analysis by Chappuis et al. [121].
I. Direct agglutination test (DAT) for VL: Andrade et al (1988) were the first to
report a proof-of-principle evaluation of the DAT in Brazil [122]. A recent meta-analysis
of the DAT performance showed sensitivity and specificity estimates of 94.8% (95%CI:
92.7-96.4) and 97.1% (95%CI: 93.9-98.7), respectively [121]. The performance of DAT
was neither influenced by the region nor by the Leishmania species. However, this metaanalysis
included only two studies from Latin –America, both from Brazil, and both with
(too) small sample sizes. Garcez et al (1996) reported 100% sensitivity on 16
parasitologically confirmed VL cases and 98.3% specificity on a mixed group of 65
healthy endemic controls and patients with other diseases [123]. Schallig et al (2002)
reported a sensitivity of 100% (n= 21 confirmed VL) and a specificity of 100% on 19
healthy controls and 42 samples of patients with other diseases [124]. More recently,
Teran-Angel et al (2007) reported 100% sensitivity on 30 confirmed VL patients in
Venezuela and 100% specificity on 39 controls [125]. Junqueira Pedras et al (2008)
compared the freeze-dried DAT (FD-DAT) and a locally produced DAT with 3 other
serological tests (rK39 ELISA, ELISA-L.chagasi and IgG-IFAT) and concluded that the
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FD-DAT was the most efficient, with 96.6% sensitivity (n=88) and 98.1% specificity
(n=105)[126]. All reported studies are laboratory-based, no large prospective clinical
studies evaluating the DAT have been reported from the Americas.
II: rK39-based immunochromatographic test (ICT): Delgado et al (2001)
evaluated the rK39 ICT in Venezuela, reporting 87.8% sensitivity (36 positive out of 41
confirmed VL) and a specificity of 100%. The deficit in sensitivity was attributed to the
fact that the false negative sera had been kept at -70° for more than 10 years [127]. A
meta-analysis of 13 studies of the rK3 ICT by Chappuis et al (2006) showed sensitivity
and specificity estimates of 93.9% (95%CI: 87.7-97.1) and 95.3% (95%CI: 88.8-98.1),
respectively, with some regional variation [121]. This meta-analysis included only two
studies from Latin-America [124,128]. De Assis et al. later confirmed the excellent
diagnostic performance of rK39 ICT in a prospective study in Brazil, with 93%
sensitivity on 213 confirmed VL cases and 97% specificity on 119 controls (i.e. clinical
suspects with confirmation of other diseases)[129]. On this basis, it seems that rK39
based diagnosis can be adopted in clinical practice, though it is safe to evaluate each
new brand put on the market thoroughly in proper phase-3 designs.
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Canine diagnosis
Seventy-seven papers were retrieved from Medline/PubMed search and 11 of
them were considered relevant. The LILACS database search retrieved 26 papers of
which 2 were considered relevant, but 1 was already obtained from the PubMed database.
In total 12 papers were included in the review.
We reviewed evaluations of the following serological tests for canine VL: IFAT,
ELISA, dot-ELISA, DAT, and rK39 ICT. IFAT is the test adopted by the Brazilian
Ministry of Health for its dog screening-and-culling campaigns. Published estimates for
sensitivity range from 72-100%, for specificity 52-100% (see Table 3). The moderate
sensitivity and specificity of this test, the long turn-around time between sample taking
and culling, and the complexity of its execution have been invoked as one of the reasons
for the low effectiveness of the culling campaign. Several ELISA tests have been
evaluated, with assays based on homologous antigens usually showing higher sensitivity.
Key questions for control
1. How to establish reliable and user-friendly diagnostic algorithms for VL for
use in peripheral health centers?
2. How to define asymptomatic infected individuals and how to manage them?
3. How to assure the quality of available VL rapid diagnostic tests?
4. How to improve clinician’s awareness about the possibility of Leishmania coinfection
in HIV/AIDS cases?
5. How to discriminate between recent infection from reactivation in the context
of HIV co-infection or other immunosuppressive conditions?
Questions for research
1. What can be the contribution of novel (molecular) parasite detection tests to
clinical diagnosis and infection detection in humans?
2. What is the performance of antibody assays in HIV-Leishmania co-infections?
3. What is the performance of antibody assays in patients from areas with
sympatric circulation of parasites causing cutaneous leishmaniasis or
Trypanosoma cruzi?
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Evans et al (1999) showed a higher sensitivity of ELISA compared to IFAT and pleaded
for a revision of the screening policy [130].
Recently more “user-friendly” diagnostics as the DAT and a canine version of the rK39
dipstick test were evaluated for canine diagnosis with good results. For the freeze-dried
DAT sensitivity ranged from 85-100%, specificity 89 – 100% and for the rk39 ICT
sensitivity ranged from 72-96%, specificity 62 – 100%. The main advantage of these
rapid tests would be to shorten the delay between diagnosis and culling/treatment.
However, the reported estimates of sensitivity in the above studies depend on the type of
dogs included in the “true cases” group with higher sensitivity in symptomatic than in
asymptomatically infected dogs, and unfortunately, several evaluations failed to include
an adequate sample of asymptomatically infected dogs for sensitivity estimation. The
sensitivity of the test in asymptomatic dogs is crucial for a control strategy, as those dogs
are infectious, and should be targeted by the campaign.
In this respect, sensitive antigen detection tests as PCR might become a relevant
marker of infection in the future offering the additional advantage that they can still be
used in vaccinated dogs that will be serologically positive because of the vaccine.
However, Quinnell et al (2001) showed in a longitudinal study of naturally infected dogs
how the sensitivity of PCR was high early after infection but declined to 50% thereafter.
The sensitivity of serology also varied with time, being lowest at the time of infection but
clearly superior thereafter (93-100%). They concluded that PCR was most useful for
detection of active disease, and considered serology as more adequate for the detection of
infection [131].
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Human treatment
Thirty-nine papers were retrieved from Medline/PubMed search and four of them
were considered relevant. The LILACS database search retrieved 42 papers of which 24
were not available from the PubMed database. Three of those 24 studies were considered
relevant, one of them, was previously identified through the PubMed search. One paper
was identified through specific author´s name searching in PubMed. The Cochrane
Central Register of Controlled Trials search retrieved 103 trials, three of them were
conducted in the Americas but all were also identified through the PubMed and LILACS
searches. Finally, a total of seven papers were included for review;[132–138].
Three papers were excluded from further analysis, one because it was a second
publication on the same trial [135], one for being a retrospective study with
heterogeneous therapeutic interventions with meglumine antimoniate and case definition
fragility [132], and one paper because of being a case-control study focused on prognostic
factors more than therapeutic response to a specific intervention [134]. The flow for the
selection of the reviewed studies appears in figure 1.
Dietze et al., 1993 reported an open-label dose-escalating trial with amphotericin
B colloidal dispersion (Amphocil®) in two small groups of patients who showed similar
cure rate suggesting that the 7 days regimen was as effective as the 10 days regimen
Key questions for control
1. What is the most cost-effective diagnostic strategy for a screen-and-treat or screenand-
cull campaign? Novel screening strategies based on combined, parallel or
sequential use, of current available tests need to be validated.
Questions for research
1. How to distinguish an antibody response due to natural infection from that
produced after vaccination in dogs?
2. What can be the contribution of novel, molecular, parasite detection tests to clinical
diagnosis and infection detection in dogs?
3. What is the value of the current diagnostic tests in terms of dog infectivity for
sandflies?
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[137]. In 1995 the same authors reported another open-label trial with Amphocil® with a
shorter regime of 5 days, observing an episode of relapse [138]. Berman et al., 1998,
reported the results of an open-label phase II trial with three therapeutic regimens
consisting of liposomal amphotericin B 10, 14 or 20 mg/kg total dose. The reported
outcomes were cure, failure and relapse and the follow-up period was of six months. This
paper suggested that the lower 10mg/kg total dose was less efficacious than the higher
20mg/kg total dose. The small number of subjects did not allow for more detailed
analysis of the prognostic factors [133]. Dietze et al., 2001, reported the results of an
open-label dose-escalating safety and efficacy trial with sitamaquine. In this study
sitamaquine was not efficacious for the treatment of VL in young adults. Severe adverse
events described as renal toxicity lead to trial interruption when using the higher dose of
3.25mg/kg/d [136].
It is relevant to note that the four selected trials were conducted in Brazil and that
no phase III clinical randomized controlled trial was so far reported from the Americas.
The overall impression in the region is that amphotericin B is a very active drug but the
lack or appropriate trials testing its efficacy and the absence of evidence on meglumine
antimoniate efficacy, the routinely recommended drug for treatment of VL in the
Americas, is very preoccupying. Nowadays, one controlled phase II clinical trial with
miltefosine is ongoing and two large randomized controlled trial with liposomal
amphotericin B, amphotericin B deoxycholate and meglumine antimoniate are expected
to initiate recruitment in 2009 in Brazil. The summarized characteristics of the four
selected studies described above are demonstrated in table 2.
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Vector and animal reservoir control
The control of VL is complex and frequently involves combined interventions.
The effects of those interventions in terms of human and /or canine disease and infection
or directly on sandfly density are not clearly defined. The Brazilian Control Program
recommends a combined intervention based on parameters of human epidemiology,
sandfly distribution and canine infection surveillance. The main interventions that have
been applied in Brazil are canine culling and vector control with insecticide spraying. In
spite of this approach, the disease burden remains high and problem-based research is
needed to improve results. Other Latin American countries, where the disease burden is
lower than Brazil have implemented similar interventions with less intensity. Insecticide-
Key questions for control
1. What is the current standard of care for VL treatment in the Americas?
2. What is the case for combination therapy for VL in the Americas?
3. What is the standard of care in VL/HIV co-infection?
Questions for research
1. What is the current efficacy of pentavalent antimonials, amphotericin B
deoxycholate and the liposomal formulations, miltefosine and drug
combinations for VL treatment in the Americas?
2. Are there more efficacious, safer, and simpler therapeutic schemes for VL than
the current ones?
3. Can a clinical prognostic score for treatment failure be developed to identify
those cases most in need for intensive care?
4. Is there a cure marker for VL?
5. What is the role of non-parasite targeted drugs such as immunomodulators,
antibiotics and others in VL treatment?
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impregnated collars for dogs and canine vaccination are not currently recommended as
public health control measures [139]
Seventy-one papers were retrieved from PubMed using the search strategy cited
above. After reading the titles and the abstracts and handsearching reference lists for
related papers, fourteen were selected for full text reading because the main subject was
at least one intervention for control VL [45,54,140–147,147,147–151].
Magalhães et al, (1980) published a retrospective –non controlled- study on the
impact of a combined intervention consisting of human VL case treatment, culling of
seropositive dogs and insecticide spraying with DDT in 19 municipalities of the Rio
Doce Valley in the State of Minas Gerais, Brazil and reported the disappearance of
human symptomatic cases after 15 years of application of this strategy. The main
limitations of this study were: i) the lack of information on the intensity and the
periodicity of control measures, ii) the low sensitivity of the complement fixation test to
detect canine infection, iii) the passive reporting of human VL cases as the data source
for evaluating the impact on human population and iv) the human and canine population
exposed to the control measures was not reported. The insecticide used, DDT, is not
available anymore for the purpose of VL control [140].
Dietze et al (1997) reported a field trial of dog screening and culling, based on
twice yearly screening with a previously validated DOT-ELISA. The trial was conducted
in three valleys of a rural area of the State of Espirito Santo, Brazil. The intervention was
conducted in two valleys and the control (no intervention) in a separate valley. The initial
seroprevalence in humans and dogs were similar between intervention and control
groups. The outcome measures were human and dog seroconversion rates. This study
failed to demonstrate a positive effect of dog culling as a control measure on human and
dog infection. At 6-months there was a 16% difference of seroconversion rate in dogs
(36% in the intervention group versus 52% in the control group), but this difference was
not significant [141]. The limitations of this study were its non-randomized design, a low
number of clusters for comparison (2:1), 26.5% loss to follow-up in humans because of
drought-related migration and the small sample of domestic dogs (140 dogs). Canine loss
to follow-up was not described.
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Braga et al (1998) reported the comparison of two strategies of dog screeningand-
culling: one based on screening by ELISA was compared to screening based on
IFAT as routinely recommended by the National Control Program. The main difference
consisted in the lag times after blood sampling (7 days for ELISA test and 80 days for
IFAT). The trial was conducted in a rural area of Northeastern Brazil where 28
communities were systematically allocated to one of the two groups. The outcome
measure was the canine seroprevalence detected through both diagnostic methods 10
month after the intervention. The main result was the higher reduction of canine
seroprevalence in the ELISA group probably caused by a combination of the effects of
faster dog removal plus higher sensitivity of the ELISA test. The main limitations of this
study were i) that the baseline seroprevalence was significantly different between the
groups and ii) the impossibility to disentangle the effect of the time to dog removal from
the effect of the lower sensitivity of the IFAT test. This paper revealed that the Brazilian
Program was using a test for dog detection with low sensitivity and that the time to dog
removal in the routine program was too long [142].
Ashford et al (1998) reported a controlled intervention trial of seropositive dog
removal in a endemic area of Bahia, Brazil. The intervention area was subjected to
screening with FAST-ELISA and removal of seropositive dogs, in the control area no
intervention was carried out. The primary outcome was annual dog seroconversion rate
and dog seroprevalence during four years (1989 to1993) and the secondary outcome was
the human VL pediatric cases detected through records of health units in the area. The
authors claim a significant reduction of dog seroconversion rate in the intervention area
as compared to the dog seroconversion rate in the control area, and a significantly lower
incidence of pediatric cases of VL in the intervention area. The main limitations of this
study were the non-randomized design; the low number of clusters in the comparison
(1:1); the different baseline prevalence of dog infection between groups; the high (40%)
loss to follow-up in the intervention group after one year; the incomplete removal of
seropositive dogs; the lack of information on the control group related to sample size,
loss to follow-up, and the dog population replacement during the study [45].
Paranhos-Silva et al (1998) described the follow- up of several clusters of
seronegative dogs in Jequié, Bahia State, Brazil, an endemic area for VL. The initial
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prevalence of infection among 1681 dogs was 23.5%. After serological screening every
six months for 18 months and removal of those that seroconverted, the annual incidence
rate of infection was 6.55 cases/100dog-years. Notoriously the risk was not homogeneous
among clusters and the clusters in the downtown neighborhood had lower risk. The
migration of dogs between clusters was 2.3cases/100dog-years. The limitation of this
study was that the intervention of dog culling was not directly evaluated because de main
objective was to detect the pattern of dog migration, but the study remains relevant
because confirming the heterogeneity of the risk and the importance of dog movement as
potential problems for any control program dealing with the canine reservoir [143].
