Manual for the Diagnosis and Treatment of Leishmaniasis

Home , Cutaneous leishmaniasis, Leishmaniasis, Leishmania major, Pentavalent antimonial

Republic of the Sudan Federal Ministry of Health Communicable and Non-Communicable Diseases Control Directorate

MANUAL FOR THE DIAGNOSIS AND TREATMENT OF LEISHMANIASIS

November 2017 Acknowledgements The Communicable and Non-Communicable Diseases Control Directorate (CNCDCD), Federal Ministry of Health, Sudan, would like to acknowledge all the efforts spent on studying, controlling and reducing morbidity and mortality of leishmaniasis in Sudan, which culminated in the formulation of this manual in April 2004, updated in October 2014 and again in November 2017. We would like to express our thanks to all National institutions, organizations, research groups and individuals for their support, and the international organization with special thanks to WHO, MSF and UK- DFID (KalaCORE).

Preface Leishmaniasis is a major health problem in Sudan. Visceral, cutaneous and mucosal forms of leishmaniasis are endemic in various parts of the country, with serious outbreaks occurring periodically. Sudanese scientists have published many papers on the epidemiology, clinical manifestations, diagnosis and management of these complex diseases. This has resulted in a better understanding of the pathogenesis of the various forms of leishmaniasis and has led to more accurate and specific diagnostic methods and better therapy. Unfortunately, many practitioners are unaware of these developments and still rely on outdated diagnostic procedures and therapy. This document is intended to help those engaged in the diagnosis, treatment and nutrition of patients with various forms of leishmaniasis. The guidelines are based on publications and experience of Sudanese researchers and are therefore evidence based. The guidelines were agreed upon by top researchers and clinicians in workshops organized by the Leishmaniasis Control response at the Communicable and Non-Communicable Diseases Control Directorate, Federal Ministry of Health, Sudan. We hope that they will be helpful to clinicians and other workers in the field of leishmaniasis.

Professor Ahmed Mohamed El-Hassan, DKSM, DCP, PhD, FRCP, FRC Path,

Emeritus Professor, Institute of Endemic Diseases,

University of Khartoum,

Chairperson, Leishmaniasis Research Group/Sudan,

Khartoum,

Sudan

Objectives of the Manual: . To provide a standardized and simplified guide for diagnosis and management of leishmaniasis; . To promote evidence-based, safe and rational use of anti-leishmanial drugs; . To serve as a training tool and reference material for health service providers, programme managers and researchers.

Targets: . Health care workers (physicians, medical assistants, nurses, pharmacy personnel, laboratory technicians) providing care to people in endemic areas; . Leishmaniasis Control response managers, health planners, and researchers; . Organizations involved in leishmaniasis control.

III

TABLE OF CONTENTS CHAPTER 1 INTRODUCTION ...... 1 HISTORY OF THE LEISHMANIASIS CONTROL PROGRAMME ...... 1 EPIDEMIOLOGY OF LEISHMANIASIS IN SUDAN ...... 1 DISEASE BURDEN ...... 1 TREATMENT CENTRES: ...... 3 PARASITES ...... 4 VECTORS ...... 4 TRANSMISSION CYCLES OF VL ...... 5 LIFE CYCLE OF VL ...... 5 CHAPTER 2 CLINICAL FEATURES AND DIAGNOSIS ...... 6 VL CLINICAL FEATURES: MAIN SYMPTOMS AND SIGNS ...... 6 DIFFERENTIAL DIAGNOSES ...... 7 DIAGNOSIS OF VISCERAL LEISHMANIASIS (VL): ...... 7 OTHER TESTS ...... 9 CHAPTER 3 TREATMENT OF LEISHMANIASIS ...... 11 REQUIRED TESTS ...... 11 FIRST-LINE TREATMENT FOR VISCERAL LEISHMANIASIS ...... 11 SSG+PM COMBINATION THERAPY: TREATMENT REGIMEN ...... 11 SSG+PM COMBINATION THERAPY: ROUTE OF ADMINISTRATION ...... 12 SODIUM STIBOGLUCONATE ...... 12 PAROMOMYCIN SULPHATE ...... 13 SECOND-LINE TREATMENT OF VISCERAL LEISHMANIASIS ...... 13 LIPOSOMAL AMPHOTERICIN B (AMBISOME) ...... 13 OTHER SECOND-LINE DRUGS FOR VL: DRUGS UNDER INVESTIGATION...... 14 SUPPORTIVE TREATMENT FOR PATIENTS WITH VL ...... 15 NUTRITION PROTOCOL FOR VISCERAL LEISHMANIASIS PATIENTS ...... 15 FOLLOW-UP AFTER TREATMENT ...... 15 CRITERIA OF CURE ...... 16 CASE DEFINITION ACCORDING TO FOLLOW-UP ...... 16 TEST OF CURE (TOC) ...... 17 TREATMENT OF NON-RESPONDERS AND RELAPSES ...... 17 CHAPTER 4 OTHER TYPES OF LEISHMANIASIS ...... 18 CUTANEOUS LEISHMANIASIS: ...... 18 MUCOSAL LEISHMANIASIS: ...... 18 POST KALA-AZAR DERMAL LEISHMANIASIS (PKDL): ...... 18 CHAPTER 5 LEISHMANIASIS AND HIV CO-INFECTION ...... 20 CLINICAL FEATURES OF LEISHMANIA/HIV CO-INFECTION ...... 20 DIAGNOSIS OF VISCERAL LEISHMANIASIS IN HIV-POSITIVE PATIENTS ...... 20 TREATMENT OF HIV/VL CO-INFECTION ...... 20 FAILURE TO CLEAR PARASITES AND TREATMENT OF RELAPSE ...... 21 PROGNOSIS OF HIV/VL COINFECTION ...... 21 PUBLIC HEALTH IMPLICATIONS OF HIV/LEISHMANIASIS ...... 21 CHAPTER 6 SHORT OUTLINE OF THE NEW TREATMENT PROTOCOL ...... 22 ANNEX 1 CUTANEOUS LEISHMANIASIS ALGORITHM ...... 24 ANNEX 2: ASPIRATION OF LYMPH NODE, SPLEEN AND BONE MARROW ...... 25 ANNEX 3 SSG + PM DOSAGE TABLES ...... 26 ANNEX 4: AMBISOME DOSAGE TABLE ...... 27 ANNEX 5: NUTRITION PROTOCOL FOR VL PATIENTS ...... 29 REFERENCES...... 55

Abbreviations

CL Cutaneous leishmaniasis

DAT Direct agglutination test

ICT Immunochromatographic test

IFAT Immunofluorescence antibody test

IM Intramuscular

IV Intravenous

LCP Leishmaniasis Control Programme

LST Leishmanin skin test

PCR Polymerase chain reaction

PKDL Post Kala-azar dermal leishmaniasis

PT Prothrombin time rK28 Recombinant 28 antigen rK39 Recombinant K39 antigen

SGOT Aspartate aminotransferase

SSG Sodium stibogluconate

TB Tuberculosis

TOC Test of cure

VL Visceral leishmaniasis

WHO World Health Organization KalaCORE Kalaazar Consortium – UK- Aid DFID Department of International Development (UK- Aid )

Chapter 1: INTRODUCTION History of the Leishmaniasis Control Programme Visceral leishmaniasis (VL) is a vector-borne protozoal disease that is estimated to cause 200 000–400 000 cases annually. More than 90% of these cases are found in six countries: Bangladesh, Brazil, Ethiopia, India, South Sudan and Sudan. The Leishmaniasis Control Programme (LCP) was part of endemic disease administration, together with schistosomiasis, guinea worm, sleeping sickness and zoonotic diseases. In February 1998, the LCP was designated as a separate programme and a national programme coordinator was nominated. Since September 2001, the programme was integrated with the National Malaria and Schistosomiasis Control Programmes within the Ministry of Health. Currently, the LCP falls under the Neglected Tropical Disease responsewithin the Ministry of Health, which falls under the Communicable and Non Communicable Diseases Control Directorate.

Epidemiology of leishmaniasis in Sudan Leishmaniasis is a group of diseases with a variety of clinical manifestations. There are four main clinical forms of leishmaniasis in Sudan: VL (kala-azar); post-kala-azar dermal leishmaniasis (PKDL); CL; and mucocutaneous leishmaniasis. VL is the most severe form, with up to 100% fatality in untreated cases. In population-based studies, incidence rates of 38/1000 per year, and case fatality rates as high as 20.5% have been observed ( Zijlstra et al., 1994). The disease is reported to be most prevalent among poor and/or malnourished individuals, displaced groups, farmers, labourers, water carriers and those who live in remote endemic areas. All these population groups have limited financial capacity to absorb the direct and indirect costs of the disease.

Disease burden Visceral leishmaniasis (VL) is among the most important health problems in Sudan, with >24,660 cases and 1193 deaths reported between 1996 and 2001, 29,700 and 1120 deaths reported in 7 states between 2002 and 2011 and 15,611 cases reported in 10 states between 2012 and 2016. The number of reported cases is mainly a reflection of reporting rather than the actual disease transmission. Reports and published work from Sudan show that the disease affects mainly children under 15 years of age with fewer adult cases. Gedarif state is the most endemic state representing about 80% of the annual incidence in Sudan. Cutaneous leishmaniasis (CL) is present in different states of Sudan, with the main foci in the Northern states and North Darfur. In 2011, 6000 cases of CL were reported.

Figure 1:Map of VL (kala-azar) in Sudan based on cases reported in 2015-2016 from 37 treatment centres in 10 states.

Treatment centres: In 2015 - 2016 the Ministry of Health designated 37 hospitals distributed over 10 states to become VL treatment centres, with the understanding that more VL treatment centres could be opened in newly emerging endemic areas, and similarly, closed, when VL cases in a particular area decline. Gedarif state: Gedarif teaching hospital, paediatric hospital, Maternity hospital, Um Alkher hospital, Bazora, Hawata hospital, Tabarak Alla hospital, Basonda hospital, Alhassan-Doka hospital, Kassab hospital, Gala Alnahal hospital Bandiguwe and Almogran hospital. Sinnar state: Azazadamos hospital, Sinnar hospital, Sinnar paediatric hospital, Aldinder hospital and Sinja hospital. Aljazera state: Wad Madani hospital and Wad Madani paediatric hospital North Kurdfan state: Alobied hospital and Um Rawaba hospital South Kurdufan state: Kadugli hospital, Abu karshola hospital and Abu Gebiha hospital. White Nilestate: Kusti hospital, Alsofi hospital and Algetaina hospital. Blue Nile state: Alruseris hospital, chineasefrinship hospital and Aldamazen hospital Khartoum state:Tropical medicine hospital, Jafer Ibn ouf hospital and Mohammed Alamin hospital North Darfur state: Almalha hospital and Alfasher hospital. South Darfur state: Nyala hospital

Figure 2: Map of VL treatment centres (2015-2016)

Parasites Worldwide, over 20 pathogenic species of the Leishmania parasite are known. In Sudan, the parasite isolated from humans and sand-flies that causes VL belongs to the Leishmania donovani sensulato cluster. There are a few reports of isolation of Leishmania archibaldi and Leishmania infantum from humans and dogs in Gedaref State, eastern Sudan. The causative parasite for CL in Sudan is Leishmania major zymodeme LON-1 (El Hassan and Zijlstra, 2001).

Vectors Phlebotomus orientalis is the primary vector for transmission of VL in Sudan. The termite hill dweller, Phlebotomus martini, has also been reported as VL vector in the neighbouring countries of the Republic of South Sudan and Ethiopia, but not in Sudan. Phlebotomus orientalis thrives in environments characterized by presence of Acacia seyal and/or or Balanites aegyptiaca trees that are growing on black cotton soil. The sylvatic behaviour of adult P.orientalis and lack of knowledge of its resting and breeding sites are the main factor precluding plans for effective vector control. Therefore, the use of long lasting insecticide impregnated bed nets (LLIN's) and insect repellents remains the only choices for protection against the bites of P.orientalis. In the VL endemic areas, P. orientalis bites humans between 8:00– 12:00 pm. This vector behaviour and the observations on bed time of people in VL-endemic areas imply that impregnated bed nets could potentially give more protection to children than adults against P.orientalis bites. Use of clothing covering most of the body can result in significant reduction of exposure to the vector.

