w w w . e l s e v ie r . c o m / l o c a t e / b j i d
The
Brazilian
Journal
of
INFECTIOUS
DISEASES
Case
report
Epidemiological
aspects
of
the
first
human
autochthonous
visceral
leishmaniosis
cases
in
Porto
Alegre,
Brazil
Ibrahim
Clós
Mahmud
a,∗,
Letícia
de
Araujo
Saraiva
Piassini
b,
Fabrizio
Motta
c,
Paulo
Renato
Petersen
Behar
d,
Getúlio
Dornelles
Souza
eaInstitutodeGeriatriaeGerontologiadaPontifíciaUniversidadeCatólicadoRioGrandedoSul(PUCRS),PortoAlegre,RS,Brazil bUniversidadeRitterdoReis(Uniritter),PortoAlegre,RS,Brazil
cHospitaldaCrianc¸aSantoAntônio,PortoAlegre,RS,Brazil
dUniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UCFSPA),Servic¸odeInfectologiadaSantaCasadeMisericórdiadePorto
Alegre,PortoAlegre,RS,Brazil
eCoordenadoriaGeraldeVigilânciaemSaúde(CGVS),PortoAlegre,RS,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received3October2018 Accepted13April2019 Availableonline21May2019
Keywords:
Visceralleishmaniasis Fevercausedbysandflies Communicablediseases
Leishmaniainfantum
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b
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HumanvisceralleishmaniasisisagrowinganthropozoonosisinBrazil,andparticularlyin thesouthernregionofthecountry.Itisaninfectiousdiseasetransmittedtohumans,dogs andotheranimalsinurbanandruralareasoftheAmericas,mainlyduetothebiteof Lut-zomyalongipalpisinfectedwithLeishmaniainfantum.Thisarticleaimstoportraythecurrent epidemiologicalsituationofthehumanvisceralleishmaniasisarrivalinPortoAlegrecity, locatedinthesouthernregionofBrazil.Itisadescriptivestudy,acaseseriesanda criti-calreview.Sixhumancaseswithhumanvisceralleishmaniasiswerenotifiedbythedate ofconclusionofthestudy,allhumanvisceralleishmaniasiscaseswerediagnosedatlate stage,leadingtofourdeaths.
©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.Thisis anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
Introduction
Humanvisceralleishmaniasis(HVL)isagrowing anthropo-zoonosisinBrazilandinRioGrandedoSul(statelocatedin southernBrazil).AccordingtotheHandbookonSurveillanceand Controlof VisceralLeishmaniasis,1 inBrazil,HVLuse to have aneminently rural character, but has reachedthe popula-tionofurbanareasduetointensemigratoryflow.Somelarge
∗ Correspondingauthor.
E-mailaddress:ibrahimmahmud@hotmail.com(I.C.Mahmud).
urbanareas,suchasRiodeJaneiro(RJ),BeloHorizonte(MG), Santarém(PA),Fortaleza(CE),andCampoGrande(MT)have sufferedthisurbanizationprocessofthedisease,highlighting severaloutbreaksthatoccurredintheregion.2,3
In the southern region, the statesof Paraná and Santa CatarinadidnotreportcasesofHVL,butRioGrandedoSul (RS) isnotinthissituation,sincethemunicipalitiesofSão Borja,UruguaianaandItaqui,borderingArgentina,presented autochthonouscasesin2008and2009.Itisbelievedthatthis
https://doi.org/10.1016/j.bjid.2019.04.004
1413-8670/©2019SociedadeBrasileiradeInfectologia.PublishedbyElsevierEspa ˜na,S.L.U.ThisisanopenaccessarticleundertheCC BY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).
situation expandeddue tothe transit ofpeople withtheir petscomingfromArgentina,ascasesofHVLwererecordedin Posadas-Misiones(2006)andVirasoro-Corrientes(2008). Dur-ingthisperiod,researchintheareaverified,bytheyear2010, fivecasesofconfirmed HVLinSão Tomé (borderwithSão Borja).4–6InPortoAlegre,capitalofRS,thefirstautochthonous caseregisteredinSeptember2016wasapatientaged1year and7monthswhoendedupdyingfourmonthsaftertheonset ofsymptoms.Thiscaseledtogreatmobilizationofthe gov-ernmenttowardsthe qualificationofthe professionalsand implementationofepidemiologicalcontrolmeasures.
