Efficacies of prevention and control measures applied during an outbreak in Southwest Madrid, Spain

Leishmania donovani Transmission Cycle Associated with Human Infection, Phlebotomus alexandri Sand Flies, and Hare Blood Meals, Israel1

Cutaneous leishmaniasis caused by Leishmania major or L. tropica and visceral leishmaniasis caused by L. infantum have been reported in Israel. We collected Phlebotomus spp. sand flies in the Negev desert of southern Israel to identify circulating Leishmania spp. Of 22,636 trapped sand flies, 80% were P. alexandri. We sequenced Leishmania-specific internal transcribed spacer 1 fragments and K26 genes. Of 5,019 Phlebotomus female sand flies, 2.5% were Leishmania DNA-positive; 92% of infections were L. donovani. Phylogenetic analyses showed separate clustering of L. donovani and L. infantum. P. alexandri flies positive for L. donovani harbored blood meals from European hares. Leishmania DNA isolated from a patient with cutaneous leishmaniasis who lived in the survey area was identical to L. donovani from P. alexandri flies. We report circulation of L. donovani, a cause of visceral leishmaniasis, in southern Israel. Prompt diagnosis and Leishmania spp. identification are critical to prevent leishmaniasis progression.

How much does it cost to prevent and control visceral leishmaniasis in Brazil? Comparing different measures in dogs

Visceral leishmaniasis (VL) is an important zoonosis in Brazil. Dogs are considered the main domestic reservoirs of the disease in the country; hence, control measures are focused on these reservoirs. Despite efforts to prevent and control VL, important reductions in disease prevalence and incidence have not been identified, stimulating the development and application of new strategies. The choice and implementation of new control strategies can benefit from the application of mathematical models that allow the simulation of different strategies in different scenarios. Selecting the best strategy to be implemented is also supported by cost-effectiveness studies. Here we used the results of a mathematical model in which scenarios, including isolated use of the vaccine and insecticide-impregnated collar (IIC), both at different coverage rates, were simulated to conduct a cost-effectiveness study. The costs were calculated for each scenario considering a simulation period of four years. Collar application in both infected and non-infected animals was the most cost-effective strategy. For example, to reduce the prevalence in humans and dogs by approximately 70%, the costs ranged from $250,000 and $550,000 for the IICs and vaccination, respectively. Even in the scenario with 40% loss/replacement of IICs, this measure was more advantageous in terms of cost-effectiveness than vaccination. If the vaccine were applied with culling of seropositive tested dogs, then the measure became more effective with a reduced cost compared with the vaccine alone. The use of the three first consecutive vaccine doses had the greatest impact on the cost of the vaccination strategy. The advantage of using IICs is that there is no need for a prior diagnosis, unlike vaccination, reducing costs and facilitating implementation. The present study aims to contribute to strategies to reduce hosts infected with VL by reducing public expenditure.

ENT involvement in Leishmania infections

INTRODUCTION

Leishmaniasis comprises a group of diseases caused by protozoan parasites of the genus Leishmania that are transmitted by the bite of infected phlebotomine mosquitoes from animal reservoirs. Three different clinical forms are generated: cutaneous, mucocutaneous and visceral. We present the findings in the head and neck of this disease observed in our health area.

PATIENTS AND METHODS

A review of the last 26 years in our hospital, noting the clinical, diagnostic and therapeutic characteristics of the cases detected.

RESULTS

Thirteen cases were identified, 7 cutaneous, 4 mucocutaneous and 2 visceral or kala-azar. The mean age was 53.7±10.8 years. Immunodeficiency was identified in 61% of the cases. The incidence of the disease was 1.5:100,000 inhabitants/year, with a prevalence of 2%. Of those infected, 69% had involvement of the ear-nose-throat area. In 12 cases the diagnosis was established by biopsy of the lesions. The time from clinical debut to diagnosis ranged from 3 to 10 months. Antimony compounds were used as treatment in 11 patients and amphotericin B in 3, alone or combined with the former. One cutaneous form resolved with excision of the lesion. Ninety-two percent healed clinically and parasitologically.

