https://orcid.org/0000-0001-8463-5326
Figures
Abstract
Background
Bangladesh became the first country to achieve World Health Organization (WHO) validation for eliminating visceral leishmaniasis (VL, Kala-azar) as a public-health problem in 2023. Sustaining this milestone demands a post-validation surveillance strategy that concentrates its efforts on residual transmission foci and deploys resources efficiently. We therefore conducted the country’s first Mouza-level micro-stratification to refine risk maps and guide targeted interventions.
Methods
The study used routinely reported VL line-list data (January 2017 – June 2025) from the national DHIS2 platform for every Upazila (sub-districts) that recorded ≥1 VL case. Each Mouza—the smallest administrative unit for land records comprising of one or more villages—was categorised as high (≥3 new VL cases), moderate (2 cases), low (1 case) or non-endemic (0 cases) over the nine-year period. Hot-spot maps were created in Python. Associations between endemicity (endemic vs non-endemic) were tested with chi-squared statistics, yielding odds ratios (OR) with 95% confidence intervals (CI).,
Results
Among 17,123 Mouzas in 128 case-reporting Upazilas, only 478 (2.8%) reported ≥1 new VL case between 2017 and 2025. High-endemic Mouzas (n = 33; 0.2%) accounted for 35% of total incident cases and clustered primarily in Mymensingh, Dhaka and Rajshahi divisions. However, year-on-year mapping showed reduction in the number of endemic Mouzas with no sustained new foci.
Conclusions
VL transmission in Bangladesh is now intensely focal, confined to <3% of Mouzas within historically endemic Upazilas. While broad surveillance coverage remains essential, micro-stratification at the Mouza level can guide the prioritization of targeted interventions, such as indoor residual spraying and active case detection in high-risk areas, improving program efficiency without compromising case detection. Periodic updating of Mouza-level risk maps will be essential to identify emerging hotspots, prevent resurgence, and inform strategies in other countries approaching VL elimination.
Author summary
We studied visceral leishmaniasis (also called kala-azar), a parasitic disease spread by sand flies that can be deadly if not treated. Since Bangladesh met global targets for public health elimination of this disease in 2023, the key challenge now is to keep it from coming back. We asked a simple question: where, exactly, do cases still occur? Using routine records from the national health information system (2017–2025), we created detailed maps at the level of mouza (small villages or village clusters). We found that recent illness was highly concentrated. Only about 3% of villages reported any new case over nine years, and fewer than thirty villages held more than one-third of all cases. This pattern tells us the disease now survives in small pockets rather than everywhere. By pointing health teams to these pockets, our maps can help focus actions such as going door-to-door to find patients early, supporting their care, and controlling sand flies in the right places. We share evidence that can help devise a practical approach that can guide local planning in Bangladesh and can be instrumental for other countries working to sustain control.
Citation: Maruf S, Uddin MR, Luba FR, Sagar SK, Ghosh D, Hossain MS, et al. (2026) Mapping the last mile: Micro-stratification for sustained visceral leishmaniasis elimination in Bangladesh. PLoS Negl Trop Dis 20(5): e0013504. https://doi.org/10.1371/journal.pntd.0013504
Editor: Mitali Chatterjee, Institute of Postgraduate Medical Education and Research, INDIA
Received: August 24, 2025; Accepted: April 27, 2026; Published: May 11, 2026
Copyright: © 2026 Maruf et al. 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.
Data Availability: The data can be made available upon reasonable request to the Research Administration of icddr,b (contact: info@icddrb.org), in accordance with the institutional Data Access Policy, to ensure ethical uses consistent with participants’ informed consent.
