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Background Bangladesh, India, and Nepal aim for the elimination of Visceral Leishmaniasis (VL), a systemic parasitic infectious disease, as a public health problem by 2020. For decades, male patients have comprised the majority of reported VL cases in this region. By comparing this reported VL sex ratio to the one observed in population-based studies conducted in the Indian subcontinent, we tested the working hypothesis that mainly socio-cultural gender differences in healthcare-seeking behavior explain this gender imbalance. Methodology/Principal findings We compared the observed sex ratio of male versus female among all VL cases reported by the health system in Nepal and in the two most endemic states in India with that observed in population-based cohort studies in India and Nepal. Also, we assessed male sex as a potential risk factor for seroprevalence at baseline, seroconversion, and VL incidence in the same population-based data. The male/female ratio among VL cases reported by the health systems was 1.40 (95% CI 1.37–1.43). In the population cohort data, the age- and study site-adjusted male to female risk ratio was 1.27 (95% CI 1.08–1.51). Also, males had a 19% higher chance of being seropositive at baseline in the population surveys (RR 1.19; 95% CI 1.11–1.27), while we observed no significant difference in seroconversion rate between both sexes at the DAT cut-off titer defined as the primary endpoint. Conclusions/Significance Our population-based data show that male sex is a risk factor for VL, and not only as a socio-cultural determinant. Biological sex-related differences likely play an important role in the pathogenesis of this disease., Author summary Visceral Leishmaniasis (VL) is a parasitic disease that is lethal if not treated timely and mainly affects impoverished populations. Bangladesh, India, and Nepal have targeted the elimination of this disease as a public health problem by 2020. The majority of VL patients attending the health services are male, and this is usually attributed to unequal access to health care for men and women in this sociocultural context. We analyzed two large datasets obtained in population surveillance projects, including regular door-to-door screening for VL, in India and Nepal. Thereby we minimized any potential differences in access to health care between both sexes, as every suspect VL case occurring in the community received a full diagnostic work-up, and the research project facilitated transport to treatment centers if needed. By comparing the observed sex ratio in the health services records with those of the population surveillance records, we aimed to reach meaningful conclusions about the pathway through which male gender exerts its leverage for increasing VL risk: socio-cultural determinants blocking women from accessing care (nurture) or biological factors (nature) making men more vulnerable to VL. Because in the population-based age adjusted-data, male VL cases were significantly more frequent than female, our findings strongly suggest that in the Indian subcontinent, biological differences between men and women play a more critical role in the pathogenesis of VL than previously assumed, and the observed male predominance in VL cases in health services cannot be explained by socio-cultural factors only. Moreover, data show that above the age of 14 years, males are seropositive more often than females and are at higher risk to develop VL disease.

Big data computing is a process to handle large volumes of information, which typically crosses different functional units in a distributed system. Like any processes involving distributed systems, it has a concern of reliability problems, such as lossy communication links between functional units and crashed computation nodes inside functional units. The paper focuses on resolving this concern in a particular distributed system scenario where the cross-boundary network connections have a high rate of failure and the internal computation nodes are relatively reliable. We propose a pure client side protocol to achieve exactly once message processing which makes big data computing in the above scenario more reliable. Moreover, we optimize the protocol to be more efficient in resource consumption using methods such as machine learning.

