Abdullah Et Al
Available online freely at www.isisn.org Bioscience Research Print ISSN: 1811-9506 Online ISSN: 2218-3973 Journal by Innovative Scientific Information & Services Network RESEARCH ARTICLE BIOSCIENCE RESEARCH, 2021 18(1): 782-787. OPEN ACCESS
The Outbreaks of Cutaneous leishmaniasis in District Malakand, KPK, Pakistan: Epidemiology and Clinical Features
Abdullah1*, Irfan Ghani2, Muddaser Shah3,4*, Mehek Majeed1, Sidra Mubin5, Fazal Akbar6 , Obaid Ullah7,4 , Amin Ullah1 and Faheem Anwar8
1Department of Health and Biological Sciences Abasyn University Peshawar, Pakistan 2Civil Dispensary Hospital Khadu District Malakand, Pakistan 3Department of Botany Abdul Wali Khan University Mardan, Pakistan 4Natural and Medical Sciences Research Center, University of Nizwa, Birkat Al Mauz 616, Nizwa Oman 5Department of Botany Hazara University Mansehra, Pakistan 6Peshawar Institute of Cardiology Peshawar, Pakistan 7Department of Chemistry University of Malakand Dir Lower, Pakistan 8Department of Genetics Hazara University Mansehra, Pakistan
*Correspondence: [email protected], [email protected] Received 13-01-2021, Revised 13-03-2021, Accepted: 20-03-2021 e-Published: 24-03-2021 Cutaneous leishmaniasis is caused by a vector-borne flagellated protozoan of genus Leishmania, which is the one of the most prevalent skin diseases all over the world. This is one of the severe mistreated tropical diseases, widely distributed in tropical and subtropical countries of the world. The purpose of the study was to determine the recent epidemiological emergences of Cutaneous leishmaniasis in district Malakand. In the current study, 1243 samples of Cutaneous leishmaniasis were collected from DHQ hospital Malakand (Batkhela), THQ Dargai, and different health care units between January 2018 and July 2019. The admitted patients were treated in an isolated ward specified for Leishmaniasis patients. The presence of amastigotes was confirmed by Giemsa staining followed by light microscopy. The highest incidence was observed in the age group 1-15 years (>54%; n=671) and the infection rate was found higher in females (52.1%; n=1243) as compared to males (46%; n=1243). Most of the patients (57%) had a single lesion, while the remaining 53% had two (25%), multiple lesions (18%). From the current study, it can be concluded that that C. leishmaniasis is the foremost health issue for the residents of district Malakand. This data can be useful for health authorities to verdict out new C. leishmaniasis attentions and to plan effective strategies for the provision of health facilities in the study area. Keywords: Leishmania, Cutaneous leishmaniasis; Prevalence; Amastigotes; Staining.
INTRODUCTION cause disease in immune-compromised patients Leishmaniasis is caused by a flagellated (Chaudhary RG et al., 2008); (Kimutair et al., protozoan known as leishmania which is the 9th 2017). Leishmania is classified into several most prevalent skin disease all over the world species but almost 20 species among all are well- (Ajvar J et al., 2012). These parasites are recognized for causing infections including abundantly found in endemic regions and almost leishmaniasis in human beings. Based on the site Abdullah et al. The Outbreaks of Cutaneous Leishmaniasis in Pakistan of infection leishmaniasis is categorized into Upper and Lower Dir Cutaneous leishmaniasis, mucoCutaneous 113 2020 71 110 (Zeb I et al., leishmaniasis, and visceral leishmaniasis. Female 2020) sand fly of genus phlebotomies is reported to District Karak transmit promastigote of leishmania to human Surgul Nawaz 803 2020 803 beings (Cleaa, 2010) . The sand-fly injects (M et al., 2020) promastigotes present in their saliva into human skin by sucking blood from the skin through bites. Elevated prevalence of Cutaneous The promastigotes are matured into amastigotes leishmaniasis is predominant in autumn season inside the host cell (Velez et al., 2009). About 3.5 i.e. from September till November, as well as high billion people are exposed to the risk of prevalence of leishmaniasis, was described to be leishmaniasis in 98 countries across five found in the regions located at high altitudes continents (Velez et al., 2009); (Deseux P, 2001). ranges from 1500-1800 meter above the sea level [8] It is globally estimated that 0.2 to 0.4 million . The exposed parts of the skin such as arms, people are infected with visceral leishmaniasis hands, legs feet, face, and neck are targeted by (VC) as well as 0.7 to 1.2 million people are the female sand flies. These parasites are suffered from Cutaneous leishmaniasis (CL) and transmitted through the bite of sand fly and cause mucocutaneous combine leishmaniasis (MCL) ulcer-like lesions on the skin. In the last 30 years, (Cleaa, 2010) . In Pakistan, the CL has been a large number of refugees were migrated to reported in the mid-Punjab, Baluchistan, Azad