Understanding the complexity of cutaneous leishmaniasis patient journey in endemic rural Sri Lanka: a qualitative study

Knowledge of early clinical manifestations, people's perceptions and behaviours is crucial in preventing and controlling neglected tropical diseases (NTDs). Cutaneous leishmaniasis is an NTD that causes skin lesions and affects millions worldwide. Delayed healthcare-seeking behaviour leading to prolonged treatment periods and complications is rife among people with cutaneous leishmaniasis. This study examined the patient-reported early clinical manifestations of cutaneous leishmaniasis, local interpretations and associated health behaviours within the socio-cultural context of rural Sri Lanka. We conducted a qualitative study among people with cutaneous leishmaniasis in three rural communities in the Anuradhapura district, Sri Lanka. Participants' experiences were explored through a study-bespoke participant experience reflection journal and in-depth interviews. We analysed the data using a narrative-thematic approach. The study included 30 people with cutaneous leishmaniasis (12 females and 18 males) aged between 18 and 75 years. We identified four major themes during the analysis: 1) patient-reported early clinical manifestations of cutaneous leishmaniasis, 2) local interpretations of the early skin lesion(s), 3) associated actions and behaviours, and 4) the time gap between the initial notice of symptoms and seeking healthcare for cutaneous leishmaniasis. Early clinical manifestations differed among the participants, while the majority misinterpreted them as a mosquito/ant bite, pimple, wart, eczema, macule, or worm infestation. Participants undertook different context-specific self-management actions to cure cutaneous leishmaniasis. We identified an average time gap between the notice of symptoms and the first visit to the healthcare facility ranging from three to twelve months. Diverse early clinical manifestations, local interpretations, and associated behaviours of people with cutaneous leishmaniasis have led to a substantial delay in healthcare-seeking. The study sheds light on the importance of understanding the manifestations of NTDs within the social context. Our findings will inform designing context-specific health interventions to improve awareness and healthcare-seeking in cutaneous leishmaniasis in rural settings.

ObjectiveTo assess community awareness of cutaneous leishmaniasis (CL) in a disease-endemic district in Sri Lanka.DesignPopulation-based cross-sectional study.SettingThis study was conducted in selected 158 Grama Niladhari divisions covering all the 22...

BackgroundThere is limited knowledge about the stigma associated with cutaneous leishmaniasis (CL) in Sri Lanka. To ensure that leishmaniasis researchers focus on CL-associated stigma, we provide an evidence-based framework that can be used in future research.MethodsWe conducted a systematic review on CL-associated stigma using international evidence and carried out a multimethod qualitative study in the Anuradhapura district in Sri Lanka. Based on that, we identified manifestations of stigma, drivers and facilitators that we synthesised to develop a conceptual framework on CL-associated stigma.ResultsOur framework consists of drivers, facilitators and self-stigma experienced by people with CL. Stigma drivers included fear, misbeliefs and misconceptions about CL; the belief that wounds are disfiguring; the treatment burden and implied blame. Facilitators that reduced stigma included knowledge of the curability of CL and awareness that CL is not contagious. The nature of social interactions in rural communities enhanced stigma formation. We identified various enacted, felt and internalised stigma experiences of people with CL.ConclusionsWe developed a conceptual framework of the stigma associated with CL that can be used to develop targeted interventions to increase CL awareness, address stigma and improve the quality of life for CL patients.