Introduction Post-kala-azar dermal leishmaniasis (PKDL) is a skin manifestation that is a late clinical outcome of visceral leishmaniasis (VL). Its presentation is similar to leprosy, and the differential diagnosis is not always easy. In VL endemic rural areas of Bihar, India, both infectious diseases co-exist. This observational study aimed to determine the prevalence and distribution of both conditions in an area that had until recently been highly endemic for VL. Methods We conducted a door-to-door survey in an area that belongs to the Health and Demographic Surveillance Site (HDSS) of Muzaffarpur, Bihar, India. Within the HDSS we selected the villages that had reported the highest numbers of VL cases in preceding years. All consenting household members were screened for skin conditions, and minor conditions were treated on the spot. Upon completion of screening activities at the level of a few villages, a dermatology clinic (“skin camp”) was conducted to which suspect leprosy and PKDL patients and other patients with skin conditions requiring expert advice were referred. We studied the association between distance from an index case of leprosy and the probability of disease in the neighborhood by fitting a Poisson model. Results We recorded a population of 33,319, out of which 25,686 (77.1%) were clinically screened. Participation in skin camps was excellent. Most common conditions were fungal infections, eczema, and scabies. There were three PKDL patients and 44 active leprosy patients, equivalent to a prevalence rate of leprosy of 17.1 per 10,000. Two out of three PKDL patients had a history of VL. Leprosy patients were widely spread across villages, but within villages, we found strong spatial clustering, with incidence rate ratios of 6.3 (95% C.I. 1.9–21.0) for household members and 3.6 (95% C.I. 1.3–10.2) for neighbors within 25 meters, with those living at more than 100 meters as the reference category. Discussion Even in this previously highly VL endemic area, PKDL is a rare condition. Nevertheless, even a single case can trigger a new VL outbreak. Leprosy is also a rare disease, but current prevalence is over 17 times the elimination threshold proclaimed by WHO. Both diseases require continued surveillance. Active case finding for leprosy can be recommended among household members and close neighbors of leprosy patients but would not be feasible for entire populations. Periodic skin camps may be a feasible and affordable alternative., Author summary We describe a survey for post kala azar dermal leishmaniasis (PKDL) and leprosy carried out in a surveillance site in Bihar, India, that has until recently been highly endemic for visceral leishmaniasis (VL). Both leprosy and VL are subject to elimination initiatives, for both diseases the target prevalence is set at less than 1 case per 10,000 population. PKDL, a dermatological sequel of VL, is important because it can act as a reservoir for VL in inter-epidemic periods. So far very little is known about prevalence of PKDL in India and the frequency of PKDL among former VL patients. Our survey was population based, allowing us to assess PKDL prevalence not only among former VL patients but also among those not known to have suffered from VL in the past. We conducted door-to-door screening and suspect cases of leprosy and PKDL were referred to a ‘skin camp’, an outreach consultation for skin conditions at village level. We recorded geographic coordinates of each household screened, thus we were able to explore spatial associations. Participation in the survey and in the skin camps was very good. On a population of over 25,000 screened we found only three PKDL cases but 44 active leprosy patients. For leprosy this equates to a prevalence of 17.1 per 10,000, way above the elimination threshold. Of our three PKDL cases, two had occurred in known former VL cases, one was in a person who reported never to have suffered from VL. For leprosy we found strong spatial associations with a six-fold increase in risk for household members but also a three to four-fold increase for neighbors at less than 25 meters. The three PKDL cases were from three different villages, their numbers were too low for any meaningful spatial analysis. We conclude that leprosy is still a major problem in the area that requires more efforts. Active screening of household contacts is rational but should be extended to nearby neighbors. Though relatively efficient, this approach would miss out on the bulk of leprosy patients. PKDL is a rare condition but needs to be kept under surveillance. Skin camps can provide a feasible alternative to door-to-door screening, allowing to target both conditions simultaneously.

Background Despite the overall decrease in visceral leishmaniasis (VL) incidence on the Indian subcontinent, there remain spatiotemporal clusters or ‘hotspots’ of new cases. The characteristics of these hotspots, underlying transmission dynamics, and their importance for shaping control strategies are not yet fully understood and are investigated in this study for a VL endemic area of ~100,000 inhabitants in Bihar, India between 2007–2015. Methodology/Principal findings VL incidence (cases/10,000/year) dropped from 12.3 in 2007 to 0.9 in 2015, which is just below the World Health Organizations’ threshold for elimination as a public health problem. Clustering of VL was assessed between subvillages (hamlets), using multiple geospatial and (spatio)temporal autocorrelation and hotspot analyses. One to three hotspots were identified each year, often persisting for 1–5 successive years with a modal radius of ~500m. The relative risk of having VL was 5–86 times higher for inhabitants of hotspots, compared to those living outside hotspots. Hotspots harbour significantly more households from the two lowest asset quintiles (as proxy for socio-economic status). Overall, children and young adelescents (5–14 years) have the highest risk for VL, but within hotspots and at the start of outbreaks, older age groups (35+ years) show a comparable high risk. Conclusions/Significance This study demonstrates significant spatiotemporal heterogeneity in VL incidence at subdistrict level. The association between poverty and hotspots confirms that VL is a disease of ‘the poorest of the poor’ and age patterns suggest a potential role of waning immunity as underlying driver of hotspots. The recommended insecticide spraying radius of 500m around detected VL cases corresponds to the modal hotspot radius found in this study. Additional data on immunity and asymptomatic infection, and the development of spatiotemporally explicit transmission models that simulate hotspot dynamics and predict the impact of interventions at the smaller geographical scale will be crucial tools in sustaining elimination., Author summary Visceral leishmaniasis (VL) is the deadliest vector-borne parasitic disease after malaria worldwide and is one of the neglected tropical diseases targeted for elimination and control by the World Health Organization. Despite the overall decrease in VL incidence in Bihar, India, a region previously highly endemic for VL, there remain hotspots of cases for reasons that are poorly understood. This study demonstrates clear spatiotemporal heterogeneity of VL in an area of ~100,000 population in Muzaffarpur, Bihar, India between 2007–2015. Identified hotspots occurred almost always in the poorest communities, confirming that VL is a disease of ‘the poorest of the poor’. Our finding that older age groups (35+ years) are at a comparable high risk for VL within hotspots, similar to the 5–14 years highest risk group, but not outside hotspots, suggests a potential role of waning immunity as driver of hotspots. To further understand the drivers and transmission dynamics underlying VL hotspots, and ultimately inform policy, additional longitudinal data are needed to understand more about the role of asymptomatic infections, human movement, sand fly distribution and immunity. Including hotspots in mathematical transmission models is relevant for predicting the feasibility of reaching and sustaining VL elimination at a smaller geographical scale.

