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Visceral Leishmaniasis: a Global Overview J Glob Health Sci. 2020 Jun;2(1):e3 https://doi.org/10.35500/jghs.2020.2.e3 pISSN 2671-6925·eISSN 2671-6933 Review Article Visceral leishmaniasis: a global overview Richard G. Wamai ,1 Jorja Kahn ,2 Jamie McGloin ,3 Galen Ziaggi 3 1Department of Cultures, Societies and Global Studies, Northeastern University, College of Social Sciences and Humanities, Integrated Initiative for Global Health, Boston, MA, USA 2Department of Behavioral Neuroscience, Northeastern University, College of Science, Boston, MA, USA 3Department of Health Sciences, Northeastern University, Bouvé College of Health Science, Boston, MA, USA Received: Feb 1, 2020 ABSTRACT Accepted: Mar 14, 2020 Correspondence to The leishmaniases are protozoan infections that are among the neglected tropical diseases Richard G. Wamai (NTDs). Over one billion people are at risk of these diseases in virtually all continents. Department of Cultures, Societies and Global These diseases debilitate large numbers of people, keeping them from full, productive lives. Studies, Northeastern University, College of Visceral leishmaniasis (VL) is the most severe form of these diseases, killing more people Social Sciences and Humanities, Integrated Initiative for Global Health, 360 Huntington than any other parasitic disease except malaria. About 90% of the global burden for VL is Ave., Boston, MA 02115, USA. found in just 7 countries, 4 of which are in Eastern Africa (Sudan, South Sudan, Ethiopia E-mail: [email protected] and Kenya), 2 in Southeast Asia (India, Bangladesh) and Brazil, which carries nearly all of cases in South America. In 2005 the World Health Organization launched a strategy to © 2020 Korean Society of Global Health. This is an Open Access article distributed eliminate VL in the Indian subcontinent resulting in significant progress there. The London under the terms of the Creative Commons Declaration on NTDs in 2012, with targets to 2020, heightened attention to VL, and NTDs Attribution Non-Commercial License (https:// were formerly adopted into the Sustainable Development agenda for 2015–2030. However, creativecommons.org/licenses/by-nc/4.0/) there has been limited progress in most regions and especially in Eastern Africa. Challenges which permits unrestricted non-commercial remain as instability, population movements and environmental changes test programming use, distribution, and reproduction in any and political commitments. We review disease transmission and management dynamics, medium, provided the original work is properly cited. epidemiology, policy interventions, and identify outstanding issue towards elimination concluding with the call that, at the start of another decade, there is need to redouble efforts ORCID iDs to control this deadly disease as part of the push towards the Sustainable Development Goals. Richard G. Wamai https://orcid.org/0000-0001-6566-5159 Keywords: Visceral leishmaniasis; Review; Global; East Africa; Southeast Asia; Jorja Kahn Neglected tropical diseases https://orcid.org/0000-0001-8658-7890 Jamie McGloin https://orcid.org/0000-0003-1577-1601 Galen Ziaggi INTRODUCTION https://orcid.org/0000-0001-6858-0986 Conflict of Interest A group of enzootic and zoonotic protozoan infections, the leishmaniases constitute among No potential conflict of interest relevant to this the most severely neglected tropical diseases (NTDs) and are found in all continents except article was reported. Oceania.1-5 Representing the most common infectious diseases, NTDs comprise an open- 6,7 Author Contributions ended list of some 20 parasitic, bacterial, viral, protozoan and helminthic infections. Conceptualization: Wamai RG; Formal Called “diseases of the poor,”8 because of their characteristic prevalence in poor populations analysis: Wamai RG, Kahn J, McGloin J, regardless of a country's income status,9 they infect over one billion people in over 140 Ziaggi G; Investigation: Wamai RG, Kahn J; countries, with about 90% of the global burden in Africa10,11 While NTDs do not contribute Methodology: Wamai RG; Resources: Wamai significantly to global deaths, they are debilitating and remain the most common infections https://e-jghs.org 1/22 A global review of visceral leishmaniasis RG, Kahn J, McGloin J; Supervision: Wamai among the poor worldwide, preventing them from escaping poverty by impacting livelihoods RG; Validation: Wamai RG; Visualization: such as agriculture and livestock, and affecting cognitive, developmental and education Wamai RG, Kahn J; Writing - original draft: outcomes.8,12,13 Wamai RG; Writing - review & editing: Wamai RG, Kahn J, McGloin J, Ziaggi G. At the turn of the century in 2000, the UN Millennium Declaration galvanized significant attention to infectious diseases in the developing world with the 