Improved kala-azar case management through implementation of health facility-based sentinel sites surveillance system in Bihar,India

BackgroundVisceral leishmaniasis (VL), also known as kala-azar (KA), is a neglected vector-borne disease, targeted for elimination, but several affected blocks of Bihar are posing challenges with the high incidence of cases, and moreover, the disease is spreading in newer areas. High-quality kala-azar surveillance in India, always pose great concern. The complete and accurate patient level data is critical for the current kala-azar management information system (KMIS). On the other side, no accurate data on the burden of post kala-azar dermal leishmaniasis (PKDL) and co-infections are available under the current surveillance system, which might emerge as a serious concern. Additionally, in low case scenario, sentinel surveillance may be useful in addressing post-elimination activities and sustaining kala-azar (KA) elimination. Health facility-based sentinel site surveillance system has been proposed, first time to do a proper accounting of KA, PKDL and co-infection morbidity, mortality, diagnosis, case management, hotspot identification and monitoring the impact of elimination interventions.Methodology/principal findingsKala-azar sentinel site surveillance was established and activated in thirteen health facilities of Bihar, India, using stratified sampling technique during 2011 to 2014. Data were collected through specially designed performa from all patients attending the outpatient departments of sentinel sites. Among 20968 symptomatic cases attended sentinel sites, 2996 cases of KA and 53 cases of PKDL were registered from 889 endemic villages. Symptomatic cases meant a person with fever of more than 15 days, weight loss, fatigue, anemia, and substantial swelling of the liver and spleen (enlargement of spleen and liver).The proportion of new and old cases was 86.1% and 13.9% respectively. A statistically significant difference was observed for reduction in KA incidence from 4.13/10000 in 2011 to 1.75/10000 in 2014 (p<0.001). There were significant increase (0.08, 0.10 per 10 000 population) in the incidences of PKDL and co-infection respectively in the year 2014 as compared to that of 2011 (0.03, 0.06 per 10 000 population). The proportion of HIV-VL co-infection was significantly higher (1.6%; p<0.05) as compared to other co-infections. Proportions of male in all age groups were higher and found statistically significant (Chi-square test = 7.6; P = 0.026). Utilization of laboratory services was greatly improved. Friedman test showed statistically significant difference between response of different anti kala-azar drugs (F = 25.0, P = 0.004).The initial and final cure rate of AmBisome was found excellent (100%). The results of the signed rank sum test showed significant symmetry of unresponsiveness rate (P = 0.03). Similarly, relapse rate of sodium antimony gluconate (SAG) was also found significantly higher as compared to other drugs (95%CI 0.2165 to 19.7035; P = 0.03). A statistically significant difference was found (p<0.001) between villages having 1–2 cases (74%) and villages with 3–5 cases (15%). Significantly higher proportion (95%) of cases were captured by existing Govt. surveillance system (KMIS) (p<0.001), as compared to private providers (5%).Conclusions/significanceEstablishment of a sentinel site based kala-azar surveillance system in Bihar, India effectively detected the rising trend of PKDL and co-infections and captured complete and accurate patient level data. Further, this system may provide a model for improving laboratory services, KA, PKDL and co-infection case management in other health facilities of Bihar without further referral. Program managers may use these results for evaluating program’s effectiveness. It may provide an example for changing the practices of health care workers in Bihar and set a benchmark of high quality surveillance data in a resource limited setting. However, the generalizability of this sentinel surveillance finding to other context remains a major limitation of this study. The justifications for this; the sentinel sites were made in the traditionally high endemic PHC’s. The other conditions were Program commitment for diagnostic (rk-39) and the first line anti kala-azar drug i.e. miltefosine throughout the study period in the sentinel sites. In addition, there were clause of fulfillment of readiness criteria at each sentinel site (already described in the line no 171 to 180 at page no-8, 181–189 at page no-9 and 192–212 at page no-10). Rigorous efforts were taken to improve all the sentinel sites to meet the readiness criteria and research activities started only after meeting readiness criteria at the site. Therefore sentinel site surveillance described under the present study cannot be integrated into other set up (medium and low endemic areas). However, it can be integrated into highly endemic areas with program commitment and fulfillment of readiness criteria.     