Objective To assess the rate of default from treatment in the Visceral Leishmaniasis (VL) Elimination Program and to identify risk factors and its underlying causes. Methods Case control study conducted between December 2009 and June 2012 in three Primary Health Centres (PHC) of Muzaffarpur District, India. Patients who defaulted from treatment from the PHCs were considered as “cases”, and those who completed their treatment as “controls”. Two controls were included in the study for each case. Respondents’ opinion and satisfaction with the services provided at the PHCs was also elicited. Logistic regression was performed to assess the contribution of socio-demographic variables on patient status, and a discriminant analysis was used (after decomposing the original data) to identify factors that can predict the patient status as defaulter or not, based on factor scores of the components as predictor variables. Results During the study period 16.3% (89/544) of patients defaulted. 87 cases and 188 controls were interviewed through a semi-structured questionnaire. Women had a higher risk for default (OR 1.8, 95% CI 1.1-3.0). Treatment received was miltefosine in 55.6% and sodium stibogluconate (SSG) in 44.4%. Most (86%) defaulters completed their treatment at other health care facilities; 70% of them preferred non-governmental institutions. Most-cited reasons for default were seeking a second opinion for VL treatment and preferring to be treated in specialized VL centers. Discriminant analysis showed only one significant predictor: dissatisfaction with the medical care received in PHCs. Conclusion Efforts are needed to enhance the quality of VL care at PHC level, which will be beneficial in increasing treatment completion rates. This article is protected by copyright. All rights reserved.

Objective To evaluate a new tool for the monitoring of Visceral Leishmaniasis (VL) treatment outcomes in primary healthcare (PHC) settings, adapted from the standardised Retrospective Quarterly Cohort Monitoring done in tuberculosis control. Methods We developed standard case definitions for early and late VL treatment outcomes, a single register allowing for one-line entry per patient as registration tool, and quarterly reporting formats for the clinical outcomes. We pilot-tested these tools in three Indian Primary Health Centres and two Nepalese district hospitals, as well as in a charity VL treatment centre and a university hospital. Results Data collection for early treatment outcome was easily implemented but information on late treatment outcome was hard to obtain. Effectiveness of Miltefosine under routine care conditions was about 87% at end of treatment, and 76% at 6 months post-treatment related to the high number of patients lost to follow up at the latter end point. Conclusion A retrospective cohort monitoring methodology is conceptually a good framework for monitoring clinical outcomes for chronic conditions as VL. The monitoring of early outcomes of VL treatment is perfectly feasible in Primary Care settings. The completeness of information on late outcomes can be improved by a number of strategies that remain to be field tested. Generally, clinical outcome monitoring should be strengthened in the VL control programmes. Objectif Evaluer un nouvel outil pour le suivi des resultats du traitement de la LV dans les etablissements de soins primaires, adapte a partir du Suivi de Cohorte Retrospective Trimestrielle standardise, utilise dans la lutte antituberculeuse. Methodes Nous avons elabore des definitions de cas standard pour les resultats precoces ou tardifs du traitement de la LV, un registre unique permettant une ligne de saisie par patient comme outil d'enregistrement et des formats de reports trimestriels pour les resultats cliniques. Nous avons mis a l'essai ces outils dans trois centres de sante primaires en Inde, dans deux hopitaux de district Nepalais, ainsi que dans un centre du traitement de charite de la LV et un hopital universitaire. Resultats La collecte des donnees pour les resultats precoces du traitement a ete facilement mise en œuvre mais l'information sur les resultats tardifs du traitement etait difficile a obtenir. L'efficacite de la miltefosine dans des conditions de soins de routine etait d'environ 87% a la fin du traitement et 76% a 6 mois post-traitement, liee au nombre eleve de patients perdus au suivi lors du dernier point de suivi. Conclusion Une methodologie de suivi de cohorte retrospective est conceptuellement un bon cadre pour le suivi des resultats cliniques des maladies chroniques comme la LV. Le suivi des resultats precoces du traitement de la LV est parfaitement realisable dans les milieux de soins primaires. L'exhaustivite de l'information sur les resultats tardifs peut etre amelioree par un certain nombre de strategies qui sont a tester sur le terrain. En general le suivi des resultats cliniques doit etre renforce dans les programmes de lutte contre la LV. Objetivo Evaluar una nueva herramienta para la monitorizacion de los resultados del tratamiento de la Leishmaniasis Visceral (LV) en centros de atencion primaria, adaptado de la Monitorizacion Trimestral Retrospectiva de Cohortes realizada para el control de la tuberculosis. Metodos Hemos desarrollado definiciones de caso estandares para los resultados tempranos y tardios del tratamiento de la LV, un registro unico que permite entrar una linea por paciente como herramienta de registro, y formatos de reporte trimestral para los resultados clinicos. Hicimos una prueba piloto de estas herramientas en tres Centros de Atencion Primaria de la India y dos Hospitales Distritales de Nepal, al igual que en un centro de tratamiento caritativo y un Hospital Universitario. Resultados La recoleccion de datos de resultados tempranos del tratamiento fue implementado facilmente, pero la informacion sobre los resultados tardios del tratamiento fue dificil de obtener. La efectividad de Miltefosina bajo condiciones de cuidados rutinarios era de aproximadamente un 87% al final del tratamiento, y del 76% a los 6 meses de terminar el tratamiento, relacionado con el alto numero de pacientes perdidos durante el seguimiento en esta ultima etapa. Conclusion Una metodologia de monitorizacion retrospectiva de cohortes es conceptualmente un buen marco para la monitorizacion de resultados clinicos para condiciones cronicas tales como la LV. La monitorizacion de resultados tempranos del tratamiento de la LV es perfectamente factible en centros de atencion primaria. Es posible mejorar el nivel de integridad de la informacion sobre los resultados tardios mediante un numero de estrategias que aun han de probarse en el terreno. En general deberia reforzarse la monitorizacion de los resultados clinicos en programas de control de la LV.

