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Leishmania donovani surface glycoprotein 63 (GP63) is a major virulence factor involved in parasite escape and immune evasion. In this study, we generated virus-like particles (VLPs) expressing L. donovani GP63 using the baculovirus expression system. Mice were intramuscularly immunized with GP63-VLPs and challenged with L. donovani promastigotes. GP63-VLP immunization elicited higher levels of L. donovani antigen-specific serum antibodies and enhanced splenic B cell, germinal center B cell, CD4+, and CD8+ T cell responses compared to unimmunized controls. GP63-VLPs inhibited the influx of pro-inflammatory cytokines IFN-γ and IL-6 in the livers, as well as thwarting the development of splenomegaly in immunized mice. Upon L. donovani challenge infection, a drastic reduction in splenic parasite burden was observed in VLP-immunized mice. These results indicate that GP63-VLPs immunization conferred protection against L. donovani challenge infection by inducing humoral and cellular immunity in mice. Author summary: Visceral leishmaniasis is a neglected tropical disease that can be fatal in humans if left untreated. Unfortunately, despite the urgent need, an efficacious vaccine for this parasitic disease continues to remain under development. Though challenging, we attempted to develop an experimental leishmaniasis vaccine using the highly immunogenic virus-like particle (VLP) platform that expressed the glycoprotein 63 antigen of Leishmania donovani, a causative agent of visceral leishmaniasis. We used this vaccine to immunize mice and after two immunizations, mice were challenge infected with L. donovani to assess vaccine-induced protection. Our results revealed that compared to the unimmunized control mice, mice immunized with the experimental vaccines were well-protected against developing visceral leishmaniasis. Specifically, VLP vaccine immunization ensured that immune responses necessary for protection were induced to high levels and this contributed to suppressing leishmaniasis-associated pathologies as well as the parasite propagation in mice. Overall, we demonstrated that this VLP-based vaccine can elicit adequate protection against visceral leishmaniasis and propose further research to enhance and optimize its efficacy. [ABSTRACT FROM AUTHOR]

The spleen plays a pivotal role in the pathogenesis of visceral leishmaniasis. In severe forms of the disease, the spleen undergoes changes that can compromise its function in surveilling blood-circulating pathogens. In this study, we present an integrated analysis of the structural and gene expression alterations in the spleens of three patients with relapsing visceral leishmaniasis, two of whom were coinfected with HIV. Our findings reveal that the IL6 signaling pathway plays a significant role in the disorganization of the white pulp, while BCL10 and ICOSLG are associated with spleen organization. Patients coinfected with HIV and visceral leishmaniasis exhibited lower splenic CD4+ cell density and reduced expression of genes such as IL15. These effects may contribute to a compromised immune response against L. infantum in coinfected individuals, further impacting the structural organization of the spleen. Author summary: While most individuals recover after contracting visceral leishmaniasis, there are cases where patients experience a relapsing form of the disease. This response pattern to Leishmania infection is linked to alterations in spleen structure. Until now, these spleen changes had only been examined in dogs and laboratory animals. In our study, we provide data on the disorganization of spleen structure in three patients diagnosed with VL, two of whom were also co-infected with HIV. The observed patterns of spleen disorganization closely resembled those seen in dogs. Our study emphasizes the involvement of IL6, BCL10, and ICOSLG in this process. [ABSTRACT FROM AUTHOR]

American tegumentary leishmaniasis (ATL) diagnosis is an open question, and the search for a solution is urgent. The available tests that detect the etiological agent of the infection are specific for ATL diagnosis. However, they present disadvantages, such as low sensitivity and the need for invasive procedures to obtain the samples. Immunological methods (leishmanin skin test and search for anti-Leishmania antibodies) are good alternatives to the etiological diagnosis of ATL. Presently, we face problems with disease confirmation due to the discontinuity in the production of leishmanin skin test antigen, particularly in resource-poor settings. Aiming to diagnose ATL, we validated rLb6H-ELISA for IgG antibodies using 1,091 samples from leishmaniasis patients and healthy controls, divided into four panels, living in 19 Brazilian endemic and non-endemic states. The rLb6H-ELISA showed a sensitivity of 98.6% and a specificity of 100.0%, with the reference panel comprising 70 ATL patient samples and 70 healthy controls. The reproducibility evaluation showed a coefficient of variation of positive samples ≤ 8.20% for repeatability, ≤ 17,97% for reproducibility, and ≤ 8.12% for homogeneity. The plates sensitized with rLb6H were stable at 4°C and -20°C for 180 days and 37°C for seven days, indicating 12 months of validity. In samples of ATL patients from five research and healthcare centers in endemic and non-endemic areas, rLb6H-ELISA showed a sensitivity of 84.0%; no significant statistical difference was observed among the five centers (chi-square test, p = 0.13). In samples of healthy controls from four areas with different endemicity, a specificity of 92.4% was obtained; lower specificity was obtained in a visceral leishmaniasis high endemicity locality (chi-square test, p<0.001). Cross-reactivity was assessed in 166 other disease samples with a positivity of 13.9%. Based on the good diagnostic performance and the reproducibility and stability of the antigen, we suggest using ELISA-rLb6H to diagnose ATL. [ABSTRACT FROM AUTHOR]

Objective: To understand the epidemiological distribution characteristics of mountain-type zoonotic visceral leishmaniasis (MT-ZVL) in Yangquan City, Shanxi Province, China, from 2006 to 2021, to explore the influencing factors leading to the re-emergence of the epidemic, and to provide a basis for the formulation of targeted control strategies. Methods: Case information spanning from 2006 to 2021 in Yangquan City was collected for a retrospective case-control study conducted from June to September 2022. A 1:3 matched ratio was employed. A questionnaire was utilized to gather data on basic information, demographic characteristics, awareness of MT-ZVL knowledge, residence, and dog breeding and living habits. The study employed a multifactorial conditional stepwise logistic regression model to analyze the influencing factors. Results: A total of 508 subjects was analyzed. Risk factors for MT-ZVL included the use of soil/stone/concrete as building materials (OR = 3.932), presence of nearby empty/stone stack houses (OR = 2.515), dog breeding (OR = 4.215), presence of stray dogs (OR = 2.767), and neighbor's dog breeding (OR = 1.953). Protective factors comprised knowledge of MT-ZVL (OR = 0.113) and using mosquito repellents (OR = 0.388). The findings indicate significant associations between environmental and behavioral factors and MT-ZVL incidence in Yangquan City, Shanxi Province, China, from 2006 to 2021. These results underscore the importance of public awareness campaigns and targeted interventions aimed at reducing exposure to risk factors and promoting protective measures to mitigate the re-emergence of MT-ZVL outbreaks. Conclusion: House building materials, presence of neighboring empty houses, breeding domestic dogs and distribution of stray dogs surrounding the home are risk factors for MT-ZVL. Awareness of MT-ZVL and implementation of preventive measures during outdoor activities in summer and autumn are protective and may reduce the risk of MT-ZVL. Author summary: In recent years, a rapid reemergence of mountain-type zoonotic visceral leishmaniasis (MT-ZVL) has been seen in the extension region of the Loess Plateau that had previously achieved elimination in China. In this study, we investigate the epidemiological characteristics of MT-ZVL and identify the factors associated with the rapid rise in MT-ZVL epidemics using a case-control design. A questionnaire was used to collect basic information, demographic characteristics, awareness of MT-ZVL knowledge, residence, and dog breeding and living habits. A multifactorial conditional stepwise logistic regression model was used to analyze the influencing factors. The study revealed that there has been a rising trend in the MT-ZVL endemic areas. House building materials, presence of neighboring empty houses, breeding domestic dogs and distribution of stray dogs surrounding the home are risk factors for MT-ZVL. Awareness of MT-ZVL and implementation of preventive measures during outdoor activities in summer and autumn are protective and may reduce the risk of MT-ZVL. We believe that our study makes a significant contribution to the literature to develop strategy for control the ongoing local transmission of MT-ZVL in hill districts. By analyzing the epidemiological characteristics and influencing factors of MT-ZVL, this research provides a basis for further optimizing the targeted control strategies. [ABSTRACT FROM AUTHOR]

This study investigated the sand fly fauna of the municipality Iguatama, in the Midwest Region of Minas Gerais state, Brazil, including Leishmania infection rates and blood meal sources. Sand flies were collected during four periods over the course of a single year, encompassing both dry and rainy seasons, using CDC light traps placed in peridomiciles where dogs were seropositive for visceral leishmaniasis (VL). A total of 762 sand fly specimens, representing 12 species across seven genera, were collected. Lutzomyia longipalpis was the most abundant species, comprising 57.6% of the collected specimens, followed by Nyssomyia neivai (19.6%) and Nyssomyia whitmani (10.5%). Species richness and diversity varied among collection periods, with the highest diversity observed in January 2019. Molecular analysis detected Leishmania DNA in 12.5% of the sand fly specimens, with Le. infantum being the predominant species. Blood meal analysis revealed feeding on multiple vertebrate species, including humans, rats, dogs, and chickens. The presence of Leishmania DNA in sand flies, and the identification of human blood meals, highlight the potential role of these species in VL transmission. These findings underscore the importance of continued surveillance and control measures to prevent the spread of VL and reduce transmission risk in the region. [ABSTRACT FROM AUTHOR]

Introduction: Neglected tropical diseases (NTDs) mainly affect underprivileged populations, potentially resulting in catastrophic health spending (CHS) and impoverishment from out-of-pocket (OOP) costs. This systematic review aimed to summarize the financial hardship caused by NTDs. Methods: We searched PubMed, EMBASE, EconLit, OpenGrey, and EBSCO Open Dissertations, for articles reporting financial hardship caused by NTDs from database inception to January 1, 2023. We summarized the study findings and methodological characteristics. Meta-analyses were performed to pool the prevalence of CHS. Heterogeneity was evaluated using the I2 statistic. Results: Ten out of 1,768 studies were included, assessing CHS (n = 10) and impoverishment (n = 1) among 2,761 patients with six NTDs (Buruli ulcer, chikungunya, dengue, visceral leishmaniasis, leprosy, and lymphatic filariasis). CHS was defined differently across studies. Prevalence of CHS due to OOP costs was relatively low among patients with leprosy (0.0–11.0%), dengue (12.5%), and lymphatic filariasis (0.0–23.0%), and relatively high among patients with Buruli ulcers (45.6%). Prevalence of CHS varied widely among patients with chikungunya (11.9–99.3%) and visceral leishmaniasis (24.6–91.8%). Meta-analysis showed that the pooled prevalence of CHS due to OOP costs of visceral leishmaniasis was 73% (95% CI; 65–80%, n = 2, I2 = 0.00%). Costs of visceral leishmaniasis impoverished 20–26% of the 61 households investigated, depending on the costs captured. The reported costs did not capture the financial burden hidden by the abandonment of seeking healthcare. Conclusion: NTDs lead to a substantial number of households facing financial hardship. However, financial hardship caused by NTDs was not comprehensively evaluated in the literature. To develop evidence-informed strategies to minimize the financial hardship caused by NTDs, studies should evaluate the factors contributing to financial hardship across household characteristics, disease stages, and treatment-seeking behaviors. Author summary: Neglected tropical diseases (NTDs) mainly affect underprivileged populations, potentially resulting in catastrophic health spending (CHS) and impoverishment from out-of-pocket (OOP) costs. This systematic review aimed to summarize the financial hardship caused by NTDs. We found that NTDs lead to a substantial number of households facing financial hardship. CHS risk due to direct OOP costs was relatively low among patients with leprosy (0.0–11.0%), dengue (12.5%), and lymphatic filariasis (0.0–23.0%), and relatively high among patients with Buruli ulcers (45.6%). CHS risk varied widely among patients with chikungunya (11.9–99.3%) and visceral leishmaniasis (24.6–91.8%). Costs of visceral leishmaniasis impoverished 20–26% of 61 households, depending on the costs captured. Nevertheless, financial hardship caused by NTDs was not comprehensively evaluated in the literature. Therefore, to develop evidence-informed strategies to minimize the financial hardship caused by NTDs, studies should evaluate the factors contributing to financial hardship across household characteristics, disease stages, and treatment-seeking behaviors. [ABSTRACT FROM AUTHOR]

Background: Diagnosis of visceral leishmaniasis (VL) in resource-limited endemic regions is currently based on serological testing with rK39 immunochromatographic tests (ICTs). However, rK39 ICT frequently has suboptimal diagnostic accuracy. Furthermore, treatment monitoring and detection of VL relapses is reliant on insensitive and highly invasive tissue aspirate microscopy. Miniature direct-on-blood PCR nucleic acid lateral flow immunoassay (mini-dbPCR-NALFIA) is an innovative and user-friendly molecular tool which does not require DNA extraction and uses a lateral flow strip for result read-out. This assay could be an interesting candidate for more reliable VL diagnosis and safer test of cure at the point of care. Methodology/Principle findings: The performance of mini-dbPCR-NALFIA for diagnosis of VL in blood was assessed in a laboratory evaluation and compared with the accuracy of rK39 ICTs Kalazar Detect in Spain and IT LEISH in East Africa. Limit of detection of mini-dbPCR-NALFIA was 650 and 500 parasites per mL of blood for Leishmania donovani and Leishmania infantum, respectively. In 146 blood samples from VL-suspected patients from Spain, mini-dbPCR-NALFIA had a sensitivity of 95.8% and specificity 97.2%, while Kalazar Detect had a sensitivity of 71.2% and specificity of 94.5%, compared to a nested PCR reference. For a sample set from 58 VL patients, 10 malaria patients and 68 healthy controls from Ethiopia and Kenya, mini-dbPCR-NALFIA had a pooled sensitivity of 87.9% and pooled specificity of 100% using quantitative PCR as reference standard. IT LEISH sensitivity and specificity in the East African samples were 87.9% and 97.4%, respectively. Conclusions/Significance: Mini-dbPCR-NALFIA is a promising tool for simplified molecular diagnosis of VL and follow-up of treated patients in blood samples. Future studies should evaluate its use in endemic, resource-limited settings, where mini-dbPCR-NALFIA may provide an accurate and versatile alternative to rK39 ICTs and aspirate microscopy. Author summary: Visceral leishmaniasis (VL) is a severe infectious disease caused by unicellular parasites of the Leishmania donovani complex. As VL is fatal when left untreated, early and confirmatory laboratory diagnosis is crucial for adequate patient management. However, currently available serological assays, such as the rK39 rapid diagnostic test, fall short in terms of sensitivity and cannot be used for detection of relapsing infections. Therefore, we evaluated an innovative and user-friendly diagnostic assay called mini-dbPCR-NALFIA, which is based on the direct detection of Leishmania kinetoplast DNA in human blood samples. We found that mini-dbPCR-NALFIA can detect down to 500 parasites per millilitre of blood, which is lower than the parasite loads generally seen in untreated VL patients. Furthermore, we assessed the accuracy of mini-dbPCR-NALFIA using a set of Spanish and East-African samples from VL patients and control groups. In the Spanish samples, sensitivity of mini-dbPCR-NALFIA was very high and somewhat better than in the East-African samples. The specificity of mini-dbPCR-NALFIA was excellent in both sample sets. In conclusion, considering its robust performance and simplicity, the mini-dbPCR-NALFIA is a promising diagnostic assay that has the potential to improve VL diagnosis and follow-up of treated patients, especially in resource-limited situations. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is a potentially fatal parasitic infection caused by Leishmania donovani in India. L. donovani is an obligate intracellular protozoan residing mostly in macrophages of the reticuloendothelial system throughout chronic infection. Monocytic phagocytes are critical in the pathogenesis of different forms of leishmaniasis. Subsets of monocytes are distinguished by their surface markers into CD14+CD16- classical monocytes, CD14+CD16+ intermediate monocytes, and CD16++CD14low non-classical monocyte subsets. During cutaneous leishmaniasis (CL), intermediate monocyte are reported to be a source of inflammatory cytokines IL-1β and TNF, and they express CCR2 attracting them to sites of inflammatory pathology. We examined monocyte subsets in the blood and bone marrow of patients with VL from an endemic site in Bihar, India, and found these contrasted with the roles of monocytes in CL. During VL, intermediate and non-classical CD16+ monocyte subsets expressed instead a non-inflammatory phenotype with low CCR2, high CX3CR1 and low microbicidal oxidant generation, making them more similar to patrolling monocytes than inflammatory cells. Bone marrow CD16+ monocyte subsets expressed a phenotype that might be more similar to the inflammatory subsets of CL, although our inability to obtain bone marrow from healthy donors in the endemic region hampered this interpretation Overall the data suggest that CD16+ intermediate monocyte subsets in VL patients express a phenotypes that contributes to an immunosuppressed pathologic immune state, but in contrast to CL, these do not mediate localized inflammatory responses. Author summary: The parasite Leishmania donovani causes the fatal systemic disease visceral leishmaniasis (VL) in endemic nations including India. The parasite is an obligate intracellular protozoan, residing mostly in monocytic cells in the bone marrow, blood and affected organs of infected human or other vertebrate hosts. Cells of the monocytic lineage can either provide a safe intracellular location in which the parasite survives, or they can be activated to kill intracellular parasites. We studied the contribution of monocyte subsets in the blood and bone marrow of patients from India with active visceral leishmaniasis, or control subjects without leishmaniasis. Our studies suggested that circulating monocytes of patients with VL are defective in their hability to kill intracellular parasites and to migrate toward sites of inflammation. These defects are most prominent in expanded subsets of monocytes expressing both the CD16 and CD14 receptors on their surface membranes. The immune defects underlying VL may be greatly influenced by subsets of blood monocytes that expand during disease. [ABSTRACT FROM AUTHOR]