Methodology
Thiswas a descriptive study,a seriesof casesand critical review.Datawerecollectedasfollows:hospitalrecordswith priorauthorization,includingtheERC(onlythefourthcase), and secondary public data of the General Coordination of HealthSurveillance(CGVS)(othercasesreported).Thisstudy wasapprovedbytheEthicsandResearchCommitteeofthe SantoAntôniodaCrianc¸aHospital–SantaCasa/RSunderno. 2,657,622.
Results
Casesofhumanvisceralleishmaniasis
PortoAlegreisacitylocatedtotheeastofthestateofRS,being themostsoutherncapitalofBrazil,belongstothe metropoli-tan mesoregionand hasa verydiversified geography, with hills,lowlandsand agreatlakeand presentsahumid sub-tropicalclimate.Accordingtothe2010census,thepopulation isapproximately1millionand500thousandinhabitants.
Until the last epidemiological bulletin ofthe CGVS, six casesofHVLhadbeendiagnosedand ofthose fourpeople died.7Ofthesixcases,fivewerediagnosedintheemergency roomofthehospitalswithdiversemanifestationsthatledto suspicionofHVL.Inallcases,thediseasewasconfirmedby bonemarrowaspirationforinvestigationofcytopenias.The sixthcasewasdiagnosedinaprimaryhealthunit(UBS).
The first case of autochthonous HVL was a 1 year and 7month-old female patient with no comorbidities.In September2016,thepatientwithsevereanemiaand throm-bocytopeniawasseenatanemergencyroomwithahistoryof episodesofintermittentfeverthathadstartedfourmonths beforewithout resolution.Asthe patientwassuspected to have leukemia, she was referred to a hospital for further investigation.Basedontheresultbonemarrowaspirationthe patientwasdiagnosedwithHVLandbegantreatmentwith liposomalamphotericinB,butdiedaftertwodays.This sit-uationledtheHealthDepartmentofPortoAlegretodeclare anepidemiologicalalertsituation,andestablisheda “Situa-tionRoom”withthemandateofanalyzingtheregionwhere thepatientlived,qualifyingprofessionalsandcapturing vec-tors.
Thesecond casehad investigation initiated inFebruary 2017,whenthehospitalnotifiedthecaseaftertheresultof bonemarrowaspirate.Thepatient,a43year-oldmale,had
a historyof tuberculosistreatmentand relapses,so it was believedthathewashavinganotherrecurrence.After evidenc-ing the parasitesinthe aspirate, treatmentwithliposomal amphotericinBwasinitiated,butthepatientdiedwithintwo days.
ThethirdcaseofHVLoccurredinMay2017.Thepatient was82year-oldfemale,hypertensiveanddiabetic.She pre-sented withahistoryofdizziness andinappetence15days beforebeingadmittedtothehospitalwithabdominalpainand aweightlosscomplaint.Leukemiawasalsosuspected, lead-ingtobonemarrowaspiration,whichconfirmedthediagnosis ofHVL.Afterthestartoftreatment,thepatientdied.