Summary objective In 2009, a random survey was conducted in Muzaffarpur district to document the clinical outcomes of visceral leishmaniasis patients (VL) treated by the public health care system in 2008, to assess the effectiveness of miltefosine against VL. We analysed the operational feasibility and cost of such periodic random surveys as compared with health facility-based routine monitoring. methods A random sample of 150 patients was drawn from registers kept at Primary Health Care centres. Patient records were examined, and the patients were located at their residence. Patients and physicians were interviewed with the help of two specifically designed questionnaires by a team of one supervisor, one physician and one field worker. Costs incurred during this survey were properly documented, and vehicle log books maintained for analysis. results Hundred and 39 (76.7%) of the patients could be located. Eleven patients were not traceable. Per patient, follow-up cost was US$ 15.51 and on average 2.27 patients could be visited per team-day. Human resource involvement constituted 75% of the total cost whereas involvement of physician costs 51% of the total cost. conclusion A random survey to document clinical outcomes is costly and labour intensive but gives probably the most accurate information on drug effectiveness. A health service-based retrospective cohort reporting system modelled on the monitoring system developed by tuberculosis programmes could be a better alternative. Involvement of community health workers in such monitoring would offer the additional advantage of treatment supervision and support.

Summary Objective In 2005 a visceral leishmaniasis (VL) elimination initiative was launched on the Indian subcontinent, with early diagnosis based on a rapid diagnostic test and treatment with the oral drug miltefosine as its main strategy. Several recent studies have signaled underreporting of VL cases in the region. Information on treatment outcomes is scanty. Our aim was to document VL case management by the primary health care services in India. Methods We took a random sample of all VL patients registered in rural primary health care (PHC) facilities of Muzaffarpur district, Bihar, India during 2008. Patients were traced at home for an interview and their records were reviewed. We recorded patient and doctor delay, treatment regimens, treatment outcomes and costs incurred by patients. Results We could review records of all 150 patients sampled and interview 139 patients or their guardian. Most patients (81%) had first presented to unqualified practitioners; median delay before reaching the appropriate primary healthcare facility was 40 days (IQR 31–59 days). Existing networks of village health workers were under-used. 48% of VL patients were treated with antimonials; 40% of those needed a second treatment course. Median direct expenditure by patients was 4000 rupees per episode (IQR 2695–5563 rupees), equivalent to almost 2 months of household income. Conclusion In 2008 still critical flaws remained in VL case management in the primary health care services in Bihar: obsolete use of antimonials with high failure rates and long patient delay. To meet the target of the VL elimination, more active case detection strategies are needed, and village health worker networks could be more involved. Costs to patients remain an obstacle to early case finding.

P>Objective Studies investigating risk factors for visceral leishmaniasis (VL) on the Indian Subcontinent have shown contradictory results related to the role of domestic animals. In some studies having animals in or around the house was a risk factor, in others it was protective. We investigated the specific hypothesis that keeping domestic animals inside the house at night is a risk factor for VL. Methods Individually matched case-control study. All patients with VL diagnosed in the study area in Bihar, India between March 1st, 2007 and December 1st, 2008 were eligible. For each case, we selected two random controls, with no history of previous VL; matched on sex, age group and neighbourhood. Patients and controls were subjected to a structured interview on the main exposure of interest and potential confounders; a conditional logistic regression model was used to analyse the data. Results We enrolled 141 patients and 282 controls. We found no significant associations between VL and keeping domestic animals inside the house (OR of 0.88 for bovines and 1.00 for 'any animal') or ownership of domestic animals (OR of 0.97 for bovines and 1.02 for 'any animal'). VL was associated with housing conditions. Living in a thatched house (OR 2.60, 95% CI 1.50-4.48) or in a house with damp floors (OR 2.60, 95% CI 1.25-5.41) were risk factors, independently from socio economic status. Conclusion Keeping animals inside the house is not a risk factor for VL in Bihar, India. Improving housing conditions for the poor has the potential to reduce VL incidence.

