Characterization and speculations on the urbanization of visceral leishmaniasis in Brazil

Spatio-temporal relative risks and priority areas for visceral leishmaniasis control in Brazil, between 2001 and 2020

Visceral leishmaniasis (VL) is a pressing public health problem in Brazil. The proper implementation of disease control programs in priority areas is a challenge for healthcare managers. The present study aimed to analyze the spatio-temporal distribution and identify high risk areas of VL occurrence in the Brazilian territory. We analyzed data regarding new cases with confirmed diagnosis of VL in Brazilian municipalities, from 2001 to 2020, extracted from the Brazilian Information System for Notifiable Diseases. The Local Index of Spatial Autocorrelation (LISA) was used to identify contiguous areas with high incidence rates in different periods of the temporal series. Clusters of high spatio-temporal risk were identified using the scan statistics. The accumulated incidence rate in the analyzed period was 33.53 cases per 100,000 inhabitants. The number of municipalities that reported cases showed an upward trend from 2001 onward, although there was a decrease in 2019 and 2020. According to LISA, the number of municipalities considered a priority increased in Brazil and in most states. Priority municipalities were predominantly concentrated in the states of Tocantins, Maranhão, Piauí, and Mato Grosso do Sul, in addition to more specific areas of Pará, Ceará, Piauí, Alagoas, Pernambuco, Bahia, São Paulo, Minas Gerais, and Roraima. The spatio-temporal clusters of high-risk areas varied throughout the time series and were relatively higher in the North and Northeast regions. Recent high-risk areas were found in Roraima and municipalities in northeastern states. VL expanded territorially in Brazil in the 21st century. However, there is still a considerable spatial concentration of cases. The areas identified in the present study should be prioritized for disease control actions.

Factors associated with the expansion of leishmaniasis in urban areas: a systematic and bibliometric review (1959-2021)

This work describes a systematic and bibliometric review of the factors that contribute to the expansion of leishmaniasis in urban areas. Three scientific databases were used: Scientific Electronic Library (SciELO), Scopus and Web of Science, encompassing all original and review articles between 1959 and 2021. Three descriptors were used: "leishmaniasis" AND "urban" AND "rural." Planning, execution, summarization, and selection processes were performed using StArt (State of the Art through Systematic Review) software. We obtained a total of 304 articles, 60 of which concerned canine leishmaniasis. The factors associated with the expansion of leishmaniasis in urban areas are interrelated, including socioenvironmental and economic complexity, the type of leishmaniasis, the reservoirs, vectors, deforestation, disorderly occupation of space, poor sanitary conditions, and human migration trends. A lack of diagnosis and underreporting of cases in some regions may reflect the increase of cases seen in urban areas. A majority (n = 121) of studies were conducted in Brazil, followed by Iran (n = 43). In relation to publications; in general, output has increased over the years, particularly in 2021. The majority of published studies were in the area of epidemiology (n = 158).

Serosurvey of anti-Leishmania (Leishmania) infantum antibodies in hunting dogs and hunters in Brazil

Background and Aim:

Although wild boar hunting activities and the hunting dog trade in the Atlantic Forest and Cerrado biomes of Brazil overlap both with endemic and with non-endemic areas for visceral leishmaniasis, no study to date has focused on Leishmania spp. exposure among hunting dogs and hunters. The aim of the present study was to assess the presence of Leishmania spp. antibodies in hunting dogs and hunters in different anthropized areas of two Brazilian biomes.

Materials and Methods:

Blood samples were collected from 170 hunting dogs and 46 hunters between October 2016 and May 2018. The presence of antibodies against Leishmania spp. in hunting dogs was screened through a dual-path platform immunochromatographic test (DPP rapid test; Bio-Manguinhos/Fundação Oswaldo Cruz, Rio de Janeiro, Brazil) and in hunters through an rK39-based rapid immunochromatographic test. Both tests were used in accordance with Brazilian Ministry of Health recommendations.

Results:

Overall, although antibodies were detected through the immunochromatographic test in 3/170 (0.02%) of these female asymptomatic hunting dogs, all living in anthropized areas of the Atlantic Forest biome in South Brazil, no sample was confirmed through the enzyme-linked immunosorbent assay. All the hunters were non-reactive in the rapid immunochromatographic test.

Conclusion:

Our study on three suspicious hunting dogs has suggested that Leishmania (Leishmania) infantum may circulate both in endemic and non-endemic areas in Brazil. In addition, a high rate of hunting dog replacement due to death and trade may have led to less chance of infection and transmission between animals and between animals and humans, which would corroborate the outcomes reported here. Further studies should be conducted to fully establish whether hunting dogs and hunters may be used as sentinels in other areas endemic for Leishmania spp.

[Epidemiological profile and time trend in visceral leishmaniasis: Piauí, Brazil, 2008-2018]

Visceral leishmaniasis (VL) or kala azar is one of the main neglected tropical diseases, of major importance due to the lethal nature of this zoonosis caused by protozoa of genus Leishmania. The study aimed to analyze the time trend in VL cases in the state of Piauí, Brazil, from 2008 to 2018, within the total period from 1971 to 2018. Data were obtained from the Brazilian Information System for Notificable Diseases (SINAN) and the Brazilian Mortality Information System (SIM). For burden of disease analysis, data were collected from the Institute for Health Metrics and Evaluation through the Global Burden of Diseases, Injuries, and Risk Factors (GBD Compare). Prais-Winsten regression analysis was used. A total of 2,374 cases were recorded with probable infection in the state of Piauí and 2,492 cases in residents of the state. The historical series analyzed, from 1971 to 2018, reaffirms the cyclical nature of the disease, based on the identification of epidemic peaks in 1983-1984, 1993-1994, 2003-2004, and 2013-2014. No significant alterations were identified in the trends in incidence, mortality, and case-fatality coefficients in the state. However, there was a significant increase in the incidence coefficient in the Chapada das Mangabeiras Development Territory, with an annual percent change of 17.5%, and a decrease in the Vale do Sambito Development Territory (-18.3%) and Vale do Rio Guaribas Development Territory (-8,1%). VL has a high burden of disease, measured by disability-adjusted life years, and is among the leading neglected tropical diseases in the state of Piauí. The study concludes by recommending the improvement of surveillance and control measures for this disease.

Biomarkers of disease severity in patients with visceral leishmaniasis co-infected with HIV

Visceral leishmaniasis (VL) is caused by the protozoan Leishmania spp, transmitted by sand fly bites. VL is one of the deadliest tropical infection diseases, yet the coinfection with HIV virus drastically increases relapses, treatment failure and mortality. The concomitant action of these two pathogens leads to high cellular activation independently of the progression to AIDS. In addition, microbial translocation and bacterial infections are thought to contribute worsening the clinical picture. Identifying biomarkers associated with disease severity is of interest for clinical management of patients with VL-HIV/AIDS. Thus, we analyzed in the sera several markers including interleukins (IL-1β, IL-6, IL-8, and IL-17), interferon-γ (IFN- γ), tumor necrosis factor (TNF), lipopolysaccharide (LPS), soluble CD14 (sCD14), macrophage migration inhibitory factor (MIF) and intestinal fatty acid-binding protein (IFABP). These markers were compared with disease severity in 24 patients with VL/HIV presenting different clinical outcomes. Disease severity was defined by the probability of death calculated using a score set system derived by the Kala-Cal® software. Probability of death ranged from 3.7% to 97.9%, with median of 28.8%. Five patients died (20%). At the univariate analysis, disease severity was correlated with TNF, IFN-γ and sCD14. LPS was positively correlated with sCD14 specifically in patients with low CD4⁺ count (CD4⁺ T-cell <200 cells/mL). Most importantly, the multivariate analysis including LPS, CD4⁺count and sCD14 showed that sCD14 was the only independent predictor for disease severity and death. Altogether, our results indicated that sCD14 is a powerful marker of pathogenicity and death for patients with VL-HIV/AIDS.