Da Silva et al (2001) reported a phase III vaccine field trial in seronegative dogs
screened with IFAT and FML-ELISA and exposed to fucose-mannose-ligand vaccine in
three subcutaneous doses at 21 day intervals. Control arm was treated with saline
placebo. Endpoints were symptomatic VL or death, seroconversion rates in FML-ELISA
and conversion of leishmanin skin test composed of crude L. donovani antigen. Followup
evaluations were performed at 2, 7, 13 and 24 months. A significant difference in the
three endpoints was observed during the trial. The overall efficacy to prevent
symptomatic VL disease was 75%. The main problems of this study were the
impossibility of accurate evaluation of the infection rate because the vaccine product and
probably the repeated leishmanin doses interfered with the serological response with
more than half of control subjects showing positive FML-ELISA tests. Other drawback
was the lack of random allocation of individuals and baseline data on relevant dog
characteristics such as age, sex, time of exposure to transmission area [152]
Giffoni et al (2002) reported the effect of application of a 65% permethrin spot-on
formulation on canine VL infection and sandfly abundance. A decrease of canine VL
prevalence was observed in the intervention area compared with increased prevalence in
the control area. No effect was observed on sandfly population. The main limitations of
this study was the non-comparable baseline prevalence between intervention and control
areas, the low sensitivity of the test used to define infection (IFAT) and the significant
losses during follow-up when some dogs died and were excluded from the analysis[150].
Feliciangeli et al (2003) described a controlled trial of pyrethroid (-cyhalothrin)
indoor spraying every 5 month and organophosphate (fenitrothion) ultra-low volume
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spatial fogging around the houses twice a month for ten months in one intervention
compared to one control area. The main vector captured was Lu. longipalpis. A
significant decrease of sandfly abundance was observed indoors in the intervention area.
The residual effect of indoor spraying was no longer than 3 months on both cement and
oil painted walls. The effect of spatial fogging was discrete on the outdoor sandfly
population. Main limitation of this study was the small number of houses observed and
the specific construction style of those houses in complete cement, plastered and oilpainted
walls and zinc roofs. Then, the external validity of obtained data from that
scenario could be low [144].
De Oliveira et al (2003) reported the evaluation of routine combined control
measures of seropositive dog-culling and insecticide spraying during six years. The
intensity of the application of control measures correlated with human VL incidence, the
coverage of canine surveys, the number of canine surveyed and the number of buildings
submitted to insecticide spraying. The main drawbacks of this study were that researchers
work with secondary source data that were not specifically collected for research
purposes and the lack of a control area without intervention for comparison [151].
Reithinger et al (2004) reported a controlled field trial to evaluate the
effectiveness of insecticide impregnated collars to prevent infection detected through
serological tests or DNA detection by PCR assay in one intervention compared to one
control area. The authors failed to detect a significant difference between groups in the
incidence of new infections but they demonstrated a significant reduction of antibody
titers in the collar protected dogs. Main limitations of this study were the one to one
comparison, the non comparable baseline prevalence of VL infection between groups, the
high rate of loss of follow-up, the high frequency of collar loss and the migration of dogs.
Mathematical modeling using the results obtained in this study suggests that dog collars
would be a better alternative than dog culling [54].
Moreira et al (2004) reported the incidence rates of canine Leishmania infection
in a cohort of dogs submitted to an optimized culling strategy consisting of: (i) ELISA
screening of serum samples; (ii) shortening of the time interval from serodiagnosis to
removal of dogs; (iii) screening a high proportion of the dog population. They
demonstrated that the incidence of canine infection remained stable through 2.5 years of
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observation under this optimized strategy. A high dog replacement rate was observed and
this replacement involved susceptible puppies and already infected dogs. The main
limitation of this study was the uncontrolled design that precluded the possibility of
detecting the impact of dog culling, taking into consideration that without the
intervention the incidence could have been higher than the one observed [147].
Courtenay et al (2007) reported the barrier effect, the 24-h mortality rate and the
human landing rates of Lu. longipalpis in households using deltamethrin-impregnated
bednets compared with households using untreated bednets. The study described a 39%
increase in barrier capacity of the impregnated bed nets, 80% reduction in sandfly landing
rates on humans and 98% increase in the 24-h sandfly mortality rates. The study was
done under field conditions with a small number of observations during a very short
period of exposure to the treated bednets (three consecutive days) and the residual effect
was not measured. However the impressive results indicate the need to explore this
intervention further considering that this intervention could bring an additional benefit in
areas where malaria is also endemic [149].
Costa et al (2007) reported a randomized community intervention trial to compare
the effect of four strategies on human VL, as follows: 1. spraying houses and animal pens
with pyrethroid insecticide; 2. spraying houses and eliminating seropositive dogs; 3.
combination of spraying houses and animal pens plus eliminating seropositive dogs; and
4. spraying houses only as the reference comparator. The outcome was evaluated by
measuring incidence of seroconversion in humans six months after the application of
interventions. The results indicated a positive effect of canine removal on incidence of
leishmanial infection in men but surprisingly, the combination of dog culling plus
outdoor spraying of peridomestic animal shelters failed to demonstrate any effect. The
main limitations of this trial were the non comparable baseline VL incidence between the
house spraying group and the other three groups, the high percentage of loss to follow-up
of susceptible individuals (44%); the suboptimal sensitivity and specificity of the method
to measure seroconversion (crude antigen-ELISA). The relevance of this study is that it
constitutes the first attempt to measure the effect of combined interventions on human
VL incidence [153].
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De Souza et al (2008) reported a randomized community intervention trial to
compare the effect of (i) pyrethroid insecticide spraying; (ii) pyrethroid insecticide
spraying plus culling of seropositive dogs with (iii) no intervention. The interventions
were maintained for two years and outcomes were registered every year, insecticide
spraying was performed every 6 months. Although a lower incidence was observed in the
groups submitted to interventions and that reduction was more intense after two years, the
study failed to detect statistically significant differences [148].
The summarized characteristics of the studies described above are detailed on
Table 4.
The present review of the main topics related to VL control in Latin America
revealed that a lot of work remains to be done in order to clarify the dynamics of
Leishmania transmission in human, canine and arthropod vector populations. The exact
magnitude of the problem remains largely unknown and the disease incidence is only
known approximately in one country in the region. The determinants of human L.
Key questions for control
1. What is the most cost-effective control strategy for VL?
2. How to conduct a valid impact evaluation?
3. Can general support measures (nutritional rehabilitation and housing
improvement) be targeted to VL endemic areas?
4. What is the potential impact of current dog vaccines on transmission?
5. Could KAP studies help to improve the impact of the interventions?
Questions for research
1. What are the determinants of dog infectiousness for the sandfly vector?
2. What are the determinants of dog susceptibility to infection?
3. What is the efficacy of current dog vaccines to prevent disease in dogs and to
reduce infectiousness for the sandfly vectors?
4. What is the effectiveness of insecticide impregnated dog collars to prevent human
and canine infection?
5. What is the efficacy/effectiveness of alternative vector control devices (insecticide
treated nets, curtains, etc) in the prevention of VL?
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chagasi infection are also poorly understood with the exception of the nutritional status
in young children. Risk factors for symptomatic disease development are not clearly
understood and all the factors currently under investigation have not shown strong
associations in spite of strong biological plausibility to explain their links with disease
risk. A big coordinated effort has to be done to determine the main risk factors for disease
development and the possible interactions among them.
In spite of this lack of knowledge a series of control interventions are practiced
with different intensity in endemic areas. In humans, specific diagnostic assays and drugs
are used, dog populations are subjected to screening-and culling and vector control
measures are applied to variable extent. However, the increasing number of VL cases
observed in Brazil and the spread of VL transmission to previously not affected areas
raises doubts about the impact of ongoing control measures.
Our systematic review of tools for human diagnosis revealed that for symptomatic
VL cases the rK39 ICT seems to be ready to use in the field in order to establish its
effectiveness with clear advantages over the traditional IFAT or ELISA based tests. The
DAT assay has shown similar diagnostic performance but is not as user-friendly as the
rK39. The research priorities in this field should be geared towards diagnostic accuracy
studies in large prospective trials (phase-3) and to study diagnostic performance in
specific groups such as HIV co-infected patients.
Human treatment is the most neglected aspect of all available interventions
against VL. Even if humans may be of lesser relevance for transmission in terms of
reservoir [43], efficacious and early treatment is of the utmost importance to reduce the
case fatality rates caused by VL. Current treatment practices are based on rather weak
scientific evidence mainly composed of specialist opinions. It is worrisome that case
fatality rates remain high and probably increasing, at least in Brazil, and the current
challenge is to demonstrate the efficacy/effectiveness of the available drugs. The research
priorities include well-designed clinical trials with pentavalent antimonials, amphotericin
B deoxycholate and the liposomal formulations, miltefosine and drug combinations.
Although the resistance to antimonials observed in India is less relevant in Latin
America, drug combinations are attractive because their potential for shortening
treatment schemes and reduction of toxicity. Clinical factors associated with treatment
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failure should be studied to contribute to the development of a prognostic score that
allows early interventions to reduce case fatality rates [134,154].
Control interventions targeting the dog reservoir for culling/treatment require
accurate assays able to detect the asymptomatic infections as well as the symptomatic
dogs. Validating such tests is no easy task, as there is no adequate gold-standard for the
diagnosis of asymptomatic infection. PCR-assays seem to be very attractive but
estimating their accuracy and reproducibility still constitutes a research priority.
Moreover, novel screening strategies based on combined, parallel or sequential use of
current available tests needs to be validated. Another challenge faced by canine diagnosis
is related to the distinction of positive serology results produced by natural infection and
the positive tests induced by currently registered vaccine products. The development and
proper validation of tests with capacity to discriminate both phenomena are crucial to
avoid interference with concomitant interventions including dog culling and vaccination
in the same area. Furthermore, the study of the determinants of dog infectiousness for the
sandfly vector is essential to define the best culling strategy [155] and the determinants
of dog susceptibility to infection [156] is crucial for the design of canine vaccine trials.
Many control interventions have not been submitted to an appropriate evaluation mainly
because of the lack of standardized techniques and protocols to measure their impact on
relevant outcomes.
Some of the problems with the design of the community intervention trials we
reviewed are related to the lack of accurate and easy-to-use diagnostic methods to define
the relevant outcomes in the human and canine population. Furthermore, the definition of
a control group is challenging because of an obvious ethical dilemma. The heterogeneity
of disease transmission within the study area often generated imbalances in the baseline
comparisons among groups and the random allocation process is also complex because of
the mobility of the human, canine and vector population. Most of the reported community
trials used a too limited number of clusters for comparison (usually a one to one
comparison). In spite of all those limitations a relevant number of reports could be
reviewed in detail, showing no strong evidence for a significant impact on VL
transmission for any of the interventions reviewed. Canine culling seems to be the less
acceptable intervention at community level for obvious reasons and has low efficiency
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due to high replacement rate of eliminated dogs with susceptible puppies and other
cultural obstacles [51,143,146,157,158]. Vector control interventions seem better
accepted by the affected populations but knowledge, attitudes and practices (KAP)
studies on this issue are lacking. Mathematical modeling suggested encouraging efficacy
for these vector control interventions, though they need further study and some
technological issues need being solved. The first challenge is the choice of the best way
to deliver the insecticide, i.e. through house and animal shelters spraying, dog
impregnated collars, bed nets for human use, etc. Better knowledge of vector seasonality
and behavior is required for proper timing of these interventions [29,144,159–161]. The
current evidence indicates that spatial fogging is useless and that the residual effect of
house wall spraying is very short [144,162]. Insecticide impregnated collars seem to have
a longer residual effect [55] and theoretical advantages over the other methods and should
be studied in larger and well-designed controlled trials. The potential emergence of
resistance to insecticides should also be considered for the long-term planning of any
vector control intervention [163].
Certainly, canine and human vaccine development needs to be prioritized in spite
of questions on long-term sustainability of such interventions [152,164–168]. The dog
vaccines already registered in Brazil seem to have some protective effect against canine
VL but non of them were properly evaluated to define their role as control measures
against human VL. Such evaluation is challenging as field trials should include relevant
canine endpoints, related to dog infectiousness for the sandfly vector, as well as relevant
human endpoints, that include symptomatic and asymptomatic infections in order to
obtain precise estimates of the vaccine effect on transmission rates. Human vaccine
development is expected to take at least years to obtain efficacious and safe candidates
for clinical trials. Furthermore, the surrogate markers of the desired protective effect are
not well understood and the definition of target population for such products will be a
matter of intense debate.
Finally, the role of sylvatic reservoirs in some relevant VL transmission scenarios
deserves more specific research. The possibility of controlling the canine enzootic brings
up the question on the role of peridomestic synanthropic animals such as foxes,
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marsupials and rodents as potential competent and efficient reservoirs to perpetuate the
VL transmission [169].
Cost-effectiveness studies are essential to formulate a control program but cannot
be done before the adequate demonstration of the effectiveness of available interventions.
However, the researchers and the control program officers should be aware of the need of
costing of interventions in order to facilitate proper economic evaluation, an essential part
in the decision-making process to translate the scientific results into policy and practice.
Last but not least, a preventive strategy that deserves more attention is the use of
nutritional support for children in endemic areas to reduce the risk of disease
development and improve the prognosis of symptomatic cases. In countries such as
Brazil, where the government has put the elimination of hunger as a political priority, the
targeted application of such nutritional support in VL risk areas would be an interesting
and probably cost-effective intervention from a society perspective. Similarly, schemes
for the improving of housing and waste management as well as other general measures
involving active community participation should be encouraged and could be studied by
qualitative research methods [170].
Evidence suggests that improved VL control in the Americas is possible if
interventions with known effectiveness would be applied in a more structured way. The
elimination of zoonotic VL in Latin America is not yet a realistic goal taking into
consideration the complexity and diversity of its transmission scenarios, the scientific
knowledge gaps and the lack of adequate and properly validated interventions. The
definition of research priorities is essential to surpass the current difficulties and the
revision of current control strategies is imperative to avoid misuse of economic and
human resources for health interventions.
