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Am. J. Trop. Med. Hyg., 00(00), 2018, pp. 1–7
doi:10.4269/ajtmh.18-0307
Copyright © 2018 by The American Society of Tropical Medicine and Hygiene
Integrating Case Detection of Visceral Leishmaniasis and Other Febrile Illness with Vector Control
in the Post-Elimination Phase in Nepal
Megha Raj Banjara,
1
* Murari Lal Das,
2
Chitra Kumar Gurung,
3
Vivek Kumar Singh,
3
Anand Ballabh Joshi,
3
Greg Matlashewski,
4
Axel Kroeger,
5,6
and Piero Olliaro
5
1
Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal;
2
BP Koirala Institute of Health Sciences, Dharan, Nepal;
3
Public
Health and Infectious Disease Research Center, Kathmandu, Nepal;
4
Department of Microbiology and Immunology, McGill University, Canada;
5
Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization (WHO), Geneva, Switzerland;
6
Centre for
Medicine and Society/Anthropology, Freiburg University, Freiburg, Germany
Abstract. Nepal has completed the attack phase of visceral leishmaniasis (VL) elimination and now needs active case
detection (ACD) and vector control methods that are suitable to the consolidation and maintenance phases. We evaluated
different ACD approaches and vector control methods in Saptari district. We assessed 1) mobile teams deployed in
villages with VL cases in 2015 to conduct combined camps for fever and skin lesions to detect VL/PKDL (post–kala-azar
dermal leishmaniasis) and other infections; 2) an incentive approach by trained female community health volunteers
(FCHVs) in villages with no VL cases in 2015. Both were followed by house-to-house visits. For vector control, four villages
were randomly allocated to insecticide impregnation of bednets, insecticide wall painting, indoor residual spraying (IRS),
and control. Sandfly density (by CDC light traps) and mortality (World Health Organization cone bioassay) were assessed
in randomly selected households. One VL, three tuberculosis, one leprosy, and one malaria cases were identified among
395 febrile cases attending the camps. Post-camp house-to-house screening involving 7,211 households identified 679
chronic fever and 461 skin lesion cases but no additional VL/PKDL. No VL/PKDL case was found by FCHVs. The point
prevalence of chronic fever in camp and FCHV villages was 242 and 2 per 10,000 populations, respectively. Indoor
residual spraying and bednet impregnation were effective for 1 month versus 12 months with insecticidal wall paint.
Twelve-month sandfly mortality was 23%, 26%, and 80%, respectively, on IRS, bednet impregnation, and insecticide wall
painting. In Nepal, fever camps and insecticidal wall paint prove to be alternative, sustainable strategies in the VL post-
elimination program.
INTRODUCTION
Visceral leishmaniasis (VL) is a public health problem mostly
affecting the poorest of the poor in the tropics.
1
Until recently,
India, Bangladesh, and Nepal contributed 60% of the global
VL burden.
2
Since 2005, under the guidance of the World
Health Organization (WHO), these three countries have un-
dertaken a VL elimination program
3
composed of three suc-
cessive phases: attack, consolidation, and maintenance. The
elimination target is less than 1 case per 10,000 inhabitants at
the subdistrict, district, and block level, respectively, in Ban-
gladesh, Nepal, and India initially by 2015.
4
In 2014, the
deadline was further extended to 2017, and Bhutan and
Thailand were also included.
5
Nepal achieved the target in
2014 and Bangladesh in 2016.
6
The pillars of the attack phase have been active case
detection (ACD) combined with treatment at the primary
health-care level and vector control through indoor residual
spraying (IRS) with insecticides in VL-endemic areas. This
has made it possible to identify more cases of VL and
post–kala-azar dermal leishmaniasis (PKDL) and treat them
earlier, thus, also limiting transmission.
7–9
These interven-
tions, however, may not be sustainable in the long term, and
alternative case identification and vector control strategies
are now needed in Nepal to protect the achievements of the
attack phase.