Background: Currently available treatment options are mostly effective in achieving long-term cure in visceral leishmaniasis (VL) patients. However, there have been reports of recurrence of this illness in both immunosuppressed and immunocompetent patients. Case presentation: We report the first case of recurrent VL relapse in a 19-year-old immunocompetent female with functional hypopituitarism (hypogonadotropic hypogonadism with central hypothyroidism) from Bangladesh, who has been treated three times previously with optimal dosage and duration- liposomal amphotericin B (LAmB) alone and in combination with miltefosine. We treated the patient successfully with a modified treatment regimen of 10 mg/kg body weight LAmB for two consecutive days along with oral miltefosine for seven days as loading dose. For secondary prophylaxis, the patient received 3 mg/kg body weight LAmB along with oral miltefosine for seven days monthly for five doses followed by hormonal replacement. The patient remained relapse free after 12 months of her treatment completion. Conclusion: In the absence of protective vaccines against Leishmania species and standard treatment regimen, this modified treatment regimen could help the management of recurrent relapse cases. Author summary: Visceral leishmaniasis is a globally recognized neglected tropical disease, and Bangladesh is a major contributor of the global burden of this illness. In this article, we present a case on a 19-year-old immunocompetent female with pubertal delay, who has been diagnosed as a case of visceral leishmaniasis for 11 years and presented to us with recurrent relapses despite being treated with standard treatment regimens. The patient also developed functional hypopituitarism due to this chronic illness, which hindered her personal, familial, as well as social life. In scarcity of evidence of a standard treatment regimen for recurrent relapse cases, we treated her with high dose liposomal amphotericin B and miltefosine, along with secondary prophylaxis combining these two drugs with excellent result. Her pubertal delay was also addressed with utmost importance to re-establish her social confidence. This article could encourage physicians to outline an effective regimen to deal with these difficult-to-treat cases. [ABSTRACT FROM AUTHOR]

Background: With the current treatment options for visceral leishmaniasis (VL), recrudescence of the parasite is seen in a proportion of patients. Understanding parasite dynamics is crucial to improving treatment efficacy and predicting patient relapse in cases of VL. This study aimed to characterize the kinetics of circulating Leishmania parasites in the blood, during and after different antileishmanial therapies, and to find predictors for clinical relapse of disease. Methods: Data from three clinical trials, in which Eastern African VL patients received various antileishmanial regimens, were combined in this study. Leishmania kinetoplast DNA was quantified in whole blood with real-time quantitative PCR (qPCR) before, during, and up to six months after treatment. An integrated population pharmacokinetic-pharmacodynamic model was developed using non-linear mixed effects modelling. Results: Parasite proliferation was best described by an exponential growth model, with an in vivo parasite doubling time of 7.8 days (RSE 12%). Parasite killing by fexinidazole, liposomal amphotericin B, sodium stibogluconate, and miltefosine was best described by linear models directly relating drug concentrations to the parasite elimination rate. After treatment, parasite growth was assumed to be suppressed by the host immune system, described by an Emax model driven by the time after treatment. No predictors for the high variability in onset and magnitude of the immune response could be identified. Model-based individual predictions of blood parasite load on Day 28 and Day 56 after start of treatment were predictive for clinical relapse of disease. Conclusion: This semi-mechanistic pharmacokinetic-pharmacodynamic model adequately captured the blood parasite dynamics during and after treatment, and revealed that high blood parasite loads on Day 28 and Day 56 after start of treatment are an early indication for VL relapse, which could be a useful biomarker to assess treatment efficacy of a treatment regimen in a clinical trial setting. Author summary: After primary treatment of visceral leishmaniasis (VL), relapse of disease occurs in a proportion of patients. Understanding parasite dynamics is crucial to improving treatment efficacy and predicting disease relapse at an early stage. Leishmania kinetoplast DNA loads in blood from East African VL patients from three clinical trials, treated with five different treatment regimens, were used to develop a semi-mechanistic model to integrate in vivo parasite replication in the host, parasite clearance by different VL drug regimens, and suppression of parasite regrowth by the host immune system after treatment. This model deepened our understanding of the parasite-drug-host interaction and described the in vivo parasite growth rate in human for the first time. Moreover, the model revealed that high blood parasite loads on Day 28 and Day 56 after start of treatment are an early indication for VL relapse, which could serve as a biomarker to predict long-term clinical outcome, an important new tool for optimizing future VL treatment regimens. [ABSTRACT FROM AUTHOR]

In Nepal, visceral leishmaniasis (VL) has been targeted for elimination as a public health problem by 2026. Recently, increasing numbers of VL cases have been reported from districts of doubtful endemicity including hills and mountains, threatening the ongoing VL elimination program in Nepal. We conducted a multi-disciplinary, descriptive cross-sectional survey to assess the local transmission of Leishmania donovani in seven such districts situated at altitudes of up to 1,764 meters in western Nepal from March to December 2019. House-to-house surveys were performed for socio-demographic data and data on past and current VL cases. Venous blood was collected from all consenting individuals aged ≥2 years and tested with the rK39 RDT. Blood samples were also tested with direct agglutination test, and a titer of ≥1:1600 was taken as a marker of infection. A Leishmania donovani species-specific PCR (SSU-rDNA) was performed for parasite species confirmation. We also captured sand flies using CDC light traps and mouth aspirators. The house-to-house surveys documented 28 past and six new VL cases of which 82% (28/34) were without travel exposure. Overall, 4.1% (54/1320) of healthy participants tested positive for L. donovani on at least one serological or molecular test. Among asymptomatic individuals, 17% (9/54) were household contacts of past VL cases, compared to 0.5% (6/1266) among non-infected individuals. Phlebotomus argentipes, the vector of L. donovani, was found in all districts except in Bajura. L. donovani was confirmed in two asymptomatic individuals and one pool of sand flies of Phlebotomus (Adlerius) sp. We found epidemiological and entomological evidence for local transmission of L. donovani in areas previously considered as non-endemic for VL. The national VL elimination program should revise the endemicity status of these districts and extend surveillance and control activities to curb further transmission of the disease. [ABSTRACT FROM AUTHOR]

Background: Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis which can occur after successful treatment of visceral leishmaniasis (VL) and is a public health problem in VL endemic areas. We conducted a systematic scoping review to assess the characteristics of published PKDL clinical studies, understand the scope of research and explore the feasibility and value of developing a PKDL individual patient data (IPD) platform. Methods: A systematic review of published literature was conducted to identify PKDL clinical studies by searching the following databases: PubMed, Scopus, Ovid Embase, Web of Science Core Collection, WHO Global Index Medicus, PASCAL, Clinicaltrials.gov, Ovid Global Health, Cochrane Database and CENTRAL, and the WHO International Clinical Trials Registry Platform. Only prospective studies in humans with PKDL diagnosis, treatment, and follow-up measurements between January 1973 and March 2023 were included. Extracted data includes variables on patient characteristics, treatment regimens, diagnostic methods, geographical locations, efficacy endpoints, adverse events and statistical methodology. Results: A total of 3,418 records were screened, of which 56 unique studies (n = 2,486 patients) were included in this review. Out of the 56 studies, 36 (64.3%) were from India (1983–2022), 12 (21.4%) from Sudan (1992–2021), 6 (10.7%) were from Bangladesh (1991–2019), and 2 (3.6%) from Nepal (2001–2007). Five (8.9%) studies were published between 1981–1990 (n = 193 patients), 10 (17.9%) between 1991–2000 (n = 230 patients), 10 (17.9%) between 2001–2010 (n = 198 patients), and 31 (55.4%) from 2011 onwards (n = 1,865 patients). Eight (14.3%) were randomised clinical trials, and 48 (85.7%) were non-randomised studies. The median post-treatment follow-up duration was 365 days (range: 90–540 days) in 8 RCTs and 360 days (range: 28–2,373 days) in 48 non-randomised studies. Disease diagnosis was based on clinical criterion in 3 (5.4%) studies, a mixture of clinical and parasitological methods in 47 (83.9%) and was unclear in 6 (10.7%) studies. Major drugs used for treatment were miltefosine (n = 636 patients), liposomal amphotericin B (L-AmB) (n = 508 patients), and antinomy regimens (n = 454 patients). Ten other drug regimens were tested in 270 patients with less than 60 patients per regimen. Conclusions: Our review identified studies with very limited sample size for the three major drugs (miltefosine, L-AmB, and pentavalent antimony), while the number of patients combined across studies suggest that the IPD platform would be valuable. With the support of relevant stakeholders, the global PKDL community and sufficient financing, a PKDL IPD platform can be realised. This will allow for exploration of different aspects of treatment safety and efficacy, which can potentially guide future healthcare decisions and clinical practices. Author summary: Post-kala-azar dermal leishmaniasis (PKDL) is a dermatosis which mostly manifests after successful treatment of visceral leishmaniasis (VL) and is characterised by macular, papular, nodular, erythematous, or polymorphic rashes. PKDL is a public health problem in VL endemic areas, as recent infectivity studies show that L. donovani parasites can be found in PKDL lesions and remain infectious to sandfly vectors. There are numerous gaps in our existing knowledge of PKDL, including its pathology, immunology, and risk factors associated with therapeutic outcomes. Currently recommended treatments are either expensive (liposomal amphotericin-B), have raised safety concerns (especially for antimony regimens), or require long treatment duration (e.g. miltefosine). In order to scope the measure of evidence supporting therapeutic efficacy recommendations for PKDL patients, we conducted a systematic literature review. Our systematic review identified 56 PKDL studies describing 2,486 patients, with a majority of the studies (31 studies and 1,865 patients) published from 2010 onwards. The Infectious Diseases Data Observatory (IDDO) already have an established data platform for VL, and the IDDO VL data platform currently hosts a critical mass of data from efficacy trials in VL conducted over the past 20 years. Based on the identified volume of data, with a substantial number of studies being relatively recent, we believe that the establishment of a PKDL data platform is feasible. Creating a platform to facilitate the sharing of the datasets would enable in-depth IPD meta-analyses with existing data to address several knowledge gaps of PKDL and guide future research priorities. With the help of relevant stakeholders, the global PKDL community and sufficient resources, a PKDL data platform can be realised and help address key research gaps. [ABSTRACT FROM AUTHOR]

Background: In the Mediterranean basin, three Leishmania species have been identified: L. infantum, L. major and L. tropica, causing zoonotic visceral leishmaniasis (VL), zoonotic cutaneous leishmaniasis (CL) and anthroponotic CL, respectively. Despite animal models and genomic/transcriptomic studies provided important insights, the pathogenic determinants modulating the development of VL and CL are still poorly understood. This work aimed to identify host transcriptional signatures shared by cells infected with L. infantum, L. major, and L. tropica, as well as specific transcriptional signatures elicited by parasites causing VL (i.e., L. infantum) and parasites involved in CL (i.e., L. major, L. tropica). Methodology/Principal findings: U937 cells differentiated into macrophage-like cells were infected with L. infantum, L. major and L. tropica for 24h and 48h, and total RNA was extracted. RNA sequencing, performed on an Illumina NovaSeq 6000 platform, was used to evaluate the transcriptional signatures of infected cells with respect to non-infected cells at both time points. The EdgeR package was used to identify differentially expressed genes (fold change > 2 and FDR-adjusted p-values < 0.05). Then, functional enrichment analysis was employed to identify the enriched ontology terms in which these genes are involved. At 24h post-infection, a common signature of 463 dysregulated genes shared among all infection conditions was recognized, while at 48h post-infection the common signature was reduced to 120 genes. Aside from a common transcriptional response, we evidenced different upregulated functional pathways characterizing L. infantum-infected cells, such as VEGFA-VEGFR2 and NFE2L2-related pathways, indicating vascular remodeling and reduction of oxidative stress as potentially important factors for visceralization. Conclusions: The identification of pathways elicited by parasites causing VL or CL could lead to new therapeutic strategies for leishmaniasis, combining the canonical anti-leishmania compounds with host-directed therapy. Author summary: Leishmaniasis is a zoonosis caused by the intracellular parasite of the genus Leishmania. In the Mediterranean region, the human disease can be present mainly in two forms: cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL), which can be fatal if untreated. The clinical presentation of the disease depends on the parasite species and host characteristics. However, the molecular mechanisms underlying the development of the visceral form of leishmaniasis are not yet fully understood. In this study, we have determined the gene expression profile in cells infected by three Leishmania species (L. infantum, L. major, L. tropica) responsible for different forms of the disease. The results have allowed us to identify an expression profile (and the related pathways) shared by cells infected by all Leishmania species. Aside this common response, we also identified a transcriptional response distinguishing cells infected by L. infantum, L. major or L. tropica, as well as the relevant pathways in which these genes participate. Therefore, our results contribute to the knowledge of the host cell mechanisms that are activated along infection with different Leishmania species causing different forms of the disease and, therefore, may help develop new host-directed therapy for Leishmaniasis. [ABSTRACT FROM AUTHOR]