BackgroundCutaneous leishmaniasis is one of the few infectious diseases whose global prevalence is on the rise. Iran ranks among the eight most affected countries in the world. Iranian military personnel are often sent to endemic areas for cutaneous leishmaniasis without prior immunity, and they have fewer health facilities in military centers than the general population. This study aims to comprehensively investigate the situation of cutaneous leishmaniasis in Iranian military personnel across all units from 2018 to 2022 and predict the disease trend using time series analysis up to the end of 2025.MethodsWe analyzed data from the Iranian Ministry of Health to perform spatiotemporal and descriptive analyses based on patient frequency. Variables examined included age distribution, cutaneous leishmaniasis types (zoonotic or anthroponotic), month of healthcare facility visits, and lesion locations. This study employed the ARIMA model (p = 2, d = 0, q = 1)(P = 3, D = 0, Q = 0), for time series analysis and forecasting the disease trend up to 36 months after 2022.ResultsOver five years, 2,894 patients were reported. The Esfahan, Khuzestan, and Ilam provinces had the highest average patient counts, with hot spots primarily found in central, south, southwestern, and western Iran. Although the total number of patients with zoonotic cutaneous leishmaniasis was almost equal to anthroponotic cutaneous leishmaniasis, in high-risk provinces such as Esfahan, Khuzestan, and Ilam, the confirmed cases of zoonotic cutaneous leishmaniasis were much more than anthroponotic cutaneous leishmaniasis. patient numbers peak in October and November. Demographic analysis revealed that younger patients outnumbered older patients. Lesion locations were frequent on the forelimbs and lower limbs. The time series analysis for 36 months after 2022 indicated the seasonal pattern of the disease and predicted an upward trend after 2022.ConclusionWhile overall cases have declined, provinces such as Esfahan exhibit an upward trend. The expansion of hotspots from the west and southwestern to the center and south of Iran, coupled with an increasing trend in time series analysis, suggests the potential emergence of new foci and a rise in patient numbers in the future. In provinces with high disease prevalence, preventive measures should be prioritized, particularly in Ilam, Khuzestan, and Esfahan.

To the Editor: In Afghanistan, most cutaneous leishmaniasis cases are caused by Leishmania tropica, which is transmitted anthroponotically by the sandfly Phlebotomus sergenti (1). Cutaneous leishmaniasis can have devastating effects on local communities because of its clinical symptoms, i.e., large, multiple, or both, disfiguring lesions, that can lead to social ostracism of affected persons (e.g., women are often deemed unsuitable for marriage or to raise children) (2). Cutaneous leishmaniasis is considered a low priority disease by international donor agencies because treatment costs are high and the disease does not cause death (3). Data on the effects of cutaneous leishmaniasis in Afghanistan previously have been available only for Kabul city; recent studies have reported an estimated 67,500 cases (4). Because of the migration of an estimated 4.5 million infected Afghan refugees returning home from other countries, the sporadic treatment of patients infected with cutaneous leishmaniasis, and limited control of the sandfly vector, L. tropica has spread to areas that were previously nonendemic for the disease, e.g., northeastern Afghanistan. A survey in Faizabad city, Badakhshan Province, was conducted in June 2003 by HealthNet International to collect data on the impact of cutaneous leishmaniasis. Leishmaniasis in this region is transmitted from April to October. The city was divided into 10 districts, and 20 households were surveyed along a randomly chosen transect drawn from the center of each district. A team of experienced medical staff clinically diagnosed cutaneous leishmaniasis (based on the presence or absence of cutaneous leishmaniasis lesions or scars, number of lesions, date of lesion onset) in household members and interviewed them to collect demographic data (gender, age). Because of logistic constraints, parasitologic diagnosis of cutaneous leishmaniasis lesions (i.e., microscopic examination or parasite culture) was not conducted. However, in Afghanistan, skin lesions attributed to causes other than cutaneous leishmaniasis are rare, and experience has shown that clinical diagnosis has a sensitivity and specificity of >80% and >90%, respectively (Reithinger et al., unpub. data). Written approval to conduct the study was obtained from the Ministry of Health. Informed consent was obtained from study participants; all study participants with active cases of the disease were offered free anti-leishmanial treatment at the HealthNet International leishmaniasis clinic. We surveyed 1,832 people from 200 households; 8.3% (152/1,832) and 7.8% (142/1,832) had active cutaneous leishmaniasis lesions or scars, respectively. Of those persons with cutaneous leishmaniasis lesions, the mean lesion number was 2.4 (range 1–14), the mean lesion size was 2.4 cm (range 1–5.5), and the mean lesion duration (to survey date) was 5.6 months (range 1–11). Active prevalence was not associated with gender (Yates-corrected χ2 = 2.16, p = 0.14); 85/152 (56%) of the cutaneous leishmaniasis case-patients were women, and 67/152 (44%) of cutaneous leishmaniasis case-patients were men. Data showed that persons aged ≤15 years were at higher risk of contracting the disease than were persons aged >15 years (odds ratio = 2.23, 95% CI 1.54 to 3.24, Yates-corrected χ2 = 19.44, p < 0.001). Based on population estimates of 65,000 people and observed prevalence, approximately 5,395 cutaneous leishmaniasis case-patients would be found in Faizabad. The low prevalence of scars, compared to the high prevalence of disease, shows that cutaneous leishmaniasis has been introduced into Faizabad only recently (1,4). Local Ministry of Health records show that the disease was virtually absent (<50 annual cases) in Badakhshan 3 years ago; this information is corroborated by the observation that the mean time since the recovery of surveyed people with cutaneous leishmaniasis scars was 1.5 years (range 0.3–15). Although no attempts were made to identify circulating Leishmania sp., the current epidemic is likely caused by L. tropica because both men and women are equally affected and younger age groups are at higher risk for cutaneous leishmaniasis than older age groups (1,4). Current analyses are under way to establish risk factors (e.g., presence or absence of animals, type of house construction) for contracting the disease. With support from HealthNet International, three leishmaniasis clinics have been established in Faizabad to increase the total number of patients whose illness is diagnosed and treated; to reduce the risk to susceptible persons through the subsidized sale of insecticide-impregnated bed nets; to train and supervise the Ministry of Health staff in diagnosis, treatment, and prevention of the disease; and to implement health education campaigns for patients attending the clinics and the community at large. Hopefully, these activities will prevent the current cutaneous leishmaniasis outbreak from becoming an epidemic, as it has been in Kabul over the past 15 years (4,5).

