Epidemic visceral leishmaniasis in southern Sudan: Treatment of severely debilitated patients under wartime conditions and with limited resources

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: Medicins sans Frontieres-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, 77 g/L) and malnourished (median body mass index of adults [greater than or equal to 18 years of age], 15.2 kg/m(2)); 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 greater than or equal to 45 years of age), long duration of illness (greater than or equal to 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% CI, 1.4 to 3.6) for those with a long duration of illness, 3.6 (CI, 2.1 to 5.9) for those 45 years of age or older, 4.6 (CI, 2.2 to 9.4) for those with a hemoglobin level less than 60 g/L, and 12.2 (CI, 3.2 to 47.2) for those with a body mass index less than 12 kg/m(2). Conclusion: Despite the severe debility of the patients and the exceptionally difficult circumstances under which they were treated, most fared remarkably well.