Background: Leishmaniasis are a group of diseases caused by more than 20 species of the protozoan that are transmitted through the bite of female sand fly. The disease is endemic to 98 countries of the world. It affects most commonly the poorest of the poor and mainly males. Several research has been conducted to propose disease control strategies. Effective medical care, vector control, environmental hygiene, and personal protection are the mainstays of the current preventative and control methods. The mathematical models for the transmission dynamics of the disease studied so far did not consider the sex-biased burden of the disease into consideration. Methodology: Unlike the previous VL works, this study introduces a new deterministic sex-structured model for understanding the transmission dynamics of visceral leishmaniasis. Basic properties of the model including basic reproduction number (R0), and conditions for the existence of backward bifurcation of the model are explored. Baseline parameter values were estimated after the model was fitted to Ethiopia's VL data. Sensitivity analysis of the model was performed to identify the parameters that significantly impact the disease threshold. Numerical simulations were performed using baseline parameter values, and scenario analysis is performed by changing some of these parameters as appropriate. Conclusion: The analysis of the model shows that there is a possibility for a backward bifurcation for R0<1 , which means bringing R0 to less than unity may not be enough to eradicate the disease. Our numerical result shows that the implementation of disease-preventive strategies, as well as effectively treating the affected ones can significantly reduce the disease prevalence if applied for more proportion of the male population. Furthermore, the implementation of vector management strategies also can considerably reduce the total prevalence of the disease. However, it is demonstrated that putting more effort in treating affected reservoir animals may not have any significant effect on the overall prevalence of the disease as compared to other possible mechanisms. The numerical simulation infers that a maximum of 60% of extra preventative measures targeted to only male population considerably reduces the total prevalence of VL by 80%. It is also possible to decrease the total prevalence of VL by 69.51% when up to 50% additional infected males receive treatment with full efficacy. Moreover, applying a maximum of 15% additional effort to reduce the number of vectors, decreases the total VL prevalence by 57.71%. Therefore, in order to reduce the disease burden of visceral leishmaniasis, public health officials and concerned stakeholders need to give more emphasis to the proportion of male humans in their intervention strategies. [ABSTRACT FROM AUTHOR]

Leishmaniasis refers to a disease with a wide range of manifestations; and there are three main forms of disease, cutaneous, mucocutaneous, and visceral. Leishmaniasis is one of the diseases with a protozoan agent which is vector-borne. Visceral leishmaniasis (VL) is the most severe form that can be fiercely life-threatening if left untreated. VL can be caused by members of Leishmania donovani complex, in Iran, Leishmania infantum is considered the primary causative agent of VL, resulting in a zoonotic form of VL. The two main goals of our work, which followed our prior sero-epidemiological and entomological survey, were to characterize and conduct a phylogenetic analysis of the Leishmania species that infect people, dogs, and sandflies. The samples were collected throughout 2017, from January to December, so blood samples were collected from humans and dogs, while sandfly samples were collected with sticky traps. DNA extracted from all seropositive samples of humans and dogs, 10% of sero-negative human samples, and all collected sandflies were subjected to kDNA-nested-PCR for tracing parasites. A total of 30 samples, including 20 human samples, 8 dog samples, and 2 sandfly samples, were found positive for the kDNA gene of L. infantum. Sequences were evaluated to study the genetic diversity among the six discovered L. infantum. Based on kDNA, the phylogenetic study of L. infantum demonstrated a high level of genetic variety and a relationship between the host, the parasite's geographic origin, and its genetic diversity. [ABSTRACT FROM AUTHOR]

Background: India is going through the maintenance phase of VL elimination programme which may be threatened by the persistence of hidden parasite pools among asymptomatic leishmanial infection (ALI) and PKDL. The present work was designed to determine the burden of VL, PKDL, and ALI and to assess the role of treatment of ALI in maintaining post-elimination phase. Methods and finding: The study was undertaken in Malda district, West Bengal, India during October 2016 to September 2021. Study areas were divided into 'Study' and 'Control' arms. VL and PKDL cases of both the arms were diagnosed by three active mass surveys with an interval of one year and treated as per National guideline. ALI of study arm was treated like VL. ALI of control arm was followed up to determine their fate. Fed sand-fly pools were analysed for parasitic DNA. No significant difference was noted between the incidence of VL and PKDL in both the arms. Incidence of ALI declined sharply in study arm but an increasing trend was observed in control arm. Significantly higher rate of sero-conversion was noted in control arm and was found to be associated with untreated ALI burden. Parasitic DNA was detected in 22.8% ALI cases and 2.2% sand-fly pools. Conclusion: Persistence of a significant number of PKDL and ALI and ongoing transmission, as evidenced by new infection and detection of leishmanial DNA in vector sand-flies, may threaten the maintenance of post-elimination phase. Emphasis should be given for elimination of pathogen to prevent resurgence of VL epidemics. Author summary: The present study was conducted in a kala-azar endemic block of Malda district, West Bengal. The study areas were divided 'Study' and 'Control' arm and three active mass survey was conducted for detection of visceral leishmaniasis (VL), post kala-azar dermal leishmaniasis (PKDL) and asymptomatic leishmanial infection (ALI). In the study arm, diagnosed ALI cases were treated with Liposomal Amphotericin B. No significant difference was noted between the incidence of VL and PKDL cases in 'Study' and 'Control' arm. But the incidence of ALI cases declined sharply in 'Study' arm and increasing trend was observed in 'Control' arm. A significantly higher rate of ser-conversion was noted in 'Control' arm. In both 'Study' and 'Control' arm, the sero-conversion rate was significantly associated with untreated ALI burden. Persistence of significant number of PKDL and ALI and ongoing transmission as evidenced by new infection and detection of leishmanial DNA in sand-flies may jeopardise the maintenance of post-elimination phase. Therefore, constant vigilance is highly needed to prevent resurgence of VL epidemic. Detection and long-term follow-up of ALI may also help to sustain the elimination. However, feasibility and cost-effectiveness study for detection and treatment of ALI should also receive attention. [ABSTRACT FROM AUTHOR]

Background: Visceral leishmaniasis (VL), or kala-azar, is a vector-borne tropical disease caused by a group of intracellular hemoflagellate protozoa belonging to the family of Trypanosomatide and the genus Leishmania. The disease is distributed around the world and transmitted via the bite of infected female Phlebotomine sandflies, and there is variation in the diagnostic accuracy. Therefore, this systematic review and meta-analysis aimed to determine the pooled global sensitivity and specificity of the rk-39 test and to evaluate if there is a difference between the different parts of the world. Methods: A systematic review and meta-analysis have been conducted on the diagnostic accuracy of dermoscopy. After setting eligibility criteria, literature was searched in four databases and one searching engine. Articles were screened, critically appraised, and extracted independently by two reviewers, and any disagreements were resolved with the involvement of a third person. The quality of the included studies had been assessed by the Quality Assessment of Diagnostic Accuracy Studies (QUADAS 2) tool. Pooled sensitivity and specificity were determined by bivariate random effect analysis. Heterogeneity was assessed by Higgins's I2, and when it was present, mitigation was conducted by using sensitivity analysis. Result: A total of 409 studies were identified, and finally 18 articles were eligible for the review with a total sample size of 5, 253. The bivariate random effect meta-analysis of the 7 diagnostic accuracy studies showed a pooled sensitivity of 0.89 (0.76–0.95) and specificity of 0.86 (0.72–0.94). The +LR was 6.32 (95% CI: 2.85–14.02), the–LR was 0.13 (95% CI: 0.06–0.30), and the diagnostic odds ratio (DOR) was 47.8 (95% CI: 11.3–203.2). Abdel-Latif (2018) was both an outlier and influential for sensitivity, and Walter (2011) was both an outlier and influential for specificity, and removing them from sensitivity and specificity, respectively, was beneficial for reducing the heterogeneity. Conclusion: Rk-39 is found to have highly accurate measures in the diagnosis of visceral leishmaniasis. Both sensitivity and specificity were found to be highly accurate in the diagnosis of leishmaniasis, with a pooled sensitivity of 0.91 (0.88–0.93) and a pooled specificity of 0.89 (0.85–0.91). Ethical consideration: As we will use secondary data for the systematic review and meta-analysis, ethical concerns are not necessary. Author summary: Leishmaniasis is a vector-borne tropical disease distributed around the world and transmitted via the bite of infected sandflies. There are 3 main forms of the disease: visceral leishmaniasis, which is fatal if left untreated in over 95% of cases and is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anemia. The other form of the disease is cutaneous leishmaniasis, which causes skin lesions and life-long scars on exposed parts of the body. Whereas the third one, mucocutaneous leishmaniasis, leads to partial or total destruction of the mucous membranes of the nose, mouth and throat. In this study, the authors examined the distribution of visceral leishmaniasis, which has significant impact on livelihoods such as agriculture and livestock and affects cognitive, developmental and educational outcomes. Moreover, since visceral leishmaniasis is a killer disease, timely and accurate diagnosis is important to give appropriate treatment. This systematic review and meta-analysis identify the pooled sensitivity and specificity of the rk-39 test regarding its accuracy by considering many studies in the different parts of the world. According to our findings, rk-39 is regarded as a crucial quick diagnostic tool for the diagnosis of visceral leishmaniasis. [ABSTRACT FROM AUTHOR]

Background: Visceral leishmaniasis (VL) resolution depends on a wide range of factors, including the instauration of an effective treatment coupled to a functional host immune system. Patients with a depressed immune system, like the ones receiving methotrexate (MTX), are at higher risk of developing VL and refusing antileishmanial drugs. Moreover, the alarmingly growing levels of antimicrobial resistance, especially in endemic areas, contribute to the increasing the burden of this complex zoonotic disease. Principal findings: To understand the potential links between immunosuppressants and antileishmanial drugs, we have studied the interaction of antimony (Sb) and MTX in a Leishmania infantum reference strain (LiWT) and in two L. infantum clinical strains (LiFS-A and LiFS-B) naturally circulating in non-treated VL dogs in Spain. The LiFS-A strain was isolated before Sb treatment in a case that responded positively to the treatment, while the LiFS-B strain was recovered from a dog before Sb treatment, with the dog later relapsing after the treatment. Our results show that, exposure to Sb or MTX leads to an increase in the production of reactive oxygen species (ROS) in LiWT which correlates with a sensitive phenotype against both drugs in promastigotes and intracellular amastigotes. LiFS-A was sensitive against Sb but resistant against MTX, displaying high levels of protection against ROS when exposed to MTX. LiFS-B was resistant to both drugs. Evaluation of the melting proteomes of the two LiFS, in the presence and absence of Sb and MTX, showed a differential enrichment of direct and indirect targets for both drugs, including common and unique pathways. Conclusion: Our results show the potential selection of Sb-MTX cross-resistant parasites in the field, pointing to the possibility to undermine antileishmanial treatment of those patients being treated with immunosuppressant drugs in Leishmania endemic areas. Author summary: Visceral leishmaniasis (VL) is the most severe form of the disease caused by the parasite Leishmania infantum. Immunosuppressive conditions such as those generated using immunosuppressive treatments (i.e., methotrexate), to treat autoimmune diseases have increased the risk of developing severe complications linked to this parasitic disease, especially in endemic areas. Of note, treatment of VL in immunosuppressed patients is very challenging and frequently results in clinical relapse. For these reasons, it is capital to better understand any potential impact of the use of immunosuppressants on the antileishmanial effect of current drugs (i.e. antimonials) and their potential contribution to the emergence and spread of drug resistance. Here we report the first evidence of the potential co-selection of antimicrobial resistance between antimonials and methotrexate in L. infantum circulating strains. In addition to shedding some light on the causes of treatment failure and relapses in patients under methotrexate immunosuppression, this new knowledge could assist in the development of better immunosuppression strategies in endemic areas of leishmaniasis. [ABSTRACT FROM AUTHOR]

Background: CD4+ T cells play a central role in control of L. donovani infection, through IFN-γ production required for activation of macrophages and killing of intracellular parasites. Impaired control of parasites can in part be explained by hampered CD4+ T cells effector functions in visceral leishmaniasis (VL) patients. In a recent studies that defined transcriptional signatures for CD4+ T cells from active VL patients, we found that expression of the IL-7 receptor alpha chain (IL-7Rα; CD127) was downregulated, compared to CD4+ T cells from endemic controls (ECs). Since IL-7 signaling is critical for the survival and homeostatic maintenance of CD4+ T cells, we investigated this signaling pathway in VL patients, relative to ECs. Methods: CD4+ T cells were enriched from peripheral blood collected from VL patients and EC subjects and expression of IL7 and IL7RA mRNA was measured by real time qPCR. IL-7 signaling potential and surface expression of CD127 and CD132 on CD4+ T cell was analyzed by multicolor flow cytometry. Plasma levels of soluble IL-7 and sIL-7Rα were measured by ELISA. Result: Transcriptional profiling data sets generated previously from our group showed lower IL7RA mRNA expression in VL CD4+ T cells as compared to EC. A significant reduction was, however not seen when assessing IL7RA mRNA by RT-qPCR. Yet, the levels of soluble IL-7Rα (sIL-7Rα) were reduced in plasma of VL patients compared to ECs. Furthermore, the levels of soluble IL-7 were higher in plasma from VL patients compared to ECs. Interestingly, expression of the IL-7Rα protein was higher on VL patient CD4+ T cells as compared to EC, with activated CD38+ CD4+ T cells showing higher surface expression of IL-7Rα compared to CD38- CD4+ T cells in VL patients. CD4+ T cells from VL patients had higher signaling potential baseline and after stimulation with recombinant human IL-7 (rhIL-7) compared to EC, as measured by phosphorylation of STAT5 (pSTAT5). Interestingly, it was the CD38 negative cells that had the highest level of pSTAT5 in VL patient CD4+ T cells after IL-7 stimulation. Thus, despite unaltered or potentially lowered IL7RA mRNA expression by CD4+ T cells from VL patients, the surface expression of the IL-7Rα was higher compared to EC and increased pSTAT5 was seen following exposure to rhIL-7. Accordingly, IL-7 signaling appears to be functional and even enhanced in VL CD4+ T cells and cannot explain the impaired effector function of VL CD4+ T cells. The enhanced plasma IL-7 may serve as part of homeostatic feedback mechanism regulating IL7RA expression in CD4+ T cells. Author summary: In visceral leishmaniasis (VL), antigen specific CD4+ T cell responses are muted hindering the control of the Leishmania donovani infection. IL-7 signaling is crucial for CD4+ T cell survival and function, and gene expression analysis indicated that the IL-7 pathway could be altered in VL. Thus, we investigate if impaired IL-7 signaling could explain the loss of antigen specific T cell response in VL. Although we didn't observe significant reduction of IL7RA mRNA by RT-qPCR, yet, the levels of soluble IL-7Rα (sIL-7Rα) were reduced in plasma of VL patients compared to ECs. Furthermore, the levels of soluble IL-7 were higher in plasma from VL patients compared to ECs and their CD4+ T cells exhibited heightened IL-7 receptor protein expression. Surprisingly, VL patient CD4+ T cells showed increased IL-7 signaling potential, as evidenced by higher phosphorylation of STAT5 upon IL-7 stimulation. While altered, the findings presented here do not attributed the impaired effector function of VL CD4+ T cells to defective IL-7 signaling. We speculate that the elevated plasma IL-7 is part of a homeostatic feedback mechanism in response to the reduced IL7RA transcription in CD4+ T cells. [ABSTRACT FROM AUTHOR]