ThefourthcasewasdiagnosedinAugust2017.Thepatient wasa1yearand5month-oldfemalewithnocomorbidities. Shehad ahistoryof15 daysofirritation,inappetence and intermittent feverof39◦C,andwasstarted on amoxicillin-clavulanateattheprimaryhealthcenterduetoradiological diagnosis ofbronchopneumonia.Asthepatient showedno improvement of his clinical condition and complained of abdominalpain, shewas admittedtoasecondaryhospital in the city, where hepatosplenomegaly and severe pancy-topenia(hemoglobin6.8g/dL,leucocytes2690/mm3,platelets 50,000/L).Asaresult,shewasreferredtoapediatrictertiary hospital for further investigation. A bone marrow aspi-rate was performed, which showed intracellular parasites characteristic ofleishmania. The patient was treated with liposomalamphotericinB4mg/kg/dayforfivedays,cefepime 150mg/kg/day for pneumonia, and blood transfusion. The patientwasdischargedinbetterclinicalconditionninedays after hospitalization. Ambulatory follow-up showed blood countnormalization60daysaftertheendoftreatmentand normalizationofhepatosplenomegalyfourmonthsafterthe end of treatment. Thepatient had no complicationof the described infectious disease 10 months after hospital dis-chargeandwasinexcellentgeneralcondition.Inthiscase, thepatientdidnotdye,emphasizingthatafterfivedaysof treatmenttherewasclinicalandlaboratoryimprovement.
Itshouldbepointed outthat, withtheexception ofthe elderly patient, all had intermittent fever with for more than sevendays. Hepatosplenomegalyandcytopeniaswere observedinallcaseswithensuingsevereopportunistic infec-tionsleadingtodeathofthesethreepatients.Itisimportant toclarifythattheelderlypatientprobablydidnotpresentthe classicpicture duetothephysiological immunosenescence stateduetoaging,thusmakingdiagnosisdifficult.
Thefifthcasewastwo-yearandeightmonthsoldgirlwho wasadmittedtoacityhospitalforcancertreatment.InherMO aspiratetheamastigoteswerefound,andshediedinOctober 2017.
Finally,themostrecentcasewasayoungadultwhostarted withfeverandlookedforcareinanemergencyroomwherehe receivedtreatmentfordengueanddischarged.Nonetheless, hisclinicalconditiondeteriorated(tiredness,pallor,dizziness) andpatientwasexaminedinotheremergencyroomsinthe region, wherelaboratorytestswere performedthatdidnot ledtothecorrectdiagnosisorsuspicionofthedisease.Onthe 13thdayoffever,hewasseenataprimaryhealthcenter(UBS), wherethediseasewasultimatelydiagnosedandthepatient transferredtoareferralhospital,wherehereceivedspecific treatmentandhadafavorableoutcome.
Entomological
study
ItisknownthatHVLisaninfectiousdiseasetransmittedto humans,todogsandtootheranimals,bothinurbanandrural areasoftheAmericas,mainlybythebiteofLutzomya longi-palpisfemalesinfectedwithLeishmaniainfantum.Thisdisease wasfirstdiagnosedindogsoftheregionintheyear2010, trig-geringanintenseinvestigationbythevectors.Accordingto datapublishedintheEpidemiologicalBulletinoftheCGVS,in 2014,afterevidenceofanothersickanimal,newinvestigation wasstarted insearch ofthe vectors.7 Thesandflies identi-fiedwerePsathyromyalanei,Brumptomyasp.,Pintomyiafischeri, Migonemyamigonei, and Nyssomyia neivai. Aftersendingthe samplestoareferenceresearchcenter,Le.infantum(PCR tech-nique)wasfoundinthefemalesofPi.fischeri,thusevidencing theimportanceofthisphlebotomineinthetransmissionof thedisease.
Thus, with the confirmation of the first case of LV in humans inSeptember 2016, anew phase beganaiming at capturingvectorsinvolvedinthetransmissionofLV, generat-inganintensecollectionofsandfliesintheregionswherethe patientslived,withinaradiusof50m,usinglightbaitedtraps (CDCtype) inthreeconsecutive nightsper monthbetween October2016andMay2017.
