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Leishmaniasis, a parasitic disease caused by the protozoan Leishmania spp occurs in two different forms - visceral and cutaneous. Higher incidences of the disease were allegedly reported in the United States after the arrival of a US soldier from the war in the Middle East. This area has higher incidences of this disease as compared to other parts of the world. In the visceral form of this disease, the internal organs suffer, while cutaneous leishmaniasis affects the skin. The management of the disease has largely been hampered by parasite intracellular mechanisms. Increased inflammation reduces the presence of protozoan parasites, although this is most effective when the disease stage is early. Leishmaniasis is also associated with increased social problems such as segregation due to visible skin marks on people, affected by it. Combined efforts through partnership and other control methods are required to combat the disease.

The Threat of Leishmaniasis

Leishmaniasis is an example of a parasitic disease. It is caused by obligate intracellular protozoa. The main vector for the protozoan parasites Leishmania spp is the sand fly (Copeland & Aronson, 2015; Pace, 2014). Blood is a bore and congenital transmissions have also been documented. Leishmaniasis exists in two forms, either visceral or cutaneous ones. The former type leads to the damage of the internal organs of the body. In contrast, cutaneous leishmaniasis presents its symptoms in the form of skin ulcerations with increased incidences of severe scarring. Individuals with immuno-compromised systems are at greater risk of contracting this disease, especially if they have its latent form (von Stebut, 2015). Leishmaniasis affects people of all populace across the world, even though there are specific regions where more incidences of this condition have been registered. In the United States, the first severe case of leishmaniasis was reported in 2015 after the US soldiers returned from the war in the Gulf region. It was assumed that most soldiers were the carriers of the disease when they returned home. Cutaneous leishmaniasis is dominantly present in Texas, while the cases of Leishmania infantum are also observed in North America, with the natural hosts being dogs and human beings. The control of this disease remains a key issue for any country due to its adverse effects on the internal and external body parts. Thus, leishmaniasis remains a major public health issue in the United States as it affects both animals and human beings.

Background Information on Leishmaniasis

Leishmaniasis is a dermal disease. In South America, people call it rubber ulcer disease. The disease is common in some countries of the Old World such as Afghanistan, Iran, Saudi Arabia, and Syria, but it is also spread in Brazil and Peru. In the latter two countries, a mucus-skin type of the disease leads to severe deformation of the face; but this type is found only in the New World. In addition, visceral leishmaniasis, which is also known as kala-azar, is distributed in Bangladesh, India, Nepal, Sudan, Ethiopia, and Brazil (Copeland & Aronson, 2015; Pace, 2014). In the absence of treatment, the mucocutaneous and visceral types of the disease may even lead to death in some cases.

Leishmaniasis causative agents are the protozoans of the genus Leishmania of the family Trypanosomidae of the Mastigophora class. Currently, several dozen species of Leishmania are isolated, while the ability to cause damage in humans is manifested by 17 species (Pace, 2014; von Stebut, 2015). Leishmania is intracellular parasites, developing in macrophages, or cells of the reticuloendothelial system. Both the mucous and cutaneous forms of leishmaniasis result in the presence of ugly scars and severely affect the internal form of the disease (Aronson, 2017). Therefore, timely intervention and the use of correct strategies in dealing with the disease are key in its management.

Environmental Issues and Population Affected

In April 2015, the world's media began to share information about a mysterious disease that spread among the inhabitants of parts of Syria and Afghanistan, occupied by IGIL forces (Adegboye & Kotze, 2012; Durrani et al., 2012). This disease led to a person rotting alive. The causative agents are streptococci from group A, which leads to necrotizing fasciitis, and unicellular leishmania parasites that are spread by flies and mosquitoes. The reason for their spread, according to scientists, is that the fighters of IGIL leave the bodies of their victims to rot in the streets, which promotes the multiplication of flies and microbes (Adegboye & Kotze, 2012). In 2004, Afghanistan suffered from an outbreak of leishmaniasis (Adegboye & Kotze, 2012). In Kabul alone, at least 67,500 cases were reported which brought the city dubious fame of the largest center of leishmaniasis on the planet (Adegboye & Kotze, 2012; Durrani et al., 2012). The presence of unpaved garbage on the streets is the biggest risk factor for infection because large gerbils Rhombomys Optimus, the natural reservoir of parasites, are fond of digging in these piles. Over the past decade, the ruined and neglected Kabul has remained one of the most dysfunctional leishmaniasis cities in the world. Presumably, American troops were infected during their peace mission. However, a specific number of infected soldiers has never been mentioned publicly due to confidentiality reasons since the troop's health is a governmental responsibility. Therefore those, who had caught the disease, were sent back to the USA and isolated until their complete recovery. Precedents became publicly announced after the cases of this disease stopped being a military issue and became a civil problem.