10
Visceral leishmaniasis is now an infrequent cause of fever in
Nepal, and a vertical program cannot be maintained. Never-
theless, ACD has proved very useful for identifying VL cases
and can be engineered to cover a range of other febrile illness,
thus, making integrated disease control and case manage-
ment possible and sustainable.
For vector control, deploying IRS is cumbersome, expen-
sive, and has limited coverage in space and time, and often is
of suboptimal quality in program routine.
11
Practical alterna-
tives can be explored. Impregnation of existing bednets
with slow-release insecticide tablet (KOTAB123) proved ef-
fective in reducing sandfly density and VL disease burden in
Bangladesh.
12,13
Insecticidal paint has been tested against
malaria and Chagas disease vectors with encouraging results,
and is also effective against pyrethroid-resistant vectors, but
has not yet been tested on sandflies.
14,15
The aim of this study was to investigate and compare in-
tervention strategies combining ACD of VL/PKDL with other
febrile illnesses on one hand and strategies for vector control
at the community level on the other hand, which could be
deployed concomitantly during the post-elimination phases of
the VL elimination program in Nepal.
MATERIALS AND METHODS
Study design. This intervention research study was
designed to determine the effectiveness of the integrated ACD
and vector control interventions.
For ACD, combined camps for the VL/PKDL cases and
other febrile and skin lesion illnesses, including malaria, tu-
berculosis, and leprosy, were conducted by mobile teams of
health workers in villages with VL cases reported in 2015. In
parallel, an incentive-based approach for active detection of
VL/PKDL along with other febrile cases conducted by female
community health volunteers (FCHVs) was tested in villages
without VL cases in 2015.
* Address correspondence to Megha Raj Banjara, Central Department
of Microbiology, Tribhuvan University, Kathmandu, Nepal. E-mail:
banjaramr@gmail.com
1
For vector control, we compared interventions consisting
of impregnation of bednets with KOTAB123, wall painting
of houses with Inesfly paint and IRS using deltamethrin for
their effects on sand fly density and mortality in VL-endemic
villages.
Study sites. The intervention activities were conducted in
the VL-endemic Saptari district from June to August 2016
among households of VL-endemic villages. The district has a
population of 639,284 living in 121,098 households. The
Saptari district has reported decreasing numbers of VL cases
detected passively by the routine surveillance system since
2012 to reach an incidence of 0.28 per 10,000 populations in
2014.
16
This district has one zonal hospital, one district public
health office, four primary health-care centers, and 112 health
posts. There were 7,211 households with a population of
44,323 in the camp approach area and 9,627 households with
a population of 52,277 in the incentive approach area.
Based on the district public health office records for the
years 2013–2015, the seven villages with high incidence of VL
cases were selected for the fever camp approach, and nine
villages with low incidence of VL for the incentive approach–
see the following paragraphs.
Sample size for interventions. We aimed at assessing, in
both study sites, the burden of the four target diseases and
calculated the sensitivity of detecting cases through the camp
approach (10.7 per 10,000 combined prevalence rates of VL,
tuberculosis, malaria, and leprosy) versus incentive approach
(9.6 per 10,000 cumulative annual incidence of VL, tubercu-
losis, malaria, and leprosy)
16
using as the gold standard the
cases detected by house-to-house screening. To get a very
high precision of our assessment of the disease burden with a
confidence interval close to zero, we decided to include
roughly 40,000 inhabitants in each assessment. This would
give us sufficient cases to determine the sensitivity of both
approaches.
Case detection interventions. Combined camp approach.
Rapid response teams from the district level were sent to
seven villages, which had newly identified VL cases to conduct
ACD of VL/PKDL, malaria, tuberculosis, leprosy, and other
febrile illnesses, along with focal spraying.
