Visceral leishmaniasis elimination in Ethiopia: insights into epidemiology, transmission, treatment access, and outcome – a systematic review and meta-analysis

Ethiopia is a high-burden country for visceral leishmaniasis (VL) and has committed to regional elimination by 2030. Current evidence on disease epidemiology, transmission dynamics, treatment access, and clinical outcomes is essential for transitioning from control to elimination efforts. This systematic review and meta-analysis synthesizes the available literature on the prevalence, associated risk factors, accessibility and effectiveness of treatment, transmission patterns, clinical outcomes, and ecological factors influencing VL distribution, including vector habitats, climate conditions, and land-use patterns. Literature searches were conducted using PubMed, SCOPUS, EMBASE, CINAHL, HINARI, ScienceDirect, Google Scholar, and grey literature sources following PRISMA 2020 reporting guidelines. Study quality was assessed using the Joanna Briggs Institute (JBI) tools. Random-effects meta-analyses were used to estimate pooled prevalence and associated risk factors. In addition to systematic review and meta-analysis, we conducted a descriptive analysis of WHO surveillance data to assess the trend of caseload, treatment access, and cured treatment outcomes using R software version 4.5.1 and ArcGIS version 10.7, respectively. The study revealed that pooled VL prevalence (32 studies, 103,962 participants) was 15.29% (95% CI: 9.25–22.51) in institution-based and 10.38% (95% CI: 5.38–16.74) in community-based settings, with substantial variation according to detection methods employed. Male sex (OR = 1.86), sleeping outdoors (OR = 2.85) or on the ground (OR = 1.92), and travel to endemic areas (OR = 3.99) were significantly associated with VL infection. Family history of VL (OR = 2.27) and rural residence (OR = 2.27) increased VL risk substantially. Environmental factors, including proximity to termite mounds (OR = 3.60), presence of acacia trees (OR = 3.75), and hyraxes near dwellings (OR = 1.90), were significantly associated with increased VL risk. Spatial analysis revealed persistent VL transmission with intermittent outbreaks concentrated in high and very high VL-risk areas, primarily in the Kolla and Lower Kolla agroecological zones. Geographic inequities in treatment access were evident, with higher case numbers treated in northern endemic foci and increasing trends in southern and eastern foci. The sodium stibogluconate and paromomycin combination regimen demonstrated high cure rates. Visceral leishmaniasis (VL) in Ethiopia shows heterogeneous prevalence, highest with leishmanin skin tests. Male sex, farming, family history, outdoor sleeping, and proximity to termite mounds, acacia trees, and domestic animals were major risk factors. VL distribution aligned with sandfly vectors, particularly Phlebotomus orientalis, across lowlands and transitional highlands. National treatment data (2017–2024) showed generally favorable outcomes, highlighting the need for targeted elimination strategies based on local prevalence, risk factors, and effective case management. Not applicable.