Adoption of new visceral leishmaniasis treatments in South Asia Visceral leishmaniasis
Providing evidence to change guidelines for visceral leishmaniasis treatment in South Asia
Policy change for control and elimination of visceral leishmaniasis brings better treatments to patients in Bangladesh, India, and Nepal
In the early 21st century, treatments for visceral leishmaniasis (also known as kala-azar) in South Asia were difficult for patients to take or growing ineffective. Resistance was increasing, including to the oral drug miltefosine. Antimonials such as sodium stibogluconate had lengthy treatment times, difficult treatment administration, and poor tolerability that caused frequent side effects.
In 2010, WHO recommended using new short-course treatments for visceral leishmaniasis in South Asia based on excellent results in Phase III studies. However, more evidence was needed on the safety and effectiveness of using these treatments for a wider population under field conditions.
DNDi convened a consortium of partners to identify the best combination therapies for South Asia. The consortium conducted a four year-long implementation study in Bangladesh and India (2012 – 2015) to assess the safety, efficacy, and patient compliance of three new treatment options including single-dose liposomal amphotericin B, paromomycin and miltefosine, and liposomal amphotericin B and miltefosine. The results showed that these treatments were safe and effective, with cure rates above 95%. They also shortened treatment length, reduced the risk of resistance, allowed reaching patients closer to home, and therefore made it simpler for patients to take the full treatment course.
The research provided key evidence for policy change by the Bangladeshi, Indian, and Nepali Ministries of Health, which made the following recommendations: single-dose liposomal amphotericin B as a first option treatment for visceral leishmaniasis patients and paromomycin & miltefosine as a second option.
At a glance
Indication: visceral leishmaniasis in Asia
Dosage: First option: single-dose liposomal amphotericin B given as an intravenous infusion; Second options: single-dose liposomal amphotericin B with miltefosine for 7 days; single-dose liposomal amphotericin B with paromomycin for 10 days; paromomycin & miltefosine, both daily for 10 days
Project start: 2006
Project cost: EUR 9.9 million (2007-2015)*
- Treatments recommended by WHO Expert Committee on the Control of Leishmaniases in 2010 as safe and effective treatments for visceral leishmaniasis in Asia (liposomal amphotericin B single or multiple dose, and all combinations tested in DNDi’s clinical trial)
- Supported policy change for the control and elimination of visceral leishmaniasis in highly endemic countries: Bangladesh, India, and Nepal
- Result of partnership in India with the Bihar State Health Society, GVK Biosciences, Indian Council of Medical Research, Kala Azar Medical Research Centre, Médecins Sans Frontières, National Vector Borne Disease Control Programme, and Rajendra Memorial Research Institute of Medical Sciences
- Result of partnership in Bangladesh with the International Centre for Diarrhoeal Disease Research, Médecins Sans Frontières, Ministry of Health and Family Welfare, Shaheed Suhrawardy Medical College and Hospital
“Earlier the ward used to be full of visceral leishmaniasis patients because of the long 28-day treatment. But since single-dose liposomal amphotericin B has been included in the national treatment protocol, the face of the disease has changed dramatically. Now patients come, take treatment, and go home the same day. This is an effective treatment, and now with this the number of patients have come down.”
Key Scientific Articles
Field safety and effectiveness of new visceral leishmaniasis treatment regimens within public health facilities in Bihar, India. PLOS Neglected Tropical Diseases, October 2018
by Goyal V, Mahajan R, Pandey K, Singh SN, Singh RS, Strub-Wourgaft N, Alves F, Das VNR, Topno RK, Sharma B, Balasegaram M, Bern C, Hightower A, Rijal S, Ellis S, Sunyoto T, Burza S, Lima N, Das P, Alvar J.
Safety and efficacy of short course combination regimens with AmBisome®, miltefosine, paromomycin for the treatment of visceral leishmaniasis (VL) in Bangladesh. PLOS Neglected Tropical Diseases, June 2017
by Rahman R, Goyal V, Haque R, Jamil K, Faiz A, Samad R, Ellis S, Balasegaram M, den Boer M, Rijal S, Strub-Wourgaft N, Alves F, Alvar J, Sharma B.
Investments in research and surveillance are needed to go beyond elimination and stop transmission of Leishmania in the Indian subcontinent. PLOS Neglected Tropical Diseases, January 2017
by Olliaro P, Shamsuzzaman TAKM, Marasini B, Dhariwal AC, Be-Nazir A, Mondal D, Banjara MR, Das P, Sundar S, Rijal S, Arana B, Alvar J, Argaw D, Peeling RW, Kroeger A, Matlashewski G.
How far are we from visceral leishmaniasis elimination in Bangladesh? an assessment of epidemiological surveillance data. PLOS Neglected Tropical Diseases, August 2014
by Chowdhury R, Mondal D, Chowdhury V, Faria S, Alvar J, Nabi SG, Boelaert M, Dash AP.
Comparison of short-course multidrug treatment with standard therapy for visceral leishmaniasis in India: an open-label, non-inferiority, randomised controlled trial. The Lancet, January 2011
by Sundar S, Sinha P.K, Rai M, Verma D.K, Nawin K, Alam S, Chakravarty J, Vaillant M, Verma N, Pandey K, Kumari P, Lal C.S, Arora R, Sharma B, Ellis S, Strub-Wourgaft N, Balasegaram M, Olliaro P, Das P, Modabber F.
- 25 January 2011 – Study shows the safety and efficacy of combination treatment for visceral leishmaniasis in India
- 7 November 2011 – Major project launched to support India and Bangladesh’s National Control Programmes in implementing new treatments to boost kala-azar elimination strategies
- 15 October 2014 – Study results support WHO recommendations for safe and effective kala-azar treatments in Bangladesh
Bihar State Health Society, India; GVK Biosciences, India; Indian Council of Medical Research, India; Institute of Tropical Medicine-Antwerp, Belgium; International Centre for Diarrhoeal Disease Research, Bangladesh; Kala Azar Medical Research Centre, India; London School of Hygiene & Tropical Medicine, UK; Médecins Sans Frontières, Spain; Ministry of Health and Family Welfare, Bangladesh; National Vector Borne Disease Control Programme, India; OneWorld Health/PATH, USA; Rajendra Memorial Research Institute of Medical Sciences, India; Shaheed Suhrawardy Medical College and Hospital, Bangladesh; WHO-TDR, Switzerland.
Bill & Melinda Gates Foundation, USA; Department for International Development (DFID), UK; Médecins Sans Frontières/Doctors without Borders, International; Spanish Agency for International Development Cooperation (AECID), Spain; Swiss Agency for Development and Cooperation (SDC), Switzerland; Other private foundations and individuals.
*Project cost includes direct and indirect costs, but it does not include in-kind contributions.
Photo credit: Kishore Pandit-DNDi
Last updated: January 2019