The mobile team consisted of two vector control officers,
two doctors, two laboratory technicians, and one health as-
sistant that visited the health post/PHCC of the area where the
new VL cases had been reported to conduct the combined
fever camps. Health workers from local health post/PHCC
were also included in organizing the camps. Any individual
with a history of fever for 2 or more weeks was invited to attend
the camp. Awareness activities were conducted before the
fever camp with the support of local health functionaries and
FCHVs. Camps were held on prescheduled days in previously
defined health posts/PHCCs. Camp attendees were screened
for VL by asking for chronic fever (> 14 days), palpating spleen
enlargement, and conducting the rK39 test. Newly detected
cases in the camp were referred to the Sagarmatha Zonal
Hospital for further diagnosis, treatment, and clinical and
biochemical monitoring for cure. Visceral leishmaniasis pa-
tients were reimbursed for travel and food costs and daily
wages lost, as per national program guidelines. Cases with
skin disease suggestive of PKDL were also tested with the
rK39 rapid test for the presence of antibodies against VL.
The serological rK39-negative febrile cases were screened
for tuberculosis (sputum samples were diagnosed through
GeneXpert), leprosy (through clinical examination), and
malaria (rapid diagnostic test through SD bioline Standard
Diagnostics Korea) and, potentially others. The suspected
PKDL cases, if found to be rK39 negative, were tested clini-
cally for leprosy at the campsite and referred to the Lalgadh
leprosy hospital for further examination. The detected malaria
and tuberculosis cases were referred to the Sagarmatha Zonal
Hospital for confirmatory diagnosis and treatment. As per
current VL national guidelines, during the fever camp, vector
control activities were conducted in the village by the district
public health staff with the aim to cover all houses with focal
IRS, where there were two or more VL cases identified.
Incentive approach. Female Community Health Volunteers
are the village-based female health volunteers in Nepal; they
provide referral services to local morbid cases and provide
health education to the community. Only those FCHVs who
accepted to participate were selected for this activity, which
was conducted through the district public health office. All the
FCHVs of nine VL-endemic VDCs were identified and a 1-day
orientation session was delivered to 49 local health workers
and 76 FCHVs by the research team in coordination with the
District Public Health Office using training materials and
methodology developed and used for the training of VL col-
laborators by the VL National Programme. Female community
health volunteers were trained to identify probable VL/PKDL
cases, leprosy, tuberculosis, and malaria and to refer them to
the district hospital for confirmation and treatment. Female
community health volunteers were informed to provide an
incentive Rs. 400 per case as transportation cost after con-
firmation from the Sagarmatha Zonal Hospital (although
FCHVs are volunteers the Nepal government provides Rs. 400
per day per activity as transportation cost). The activities of the
FCHVs were recorded and monitored.
Blanket household screening and evaluation of interventions.
In the fever camp villages, house-to-house visits covering all
households of the intervention area were conducted immedi-
ately after the fever camps. In the incentive approach villages,
the blanket household screening was conducted 12 months
after the training of the FCHVs.
All VL, tuberculosis, malaria, and leprosy cases identified
through any of the aforementioned approaches were con-
firmed and treated according to national guidelines. The pa-
tients were reimbursed for travel and food costs and daily
wages lost as per program guidelines and norms.
Vector control interventions. A randomized controlled
trial for vector control was performed to compare bednet
impregnation with KOTAB123, wall painting with Inesfly
5AIGRNG
™
, IRS with deltamethrin (as per national guidelines),
and a no-intervention control group.
Inesfly5AIGRNG contains alphacypermethrin 0.7%, d-allethrin
1.0%, and pyriproxyfen (0.063%). The formulation is vinyl paint
with an aqueous base, with the active ingredients residing
within CaCO
3
and resin microcapsules, allowing a gradual re-
lease of active ingredients. Microcapsules range from one to
several hundred micrometers in size.
Sandfly density was measured in eight villages at baseline
to identify four villages with similar sandfly densities. Four
villages with no significant differences in the sandfly density
were assigned randomly to receive no intervention (control, 92
households) or one of the following three vector control in-
terventions: wall painting (118 households), bednet impreg-
nation (79 households), and IRS (67 households).