CONCLUSIONS

Leishmaniasis in Spain frequently entails cutaneous and mucocutaneous involvement, often of the skin of the head, face and neck or upper-airway mucosa. Its clinical presentation varies greatly, and it should be suspected if there is no response to conventional therapies and in conditions of immunodeficiency.

The Delay in the Licensing of Protozoal Vaccines: A Comparative History

Although viruses and bacteria have been known as agents of diseases since 1546, 250 years went by until the first vaccines against these pathogens were developed (1796 and 1800s). In contrast, Malaria, which is a protozoan-neglected disease, has been known since the 5th century BCE and, despite 2,500 years having passed since then, no human vaccine has yet been licensed for Malaria. Additionally, no modern human vaccine is currently licensed against Visceral or Cutaneous leishmaniasis. Vaccination against Malaria evolved from the inoculation of irradiated sporozoites through the bite of Anopheles mosquitoes in 1930's, which failed to give protection, to the use of controlled human Malaria infection (CHMI) provoked by live sporozoites of Plasmodium falciparum and curtailed with specific chemotherapy since 1940's. Although the use of CHMI for vaccination was relatively efficacious, it has some ethical limitations and was substituted by the use of injected recombinant vaccines expressing the main antigens of the parasite cycle, starting in 1980. Pre-erythrocytic (PEV), Blood stage (BSV), transmission-blocking (TBV), antitoxic (AT), and pregnancy-associated Malaria vaccines are under development. Currently, the RTS,S-PEV vaccine, based on the circumsporozoite protein, is the only one that has arrived at the Phase III trial stage. The “R” stands for the central repeat region of Plasmodium (P.) falciparum circumsporozoite protein (CSP); the “T” for the T-cell epitopes of the CSP; and the “S” for hepatitis B surface antigen (HBsAg). In Africa, this latter vaccine achieved only 36.7% vaccine efficacy (VE) in 5–7 years old children and was associated with an increase in clinical cases in one assay. Therefore, in spite of 35 years of research, there is no currently licensed vaccine against Malaria. In contrast, more progress has been achieved regarding prevention of leishmaniasis by vaccine, which also started with the use of live vaccines. For ethical reasons, these were substituted by second-generation subunit or recombinant DNA and protein vaccines. Currently, there is one live vaccine for humans licensed in Uzbekistan, and four licensed veterinary vaccines against visceral leishmaniasis: Leishmune® (76–80% VE) and CaniLeish® (68.4% VE), which give protection against strong endpoints (severe disease and deaths under natural conditions), and, under less severe endpoints (parasitologically and PCR-positive cases), Leishtec® developed 71.4% VE in a low infective pressure area but only 35.7% VE and transient protection in a high infective pressure area, while Letifend® promoted 72% VE. A human recombinant vaccine based on the Nucleoside hydrolase NH36 of Leishmania (L.) donovani, the main antigen of the Leishmune® vaccine, and the sterol 24-c-methyltransferase (SMT) from L. (L.) infantum has reached the Phase I clinical trial phase but has not yet been licensed against the disease. This review describes the history of vaccine development and is focused on licensed formulations that have been used in preventive medicine. Special attention has been given to the delay in the development and licensing of human vaccines against Protozoan infections, which show high incidence worldwide and still remain severe threats to Public Health.