Health education is key for prevention of VL. Health education messages on how to avoid sand fly bites should be incorporated in syllabi of primary, middle and high schools of the endemic areas. Clinicians should also be equipped with essential knowledge on the vector and the epidemiology of the disease, so that they can provide sound counseling for patients and help in disseminating correct knowledge on transmission.

Further research is needed before advocating reduction or replacement of Acacia seyal and/or Balanites aegyptiaca in villages and surrounding habitats. This should include studies to determine the threshold level of tree density beyond which no transmission of VL is possible. Similarly use of dog collars or dog culling strategy cannot be advocated without having substantial evidence implicating dogs as a major risk factor for acquiring VL by human populations. Current evidence only shows presence of dogs infected by L. donovani but does not demonstrate whether dog a reservoir or a dead-end host. Ongoing research is trying to understand this and to correlate tree density with transmission.

Depending on climatic conditions, especially rainfall, temperature and humidity, the abundance and man-biting rates of P. orientalis shows a remarkable inter-annual fluctuation, resulting in corresponding fall and rise in the annual case load of VL. Proper future climate based studies on annual P. orientalis abundance and VL cases load can lead to construction of Early-Warning models for the disease. Additionally proper surveillance of vector abundance during March-June can allow early prediction of VL case load in the subsequent epidemiologic year (September to August).

Phlebotomus papatasi is the only vector of CL in Sudan. In contract to P. orientalis, this sandfly species is highly endophilic and endophagic, both resting and biting human and at indoor sites.

Therefore, in addition to LLIN, this CL vector can effectively be controlled by Indoor residual spraying of insecticides (IRS) and use of insecticide impregnated curtains. Transmission cycles of VL There are two different transmission cycles of VL in Sudan:

1) Anthroponotic transmission in which humans are the sole source of infection for the vector; 2) Zoonotic cycle in un-inhabited woodland, such as in Dinder National Park, and other dense Acacia seyal and/or Balanites aegyptica forests in VL endemic areas. The role of wild animals and dogs as reservoirs of L. donovani should be substantiated before policies can be made on control of zoonotic cycles. Congenital transmission has been reported sporadically from some endemic areas. There are no reports on other routes of transmission such as sexual or transdermal.

Life cycle of VL Two developmental stages are formed: amastigotes and promastigotes. The amastigote form is found in the mononuclear phagocyte and circulatory systems of humans. It is an intracellular and non-motile form, 2-4µm in diameter. The amastigote is also called the Leishman-Donovan (LD) body. Amastigotes spread in the body through circulating macrophages, but few are present in peripheral blood. The promastigote is formed in the alimentary tract of the sandfly after ingestion of amastigotes. It is an extracellular and motile, flagellated form. Fully developed promastigotes measure 15– 30 µm in length and 5 µm in width. Figure 3: Life cycle of L.donovani

www.cdc.gov/parasites/leishmaniasis/biology

Chapter 2 : CLINICAL FEATURES AND DIAGNOSIS

VL clinical features: main symptoms and signs

The main symptoms and signs of VL are:  Prolonged fever, usually 2 weeks or more, irregular, with or without rigors  Enlarged spleen, which is soft at the start of the disease and later can become hard  Weight loss, progressing to wasting  Enlarged lymph nodes, usually inguinal  Cough  Anaemia, secondary to bone marrow invasion  Leucopenia, causing opportunistic infections  Thrombopenia, causing bleeding About half of Sudanese VL patients present with hepatomegaly, nasal bleeding, diarrhoea and vomiting (see below table). Few patients show oedema or jaundice. Other signs and symptoms occasionally seen are neurological symptoms (psychosis, confusion), insomnia, arthralgia, ascites and uveitis. Patients become gradually ill over a period of a few months and nearly always die if not treated.

Table 1: Occurrence of clinical features in patients with VL in Sudan

Symptoms/signs Percentage 1- Fever 95% 2- Splenomegaly 95% 3- Uncomfortable spleen 85% 4- Weight loss (wasting) 80% 5- Anaemia 75% 6- Lymph node enlargement 75% 7- Loss of appetite 70% 8- Cough 75% 9- Hepatomegaly 60% 10- Epistaxis 50% 11- Diarrhoea 40% 12- Vomiting 15% 13- Jaundice 5% 14- Oedema 5%

Source: adapted by permission of the publisher, from WHO, 1996

Table 2: Abnormal laboratory findings in VL patients

Finding Percentage

Anaemia 60–90% Leukopenia 84% Thrombocytopenia 73% Albumin < 30 g/l 88% Globulin > 30 g/l 98% Elevated bilirubin 17% Elevated SGOT/PT 22% Elevated alkaline phosphatase 40%

*PT (Prothrombin Time); SGOT (aspartate aminotransferase). Source: adapted, by permission of the publisher, from El-hag et al. (1994).

Differential diagnoses In Sudan, malaria is the most important disease with a similar presentation to VL. Therefore, malaria should be considered as one of the main differential diagnoses. Other differential diagnoses which should be considered are enteric fever, schistosomiasis, haemoglobinopathy (especially sickle cell anaemia), malnutrition, tuberculosis (TB), brucellosis, hyper-reactive malarial splenomegaly (formerly known as tropical splenomegaly syndrome), typhoid fever, typhus and HIV/AIDS.

Diagnosis of visceral leishmaniasis (VL):

Clinical diagnosis Clinically suspect case: Any patient presenting with fever of ≥2 weeks duration, with one of the following signs: splenomegaly, weight loss and/or lymphadenopathy, who lives in or has travelled to endemic area

Confirmed case There are two accepted ways of confirming VL in a clinically suspected case: either by parasitology or serology.

Laboratory diagnosis After taking a proper history and performing a thorough clinical examination, parasitological or serological tests are required to decide who should be treated (see the national recommended diagnostic algorithm below).

Parasitological diagnosis Microscopic examination of Giemsa-stained spleen, bone marrow or lymph node aspirates to detect amastigotes remains the reference standard in VL diagnosis. However, these methods are either invasive or insensitive. It takes <1 h from sample collection to obtain the result. The sensitivity of lymph node aspiration is 52–65%, whereas the sensitivity of bone marrow aspiration can reach up to 75% (Kager et al., 1983; Siddig et al., 1988; Zijlstra, 1998). Splenic aspiration sensitivity is 90–95%. Negative slides do not prove absence of the parasite, and low parasite density can be missed microscopically. Lymph node aspiration is safe, easy and can be done by paramedical staff, compared with bone marrow aspiration, which is painful and needs specific and sterile needles, and trained personnel. Spleen aspiration is the most sensitive procedure, but it may be hazardous. If indicated, it needs an experienced physician and should be performed in hospital, where blood transfusion is available because bleeding is a life-threatening complication. Parasitological methods require highly trained laboratory personnel and the results are dependent on the quality of microscopic examination and reagents.

Serological diagnosis Several immunological blood tests that identify specific antibodies against Leishmania are available: direct agglutination test (DAT), arecombinant K39 antigen (rK39) rapid immunochromatographic test (ICT) and arK28ICT. The LCP of Sudan selected these three serological tests (rK39 ICT, rK28 ICT and DAT) for use in diagnosis of VL in Sudan. Only ICT's from approved manufacturers can be used. The use of serological tests is limited to the diagnosis of primary VL. Antibodies can remain detectable up to several years after cure. A significant proportion of healthy people living in endemic areas with no history of VL are positive for Leishmania antibodies. Therefore these tests cannot distinguish between active VL and subclinical and past infection, and cannot be used for diagnosis of relapse or for evaluation of cure.

Direct agglutination test The DAT is a highly sensitive serological but its drawbacks include a prolonged incubation time (18 h), specialized equipment (micro titre plates and micropipettes) and well-trained laboratory personnel. Table 3: DAT results interpretation

DAT Freeze dried Positive: ≥ 1:3200 Borderline (BL): 1:1600; 1:800; 1:400 Negative: ≤ 1:200

8 rK39 and rK28-based immunochromatographictests: rK39 is a cloned antigen of 39 amino acid repeats of a gene found in Leishmania chagasi. Ameta-analysis of 13 studies evaluating the rK39 ICT showed excellent diagnostic performance (sensitivity and specificity estimates of 93.9% and 95.3%, respectively). The overall sensitivity was lower in studies from East Africa than in those from South Asia. Several brands of the rK39 ICT have been evaluated. Higher values for both sensitivity (90%) and specificity (99%) have been obtained with the rK39 ICT (IT-LEISH) manufactured by Bio-Rad (previously Dia Med) (WHO-TDR Diagnostic Evaluation Series No.4). The rK28 ICT produced by CTK Biotech in USA is another antigen antibody based test which has been evaluated in Sudan and had similar sensitivity and specificity (Maowia et al, 2015). These rapid tests are easy to use in the field, reproducible, rapid (10–20 min) and inexpensive, therefore, diagnosis can be established at the primary health care level.

Fig.4 :National Diagnostic Algorithm for clinical suspects of VL:

Other tests

Nucleic-acid-based assays Polymerase chain reaction (PCR) is usually highly sensitive for detection of Leishmania infection, but this does not imply it will be useful for the confirmation of acute VL disease in patients in an endemic area, because many carriers of the infection in the area will be PCR positive without developing VL disease.

Latex agglutination test (KAtex) The KAtex latex agglutination test was developed to detect heat-stable, low-molecular-weight carbohydrate antigen in urine (Attar et al., 2001). It is a simple, rapid and economical test, and is most suitable for use in remote areas. In a multicenter study in east Africa (Ethiopia, Kenya and Sudan), KAtex showed good specificity but moderate to very low sensitivity (Boelaert et al., 2008). A field evaluation of the test in Sudan indicated that the test had a sensitivity of 95.2% and good agreement with microscopy but poor agreement with serological tests and a specificity of 100% (El-Safi et al., 2003). In addition, the test was also positive for the two confirmed VL cases co-infected with HIV. One of the advantages of the test is its ability to distinguish active from past infections. Accordingly, it can be used as a TOC and for diagnosis of relapse. However, the need to boil the urine before testing to avoid false-positive reactions is a limitation. Work to improve the format of this urine antigen detection test is ongoing.

Leishmanin skin test LST is a test that measures the delayed hypersensitivity type IV reaction in terms of induration of the skin in response to intra dermal injection of Leishmania antigens: • values ≥5 mm are considered to be positive • it is typically negative during active primary VL • it is positive in 80% of cases after 3–6 months following successful treatment • it is positive in 50% of PKDL patients and nearly 100% of those with active CL, particularly at the advanced phases • it has great value in field epidemiological surveys • it has a limited place in diagnosis to augment serology.

Chapter 3: TREATMENT OF LEISHMANIASIS

Required tests Before starting anti-leishmaniasis drugs, the patient must be tested for HIV and pregnancy and nutritional status must be assessed. Other basic investigations required before starting treatment are HB, HBV, HCV, RFT (at least Blood Urea), ECG and hearing assessment by tuning fork and the whispering test to assess contra-indication to paromomycin use (risk of hearing loss).

First line treatment is a combination of 17 days of 20 mg/kg/day sodium stibogluconate (SSG) +15 mg/kg/day paromomycin sulphate (PM). If the patient is pregnant, HIV-coinfected, infant or elderly (> 45 years)or other contra-indications for SSG+PM exist, AmBisome is the treatment of choice.

VL patients must be admitted during the treatment course with proper daily follow up by a clinician, and NO outpatient treatment or empirical treatmentis recommended because of the complexity and toxicity of treatment.

