Investigating the Effects of Demographic Factors on the Prevalence of Cutaneous Leishmaniasis in a Focus Area of Northeastern Iran

To the Editor: War, infection, and disease have always made intimate bedfellows, with disease recrudescence characterizing most conflict zones (1). Recently, increasing violence from civil war and terrorist activity in the Middle East has caused the largest human displacement in decades. A neglected consequence of this tragedy has been the reemergence of a cutaneous leishmaniasis epidemic. Old World cutaneous leishmaniasis is one of the most prevalent insectborne diseases within the World Health Organization’s Eastern Mediterranean Region (2). Zoonotic cutaneous leishmaniasis is caused by the protozoan parasite Leishmania major, which is transmitted through the infectious bite of the female Phlebotomus papatasi sand fly; the animal reservoirs are the rodent genera Rhombomys, Psammomys, and Meriones. Anthroponotic cutaneous leishmaniasis is caused by L. tropica and transmitted between humans by the Ph. sergenti sand fly. Until 1960, cutaneous leishmaniasis prevalence in Syria was restricted to 2 areas to which it is endemic (Aleppo and Damascus); preconflict (c. 2010) incidence was 23,000 cases/year (3). However, in early 2013, an alarming increase to 41,000 cutaneous leishmaniasis cases was reported (3,4). The regions most affected are under Islamic State control; 6,500 cases occurred in Ar-Raqqah, Diyar Al-Zour, and Hasakah. Because these places are not historical hotspots of cutaneous leishmaniasis, this change might be attributed to the massive human displacement within Syria and the ecologic disruption of sand fly (Ph. papatasi) habitats. According to the United Nations High Commissioner for Refugees, >4.2 million Syrians have been displaced into neighboring countries; Turkey, Lebanon, and Jordan have accepted most of these refugees. As a result, cutaneous leishmaniasis has begun to emerge in areas where displaced Syrians and disease reservoirs coexist (5). According to the Lebanese Ministry of Health, during 2000–2012, only 6 cutaneous leishmaniasis cases were reported in Lebanon. However in 2013 alone, 1,033 new cases were reported, of which 96.6% occurred among the displaced Syrian refugee populations (5). Similarly in Turkey, nonendemic parasite strains L. major and L. donovani were introduced by incoming refugees (6). Many of the temporary refugee settlements are predisposed to increased risk because of malnutrition, poor housing, absence of clean water, and inadequate sanitation. The combination of favorable climate, abundant sand fly populations, displaced refugees, and deficient medical facilities and services has created an environment conducive to cutaneous leishmaniasis reemergence. For example, refugee settlements in Nizip in southern Turkey have reported several hundred cases (7). Using current datasets published in English and Arabic, we mapped cutaneous leishmaniasis prevalence within Syria and its neighboring countries (Figure). Our results demonstrate that cutaneous leishmaniasis prevalence coincides with the presence of refugee camps (Figure, panel A), which is plausible given the strong association between disease outbreaks and refugee settlements (8). The deterioration of Syrian health systems, including the cessation of countrywide vector control programs, has created an ideal environment for disease outbreaks (9). Likewise, the sand fly vectors are widely distributed throughout the Middle East; expansive Ph. papatasi and Ph. sergenti sand fly populations exist in Syria and Iraq (4). The presence of these vectors in regions of instability can create new cutaneous leishmaniasis foci, which might have debilitating, and often stigmatizing, consequences for residents and deployed military personnel (10). In addition, the distribution of Leishmania spp. overlaps with sand fly habitats (Figure, panel B) and disease reservoirs (W. Al-Salem, unpub. data). Consequently, the movement of large refugee populations into regions that are ill-equipped to manage imported cutaneous leishmaniasis has resulted in outbreaks in Turkey and Lebanon (5,6). Figure Cutaneous leishmaniasis prevalence within Syria and neighboring countries of the World Health Organization’s Eastern Mediterranean Region, 2013. A) Prevalence among refugee camps. Case data were taken from http://datadryad.org/resource/doi:10.5061/dryad.05f5h ... Our findings emphasize the importance of contemporaneous disease tracking to identify human populations at highest disease risk. To ameliorate the current cutaneous leishmaniasis crisis, particularly during the winter when cases start to appear, accurate disease monitoring and strategic training of persons based within refugee camps (medical staff, aid workers, volunteers, and military personnel) needs to be prioritized. Moreover, clinicians and other medical personnel residing in refugee-hosting countries must be suitably trained to diagnose cutaneous leishmaniasis because other local diseases (e.g., sarcoidosis and cutaneous tuberculosis) can have similar manifestations. Along with vector and rodent control, new cutaneous leishmaniasis outbreaks should be managed by prompt diagnosis and treatment, which are even more pertinent given that L. tropica–associated cutaneous leishmaniasis typically is resistant to several treatment regimens. In summary, the coexistence of sand fly populations and Leishmania spp. within refugee camps, together with the considerable influx of persons who already have cutaneous leishmaniasis, create a dangerous cocktail that can lead to an outbreak unprecedented in modern times.