Acknowledgments
This review has financial support from BIREME/OPAS/OMS. Authors thank to Ms.
Anne Marie Trooskens for her assistance with the bibliography, Dr. Daniel Salomon and
Dr. Ana Rabello for reviewing the manuscript.
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Figure 1. Flow of Included Treatment Studies
Potentially relevant studies
identified and screened for
retrieval (n=40 from Pub Med;
n=42 from LILACS)
Studies excluded from PubMed search (n=35). 13
case-reports, 9 reviews, 5 focused on
epidemiological, 4 focused on cutaneous
leishmaniasis, 2 focused on diagnostics, 1 focused
on in vitro drug susceptibility, 1 no abstract
available
Studies retrieved for more
detailed evaluation (n=7), 5 from
PuBMed, and 2 from LILACS
Potentially appropriate studies to be
included in the systematic review
(n=4)
Studies included in the systematic
review (n=4)
Studies excluded, with reasons (n=3) 1 redundant
publication, 1 retrospective study with
heterogeneous intervention, and 1 focused mainly
on prognostic factors other than treatment.
Studies excluded from LILACS search (n=40). 13
case-reports, 2 reviews, 6 focused on epidemiology,
5 guidelines, 4 focused on diagnostics, 7 focused on
basic science aspects , 1 no abstract available.
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Table 1. Main characteristics of diagnostic accuracy studies reporting on tests for human visceral leishmaniasis in Latin America
Country Type of
study
Diagnostic
test
Reference test Number of
confirmed VL
Sensitivity Number of
controls
Specificity Reference
Brazil Phase-2 DAT Not described 33 94% - 173 OD
- 178 HEC
- 100 %
- 100 %
[171]
Brazil Phase-2 DAT Parasitology or
improving after
antimonial
treatment
16 100% - 102 OD
- 105 HEC
- 100 %
- 100 %
[123]
Brazil/
other
Phase-2 FD-DAT Parasitology 36 100% - 42 OD
- 19 HEC
- 100 %
- 100 %
[124]
Venezuela Phase-2 FD-DAT Parasitology 30 100% - 20 OD
- 19 HEC
- 100 %
- 100 %
[125]
Brazil Phase-2 FD-DAT Parasitology 88 96.6% - 85 OD
- 20 HEC
- 97.6 %
- 100 %
[126]
Venezuela Phase-2 rK39 ICT Composite
reference *
41 87.8% - 76 OD - 100% [127]
Brazil/
other
Phase-2 rK39 ICT Parasitology 36 85.7% - 42 OD
- 19 HEC
- 80.9 %
- 84.2%
[124]
Brazil Phase-2 rK39 ICT Parasitology 128 90% - 50 OD
- 10 HEC
- 100 %
- 100 %
[128]
Brazil Phase-3 rK39 ICT Parasitology 213 93% - 119 OD - 97% [129]
* FD-DAT : Freeze-dried DAT
** Composite reference: at least 2 positive tests out of 4 (bone marrow, IFAT, CIEP,Western blot)
*** OD : patients with other, potentially cross-reacting infectious diseases
**** HEC: Healthy Endemic Controls
Phase 2: Case-Control design, laboratory based study on banked serum samples; Phase 3: Prospective clinical study, recruiting representative patients
(all presenting with febrile splenomegaly)
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Table 2. Main characteristics of selected studies reporting treatment of human visceral leishmaniasis in Latin America
Country Type of study Number
of
subjects
Mean
patient
age
(years)
Treatment
interventions
Dose and
route
Follow-up
period
Outcomes (%) Reference
Brazil Open-label 10 20.0 Amphotericin B
cholesterol
dispersion
2.0mg/kg/d for
10 d. I.V.
6-12 months Cure 10/10 (100) [137]
Brazil Open-label 10 19.0 Amphotericin B
cholesterol
dispersion
2.0mg/kg/d for
7 d. I.V.
6-12 months Cure 10/10 (100) [137]
Brazil Open-label 10 16.5 Amphotericin B
cholesterol
dispersion
2.0mg/kg/d for
5 d. I.V.
12 months Cure:9/10 (90)
Relapse:1/10
[138]
Brazil Open-label
Phase II
13 7.6 Liposomal
amphotericin B
14mg/kg
(total) . I.V.
6 months Cure=8/13 (62)
Failure=1/13
Relapse=4/13
[133]
Brazil Open-label
Phase II
4 7.5 Liposomal
amphotericin B
10mg/kg
(total) I.V.
6 months Cure=4/4 (100)
Failure=0
Relapse=0
[133]
Brazil Open-label
Phase II
15 10.1 Liposomal
amphotericin B
20mg/kg
(total) I.V.
6 months Cure=13/15 (87)
Failure=0
Relapse=2
[133]
Brazil Open-label,
doseescalating
trial
4 19.0 WR6026
(sitamaquine)
1.0mg/kg/d for
28 d. Oral.
12 months Cure=0/4 (0)
[136]
Brazil Open-label,
doseescalating
trial
6 32.8 WR6026
(sitamaquine)
1.5mg/kg/d for
28 d. Oral
12 months Cure=1/6 (17)
[136]
Brazil Open-label,
doseescalating
trial
6 23.8 WR6026
(sitamaquine)
2.0mg/kg/d for
28 d. Oral.
12 months Cure=4/6 (67)
[136]
Brazil Open-label,
doseescalating
trial
5 23.8 WR6026
(sitamaquine)
2.5mg/kg/d for
28 d. Oral
12 months Cure=1/5 (20)
[136]
Brazil Open-label,
doseescalating
trial
1 22.0 WR6026
(sitamaquine)
3.25mg/kg/d
for 28 d. Oral
12 months Cure=0/1 (0)
[136]
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Table 3. Main characteristics of diagnostic tests for canine visceral leishmaniasis in Latin America
Country Diagnostic
test
Reference test Number of
confirmed VL
Sensitivity Number and
type of
controls
Specificity Reference
Brazil IFAT Parasitology 46 78% - 102 NEC
- 100 % [79]
Brazil IFAT Parasitology 21 100% - 14 NEC
- 100 %
[123].
Brazil IFAT Parasitology 112 72% - 20 NEC
- 20 OD
- 100 %
- 52 %
[172]
Brazil IFAT CRS 36 100% - 67 EC - 66% [173]
Brazil cELISA Parasitology 46 98% - 102 NEC
- 99 % [79]
Brazil cELISA Parasitology 21 71% - 14 NEC
- 86 %
[123]
Brazil cELISA Parasitology 106 98-100 - 25 HEC - 100% [174]
Brazil cELISA Parasitology 112 95% - 20 NEC
- 20 OD
- 100 %
- 64 %
[172]
Brazil cELISA Parasitology 76 95% - 33 NEC - 100 % [175]
Brazil cELISA Parasitology 50 sympt.
50 asympt.
-88%
- 30%
-25 NEC
-14 OD
- 100%
- 64%
[176]
Brazil rK39 ELISA Parasitology 106 98.1% - 25 HEC - 100% [174]
Brazil rK39ELISA Parasitology 50 sympt.
50 asympt.
-100%
- 66%
-25 NEC
-14 OD
- 100%
- 71%
[176]
Brazil rK26 ELISA Parasitology 106 99.1% - 25 HEC - 100% [174]
Brazil rK26ELISA Parasitology 50 sympt.
50 asympt.
-94%
- 66%
-25 NEC
-14 OD
- 100%
- 57%
[176]
Brazil rA2ELISA Parasitology 50 sympt.
50 asympt.
-70%
- 88%
-25 NEC
-14 OD
- 100%
- 93%
[176]
Brazil Dot-ELISA Parasitology 37 -97% - 63 HEC
- 30 NEC
- 100%
- 100%
[177]
Brazil DAT Parasitology 21 71% - 14 NEC - 71 % [123]
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Brazil DAT Parasitology 112 93% - 20 NEC
- 20 OD
- 100 %
- 95 %
[172]
Brazil FD-DAT CRS 36 100% - 67 EC - 89.5% [173]
Venezuela FD-DAT Parasitology 26 85% - 16 HEC - 100 % [125]
Brazil rK39 ICT CRS 74 72 - 101 HEC - 61% [178]
Brazil rK39 ICT
(6 formats)
Clinical + IFAT 50 84- 96 % - 50HEC
- 14 OD
- 100 %
- 100 %
[179]
Brazil rK39 ICT Parasitology 76 83% - 33 NEC
- 25 OD
- 100 %
- 84 %
[175]
DAT : variable cut-offs were used, and different antigens, see original papers
cELISA: ELISA based on crude soluble antigen; rELISA: ELISA based on recombinant antigens; FD-DAT : Freeze-dried DAT; CRS: Composite
Reference Standard ( in Da Silva 2006 (ref 173): positive if direct microscopy or culture or PCR positive; in Reithinger 2002 (ref 178):Positive if
ELISA or PCR positive) ; NEC healthy dogs from non-endemic areas; OD : dogs with other, potentially cross-reacting infectious diseases; HEC:
healthy dogs from endemic areas
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Table 4. Main characteristics of selected studies reporting effects of control interventions against visceral leishmaniasis in Latin America
Country
and
period
Study setting Intervention Comparison Number of
subjects in
intervention and
control arm
Followup
Outcomes
(measures)
Effect measures Results References
Brazil
1965-1979
Mainly rural
communities
of 19
municipalities
of Minas
Gerais State
Dog culling +
Human
treatment +
DDT spraying
of houses
Before/after 81,162 dogs.
Unreported
number of human
subjects.
No control
15 years Human VL
(clinical
AND/OR
CFR
AND/OR
parasitology)
Canine VL
(seroconversi
on – CFR)
Incidence of human
and canine VL
before/after
Human VL
disappearing ~0%
Canine VL ~0%
[140]
Brazil
Period:
NR
Three
adjacent rural
valleys in the
Espírito Santo
State
Culling of
seropositive
dogs 0 and 6
months after
inclusion
2 intervention
valleys vs 1
control valley
Intervention
valleys – 267
humans
Control valley –
202 humans
Dogs – NR
12
months
Human
infection
(seroconversi
on in
Dot-ELISA)
Canine
infection
(seroconversi
on in Dot-
ELISA)
Difference in
infection rates in
humans and dogs in
intervention vs
control valleys
0% difference in human
seroconversion rates
and not significant
difference (4%) in dog
seroconversion
conversion rate
[141]
Brazil
Period:
NR
28 rural
villages in the
São Luiz do
Curu
municipality
in the state of
Ceará
Rapid culling
based on
ELISA
versus
conventional
culling based
on IFAT
1 intervention
group
composed by
14 villages vs
1 control
group
composed by
14 villages
Intervention group
– 276 dogs
Control group –
254 dogs
10
months
Canine
infection
(seroconversi
on in ELISA)
Difference of
seroprevalence
between groups
Significant reduction of
seroprevalence in the
intervention group
(27% versus 9%;
P=0.001)
[142]
Brazil
1989-1993
Two
neighborhood
s of the city of
Jequié in the
Bahia State
Yearly culling
of
seropositive
dogs
1 intervention
area vs 1
control
Humans – NR
Dogs in the
intervention area:
1989-1980 – 235
1990-1991 – 248
1991-1992 – 70
1992-1993 – 131
1993 - 164
5 years Canine
infection
(seroconversi
on in FASTELISA)
Human
pediatric VL
cases
Difference in
cumulative incidence
of canine infection
between
neighborhoods
Difference in
incidence of pediatric
VL
Canine infection
cumulative incidence
did not change (P=0.07)
Pediatric VL incidence
decreased in the
intervention area
(P<0.01)
[45]
Brazil
Period:
Urban and
periurban
Culling of
seropositive
Before/after Cohort of 1286
susceptible dogs,
18
month
Dog
emigration
Dog emigration rate
Canine infection
Emigration rate: 2.26
cases/100 dogs-year;
[143]
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35
NR
areas of the
Jequié
Municipality
in the Bahia
State
dogs at
baseline and
every 6
months
no controls Canine
infection
(seroconversi
on in ELISA)
evaluated
every 6
months
incidence
Overall annual
incidence of 6.55
cases/100dogs-year;
Two risk strata for
seroconversion rates
with higher risk in the
periurban versus
downtown clusters
Brazil
Period:
NR
São Gonçalo
do Amaranto
municipality
in the Rio
Grande do
Norte State
Vaccination
with Fucose-
Mannoseligand
antigen, 3
sucutaneous
doses at 21
day intervals
Intervention
arm – FML
vaccine
Control arm –
Saline
placebo
Intervention – 58
seronegative
healthy dogs (in
IFAT and FML –
ELISA)
Control – 59
seronegative dogs
(in IFAT and
FML-ELISA)
24
months
-Symptomatic
VL
-FML-ELISA
seroconversio
n
-Leishmanin
conversion
(L. donovani
antigen) at
2, 7, 13 and
24 months
Difference in
symptomatic VL rate
Differences in
seroconversion rates
Difference in
leishmanin positive
rate
(cumulative at 24
months follow-up)
-8% (intervention) vs
67% (placebo)
symptomatic VL
-100% (intervention) vs
68% (placebo)
seroconversion rate
-94% (intervention) vs
14% (placebo)
leishmanin positive rate
[152]
Brazil
1999
Two localities
in the
Corumba
municipality,
state of Mato
Grosso
65%
permethrin
spot-on three
times monthly
1 intervention
locality vs 1
control
Intervention area:
150 dogs
Control area: 146
dogs
5 months Canine
seroconversio
n in IFAT
VL prevalence three
months after
treatment
Reduction of VL
prevalence in the
intervention area
(19.3% to 10.8%) and
increase of VL
prevalence in the
control area (4.1% to
16.8%)
[150]
Venezuela
1999
Two rural
villages in the
Island of
Margarita
Pyrethroid -
cyhalothrin
sprayed
indoors every
5 months;
AND
Organophosp
hate
fenitrothion
through peridomestic
fogging 16
times during
the year vs
control( no
intervention)
1 intervention
village vs 1
control
Five houses in
each village
(control and
intervention)
12
months
Plebotomine
sandfly
density
Differences in indoor
and outdoor sandfly
density between
intervention and
control groups
Significant reduction of
the sandfly density in
the intervention village
(P<0.001)
[144]
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Brazil
1995-2000
Municipality
of Feira de
Santana, state
of Bahia
Culling of
seropositive
dogs and
house and
animal
shelters
pyrethroid
insecticide
spraying
None 124 localities
(30 urban and 58
rural with human
VL incident cases
and 36 localities
around them)
6 years Human VL
incidence
Correlation between
measure coverage
and frequency with
human VL incidence
Positive correlation
with number canine
surveys, coverage of
canine surveys and
number of sprayed
buildings
[151]
Brazil
1999-2000
Two
neigborhoods
in the Capitão
Eneas
municipality,
state of Minas
Gerais
Deltamethrinimpregnated
dog collars vs
none
intervention
1 intervention
vs 1 control
area
Intervention area:
290 dogs
Control area: 190
dogs
5 months Canine
infection
(conversion in
ELISA or
peripheral
blood PCRhibridisation
assay)
Difference in the
infection rates
between groups
11.9% intervention
group vs 17.6% in the
control group (P=0.24)
[54]
Brazil
1997-2000
Jequié city,
state of Bahia
Culling of
seropositve
dogs at
baseline and
every 8
months
Before/after Dynamic cohort of
447 dogs at study
entry
31
months
Canine
infection
(seroconversi
on in ELISA)
evaluated
every 8
months
Difference in
incidence rates every
8 months
No significant changes
in the incidence rates
through the study
period
[147]
Brazil
2003
Salvaterra
municipality
in the Marajó
Island, state
of Pará
Deltamethrin
impregnated
bednets vs
untreated
bednets
Crossover
study
Two houses in
each group
Three
consecuti
ve nights
Main
outcomes:
bednet barrier
effect, human
landing rates
and 24-h
sandfly
mortality
rates
Differences in barrier
effect magnitude,
landing rates and
sandfly mortality
rates
39% increasing in
barrier effect
80% reduction in
human landing rates
98% increasing in
sandfly mortality
[149]
Brazil
1995-1996
One
neighborhood
of the city of
Teresina, state
of Piaui
(A)spraying
houses and
animal pens
with
insecticide
(B) spraying
houses and
infected dogculling
(C)
Random
allocation of
34 clusters to
one of four
arms
213 susceptible
humans (120
evaluated).