First-line treatment for visceral leishmaniasis First-line treatment is a combination of sodium stibogluconate(SSG; Albert David, Kolkata, India) and paromomycin sulphate (PM; Gland Pharma, Hyderabad, India). SSG is a pentavalent antimony compound and paromomycin sulphate is an aminoglycoside antibiotic. SSG&PM combination therapy is recommended by WHO and its efficacyis better than SSG alone or AmBisome, and it has other benefits:

 reduced duration of treatment (17 days vs 30 days SSG monotherapy)  reduced potential risk of resistance  reduced long exposure to SSG monotherapy toxicity.

Other alternative options for first line treatment for VL:

 In some clinical settings where PM is not available or contraindicated, SSG can be used alone (30 days,20 mg/kg/day)  Meglumineantimoniate (Glucantime, Sanofi)is another pentavalent antimonial which can be used but care must be taken to recalculate the dose to reflect the proper amount of antimonial.

SSG+PM combination therapy: treatment regimen SSG: 20 mg/kg/day for 17 days as a single daily dose. No upper limit should be set for the daily dose, which should be determined by the patient’s body weight. PM: 15 mg/kg/day (11 mg/kg paromomycin base) for 17 days as a single daily dose.

The two drugs should be prepared in separate syringes. There is no trough concentration (amount of drug following the last dose), therefore, if treatment is interrupted for >5 days, it should be resumed from day 1.

SSG+PM combination therapy: route of administration SSG is administered by slow intramuscular (IM) injection with proper follow up to avoid abscesses. A vial of 30 ml solution contains the equivalent of 100 mg/ml pentavalent antimony..If SSG dose is 10 ml or more, the dose should be divided between the two buttocks. It is recommended to administer SSG by IM injection but if IM injection is contraindicated, administer by slow IV (1 ml/min). PM is administered by the IM route only. An ampoule of 2 ml solution containing 375 mg/ml paromomycin base.

Sodium stibogluconate

Toxicity/side effects  Clinical: injection site pain, vomiting, nausea, anorexia, arthralgia, myalgia, headache, fatigue, renal function impairment, cardiac toxicity (arrhythmias and cardiac arrest) and pancreatitis;  Laboratory: elevated amylase (biochemical pancreatitis), elevated liver enzymes (biochemical hepatitis), elevated renal function tests, leukopenia, anaemia and thrombocytopenia;  Electrocardiographic (ECG) changes are dose dependent and the most common are T- wave inversion and prolonged QT interval.

Treatment of side effects  Patients with nausea or vomiting should continue eating and drinking but in small amounts;  Treat vomiting with oral promethazine or other antiemetics for 2 days;  Patients who vomit too much should be given oral rehydration salt or milk;  Stop SSG for 2–5 days until vomiting is resolved;  Consider injection of metoclopramide or promethazine;  Patients taking tinidazole or metronidazole should be asked about vomiting and given antiemetics, and if necessary, the drug should be stopped;  The most common cause of death is concomitant disease such as pneumonia, malaria or dysentery;  Patients with concomitant diseases should be treated carefully.

Contraindications Contraindications to SSG include: Cardiac disease, liver disease (jaundice), renal failure, age >45 years, HIV/AIDS, pregnancy, and infancy

Pregnant women and neonates The data on the safety of pentavalent antimonials in pregnancy are confined to case reports, which indicate that they are relatively safe. However, recent published work indicates some reservations for using SSG in pregnant women and infants. There was some excretion of antimony in breast milk following administration of SSG to one woman. More evaluation is required before pronouncing on the safety of antimony in breast-feeding infants.

Paromomycin sulphate The bioavailability of PM is high (approaching 100%) following IM injection but it is negligible following oral administration; thus the IM route is required to treat a systemic disease such as VL. The half-life of PM in humans is 2–3 h. It is not metabolized; it is excreted unchanged in the urine, thus, accumulation can occur in patients with diminished renal function.

PMS should be stored below 30°C and protected from light. It should not be frozen.

Toxicity/side effects The most common adverse effects are injection site pain, transient elevation of alanine aminotransferase and aspartate aminotransferase, and increased blood alkaline phosphatase, creatinine and bilirubin. Toxicological studies have been conducted in animals. At high doses, paromomycin exhibits nephrotoxicity, ototoxicity and neuromuscular blockade. No cases of overdose have occurred in clinical trials of IM PM. General supportive care is indicated. The effectiveness of renal dialysis as a treatment of overdose has not been formally studied.

Contraindications • Patients who have shown hypersensitivity to paromomycin or other aminoglycosides. Discontinue use if an allergic reaction occurs. • Relatively contraindicated in patients with impaired renal function. • Pre-existing hearing impairment (hearing test is required)

Pregnant women and neonates Reproductive studies in rats and rabbits indicate that PM is not teratogenic but does affect fertility and implantation. Aminoglycosides can cross the placenta, thus, PM may cause foetal injury when administered to pregnant women. It is therefore contraindicated during pregnancy. PM can be recovered in breast milk. The absorption of PM is negligible after oral administration, thus, it is expected that breast-fed infants have no systemic exposure to PM.

Second-line treatment of visceral leishmaniasis

Liposomal amphotericin B (AmBisome) AmBisome is administered at a dose of 3mg/kg/daily days over 10 days (total of 30 mg/kg as initial dose), and if needed for slow/non-responders an additional 20 mg/kg given over 7days can be added. AmBisome can be given on alternate days: 1, 3, 5, 7, 9, 11 , for special groups, e.g. renal impairment or heart disease to avoid fluid overload; see annex 4 for calculation.

Indications  Lack of response or relapse after SSG–PM or SSG monotherapy  Contra-indication to SSG or PM.  SSG-induced toxicity  Age >45 or <2 years  HIV co-infection

 Pregnancy  Severely ill patients  Relapse PKDL  HBV, HCV patients  Non responder or slow responder to the first line treatment

Route of administration Before administration of the first dose, a hypersensitivity test should be done as follows: Taking 0.25ml of reconstituted AmBisome in a 1 ml disposable syringe and dilute it up to 10 ml with 5% dextrose for the test dose. Intravenously inject slowly 1ml per minute,then wait for 30 minutes. AmBisome comes in vials of 50 mg and needs to be reconstituted in 12 ml distilled water and diluted in 5% dextrose (at a concentration of 1 ml in 20 ml 5% dextrose) before administration by IV infusion over 30–60 min. The drug should be reconstituted using gloves. The reconstituted drug should be protected from light during the infusion session. Do not dilute with saline solutions or mix with other electrolytes or drugs.

Storage Prior to mixing, AmBisome should be stored at 2–8°C and protected from exposure to light. Do not freeze the drug. The mixture of AmBisome and 5% dextrose may be stored for 15 h at 2–8°C and an additional 6 h at room temperature. Short interruption of the cold chain will not damage the drug.

Side effects The major side effect is renal failure, usually reversible, which can be mostly prevented by providing adequate hydration. A frequent but benign side effect is the occurrence of chills and fever during or after infusion. In the event of occurrence of chills and fever give paracetamol and continue AmBisome. Fever and chills can be partially prevented by infusing AmBisome slowly (over 2 hours). Patient often feel a low backache if the infusion is given too fast.

Pregnant women and neonates AmBisome appears safe during pregnancy and is recommended as first-line treatment.

Contraindications AmBisome is contraindicated in patients who have shown hypersensitivity to amphotericin or the lipid content of AmBisome.

Other second-line drugs for VL: drugs under investigation

Miltefosine (MF) Miltefosine was developed as an antineoplastic drug. It is the first oral drug with demonstrated efficacy against VL. The drug has also been extensively studied in India, where it is registered.In

Ethiopia, improved survival of HIV-VL coinfected patients when using a combination of AmBisome and miltefosine(30 mg/kg total dose + miltefosine 100 mg for 28 days) vs AmBisome alone (40 mg/kg total dose) was demonstrated in a recent clinical trial (DNDi, HIV/VL 0511 study). Studies are required to introduce this combination among select groups of Sudanese HIV-VL coinfected patients in a pilot setting in Sudan.

Pentamidine Pentamidine is successfully used as secondary prophylaxis of relapses in HIV-VL coinfected patients in other countries in a dose of 4 mg/kg monthly. A recent study in Ethiopia showed improved relapse-free survival rates at 12 months (Diro et al, PLoS 2015). Studies are required to introduce this secondary prophylaxis among select groups of Sudanese HIV-VL co-infected patients in a pilot setting in Sudan.

Supportive treatment for patients with VL Care under direct medical supervision and observation

. Nutritional support. . Multivitamins. . Iron sulphate/gluconate and folic acid. . Tinidazole for parasitic infections if indicated. . Care for concurrent infection (e.g., malaria, pneumonia, TB and HIV/AIDS). . Blood transfusion is not generally needed; haemoglobin increases with successful treatment. Blood transfusion should be undertaken if the setting is optimal for donor screening and one has the ability to deal with any complications that may arise.

Nutrition protocol for visceral leishmaniasis patients The overall objectives of nutritional care for patients with VL are to assist the recovery period and improve the response to treatment. The specific objectives focus on:

. supporting all patients with nutritional support during treatment . reducing the incidence of concomitant illness/infection . treating severe and moderate acute malnutrition. All patients with VL should receive adequate nutritional support. This can be done through general food distribution, which must be appropriate in quality and quantity. The quality can be improved through supplementation of food items. Moderately and severely malnourished patients need to receive therapeutic food. Please see nutritional protocol for VL patients in annex No 5.

Follow-up after treatment Follow-up at the end of treatment, at 6 months post-treatment, and at any time whenever symptoms return is important to detect treatment failure.

Criteria of cure Primary VL: clinical cure with no fever, absence/reduction in the size of the spleen, weight gain and increase in haemoglobin.

Case definition according to follow-up Cases can be defined as follows:

 Primary VL: A patient who is diagnosed with VL for the first time has primary VL. There is no previous history of treatment of VL. Informal, incomplete treatments in the villages do occur and should be asked for explicitly.  Initial Cure: A patient that shows improvement of signs and symptoms at end of treatment (no fever, absence/reduction in the size of the spleen, weight gain and increase in haemoglobin)  Initial treatment failure: A positive TOC (parasitological failure) and persisting clinical signs/symptoms. There are two types: slow-responders and non-responders  Non-responder:Patients with persistent clinical symptoms and signs and a positive parasitology aspiration after completion of treatment (after 17 days of combination therapy or 30 days of SSG treatment or full dose of AmBisome). Patients who do not show any decrease in parasite load are also classified as non-responders.  Slow responder: Patients who show a slow clinical response and a decrease but not a disappearance of parasite load in lymph node or bone marrow aspirate examination after completion of therapy (17 days of combination therapy or 30 days of SSG treatment or full dose Ambisome).  Definitive cure: Patients who have an initial cure and show no sign or symptom of relapse within 6 months.  Discontinuation due to drug toxicity: Discontinuation of treatment due to SSG/PM- related drug toxicity  Defaulter: A patient that took less than 14 doses of SSG/PM or less than a total dose of 25mg/kg of AmBisome.  Relapse: a patient with clinically and parasitologically confirmed VL after successful treatment of VL. A person who has VL more than once is considered to have a relapse rather than reinfection. The term reinfection is not used with VL patients. We assume that reinfection occurs but does not lead to clinical disease because of immunity after successful treatment.  PKDL: a cutaneous manifestation caused by the same parasite that causes VL and usually occurs several weeks after recovery from VL.  Referred out: Any patients referred to other hospital for further management.  Death: Patient that died before or during the treatment of VL  Severe adverse effect (SAE) : any severe adverse effect related to theVL drug, which should be reported

Test of cure (TOC) TOC is a parasitological test (lymph node or bone marrow aspiration) performed at the end of treatment to assess the parasitological response to therapy. If the TOC is performed too early (<28 days), parasites may still be present and a diagnosis of non-response or slow response could be wrongly made. This is particularly important now that shorter treatment regimens are administered (i.e. SSG/PM 17 days, Ambisome 10 days). Therefore, the interpretation of a positive TOC made earlier than day 28 must take into account the presence or absence of clinical and biological signs of non-response.

