Entomological efficacy of durable wall lining with reduced wall surface coverage for strengthening visceral leishmaniasis vector control in Bangladesh, India and Nepal.

BACKGROUND: New methods for controlling sand fly are highly desired by the Visceral Leishmaniasis (VL) elimination program of Bangladesh, India and Nepal for its consolidation and maintenance phases. To support the program we investigated safety, efficacy and cost of Durable Wall Lining to control sand fly. METHODS: This multicentre randomized controlled study in Bangladesh, India and Nepal included randomized two intervention clusters and one control cluster. Each cluster had 50 households except full wall surface coverage (DWL-FWSC) cluster in Nepal which had 46 households. Ten of 50 households were randomly selected for entomological activities except India where it was 6 households. Interventions were DWL-FWSC and reduced wall surface coverage (DWL-RWSC) with DWL which covers 1.8 m and 1.5 m height from floor respectively. Efficacy was measured by reduction in sand fly density by intervention and sand fly mortality assessment by the WHO cone bioassay test at 1 month after intervention. Trained field research assistants interviewed household heads for socio-demographic information, knowledge and practice about VL, vector control, and for their experience following the intervention. Cost data was collected using cost data collection tool which was designed for this study. Statistical analysis included difference-in-differences estimate, bivariate analysis, Poisson regression model and incremental cost-efficacy ratio calculation. RESULTS: Mean sand fly density reduction by DWL-FWSC and DWL-RWSC was respectively -4.96 (95 % CI, -4.54, -5.38) and -5.38 (95 % CI, -4.89, -5.88). The sand fly density reduction attributed by both the interventions were statistically significant after adjusting for covariates (IRR = 0.277, p < 0.001 for DWL-RWSC and IRR = 0.371, p < 0.001 for DWL-FWSC). The efficacy of DWL-RWSC and DWL-FWSC on sand fly density reduction was statistically comparable (p = 0.214). The acceptability of both interventions was high. Transient burning sensations, flash on face and itching were most common adverse events and were observed mostly in Indian site. There was no serious adverse event. DWL-RWSC is cost-saving compared to DWL-FWSC. The incremental cost-efficacy ratio was -6.36, where DWL-RWSC dominates DWL-FWSC. CONCLUSIONS: DWL-RWSC intervention is safe, efficacious, cost-saving and cost-effective in reducing indoor sand fly density. The VL elimination program in the Indian sub-continent may consider DWL-RWSC for sand fly control for its consolidation and maintenance phases.

Factors Associated with Mothers Health Seeking Behavior among Newborn Illness.

BACKGROUND: Inappropriate, delayed and poor health seeking behavior increases the high risk of morbidity and mortality among newborns, infants and children. Newborns health status depends upon mothers' health seeking behavior. This study aimed to determine the factors associated with mother's health seeking behavior among newborn illness in Rupandehi District, Nepal. METHODS: Community based cross-sectional study among 372 mothers aged 15-49 years was conducted in Rupandehi district Nepal from May to November 2019. Multistage probability random sampling was used as the sampling technique. Siddharthanagar municipality and Mayadevi rural municipality were selected randomly among 16 local units of Rupandehi district. Two wards from each unit were selected by stratified random sampling using non replacement lottery method. As the sample size was 372, ninety three respondents were selected randomly from each ward. RESULTS: The mean age and standard deviation of mothers was 25.32±4.36 years respectively. Among 372 mothers, 21.24% had poor health seeking behavior. Mothers having more than one child (AOR=0.15; CI: 0.02-0.98), primary and above education (AOR=8.89; CI: 3.15-25.08), visited hospital after 24 hours of newborn illness (AOR=13.59; CI: 1.73-106.7), knew danger signs of newborn (AOR=18.74; CI: 5.65-62.23), practiced exclusive breastfeeding (AOR=8.20; CI: 3.36-20.03) were significantly associated with health seeking behavior. CONCLUSIONS: Almost 22 % of mothers had poor health seeking behavior regarding their newborn illness. Number of living child, education of mother, appropriate time for treatment, receive health services when there is dangers signs of newborn and exclusive breast feeding practice were independent factors associated with mother's health seeking behavior. Hence, decision-makers and local administrator should provide specific intervention to newborns' mother regarding family planning, identifying and preventing danger signs of newborn, importance of appropriate time of treatment and exclusive breastfeeding.

Depressive Symptoms among People Living with HIV Attending ART Centers of Lumbini Province, Nepal: A Cross-Sectional Study.