Sexuality is an integral part of the human experience--a complex phenomenon with physical emotional intellectual social and spiritual dimensions. While deeply personal sexuality occurs within specific social economic cultural political and religious contexts. Those contexts in turn profoundly shape the possibilities and limitations of an individuals sexual experience and with that many other aspects of the individuals life. At the same time evolving expressions of sexuality by individuals and groups influence culture politics and religion. Sexuality is both central to some of the greatest problems of our time and at the core of human well-being for people of all ages. A cultures treatment of sexuality can influence whether an individual is safe or unsafe; ill or healthy; rich or poor; educated or not; employed or enslaved; treated with justice or with contempt. Sexuality plays a crucial role in determining womens social status which in turn affects the number of women children and families living in poverty. It influences a womans ability to protect herself against violence disease and unwanted pregnancy; to survive pregnancy and childbirth; and to manage her fertility. Sex can be an arena for contested power relations and result in debilitating discrimination abuse and violence based on gender and sexual orientation. Sex can also be a means for transmitting devastating diseases as evidenced by extraordinary rates of morbidity and mortality from sexually transmitted infections (STIs) and HIV/AIDS. Young people today as in past generations are particularly vulnerable to the risks of unintended pregnancy unsafe abortion maternal mortality violence and sexual exploitation. (excerpt)

To identify factors associated with incidence of visceral leishmaniasis (VL), we surveyed 13,416 households in Bihar State, India. VL was associated with socioeconomic status, type of housing, and belonging to the Musahar caste. Annual coverage of indoor residual insecticide spraying was 12%. Increasing such spraying can greatly contribute to VL control.

Background Visceral Leishmaniasis (VL) is a vector-borne infectious disease, caused by the protozoan Leishmania donovani, which is transmitted by phlebotomine sand flies. In an earlier study in Bihar, India, we found an association between incidence of VL and housing conditions. In the current study we investigated the influence of housing structure and conditions in and around the house on the indoor abundance of Phlebotomus argentipes, the vector of VL in this area. Methods In each of 50 study villages in Muzaffarpur district, we randomly selected 10 houses. Light traps were installed in each house for one night during three annual peaks of sand fly density over two successive years. Sand flies captured were morphologically identified and segregated by species, sex and feeding status. Data on housing conditions and socio-economic status were also collected. We fitted a linear mixed-effects regression model with log-transformed P. argentipes counts as outcome variable and village as random effect. Results P. argentipes was found in all but four of the 500 households. There was considerable variability between the years and the seasons. On bivariate analysis, housing structure, dampness of the floor, keeping animals inside, presence of animal dung around the house, and socio-economic status were all significantly associated with sand fly density. Highest sand fly densities were observed in thatched houses. In the multivariate model only the housing structure and socio-economic status remained significant. Conclusions Better housing conditions are associated with lower sand fly densities, independent of other socio-economic conditions. However, in this area in Bihar even in the better-built houses sand flies are present.

Introduction Asymptomatic persons infected with the parasites causing visceral leishmaniasis (VL) usually outnumber clinically apparent cases by a ratio of 4–10 to 1. We assessed the risk of progression from infection to disease as a function of DAT and rK39 serological titers. Methods We used available data on four cohorts from villages in India and Nepal that are highly endemic for Leishmania donovani. In each cohort two serosurveys had been conducted. Based on results of initial surveys, subjects were classified as seronegative, moderately seropositive or strongly seropositive using both DAT and rK39. Based on the combination of first and second survey results we identified seroconvertors for both markers. Seroconvertors were subdivided in high and low titer convertors. Subjects were followed up for at least one year following the second survey. Incident VL cases were recorded and verified. Results We assessed a total of 32,529 enrolled subjects, for a total follow-up time of 72,169 person years. Altogether 235 incident VL cases were documented. The probability of progression to disease was strongly associated with initial serostatus and with seroconversion; this was particularly the case for those with high titers and most prominently among seroconvertors. For high titer DAT convertors the hazard ratio reached as high as 97.4 when compared to non-convertors. The strengths of the associations varied between cohorts and between markers but similar trends were observed between the four cohorts and the two markers. Discussion There is a strongly increased risk of progressing to disease among DAT and/or rK39 seropositives with high titers. The options for prophylactic treatment for this group merit further investigation, as it could be of clinical benefit if it prevents progression to disease. Prophylactic treatment might also have a public health benefit if it can be corroborated that these asymptomatically infected individuals are infectious for sand flies., Author Summary To study the association between positive serology for VL among asymptomatic persons and progression to disease, we analyzed combined data from two different cohort studies in which over 32,000 subjects were enrolled. All subjects were screened for presence of antibodies to L. donovani with DAT and rK39. After an interval of 6–12 months, a second round of surveys was conducted in which seroconvertors were identified, i.e. persons seronegative at baseline that had become seropositive in the interval between surveys. We subdivided the subjects according to serologic titers scored as negative, moderately positive or strongly positive. During follow-up we observed that the risk of progressing to disease was not very much different between seronegative and moderately seropositive subjects, but strongly increased for high titer seropositive subjects. This pattern was true for the initial serology, and even more pronounced among seroconvertors. Given the strongly increased risk of progression to disease among those with high DAT or rK39 titers, these data raise the question whether prophylactic treatment would be beneficial. The case for prophylactic treatment would be further strengthened if it could be shown that asymptomatically infected individuals are infectious to sand flies.

