Comprehensive Clinical and Laboratory Assessment of Visceral Leishmaniasis to Develop Clinical Prognostic Tools to Predict Relapse: a Prospective Cohort Study in Ethiopia

Certain patient groups seem to be at higher risk of poor outcomes. Although the average case fatality rate was <10% in Ethiopia , certain subgroups of VL patients are at significantly higher risk of dying, with case fatality rates as high as 39% when patients coinfected with HIV or sepsis. The host's immunocompetence appears to play a critical factor associated with disease development, severity, treatment success and disease relapse. Yet, a substantial group of immunocompetent patients also fail to respond well to treatment, or develop relapse after cure. Relapse is increasingly recognized as an important clinical challenge, with 10-15% estimated to develop relapse in the Ethiopian setting. Understanding which factors determine prognosis among VL patients is key in improving outcomes, as high-risk patients can be identified and receive additional monitoring, care, investigations or preferential treatment with safer or more effective drugs.

One of the strategies to improve patient outcome is identification of factors that determine the prognosis of a patient. These factors can be used in clinical decision tools to provide the most appropriate care for each patient. With the key prognostic factors, patients can be stratified in high and low risk of relapse, treatment failure and mortality and can be treated accordingly, providing intensive monitoring and/or treatment of comorbidities of high-risk patients and a more decentralized follow-up for low-risk patients. This approach would result in more efficient patient care and would reduce the case fatality and morbidity, and improve follow-up and care for those at risk of VL relapse.

No clinical tools for prediction of relapse and treatment failure currently exist. The existing clinical tools for predicting mortality developed so far have a fair accuracy but these tools could further be improved by using prognostic markers both before and during treatment and including more relevant parameters which were previously ignored, such as more laboratory parameters including coagulation profile, blood culture, immunological markers and more relevant clinical parameters such as sepsis and comorbidities.

This study will perform a comprehensive clinical and laboratory characterization of all confirmed VL patients before and during treatment with the main objective to develop a prognostic tool for unfavorable outcome among hospitalized patients. It is planned to develop tools of different complexity, geared towards the capacity of the health facility and also study the added effect of each variable in the tool. The data from this study will address a number of outstanding unanswered questions that could help to improve or standardize VL management.