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EPIDEMIOLOGY OF AMERICAN TEGUMENTENT LEISHMANIASIS
IN THE FEDERAL DISTRICT AND THE IMPORTANCE OF THE
MULTIDISCIPLINARY APPROACH
Edis Rodrigues Junior1
Abraao Gomes Abreu 2
Carolyne Almeida Sarmento3
Liniker Lima Luz4
Thays Roiz Casarin5
Letícia Cristina Barbosa Serejo6
Lindsay Sandy Barbosa de Lima7
Aianne Lannara Freire e Silva8
Thaís Ferreira Dantas da Silva9
Lucas Boni Inácio10
Ricardo Rangel de Freitas Rodrigues11
Suely Gomes de Jesus12
Thamyres kryssia Bastos Teles13
1 UB - University Brazil
2 UCP- Central University of Paraguay
3 UCP- Central University of Paraguay
4 UCP- Central University of Paraguay
5 UNITED - University of Integration of the Americas
6 UCP- Central University of Paraguay
7 UCP- Central University of Paraguay
8 UCP- Central University of Paraguay
9 UDF -Universidade do Federal District
10 UCP- Central University of Paraguay
11 UB - University Brazil
12 UB - University Brazil
13 UCP- Central University of Paraguay
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Glenya Gilkla da Silva Abreu14
Juliana Oliveira de Toledo15
Abstract: Introduction: American Tegumentary Leishmaniasis is an infectious, non-contagious
disease, with compulsory notication and severe evolution, caused by protozoa of the genus
Leishmania. The medications used for treatment are multidisciplinary approach strategies. Objective:
To survey the epidemiological prole of a decade, 2009 to 2019, specically in the Federal District,
with the participation of a multidisciplinary approach in treatment. Methods: The procedures
involved stages of preparing maps and graphs using the Power Bi program, to identify numbers of
conrmed cases, with data by administrative regions of the Federal District, with treatment analysis.
The epidemiological survey was carried out using data from SINAN and the Epidemiological
Information on Leishmaniasis of the Federal District. Results: It was evident that the treatment is
carried out at the reference center, Hospital Universitário de Brasília. Epidemiological information
by Health Superintendencies, with constant case records, however in 2019 there was a signicant
decrease. Conclusion: It is pointed out that conrmed cases during the decade uctuated and were
recurrent. Participation in treatment, within the scope of the multidisciplinary approach, is necessary
and requires, in addition to dispensing, monitoring the use of the medication by the patient, it is
important to guarantee safety and eectiveness, guaranteeing health quality, avoiding errors related
to medication. .
Keywords: American Cutaneous Leishmaniasis. Federal District. Multidisciplinary approach
14 UCP- Central University of Paraguay
15 ABMDF-ASSOCIAção Biomedical do Federal District
INTRODUCTION
American Cutaneous Leishmaniasis (ATL) is an infectious, non-contagious disease caused by
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dierent species of protozoa of the genus Leishmania, which aects the skin and mucous membranes.
(BRAZIL, 2017). Primarily, it is a zoonotic infection, aecting animals other than humans, which can
be involved secondarily. In Brazil, there are seven species of leishmanias, responsible for the cases. Its
main species are: Leishmania (Leishmania) amazonensis, L. (Viannia) guyanensis and L(V.) braziliensi,
transmitted by the bite of infected female sandies (sandy, birigui, etc.), in which the dog is the main
reservoir, as untreated cases lead to a lethality of 90%, (ATL) is an important public health problem.
(BRAZIL, 2016). (BRAZIL, 2019)
In Brazil, Cutaneous Leishmaniasis (TL) has a high frequency, in addition to wide territorial
expansion and essentially local transmission (BRASIL, 2002). It is one of the dermatological conditions
that demands attention, due to its magnitude, as well as the risk of occurrence of deformities that it can
produce in human beings, and in addition to the psychological involvement with reections in the social
and economic eld, since it can be considered an occupational disease. It has a wide distribution with
records of cases in all Brazilian regions (BRASIL, 2017). ATL is a notiable disease, which consists of
the communication of the event of individual cases, clusters of cases, suspected, conrmed or outbreaks,
from the list of diseases listed in the ordinance and which must be made to the health authorities by
health professionals or any citizen, aiming at the adoption of the pertinent control measures, with
clinical characteristics of severe evolution, the diagnosis must be accurate and early (BRASIL, 2010).