Oxidative stress and cholinesterase inhibition in saliva and plasma of rats following subchronic exposure to malathion

The aim of this study was to examine whether malathion, a commonly used organophosphate (OP), might induce oxidative stress and cholinesterase (ChE) depression in saliva and plasma in rats following subchronic exposure mimicking human exposure. Malathion was administered orally at doses of 100, 500 and 1500 ppm for 4 weeks. Oxidative stress was determined by measuring the malondialdehyde concentration, the end product of lipid peroxidation, and assessing total antioxidant power. Four weeks oral administration of malathion at doses of 100 ppm, 500 ppm and 1500 ppm depressed plasma ChE activity to 45% (P<0.01), 48% (P<0.01) and 41% (P<0.01) of control, respectively. Malathion at doses of 100 ppm, 500 ppm and 1500 ppm depressed saliva ChE activity to 73% (P<0.01), 75% (P<0.01) and 78% (P<0.01) of control, respectively. Malathion at doses of 100 ppm, 500 ppm and 1500 ppm increased plasma antioxidant power by 33% (P<0.01), 59% (P<0.01) and 118% (P<0.01) of control, respectively. Malathion did not change saliva antioxidant power. Malathion at doses of 100 ppm, 500 ppm and 1500 ppm increased plasma thiobarbituric acid reactive substances (TBARS) by 61% (P<0.01), 69% (P<0.01) and 63% (P<0.01) of control, respectively. Malathion at doses of 500 ppm and 1500 ppm increased saliva TBARS by 19% (P<0.01) and 22% (P<0.01) of control, respectively. Malathion (100 ppm) did not change saliva TBARS level. We concluded that in OP subchronic exposure, depression of ChE is accompanied by induction of oxidative stress that might be beneficial in monitoring OP toxicity.     

Appraisal of Phlebotomus argentipes habitat suitability using a remotely sensed index in the kala-azar endemic focus of Bihar,India

Visceral leishmaniasis, or kala-azar, is recognised as a serious emerging public health problem in India. In this study, environmental parameters, such as land surface temperature (LST) and renormalised difference vegetation indices (RDVI), were used to delineate the association between environmental variables and Phlebotomus argentipes abundance in a representative endemic region of Bihar, India. The adult P. argentipes were collected between September 2009-February 2010 using the hand-held aspirator technique. The distribution of P. argentipes was analysed with the LST and RDVI of the peak and lean seasons. The association between environmental covariates and P. argentipes density was analysed a multivariate linear regression model. The sandfly density at its maximum in September, whereas the minimum density was recorded in January. The regression model indicated that the season, minimum LST, mean LST and mean RDVI were the best environmental covariates for the P. argentipes distribution. The final model indicated that nearly 74% of the variance of sandfly density could be explained by these environmental covariates. This approach might be useful for mapping and predicting the distribution of P. argentipes, which may help the health agencies that are involved in the kala-azar control programme focus on high-risk areas.     

Phlebotomine sandfly ecology on the Indian subcontinent: does village vegetation play a role in sandfly distribution in Bihar,India?

Visceral leishmaniasis (VL) is a disease that results in approximately 50 000 human deaths annually. It is transmitted through the bites of phlebotomine sandflies and around two‐thirds of cases occur on the Indian subcontinent. Indoor residual spraying (IRS), the efficacy of which depends upon sandfly adults resting indoors, is the only sandfly control method used in India. Recently, in Bihar, India, considerable sandfly numbers have been recorded outdoors in village vegetation, which suggests that IRS may control only a portion of the population. The purpose of this study was to revisit previously published results that suggested some sandflies to be arboreal and to rest on outlying plants by using Centers for Disease Control light traps to capture sandflies in vegetation, including banana plants and palmyra palm trees, in two previously sampled VL‐endemic Bihari villages. Over 3500 sandflies were trapped in vegetation over 12 weeks. The results showed the mean number of sandflies collected per trap night were significantly higher in banana trees than in other vegetation (P = 0.0141) and in female rather than male palmyra palm trees (P = 0.0002). The results raise questions regarding sandfly dispersal, oviposition and feeding behaviours, and suggest a need to refine current control practices in India and to take into account an evolving understanding of sandfly ecology.     