2BANJARA AND OTHERS
After the deployment of the interventions, six HHs from each
cluster were selected randomly for entomological analysis,
which included sandfly density measurement (baseline and 1,
3, 9, and 12 months after intervention), and WHO cone bio-
assay to measure sandfly killing on the IRS, wall paint and
bednet impregnation (in intervention HHs), and wall (control
HHs) at 1, 3, 9, and 12 months after intervention.
Sandfly collection and density measurement. Sandflies
were collected during two consecutive nights with two CDC
light traps per household by trained personnel under the
guidance of an entomologist of the study team, from six ran-
domly selected HHs at 1, 3, 9, and 12 months after the de-
ployment of the vector control activities in each study arm.
Sandfly density was calculated as the mean density per CDC
light trap per night.
Intervention effect was calculated by the difference-in-
difference method using the following formula: (B−A)−(D−
C), where; A= baseline mean sand fly count in the intervention
group; B= follow-up mean sand fly count in the intervention
group; C= baseline mean sand fly count in the control group;
and D= follow-up mean sand fly count in the control group.
Negative values indicate the intervention is effective.
17
World Health Organization cone bioassay test. The cone
bioassay test was performed by using the WHOPES method
on 15 randomly selected impregnated nets and 10 control
nets, or sprayed and non-sprayed surfaces, or painted walls
and control walls, at 1, 3, 9, and 12 months after the in-
tervention. The procedures for the bioassay followed the TDR
monitoring and evaluation toolkit.
18
Community people’s perceptions of vector control
interventions. The acceptability of vector control interven-
tions was assessed by interviewing the household heads in
the study area. The interviews were conducted 1 month after
the interventions to collect information on perceived reduction
of sandfly and mosquito levels after intervention, and any side
effects or inconvenience the intervention might have caused.
Data management and statistical analysis. Data were
analyzed using SPSS version 21. Double entry of data was
performed for quality assurance. Descriptive statistics were
generated. Differences between means were compared by
parametric and nonparametric methods depending on the
distribution of the variables. Differences between proportions
were compared by the chi-squared test.
Ethical issues. Study participants signed a consent form.
The protocol was reviewed and approved by WHO Ethical Re-
view Committee and by the Nepal Health Research Council.
RESULTS
Case detection. The camps were attended by 398 people
(395 with fever for more than 2 weeks and three with skin
lesions). The point prevalence of self-reported febrile illness in
the seven villages where the camp took place in summer
season was 89.12 per 10,000 populations.
Among the 398 people who attended the camp, 275 were
further tested: 76 for suspected VL, 97 for tuberculosis, three
for leprosy, and 99 for malaria. Of these, one each was positive
for VL, leprosy, and malaria; and three were positive for tu-
berculosis. Immediately following the camp, house-to-house
screening of 44,323 people from 7,211 households identified
an additional 679 chronic fever and 461 skin lesion cases,
none of which was positive for VL, PKDL, tuberculosis,
malaria, or leprosy. The camp approach, therefore, identified
all of the VL, tuberculosis, malaria, and leprosy in these vil-
lages. The overall point prevalence of chronic fever in these
villages (between self-reported cases through the fever camp
and actively detected cases through blanket household
screening) was 242 per 10,000 population (Table 1).
Comparatively, in the incentive approach villages, no case
was reported by FCHVs during the year following their training.
The blanket screening of 9,627 households was conducted
12 months after FCHVs training (total population 52,277)
identified 11 cases of chronic fever and six skin lesions, none
of which were confirmed to be either VL, PKDL, tuberculosis,
malaria, or leprosy. The overall point prevalence of chronic
fever in the incentive approach villages was 2 per 10,000
population (Table 1).
Vector control interventions. The household and socio-
economic characteristics showing the typical indicators of
poverty (high illiteracy rate and agriculture as the only income)
were very similar in intervention and control villages. The
sandfly density was reduced upto 1 month only by IRS and
bed net impregnation, whereas it was reduced for 12 months
(last follow-up measurement) by insecticidal wall paint
(Figure 1).