FML/QuilA-Vaccinated Dogs Naturally Infected with Leishmania infantum: Serum Cytokines, Clinicopathological Profile, and Parasitological Parameters

Dogs are the main reservoir of Leishmania infantum in endemic regions. Canine leishmaniasis, caused by L. infantum, can progress to a chronic disease resulting in death. Vaccines have been developed with a certain degree of success. The pathogenesis of this disease is not completely understood, especially in previously vaccinated dogs. We herein described clinical data, parasite load, serum levels of cytokines, and the reservoir potential in vdogs vaccinated with the fucose-mannose ligand (FML)/QuilA saponin vaccine (Leishmune™) naturally infected (Vi) and compared to vaccinated not infected dogs (Vn). Thirty-four dogs from private owners were divided into two groups: vaccinated/infected and vaccinated/uninfected. Clinical evaluation, hematological and biochemical parameters, and serum levels of cytokines were measured by conventional methods. The parasite burden in the bone marrow was measured by quantitative real-time PCR, and the transmissibility of parasites to sand flies was assessed by xenodiagnosis. Clinical, biochemical, and hematological parameters of vaccinated infected dogs were mostly normal. Vi dogs developed mild disease with low clinical scores. Serum levels of IL-10 were higher in Vi dogs, and a strong correlation was observed in IL-4 levels and the A/G ratio in Vi dogs. These results suggest a role of TH2 response in Vi dogs, although more data is needed to better understand the disease in vaccinated dogs.

The sand fly (Diptera: Psychodidae) fauna of the urban area of Lassance, Northeast Minas Gerais, Brazil

The present study aimed to check the sand flies' fauna on the municipality of Lassance, Minas Gerais, Brazil and detect the presence of Leishmania DNA on the female captured and determine the risk areas of the municipality. Sand flies were collected monthly from May 2018 to April 2019 using automatic light traps for 3 consecutive nights. Eight houses were selected as sample points due its previous reports of tegumentary leishmaniasis and/or canine leishmaniasis. The sand fly's fauna found on the present study it's represented by several medical importance species and the most abundant species found were Lutzomyia longipalpis (77.09%) and Nyssomyia intermedia (10.06%). Leishmania infantum DNA was detected in a pool of Lu. longipalpis resulting on a 2.81% of infection rate. By the frequency of the two most abundant species on this study, we developed a risk area map and it draws attention to sample point 6 due to disparate abundance of sand flies at this site (81.81%). Statistical overview shows Lu. longipalpis as dominant species and, still, Non-Metric Multidimensional Scaling analysis reveal high similarity on fauna's diversity on the study area. Our findings suggest that the diversity of sand flies from the municipality of Lassance may promote the circulation of Leishmania infantum parasites putting in risk the habitants and other mammal's species. Still, our study reinforces the necessity of specific studies focused on breed sites of phlebotomine and its' ecology to expand the knowledge about the behaviour of this group of insects applying directly to leishmaniases' epidemiology.

Knowledge, attitudes and practices concerning visceral leishmaniasis among residents of a sporadic transmission area in southeast Brazil

BACKGROUND

In the last four decades, visceral leishmaniasis (VL) has undergone an urbanization process in Brazil. This research aimed to assess the knowledge, attitudes and practices concerning VL among residents of a sporadic transmission urban area in southeast Brazil.

METHODS

A community-based, cross-sectional quantitative study was conducted. Scores for knowledge, attitudes and practices concerning VL were evaluated and the bivariate analysis was performed.

RESULTS

The analysis indicated that 29.9% had good knowledge, 5.2% had appropriate attitudes and 62.1% had appropriate practices. Notwithstanding that, pivotal practices for controlling VL had unsatisfactory individual frequencies. Good knowledge on VL was related to women, a higher level of education, a higher income, the place of residence and having pets. Appropriate attitudes were related to the place of residence. The practices had no significant associations with the sociodemographic and epidemiological variables.

CONCLUSION

This study demonstrated that even in the area of disease transmission, knowledge on VL is very limited, including at the most basic level. In order to achieve effectiveness in actions against VL in Brazil, the participation of the affected communities is imperative, therefore popular health education interventions are necessary to improve the population's understanding of the disease and to avoid inappropriate attitudes and practices.

Leishmaniasis: where are we and where are we heading?

Leishmaniasis is a zoonotic disease in humans caused by the bite of a parasite-infected sandfly. The disease, widely referred to as "poor man's disease," affects millions of people worldwide. The clinical manifestation of the disease depends upon the species of the parasite and ranges from physical disfigurement to death if left untreated. Here, we review the past, present, and future of leishmaniasis in detail. The life cycle of Leishmania sp., along with its epidemiology, is discussed, and in addition, the line of therapeutics available for treatment currently is examined. The current status of the disease is critically evaluated, keeping emerging threats like human immunodeficiency virus (HIV) coinfection and post kala-azar dermal leishmaniasis (PKDL) into consideration. In summary, the review proposes a dire need for new therapeutics and reassessment of the measures and policies concerning emerging threats. New strategies are essential to achieve the goal of leishmaniasis eradication in the next few decades.

Effects of larval rearing substrates on some life-table parameters of Lutzomyia longipalpis sand flies

Sand flies are the insects responsible for transmitting Leishmania parasites, the causative agents of leishmaniasis in humans. However, the effects of sand fly breeding sites on their biology and ecology remain poorly understood. Herein, we studied how larval nutrition associated with putative breeding sites of the sand fly Lutzomyia longipalpis affects their oviposition, development, microbiome, and susceptibility to Leishmania by rearing L. longipalpis on substrates collected from an endemic area for leishmaniasis in Brazil. The results showed that female L. longipalpis select the oviposition site based on its potential to promote larval maturation and while composting cashew leaf litter hindered the development, larvae reared on chicken feces developed rapidly. Typical gut microbial profiles were found in larvae reared upon cashew leaf litter. Adult females from larvae reared on substrate collected in chicken coops were infected with Leishmania infantum, indicating that they were highly susceptible to the parasite. In conclusion, the larval breeding sites can exert an important role in the epidemiology of leishmaniasis.

Sand flies are the insect vectors involved in the transmission of many pathogens, however, the transmission of parasites to humans leading to visceral leishmaniasis is currently the most critical threat caused by this insect. Despite the importance of the vector, many aspects of the biology of sand flies are poorly understood, especially their breeding sites. This study was designed to evaluate the oviposition, life span, microbiome, and parasite infections in the main species of sand fly responsible for visceral leishmaniasis in America. Insects were reared on substrates collected from different putative habitats of sand flies in an endemic area for the disease in Brazil. The results showed that female vectors selected an oviposition site depending on the potential offered to their offspring. Furthermore, the development of immature stages varied according to the type of substrate evaluated, with cashew leaves litter delaying larval development, while chicken shelter promoted larval development. The challenge of females emerging from chicken shelter substrate with the parasite indicates that insects reared in such an environment could successfully sustain the infection. These results suggest that the type of breeding site can affect insect biology as well as the epidemiology of the disease.

Differentials in the epidemiological profile of canine visceral leishmaniasis in the semi-arid region of Paraíba, Brazil

ABSTRACT: The objective of this study was to estimate the prevalence of canine visceral leishmaniasis (CVL) and to identify the differences in associated factors to its occurrence in urban area and countrysides in the municipality of Santa Luzia located in the semi-arid region of Paraíba. In the years 2015 and 2016, 779 blood samples from dogs were collected. The prevalence was determined by three serological techniques, ELISA-S7® Kit, DPP® Rapid Test and EIE-LVC® Kit, considering positive the samples that reacted in at least two assays. Associated factors were determined by univariate and multivariate analyzes of the guardians’ responses to the epidemiological questionnaire. The prevalence of anti-Leishmania infantum antibodies in the studied municipality was 15.00% (117/779), being higher in the urban area (15.20%) than in the countryside (13.60%). The neighborhood with the highest prevalence was Frei Damião with 26.40% (33/125), being considered a hotspot (OR 1.245, p=0.007). Other associated factors were the semi-domiciliary breeding (OR 1.798, p=0.025), in the urban area, and hunting dog (OR 18.505, p=0.016), contact with cattle (OR 17.298, p=0.022) and environment where the dog is raised (OR 4.802, p=0.024) in the countryside. In the municipality of Santa Luzia, the prevalence of canine visceral leishmaniasis is high and the disease is widely distributed. Epidemiological differences between urban area and the countryside could be observed demonstrating the need for more adequate control measures for each locality and proving the urbanization process.