Objectives To determine whether medical staff at PHC level would have the time to take up additional activities such as 1-day fever camps for active VL case detection. Methods This article assessed the workload of health staff of different professional categories working at health facilities in Bangladesh, India and Nepal. Data were collected from different sites in high endemic VL areas. The study population was the health staff of government health facilities at all levels. Workload indicators of staffing need (WISN) software were adopted to carry out the analysis of staff workload and their availability in the selected health facility. The WISN difference and WISN ratio for a particular health facility were calculated from actual staffing available and calculated staffing requirement. Results The results showed a mixed picture of the availability of health workers. In most settings of Bangladesh and India, physicians with or without laboratory technicians would have time for active case detection. In Nepal, this would be performed by trained nurses and paramedical personnel. Conclusion If all vacant posts were filled, active case detection could be performed more easily. The elimination programme can be scaled up with the current staffing levels in the endemic areas with some short training if and when necessary. Objectifs Determiner si le personnel medical au niveau des SSP aurait le temps d'entreprendre des activites supplementaires telles que des camps d'une journee de mesure de la fievre pour le depistage actif des cas de LV. Methodes Cette etude a evalue la charge de travail du personnel de sante de differentes categories professionnelles travaillant dans les etablissements de sante au Bangladesh, en Inde et au Nepal. Les donnees ont ete recueillies aupres de differents sites dans les zones d'endemie elevee pour la LV. La population de l’etude etait le personnel de sante des centres de sante publics a tous les niveaux. Un logiciel pour les indicateurs de charge de travail en besoins de personnel (CTBP) a ete adopte pour mener a bien l'analyse de la charge de travail du personnel et leur disponibilite dans l’etablissement de sante choisi. La difference de CTBP et le rapport de CTBP pour un etablissement de sante particulier ont ete calcules a partir de l'effectif de personnel disponible et le besoin en personnel calcule. Resultats Les resultats ont montre une image contrastee de la disponibilite des agents de sante. Dans la plupart des sites au Bangladesh et en Inde, les medecins avec ou sans techniciens de laboratoire auraient le temps pour effectuer la detection active des cas. Au Nepal, cela serait realise par des infirmier(e)s qualifie(e)s et par du personnel paramedical. Conclusion Si tous les postes vacants etaient pourvus, le depistage actif pourrait etre realise plus facilement. Le programme d’elimination peut etre deploye avec les taux actuels de personnel dans les zones endemiques moyennant une certaine courte formation lorsque et si cela est necessaire. Objetivos Determinar si el equipo medico de atencion primaria tendria el tiempo de asumir actividades adicionales tales como campanas de deteccion de fiebre de un dia como parte de la deteccion activa de casos de LV. Metodos En este articulo se evalua la carga de trabajo de los trabajadores sanitarios con diferentes categorias trabajando en los centros sanitarios en Bangladesh, India y Nepal. Se recolectaron datos de diferentes lugares en areas con una altamente endemicas para LV. La poblacion de estudio era el personal sanitarios de centros gubernamentales de todos los niveles. Se adaptaron los indicadores de carga de trabajo del software WISN (Workload Indicators of Staffing Needs) para llevar a cabo el analisis de la carga de trabajo y la disponibilidad del personal sanitario en el centro elegido. Se calculo la diferencia en WISN y el ratio de WISN para un centro sanitario en particular segun el personal sanitario realmente disponible y el personal requerido segun calculos. Resultados Los resultados mostraban un panorama mixto de la disponibilidad de los trabajadores sanitarios. En la mayoria de los emplazamientos de Bangladesh y los medicos hindues con y sin tecnicos de laboratorio tenian tiempo para la deteccion activa de casos. En Nepal lo llevarian a cabo enfermeras entrenadas y personal paramedico. Conclusion Si se ocupasen todos los puestos vacantes, seria mas facil llevar a cabo la deteccion activa de casos. El programa de eliminacion puede llevarse a escala con los niveles actuales de recursos humanos en areas endemicas con poco entrenamiento si fuese necesario.

The eleventh author's name was incorrectly reported. The correct name is: Mary Edyth Wilson.

Background Active case detection (ACD) significantly contributes to early detection and treatment of visceral leishmaniasis (VL) and post kala-azar dermal leishmaniasis (PKDL) cases and is cost effective. This paper evaluates the performance and feasibility of adapting ACD strategies into national programs for VL elimination in Bangladesh, India and Nepal. Methods The camp search and index case search strategies were piloted in 2010-11 by national programs in high and moderate endemic districts / sub-districts respectively. Researchers independently assessed the performance and feasibility of these strategies through direct observation of activities and review of records. Program costs were estimated using an ingredients costing method. Results Altogether 48 camps (Bangladesh-27, India-19, Nepal-2) and 81 index case searches (India-36, Nepal-45) were conducted by the health services across 50 health center areas (Bangladesh-4 Upazillas, India-9 PHCs, Nepal-37 VDCs). The mean number of new case detected per camp was 1.3 and it varied from 0.32 in India to 2.0 in Bangladesh. The cost (excluding training costs) of detecting one new VL case per camp varied from USD 22 in Bangladesh, USD 199 in Nepal to USD 320 in India. The camp search strategy detected a substantive number of new PKDL cases. The major challenges faced by the programs were inadequate preparation, time and resources spent on promoting camp awareness through IEC activities in the community. Incorrectly diagnosed splenic enlargement at camps probably due to poor clinical examination skills resulted in a high proportion of patients being subjected to rK39 testing. Conclusion National programs can adapt ACD strategies for detection of new VL/PKDL cases. However adequate time and resources are required for training, planning and strengthening referral services to overcome challenges faced by the programs in conducting ACD.