Funding: This study was funded by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) under project number P22-00865 (awarded to SM). The funders contributed to the study design and manuscript review. However, the authors alone are responsible for the content of this article, and the views expressed do not necessarily reflect the decisions, policies, or positions of the funding agency or the institutions with which the authors are affiliated.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Visceral Leishmaniasis (VL), often known as Kala-azar (KA), is a potentially life-threatening disease caused by Leishmania parasites and transmitted by the bites of female phlebotomine sandflies [1]. An approximate number of 50,000–90,000 new cases of VL occur globally every year [2]. Historically, densely populated and impoverished countries like India, Bangladesh, and Nepal in the Indian Subcontinent (ISC) had contributed substantially to VL burden [3,4]. These three countries committed to eliminating VL by 2015 through a memorandum of understanding (MoU) signed in 2005 [1]. While Nepal successfully reached the elimination goals in 2013, it unfortunately lost this status by 2017, highlighting the challenges of sustaining such achievements [5]. On a similar note, Bangladesh became the first country to receive official validation from the World Health Organization (WHO) in 2023 for eliminating visceral leishmaniasis as a public health problem. However, sustainment of this elimination status is crucial to ensure the success of the Regional Kala-azar Elimination Initiative. Recognizing the importance of sustained elimination, the National Kala-azar Elimination Programme (NKEP) in Bangladesh is currently prioritizing effective surveillance as part of its post-validation efforts [6].
The efforts encompass investigations into strategies for optimizing targeted risk surveillance, assessing disease burden, and implementing integrated intervention programs [7]. The sub-district (Upazila), also known as Upazila, serves as the primary reporting unit for this surveillance system under the NKEP [8]. Upazila is considered a focal point of the government administrative unit of Bangladesh, consisting of several Mouzas with an average population of around 333,653 and a mean area of 298 square kilometres [9–11]. According to DHIS2 data of 2019, 100 Upazilas among 495 were considered endemic for VL, further categorized as low, moderate, and high endemic regions [8]. However, the epidemiology of visceral leishmaniasis (VL) has undergone substantial changes in recent years, particularly during the consolidation phase. In addition to the emergence of VL in new areas, a concerning resurgence of cases was observed in areas where the disease was once prevalent [12]. Moreover, a continuous allocation of resources to cover a larger sub-district (Upazila) area for disease surveillance and vector control has become a major concern for the NKEP. Given these factors, directing concentrated attention towards specific Mouzas, the base-level administrative unit consisting of subplots of Upazilas, has become an essential strategy [13,14]. They have an average area of 2.5 square kilometres and a population of 2,806 [15].
An analysis of historical VL data at the Upazila level reveals that the entire population is not equally at risk, as the disease disproportionately affects the poorest and most marginalized communities. While the Upazila-wide approach was practical during the attack phase, it clearly requires revision in the post-elimination phase. The limited resources available in Bangladesh necessitate a more targeted approach to VL control. Implementing interventions across large populations covering vast areas of the endemic Upazilas can be inefficient, time-consuming, and may not yield optimal results. To maximize the resource efficiency in the post-validation phase, a shift towards focal surveillance within smaller geographical units than the Upazila is essential. Focusing on smaller areas or micro-stratification will lessen the burden of the NKEP in this regard. Therefore, in this study, we have analysed spatial data to investigate VL risk at the Mouza level by assessing the incidence of New VL cases in Bangladesh between 2017 and 2025. We have also assessed the disease shifting patterns during this period and ascertained the probable causes. This strategic information will be helpful to the NKEP in identifying VL hotspots and new foci in Bangladesh and plan targeted interventions in high-risk active foci areas, ensuring the optimum use of the available resources to sustain the elimination of VL in Bangladesh.
Methods
Ethical statement
This research is based on secondary data obtained from DHIS2, Management Information System (MIS), Directorate General of Health Services (DGHS). The study was approved by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) Ethical Review Committee (PR-23016).
Study design
This study was the first-ever micro-stratified study of visceral leishmaniasis (VL), aiming to develop and evaluate a Mouza-level micro-stratification framework for post-validation visceral leishmaniasis surveillance in Bangladesh, using routine national data to identify residual transmission foci and inform targeted resource allocation. We conducted the micro-stratification using existing secondary data available at the Directorate General of Health Services (DGHS), Bangladesh. The stratification was done at the Mouza level within the Upazila utilizing the data available from the line listing of VL cases, categorized as high, moderate, low, and non-endemic Mouzas.
