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.