• The epidemic of visceral leishmaniasis in western Upper Nile, southern Sudan: course and impact from 1984 to 1994.

      Seaman, J; Mercer, A; Sondorp, H; MSF (Médecins sans Frontières)-Holland, Amsterdam, The Netherlands. (Oxford University Press, 1996-08)
      BACKGROUND: Although endemic in parts of southern Sudan, visceral leishmaniasis (VL) had not been reported in Western Upper Nile (WUN) until an epidemic was confirmed in 1989. A combination of circumstances created conditions for transmission among a population of mainly Nuer and Dinka people who had no immunity. The civil war which restarted in 1983 has been a major contributing cause and continues to hinder provision of treatment, data collection and control measures. METHODS: Since the first of three clinics to treat VL was established in WUN in 1989, data on the epidemic and mortality have been collected in seven retrospective surveys of villages and among patients. Adults were interviewed about surviving family members and those who had died since the epidemic came. Survey death rates are used here to estimate mortality from VL and 'excess mortality' above expected levels. RESULTS: The surveys found high mortality at all ages and suggest an overall death rate of 38-57% since the epidemic started in 1984, and up to 70% in the most affected areas. Both methods of estimation suggest that around 100,000 deaths, among about 280,000 people in the epidemic area, might be attributable to VL. CONCLUSIONS: This continuing epidemic has shown that VL can cause high mortality in an outbreak with astonishingly high infection rates. Population movement has been a major factor in transmission and poor nutritional status has probably contributed to the risk of clinical infection. Although over 17,000 people have been successfully treated for VL at the clinics in WUN, the disease is likely to become endemic there.
    • Epidemic Visceral Leishmaniasis in Southern Sudan: Treatment of Severely Debilitated Patients Under Wartime Conditions and with Limited Resources.

      Seaman, J; Mercer, A; Sondorp, H; Herwaldt, B L; Médecins sans Frontières-Holland, Amsterdam, The Netherlands. (1996-04-01)
      OBJECTIVES: 1) To determine the proportions of patients with visceral leishmaniasis who had various treatment outcomes when cared for under wartime conditions and with limited resources and 2) to identify patient characteristics associated with the outcomes. DESIGN: Cohort study. SETTING: Médecins sans Frontières-Holland's treatment center in Duar, Western Upper Nile Province, an area in southern Sudan that has been severely affected by Sudan's civil war and a massive epidemic of visceral leishmaniasis. PATIENTS: 3076 consecutive patients who had visceral leishmaniasis, were admitted to the treatment center the first year the center was operational (August 1990 to July 1991), and were treated with the pentavalent antimonial compound sodium stibogluconate. MEASUREMENTS: Patient characteristics on admission and four mutually exclusive treatment outcomes (default during first admission, death during first admission, discharge and readmission for retreatment [relapse], and discharge and no readmission for retreatment [successful treatment]). RESULTS: The patients had a median age of 15 years and were notably anemic (median hemoglobin level, 77g/L) and malnourished (median body mass index of adults [> or = 18 years of age], 15.2 kg/m2); most (91.0%) had been sick less than 5 months. Although patients could not be monitored after treatment to document cure, most (2562 [83.3%]) were successfully treated; 336 (10.9%) died during their first admission, and 79 are known to have relapsed (3.0% of those discharged alive [that is, those whose final treatment outcome was successful treatment or relapse]). In univariable analysis, young and older age (<5 or > or = 45 years of age), long duration of illness (> or = 5 months), markedly low hemoglobin level or body mass index, large spleen, high parasite density, and vomiting at least once during the treatment course were associated with death. In multiple logistic regression analysis of data for a subgroup of 1207 adults (those who did not default or relapse and for whom data were recorded on age, sex, duration of illness, hemoglobin level, body mass index, and spleen size), the approximate risk ratios for death were 2.2 (95% Cl, 1.4 to 3.6) for those with a long duration of illness, 3.6 (Cl, 2.1 to 5.9) for those 45 years of age or older, 4.6 (Cl, 2.2 to 9.4) for those with a hemoglobin level less than 60 g/L, and 12.2 (Cl, 3.2 to 47.2) for those with a body mass index less than 12.2 kg/m2. CONCLUSION; Despite the severe debility of the patients and the exceptionally difficult circumstances under which they were treated, most fared remarkably well.
    • Epidemic visceral leishmaniasis in southern Sudan: treatment of severely debilitated patients under wartime conditions with limited resources

      Mercer, A; Herwaldt, B; Seaman, J; Sondorp, H; Medecins Sans Fronteres - Amsterdam (American College of Physicians, 2008-03-06)