Parasitic Infections in Solid Organ Transplant Recipients

Cutaneous leishmaniasis (CL) has been a significant public health concern in Libya for five decades, with transmission dynamics that are both zoonotic and anthroponotic. The disease was first reported in 1930, and since then, it has become widespread, particularly in the north-western region. This study aimed to illustrate changes in the epidemiological characteristics and treatment practices of CL in Libya during the period 2019-2022. Data for this study were obtained from the Administration of Zoonotic Disease Control at the Libyan National Center for Disease Control NCDCL in Tripoli. The dataset included information from 40 endemic sites across 10 municipalities. A chi-square test was performed to analyze the relationships among 19 key variables related to the incidence, demographic distribution, and treatment patterns of CL. Between 2019 and 2022, an estimated 13,625 CL cases were reported in Libyan hospitals, with fluctuating annual incidence rates. The highest number of cases was recorded in 2019, followed by a gradual decline over subsequent years. The age range of affected individuals ranged from 1 month to 95 years, with males accounting for 57.60% of cases and females accounting for 42.40%. Clinical diagnosis relied primarily on lesion features and epidemiological data, while laboratory confirmation was achieved using Giemsa staining. Cryotherapy has emerged as the predominant first-line treatment in regions with high disease prevalence. CL continues to pose a substantial public health challenge in Libya, intensified by the ongoing socio-political instability affecting disease surveillance and management systems. Comprehensive strategies integrating medical interventions and community-based initiatives are essential for mitigating the adverse medical and social impacts of CL in the country.

Randomised vaccine trial of single dose of killed Leishmania major plus BCG against anthroponotic cutaneous leishmaniasis in Bam, Iran