TOC is NOT mandatory for all cases. It is only indicated in the following situations:

 Primary VL patients who show no clinical improvement at the completion of first line therapy (persistence of fever, Hb not increasing and/or no regression of the spleen)  Relapsed VL patients who received second line therapy  In all HIV-VL co-infected patients  Non-responders shifted to another anti-leishmanial treatment.  Slow responders during the extended course of treatment (weekly). NOTE: TOC is not necessary for primary VL if the patient improved clinically (clinically well, gained weight, Hb increase and decrease in spleen size).

Treatment of non-responders and relapses Initial non-responders: Consider second-line drugs (e.g., AmBisome). Do not repeat combination therapy (SSG+PM); instead switch to another antileishmanial drug. In case there are no others drugs available, one can stop PM and continue alone with SSG for first relapse up to 60 doses First relapse: Any patients treated before by SSG alone should receive SSG/PM and any patient treated by SSG/PM should be treated with AmBisome30 mg/kg total dose, divided in 6-10 doses of 3-5 mg/kg. Second and third relapse: AmBisome 50 mg/kg (3- 5 mg/kg twice weekly). Patients should be examined for risk factors for relapse such as TB and HIV.

Chapter 4 : OTHER TYPES OF LEISHMANIASIS

Cutaneous leishmaniasis: Cutaneous leishmaniasis (CL) is defined as ulcers, macules, papules or nodules of the skin caused by leishmaniasis. Atypical forms are frequent. There is no involvement of other organs. Cutaneous leishmaniasis (CL) in Sudan is caused by L. major. The disease is endemic in many parts of the country. The vector is P. papatasi and the animal reservoir is probably the Nile rat (A. niloticus). Clinically, patients usually present with papules, nodules, or noduloul cerative lesions, mainly on the exposed parts of the skin. In 20% of cases, the parasite disseminates through the lymphatics, producing sporotrichoid-like lesions. Diagnosis is confirmed by the demonstration of parasites in slit smears in 50–70% of cases and in histological sections in 70%. CL is a self-limiting disease; therefore, treatment is confined to patients with severe disease (El-Hassan & Zijlstra, 2001). See for diagnostic and treatment algorithm in annex 1.

Mucosal leishmaniasis: Mucosal leishmaniasis is a chronic infection of the upper respiratory tract and/or oral mucosa, which is caused mainly by L. donovani. The disease occurs in areas of the country that are endemic for VL, particularly among Masalit and other closely related tribes in western Sudan. The condition may develop during or after an attack of VL, but in most cases it is a primary mucosal disease. The diagnosis is established by demonstration of parasites in smears or biopsies, by culture or animal inoculation. Most patients yield positive results in the DAT and leishmanin skin test (LST). Patients respond well to treatment with SSG (El-Hassan & Zijlstra, 2001).

Treatment of mucosal leishmaniasis Single doses of 10–20 mg/kg/day of SSG are given for a minimum of 4 weeks. Relapse should be treated with the same drug given for at least twice as long as the original treatment. Only when this fails should alternative treatment be given.

Post Kala-azar Dermal Leishmaniasis (PKDL): PKDL is a known complication of VL. In the majority of cases, dermal lesions develop several months after the clinical cure of VL, but sometimes PKDL occurs during or even before treatment. However, cases have been reported in the absence of a history of VL. About 55% of successfully treated VL patients develop PKDL. The lesions of PKDL start on the face as small scattered hypopigmented macules and papules. The rash can become nodular and spread to the trunk and limbs. Lesions are symmetrical and not itchy. A grading system is used to describe the spread of the skin lesions. • Grade 1: scattered macular, papular or nodular rash on the face with some lesions on the upper chest and upper arms.

• Grade 2:dense macular, papular or nodular rash covering most of the face and extending on the chest, back, and upper arms and legs. • Grade 3:dense macular, papular rash, covering most of the body, including hands and feet. In grade 3, crusting, ulcers, scaling and spreading to the mucosa of the lip and the palate occur. It is referred to as PKDL with mucosal involvement (or combined PKDL and post VL mucosal leishmaniasis). Lesions are often restricted to sun-exposed areas (whole body in children, face and collar distribution for men, and face for women). Parasites can be detected in skin smears, but not in all cases. Parasites have also been detected in the normal skin in patients with VL. PKDL might persist for up to 10 years. It is speculated that PKDL patients could form a reservoir of the parasite in the community. Bed nets may be indicated to prevent transmission. PKDL is distinct from CL, which consists of one or more ulcers caused by other species of Leishmania. PKDL can easily be confused with diffuse leprosy and other skin diseases.

Treatment of PKDL: Spontaneous healing occurs in mild cases (grade 1 or mild grade 2). The indications for treatment are: o Grade 3 and advanced grade 2 lesions o Persistence of lesions for >12 months o Concomitant anterior uveitis or mucosal lesions or lesion more than 1 year. Treat until the lesions are definitely improving and not until the lesions have disappeared. Once healing begins during treatment, it usually continues off treatment. There are no parasitic criteria for cure because of the difficulties of demonstrating the parasite in the lesions. Follow-up is monthly until full resolution of lesions. It is advisable to take pictures of PKDL patients (after obtaining consent) at admission to ensure proper follow-up of the clearing of lesions.  The following drugs can be used to treat PKDL: o SSG&PM for 17 days (SSG: 20 mg/kg/day and PM 15 mg/kg paromomycin for 17 days) o SSG at a dose of 20 mg/kg/day for 60–90 days is effective (El Hassan &Zijlstra, 2001). Stop treatment when there is clear improvement of the PKDL rash; there is no need to continue until the skin rash has completely gone. It is advised to continue treatment until 4–7 days after lesions have regressed and are no longer palpable, but discoloration is still visible. Approximately 4–8 weeks of treatment are needed, but longer courses are common. o Relapse PKDL: AmBisome at a dose of 2.5 mg/kg/day for 20 days has been used successfully in some patients (Hashim et al., 1995; Musa et al., 2005).

Chapter 5 : LEISHMANIASIS AND HIV CO-INFECTION

HIV and leishmaniasis are both expanding. Due to the increasingly overlapping geographical distribution of the two causative pathogens the number of cases with co-infection is expected to rise. HIV infection and VL influence each other reciprocally. HIV has caused an increase in VL cases. HIV patients with VL have a poor prognosis, and VL stimulates replication of HIV (Davidson, 1997).

Clinical features of Leishmania/HIV co-infection The diagnosis of VL in patients co-infected with HIV can be particularly difficult. The usual clinical features of VL (splenomegaly, pancytopenia, fever and weight loss) are not always present or may be hidden by other opportunistic infections mimicking the same symptoms. Patients may have atypical VL with slight or no splenomegaly and only non-specific symptoms of fever, weight loss and malaise. VL may be rapidly progressive, resembling bacterial sepsis. Alternatively, VL may have unusually slow progression with a few non-specific symptoms, and some patients with VL may be entirely asymptomatic. HIV/Leishmania co-infected patients may have predominantly gastrointestinal involvement with symptoms of diarrhoea and weight loss. Leishmania parasites can be detected in biopsies of the oesophagus, duodenum and rectum. The larynx may also be involved, either alone or with gastrointestinal involvement.

Diagnosis of visceral leishmaniasis in HIV-positive patients In AIDS patients, the cells responsible for the immune response are destroyed, impairing the capacity of the immune system to react to invasion by the leishmaniasis parasite. Consequently, the serological test for detection of Leishmania antibodies (IFAT or ELISA) is negative in 20–40 % of patients with HIV and VL co-infection. It is expected that DAT titres in Africa will be lower in such cases as well. The diagnosis is better by lymph node/bone marrow aspirate, and not DAT alone. Parasites are abundant in lymph nodes/bone marrow, and microscopy of bone marrow aspirates yields a diagnosis in 91–97% of cases Therefore a parasitological test must be conducted for HIV/VL patients at admission and discharge. In 50% of HIV/VL patients, the buffy coat (white cell concentrate) of peripheral blood is positive. Sensitivity of culture of the buffy coat can reach 90%. About 80% of HIV/Leishmaniaco infected patients usually have another AIDS-defining opportunistic infection, and 90% have CD4+ count <200/mm3 at the time of diagnosis. This may not be the case in Africa where the causative species is L. donovani, which is probably more virulent than L. infantum. All VL patients must be screened for HIV, and microscopy of a lymph node/bone marrow aspirate is the recommended test for diagnosis and test of cure.

Treatment of HIV/VL co-infection All VL patients should be counselled and tested for HIV because first-line antileishmanial treatment in HIV-positive patients with SSG+PM combintaion therapy is contra-indicated as it is

20 more toxic in this group of patients. For safety reasons, patients with VL/HIV co-infection should be treated with AmBisome as a first line treatment. The response to antimonials, AmBisome or other anti-leishmaniasis drugs is both slow and less satisfactory in HIV/Leishmania co-infected patients. These patients have a huge parasite load and lack cell-mediated immunity to assist in parasite clearance.

Failure to clear parasites and treatment of relapse A positive TOC in a patient with HIV/Leishmania co-infection should be followed by further treatment. If patients do not have relief of the symptoms of VL by 30 days, they will not benefit from a longer course of treatment. Thus, if HIV infection is suspected in patients with a positive TOC, aHIV test should be performed. Relapse of VL in known HIV patients should only be treated if symptoms are present. If HIV infection is suspected in patients who have relapsed, an HIV test should be performed.

Prognosis of HIV/VLcoinfection The prognosis for HIV/KA coinfected patients is poor and characterized by a high mortality rate during the first episode, increased anti–leishmanial drug toxicity and a poor long term clinical and parasitological response to treatment with a high relapse rate. The prognosis is significantly improved when CD4 counts can be kept at >200 with ART for 3 months or more. When not on ART, 60% of patients relapse within 6-9 months and 90% within one year. ART was shown to be only partially protective against relapses-overall; ART reduced the risk of relapse by ~50%. A lower risk of relapse was associated with higher CD4 counts; when on ART, the probability of a first relapse decreased from 30% with CD4 counts <100 to less than 10% when >200. The protective effect became less strong for any consequent relapse (ter Horst R et al, CID 2008). Public health implications of HIV/leishmaniasis HIV/Leishmania co-infected patients must be considered as highly infectious reservoirs of Leishmania in areas of active transmission because of the presence of amastigotes in the blood. The reservoir of VL in Africa is probably humans, so drug-resistant transmission can occur. There is a clear correlation between the severity of immunosuppression and the percentage of sandflies becoming infected. Every VL patient should sleep under a LLIN and every HIV- positive patient should be sleeping under a LLIN whether or not they have VL.

Chapter 6 : SHORT OUTLINE OF THE NEW TREATMENT PROTOCOL

1 First-line VL treatment: SSG and paromomycin sulphate (PM) injection combination

Drug Dose Duration Route of Contraindications administration SSG 20 mg/kg single 17 days IM (avoid IV Cardiac disease, liver disease dose unless CI) (jaundice), renal failure, age >45 years, + HIV/AIDS, pregnancy, and infancy 15 mg/kg single 17 days IM only Patients who have shown Paromomycin dose hypersensitivity to paromomycin or sulphate (PM) other aminoglycosides Relatively contraindicated in patients with impaired renal function. Patients with pre-existing hearing impairment.