Pakistan from different neighboring regions like Jammu Kashmir (AJK), Khyber Pakhtunkhwa (KP) Afghanistan. These parasites were spread in and Ex-Federally Administrated Tribal Areas (Ali A refugee camps which in turn also spread et al., 2016); (Kassi M et al., 2008). There are 37 infections in nearby localities of Pakistani [10, 11]. Phlebotomies species of leishmania in Pakistan, population Treatment of Cutaneous where 65% prevalence of Leishmania is found in leishmaniasis in Pakistan is insignificant, the several regions of the country (Durani AZ et al., reasons may be unavailability of medicines and 2012). Since 1999, several outbreaks of CL have financial problems. Due to lack of knowledge been occurred in various regions of KP province about leishmaniasis and its transmission, as a (Table 1). result patient rigorously faced active Cutaneous leishmaniasis or Cutaneous leishmaniasis scars, Table 1: Supplementary Data of Leishmaniasis in several regions of the country (Ali A et al., in KPK 2016); (Kassi M et al., 2008). The current study No. was focused to investigate epidemiological Microsco Study area positive Year PCR py features of the recent outbreaks of CL in the cases residents of district Malakand of Khyber Timergara Pakhtunkhwa province, Pakistan from January ( Rowland M et 23 1999 All al., 1999) 2018 to July 2019. The data were collected from Dir (Rahim F et amastigote positive CL patients to determine the 51 2003 All al., 2003) figure and locations of CL lesions as well as the Dargai gender and age if they were at risk factors for CL. (Jamal Q et al., 100 2013 100 2013) KPK Whole MATERIALS AND METHODS ( Mumtaz S et 340 2016 340 al., 2016) 2.1 STUDY SITE: Peshawar The study was conducted in District ( Mumtaz S et 125 2016 61 111 al., 2016) Malakand, Khyber Pakhtunkhwa (KP), Pakistan. Kohat Geographically its area is 952 km² and its total (Hussain M et 300 2017 193 254 population is 720,295 (2017 census) It had al., 2017) previously been a tribal area known as the Waziristan Malakand Protected Area, part of the Malakand (Hussain M et 759 2018 330 429 al., 2018) Agency. It is situated southeast to Mardan district Lower Dir and is about 100 km away from Peshawar (Rahman HU 213 2018 213 (provincial capital). and Rahman Au, 2018)
Bioscience Research, 2021 volume 18(1): 782-787 783
Abdullah et al. The Outbreaks of Cutaneous Leishmaniasis in Pakistan
Figure 1.1 Geographic location of District Bootano khpa regions of Malakand (Table. 1). Malakand Khyber Pakhtunkhwa The CL lesions were found on various body parts such as belly, hands, face, legs, lips, mouth, 2.2 Data collection: neck, nose and whole-body are presented. Face Current retrospective epidemic report is based and hands were found the most affected body on the collection of data from district headquarter parts at the frequency of 469 (37.7%) and 224 hospital Batkhela, Malakand with prior approval (18%) respectively (Table 2). Prevalence of CL district health officer (DHO) Malakand. District was higher among the age group 1 to 15 (54%), Malakand is consisting of three tehsils. i.e., followed by age group 16 to 30 (19.5%), 31 to 45 Dargai, Batkhela, and Thana. Data was collected (18.8%), and > 46 (7.7%). In this study, all the from 1243 patients belongs to Totakan, Bootano cases were Cutaneous leishmaniasis (Table.3). Khpa, Kharkai dherai. Palai, Dargai, and Kot About 57% of the patients were found with single areas of district Malakand. The information about lesion, 25% were with double lesion and that of sand-fly bite history, gender, age, and lesion 18% were found with multiple lesions (Table 4). location were obtained via interviews and According to tehsil and gender, wise distribution of questionnaires. Cutaneous leishmaniasis shows that in tehsil Dargai a total of 945 individuals were affected with 2.3 Slide Preparation and Microscopy: Cutaneous leishmaniasis among them 440 After the completion of the history and clinical individuals were male, and 505 individuals were checkup of the patients, a blood sample was female. Similarly, in tehsil Batkhela a total of 298 collected from each patient by taking blood people were affected with Cutaneous samples from the site of the wound with sterile leishmaniasis, among all the affected individuals lancets prick for making blood smears. Slides 150 were male and 148 were female affected were kept for air drying; methyl alcohol was used individuals. for slide fixation. CL was diagnosed by direct observation of parasite in impression smears, skin Table 1: Hospital-wise Cutaneous biopsies stained with Giemsa stain (Nawaz M et leishmaniasis cases al., 2020). Light microscope was used for the observation of slides with emersion oil. Whole Name of Hospital No of Males Females smear slides were scanned, and positive results Area Categories cases THQ and were reported. Dargai 