Numbers of
susceptible
humans in each
intervention were
not reported.
Control arm: group
submitted to house
12
month
Human
infection
(seroconversi
on in ELISA)
at least 6
months after
intervention
Difference in
incidence rate
Significant reduction in
incidence in the group
exposed to intervention
B.
No significant decrease
in incidence in A and C
intervention groups.
[145]
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combination
of (A) and (B)
(D) spraying
houses
spraying (D)
Brazil
2004-2006
Two
neighborhood
s of the Feira
de Santana
city, state of
Bahia
(A) No
intervention
(B)
insecticide
spraying
(C)
combination
of insecticide
spraying and
seropositive
dog culling
Intervention
was randomly
allocated to
one of 3 areas
in each
neighborhood
Dynamic cohort of
2362 children
(688, 782 and 892
allocated to
interventions A, B
and C, respectively
27
months
Human
incidence
(seroconversi
on in ELISA)
Relative risk for
infection every 12
months
Lower but not
significant incidence
decrease in the
intervention areas
[148]
CFR=complement fixation reaction. NR=Not reported.
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Expert Rev Vaccines 7: 833-851.
165. Borja-Cabrera GP, Correia Pontes NN, da S, V, Paraguai de SE, Santos WR, Gomes
EM, Luz KG, Palatnik M, Palatnik de Sousa CB (2002) Long lasting
protection against canine kala-azar using the FML-QuilA saponin vaccine in
an endemic area of Brazil (Sao Goncalo do Amarante, RN). Vaccine 20:
3277-3284.
166. Parra LE, Borja-Cabrera GP, Santos FN, Souza LO, Palatnik-de-Sousa CB, Menz I
(2007) Safety trial using the Leishmune vaccine against canine visceral
leishmaniasis in Brazil. Vaccine 25: 2180-2186.
167. Fernandes AP, Costa MM, Coelho EA, Michalick MS, de FE, Melo MN, Luiz TW,
Resende DM, Hermont V, Abrantes CF, Gazzinelli RT (2008) Protective
immunity against challenge with Leishmania (Leishmania) chagasi in beagle
dogs vaccinated with recombinant A2 protein. Vaccine 26: 5888-5895.
168. Rodriguez-Cortes A, Ojeda A, Lopez-Fuertes L, Timon M, Altet L, Solano-Gallego
L, Sanchez-Robert E, Francino O, Alberola J (2007) Vaccination with plasmid
DNA encoding KMPII, TRYP, LACK and GP63 does not protect dogs
against Leishmania infantum experimental challenge. Vaccine 25: 7962-7971.
169. Lainson R, Rangel EF (2005) Lutzomyia longipalpis and the eco-epidemiology of
American visceral leishmaniasis, with particular reference to Brazil: a review.
Mem Inst Oswaldo Cruz 100: 811-827.
170. Borges BK, Silva JA, Haddad JP, Moreira EC, Magalhaes DF, Ribeiro LM, Fiuza VO
(2008) [Assessment of knowledge and preventive attitudes concerning
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171. Andrade CR, Nascimento AE, Moura PM, Andrade PP (1989) Leishmania donovani
donovani and Leishmania donovani chagasi as antigens in a direct
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611-615.
172. Ferreira SA, Ituassu LT, de Melo MN, de Andrade AS (2008) Evaluation of the
conjunctival swab for canine visceral leishmaniasis diagnosis by PCRhybridization
in Minas Gerais State, Brazil. Vet Parasitol 152: 257-263.
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173. da Silva ES, van der Meide WF, Schoone GJ, Gontijo CM, Schallig HD, Brazil RP
(2006) Diagnosis of canine leishmaniasis in the endemic area of Belo
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assays. Vet Res Commun 30: 637-643.
174. Rosario EY, Genaro O, Franca-Silva JC, da Costa RT, Mayrink W, Reis AB,
Carneiro M (2005) Evaluation of enzyme-linked immunosorbent assay using
crude Leishmania and recombinant antigens as a diagnostic marker for canine
visceral leishmaniasis. Mem Inst Oswaldo Cruz 100: 197-203.
175. Lemos EM, Laurenti MD, Moreira MA, Reis AB, Giunchetti RC, Raychaudhuri S,
Dietze R (2008) Canine visceral leishmaniasis: performance of a rapid
diagnostic test (Kalazar Detect) in dogs with and without signs of the disease.
Acta Trop 107: 205-207.
176. Porrozzi R, Santos da Costa MV, Teva A, Falqueto A, Ferreira AL, dos Santos CD,
Fernandes AP, Gazzinelli RT, Campos-Neto A, Grimaldi G, Jr. (2007)
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crude and recombinant leishmanial antigens for serodiagnosis of symptomatic
and asymptomatic Leishmania infantum visceral infections in dogs. Clin
Vaccine Immunol 14: 544-548.
177. Dietze R, Falqueto A, Valli LC, Rodriques TP, Boulos M, Corey R (1995) Diagnosis
of canine visceral leishmaniasis with a dot-enzyme-linked immunosorbent
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178. Reithinger R, Quinnell RJ, Alexander B, Davies CR (2002) Rapid detection of
Leishmania infantum infection in dogs: comparative study using an
immunochromatographic dipstick test, enzyme-linked immunosorbent assay,
and PCR. J Clin Microbiol 40: 2352-2356.
179. da Costa RT, Franca JC, Mayrink W, Nascimento E, Genaro O, Campos-Neto A
(2003) Standardization of a rapid immunochromatographic test with the
recombinant antigens K39 and K26 for the diagnosis of canine visceral
leishmaniasis. Trans R Soc Trop Med Hyg 97: 678-682.
Background While three countries in South-Asia decided to eliminate visceral
leishmaniasis (VL) by 2015, its control in other regions seems fraught with difficulties. Is
there a scope for more effective VL control in the Americas? We reviewed the evidence
on the effectiveness of VL control strategies in Latin America – diagnosis, treatment,
veterinary interventions, vector control - with respect to entomological and clinical
outcomes.
Methodology/Principal findings We searched the electronic databases of MEDLINE,
LILACS, the Cochrane Central Register of Controlled Trials, from 1960 to November
2008 and references of selected articles, restricted to English, Portuguese and Spanishlanguage
publications. Intervention trials as well as observational studies that evaluated
control strategies of VL in the Americas were included. Evidence suggests that improved
VL control in the Americas is possible if interventions with known effectiveness would
be applied in a more structured approach but the impact of the existing control strategies
on transmission still needs to be demonstrated. Elimination of VL does not seem a
realistic goal at this point in the Americas.
Conclusion: A substantial number of descriptive observational studies have been carried
on VL in the Americas, but few controlled intervention studies. Research priorities and
current strategies should be reviewed with the aim of achieving better VL control.
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Visceral leishmaniasis (VL) in Latin America is a zoonosis and is caused by an
intracellular protozoon, Leishmania infantum (syn. L. chagasi). The domestic dog is the
main animal reservoir [1–4]. Other domestic animals such as cats have been found
naturally infected with L. chagasi [5]. Foxes and other wild animals might play a role in
sylvatic transmission [6–16]. VL is a vector-born disease, and knowledge of the
characteristics of the vector population and its behavior is crucial for defining potential
control measures. The parasite is transmitted from one mammalian host to another by a
night-biting sandfly, Lutzomyia longipalpis, a 2 to 3mm long insect that is well adapted to
the peri-domestic and intra-domiciliary environment [17–21]. The distribution of Lu.
longipalpis is wide-ranging throughout Latin America -from Mexico to Argentina- [22–
34]. Other vector species have been incriminated in L. infantum transmission: Lu. cruzi
in Brazil [35] and Lu. evansi in Colombia , Venezuela and Mexico [36–39].
The disease burden of VL in Latin America is not easy to assess because most
countries lack effective surveillance systems. The number of exposed individuals is also
hard to estimate due to the focal and sparse geographical distribution of the disease [40–
42].
Control of VL in the Americas has proved challenging so far. Early diagnosis and
treatment of human cases is essential to improve the prognosis of the individual patient,
but will have limited impact on transmission if the animal reservoir is not tackled,
considering that the efficiency of man as a reservoir for L. infantum is poor [43].
Mathematical modeling suggests that vector control and vaccination of dogs would be
more efficacious than interventions targeting infected dogs such as dog culling [44].
Some experimental studies showed a decreased incidence of VL in both dogs and
children following serological screening and culling of seropositive dogs [45–47], but this
control strategy is increasingly debated [48]. Despite intensive application of this strategy
in Brazil in recent years, human VL incidence remained high [49]. The lack of
effectiveness of this culling strategy has been attributed to the low sensitivity of the
screening test, the long delays between diagnosis and culling and the rejection to this
intervention by the dog owners. Treatment of infected dogs is not an effective control
strategy as relapses are frequent, and dogs quickly become infectious again despite
VL REVIEW VERSION May 28th, 2009
clinical cure [50–52]. A controlled trial in Iran showed how the use of deltamethrine
treated dog collars reduced the risk of infection in dogs (by 54%) and in children (by
43%)[53]. Another controlled trial in Brazil showed only a modest effect on canine
seroconversion rates [54] in spite of the proven effect of deltamethrin impregnated dog
collars on vector density in the same country [55]. Vaccination of dogs would be the best
strategy, if an efficacious vaccine can be developed. At present, two canine vaccines are
registered in Brazil, but none has proven to be a tool for controlling transmission. Finally,
the sandfly vector population can be directly targeted through a variety of insecticide
delivery tools or other interventions.
Recently, an ambitious VL elimination initiative was launched by the
governments of India, Bangladesh and Nepal, aiming to reduce the annual incidence of
VL to less than one per 10,000 population at the district or sub district level by 2015 [56].
This strategy exploits recent technological developments of easy-to-use diagnostic tests,
new drugs and some evidence on the efficacy of integrated vector control. The epidemic
is thought amenable to elimination in that region because of the anthroponotic nature of
the disease, the relative confinement to 96 districts in 3 countries and because of the
historic evidence that intensive DDT spraying for malaria eradication almost eliminated
VL [57–59]. Contrastingly, in Latin America the zoonotic transmission pattern constitutes
a major constraint for such endeavor, and moreover, the efficacy of diagnostics and drugs
for VL as demonstrated in Asia cannot be readily extrapolated to Latin-America because
VL could be heterogeneous across the regions regarding clinical presentation and
prognosis.
We report a systematic review of the literature on the effectiveness of VL control
strategies in Latin-America aiming to identify key questions for better control and
research in this area. Our review is based on an evidence report that was requested by the
Pan American Health Organization to support cooperative action for neglected infectious
diseases in Latin America.
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No ethical approval was required for this review.
Firstly, we reviewed the epidemiological issues related to VL occurrence in Latin
America to be able to contextualize the systematic review of control interventions. We
screened titles and abstracts of 573 papers retrieved by PubMed using the key-words and
MeSH terms without limits: (visceral leishmaniasis OR Leishmania chagasi OR L
chagasi OR Kala-azar OR Leishmania infantum) AND “Americas” [MeSH], and
selected those found relevant for full reading.
The systematic literature review on VL control interventions was structured
around the following themes: 1. Diagnosis of human VL, 2. Treatment of human VL, 3.
Diagnosis of canine VL, 4. Control of the animal reservoir and arthropod vector.
We searched for English, Portuguese and Spanish–language articles in
MEDLINE, LILACS, as well as the Cochrane Central Register of Controlled Trials from
1960 to November 2008. We considered only original research, mainly but not
exclusively intervention trials, diagnostic accuracy studies and observational studies, with
scope targeted to American VL. Additional articles were obtained through citation
tracking of review articles and original articles.
We used the following Medical Subject Heading (MeSH) terms and keywords;
i. for diagnosis of human VL: For the PubMed search: (visceral leishmaniasis OR
kala-azar OR L.infantum OR L. chagasi OR L.donovani OR Leishmania infantum
OR Leishmania chagasi OR Leishmania donovani) AND (diagnostic accuracy OR
diagnostic performance OR sensitivity OR specificity OR validation) AND
“Americas” [MeSH] . For the LILACS search the key-words: leishmaniasis AND
visceral AND (diagnosis OR DAT OR dipstick) were used.
ii. for treatment of human VL: For the PubMed search the following key-words were
used: (visceral leishmaniasis OR kala azar OR L. chagasi OR L donovani) AND
(amphotericin b OR glucantime OR sodium stibogluconate OR miltefosine OR
sitamaquine OR pentavalent antimonials OR paromomycin) AND “Americas”
[MeSH]. For the LILACS search the key-words: leishmaniasis AND visceral AND
treatment were used. For the Cochrane Central Register of Controlled Trials we used
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the term visceral leishmaniasis because the search with the key-words and MeSH terms
used for the PubMed searching failed to retrieved any paper.
ii. for diagnosis of canine VL: For the PubMed search: (canine visceral leishmaniasis
OR L.infantum OR L.chagasi OR L.donovani OR Leishmania infantum OR
Leishmania chagasi OR Leishmania donovani) AND (diagnostic accuracy OR
diagnostic performance OR sensitivity OR specificity OR validation) AND
“Americas” [MeSH]. For the LILACS search the key-words: canine AND
leishmaniasis AND visceral AND diagnosis were used.
iii. Control of the animal reservoir and arthropod vector: for the PubMed search:
(visceral leishmaniasis OR Leishmania chagasi OR L chagasi OR Kala-azar OR
Leishmania infantum) AND “Americas” [MeSH] AND control.