Transmission of Leishmania infantum from cats to dogs

Leishmania infantum infection in cats has been reported in several countries, including Brazil. However, the transmission of visceral leishmaniasis (VL) from cats to another host has not been proven yet. Therefore, the aim of this study was to verify the possibility of L. infantum transmission from cats to dogs. In order to verify the possibility of VL transmission from the cat to the dog, xenodiagnosis was carried out in a VL-positive cat, using 55 female Lutzomyia longipalpis. Five days later, 40 insects were dissected to verify Leishmania infection. The remaining 15 females were fed in a healthy dog. The potential infection of the dog was verified through clinical, serological, parasitological examinations, and PCR, at three, six, and twelve months post-infection. All 55 L. longipalpis females became visibly engorged. Leishmania promastigotes were detected in 27.5% of the dissected insects. Leishmania infection in the dog was confirmed upon first evaluation. DNA sequencing of the parasite isolated from the cat confirmed L. infantum infection and showed 99% similarity with the L. infantum DNA sequences from the dogs. Through this study, it was possible to confirm the L. infantum experimental transmission from a domestic cat to a domestic dog through its biological vector L. longipalpis.

Multi-omic Analyses of Plasma Cytokines, Lipidomics, and Transcriptomics Distinguish Treatment Outcomes in Cutaneous Leishmaniasis

Leishmania braziliensis infection frequently results in cutaneous leishmaniasis (CL). An increase in incidence of drug-resistant CL leading to treatment failure has been reported. Identification of reliable predictors of treatment outcomes is necessary to optimize patient care. Here, we performed a prospective case-control study in which plasma levels of cytokines and lipid mediators were assessed at different time points during antileishmanial therapy in patients with CL from Brazil. Multidimensional analyses were employed to describe a combination of biomarkers able to predict and characterize treatment failure. We found a biosignature influenced mainly by plasma levels of lipid mediators that accurately predicted treatment failure. Furthermore, transcriptomic analysis of a publicly available data set revealed that expression levels of genes related to lipid metabolism measured in skin lesions could distinguish treatment outcomes in CL. Thus, activation of pathways linked to lipid biosynthesis predicts treatment failure in CL. The biomarkers identified may be further explored as therapeutic targets.

Biomarkers of the early response to treatment of visceral leishmaniasis: A prospective cohort study

BACKGROUND

Early biomarkers of the response to treatment are lacking and may help to reduce mortality by the vector-borne disease visceral leishmaniasis (VL).

METHODS

A prospective cohort study was conducted to investigate plasma cytokines and clinical laboratory data as biomarkers of the early response to specific treatment for VL in 36 patients.

RESULTS

The mean interleukin 6 (IL-6) concentration on the 7th day was 2.3% of the pre-treatment concentration, interleukin 10 (IL-10) was 8.0%, and interleukin 8 (IL-8) was 8.2%. On the 7th day, IL-10 was below half of the pre-treatment concentration in 100.0%, IL-8 in 95.5% and IL-6 in 90.9%. The spleen and liver sizes, haemoglobin, interleukin 1 beta (IL-1β) and tumour necrosis factor alpha (TNF-α) showed a slower recovery. Fever disappeared in 91% on the 7th day, 69.4% had a normal white cell count, and 77.8% had a normal platelet value by this time.

CONCLUSIONS

The plasma cytokines IL-6, IL-10 and IL-8 were demonstrated to be excellent markers of the early response to VL treatment and if tested before the 7th day, will likely prove to be better than fever measurement.

Lutzomyia evandroi in a New Area of Occurrence of Leishmaniasis

PURPOSE

Sand flies are vectors of medical and veterinary concern, responsible for the transmission of Leishmania parasites. These invertebrates are widely distributed throughout the world and their abundance and diversity is dependent on several biotic and physical factors. Based on the epidemiological importance of these insects, the aim of this study was to assess the sand fly fauna of a new area of occurrence of leishmaniasis.

METHODS

From October 2018 to September 2019, samplings were performed using CDC light traps at six different collection points located in a high altitude area in the municipality of Garanhuns, Northeastern Brazil. Geographic coordinates were recorded using the satellite remote sensing Global Positioning System (GPS) Garmin Etrex20. The spatial distribution of sand flies was evaluated using kernel density estimation (KDE). Engorged females (n = 12) were molecularly processed to search for Leishmania DNA.

RESULTS

A total of 138 sand fly specimens were collected during the study period, with 100% (138/138) identified as Lutzomyia evandroi. Climatic conditions did not influence the number of sand flies (males and females) collected monthly, but a statistically significant difference was observed between the number of specimens and different collections points. The kernel map showed a heterogeneous spatial distribution of sand flies in the municipality of Garanhuns with a hotspot in the south of the region.

CONCLUSION

Data presented herein are pivotal in filling the gap on the epidemiology of leishmaniasis in this high altitude area, serving as an alert to local health authorities. It also indicated that the putative role of L. evandroi in the transmission of Leishmania parasites should be clarified.

Development of Lutzomyia evansi immature stages in peridomiciliary environment in a leishmaniasis urban focus in the Colombian Caribbean

In the Caribbean region of Colombia, Lutzomyia evansi is recognized as the vector for Leishmania infantum and Leishmania braziliensis. Identifying breeding sites and surveying abundance of immature phlebotomine sand flies in urban foci of leishmaniasis are useful tool to design new vector control strategies. The objective of this study was to describe the natural breeding sites of Lu. evansi in peridomiciliary vegetation in a peri-urban area of the Colombian Caribbean region. Between 2013 and 2015, 466 microhabitats were sampled, collecting 621 kg of soil samples. The explored microhabitats were bases and tree holes, fallen trees, animal caves, leaf litter, domestic animal shelters, and the inside of dwellings. The immature phlebotomines were recovered by direct search under the stereoscope and incubation of soil samples. In total, 103 microhabitats, associated with 17 arboreal species, were identified as natural breeding sites. Of 422 immature sandflies detected, 98.6% were found in soils at the base of the trees. Eight species of the genus Lutzomyia were identified, of which Lu. evansi (52.6%) was the most abundant, followed by Lu. rangeliana, Lu. cayennensis cayennensis, Lu. atroclavata, Lu. micropyga, Lu. trinidadensis, Lu. dubitans and Lu. gomezi. The arboreal species Cordia alba was the most used by phlebotomines for the development of their immature stages. From 63 natural breeding sites identified 268 immatures were recovered including 176 Lu. evansi. The accumulated precipitation showed correlation (R2 = 0.643, p = 0.013) with the abundance of developmental stages, which increased in September and October. The natural breeding sites of Lu. evansi exhibited a local pattern of occurrence dependent on rainfall. The physicochemical analysis of the soil samples showed that the natural sites for C. alba were categorized as fertile loam soils. This is the first systematic study that estimates the temporal variation of immature sand flies in peridomiciliary vegetation in a peri-urban focus of leishmaniasis in Colombia.

Study of in vitro biological activity of thiazoles on Leishmania (Leishmania) infantum

OBJECTIVES

In the prospection of possible agents against neglected diseases, thiazole compounds are presented as promising candidates and are known to have activity against trypanosomatid parasites. Thus, this work aimed to evaluate the effects of thiazole compounds on Leishmania infantum, the aetiological agent of visceral leishmaniasis.

METHODS

Thiazole compounds (five thiazoacetylpyridines [TAPs-01, -04, -05, -06, -09) and five thiazopyridines [TPs-01, -04, -05, -06, -09]) were tested regarding their leishmanicidal activity on both promastigote and amastigote forms of L. infantum. Cytotoxicity was tested using peritoneal macrophages of BALB/c mice. Ultrastructural analyses were performed to identify possible intracellular targets of the most effective compound on promastigote forms. To observe routes that can clarify the possible mechanism of action of the compounds on the intracellular amastigote forms, the nitrite dosage was performed.

RESULTS

All compounds inhibited the growth of promastigote and presented low cytotoxicity, being more selective to the parasite than to mammalian cells. All compounds tested were able to decrease macrophage infection. There was a significant decrease in the survival rate of the amastigote when compared with the untreated cells, with TAP-04 presenting the best index. TAP-04 induced ultrastructural changes that are related to cell death by apoptosis. None of the macrophage groups infected with L. infantum and subsequently treated showed increased nitrite release.

