American Tegumentary Leishmaniasis in Montes Claros: an epidemiological study

Introduction: American Tegumentary Leishmaniasis (ATL), or kala azar, is a serious chronic disease caused by Leishmania spp. It is an infectious and non-contagious disease that affects both humans and several species of wild and domestic animals, presenting the clinical forms of cutaneous, mucocutaneous and diffuse cutaneous. ATL is classified as a generalized zoonotic disease that has a global impact. It is caused by protozoa of the genus Leishmania and is considered a serious public health problem. Objective: To describe the epidemiological profile of cases found in Montes Claros-MG. Methodology: An epidemiological assessment was performed based on secondary data from SINAN/MS from January 2010 to December 2015. Results: From 2010 to 2015, 286 cases of ATL were registered, with the majority of cases occurring in children under 19 years of age (31.81%) and patients over 59 years (17.83%) had a lower percentage of disease involvement. The first choice drug used by patients was Glucantime (87.06%). The most affected gender was male (52.44%) and most patients had no comorbidities (76.96%). Conclusion: In Montes Claros, Minas Gerais, ATL presented high cases during the research period. In this sense, this study guides the development of new researches that address and monitor the spread of the disease by monitoring urban areas concomitantly with the capture of animals for the presence of the parasite, thus assisting in public health decisionmaking in controlling the disease.

According to the World Health Organization, TL is a public health problem in 85 countries, affecting four continents (Americas, Europe, Africa, and Asia), with an annual record of 0.7 to 1.3 million new cases. TL is one of the six most important infectious diseases due to its high detection rate and ability to produce deformities (Guerra et al., 2015).
In Brazil, ATL is one of the dermatological conditions that deserves the most attention due to its magnitude, its risk of causing deformities in humans, and its psychological involvement. In the last 20 years, ATL incidence in Brazil has increased in practically all States (Brazil, 2017).
Endemic outbreaks have occurred in the Southeast, Midwest, Northeast, and more recently in the Amazon region, the latter being related to the predatory process of colonization (Gontijo & de Carvalho Mde, 2003). Over the last years, the Ministry of Health registered an annual average of 35,000 new cases of ATL in Brazil. In the state of Minas Gerais, American Tegumentary Leishmaniasis (ATL) was first reported in 1940 and its transmission has been reported in rural and peri-urban areas. Minas Gerais is a state in which 1,000-2,000 LTA cases are reported annually (Miranda et al., 2011).
In the metropolitan region of Belo Horizonte, capital of the State of Minas Gerais, autochthonous cases of ATL have been registered by official health institutions since 1987 (Miranda et al., 2011). In this sense, this study aimed to carry out a descriptive study of ATL in the municipality of Montes Claros, state of Minas Gerais, between 2010 and 2015.
As a disease neglected by many countries, the need for epidemiological knowledge is necessary (Romero, 2016; Torres-Guerrero, Quintanilla-Cedillo, Ruiz-Esmenjaud, & Arenas, 2017) with the aim of promoting public policies favorable to the citizen.

Study area
The present study was conducted in the Municipality of Montes Claros (16º 43 '41"S and 43º51'54"W, 638 m sea level), located in the north of the state of Minas Gerais, Brazil. Montes Claros has 413,487 inhabitants, with a population density of 3,568,941 inhabitants/km². The region has a semi-arid tropical climate, hot and dry seasons with rainy periods between October and March. It constitutes an endemic area, with a high number of cases, which motivated our studies.

Study design and data collection
We performed a cross-sectional study based on notification forms of patients with an epidemiological and laboratory diagnosis of ATL registered between 2010 and 2015. Data were obtained from the database of the National, free public agencies and, System of Notifiable Diseases (SINAN) and provided by the Health Department in force. We collected sociodemographic (gender, age, place of residence) and epidemiological (probable site of infection, comorbidities, start of treatment, type of drug) data (Schneider, Fujii, & Corazza, 2017). In compliance with ethnic principles, the present work was submitted to the Ethics Committee for Research with Human Beings at Plataforma Brasil -Ministry of Health, CAAE 69738117.2.0000.5146.

Georeferencing
For the elaboration of the mappings where the technical procedures were carried out, processes were performed using data in loco, database of free public agencies and software. All steps will be described in chronological order. In the first step, the geographic coordinates of the collection sites were confirmed using the Google Earth software. After manually entering the collection locations in the program, the collection location was visually confirmed by extracting the geographic coordinates.
After completion of the first step, the second step proceeded by converting the coordinates to kml format, for better management of the ArcGIS 10.6.1 software. Data input in this software was from the databases of the Brazilian Institute of Geography and Statistics -IBGE, after data input and then superimposing the collected points on the database, we selected and cut the municipality of Montes Claros using the tools to select and to extract selects.
Subsequently, we opened the ArcTool Box toolbox: Analysis Tools -Overlay folder. After the union between the collected points and the delimitation of the area is made, this process allows the generation of the location of the area of the collected points.
Following the aforementioned procedures. We navigated through the following options: ArcTool Box -Spatial Analyst Tools -Density -Kernel Density, to generate the kernel map. Kernel Map is an alternative for geographic analysis of pattern behavior. On the map, the punctual intensity of a given phenomenon in the entire study region is plotted using interpolation methods. As a result, we generated an overview of the intensity of the process in all regions of the map. Kernel Map is an alternative for geographic analysis of pattern behavior. On the map, the punctual intensity of a given phenomenon in the entire study region is plotted using interpolation methods. Thus, we have an overview of the intensity of the process in all Research, Society and Development, v. 10, n. 13, e521101321642, 2021 (CC BY 4.0) | ISSN 2525-3409 | DOI: http://dx.doi.org/10.33448/rsd-v10i13.21642 regions of the map.