In a next step, the titles, abstracts and if necessary the full text of the studies was
examined to identify relevant papers for the review. The inclusion criteria are listed
below.
The inclusion criteria for the papers on diagnostics were as follows: original studies
evaluating the DAT or the rK39 immunochromatographic test; clinical visceral
leishmaniasis diseases in humans as target condition; adequate reference classification;
absolute numbers of true-positive, true-negative, false-positive and false-negative
observations available or derivable from the data presented.
The inclusion criteria for treatment papers were as follows: clinical trials including
uncontrolled and retrospective studies; description of the intervention; description of case
definition; description of follow-up schedule; description of therapeutic endpoints;
description of the control group; and efficacy measure.
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The inclusion criteria for the papers were as follows: original studies evaluating any
diagnostic test for canine leishmaniasis; Leishmania infection and/or VL disease in
domestic dogs as target condition; adequate reference classification; absolute numbers of
true-positive, true-negative, false-positive and false-negative observations available or
derivable from the data presented.
The inclusion criteria for efficacy/effectiveness studies of control measures (canine
culling, impregnated dog collars, canine vaccination, insecticide spraying, insecticide
treated bed nets, environmental management) were: field trials only; main objective
directed to evaluate at least one control measure (even if there was no control group);
clear definition of the intervention under analysis; description of the period of
intervention and follow-up; description of target population; description of sampling
procedure if any; description of the randomization process if any; adequate case
definitions for asymptomatic infection or VL; definition of outcomes related to effects on
humans or dogs or sand flies; at least one effect measure; and at least one point
estimation for the magnitude of the expected effect.
Data Extraction: characteristics of interventions, study setting, study design, population
characteristics, and entomological or clinical outcomes were recorded.
$%&
VL in the Americas is characterized, as in other regions, by prolonged fever,
weight loss, hepatomegaly, splenomegaly, hypergammaglobulinemia and pancytopenia
and it is usually fatal if it is not adequately treated. However, not all leishmanial
infections lead to overt clinical disease: in Brazil ratios of 8-18 incident asymptomatic
infections to 1 incident clinical case were described [60–64]. Some studies suggest that
the susceptibility/resistance to VL disease in humans could be genetically determined
[65–70]. VL prognosis has been studied in Brazil and severe anemia, fever for more than
60 days, diarrhea and jaundice have been reported as poor prognostic factors [71]. A
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localized non-ulcerated form of leishmaniasis caused by L. infantum was reported from
Honduras in the same region where VL cases had been observed [72–74].
Canine VL is relevant both as the source of sandfly infection within the domestic
environment as well as relevant in itself because of the burden of animal disease.
Incidence and prevalence estimates of canine VL in the Americas have been reported
from several endemic foci [75–85]. However the magnitude and the specific relationship
between canine and human infections, and most importantly, the association with human
VL cases are not well understood. The maintenance of transmission in the dog population
is mainly due to infected sandfly bites but alternative transmission routes have been
described such as other vectors [86,87] and sexual transmission [86,88]. The latter routes
were invoked to explain the presence of Leishmania infection in dogs in environments
where no sandfly vectors were detected.
Brazil declared a total of 50,060 clinical VL cases between 1990 and 2006 and
this number accounts for 90% of all reported VL cases in the Americas [41,49].
However, substantial underreporting (42- 45%) of VL in the Brazilian surveillance
system has been recently documented [89]. In the past VL affected mainly the poor rural
areas in the northeast of the country, but since the 1980s, epidemics have occurred in
major cities of over 500,000 inhabitants such as Teresina, São Luis, Belo Horizonte,
Campo Grande, Natal, Araçatuba and others[90–94]. Some of these urban VL outbreaks
were attributed to the migration of families from the rural areas to the peri-urban slums
after periods of prolonged drought. Whereas the reported VL incidence in the 1980s
averaged at 1,500 cases per year, this figure increased to an average 3,362 per year
between 2000 and 2006 [49]. The disease has gradually spread south and east ward and
has been reported since 1999 from the states of São Paulo and Mato Grosso do Sul [95].
More recently, a few human cases have been reported in Brasilia, the federal capital
where the canine infection prevalence is around 18% affecting dogs in poor peripheral
settlements as well as high-income neighborhoods. Human VL outbreaks have also been
reported from Honduras [96], Venezuela [83], Colombia [78], Paraguay [97] and
Argentina [98]. Sporadic and/or import human or canine cases were described in Chile
[99], Ecuador [100], Bolivia[101], Mexico[102], Central-America and the
Caribbean[28,103], and French Guyana[104].
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While the increasing trend in VL in Latin-America has largely been attributed to
the rural exodus, the emergence of HIV could be another risk factor. So far the
contribution of the HIV-epidemic to the VL burden has been less than was feared
initially, as the number of reported cases of VL with AIDS stayed low. Brazil reported
176 HIV-coinfected VL cases [105] in spite of a significant number of asymptomatic coinfected
individuals [106]. Risk factors for the development of human disease are only
partially understood. In Latin-America, VL primarily affects children, and those with
malnutrition are at higher risk [107–109]. Being a young male and the presence of
animals in the neighborhood were identified as risk factors for VL in one case-control
study [110]. Dog ownership and socioeconomic factors could also be linked with a higher
risk of asymptomatic infection – measured by positive leishmanin skin test [111,110].
Poor urban services and sanitation have also been associated with higher VL risk. After
controlling for age, crowding, and the background incidence of VL in the area where the
subjects lived, the risk of acquiring the disease was found to be significantly higher for
those who lived in houses with an inadequate sewage system and those who had no
regular waste collection [112]. Associations between VL incidence and residence in an
urban slum or in areas with green vegetation have also been reported [113,114].
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VL is a fatal condition if not treated and the currently available drugs are quite
toxic. As its clinical manifestations are non-specific, diagnostic tests are needed that are
highly sensitive as well as very specific [115]. An effective control strategy requires
moreover a user-friendly and robust test that can easily be used in primary care settings.
Definite diagnosis of VL is classically established by the microscopic demonstration of
the amastigote form of the parasite, in aspirates from spleen, bone marrow or lymph
nodes. The diagnostic sensitivity and specificity of splenic aspirates is excellent (93–
99%), but the technique carries a risk of potentially fatal internal bleeding in
approximately 1/1000 procedures, which prevents its large-scale use in primary care
settings. Bone marrow and lymph node aspiration are safer but less sensitive - 53–86%
and 53–65% respectively- and equally require technical expertise for aspiration and
Key questions for control
1. How to establish or improve the current VL reporting systems?
2. How to establish the cross-border veterinary surveillance of the dog
populations?
3. How to better document vector distribution and vector behaviour?
4. How to improve the health system capacity for the detection of Leishmania coinfection
in HIV/AIDS patients?
Questions for research
1. What are the risk factors of VL infection and disease at individual and at
community level in the current epidemic context?
2. What is the minimal protocol to assess risk factors in each transmission
scenario and how to make the results from different scenarios comparable?
3. How to document the frequency of asymptomatically infected humans and dogs
individuals in endemic areas and what is their role in transmission?
4. What is the role of sylvatic animals for maintenance of transmission and
spreading to new areas?
5. What is the role of transmission routes such as blood transfusion, organ
transplantation and hemodialysis in humans or sexual transmission in dogs?
6. How to assess hot spots of high transmission focus in space and time so to be
useful for the prioritization of control interventions?
7. What is the role of permissive vectors in transmission?
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reading which is usually not available in primary care settings [115]. Several
immunological tests have been developed for the diagnosis of VL, but all suffer from two
major drawbacks. Firstly, antibodies remain detectable up to several years after
successful treatment, precluding the diagnosis of relapse. Secondly, a significant
proportion of healthy people living in endemic areas are positive for anti-leishmanial
antibodies because of asymptomatic infections. Therefore, antibody tests must always be
used in combination with a standardized clinical case definition for VL diagnosis.
Several antibody detection assays are used in current practice. The
Immunofluorescent Antibody Test (IFAT) uses whole promastigote forms of L. donovani
or L. infantum. The Enzyme Linked Immunosorbent Assay (ELISA) uses a crude soluble
extract of these parasites, or recombinant antigens (a.o. rK39). However, the relevance of
IFAT or ELISA as a test for human VL is limited in the primary care setting, because
they require a well equipped laboratory and skilled personnel. Two antibody detection
tests are considered as appropriate for the diagnosis of VL in field conditions: the Direct
Agglutination Test (DAT) based on whole promastigotes of L. donovani or L. infantum
and the rK39 immunochromatographic test (ICT)[116]. The DAT is a semi-quantitative
test performed in microtitre plates in which increasing dilutions of patient’s serum or
blood is mixed with stained killed promastigotes of L. donovani or L. infantum.
Agglutination results have to be read visually after 18 hours of incubation at ambient
temperature. The test has been extensively validated in most endemic areas. The DAT is
simpler than many other serological tests but requires cool storage (2-8°C), some
equipment, well-trained laboratory technicians and regular quality control. Freeze-dried
DAT antigen is more robust than liquid antigen [117]. rK39 is a 39-amino acid repeat that
is part of a kinesin-related protein of L. chagasi that is highly conserved amongst
viscerotropic Leishmania species. rK39-based ELISA showed excellent sensitivity (93 -
100%) and specificity (97-98%) in numerous VL endemic countries. An ICT or ‘dipstick’
format was later developed to make the test more suitable for field use. rK39 ICTs are
easy-to-perform, reproducible, rapid (10-20 minutes) and affordable (approx. US$1-
2/test). The VL Elimination Initiative in the Indian subcontinent has selected the rK39
ICT in combination with a clinical case definition as the basis for treatment. Although
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performance of both tests is similar in terms of sensitivity and specificity, rK39 is more
suitable as a diagnostic test in the primary care setting.
A recently developed latex agglutination test which detects the Leishmania
antigen in the urine of infected patients, is easy to perform, gives rapid results and has a
high specificity [118]. Because of its variable sensitivity, lack of objectivity in
interpretation, requirement of refrigeration of the reagents and need to boil the urine,
application of this test in the field is difficult [119]. The detection of parasites in the blood
or organs by culture or molecular techniques (PCR) is more sensitive but these
techniques remain restricted to referral hospitals and research centres, despite current
efforts for simplification. PCR seems to be a valuable marker for infection [120].
We concentrated our systematic review of diagnostics for human VL in Latin-
America on the two diagnostic tests that are considered suitable for use in the primary
care level. A Medline search generated 77 papers, and LILACS 167. After screening the
titles and abstracts of those papers for evaluations of the DAT or rK39 in human VL (see
inclusion criteria), we retrieved eight original papers (See Table 1). We discuss them in
comparison with results of a meta-analysis by Chappuis et al. [121].
I. Direct agglutination test (DAT) for VL: Andrade et al (1988) were the first to
report a proof-of-principle evaluation of the DAT in Brazil [122]. A recent meta-analysis
of the DAT performance showed sensitivity and specificity estimates of 94.8% (95%CI:
92.7-96.4) and 97.1% (95%CI: 93.9-98.7), respectively [121]. The performance of DAT
was neither influenced by the region nor by the Leishmania species. However, this metaanalysis
included only two studies from Latin –America, both from Brazil, and both with
(too) small sample sizes. Garcez et al (1996) reported 100% sensitivity on 16
parasitologically confirmed VL cases and 98.3% specificity on a mixed group of 65
healthy endemic controls and patients with other diseases [123]. Schallig et al (2002)
reported a sensitivity of 100% (n= 21 confirmed VL) and a specificity of 100% on 19
healthy controls and 42 samples of patients with other diseases [124]. More recently,
Teran-Angel et al (2007) reported 100% sensitivity on 30 confirmed VL patients in
Venezuela and 100% specificity on 39 controls [125]. Junqueira Pedras et al (2008)
compared the freeze-dried DAT (FD-DAT) and a locally produced DAT with 3 other
serological tests (rK39 ELISA, ELISA-L.chagasi and IgG-IFAT) and concluded that the
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FD-DAT was the most efficient, with 96.6% sensitivity (n=88) and 98.1% specificity
(n=105)[126]. All reported studies are laboratory-based, no large prospective clinical
studies evaluating the DAT have been reported from the Americas.
II: rK39-based immunochromatographic test (ICT): Delgado et al (2001)
evaluated the rK39 ICT in Venezuela, reporting 87.8% sensitivity (36 positive out of 41
confirmed VL) and a specificity of 100%. The deficit in sensitivity was attributed to the
fact that the false negative sera had been kept at -70° for more than 10 years [127]. A
meta-analysis of 13 studies of the rK3 ICT by Chappuis et al (2006) showed sensitivity
and specificity estimates of 93.9% (95%CI: 87.7-97.1) and 95.3% (95%CI: 88.8-98.1),
respectively, with some regional variation [121]. This meta-analysis included only two
studies from Latin-America [124,128]. De Assis et al. later confirmed the excellent
diagnostic performance of rK39 ICT in a prospective study in Brazil, with 93%
sensitivity on 213 confirmed VL cases and 97% specificity on 119 controls (i.e. clinical
suspects with confirmation of other diseases)[129]. On this basis, it seems that rK39
based diagnosis can be adopted in clinical practice, though it is safe to evaluate each
new brand put on the market thoroughly in proper phase-3 designs.
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Canine diagnosis
Seventy-seven papers were retrieved from Medline/PubMed search and 11 of
them were considered relevant. The LILACS database search retrieved 26 papers of
which 2 were considered relevant, but 1 was already obtained from the PubMed database.
In total 12 papers were included in the review.