A Case of Post Kala-Azar Dermal Leishmaniasis in India

Post kala-azar dermal leishmaniasis (PKDL) is a rare disease. This is a solitary case report from Orissa, India. We describe a case of PKDL in a 55-year-old male who presented with multiple nodular lesions over face, trunk, and extremities. The patient had been to an endemic area of kala-azar and had a previous history of leishmaniasis. Fine needle aspiration cytology samples from skin nodules revealed Leishmania amastigotes.     

An analysis of T cell responsiveness in Indian kala-azar

The inability of most untreated patients with Kala-azar to control their visceral infections with Leishmania donovani has been attributed to a defective cell-mediated immune response to leishmanial antigens. We examined the in vitro response of T cells, including Leu-2+-depleted T cell populations, to determine whether unresponsiveness could be reversed. These studies on patients with visceral leishmaniasis in Bihar, north India, support previous observations regarding T cell unresponsiveness in patients with active disease: it is profound, it is specific, and it is reversible after successful chemotherapy. However, these studies also indicate that the specific unresponsiveness cannot be reversed by depletion of "suppressor" Leu-2+ T lymphocytes, nor by the addition of exogenously supplied human IL 2 to the cultures. One interpretation of these results is that in active cases of Kala-azar, there is an absence of Leishmania-specific T cells in the periphery. The possibility that reactive cells can be found in situ cannot be excluded. The observation that 13 of 25 family members of active cases were able respond to L. donovani in vitro or by skin testing suggests that the frequency of infection within an endemic area in Bihar is very high, and that assays for T cell responsiveness are far better epidemiologic tools for the detection of asymptomatic infection than is ELISA. Identification of such an exposed, Kala-azar-resistant population will be required to study host factors which influence the development of disease in infected individuals.     

Human Exposure to Malathion during a Possible Vector-Control Intervention against West Nile Virus. I: Methodological Framework for Exposure Assessment

The arrival of West Nile Virus in North America prompted public health authorities to develop intervention plans in order to prevent the propagation of this mosquito-transmitted pathogen. The last-resort measure proposed by the Government of Quebec (Canada) is the large-scale application of insecticides by aerial or ground Ultra Low Volume (ULV) treatment. This article presents an assessment of the exposure to malathion and its metabolite, malaoxon, for a population where an eventual application of malathion would occur. Each exposure pathway is detailed by describing the equation and every conservative assumption. This methodological framework was then used with the aim of assessing the toxicological risk based on a probabilistic approach (see companion article, this issue). In the current study, a daily absorbed dose of the mixture of malathion and malaoxon was estimated in terms of “malathion equivalent dose.” Each exposure pathway following a single event of ground or aerial ULV spraying of malathion was investigated for the population, classified into five age groups. Dermal exposure to dislodgeable residues on turf, foliage, and hard surfaces was estimated to be the most important source of exposure compared to any other pathways; it accounts for 63% to 98% of the estimated cumulative absorbed doses. The hand-to-mouth behavior of toddlers may also contribute considerably to their “malathion-equivalent” exposure (i.e., approximately 15% of the cumulative dose). Otherwise, the current study shows that ground ULV spraying is the type of treatment that may induce lower exposure, because the predicted concentration of malathion on turf and foliar surfaces is less than the one predicted for aerial ULV spraying.     

Metrifonate induces cholinesterase inhibition exclusively via slow release of dichlorvos

Metrifonate, a long-acting cholinesterase (ChE) inhibitor with very low toxicity in warm-blooded animals, inhibits rat brain and serum cholinesterase (ChE) in vitro through its hydrolytic degradation product, dichlorvos. This conclusion is based on the finding that metrifonate-induced ChE inhibition showed the same pH dependence as its reported dehydrochlorination to dichlorvos. The ChE inhibition induced by dichlorvos was not pH dependent. It was mediated by a competitive drug interaction with the catalytic site of the enzyme, which led to irreversible inhibition within several minutes of incubation. After this time, addition of further substrate to the inhibited enzyme was not able to promote drug dissociation and hence enzyme reactivation. Similar characteristics of inhibition, i.e. interaction with the substrate binding site and time-dependent switch to non-competitive inhibition were observed with the reference compound, physostigmine. However, the physostigmine-induced inhibition of ChE could be readily reversed by further substrate addition. Another reference compound, tetrahydroaminoacridine (THA), also induced a reversible inhibition of rat brain and serum cholinesterase, but with a mechanism of action different from that of both dichlorvos and physostigmine in that enzyme inhibition occurred rapidly upon drug addition at an allosteric site on the enzyme surface. It is suggested that the unique slow release plus the slow inhibition of ChE by dichlorvos is responsible for the lower toxicity of metrifonate compared to that of directly acting ChE inhibitors.     

