Overview of Leishmaniasis with Special 1 Emphasis on Kala-azar in South Asia 2 Kwang Poo Chang, Bala K. Kolli and Collaborators 3 4 Contents 5 1 Global Overview of Leishmaniasis .......................................................... 2 6 1.1 Disease Types .......................................................................... 2 7 1.2 Disease Incidence/Distribution ......................................................... 2 8 1.3 Transmission ............................................................................ 3 9 1.4 Diagnosis ............................................................................... 5 10 1.5 Prevention ............................................................................... 6 11 1.6 Treatment ............................................................................... 8 12 1.7 Epidemiology Mathematical Modeling ................................................ 9 13 1.8 Control Programs ....................................................................... 9 14 2 Leishmaniasis in South Asia ................................................................. 10 15 2.1 Clinico-epidemiological Types ........................................................ 10 16 2.2 Indian Kala-azar or visceral leishmaniasis ............................................ 12 17 3 Experimental Leishmaniasis ................................................................. 16 18 3.1 Causative Agents ....................................................................... 16 19 3.2 Host-Parasite Interactions .............................................................. 19 20 3.3 Leishmania Model for Microbial Virulence ........................................... 25 21 4 Basic and Applied Kala-azar Research in India ............................................. 27 22 4.1 Indian Institutions with Kala-azar Research Components . ........................... 27 23 4.2 Indian Kala-azar Research ............................................................. 28 24 5 Concluding Remarks ......................................................................... 29 25 5.1 “Leishmaniome” and Diversity of Leishmaniasis ..................................... 29 26 5.2 Issues Emerged from South Asia Kala-azar Elimination Initiatives . .............. 30 27 5.3 Indian Leadership in One-Health Approach to Research Collaboration . .......... 31 28 6 List of Collaborators .......................................................................... 31 29 Appendix .......................................................................................... 35 30 References ........................................................................................ 53 31 For collaborator details please see the list provided at the end. K.P. Chang (*) • B.K. Kolli Department of Microbiology and Immunology, Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, IL 60064, USA e-mail: [email protected] © Springer International Publishing AG 2018 1 S.K. Singh (ed.), Neglected Tropical Diseases - South Asia, Neglected Tropical Diseases, https://doi.org/10.1007/978-3-319-68493-2_1 2 K.P. Chang and B.K. Kolli 32 Abbreviations 33 AVL Anthroponotic visceral leishmaniasis 34 CL Cutaneous leishmaniasis 35 DALY Disability-adjusted life year 36 IRS Insecticide residue spread 37 MCL Mucocutaneous leishmaniasis 38 NTD Neglected tropical diseases 39 PKDL Post-kala-azar dermal leishmaniasis 40 PV Parasite-containing vacuole 41 rK39 Recombinant kinesin 39 amino acid repeats 42 rKE16 Recombinant kinesin antigen from L. donovani 43 VL Visceral leishmaniasis 44 ZCL Zoonotic cutaneous leishmaniasis 1 Global Overview of Leishmaniasis 45 1.1 Disease Types 46 Leishmaniasis is a complex disease caused by Leishmania infection, producing 47 variable clinical symptoms, e.g., cutaneous, mucocutaneous, and visceral leishman- 48 iases [1–3]. Cutaneous leishmaniasis (CL) caused, for example, by Leishmania 49 major/L. tropica is marked by the appearance of skin lesion in various forms, which 50 are often innocuous and self-healing, while mucocutaneous leishmaniasis (MCL) 51 caused, for example, by L. braziliensis is a protracted disease, resulting sometimes 52 in facial disfigurement of the ear, mouth, and nose. Neither CL nor MCL is life- 53 threatening per se. Only in non-healing case has death of these patients been 54 reported due to secondary infections or other causes, e.g., suicide as a result of 55 unbearable psychological stress. Visceral leishmaniasis (VL) caused by 56 L. donovani/L. infantum is far more severe. It is often fatal, if untreated, resulting 57 from systemic and progressive infection of macrophages by Leishmania in the 58 reticuloendothelial systems or lymphoid organs, chiefly the spleen, liver, and 59 bone marrow. Disorders of hematological and hepatosplenic functions are thus 60 the clinical manifestations of VL, including hepatosplenomegaly, fever, anemia, 61 leucopenia, hypergammaglobulinemia, and cachexia. The development of all leish- 62 maniases follows a chronic course lasting for months and sometimes years. 