Visceral leishmaniasis on the Indian Subcontinent: Efficacy of fipronil-based cattle treatment in controlling sand fly populations is dependent on specific aspects of sand fly ecology

BACKGROUND

Visceral leishmaniasis (VL) is a deadly disease transmitted by the sand fly Phlebotomus argentipes on the Indian subcontinent, with a promising means of vector control being orally treating cattle with fipronil-based drugs. While prior research investigating the dynamic relationship between timing of fipronil-based control schemes and the seasonality of sand flies provides insights into potential of treatment on a large scale, ecological uncertainties remain. We investigated how uncertainties associated with sand fly ecology might affect our ability to assess efficacy of fipronil-based control schemes. To do this, we used a previously-described, individual-based, stochastic sand fly model to quantify how uncertainties associated with 1) the percentage of female sand flies taking blood meals from cattle, and 2) the percentage of female sand flies ovipositing in organic matter containing feces from treated cattle might impact the efficacy of fipronil-based sand fly control schemes.

PRINCIPAL FINDINGS

Assuming no prior knowledge of sand fly blood meal and oviposition sites, the probabilities of achieving effective sand fly population reduction with treatments performed 3, 6 and 12 times per year were ≈5-22%, ≈27-36%, and ≈46-54%, respectively. Assuming ≥50% of sand flies feed on cattle, probabilities of achieving efficacious control increased to ≈8-31%, ≈15-42%, and ≈52-65%. Assuming also that ≥50% of sand flies oviposit in cattle feces, the above probabilities increased further to ≈14-53%, ≈31-81%, and ≈89-97%.

CONCLUSIONS

Our assessments of the efficacy of fipronil-based cattle treatments in controlling sand fly populations depend on our assumptions regarding key aspects of sand fly ecology. Assessments are most sensitive to assumptions concerning the percentage of sand flies ovipositing in feces of treated cattle, thus emphasizing the importance of identifying sand fly oviposition sites. Our results place the evaluation of fipronil-based cattle treatment within a broader ecological context, which could aid in the planning and execution of a largescale field trial.

18F-FDG PET/CT in visceral leishmaniasis: uptake patterns in the context of a multiannual outbreak in Northern Italy

OBJECTIVES

Visceral leishmaniasis (VL) is the most severe manifestation of the infection caused by the protozoan Leishmania, recently on increase in Italy and Spain. The aim of the study was to describe FDG uptake patterns in VL patients (pts) who underwent 18F-FDG PET/CT.

METHODS

A retrospective monocentric study of pts who underwent FDG PET/CT between 2008 and 2017 and later diagnosed with VL was performed. Semi-quantitative parameters were calculated in FDG-positive lesions: SUVmax, SUVmax spleen/SUVmax liver ratio (SLR), SUVmax focal/diffuse spleen ratio (FDR).

RESULTS

Overall, 23 pts were included. PET/CT was negative in 2 immunocompromised pts, positive in 21/23 (91%) [6 spleen only, 2 spleen + nodes, 7 spleen + bone marrow (BM), 4 spleen + BM + nodes, 1 spleen + BM + lung, 1 BM only + nodes, 2 nodes only]. Splenic involvement was demonstrated in 20/23 (87%) pts. Two different splenic patterns were observed: diffuse (13/20 pts, mean spleen SUVmax = 7.3 ± 4.2 [4.0-14.1], mean SLR = 2.2 ± 1.6 [1.3-6.7]) and focal over diffuse (7/20 pts, mean SUVmax = 12.6 ± 4.5 [9.5-20.5], mean SLR = 2.8 ± 0.8 [2.1-4.4], mean FDR = 2.1 ± 0.8 [1.2-3.6]). Extra-splenic FDG-avid findings were detected in 15/21 pts (65%): bone marrow in 13/15 (mean SUVmax = 4.0 ± 1.3 [2.8-6.0]), nodes in 67/15 and lung in 1/15.

CONCLUSIONS

PET/CT demonstrated splenic FDG uptake in all immunocompetent VL pts; two splenic patterns (diffuse/focal over diffuse) were observed and indistinguishable from splenic involvement by other disorders. The most frequent extra-splenic FDG-positive sites were BM and lymph nodes. Considering the potential disease aggressiveness and recent outbreaks in north-eastern Italy, VL should be considered in the differential diagnosis of FDG-positive splenic findings in pts from endemic areas or reporting travels to endemic countries.