The current treatment scenario in Brazil has peculiar characteristics due to the variety of contexts where
transmission occurs, which is correlated with parasite species, vectors, reservoirs and ecosystems. The
clinical presentation exhibits polymorphism and the spectrum of severity of signs and symptoms is also
variable, although there is a certain correspondence between the dierent clinical presentations and the
dierent species of the parasite (BRASIL, 2017).
Cutaneous leishmaniasis is included in the national list of diseases and conditions of compulsory
notication, according to Consolidation Ordinance No. 4, of September 28, 2017, annex V - Chapter I
(BRASIL, 2018). According to the Ministry of Health, in ten years, the number of cases of Tegumentary
Leishmaniasis in this period was reduced by 27%, from 26,685 cases in 2005 to 19,395 cases in 2015.
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The North region recorded the highest number of cases (8,939), followed by the Northeast (5,152);
Midwest (2,937); Southeast (1,762; and South (493). (BRAZIL, 2019).
ATL transmission cycles vary according to geographic region, involving a diversity of parasite
species, vectors, reservoirs, and hosts (BRASIL, 2017). According to the parameters of the Ministry of
Health, the Federal District is classied as an area of sporadic transmission, or seja, (MINISTRY OF
HEALTH, 2019).
Even though it is an important pathology that places Brazil among the countries with the
highest number of scientic publications on the subject; on the other hand, it is also the country that
stands out for the lack of access to eective treatments for patients and also registered an increase in the
number of registered cases, nationally. (FIOCRUZ, 2020)
The drug of choice for treatment is pentavalent antimony, with the exception of patients co-
infected with HIV and pregnant women. If there is no satisfactory response with pentavalent antimony,
the drugs of second choice are amphotericin B and pentamidine isothione (BRASIL, 2011). In patients
coinfected with Leishmania-HIV, the drug of choice is amphotericin B (BRASIL, 2011).
All drugs used for the treatment of endemic diseases, such as Leishmaniasis, whose control
and treatment have an established protocol and standards and that have a socioeconomic impact, are
considered strategic for multidisciplinary care (BRASIL, 2020).
The Unied Health System (SUS) oers specic and free treatment for Cutaneous Leishmaniasis
(TL) (BRASIL, 2019). Treatment is done with the use of specic medications, rest and a good diet.
Treatment should be conducted under the responsibility of the physician, with the eective participation
of the other professionals of the health team, after evaluation of possible contraindications, provided that
the monitoring of adverse eects of the treatment is ensured (BRASIL, 2017).
Epidemiological information on Cutaneous Leishmaniasis by Administrative Areas of
the Federal District, as well as multidisciplinary care for patients in basic health, are of paramount
importance to formulate hypotheses about the main causes and incidences, enabling the organization
and planning of health actions, vector control and greater clarication to the population about treatment.
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The treatment and management of this condition can benet from a multidisciplinary approach,
which involves the collaboration of dierent areas of health. For an Integrated diagnosis, professionals
from dierent areas, such as dermatologists, infectious disease specialists, and pathologists, can
work together to ensure an accurate and fast diagnosis, using laboratory and clinical-epidemiological
techniques. (BRAZIL, 2017)
For pharmacological treatment, medical specialists, such as infectious disease specialists and
general practitioners, can determine the appropriate drug therapy, considering factors such as the severity
of the infection, the response to previous treatments, and the patient’s comorbidities. Dermatological
care can act in the treatment of skin lesions, oering aesthetic and dermatological interventions, such as
the use of healing creams and the monitoring of possible complications, such as secondary infections.