440 505 945 BHU Kharki 2.4 Data analysis: Totakan Cat-D 42 44 86 Kot RHC 68 69 137 Based on smear examination and clinical Palai RHC 36 32 68 findings, the diagnosis of all the cases was Kharkai BHU 03 03 06 performed. An Amastigotes form of the parasite Dherai Bootano BHU 01 00 01 was observed in active lesion. The data obtained Khpa in the current study were analyzed based on; 1) Total N/A 595 648 1243 month-wise (from Jan 2018 to July 2019) 2) age- wise (1-15, 16-30, 41-45, and >46) and socio- Table 2: Site wise distributions of Cutaneous demographically (gender-wise and clinical leishmaniasis manifestation and clinical outcomes). Affected Frequency Percentage RESULTS body parts From January 2018 to July 2019, a total of Belly 1 .1 1243 cases of Cutaneous leishmaniasis were Face 469 37.7 recorded. In total infected subjects, 648 patients Hand 224 18 Leg 198 15.9 were females (52.13%) and 595 were males Lips 50 4 (47.86%). In the case of month-wise prevalence, Mouth 52 4.1 the highest numbers of prevalence were found in Neck 40 3.2 January 17 %, followed by February (12.1%) and Nose 161 12.9 June (11%). The lowest prevalence 2.5% was Whole body 49 3.9 observed in October. The geographic distribution was reported as 945 cases in Dargai, 137 in Kot, 68 Palai, 86 in Totakan 6 in Kharki dherai and 1 in
Bioscience Research, 2021 volume 18(1): 782-787 784
Abdullah et al. The Outbreaks of Cutaneous Leishmaniasis in Pakistan
Table 3: Age-wise data of Cutaneous from tehsil Thana. The highest prevalence in leishmaniasis Dargai might be attributed to the large population, humid environment and free flow of people from Age range Number Percentage the surrounding areas which may supports the in years of cases propagation of leishmanial vector in the affected 1 to 15 671 (54% territory. In the current study, different age groups 16 to 30 242 19.5% 31 to 45 234 18.8% were studied for CL the higher prevalence was >46 96 7.7% found in the young age group (1-15years). Total 1243 100% According to previous studies, in 2016-17 a similar prevalence of CL was recorded at the young age group ( Mumtaz S et al., 2016); (Hussain M Table 4: Lesion-wise prevalence of Cutaneous et al., 2017). Similarly Din et al. revealed that the leishmaniasis population belongs to young age domain are at risk for CL infection in the endemic area of the One Two Multiple country (Nawaz M et al., 2020). We observed Total Lesion Lesion Lesion seasonal examination in these two years in which 709 310 224 1243 most of the cases were recorded in the winter 57% 25% 18% 100% season (January, February) as compared to summer which contrasts with the conducted in Table 5: Tehsil wise distributions of 2013 in the same area [19]. The contrast may occur Cutaneous leishmaniasis due to seasonal variation in the examined region due migration of shepherds from the hilly areas of No of No of female No of male Tehsil other districts like Swat, Dir and cases effected Effected Kohistan.Whereas another study reports the Dargai 945 505 440 similar observations (Nawaz M et al., 2020). Batkhela 298 148 150 The current work revealed that females have Tana 00 00 00 more active lesions as compared to males so, it shows that female’s population are vulnerable to CL than male individuals of the same region. Our DISCUSSION findings are in a correlation with previously Although molecular diagnosis including PCR reported study in district Karak (Jamal Q et al., has shown more accuracy than the routine 2013). diagnosis of infectious diseases (Abdullah et al., On the contrary, majority of reports showed that 2019);(Hussain M et al., 2018). Likewise, higher prevalence was found in the male leishmaniasis can also be diagnosed through population [13,14]. The reason may be females are PCR as mentioned below in (table 1.6) but it is not more exposed to the bites of sand flies as they readily and easily available in health settings. On are confined to homes and the people of the the other hand, direct Giemsa stained smear affected area keeps cattle and they grow fruit (microscopy) is easily available, simple and trees especially grapes in homes which is a good inexpensive. Pakistan is a tropical country and reservoir for sand flies. Our findings also shows situated in the northwest of South Asia and shares that the manifestation of active CL lesions are its borders with India, China, Iran, and least numbers as compared to other age groups Afghanistan. Unfortunately, all the neighboring (> 46 presented in table 1.3). The minimum lesion countries along with Pakistan are endemic presence in older individuals is associated with for Leishmania. There are three major types acquired immunity [20]. The current study also of leishmania in which visceral leishmaniasis and revealed several lesions of CL patients in which Cutaneous leishmaniasis are endemic in most of the patients had a single lesion (57%), our Pakistan. Various reports are available endemic findings correlates with the previous reported Anthroponotic CL and Zoonotic CL in various studies in this regard (Jaffernay M and Nighat, parts of the country [7,13,14]. The current study 2001); (Nawaz M et al., 2020). focuses on the burden of CL among the three tehsils of district Malakand KPK province, most of CONCLUSION the cases were reported in tehsil Dargai with From the current study, it can be concluded highest ratio of 945 cases followed by Batkhela that some additional studies and awareness are (298 cases) while no positive cases were reported needed to determine the reservoirs and vectors of