Data analysis
Notification forms for ATL were tabulated in Microsoft office Excel® 2013 software (2013 version) and later treated in Origin 8.0 software, using the Chi-square test (X2), with a confidence interval of 95% and significance at p<0.05.

Results and Discussion
From 2010 to 2015, 286 cases of ATL were registered and confirmed in Montes Claros area, according to data obtained by SINAN. The presence of ATL was verified in different parts of the municipality, with a greater density in the suburbs (Figure 1). However, the advance of cases to the central region stands out. Between the analyzed period, there was a significant reduction (p<0.05) of 50% of the registered cases (Figure 2A). Regarding the age variable, ATL occurred in all age groups ( Figure 2B). However, the distribution of patients showed that the number of cases increased significantly (p<0.05) in patients under 19 years old (31.81%, n=91), followed by the age group 20 to 39 years old (25.52%, n= 73), 40 to 59 years old (24.82%, n=71) and over 59 years old (17.83%, n=51). In addition, most of those affected by ATL were male (52.44%, n=150), while 47.55% (136) were female ( Figure 2C). Of this total, 84.26% (n=241) and 15.73% (n=45) of patients lived in urban and rural areas of Montes Claros, respectively ( Figure 2D). The presence of comorbidities was observed in 5.61% (3) of the patients, whereas 76.96% (n=116) had no comorbidities, and 17.41% (n=167) did not disclose this information on their files ( Figure 2E). As to fatality due to TL (0.7%) notified and confirmed by SINAN, the two patients who died were male aged over 62 years. The drug of first choice used by both patients was Glucantime®. The presence of comorbidities was observed in only one of the patients who died ( Figure 2F). The rate of initial lesions reported by patients at the time of diagnosis are presented in Table 1. Cutaneous injuries were the most prevalent manifestation, being reported by 98.25% of patients.
As for the type of drug, 87.06% (n=249) of the patients used antimoniate-N-methyl glucamine (Glucantime®) as the first choice, 10.13% (n=29) used the common amphotericin B and 2.97% (n=8) patients used pentamidine and other drugs. Of these patients, 14 relapsed, and 10 patients used Glucantime and the rest were treated with amphotericin b (Table 2).
Tegumentary leishmaniasis (TL) mainly affects the skin and mucous membranes and can also be fatal in the absence of treatment (de Souza, da Silva, Afonso-Cardoso, Favoreto, & Ferreira, 2005). The results presented in this study regarding the gender of the patients showed a greater predominance of males. The literature indicates the male sex as more susceptible to illness (JCF., 2009;Murback, Hans Filho, Nascimento, Nakazato, & Dorval, 2011;Ribeiro, Roewer, & Nascimento, 2014) This is also a common feature found in several published studies, which can be attributed to genetic factors and exposure to the etiological agent (Lima, Porto, Motta, & Sampaio, 2007). In Brazil, integument affects people of all ages, but mostly in endemic areas, 80% of recorded cases occur in children under 10 years of age (CUNHA, OLIVEIRA, & POMPEU, 2006). In some urban areas studied, there is a tendency to change the distribution of cases by age group, with the occurrence of high rates also in the group of young adults (Abraão et al., 2020;Silva et al., 2021).
As for the clinical manifestations, they were similar to epidemiological studies, with the most frequent symptoms being fever, splenomegaly, pallor and hepatomegaly (Oliveira, Figueiredo, & Braga, 2014) In The types of lesions were verified, the most frequent lesion was the skin lesion, as it is the area of the body that is most exposed, it occurs through the bite of the sand fly, the mucosal lesion occurred in 14 patients and the classic form is secondary to skin lesion (Pinto, Paiva, Queiroz, Rapela, & Oliveira, 2010) The presence of comorbidity, regardless of sex, demonstrates that the clinical manifestations are similar to TL in immunocompetent patients, however, the immune system of HIV carriers is more susceptible to poor disease evolution (Sampaio, Salaro, Resende, & de Paula, 2002).
The most used treatment was Glucantime® 87.06%, 10.13% used amphotericin B and 21.97% used pentamidine and other drugs. Methylglucamine antimoniate is especially effective in the treatment of cutaneous, mucocutaneous leishmaniasis.
The drug causes rapid regression of the clinical and hematological manifestations of the disease, as well as sterilization of the parasite (Pelissari, Cechinel, Sousa-Gomes, & Júnior, 2011).

Conclusion
Studies that verify the profile of this disease should be carried out more frequently, with the intention of generating characteristics of local populations with a higher incidence of the disease, consequently providing a greater possibility of rapid intervention in the diagnosis, thus the influence on inserting data in information systems, such as SINAN, provide a variety of exceptional bases in the evaluation of epidemiological profiles, so this tool is extremely important in the preventive care of communities, in relation to American Tegumentary Leishmaniasis, among others. In this sense, this study guides the development of new studies that address and monitor the spread of disease through monitoring of urban areas concomitant with the capture of animals for the presence of the parasite, thus helping in public health decision-making in the control of vector and shells.