Epidemiology and risk factors for cutaneous leishmaniasis in Pakistan.

Cutaneous leishmaniasis (CL) is endemic in Khyber Pakhtunkhwa (KP) Province of Pakistan, and exploring its epidemiological status is critical for its control. The current study described the spatial occurrence of CL and its associated risk factors in KP. Records of 5123 confirmed CL patients obtained from 17 district hospitals for the year 2020 revealed that Khyber district hospital had the highest influx of CL patients, followed by North Waziristan and Mardan districts. Additionally, a questionnaire to assess CL risk factors was administered to the heads of 576 randomly selected households across the same 17 districts. Multivariate logistic regression analysis of risk factors showed that education, family size greater than five individuals, information about CL, knowledge of the difference between sand flies and mosquitoes and use of insecticide sprays were risk factors for CL. Adult sand flies were sampled using sticky traps that were placed at variable heights at multiple locations within Mardan and Lower Dir districts. Collections showed that the number captured was maximum at the heights of 30–121 cm above the ground. Risk factors for CL and assessment of specific sand fly nocturnal height activities may assist in developing effective control strategies for CL in the province.

Several species of the genus Leishmania are causative agents of cutaneous leishmaniasis in Pakistan. This study aimed to determine phylogenetic placement of Leishmania species causing cutaneous leishmaniasis in Khyber Pakhtunkhwa province, Pakistan (34 Leishmania tropica, 3 Leishmania infantum), in-relation to species from other geographical areas using gene sequences encoding cytochrome b (cytb) and internal transcribed spacer 2 (its2). Based on cytochrome b sequence analysis, L. tropica strains from Pakistan and other geographical regions were differentiated into two genotype groups, A and B. Within the province, five distinct L. tropica genotypes were recognized; two in group A, three in group B. Two L. infantum isolates from the province were closely associated with both Afro-Eurasian and American species of the Leishmania donovani complex, including Leishmania chagasi, L. infantum and L. donovani from Sudan and Ethiopia; while a third L. infantum isolate could not be differentiated from visceralizing Kenyan and Indian L. donovani. We observed apposite phylogenetic placement of CL-causing L. tropica and L. infantum from Khyber Pakhtunkhwa. Affinities ascribed to Leishmania spp. From the region are valuable in tracing potential importation of leishmaniasis.

To compare FNAC with histopathology as an alternate method of diagnosing cutaneous leishmaniasis. Comparative study. The duration of the study was from August 2003 to April 2004 at CMH, Peshawar. A total of 40 patients were included in this study. They were referred from various areas of North-West Frontier Province. FNAC and skin biopsy was performed on every patient. Haematoxylin and eosin (H&E) stain was used for both procedures. The study group included 39 males and one female, their age ranging from 8-60 years with a mean age of 31.97 years. Detection of LT bodies was considered as a single criterion of the positive result. Histopathological examination was able to diagnose 14 out of 40 patients (positive yield of 35%), while FNAC picked up 11 out of 40 patients (positive yield of 27.5%). FNAC is easier, less painful and more cost-effective than the conventional skin biopsy. The high sensitivity and specificity eliminate the need for other time-consuming and invasive procedures. However, if LT bodies are not detected then any further comment cannot be made regarding the diagnosis and it is necessary to perform skin biopsy.

Present study was carried to determine the sand fly species composition, breeding sites ecology, seasonal abundance, and spatial distribution in district Malakand, Khyber Pakhtunkhwa, Pakistan. In addition, risk factors associated with cutaneous leishmaniasis (CL) were also evaluated. Survey of indoor and outdoor habitats was carried out using sticky traps in 31 villages of Dargai and Batkhela tehsils of Malakand. Soil from habitats of adult and immature sand flies was analysed. Questionnaire-based household survey was also performed in these villages to assess risk factors associated with CL. Soil samples from selected CL positive households were analysed for its contents. Additionally, clinicoepidemiological data from local health centres was examined for the year 2019. Total of 3,140 sand flies belonging to 18 species were collected. Phlebotomus sergenti was the most abundant species (38.16%). Its abundance had a strong positive correlation with mean monthly relative humidity and negative correlation with average temperature. Phlebotomus sergenti and Phlebotomus papatasi were abundant at an elevation ranging from 320 to 1,120m above sea level and in agricultural lands near human settlements. Flight height preference apparatus collected maximum sand flies at 30cm (1ft) above the ground and all species associated negatively with height. Soil analysis from habitats of adult and immature flies showed that highest mean number of adults and immatures were recorded from silt loam which carried highest concentrations of K2 O, Mg, Ca, and Zn. Number of immature sand flies correlated moderately (r=.7, p<.05) with K2 O soil concentrations. There was significant similarity between organic matter contents in soil samples from positive breeding sites and CL households (Wilcoxon rank-sum test, p=.1976). In multivariate analysis model for CL risk factors, age (26-35 and >35years), knowledge of leishmaniasis, living in a middle and upper class, preachers visit to villages, and assumption that Afghan refugees are more prone to CL were significant. CL patient's archived data from health centres showed that majority of patients had lesions on face and hands. Patient's influx was highest in February and March.

