Research Article: Epidemiological Changes in Leishmaniasis in Spain According to Hospitalization-Based Records, 1997–2011: Raising Awareness towards Leishmaniasis in Non-HIV Patients

Date Published: March 10, 2015

Publisher: Public Library of Science

Author(s): Zaida Herrador, Alin Gherasim, B. Carolina Jimenez, Marisol Granados, Juan Victor San Martín, Pilar Aparicio, Edgar M. Carvalho.

Abstract: In Spain, Leishmania infantum is endemic, human visceral and cutaneous leishmaniasis cases occurring both in the Peninsula, as well as in the Balearic Islands. We aimed to describe the clinical characteristics of leishmaniasis patients and the changes in the disease evolution after the introduction of antiretroviral therapy in 1997. In this descriptive study, we used Spanish Centralized Hospital Discharge Database for the hospitalized leishmaniasis cases between 1997 and 2011. We included in the analysis only the records having leishmaniasis as the first registered diagnosis and calculated the hospitalization rates. Disease trend was described taking into account the HIV status. Adjusted odds-ratio was used to estimate the association between clinical and socio-demographic factors and HIV co-infection. Of the total 8010 Leishmaniasis hospitalizations records, 3442 had leishmaniasis as first diagnosis; 2545/3442 (75.6%) were males and 2240/3442 (65.1%) aged between 14-65 years. Regarding disease forms, 2844/3442 (82.6%) of hospitalizations were due to visceral leishmaniasis (VL), while 118/3442 (3.4%) hospitalizations were cutaneous leishmaniasis (CL). Overall, 1737/2844 of VL (61.1%) were HIV negatives. An overall increasing trend was observed for the records with leishmaniasis as first diagnosis (p=0.113). Non-HIV leishmaniasis increased during this time period (p=0.021) while leishmaniasis-HIV co-infection hospitalization revealed a slight descending trend (p=0.717). Leishmaniasis-HIV co-infection was significantly associated with male sex (aOR=1.6; 95% CI: 1.25-2.04), 16-64 years age group (aOR=17.4; 95%CI: 2.1-143.3), visceral leishmaniasis aOR=6.1 (95%CI: 3.27-11.28) and solid neoplasms 4.5 (95% CI: 1.65-12.04). The absence of HIV co-infection was associated with lymph/hematopoietic neoplasms (aOR=0.3; 95%CI:0.14-0.57), other immunodeficiency (aOR=0.04; 95% CI:0.01-0.32) and transplant (aOR=0.01; 95%CI:0.00-0.07). Our findings suggest a significant increase of hospitalization in the absence of HIV co-infection, with a predomination of VL. We consider that clinicians in Spain should be aware of leishmaniasis not only in the HIV population but also in non HIV patients, especially for those having immunosuppression as an associate condition.

Partial Text: Leishmaniasis represents a complex of mammalian diseases caused by parasitic protozoans classified as Leishmania species and spread through the bite of the sand fly. Two major clinical forms are known: cutaneous leishmaniasis (CL), causing scars and eventually disfiguration, and systemic or visceral leishmaniasis (VL) that can lead to deadly complications if left untreated [1]. Worldwide, at least 20 Leishmania species are causing leishmaniasis. Most foci occur in the tropics or subtropics, and only zoonotic L. infantum is transmitted in both the Old and the New World. L. infantum is the causative agent of both the cutaneous and visceral forms of leishmaniasis in Southwest Europe [2].

A retrospective descriptive study was conducted using the CMBD, which is a national hospital admission database managed by the Ministry of Health and Social Policy that includes all hospitalizations and where diagnoses are coded according to the Spanish version of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) [12]. The CMBD registry includes encrypted patient administrative and clinical data. It receives notification from around 98% of the public hospitals in Spain. Compulsory health insurance covers an estimated 99.5% of the registered Spanish population, although persons not covered by health insurance can receive treatment in public hospitals. Since 2005, CMBD also has a gradual coverage from private hospitals [13].

This study provides a 15-year review of the epidemiological trends and patient characteristics of Leishmania hospitalizations in Spain. We particularly covered all the antiretroviral therapy era since 1997 and stratified the results by HIV status. The CMBD database provides a reliable picture of the Spanish leishmaniasis related hospitalization as it covers 98% of public hospital´s admissions. Public healthcare insurance is covering almost 100% of the Spanish population as of 2011, and private hospitals represent only a small proportion of all hospital admissions [15].



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