Lipids stored in lipid-bodies (LBs) in host cells are potential sources of fatty acids for pathogens. However, the mechanism of recruitment of LBs from the host cells by pathogens to acquire fatty acids is not known. Here, we have found that Leishmania specifically upregulates the expression of host Rab18 and its GEF, TRAPPC9 by downregulating the expression of miR-1914-3p by reducing the level of Dicer in macrophages via their metalloprotease gp63. Our results also show that miR-1914-3p negatively regulates the expression of Rab18 and its GEF in cells. Subsequently, Leishmania containing parasitophorous vacuoles (Ld-PVs) recruit and retain host Rab18 and TRAPPC9. Leishmania infection also induces LB biogenesis in host cells and recruits LBs on Ld-PVs and acquires FLC12-labeled fatty acids from LBs. Moreover, overexpression of miR-1914-3p in macrophages significantly inhibits the recruitment of LBs and thereby suppresses the multiplication of parasites in macrophages as parasites are unable to acquire fatty acids. These results demonstrate a novel mechanism how Leishmania acquire fatty acids from LBs for their growth in macrophages. Author summary: Leishmania donovani which causes fatal disease known as visceral leishmaniasis, is dependent on its host to scavenge fatty acids for its survival. But, how Leishmania get fatty acids from host macrophages is not known. Lipid bodies are unique organelles that contain neutral lipids and fatty acids, therefore, LBs in macrophages could be the potential source of fatty acids for parasites. We have found that Leishmania upregulate the expression of host Rab18 and its GEF by downregulating the expression of miR-1914-3p in infected macrophages via the Ld-gp63-mediated inhibition of dicer expression. As biogenesis of LBs is shown to be regulated by Rab18, we have found that Leishmania infection induces LB biogenesis in macrophages and subsequently recruits LBs along with Rab18 and its GEF on Leishmania containing parasitophorous vacuoles. Finally, parasites-containing vacuoles acquire FLC12-labeled fatty acids from LBs to meet their nutritional requirement. We have also shown that overexpression of miR-1914-3p in macrophages significantly inhibits the recruitment of LBs and thereby suppresses the growth of parasites in macrophages as parasites are unable to acquire nutrients from LBs. These results demonstrate how Leishmania acquire nutrients like fatty acids from LBs for their proliferation in macrophages. [ABSTRACT FROM AUTHOR]

The host immune system plays a significant role in managing and clearing pathogen material during an infection, but this complex process presents numerous challenges from a modeling perspective. There are many mathematical and statistical models for these kinds of processes that take into account a wide range of events that happen within the host. In this work, we present a Bayesian joint model of longitudinal and time-to-event data of Leishmania infection that considers the interplay between key drivers of the disease process: pathogen load, antibody level, and disease. The longitudinal model also considers approximate inflammatory and regulatory immune factors. In addition to measuring antibody levels produced by the immune system, we adapt data from CD4+ and CD8+ T cell proliferation, and expression of interleukin 10, interferon-gamma, and programmed cell death 1 as inflammatory or regulatory factors mediating the disease process. The model is developed using data collected from a cohort of dogs naturally exposed to Leishmania infantum. The cohort was chosen to start with healthy infected animals, and this is the majority of the data. The model also characterizes the relationship features of the longitudinal outcomes and time-to-death due to progressive Leishmania infection. In addition to describing the mechanisms causing disease progression and impacting the risk of death, we also present the model's ability to predict individual trajectories of Canine Leishmaniosis (CanL) progression. The within-host model structure we present here provides a way forward to address vital research questions regarding the understanding of the progression of complex chronic diseases such as Visceral Leishmaniasis, a parasitic disease causing significant morbidity worldwide. [ABSTRACT FROM AUTHOR]

Background: As of 2021, the National Kala-azar Elimination Programme (NKAEP) in India has achieved visceral leishmaniasis (VL) elimination (<1 case / 10,000 population/year per block) in 625 of the 633 endemic blocks (subdistricts) in four states. The programme needs to sustain this achievement and target interventions in the remaining blocks to achieve the WHO 2030 target of VL elimination as a public health problem. An effective tool to analyse programme data and predict/ forecast the spatial and temporal trends of VL incidence, elimination threshold, and risk of resurgence will be of use to the programme management at this juncture. Methodology/principal findings: We employed spatiotemporal models incorporating environment, climatic and demographic factors as covariates to describe monthly VL cases for 8-years (2013–2020) in 491 and 27 endemic and non-endemic blocks of Bihar and Jharkhand states. We fitted 37 models of spatial, temporal, and spatiotemporal interaction random effects with covariates to monthly VL cases for 6-years (2013–2018, training data) using Bayesian inference via Integrated Nested Laplace Approximation (INLA) approach. The best-fitting model was selected based on deviance information criterion (DIC) and Watanabe-Akaike Information Criterion (WAIC) and was validated with monthly cases for 2019–2020 (test data). The model could describe observed spatial and temporal patterns of VL incidence in the two states with widely differing incidence trajectories, with >93% and 99% coverage probability (proportion of observations falling inside 95% Bayesian credible interval for the predicted number of VL cases per month) during the training and testing periods. PIT (probability integral transform) histograms confirmed consistency between prediction and observation for the test period. Forecasting for 2021–2023 showed that the annual VL incidence is likely to exceed elimination threshold in 16–18 blocks in 4 districts of Jharkhand and 33–38 blocks in 10 districts of Bihar. The risk of VL in non-endemic neighbouring blocks of both Bihar and Jharkhand are less than 0.5 during the training and test periods, and for 2021–2023, the probability that the risk greater than 1 is negligible (P<0.1). Fitted model showed that VL occurrence was positively associated with mean temperature, minimum temperature, enhanced vegetation index, precipitation, and isothermality, and negatively with maximum temperature, land surface temperature, soil moisture and population density. Conclusions/significance: The spatiotemporal model incorporating environmental, bioclimatic, and demographic factors demonstrated that the KAMIS database of the national programmme can be used for block level predictions of long-term spatial and temporal trends in VL incidence and risk of outbreak / resurgence in endemic and non-endemic settings. The database integrated with the modelling framework and a dashboard facility can facilitate such analysis and predictions. This could aid the programme to monitor progress of VL elimination at least one-year ahead, assess risk of resurgence or outbreak in post-elimination settings, and implement timely and targeted interventions or preventive measures so that the NKAEP meet the target of achieving elimination by 2030. Author summary: In India, VL has been endemic in four states (Bihar, Jharkhand, Uttar Pradesh, and West Bengal), having over 165 million population. The national programme achieved elimination (<1 case / 10,000 population/year per 'block') in 625 of the 633 endemic blocks in 2021. While sustaining elimination level, the programme needs to target other blocks yet to reach elimination to achieve the WHO 2030 target. We fitted a variety of spatiotemporal models to 72-monthly reported VL cases (2013–2018, training period) from 491 endemic and 27 non-endemic blocks in Bihar and Jharkhand. The best fitting model was validated with 24-month reported cases (2019–2020, test period). Model predictions agree with >93 and 99% of the monthly-observations for the periods. Forecasting for 2021–2023 showed that incidence is likely to exceed elimination threshold in 16–18 and 33–38 historically high endemic blocks of Jharkhand and Bihar. Fitted model showed that VL incidence is positively associated with mean temperature, minimum temperature, enhanced vegetation index, precipitation, and isothermality, and negatively with maximum temperature, land surface temperature, soil moisture and population density. Forecasting VL incidence at block level can aid to monitor elimination progress, target the blocks yet to reach elimination and long-term monitoring of risk of resurgence during post-elimination. [ABSTRACT FROM AUTHOR]

Domestic dogs are the primary urban reservoirs of Leishmania infantum, the causative agent of visceral leishmaniasis. In Canine Leishmaniasis (CanL), modulation of the host's immune response may be associated with the expression of small non-coding RNAs called microRNA (miR). miR-194 expression increases in peripheral blood mononuclear cells (PBMCs) of dogs with leishmaniasis with a positive correlation with the parasite load and in silico analysis demonstrated that the TRAF6 gene is the target of miR-194 in PBMCs from diseased dogs. Here, we isolated PBMCs from 5 healthy dogs and 28 dogs with leishmaniasis, naturally infected with L. infantum. To confirm changes in miR-194 and TRAF6 expression, basal expression of miR-194 and gene expression of TRAF6 was measured using qPCR. PBMCs from healthy dogs and dogs with leishmaniasis were transfected with miR-194 scramble, mimic, and inhibitor and cultured at 37° C, 5% CO2 for 48 hours. The expression of possible targets was measured: iNOS, NO, T-bet, GATA3, and FoxP3 were measured using flow cytometry; the production of cytokines IL-1β, IL-4, IL-6, IL-10, TNF-α, IFN-γ, and TGF-β in cell culture supernatants was measured using capture enzyme-linked immunosorbent assays (ELISA). Parasite load was measured using cytometry and qPCR. Functional assays followed by miR-194 inhibitor and IL-1β blockade and assessment of NO production were also performed. Basal miR-194 expression was increased in PBMC from dogs with Leishmaniasis and was negatively correlated with TRAF6 expression. The mimic of miR-194 promoted an increase in parasite load. There were no significant changes in T-bet, GATA3, or FoxP3 expression with miR-194 enhancement or inhibition. Inhibition of miR-194 increased IL-1β and NO in PBMCs from diseased dogs, and blockade of IL-1β following miR-194 inhibition decreased NO levels. These findings suggest that miR-194 is upregulated in PBMCs from dogs with leishmaniasis and increases parasite load, possibly decreasing NO production via IL-1β. These results increase our understanding of the mechanisms of evasion of the immune response by the parasite and the identification of possible therapeutic targets. Author summary: Visceral leishmaniasis (VL) is a zoonosis in tropical and subtropical regions. In the new world, it is caused by the obligate intracellular protozoan Leishmania infantum. In urban areas, domestic dogs are the primary reservoir. Increase in canine leishmaniasis (CanL) contributes to the increase in VL in humans. One mechanism of parasite survival is through regulation of microRNA (miRNA), responsible for translational control of transcripts related to anti-parasite immunity. One example is miR-194, which is increased in the peripheral blood mononuclear cells (PBMCs) of dogs with leishmaniasis. In the present study, we found that increasing miR-194 increases parasite load, and decreasing miR-194 increases IL1β and NO. Subsequently, we found that the increase in NO depends on IL1β. Since NO its directly involved in parasite load control, these findings contribute to understanding how the parasite evades immune responses and paves the way for the discovery of new therapeutic targets. [ABSTRACT FROM AUTHOR]

Background: Leishmaniasis is caused by infection with intracellular protozoans of the genus Leishmania. Transmission occurs predominantly by the bite of phlebotomine sandflies, other routes, including congenital transmission, are rare. The disease manifests as either cutaneous, visceral or mucosal/mucocutaneous leishmaniasis. In recent years, changes in the epidemiological pattern have been reported from Europe. Principal findings: A total of 311 new and 29 published leishmaniasis cases occurring between 01/01/2000 and 12/31/2021 in Austria were collected and analyzed. These encompassed 146 cutaneous (CL), 14 visceral (VL), 4 mucosal, and 3 cases with concurrent VL and CL. In addition, asymptomatic infections, comprising 11 unspecified cases with Leishmania DNA detectable only in the blood and 162 cases with anti-Leishmania antibodies were reported. Particularly since 2016, the incidence of leishmaniasis has steadily risen, mainly attributable to increasing numbers of CL and cases with positive serology against Leishmania species, whereas the incidence of VL has slowly decreased. Analysis revealed that a shift in the causative species spectrum had occurred and that a substantial number of CL cases were caused by members of the Leishmania donovani/infantum complex. Simultaneous occurrence of VL and CL was identified in immunocompromised individuals, but also in a not yet reported case of an immunocompetent child after vertical transmission. Conclusions: The incidence of leishmaniasis has risen in the recent years. The numbers are anticipated to keep rising due to increasing human mobility, including travel and forced migration, growing reservoir host populations as well as expansion and dispersal of vector species caused by climate and habitat changes, urbanization and globalization. Hence, elevated awareness for the disease, including possible transmission in previously non-endemic regions and non-vector transmission modes, support of sandfly surveillance efforts and implementation and establishment of public health interventions in a One Health approach are pivotal in the global efforts to control and reduce leishmaniasis. Author summary: Leishmaniasis is a vector-borne infectious disease caused by intracellular parasites and affects 12–15 million people worldwide. The clinical presentation is variable, and the disease mainly manifests as cutaneous, visceral or mucosal forms. We collected 340 cases of leishmaniasis occurring in Austria over a period of 21 years and performed an analysis of trends to understand the epidemiology of the disease in a non-endemic Central European country. In addition, we report a rare case of concurrent visceral and cutaneous leishmaniasis which was vertically transmitted to an immunocompetent child. Our analyses revealed that the incidences of cutaneous leishmaniasis are rising in Austria and that a shift in the causative species spectrum has occurred. Due to increased population migration, travel activities of humans and animal hosts, growth and spread of the vector populations facilitated primarily by climate changes, a rising number of leishmaniasis cases can be anticipated in many endemic, but intriguingly also in non-endemic regions. The potential expansion of endemicity necessitates raising awareness towards the burden of this disease and provides an incentive to the global health community to continue their efforts in disease control. [ABSTRACT FROM AUTHOR]

The parasite Leishmania donovani is one of the species causing visceral leishmaniasis in humans, a deadly infection claiming up to 40,000 lives each year. The current drugs for leishmaniasis treatment have severe drawbacks and there is an urgent need to find new anti-leishmanial compounds. However, the search for drug candidates is complicated by the intracellular lifestyle of Leishmania. Here, we investigate the use of human induced pluripotent stem cell (iPS)-derived macrophages (iMACs) as host cells for L. donovani. iMACs obtained through embryoid body differentiation were infected with L. donovani promastigotes, and high-content imaging techniques were used to optimize the iMACs seeding density and multiplicity of infection, allowing us to reach infection rates up to 70% five days after infection. IC50 values obtained for miltefosine and amphotericin B using the infected iMACs or mouse peritoneal macrophages as host cells were comparable and in agreement with the literature, showing the potential of iMACs as an infection model for drug screening. Author summary: Author summary: Yearly, up two million people in poverty-stricken areas contract leishmaniasis, a disease caused by parasites of the genus Leishmania. When an infected sandfly takes a blood meal, Leishmania parasites enter the host where they are taken up by macrophages. Inside the macrophage, Leishmania parasites establish a niche where they can proliferate. The infection often leads to disability and can result in death. Moreover, the drugs currently available are unsatisfactory due to toxic side effects, high expenses or difficulties in usage. Drug screening assays that are currently used for compound screening often rely on mouse peritoneal macrophages. We have generated human induced pluripotent stem cell derived macrophages and used these as new host cells for Leishmania donovani in the testing of anti-leishmanial compounds. This model has many advantages. For one, it allows us to work with human cells, mimicking the natural infection more closely than murine cells. Secondly, it allows us to obtain bigger batches of uniform cells for screening campaigns. Finally, this approach aligns with the principles of the 3Rs, replacing the use of animals for cultivation of Leishmania and drug screening purposes. [ABSTRACT FROM AUTHOR]