It was found that several people in Texas and Oklahoma had immediately sought help with the symptoms that resembled leishmaniasis. This fact prompted some researchers to study the possible sources of this infection in North America, where the flies and mosquitoes that could distribute it did not live (Copeland & Aronson, 2015; van Griensven & Diro, 2012). As their analysis had shown, the leishmania cells from the tissues and blood of patients were the relatives of these parasites from one of the two corners of the world - the Middle East, where the representatives of the Leishmania tropical species were distributed. Consequently, the infection sources, in this case, are not the same. Thus, in the Middle East, as scientists assume, the infection affects mostly the US Army troops since they contact the bodies of the dead from this disease, while in South America, the victims of the disease are tourists who like wildlife travel. Loria (2015) notes that the cases of leishmaniasis have significantly increased in the United States over the past few years, although the number of cases is still low. Nonetheless, there is still an increased risk of more people being affected by the disease, with one study indicating that by 2080, some of the vectors of the disease will be present in the north of Canada (Loria, 2015). This indicates that there will be increased incidences of the disease shortly.

Epidemiological Research

To date, there is no effective vaccine for leishmaniasis due to the intracellular mechanisms imposed by the protozoan. First-generation vaccines were made completely from killed parasites or by mixing killed parasites with Bacille Calmette (BC). The combination of major promastigote leishmaniasis with BC as an adjuvant treated in an autoclave was tested in Iran against cutaneous leishmaniasis and in Sudan - against visceral one. Similar observations were made in Brazil, where dead parasites without Bacille Calmette were used (Machado & Penna, 2012; Safi, 2012). The combination of major promastigote leishmaniasis with Bacille Calmette and aluminum as an adjuvant treated in an autoclave showed high vaccine safety and sufficient immunogenicity in Phase 1 studies in Sudan. It is noteworthy that the combination of treatment with pentavalent antimony preparations with first-generation vaccines for the patients suffering from post-sisal dermal leishmaniasis was quite effective. Therefore, this indicates that even the use of incompletely accomplished vaccines plays a significant role in achieving a therapeutic effect.

The struggle with the animal carriers of leishmania is organized on a large scale only with zoonotic skin and visceral types of leishmaniasis. To prevent being infected it is recommended to take desensitization measures, improve populated areas, eliminate empty gardens and landfills in them, drain basements, and treat the residential, yard, and livestock facilities with insecticides. The usage of repellent or mechanical protection against bites of mosquitoes is recommended as well. After the detection and treatment of sick people, the source of infection should be neutralized by using available means. Also, chemoprophylaxis is administered as a prescription for chloride (pyrimethamine) during the epidemic season (Machado & Penna, 2012; Pace, 2014). Finally, the usage of pharmacological drugs remains among the common methods for the management of leishmaniasis.

Morbidity and Mortality Patterns

When skin leishmaniasis develops, the destruction of the skin in the place of the former tubercle, ulcer, and then the scaling of the ulcer with the formation of a scar simultaneously begins. The skin starts to rot, but eventually, rotting and infection spread to other visceral organs. If this is not prevented, the infection affects the inner parts of the body. There are cases, where the disease affects both the ears and eyes, thus resulting in the surgical replacement of these organs. The mucus form of the disease largely leads to the destruction of the soft tissues as well as cartilage in the process of affecting the internal parts of the body. While both forms of the disease have been registered in the countries of South America, nothing similar has ever happened in the USA so far.