Psychological support, cutaneous leishmaniasis can have a signicant impact on the patient’s
self-esteem and mental health. Psychologists and psychiatrists can oer emotional and psychological
support, helping with adaptation and acceptance of the condition.
Physiotherapy in cases of extensive injuries or sequelae, physiotherapists can help in
rehabilitation, promoting the recovery of function and improving the patient’s quality of life. (BRAZIL,
2017)
Research and Innovation Collaborations between research institutions, universities and health
services can boost studies on new therapies, vaccines and prevention strategies, contributing to a
more eective management of leishmaniasis, so this research is justied by the need to highlight the
occurrence of continuous cases during the last decade, with the presentation of statistical data to be
exposed and report the importance and relevance of the multiprofessional team in the participation of
assistance to the population.
The present study aimed to evaluate the epidemiological prole of Leishmaniasis in the last
decade in Brazil, specically to survey the epidemiology of the Federal District in the period from 2009
to 2019, with the emphasis on evaluating the multidisciplinary approach to the treatment of the disease
in the Federal District.
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METHODOLOGY
The study area was the Federal District, which is located at 15°47’ south latitude and 47°56′
west longitude and occupies an area of 5,779 km². It is about 1,000 meters above sea level and has a
predominantly at relief.
Unlike the states of the country, Brasília is not divided into cities and neighborhoods, so there
are no city halls. The capital is composed of 31 Administrative Regions (RA’s) ocially constituted as
dependent on the Government of the Federal District.
The study was restricted to the following regions: Águas Claras, Asa Norte, Asa Sul, Brazlândia,
Ceilândia, Estrutural, Fercal, Gama, Guará, Itapoã, Núcleo Bandeirante, Paranoá, Planaltina, Recanto
das Emas, Riacho Fundo, Samambaia, Santa Maria, São Sebastião, Sobradinho, Taguatinga, Vicente
Pires and other Federation Units.
This is a prospective analytical study in the form of a survey of data related to the occurrence of
cases and the prevalence of American Cutaneous Leishmaniasis in the Federal District in the estimated
period of one decade prior to the study. From 2009 to 2019.
To survey the procedures followed in the treatment, an on-site survey was carried out,
searching for the hospitals that perform treatment, addressing which protocols are followed, how
the treatment is conducted and the participation in the stage of pharmaceutical care, the doctor, as
well as multidisciplinary care in the treatment. The methodological procedures of this study involved
elaboration stages, with tables and graphs to identify the number of conrmed cases of ATL, using data
from the Federative Unit of Brazil, with its administrative regions.
The Notiable Diseases Information System (SINAN), the Undersecretary of Health
Surveillance (SVS) of the Federal District, the Epidemiological Bulletin of Leishmaniasis made available
by the Health Department of the Federal District, and the administration of the University Hospital of
Brasília were used as sources for data search.
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Secondary data on the number of ACL cases were used to carry out the study, according to the
SINAN Net version of the Notiable Diseases Information System, made available by the Ministry of
Health and the Undersecretary of Health Surveillance (SVS) of the Federal District.
For the visual generation of the map and table for collecting and processing information on the
diusion of diseases, the Power Bi Desktop Free 2019 program was used for research.
FINDINGS
The data in the graph in Figure 1 show the conrmed cases of American Cutaneous
Leishmaniasis in the Federal District, added to the total number of cases in each Superintendence,
according to each year, in a period of one decade, according to the Notiable Diseases Information
System (SINAN) and the Epidemiological Bulletin of Leishmaniasis made available by the Health
Department of the Federal District.
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FIGURE 1. Total number of cases of American Cutaneous Leishmaniasis in the Federal District per
year, in the period of one decade (2009-2019).
Source: Notiable Diseases Information System (SINAN NET).
Figure one shows that the years 2010 and 2015 were the years with the highest number of cases,
unlike the years 2009, with 44 cases and in 2019 with only 28 cases. The map in Figure 2 shows the
number of total cases by divisions of each Health Superintendencies of the Federal District, including
cases of residents of other Federation Units. It is portrayed by total cases of one decade according to the
Notiable Diseases Information System (SINAN) and the Undersecretary of Health Surveillance (SVS)
of the Federal District.
