Kala-azar in Darfur: Evidence for indigenous transmission in Al-Malha Locality, North Darfur, western Sudan

Background: Recent reports showed high numbers of visceral leishmaniasis cases in North Darfur, western Sudan. Due to a lack of previous studies, no information is available on local transmission of the disease in these areas. Therefore, a pilot entomological and epidemiological study was conducted in Al-Malha Locality during the year 2013, to investigate possibility of local transmission and places and times of the year where and when people contract the infection. Methods: Kala-azar incidence data were obtained from records of Ministry of Health, North Darfur; Al-Malha rural hospital; and the Federal Ministry of Health, Division of Communicable and Non-communicable Diseases. Sand flies were collected using sticky paper and rodent burrow traps from five different microhabitats during three different phases of the year. Species identification was undertaken using appropriate taxonomic keys. Data were statistically analyzed to determine the distribution of kala-azar among different age groups and between sexes, and to compare the species richness and distribution of different sandfly species between the different microhabitats. Results: The most affected age groups with kala-azar during the period 2013-2016 were children between one and five years old and those under one year. Females were found to be more affected than males. A total of 918 sand fly specimens were collected using sticky paper and rodent burrow traps from five microhabitats. Identified specimens belong to 13 species; 5 Phlebotomus and 8 Sergentomyia. Phlebotomus orientalis, the principal vector of visceral leishmaniasis (VL) in Sudan and other East African countries, was found for the first time in the area. No other known vector of VL was found in the collection. The highest number of sand flies was recorded during the summer season (63%), with S. antennata (48%) and S. schwetzi (24.1%) being the most abundant species. Among Phlebotomus species, P. orientalis showed relatively high density (8.6%). A dry seasonal water course (called "Khor") seems to be the most preferred habitat for most of the sand fly species since most of the collections (41.2%) were made from this site, followed by the rodent burrows. Conclusions: The presence of P. orientalis and the high prevalence of VL in infants in the Al-Malha area provide the first evidence for local transmission of the parasite causing kala-azar in Darfur. Transmission is probably occurring during summer near the woodland where a high density of the vector was recorded. As a pre-requisite for designing effective control of VL in North Darfur, large scale entomological and epidemiological studies are recommended.