Pakistan faces critical challenges pertaining to cutaneous leishmaniasis (CL), where it's distribution is more or less patchy. The goal of this study was to assess the incidence of CL as well as to identify potential risk factors in Peshawar region, Khyber Pakhtunkhwa, Pakistan. The study was conducted in the dermatology outpatient unit at Kuwait Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan. Longitudinal out-patient department visit data for 9,631 CL patients spanning a 42-mo (April 2011-October 2014) period was analyzed using autoregressive integrated moving average (ARIMA) time series models ARIMA(1,0,0)(0,1,0)12 and ARIMA(0,0,0)(0,1,0)12. The ARIMA concluded that the number of patients was increasing over time. Over the duration, frequency of male patients (58.2%) was higher. The mean age of CL patients was 16.4 (confidence interval = 16.14-16.70) yr and the majority of the patients were aged 5-20 yr (52.6%). Inflow of CL patients peaked close to February and March, followed by a decline until its lowest point in the months of August and September (P < 0.001). Two hundred individuals, including 88 cases and 112 controls, were matched by gender and age categories (<5, 5-20, >20 yr) to derive 63 matched pairs. Using univariate conditional logistic regression analyses of the matched pairs, we found that living in congested rooms (>6 persons), having family members with lesions (active/scars), keeping cattle inside dwellings at night, and having in-door vegetation were established as factors that significantly increased the risk of CL. On the other hand, living in houses constructed with bricked walls or wooden roofs (thatched/beam), ownership of treated bed nets, and having meshed windows were proven to be protective against CL. It was evident that the disease incidence has been on a gradual rise over the past few years. It was concluded that household clustering, house construction, and conventional behavioral practices (living with cattle) greatly impact the epidemiology of CL in the region. Conclusions from this study have significant implications for prospective control programs.

Cutaneous leishmaniasis (CL) stands out as a significant vector-borne endemic in Pakistan. Despite the rising incidence of CL, the genetic diversity of Leishmania species in the country's endemic regions remains insufficiently explored. This study aims to uncover the genetic diversity and molecular characteristics of Leishmania species in CL-endemic areas of Baluchistan, Khyber Pakhtunkhwa (KPK), and Punjab in Pakistan. Clinical samples from 300 CL patients were put to microscopic examination, real-time ITS-1 PCR, and sequencing. Predominantly affecting males between 16 to 30years of age, with lesions primarily on hands and faces, the majority presented with nodular and plaque types. Microscopic analysis revealed a positivity rate of 67.8%, while real-time PCR identified 60.98% positive cases, mainly L. tropica, followed by L. infantum and L. major. Leishmania major (p = 0.009) showed substantially greater variation in nucleotide sequences than L. tropica (p = 0.07) and L. infantum (p = 0.03). Nucleotide diversity analysis indicated higher diversity in L. major and L. infantum compared to L. tropica. This study enhances our understanding of CL epidemiology in Pakistan, stressing the crucial role of molecular techniques in accurate species identification. The foundational data provided here emphasizes the necessity for future research to investigate deeper into genetic diversity and its implications for CL control at both individual and community levels.

Cutaneous Leishmaniasis (CL): A Cross-Sectional Community Based Survey on Knowledge, Attitude and Practices in a Highly Endemic Area of Waziristan (KPK Province), Pakistan

In Pakistan, cutaneous leishmaniasis is an emerging tropical disease and a very high number (>70%) of children are afflicted by this marring infection. This study aimed to scrutinise the prevalence, spatial distribution and socio-demographic and behavioural risk factors associated with cutaneous leishmaniasis in children aged <5-15 years in Khyber Pakhtunkhwa. A total of 1, 559 clinically confirmed records of children diagnosed with cutaneous leishmaniasis (January-December) from 2020 and 2022 were obtained from selected district hospitals. In addition, a risk factors-related questionnaire was administered to 1, 011 households (400 in 2020 and 611 in 2022) in nine districts during a household survey. The maximum number of cutaneous leishmaniasis cases was recorded in 2022 (n = 877, 56.25%) as compared to 2020 (n = 682, 43.75%). The hospital records showed a greater number of male patients in the 2022 cohort (n = 603, 68.76%). The highest number of cases were observed in children aged 5-9 years in 2022 (n = 282, 32.16%) and 2020 (n = 255, 37.39%). In 2020 and 2022, cutaneous leishmaniasis cases showed peak aggregation in March (n = 118, 17.3%) and January (n = 322, 36.72%). From a spatial analysis, the maximum number of cutaneous leishmaniasis cases was recorded at 59-1700 m elevation in various land-use/land-cover and climatic regions with quaternary alluvium rock formations. A multivariate logistic regression model analysis of risk factors from the households survey suggested that age group, socio-economic status, construction materials of the house, use of insect repellents, Afghan refugee camps in the village/district, knowledge and biting times of sand flies, frequent use of mosquito bed nets, presence of domestic animals in the house, knowledge of the transmission period and peak month of leishmaniasis infection increased the risk of acquiring cutaneous leishmaniasis (p value < 0.05). Our analysis demonstrated that cutaneous leishmaniasis in children is influenced by a variety of environmental, socio-demographic and behavioural risk factors in Khyber Pakhtunkhwa. The increase in recorded cases of cutaneous leishmaniasis in children in 2022 compared to 2020 suggests that the infection likely extended to new foci in the province.

