Treatment outcomes of visceral leishmaniasis in Ethiopia from 2001 to 2017:a systematic review and meta-analysis

Background:Ethiopia has the highest number of visceral leishmaniasis(VL)cases after Sudan in Sub-Saharan Africa.However,there was lack of comprehensive data on VL treatment outcome despite the huge burden of the diseases in the country.Hence,we aimed to perform a systematic review and meta-analysis on this topic to obtain stronger evidence on treatment outcomes of VL from the existing literature in Ethiopia.Methods:The Cochrane guidelines to conduct meta-analysis following the Preferred Reporting Items for Systematic review and Meta-Analysis statement was used to conduct a computerized systematic search of the PubMed,Google Scholar,and ScienceDirect databases.Random effects model was used to combine studies showing heterogeneity of Cochrane Q P<0.10 and I2>50.Treatment outcomes were assessed at end of treatment and at 6 months follow-up.Subgroup analyses were performed on treatment outcomes based on the different antileishmanial treatment options and patients’HIV status.Results:Fifteen studies were included in the final analyses.At end of treatment,an overall treatment success rate of 82.6%was noticed.At 6 months follow-up,the overall treatment success rate was 72.2%.For patients treated with sodium stibogluconate(SSG),the treatment success rates at the end of treatment and at six-month follow-up were 81.5%and 80.7%,respectively.Multiple doses of liposomal-amphotericin B(L-AMB)had treatment success rates of 96.7 and 71-100%at the end of treatment and at 6 months follow-up,respectively.The combination of SSG with paromomycin(PM)gave treatment success rates of up to 90.1%at the end of treatment.HIV-infected individuals were found to have a higher mortality(odds ratio=4.77,95%CI:1.30-17.43,P=0.009)rate at 6 months follow-up.Conclusions:SSG alone has shown lower treatment efficacy in the management of VL when compared to combination of SSG with PM and multiple doses of L-AMB.The combination of SSG with PM gave good treatment success rates with shorter duration of treatment.Hence,the combination of SSG with PM should be used preferentially over SSG monotherapy.Multiple doses of L-AMB showed great efficacy especially among patients with complications,severe disease,HIV co-infection,and intolerance to the adverse effects of antimonials.HIVinfected individuals had a worse prognosis than their HIV-negative counterparts.

Health economic evaluation of moist wound care in chronic cutaneous leishmaniasis ulcers in Afghanistan

Background:The present health economic evaluation in Afghanistan aims to support public health decision makers and health care managers to allocate resources efficiently to appropriate treatments for cutaneous leishmaniasis(CL)elicited by Leishmania tropica or Leishmania major.Methods:A decision tree was used to analyse the cost and the effectiveness of two wound care regimens versus intra-lesional antimony in CL patients in Afghanistan.Costs were collected from a societal perspective.Effectiveness was measured in wound free days.The incremental cost-effectiveness ratio(ICER)and incremental net monetary benefit(NMB)were calculated.The model was parameterized with baseline parameters,sensitivity ranges,and parameter distributions.Finally,the model was simulated and results were evaluated with deterministic and probability sensitivity analyses.Final outcomes were the efficiency of the regimens and a budget impact analysis in the context of Afghanistan.Results:Average costs per patients were US$11(SE=0.016)(Group I:Intra-dermal Sodium Stibogluconate[IL SSG]),US$16(SE=7.58)(Group II:Electro-thermo-debridement[ETD]+Moist wound treatment[MWT])and US$25(SE=0.48)(Group III:MWT)in patients with a single chronic CL ulcer.From a societal perspective the budget impact analysis shows that the regimens’drug costs are lower than indirect disease cost.Average effectiveness in wound free days are 177(SE=0.36)in Group II,147(SE=0.33)in Group III,and 129(SE=0.27)in Group I.The ICER of Group II versus Group I was US$0.09 and Group III versus Group I US$0.77,which is very costeffective with a willingness-to-pay threshold of US$2 per wound free day.Within a Monte-Carlo probabilistic sensitivity analysis Group II was cost-effective in 80%of the cases starting at a willingness-to-pay of 80 cent per wound free day.Conclusions:Group II provided the most cost-effective treatment.The non-treatment alternative is not an option in the management of chronic CL ulcers.MWT of Group III should at least be practiced.The costeffectiveness of Group III depends on the number of dressings necessary until complete wound closure.