Historical series of patients with visceral leishmaniasis treated with meglumine antimoniate in a hospital for tropical diseases, Maceió-AL, Brazil

Demographic and spatial study of visceral leishmaniasis in the state of Alagoas, Brazil, during 2007-2018

INTRODUCTION

Visceral leishmaniasis has a broad worldwide distribution and constitutes a public health problem in the Northeast of Brazil. Located in this region is the state of Alagoas, where the disease is endemic in humans and where there has been a significant increase in the number of positive dogs. The objective of this study was to describe the temporal and spatial distribution of the cases of human VL in the state of Alagoas with the aim of identifying transmission risk areas in the period from 2007 to 2018.

METHODS

The data available in the National Disease Notification System (SINAN-NET) were used. The Bayesian incidence rate and the Moran's global index were calculated using the Terra View 4.2.2 program, and the maps were created using QGIS2.18.0.

RESULTS

From the 102 municipalities, 68.6% (n= 70) had at least one notified case of VL in the years of study. A total of 489 cases were registered, with an average of 40.7 cases per year and an incidence rate of 1.25/100,000 inhabitants. The highest number of confirmed cases (105) occurred in 2018. Male individuals and children between 1-4 years old were the most affected, and 64% of the cases were in rural areas. Spatial dependence was detected in all the intervals except for the first triennium, and clusters were formed in the west of the state.

CONCLUSIONS

Alagoas presented an accentuated geographical expansion of VL, and it is necessary to prioritize areas and increase surveillance actions and epidemiological control.

Monocyte subpopulations as important biomarkers of resistence and susceptibility during experimental infection with Leishmania (Leishmania) major

Visceral Leishmaniasis is a chronic and lethal, parasitic disease. In the later infection stages, it is known that expressive hematological disorders can be observed, including changes in the frequency and phenotype of certain leukocytes. There is a lack of good prognostic indicators to characterize the on-goin clinical status of the patient. In this study, we have analyzed the frequency of monocyte subpopulations in mice infected with Leishmania major (L. major). Our results show a significant correlation between increased blood monocyte frequency and lesion development in both BALB/c and in the C57BL/6 mice infected with L. major. In BALB/c mice we observed a significant correlation between the frequency of GR1⁺ monocytes and lesion size. Furthermore, treatment of infected BALB/c mice with Anfotericin B, to resolve lesions, resulted in a lower frequency of GR1⁺ monocytes compared to untreated infected BALB/c mice. C57BL/6 infected mice, which normally resolve infections, show decreased numbers of monocytes during the healing phase of infection. The results indicate that disease severity can be predicted by analyzing monocyte frequency. Thus, we propose that the frequency of monocytes, can be used to define the severity of the disease as well as the success of the treatment in experimental leishmaniasis.

Recent Development of Visceral Leishmaniasis Treatments: Successes, Pitfalls, and Perspectives

Research in visceral leishmaniasis in the last decade has been focused on how better to use the existing medicines as monotherapy or in combination. Systematic research by geographical regions has shown that a universal treatment is far from today's reality. Substantial progress has been made in the elimination of kala-azar in South Asia, with a clear strategy on first- and second-line therapy options of single-dose liposomal amphotericin B and a combination of paromomycin and miltefosine, respectively, among other interventions. In Eastern Africa, sodium stibogluconate (SSG) and paromomycin in combination offer an advantage compared to the previous SSG monotherapy, although not exempted of limitations, as this therapy requires 17 days of painful double injections and bears the risk of SSG-related cardiotoxicity. In this region, attempts to improve the combination therapy have been unsuccessful. However, pharmacokinetic studies have led to a better understanding of underlying mechanisms, like the underexposure of children to miltefosine treatment, and an improved regimen using an allometric dosage. Given this global scenario of progress and pitfalls, we here review what steps need to be taken with existing medicines and highlight the urgent need for oral drugs. Furthermore, it should be noted that six candidates belonging to five new chemical classes are reaching phase I, ensuring an optimistic near future.

