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Mapping the last mile: Micro-stratification for sustained visceral leishmaniasis elimination in Bangladesh
Shomik Maruf1, Rasel Uddin1, Farhana Rahman Luba1
1NTD Research Group, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddrb), Dhaka, Bangladesh.
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.