Table 2 presents the baseline and post-intervention vector
densities at 1, 3, 9, and 12 months. Baseline vector densities
in the four villages varied from 2.21 per household per night in
the IRS village to the 16.08 in the wall painting village. Table 2
also presents the intervention efficacy as “difference-in-
difference”(with 95% confidence intervals) of the sandflies’
densities for 12 months after each intervention application
relative to control (Figure 2).
TABLE 1
Findings of house-to-house screening after camp and incentive approach
Particulars Camp approach Incentive approach
Number of houses screened
(house-to-house)
7,211 9,627
Number of people screened 44,323 52,277
Number of people with fever lasting
more than 15 days
679 11
Number of people with skin lesions 461 6
Overall prevalence rate of chronic fever
(self-reported and actively
detected cases)
242 per 10,000 2 per 10,000
VL, PKDL, leprosy, malaria and
tuberculosis identified
6 (VL-1, leprosy-1, malaria-1, TB-3) 0
PKDL = post-kala-azar dermal leishmaniasis; VL = visceral leishmaniasis.
VISCERAL LEISHMANIASIS ELIMINATION IN NEPAL 3
Indoor residual spraying and insecticide-impregnated bed-
nets were effective for upto 1 month after application, re-
spectively, but their efficacy waned thereafter. Insecticidal paint
was still effective at the 12-month follow-up measurement.
The bioassays performed on the treated surfaces showed
that the mortality of P. argentipes sandflies was about 95% at
the 1-month follow-up and 80% at the 12-month follow-up on
the painted surfaces; 50% and 26%, respectively, for
insecticide-treated bednets; and 99% and 23%, respectively,
for IRS (Figure 3).
A total of 264 household heads were interviewed for their
perceptions and satisfaction about these vector control in-
terventions: 94% perceived a reduction of sandflies after the
application of insecticidal paint, 72% after bed net impreg-
nation with insecticide, and 79% after IRS. Overall 10 (seven
from insecticide-painted villages, three from bednet impreg-
nation villages, and none from IRS villages) reported mild
adverse events (Table 3).
DISCUSSION
This study was conducted to identify sustainable options to
consolidate the achievements of the VL elimination program
and eventually break VL transmission in Nepal. This involves
coordinated case-finding and vector control activities that can
be deployed in the long term and are sustainable. On the one
hand, there is the camp approach, which is carried out at one
point in time, whereby a team is being dispatched for detecting
new cases in highly endemic areas or in areas with a sudden
burst in the number of cases. On the other hand, the incentive
approach is a continuous activity that can be applied to low-
endemicity areas (in our study over a year) and uses the
Nepalese system of FCHVs as a community-based “active
surveillance”to detect potential VL cases. The study intended
to measure the sensitivity of each of these two approaches by
conducting a house-to-house survey to see how many cases
have been missed. We found that fever camps are effective in
identifying active VL, tuberculosis, and malaria cases in the
village, thus, achieving the dual objective of potentially re-
ducing VL transmission and providing better care for other
causes of febrile illness. We also found that insecticide wall
painting provides long-lasting effects and is well accepted by
the communities.
This study primarily focused on ACD of VL cases for the
maintenance phase of the VL elimination programme. Be-
cause all VL-endemic districts of Nepal have achieved the
FIGURE 1. Flowchart of vector control interventions and follow-up. Inesfly paint-Inesfly %AIGRNG TM contains alphacypermethrin 0.7%;
d-allethrin 1.0%, and pyriproxyfen (0.063%). KOTAB 123-WHO specified deltamethrin same as used in Permanet. Indoor residual spraying–
deltamethrin. This figure appears in color at www.ajtmh.org.