CONCLUSIONS

The low toxicity to mammalian cells and the leishmanicidal activity observed demonstrate that the synthesis of drugs based in thiosemicarbazone nucleus, thiazole and pyridine derivatives are promising for the treatment of visceral leishmaniasis.

Recombinant Cysteine Proteinase B from Leishmania braziliensis and Its Domains: Promising Antigens for Serodiagnosis of Cutaneous and Visceral Leishmaniasis in Dogs

Leishmaniasis represents a group of parasitic diseases caused by a protozoan of the genus Leishmania and is widely distributed in tropical and subtropical regions. Leishmaniasis is one of the major tropical neglected diseases, with 1.5 to 2 million new cases occurring annually. Diagnosis remains a challenge despite advances in parasitological, serological, and molecular methods. Dogs are an important host for the parasite and develop both visceral and cutaneous lesions. Our goal was to contribute to the diagnosis of canine cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) using the recombinant cysteine proteinase B (F-CPB) from Leishmania braziliensis and its N- and C-terminal domains (N-CPB and C-CPB) as antigens in an enzyme-linked immunosorbent assay (ELISA). Sera from dogs from Northwest Argentina diagnosed with CL were tested by ELISA against a supernatant of L. braziliensis lysate, the F-CPB protein, and its domains. We found values of sensitivity (Se) of 90.7%, 94.4%, and 94.3% and specificity (Sp) of 95.5%, 90.9%, and 91.3% for F-CPB and its N- and C-terminal domains, respectively. In sera from dogs diagnosed with VL from Northeast Argentina, we found Se of 93.3%, 73.3%, and 66.7% and Sp of 92.3%, 76.9%, and 88.5% for F-CPB and its N- and C-terminal domains, respectively. These results support CPB as a relevant antigen for canine leishmaniasis diagnosis in its different clinical presentations. More interestingly, the amino acid sequence of CPB showed high percentages of identity in several Leishmania species, suggesting that the CPB from L. braziliensis qualifies as a good antigen for the diagnosis of leishmaniasis caused by different species.

Dispersion of Leishmania (Leishmania) infantum in central-southern Brazil: Evidence from an integrative approach

Leishmania (Leishmania) infantum is the zoonotic agent of visceral leishmaniasis (VL), a disease with a global distribution. The transmission scenario of VL has been undergoing changes worldwide, with the biologic cycle invading urbanized areas and dispersing the parasites into other previously free areas. The epidemiological cycle in Brazil has dispersed from the Northeast to other regions of the country. In this study, an integrative approach, including genotyping Brazilian strains of L. (L.) infantum for 14 microsatellite markers and reviewing historical records of the disease, was used to assess dispersion routes throughout central-southern Brazil. Our results support three L. (L.) infantum dispersion routes: A) dispersion from Bolivia to the states of Mato Grosso, Mato Grosso do Sul and São Paulo via the Bolivia-Brazil gas pipeline from 1998 to 2005; B) VL dispersion from Paraguay to the Brazilian side of the triple border (Foz do Iguaçu and Santa Terezinha de Itaipu) during after 2012; and C) emergence of a new L. (L.) infantum cluster in western Santa Catarina State and its dispersion to southern Paraná State (municipality of Pato Branco), after 2013. Hypotheses regarding possible entries of Leishmania (L.) infantum into the area of the triple border are presented and discussed. Understanding how VL has dispersed is vital to the development of control measures for this disease and to avoid future dispersion events.

The dispersion of visceral leishmaniasis is an enigma. The State of Paraná, in southern Brazil, borders the states of São Paulo and Mato Grosso, which have experienced LV epidemics over the past 20 years. Therefore, we expected that the disease would enter this state through the contiguity of epidemics from other regions following by "ghost shadows". However, in 2012, the vectors of the parasite were reported in the western region (Foz do Iguaçu) of Paraná state, far from the epidemic regions. In the cross-sectional study, 23.8% of the dogs were infected, which is more than the eyes can see, showing an unexpected scenario where the disease was already widespread in the city. Now the question was: where does the life cycle element came from? In this study, we used genetic markers to understand the dispersion of Leishmania infantum throughout central-southern Brazil. Our results showed two possible agent inputs in the Paraná state, one coming from Paraguay and, another from Santa Catarina state. When we verify our results we perceived the monitoring importance of the distribution of these agents by diverse hypotheses, not only those that the scientific literature presents. Another relevant factor is always to be attentive to the environmental and socioeconomic events that can provide this dispersion.

Factors associated with Leishmania spp. infection in domestic dogs from an emerging area of high endemicity for visceral leishmaniasis in Central-Western Brazil

The factors associated with Leishmania spp. infection in dogs are still poorly understood. This study aimed to identify such factors among domestic dogs from the Brazilian municipality of Rondonópolis, which recently emerged as an endemic area with intense transmission of human visceral leishmaniasis (VL). It was a household-based cross-sectional study conducted between 2016 and 2017. Interviews were conducted with 405 dog owners considering their socioeconomic characteristics, and environmental aspects of the household and its adjacent areas. In addition, 600 dogs were evaluated regarding physical characteristics, behavior, and care provided by the owner. Seropositive animals were those that showed reactivity in a rapid immunochromatographic test and enzyme-linked immunosorbent assay, which are currently recommended for canine visceral leishmaniasis (CVL) diagnosis in Brazil. A multivariable logistic regression analysis was employed to determine the associated factors. Low social class [OR = 2.0; _95%CI = (1.2-3.2)], presence of acerola tree (Malpighia emarginata) in the yard [OR = 2.2; _95%CI = (1.2-4.1)], presence of more than one dog in the household [OR = 2.0; _95%CI = (1.3-3.3)], horse and/or cattle breeding [OR = 12.0; _95%CI = (1.9-73.6)], existence of houses with yard adjacent to the home [OR = 4.0; _95%CI = (1.3-12.2)], presence of apparent signs consistent with CVL [OR = 10.6; _95%CI = (5.8-19.4)], dog staying mostly in the yard during the day [(OR = 4.8; _95%CI = (1.1-21.4)], and lack of cleaning of the dog's shelter [(OR = 1.9; _95%CI = (1.1-3.2)] were identified as the factors associated with Leishmania spp. infection. These results support the importance of socioeconomic and environmental aspects in the occurrence of Leishmania spp. infection. In addition, they may be useful in guiding control strategies in areas where zoonotic VL is endemic.

Spatiotemporal analysis and environmental risk factors of visceral leishmaniasis in an urban setting in São Paulo State, Brazil

Background

In Latin America, Brazil harbors the most cases of human visceral leishmaniasis (HVL). Since the early 1980s, the disease has spread to the urban centers of the north, and now the south and west of Brazil; it reached São Paulo state in the southeast in 1996, and Presidente Prudente in the western region in 2010. Our aim was to describe the spatiotemporal analysis and environmental risk factors associated with the dispersion of VL in Presidente Prudente, an urban setting with recent transmission.

Methods

An entomological survey was carried out from 2009 to 2015. A canine visceral leishmaniasis (CVL) serosurvey was performed from 2010 to 2015 using enzyme-linked immunosorbent assays (ELISA), a dual-path platform CVL rapid test, and indirect fluorescent antibodies (IFAT). Data from HVL cases were obtained from the Municipal Surveillance Epidemiology Center from 2013 to 2017. Data on water drainage and forest fragments were obtained from public platforms and irregular solid-waste deposits were determined by monthly inspections of the urban area. Kernel density maps of the distribution of CVL were constructed.

Results

From 2009 to 2015, Lutzomyia longipalpis sand flies were found in all seven areas of Presidente Prudente. From 2010 to 2015, 40,309 dogs were serologically screened and 638 showed positive results, i.e. a prevalence rate of 1.6%. From 2013 to 2017, six human cases were diagnosed with a mortality rate of 33.3%. In 2015, 56 points of irregular solid-waste deposits were identified, predominantly in the neighborhoods. Three different hotspots of CVL showed an increased distribution of vectors, seropositive dogs, irregular solid-waste deposits, forest fragments and water drainage.

Conclusions

The use of tools that analyze the spatial distribution of vectors, canine and human VL as environmental risk factors were essential to identifying the areas most vulnerable to the spread or maintenance of VL. The results may help public health authorities in planning prevention and control measures to avoid expansion and future outbreaks.

