Primary prevention

Primary prevention depends on the sleeping habits of people in endemic areas; sand fly abundance, distribution, and diversity; and the type of transmission (anthroponotic versus zoonotic).[1][2] Prevention of infection and disease is based on controlling the human or non-human reservoir.[63] This entails early detection and treatment of patients for anthroponotic transmission cycles; destruction of rodent burrows, or collaring of dogs, for zoonotic transmission cycles; vector control (e.g., indoor spraying of households with insecticide for some sand fly species); or methods of personal protection (e.g., use of topical repellent to exposed skin, covering with clothing, and insecticide-treated bed nets, curtains, or blankets).[1][2][64][65]

There is limited evidence to show that a prevention and control approach can consistently result in reduced disease incidence.[66] Therefore, it is inconclusive whether large-scale distribution of long-lasting insecticidal bed nets can provide additional protection compared with existing visceral leishmaniasis (VL) control measures in India and Nepal.[67][68] Dog culling for controlling zoonotic VL is unproven as a control measure.[69][70]

While controlled Leishmania major infection (leishmanisation) protects from homologous infection, an effective human leishmaniasis vaccine does not yet exist.[71] However, a third-generation vaccine for human VL and post-kala-azar dermal leishmaniasis has undergone investigation in a phase 1 clinical trial.[72] Additionally, a phase 2 safety and immunogenicity trial in Sudan evaluated a chimpanzee adenovirus-based (ChAd63-KH) vaccine, where 7/23 patients (30.4%) showed >90% clinical improvement and minimal adverse reactions were reported.[73][74][75] A randomised controlled trial is underway.[73]

Secondary prevention

Secondary prophylaxis with an appropriate anti-leishmanial drug should be given to patients with HIV infection and a CD4 count <200 to 350 cells/microlitre (the higher CD4 cut-off is recommended by the Pan American Health Organization) due to the high risk of relapse.[8][145][169]​[170]​​ In patients with other forms of immunosuppression, consider secondary prophylaxis on an individual basis, especially among patients with a history of prior relapse for whom an immunosuppressive condition is ongoing. See Management approach.

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