Different sensitivity of Ca(2+)-ATPase and cholinesterase to pure and commercial pesticides in nervous ganglia of Phyllocaulis soleiformis (Mollusca)

We measured the effects in vitro of pure and commercial pesticides on Ca(2+)-activated ATPase and cholinesterase (ChE) activities in the nervous system of the slug Phyllocaulis soleiformis. The pesticides used in this study included carbamate and organophosphates, which acts as reversible and irreversible anticholinesterases, respectively. Both enzymes were insensitive to pure carbofuran (1 mM), glyphosate (1 mM) and malathion (120 microM). However, the carbamate carbofuran, in the commercial formulation Furandan 350S, inhibited ATPase and ChE activities. The organophosphate glyphosate used in the commercial preparation of Gliz 480CS inhibited ATPase activity and increased cholinesterase activity. These effects are likely due to the action of adjuvant substances of the chemical formulation. The commercial formulation (Malatol 500CE) did not alter enzymes activities. Our results suggest that cholinesterase present in the slug nervous tissue has a different behavior to those identified in vertebrate nervous tissue, since it was insensitive to pure compounds, known as anticholinesterases in vertebrates. Considering the insensitivity of the Ca(2+)-activated ATPase, we suggested that the purinergic neurotransmission and other roles of ATP might not be affected by the pure pesticides tested.     

Insecticide susceptibility of Phlebotomus argentipes in visceral leishmaniasis endemic districts in India and Nepal

Objectives

To investigate the DDT and deltamethrin susceptibility of Phlebotomus argentipes, the vector of Leishmania donovani, responsible for visceral leishmaniasis (VL), in two countries (India and Nepal) with different histories of insecticide exposure.

Methods

Standard WHO testing procedures were applied using 4% DDT and 0.05% deltamethrin impregnated papers. The effect of the physiological status (fed and unfed) of females on the outcome of the bioassays was assessed and the optimal time of exposure for deltamethrin was evaluated on a colony population. Field populations from both countries were tested.

Results

Fed and unfed females responded in a similar way. For exposure time on field samples 60 min was adopted for both DDT and deltamethrin. In Bihar, knockdown and mortality with DDT was respectively 20 and 43%. In Nepal almost all sand flies were killed, except at the border with Bihar (mortality 62%). With 0.05% deltamethrin, between 96 and 100% of the sand flies were killed in both regions.

Conclusions

Based on literature and present data 4% DDT and 0.05% deltamethrin seem to be acceptable discriminating concentrations to separate resistant from susceptible populations. Resistance to DDT was confirmed in Bihar and in a border village of Nepal, but the sand flies were still susceptible in villages more inside Nepal where only synthetic pyrethroids are used for indoor spraying. The low effectiveness of indoor spraying with DDT in Bihar to control VL can be partially explained by this resistance hence other classes of insecticides should be tested. In both countries P. argentipes sand flies were susceptible to deltamethrin.     

Muscular and brain cholinesterase sensitivities to azinphos methyl and carbaryl in the juvenile rainbow trout Oncorhynchus mykiss

The organophosphate azinphos methyl (AzMe) and the carbamate carbaryl are the insecticides mostly used in the irrigated valley of Río Negro and Neuquén, Patagonia, Argentina. Juvenile rainbow trout were exposed to AzMe and carbaryl and the sensitivity of skeletal muscular cholinesterase (ChE) and the time course of inhibition and recovery were evaluated. EC50 values demonstrated that AzMe was a stronger in vivo inhibitor of muscular ChE (1.05+/-0.23 microg/L) than carbaryl (270+/-62.23 microg/L). Muscular ChE was significantly less sensitive to both insecticides than brain ChE. EC50 values obtained for muscular ChE were closer than those for brain ChE to the respective pesticide lethal concentrations, pointing out the relevance of the muscular enzyme in determining acute toxicity. The recovery process of ChE activity after carbaryl exposure (500 microg/L) was fast, whereas no significant recovery was observed with AzMe (1 microg/L) after 21 days in uncontaminated media. Brain and muscular ChE were inhibited and showed a significant but not complete recovery after three consecutive 48-h exposures to AzMe (1 microg/L) followed by a recovery period of 7 days. This scheme mimics the periodical application of the insecticides in the region and suggests a certain probability of a sustained ChE inhibition under field conditions, affecting fish development and survival.     