Background: Leishmaniasis has emerged as a significant global public health concern and has been notable in Sri Lanka since 1992, particularly in the Anuradhapura district, where Cutaneous Leishmaniasis is prevalent. The disease is caused by the Leishmania parasite, which is transmitted by sand flies of the genus Phlebotomus. Objective: This study compared the diversity, dominance, and density of sandfly species in selected locations within the Anuradhapura and Kegalle districts.Methods: Sand flies were collected monthly from January to March 2024 from locations identified through patient records from the Regional Epidemiologist’s unit. Collection was conducted using cattle-baited traps (CBT), and identification was performed morphologically and through DNA analysis. Ecological indices, includ-ing Simpson’s Dominance Index for species dominance and Shannon’s diversity index for species diversity, were calculated using the collected data.Results: A total of 154 sandflies were collected from ten locations in both areas. Among the collected samples, 87.6% (n=135) were P. argentipes and 5.19% (n=8) were P. stantoni, both of which belong to the genus Phle-botomus. Additionally, 7.4% (n=11) were Sergentomiya zelanica belonging to the genus Sergentomiya. P. ar-gentipes predominantly dominates locations in the Anuradhapura district, where Simpson’s dominance index is one (D=1), highlighting its high-risk status. In contrast, the Kegalle district showed higher species diversity with uneven distribution patterns. The Shannon Diversity Index reflected the highest diversity in Kegalle (H=0.6365), likely due to multiple species assemblages and ecological complexity.Conclusions and Recommendations: This comparative study underscores the importance of understanding sandfly population dynamics for targeting integrated vector control strategies. Tailored vector control is essential to prevent the annual emergence of new endemic foci of leishmaniasis in Sri Lanka. This study also emphasizes the integration of environmental, entomological, and epidemiological approaches for effective leishmaniasis control in Sri Lanka.

BackgroundLeishmaniasis is a notifiable disease in Sri Lanka since 2008. Previous studies show a gap in the notification of leishmaniasis. The purpose of the present study was to determine the Knowledge, attitudes and practice of medical officers regarding leishmaniasis.MethodsA cross-sectional study was conducted in the Anuradhapura district which reported the highest case load of leishmaniasis. Medical officers from public and private health care institutes in the area filled a self-administered questionnaire in the presence of the investigators.ResultsOne hundred and eighty-eight (188) medical officers completed the questionnaire. Of them, 95.7% were aware of leishmaniasis as a parasitic infection and 84.7% correctly identified Leishmania donovani as the causative organism in Sri Lanka. From the respondents, 181 (96.8%) knew that the vector of leishmaniasis is sand fly. Cutaneous leishmaniasis was reported as the most prevalent form of leishmaniasis in the country by 176 (94.1%). Nearly half of the respondents (98, 54.1%) were aware of the fact that the Anuradhapura district has the highest disease burden. Many of them had the idea that leishmaniasis is an emerging disease (155, 84.3%,) and early diagnosis is important in controlling the disease (163, 89.1%). Although about three fourth (123, 73.7%,) of the participants mentioned that leishmaniasis should be notified at first clinical suspicion, only 74 (42.5%) were aware that it is a legal requirement. Some medical officers (39, 22%) believed that the current notification system in the country is not effective. Unavailability of notification forms (60, 36.8%) heavy workload (85, 50.3%) and inadequate supportive staff (55, 35.1%) were reported as barriers for timely notification. Even though 105 (58.0%) of medical officers had suspected leishmaniasis during the last 8 years period only 35 (19.4%) had notified.ConclusionsEven though more than 90% of the participants had good theoretical knowledge about leishmaniasis; notification of leishmaniasis is considerably inadequate. This study emphasizes the need for greater efforts to improve the notification of leishmaniasis in Sri Lanka.

Phlebotomus argentipes Annandale & Brunetti, 1908 (Diptera: Psychodidae) is the main vector responsible for the transmission of Leishmania donovani (Laveran & Mesnil, 1903) Ross, 1903 in the subcontinent of India. It is the potential vector of cutaneous leishmaniasis in Sri Lanka. The present study determined ecological factors that influence the abundance of P. argentipes in areas with high disease prevalence in the Anuradhapura district, North Central Sri Lanka. CDC light traps and yellow sticky traps were used for sampling, and abundance was recorded throughout 12 months with selected environmental parameters namely, relative humidity, wind speed, and temperature. The relationships between the abundance of P. argentipes with mean temperature, % relative humidity, and wind speed were tested with regression analysis. The temporal distribution of the vector population was tested with a time series analysis. The study identified the most preferable microhabitats of P. argentipes: shrubs, unclear areas, gardening areas, wet soil areas with leaf litter, and termite hills. The results indicated that the abundance of P. argentipes was highly dependent on mean temperature (P = 0.00, R2 = 68%), and a high number of P. argentipes was recorded for a low mean temperature range of 24.7-27.3°C. Furthermore, the abundance of P. argentipes exhibited an increasing trend with high humidity levels of 72-88% (P = 0.00, R2 = 91.6%). These findings may help predict the temporal variation of the potential vector population with studied ecological parameters and contribute to a successful vector management strategy with thorough knowledge of the behavioral pattern of P. argentipes.