2 Second-line VL treatment: AmBisome

Drug Dose Duration Route of Contraindications administration AmBisome 3 mg/kg per 10 10 days IV only Patients who have shown (liposomal day (total of 30 or hypersensitivity to amphotericin or the amphotericin B) mg/kg/10 days) alternate lipid content of AmBisome If the patient day to

needs extension avoid extra 20 mg can fluid be given over 7 overload days in some cases

3 Mucosal leishmaniasis (for cutaneous leishmaniasis see annex 1)

Drug Weight/age Dose/day Duration Route of administration

SSG All new cases 20 mg/kg single Minimum of 4 IM/IV dose weeks

SSG Relapse 20 mg/kg twice Minimum of 4 IM/IV weeks

4 Post Kala-azar Dermal Leishmaniasis (PKDL)

Drug Weight/age Dose Duration Route of administration

Sodium 20 mg/kg/day 17 days IM/IV stibogluconate + All patients paromomycin sulphate (PM) 15mg/kg/day

AmBisome All patients 2.5 mg/kg/day Daily for 20 days IV only

5 HIV/VL co-infection

Drug Patient category Dose Duration Route of administration

AmBisome Co-infected 3-5 mg/kg per dose 10 days or alternate IV patients for up to 50 mg/kg days for some cases to avoid fluid

overload

ANNEX 1: CUTANEOUS LEISHMANIASIS ALGORITHM Treatment of cutaneous leishmaniasis: Step-wise treatment decision algorithm

Manual for case management of cutaneous leishmaniasis in the WHO Eastern Mediterranean 2014

ANNEX 2: Aspiration of lymph node, spleen and bone marrow

Lymph nodes Lymph node aspiration is commonly taken from less hazardous clear lymph groups (e.g., inguinal or trochlear). The nodes are grasped between the thumb and finger after sterilization. A 21-gauge needle is attached to a 5-ml syringe and introduced, pushing the needle in and out to force the cells into the needle. A few drops of the aspirated fluid are placed onto a slide, smeared thinly, dried, fixed with methanol, stained with Giemsa, and examined. Spleen Spleen aspiration is the simplest, fastest and most reliable procedure for detection of Leishmania parasites. However, it carries a risk of bleeding, visceral puncture and splenic rupture, therefore, it requires expertise (physician) and should be performed in hospital with ready access to blood and an operating theatre. Contraindications for spleen aspiration are: impalpable spleen, bleeding tendency, untrained staff, jaundice and late pregnancy. Technique • Sterilization of the site and equipment. • A 21-gauge needle attached to a 5-ml syringe is inserted in the midline of the spleen. The needle is inserted quickly to the full needle depth (3 cm). A vacuum is created by pulling the plunger back and the needle is removed immediately. The speed ensures that no tearing occurs. The content of the syringe is deposited on a slide; a thin smear is made; and the slide is stained with Giemsa and examined. • Puncture is performed at expiration, especially in children. • No local anaesthesia is given. • Sedation is recommended in restless or crying child (lymph node or bone marrow aspiration is preferred). • Patient must be observed for 24 h. Bone marrow Bone marrow aspirate is usually taken from the sternum or iliac crest under local anaesthesia, with a sterile bone marrow aspirate needle attached to a 10-ml syringe. This smears are formed immediately on at least three slides, fixed with 100% methanol, dried labelling, and stained with Giemsa. Examined fewer than 100 magnifications (1000 field).

ANNEX 3: SSG + PM DOSAGE TABLES

Sodium stibogluconate (SSG) = 20mg X (patient wt)/100= (dose)ml Weight (kg) Dose (ml) Weight (kg) Dose (ml)

10 2 29 5.8 11 2.2 30 6 12 2.4 31 6.2

13 2.6 32 6.4

14 2.8 33 6.6 15 3 34 6.8 16 3.2 35 7 17 3.4 36 7.2 18 3.6 37 7.4

19 3.8 38 7.6

20 4 39 7.8 21 4.2 40 8 22 4.4 41 8.2

23 4.6 42 8.4

24 4.8 43 8.6 25 5 44 8.8 26 5.2 45 9

27 5.4 46 9.2

28 5.6 50 10

Dosage per weight of PM sulphate 15mg/kg (11mg/kg base):

Weight (kg) Dose (ml) Weight (kg) Dose (ml) 48 – 45 1.4 11 – 10 0.3 51 – 49 1.5 14 – 12 0.4

54 – 52 1.6 18 – 15 0.5 58 – 55 1.7 21 – 19 0.6 61 – 59 1.8 24 – 22 0.7 64 – 62 1.9 28 – 25 0.8

68 – 65 2.0 31 – 29 0.9 71 – 69 2.1 34 – 32 1.0 74 – 72 2.2 38 – 35 1.1 75 and over 2.3 41 – 39 1.2 44 – 42 1.3

ANNEX 4: AmBisome dosage table

Regimen:3 mg/kg/day for 10 days Calculation:Dosage in ml = dosage in mg X 19 = ml of dextrose 5% 4 Rate for infusion: weight in Kg x 2,375 AmBisome doses (~30 mg/kg divided in 10 doses)

Weight (kg) D1 D2 D3 D4 D5 D6 D7 D8 D9 D10

3.5 – 5 1 - - - 1 - - - 1 -

5.1 – 6.6 1 - 1 - 1 - - - 1 -

6.7 – 8.3 1 - 1 - 1 - 1 - 1 -

8.4 – 10 1 1 1 - 1 - 1 - 1 -

10.1 – 11.7 1 1 1 - 1 1 1 - 1 -

11.8 – 13.3 1 1 1 - 1 1 1 - 1 1

13.4 – 15.0 1 1 1 1 1 1 1 - 1 1

15.1 – 16.7 1 1 1 1 1 1 1 1 1 1

16.8 – 18.3 2 1 1 1 1 1 1 1 1 1

18.4 – 20.0 2 1 1 1 2 1 1 1 1 1

20.1 – 21.7 2 1 2 1 2 1 1 1 1 1

21.8 – 23.3 2 1 2 1 2 1 2 1 1 1

23.4 – 25.0 2 1 2 1 2 1 2 1 2 1

25.1 – 26.7 2 2 2 1 2 1 2 1 2 1

26.8 – 28.3 2 2 2 1 2 2 2 1 2 1

28.4 – 30.0 2 2 2 1 2 2 2 1 2 2

30.1 – 31.7 2 2 2 2 2 2 2 1 2 2

31.8 – 33.3 2 2 2 2 2 2 2 2 2 2

33.4 – 35.0 3 2 2 2 2 2 2 2 2 2

35.1 – 36.7 3 2 2 2 3 2 2 2 2 2

36.8 – 38.3 3 2 3 2 3 2 2 2 2 2

38.4 – 40.0 3 2 3 2 3 2 3 2 2 2

40.1 – 41.7 3 2 3 2 3 2 3 2 3 2

41.8 – 43.3 3 3 3 2 3 2 3 2 3 2

43.4 – 45.0 3 3 3 2 3 3 3 2 3 2

45.1 – 46.7 3 3 3 2 3 3 3 2 3 3

46.8 – 48.3 3 3 3 3 3 3 3 2 3 3

48.4 – 50.0 3 3 3 3 3 3 3 3 3 3

50.1 – 51.7 4 3 3 3 3 3 3 3 3 3

51.8 – 53.3 4 3 3 3 4 3 3 3 3 3

53.4 – 55.0 4 3 4 3 4 3 3 3 3 3

55.1 – 56.7 4 3 4 3 4 3 4 3 3 3

56.8 – 58.3 4 3 4 3 4 3 4 3 4 3

58.4 – 60.0 4 4 4 3 4 3 4 3 4 3

60.1 – 61.7 4 4 4 3 4 4 4 3 4 3

61.8 – 63.3 4 4 4 3 4 4 4 3 4 4

63.4 – 65.0 4 4 4 4 4 4 4 3 4 4

65.1 – 66.7 4 4 4 4 4 4 4 4 4 4

ANNEX 5: Nutrition protocol for VL patients 1 Screening For each patient: - Take anthropometric measurements at admission and at each visit (see how to take the measurements in Appendix 1), - Refer to the below table to decide if the patient is malnourished or not, - According to the result refer to section 2 for treatment of malnutrition or section 3 for support of malnutrition. Important: at any time, if the patient becomes malnourished, you have to treat him.

Table 1: Anthropometric measurements by category

Malnourished Non malnourished  need treatment  need nutritional support (see section 2) (see section 3)

Children from 6 to 59 months (<5 years) ▪ W/H < -2 z-score ▪ W/H ≥ -2 z-score (From 67 to < 110 cm) and/or and

▪ MUAC < 125 mm ▪ MUAC ≥ 125 mm

and/or and

▪ Bilateral pitting oedema** ▪ No bilateral pitting oedema

Children from 5 to 10 years ▪ Children: W/H < -2 z-score ▪ Children: W/H ≥ -2 z-score (≥ 110.0 to 140.0 cm) ▪ Adolescent: W/H < 80 % ▪ Adolescent: W/H ≥ 80 % Adolescents from > 10 to 18 years and/or and (≥ 140.0 cm) ▪ Bilateral pitting oedema** ▪ No bilateral pitting oedema

Adults and Elderly (Except pregnant and ▪ MUAC < 210 mm ▪ MUAC ≥ 210 mm lactating women) > 18 years and/or and ▪ BMI < 17 ▪ BMI ≥ 17

and/or and

▪ Bilateral pitting oedema at knees or above ▪ No bilateral pitting oedema or at (grade ≥ 3) ** ankles or below (grade ≤ 2)

Pregnant and lactating women ▪ MUAC < 230 mm ▪ MUAC ≥ 230 mm and/or and

▪ Bilateral pitting oedema at knees or above ▪ No bilateral pitting oedema at ankles (grade ≥ 3) ** or below (grade ≤ 2

** Bilateral pitting oedema: to be confirmed with medical consultation as oedema can also appear due to other diseases (renal, cardiac,hepatic etc.)..

Treatment of malnutrition As hospitalised VL patients are in severe medical condition, moderate and severe malnutrition will be both treated with the same protocol for these patients. Below is a summary and simplification of the management of malnutrition. For more details, please refer to the last Sudan National protocol for management of malnutrition. a. MEDICAL SYSTEMATIC TREATMENT for children 6-59months with KA

Prevention Treatment Day Day Day Day Day Day Day Day 1 2 3 4 5 6 7 8

1. Infections only Amoxicillin + + + + + + + + + + for SAM patients 1 2. Digestive Albendazole (it can + + + parasites be delay if needed)

3. Malaria RDT in endemic areas + (repeat if fever re- appears)

Treat if RDT positive Treat according to national protocol

4. TB diagnosis TB decision tools + Repeat every 2 weeks

Treat if positive Treat according to national protocol 5. HIV diagnosis HIV counselling + In the 5 days of admission testing if agreed

Treat if positive Treat according to national protocol 6. Vaccine- Vaccination Complete the vaccination according to the age (refer to preventable EPI and confirm the vaccination are up to date before diseases discharge)

Amoxicillin tablet, 250 mg (80 mg / kg / day) twice a day for 5 days Weight Dose for 5 days

 4kg ½ tablet twice a day

4 - 7.9 kg 1 tablet twice a day

8 - 11.9 kg 1 ½ tablet twice a day

≥ 12 kg 2 tablet twice a day

NB: This antibiotherapy has to be adapted to the child’s disease

1 SAM anthropometric criteria: MUAC <115mm, or oedema, or WHZ <-3Zscore

Albendazole tablet, 400 mg single dose (Do not treat children < 6 months) Weight Quantity < 8 kg ½ tablet, single dose

≥ 8 kg 1 tablet, single dose

NB: If anaemia <11 g/l: treat accordingly, by iron (or transfusion if severe/unstable) according to national protocol. No systematic Ferrous/iron, due to infectious risk (during the 1st week), and because it is now included in the PlumpyNut/RUTF recent nutritional products. b. NUTRITIONAL TREATMENT (see tables of quantity per weight in annexes)

- Adolescents and adults can usually start the nutritional treatment directly in phase 2 (but if needed do not hesitate to start in phase 1 with F75, depending of their appetite and medical conditions). - Children need usually to start in phase 1 with F75. But if the child has appetite (see in annex the appetite test), good absorption functions and good enough health conditions then they can start the nutritional treatment directly in phase 2, specially for the MAM patient (moderate acute malnutrition: 115mm≤MUAC <125mm or -3Z≤WHZ <-2Zscore (NO oedema))

Phase 1* F-75 milk

- 6months to 10years: Stabilisation 100 kcal / kg / day - (130 ml / kg / day)

2 to 7 days (but might be longer depending - 10 to 18 years: of the severity at admission) 55 Kcal / kg / d - (75 ml / kg / d) 8 meals per day - Adults: (every 3Hours) 40 kcal / kg / d - (55 ml / kg / d)

Phase T RUTF*(with unlimited drinking water) Transition or F-100 if needed - 6months to 10years: usually 1 to 3 days 130 kcal / kg / day (130 ml / kg / day) 6 meals per day - 10 to 18 years: 75 Kcal / kg / d - (75 ml / kg / d) -Adults: 55 kcal / kg / d - (55 ml / kg / d)

RUTF*(with unlimited drinking water) Phase 2 - 6months to 10 years: 200 kcal / kg / day - max. 3000 kcal/day Re-nutrition

Until recovery - 10 to 18 years: 100 kcal/kg/day - max. 3000 kcal/day

6 meals per day for children - Adults: 80 kcal/kg/day - max. 3000 kcal/day

*RUTF Ready to Use Therapeutic Food, 2 main sorts: Biscuits (BP100®) and paste (Plumpy nut®, eeZeepaste®...).