Synanthropy and diversity of Phlebotominae in an area of intense transmission of visceral leishmaniasis in the South Pantanal floodplain, Midwest Brazil

Phlebotomines have been recorded from a wide variety of habitats, and some of these vector species have shown preference for human environments, with high levels of adaptation. This study evaluated the degree of preference of these vectors for urban, rural, and forested environments (synanthropic behavior), as well as the diversity of these species, in three areas (forested, rural, and urban, exhibiting different degrees of anthropogenic changes) in a region of intense transmission of visceral leishmaniasis in Corumbá county, Mato Grosso do Sul, Brazil. Using light traps, sand fly specimens were collected from the three environments simultaneously, from May 2015 to April 2017, totaling 7 213 sand flies of 14 species in eight genera. Nuorteva's synanthropy index was determined for the species Lutzomyia cruzi, Brumptomyia brumpti, Micropygomyia peresi, Lu. forattinii, Martinsmyia oliveirai and Evandromyia corumbaensis. Lutzomyia cruzi, the vector of Leishmania infantum in Corumbá, was the most abundant vector species, recorded from all three areas and sampling plots, on all 24 months investigated. This species exhibited the highest synanthropic index (+75.09), indicating a strong preference for urban environments. Brumptomyia brumpti, Micropygomyia peresi, Lu. forattinii, and Martinsmyia oliveirai showed preference, albeit not strong, for urban environments. Overall, males were more abundant than females (W = 490; p < 0.0001). High density, high synanthropic index, and sustained indoor presence were found for Mi. peresi in the rural area. Monitoring changes in the ecological behavior of sand flies is of vital importance, as these changes may indicate an increased likelihood of leishmaniasis emergence or reemergence.

Human Competence to Transmit Leishmania infantum to Lutzomyia longipalpis and the Influence of Human Immunodeficiency Virus Infection

Visceral leishmaniasis (VL) caused by Leishmania infantum is a lethal disease transmitted by sand flies. Although, considered a zoonosis with dogs held as the main reservoirs, humans are also sources of infection. Therefore, control policies currently focused on dog culling may need to consider that VL and human immunodeficiency virus (HIV)/VL patients may also be infectious, contributing to transmission. Reservoir competence of patients with VL without and with HIV infection and of persons asymptomatically infected with Leishmania was assessed by xenodiagnosis with the vector Lutzomyia longipalpis. Parasites in sand fly's guts were identified by using optical microscopy and by conventional polymerase chain reaction (PCR). Leishmania infantum blood parasite burden was determined by quantitative PCR. Among the 61 participants, 27 (44%) infected sand flies as seen by microscopy or PCR. When infectiousness was assessed by microscopy, xenodiagnosis was positive in five (25%) patients not infected with HIV, whereas nine (45%) of those harboring HIV were positive. Among the 19 asymptomatic patients four (21%) infected sand flies only demonstrated by PCR. One (50%) asymptomatic patient with HIV had a positive xenodiagnosis by microscopy. 9/372 (2.4%) and 37/398 (9.2%) sand flies were infected when feeding in patients without and with HIV, respectively. Infectiousness was poorly correlated with quantitative PCR. The study shows that asymptomatic humans are capable of transmitting L. infantum, that ill persons with HIV infection are more infectious to sand flies, and that humans are more important reservoirs than previously thought. This fact may be considered when designing control policies for zoonotic VL.

Plant-feeding phlebotomine sand flies, vectors of leishmaniasis, prefer Cannabis sativa

Blood-sucking phlebotomine sand flies (Diptera: Psychodidae) transmit leishmaniasis as well as arboviral diseases and bartonellosis. Sand fly females become infected with Leishmania parasites and transmit them while imbibing vertebrates' blood, required as a source of protein for maturation of eggs. In addition, both females and males consume plant-derived sugar meals as a source of energy. Plant meals may comprise sugary solutions such as nectar or honeydew (secreted by plant-sucking homopteran insects), as well as phloem sap that sand flies obtain by piercing leaves and stems with their needle-like mouthparts. Hence, the structure of plant communities can influence the distribution and epidemiology of leishmaniasis. We designed a next-generation sequencing (NGS)-based assay for determining the source of sand fly plant meals, based upon the chloroplast DNA gene ribulose bisphosphate carboxylase large chain (rbcL). Here, we report on the predilection of several sand fly species, vectors of leishmaniasis in different parts of the world, for feeding on Cannabis sativa We infer this preference based on the substantial percentage of sand flies that had fed on C. sativa plants despite the apparent "absence" of these plants from most of the field sites. We discuss the conceivable implications of the affinity of sand flies for C. sativa on their vectorial capacity for Leishmania and the putative exploitation of their attraction to C. sativa for the control of sand fly-borne diseases.

Visceral leishmaniasis in a Brazilian endemic area: an overview of occurrence, HIV coinfection and lethality

The Brazilian municipality of Rondonópolis, Mato Grosso State, represents an important visceral leishmaniasis (VL) endemic area. This study described epidemiological and clinical aspects of the occurrence, VL/HIV coinfection and lethality related to VL in Rondonópolis. Data from autochthonous cases reported between 2011 and 2016 were obtained from official information systems. During this period, 81 autochthonous cases were reported, with decreasing incidence through 2016. Contrastingly, the lethality rate was 8.6% overall, but varied widely, reaching a peak (20%) in 2016. Almost 10% of patients had VL/HIVcoinfection. The occurrence of VL prevailed among men (56.8%), brown-skinned (49.4%), urban residents (92.6%), aged 0-4 years (33.3%). Housewives or retired (29.6%) were the most affected occupational groups. Lower age was the main difference among the total VL cases and those who were coinfected or died. Clinically, fever, weakness and splenomegaly were more frequent among all VL cases and VL/HIV coinfected individuals. Bacterial infections (p=0.001) and bleeding (p<0.001) were associated with death due to VL. Pentavalent antimonial and liposomal amphotericin B were the first choices for treatment among all VL cases (71.6%) and those who died (71.4%), respectively. VL/HIV patients were equally treated with both drugs. These findings may support control measures and demonstrate the need for further investigations.

High seroprevalence and peripheral spatial distribution of visceral leishmaniasis among domestic dogs in an emerging urban focus in Central Brazil: a cross-sectional study

The Brazilian municipality of Rondonópolis is an emerging urban focus of intense transmission of visceral leishmaniasis (VL), where few investigations have addressed canine reservoirs. This study assessed the seroprevalence and spatial distribution of canine visceral leishmaniasis (CVL) in the urban area of Rondonópolis. A CVL serosurvey was conducted between October 2016 and February 2017 using an immunochromatographic rapid test and enzyme-linked immunosorbent assay. Domestic dogs were sampled from 25 heterogeneous regions previously defined by the Spatial 'K'luster Analysis by Tree Edge Removal algorithm, which considered the socioeconomic and environmental features from the last demographic census. The CVL spatial distribution was analyzed by kernel density estimation (KDE) and spatial scan statistic. All the  autochthonous human VL cases reported between 2014 and 2016 were georeferenced. Of the 600 dogs tested, 115 were seropositive in both tests. The overall CVL prevalence was 19.2% (95%CI: 16.1-22.3%), which varied widely among the evaluated regions (0.0-35.1%). Almost 25% of the sampled households (n = 405) had at least one infected dog. KDE demonstrated that positive CVL households were concentrated in the peripheral areas of the city. Spatial scan statistics detected a spatial cluster with significantly low CVL prevalence in the central region (relative risk = 0.37; p = 0.04), where only one human VL case was reported. Thus, we demonstrated a high prevalence of CVL in domestic dogs from diverse socioeconomic and environmental urban contexts in Rondonópolis. The CVL cases were peripherally distributed and occurred more frequently in areas that had reported human VL.

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.

Serological tests fail to discriminate dogs with visceral leishmaniasis that transmit Leishmania infantum to the vector Lutzomyia longipalpis

INTRODUCTION

The control of reservoirs for Leishmania infantum -induced zoonotic visceral leishmaniasis requires the identification of dogs posing a population risk. Here, we assessed the performance of several assays to identify Lutzomyia longipalpis infectious dogs.