Leishmaniasis is a major health problem worldwide. It is also a particular problem in the rural areas of Pakistan. The disease occurs in varying presentations, from the self-limited and even self-healing cutaneous forms to fatal systemic disease. Lesions of cutaneous leishmaniasis may occur anywhere on the body but the most likely sites are the exposed parts. The initial papule rapidly gives rise to an ulcer. Systemic leishmaniasis is rarer in Pakistan and invariably fatal if not treated promptly. It affects the internal body organs, particularly the spleen and the liver. Leishmaniasis is transmitted by an infected female sandfly. Cutaneous lesions are usually single and often self-healing, but a presentation with multiple ulcers resulting from multiple bites from the sandfly is not rare in Pakistan. The disease has a very long history and lesions like leishmaniasis have been described dating back to the ninth century (Balkan sore). Cutaneous leishmaniasis has been given various names in different civilizations such as "Delhi boil" in India, "Baghdad boil" in Iraq, and "saldana" in Afghanistan. The organism responsible for leishmaniasis was discovered 100 years ago but the disease has not been eradicated; rather it is on rise in many parts of the world. If control measures are not taken, it might emerge as a major health problem. Pakistan has a burden of cutaneous and visceral leishmaniasis, the mucocutaneous form being almost nonexistent. The physicians need to know the diagnostic criteria as well as the treatment of the disease. Because of a scarcity of dermatologists in the rural areas, most of these cases present to general practitioners. Control of this disease is further complicated by an inadequate supply of appropriate drugs.

(1) Background: In endemic areas of Pakistan, local community knowledge and attitudes towards cutaneous leishmaniasis (CL) are critical elements in the effective control and management of the disease. A cross-sectional epidemiologic design was used to assess the disease concern, preparedness, practices, and preventive behavior of the households and to assist the personnel and health care professionals in strengthening their planning efforts and awareness of CL. (2) Methods: A two-stage cluster sampling process, i.e., Community Assessment for Public Health Emergency Response (CASPER) was conducted from September 2020 to March 2021 on present household-level information about community needs and health status regarding CL in a cost-effective, timely, and representative manner. (3) Results: In the current study, 67% of the respondents were aware of CL and its causative agent and showed a low level of pandemic preparedness. The majority (74%) of the respondents mentioned that they did not avoid sandfly exposure areas. The majority (84%) of respondents had unsatisfactory behavior towards using bed nets, sprays, or repellents. (4) Conclusion: In endemic areas of Pakistan, the inadequate concern and low preparedness of the local community toward CL are critical aspects in efficient control and management of the disease.

Epidemic outbreak of anthroponotic cutaneous leishmaniasis in Kohat District, Khyber Pakhtunkhwa, Pakistan

Cutaneous leishmaniasis is a neglected disease known to cause significant morbidity among the poor. We investigated a suspected outbreak to determine the magnitude of cases, characterize the cases and identify risk factors of cutaneous leishmaniasis in Gilgil, a peri-urban settlement in Central Kenya. Hospital records for the period 2010-2016 were reviewed and additional cases were identified through active case search. Clinical diagnosis of cutaneous leishmaniasis was made based on presence of ulcerative, nodular or papular skin lesion. The study enrolled 58 cases matched by age and neighbourhood to 116 controls in a case control study. Data was collected using structured questionnaires and simple proportions, means and medians were computed, and logistic regression models were constructed for analysis of individual, indoor and outdoor risk factors. Of the 255 suspected cases of cutaneous leishmaniasis identified, females constituted 56% (142/255) and the median age was 7 years (IQR 7-21). Cases occurred in clusters and up to 43% of cases originated from Gitare (73/255) and Kambi-Turkana (36/255) villages. A continuous transmission pattern was depicted throughout the period under review. Individual risk factors included staying outside the residence in the evening after sunset (OR 4.1, CI 1.2-16.2) and visiting forests (OR 4.56, CI 2.04-10.22). Sharing residence with a case (OR 14.4, CI 3.8-79.3), residing in a thatched house (OR 7.9, CI 1.9-45.7) and cracked walls (OR 2.3, CI 1.0-4.9) were identified among indoor factors while sighting rock hyraxes near residence (OR 5.3, CI 2.2-12.7), residing near a forest (OR 7.8, CI 2.8-26.4) and having a close neighbour with cutaneous leishmaniasis (OR 6.8, CI 2.8-16.0) were identified among outdoor factors. We identify a large burden of cutaneous leishmaniasis in Gilgil with evidence of individual, indoor and outdoor factors of disease spread. The role of environmental factors and rodents in disease transmission should be investigated further.