Background. National VL Elimination Programs in India, Nepal and Bangladesh face challenges as home-based Miltefosine treatment is introduced.Objectives. To study constraints of VL management in endemic districts within context of national elimination programs before and after intervention.Methods. Ninety-two and 41 newly diagnosed VL patients were interviewed for clinical and provider experience in 2009 before and in 2010 after intervention (district training and improved supply of diagnostics and drugs). Providers were assessed for adherence to treatment guidelines. Facilities and doctor-patient consultations were observed to assess quality of care.Results. Miltefosine use increased from 33% to 59% except in Nepal where amphotericin was better available. Incorrect dosage and treatment interruptions were rare. Advice on potential side effects was uncommon but improved significantly in 2010. Physicians did not rule out pregnancy prior to starting Miltefosine. Fever measurement or spleen palpation was infrequently done in Bangladesh but improved after intervention (from 23% to 47%). Physician awareness of renal or liver toxicity as Miltefosine side effects was lower in Bangladesh. Bio-chemical monitoring was uncommon. Patient satisfaction with services remained low for ease of access or time provider spent with patient. Health facilities were better stocked with rK39 kits and Miltefosine in 2010.

In 2009, a random survey was conducted in Muzaffarpur district to document the clinical outcomes of visceral leishmaniasis patients (VL) treated by the public health care system in 2008, to assess the effectiveness of miltefosine against VL. We analysed the operational feasibility and cost of such periodic random surveys as compared with health facility-based routine monitoring.A random sample of 150 patients was drawn from registers kept at Primary Health Care centres. Patient records were examined, and the patients were located at their residence. Patients and physicians were interviewed with the help of two specifically designed questionnaires by a team of one supervisor, one physician and one field worker. Costs incurred during this survey were properly documented, and vehicle log books maintained for analysis.Hundred and 39 (76.7%) of the patients could be located. Eleven patients were not traceable. Per patient, follow-up cost was US$ 15.51 and on average 2.27 patients could be visited per team-day. Human resource involvement constituted 75% of the total cost whereas involvement of physician costs 51% of the total cost.A random survey to document clinical outcomes is costly and labour intensive but gives probably the most accurate information on drug effectiveness. A health service-based retrospective cohort reporting system modelled on the monitoring system developed by tuberculosis programmes could be a better alternative. Involvement of community health workers in such monitoring would offer the additional advantage of treatment supervision and support.

Background Visceral Leishmaniasis (VL) is a vector-borne disease transmitted by Phlebotomus argentipes. To understand the VL seasonality, annual and monthly variations of VL incidence and its relationship to meteorological variables, the numbers of VL cases reported in Muzaffarpur district, Bihar, India from 1990 to 2008 were studied. Methods Annual VL incidence per 10,000 and the total number of annual VL cases reported at block Community Health Centres (CHC), Public Hospitals or Non-Governmental Organisations (NGO) and the number of VL cases per month from 2000 to 2008 as well as the monthly average of cases for 2000–08, 2000–04 and 2005–08 periods along with the monthly averages of temperature, rainfall and relative humidity were plotted. VL Standardised Incidence Ratios per block were computed for the periods of 1990–1993, 1994–1998, 1999–2004 and 2005–2008 and month wise from 2002 to 2008. A negative binomial regression model was used to evaluate the association between meteorological variables and the number of VL cases per month from 2000 to 2008. Results A total of 68,358 VL cases were reported in Muzaffarpur district from 1990 to 2008, ranging from 1,2481 in 1992 to 1,161 in 2001. The blocks with the highest number of cases shifted from East (1990–98) to West (1999–2008). Monthly averages of cases ranged from 149 to 309, highest peak in March–April and another one in July. Monthly VL incidence was associated positively to rainfall and negatively to relative humidity and the numbers of VL cases in the previous month. Interpretation The number of cases reported to the public health sector allowed the describing of the spatial distribution and temporal variations in the Muzaffarpur from 1990 to 2008. However, to assess the actual VL burden, as well as the efficacy of the control measures applied in the district, reporting from private practices and NGOs should be encouraged.