METHODS

We evaluated 99 dogs that were positive for visceral leishmaniasis based on parasite identification. Serological analyses were performed using an enzyme-linked immunosorbent assay, immunofluorescence antibody tests in 1:40 and 1:80 dilutions, rapid dual path platform tests, immunochromatographic assay with a recombinant rK39 antigen, fast agglutination screening tests, and direct agglutination tests. We also performed PCR to analyze peripheral blood and xenodiagnosis.

RESULTS

Forty-six dogs infected at least one L. longipalpis specimen. Although the serological test sensitivities were above 85% for detecting L. longipalpis infectious dogs, none showed a satisfactory performance, as both specificity (0.06 to 13%) and the area under the receiver operating characteristic curve (45 to 53%) were low. The PCR results were also weak, with a sensitivity of 30%, specificity of 72%, and an area under the receiver operating characteristic curve of 51%. The infected L. longipalpis proportion was higher among asymptomatic dogs than symptomatic dogs. Among the symptomatic dogs, those with ulceration-free skin diseases were more infectious, with an odds ratio of 9.3 (confidence interval of 1.10 - 428.5). The larger the number of insects fed, the greater the detected infectiousness.

CONCLUSIONS

Our study supports the imperative to develop novel technologies for identifying the infectious dogs that transmit L. infantum for the benefit of public health.

Molecular characterization of Leishmania infantum in domestic cats in a region of Brazil endemic for human and canine visceral leishmaniasis

Leishmaniasis is a "neglected tropical disease" and serious public health issue in Brazil. While dogs are recognized as particularly important reservoirs, recent reports of domestic cats infected with Leishmania sp. in urban areas suggest their participation in the epidemiological chain of the parasite in endemic areas. The aim of this study was to screen domestic cats for Leishmania sp. infection in an area where human and canine visceral leishmaniasis are endemic, followed by the identification of the species circulating in cats. We collected peripheral blood, lymph-node aspirates and bone marrow from 100 adult animals, both male and female, and analyzed the samples using cytological and molecular (PCR) detection techniques. We detected Leishmania in 6% of animals, which were then analyzed by RFLP-PCR to identify the species. Leishmania infantum (synonym: L. chagasi), a species responsible for visceral leishmaniasis in humans and other animals, was identified from all six samples. Amastigotes were observed in the peripheral blood, bone marrow and lymph-node aspirates in 4 of the 6 PCR-positive animals. The presence of infected cats in endemic areas should not be neglected, because it demonstrates the potential role of these animals in the biological cycle of the pathogen.

DNA barcode for the identification of the sand fly Lutzomyia longipalpis plant feeding preferences in a tropical urban environment

Little is known about the feeding behavior of hematophagous insects that require plant sugar to complete their life cycles. We studied plant feeding of Lutzomyia longipalpis sand flies, known vectors of Leishmania infantum/chagasi parasites, in a Brazilian city endemic with visceral leishmaniasis. The DNA barcode technique was applied to identify plant food source of wild-caught L. longipalpis using specific primers for a locus from the chloroplast genome, ribulose diphosphate carboxylase. DNA from all trees or shrubs within a 100-meter radius from the trap were collected to build a barcode reference library. While plants from the Anacardiaceae and Meliaceae families were the most abundant at the sampling site (25.4% and 12.7% of the local plant population, respectively), DNA from these plant families was found in few flies; in contrast, despite its low abundance (2.9%), DNA from the Fabaceae family was detected in 94.7% of the sand flies. The proportion of sand flies testing positive for DNA from a given plant family was not significantly associated with abundance, distance from the trap, or average crown expansion of plants from that family. The data suggest that there may indeed be a feeding preference of L. longipalpis for plants in the Fabaceae family.

Study of implementation and direct cost estimates for diagnostic tests for human visceral leishmaniasis in an urban area in Brazil

This work reports the process and costs of comprehensively implementing two tests to decentralize the diagnosis of visceral leishmaniasis (VL) in an endemic city in Brazil: a rapid test (IT LEISH) and a direct agglutination test (DAT-LPC). The implementation began by training health professionals to perform the tests. Estimation of the training costs considered the proportional remuneration of all professionals involved and the direct costs of the tests used for training. The study was conducted between November 2011 and November 2013. During that time, 17 training sessions were held, and 175 professionals were trained. The training cost for each professional was US$ 7.13 for the IT LEISH and US$ 9.93 for the DAT-LPC. The direct costs of the IT LEISH and DAT-LPC were estimated to be US$ 6.62 and US$ 5.44, respectively. This first evaluation of the implementation of these diagnostic tests indicates the feasibility of decentralizing both methods to extend access to VL diagnosis in Brazil.

CANINE VISCERAL LEISHMANIASIS CASE INVESTIGATION IN THE JACARE REGION OF NITEROI, RIO DE JANEIRO, BRAZIL

American visceral leishmaniasis is a vector-borne zoonosis in expansion in Brazil. Dogs are the main urban reservoir. Departing from a case of canine visceral leishmaniasis (CVL) in Jacaré, Niterói, Rio de Janeiro State, an epidemiological canine and entomological study was performed to assess the extension of the disease at the location. Sample was collected around the case and the dogs identified by serological tests (rapid double platform immunochromatographic exams, immunoenzymatic assay/ELISA, indirect immunofluorescence/IFAT). The parasitological diagnosis was performed in animals positive in at least one of these tests. The entomological study was carried out by using light traps and manual collection. The associations between canine variables and outcome (ELISA and IFAT reagents) were assessed by the chi-square test and adjusted by multivariate logistic regression for those associations with p < 0.1 in the bivariate analysis. Seventeen cases of CVL were detected among 110 evaluated dogs (prevalence of 15.5%). Presence of ectoparasites (OR 6.5; 95% CI 1.1-37.4), animals with clinical signs (OR 9.5; 95% CI 1.2-76.6), and previous cases of CVL in the same house (OR 17.9; 95% CI 2.2-147.1) were associated with the outcome. Lutzomyia longipalpiswas not detected. Our results are indicative of an ongoing transmission in the area.

VISCERAL LEISHMANIASIS IN PETROLINA, STATE OF PERNAMBUCO, BRAZIL, 2007-2013

Visceral leishmaniasis is a life-threatening disease of great public health relevance in Brazil. The municipality of Petrolina is an endemic area in the State of Pernambuco, Brazil. This study was designed to assess the recent expansion of VL in the municipality of Petrolina, Pernambuco. Patients data were obtained from the Brazilian National Information System for Notifiable Diseases (SINAN). A total of 111 records from 2007 to 2013 were investigated, of which 69 were residents in Petrolina. The disease has predominantly affected 1-4 year old children (34.8%). Most of the patients were males (59.4%). Co-infection with human immunodeficiency virus occurred in 14.5% of the cases. The criterion most frequently used was the clinical and epidemiological confirmation (59.4%), with clinical cure in 78.3% of cases and one fatal outcome. Visceral leishmaniasis is endemic in Petrolina with transmission levels varying from moderate to high. The present study has shown the precariousness of the use of diagnostic tests in primary healthcare units, and this misuse has interfered with the diagnosis and treatment of cases.

Identification of Leishmania infantum in Puerto Iguazú, Misiones, Argentina

The emergence of zoonotic visceral leishmaniasis (ZVL) in Latin America is a growing public health problem. The urbanization of ZVL has been observed in different countries around the world, and there are a growing number of reports drawing attention to the emergence of this infection in new locations, as well as its increase in previously established areas of endemicity. In the city of Posadas, Misiones province, Northeastern Argentina, the transmission of ZVL associated with canines and Lutzomyia longipalpis was first reported in 2006. In the city of Puerto Iguazú, also in Misiones province, the first human case of ZVL was reported in February 2014. From 209 surveyed dogs, 15 (7.17%) were identified as positive by serological and/or parasitological methods. Amplification was observed in 14 samples and in all cases the species implicated was Leishmania infantum. To the authors' knowledge, this is the first molecular characterization of L. infantum from dogs in this area.

Lutzomyia longipalpis urbanisation and control

Since the description of Lutzomyia longipalpis by Lutz and Neiva more than 100 years ago, much has been written in the scientific literature about this phlebotomine species. Soares and Turco (2003) and Lainson and Rangel (2005) have written extensive reviews focused on vector-host-parasite interactions and American visceral leishmaniasis ecology. However, during the last two decades, the success of Lu. longipalpis in colonising urban environments and its simultaneous geographical spreading have led to new theoretical and operational questions. Therefore, this review updates the general information about this species and notes the more challenging topics regarding the new scenario of urbanisation-spreading and its control in America. Here, we summarise the literature on these issues and the remaining unsolved questions, which pose recommendations for operational research.