2000–2015 Millennium Development Goals (MDGs). However, NTDs were overshadowed by other diseases, causing them to remain neglected in research, funding and global health implementation,14-18 receiving only 0.6% of development aid during the MDGs period.15,19 Unprecedented mobilization of resources saw significant progress on the major diseases (namely, HIV/AIDS, malaria and tuberculosis), but not for NTDs.20,21 This galvanized calls for the inclusion of NTDs in the post-2015 Sustainable Development Goals (SDGs) agenda.17,22-24 NTDs are now recognized in the SDGs for health with target 3.3 articulated as “the end of NTDs” by 2030, to be measured by “number of people requiring interventions against” these diseases among which leishmaniasis is included.25 Following its first report on NTDs in 2010,26 on January 30, 2012 the World Health Organization (WHO) launched an implementation roadmap for accelerating work on NTDs27 during a gathering in London, resulting in the London Declaration on NTDs.28 The “Uniting to Combat NTDs – Ending the Neglect and Reaching 2020 Goals” campaign generated an unprecedented renewed focus on these diseases. This roadmap targets 10 diseases, including visceral leishmaniasis (VL), for elimination by year 2020 and the WHO has been rallying regional processes for strategic and integrated activities towards the goal with notable progress to date.29 In 2013, the Commission on Investing in Health estimated that spending US $300–400 million annually up until around 2020 could virtually eliminate the leading NTDs, representing a good value for money.30 While there was strong optimism that several NTDs could be eliminated within this timeframe and there is notable progress, various gaps persist for key diseases such as VL especially in sub-Saharan Africa and the Americas.29 For this reason, the WHO has launched a new goal for 2030, aligned with the SDG framework, aiming at “90% reduction in the number of people requiring interventions against NTDs.”31 Among the leishmaniases, 4 types are prevalent, namely VL, cutaneous leishmaniasis (CL), mucosal (or mucocutaneous) leishmaniasis (MCL), and post-kala-azar dermal leishmaniasis (PKDL).32,33 PKDL, which is subcutaneous, often occurs after treatment of VL34,35 and thus has been known as an intermediate disease state before full recovery from VL.36,37 On the other hand, CL is the most widespread type of leishmaniasis.38,39 Using the common measure of disease burden, the disability adjusted life years (DALYs),40 NTDs were responsible for over 26 million DALYs in the 2010 Global Burden of Disease Study, with leishmaniasis ranked second among NTDs with 3.3 million DALYs.20 The more recent 2017 Global Burden of Disease Study estimated NTDs were responsible for 62 million DALYs, with 774,000 DALYs from leishmaniasis.41 In 2015 VL contributed 97% of the total DALYs for the leishmaniases,42 ranking it as the second leading cause of parasitic deaths after malaria.43 Given that 90% contribution of the DALYs for VL are due to years of life lost due to premature mortality, the disease is almost always fatal without treatment,20 with fatality varying by factors such as age, gender and residence in countries like Brazil44 and India.45 Furthermore, VL contributes significantly to household economic loss, as shown by individual studies across countries46-50 and systematic reviews.51,52 The high risk of fatality and impoverishing effect of VL would be expected to draw heightened attention. Consequently, in 2005 the https://e-jghs.org https://doi.org/10.35500/jghs.2020.2.e3 2/22 A global review of visceral leishmaniasis WHO launched an elimination strategy for VL with a focus on Southeast Asia, requiring detection and treatment of all cases.53,54 As a result, there is evidence of significant progress on VL in Southeast Asia55-57 whereas increased incidence is reported in the Americas58 and there is no reliable data from Africa to indicate trends. Furthermore, despite having a high research intensity relative to its burden among other infectious diseases,18 attention in the African region is still inadequate.59 As we enter the next decade for VL (and other NTDs) programming with eyes on 2030, it is timely to review the global problem of VL. Here we review disease transmission and management dynamics, epidemiology, policy interventions in Southeast Asia and Africa, and identify outstanding issue towards elimination. This review serves to update the global evidence base for VL, highlighting significant issues in science and policy. An understanding of the current status of VL will help to inform the next decade of NTD control. ETIOLOGY AND TRANSMISSION OF VL The 2010 WHO Technical Report Series 949, “Control of the Leishmaniasis,” provides a detailed account of the transmission dynamics of
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