Duringthisperiod,437phlebotominesofdifferentspecies werefound,andintheinternalenvironmentoftheresidences threespecieswerecaptured:Pi.Fischeri,Mg.migoneiandLu. gaminarai,thelatterreached90.4%ofthespecimensdetected inhouses.Intheperidomiciliaryenvironment,therewas a predominanceofMg.migonei(45.79%),followedbyPi.Fischeri
(26.01%)andLu.gaminaria(17.58%).Itshouldbeemphasized thatinPi.FischeriandMg. migoneispeciesLe.infantumwere foundbyPCR-multiplextechnique.
Discussion
Diagnosis,symptomatologyandwarningsigns
HVLisaserious andlethalzoonosis in90%ofcases.After beinginfectedbythevector,theindividualundergoesan incu-bationperiodthatvariesaccordingtohis/herimmunestatus, between10daysand24months.Itshouldbeunderscoredthat notallinfectedpatientswilldevelopthedisease.TheBrazilian MinistryofHealthrecommendsthattheavailablediagnostic methodsbeusedonlyincaseswithcompatible symptoma-tology,sincepersonsresidinginhighprevalenceareasmaybe asymptomaticdespitebeinginfectedanddonotrequireany treatment.1,8
AccordingtotheMinistryofHealth1andtheGCVS diag-nostic flowchart,9 every patient with a prolonged fever of atleast sevendays, and presenceof hepatomegalyand/or splenomegalyshouldbenotifiedandinvestigatedifcoming fromanendemicarea.Theremustbeapreviousdiscussion withtheprofessionaloftheCGVSforfurtherserological exam-ination.
InthecityofPortoAlegre,therapidtestisfoundin spe-cifichealth unitsofeach district healthmanagement, and
patientsarescreenedwiththerapidimmunochromatographic testrK39.In2003,theMinistryofHealthfundedamulticenter studytovalidatetheDiaMed-IT(IT-Leish)testthatpresented promising results.However, in2009the Ministry ofHealth acquiredtherK39testofKalazarDetect®.10,11
In2015,KalazarDetect®wasreplacedbyIT-Leish®,which was widely used by the Ministry of Health. It has as the advantageofusing wholeblood, unlikerK39that uses the bloodserum.12AccordingtotheBrazilianMinistryofHealth,12 studiesconductedforevaluatingIT-Leish® inBrazilshowed 92–93%sensitivityand95.6–97%specificity,betterresultsthan those obtainedwithKalazar Detect®, 84.7–88.1%sensitivity and90.6–96.8%specificity.Itisemphasizedintheflowchart9 thatthepatientmustbepreviouslysubmittedtotherapidtest toruleoutinfectionbytheHumanImmunodeficiencyVirus (HIV).12,13
Thepatientshouldbereferredtoareferralhospital,if pos-sible,toperformbonemarrowaspiration,whichwillevidence the presenceor absence of the parasite. In the four cases reportedonlyspinalaspiratewasobtained,sincetherewas no suspicionofHVL,and thusthe rapidtestrK39wasnot performed.Thatmeanstheflowchartwasnot“followed”.
The symptomatology varies quite considerably, but as shownintheflowchart,9patientswillhaveprolongedfever, increasedliverand/orspleen,andcytopenias arecommon. Anemia is the most frequent and translated by a pallor appearance,fatigue,adynamia,dyspnea,andgeneralmalaise. Neutropenia canoccur andleadtoinfectionswhichshould betreatedearlytoavoidsepsisand,potentially,death.Other associated symptoms are: weight loss in recent months, chroniccough,diarrhea,abdominalpain,andedema(onlower limbs).
Thecasespresentedherein werediagnosed withsevere cytopenias, but five out of six had classic symptoms that shouldhaveraisedthesuspicionofleishmaniasis.We empha-size theclinical picture ofthe elderlypatient, who,dueto physiologicalimmunosenescence,didnotdevelopfeverand hepatosplenomegaly,thusmakingdiagnosismore challeng-ing.
Thefourthandsixthcaseshadarapidevolutionand pre-sentedallclassicsymptomsofthedisease,butnonetheless therewasadelayinsuspectingHVL.Itshouldbenotedthat thepatientshadafavorableprognosisastheyhadbeen diag-nosedatanearlystageofthedisease,evenafteralongfebrile period.