Questionnaire/checklist design
We developed specific forms to collect secondary data at the Mouza level. VL burden data was collected from the DGHS Bangladesh, which has a line listing of VL. The Mouza-level information was collected using the questionnaire template, which had two parts; the first part contains demographic, climate, and vector density data, whereas the second part contains VL disease, diagnosis and treatment data. These tools were finalized following the technical consultation meetings with NKEP and other stakeholders.
Study/mapping unit
This study selected Mouzas as the unit for micro-stratification as they are the smallest administrative units of communities living in Bangladesh. Each Mouza in the 495 Upazila was stratified into high, moderate, low, and no VL risk Mouzas. The endemicity was determined after reviewing the previous nine-year VL data (2017–2025) available at the DGHS Bangladesh.
Data collection
Mouza-wise VL burden data from all the Upazilas that reported any new VL cases during the period of 2017–2025 was obtained from the DGHS Bangladesh (Table 1). New VL cases were defined as the National Kala-azar Management Guideline [1]. The lists of Mouzas under the Upazilas were finalized and all the Mouzas were categorized as per their endemicity, based on the review of the VL burden data obtained from DGHS. The Mouzas that reported at least one new VL case during this period were considered as VL endemic Mouzas, and rest were considered as VL non-endemic Mouzas (Fig 1). At first, we plotted year-wise VL non-endemic and endemic Mouzas into maps and observed shifting pattern for VL endemicity. Similarly, an endemicity grading was done and a hotspot Mouza-wise map was developed based on a nine-year cumulative VL case burden. The VL endemic Mouzas were sub-categorized into low, moderate and high VL endemic Mouzas based on the number of cases reported.
Data management and analysis
Data were extracted from DHIS2, MIS, DGHS in electronic format, which were cross-checked and verified for any discrepancies. A meticulously crafted data entry program was established using Microsoft Access 2019, ensuring a robust foundation for data integrity. Before input into this system, we implemented a rigorous double-checking process, strictly adhering to data management guidelines. The subsequent dataset analysis was conducted utilizing STATA (Stata Statistical Software: Release 16, College Station, Texas, USA: StataCorp LLC). Descriptive statistics were generated to unveil the inherent characteristics of the data. Parametric methods were selectively employed based on the distributional attributes of variables for comparing mean differences. ANOVA was employed to compare mean differences between groups, providing insight into the dataset. This meticulous approach ensured the fidelity of the data analysis process and fortified the reliability of the study’s findings. Chi-squared tests were performed to compare between groups and odds ratio was calculated to determine association of endemicity with different parameters. All the tests were two-tailed, and a p-value of <0.05 was considered statistically significant. Python (version 3.12.0) was used to generate hotspot maps.
Results
We determined the endemicity of the Mouzas for each year from 2017 to 2025 and plotted them in the map. The number of endemic Mouzas declined over time (Table 2), with no evidence of sustained large-scale expansion into new geographic regions (Fig 2); however, substantial turnover of endemic Mouzas was observed between time blocks.
We further performed the same exercise based on the cumulative burden of New VL cases. We have found that 478 Mouzas reported at least one new VL case – which we defined as VL endemic Mouzas. These endemic mouzas belong to 128 endemic sub-districts (Upazila) from 41 districts from all eight divisions of the country. The endemic mouzas were further categorized based on the incidence of New VL cases in last nine years into low (n = 395), moderate (n = 50) and high endemic (n = 33) Mouzas with 1, 2 and ≥3 New VL cases reported, respectively (Table 3).
The total number of Mouzas in these 128 Upazilas is 17123, whereas only 478 Mouzas reported new VL cases, which is about 2.8% of the total Mouza count in those Upazila (Table 2). We plotted all the 478 endemic Mouzas in the Mouza-wise map. We observed large clustering of endemic Mouzas in the Mymensingh (34.31%), Dhaka (28.24%), and Rajshahi division (23.22%). We found that the highest number of endemic Mouzas for VL was in Mymensingh district, followed by Tangail and Pabna districts encompassing 122 (25.52%), 73 (15.27%) and 46 (9.62%) endemic mouzas, respectively (S1 Table). Rest of the endemic Mouzas has been distributed sporadically in different parts of the country, especially along the western borders with India and a small cluster in the southern part of Barishal (Fig 3).