BackgroundLeishmaniasis is listed as one of the eight neglected tropical diseases by the World Health Organization and the number of cases in endemic areas has seen a sharp rise in the past decade. More alarmingly, reports have shown that leishmaniasis is spreading to non-endemic areas of the world due to co-infection with HIV. In Sri Lanka, leishmaniasis is considered as a notifiable disease from 2008 and has seen a rising trend of incidence since then. This is the first study describing the burden, seasonal variation and spatial distribution of leishmaniasis in Sri Lanka since the disease has been included as a notifiable disease.MethodsData on health statistics from 2009 to 2016 were obtained from published databases maintained by the Epidemiology Unit of the Ministry of Health in Sri Lanka. Climatic data for Sri Lanka were obtained from the Department of Meteorology and the populations in administrative districts were obtained from the Department of Census and Statistics, Sri Lanka. Descriptive spatiotemporal analysis, correlation between leishmaniasis incidence and climatic variables were analyzed using SPSS statistical software.ResultsThe total number of people reported with leishmaniasis during the study period was 8487. Cutaneous leishmaniasis is the prominent form in Sri Lanka while few visceral and muco-cutaneous cases were reported. Although leishmaniasis patients were identified from all 25 districts in the island, almost 90% of the total caseload was reported from Anuradhapura, Hambantota, Polonnaruwa, Kurunegala and Matara districts. The highest number of patients was reported from the Anuradhapura district and the highest incidence per 100,000 persons was reported from the Hambantota district. The disease has a seasonal trend, a peak of leishmaniasis occur in July to September in the north-central region and in October to December in the southern region. Maximum temperature, humidity and wind speed are significantly associated climatic variables with leishmaniasis in endemic regions.ConclusionsLeishmaniasis is an emerging public health problem in north-central and southern Sri Lanka. Public awareness programs for the prevention and control of the disease in endemic regions are essential to reduce the incidence of leishmaniasis.

In Denmark approx. 40,000-50,000 patients are treated annually with chronic wounds. Treatment is time consuming, requiring more resources and different specialities according to their genesis. At Lillebaelt Hospital, chronic wounds are treated by either orthopedic, vascular consultants or by our multidisciplinary team. Directing the chronic wound patient to the correct speciality to get the right and timely treatment, requires sufficient referral information. The danish referral system allows free text, thus many referrals lack essential information. The goal of the orthopedic-QI-team was to increase the quality of information in chronic wound referrals via APP-based patient engagement prior to the first consultation. To provide the chronic wound patient with a safe, efficient and smooth patient journey, the referral must contain specific background infomation. Many referrals were lacking basic information and due to this, many patients had to be rescheduled upon arriving at the hospital to be seen by another speciality/team another day. The danish referral system cannot be changed easily, but via app-based-patient-engagement prior to first consultation along with one medical practitioner working systematically, increases the quality of information in chronic wound referrals, thereby improving the quality and efficiency of the first consultation. All referred patients received a link to the designed app. It was determined that a single doctor would handle all referrals and check the patients' medication status and the answers provided by the app. The app contains 6 multiple choice questions and asks the patient to take 2 pictures of the wound. This allows the doctor to direct the patient to the correct speciality and provide correct facilities and staff saving time and resources, providing timely treatment and a smoother patient journey. All referrals were graded to show how much relevant information was available prior to the first consultation. This data was plottet in a run chart to show the impact of intervention in phase A and B. The impact on Patient Journey was measured by how many patients needed to be rescheduled in each intervention phase. Impact on Patient Journey: Why is it important to know if the patient is diabetic? Upon arriving at their initial consultation, 42% need to be rescheduled to be seen by our multidisciplinary diabetic foot care team another day. 6% of the referred patients who lacked information about diabetes did not have diabetes and did not need to be rescheduled. Impact on Patient Journey: Why is it important to know ""where"" AND ”for how long the patient has had the wound""? 58% of the referrals did not contain enough information in order to plan an x-ray (osteomyelites) prior to the first consultation. Not all patients used the app initally. A telephone call provided a trigger and engaged the majority. Engaging patients, especially patients with compliance issues, is difficult, but we believe patients can be engaged to supply the information needed to provide a safe and efficient patient journey.