Visceral Leishmaniasis without Fever in an 11-Month-Old Infant: a Rare Clinical Feature of Kala-azar

Visceral leishmaniasis or kala-azar is an endemic parasitic disease in some parts of the world which is characterized by fever, splenomegaly, and pancytopenia in most of the cases. Herein we report an 11 month-old male infant with diagnosis of kala-azar who presented with pallor, hepatosplenomegaly, failure to gain weight, and no history of fever. Surprisingly, fever started after beginning of meglumine antimoniate treatment in this patient. As far as we are aware of, this is a rare presentation of visceral leishmaniasis. Therefore, clinicians especially in endemic areas are highly recommended to include kala-azar among differential diagnosis of unexplained anemia without fever to prevent misdiagnosis of this potentially fatal, but treatable condition.     

Observations on the susceptibility of Ctenocephalides felis (Siphonaptera: Pulicidae) to malathion and permethrin in Tanzania

Laboratory-reared Ctenocephalides felis (Bouche) adults were tested with 0.5% malathion and 0.5% permethrin, using the standard WHO methods. After 24 h exposure to malathion (3.6 mg/cm2), 92% of the fleas died. The LT50 for malathion was approximately 8 h. Permethrin (0.45 mg/cm2) produced 100% mortality of exposed insects after 24 h while with a higher dose (0.9 mg/cm2) all fleas died after 8 h exposure. LT50 for the two doses of permethrin were 7.7 and 1.05 h, respectively. The failure of the diagnostic dose of malathion to kill 100% of the population was attributed to resistance. Permethrin is a suitable pesticide for controlling fleas of domestic animals in Tanzania.     

Boll weevil (Coleoptera: Curculionidae) bait sticks: toxicity and malathion content

Assays of malathion content and toxicity to boll weevil, Anthonomus grandis grandis Bohemian, were conducted on boll weevil bait sticks, now marketed as Boll Weevil Attract and Control Tubes (BWACTs; Plato Industries, Houston, TX). In general, the longer BWACTs were in the field, the lower the mortality of weevils that were exposed to them. Bioassays of weevil mortality correlated with hexane washes of BWACT surfaces showed highly variable mortality when surface malathion fell below approximately 20 ng per 1 microl of hexane, but consistently high mortality (> or = 90%) when surface malathion was above 30 ng per 1 microl of hexane. A linear equation was calculated to predict mortality as a function of malathion on a BWACT surface. Although mortality was related to surface amounts of malathion, it was unrelated to the total amount of malathion present in BWACTs. Similarly, surface malathion was unrelated to the total amount present in BWACTs. As with mortality, amount of surface malathion declined with time, but total malathion did not decline with time. Boll weevils placed on fresh BWACTs tended to accumulate more malathion and died in greater numbers as time spent on fresh tubes increased, but not as time spent on tubes aged in the field (for 5 mo total) increased. Weevils that landed on tubes after a short flight died in approximately the same numbers as those that were placed on tubes using proper methodology. The amount of malathion expected to cause 90% mortality of boll weevils subjected to proper methodology was 47% higher than for a less stringent methodology (34.3 versus 23.4 ng), which demonstrates the importance of strictly adhering to proper methodology; nevertheless, chemical assay of malathion on the BWACT surface proved to be a more consistent measure of BWACT toxicity than bioassay, and it should replace the bioassay.     

Is imidacloprid an effective alternative for controlling pyrethroid-resistant populations of Triatoma infestans (Hemiptera: Reduviidae) in the Gran Chaco ecoregion?