We reviewed evaluations of the following serological tests for canine VL: IFAT,
ELISA, dot-ELISA, DAT, and rK39 ICT. IFAT is the test adopted by the Brazilian
Ministry of Health for its dog screening-and-culling campaigns. Published estimates for
sensitivity range from 72-100%, for specificity 52-100% (see Table 3). The moderate
sensitivity and specificity of this test, the long turn-around time between sample taking
and culling, and the complexity of its execution have been invoked as one of the reasons
for the low effectiveness of the culling campaign. Several ELISA tests have been
evaluated, with assays based on homologous antigens usually showing higher sensitivity.
Key questions for control
1. How to establish reliable and user-friendly diagnostic algorithms for VL for
use in peripheral health centers?
2. How to define asymptomatic infected individuals and how to manage them?
3. How to assure the quality of available VL rapid diagnostic tests?
4. How to improve clinician’s awareness about the possibility of Leishmania coinfection
in HIV/AIDS cases?
5. How to discriminate between recent infection from reactivation in the context
of HIV co-infection or other immunosuppressive conditions?
Questions for research
1. What can be the contribution of novel (molecular) parasite detection tests to
clinical diagnosis and infection detection in humans?
2. What is the performance of antibody assays in HIV-Leishmania co-infections?
3. What is the performance of antibody assays in patients from areas with
sympatric circulation of parasites causing cutaneous leishmaniasis or
Trypanosoma cruzi?
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Evans et al (1999) showed a higher sensitivity of ELISA compared to IFAT and pleaded
for a revision of the screening policy [130].
Recently more “user-friendly” diagnostics as the DAT and a canine version of the rK39
dipstick test were evaluated for canine diagnosis with good results. For the freeze-dried
DAT sensitivity ranged from 85-100%, specificity 89 – 100% and for the rk39 ICT
sensitivity ranged from 72-96%, specificity 62 – 100%. The main advantage of these
rapid tests would be to shorten the delay between diagnosis and culling/treatment.
However, the reported estimates of sensitivity in the above studies depend on the type of
dogs included in the “true cases” group with higher sensitivity in symptomatic than in
asymptomatically infected dogs, and unfortunately, several evaluations failed to include
an adequate sample of asymptomatically infected dogs for sensitivity estimation. The
sensitivity of the test in asymptomatic dogs is crucial for a control strategy, as those dogs
are infectious, and should be targeted by the campaign.
In this respect, sensitive antigen detection tests as PCR might become a relevant
marker of infection in the future offering the additional advantage that they can still be
used in vaccinated dogs that will be serologically positive because of the vaccine.
However, Quinnell et al (2001) showed in a longitudinal study of naturally infected dogs
how the sensitivity of PCR was high early after infection but declined to 50% thereafter.
The sensitivity of serology also varied with time, being lowest at the time of infection but
clearly superior thereafter (93-100%). They concluded that PCR was most useful for
detection of active disease, and considered serology as more adequate for the detection of
infection [131].
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Human treatment
Thirty-nine papers were retrieved from Medline/PubMed search and four of them
were considered relevant. The LILACS database search retrieved 42 papers of which 24
were not available from the PubMed database. Three of those 24 studies were considered
relevant, one of them, was previously identified through the PubMed search. One paper
was identified through specific author´s name searching in PubMed. The Cochrane
Central Register of Controlled Trials search retrieved 103 trials, three of them were
conducted in the Americas but all were also identified through the PubMed and LILACS
searches. Finally, a total of seven papers were included for review;[132–138].
Three papers were excluded from further analysis, one because it was a second
publication on the same trial [135], one for being a retrospective study with
heterogeneous therapeutic interventions with meglumine antimoniate and case definition
fragility [132], and one paper because of being a case-control study focused on prognostic
factors more than therapeutic response to a specific intervention [134]. The flow for the
selection of the reviewed studies appears in figure 1.
Dietze et al., 1993 reported an open-label dose-escalating trial with amphotericin
B colloidal dispersion (Amphocil®) in two small groups of patients who showed similar
cure rate suggesting that the 7 days regimen was as effective as the 10 days regimen
Key questions for control
1. What is the most cost-effective diagnostic strategy for a screen-and-treat or screenand-
cull campaign? Novel screening strategies based on combined, parallel or
sequential use, of current available tests need to be validated.
Questions for research
1. How to distinguish an antibody response due to natural infection from that
produced after vaccination in dogs?
2. What can be the contribution of novel, molecular, parasite detection tests to clinical
diagnosis and infection detection in dogs?
3. What is the value of the current diagnostic tests in terms of dog infectivity for
sandflies?
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[137]. In 1995 the same authors reported another open-label trial with Amphocil® with a
shorter regime of 5 days, observing an episode of relapse [138]. Berman et al., 1998,
reported the results of an open-label phase II trial with three therapeutic regimens
consisting of liposomal amphotericin B 10, 14 or 20 mg/kg total dose. The reported
outcomes were cure, failure and relapse and the follow-up period was of six months. This
paper suggested that the lower 10mg/kg total dose was less efficacious than the higher
20mg/kg total dose. The small number of subjects did not allow for more detailed
analysis of the prognostic factors [133]. Dietze et al., 2001, reported the results of an
open-label dose-escalating safety and efficacy trial with sitamaquine. In this study
sitamaquine was not efficacious for the treatment of VL in young adults. Severe adverse
events described as renal toxicity lead to trial interruption when using the higher dose of
3.25mg/kg/d [136].
It is relevant to note that the four selected trials were conducted in Brazil and that
no phase III clinical randomized controlled trial was so far reported from the Americas.
The overall impression in the region is that amphotericin B is a very active drug but the
lack or appropriate trials testing its efficacy and the absence of evidence on meglumine
antimoniate efficacy, the routinely recommended drug for treatment of VL in the
Americas, is very preoccupying. Nowadays, one controlled phase II clinical trial with
miltefosine is ongoing and two large randomized controlled trial with liposomal
amphotericin B, amphotericin B deoxycholate and meglumine antimoniate are expected
to initiate recruitment in 2009 in Brazil. The summarized characteristics of the four
selected studies described above are demonstrated in table 2.
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Vector and animal reservoir control
The control of VL is complex and frequently involves combined interventions.
The effects of those interventions in terms of human and /or canine disease and infection
or directly on sandfly density are not clearly defined. The Brazilian Control Program
recommends a combined intervention based on parameters of human epidemiology,
sandfly distribution and canine infection surveillance. The main interventions that have
been applied in Brazil are canine culling and vector control with insecticide spraying. In
spite of this approach, the disease burden remains high and problem-based research is
needed to improve results. Other Latin American countries, where the disease burden is
lower than Brazil have implemented similar interventions with less intensity. Insecticide-
Key questions for control
1. What is the current standard of care for VL treatment in the Americas?
2. What is the case for combination therapy for VL in the Americas?
3. What is the standard of care in VL/HIV co-infection?
Questions for research
1. What is the current efficacy of pentavalent antimonials, amphotericin B
deoxycholate and the liposomal formulations, miltefosine and drug
combinations for VL treatment in the Americas?
2. Are there more efficacious, safer, and simpler therapeutic schemes for VL than
the current ones?
3. Can a clinical prognostic score for treatment failure be developed to identify
those cases most in need for intensive care?
4. Is there a cure marker for VL?
5. What is the role of non-parasite targeted drugs such as immunomodulators,
antibiotics and others in VL treatment?
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impregnated collars for dogs and canine vaccination are not currently recommended as
public health control measures [139]
Seventy-one papers were retrieved from PubMed using the search strategy cited
above. After reading the titles and the abstracts and handsearching reference lists for
related papers, fourteen were selected for full text reading because the main subject was
at least one intervention for control VL [45,54,140–147,147,147–151].
Magalhães et al, (1980) published a retrospective –non controlled- study on the
impact of a combined intervention consisting of human VL case treatment, culling of
seropositive dogs and insecticide spraying with DDT in 19 municipalities of the Rio
Doce Valley in the State of Minas Gerais, Brazil and reported the disappearance of
human symptomatic cases after 15 years of application of this strategy. The main
limitations of this study were: i) the lack of information on the intensity and the
periodicity of control measures, ii) the low sensitivity of the complement fixation test to
detect canine infection, iii) the passive reporting of human VL cases as the data source
for evaluating the impact on human population and iv) the human and canine population
exposed to the control measures was not reported. The insecticide used, DDT, is not
available anymore for the purpose of VL control [140].
Dietze et al (1997) reported a field trial of dog screening and culling, based on
twice yearly screening with a previously validated DOT-ELISA. The trial was conducted
in three valleys of a rural area of the State of Espirito Santo, Brazil. The intervention was
conducted in two valleys and the control (no intervention) in a separate valley. The initial
seroprevalence in humans and dogs were similar between intervention and control
groups. The outcome measures were human and dog seroconversion rates. This study
failed to demonstrate a positive effect of dog culling as a control measure on human and
dog infection. At 6-months there was a 16% difference of seroconversion rate in dogs
(36% in the intervention group versus 52% in the control group), but this difference was
not significant [141]. The limitations of this study were its non-randomized design, a low
number of clusters for comparison (2:1), 26.5% loss to follow-up in humans because of
drought-related migration and the small sample of domestic dogs (140 dogs). Canine loss
to follow-up was not described.
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Braga et al (1998) reported the comparison of two strategies of dog screeningand-
culling: one based on screening by ELISA was compared to screening based on
IFAT as routinely recommended by the National Control Program. The main difference
consisted in the lag times after blood sampling (7 days for ELISA test and 80 days for
IFAT). The trial was conducted in a rural area of Northeastern Brazil where 28
communities were systematically allocated to one of the two groups. The outcome
measure was the canine seroprevalence detected through both diagnostic methods 10
month after the intervention. The main result was the higher reduction of canine
seroprevalence in the ELISA group probably caused by a combination of the effects of
faster dog removal plus higher sensitivity of the ELISA test. The main limitations of this
study were i) that the baseline seroprevalence was significantly different between the
groups and ii) the impossibility to disentangle the effect of the time to dog removal from
the effect of the lower sensitivity of the IFAT test. This paper revealed that the Brazilian
Program was using a test for dog detection with low sensitivity and that the time to dog
removal in the routine program was too long [142].
Ashford et al (1998) reported a controlled intervention trial of seropositive dog
removal in a endemic area of Bahia, Brazil. The intervention area was subjected to
screening with FAST-ELISA and removal of seropositive dogs, in the control area no
intervention was carried out. The primary outcome was annual dog seroconversion rate
and dog seroprevalence during four years (1989 to1993) and the secondary outcome was
the human VL pediatric cases detected through records of health units in the area. The
authors claim a significant reduction of dog seroconversion rate in the intervention area
as compared to the dog seroconversion rate in the control area, and a significantly lower
incidence of pediatric cases of VL in the intervention area. The main limitations of this
study were the non-randomized design; the low number of clusters in the comparison
(1:1); the different baseline prevalence of dog infection between groups; the high (40%)
loss to follow-up in the intervention group after one year; the incomplete removal of
seropositive dogs; the lack of information on the control group related to sample size,
loss to follow-up, and the dog population replacement during the study [45].
Paranhos-Silva et al (1998) described the follow- up of several clusters of
seronegative dogs in Jequié, Bahia State, Brazil, an endemic area for VL. The initial
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prevalence of infection among 1681 dogs was 23.5%. After serological screening every
six months for 18 months and removal of those that seroconverted, the annual incidence
rate of infection was 6.55 cases/100dog-years. Notoriously the risk was not homogeneous
among clusters and the clusters in the downtown neighborhood had lower risk. The
migration of dogs between clusters was 2.3cases/100dog-years. The limitation of this
study was that the intervention of dog culling was not directly evaluated because de main
objective was to detect the pattern of dog migration, but the study remains relevant
because confirming the heterogeneity of the risk and the importance of dog movement as
potential problems for any control program dealing with the canine reservoir [143].
Da Silva et al (2001) reported a phase III vaccine field trial in seronegative dogs
screened with IFAT and FML-ELISA and exposed to fucose-mannose-ligand vaccine in
three subcutaneous doses at 21 day intervals. Control arm was treated with saline
placebo. Endpoints were symptomatic VL or death, seroconversion rates in FML-ELISA
and conversion of leishmanin skin test composed of crude L. donovani antigen. Followup
evaluations were performed at 2, 7, 13 and 24 months. A significant difference in the
three endpoints was observed during the trial. The overall efficacy to prevent
symptomatic VL disease was 75%. The main problems of this study were the
impossibility of accurate evaluation of the infection rate because the vaccine product and
probably the repeated leishmanin doses interfered with the serological response with
more than half of control subjects showing positive FML-ELISA tests. Other drawback
was the lack of random allocation of individuals and baseline data on relevant dog
characteristics such as age, sex, time of exposure to transmission area [152]
Giffoni et al (2002) reported the effect of application of a 65% permethrin spot-on
formulation on canine VL infection and sandfly abundance. A decrease of canine VL
prevalence was observed in the intervention area compared with increased prevalence in
the control area. No effect was observed on sandfly population. The main limitations of
this study was the non-comparable baseline prevalence between intervention and control
areas, the low sensitivity of the test used to define infection (IFAT) and the significant
losses during follow-up when some dogs died and were excluded from the analysis[150].
Feliciangeli et al (2003) described a controlled trial of pyrethroid (-cyhalothrin)
indoor spraying every 5 month and organophosphate (fenitrothion) ultra-low volume
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spatial fogging around the houses twice a month for ten months in one intervention
compared to one control area. The main vector captured was Lu. longipalpis. A
significant decrease of sandfly abundance was observed indoors in the intervention area.
The residual effect of indoor spraying was no longer than 3 months on both cement and
oil painted walls. The effect of spatial fogging was discrete on the outdoor sandfly
population. Main limitation of this study was the small number of houses observed and
the specific construction style of those houses in complete cement, plastered and oilpainted
walls and zinc roofs. Then, the external validity of obtained data from that
scenario could be low [144].
De Oliveira et al (2003) reported the evaluation of routine combined control
measures of seropositive dog-culling and insecticide spraying during six years. The
intensity of the application of control measures correlated with human VL incidence, the
coverage of canine surveys, the number of canine surveyed and the number of buildings
submitted to insecticide spraying. The main drawbacks of this study were that researchers
work with secondary source data that were not specifically collected for research
purposes and the lack of a control area without intervention for comparison [151].