- 1 sachet of paste RUTF (e.g. Plumpy nut®) contains 500 kcal - 1 bar of biscuit RUTF (eg BP100®) is made out of two tablets, each containing 150 kcal (total 300 kcal / bar).  In phase I the patient should receive therapeutic milk recommended for phase I and no other foods. If adolescents or adults do not want therapeutic milk or do not digest easily it, then give RUTF (paste or bar) following phase I quantity in terms of kcal/kg (but be aware that RUTF contains iron, contrary to F75).  In phase II patients should consume as much as they like and children >10years, adolescents and adults can eat the family meal in addition to the RUTF.  Following movement criteria between the different phases have to be met within the therapeutic care. Flow chart: Anthropometric and clinical criteria on therapeutic program phase movement of malnourished patients All criteria need to be fulfilled

Phase I  Transition phase Transition phase Phase II Phase II  Patient meals

 Appetite improved;  Stable and ascending  Discharge criteria taking all prescribed milk weight fulfilled according to age quantity  Good appetite group  Absence or reduction of  Stable medical condition  Absence of oedema or oedema grade  Absence or reduction of accepted grade within  Stabilised medical oedema grade adults condition  Good appetite  No diarrhoea or vomiting  Good physical condition  Alert

c. Follow up and Discharge: All malnourished patients should be carefully monitored, especially children. Example of a Routine Monitoring schedule of patients in nutritional care

After completion of the VL treatment: When the patient is still malnourished (see table in screening part) with the completion of the VL treatment: - Adolescents and adults in good clinical condition are discharged from the nutrition program receiving a final ration of RUTF for two weeks. - Children (specially less than 5 years) have to continue the nutritional treatment until being cured

If the child has medical complications and / or no appetite, the child need be keep hospitalised to treat medical complication and continue nutritional treatment until being ready to be follow in ambulatory. If the child has no medical complications and has appetite, refer the child to an ATFC (ambulatory therapeutic nutritional centre) to finish the nutritional treatment. If there is no ATFC to refer to, then organise a follow up, every 2 weeks, until the child get cured. At each visit: take the weight, the MUAC and the oedema, do a medical consultation, treat accordingly and give the nutritional treatment (RUTF) for 2 weeks.

NUTRITIONAL SUPPORT There is no evidence of what are the specific nutrients needs for VL patients. Anyway, in order to assist the recovery period, to improve the response to VL treatment and to reduce incident of concomitant illness/infection, all VL patients should receive at least balanced meal, in terms of quality and quantity (Kcal, protein, lipids, vitamins and minerals), according to the requirements for their age. Patients should receive an energy and protein-dense diet fortified with micronutrients. For an adult, the meals should contain around 2500 kcal per day and fulfil the daily recommended micronutrients intake. The meals should be composed with: - Minimum 17% of kcal provided by fat - 10 to 15 % of kcal provided by protein. As it is difficult to fulfil the micronutrients daily requirements with local food, specific nutritional product and /or fortified food should be added. Moreover remember the salt should be always fortified with iodine and when possible prefer also fortified food products as oil fortified with vitamin A Example of nutritional product and /or fortified food: - High energy Biscuit - Emergency Food ration (eg BP5, NRG5) - Fortified Blended Food (eg Supercereal, supercereal+) - Micronutrients Powder (eg mixme, sprinkles…) or Paste (QBmix) - LNS (Lipid based Nutrient Supplement) small, medium or large quantity (eg EeZee20, PlumpyDoz, EeZeeRUSF, etc):

Example of a standard full food ration in g / person / day

Food Ration (g / person / day)

Cereal (Sorghum, Maize, Rice…) 400

Puses (Beans, lentils,..) 100

Oil 30

Fortified blended food (Superceral) 100

Sugar 15

Salt 5

Energy content (kcal) 2486 kcal

Protein (in g and in % of kcal) 73 g; 12%

Fat (in g and in % of kcal) 52 g; 19%

Upgrade the meals with additional items such as carrots, tomato, onion etc and when possible meat or fish (once a week for example).

When the patient is discharged from the in-patient VL care: Nutritional support should continue throughout the VL follow-up period at household level (to support the recovery and prevent pathologies). It can be based on complete (as proposed above) or partial rations, preferably fortification.

Monitoring Regular monitoring of the outcome indicators allow to assess successes and difficulties in the nutritional support of VL patients and adaptations. A data collection format or database on basic monitoring indicators should be outlined. The minimum data to be monitored and analysed for overall program information are:

 Number of admissions within severe and moderate malnutrition (SAM and MAM)  Number of exits with detailed outcome indicators: *Cured, *Stabilised, *Non-respondent, *Death, *Defaulter and *Transfer to other health facilities.  Length of stay for SAM, MAM and non malnourished.

Appendix

Appendix 1: Anthropometric and oedema measurements & Weight for Height and BMI tables

1. Weight

a. Children  Install a 25 kg hanging spring scale (graduated by 100 gram).  Suspend the basin from the lower hook of the scale and recalibrate to zero.  Remove child’s clothes and place him/her in the hanged basin.  Read scale at eye level and ensure that the child is not holding on mothers, caretakers or staffs.

For baby preferable use a mechanical or electronic scale precise to 10 grams.

b. Adolescents and adults Scales used for adults or adolescents should provide a degree of precision of 100 gram. A mechanical or electronic scale (i.e. Uniscale from UNICEF) can be used.

2. Height / Length

c. Children below 87 cm  Place the measuring board on the ground or on a table; gently lay the child supine in the middle.  An assistant should hold the side of the child’s head, and position it until it touches the “foot board” (stable end of the measuring board).  A measurer should position and hold the child’s knees or ankles in a straight line, and place the “cursor” (movable portion) at a right angle against the child’s feet.  The measurer should read the length to the nearest 0.1 cm.

d. Children above or equal to 87 cm and Adolescents and adults  Place the measuring board upright.  Remove the person’s shoes and stand her/him on the middle of the measuring board.  An assistant should press the person’s ankles and knees against the board, ensuring his/her head, shoulders, buttocks, knees and heals touch the board.  The measurer should position the head at a right angle to the cursor.  The measurer should read the height to the nearest 0.1 cm.

The height/length is ALWAYS TAKEN WITH TWO PEOPLE for chidren

3. MUAC MUAC measurement is fast and simple but not easy and variations in measurements often occur between different measurers. This is mainly due to identified positioning on the mid-upper-arm and how the tape is pulled or “squeezed” around the arm. Taking the MUAC  Let the left arm hang relaxed at the side of the body.  Place the MUAC measuring tape midway between the elbow and the shoulder and identify the mid- arm.  Fit the tape securely around the arm. The tape should not be too slack, nor pulled too tightly.  Read the measurement at the window of the tape and record the millimetres.

a. MUAC cut off points for children 6-59 months

Severe acute Moderate acute Normal malnutrition malnutrition

< 115 mm 115 to 125 mm ≥ 125 mm

b. MUAC cut-off points for adults, the elderly and pregnant and lactating women

4. Oedema Oedema in malnutrition is always bilateral: both feet, both legs, both hands...  Moderate thumb pressure is applied to lower extremities bilaterally (just above the ankle or the tops of the feet).  Count 3 seconds (101, 102, 103).  If fingers are removed and a saucer shape persists, oedema is considered.  Oedema is generally first present in the feet/internal malleolus then, oedema develop on the feet, tibias and legs and finally, oedema generalizes on the feet, tibias, legs and face

39 a. Grading of bilateral pitting oedema for children

b. Grading of oedema for adults based on the Beattie classification

Weight for height table: WHO 2006 new references in Z- score Weight for length (lying down)

Boys Girls -3 -2 -1 median Cm Median -1 -2 -3 1.9 2.0 2.2 2.4 45 2.5 2.3 2.1 1.9 1.9 2.1 2.3 2.5 45.5 2.5 2.3 2.1 2.0 2.0 2.2 2.4 2.6 46 2.6 2.4 2.2 2.0 2.1 2.3 2.5 2.7 46.5 2.7 2.5 2.3 2.1 2.1 2.3 2.5 2.8 47 2.8 2.6 2.4 2.2 2.2 2.4 2.6 2.9 47.5 2.9 2.6 2.4 2.2 2.3 2.5 2.7 2.9 48 3.0 2.7 2.5 2.3 2.3 2.6 2.8 3.0 48.5 3.1 2.8 2.6 2.4 2.4 2.6 2.9 3.1 49 3.2 2.9 2.6 2.4 2.5 2.7 3.0 3.2 49.5 3.3 3.0 2.7 2.5 2.6 2.8 3.0 3.3 50 3.4 3.1 2.8 2.6 2.7 2.9 3.1 3.4 50.5 3.5 3.2 2.9 2.7 2.7 3.0 3.2 3.5 51 3.6 3.3 3.0 2.8 2.8 3.1 3.3 3.6 51.5 3.7 3.4 3.1 2.8 2.9 3.2 3.5 3.8 52 3.8 3.5 3.2 2.9 3.0 3.3 3.6 3.9 52.5 3.9 3.6 3.3 3.0 3.1 3.4 3.7 4.0 53 4.0 3.7 3.4 3.1 3.2 3.5 3.8 4.1 53.5 4.2 3.8 3.5 3.2 3.3 3.6 3.9 4.3 54 4.3 3.9 3.6 3.3 3.4 3.7 4.0 4.4 54.5 4.4 4.0 3.7 3.4 3.6 3.8 4.2 4.5 55 4.5 4.2 3.8 3.5 3.7 4.0 4.3 4.7 55.5 4.7 4.3 3.9 3.6 3.8 4.1 4.4 4.8 56 4.8 4.4 4.0 3.7 3.9 4.2 4.6 5.0 56.5 5.0 4.5 4.1 3.8 4.0 4.3 4.7 5.1 57 5.1 4.6 4.3 3.9 4.1 4.5 4.9 5.3 57.5 5.2 4.8 4.4 4.0 4.3 4.6 5.0 5.4 58 5.4 4.9 4.5 4.1 4.4 4.7 5.1 5.6 58.5 5.5 5.0 4.6 4.2 4.5 4.8 5.3 5.7 59 5.6 5.1 4.7 4.3 4.6 5.0 5.4 5.9 59.5 5.7 5.3 4.8 4.4 4.7 5.1 5.5 6.0 60 5.9 5.4 4.9 4.5 4.8 5.2 5.6 6.1 60.5 6.0 5.5 5.0 4.6 4.9 5.3 5.8 6.3 61 6.1 5.6 5.1 4.7 5.0 5.4 5.9 6.4 61.5 6.3 5.7 5.2 4.8 5.1 5.6 6.0 6.5 62 6.4 5.8 5.3 4.9 5.2 5.7 6.1 6.7 62.5 6.5 5.9 5.4 5.0 5.3 5.8 6.2 6.8 63 6.6 6.0 5.5 5.1 5.4 5.9 6.4 6.9 63.5 6.7 6.2 5.6 5.2 5.5 6.0 6.5 7.0 64 6.9 6.3 5.7 5.3 5.6 6.1 6.6 7.1 64.5 7.0 6.4 5.8 5.4 5.7 6.2 6.7 7.3 65 7.1 6.5 5.9 5.5 5.8 6.3 6.8 7.4 65.5 7.2 6.6 6.0 5.5 5.9 6.4 6.9 7.5 66 7.3 6.7 6.1 5.6 6.0 6.5 7.0 7.6 66.5 7.4 6.8 6.2 5.7 6.1 6.6 7.1 7.7 67 7.5 6.9 6.3 5.8 6.2 6.7 7.2 7.9 67.5 7.6 7.0 6.4 5.9