Alarm or severity signals are associated withincreased lethalityofthedisease,whichcallformoreaggressivetherapy fromthestart.TheMinistryofHealth12carriedouta system-atic reviewinwhichthefactorsassociatedwithhigherrisk ofdeathinpatientswithHVLarecategorizedaccordingtothe levelofimportanceasA,B,CandD,whereAandBareevidence basedonobservationalandexperimentalstudies.Riskfactors stratifiedasAandBare:agelessthanoneyearandover40 years,associatedbacterialinfection,presenceofdiarrheaor vomiting,edema,feverformorethan60days,jaundice, hem-orrhagic episodes, signs oftoxemia, comorbidities, platelet count≤50,000/mm3,hemoglobinlevel≤6g/dLand bilirubin above the reference values. The morecriteria present, the worsethepatient’sprognosis.12
Treatment
of
human
visceral
leishmaniasis
Currently,fewdrugsareavailablefortreatingHVL.InBrazil, theavailabledrugsarepentavalentantimoniateand ampho-tericinB (deoxycholateand liposomal). Thechoiceofdrug shouldtakeintoaccounttheagerange,pregnancy,and pres-enceofcomorbidities.Pentavalentantimonial(Glucantime®) isthemostused drug,sinceit hasthe advantageofbeing administered in the clinic, thus reducing the risks associ-atedwithhospitalization.However,thistreatmenthasseveral contraindicationsandadverseeffects,besideslastingfor30 days.
Amphotericin Bis the mostpotent leishmanicidaldrug available commercially, acting against promastigote and amastigoteformsoftheparasite. Currently,theMinistryof Healthofferstwopresentations,amphotericinBdeoxycholate andliposomalamphotericinB,thelatterbeinglesstoxic.
AccordingtotheMinistry ofHealth guidelines,14 liposo-malamphotericinBhasspecific indicationsandshould be requestedinaseparateform,asitisrestrictedonlyforpatients withrenalimpairmentorrenaltransplantation,over50years ofage,orpresentingeithercardiacorhepaticabnormalities.14 The use of liposomal amphotericin B can be adminis-tered for a period of only 5–7 days according to the dose usedandprovidesafasterresponsecomparedtootherdrugs. Thus,hospitallengthofstayismuchshorterwhencompared toamphotericinB deoxycholateregimen, which should be administeredforaperiodof14–20days.
ThetreatmentofHVLisbasednotonlyonspecific man-agement with leishmanicidal drugs, but often the patient willrequire redbloodcellstransfusions andevenplatelets. Inaddition, themanagementofneutropeniaandinfectious foci is important for the patient’s prognosis, with sepsis and febrile neutropenia being very frequent in this group ofpatients. In the case reported, the patient required red bloodcellconcentrateandantibiotictherapydueto respira-toryinfection,aswellastheuseofliposomalamphotericin B forfive days, achieving a rapid improvement in clinical status.
Afterendingtreatmentand improvementoftheclinical picture,thepatientisdischarged,butshouldbefollowedup, since relapses occur in 5% ofcases in the first year after treatment, being more frequent in the first three months. Theclinicalpictureofthepatientimprovesprogressivelyand slowly,curecriteriaare essentiallyclinical,and earlysigns ofresponse are usually nonspecific, such as improvement inappetiteandoverallhealth.Defervescenceoffeveroccurs betweenthesecondandfifthdayoftreatment.Weightgain and reduction of spleen and liver volume can be seen in thefirstfewweeks,althoughfullregressionmaytakeafew months.Hematologicalparametersimproveafterthesecond week.Normalizationofserumproteinsisslowandmaylast formonths.14
The Ministry of Health1 recommends consultations for clinical controlofthe patient at3, 6and 12 months post-treatment. Only after this period without symptoms and laboratoryabnormalitiesthepatientisconsideredtobe clin-icallycured.SurvivorsofHVLepisodeshouldbefollowedup for12monthsaftertheirepisode.