Visceral leishmaniasis is registered among adults less frequently, while children are more likely to contract this disease. After the introduction of pathogens into the body, the infection spreads throughout internal organs, starting from the lymph nodes to the lungs (Copeland & Aronson, 2015; von Stebut, 2015). Thus, the internal organs suffer from dysfunctions. The body responds to such reactions through increased inflammation as a method of decreasing the effects of the disease. However, the late-stage conditions of leishmaniasis normally result in increased hypersensitivity due to increased release of inflammatory elements (Copeland & Aronson, 2015; von Stebut, 2015). The development of hypersensitivity of the delayed-type contributes to the destruction of early-stage Leishmania. Nonetheless, at the advanced stages, some form of the disease may enter the latent form and recur immediately after the body has been immuno-compromised. Due to reduced reactivity, parasites multiply actively. Thus, their products of metabolism cause fever and other manifestations of intoxication, while generalized endothelins cause the development of pathomorphological changes in the internal organs and their dysfunction (Copeland & Aronson, 2015; von Stebut, 2015). In the hepatic state, endothelial hypertrophy leads to compression and atrophy of hepatocytes of tissue cells. The atrophy of the pulp of the spleen (sometimes with necrosis and infarcts) and the embryonic centers of the lymph nodes is possible. The violations of the bone marrow lead to anemia. The treatment of leishmaniasis has been hampered by the very nature of intracellular parasites. The currently generated antibodies exhibit weakly expressed protective activity since most of the leishmania parasitizes are intracellular or localized in granulomas. In this case, a high level of autoantibodies is formed, indicating the development of immune pathological processes. The body does not endeavor to attack its own antibodies, thus making the management of this condition more difficult. Against this backdrop, there is an increased prevalence of secondary infections, the phenomena of amyloidosis of the kidneys, and hypochromic anemia despite the use of different diagnostic measures. The incidences of leishmaniasis in the United States vary on a yearly basis. The first cases were reported in 1990, with 1991 having increased incidences of about 3,800 (Pace, 2014). No cases were reported in 1994. In the latter years, there was an increased number of cases of cutaneous leishmaniasis.


Figure 1. Reported incidences of cutaneous leishmaniasis in the United States from 1990 to 2008 adapted from (Pace, 2014).

Public Health Issues & Interventions

In visceral leishmaniasis, the diagnosis is made based on clinical signs in combination with the results of parasitological or serological tests such as diagnostic rapid tests and others. The effectiveness of treatment depends on some factors, including the type of the disease, associated pathology, the type of parasite, and geographical location. The diagnosis of cutaneous leishmaniasis confirms the clinical manifestations and the results of parasitological tests. The treatment is dependent on the species of parasites and the form of the disease as well as its origin. Leishmaniasis can be treated and cured, but for medications to help the body get rid of parasites, a healthy immune system is necessary since, with immunodeficiency, there is a risk of relapse (Pace, 2014). Detailed information on the treatment of different forms of the disease, depending on its sources geographical location, is available in the specialized literature.

Government Response

The US government and all Federal state representatives control the prevention of leishmaniasis. Thus, control and prevention of this disease involve a complex biological system of the carrier (sandfly) and, in some cases, the host (animal reservoir) (Copeland & Aronson, 2015). The identification in the early stages and the timely treatment of patients help to reduce transmission rates and monitor the spread of the disease. Currently, a number of effective drugs can be utilized to manage the spread of leishmaniasis.

The control of vectors, especially at home, contributes to reducing or stopping the transmission of infection. Methods used to control the spread of leishmaniasis includes spraying the area with insecticides and using insecticide-treated nets as well as personal protection and environmental management. Effective surveillance remains one of the used methods to map different locations associated with the disease. The rapid data provision is critical to monitoring and taking action during epidemics and in situations with high mortality rates among patients receiving treatment (Copeland & Aronson, 2015). The strengthening of partnerships and social mobilization is another applicable strategy. Thus, partnership and cooperation with various stakeholders and programs to combat other vector-borne diseases are critical at all levels (Copeland & Aronson, 2015). Moreover, in addition to spreading information about the disease and educating citizens regarding its symptoms, treatment, first help, and precautious actions as described above, it is necessary to prevent society from creating stereotypes about people who have had a disease and get cured.

