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Afbeelding 1/1 : Migrant workers in North West Ethiopia / © Rachel ter Horst

PhD defence Charles Abongomera

Challenges in clinical management of visceral leishmaniasis patients in East Africa

30 mei 201816:00

Reservatie aangeraden

Supervisors: 

  • Prof. Dr. Johan Van Griensven (Institute of Tropical Medicine)
  • Prof. Em. Bob Colebunders (University of Antwerp)

Summary:

This research aimed to improve the clinical management of visceral leishmaniasis (VL) patients in East Africa through provision of a clinical prognostic tool for death, determination of the risk and predictors of relapse and the identification of more effective treatment. The studies were conducted using routine program data.

Case fatality rates among VL subgroups are high and resources for care limited. A clinical prognostic score for death in VL patients could contribute to optimal management and reduced mortality. We developed and externally validated a clinical prognostic score for death in Ethiopia. The performance of the score was good with an area under the receiver operating characteristic curve of 0.83 in derivation and 0.78 in external validation. The score can help triaging patients needing more intensive care.

Data on the risk and predictors of VL relapse are scarce. This information is vital to target medical interventions to those at highest risk. We identified the risk and predictors of relapse in HIV patients in Ethiopia. The risk of relapse was high (15% at 6 months, 26% at 12 months and 35% at 24 months), particularly in those not on antiretroviral therapy (ART) or presenting with a high tissue parasite load. These patients should be preferentially targeted for secondary prophylaxis. Timely ART initiation is crucial.

VL-HIV patients have high (initial) parasitological failure rates with all anti-leishmanial drugs. We determined the effectiveness of liposomal amphotericin B (AmBisome) and miltefosine combination for treatment of VL in HIV patients in Ethiopia. This regimen seems a suitable treatment option: parasitological failure rate was low (3.5%), cure rate high (83.8%) and death rate similar to other studies (12.7%). Tuberculosis at VL diagnosis was predictive of parasitological failure. Age >40 years, hemoglobin level <6.5 g/dL and primary VL were predictive of death. Knowledge of these predictors may facilitate better management. These findings remain to be confirmed in clinical trials.

Sodium stibogluconate (SSG), the main post-kala-azar dermal leishmaniasis (PKDL) treatment is potentially toxic whereas AmBisome, the alternative is prohibitively expensive. We compared the effectiveness of SSG to SSG and paromomycin (PM) combination for treatment of severe PKDL in South Sudan. With SSG/PM, cure rate was higher (97% vs. 90%; p=0.02), treatment duration shorter (mean 34 days vs. 42 days; p=0.005), and defaulter rate lower (3% vs. 9%; p=0.03). There was no significant difference in death rate (0% vs. 1%; p=0.5). SSG/PM combination is a suitable treatment option for severe PKDL.