The variation of colors in the map is ordered according to the variables according to the number
of cases, so in a greater number of cases the darkest colors predominate, and for the smallest number of
cases, the lightest ones.
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FIGURE 2. Total number of cases recorded by the Health Superintendence of the Federal District in the
period of a decade (2009-2019).
Source: Notiable Diseases Information System (SINAN NET). Undersecretary of Health Surveillance
– DF.
According to the Department of Primary Care and Health Surveillance, the multiprofessional
team should be involved in all services that develop surveillance and control actions for ATL, for early
diagnosis and appropriate treatment. It is of utmost importance to provide continuous care, articulated
with the other levels of care, aiming at longitudinal care and educational actions and community
mobilization in relation to the control of ATL (BRASIL, 2009).
Regarding the treatment of ATL, oered free of charge by the SUS, it is done with the use of
specic and alternative medications. The treatment is conducted under the responsibility of the doctor,
together with the professionals of the health team according to the protocol, who are adequate to the
hospitals in the Federal District, according to the management and protocol adopted by each of them.
The Reference Center for the Care of Patients with Cutaneous Leishmaniasis in the Federal
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District, according to the diagnostic and treatment manuals of the Ministry of Health and as made
available by the Health Department of the Federal District, is the University Hospital of Brasília (HUB).
It is currently the only one in the one that performs the treatment and follow-up of conrmed cases
of American Cutaneous Leishmaniasis, so the other hospitals in the Federative Units of the Federal
District carry out the diagnosis, notication according to the protocol and refer those diagnosed for
treatment at the reference center, also including emergency cases.
According to the Department of Health and the team of the LTA treatment sector at the
University Hospital of Brasília, the follow-up is carried out on Wednesdays of the month, so the
appointments for the follow-up of the treatment are carried out four times a month with previously
scheduled times, with the exception of emergency cases.
The participation of the team of professionals is composed of a doctor and a nursing technician.
The nursing technician is the professional who performs the triage of the patient, who is waiting for
medical care. The standardized medication is dispensed by the pharmacist to the nursing team, which
during the patient’s care is delivered to him, being the last contact with the patient in his care.
DISCUSSION
It is pointed out that most of the conrmed cases in the Federal District were predominant
in the Residents of other Federation Units, totaling 138, followed by the second highest number of
registered cases and the rst of the Superintendence of the Federal District to the Southwest with 92
cases, followed respectively in descending order by the Superintendencies North, West, Central, Center-
South, East, and the South Superintendence, which recorded the lowest amount, totaling 28, considering
imported and autochthonous cases.
The year with the number recorded in the decade was in 2010, with a total of 91 cases, and the
lowest number was in 2019, totaling 28, but the region is not currently endemic. In the years 2018 and
2019 in relation to the average of the other years there was no signicant decrease, however in 2019 there
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was a reasonable decrease with almost half the number of cases of the previous year.
Part of the strategic component of disease control is the notication to the National Health
Surveillance Agency by those responsible for monitoring patients, in case of the appearance of serious
or rare adverse eects and technical complaints associated with the use of drugs prescribed for the
treatment of Leishmaniasis (BRASIL, 2018).
The pharmacist must work together with the nursing team, as co-responsible for the
implementation and adjustment of the therapeutic plan, for supporting the user and for monitoring the
therapeutic results, giving feedback to the team and allowing the entire system to feed back and remain
organized (BRASIL, 2015).
The World Health Organization (WHO) recommends a multidisciplinary approach to the
control and ght against Leishmaniasis, which involves several integrated strategies. These strategies
include: Epidemiological Surveillance - Constant monitoring of Leishmaniasis cases to identify
outbreaks and risk areas, allowing the rapid implementation of control measures.
Education and Awareness-Awareness campaigns to inform the population about the disease,
modes of transmission, prevention and treatment.