Cutaneous leishmaniasis is gradually becoming an increasing public health concern. Therefore, it is essential to generate knowledge on the epidemiological determinants of the infection to develop effective control strategies on the transmission of the disease. Environmental changes, the immune status of the host, and treatment failure are the three most important risk factors associated with cutaneous leishmaniasis. The aim of this study was the prevalence of cutaneous leishmaniasis at the ALERT center, over a five-year (2014-2018). A total of 2329 study participants comprising 1174 (50.4%) males and 1155 (49.6%,) females participated. The data was collected retrospectively from ALERT center clinical laboratory records within the study period (2014-2018). The overall prevalence of cutaneous leishmaniasis among the study participants was 33%. Of this, the prevalence of cutaneous leishmaniasis among male and female study participants was 34.9% and 31.1%, respectively. The prevalence in the age group less than 18, 19-28, 29-38, and greater than 39 years was 37.0%, 26.6%, 13.3%, and 23.1%, respectively. Generally, this study showed that cutaneous leishmaniasis, prevalent in the study area, is still a public health problem associated with many risk factors. Hence, there is a need to implement a sound control program, strengthened behavioral change, communication, and social mobilization-related activities.

Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis affecting humans. The purpose of this study was to determine the prevalence and epidemiological features of CL in Iran by a systematic review and meta-analysis. The literature search was performed in the SID, Magiran, IranDoc, PubMed, Scopus, Medlib, as well as the Google Scholar search engine databases to find studies on the prevalence of CL. The reference lists of the found articles were also reviewed to obtain additional relevant articles. Studies that were related to treatment and reservoirs of CL were excluded. Forty-four studies were selected for the final analysis. Meta-analysis with a random-effects model showed that the prevalence of leishmaniasis in Iran was 77 per 100,000 population. Overall, 60% of the patients were men. Most cases of CL occurred in autumn, and the majority of the patients had one lesion, mostly on hands. The most common age group was 20-30 years. In conclusion, CL is an endemic disease in Iran, and its prevalence is largely affected by geographical locations and regional customs. Appropriate preventing measures should be considered to decrease the incidence of CL in Iran.

Cutaneous leishmaniasis prevalence and morbidity based on environmental factors in Ilam, Iran: Spatial analysis and land use regression models

Prevalence of cutaneous leishmaniasis in different regions of Larestan and its relationship with public health condition during 2014–2015

Abstract:Cutaneous Leishmaniasis is the most common form of Leishmaniasis, it affects the skin and cause a painless and chronic papule at the site of the infected sand fly bite. The current study amied to assess the associated-risk determinants for cutaneous leishmaniasis in patients with diabetes compared to patients without diabetes. The direct stain method used to diagnose the cutaneous leishmaniasis. Blood samples were collected form 45 confirmed cutaneous leishmaniasis patients for the purpose of measuring HBA1C for patients with cutaneous leishmaniasis. The results of current study showed that 276 out of 315 (87.61%) were infected with cutaneous leishmaniasis by microscopic examination. Significant differences (P<0.05) were recorded in the prevalence of cutaneous leishmaniasis according to patient sex and the infected males 65.21% more than infected females 34.78%. Eleven out of 45 cutaneous leishmaniasis patients were suffered from diabetes with prevalence 24.44%. A high association between diabetes and increase in the size of the skin lesions was recorded in current study, the prevalence of diabetic patients with large skin lesions 17.78% higher than the prevalence of diabetic patients with small skine lesions 6.67%, also an association between diabetes and increased the number of cutaneous skin lesions was reported. The prevalence of cutaneous leishmaniasis patients with diabetes who suffered from multiple skin lesions was 13.33% higher than the prevalence of cutaneous leishmaniasis patients with diabetes who had a single skin lesions 11.11% and an association between diabetes and non-response to treatment of cutaneous leishmaniasis patients was recorded, the prevalence of cutaneous leishmaniasis patients with diabetes who did not respond to treatment was 15.56% higher than the prevalence of cutaneous leishmaniasis patients with diabetes who responded to treatment 8.89%. The results of current study demonstrated a significant relationship between diabetes and cutaneous leishmanasis in distinct risk determinants. Also, the study showed that the diabetes increased the severity of active cutaneous leihmaniasis.