Late diagnosis: a factor associated with death from visceral leishmaniasis in elderly patients

Visceral leishmaniasis (VL) is among the seven global endemic diseases assigned a high priority by the World Health Organization. In Latin America, most cases occur in Brazil. Despite the availability of intensive treatment resources and protocols for specific treatment, lethality rates for VL have increased in several regions in the country over the past 10 years, particularly in patients under one and over 50 years of age. As the growth of the elderly population accelerates in Brazil, VL poses a greater challenge to public health. Given the scarcity of studies addressing the disease in this age group, the purpose of this study was to identify factors associated with VL lethality among the elderly. METHODS/KEY FINDINGS: This analytical, cross-sectional epidemiological study comprised 80 elderly patients who sought treatment at the teaching hospital of the Universidade Federal de Mato Grosso do Sul, Campo Grande, MS, Brazil, in the period 2000-2013.Clinical, laboratory and treatment variables were investigated from records of elderly patients with VL diagnosis confirmed by at least one laboratory test positive (culture for parasite or direct parasitological examination; reactive immunofluorescence; immunochromatographic test with recombinant antigens) or patients without laboratory confirmation who lived in endemic areas and responded favorably to therapeutic trial, as defined by the Brazilian Ministry of Health. Of the 80 patients included, 78 tested positive to at least one exam; in two cases, diagnosis was based on clinical and epidemiological criteria. The lethality rate was 20%. Multivariate analysis revealed an association between death and time elapsed from symptom onset.

An Integrated Approach Using Spatial Analysis to Study the Risk Factors for Leishmaniasis in Area of Recent Transmission

Some epidemiological aspects of leishmaniasis in the municipality of Formiga, Brazil, an important touristic site, were evaluated. Those included phlebotomine sand fly vectors, canine infection, and geoprocessing analysis for determining critical transmission areas. Sand flies (224 insects) belonging to ten different species were captured. The most captured species included Lutzomyia longipalpis (35.3%), Lutzomyia cortelezzii (33.5%), and Lutzomyia whitmani (18.3%). A significant correlation between sand fly densities and climatic conditions was detected. Serological diagnosis (DPP and ELISA) was performed in 570 dogs indicating a prevalence of 5.8%. After sequencing the main species circulating in the area were Leishmania infantum and Leishmania braziliensis. Spatial analysis demonstrated that vegetation and hydrography may be related to sand fly distribution and infected dogs. The municipality of Formiga has proven leishmaniasis vectors and infected dogs indicating the circulation of the parasite in the city. Correlation of those data with environmental and human cases has identified the critical areas for control interventions (south, northeast, and northwest). In conclusion, there is current transmission of visceral and canine human cases and the city is on the risk for the appearance of cutaneous cases.

Mixed infection of Leishmania infantum and Leishmania braziliensis in rodents from endemic urban area of the New World

Background

In Brazil Leishmania braziliensis and L. infantum are the principal species responsible for cutaneous and visceral leishmaniases, respectively. Domestic dogs are the main reservoirs of visceral leishmaniasis, while rodents and marsupials are the main reservoirs for cutaneous leishmaniasis. It has also been suggested that dogs could play a role in transmission of cutaneous leishmaniasis. The identification of the species of Leishmania, the reservoirs, and the vectors involved in each particular transmission cycle is critical for the establishment of control activities. Belo Horizonte has emerged as an endemic region for leishmaniases, however, epidemiological studies assessing the contribution of wild reservoirs to transmission are scarce in the area. The aim of this study was to investigate Leishmania spp. infection in possible reservoirs of an urbanized area.

Results

A high rate of infection was found in small mammals (64.9%) and dogs (DG1 30.4% and DG2 48.6%). The presence of L. infantum and L. braziliensis was detected in small mammals and dogs, and mixed infections by both species were detected in rodents which, to the best of our knowledge, is the first description of this phenomenon in an urban area. Additionally, L. amazonensis was detected in the canine samples.

Conclusion

The possible role of these animals as a source of infection of the vector of each species of Leishmania identified should not be overlooked and should be taken into account in future control activities. The results of mixed infection by L. braziliensis and L. infantum in cosmopolitan rodents as M. musculus and R. rattus, may have important implications in the context of the control of leishmaniasis in urban areas, especially when considering that these rodents live in close relationship with human dwellings, especially those in more precarious conditions.

Emerging and reemerging neglected tropical diseases: a review of key characteristics, risk factors, and the policy and innovation environment

In global health, critical challenges have arisen from infectious diseases, including the emergence and reemergence of old and new infectious diseases. Emergence and reemergence are accelerated by rapid human development, including numerous changes in demographics, populations, and the environment. This has also led to zoonoses in the changing human-animal ecosystem, which are impacted by a growing globalized society where pathogens do not recognize geopolitical borders. Within this context, neglected tropical infectious diseases have historically lacked adequate attention in international public health efforts, leading to insufficient prevention and treatment options. This subset of 17 infectious tropical diseases disproportionately impacts the world's poorest, represents a significant and underappreciated global disease burden, and is a major barrier to development efforts to alleviate poverty and improve human health. Neglected tropical diseases that are also categorized as emerging or reemerging infectious diseases are an even more serious threat and have not been adequately examined or discussed in terms of their unique risk characteristics. This review sets out to identify emerging and reemerging neglected tropical diseases and explore the policy and innovation environment that could hamper or enable control efforts. Through this examination, we hope to raise awareness and guide potential approaches to addressing this global health concern.

Evaluation of PCR in the diagnosis of canine leishmaniasis in two different epidemiological regions: Campinas (SP) and Teresina (PI), Brazil

Using the polymerase chain reaction (PCR) test for diagnosis of canine leishmaniasis has greater sensitivity and specificity than culture and visualization of the parasite. This study compares PCR for the diagnosis of the genus and species ofLeishmaniawith serological techniques used for the control of canine visceral leishmaniasis (CVL) in Brazil, considering two regions. We analysed peripheral blood samples collected from 195 dogs in the Campinas (SP) and Teresina (PI) regions. ELISA was performed as a serological method and PCR was performed using specific primers for the genusLeishmaniaspp. and the speciesLeishmania chagasi. In Campinas, a greater sensitivity of PCR (88·24%) (P = 0·0455) compared to Teresina (14·71%) (P < 0·0001) was observed, and an agreement was observed for Cohen's kappa index (0·9096). Both PCR and ELISA showed discordance for sensitivity (Campinas 100%, Teresina 21·74%), specificity (Campinas 30·77%, Teresina 100%), positive predictive value (Campinas 68·97%, Teresina 100%), negative predictive value (Campinas 100%, Teresina 37·94%) and Cohen's kappa index (0·1238). This study confirms the importance of PCR in analysis of the canine reservoir, and as an effective method for the detection of active and recent infection.

Spatial analysis for identification of priority areas for surveillance and control in a visceral leishmaniasis endemic area in Brazil

Spatial analysis of epidemiological data may be used to assist in the implementation of surveillance and control measures against visceral leishmaniasis (VL) in endemic areas. This ecological study aimed to identify priority areas for surveillance and control of VL in São Luís, the capital of the state of Maranhão in northeast Brazil, a highly endemic area for the disease. We evaluated the spatial structure of the incidence rates of human VL and of the mean number of human and canine cases occurring between 2005 and 2007 in 355 neighborhoods (aggregated into 203 geographical analytical units) within the municipality. The presence of spatial autocorrelation was explored using global and local Moran's I statistics. A local indicator of spatial autocorrelation was used to generate maps for the identification of VL clusters. The global Moran's I index revealed a weak, but statistically significant spatial autocorrelation for human VL incidence rates (I=0.138). A total of 43 geographical analytical units, encompassing 121 neighborhoods, were identified as priority areas for implementing surveillance and control actions. For the purpose of defining an action plan for the delivery of these measures, those 16 geographical analytical units (encompassing 54 neighborhoods) identified as clusters with high incidence rates of human VL should receive the highest priority. An additional nine geographical analytical units (comprising 28 neighborhoods) showed non-significant clustering of high rates of human, and might be considered as the next priority for VL management. Finally, a further 18 geographical analytical units (covering 39 neighborhoods) had records of coexisting human and canine VL cases during the study period, and these should receive priority attention when resources become available. Spatial data analysis is a valuable tool for defining priority areas for VL surveillance in high transmission areas contributing to a more effective management of financial and technical resources, increasing the sustainability and efficiency of control efforts.