Bioscience Research, 2021 volume 18(1): 782-787 785
Abdullah et al. The Outbreaks of Cutaneous Leishmaniasis in Pakistan the disease for the understanding of parasites, leishmaniasis in Pakistan and future associated risk factors and host immunological epidemics threats. Asian Pacific Journal of progressions that describe other co-infections Tropical Disease, 6(2), 155-159. such as HIV and TB. Additional evidence is Alvar J, Vélez I. D, Bern, C, Herrero M, Desjeux provided by this study that leishmaniasis is a P, Cano (2012). & WHO Leishmaniasis serious skin disease issue in the Malakand district Control Team. Leishmaniasis worldwide and of Khyber-Pakhtunkhwa. It is necessary to explore global estimates of its incidence. PloS the conditions which promote leishmaniasis in one, 7(5). KPK and to increase awareness about Ayaz M, M Nazir, MM, Ullah N, Zaman A, Akbar leishmaniasis in Pakistan. Moreover, the A, Zeeshan M, Lindsay DS, (2018). government of KPK might have done some better Cutaneous leishmaniasis in the Metropolitan arrangement for the control of such infections to City of Multan, Pakistan, a Neglected other cities and districts of the province. Tropical Disease. Journal of medical entomology, 55(4), 1040-1042. CONFLICT OF INTEREST Chaudhary RG, Bilimoria FE, Katare SK. (2008). The authors declared that present study was Diffuse Cutaneous leishmaniasis: co- performed in absence of any conflict of interest. infection with human immunodeficiency virus (HIV). Indian Journal of Dermatology, ACKNOWLEGEMENT Venereology, and Leprology, 74(6), 641. We would like to acknowledge all the supports Cle AA, (2010). Current perspective on and guidance provided by district health officer Leishmaniasis. J Global Infect Dis 2 (2): Batkhela for providing data. We are also thankful 124–126. to our colleagues especially Mr. Mahboob ul Haq Desjeux P (2001). The increase in risk factors for for technical support. leishmaniasis worldwide. Transactions of the royal society of tropical medicine and AUTHOR CONTRIBUTIONS hygiene, 95(3), 239-243. Mr Abdullah, IG, MS and MM designed, Durrani AZ, Durrani HZ, Kamal N (2012). analyzed and wrote the whole manuscript.SM, Prevalence of Leishmania in sand fly in AU, FA and OU helped in data collection and also Pakistan. Pakistan Journal of Zoology, 44(1). helped in materials\analysis. All authors read and Hussain, M., Munir, S., Jamal, M. A., Ayaz, S., approved the final version. Akhoundi, M., & Mohamed, K. (2017). Epidemic outbreak of anthroponotic Copyrights: © 2021@ author (s). Cutaneous leishmaniasis in Kohat District, This is an open access article distributed under the Khyber Pakhtunkhwa, Pakistan. Acta terms of the Creative Commons Attribution License Tropica, 172, 147-155. (CC BY 4.0), which permits unrestricted use, Hussain, M., Munir, S., Khan, T. A., Khan, A., distribution, and reproduction in any medium, Ayaz, S., Jamal, M. A., ... & Kasbari, M. (2018). Epidemiology of Cutaneous provided the original author(s) and source are leishmaniasis outbreak, Waziristan, credited and that the original publication in this Pakistan. Emerging Infectious journal is cited, in accordance with accepted Diseases, 24(1), 159. academic practice. No use, distribution or Jaffernay M, Nighat R md (2001). Cutaneous reproduction is permitted which does not comply leishmaniasis in Pakistan. International with these terms. journal of dermatology, 40(2), 159-159. Jamal, Q., Shah, A., Ali, N., Ashraf, M., Awan, M. REFERENCES M., & Lee, C. M. (2013). Prevalence and Abdullah SA, Salman M, Din M, Khan K, Ahmad comparative analysis of Cutaneous M, Khan F. H, Arif M (2019). Dengue leishmaniasis in Dargai Region in outbreaks in Khyber Pakhtunkhwa (KPK), Pakistan. Pakistan Journal of Zoology, 45(2). Pakistan in 2017: an integrated disease Kassi M, Kassi M, Afghan AK., Rehman R, Kasi surveillance and response system (IDSRS)- PM (2008). Marring leishmaniasis: the based report. Polish journal of stigmatization and the impact of Cutaneous microbiology, 68(1), 115-119. leishmaniasis in Pakistan and Ali A, Rehman TU, Qureshi NA, Rahman HU Afghanistan. PLoS neglected tropical (2016). New endemic focus of Cutaneous diseases, 2(10).
