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Leishmaniasis – Authors' reply

2019; Elsevier BV; Volume: 393; Issue: 10174 Linguagem: Inglês

10.1016/s0140-6736(18)33057-5

1474-547X

Sakib Burza, Simon L. Croft, Marleen Boelaert,

Reproductive Health and Contraception

We share the concern raised by Suman Saurabh about duration of contraception when miltefosine is used as a treatment for leishmaniasis, since it is a major gap in clinical practice. WHO1WHOControl of the Leishmaniasis: report of a meeting of the WHO Expert Committee on the Control of Leishmaniases. World Health Organization, Geneva2010Google Scholar recommendations indeed state: "Women of child-bearing age should be tested for pregnancy before treatment and use effective contraception for 3 months after treatment". We agree that Table 3 in our Seminar2Burza S Croft SL Boelaert M Leishmaniasis.Lancet. 2018; 392: 951-970Summary Full Text Full Text PDF PubMed Scopus (864) Google Scholar is not explicit enough that this WHO recommendation should include the treatment duration, thus a total of 4 months. Of great concern is the 3-month long miltefosine monotherapy used in Asia as first-line therapy for post-kala-azar dermal leishmaniasis, which, based on the modelling study cited by Saurabh, would require more than 7 months of contraceptive cover. In practice, neither pretreatment pregnancy testing nor adequate contraceptive cover are routinely provided as a package of care for post-kala-azar dermal leishmaniasis. Contraception is an area that needs to be urgently strengthened and monitored, and safer treatments are required. We acknowledge WHO's Special Programme for Research and Training in Tropical Diseases pivotal role in developing miltefosine.3Sunyoto T Potet J Boelaert M Why miltefosine—a life-saving drug for leishmaniasis—is unavailable to people who need it the most.BMJ Glob Heal. 2018; 3: e000709Crossref PubMed Scopus (67) Google Scholar Saurabh correctly points out that Impavido is not prequalified by WHO, rather it has been approved by the US Food and Drug Administration, a Stringent Regulatory Authority, which pre-empts the need for WHO prequalification. We also note that the WHO-negotiated price of Impavido by brand is specifically mentioned in WHO's technical guidelines for visceral leishmaniasis.1WHOControl of the Leishmaniasis: report of a meeting of the WHO Expert Committee on the Control of Leishmaniases. World Health Organization, Geneva2010Google Scholar Saurabh's final point relates to our statement that clinical cases of visceral leishmaniasis and post-kala-azar dermal leishmaniasis are important in transmission. Our reference was directed at the role of acute clinical cases; for post-kala-azar dermal leishmaniasis, several other studies are available that show in-vivo infectivity of post-kala-azar dermal leishmaniasis lesions to sandflies,4Zijlstra EE Alves F Rijal S Arana B Alvar J Post-kala-azar dermal leishmaniasis in the Indian subcontinent: a threat to the South-East Asia Region Kala-azar Elimination Programme.PLoS Negl Trop Dis. 2017; 11: e0005877Crossref PubMed Scopus (71) Google Scholar whereas patients with the disease are thought to have provided the interepidemic reservoir that resulted in an oft-cited outbreak in southern West Bengal in the 1980s.5Addy M Nandy A Ten years of kala-azar in West Bengal, part I: did post-kala-azar dermal leishmaniasis initiate the outbreak in 24-Parganas?.Bull World Health Organ. 1992; 70: 341-346PubMed Google Scholar We agree that the role of post-kala-azar dermal leishmaniasis in transmission and control needs to be better understood. Jérôme Depaquit and colleagues point to the burden of leishmaniasis in Thailand. In our Seminar, Thailand was included in figure 2 as an endemic country reporting less than 100 cases of leishmaniasis in 2016.2Burza S Croft SL Boelaert M Leishmaniasis.Lancet. 2018; 392: 951-970Summary Full Text Full Text PDF PubMed Scopus (864) Google Scholar We agree that the unresolved questions highlighted by the authors are of utmost epidemiological interest. Finally, Amir Abdoli refers to his recent literature review about 30 cases of viscerotropic leishmaniasis. Viscerotropic leishmaniasis, by contrast with visceral leishmaniasis, is a rare clinical variant of disease caused by Leishmania tropica and other dermotropic species. The visceral infection does not necessarily present with the classical manifestations of visceral leishmaniasis. We agree that this entity requires greater consideration in areas endemic for cutaneous leishmaniasis, particularly in immunocompromised patients. We declare no competing interests. LeishmaniasisLeishmaniasis is a poverty-related disease with two main clinical forms: visceral leishmaniasis and cutaneous leishmaniasis. An estimated 0·7–1 million new cases of leishmaniasis per year are reported from nearly 100 endemic countries. The number of reported visceral leishmaniasis cases has decreased substantially in the past decade as a result of better access to diagnosis and treatment and more intense vector control within an elimination initiative in Asia, although natural cycles in transmission intensity might play a role. Full-Text PDF LeishmaniasisSakib Burza and colleagues1 adeptly reviewed different aspects of visceral leishmaniasis and cutaneous leishmaniasis. Full-Text PDF LeishmaniasisSakib Burza and colleagues1 infer that no autochtonous cases of visceral leishmaniasis have been reported in Thailand. Several cases of visceral leishmaniasis, however, have been recorded in this country in the past few years.2 All these cases were caused by Leishmania (Mundinia) martiniquensis except one, which was caused by L (Mundinia) siamensis.2 A new autochtonous species causing cutaneous leishmaniasis, L (Mundinia) orientalis, has also been described in Thailand in 2018,3 so three species of Leishmania are now known to cause leishmaniasis in this country. Full-Text PDF LeishmaniasisI congratulate Sakib Burza and colleagues (Sept 15, 2018, p 951)1 for their comprehensive Seminar on leishmaniasis. Full-Text PDF