Risk factors for seroconversion by Leishmania infantum in a cohort of dogs from an endemic area of Brazil

Visceral leishmaniasis (VL) has recently emerged in various urban and peri-urban areas of Brazil and other countries. Understanding the urbanization of VL requires identification of risk factors associated with human and canine infection. To determine the predictors of risk for canine VL, a survey was conducted of 1,443 dogs, from which a cohort was selected (n = 455) and evaluated for approximately 26 months. Serology was conducted with two enzyme-linked immunosorbent assays (ELISA): one conducted in the Laboratory of Zoonosis of the Belo Horizonte Health Department (LZOON) and the other in the Laboratory of Immunopathology of the Federal University of Ouro Preto (LIMP). A molecular diagnostic method (PCR–restriction fragment length polymorphism) and a structured questionnaire were also used. To identify the factors associated with seroconversion, two time-dependent Cox regression models were performed with different sensitivities (model 1, seroconversion by ELISA/LZOON; model 2, seroconversion by ELISA/LIMP). The overall incidences of seroconversion were 6.5/1000 dogs-months and 11.2/1000 dogs-months for ELISA/LZOON and ELISA/LIMP, respectively. Increased risk of seroconversion was associated with short fur (model 1: hazard ratio [HR] 1.9), the presence of dry leaves (model 1: HR 2.8) or manure (model 1: HR 3.5) in the backyard, dogs sleeping predominantly in the backyard (model 2: HR 2.1), the presence of symptoms (model 2: HR 2.0), and positive molecular results during follow-up (model 2: HR 1.5). Decreased risk was associated with insecticide spraying in the house (model 2: HR 0.5). These results indicate that more-vulnerable domiciles, certain dog behaviors, lack of vector control measures, and positive molecular results were associated with the occurrence of canine VL. Furthermore, it is important to emphasize that PCR-positive dogs should be monitored, owing to the possibility of seroconversion. Identifying risk factors for seroconversion in dogs is crucial for developing adequate strategies for VL prevention and control.

Space-time cluster analysis of American visceral leishmaniasis in Bauru, São Paulo State, Brazil

A space-time analysis of American visceral leishmaniasis (AVL) in humans in the city of Bauru, São Paulo State, Brazil was carried out based on 239 cases diagnosed between June 2003 and October 2008. Spatial analysis of the disease showed that cases occurred especially in the city's urban areas. AVL annual incidence rates were calculated, demonstrating that the highest rate occurred in 2006 (19.55/100,000 inhabitants). This finding was confirmed by the time series analysis, which also showed a positive tendency over the period analyzed. The present study allows us to conclude that the disease was clustered in the Southwest side of the city in 2006, suggesting that this area may require special attention with regard to control and prevention measures.

Phlebotomine sandflies and the spreading of leishmaniases and other diseases of public health concern

Phlebotomine sandflies transmit pathogens that affect humans and animals worldwide. We review the roles of phlebotomines in the spreading of leishmaniases, sandfly fever, summer meningitis, vesicular stomatitis, Chandipura virus encephalitis and Carrión's disease. Among over 800 species of sandfly recorded, 98 are proven or suspected vectors of human leishmaniases; these include 42 Phlebotomus species in the Old World and 56 Lutzomyia species in the New World (all: Diptera: Psychodidae). Based on incrimination criteria, we provide an updated list of proven or suspected vector species by endemic country where data are available. Increases in sandfly diffusion and density resulting from increases in breeding sites and blood sources, and the interruption of vector control activities contribute to the spreading of leishmaniasis in the settings of human migration, deforestation, urbanization and conflict. In addition, climatic changes can be expected to affect the density and dispersion of sandflies. Phlebovirus infections and diseases are present in large areas of the Old World, especially in the Mediterranean subregion, in which virus diversity has proven to be higher than initially suspected. Vesiculovirus diseases are important to livestock and humans in the southeastern U.S.A. and Latin America, and represent emerging human threats in parts of India. Carrión's disease, formerly restricted to regions of elevated altitude in Peru, Ecuador and Colombia, has shown recent expansion to non-endemic areas of the Amazon basin.

Reactive oxygen species-mediated immunity against Leishmania mexicana and Serratia marcescens in the sand phlebotomine fly Lutzomyia longipalpis

Phlebotomine sand flies are the vectors of medically important Leishmania. The Leishmania protozoa reside in the sand fly gut, but the nature of the immune response to the presence of Leishmania is unknown. Reactive oxygen species (ROS) are a major component of insect innate immune pathways regulating gut-microbe homeostasis. Here we show that the concentration of ROS increased in sand fly midguts after they fed on the insect pathogen Serratia marcescens but not after feeding on the Leishmania that uses the sand fly as a vector. Moreover, the Leishmania is sensitive to ROS either by oral administration of ROS to the infected fly or by silencing a gene that expresses a sand fly ROS-scavenging enzyme. Finally, the treatment of sand flies with an exogenous ROS scavenger (uric acid) altered the gut microbial homeostasis, led to an increased commensal gut microbiota, and reduced insect survival after oral infection with S. marcescens. Our study demonstrates a differential response of the sand fly ROS system to gut microbiota, an insect pathogen, and the Leishmania that utilize the sand fly as a vehicle for transmission between mammalian hosts.

Canine skin and conjunctival swab samples for the detection and quantification of Leishmania infantum DNA in an endemic urban area in Brazil

BACKGROUND

We evaluated kDNA PCR/hybridization and quantitative real-time PCR (qPCR) targeting the gene of DNA polymerase of Leishmania infantum for CVL diagnosis and assessment of parasite load in clinical samples obtained invasively and non-invasively.

METHODOLOGY/PRINCIPAL FINDINGS

Eighty naturally infected dogs from an endemic urban area in Brazil were used. Animals were divided into two groups based on the presence or absence of CVL clinical sings. Skin biopsies, bone marrow, blood and conjunctival swabs samples were collected and submitted to L. infantum DNA detection. In addition, anti-Leishmania antibody titers were measured by Immunofluorescence antibody test. The symptomatic dogs had increased titers compared to asymptomatic dogs (P = 0.025). The frequencies of positive results obtained by kDNA PCR/hybridization for asymptomatic and symptomatic dogs, respectively, were as follows: right conjunctiva, 77.5% and 95.0%; left conjunctiva, 75.0% and 87.5%; skin, 45.0% and 75.0%; bone marrow, 50.0% and 77.5%; and blood, 27.5% and 22.5%. In both groups, the parasite load in the skin samples was the highest (P<0.0001). The parasite loads in the conjunctival swab and bone marrow samples were statistically equivalent within each group. The parasite burden in conjunctival swabs was higher in the dogs with clinical signs than in asymptomatic dogs (P = 0.028). This same relationship was also observed in the bone marrow samples (P = 0.002). No differences in amastigotes load in the skin were detected between the groups.

CONCLUSIONS

The conjunctival swab is a suitable clinical sample for qualitative molecular diagnosis of CVL. The highest parasite burdens were detected in skin regardless of the presence of VL-associated clinical signs. The qPCR results emphasized the role of dogs, particularly asymptomatic dogs, as reservoirs for CVL because of the high cutaneous parasite loads. These results may help to explain the maintenance of high transmission rates and numbers of CVL cases in endemic urban regions.

New challenges in the epidemiology and treatment of visceral leishmaniasis in periurban areas

Visceral leishmaniasis [VL] represents a major public health problem in many areas of the world. This review focuses on the impact of periurbanization on the epidemiology and treatment of VL, using Brazil as an example. VL continues to be mostly a disease of poverty with impact on families. However, the disease has expanded in Latin America, with foci reported as far south as Argentina. There is an increasing overlap of Leishmania infantum chagasi and HIV infections and other immunosuppressive conditions, resulting in VL emerging as an opportunistic infection. This new setting poses new challenges for VL disease control and patient management.