Etiologic
agent,
vectors,
reservoirs
and
their
implications
TheetiologicalagentsofHVLaretrypanosomatidprotozoans ofthegenusLeishmania,whichareobligateintracellular par-asites of cells of the mononuclear phagocytic system and canhavetwoforms:flagellateorpromastigote.Thefirstcan befoundinthedigestivetractoftheinsectvector,and the second,non-flagellateoramastigote,intissuesofvertebrate animals. The life cycle of the parasite in the insect takes around72h.1
ThevectorsofHVLareinsectsclassifiedassandflies, pop-ularlyknownasmosquito-straw,birigui,tatuquirasetc.They are verysmalldipterans,measuring4–5mm, have compos-iteeyesthattakesalargepartofthehead,absentocelli,long antennae,wingswithlancearianshapeandwithparallel lon-gitudinalveins,abdomenwith10segments–thatfromthe eighthonwardsaremodifiedtoformthepartsofthegenital tract–andhavesuckingmouthparts,andthusareconsidered hematophagous.Thebiologicalcyclepresentsfourstagesof development:egg,larva(fourstages),pupa,andadult.After copulation,thefemalelayseggsonhumidsubstratesinsoil withpresenceofalotoforganicmatter,whichunderoptimal conditionsoftemperatureandhumiditydevelopin approx-imately a week,resulting in larvalhatching. Thelarva are vermiform, apodic and, afterecdysis, onlymove after the hardeningofthechitin.Itsdevelopmentoccursaround20–30 daysindecayingvegetablematter,treeholesfilledwith rot-tingleavesandinexcrementfoundwithvegetableremains andfoodinanimaldens.Thepupaphasetakes10–15days, doesnotfeedandcanbreathe.Thewholecyclelastsaround 30–40days,resultinginhematophagousfemalesandmales thatfeedonvegetablesap.Theactivityoftheseinsectsis twi-lightandnocturnal.Theyhavelittleabilitytoflyanddonot seekfoodmorethan200maway.Duringtheday,theyare shel-tered fromthewindandfromnaturalpredators,atrest,in shadyandhumidplaces.Phlebotominesarefoundperiand in-house,closetofoodsources.Thelongevityofadultinsects is27days.
FromFebruarytoMay2017,themostprevalentspeciesin Porto Alegre were Mg.migonei, Lu.gaminaraiand Pi. fischeri,
whichpresentahighdegreeofanthropophiliaandcanbe cap-turedintheresidualforestsofthemarginalareasofthecities, insheltersofdomesticanimalsandinternalwallsofhuman households.Therampanturbanization,withresidencesnear areas of forests, makespossible the development ofthese insectsintheseplaces.7
ThereservoirsofVLintheurbanareaaredogs(canis famil-iaris), eventhough casesof catsand poultry infectedwith parasiteshavebeendetected.Thehighreproductiverateof theseanimalsandtheincreasingabandonmentfacilitatesthe dispersionofthevectorintheurbanenvironment, generat-ing idealconditions foran epidemicofthe disease.In the wild,themainreservoirsarefoxes(Dusicyonvetulusand Cerdo-cyonthous)andmarsupials(Didelphisalbiventris).13Theinfected foxes werefoundintheNortheast,Southeastand Amazon regions,andmarsupialswerefoundinBrazilandColombia.1
HVLisanimmune-mediateddisease,butwhendogsand humansarecompared,dogspresenthigherratesofmorbidity
andmortality,andthiscanbeexplainedbythegreater para-siteloadintheskin,favoringvectorinfestation.Theimmune responseofhumansisgreaterandmoreeffectivewhen com-paredtothatofdogs.14
Methods
of
prevention
and
control
of
the
vector
ThegeographicaldistributionofPorto Alegre assistsinthe entomologicalandepidemiologicalstudyofVL,sinceitis pos-sibletoverifytheendemicareasofdiseasetransmission,to observethetypeofvegetation,andthesocioeconomic con-ditionsofthepopulation. Inthesix casesdescribed inthe municipalityin 2017, the patients’ residences were always in the last blocks of the streets, located in the middle of native forest,with sandyand humid soil,presenceof sev-eraldogsandchickens,andgarbageaccumulation.Thehigh socialvulnerabilityofthispopulationwasalsonoted.Adding allthesefactors,theenvironmentisoptimalforproliferation andreproductionofthesand-fly.Basedonthesedata,it is importanttochartaseriesofvectorpreventionandcontrol actionstoreducediseasetransmission.
