Endemic Transmission of Visceral Leishmaniasis in Bhutan

Thinley Yangzom JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Israel Cruz JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Caryn Bern JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Daniel Argaw JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Margriet den Boer JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Iván Dario Vélez JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Sujit K. Bhattacharya JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Ricardo Molina JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Jorge Alvar JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu, Bhutan; WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, California; Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland; Programa de Estudio y Control de Enfermedades Tropicales,Universidad de Antioquia, Medellín, Colombia; WHO/South-East Asia Regional Office, New Delhi, India

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Visceral leishmaniasis was first reported in Bhutan in 2006. We conducted studies of the parasite, possible vectors and reservoirs, and leishmanin skin test and risk factor surveys in three villages. Nineteen cases were reported from seven districts. Parasite typing yielded two novel microsatellite sequences, both related to Indian L. donovani. In one case village, 40 (18.5%) of 216 participants had positive leishmanin skin test results, compared with 3 (4.2%) of 72 in the other case village and 0 of 108 in the control village. Positive results were strongly associated with the village and increasing age. None of the tested dogs were infected. Eighteen sand flies were collected, 13 Phlebotomus species and 5 Sergentomyia species; polymerase chain reaction for leishmanial DNA was negative. This assessment suggests that endemic visceral leishmaniasis transmission has occurred in diverse locations in Bhutan. Surveillance, case investigations, and further parasite, vector, and reservoir studies are needed. The potential protective impact of bed nets should be evaluated.

Author Notes

* Address correspondence to Jorge Alvar, Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, 20 Avenue Appia, CH-1211 Geneva 27, Switzerland. E-mail: alvarj@who.int

Authors' addresses: Thinley Yangzom, JDWNR-Hospital and Vector Borne Diseases Control Programme, Timphu Ministry of Health, Timphu, Bhutan, E-mail: thinleyangzom@gmail.com. Israel Cruz and Ricardo Molina, WHO Collaborating Center for Leishmaniasis, Servicio de Parasitología, Centro Nacional de Microbiología, Instituto de Salud Carlos III, Madrid, Spain, E-mails: cruzi@isciii.es and rmolina@isciii.es. Caryn Bern, Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, E-mail: Caryn.Bern2@ucsf.edu. Daniel Argaw, Margriet den Boer, and Jorge Alvar, Department for the Control of Neglected Tropical Diseases (CDS/NTD/IDM), Leishmaniasis Control Program, World Health Organization, Geneva, Switzerland, E-mails: daniel@who.int, margrietdenboer@gmail.com, and alvarj@who.int. Iván Dario Vélez, Programa de Estudio y Control de Enfermedades Tropicales, Universidad de Antioquia, Medellín, Colombia, E-mail: id_velez@yahoo.com. Sujit K. Bhattacharya, WHO/South-East Asia Regional Office, New Delhi, India, E-mail: bhattacharyas@searo.who.int.

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