Our exploratory sensitivity analysis using rolling five-year and three-year blocks shows that VL risk at Mouza level is highly dynamic. While the overall incidence is falling, the locations of endemic Mouzas shift between blocks. Five-year blocks showed that out of the 301 endemic Mouzas in 2022–2025*, only 144 (47.8%) had been endemic in 2017–2021. Thus, 157 (52.2%) were “new” relative to the previous block—i.e., they reported no cases in 2017–2021. A three-year block showed that during 2020–2022 and 2023–2025, only 128 (46.9%) and 60 (28.8%) mouzas persisted from the previous blocks, respectively, while the rest were new (Table 4).
Discussion
Bangladesh has achieved public health elimination for VL in 2023 as the first country in the world. This remarkable achievement has propelled the National Kala-azar Elimination Programme (NKEP) to set two more targets – firstly, zero transmission of infection by 2025 and secondly, zero case reporting by 2030. However, to sustain the current success and march towards achieving the other two, the programme needs to devise a strategy through optimization of its available resources.
Periodic surveillance for new cases along with targeted vector control measures is imperative in the VL endemic areas to sustain VL elimination. To address this issue, we have tried to micro-stratify the VL endemic Upazilas into endemic Mouzas. Here in this study, we have tried to re-adjust our focus taking Mouza - the smallest administrative unit in Bangladesh as an implementation unit for VL control rather than Upazilas in the post-validation phase. The study revealed that a total of 128 Upazilas reported at least one new VL case between the period of 2017 – 2025. The total number of Mouzas in these 128 Upazilas is 17,123 – out of which only 478 (2.8%) Mouzas reported new VL cases. This nationwide Mouza‑level analysis confirms that VL transmission has contracted into a handful of residual micro‑foci since Bangladesh achieved the WHO elimination target in 2017 (Received WHO validation in 2023). The pattern emulates the “last‑mile” heterogeneity seen for malaria in Sri Lanka, lymphatic filariasis in Nigeria and VL in India, underscoring a well‑established epidemiological principle that, transmission becomes increasingly focal with the reduction of incidence to zero [16–18].
With <3% of Mouzas still reporting new VL, blanket Upazila‑wide interventions will no longer be cost‑effective. Redirecting IRS and active case detection to these endemic Mouzas alone could cut annual vector‑control expenditure by 80–90% (based on a current cost of US$ 34–38 per protected household) per year without jeopardising impact, ensuring maximum utilization of available resources [19–21]. Additionally, DHIS2’s configurable dashboards are widely used for national disease surveillance and already powering DGHS hotspot dashboards. This can likewise be set to refresh at regular intervals (quarterly/yearly) at Mouza scale, instantly flagging areas that require a rapid test–treat–track response.
The distribution of cases on the hotspot mapping shows clustering of cases in the northern part of the country mostly comprising of Mymensingh and Jamalpur districts of Mymensingh division and Tangail and Gazipur districts of Dhaka division. We have also noticed a small cluster in the western part of the Padma River (Pabna, Sirajganj and Naogaon districts of Rajshahi division) and another in the southern part of the country mainly in the Patuakhali district of Barishal division. Rest of the cases are scattered sporadically in different parts of the country.
Two patterns were evident from our sensitivity analysis. First, the number of endemic mouzas decreased over time (five-year block: 643 → 301; three-year block: 556 → 273 → 208), consistent with national elimination progress (2). Second, each new timeline block comprised >50% “newly classified” endemic mouzas. This pattern was most pronounced in 2023–2025 (~71% newly classified), suggesting that a three-year block is more responsive to recent case detection, while the five-year block provides greater stability. The high turnover of endemic Mouzas suggests that VL transmission in the post-elimination phase behaves as dynamic, short-lived micro-foci, reinforcing the need for adaptive surveillance and response strategies rather than fixed geographic targeting. We believe that presenting both approaches offers policymakers practical insight into how periodic updating of the endemicity list may be optimized under varying resource scenarios.