The prevention of Chagas disease is based primarily on the chemical control of Triatoma infestans (Klug) using pyrethroid insecticides. However, high resistance levels, correlated with control failures, have been detected in Argentina and Bolivia. A previous study at our laboratory found that imidacloprid could serve as an alternative to pyrethroid insecticides. We studied the delayed toxicity of imidacloprid and the influence of the blood feeding condition of the insect on the toxicity of this insecticide; we also studied the effectiveness of various commercial imidacloprid formulations against a pyrethroid-resistant T. infestans population from the Gran Chaco ecoregion. Variations in the toxic effects of imidacloprid were not observed up to 72 h after exposure and were not found to depend on the blood feeding condition of susceptible and resistant individuals. Of the three different studied formulations of imidacloprid on glass and filter paper, only the spot-on formulation was effective. This formulation was applied to pigeons at doses of 1, 5, 20 and 40 mg/bird. The nymphs that fed on pigeons treated with 20 mg or 40 mg of the formulation showed a higher mortality rate than the control group one day and seven days post-treatment (p < 0.01). A spot-on formulation of imidacloprid was effective against pyrethroid-resistant T. infestans populations at the laboratory level.     

Population preference of net texture prior to bed net trial in Kala-Azar-endemic areas

Prior to a community-based efficacy trial of long-lasting insecticidal nets (LLINs) in the prevention of visceral leishmaniasis (VL; also called kala-azar), a pilot study on preference of tools was held in endemic areas of India and Nepal in September 2005.LLINs made of polyester and polyethylene were distributed to 60 participants, who used the nets sequentially for 7 d. Acceptability and preference were evaluated via indirect indicators through questionnaires at three defined time points before and after use of the LLINs and through focus group discussions (FGDs). In the latter, preferences for color and size were also assessed. Untreated bed nets were owned by 87% of the households prior to the study. All users liked textures of both LLIN types after 7 d of use, but had a slight preference for those made of polyester if they were to recommend a LLIN to relatives or friends (p<0.05), mainly because of their relatively greater softness in comparison to polyethylene LLINs. Users reported that both net types reduced mosquito bites and number of insects, including sand fly (bhusana; genus Phlebotomus), inside the house. Side effects were minor and disappeared quickly.The large-scale intervention trial considered the preferences of the study population to decide on the best tool of intervention--light-blue, rectangular, polyester LLINs of different sizes.     

Susceptibility of the bedbug,Cimex lectularius,to selected insecticides and various treated surfaces

Abstract. Adult bedbugs, Cimex lectularius, were exposed for 24 h (25^oC) to filter paper treated with various dilutions of the technical grade of nine insecticides dissolved in acetone to determine the concentration-response relationships. The order of toxicity, from most to least based on the LC₅₀'s was: dichlorvos, pirimiphos methyl, lambda-cyhalothrin, bendiocarb, permethrin, malathion, carbaryl, tetrachlorvinphos, and fenvalerate. The residual toxicities of commercial formulations of six of the chemicals diluted with water and applied to wood, cardboard, cloth and galvanized metal, were determined by exposing adult bedbugs at 3,7 and 12 weeks after treatment. The formulation of bendiocarb (FICAM® 76% W) had little residual activity on all surfaces at 12 weeks after treatment. The formulation of carbaryl (SEVIN® 21.5% L) was toxic to bedbugs on all surfaces at 12 weeks after treatment, but required high concentrations on wood, cardboard, and cloth. The formulation of pirimiphos methyl (ACTELLIC® 57% EC) had no residual activity on any of the surfaces at 12 weeks after treatment. The formulation of tetrachlorovinphos (RABON® 50% W) had residual activity for 12 weeks on all surfaces except metal. The formulation of permethrin (ATROBAN® 11% EC) had residual activity on only metal and wood while the formulation of lambda-cyhalothrin (KARATE® 13.1% EC) had residual activity 12 weeks on all surfaces.     