Miranda Municipality of Mato Grosso do Sul, borders the Pantanal wetland, a famous fishing destination visited by tourists from all over the world, and is a location where visceral leishmaniasis has been reported. To assess the risk of Leishmania infantum transmission, we studied the sandfly community, focusing on known vector and parasite presence. We conducted light trap collections twice per month at nine sites within the city (including two forested areas) for one year. We collected a total of 12,727 sand flies, 10,891 males and 1,836 females belonging to 11 species: Brumptomyia avellari, Evandromyia aldafalcaoae, Ev. evandroi, Ev. lenti, Ev. sallesi, Ev. walkeri, Lu. longipalpis, Nyssomyia whitmani, Psathyromyia bigeniculata, Pa. hermanlenti and Pa. punctigeniculata. Lutzomyia longipalpis, the proven vector of Leishmania infantum, was captured each month, and was the most abundant species observed, accounting for more than 99% of sand flies captured in most sites, especially where chicken coops were present. Evidence of Leishmania infantum infection was detected in 0.40% of Lu. longipalpis tested. We developed a generalized mixed multilevel model for Lu. longipalpis, that includes within-year seasonality, location of capture (indoors vs. outdoors), vector abundance, and sex ratio. The VL vector was abundant both inside and outside houses. Large numbers of Lu. longipalpis were observed in outdoor sites where domestic animals were present but were absent from forest sites. Our findings suggest high vector populations and Le. infantum presence in a city where tourists could be exposed to visceral leishmaniasis, with significant implications for more surveillance and control activities. Author summary: Several localities in Mato Grosso do Sul have already recorded human visceral leishmaniasis cases, including the city of Miranda, which is a famous fishing and tourism destination. Due to the high number of visitors, we decided to evaluate the risk of Leishmania infantum transmission in the area. Thus, we conducted vector collections over one year, detecting both the presence of the main vector (Lutzomyia longipalpis) and the Le. infantum parasite. We used nonlinear multilevel mixed models, under the Bayesian framework, to investigate the seasonal changes on transmission risk (i.e.; overall vector abundance and the proportion of females), taking into account the residence space. We found that the overall vector abundance outdoors was higher than in the indoors. Outdoors abundance was more consistent with two-peaks during the year, whereas indoors abundance was more seasonal with a single peak. Although, indoor abundance was lower than observed outdoors, the proportion of females captured was up to twice that observed outdoors. These findings highlighted the spatiotemporal component of leishmaniasis transmission risk, which can guide entomological surveillance and control measures. [ABSTRACT FROM AUTHOR]

Background: This paper identifies opportunities and challenges for leishmaniasis control and elimination in Colombia, emphasizing the role of pooled procurement of essential medicines and supplies. Colombia is among the countries most affected by leishmaniasis globally, and also faces the dual challenge of procuring critically needed medicines in the context of limited national resources. It recently renewed its commitment to the control and elimination of leishmaniasis under its 2022–2031 Public Health Plan (PDSP) through a comprehensive public health approach. Methodology/Principal findings: The methodology comprises a comprehensive literature review and key informant interviews with leishmaniasis experts from the Colombian national control program and PAHO/WHO, focusing on cutaneous, mucocutaneous, and visceral leishmaniasis. Leishmaniasis is endemic throughout Colombia, with over 11 million people at risk, many of whom live in poverty-stricken, remote and isolated rural areas with limited access to health services. Leishmaniasis care, including medicines, is provided free of charge, but many barriers were nonetheless identified at environmental, population, and health system levels, including the supply of quality-assured medicines. Opportunities to alleviate these barriers were identified, including the support of the PAHO Strategic Fund. Within the context of the sustainable development goals and international leishmaniasis control and elimination targets, Colombian officials have established their own priorities, the highest of which is the reduction of deaths from visceral leishmaniasis. Conclusions/Significance: The elimination of leishmaniasis as a public health problem presents significant challenges, given its biological complexity and diversity, physical and clinical manifestations, social and economic impacts, frequently burdensome treatment regimens, and insufficient supply of necessary medicines. However, rigorous prevention and control efforts through strong political commitment and a highly motivated workforce can dramatically reduce its burden. Colombia's new PDSP, which highlights leishmaniasis control, is an opportunity for a revitalized health system response through committed leadership, intersectoral actions, and partnerships with international organizations that share a common vision. Author summary: Leishmaniasis is a vector-borne disease transmitted by female sand flies to humans and animals, causing infections ranging from asymptomatic and self-healing cutaneous leishmaniasis to visceral leishmaniasis which is highly lethal if untreated. Although all forms of leishmaniasis are treatable and curable with early diagnosis and treatment, the disease presents many challenges for affected populations, many of whom live in remote rural areas of the developing world, with limited access to public health facilities. Health services also face major constraints in supplying critically needed, yet costly medicines, in the context of limited financial resources. This paper presents the case of Colombia which is among the countries most affected by leishmaniasis globally, and discusses its many challenges in responding to the disease, including the guaranteed supply of necessary medicines. Our results uncover new opportunities for a revitalized health system response through committed leadership, intersectoral actions, such as a One Health approach, and partnerships with like-minded international organizations. These include Colombia's new 10-Year Public Health Plan that contains specific time-bound goals for leishmaniasis control and elimination as a public health problem, prioritizing a reduction in deaths from visceral leishmaniasis, and potential cost-savings from the acquisition of essential medicines and supplies through the Strategic Fund of the Pan American Health Organization. [ABSTRACT FROM AUTHOR]

Nepal, Bangladesh, and India signed a Memorandum of Understanding (MoU) in 2005 to eliminate visceral leishmaniasis (VL) as a public health problem from the Indian subcontinent by 2015. By 2021, the number of reported VL cases in these countries had declined by over 95% compared to 2007. This dramatic success was achieved through an elimination programme that implemented early case detection and effective treatment, vector control, disease surveillance, community participation, and operational research that underpinned these strategies. The experience offered an opportunity to assess the contribution of implementation research (IR) to VL elimination in Nepal. Desk review and a stakeholder workshop was conducted to analyse the relationship between key research outputs, major strategic decisions in the national VL elimination programme, and annual number of reported new cases over time between 2005 and 2023. The results indicated that the key decisions across the strategic elements, throughout the course of the elimination programme (such as on the most appropriate tools for diganostics and treatment, and on best strategies for case finding and vector management), were IR informed. IR itself responded dynamically to changes that resulted from interventions, addressing new questions that emerged from the field. Close collaboration between researchers, programme managers, and implementers in priority setting, design, conduct, and review of studies facilitated uptake of evidence into policy and programmatic activities. VL case numbers in Nepal are now reduced by 90% compared to 2005. Although direct attribution of disease decline to research outputs is difficult to establish, the Nepal experience demonstrates that IR can be a critical enabler for disease elimination. The lessons can potentially inform IR strategies in other countries with diseases targeted for elimination. Author summary: Investigators supported by TDR, WHO, and other partners engaged with national stakeholders (policy makers, implementers, clinicians, public health workers, and others) in the development and validation of strategies for elimination of visceral leishmaniasis (VL) in Nepal in the context of the regional Kala Azar Elimination Programme. Linkage and regular consultations with the national programme guided the research focus and facilitated continued uptake of results into policy and implementation of evidence-based interventions. Knowledge from implementation research led to public health programme decisions that facilitated VL elimination in Nepal. [ABSTRACT FROM AUTHOR]

Molecular surveillance of resistance is an increasingly important part of vector borne disease control programmes that utilise insecticides. The visceral leishmaniasis (VL) elimination programme in India uses indoor residual spraying (IRS) with the pyrethroid, alpha-cypermethrin to control Phlebotomus argentipes the vector of Leishmania donovani, the causative agent of VL. Prior long-term use of DDT may have selected for knockdown resistance (kdr) mutants (1014F and S) at the shared DDT and pyrethroid target site, which are common in India and can also cause pyrethroid cross-resistance. We monitored the frequency of these marker mutations over five years from 2017–2021 in sentinel sites in eight districts of north-eastern India covered by IRS. Frequencies varied markedly among the districts, though finer scale variation, among villages within districts, was limited. A pronounced and highly significant increase in resistance-associated genotypes occurred between 2017 and 2018, but with relative stability thereafter, and some reversion toward more susceptible genotypes in 2021. Analyses linked IRS with mutant frequencies suggesting an advantage to more resistant genotypes, especially when pyrethroid was under-sprayed in IRS. However, this advantage did not translate into sustained allele frequency changes over the study period, potentially because of a relatively greater net advantage under field conditions for a wild-type/mutant genotype than projected from laboratory studies and/or high costs of the most resistant genotype. Further work is required to improve calibration of each 1014 genotype with resistance, preferably using operationally relevant measures. The lack of change in resistance mechanism over the span of the study period, coupled with available bioassay data suggesting susceptibility, suggests that resistance has yet to emerge despite intensive IRS. Nevertheless, the advantage of resistance-associated genotypes with IRS and under spraying, suggest that measures to continue monitoring and improvement of spray quality are vital, and consideration of future alternatives to pyrethroids for IRS would be advisable. Author summary: Visceral leishmaniasis (VL) is a deadly parasitic disease with a primary focus in north-eastern India. Control of the sand fly, Phlebotomus argentipes, vector of VL in India, is primarily reliant upon spraying the internal walls of houses and animal shelters with residual pyrethroid insecticide. Spray programmes depend upon well-controlled spraying and effective insecticides to which the targeted insects are susceptible. Changing insecticides is logistically challenging, therefore early detection of insecticide resistance is crucial. As part of a wider programme of entomological surveillance we used molecular resistance assays of knockdown resistance (kdr) mutations to investigate evidence for changing resistance profiles, and possible links with the spraying programme across a system of eight districts in north-eastern India. Mutant frequencies varied substantially in space and time, with a major change across the first two years of the study, but stability for the remainder. Resistance-associated kdr alleles were positively associated with indices of spray coverage and with under spraying, suggesting that this creates vulnerability to development of pyrethroid resistance. However, the most strongly resistance conferring mutant genotype was rarely detected, suggesting overall that notable resistance is not yet emerging, despite wide coverage of the spray programme. This is an encouraging result for the VL elimination programme but with apparent advantage of resistance alleles in sprayed areas it would be wise to seek alternative insecticides for spraying. [ABSTRACT FROM AUTHOR]

Background: Co-endemicity of neglected tropical diseases (NTDs) necessitates that these diseases should be considered concomitantly to understand the relationship between pathology and to support disease management and control programs. The aims of the study were to assess the prevalence of filarial infection in asymptomatic Leishmania donovani infected individuals and the correlation of Wuchereria bancrofti infection with progression to clinical visceral leishmaniasis (VL) in Bihar, India. Methodology/Principal findings: Within the Muzaffarpur-TMRC Health and Demographic Surveillance System (HDSS) area, a cohort of Leishmania seropositive (n = 476) or seronegative individuals (n = 1130) were sampled annually for three years for filarial infection and followed for progression to clinical VL. To corroborate the results from the cohort study, we also used a retrospective case-control study of 36 VL cases and 71 controls selected from a subset of the HDSS population to investigate the relationship between progression to clinical VL and the prevalence of filarial infection at baseline. Our findings suggest a higher probability of progression to clinical VL in individuals with a history of filarial infection: in both the cohort and case-control studies, progression to clinical VL was higher among filaria infected individuals (RR = 2.57, p = 0.056, and OR = 2.52, p = 0.046 respectively). Conclusion: This study describes that progression to clinical VL disease is associated with serological evidence of prior infection with W. bancrofti. The integration of disease programs for Leishmania and lymphatic filariasis extend beyond the relationship of sequential or co-infection with disease burden. To ensure elimination targets can be reached and sustained, we suggest areas of co-endemicity would benefit from overlapping vector control activities, health system networks and surveillance infrastructure. Author summary: India has committed to eliminate two neglected tropical diseases (NTDs) as a public health problem: visceral leishmaniasis (VL) and lymphatic filariasis (LF), both of which are transmitted by vectors and are caused by the parasites Leishmania donovani and Wuchereria bancrofti, respectively. Notably, the majority of L. donovani infections do not lead to a clinical event of VL and asymptomatic infections significantly outnumber the clinical cases. While mixed infections with Leishmania parasites and those causing lymphatic filariasis have been reported, the influence of the immune response triggered by filarial infection on the clinical manifestations and progression of both disorders is not well understood. The Muzaffarpur-TMRC Health and Demographic Surveillance System (HDSS) in Bihar is a well-established demographic platform in an area with the highest incidence of L. donovani infections in India which is also co-endemic for lymphatic filariasis. We used both cohort and case-control study designs within the HDSS population to assess the prevalence of filarial infection in blood samples and examine the association between filarial infection and the progression to clinical VL. Our findings strongly suggest there is an increased risk of progression to clinical VL in individuals with a history of infection with W. bancrofti: in both the study designs, progression to clinical VL was higher among filaria-infected individuals. These results highlight that the co-endemicity of these NTDs necessitates an integrated approach in diagnosis and disease management to ensure elimination targets can be achieved and sustained. [ABSTRACT FROM AUTHOR]

Background: Serum or whole blood collection, processing, transport and storage still present significant challenges in low resource settings where mass surveillance is required to sustain disease elimination. Therefore, in this study, we explored the diagnostic efficacy of dried blood spots (DBS) as a minimally invasive and potentially cost-effective alternative sampling technique to whole blood sampling procedures for subsequent detection of Leishmania donovani antibodies or DNA. Methodology and principal findings: Archived serum, DNA samples from whole blood of visceral leishmaniasis (VL) cases and healthy controls, and DBS from corresponding cases and controls, were used. Both molecular and serological assays were optimized to detect L. donovani antibodies or DNA in DBS elute and results were compared against those obtained with whole blood. Serological assays (both rK28 ELISA and rK39 ELISA) of DBS samples showed sensitivity and specificity of 100% and had excellent agreement with results from whole blood samples (kappa value ranged from 0.98–1). Bland-Altman analysis of OD values from rK28-ELISA with DBS elute and patients' serum showed an excellent agreement (ICC = 0.9) whereas a good agreement (ICC = 0.8) was observed in the case of rK39-ELISA. However, qPCR and RPA of DBS samples had a diminished sensitivity of 76% and 68%, respectively, and poor agreement was observed with the whole blood samples. Conclusion: Our results demonstrate that DBS offer excellent diagnostic efficiency for serological assays and represent a viable alternative to whole blood sampling procedures. Author summary: Since the inception of the National Kala-azar Elimination Program (NKEP) in 2005, visceral leishmaniasis (VL) cases have declined significantly in Bangladesh. Bangladesh has achieved the elimination targets set by the WHO and continuous strides have been enforced by the government and non-government organizations in the present maintenance phase. To sustain the outcomes of the NKEP, move towards a zero-transmission goal and subvert the endgame challenges, an effective surveillance strategy is a primary focus. As part of this strategy, we examined whether using dried blood spots (DBS), rather than whole blood samples as currently recommended, could serve as a minimally invasive sampling technique prior to subsequent diagnostic tests. We determined the accuracy of molecular and serological assays using DBS samples compared with whole blood samples. While using DBS, excellent diagnostic accuracy was observed for serological assays (rK28 ELISA and rK39 ELISA), whereas sensitivity and specificity using molecular assays for DNA detection (qPCR and RPA) declined in comparison to whole blood. Given the low cost and field feasibility of DBS, we believe this simple sample collection technique coupled with serology-based detection of L. donovani meets the requirements for mass surveillance towards detecting residual VL transmission. [ABSTRACT FROM AUTHOR]

