Characterization of visceral leishmaniasis outbreak, Marsabit County, Kenya, 2014

Abstract

Background: Visceral leishmaniasis (VL) is caused by protozoa of the Leishmania donovani complex. Annually, an estimated 500,000 cases of VL are reported globally posing a public health challenge. The objectives of our study were to confirm and determine the magnitude of VL outbreak, characterize the outbreak clinically and epidemiologically and evaluate the county preparedness and response in Marsabit County, Kenya.

Methods: A retrospective review of laboratory registers and patients' clinical notes was done at Marsabit County Hospital. Cases were persons with confirmed VL diagnosis either by microscopy, serology or molecular technique coming from Marsabit County from May to October 2014. Cases were interviewed using structured questionnaire to collect clinical and epidemiologic information. Blood samples were collected from cases for laboratory confirmation.

Results: A total of 136 cases were confirmed of which 77% (105) were male with a median age of 17 (IQR: 22) years and 9.6% (13) case fatality rate. All cases were admitted at Marsabit County Referral Hospital, Kenya. Medical records of 133 cases were retrieved. Of the 133 cases, 102 (77%) presented with fever, 43 (32%) with splenomegaly, 26 (20%) with hepatomegaly and 96 (72%) were managed with Sodium stibogluconate (SSG) monotherapy. Thirty-four cases (26%) received Full haemogram (FHG) test and none had more than one Liver Function Tests (LFTs) in a span of 6 months. Presenting with headache (OR: 4.21, 95% CI: 1.10-16.09) and hepatomegaly (OR: 4.2, 95% CI: 1.30-14.11) were associated with VL death. No VL case management training had been conducted nor VL treatment guidelines distributed among health care workers (HCWs) in the last 1 year.

Conclusions: VL cases were confirmed. Inadequate case monitoring and management was evident. VL case management sensitization training was conducted. The County health department should put in place one health VL surveillance and facilitate periodic case management trainings.

Keywords: Kala-azar; Kenya; Marsabit County; VL case management; Visceral leishmaniasis (VL).

Fig. 1

Flowchart of visceral leishmaniasis cases, Marsabit County Referral Hospital, Kenya, 2014. Four hundred thirty-three suspected visceral leishmaniasis (VL) cases were reported from May 2013 to October 2014. Of the 433 VL cases, 136 cases tested positive with rK39 test kit. However, only 133 VL cases clinical notes were available for review during the study period. On the other hand only 18 confirmed VL cases underwent differential diagnosis to rule out possible co-morbidities and or other causes of febrile illness

Fig. 2

Epicurve of visceral leishmaniasis cases, Marsabit County Referral Hospital, Kenya, 2014 n = 136. The index case was reported in October 2013. On 11th May 2014, the Ministry of Health was notified of 18 laboratory (rK39) confirmed visceral leishmaniasis cases in Marsabit County from 10th to 21st May 2014. This prompted the Ministry of Health to conduct field investigation to confirm the existence of an outbreak and epidemiologically characterize the outbreak in Marsabit County. New cases continued being seen at the various facilities within the county after visceral leishmaniasis sensitization. Between May and September 2014, 118 visceral leishmaniasis cases have been reported in Marsabit County Hospital of which 12 (10%) cases have been lost to death. In the month of October 2014, follow up investigation was conducted to update the line list, clinically characterize the cases, and describe regimens used to manage the cases and their treatment outcome

Fig. 3

Clinical presentation of visceral leishmaniasis cases, Marsabit County Referral Hospital, Kenya, 2014 n = 133. These are the clinical presentation of visceral leishmaniasis cases reported in Marsabit County. All the cases upon diagnosis were hospitalized in Marsabit County Referral Hospital for directly observed treatment

Fig. 4

Biomarkers monitored in visceral leishmaniasis cases management, Marsabit County Referral Hospital, Kenya, 2014 n = 133. Visceral leishmaniasis cases progress on treatment was monitored using various biomarkers namely full haemogram (FHG), kidney function test (creatinine levels) and liver function test. These tests were performed on admission before treatment initiation and during treatment. This shows inconsistent in monitoring of biomarkers

Fig. 5

Biomarkers monitored among diseased visceral leishmaniasis cases, Marsabit County Referral Hospital, Kenya, 2014 n = 13. This is the clinical picture of biomarkers presentation among the diseased visceral leishmaniasis cases. This illustrates that majority of the cases did not receive any form of monitoring