Human Exposure to Malathion during a Possible Vector-Control Intervention against West Nile Virus. II: Evaluation of the Toxicological Risks Using a Probabilistic Approach

In order to prevent the propagation of West Nile Virus (WNV), insecticide sprayings have been carried out in several locations in North America since 1999 with the objective of controlling the mosquito populations that transmit this pathogen. An attempt to quantitatively compare the risk of developing a health response to WNV infection with the toxicological risk of insecticides is presented here. First, the acute and subchronic environmental concentrations resulting from repeated spraying events were modeled according to a reasonable worst-case spraying sequence established in an intervention program proposed by the Government of Quebec (Canada). Second, probability density functions (PDF) were established for some exposure parameters according to the data for the concerned population, when feasible. Monte Carlo analyses were performed by incorporating these PDF into the equations used to calculate the daily absorbed doses resulting from the exposure scenarios presented in the companion article (this issue). The results showed that for a significant proportion of the population, aerial and, to a lesser extent, ground sprayings of malathion can generate acute and subchronic exposure that may exceed some levels of toxicological concern based on the USEPA's reference values. Indeed, in the case of acute exposure following aerial spraying for infants, toddlers, and children, these proportions were respectively 37.1%, 59.5%, and 32.8% of the individuals, and 27.3%, 41.3%, and 24.9% following subchronic exposure. For ground spraying, these values were 12.5%, 24.2%, 8.8%; and 9.8%, 16.5%, and 7.4%. These results allowed the comparison of the probability of exceeding a level of toxicological concern for malathion exposure with the probability of developing WNV symptoms. This comparison shows that in some circumstances, the toxicological risk of malathion may exceed the infectious risk of WNV.     

Early diagnosis of kala-azar in Bangladesh: Findings from a population based mixed methods research informing the post-elimination era

BackgroundGlobal annual reports of visceral leishmaniasis or kala-azar (“black fever”) reduced from 200,000 cases in 2012 to 23,804 in 2015. India, Bangladesh and Nepal reported 80% of the global cases in 2012, but 39% in 2015. We sought to identify major amenable barriers to early diagnosis of kala-azar in peripheral areas of Mymensingh district, an area of Bangladesh that was highly endemic for kala-azar.MethodsWe conducted sequential exploratory mixed methods research. Qualitative data were first derived from in-depth interviews and focus group discussions among 29 patients diagnosed with kala-azar, their families, and neighbours. Preliminary results from qualitative analysis were used to design a structured questionnaire, which was administered to collect data on the processes leading to the diagnosis of kala-azar from 102 patients. Qualitative and quantitative data were integrated consistent with the chronology for kala-azar patients seeking care. The study was conducted from September 2011 to May 2012 in Fulbaria and Gaffargaon sub-districts of Mymensingh.ResultsThe median delay from fever onset to confirmatory diagnosis of kala-azar was 60 days, with 38% of the cases diagnosed within 30 days. Public health facilities and Gaffargaon sub-district achieved high proportions of early diagnosis. Individual barriers to early diagnosis were low awareness of symptoms and treatment facilities, poverty, and traditional beliefs. Other factors were the remoteness of health care centres, wet season transport difficulty, mis-diagnosis as typhoid, limited availability of rK-39 testing at the community level, and the inclusion of splenomegaly in the case definition.ConclusionsTargeted community awareness campaigns appropriate for underprivileged communities will increase care seeking and consequently diagnosis. Improved diagnostic guidelines and a strong referral chain for kala-azar will accelerate diagnosis. These steps will contribute significantly to the National Kala-azar Elimination Program of Bangladesh, especially during the post-elimination era.     

The perturbation ofDrosophila melanogaster esterase-6 allozyme frequencies by selection for malathion resistance

The effects of selection for resistance to the organophosphate insecticide malathion on esterase-6 polymorphism was studied in laboratory populations ofD. melanogaster. A genetically well-mixed population was constructed from 40 locally-caught, iso-female lines, divided into control and malathion-selected lines and the frequency of the majorEst-6 alleles was followed for more than 100 generations. The main findings were: (1) The allele frequency in control replicates remained stable for over one hundred generations; (2) the allele frequency in the populations exposed to malathion changed dramatically and in the opposite direction between replicates during the early generations of the selection experiment; (3) all selected populations eventually returned to the controlEst-6 allele frequencies. This return was more rapid in populations exposed to lower selection intensity compared to those exposed to higher selection intensity; (4) the convergence ofEst-6 allele frequencies to control values was also observed in three populations obtained by mixing flies of appropriate genotypes from the control population to give different initial frequencies. These results have been interpreted to mean that esterase-6 does not have a direct role in malathion resistance, and that theEst-6 polymorphism in our experimental population was maintained by balancing selection.