Background: Depression is a common mental disorder and is a leading cause of disability globally. Depressive symptoms among people living with HIV can be a significant barrier to ART initiation and thus lead to poor ART adherence. Global studies have found the prevalence of depressive symptoms among people living with HIV ranges from 12 to 63%. The real scenario of Nepal still needs to be explored. Thus, this study aimed to identify the prevalence and predictors of depression in individuals with HIV. Methods: An institutional-based cross-sectional study was carried out from August to December 2020 among 406 people living with HIV attending ART centers in Lumbini province. Participants were selected using a systematic random sampling technique and surveyed with a structured questionnaire consisting of sociodemographic variables, HIV AIDS-related variables, and 21 items Beck Depression Inventory tool. The odds ratio was used as the ultimate measure of association, with a 95% confidence interval computed to establish statistical significance. A multivariate regression analysis was carried out to identify the final predictors of depressive symptoms. Results: The study found that 26.8% of the respondents had depressive symptoms. Those who were literate (AOR = 0.24, 95% CI: 0.10-0.61), in the poorest wealth quintile (AOR = 7.28, 95% CI: 2.22-23.87), initiated ART within 12 months (AOR = 1.88, 95% CI: 1.03-3.42), had CD4 cell counts below 200 (AOR = 2.50, 95% CI: 1.54-4.06), and had a time difference of 3 months or less between HIV diagnosis and ART initiation (AOR = 0.50, 95% CI: 0.29-0.86) were independently associated with depressive symptoms. Conclusion: Routine screening for depressive symptoms should be integrated into national HIV prevention and control programs for people living with HIV. An enabling environment should be created to facilitate the rapid enrollment of individuals newly diagnosed with HIV in ART services, thereby reducing the time gap between HIV diagnosis and ART initiation.

Susceptibility of field-collected Phlebotomus argentipes (Diptera: Psychodidae) sand flies from Bangladesh and Nepal to different insecticides.

BACKGROUND: The sand fly Phlebotomus argentipes is the vector for visceral leishmaniasis (VL) in the Indian sub-continent. In Bangladesh since 2012, indoor residual spraying (IRS) was applied in VL endemic areas using deltamethrin. In Nepal, IRS was initiated in 1992 for VL vector control using lambda-cyhalothrin. Irrational use of insecticides may lead to vector resistance but very little information on this subject is available in both countries. The objective of this study was to generate information on the susceptibility of the vector sand fly, P. argentipes to insecticide, in support of the VL elimination initiative on the Indian sub-continent. METHODS: Susceptibility tests were performed using WHO test kits following the standard procedures regarding alpha cypermethrin (0.05%), deltamethrin (0.05%), lambda-cyhalothrin (0.05%), permethrin (0.75%), malathion (5%) and bendiocarb (0.1%) in six upazilas (sub-districts) in Bangladesh. In Nepal, the tests were performed for two insecticides: alpha cypermethrin (0.05%) and deltamethrin (0.05%). Adult P. argentipes sand flies were collected in Bangladesh from six VL endemic upazilas (sub-districts) and in Nepal from three endemic districts using manual aspirators. RESULTS: The results show that VL vectors were highly susceptible to all insecticides at 60 minutes of exposure in both countries. In Bangladesh, corrected mortality was 100% at 15 minutes as well as 30 minutes of exposure. The study sites in Nepal, however, showed some diverse results, with a mortality rate less than 90% for 15 minutes of exposure with alpha cypermethrin and deltamethrin in two districts but was above 95% after 30 minutes of exposure. CONCLUSIONS: These results suggest that the insecticides tested can still be used in the national programmes of Bangladesh and Nepal. However, insecticide rotation should be performed to mitigate the possible development of insecticide resistance. Periodic susceptibility tests should be performed by the countries to get timely alerts regarding insecticide resistance.

Efficacy, Safety and Cost of Insecticide Treated Wall Lining, Insecticide Treated Bed Nets and Indoor Wall Wash with Lime for Visceral Leishmaniasis Vector Control in the Indian Sub-continent: A Multi-country Cluster Randomized Controlled Trial.

BACKGROUND: We investigated the efficacy, safety and cost of lime wash of household walls plus treatment of sand fly breeding places with bleach (i.e. environmental management or EM), insecticide impregnated durable wall lining (DWL), and bed net impregnation with slow release insecticide (ITN) for sand fly control in the Indian sub-continent. METHODS: This multi-country cluster randomized controlled trial had 24 clusters in each three sites with eight clusters per high, medium or low sand fly density stratum. Every cluster included 45-50 households. Five households from each cluster were randomly selected for entomological measurements including sand fly density and mortality at one, three, nine and twelve months post intervention. Household interviews were conducted for socioeconomic information and intervention acceptability assessment. Cost for each intervention was calculated. There was a control group without intervention. FINDINGS: Sand fly mortality [mean and 95%CI] ranged from 84% (81%-87%) at one month to 74% (71%-78%) at 12 months for DWL, 75% (71%-79%) at one month to 49% (43%-55%) at twelve months for ITN, and 44% (34%-53%) at one month to 22% (14%-29%) at twelve months for EM. Adjusted intervention effect on sand fly density measured by incidence rate ratio ranged from 0.28 (0.23-0.34) at one month to 0.62 (0.51-0.75) at 12 months for DWL; 0.72 (0.62-0.85) at one month to 1.02 (0.86-1.22) at 12 months for ITN; and 0.89 (0.76-1.03) at one months to 1.49 (1.26-1.74) at 12 months for EM. Household acceptance of EM was 74% compared to 94% for both DWL and ITN. Operational cost per household in USD was about 5, 8, and 2 for EM, DWL and ITN, respectively. Minimal adverse reactions were reported for EM and ITN while 36% of households with DWL reported transient itching. INTERPRETATION: DWL is the most effective, durable and acceptable control method followed by ITN. The Visceral Leishmaniasis (VL) Elimination Program in the Indian sub-continent should consider DWL and ITN for sand fly control in addition to IRS.