TABLE 2
Effects on sandfly density due to intervention
Month
Sandfly density per household per night Effects of intervention* (95% CI)
P-value comparing with baseline
and control
IRS WP BNI Control IRS WP BNI IRS WP BNI
0 2.21 16.08 4.96 6.29 ––––––
1 2.75 7.92 17.38 31.96 −25.13 (−49.23,−1.02) −33.83 (−60.36,−7.29) −13.25 (−40.25,13.75) 0.0414 0.0124 0.3370
3 3.36 1.29 4.58 2.42 5.02 (+2.17,+7.86) −10.92 (−19.30,−2.53) 3.49 (+0.13,+6.84) 0.0005 0.0110 0.0414
9 3.83 0.58 3.75 1.62 5.82 (+3.11,+8.52) −10.83 (−19.05,−2.60) 3.46 (−0.49, +7.41) 0.0000 0.0110 0.0872
12 23.67 5.29 3.63 6.46 21.29 (+17.70,+24.87) −10.96 (−20.27,−1.65) −1.50 (−5.18,+2.18) 0.0000 0.0208 0.4228
IRS = indoor residual spraying. Reduction was estimated as the difference-in-difference method. The effect is negative/positive if the sand fly density is decreased/increased after intervention. The
effect is zero if there are no changes of sand fly density after intervention.
* Effect of intervention was calculated as: (B−A)−(D−C), where, A= baseline mean sand fly count for the intervention group; B= follow-up mean sand fly count for the intervention group; C=
baseline mean sand fly count for the control group; D= follow-up mean sand fly count for the control group.
4BANJARA AND OTHERS
elimination target (incidence of VL below 1 per 10,000 pop-
ulation at the district level), we combined VL and PKDL case
detection with tuberculosis, malaria, and leprosy. Among the
febrile patients who attended the camp, we detected three
cases of tuberculosis, one each of VL, malaria and leprosy,
and no case of PKDL. Because no additional such cases were
found through the house-to-house screening immediately
after the camp, we conclude that this approach is highly
effective—thus confirming previous findings—and speaks in
favor of broadening the spectrum of febrile illnesses covered
by the national communicable diseases control program.
9
Applying the combined fever camp approach described here
would reduce long delays in seeking care for VL diagnosis and
treatment and would be more sustainable in the long term.
19
These observations are also consistent with the overall re-
duction in VL cases in this endemic district of Nepal. More-
over, this study identified three new cases of tuberculosis.
Case identification is one of the major challenges countries are
facing in achieving the objectives of the WHO end TB strat-
egy.
20
This approach should, therefore, be considered to
complement existing case-finding strategies by the national
TB control program in Nepal.
The overall point prevalence of febrile illness in the camp
approach villages was 242 per 10,000, of which approximately
one-third were self-reported (detected through the camp) and
two-thirds were identified through house-to-house screening
(which also included more acute fevers). The optimum sea-
sonal periodicity of fever camps still needs to be determined.
FIGURE 2. Intervention effect on sandfly density after the application of insecticidal paint (WP), bed net impregnation (BN) with slow-release
insecticide, and indoor residual spraying (IRS). Negative values indicate the intervention is effective. This figure appears in color at www.ajtmh.org.
FIGURE 3. Average Abbot-corrected mortality rate of P. argentipes by intervention at follow-up. IRS = indoor residual spraying. This figure appears
in color at www.ajtmh.org.
VISCERAL LEISHMANIASIS ELIMINATION IN NEPAL 5
The incentive approach implemented through FCHVs did
not identify any VL, PKDL, leprosy, malaria, and tuberculosis
cases. By contrast, in Bihar, India, the accredited social health
activists were able to refer 27% of the VL cases after one
training session and 46% after two training sessions.
21,22
This
difference could be due to very low VL caseload in these vil-
lages in Nepal (these villages had had no recent VL case) and
the need for repeated training of FCHVs.
Although both approaches were applied in the same district,
the characteristics of the villages were different. The villages
with VL cases had also higher prevalence rates of other
tropical diseases and fever in general; those with low ende-
micity for VL also had much fewer cases of fever and none of
the tropical diseases being looked for. It was unexpected to
find significantly more febrile cases during the house-to-
house screening in camp approach villages than in the in-
centive approach villages. While the different timing of the two
surveys (they were 1 year apart) or increased awareness of
fever in the communities which had had recent VL cases could
offer potential explanations, such large difference in the point
prevalence of febrile cases between the two areas deserves
further investigation.