In this paper state of the art of the fuzzy logic based visual object recognition systems is discussed. One of the major objectives of the computer vision is to recognize various objects from images. Application of fuzzy logic facilitates the smooth translation of ambiguous image information into natural language which can be processed by fuzzy set theory. Various methods of fuzzy object recognition are presented. Some rule based techniques are mentioned to show the applicability of object recognition in consumer electronics. A brief summary of fusion with neural networks and genetic algorithms is given. The problem of object recognition can be viewed as a part of a computer vision system. In which the image patterns will be converted into a feature space and in turn this will be transformed into the classification or decision space comprising the prototypical definition of the various objects to be identified. Context finding and image understanding is the following stage. The object recognition problem can be divided into two basic blocks: low level and high level vision. The low level vision task can be seen as to isolate objects and regions from the given image and similarly extracting other characteristic features from an image. The high level vision means the interpretation of these objects or features in the frame of a reference scene. In other words the task of object recognition is to find and label various parts of the two dimensional image of the scene. To accomplish the object recognition task one must first establish the models or a linguistic description of the object which has to be recognized. This implies that the object recognition requires an apriori knowledge of the object description. Typically these descriptions include shape, texture, color, size and context knowledge of the occurrence of such objects in a scene. A digital image may contain several distinct kinds of information. These kinds of information can be interpreted in entirely distinct ways. The most elementary information comes from the measured pixel values without its meaning. Semantic information in contrast deals with the meaning of certain pixel values. This distinction is very much related to the spatial relationships "local" and "global". A combination of these knowledge factors facilitates the process of object recognition. For this reason context plays an essential role in the object recognition. Sometimes ill-posed questions and insufficient information regarding context may lead us to ambiguous situations. In this type of situations fuzzy logic[53] can help to translate these uncertainties into linguistic information or knowledge base. This information in turn can be processed with fuzzy set theoretic techniques (fuzzy rule based inferencing, minimization of fuzzy object functional, fuzzy relation, and graphs, fuzzy tree automata, fuzzy statistics etc.). The conventional approaches to object recognition[35] rely entirely on local operators that analyze the measured light intensities of the image. The real objects are defined by their geometric and semantic characteristics as well as by their statistical properties. Thus the conventional methods may fail to recognize the objects properly. For example, depending on the arbitrary threshold settings, edge detector methods will either produce so many edges that the relevant information will be very difficult to be interpreted or sometimes extract very few from the all relevant boundaries. Similarly the region segmentation algorithms will either undersegment or oversegment. Undersegmenting implies combining two or more meaningful objects into one and oversegmenting implies breaking the coherent objects into unrecognizable pieces of pattern. This shows the lack of geometric and semantic knowledge in the interpretation strategy. On the whole we can say that in the low level vision there can be certain imprecision in computation and vagueness in the class definition. Similarly in the high level vision there may occur ambiguities in the interpretation of a scene. We will present a summary of the research being done in both fields. In the low level vision ambiguities can be eradicated with the help of fuzzy object functional methods [2][3] which try to minimize the within group sum of squared errors. This has been successfully used for detecting edges from the images[51][21][6]. There are other techniques used in the low level vision, histogram

Background Asymptomatic Leishmania donovani infections outnumber clinical presentations, however the predictors for development of active disease are not well known. We aimed to identify serological, immunological and genetic markers for progression from L. donovani infection to clinical Visceral Leishmaniasis (VL). Methods We enrolled all residents >2 years of age in 27 VL endemic villages in Bihar (India). Blood samples collected on filter paper on two occasions 6–12 months apart, were tested for antibodies against L. donovani with rK39-ELISA and DAT. Sero converters, (negative for both tests in the first round but positive on either of the two during the second round) and controls (negative on both tests on both occasions) were followed for three years. At the start of follow-up venous blood was collected for the following tests: DAT, rK39- ELISA, Quantiferon assay, SNP/HLA genotyping and L.donovani specific quantitative PCR. Results Among 1,606 subjects enrolled,17 (8/476 seroconverters and 9/1,130 controls) developed VL (OR 3.1; 95% CI 1.1–8.3). High DAT and rK39 ELISA antibody titers as well as positive qPCR were strongly and significantly associated with progression from seroconversion to VL with odds ratios of 19.1, 30.3 and 20.9 respectively. Most VL cases arose early (median 5 months) during follow-up. Conclusion We confirmed the strong association between high DAT and/or rK39 titers and progression to disease among asymptomatic subjects and identified qPCR as an additional predictor. Low predictive values do not warrant prophylactic treatment but as most progressed to VL early during follow-up, careful oberservation of these subjects for at least 6 months is indicated., Author summary Visceral Leishmaniasis (VL) or Kala-azar is a vector born disease, deadly if not treated. On the Indian subcontinent VL is caused by the protozoan parasite Leismania donovani, transmitted by an insect vector, sand fly of the Phlebotomus argentipes species, and considered an anthroponotic disease. Not every L.donovani infection progresses to clinical VL disease, and only a small minority of those infected will progress to disease and therefore not all those infected need to be treated. Importantly, diagnostic and treatment options have considerably improved over the past 10 years. There are several markers of infection in VL: antibody-tests as DAT, rK39-ELISA, markers of cellular immunity as the Quantiferon assay, and molecular markers as quantitative PCR. Also SNP/HLA genotyping has been shown to be associated with VL. However the factors that determine who will and who will not progress from infection to disease remain largely unknown. To try and elucidate the factors associated with progression to disease we identified a cohort of healthy recently infected persons in a highly VL endemic area of Bihar, India, and followed them up for three years. We also included in the follow-up an age and village matched group of initially seronegative controls. SNP/HLA genotyping was performed on all subjects to identify genetic predisposition. The only factors strongly and significantly associated with progression to disease turned out to be high DAT and/or rK39 titers and positive qPCR. The proportion progressing to disease was too low to merit preventive treatment. As most disease tends to occur early during follow-up, it is recommendable to closely follow up those with high antibody titers or testing qPCR positive over at least a 6-months period.