Vector Control – Implementation of measures to control vector populations, such as the sandy
mosquito, which transmits Leishmaniasis. This can include the use of insecticides, improving housing
conditions, and eliminating breeding sites.
Diagnosis and Treatment-Access to accurate diagnoses and adequate and timely treatment for
Leishmaniasis cases, with the use of eective and safe therapies.
Intersectoral Approach - Engaging dierent sectors, such as health, environment, education,
and social care, to address the social and environmental determinants of health.
Research and Development - Promotion of research for the development of new vaccines,
treatments and control methods.
Community Support – Mobilization and involvement of local communities in the planning and
execution of control actions, supporting public health eorts.
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These actions should be coordinated by multidisciplinary teams that include health
professionals, epidemiologists, veterinarians, biologists, educators, and community representatives,
ensuring an eective and sustainable response to the problem of leishmaniasis.
It was evidenced that in the treatment at the reference hospital in the Federal District, it is
conducted by the physician in charge, with the participation of the technical nursing team directly in
contact with the patient, while the participation of the pharmaceutical care related to the treatment is
carried out in the scope of selection, acquisition and dispensation of the medication indirectly to the
patient.
The stages of follow-up directly to the patient and pharmaceutical care in the evaluation of
the safety, ecacy, correct and rational use of the drug, despite being an attribution of the pharmacist,
are not monitored in this context. Therefore, for it to be successful, a multidisciplinary approach in the
treatment of Leishmaniasis is essential, according to the guidelines of PAHO, WHO and the Ministry of
Health, involving several integrated strategies such as the strengthening of epidemiological surveillance
to identify and monitor cases and the use of appropriate laboratory and clinical diagnostics.
Clinical treatment and use of antiparasitic medications, with a choice based on the type of
Leishmaniasis (cutaneous or visceral) and the patient’s condition. Follow-up by specialist doctors, such
as infectologists and dermatologists. Education and community mobilization, and it is important to
inform the population about prevention and treatment. Involve the community in vector surveillance and
control, implementing mosquito control strategies (such as the elimination of breeding sites, applying
the promotion of individual and environmental protection measures. Not forgetting that psychosocial
support, psychological and social monitoring for patients and their families, is also part of the patient’s
treatment and recovery, considering integration with mental health services, when necessary.
Rehabilitation and follow-up rehabilitation services to deal with possible sequelae, long-term
monitoring to identify complications. Intersectorality collaboration between dierent sectors, such
as health, environment, education and social care, for a comprehensive approach. These actions must
be adapted to the local context, promoting an integrated and eective response in the ght against
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Leishmaniasis.
Interaction must also involve the conceptions of its subjects, respecting their biopsychosocial
specicities, from the perspective of the integrality of health actions (PAHO, 2002, 2024)
CONCLUSION
The results show that due to the particularities of each Administrative Region of the Federal
District, each one presents dierent results according to its peculiar characteristics, so public policies
and strategies should meet these individualities.
The implementation of the multidisciplinary approach is a strategy to ensure the qualication
and humanization of user care, as well as possible adverse eects, drug interactions and notication of
adverse events and/or side eects, being one of the most important steps in the follow-up of rational
pharmacotherapy and prevention of other factors unfavorable to the success of treatment.
Pharmacotherapeutic follow-up is important to reduce errors with medications that impact the
eectiveness of treatment, such as abandonment of drug therapy, aimed at ensuring improved quality
of life. The implementation of the multidisciplinary approach, which makes up the care, is necessary
in aggravating diseases such as Leishmaniasis, as it allows for greater benets to the patient and better
strategies for promoting public health.
Currently, treatment is based on parenterally administered drugs, highlighting the need for
other and new treatment options, especially those administered orally, which could improve access
to treatment in remote areas, analyzing the epidemiological and social prole of populations aected
by these diseases. The information included in this research becomes a valuable instrument for the
construction of public policies that encourage the early diagnosis of the disease in the various regions,
aiming at reducing mortality rates and improving the quality of life of patients.
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