6.3 6.8 7.3 8.0 68 7.7 7.1 6.5 6.0 6.4 6.9 7.5 8.1 68.5 7.9 7.2 6.6 6.1 6.5 7.0 7.6 8.2 69 8.0 7.3 6.7 6.1 6.6 7.1 7.7 8.3 69.5 8.1 7.4 6.8 6.2 6.6 7.2 7.8 8.4 70 8.2 7.5 6.9 6.3 6.7 7.3 7.9 8.5 70.5 8.3 7.6 6.9 6.4 6.8 7.4 8.0 8.6 71 8.4 7.7 7.0 6.5 6.9 7.5 8.1 8.8 71.5 8.5 7.7 7.1 6.5 7.0 7.6 8.2 8.9 72 8.6 7.8 7.2 6.6 7.1 7.6 8.3 9.0 72.5 8.7 7.9 7.3 6.7 7.2 7.7 8.4 9.1 73 8.8 8.0 7.4 6.8 7.2 7.8 8.5 9.2 73.5 8.9 8.1 7.4 6.9 7.3 7.9 8.6 9.3 74 9.0 8.2 7.5 6.9 7.4 8.0 8.7 9.4 74.5 9.1 8.3 7.6 7.0 7.5 8.1 8.8 9.5 75 9.1 8.4 7.7 7.1 7.6 8.2 8.8 9.6 75.5 9.2 8.5 7.8 7.1 7.6 8.3 8.9 9.7 76 9.3 8.5 7.8 7.2 7.7 8.3 9.0 9.8 76.5 9.4 8.6 7.9 7.3 7.8 8.4 9.1 9.9 77 9.5 8.7 8.0 7.4 7.9 8.5 9.2 10.0 77.5 9.6 8.8 8.1 7.4 7.9 8.6 9.3 10.1 78 9.7 8.9 8.2 7.5 8.0 8.7 9.4 10.2 78.5 9.8 9.0 8.2 7.6 8.1 8.7 9.5 10.3 79 9.9 9.1 8.3 7.7 8.2 8.8 9.5 10.4 79.5 10.0 9.1 8.4 7.7 8.2 8.9 9.6 10.4 80 10.1 9.2 8.5 7.8 8.3 9.0 9.7 10.5 80.5 10.2 9.3 8.6 7.9 8.4 9.1 9.8 10.6 81 10.3 9.4 8.7 8.0 8.5 9.1 9.9 10.7 81.5 10.4 9.5 8.8 8.1 8.5 9.2 10.0 10.8 82 10.5 9.6 8.8 8.1 8.6 9.3 10.1 10.9 82.5 10.6 9.7 8.9 8.2 8.7 9.4 10.2 11.0 83 10.7 9.8 9.0 8.3 8.8 9.5 10.3 11.2 83.5 10.9 9.9 9.1 8.4 8.9 9.6 10.4 11.3 84 11.0 10.1 9.2 8.5 9.0 9.7 10.5 11.4 84.5 11.1 10.2 9.3 8.6 9.1 9.8 10.6 11.5 85 11.2 10.3 9.4 8.7 9.2 9.9 10.7 11.6 85.5 11.3 10.4 9.5 8.8 9.3 10.0 10.8 11.7 86 11.5 10.5 9.7 8.9 9.4 10.1 11.0 11.9 86.5 11.6 10.6 9.8 9.0

WHO 2006 new references in Z-score

Boys Girls -3 -2 -1 median Cm Median -1 -2 -3 9.6 10.4 11.2 12.2 87 11.9 10.9 10.0 9.2 9.7 10.5 11.3 12.3 87.5 12.0 11.0 10.1 9.3 9.8 10.6 11.5 12.4 88 12.1 11.1 10.2 9.4 9.9 10.7 11.6 12.5 88.5 12.3 11.2 10.3 9.5 10.0 10.8 11.7 12.6 89 12.4 11.4 10.4 9.6 10.1 10.9 11.8 12.8 89.5 12.5 11.5 10.5 9.7 10.2 11.0 11.9 12.9 90 12.6 11.6 10.6 9.8 10.3 11.1 12.0 13.0 90.5 12.8 11.7 10.7 9.9 10.4 11.2 12.1 13.1 91 12.9 11.8 10.9 10.0 10.5 11.3 12.2 13.2 91.5 13.0 11.9 11.0 10.1 10.6 11.4 12.3 13.4 92 13.1 12.0 11.1 10.2 10.7 11.5 12.4 13.5 92.5 13.3 12.1 11.2 10.3 10.8 11.6 12.6 13.6 93 13.4 12.3 11.3 10.4 10.9 11.7 12.7 13.7 93.5 13.5 12.4 11.4 10.5 11.0 11.8 12.8 13.8 94 13.6 12.5 11.5 10.6 11.1 11.9 12.9 13.9 94.5 13.8 12.6 11.6 10.7 11.1 12.0 13.0 14.1 95 13.9 12.7 11.7 10.8 11.2 12.1 13.1 14.2 95.5 14.0 12.8 11.8 10.8 11.3 12.2 13.2 14.3 96 14.1 12.9 11.9 10.9 11.4 12.3 13.3 14.4 96.5 14.3 13.1 12.0 11.0 11.5 12.4 13.4 14.6 97 14.4 13.2 12.1 11.1 11.6 12.5 13.6 14.7 97.5 14.5 13.3 12.2 11.2 11.7 12.6 13.7 14.8 98 14.7 13.4 12.3 11.3 11.8 12.8 13.8 14.9 98.5 14.8 13.5 12.4 11.4 11.9 12.9 13.9 15.1 99 14.9 13.7 12.5 11.5 12.0 13.0 14.0 15.2 99.5 15.1 13.8 12.7 11.6 12.1 13.1 14.2 15.4 100 15.2 13.9 12.8 11.7 12.2 13.2 14.3 15.5 100.5 15.4 14.1 12.9 11.9 12.3 13.3 14.4 15.6 101 15.5 14.2 13.0 12.0 12.4 13.4 14.5 15.8 101.5 15.7 14.3 13.1 12.1 12.5 13.6 14.7 15.9 102 15.8 14.5 13.3 12.2 12.6 13.7 14.8 16.1 102.5 16.0 14.6 13.4 12.3 12.8 13.8 14.9 16.2 103 16.1 14.7 13.5 12.4 12.9 13.9 15.1 16.4 103.5 16.3 14.9 13.6 12.5 13.0 14.0 15.2 16.5 104 16.4 15.0 13.8 12.6 13.1 14.2 15.4 16.7 104.5 16.6 15.2 13.9 12.8 13.2 14.3 15.5 16.8 105 16.8 15.3 14.0 12.9 13.3 14.4 15.6 17.0 105.5 16.9 15.5 14.2 13.0 13.4 14.5 15.8 17.2 106 17.1 15.6 14.3 13.1 13.5 14.7 15.9 17.3 106.5 17.3 15.8 14.5 13.3 13.7 14.8 16.1 17.5 107 17.5 15.9 14.6 13.4 13.8 14.9 16.2 17.7 107.5 17.7 16.1 14.7 13.6 13.9 15.1 16.4 17.8 108 17.8 16.3 14.9 13.7 14.0 15.2 16.5 18.0 108.5 18.0 16.4 15.0 13.8 14.1 15.3 16.7 18.2 109 18.2 16.6 15.2 13.9 14.3 15.5 16.8 18.3 109.5 18.4 16.8 15.4 14.1 14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2 14.5 15.8 17.1 18.7 110.5 18.8 17.1 15,7 14.4 14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5

14.8 16.0 17.5 19.1 111.5 19.2 17.5 16.0 14.7 14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8 15.0 16.3 17.8 19.4 112.5 19.6 17.9 16.3 15.0 15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1 15.3 16.6 18.1 19.8 113.5 20.0 18.2 16.7 15.3 15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4 15.6 16.9 18.5 20.2 114.5 20.5 18.6 17.0 16.6 15.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7 15.8 17.2 18.8 20.6 115.5 20.9 19.0 17.3 15.9 16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0 16.1 17.5 19.2 21.0 116.5 21.3 19.4 17.7 16.2 16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3 16.4 17.9 19.5 21.4 117.5 21.7 19.8 18.0 16.5 16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6 16.7 18.2 19.9 21.8 11.5 22.2 20.1 18.4 16.8 16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9 16.9 18.5 20.2 22.2 119.5 22.6 20.5 18.7 17.1 17.1 18.6 20.4 22.4 120 22.8 20.7 18.9 17.3

RECONSTRUCTED FROM BMI charts: height between 120.5 and 140.0 cm Reconstruction based on WHO 2007 references Older children from 60 months to 10 years (110.0- 140.0 cm) Weight-for-Height (Standing up)

MALE FEMALE -3 -2 -1 Median Cm Median -1 -2 -3 14.4 15.6 17.0 18.5 110 18.6 17.0 15.5 14.2 14.5 15.8 17.1 18.7 110.5 18.8 17.1 15.7 14.4 14.6 15.9 17.3 18.9 111 19.0 17.3 15.8 14.5 14.8 16.0 17.5 19.1 111.5 19.2 17.5 16.0 14.7 14.9 16.2 17.6 19.2 112 19.4 17.7 16.2 14.8 15.0 16.3 17.8 19.4 112.5 19.6 17.9 16.3 15.0 15.2 16.5 18.0 19.6 113 19.8 18.0 16.5 15.1 15.3 16.6 18.1 19.8 113.5 20.0 18.2 16.7 15.3 15.4 16.8 18.3 20.0 114 20.2 18.4 16.8 15.4 15.6 16.9 18.5 20.2 114.5 20.5 18.6 17.0 15.6 16.7 17.1 18.6 20.4 115 20.7 18.8 17.2 15.7 15.8 17.2 18.8 20.6 115.5 20.9 19.0 17.3 15.9 16.0 17.4 19.0 20.8 116 21.1 19.2 17.5 16.0 16.1 17.5 19.2 21.0 116.5 21.3 19.4 17.7 16.2 16.2 17.7 19.3 21.2 117 21.5 19.6 17.8 16.3 15.4 17.9 19.5 21.4 117.5 21.7 19.8 18.0 16.5 16.5 18.0 19.7 21.6 118 22.0 19.9 18.2 16.6 16.7 18.2 19.9 21.8 118.5 22.2 20.1 18.4 16.8 16.8 18.3 20.0 22.0 119 22.4 20.3 18.5 16.9 16.9 18.5 20.2 22.2 119.5 22.6 20.5 18.7 17.1 17.1 18.6 20.4 22.4 120 22.8 20.7 18.7 17.2 17.5 19.0 20.6 22.4 120.5 22.8 20.8 18.8 17.3 17.9 19.2 20.8 22.5 121 22.9 20.9 18.9 17.3 18.0 19.3 21.0 22.9 121.5 23.0 20.9 19.0 17.4 18.3 19.6 21.1 23.1 122 23.1 21.0 19.1 17.6 18.5 19.8 21.3 23.3 122.5 23.3 21.1 19.2 17.7 18.6 20.0 21.6 23.4 123 23.4 21.2 19.4 17.9 18.8 20.1 21.8 23.8 123.5 23.6 21.4 19.5 18.0 18.9 20.3 22.0 24.0 124 23.8 21.5 19.7 18.1 19.1 2.5 22.2 24.2 124.5 24.2 21.7 19.8 18.3 19.2 20.6 22.3 24.4 125 24.4 22.0 20.0 18.4 19.4 20.8 22.5 24.6 125.5 24.6 22.2 20.3 18.7 19.7 21.1 22.7 24.9 126 24.9 22.4 20.5 18.9 19.8 21.3 23.0 25.1 126.5 25.1 22.6 20.6 19.0 20.0 21.5 23.2 25.3 127 25.3 22.7 20.8 19.2 20.2 21.6 23.4 25.7 127.5 25.5 23.1 21.0 19.3 20.3 21.8 23.6 25.9 128 25.9 23.3 21.1 19.5 20.5 22.0 23.8 26.1 128.5 26.1 23.4 21.5 19.6 20.6 22.3 24.1 26.3 129 26.3 23.6 21.6 20.0 21.0 22.5 24.3 26.7 129.5 26.7 24.0 21.8 20.1 21.1 55.6 24.5 26.9 130 26.9 24.2 22.0 20.3 21.3 22.8 24.7 27.1 130.5 27.1 24.4 22.1 20.4 21.5 23.0 24.9 27.3 131 27.5 24.5 22.5 20.6 21.6 23.2 25.2 27.7 131.5 27.7 24.9 22.7 20.9