TheMunicipalHealthDepartmentofPortoAlegrecreated aMunicipalPlanforIntensificationoftheActionsof Surveil-lanceandControlofVisceralLeishmaniasis,inwhich,firstly, thecitywasstratified,highlightingtheriskareasforthe dis-ease,usingasaparameterinfecteddogsandthepresenceof vectors,whichwerecollectedwiththehelpofspecifictraps. Thehealthteamshadtolearnhowtoapproachandhostthe suspectpatient,aswellastoeducatethepopulationonways todecreasevectorspread.
Community agentsand endemic disease control agents carriedoutactivesearchvisitstohomesneartheconfirmed cases,tosearchforpossiblesymptomaticpatients.In addi-tion,basedonactionsoftheSanitarySurveillance,atthetime ofbloodcollection (rapid test)ofdogsresiding 50mofthe patient’sareathe agentsinstructedthe residentstoalways keeptheirpatioclean,collectinggarbageandanimalwaste. Inthe200-mradiusofconfirmedcases,alpha-cypermethrin insecticidewasappliedintheperidomicile,inthe external wallsofthehousesandinotherexternalareas,and inthe in-dwelling for the residents who accepted this measure, sincetheyshould returntotheirresidences only24hafter application.7
AccordingtotheMinistryofHealth,1thepopulationneeds to follow individual protection methods, such as the use ofthin mesh nets,door and window sizing, repellent use andnoexposureduringvectoractivitytimes.Environmental managementissuessuchasyardhygiene,publiclandsand squares,properdisposal oforganicsolidwaste,elimination ofsourcesofmoisture,and avoidingdomesticanimals are required.
Anotherimportantissueispreventivemeasuresandcare ofdomesticanimals,astheyarecarriersofthedisease. Treat-ment of positive dogs and the preventive vaccination are notrecommendedbytheMinistryofHealthbecausetheydo notmakefullcoverage andtheanimalremainssusceptible to contracting leishmaniasis. The best alternative is hav-ingdogstowearcollars,asimpleactionthatcanrepelthe phlebotomine.15,16
Final
considerations
Health teams ofthe city ofPorto Alegre shouldbe trained consideringthatprofessionalsarenotawareofHVL.Inthe majorityofthecases,professionalsdidnotsuspectofHVLin thedifferentialdiagnosesinfebrilepatients.Itisalsoworth noting the significant lethality rate ofHVL inour patients whichdeservesfurtherinvestigation.
According to the diagnosed casesof HVL, it was possi-bletodrawaprofileofvectorbehavior,whichwasrural,but isbecomingurbanbecausepeopleincreasinglyinvadethese regionsofnativeforesttobuildtheirhomes.Phlebotomine andtheHVLparasitedonothaveapredilectionforthehuman speciesforitsdevelopment,butthelackofotherhostsandthe proximityofthepopulationwithforestenvironmentsendup facilitatingthespreadofthedisease.Regardingdogs,thebest formofpreventionisstillthenesting;andforhumans,isthe useofrepellents,window-sizingandshrinkageofthevector breedinggrounds.
Acknowledgments
Dr.LuisCarlosRibeiro,headofthePediatricInfectologyService oftheSantoAntônioChildren’sHospital.
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