Localized cutaneous leishmaniasis (CL) typically presents as papules, crusted nodules, plaques, or noduloulcerative lesions. Atypical CL does not show these features or mimic malignant lesion. In atypical forms, CL may be overlooked because of its similarity to other dermal diseases. To compare conventional, molecular, and immunohistochemical methods in the diagnosis of typical and atypical CL. The kinetoplast DNA, nested, polymerase chain reaction assay and immunohistochemical methods were compared and validated against conventional methods, including cytology and pathology, using 100 specimens of typical and atypical lesions of suspected CL. Compared with other methods, polymerase chain reaction of the kinetoplast DNA showed the highest sensitivity (typical positive, 100%, 67 of 67; atypical positive, 94%, 31 of 33) and specificity (100%), followed by immunohistochemistry (typical positive, 97%, 65 of 67, with 100% specificity; atypical positives, 94%, 31 of 33, with 100% specificity), and cytology (typical positive, 79%, 53 of 67, with 100% specificity; atypical positive, 58%, 19 of 33, with 100% specificity), followed by pathology (typical positive, 70%, 47 of 67, with 100% specificity; atypical positive, 42%, 14 of 33, with 100% specificity). In addition, polymerase chain reaction enabled identification of 98% (98 of 100) of the positive samples that included strains of Leishmania major (99% [99 of 100] cases) and Leishmania tropica (1% [1 of 100] cases). Because cytology is cheap and easy to perform with high sensitivity, it is the preferred, primary approach for typical CL, but cytology and pathology do not have sufficient sensitivity for diagnosis of atypical CL cases. Nested polymerase chain reaction and immunohistochemistry are sensitive tests for diagnosis of both typical and atypical CL and are recommended as complementary tests in suspected CL with negative conventional microscopy results.

مقدمهلیشمانیوز یک بیماری عفونی انگلی است که توسط تک یاخته ای به نام لیشمانیا ایجاد می شود. دارای سه شکل بالینی جلدی(سالک)، جلدی- مخاطی و احشایی(کالا-آزار) است. شیوع و بروز بیماری سالک تحت تاثیر عوامل مختلفی است که مهم ترین آن عوامل اقلیمی(آب و هوائی ) می باشد. هدف از این مطالعه، بررسی وضعیت کنونی لیشمانیوز جلدی در شهر مشهد به عنوان یکی از کانونهای مهم این بیماری و اثر عوامل زیستی آب و هوایی در شیوع این آن در بیست سال گذشته می باشد.روش کاردر این مطالعه اپیدمیولوژیکی، اطلاعات مربوط به بیماران مبتلا به لیشمانیوز جلدی از مراکز بهداشتی درمانی پنجگانه دانشگاه علوم پزشکی مشهد جمع آوری شد. همچنین داده های اقلیمی( آب و هوایی ) از اداره هواشناسی اخذ شد. داده ها با استفاده از نرم افزار اکسل و آزمون همبستگی پیرسون آنالیز گردید. نتایجتعداد 68958 مورد لیشمانیوز جلدی در طول 22 سال (1992-2014) در مراکز بهداشتی درمانی مشهد تشخیص داده شدند که بالاترین موارد ابتلا در میان بیمارانی مشاهده گردید که در طول فصل سرد هر سال به این مراکز تشخیصی مراجعه کرده بودند. ارتباط معنی داری بین ساعات آفتابی، سرعت باد و لیشمانیوز جلدی مشاهده نشد، اما همبستگی قابل توجهی بین میزان بارش، دمای فصلی، رطوبت و میزان شیوع بیماری، مشاهده گردید. بالاترین تعداد موارد بیماری در طول 20 سال گذشته در سالهای 1380-1381 مشاهده شد. روند بیست ساله نمودار هیستوگرام بیماری نشان دهنده توزیع فراوانی لیشمانیوز جلدی از نوع آنتروپونوتیک در شهر مشهد می باشد.نتیجه گیریعوامل اقلیمی تاثیر نسبی در شیوع لیشمانیازیس جلدی آنتروپونوتیک در این شهر دارد و بیشترین تعداد بیماران، در منطقه حاشیه شهر ساکن بودند که این مناطق دارای جمعیت حساس، خدمات شهری کم، ساخت و سازهای جدید و مخازن بیماری می باشد.