21.8 23.5 25.4 27.9 132 28.1 25.1 22.8 21.1 22.1 23.7 25.6 28.1 132.5 28.3 25.3 23.0 21.2 22.3 23.9 25.8 28.5 133 28.5 25.6 23.3 21.4 22.5 24.1 26.2 28.7 133.5 28.9 25.8 23.5 21.6 22.6 24.2 26.4 28.9 134 29.1 26.0 23.7 21.9 22.8 24.6 26.6 29.3 134.5 29.5 26.4 23.9 22.1 23.1 24.8 27.0 29.5 135 29.7 26.6 42.2 22.2 23.3 25.0 27.2 29.9 135.5 29.9 26.8 24.4 22.4 23.5 25.2 27.4 30.1 136 30.3 27.2 24.6 22.8 23.7 25.5 27.6 30.4 136.5 30.6 27.4 25.0 22.9 23.8 25.7 28.0 30.8 137 31.0 27.6 25.2 23.1 24.2 25.9 28.2 31.0 137.5 31.2 28.0 25.3 23.3 24.4 26.3 28.6 31.4 138 31.6 28.2 25.5 23.6 24.6 26.5 28.8 31.7 138.5 31.8 28.4 25.9 23.8 24.7 26.7 29.0 32.1 139 32.3 28.8 26.1 24.0 25.1 26.9 29.2 32.3 139.5 32.5 29.0 26.3 24.1 25.3 27.2 29.6 32.5 140 32.9 29.4 26.7 24.5

Weight adaptation between 140.0 (BMI charts WHO 2007) to 145.0 cm (NCHS 1982) Reconstruction based on NCHS-CDC-WHO 1982 references Adolescents from 10 to approx. 18 years (140.0- 165.0 cm) Weight-for-Height (Standing up)

Male Female 70% 80% 85% Median cm Median 85% 80% 70% 25.1 27.2 29.6 32.5 140 32.9 29.4 26.7 24.5 25.2 27.4 29.7 33.0 140.5 33.2 29.6 26.8 24.7 25.2 27.6 29.9 33.4 141 33.6 29.8 27.0 24.9 25.3 28.0 30.0 33.8 141.5 33.8 30.2 27.4 25.0 25.4 28.2 30.2 34.1 142 34.1 30.4 27.6 25.2 25.4 28.4 30.3 34.7 142.5 34.8 30.7 27.8 25.6 25.5 28.8 30.5 35.0 143 35.6 31.1 28.0 25.7 25.6 29.0 30.6 35.3 143.5 36.0 31.3 28.4 25.8 25.6 29.1 30.8 35.7 144 36.4 31.4 28.6 25.9 25.7 29.2 30.9 36.1 144.5 36.9 31.5 29.1 26.0 25.8 29.2 31.0 36.5 145 37.1 31.5 29.7 26.0 25.8 29.5 31.3 36.8 145.5 37.4 31.8 29.9 26.2 26.0 29.7 31.6 37.2 146 37.8 32.1 30.2 26.5 26.3 30.0 31.9 37.6 146.5 38.1 32.4 30.5 26.7 26.5 30.3 32.2 37.9 147 38.4 32.6 30.7 26.9 26.8 30.6 32.5 38.3 147.5 38.8 33.0 31.0 27.2 27.0 30.9 32.8 38.6 148 39.1 33.2 31.3 27.4 27.3 31.2 33.1 39.0 148.5 39.5 33.6 31.6 27.7 27.5 31.5 33.4 39.3 149 39.8 33.8 31.8 27.9 27.8 31.7 33.7 39.7 149.5 40.1 34.1 32.1 28.1 28.0 32.0 34.0 40.0 150 40.5 34.4 32.4 28.4 28.3 32.3 34.3 40.4 150.5 40.8 34.7 32.6 28.6 28.5 32.6 34.7 40.8 151 41.2 35.0 33.0 28.8 28.8 32.9 34.9 41.0 151.5 41.5 35.3 33.2 29.1 29.1 33.2 35.3 41.5 152 41.9 35.6 33.5 29.3 29.3 33.5 35.6 41.9 152.5 42.3 36.0 33.8 29.6 29.6 33.8 35.9 42.3 153 42.6 36.2 34.1 29.8 29.8 34.1 36.2 42.6 153.5 43.0 36.6 34.4 30.1 30.1 34.4 36.6 43.0 154 43.4 36.9 34.7 30.4 30.4 34.7 36.9 43.4 154.5 43.8 37.2 35.0 30.7 30.7 35.0 37.2 43.8 155 44.2 37.6 35.4 30.9 30.9 35.4 37.6 44.2 155.5 44.6 37.9 35.7 31.2 31.2 35.7 37.9 44.6 156 45.1 38.3 36.1 31.6 31.5 36.0 38.3 45.0 156.5 45.5 38.7 36.4 31.9 31.8 36.3 38.6 45.4 157 46.0 39.1 36.8 32.2 32.1 36.7 38.9 45.8 157.5 46.5 39.5 37.2 32.6 32.4 37.0 39.3 46.2 158 47.0 40.0 37.6 32.9 32.7 37.3 39.6 46.6 158.5 47.6 40.5 38.1 33.3 33.0 37.7 40.0 47.1 159 48.2 41.0 38.6 33.7 33.3 38.0 40.4 47.5 159.5 48.9 41.6 39.1 34.2 33.6 38.4 40.8 48.0 160 49.7 42.2 39.8 34.8 33.9 38.7 41.1 48.4 160.5 50.5 42.9 40.4 35.4 34.2 39.1 41.5 48.8 161 51.6 43.9 41.3 36.1 34.5 39.4 41.9 49.3 161.5 52.8 44.9 42.2 37.0

34.8 39.8 42.3 49.8 162 54.5 46.3 43.6 37.8 35.1 40.2 42.7 50.2 162.5 56.1 47.7 44.9 38.3 35.5 40.5 43.1 50.7 163 56.4 47.9 45.1 38.8 35.8 40.9 43.5 51.1 163.5 56.7 48.2 45.4 39.0 36.1 41.3 43.9 51.6 164 57.0 48.4 45.6 39.5 36.5 41.7 44.3 52.1 164.5 57.3 48.7 45.8 39.8 36.8 42.1 44.7 52.6 165 57.6 48.9 46.0 40.0

BODY MASS INDEX (ADULTS) (=Weight/Height2, height in meters) Body weight corresponding to specified BMI, for given height

Height BMI (cm) 18.5 18 17.5 17 16.5 16

140 36.3 35.3 34.3 33.3 32.3 31.4 141 36.8 35.8 34.8 33.8 32.8 31.8 142 37.3 36.3 35.3 34.3 33.3 32.3 143 37.8 36.8 35.8 34.8 33.7 32.7 144 38.4 37.3 36.3 35.3 34.2 33.2

145 38.9 37.8 36.8 35.7 34.7 33.6 146 39.4 38.4 37.3 36.2 35.2 34.1 147 40.0 38.9 37.8 36.7 35.7 34.6 148 40.5 39.4 38.3 37.2 36.1 35.0 149 41.1 40.0 38.9 37.7 36.6 35.5

150 41.6 40.5 39.4 38.3 37.1 36.0 151 42.2 41.0 39.9 38.8 37.6 36.5 152 42.7 41.6 40.4 39.3 38.1 37.0 153 43.3 42.1 41.0 39.8 38.6 37.5 154 43.9 42.7 41.5 40.3 39.1 37.9

155 44.4 43.2 42.0 40.8 39.6 38.4 156 45.0 43.8 42.6 41.4 40.2 38.9 157 45.6 44.4 43.1 41.9 40.7 39.4 158 46.2 44.9 43.7 42.4 41.2 39.9 159 46.8 45.5 44.2 43.0 41.7 40.4

160 47.4 46.1 44.8 43.5 42.2 41.0 161 48.0 46.7 45.4 44.1 42.8 41.5 162 48.6 47.2 45.9 44.6 43.3 42.0 163 49.2 47.8 46.5 45.2 43.8 42.5 164 49.8 48.4 47.1 45.7 44.4 43.0

BODY MASS INDEX (ADULTS) (=Weight/Height2, height in meters) Body weight corresponding to specified BMI, for given height

Height BMI

(cm) 18.5 18 17.5 17 16.5 16

165 50.4 49.0 47.6 46.3 44.9 43.6 166 51.0 49.6 48.2 46.8 45.5 44.1 167 51.6 50.2 48.8 47.4 46.0 44.6 168 52.2 50.8 49.4 48.0 46.6 45.2 169 52.8 51.4 50.0 48.6 47.1 45.7

170 53.5 52.0 50.6 49.1 47.7 46.2 171 54.1 52.6 51.2 49.7 48.2 46.8 172 54.7 53.3 51.8 50.3 48.8 47.3 173 55.4 53.9 52.4 50.9 49.4 47.9 174 56.0 54.5 53.0 51.5 50.0 48.4

175 56.7 55.1 53.6 52.1 50.5 49.0 176 57.3 55.8 54.2 52.7 51.1 49.6 177 58.0 56.4 54.8 53.3 51.7 50.1 178 58.6 57.0 55.4 53.9 52.3 50.7 179 59.3 57.7 56.1 54.5 52.9 51.3

180 59.9 58.3 56.7 55.1 53.5 51.8 181 60.6 59.0 57.3 55.7 54.1 52.4 182 61.3 59.6 58.0 56.3 54.7 53.0 183 62.0 60.3 58.6 56.9 55.3 53.6 184 62.6 60.9 59.2 57.6 55.9 54.2

185 63.3 61.6 59.9 58.2 56.5 54.8 186 64.0 62.3 60.5 58.8 57.1 55.4 187 64.7 62.9 61.2 59.4 57.7 56.0 188 65.4 63.6 61.9 60.1 58.3 56.6 189 66.1 64.3 62.5 60.7 58.9 57.2 190 66.8 65.0 63.2 61.4 59.6 57.8

Interpretation: Commonly used BMI cut-off points

Appendix 2: Nutritional treatment Quantities of milk & RUTF depending on weight and phases

ALWAYS GIVING WATER TO DRINK DURING RUTF MEAL

Phase 2

Quantity of Quantity of

Body weight Paste RUTF (Plumpy nut®, Biscuit RUTF (BP100®) eeZeepaste®...).

sachet /day bar/ day

< 6 kg 2 4

6-10 kg 3 5

10 - 12 kg 4 6

12-15 Kg 5 8

>15Kg 6 10

Biscuit RUTF is usually favourite by adult ALWAYS GIVING WATER TO DRINK DURING RUTF MEAL

Appendix 3: Appetite test

Appetite test

For treatment with RUTF, the child must be capable of absorbing a sufficient quantity of RUTF.

The appetite test must be carried out in a quiet place.

Explain to the caretaker the aim of the test and how it will be carried out.

The caretaker and the child must first of all wash their hands.

The caretaker must be comfortably seated with the child on her knee.

The caretaker gives a small quantity of RUTF either directly from the sachet, or using her finger. This must be done gently, while encouraging the child.

If the child refuses the RUTF, the caretaker should continue gently to encourage the child, taking her time to do so. The test normally takes only a short time, but it can last up to one hour maximum. The child must not be forced to take the RUTF.

Water must be offered to the child in a cup throughout the entire test.

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