Background: The kala-azar elimination programme has resulted in a significant reduction in visceral leishmaniasis (VL) cases across the Indian Subcontinent. To detect any resurgence of transmission, a sensitive cost-effective surveillance system is required. Molecular xenomonitoring (MX), detection of pathogen DNA/RNA in vectors, provides a proxy of human infection in the lymphatic filariasis elimination programme. To determine whether MX can be used for VL surveillance in a low transmission setting, large numbers of the sand fly vector Phlebotomus argentipes are required. This study will determine the best method for capturing P. argentipes females for MX. Methodology/Principal findings: The field study was performed in two programmatic and two non-programmatic villages in Bihar, India. A total of 48 households (12/village) were recruited. Centers for Disease Control and Prevention light traps (CDC-LTs) were compared with Improved Prokopack (PKP) and mechanical vacuum aspirators (MVA) using standardised methods. Four 12x12 Latin squares, 576 collections, were attempted (12/house, 144/village,192/method). Molecular analyses of collections were conducted to confirm identification of P. argentipes and to detect human and Leishmania DNA. Operational factors, such as time burden, acceptance to householders and RNA preservation, were also considered. A total of 562 collections (97.7%) were completed with 6,809 sand flies captured. Females comprised 49.0% of captures, of which 1,934 (57.9%) were identified as P. argentipes. CDC-LTs collected 4.04 times more P. argentipes females than MVA and 3.62 times more than PKP (p<0.0001 for each). Of 21,735 mosquitoes in the same collections, no significant differences between collection methods were observed. CDC-LTs took less time to install and collect than to perform aspirations and their greater yield compensated for increased sorting time. No significant differences in Leishmania RNA detection and quantitation between methods were observed in experimentally infected sand flies maintained in conditions simulating field conditions. CDC-LTs were favoured by householders. Conclusions/Significance: CDC-LTs are the most useful collection tool of those tested for MX surveillance since they collected higher numbers of P. argentipes females without compromising mosquito captures or the preservation of RNA. However, capture rates are still low. Author summary: Molecular xenomonitoring, screening insects for pathogen DNA/RNA, may be used for surveillance of diseases transmitted by insects. Since the proportion of insects infected with pathogens is very low in areas targeted for disease elimination, large numbers of females need to be screened. We compared three different methods for collecting Phlebotomus argentipes sand fly females, the vector of parasites causing the disease visceral leishmaniasis in the Indian subcontinent, to determine which collected the largest number of females. Other factors that may also influence selection of a particular method of collection by a disease control programme, such as the time it takes to collect and sort samples, the acceptance of householders for a particular collection method and whether RNA degradation in insect samples differed between collection methods, were also considered. Centers for Disease Control and Prevention light traps (CDC-LTs) proved to be more useful than two types of aspiration methods for collecting higher numbers of sand fly females and RNA preservation was retained. Furthermore, they took less time to install than to perform aspirations and were favoured by householders. Therefore, CDC-LTs were considered to be the most suitable collection method for molecular xenomonitoring of sand flies in India. [ABSTRACT FROM AUTHOR]

Endemic in Brazil, visceral leishmaniasis (VL) is a zoonotic infection that is among the most important parasitic diseases transmitted by vectors. Dogs are the main reservoirs of canine leishmaniasis (CanL) and their identification is used in some countries as part of disease prevention and control measures in the canine and human population. In this context, serological tests are necessary, composed of antigens capable of correctly identifying infected dogs, minimizing the number of false-negative cases. This study aimed to identify more immunoreactive peptides derived from two previously described whole proteins (rDyn-1 and rKDDR-plus) and compare their performance to the control antigens rK39 and the crude extract for the detection of dogs infected with L. infantum, especially the asymptomatic ones. The three selected peptides and a mixture of them, along with the rDyn-1, rKDDR-plus, rK39, and crude extract antigens were evaluated using indirect ELISA with sera samples from 186 dogs with CanL, being asymptomatic (n = 50), symptomatic (n = 50), co-infected (n = 19), infected with Babesia sp. (n = 7), Ehrlichia sp. (n = 6), T. cruzi (n = 20) and uninfected (n = 34). The results showed that the rDyn-1 protein and the peptide mixture had the highest sensitivity (100% and 98.32%, respectively) and specificity (97.01 and 98.51, respectively). A high degree of kappa agreement was found for rDyn-1 protein (0.977), mixed peptides (0.965), rKDDR-plus protein (0.953), K-plus peptide 1 (0.930) and Dyn-1 peptide (0.893). The mixture of peptides showed the highest likelihood (65.87). The ELISA using the mixture of peptides and the rDyn-1 protein showed high performance for CanL serodiagnosis. More mix combinations of the peptides and additional extended field tests with a larger sample size are recommended. Author summary: Canine leishmaniasis (CanL) is a parasitic zoonotic infection of dogs caused by Leishmania spp. parasites. In Brazil, CanL is among the most important vector-borne parasitic diseases. Dogs are the main reservoirs of the disease and in some countries have been regularly culled as part of government policy to control human leishmaniasis. The identification of infected dogs, regardless of the clinical condition, is necessary as part of the prevention and control measures of the disease in the canine population and consequently in the human population. In this context, it is necessary serological tests, composed of antigens capable of correctly identifying infected, asymptomatic, as well as symptomatic dogs, minimizing the number of false negative cases. Therefore, this study aimed to compare the efficacy between two previously described whole proteins (rDyn-1 and rKDDR-plus) with their more immunoreactive synthetic peptides to sera from symptomatic and asymptomatic dogs selected in immunoblotting assays and to evaluate in ELISA assays. ELISA using the rDyn-1 protein and mixed peptides showed high performance in the diagnosis of CanL. [ABSTRACT FROM AUTHOR]

Background: This study describes the spatial and temporal distribution between 2005 and 2020 of human and animal leishmaniasis by Leishmania infantum in European countries reporting autochthonous cases, and highlights potential activities to improve disease control. Methodology/Principal findings: It was based on a review of the scientific literature and data reported by the World Health Organization (WHO), the World Organization for Animal Health (WOAH) and the Ministries of Health, including hospital discharges in some countries. Autochthonous infections were reported in the scientific literature from 22 countries, including 13 and 21 countries reporting human and animal infections, respectively. In contrast, only 17 countries reported autochthonous human leishmaniasis cases to the WHO and 8 countries animal infections to the WOAH. The number of WOAH reported cases were 4,203, comprising 4,183 canine cases and 20 cases in wildlife. Of 8,367 WHO reported human cases, 69% were visceral leishmaniasis cases—of which 94% were autochthonous—and 31% cutaneous leishmaniasis cases—of which 53% were imported and mostly in France. The resulting cumulative incidence per 100,000 population of visceral leishmaniasis between 2005–2020, was highest in Albania (2.15 cases), followed by Montenegro, Malta, Greece, Spain and North Macedonia (0.53–0.42), Italy (0.16), Portugal (0.09) and lower in other endemic countries (0.07–0.002). However, according to hospital discharges, the estimated human leishmaniasis incidence was 0.70 in Italy and visceral leishmaniasis incidences were 0.67 in Spain and 0.41 in Portugal. Conclusions/Significance: Overall, there was no evidence of widespread increased incidence of autochthonous human leishmaniasis by L. infantum in European countries. Visceral leishmaniasis incidence followed a decreasing trend in Albania, Italy and Portugal, and peaked in Greece in 2013, 2014 and 2017, and in Spain in 2006–2007 and 2011–2013. Animal and human cutaneous leishmaniasis remain highly underreported. In humans, hospital discharge databases provide the most accurate information on visceral leishmaniasis and may be a valuable indirect source of information to identify hotspots of animal leishmaniasis. Integrated leishmaniasis surveillance and reporting following the One Health approach, needs to be enhanced in order to improve disease control. Author summary: Leishmaniasis caused by the protozoan parasite Leishmania infantum, is a zoonotic sand fly-transmitted disease endemic in southern Europe, of great medical and veterinary importance. Environmental and human-related changes affecting the risk of exposure to vectors, such as travelling of infected animals, urbanization of endemic rural areas and climate change are some examples of drivers of the epidemiology of leishmaniasis. In this paper, we review the distribution and assess the evidence of emergence of human and animal leishmaniasis between 2005 and 2020 in endemic European countries. We found autochthonous infections in every Mediterranean and Balkan countries with a highly variable incidence. However, we detected no evidence of a widespread increased incidence across Europe. Notwithstanding this, underreporting is very high for animal and cutaneous human leishmaniasis. Moreover, human hospital discharges are the most accurate source of data for estimating the incidence of severe human visceral leishmaniasis, and this could be used to identify hotspots of leishmaniasis in animal reservoirs of infection. Consequently, we encourage integrated surveillance and accurate notification of cases following the One Health approach to adopt effective strategies resulting in a better control of leishmaniasis. [ABSTRACT FROM AUTHOR]

Background: Leishmaniases are vector borne diseases caused by Leishmania spp. parasites transmitted by female sandflies (Diptera: Psychodidae) whose geographic distribution is influenced by environmental factors. Among the main tools for studying the distribution of vector species, modeling techniques are used to analyze the influence of climatic and environmental factors on the distribution of these insects and their association with human cases of the disease. Methodology/Principal findings: Here, we used a multiscale ecological niche modeling approach to assess the environmental suitability of sandfly vectors of the etiological agents of Visceral (VL) and American Cutaneous Leishmaniasis (ACL) in Piauí state, northeastern Brazil, and then evaluated their relationship with human disease incidence. For this, we obtained the geographic coordinates of the vector species Lutzomyia longipalpis and Nyssomyia whitmani through literature review, online databases and unpublished records. These data were used for the development of predictive models of the distribution of both sandflies species based on climatic and environmental variables. Finally, the environmental suitability for the presence of these vectors was compared with the incidence of both the diseases at the municipality level. The final models for each sandfly species showed good predictive powers with performance metric values of 0.889 for Lu. longipalpis and 0.776 for Ny. whitmani. The areas with greater environmental suitability for the presence of these species were concentrated in the central-north region of Piauí and coincide with the location of those municipalities presenting higher incidences of VL and ACL, situated in the central-north and extreme north of the state, respectively. The south and southeast regions of Piauí state have low incidence of these diseases and presented low environmental suitability for the presence of both vectors. Conclusions/Significance: We discuss how predictive modeling can guide entomological and epidemiological surveillances and recommend an increased supervision and control activities in Teresina (capital of the state of Piaui), Altos and Pedro II, in addition to other municipalities with similar social and environmental characteristics. Author summary: Sandflies are insects that actively participate in the transmission cycles of leishmaniasis and other diseases, and these invertebrate vectors are frequently found in areas with hot and humid climates. However, in addition to the climate, there are several factors that contribute to the occurrence of sandfly vectors, such as, the vegetation type, altitude, and land use and cover. Understanding which environmental variables are important for the presence of sandflies can help us to understand how these insects are distributed and overall, how this affects the transmission of the etiological agents of leishmaniasis. In this study, we performed a set of ecological models where environmental and climatic variables were combined in multiple scales and correlated with the presence of two sandflies species, Lutzomyia longipalpis and Nyssomyia whitmani, vectors of parasites causing visceral and cutaneous leishmaniasis, respectively. We then combined this information with human disease data to assess potential risk areas in the state of Piauí, northeast Brazil. The resulting maps showed that municipalities of the central-north region of the state have favorable environment for the occurrence of these vectors in addition to higher incidence of leishmaniasis in humans. We thus recommend that control activities should be focused on this region of the state. [ABSTRACT FROM AUTHOR]

Background: The leishmaniases are a group of four vector-borne neglected tropical diseases caused by 20 species of protozoan parasites of the genus Leishmania and transmitted through a bite of infected female phlebotomine sandflies. Endemic in over 100 countries, the four types of leishmaniasis–visceral leishmaniasis (VL) (known as kala-azar), cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (MCL), and post-kala-azar dermal leishmaniasis (PKDL)–put 1.6 billion people at risk. In Kenya, the extent of leishmaniasis research has not yet been systematically described. This knowledge is instrumental in identifying existing research gaps and designing appropriate interventions for diagnosis, treatment, and elimination. Methodology/Principal findings: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology to determine the state of leishmaniases research in Kenya and identify research gaps. We searched seven online databases to identify articles published until January 2022 covering VL, CL, MCL, and/or PKDL in Kenya. A total of 7,486 articles were found, of which 479 underwent full-text screening, and 269 met our eligibility criteria. Most articles covered VL only (n = 141, 52%), were published between 1980 and 1994 (n = 108, 39%), and focused on the theme of "vectors" (n = 92, 34%). The most prevalent study types were "epidemiological research" (n = 88, 33%) tied with "clinical research" (n = 88, 33%), then "basic science research" (n = 49, 18%) and "secondary research" (n = 44, 16%). Conclusion/Significance: While some studies still provide useful guidance today, most leishmaniasis research in Kenya needs to be updated and focused on prevention, co-infections, health systems/policy, and general topics, as these themes combined comprised less than 4% of published articles. Our findings also indicate minimal research on MCL (n = 1, <1%) and PKDL (n = 2, 1%). We urge researchers to renew and expand their focus on these neglected diseases in Kenya. Author summary: The leishmaniases are a group of four vector-borne neglected tropical diseases (NTDs) that are endemic in over 100 countries, putting over 1.6 billion people at risk. In Kenya, the extent of research on leishmaniasis remains unclear. Therefore, this scoping review aims to uncover and classify the body of literature on leishmaniasis in Kenya to elucidate gaps in knowledge and inform future research, related health policies, and interventions in Kenya. Through a database search, we identified 269 articles that met our eligibility criteria, which were included in our final analysis. Our analysis revealed that the majority of articles discussed VL. Most articles were published between 1980 and 1994. There was uneven distribution between the themes of published articles, with vector-related research dominating the list, followed by treatment, diagnostics, general epidemiology, and pathophysiology. The most prevalent type of study was a tie between epidemiological and clinical research, followed by basic science research and then secondary research. There is minimal research coverage on MCL and PKDL, which is as expected given the low prevalence of these diseases in Kenya. Furthermore, little research spans prevention, co-infections, health systems/policy, and general topics. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is a vector-borne protozoan disease, which can be fatal if left untreated. Synthetic chemical insecticides are very effective tools for controlling of insect vectors, including the sand fly Phlebotomus argentipes, the vector of VL in the Indian subcontinent. However, repeated use of the same insecticide with increasing doses potentially can create high selection pressure and lead to tolerance and resistance development. The objective of this study was to determine the lethal concentrations and assess levels of susceptibility, diagnostic doses and times to death of laboratory-reared P. argentipes to five insecticides that are used worldwide to control vectors. Using the Center for Disease Control and Prevention (CDC) bottle bioassay, 20–30 sand flies were exposed in insecticide- coated 500-ml glass bottles. Flies were then observed for 24 hours and mortality was recorded. Dose-response survival curves were generated for each insecticide using QCal software and lethal concentrations causing 50%, 90% and 95% mortality were determined. A bioassay was also conducted to determine diagnostic doses and diagnostic times by exposing 20–30 flies in each bottle containing set concentrations of insecticide. Mortality was recorded at 10-minute intervals for 120 minutes to generate the survival curve. Phlebotomus argentipes are highly susceptible to alpha-cypermethrin, followed by deltamethrin, malathion, chlorpyrifos, and least susceptible to DDT. Also, the lowest diagnostic doses and diagnostic times were established for alpha-cypermethrin (3μg/ml for 40 minutes) to kill 100% of the flies. The susceptibility data, diagnostic doses and diagnostic times presented here will be useful as baseline reference points for future studies to assess insecticide susceptibility and resistance monitoring of field caught sand flies and to assist in surveillance as VL elimination is achieved in the region. Author summary: Synthetic chemical insecticides are mainly used for controlling sand flies via indoor residual spraying (IRS) and insecticide treated nets. Sand flies had developed resistance against DDT in endemic areas of Bihar, India, and was replaced by synthetic pyrethroids (alpha-cypermethrin) in the second phase of IRS in 2015. The substantial increase in the use of synthetic pyrethroids will potentially lead to increased resistance because DDT and pyrethroids both have the same target site. To monitor insecticide resistance in field caught sand flies, susceptibility status and diagnostic doses and times are warranted, as no diagnostic dose for resistance detection has been established for Indian sand flies. A laboratory reared P. argentipes was used to quantify insecticide susceptibility and determination of diagnostic doses and times. The CDC bottle bioassay was used with five insecticides viz., alpha-cypermethrin, deltamethrin, malathion, chlorpyrifos and DDT. Results indicate that the P. argentipes were highly susceptible to alpha-cypermethrin followed by deltamethrin, malathion, chlorpyrifos and least susceptible to DDT. This study provides critical base line reference data for further studies to assess insecticide susceptibility and resistance monitoring in field populations, as well as determining diagnostic doses and times for other insecticide susceptible sand fly populations undergoing surveillance to sustain VL elimination. [ABSTRACT FROM AUTHOR]