Leishmaniasis in Yemen is still not fully investigated nor well studied. Recently, outbreaks of cutaneous leishmaniasis (CL) in western highland were declared. However, there are no reports concerning the disease and the circulating species in the region. The aim of this study was to determine the prevalence of cutaneous leishmaniasis in Utmah district located in Western Highlands in Yemen. A cross-sectional survey was carried out at those highlands. For the survey, 1165 participants were subjected to Leishmanin Skin Test (LST) accompanied with direct interviews and physical examination. The overall prevalence of cutaneous leishmaniasis in the district was 18.5% and the cutaneous leishmaniasis (CL) was more frequent in the escarpments with a prevalence of 37%, including 5.5% for active lesion and 31.5% for scar of healed lesions. Children under the age of 16 years old comprised most of the CL cases (76.3%). The escarpments of western highlands in Yemen were hyperendemic areas for CL and the infection was more prevalent in children.


 
 Background
 Cutaneous leishmaniasis (CL) remains a serious public health concern in some parts of Iraq. The aims of this study to report of CL in some parts of Iraq, by different parasitological, cultural, and molecular methods and evaluate sex differences among infected patients. This is the first study conducted to characterize Leishmania species causing CL among Iraqi patients using the sequence analysis of Internal Transcribed Spacer1(ITS1) at Wasit Province.
 Methods
 A total of 700 cases of suspected CL were referred to the Iraqi clinics and health centres and they checked for Leishmania amastigote using a Giemsa-stain; however, the Novy Macneal Nicolle (NNN) culture led to the growth of promastigotes in all samples, then the samples were examined using polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP)-PCR methods.
 Results
 The present study indicated that the prevalence of CL as follow: AL-Diwaniyah 88(15.1%), Wasit 85 (14.5%), Najaf 79 (13.6%), Thi-Qar76 (13.1%), Basrah 67 (11.5%), Baghdad 65 (11.2%), Diyala 63(10.8%), and Salah-Edin province which recorded lower infection 60 (10.3%), and it appeared in 83.3% by using Giemsa- smeared stain. The highest infection rate (100%) appeared using PCR while the lowest infection (68%) appeared by culture on NNN media. The present study was revealed that the highest infection (60%) was caused by L.major rather than L.tropica (40%). Our results showed that 368 (52.6%) of CL patients were had single lesion and 215 (30.7%) had multiple lesions, and the ulcerative wet type lesions were present in 49.6%, while the nodule dry type lesions were present in 33.7%. The overall prevalence of cutaneous leishmaniasis in the study area was very high (83.3%) having a statistically significant association with sex; males are more prone (56.4%) to CL as compared to females (43.6%)
 
 Conclusions
 A clear and reliable bias toward males exists in some tropical diseases, such as leishmaniasis. CL is a major health problem in Iraq and CL caused by many countries including Iraq. Health authorities should be aware of the fact that war and terrorist activities induce expansion of the disease and increase the incidence rate in the situation that access to medical treatment is not easy especially in poor conditions in leishmaniasis endemic areas.
 
 

Two known types of cutaneous leishmaniasis (CL) including zoonotic CL due to Leishmania major and anthroponotic CL due to Leishmania tropica are prevalent in 14 of 22 countries located in the Eastern Mediterranean region including Iran. According to existing data, CL is endemic in Sabzevar City (northeast of Iran) and, because of the climatic conditions in this semi-desert region, is suitable for living vector/reservoir hosts of infection. The aim of our study was to identify the recent status of CL causative species in rural areas of Sabzevar County. Suspected patients of CL who were referred to health centers in suburban areas of Sabzevar and confirmed via microscopic observation of amastigotes were included in the study. Molecular identification of Leishmania species was done via nested PCR assay, based on amplification of kinetoplast minicircle fragments of L. major and L. tropica. In total, 153 patients including 89 males and 64 females were enrolled in this study. A high infection rate was reported in the autumn season (with a peak in October). Our findings revealed that L. major is responsible for 100% of infections. In addition, there was no association between CL and risk factors after statistical analysis. It seems that the infection pattern of CL is changing predominantly to L. major in most regions of Iran, which may be due to environmental changes, or ecological amendment and their effects on (vector/reservoir) host distribution in rural parts. Finally, controlling programs as well as promotion in public health systems should be considered in this area.