As these mouzas had zero notified cases in the preceding blocks, their newly classified endemic status does not necessarily indicate previously sustained local transmission. The detected cases may represent infections acquired elsewhere, e.g., in nearby endemic mouzas and subsequently identified following population movement. However, the absence of reported cases in earlier periods does not definitively exclude the possibility of low-level or undetected local transmission. Relapse VL cases and post-kala-azar dermal leishmaniasis (PKDL) cases are recognized reservoirs of infection and may contribute to continued transmission in endemic settings [22]. Therefore, the emergence of cases in previously non-endemic mouzas may reflect importation, localized transmission, or a combination of both mechanisms. From a policy perspective, distinguishing between these scenarios is critical. Strengthening case investigation protocols—including travel history documentation, PKDL screening, and focal entomological assessment—would help determine the underlying transmission dynamics and guide appropriate responses, whether enhanced reactive surveillance or targeted vector-control interventions.
Despite the lack of evidence on the probable associating factors for VL endemicity, it is clear that at the post elimination stage the cases are much sparser with only a handful of Mouzas from the endemic Upazilas are still reporting new cases. Moreover, reporting of new VL cases outside the listed hundred endemic Upazilas warrants attention as well. Micro-stratification, therefore, should not be interpreted as restricting surveillance to endemic Mouzas; rather, it provides a framework for prioritizing targeted interventions while maintaining comprehensive surveillance coverage. Following the current strategy, addressing the need for a periodic surveillance and vector control measures in all these Upazilas will be a gigantic task requiring substantial amount of resources. However, concentrating the interventions (e.g., IRS, ACD) on a micro level can ensure maximum utilization of available resources without the need for increasing the cost for additional resources. Studies on various vector borne diseases in Asia and Africa on micro-stratification have proven to devise a more targeted and effective allocation of public health resources [23–25]. Bangladesh, being the pioneer in eliminating visceral leishmaniasis as a public health problem thus must strive to create an example for other countries closing in on VL elimination on how to sustain the success in the post elimination phase. A periodic update of the micro-stratification of VL endemic Mouzas aligning with the five-yearly operational plan of NKEP can thus be an excellent strategy for Bangladesh and other countries nearing to their public health elimination of VL.
Limitation
The absence of comprehensive entomological data informing routine, longitudinal sand-fly monitoring limited the ability to correlate year-on-year changes in vector abundance with shifting VL incidence. Mouza-wise climate variables were not available, and the zonal climate data were insufficient to accurately capture localized environmental influences on VL endemicity. Key demographic and geographical modifiers of VL risk, e.g., housing material, livestock corrals, sleeping habits, and socioeconomic status were also unavailable at Mouza level, potentially excluding important explanatory variables.
Although Mouza-level population data exist from census sources, their infrequent updates and potential inaccuracies may limit their utility for dynamic, real-time micro-stratification; therefore, case counts were used as a pragmatic, programmatically aligned proxy. As a result, the micro-stratification framework primarily relied on case data, with limited integration of contextual risk factors.
Finally, cost-savings projections relied on national unit-cost standards assuming perfect targeting and operational efficiency. A real-world savings may be lower once implementation costs, such as, mobilization, logistics, and community-engagement in micro-foci are considered.
Conclusion
While VL transmission is now highly focal, the observed dynamic shifts in endemic Mouzas highlight the need to maintain broad surveillance coverage. Micro-stratification at the Mouza level can guide the prioritization of targeted interventions such as indoor residual spraying and active case detection in high-risk areas, thereby improving program efficiency without compromising case detection. These findings support a strategic shift from blanket Upazila-level approaches to adaptive, Mouza-level micro-stratification for the post-validation phase of VL elimination in Bangladesh.
Supporting information
S1 Table. District-wise distribution of endemic Upazilas and Mouzas for VL.
https://doi.org/10.1371/journal.pntd.0013504.s001
(PDF)
Acknowledgments
We thank National Kala-azar Elimination Programme (NKEP) for sharing relevant data on VL burden in Bangladesh.
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