Leishmaniasis is a neglected tropical disease with three main clinical types; cutaneous leishmaniasis (CL), mucocutaneous leishmaniasis (MCL), and visceral leishmaniasis (VL). CL and MCL are considered to be highly stigmatizing due to potentially disfiguring skin pathology. CL and MCL-associated stigma are reported across the world in different contexts assimilating different definitions and interpretations. Stigma affects people with CL, particularly in terms of quality of life, accessibility to treatment, and psycho-social well-being. However, evidence on CL- and MCL-associated stigma is dispersed and yet to be synthesized. This systematic review describes the types, measurements, and implications of the stigma associated with CL and MCL and identifies any preventive strategies/interventions adopted to address the condition. This study was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) statement which is registered in the International Platform of Registered Systematic Review and Meta-analysis Protocols PROSPERO (ID- CRD42021274925). We will perform an electronic search in MEDLINE, Embase, Scopus, PubMed, EBSCO, Web of Science, Global Index Medicus, Trip, and Cochrane Library databases, and in Google Scholar, using a customized search string. Any article that discusses any type of CL- and/or MCL-associated stigma in English, Spanish and Portuguese will be included. Articles targeting veterinary studies, sandfly vector studies, laboratory-based research and trials, articles focusing only on visceral leishmaniasis, and articles on diagnostic or treatment methods for CL and MCL will be excluded. Screening for titles and abstracts and full articles and data extraction will be conducted by two investigators. The risk of bias will be assessed through specific tools for different study types. A narrative synthesis of evidence will then follow. This review will identify the knowledge gap in CL-associated stigma and will help plan future interventions. [ABSTRACT FROM AUTHOR]

Background: The potential reservoirs of visceral leishmaniasis (VL) in South Asia include asymptomatic and relapsed cases of VL, along with patients with post kala-azar dermal leishmaniasis (PKDL). Accordingly, accurate estimation of their parasite load is pivotal for ensuring disease elimination, presently targeted for 2023. Serological tests cannot accurately detect relapses and/or monitor treatment effectiveness, and therefore, parasite antigen/nucleic acid based detection assays remain the only viable option. An excellent option is the quantitative polymerase chain reaction (qPCR) but the high cost, technical expertise and time involved precludes its wider acceptability. Accordingly, the recombinase polymerase amplification (RPA) assay operated in a mobile suitcase laboratory has emerged not simply as a diagnostic tool for leishmaniasis but also to monitor the disease burden. Methodology/Principal findings: Using total genomic DNA isolated from peripheral blood of confirmed VL cases (n = 40) and lesional biopsies of PKDL cases (n = 64), the kinetoplast-DNA based qPCR and RPA assay was performed and parasite load expressed as Cycle threshold (Ct) and Time threshold (Tt) respectively. Using qPCR as the gold standard, the diagnostic specificity and sensitivity of RPA in naïve cases of VL and PKDL was reiterated. To assess the prognostic potential of the RPA, samples were analyzed immediately at the end of treatment or ≥6 months following completion of treatment. In cases of VL, the RPA assay in terms of cure and detection of a relapse case showed 100% concordance with qPCR. In PKDL following completion of treatment, the overall detection concordance between RPA and qPCR was 92.7% (38/41). At the end of treatment for PKDL, 7 cases remained qPCR positive, whereas RPA was positive in only 4/7 cases, perhaps attributable to their low parasite load. Conclusions/Significance: This study endorsed the potential of RPA to evolve as a field applicable, molecular tool for monitoring parasite load, possibly at a point of care level and is worthy of consideration in resource limited settings. Author summary: Visceral leishmaniasis (VL) or kala-azar caused by the digenetic parasite Leishmania donovani is a fatal form of leishmaniasis, unless treated. In South Asia, approximately 10–20% of apparently cured cases of VL develop a dermal sequela termed post kala-azar dermal leishmaniasis (PKDL). It presents with macular or papulonodular lesions that harbour Leishmania parasites. Importantly, these cases of PKDL in addition to asymptomatic and relapsed VL cases serve as mobile disease reservoirs and sustain disease transmission. In macular PKDL, that presently comprise over 50% of cases, the diagnosis is particularly challenging as parasites are often not detectable by microscopy. Accordingly, development of strategies for molecular diagnosis is one of the major foci of the ongoing leishmaniasis elimination programme targeted for 2023, that aims to decrease the burden to <1/10,000 cases of VL at the block/zilla level. Serological tests have limited applicability when it is necessary to distinguish present from past infection of VL, and in cases of PKDL when the positivity maybe due to a past history of VL. An excellent option is the quantitative polymerase chain reaction (qPCR) but limitations for its wider field applicability include the high cost, technical expertise and time factor. Accordingly, an urgent need exists for availability of field applicable molecular tests. The RPA tested in this study could well be the desired game-changer as it provided accurate diagnosis of VL and PKDL, can be performed in a primary health centre, and demonstrated the potential to be a monitoring tool for parasite load after treatment, that eventually can accelerate achieving the end-goal of elimination of leishmaniasis. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is a neglected tropical disease that is globally distributed and has the potential to cause very serious illness. Prior literature highlights the emergence and spread of VL is influenced by multiple factors, such as socioeconomic status, sanitation levels or animal and human reservoirs. The study aimed to retrospectively investigate the presence and infectiousness of VL in Rio Grande do Norte (RN), Brazil between 2007 and 2020. We applied a hierarchical Bayesian approach to estimate municipality-specific relative risk of VL across space and time. The results show evidence that lower socioeconomic status is connected to higher municipality-specific VL risk. Overall, estimates reveal spatially heterogeneous VL risks in RN, with a high probability that VL risk for municipalities within the West Potiguar mesoregion are more than double the expected VL risk. Additionally, given the data available, results indicate there is a high probability of increasing VL risk in the municipalities of Natal, Patu and Pau dos Ferros. These findings demonstrate opportunities for municipality-specific public health policy interventions and warrant future research on identifying epidemiological drivers in at-risk regions. Author summary: As a neglected tropical disease (NTD), Leishmaniasis contributes to poor health outcomes, suffering, and death of vulnerable populations. Leishmania infantum or Leishmania donovani is transmitted from animals to humans through the sandfly vector and can be fatal in 5% of the cases even with treatment. Visceral leishmaniasis is a severe form of Leishmaniasis. The purpose of this study was to estimate regions of high Visceral leishmaniasis risk in Rio Grande do Norte, Brazil between 2007 and 2020 to help inform public health initiatives and potential health policy interventions for this disease. Visceral leishmaniasis is a reportable disease and therefore VL cases are documented to the Brazilian Ministry of Health database through passive surveillance. Passive surveillance data can suffer from missing information; individuals may be asymptomatic, or may not seek medical care allowing for diagnosis. When modeling disease risk from passive surveillance data, assuming there is an absence of disease in regions without documented cases can underestimate disease risk. In this paper we estimate disease risk and identify areas with high-risk and increasing infection trends over time while considering data characteristics such as missing information and high correlation of risk factors. [ABSTRACT FROM AUTHOR]

The evolution in Leishmania is governed by the opposite forces of clonality and sexual reproduction, with vicariance being an important factor. As such, Leishmania spp. populations may be monospecific or mixed. Leishmania turanica in Central Asia is a good model to compare these two types. In most areas, populations of L. turanica are mixed with L. gerbilli and L. major. Notably, co-infection with L. turanica in great gerbils helps L. major to withstand a break in the transmission cycle. Conversely, the populations of L. turanica in Mongolia are monospecific and geographically isolated. In this work, we compare genomes of several well-characterized strains of L. turanica originated from monospecific and mixed populations in Central Asia in order to shed light on genetic factors, which may drive evolution of these parasites in different settings. Our results illustrate that evolutionary differences between mixed and monospecific populations of L. turanica are not dramatic. On the level of large-scale genomic rearrangements, we confirmed that different genomic loci and different types of rearrangements may differentiate strains originated from mixed and monospecific populations, with genome translocations being the most prominent example. Our data suggests that L. turanica has a significantly higher level of chromosomal copy number variation between the strains compared to its sister species L. major with only one supernumerary chromosome. This suggests that L. turanica (in contrast to L. major) is in the active phase of evolutionary adaptation. Author summary: Leishmaniasis is one of the major neglected tropical diseases caused by members of the genus Leishmania. It can manifest in the symptoms ranging from rapidly self-healing ulcers in the cases of cutaneous leishmaniasis (CL) to systemic multiorgan failures in the cases of visceral leishmaniasis. The CL can be of anthroponotic (ACL, mainly caused by L. tropica) and zoonotic (ZCL, mainly caused by L. major) origin. In Central Asia, great gerbils are the main animal reservoirs for ZCL. These animals may be co-infected with L. major, L. turanica, and L. gerbilli. The evolution in Leishmania is driven by clonality and genetic exchange, with geographical isolation playing an important role. In this sense, Leishmania spp. may either co-exist in the same area (mixed infections) or be geographically isolated without mixing-up with other species (monospecific infections). Leishmania turanica in Central Asia presents a good model to compare these two modes. Indeed, in most areas of great gerbils' distribution, populations of Leishmania spp. are mixed. Conversely, the populations of L. turanica in Mongolia are monospecific and geographically isolated. In this work, we compare genomes of several strains of L. turanica in order to shed light on genetic factors, which may drive evolution of these important parasites. [ABSTRACT FROM AUTHOR]

In the Americas, visceral leishmaniasis (VL) is caused by the protozoan Leishmania infantum, leading to death if not promptly diagnosed and treated. In Brazil, the disease reaches all regions, and in 2020, 1,933 VL cases were reported with 9.5% lethality. Thus, an accurate diagnosis is essential to provide the appropriate treatment. Serological VL diagnosis is based mainly on immunochromatographic tests, but their performance may vary by location, and evaluation of diagnostic alternatives is necessary. In this study, we aimed to evaluate the performance of ELISA with the scantily studied recombinant antigens, K18 and KR95, comparing their performance with the already known rK28 and rK39. Sera from parasitologically confirmed symptomatic VL patients (n = 90) and healthy endemic controls (n = 90) were submitted to ELISA with rK18 and rKR95. Sensitivity (95% CI) was, respectively, 83.3% (74.2–89.7) and 95.6% (88.8–98.6), and specificity (95% CI) was 93.3% (85.9–97.2) and 97.8% (91.8–99.9). For validation of ELISA with the recombinant antigens, we included samples from 122 VL patients and 83 healthy controls collected in three regions in Brazil (Northeast, Southeast, and Midwest). When comparing the results obtained with the VL patients' samples, significantly lower sensitivity was obtained by rK18-ELISA (88.5%, 95% CI: 81.5–93.2) compared with rK28-ELISA (95.9%, 95% CI: 90.5–98.5), but the sensitivity was similar comparing rKR95-ELISA (95.1%, 95% CI: 89.5–98.0), rK28-ELISA (95.9%, 95% CI: 90.5–98.5), and rK39-ELISA (94.3%, 95% CI: 88.4–97.4). Analyzing the specificity, it was lowest with rK18-ELISA (62.7%, 95% CI: 51.9–72.3) with 83 healthy control samples. Conversely, higher and similar specificity was obtained by rKR95-ELISA (96.4%, 95% CI: 89.5–99.2), rK28-ELISA (95.2%, 95% CI: 87.9–98.5), and rK39-ELISA (95.2%, 95% CI: 87.9–98.5). There was no difference in sensitivity and specificity across localities. Cross-reactivity assessment, performed with sera of patients diagnosed with inflammatory disorders and other infectious diseases, was 34.2% with rK18-ELISA and 3.1% with rKR95-ELISA. Based on these data, we suggest using recombinant antigen KR95 in serological assays for VL diagnosis. [ABSTRACT FROM AUTHOR]

Dogs living in areas of Leishmania (Viannia) braziliensis transmission may present canine tegumentary leishmaniasis (CTL) characterized by cutaneous or muzzle ulcers as well as asymptomatic L. braziliensis infection. It is not clear if dogs participate in the transmission chain of L. braziliensis to humans. However, dogs may remain with chronic ulcers for a long time, and as there are no public policies about CTL, these animals die or are sacrificed. Here we compare the efficacy of intralesional meglumine antimoniate with intralesional 0.9% NaCl solution in CTL treatment. This randomized control study included 32 dogs with cutaneous or muzzle lesions who had L. braziliensis DNA detected by PCR in tissue biopsied. Group one received 5ml of intralesional Glucantime, and group two received 5ml 0.9% NaCl solution, both applied in the four cardinal points on days 0, 15, and 30. Cure was defined as complete healing of the ulcers in the absence of raised borders on day 90. There was no difference in animals' demographic and clinical features in the two groups (p >.05). While at the endpoint, the cure rate was 87.5% in the group test, and in those who received 0.9 NaCl the cure rate was only 12.5%. As important as the high cure rate, the healing time was faster in dogs treated with antimony than in those treated with saline (p <.001). Intralesional meglumine antimoniate is effective in the treatment of dogs with L. braziliensis infection and accelerates the healing time of CTL. Author summary: Dogs play an important role in the transmission of Leishmania infantum, the causal agent of visceral leishmaniasis. But very little is known about L. braziliensis infection in dogs. Canine tegumentary leishmaniasis (CTL) caused by L. braziliensis is documented in endemic areas of human cutaneous leishmaniasis. CTL occurs predominantly in males, and the scrotal sac and muzzle are the primary site of infection. As there are no policies regarding therapy for CTL, dogs die from the disease or are sacrificed. A few uncontrolled studies showed a cure of CTL after treatment with intralesional Glucantime (Sanofi-Aventis). Here, we compare the efficacy of intralesional Glucantime (N = 16) versus intralesional saline (N = 16) in the treatment of CTL. All dogs presented ulcerated lesions. The DNA of L. braziliensis was documented by PCR in biopsied tissue of all animals in the study. There were no differences among the two groups regarding age, gender, illness duration, lesion size, and lesion site. However, a higher cure rate (87.5%) was observed in the dogs treated with Glucantime compared to 12.5% in those treated with saline (p <.001). This study showed that intralesional Glucantime cures dogs infected with L. braziliensis and should be used to treat canine tegumentary leishmaniasis. [ABSTRACT FROM AUTHOR]