63 1.2 Disease Incidence/Distribution 64 Leishmaniasis is very widespread, currently putting a world population of >350 65 million at risk with up to ~1.2 million cases at a death rate in the tens of thousands 66 per year [4]. Of the 16 categories of neglected tropical diseases (NTD) assessed for Overview of Leishmaniasis with Special Emphasis on Kala-azar in South Asia 3 the period from 2005 to 2013, leishmaniasis ranks next only to malaria as the 67 second worst in the age-standardized DALYs (disability-adjusted life years) and 68 second only to dengue fever in the rate of DALY increase from 5.7 to 5.9 million 69 [5]. In 1985, historical, parasitological, clinical, epidemiological, and control pro- 70 gram information was compiled for the endemic areas in the Indian subcontinent, 71 the Middle East, Central Asia, North and East Africa, China, Europe, and Central 72 and South America [6]. Recent efforts published in 2012 have yielded bionomic 73 data of leishmaniasis with more details for each of the ~100 countries or territories 74 included [4]. There are still endemic areas, e.g., West Africa, where information is 75 not readily available in any detail, indicating that leishmaniasis is still more 76 pervasive and entrenched than is known. 77 Leishmaniasis is a disease of poverty and often flares up in areas of low 78 endemicity into epidemic proportion due to natural or man-made disasters, includ- 79 ing famine, drought, flood, earthquakes, and wars. This is currently most evident in 80 Sudan, Iraq, Syria, and Afghanistan where military conflicts further trigger refugee 81 migration in droves, thereby bringing the disease into neighboring countries and 82 beyond. 83 1.3 Transmission 84 Leishmaniasis is a vector-borne disease, which is transmitted by the blood-feeding 85 female sand fly of different species in various locations (Fig. 1, Lower). There are 86 hundreds of different sand fly species, of which dozens serve as the vector of 87 leishmaniasis in different endemic sites [7]. Sand flies are inconspicuous, fragile, 88 and hairy winged dipterans, similar to, but smaller than, mosquitoes in size. For 89 epidemiological surveys and other studies, these flies are captured in the field by 90 CDC-light trap, suction pump, and sticky paper at dawn and at dusk when they are 91 active. The distribution of the vector species coincides well globally with that of the 92 disease. The disease is largely a zoonosis and is considered as an anthroponosis in 93 few places where reservoir animals have not been found, e.g., Indian VL. The 94 animals, which are recognized as reservoirs, include rodents; domestic and wild 95 dogs or canids, such as fox; and other wild animals, like sloths in South America 96 and possibly hares in Eurasia (Fig. 1, Upper). Humans acquire infection when 97 stepping into the sylvatic cycle of ongoing transmission by vectors among the 98 reservoir animals. The most well-established and best-studied reservoir for 99 human VL is dog in the Mediterranean basin, Brazil, and many other places of 100 low endemicity where this animal suffers from canine leishmaniasis with clinical 101 manifestations akin to human CL and VL. Transmission of leishmaniasis has been 102 reported on rare occasions via blood transfusion, coitus and accidental inoculation 103 via contaminated needles, but not by oral or respiratory route. Risk factors for 104 natural transmission include exposure to infected sand flies in the endemic areas, 105 human genetic factors, malnutrition (Cf. Appendix—Box 1), immunosuppression 106 4 K.P. Chang and B.K. Kolli Fig. 1 Diagrammatic depiction of Leishmania transmission cycle. Upper, Amastigote stage, which lives intracellularly as non-motile entities in macrophages of infected mammalian hosts, i.e., human/animal reservoirs. “?”, Hare as a potential reservoir. Lower, Promastigote stage, which lives as motile flagellated forms each with an anterior flagellum in the gut lumen of female sand fly. Modified from: Chang KP 2012 Leishmaniasis. Encyclopedia Life Science, John Wiley & Sons, Ltd. www.els.net Overview of Leishmaniasis with Special Emphasis on Kala-azar in South Asia 5 of individuals after organ transplantation or due to AIDS/other infectious diseases, 107 and needle sharing among drug addicts. 108 Life Cycle Stages The life stages of Leishmania in the transmission cycle are 109 depicted in Fig. 1. The mammalian stage is known as amastigotes—nonmotile round 110 to oval bodies,