Finding every VL case with the help of community members
Leveraging multiple donors and research organizations for a coordinated approach
In remote places such as Bihar, India, people with visceral leishmaniasis (VL) symptoms remain in the community for weeks or months before seeking medical care from a qualified practitioner. As a result, they can die from an opportunistic co-infection, internal bleeding or severe anemia. Although the best available treatments may be present at the primary health care centres only several kilometres away, this is of limited value if VL cases remain undiagnosed in the villages.
Consequently, TDR is working with multiple partners to study new ways to reach into the community to find potential VL cases in India, Bangladesh and Nepal, as part of the WHO programme to eliminate VL in those countries by 2015. Early diagnosis and treatment are essential for not only individual patients, but also for the community because it reduces VL transmission. Humans are the only reservoir in the Indian subcontinent, unlike other parts of the world where animals are reservoirs for the Leishmania parasite. If a community's overall level of infection is reduced, fewer cases can be transmitted by the sandflies that carry the parasite.
TDR has investigated several approaches to actively find cases in endemic villages and determined that training of village ASHAs (accredited social health activists) can be an effective and sustainable approach. ASHAs are women who live in the village, are literate and are the first point of call for any health needs, especially for women and children.
Two different studies now involve ASHAs. The first is part of a larger project managed by the Drugs for Neglected Diseases iniatitive (DNDi), with One World Health (OWH) and TDR. TDR's role is to: 1. determine whether treatment with a single dose of liposomal amphotericin B (manufactured as AmBisome®) can be managed effectively in the government primary health centres; and 2. support active case detection activities at the community level through ASHAs.
The second study in Patna, India is supporting the point-of-care diagnosis and active case detection research with the ASHAs.
TDR earlier research shows that in highly endemic areas, the camp approach can be an effective way to identify new cases. A ‘fever camp’ is organized in a central place in an endemic village and the community is encouraged to actively participate through previous advertising, posters and coordination with the ASHAs. Patients with fever of more than two weeks or with skin lesions after past VL treatment will be invited for a simple medical check-up. Suspect cases will be transported to the closest participating primary health care centre where they will be evaluated by a physician and tested with a rapid diagnostic test for visceral leishmaniasis.
ASHAs are the first point of entry for any health demand in a typical village of about 500 people, especially for women and children, and they facilitate community access to health services available at primary health care centres and district hospitals. They play an important role in reproductive and child health and provide information to the village on nutrition, sanitation, hygiene and prevention of common infections.
The ASHAs will continue to be trained through these two complementary grants, forming an integral part of the case detection strategies which will last beyond the completion of these projects.
Greg Matlashewski, formerly from TDR and currently at McGill University, is continuing to work with TDR in both studies to ensure that potential cases detected in the endemic villages undergo point-of-care diagnosis and feed into the single dose AmBisome® treatment study at the primary health care centres.