International Journal of DermatologyVolume 40, Issue 2 p. 159-159 Cutaneous leishmaniasis in Pakistan Mohammad Jaffernay, Mohammad Jaffernay Makkah, Saudi ArabiaSearch for more papers by this authormd, md Makkah, Saudi ArabiaSearch for more papers by this authorRubina Nighat, Rubina Nighat Makkah, Saudi ArabiaSearch for more papers by this authormd, md Makkah, Saudi ArabiaSearch for more papers by this author Mohammad Jaffernay, Mohammad Jaffernay Makkah, Saudi ArabiaSearch for more papers by this authormd, md Makkah, Saudi ArabiaSearch for more papers by this authorRubina Nighat, Rubina Nighat Makkah, Saudi ArabiaSearch for more papers by this authormd, md Makkah, Saudi ArabiaSearch for more papers by this author First published: 21 December 2001 https://doi.org/10.1046/j.1365-4362.2001.00970-2.xCitations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume40, Issue2February 2001Pages 159-159 RelatedInformation

BackgroundThe vector-borne cutaneous leishmaniasis (CL) is endemic in several regions of Pakistan mainly affecting poor populations. Host genetic factors, particularly SLC11A1 (solute carrier transmembrane protein) within macrophages, play a crucial role in disease pathology and susceptibility. Association of SLC11A1 with cutaneous leishmaniasis, a neglected tropical disease, is not well established. Inconsistencies have been observed within different populations worldwide with respect to genetic susceptibility. This study was designed to investigate genetic variation(s) in SLC11A1 and to assess possible association with cutaneous leishmaniasis in Pakistan.ResultsEight polymorphisms (rs2276631, rs3731864, rs2290708, rs2695342, rs201565523, rs17215556, rs17235409, rs17235416) were genotyped across SLC11A1 in 274 patients and 119 healthy controls. Six polymorphisms were studied by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and sequencing. Two single nucleotide polymorphisms were analyzed with newly designed semi-nested PCR assays. Case-control analysis showed no association between selected polymorphisms in SLC11A1 and cutaneous leishmaniasis. No significant difference was observed in the distribution of alleles between leishmaniasis patients and healthy individuals. Strong pairwise linkage disequilibrium was observed between rs2276631 and rs2290708 (r2 = 64); and rs17235409 and rs17235416 (r2 = 78).ConclusionsThis study shows that genetic variations in the candidate gene SLC11A1 do not affect susceptibility to cutaneous leishmaniasis in the sample population from Pakistan.

BackgroundAmerican cutaneous leishmaniasis (CL) is a neglected tropical disease typically associated with men working in remote, sylvatic environments. We sought to identify CL risk factors in a highly deforested region where anecdotal reports suggested an atypical proportion of women and children were infected with CL raising concern among authorities that transmission was shifting towards domestic spaces and population centers.MethodsWe describe the characteristics of CL patients from four participating clinics after digitizing up to 10 years of patient data from each clinic’s CL registries. We assessed risk factors of CL associated with intradomestic, peridomestic, or non-domestic transmission through a matched case-control study with 63 patients who had visited these same clinics for CL (cases) or other medical reasons (controls) between January 2014 and August 2016. The study consisted of an in-home interview of participants by a trained field worker using a standard questionnaire. Risk factors were identified using bivariable and multivariable conditional logistic regression.ResultsBetween 2007 and 2016, a total of 529 confirmed CL positives were recorded in the available CL registries. Children and working aged women made up 58.6% of the cases. Our final model suggests that the odds of sleeping in or very near an agricultural field were five times greater in cases than controls (p = 0.025). Survey data indicate that women, children, and men have similar propensities to both visit and sleep in or near agricultural fields.ConclusionsWomen and children may be underappreciated as CL risk groups in agriculturally dependent regions. Despite the age-sex breakdown of clinical CL patients and high rates of deforestation occurring in the study area, transmission is mostly occurring outside of the largest population centers. Curbing transmission in non-domestic spaces may be limited to decreasing exposure to sandflies during the evening, nighttime, and early morning hours. Our paper serves as a cautionary tale for those relying solely on the demographic information obtained from clinic-based data to understand basic epidemiological trends of vector-borne infections.