Reithinger et al (2004) reported a controlled field trial to evaluate the
effectiveness of insecticide impregnated collars to prevent infection detected through
serological tests or DNA detection by PCR assay in one intervention compared to one
control area. The authors failed to detect a significant difference between groups in the
incidence of new infections but they demonstrated a significant reduction of antibody
titers in the collar protected dogs. Main limitations of this study were the one to one
comparison, the non comparable baseline prevalence of VL infection between groups, the
high rate of loss of follow-up, the high frequency of collar loss and the migration of dogs.
Mathematical modeling using the results obtained in this study suggests that dog collars
would be a better alternative than dog culling [54].
Moreira et al (2004) reported the incidence rates of canine Leishmania infection
in a cohort of dogs submitted to an optimized culling strategy consisting of: (i) ELISA
screening of serum samples; (ii) shortening of the time interval from serodiagnosis to
removal of dogs; (iii) screening a high proportion of the dog population. They
demonstrated that the incidence of canine infection remained stable through 2.5 years of
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observation under this optimized strategy. A high dog replacement rate was observed and
this replacement involved susceptible puppies and already infected dogs. The main
limitation of this study was the uncontrolled design that precluded the possibility of
detecting the impact of dog culling, taking into consideration that without the
intervention the incidence could have been higher than the one observed [147].
Courtenay et al (2007) reported the barrier effect, the 24-h mortality rate and the
human landing rates of Lu. longipalpis in households using deltamethrin-impregnated
bednets compared with households using untreated bednets. The study described a 39%
increase in barrier capacity of the impregnated bed nets, 80% reduction in sandfly landing
rates on humans and 98% increase in the 24-h sandfly mortality rates. The study was
done under field conditions with a small number of observations during a very short
period of exposure to the treated bednets (three consecutive days) and the residual effect
was not measured. However the impressive results indicate the need to explore this
intervention further considering that this intervention could bring an additional benefit in
areas where malaria is also endemic [149].
Costa et al (2007) reported a randomized community intervention trial to compare
the effect of four strategies on human VL, as follows: 1. spraying houses and animal pens
with pyrethroid insecticide; 2. spraying houses and eliminating seropositive dogs; 3.
combination of spraying houses and animal pens plus eliminating seropositive dogs; and
4. spraying houses only as the reference comparator. The outcome was evaluated by
measuring incidence of seroconversion in humans six months after the application of
interventions. The results indicated a positive effect of canine removal on incidence of
leishmanial infection in men but surprisingly, the combination of dog culling plus
outdoor spraying of peridomestic animal shelters failed to demonstrate any effect. The
main limitations of this trial were the non comparable baseline VL incidence between the
house spraying group and the other three groups, the high percentage of loss to follow-up
of susceptible individuals (44%); the suboptimal sensitivity and specificity of the method
to measure seroconversion (crude antigen-ELISA). The relevance of this study is that it
constitutes the first attempt to measure the effect of combined interventions on human
VL incidence [153].
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De Souza et al (2008) reported a randomized community intervention trial to
compare the effect of (i) pyrethroid insecticide spraying; (ii) pyrethroid insecticide
spraying plus culling of seropositive dogs with (iii) no intervention. The interventions
were maintained for two years and outcomes were registered every year, insecticide
spraying was performed every 6 months. Although a lower incidence was observed in the
groups submitted to interventions and that reduction was more intense after two years, the
study failed to detect statistically significant differences [148].
The summarized characteristics of the studies described above are detailed on
Table 4.
The present review of the main topics related to VL control in Latin America
revealed that a lot of work remains to be done in order to clarify the dynamics of
Leishmania transmission in human, canine and arthropod vector populations. The exact
magnitude of the problem remains largely unknown and the disease incidence is only
known approximately in one country in the region. The determinants of human L.
Key questions for control
1. What is the most cost-effective control strategy for VL?
2. How to conduct a valid impact evaluation?
3. Can general support measures (nutritional rehabilitation and housing
improvement) be targeted to VL endemic areas?
4. What is the potential impact of current dog vaccines on transmission?
5. Could KAP studies help to improve the impact of the interventions?
Questions for research
1. What are the determinants of dog infectiousness for the sandfly vector?
2. What are the determinants of dog susceptibility to infection?
3. What is the efficacy of current dog vaccines to prevent disease in dogs and to
reduce infectiousness for the sandfly vectors?
4. What is the effectiveness of insecticide impregnated dog collars to prevent human
and canine infection?
5. What is the efficacy/effectiveness of alternative vector control devices (insecticide
treated nets, curtains, etc) in the prevention of VL?
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chagasi infection are also poorly understood with the exception of the nutritional status
in young children. Risk factors for symptomatic disease development are not clearly
understood and all the factors currently under investigation have not shown strong
associations in spite of strong biological plausibility to explain their links with disease
risk. A big coordinated effort has to be done to determine the main risk factors for disease
development and the possible interactions among them.
In spite of this lack of knowledge a series of control interventions are practiced
with different intensity in endemic areas. In humans, specific diagnostic assays and drugs
are used, dog populations are subjected to screening-and culling and vector control
measures are applied to variable extent. However, the increasing number of VL cases
observed in Brazil and the spread of VL transmission to previously not affected areas
raises doubts about the impact of ongoing control measures.
Our systematic review of tools for human diagnosis revealed that for symptomatic
VL cases the rK39 ICT seems to be ready to use in the field in order to establish its
effectiveness with clear advantages over the traditional IFAT or ELISA based tests. The
DAT assay has shown similar diagnostic performance but is not as user-friendly as the
rK39. The research priorities in this field should be geared towards diagnostic accuracy
studies in large prospective trials (phase-3) and to study diagnostic performance in
specific groups such as HIV co-infected patients.
Human treatment is the most neglected aspect of all available interventions
against VL. Even if humans may be of lesser relevance for transmission in terms of
reservoir [43], efficacious and early treatment is of the utmost importance to reduce the
case fatality rates caused by VL. Current treatment practices are based on rather weak
scientific evidence mainly composed of specialist opinions. It is worrisome that case
fatality rates remain high and probably increasing, at least in Brazil, and the current
challenge is to demonstrate the efficacy/effectiveness of the available drugs. The research
priorities include well-designed clinical trials with pentavalent antimonials, amphotericin
B deoxycholate and the liposomal formulations, miltefosine and drug combinations.
Although the resistance to antimonials observed in India is less relevant in Latin
America, drug combinations are attractive because their potential for shortening
treatment schemes and reduction of toxicity. Clinical factors associated with treatment
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failure should be studied to contribute to the development of a prognostic score that
allows early interventions to reduce case fatality rates [134,154].
Control interventions targeting the dog reservoir for culling/treatment require
accurate assays able to detect the asymptomatic infections as well as the symptomatic
dogs. Validating such tests is no easy task, as there is no adequate gold-standard for the
diagnosis of asymptomatic infection. PCR-assays seem to be very attractive but
estimating their accuracy and reproducibility still constitutes a research priority.
Moreover, novel screening strategies based on combined, parallel or sequential use of
current available tests needs to be validated. Another challenge faced by canine diagnosis
is related to the distinction of positive serology results produced by natural infection and
the positive tests induced by currently registered vaccine products. The development and
proper validation of tests with capacity to discriminate both phenomena are crucial to
avoid interference with concomitant interventions including dog culling and vaccination
in the same area. Furthermore, the study of the determinants of dog infectiousness for the
sandfly vector is essential to define the best culling strategy [155] and the determinants
of dog susceptibility to infection [156] is crucial for the design of canine vaccine trials.
Many control interventions have not been submitted to an appropriate evaluation mainly
because of the lack of standardized techniques and protocols to measure their impact on
relevant outcomes.
Some of the problems with the design of the community intervention trials we
reviewed are related to the lack of accurate and easy-to-use diagnostic methods to define
the relevant outcomes in the human and canine population. Furthermore, the definition of
a control group is challenging because of an obvious ethical dilemma. The heterogeneity
of disease transmission within the study area often generated imbalances in the baseline
comparisons among groups and the random allocation process is also complex because of
the mobility of the human, canine and vector population. Most of the reported community
trials used a too limited number of clusters for comparison (usually a one to one
comparison). In spite of all those limitations a relevant number of reports could be
reviewed in detail, showing no strong evidence for a significant impact on VL
transmission for any of the interventions reviewed. Canine culling seems to be the less
acceptable intervention at community level for obvious reasons and has low efficiency
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due to high replacement rate of eliminated dogs with susceptible puppies and other
cultural obstacles [51,143,146,157,158]. Vector control interventions seem better
accepted by the affected populations but knowledge, attitudes and practices (KAP)
studies on this issue are lacking. Mathematical modeling suggested encouraging efficacy
for these vector control interventions, though they need further study and some
technological issues need being solved. The first challenge is the choice of the best way
to deliver the insecticide, i.e. through house and animal shelters spraying, dog
impregnated collars, bed nets for human use, etc. Better knowledge of vector seasonality
and behavior is required for proper timing of these interventions [29,144,159–161]. The
current evidence indicates that spatial fogging is useless and that the residual effect of
house wall spraying is very short [144,162]. Insecticide impregnated collars seem to have
a longer residual effect [55] and theoretical advantages over the other methods and should
be studied in larger and well-designed controlled trials. The potential emergence of
resistance to insecticides should also be considered for the long-term planning of any
vector control intervention [163].
Certainly, canine and human vaccine development needs to be prioritized in spite
of questions on long-term sustainability of such interventions [152,164–168]. The dog
vaccines already registered in Brazil seem to have some protective effect against canine
VL but non of them were properly evaluated to define their role as control measures
against human VL. Such evaluation is challenging as field trials should include relevant
canine endpoints, related to dog infectiousness for the sandfly vector, as well as relevant
human endpoints, that include symptomatic and asymptomatic infections in order to
obtain precise estimates of the vaccine effect on transmission rates. Human vaccine
development is expected to take at least years to obtain efficacious and safe candidates
for clinical trials. Furthermore, the surrogate markers of the desired protective effect are
not well understood and the definition of target population for such products will be a
matter of intense debate.
Finally, the role of sylvatic reservoirs in some relevant VL transmission scenarios
deserves more specific research. The possibility of controlling the canine enzootic brings
up the question on the role of peridomestic synanthropic animals such as foxes,
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marsupials and rodents as potential competent and efficient reservoirs to perpetuate the
VL transmission [169].
Cost-effectiveness studies are essential to formulate a control program but cannot
be done before the adequate demonstration of the effectiveness of available interventions.
However, the researchers and the control program officers should be aware of the need of
costing of interventions in order to facilitate proper economic evaluation, an essential part
in the decision-making process to translate the scientific results into policy and practice.
Last but not least, a preventive strategy that deserves more attention is the use of
nutritional support for children in endemic areas to reduce the risk of disease
development and improve the prognosis of symptomatic cases. In countries such as
Brazil, where the government has put the elimination of hunger as a political priority, the
targeted application of such nutritional support in VL risk areas would be an interesting
and probably cost-effective intervention from a society perspective. Similarly, schemes
for the improving of housing and waste management as well as other general measures
involving active community participation should be encouraged and could be studied by
qualitative research methods [170].
Evidence suggests that improved VL control in the Americas is possible if
interventions with known effectiveness would be applied in a more structured way. The
elimination of zoonotic VL in Latin America is not yet a realistic goal taking into
consideration the complexity and diversity of its transmission scenarios, the scientific
knowledge gaps and the lack of adequate and properly validated interventions. The
definition of research priorities is essential to surpass the current difficulties and the
revision of current control strategies is imperative to avoid misuse of economic and
human resources for health interventions.
Acknowledgments
This review has financial support from BIREME/OPAS/OMS. Authors thank to Ms.
Anne Marie Trooskens for her assistance with the bibliography, Dr. Daniel Salomon and
Dr. Ana Rabello for reviewing the manuscript.
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Figure 1. Flow of Included Treatment Studies
Potentially relevant studies
identified and screened for
retrieval (n=40 from Pub Med;
n=42 from LILACS)
Studies excluded from PubMed search (n=35). 13
case-reports, 9 reviews, 5 focused on
epidemiological, 4 focused on cutaneous
leishmaniasis, 2 focused on diagnostics, 1 focused
on in vitro drug susceptibility, 1 no abstract
available
Studies retrieved for more
detailed evaluation (n=7), 5 from
PuBMed, and 2 from LILACS
Potentially appropriate studies to be
included in the systematic review
(n=4)
Studies included in the systematic
review (n=4)
Studies excluded, with reasons (n=3) 1 redundant
publication, 1 retrospective study with
heterogeneous intervention, and 1 focused mainly
on prognostic factors other than treatment.
Studies excluded from LILACS search (n=40). 13
case-reports, 2 reviews, 6 focused on epidemiology,
5 guidelines, 4 focused on diagnostics, 7 focused on
basic science aspects , 1 no abstract available.
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Table 1. Main characteristics of diagnostic accuracy studies reporting on tests for human visceral leishmaniasis in Latin America
Country Type of
study
Diagnostic
test
Reference test Number of
confirmed VL
Sensitivity Number of
controls
Specificity Reference
Brazil Phase-2 DAT Not described 33 94% - 173 OD
- 178 HEC
- 100 %
- 100 %
[171]
Brazil Phase-2 DAT Parasitology or
improving after
antimonial
treatment
16 100% - 102 OD
- 105 HEC
- 100 %
- 100 %
[123]
Brazil/
other
Phase-2 FD-DAT Parasitology 36 100% - 42 OD
- 19 HEC
- 100 %
- 100 %
[124]
Venezuela Phase-2 FD-DAT Parasitology 30 100% - 20 OD
- 19 HEC
- 100 %
- 100 %
[125]
Brazil Phase-2 FD-DAT Parasitology 88 96.6% - 85 OD
- 20 HEC
- 97.6 %
- 100 %
[126]
Venezuela Phase-2 rK39 ICT Composite
reference *
41 87.8% - 76 OD - 100% [127]
Brazil/
other
Phase-2 rK39 ICT Parasitology 36 85.7% - 42 OD
- 19 HEC
- 80.9 %
- 84.2%
[124]
Brazil Phase-2 rK39 ICT Parasitology 128 90% - 50 OD
- 10 HEC
- 100 %
- 100 %
[128]
Brazil Phase-3 rK39 ICT Parasitology 213 93% - 119 OD - 97% [129]
* FD-DAT : Freeze-dried DAT
** Composite reference: at least 2 positive tests out of 4 (bone marrow, IFAT, CIEP,Western blot)
*** OD : patients with other, potentially cross-reacting infectious diseases
**** HEC: Healthy Endemic Controls
Phase 2: Case-Control design, laboratory based study on banked serum samples; Phase 3: Prospective clinical study, recruiting representative patients
(all presenting with febrile splenomegaly)
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Table 2. Main characteristics of selected studies reporting treatment of human visceral leishmaniasis in Latin America
Country Type of study Number
of
subjects
Mean
patient
age
(years)
Treatment
interventions
Dose and
route
Follow-up
period
Outcomes (%) Reference
Brazil Open-label 10 20.0 Amphotericin B
cholesterol
dispersion
2.0mg/kg/d for
10 d. I.V.