Leishmaniases, a group of vector-borne diseases, are caused by the protozoan intracellular parasite Leishmania (L.) and are transmitted by the phlebotomine sandflies. A wide range of clinical manifestations in L- infection is observed. The clinical outcome ranges from asymptomatic, cutaneous leishmaniasis (CL) to severe mucosal leishmaniasis (ML) or visceral leishmaniasis (VL), depending on the L. species. Interestingly, only a fraction of L.-infected individuals progress to disease development, suggesting a key role of host genetics in the clinical outcome. NOD2 plays a critical role in the control of host defense and inflammation. The NOD2-RIK2 pathway is involved in developing a Th1- type response in patients with VL and C57BL/6 mice infected with L. infantum. We investigated whether variants in the NOD2 gene (R702W rs2066844, G908R rs2066845, and L1007fsinsC rs2066847) are associated with susceptibility to CL caused by L. guyanensis (Lg) in 837 patients with Lg-Cl and 797 healthy controls (HC) with no history of leishmaniasis. Both patients and HC are from the same endemic area of the Amazonas state of Brazil. The variants R702W and G908R were genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP), and L1007fsinsC was by direct nucleotide sequencing. The minor allele frequency (MAF) of L1007fsinsC was 0.5% among the patients with Lg-CL and 0.6% in the healthy controls group. R702W genotypes frequencies were similar in both groups. Only 1% and 1.6% were heterozygous for G908R among the patients with Lg-CL and HC, respectively. None of the variants revealed any association with susceptibility to the development of Lg-CL. Correlations of genotypes with the level of plasma cytokines revealed that individuals with the mutant alleles of R702W tend to have low levels of IFN-γ. G908R heterozygotes also tend to have low IFN-γ, TNF-α, IL-17, and IL-8. Variants of NOD2 are not involved in the pathogenesis of Lg-CL. [ABSTRACT FROM AUTHOR]

Background: As untreated visceral leishmaniasis (VL) is fatal, reliable diagnostics are pivotal for accurate treatment allocation. The current diagnostic algorithm for VL in Ethiopia, which is based on the rK39 rapid diagnostic test and microscopy of tissue smears, lacks sensitivity. This probably leads to missed cases and patients not receiving treatment. Methodology: We conducted a retrospective study on stored microscopically negative spleen and bone marrow smears from suspected VL patients collected at the Leishmaniasis Research and Treatment Center (LRTC) in Gondar, northern Ethiopia between June 2019 and November 2020. Sociodemographic, clinical and treatment data were collected and samples were tested by real-time PCR targeting kinetoplast DNA. Principle findings: Among the 191 eligible samples (135 spleen and 56 bone marrow) with a microscopically negative and valid PCR result, 119 (62.3%) were positive by PCR, although Ct values for some were high (median 33.0). Approximately three quarters of these undiagnosed primary VL (77.3%) and relapse (69.6%) patients did not receive antileishmanial treatment. Of the 56 microscopically negative bone marrow samples, 46 (82.1%) were PCR positive, which is considerably higher compared to the microscopically negative spleen samples, for which 73 out of 135 (54.1%) were PCR positive. The odds of being PCR positive were significantly higher for bone marrow aspirates and higher when white blood cell values were lower and splenomegaly (in cm) was more pronounced. Conclusions: This study demonstrates that a lot of suspected VL patients remain undiagnosed and untreated. This indicates the urgent need for better diagnostics for VL in the East-African region. The outcomes of PCR positive should be closely monitored and treatment should be provided if the patient deteriorates. In resource limited settings, implementation of PCR on bone marrow aspirate smears of patients with low WBC values and splenomegaly could lead to considerable improvements in patient management. Author summary: As untreated visceral leishmaniasis (VL) is fatal, reliable diagnostics are important for accurate treatment allocation. The current diagnostic algorithm for VL in Ethiopia, which is based on the rK39 rapid diagnostic test and microscopy of tissue smears, lacks sensitivity. This probably leads to missed cases and patients not receiving treatment. To prove this, we conducted a study on stored microscopically negative spleen and bone marrow aspirate smears from suspected VL patients in Gondar, Ethiopia. Clinical and treatment data were collected and samples were tested for Leishmania by PCR. We found that about 60% of these microscopically negative samples were PCR positive. This PCR positivity rate was considerably higher in patients with a microscopically negative bone marrow compared to splenic aspirate. Importantly, more than three quarters of the patients with a PCR positive sample was not treated for VL. Overall, our study demonstrates the gap in the diagnostic algorithm for VL in northern Ethiopia, especially when bone marrow samples are used. In resource limited settings, we advise to challenge the current diagnostic algorithm and implement molecular tools to accurately diagnose patients. This could lead to considerable improvements in patient management in Ethiopia and beyond. [ABSTRACT FROM AUTHOR]

Background: In Nepal, the burden of post kala-azar dermal leishmaniasis (PKDL) is not known since there is no active case detection of PKDL by the national programme. PKDL patients could pose a challenge to sustain visceral leishmaniasis (VL) elimination. The objective of this study was to determine the prevalence of PKDL and assess PKDL patients' knowledge on VL and PKDL, and stigma associated with PKDL. Methodology/Principal findings: Household surveys were conducted in 98 VL endemic villages of five districts that reported the highest number of VL cases within 2018–2021. A total of 6,821 households with 40373 individuals were screened for PKDL. Cases with skin lesions were referred to hospitals and examined by dermatologists. Suspected PKDL cases were tested with rK39 and smear microscopy from skin lesions. An integrated diagnostic approach was implemented in two hospitals with a focus on management of leprosy cases where cases with non-leprosy skin lesions were tested for PKDL with rK39. Confirmed PKDL patients were interviewed to assess knowledge and stigma associated with PKDL, using explanatory model interview catalogue (EMIC) with maximum score of 36. Among 147 cases with skin lesions in the survey, 9 (6.12%) were confirmed as PKDL by dermatologists at the hospital. The prevalence of PKDL was 2.23 per 10,000 population. Among these 9 PKDL cases, 5 had a past history of VL and 4 did not. PKDL cases without a past history of VL were detected among the "new foci", Surkhet but none in Palpa. None of the cases negative for leprosy were positive for PKDL. There was very limited knowledge of PKDL and VL among PKDL cases. PKDL patients suffered to some degree from social and psychological stigma (mean ± s.d. score = 17.89 ± 12.84). Conclusions/Significance: Strengthening the programme in PKDL case detection and management would probably contribute to sustenance of VL elimination. Awareness raising activities to promote knowledge and reduce social stigma should be conducted in VL endemic areas. Author summary: Post kala-azar dermal leishmaniasis (PKDL) is a sequel of visceral leishmaniasis (VL) and occurs in VL endemic areas. PKDL patients can be a reservoir for Leishmania donovani parasites and thus sustaining the occurrence of VL. Since Bangladesh, India and Nepal have targeted the elimination of VL, it is important to eliminate PKDL as well. However, in Nepal there is no active case detection of PKDL and the real burden of PKDL is not known. This community based survey encountered a PKDL prevalence of 2.23 per 10,000 population. PKDL patients had limited knowledge of VL and PKDL. They suffered to some degree from social and psychological stigma. Therefore, PKDL case detection and management should be strengthened in the national programme in the context of the VL elimination initiative. [ABSTRACT FROM AUTHOR]

Visceral leishmaniasis (VL) is the second most common protozoosis that affects people around the world. The aim of this study is to understand how environmental and socioeconomic factors, as well as VL control and surveillance interventions, influence the spread and detection of VL cases in Pernambuco state (Brazil). A novel model was developed to analyze cases of VL between 2007 and 2018, enabling the quantification of the association of these variables with two processes: the probability of "invasion" (emergence of new cases) at municipalities by VL, and the probability of detecting cases not reported in municipalities that have already been invaded. Pernambuco state identified 1,410 cases of VL between 2007 and 2018, with an average of 128 cases per year and average incidence of 1.28/100 thousand people. These cases were distributed in 77.1% (142/184) of the municipalities, and 54.8% (773/1,410) of them were autochthonous. Our model reveals that the proportion of agriculture was positively associated with VL invasion probability. We also find that municipalities that are closer to notification centers and/or that have received technical training and support tend to have higher detection rates of VL cases. Taken together, these results suggest that a municipality with almost no agriculture and that received technical training, located close to a notification center, is unlikely to be invaded if no cases have ever been detected. On the other hand, a municipality that is far from the notification center, with no technical training, with a large agricultural area might have already been invaded but the surveillance system might have routinely failed to detect VL cases due to low detection probability. By disentangling the processes of invasion and detection, we were able to generate insights that are likely to be useful for the strategic allocation of VL prevention and control interventions. Author summary: Visceral leishmaniasis (VL) is an important neglected zoonosis around the world. We evaluated how environmental and socioeconomic factors, as well as VL control and surveillance interventions, influence the spread and detection of VL cases in Pernambuco state (Brazil), which is endemic. Our results reveal that municipalities with almost no agriculture that received technical training and are located close to a notification center are unlikely to have VL infected individuals if no cases have ever been detected. On the other hand, a municipality distant from the notification center, with no technical training, and with a large agricultural area might have already had unreported cases. These results can serve as a foundation to improve the personnel training and notification system strategies adopted by VL Public Health Programs. [ABSTRACT FROM AUTHOR]

Canine leishmaniasis (CanL) is a severe public health threat. Infected animals mediate transmission of the Leishmania protozoan to humans via the sandfly's bite during a blood meal. CanL progression depends on the degree of suppression of the immune response, possibly associated with microRNAs (miR), which can modulate mRNA translation into proteins and (consequently) regulate cell function. Increased miR-148a in splenic leukocytes (SL) of dogs with CanL was observed in previous studies, and in silico analysis, identified possible pathways involved in immune response regulation that are affected by this miR. Therefore, we evaluated the involvement of miR-148a in the regulation of TNF-α, IL-6, IL-12, IL-1β, iNOS, MHCII, CD80, CD3, T-bet, and GATA-3 transcription factors and their relationship with parasite load in SL of dogs with CanL. Splenic leukocytes obtained from healthy and diseased dogs were transfected with miR-148a mimic and inhibitor oligonucleotides. After 48 hours, expression levels of MHCII, CD80, iNOS, CD3, T-bet, and GATA-3 were evaluated by flow cytometry, and concentrations of TNF-α, IL-12, IL-6, and IL-1β were measured in culture supernatants by capture enzyme-linked immunosorbent assays. Transfection of SL with miR-148a mimics decreased iNOS levels in cells and TNF-α, IL-6, and IL-12 in the supernatants of cultured SL from CanL dogs. Interestingly, transfection with miR-148a inhibitor decreased parasite load in SL cells. These results suggest a direct or not regulatory role of this miR in the immune response to Leishmania infantum infection. We conclude that miR-148a can modulate immune responses by regulating inflammatory cytokines during CanL. Our results contribute to understanding the complex host/parasite interaction in CanL and could assist the development of treatments. Author summary: The Leishmania infantum is a protozoan parasite that causes visceral leishmaniasis (VL), the most lethal form of the disease in humans. In the domestic environment, dogs are the primary reservoir of this parasite; the infection may present as slimming, extensive skin lesions, excessive nail growth, and others. Treatments for canine leishmaniasis (CanL) are ineffective because treated dogs often re-develop signs and symptoms when the medication is stopped. However, the immune response determines the presentation and cellular immune responses are most effective for parasite replication control. Resistance depends on the inflammatory or microbicidal activity of cytokines. Nevertheless, the suppression of this immune response is evident during CanL and is related to many factors. Recent reports of dogs with CanL found increased small RNAs called microRNAs (miR) that regulate cell function and might be associated with the immune regulation observed during this disease. Therefore, we inhibited and increased levels of a specific miR (miR-148a) in vitro in cells of dogs (Leishmania-infected/sick and uninfected/heathy) and measured immunological markers. We observed a reduction of some essential inflammatory cytokines when the miR was increased and parasite number reduction when the miR was inhibited. These results suggest that this miR influences immunological responses in dogs with CanL related to disease progression. The findings contribute to the understanding of immunological aspects of CanL, facilitating the development of immunotherapeutic approaches. [ABSTRACT FROM AUTHOR]

Para Kala-azar Dermal Leishmaniasis (Para-KDL) manifests the concomitant presence of Post Kala-azar Dermal Leishmaniasis and Visceral Leishmaniasis and works as a reservoir of infection. The study discusses the cases and their management and aims to address the gaps within existing methods of diagnosis and treatment. This retrospective cross-sectional study discusses 16 Para-KDL cases with one-year follow-up data, treated between 2012–2021 at the Surya Kanta Kala-azar Research Center, Bangladesh. We collected data from hospital records and used STATA 16 to analyze and see the frequency distribution and variable means. We found five patients without any history of kala-azar infection. All the patients were treated with 20 mg/kg Liposomal Amphotericin B in 4 divided doses except one with a history of AmBisome hypersensitivity. One year after treatment, all patients were free from skin lesions, with no hepatosplenomegaly, and observed significant improvement in BMI and hemoglobin levels. The Para-KDL patients are challenging to diagnose, and the relapse and treatment failure leishmania patients might have belonged to this rare group, contributing to their poor prognosis. Therefore, developing an appropriate diagnostic workflow and a new drug regimen is essential to sustain the success of our elimination efforts. [ABSTRACT FROM AUTHOR]

People are infected with Leishmania donovani when the parasite is deposited in the dermis during the blood meal of the sand fly vector. Most infected people develop a subclinical latent infection, but some develop progressive visceral leishmaniasis. Malnutrition is a risk factor for the development of active VL. We previously demonstrated increased parasite dissemination from the skin to visceral organs in a murine model of malnutrition. Here we investigated the mechanism of early parasite dissemination. After delivery of L. donovani to the skin, we found enhanced capture of parasites by inflammatory monocytes and neutrophils in the skin of malnourished mice. However, parasite dissemination in malnourished mice was driven primarily by infected inflammatory monocytes, which showed increased CCR7 expression, greater intrinsic migratory capacity, and increased trafficking from skin to spleen. PGE2 production, which was increased at the site of skin infection, increased monocyte CCR7 expression and promoted CCR7-related monocyte-mediated early parasite dissemination in malnourished mice. Parasite dissemination in monocytes was reduced by inhibition of PGE2, knockdown or silencing of CCR7 in monocytes, and depletion of inflammatory monocytes through administration of diphtheria toxin to CSFR1-DTR transgenic mice that have monocyte-specific DT receptor expression. CCR7-driven trafficking of infected inflammatory monocytes through the lymph node was accompanied by increased expression of its ligands CCL19 and CCL21. These results show that the CCR7/PGE2 axis is responsible for the increased trafficking of L. donovani-infected inflammatory monocytes from the skin to the spleen in the malnourished host. Undernutrition and production of PGE2 are potential targets to reduce the risk of people developing VL. Nutritional interventions that target improved immune function and reduced PGE2 synthesis should be studied in people at risk of developing VL. Author summary: This study established that inflammatory monocytes contribute to the visceralization of L. donovani parasites in the malnourished host. We found that the prostaglandin E2 produced during the first 72 hours of infection amplified the parasite burden at the site of skin infection and induced a high expression of CCR7 receptor in inflammatory monocytes. CCR7-bearing inflammatory monocytes carried L. donovani parasites via enhanced migration from the skin infection site to the viscera of malnourished mice. This dissemination of Leishmania parasites was abrogated in CCR7 deficient inflammatory monocytes and in mice treated with a prostaglandin E synthase inhibitor. We conclude that PGE2 contributes to monocyte-mediated parasite dissemination through the expression of CCR7 and its ligands in malnourished mice. [ABSTRACT FROM AUTHOR]