Spatial and temporal trends of visceral leishmaniasis by mesoregion in a southeastern state of Brazil, 2002-2013.

This article presents the spatial and temporal distribution of visceral leishmaniasis (VL) in Minas Gerais State and identifies the greater risk areas of transmission. This study is both timely and substantive because Minas Gerais is an important Brazilian state in the number of cases of visceral leishmaniasis. The results showed that during the 12-year time series the VL had a heterogeneous spatial and temporal distribution in the state of Minas Gerais. Among the 12 existing mesoregions, six (Central Mineira, Jequitinhonha, Metropolitan area of Belo Horizonte, Northwest of Minas, North of Minas, and Vale do Rio Doce) were responsible for the expansion and maintenance of VL in the state. Among them, the Vale do Rio Doce and Jequitinhonha mesoregions presented a considerable increase in the incidence rates of the disease in the last period. In the other six mesoregions only sporadic cases of the disease were reported during the study period. The results of in this study may contribute to a better understanding the dynamic of the disease in Minas Gerais. Also these findings can provide subsidies to assist the actions of the control program of VL

Tratamento da leishmaniose visceral com anfotericina B lipossomal, Minas Gerais, 2008-2012

Exportado OPUSMade available in DSpace on 2019-08-10T18:41:28Z (GMT). No. of bitstreams: 1 bruna_dias_tourinho_disserta__o_fev_2015.pdf: 3320119 bytes, checksum: f80bae5ed3683d87b94d33c8d36b1c8c (MD5) Previous issue date: 25Introdução: A Leishmaniose Visceral (LV) é uma doença grave, sistêmica e fatal se não diagnosticada e tratada oportunamente. Nas últimas décadas ela se expandiu para o ambiente urbano, apresentando aumento das taxas de letalidade no Brasil e em Minas Gerais. A anfotericina B lipossomal é a opção menos tóxica para o tratamento da LV e indicada para um grupo especial de pacientes que apresentam risco aumentado para o óbito. É um medicamento de alto custo, adquirido pelo Ministério da Saúde (MS) a preços reduzidos e teve sua distribuição descentralizada em Minas Gerais em 2008. Apesar do aumento crescente do seu uso, pouco se sabe sobre os tratamentos autorizados, a adequação das indicações aos critérios preconizados, as características clínicas e epidemiológicas e fatores associados ao óbito dos pacientes. Objetivo: Avaliar o tratamento da LV com a anfotericina B lipossomal no Estado de Minas Gerais no período de 2008 a 2012. Método: (i) estudo epidemiológico descritivo e (ii) coorte histórica de pacientes tratados com anfotericina B lipossomal. Foram utilizadas como fonte secundária de dados fichas de solicitação e evolução de tratamento, Sistema de Informação de Agravos de Notificação (SINAN) e Sistema de Informação de Mortalidade (SIM). Resultados: Foram realizadas 646 solicitações de tratamento e 577 pacientes foram tratados, permitindo que 22,4% dos pacientes com LV no Estado utilizassem o medicamento. A descentralização do tratamento atingiu pacientes residentes em 97 municípios de 20 Unidades Regionais de Saúde (URSs) e 29 municípios de 15 URSs solicitaram o tratamento. O município e a URS de Belo Horizonte apresentaram as maiores proporções de solicitações (77,1% e 79,9%) e de pacientes residentes (41,5% e 68,0%). Cerca de 83,8% das solicitações de tratamento apresentavam critérios para o uso do medicamento, sendo a insuficiência renal (58,4%) e a idade acima de 50 anos (37,8%) as indicações mais frequentes. A anfotericina B lipossomal foi a primeira opção de tratamento em cerca de 45,6% dos pacientes, constituídos por indivíduos do sexo masculino (75,4%), com idade entre de 50-64 (25,5%) e 35-49 anos (23,2%). A taxa de letalidade geral foi de 19,4%, mais elevada em 2009 (32,5%). Os fatores associados ao óbito nos pacientes tratados com a anfotericina B lipossomal foram: a idade superior a 35 anos (OR: 2,64; IC: 1,46-4,78), icterícia (OR: 2,17; IC: 1,25-3,76), doença renal (OR: 2,83; IC: 1,66-4,85), infecções (OR: 2,46; IC: 1,47-4,09), edema (OR: 1,97; IC: 1,15-3,76), plaquetas 100U/L (OR: 2,19; IC: 1,26-3,76) e a assistência em instituição não especializada (OR: 1,86; IC: 1,01-3,44). Conclusão: O processo de expansão e descentralização do acesso à anfotericina B lipossomal em Minas Gerais reflete uma resposta positiva das equipes de assistência e vigilância tanto dos níveis regionais quanto municipais do Estado. Os fatores associados ao óbito identificados neste estudo poderá permitir a identificação precoce dos pacientes propensos a este desfecho, o que possibilitará o manejo clínico adequado dos mesmos e contribuir para a redução da letalidade da LV. A disponibilidade de um tratamento menos tóxico não constitui a única estratégia necessária para a da redução da letalidade por LV, sendo necessários esforços para a melhoria da qualidade assistencial e a estruturação das atividades relacionadas à vigilância e controle da LV em caráter contínuo.Background: Visceral leishmaniasis (VL) is a serious, systemic and fatal disease if not diagnosed and treated in time. In recent decades it expanded into the urban environment, showing an increase of mortality rates in Brazil and in Minas Gerais. Liposomal amphotericin B is the less toxic option for VL treatment, indicated to a special group of patients who are at increased risk of death. It is a high cost drug, purchased by the Health Ministry at reduced prices and had its distribution decentralized in Minas Gerais since 2008. It is a high cost drug, purchased by the Health Ministry at reduced prices and had its distribution decentralized in Minas Gerais since 2008. Despite the growing increase in its use, little is known about authorized treatments, the adequacy of indications to the recommended criteria, the clinical and epidemiological characteristics and factors associated with death of patients. Objective: To evaluate the treatment of VL with liposomal amphotericin B in the State of Minas Gerais from 2008 to 2012. Method: (i) descriptive epidemiological study and (ii) historical cohort of patients treated with liposomal amphotericin B. Treatment request and evolution forms, National System for Notifiable Diseases (SINAN) and Mortality Information System (SIM) were used as secondary data. Results: 646 treatment requests were made and 577 patients were treated, enabling 22.4% of patients with VL in the state to use the product. The decentralization of treatment reached patients residing in 97 municipalities of 20 Regional Health Units (URS's) and 29 municipalities of 15 URS's requested treatment. The municipality and the URS of Belo Horizonte had the highest proportions of requests (77.1% and 79.9%) and resident patients (41.5% and 68.0%). About 83.8% of treatment requests meet the criteria use of the drug. Renal failure (58.4%) and age over than 50 years (37.8%) were the most frequent indications. Liposomal amphotericin B was the first choice of treatment in about 45.6% of patients, consisting of males (75.4%), aged 50-64 (25.5%) and 35-49 years (23.2%). The overall lethality rate was 19.4%, higher in 2009 (32.5%). Factors associated with death in patients treated with liposomal amphotericin B were: age over 35 years (OR: 2,64; CI: 1,46-4,78), jaundice (OR: 2,17; CI: 1,25-3,76), kidney disease (OR: 2,83; CI: 1,66-4,85), infections (OR: 2,46; CI: 1,47-4,09), edema (OR: 1,97; CI: 1,15-3,36), platelets 100 U / L (OR: 2,19; CI: 1,26-3,76) and assistance in non-specialized institutions (OR: 1,86; CI: 1,01-3,44). Conclusion: The process of expansion and decentralization of access to liposomal amphotericin B in Minas Gerais reflects a positive response from the assistance and surveillance teams of regional and municipal levels of the state. Factors associated with death identified in this study may allow early identification of patients prone to this outcome, which will enable the appropriate clinical management of them and contribute to the reduction of VL lethality. The availability of a less toxic treatment is not the only strategy required for the reduction of VL lethality. Efforts to improve care quality and the structuring of activities related to VL surveillance and control continuously will contribute for favorable results