Among the vector control interventions, insecticidal wall
paint was effective for upto 12 months after intervention on
sandfly density and mortality. By contrast, IRS, even in study
conditions, was effective in the first month, but its efficacy
waned thereafter both on density and mortality. Bednet im-
pregnation with slow-release insecticide reduced density for
the first month and had an effect on mortality for 9 months. The
spatial effect of the intervention seems to be crucial to ensure
the efficacy of bed net intervention, because bednet impreg-
nation was carried out only in some target houses, and thus,
the community effect was lost. Painting of walls with in-
secticidal paint can therefore become a valuable and sus-
tainable intervention for VL vector control during the
maintenance phase of the VL elimination program as its effect
lasts longer and is less technically challenging than IRS. It can
be combined with other vector control measures (e.g. impreg-
nated bednets), and lends itself to local development for in-
stance through innovative models of social entrepreneurship.
We have now started the economic analysis of the different
interventions and their effects, and they can be optimally in-
tegrated to produce a durable elimination of VL in Nepal.
CONCLUSION
In the maintenance phase of the VL elimination, the com-
bined camp approach offers the dual advantage of being
suitable for detecting new cases at an early stage as well as
providing a common platform for febrile illnesses at large,
hence, being cost-effective and more sustainable. In-
secticidal paint can be a valuable alternative to IRS for vector
control particularly for the VL post-elimination phase in
Nepal.
Received April 11, 2018. Accepted for publication August 14, 2018.
Acknowledgments: We would like to acknowledge Epidemiology and
Disease Control Division Department of Health Services, District
Public Health Office Saptari, Sagarmatha Zonal Hospital for their
support to the study. Thanks also go to Primary Health Care Centers
and Health Posts, Female Community Health Volunteers for their ac-
tive participation in conducting the camps and vector control inter-
ventions. We acknowledge the household heads and participants of
the study area.
Financial support: The study was financially supported by Special
Programme for Research and Training in Tropical Diseases (TDR),
World Health Organization (WHO), Geneva, Switzerland.
Disclaimer: P. O. is a staff member of the WHO. The authors alone are
responsible for the content and opinions expressed in the paper,
which may not reflect the opinions and policies of the WHO.
Authors’addresses: Megha Raj Banjara, Central Department of Mi-
crobiology, Tribhuvan University, Kathmandu, Nepal, E-mail: banjaramr@
gmail.com. Murari Lal Das, BP Koirala Institute of Health Sciences, Dharan,
Nepal, E-mail: mldas29@gmail.com. Chitra Kumar Gurung, Vivek Kumar
Singh, and Anand Ballabh Joshi, Public Health and Infectious Disease
Research Center, Kathmandu, Nepal, E-mails: ckgurung@gmail.com,
viveksingh1424@gmail.com, and anandbjoshi2018@gmail.com. Greg
Matlashewski, Department of Microbiology and Immunology, McGill
University, Canada, E-mail: greg.matlashewski@mcgill.ca. Axel Kroeger,
Special Programme for Research and Training in Tropical Diseases (TDR),
World Health Organization (WHO), Geneva, Switzerland, and Centre for
Medicine and Society/Anthropology, Freiburg University, Freiburg, Ger-
many, E-mail: kroegera@who.int. Piero Olliaro, Special Programme for
Research and Training in Tropical Diseases (TDR), World Health Organi-
zation (WHO), Geneva, Switzerland, E-mail: olliarop@who.int.
This is an open-access article distributed under the terms of the
Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the
original author and source are credited.
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TABLE 3
Perceptions of community people on vector control interventions
Particulars
Village with insecticidal paint
(n= 118)
Village with slow-release insecticide impregnation
of bednets (n= 79)
Village with IRS
(n= 67)
Perceived reduction of sandfly density
after intervention
111 (94.1) 57 (72.2) 53 (79.1)
Adverse events after interventions 7 (5.9) 3 (3.8) 0 (0.0)
Reported adverse events
Headache 1 0 0
Itching 6 3 0
IRS = indoor residual spraying.
6BANJARA AND OTHERS
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