Epidemiological aspects of human and canine visceral leishmaniasis in State of Alagoas, Northeast, Brazil

Abstract Zoonotic visceral leishmaniasis (ZVL), caused by protozoans of the genus Leishmania, it is a worldwide of great importance disease. In the northeast region of Brazil, the state of Alagoas has an endemic status for ZVL. Thus, this work aimed to analyze the epidemiological situation of human and canine visceral leishmaniasis in Alagoas, Northeast, Brazil, from 2007 to 2013. We conducted a descriptive, observational, retrospective study using secondary data from the Notifiable Diseases Information System, the Center of Zoonosis Control of Maceió, and the Central Laboratory of Public Health of Alagoas. During the studied period, it was observed that the highest incidence of human visceral leishmaniasis was in 2011 and the lowest in 2013. On the other hand, canine visceral leishmaniasis had its highest incidence in 2007 and its lowest in 2012. Of the 55 municipalities in the State of Alagoas that showed human visceral leishmaniasis (HVL), São José da Tapera presented an average of 4.4 cases over the past five years, being classified as of intense transmission. Regarding canine visceral leishmaniasis, in the same studied period, 45,112 dogs were examined in the State, of which 4,466 were positive. It resulted, thus, in a 9.9% positivity rate. Conclusions: Our data are important because canine infection is an important risk factor for the human disease.

Changes in the epidemiology of visceral leishmaniasis in Brazil from 2001 to 2014

INTRODUCTION

Visceral leishmaniasis (VL) is a neglected disease, with territorial expansion and regional differences in Brazil that require explanation. This study aimed to describe changes in the epidemiology of VL in Brazil from 2001 to 2014.

METHODS

The incidence rates, sociodemographic and clinical data, and case evolution were subgrouped from 2001 to 2006 and from 2007 to 2014 and presented descriptively. Spatial distribution of disease incidence rates and changes in the spatial and temporal pattern were examined.

RESULTS

In total, 47,859 VL cases were reported in Brazil between 2001 and 2014, with predominance in the Northeast macroregion (55%), though the incidence rate in this region declined between the two study periods. The State of Tocantins had the highest crude rate (26.2/100,000 inhabitants), which was responsible for VL increasing in the North macroregion. VL predominated in the urban zone (70%), in children under 4 years (34%); however, an increase in the incidence of VL in adults older than 40 years was identified, with 12.3% and 31% in the first and second period, respectively. The mapping of crude rates and autochthonous canine cases showed territorial expansion. The temporal distribution of VL was consistent in Brazil in general, with no pattern observed, but regional differences were found.

CONCLUSIONS

The incidence of VL is increasing in Brazil. In addition to the State of Tocantins, which had the highest rate, new outbreaks of VL have occurred in the South macroregion of Brazil with small decreases identified in the incidence rate in the Northeast.

The direct costs of treating human visceral leishmaniasis in Brazil

INTRODUCTION:

The drugs available for visceral leishmaniasis (VL) treatment in Brazil have specific characteristics in terms of operability, effectiveness, toxicity, and cost. The aim of this study was to estimate the direct costs of therapies recommended by the Ministry of Health (MH) for VL treatment in Brazil.

METHODS:

The analytical perspective used was that adopted by the Brazilian Public Health System. Three drugs and four regimens were included: 1) N-methyl glucamine antimoniate intramuscularly at 20mg per kg per day for 30 days; 2) N-methyl glucamine antimoniate intravenously at 20mg per kg per day for 30 days; 3) amphotericin B deoxycholate at 1mg per kg per day for 21 days; and 4) liposomal amphotericin B at 3mg per kg per day for a 7 days treatment.

RESULTS:

The estimated direct costs of treatment for an adult patient using N-methylglucamine antimoniate administered via the intramuscular and intravenous routes were USD 418.52 and USD 669.40, respectively. The estimated cost of treatment with amphotericin B deoxycholate was USD 1,522.70. Finally, the estimated costs of treatment with liposomal amphotericin B were USD 659.79, and USD 11,559.15 using the price adopted by the WHO and the Drug Regulation Board, respectively.