Population, municipalities and occurrence of visceral leishmaniasis (VL) in the mesoregions of Minas Gerais, Brazil.

<p>Population, municipalities and occurrence of visceral leishmaniasis (VL) in the mesoregions of Minas Gerais, Brazil.</p

Thematic maps of the smoothed cumulative incidence of visceral leishmaniasis, 2002–2013, Minas Gerais, Brazil.

<p>Thematic maps of the smoothed cumulative incidence of visceral leishmaniasis, 2002–2013, Minas Gerais, Brazil.</p

Fluxogram of the population analysed.

<p>Fluxogram of the population analysed.</p

Spatial and temporal trends of visceral leishmaniasis by mesoregion in a southeastern state of Brazil, 2002-2013

<div><p>Background</p><p>Visceral leishmaniasis (VL) is expanding in Brazil and in other South American countries, a process that has been associated with the urbanization of the disease. This study analyzes the spatial and temporal distribution of VL in the Brazilian state of Minas Gerais and identifies the areas with higher risks of transmission.</p><p>Methodology</p><p>An ecological study with spatial and time series analyzes of new confirmed cases of VL notified to the Brazilian Notifiable Disease Information System between 2002 and 2013, considering the 12 mesoregions of Minas Gerais. Two complementary methodologies were used: thematic maps of incidence and Poisson (log-linear) generalized linear model. Thematic maps using crude and smoothed cumulative incidences were generated for four trienniums. Poisson Regression measured the variation of the average number of cases from one year to the following, for each mesoregion.</p><p>Principal findings</p><p>The 5,778 cases analyzed revealed a heterogeneous spatial and temporal distribution of VL in Minas Gerais. Six mesoregions (Central Mineira, Jequitinhonha, Metropolitan area of Belo Horizonte, Northwest of Minas, North of Minas, and Vale do Rio Doce) were responsible for the expansion and maintenance of VL, with incidence rates as high as 26/100,000 inhabitants. The Vale do Rio Doce and Jequitinhonha mesoregions showed a considerable increase in the incidence rates in the last period studied. The other six mesoregions reported only sporadic cases and presented low and unsteady incidence rates, reaching a maximum of 1.2/100,000 inhabitants.</p><p>Conclusions/Significance</p><p>The results contribute to further the current understanding about the expansion of VL in Minas Gerais and may help guide actions for disease control.</p></div

Number of cases and incidence rates of visceral leishmaniasis per 100,000 inhabitants in each mesoregion of Minas Gerais, Brazil, 2002–2013.

<p>Number of cases and incidence rates of visceral leishmaniasis per 100,000 inhabitants in each mesoregion of Minas Gerais, Brazil, 2002–2013.</p

Poisson Model, variation in the average number of visceral leishmaniasis cases per year in the mesoregions of Minas Gerais, Brazil, 2002–2013.

<p>Poisson Model, variation in the average number of visceral leishmaniasis cases per year in the mesoregions of Minas Gerais, Brazil, 2002–2013.</p