Health professionals’ knowledge about prevention and control of leishmaniosis

Leishmaniasis is an important worldwide disease with a zoonotic potential that presenting visceral and cutaneous clinical forms. The domestic dog is seen as the main reservoir of Leishmania spp. and for this reason, it is the target of the control program in some countries. The health professionals’ knowledge about prevention and control of leishmaniasis was investigated. Through interviews with health professionals from endemic regions, it was observed that there are several conceptuais gaps about leishmaniasis. Therefore, it is essential to put into practice the concepts of single health, bringing human, animal and environmental health, next to population. Journal of Community Medicine


Introduction
Leishmaniasis is an infectious disease transmitted by vectors, caused by different species of the genus Leishmania [1]. This disease is transmitted to humans and domestic and wild animals by the bite of females sand flies during blood repast [2].
Classically, there are two main clinical forms of leishmaniasis: Visceral Leishmaniasis (VL) and Cutaneous Leishmaniasis (CL). Although VL is more severe, CL is more widespread worldwide. According to estimates, approximately 0.4 million cases of VL and 1.2 million cases of CL occur annually. More than 90% of global VL cases occur in only six countries: India, Bangladesh, Sudan, South Sudan, Brazil and Ethiopia. However, cutaneous leishmaniasis is widely distributed, with about one third of cases occurring in the Americas, the Mediterranean basin and western Asia, the Middle East to Central Asia [3].
Visceral leishmaniasis, known as kalazar, is a zoonotic and parasitic disease caused by obligate intracellular protozoa of the genus Leishmania. The most common Leishmania species are Leishmania donovani and Leishmania infantum or also known as Leishmania chagasi. The parasite is transmitted to humans and animals through the bites of female sand flies infected [4], of the genus Lutzomyia [5,6] and Pintomyia [7,8].
Cutaneous leishmaniasis in the New World is an autochthonous disease caused by different Leishmania species (Ross, 1903), that present a zoonotic character in which the wild animals play an important role in the maintenance of the cycle. However, due to the environmental modifications there are occurrences of synanthropic and domestic animals in the cycle of this disease. To date, twelve Leishmania species are responsible for cutaneous leishmaniasis in the Americas, three belonging to the subgenus Leishmania, nine to the subgenus Viannia. Due to the Leishmania species diversity involved and a wide geographical distribution, there are also a variable number of vectors [9].
The domestic dog (Canis familiaris) is seen as the main reservoir for Leishmania spp. For this reason, it is the target of a control program in some countries, such as Brazil [10]. Canine Visceral Leishmaniasis (CVL) is recognized as an important disease that is present in four continents and is endemic in more than 70 countries, affecting almost 2.5 million dogs [11].
For the control of this zoonosis, the main recommendation is euthanasia [12]. However, it does not have total approval of the population, due to the importance of the pets to their tutors [13]. Also, part of the scientific society questions the real effectiveness of this measure [13,14]. However, public health should not exceed ethical values, but seek clever and creative options to control the harm done to the community [15]. Therefore, the health education and social mobilization actions that play an essential role in the field of visceral leishmaniasis surveillance and control are important, since they represent a transformative potential in the construction of new tools for the prevention and control of this disease [16].
Considering the involvement of health professionals in the leishmaniasis prevention and control directly with the population, this review was carried out to verify the professionals' knowledge in relation to these diseases. Thus, we investigate the health professionals' knowledge regarding visceral and cutaneous leishmaniasis. We carried out this work with the objective of investigating professionals' knowledge regarding visceral and cutaneous leishmaniasis.

Methods
The search for articles was carried out in August 2018, in the databases: LILACS (Bireme) and Pubmed, with the descriptors "Knowledge OR Awareness OR Perceptions AND Veterinarians AND Healthcare Professionals AND Visceral Leishmaniasis".
Inclusion criteria: publication date (as of 2013), language (English and Portuguese). The first step was based on the analysis of the title and abstract of the manuscripts with the intention of selecting those that met the selection criteria. After this step, the articles were analyzed in their entirety and included those who approached the health professionals' knowledge regarding visceral and cutaneous leishmaniasis ( Figure 1).
As exclusion criterion were articles with paid access, as well as monographs, dissertations, theses and abstracts of congresses.

Results and discussion
In studies carried out in four Brazilian states, Mato Grosso (MT) [17], Pernambuco (PE) [18], São Paulo (SP) [19] and Minas Gerais (MG) [20,21], endemic for visceral leishmaniasis, the health professionals' knowledge about VL was investigated. Although they had direct contact with patients and dogs infected with Leishmania spp., all had doubts about VL (Table 1).
In endemic regions for VL and CL in the state of Minas Gerais, Brazil, research with health professionals (endemic disease control agents, community health agents and zoonotic agents) unsatisfactory results were observed in relation to the questions about clinical manifestations, popular names of the disease, transmission [20], preventive and control measures [21].
With increasing deforestation, human migration and urbanization, the leishmaniasis is a growing concern for professionals working in public health in many countries [22]. This is happening in the city of San Pedro, Asunción, Paraguay, where the highest levels of endemicity of cutaneous Leishmaniasis (LC) and Mucocutaneous (CML) in the country were verified, due to the increase in deforestation as a consequence of its agricultural and livestock economy [23]. Health professionals (nurses, nursing assistants and physicians) who had experience with CL and MCL underwent a prior knowledge assessment. Most had already seen a lesion of these diseases, and that it affected mainly the nose and mouth [24], and they knew that the disease is transmitted by sand flies vectors [25]. However, health professionals request a routine and standardized diagnosis and treatment for CL and MCL so that all patients can receive simple information to raise awareness in the community [23].
In Europe, questionnaires were sent to 459 veterinarians with the intention of assessing the level of awareness of these professionals about the spread of visceral leishmaniasis in the continent. In an endemic region of Spain, 82% of veterinarians always indicate some measure to their clients, dogs tutors, compared to only 37% in the South and 0% in the north of France in non-endemic regions. The main preventive measures recommended were repellents, topical insecticidal application, vaccination and administration of domperidone [26]. In Brazil, the first option was vaccine application [17,19] followed by topical use of insecticides (sprays on), repellent spray and use of repellent collars [19].
These professionals also advised about the environmental management, daily cleaning with the organic matter collection, the maintenance of the garbage capped, the trash-free yard [19], in order to avoid the proliferation and shelter of sand flies in these environments [27].
In health education it is possible to reconcile concepts about the cycle, symptoms and preventive measures of leishmaniasis to the population habits, which may be able to minimize the impact of these diseases [20], since that measures are put into practice [18]. In this scenario, health professionals are extremely important to link knowledge and the population [28], therefore the need for continuous training [20], thus generating a link between the population and the Health System [29].
Therefore, these professionals should be on alert with the recommendations indicated by the Ministry of Health and WHO, as well as participate in permanent education, as well as educational actions with the community, through preventive activities to combat this disease.

Conclusion
Health professionals demonstrate doubts in epidemiology, preventive and control measures of visceral and cutaneous leishmaniasis, so the need to elaborate a permanent education where these professionals contextualize the information about this disease to their reality.

FAPESP (Foundation for Research Support of the State of São
Paulo), process n 0 2017/24538-0, for the financing of the doctoral scholarship of the author and for the budget for the development of her project. Table 1: Characteristics presented in the five articles discussed in the review, type of questionnaire, interviewed number, profession and statistical analysis used.