Bioscience Research, 2021 volume 18(1): 782-787 786
Abdullah et al. The Outbreaks of Cutaneous Leishmaniasis in Pakistan
Khan, N. H., ul Bari, A., Hashim, R., Khan, I., Colombia resistant to meglumine antimonial Muneer, A., Shah, A., ... & Sutherland, C. J. treatment. Revista do Instituto de Medicina (2016). Cutaneous leishmaniasis in Khyber Tropical de São Paulo, 51(4), 231-236. Pakhtunkhwa province of Pakistan: clinical Zeb, I., Ali, A., Nawab, J., Khan, M. Q., Kamil, A., diversity and species-level diagnosis. The & Tsai, K. H. (2020). Cutaneous American journal of tropical medicine and leishmaniasis in Male Schoolchildren in the hygiene, 95(5), 1106-1114. Upper and Lower Dir Districts of Khyber Kimutai R, Musa AM, Njoroge S, Omollo R., Alves Pakhtunkhwa, and a Review of Previous F, Hailu A, Salman K (2017). Safety and Record in Pakistan. Acta Tropica, 105578 effectiveness of sodium stibogluconate and paromomycin combination for the treatment of visceral leishmaniasis in eastern Africa: results from a pharmacovigilance programme. Clinical drug investigation, 37(3), 259-272. Mujtaba, G., & Khalid, M. (1998). Cutaneous leishmaniasis in Multan, Pakistan. International journal of dermatology, 37(11), 843-845. Mumtaz S, Munir AH, Asghar M, Naheed N (2016). FREQUENCY AND TYPES OF LEISHMANIASIS IN KHYBER PAKHTUNKHWA (KPK). Journal of Medical Sciences, 24(3), 136-140. Nawaz, M., Din, M., Khan, A., Khan, A., Ali, M., Din, S. U., & Aslam, K. (2020). Epidemiological features of Cutaneous leishmaniasis endemic in hilly areas of district Karak, Khyber-Pakhtunkhwa province of Pakistan. Journal of Parasitic Diseases, 1- 5. Rahim, F., Jamal, S., Raziq, F., Uzair, M., Sarwar, B., Ali, H., & Sherin, M. (2003). An outbreak of Cutaneous leishmaniasis in a village of district Dir, NWFP. Journal of Postgraduate Medical Institute (Peshawar-Pakistan), 17(1). Rahman, H. U., & Rehman, A. U. (2018). Cutaneous leishmaniasis in Dir Lower District, North-West Pakistan: epidemiology and treatment response. Journal of Pakistan Association of Dermatology, 27(4), 353-362 Rowland, M., Munir, A., Durrani, N., Noyes, H., & Reyburn, H. (1999). An outbreak of Cutaneous leishmaniasis in an Afghan refugee settlement in north-west Pakistan. Transactions of the Royal Society of Tropical Medicine and Hygiene, 93(2), 133-136 Simon Brooker NM, Adil K, Agha S, Reithinger R, Rowland M, Ali I, Kolaczinski J (2004). Leishmaniasis in refugee and local Pakistani populations. Emerging infectious diseases, 10(9), 1681. Vélez I D, Colmenares LM, Muñoz CA (2009). Two cases of visceral leishmaniasis in
Bioscience Research, 2021 volume 18(1): 782-787 787