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Evidence of Visceral Leishmaniasis (VL) in Somaliland

Jamila Ahmed Aden MSc, PhD in Public Health candidate, Curtin University, Australia

Dean of Graduate Studies and Research

East Africa University

Puntland State of Somalia

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Has seven campuses across Bari, Karkaar, Sanaag and two campuses in Nugal and Mudug region of Somalia.

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Stablished 23 years ago in 1998.

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Provide courses up to PhD level

EAST AFRICA UNIVERSITY

Puntland State, Somalia

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Visceral Leishmaniasis

Second commonest killing parasite disease after malaria, yet unknown to general public, even to many medical doctors.

Caused by Leishmania donovani complex parasites and transmitted by Phlebotomus sandflies

Effected organs: Spleen, bone marrow, liver, lymph nodes

Outcome: Always fatal without treatment, always curable with early treatment

Symptoms: Irregular bouts of fever, Anemia, weight loss, splenomegaly, severe pancytopenia

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Diagnostics & Treatment

Rapid Diagnostic Tests, low sensitivity, high specificity

Microscopy examination of bone marrow and spleen aspirates

Parasite culture: motile parasites by microscopy

DNA hybridisation using PCR of above aspirates, PCR of blood low sensitivity for VL

Specific treatment: Sodium Stibogluconate (the mainstay of VL therapy in Eastern Africa.

or with Paromomycin, back up: Liposomal Amphotericin B

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Unknown hidden killer

Unknown to be present in Northern Somalia until 2013

Children dying from it were thought to have leukaemia

Results of 118 cases VL positive was published from Bosaso General Hospital in 2020 in Emerging Infectious Diseases

Its presence for decades or centuries without never being diagnosed raised the question if it is also present, but never diagnosed in many other low resource regions

Active search in Tanzania in 2019: found also in Tanzania

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VL in Somaliland

  • Was largely unknown in Somaliland, supposed to be absent and the MoH was unaware of it
  • But epidemic VL reported in 1952 in Daarbuduq
  • Patients with confirmed VL from Laasqoray were treated in Bosaso General Hospital were permanent surveillance is in place
  • We supposed that health care facilities in Somaliland do not have capacity to diagnose it

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Reports of VL in Somaliland Prier the Study

  • Burao hospital reported that a foreign team had confirmed and treated VL cases there in 2012, but reported them only to their HQ in Europe, and not to the MoH of Somaliland nor to WHO.
  • A doctor in Hargeisa reported having diagnosed and treated one VL patient in Hargeisa ten years ago and reported to WHO. WHO has no records of it.
  • None of the cases had travel history

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Public Health Impact

  • Demonstrating the presence of VL in areas where it is generally thought not to exist

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  • Will enable building capacity for diagnosis and treatment of patients with VL

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  • Starting control measures in these areas.

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  • General Objective: To determine the probable endemic areas of VL in Somaliland in order to enable diagnosis and treatment of VL in the closest health care facilities and start first steps for its prevention thus avoidable deaths.

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  • Specific objective: To identify the number of patients presenting with symptoms of VL and number of confirmed VL patients during study period of one year in five selected hospitals in Somaliland.

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  • Research question: Is VL endemic and common in Somaliland?

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Objectives

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Methodology

Study area:

  • Health care facilities in, or receiving patients from hot and semiarid ecosystem, similar to those in Northern Somalia
    • East: Daarbuduq, Berbera, Burao and Erigavo, Badhan and Laasqoray.
    • West: Borama, Geerisa, Sayla, Lughaya, Lawyado, Fiqi Adan, Jidhi, Abdiqadir, Habaas and Harirad
  • Due to time restrictions Hargeisa hospitals were not included

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Methodology

Data collection:

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To enhance awareness and a diagnostic capacity of VL in the selected health care facilities

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    • Short visitation of the site was conducted

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    • Clinicians and laboratory staff were trained

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    • rK39 VL RDTs and instructions were provided

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Methodology

Inclusion criteria:

  • Patients sick with fevers over 2 weeks, without malaria or other evident cause and not responding to antibiotics and especially ceftriaxone were advised to be tested with VL RDT.

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  • Patients sick for months and with pancytopenia and splenomegaly were advised to be tested with VL RDT and to be referred to Borama Regional Hospital irrespective of the VL RDT result.

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  • Patients sick less than two weeks with normal FBC and splenomegaly were advised not to be tested.

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���Methodology ���l

Laboratory testing of suspected VL patients

Full differential diagnostics for patients suspected of having VL

              • Full Blood Count
        • Malaria Rapid Diagnostic Test
        • HIV Rabid Diagnostic Test
        • Random Blood Sugar
        • Creatinine
        • Urine analysis
        • Stool microscopy
        • Chest X-ray.

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Results

  • Second October 2021, in Geerisa, Public Health Officer Abdi Khadar Muse Ali diagnosed VL in a small child with history of fevers of 3 months not responding to any treatments, aneamia and splenomegaly symptoms. No Complete Blood Count machine available.
  • In Borama CBC with:
    • pancytopenia, rK39 RDT IT-Leish Positive, and
    • malaria RDT was Negative.
  • Fever decreased in less than 24 hours with Sodium Stibogluconate treatment, cured and completely well during controls
  • Patient did not travel outside Geerisa, except to Borama

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Results cnt.

  • A few other suspected with VL but lost from controls before confirmatory tests or treatment
  • Phlebotomus sp sandflies caught in Geerisa and sent to Prague for Leishmania PCR, no results available yet
  • Many wild rodents caught and spleens aspirates sent to Prague for Leishmania PCR, no results available yet

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Conclusions

  • Visceral Leishmaniasis cases without travel history was confirmed in the centre of Somaliland.
  • Low number of health facilities were covered in this study therefore, it is necessary to have VL diagnostics and treatment strategies for the whole Somaliland.
  • It is also necessary to improve the level of training and equipment in the health centres in addition to providing RDTs.

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Challenges

  • Lack of interest from health care professionals in Somaliland due to the perception that the disease is absent.

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  • Delays in funding due to Covid 19 pandemic.

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  • Limited resources and time for recruiting employed staff in the facilities.

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Abdikhadir, the one with eye glasses

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Thank you

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