BackgroundIndigenous Australians are slightly more than 2% of the total Australian population however, in recent years they have comprised between 6 and 10% of new patients beginning treatment for end-stage kidney disease (ESKD). Although transplant is considered the optimal form of treatment for many ESKD patients there is a pronounced disparity between the rates at which Indigenous ESKD patients receive transplants compared with their non-Indigenous counterparts. The IMPAKT (Improving Access to Kidney Transplants) Interview study investigated reasons for this disparity through a large scale, in-depth interview study involving patients, nephrologists and key decision-making staff at selected Australian transplant and dialysis sites.MethodsThe design and conduct of the study reflected the multi-disciplinary membership of the core IMPAKT team. Promoting a participatory ethos, IMPAKT established partnerships with a network of hospital transplant units and hospital dialysis treatment centres that provide treatment to the vast majority of Indigenous patients across Australia. Under their auspices, the IMPAKT team conducted in-depth interviews in 26 treatment/service centres located in metropolitan, regional and remote Australia. Peer interviewing supported the engagement of Indigenous patients (146), and nephrologists (19). In total IMPAKT spoke with Indigenous and non-Indigenous patients (241), key renal nursing and other (non-specialist) staff (95) and a small number of relevant others (28). Data analysis was supported by QSR software. At each site, IMPAKT also documented educational programs and resources, mapped an hypothetical ‘patient journey’ to transplant through the local system and observed patient care and treatment routines.DiscussionThe national scope, inter-disciplinary approach and use of qualitative methods in an investigation of a significant health inequality affecting Indigenous people is, we believe, an Australian first. An exceptionally large cohort of Indigenous participants provided evaluative comment on their health services in relation to dialysis and transplant. Additionally, the data includes extensive parallel commentary from a cohort of specialists, nurses and other staff. The study considers a ‘patient journey’ to transplant within a diverse range of Australian treatment centre/workplace settings. The IMPAKT Interview study protocol may contribute to improvements in multi-disciplinary, flexible design health services research with hard to reach or vulnerable populations in Australia and elsewhere.

Aims: The primary focus of this empirical study was to investigate the factors influencing the level of GAP adoption for cucurbit vegetable in the Anuradhapura district of Sri Lanka.&#x0D; Study Design: Three-stage purposive and proportionate sampling &#x0D; Place and Duration of Study: The study was carried out in the Anuradhapura district, North Central Province of Sri Lanka in 2018. &#x0D; Methodology: Primary and secondary data were used in the study. The primary data were collected mainly through a field survey using a structured and pre-tested questionnaire. The total sample size was 120. Key informant interviews (KII), and a focus group discussion (FGD) were conducted to triangulate data and information obtained from the questionnaire survey and to obtain additional qualitative information. Descriptive analytical techniques, analysis of variance (ANOVA) test, and the General Linear Model (GLM) were employed for the data analysis. &#x0D; Results: Results revealed that 40% of respondents are moderate level GAP adopters, whilst about 68% practiced more than half of the recommended GAPs. The results of ANOVA revealed that farmers who adopted a higher proportion of GAPs earned a higher farming income, than those who practiced a moderate or low proportion of GAPs. Similarly, when compared to moderate and poor level GAP adopters, the average cost of production of higher-level adopters decreased significantly (p &lt; 0.05). The results of the regression analysis revealed that farmer awareness of GAPs, farmer education level, farming experience, farming income, and cost of cultivation have a significant (p &lt; 0.05) effect on the level of GAP adoption by cucurbit farmers.&#x0D; Conclusion: Awareness of GAPs, farmer education level, farming experience, and farming income significantly affect the adoption level of GAPs. Policy priority should be given to planning for a long-term farmer awareness program on GAPs through proper training and extension programs.