6-12 months Cure 10/10 (100) [137]
Brazil Open-label 10 19.0 Amphotericin B
cholesterol
dispersion
2.0mg/kg/d for
7 d. I.V.
6-12 months Cure 10/10 (100) [137]
Brazil Open-label 10 16.5 Amphotericin B
cholesterol
dispersion
2.0mg/kg/d for
5 d. I.V.
12 months Cure:9/10 (90)
Relapse:1/10
[138]
Brazil Open-label
Phase II
13 7.6 Liposomal
amphotericin B
14mg/kg
(total) . I.V.
6 months Cure=8/13 (62)
Failure=1/13
Relapse=4/13
[133]
Brazil Open-label
Phase II
4 7.5 Liposomal
amphotericin B
10mg/kg
(total) I.V.
6 months Cure=4/4 (100)
Failure=0
Relapse=0
[133]
Brazil Open-label
Phase II
15 10.1 Liposomal
amphotericin B
20mg/kg
(total) I.V.
6 months Cure=13/15 (87)
Failure=0
Relapse=2
[133]
Brazil Open-label,
doseescalating
trial
4 19.0 WR6026
(sitamaquine)
1.0mg/kg/d for
28 d. Oral.
12 months Cure=0/4 (0)
[136]
Brazil Open-label,
doseescalating
trial
6 32.8 WR6026
(sitamaquine)
1.5mg/kg/d for
28 d. Oral
12 months Cure=1/6 (17)
[136]
Brazil Open-label,
doseescalating
trial
6 23.8 WR6026
(sitamaquine)
2.0mg/kg/d for
28 d. Oral.
12 months Cure=4/6 (67)
[136]
Brazil Open-label,
doseescalating
trial
5 23.8 WR6026
(sitamaquine)
2.5mg/kg/d for
28 d. Oral
12 months Cure=1/5 (20)
[136]
Brazil Open-label,
doseescalating
trial
1 22.0 WR6026
(sitamaquine)
3.25mg/kg/d
for 28 d. Oral
12 months Cure=0/1 (0)
[136]
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Table 3. Main characteristics of diagnostic tests for canine visceral leishmaniasis in Latin America
Country Diagnostic
test
Reference test Number of
confirmed VL
Sensitivity Number and
type of
controls
Specificity Reference
Brazil IFAT Parasitology 46 78% - 102 NEC
- 100 % [79]
Brazil IFAT Parasitology 21 100% - 14 NEC
- 100 %
[123].
Brazil IFAT Parasitology 112 72% - 20 NEC
- 20 OD
- 100 %
- 52 %
[172]
Brazil IFAT CRS 36 100% - 67 EC - 66% [173]
Brazil cELISA Parasitology 46 98% - 102 NEC
- 99 % [79]
Brazil cELISA Parasitology 21 71% - 14 NEC
- 86 %
[123]
Brazil cELISA Parasitology 106 98-100 - 25 HEC - 100% [174]
Brazil cELISA Parasitology 112 95% - 20 NEC
- 20 OD
- 100 %
- 64 %
[172]
Brazil cELISA Parasitology 76 95% - 33 NEC - 100 % [175]
Brazil cELISA Parasitology 50 sympt.
50 asympt.
-88%
- 30%
-25 NEC
-14 OD
- 100%
- 64%
[176]
Brazil rK39 ELISA Parasitology 106 98.1% - 25 HEC - 100% [174]
Brazil rK39ELISA Parasitology 50 sympt.
50 asympt.
-100%
- 66%
-25 NEC
-14 OD
- 100%
- 71%
[176]
Brazil rK26 ELISA Parasitology 106 99.1% - 25 HEC - 100% [174]
Brazil rK26ELISA Parasitology 50 sympt.
50 asympt.
-94%
- 66%
-25 NEC
-14 OD
- 100%
- 57%
[176]
Brazil rA2ELISA Parasitology 50 sympt.
50 asympt.
-70%
- 88%
-25 NEC
-14 OD
- 100%
- 93%
[176]
Brazil Dot-ELISA Parasitology 37 -97% - 63 HEC
- 30 NEC
- 100%
- 100%
[177]
Brazil DAT Parasitology 21 71% - 14 NEC - 71 % [123]
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Brazil DAT Parasitology 112 93% - 20 NEC
- 20 OD
- 100 %
- 95 %
[172]
Brazil FD-DAT CRS 36 100% - 67 EC - 89.5% [173]
Venezuela FD-DAT Parasitology 26 85% - 16 HEC - 100 % [125]
Brazil rK39 ICT CRS 74 72 - 101 HEC - 61% [178]
Brazil rK39 ICT
(6 formats)
Clinical + IFAT 50 84- 96 % - 50HEC
- 14 OD
- 100 %
- 100 %
[179]
Brazil rK39 ICT Parasitology 76 83% - 33 NEC
- 25 OD
- 100 %
- 84 %
[175]
DAT : variable cut-offs were used, and different antigens, see original papers
cELISA: ELISA based on crude soluble antigen; rELISA: ELISA based on recombinant antigens; FD-DAT : Freeze-dried DAT; CRS: Composite
Reference Standard ( in Da Silva 2006 (ref 173): positive if direct microscopy or culture or PCR positive; in Reithinger 2002 (ref 178):Positive if
ELISA or PCR positive) ; NEC healthy dogs from non-endemic areas; OD : dogs with other, potentially cross-reacting infectious diseases; HEC:
healthy dogs from endemic areas
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Table 4. Main characteristics of selected studies reporting effects of control interventions against visceral leishmaniasis in Latin America
Country
and
period
Study setting Intervention Comparison Number of
subjects in
intervention and
control arm
Followup
Outcomes
(measures)
Effect measures Results References
Brazil
1965-1979
Mainly rural
communities
of 19
municipalities
of Minas
Gerais State
Dog culling +
Human
treatment +
DDT spraying
of houses
Before/after 81,162 dogs.
Unreported
number of human
subjects.
No control
15 years Human VL
(clinical
AND/OR
CFR
AND/OR
parasitology)
Canine VL
(seroconversi
on – CFR)
Incidence of human
and canine VL
before/after
Human VL
disappearing ~0%
Canine VL ~0%
[140]
Brazil
Period:
NR
Three
adjacent rural
valleys in the
Espírito Santo
State
Culling of
seropositive
dogs 0 and 6
months after
inclusion
2 intervention
valleys vs 1
control valley
Intervention
valleys – 267
humans
Control valley –
202 humans
Dogs – NR
12
months
Human
infection
(seroconversi
on in
Dot-ELISA)
Canine
infection
(seroconversi
on in Dot-
ELISA)
Difference in
infection rates in
humans and dogs in
intervention vs
control valleys
0% difference in human
seroconversion rates
and not significant
difference (4%) in dog
seroconversion
conversion rate
[141]
Brazil
Period:
NR
28 rural
villages in the
São Luiz do
Curu
municipality
in the state of
Ceará
Rapid culling
based on
ELISA
versus
conventional
culling based
on IFAT
1 intervention
group
composed by
14 villages vs
1 control
group
composed by
14 villages
Intervention group
– 276 dogs
Control group –
254 dogs
10
months
Canine
infection
(seroconversi
on in ELISA)
Difference of
seroprevalence
between groups
Significant reduction of
seroprevalence in the
intervention group
(27% versus 9%;
P=0.001)
[142]
Brazil
1989-1993
Two
neighborhood
s of the city of
Jequié in the
Bahia State
Yearly culling
of
seropositive
dogs
1 intervention
area vs 1
control
Humans – NR
Dogs in the
intervention area:
1989-1980 – 235
1990-1991 – 248
1991-1992 – 70
1992-1993 – 131
1993 - 164
5 years Canine
infection
(seroconversi
on in FASTELISA)
Human
pediatric VL
cases
Difference in
cumulative incidence
of canine infection
between
neighborhoods
Difference in
incidence of pediatric
VL
Canine infection
cumulative incidence
did not change (P=0.07)
Pediatric VL incidence
decreased in the
intervention area
(P<0.01)
[45]
Brazil
Period:
Urban and
periurban
Culling of
seropositive
Before/after Cohort of 1286
susceptible dogs,
18
month
Dog
emigration
Dog emigration rate
Canine infection
Emigration rate: 2.26
cases/100 dogs-year;
[143]
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NR
areas of the
Jequié
Municipality
in the Bahia
State
dogs at
baseline and
every 6
months
no controls Canine
infection
(seroconversi
on in ELISA)
evaluated
every 6
months
incidence
Overall annual
incidence of 6.55
cases/100dogs-year;
Two risk strata for
seroconversion rates
with higher risk in the
periurban versus
downtown clusters
Brazil
Period:
NR
São Gonçalo
do Amaranto
municipality
in the Rio
Grande do
Norte State
Vaccination
with Fucose-
Mannoseligand
antigen, 3
sucutaneous
doses at 21
day intervals
Intervention
arm – FML
vaccine
Control arm –
Saline
placebo
Intervention – 58
seronegative
healthy dogs (in
IFAT and FML –
ELISA)
Control – 59
seronegative dogs
(in IFAT and
FML-ELISA)
24
months
-Symptomatic
VL
-FML-ELISA
seroconversio
n
-Leishmanin
conversion
(L. donovani
antigen) at
2, 7, 13 and
24 months
Difference in
symptomatic VL rate
Differences in
seroconversion rates
Difference in
leishmanin positive
rate
(cumulative at 24
months follow-up)
-8% (intervention) vs
67% (placebo)
symptomatic VL
-100% (intervention) vs
68% (placebo)
seroconversion rate
-94% (intervention) vs
14% (placebo)
leishmanin positive rate
[152]
Brazil
1999
Two localities
in the
Corumba
municipality,
state of Mato
Grosso
65%
permethrin
spot-on three
times monthly
1 intervention
locality vs 1
control
Intervention area:
150 dogs
Control area: 146
dogs
5 months Canine
seroconversio
n in IFAT
VL prevalence three
months after
treatment
Reduction of VL
prevalence in the
intervention area
(19.3% to 10.8%) and
increase of VL
prevalence in the
control area (4.1% to
16.8%)
[150]
Venezuela
1999
Two rural
villages in the
Island of
Margarita
Pyrethroid -
cyhalothrin
sprayed
indoors every
5 months;
AND
Organophosp
hate
fenitrothion
through peridomestic
fogging 16
times during
the year vs
control( no
intervention)
1 intervention
village vs 1
control
Five houses in
each village
(control and
intervention)
12
months
Plebotomine
sandfly
density
Differences in indoor
and outdoor sandfly
density between
intervention and
control groups
Significant reduction of
the sandfly density in
the intervention village
(P<0.001)
[144]
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Brazil
1995-2000
Municipality
of Feira de
Santana, state
of Bahia
Culling of
seropositive
dogs and
house and
animal
shelters
pyrethroid
insecticide
spraying
None 124 localities
(30 urban and 58
rural with human
VL incident cases
and 36 localities
around them)
6 years Human VL
incidence
Correlation between
measure coverage
and frequency with
human VL incidence
Positive correlation
with number canine
surveys, coverage of
canine surveys and
number of sprayed
buildings
[151]
Brazil
1999-2000
Two
neigborhoods
in the Capitão
Eneas
municipality,
state of Minas
Gerais
Deltamethrinimpregnated
dog collars vs
none
intervention
1 intervention
vs 1 control
area
Intervention area:
290 dogs
Control area: 190
dogs
5 months Canine
infection
(conversion in
ELISA or
peripheral
blood PCRhibridisation
assay)
Difference in the
infection rates
between groups
11.9% intervention
group vs 17.6% in the
control group (P=0.24)
[54]
Brazil
1997-2000
Jequié city,
state of Bahia
Culling of
seropositve
dogs at
baseline and
every 8
months
Before/after Dynamic cohort of
447 dogs at study
entry
31
months
Canine
infection
(seroconversi
on in ELISA)
evaluated
every 8
months
Difference in
incidence rates every
8 months
No significant changes
in the incidence rates
through the study
period
[147]
Brazil
2003
Salvaterra
municipality
in the Marajó
Island, state
of Pará
Deltamethrin
impregnated
bednets vs
untreated
bednets
Crossover
study
Two houses in
each group
Three
consecuti
ve nights
Main
outcomes:
bednet barrier
effect, human
landing rates
and 24-h
sandfly
mortality
rates
Differences in barrier
effect magnitude,
landing rates and
sandfly mortality
rates
39% increasing in
barrier effect
80% reduction in
human landing rates
98% increasing in
sandfly mortality
[149]
Brazil
1995-1996
One
neighborhood
of the city of
Teresina, state
of Piaui
(A)spraying
houses and
animal pens
with
insecticide
(B) spraying
houses and
infected dogculling
(C)
Random
allocation of
34 clusters to
one of four
arms
213 susceptible
humans (120
evaluated).
Numbers of
susceptible
humans in each
intervention were
not reported.
Control arm: group
submitted to house
12
month
Human
infection
(seroconversi
on in ELISA)
at least 6
months after
intervention
Difference in
incidence rate
Significant reduction in
incidence in the group
exposed to intervention
B.
No significant decrease
in incidence in A and C
intervention groups.
[145]
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combination
of (A) and (B)
(D) spraying
houses
spraying (D)
Brazil
2004-2006
Two
neighborhood
s of the Feira
de Santana
city, state of
Bahia
(A) No
intervention
(B)
insecticide
spraying
(C)
combination
of insecticide
spraying and
seropositive
dog culling
Intervention
was randomly
allocated to
one of 3 areas
in each
neighborhood
Dynamic cohort of
2362 children
(688, 782 and 892
allocated to
interventions A, B
and C, respectively
27
months
Human
incidence
(seroconversi
on in ELISA)
Relative risk for
infection every 12
months
Lower but not
significant incidence
decrease in the
intervention areas
[148]
CFR=complement fixation reaction. NR=Not reported.
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