With the devastating effects of leishmaniasis on the body, cutaneous leishmaniasis (CL) also has serious consequences in an individual's social life. Since ulcers with CL appear at the site of an insect bite, it is usually open areas of the skin - the face, arms, and legs. In other words, terrible ulcers are visible on an individual's skin, thus resulting in the segregation of such individuals. A survey conducted in Kabul (Afghanistan) has shown that the overwhelming majority of Afghani women are confident that leishmaniasis can be infected through utensils and household items (Safi, 2012). One in five has said that a woman with a CL should not breastfeed a child, and 50% believe that they should not be allowed to touch children (Safi, 2012). It is not surprising that such patients are expelled from society and treated badly in every possible way. With such an attitude from society, a woman with leishmaniasis has little chance of ever getting married and starting a family. Skin leishmaniasis in developing countries, where superstition is placed above knowledge, still leads patients to psychiatric hospitals, and many simply commit suicides, being rejected by all. Since the USA in general is an open society, it is not likely to be as judgmental and stereotypical as traditional Afghanistan and other developing eastern countries (Safi, 2012). However, it is important to make sure that overcoming this terrible disease will not spoil one's social life and involvement. Implicit content should be exposed in media to make people understand that there is no risk to get infected somehow from an already cured person, and generally, it is not a catchy virus in the condition of US society.

Media Coverage

Interestingly, the issue of the disease in question had not been mentioned to the public until after it had affected the populace. The media play a perilous role in reporting the outbreaks of specific diseases since they reach a larger population of people and they can pass the message effectively. They are also supposed to report on any new occurrences of the disease, provided they have been proven by any authentic and recognized medical body. Moreover, peoples response is sometimes dependent on the coverage given by the media. Thus, high coverage means more people access the information and respond appropriately by taking the required measures. However, media may also serve to distract people from the real information regarding specific diseases. This hypothesis was made with the help of communicative process theory by Laswell. Spee (2013) indicates that the formula of the communicative process described by G. Lausell is in itself an outline of the real communicative plan. Ideally, it means that the media provides limited information on a specific issue. However, this approach has a significant disadvantage because it is monologic, its configuration does not include the feedback, through which one considers communication unidirectional and not in itself but as a two-way process in its relation to social, cultural, and economic factors. The situation in mass media is presented as rather critical, which is easy to understand, on the one hand, since the disease of poor developing countries has interfered with the life of a wealthy and blooming country. However, on the other hand, the way mass media campaign on this topic unfolded was quite suspicious. It started suddenly, lasted for not too long, and no statistic of victims of the disease for the year 2016 was presented. Hence, it is hard to tell what a particular situation or what case made the topic top-news.

It is also important to mention that since the problem has become so urgent, the government and some public and rich people, such as Bill Gates, announced their donation to underdeveloped countries that suffer from leishmaniasis. Local governmental representatives comment commented upon the concrete cases in their states. They were mainly focused on the conditions that they had managed to arrange for the people with leishmaniasis, but the federal government skipped that part and discussed publicly their intentions to send volunteering missions to underdeveloped countries to start conquering the problem. As it is possible to see, the points of main attention were shifted a little bit. Generally, three main topics were discussed: the war and leishmaniasis, particular cases of illness within the United States, and the problem of leishmaniasis in the world.

After a precise overview of accessible sources of mass media and their analysis, it would be fair to conclude that the USA was ready to face leishmaniasis and to provide the citizens of Texas and Oklahoma with the necessary care and treatments. The disease spread was curtailed, and all the necessary information was circled among Americans. However, it was hard to tell about the victim's recovery, since no information was presented in mass media. At the same time, no information was found about promised and following missions to Old World countries to help them combat the disease and cope with consequences. Moreover, it is important to emphasize that scientists have managed to make a hypothesis on the possible ways of spreading disease. Hence, now, it becomes possible to prevent leishmaniasis in the areas along the vector, which eventually leads to Canada. The most important thing at this point is to make people aware of the potential infection and the ways it can be contracted. This task has been completely covered by the US government.

Leishmaniasis remains a major health burden in the United States, although the incidences of the disease have been localized in specific regions of the country. However, the USA remains at risk of the disease if new incidences of the disease are reported. The major method of controlling the disease is mostly limited to early diagnosis and treatment of the disease. Pharmacological treatment remains the most effective method currently used in the management of leishmaniasis since an effective vaccine has not been discovered due to the intracellular mechanisms utilized by the protozoan parasite inside cells. Other effective methods, which have been suggested, including controlling the vector population and using insecticides. More research is required regarding the control of leishmaniasis in the United States and other areas.

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