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Analysis Innovating for Neglected Diseases in South Asia

Eliminating visceral leishmaniasis in South Asia: the road ahead

BMJ 2019; 364 doi: (Published 22 January 2019) Cite this as: BMJ 2019;364:k5224
  1. Suman Rijal, director1,
  2. Shyam Sundar, professor2,
  3. Dinesh Mondal, senior scientist3,
  4. Pradeep Das, director4,
  5. Jorge Alvar, senior adviser5,
  6. Marleen Boelaert, professor6
  1. 1Drugs for Neglected Diseases Initiative, New Delhi, India
  2. 2Benaras Hindu University, Varanasi, India
  3. 3International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
  4. 4Rajendra Memorial Research Institute of Medical Sciences, Patna, India
  5. 5Drugs for Neglected Diseases Initiative, Geneva, Switzerland
  6. 6Institute of Tropical Medicine, Antwerp, Belgium.
  1. Correspondence to: S Rijal srijal{at}

Suman Rijal and colleagues highlight lessons from a regional collaboration to eliminate visceral leishmaniasis and identify priorities for the post-elimination plan

Devastating epidemics of visceral leishmaniasis, also known as kala-azar, have been recorded on the Indian subcontinent since the early 19th century,1 most commonly affecting poor people.2 The three most affected countries in South Asia are India, Bangladesh, and Nepal. Sporadic cases have been reported in Bhutan and Sri Lanka. Box 1 describes key features of kala-azar in South Asia. Efforts to control the disease have had limited impact.3 Until recently, these countries accounted for more than 50% of the global disease burden.4 Sustained elimination efforts have led to a steady decline in recent years. However, some transmission continues and outbreaks in non-immune populations remain likely. As the number of kala-azar cases becomes negligible, newer tools and strategies will be required for diagnosis, treatment, and vector control.

Box 1

Key features of kala-azar in Bangladesh, India, and Nepal

  • Visceral leishmaniasis or kala-azar is caused by Leishmania donovani parasites and transmitted by the sand fly, Phlebotomus argentipes. Humans are considered the only reservoirs of infection

  • After an incubation period of 2-6 months, patients develop a syndrome characterised by fever, splenomegaly, wasting, and anaemia. It is fatal if left untreated

  • Demonstration of parasites in a smear or culture of aspirate from spleen, bone marrow, or lymph node is required to confirm the diagnosis. Alternatively, serological evidence in a patient with recent onset of febrile splenomegaly in endemic areas will suffice

  • Treatment regimens vary by region. In Asia, a single dose infusion of liposomal amphotericin B is the first treatment, with several combination regimens as alternatives

  • Around 5-10% of patients develop post-kala-azar dermal leishmaniasis 6 months or more after the disease has apparently been cured. They are a potential source of infection


Regional collaboration to eliminate kala-azar

In 2005, the governments of three endemic …

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