CONCLUSIONS:

This analysis indicates the economic feasibility of replacing N-methyl glucamine antimoniate with liposomal amphotericin B, which allows a shorter treatment period with less toxicity compared with other treatments, provided that the purchase value used by the WHO and transferred to the MH is maintained.

Efficacy and safety of available treatments for visceral leishmaniasis in Brazil: A multicenter, randomized, open label trial

Background

There is insufficient evidence to support visceral leishmaniasis (VL) treatment recommendations in Brazil and an urgent need to improve current treatments. Drug combinations may be an option.

Methods

A multicenter, randomized, open label, controlled trial was conducted in five sites in Brazil to evaluate efficacy and safety of (i) amphotericin B deoxycholate (AmphoB) (1 mg/kg/day for 14 days), (ii) liposomal amphotericin B (LAMB) (3 mg/kg/day for 7 days) and (iii) a combination of LAMB (10 mg/kg single dose) plus meglumine antimoniate (MA) (20 mg Sb⁺⁵/kg/day for 10 days), compared to (iv) standard treatment with MA (20 mg Sb⁺⁵/kg/day for 20 days). Patients, aged 6 months to 50 years, with confirmed VL and without HIV infection were enrolled in the study. Primary efficacy endpoint was clinical cure at 6 months. A planned efficacy and safety interim analysis led to trial interruption.

Results

378 patients were randomized to the four treatment arms: MA (n = 112), AmphoB (n = 45), LAMB (n = 109), or LAMB plus MA (n = 112). A high toxicity of AmphoB prompted an unplanned interim safety analysis and this treatment arm was dropped. Per intention-to-treat protocol final analyses of the remaining 332 patients show cure rates at 6 months of 77.5% for MA, 87.2% for LAMB, and 83.9% for LAMB plus MA, without statistically significant differences between the experimental arms and comparator (LAMB: 9.7%; CI95% -0.28 to 19.68, p = 0.06; LAMB plus MA: 6.4%; CI95% -3.93 to 16.73; p = 0.222). LAMB monotherapy was safer than MA regarding frequency of treatment-related adverse events (AE) (p = 0.045), proportion of patients presenting at least one severe AE (p = 0.029), and the proportion of AEs resulting in definitive treatment discontinuation (p = 0.003).

Conclusions

Due to lower toxicity and acceptable efficacy, LAMB would be a more suitable first line treatment for VL than standard treatment. ClinicalTrials.gov identification number: NCT01310738.

Trial registration

ClinicalTrials.gov NCT01310738

Visceral leishmaniasis remains a worldwide public health concern with high mortality even when proper treatment is instituted. There is a need to develop efficacious, safer and shorter treatment alternatives as the current options suffer from high toxicity and long treatment duration. Combination therapies emerge as an alternative, and WHO has encouraged the conduct of studies to evaluate drug combinations where evidence for current treatment regimens is not available. In Brazil, there is no local evidence to support the current treatment recommendations. Therefore, a clinical trial was conducted in five hospitals in Brazil to evaluate the efficacy and safety of the current available treatments—meglumine antimoniate, amphotericin B deoxycholate and liposomal amphotericin B—and of a combination of liposomal amphotericin B, single dose, and meglumine antimoniate, in a shorter administration regimen. Preliminary safety results led to the discontinuation of the amphotericin B deoxycholate treatment arm and a planned interim analysis resulted in the trial interruption. The final results, comparing liposomal amphotericin B and liposomal amphotericin B plus meglumine antimoniate to the standard meglumine antimoniate treatment, did not show a statistically significant difference in cure rates, though cure rate was higher in the liposomal amphotericin B group. Liposomal amphotericin B treatment showed a better safety profile compared to meglumine antimoniate. These results will support future changes in treatment protocols in Brazil and potentially in Latin America.