Cutaneous Leishmaniasis Caused by<i>Leishmania killicki,</i>Algeria

Multilocus sequence typing analysis of Leishmania clinical isolates from cutaneous leishmaniasis patients of Iran.

BackgroundCutaneous leishmaniasis is one of the most neglected tropical diseases increasing in its public health importance. In Ethiopia over 28 million people are living at risk of infection.MethodInstitution based cross-sectional study was conducted at Borumeda Hospital from February to May 2019. A total 205 leishmaniasis suspected patients were included by systematic random sampling technique. Socio demographic characteristics were collected using pre-tested questionnaires. Parasitological investigation was done from skin slit sample by using Geimsa staining method. Species identification was done by PCR-RFLP. Data were entered in to EpiData version 3.1 and analyzed using SPSS version 20 software. P-value of ≤ 0.05 was considered as statistically significant.ResultA total of 205 participants consisting 59% male and 41% female included in this study. The mean age (±SD) of the study participants was 31.9 (±14.29). The overall prevalence of cutaneous leishmaniasis was 22.4% (46/205). The prevalence in males (13.7%) was higher than in females (8.8%). It was more prevalent in the age group 16-45years old (15.6%). Clinically, 60% of patients’ hade single lesion with 1.55 average number of lesions. About 30.7% of patients’ had indurated plaque type of lesion. Most of the lesions were found on head and face (59%). House near to farmland, presence of hyrax in the village and presence of other cutaneous leishmaniasis cases in the neighborhood were independent predicator of cutaneous leishmaniasis prevalence. L.aethopica was found to be the etiologic agent of cutaneous leishmaniasis in the study participants.ConclusionThe prevalence of cutaneous leishmaniasis was 22.4%, this alerts the need of intervention. It is statistically associated with house near to farm land, presence of other cutaneous leishmaniasis cases in the neighborhood and presence of hyrax in village. Head and face were the most common sites of lesion.

Background: Cutaneous leishmaniasis is one of the endemic diseases in Iraq. Both types of cutaneous leishmaniasis that cause different ulcers are present, namely Leishmania major and Leishmania tropica, The disease also represents a major public and global health problem all over the world. Objective: Investigation of the relationship between parasitic infection with cutaneous leishmaniasis and some antioxidants Superoxide, Nitric oxide and immune cytokines tumor necrosis factor-alpha, Interferon-gamma. Materials and Methods: The demographic and epidemiological study included 55 cases suspected of being infected with cutaneous leishmaniasis. They visited Ramadi Teaching Hospital, with 25 volunteers. After obtaining their consent, they were used as control samples, where blood serum samples were obtained from both study groups. After that, work was done in laboratories. Department of Biology - College of Education for Pure Sciences - Anbar University. Results: The patients and healthy people were of different genders, and among the 55 samples from the infected, the number of males was 36 (65.5)% and females 19 (34.5)%, with statistically significant differences p&lt;0.05, and the age groups of the patients were from one year to 60 years. With an average age of (31 years), they were distributed into 6 groups. Also, among the 25 samples from the control group, the number of males was 12 (48%) and females were 13 (52%), Their ages also ranged from one year to 60 years, with an average age of (13) years, the enzyme-linked immunoabsorbent assay (ELISA) technique was used to detect the level of immunological indicators TNF-α, IFN-γ, SOD, NO, where the results showed High levels in the serum of cutaneous leishmaniasis patients (120.00 ± 52.11, 123.00 ± 44.21, 3.10 ± 1.21 and 121.93 ± 33.22), respectively compared to healthy subjects (72.86 ± 14.94, 21.91 ± 45.40, 0.88 ± 0.12, and 81.46 ± 4.50 ) respectively With statistically significant differences at the level of p &lt; 0.05, p &lt; 0.001. Conclusions: The inflammatory cytokines TNF-α, IFN-γ play a vital role in increasing or decreasing the severity in the pathogenesis of the disease and eliminating it.