A newly emerged cutaneous leishmaniasis focus in central Iran

Health condition of Afghan refugees residing in Iran in comparison to Germany: a systematic review of empirical studies

BACKGROUND

The re-emerging dominance of the Taliban in Afghanistan in 2021 caused a new wave of Afghan refugees heading Iran and neighboring countries. Iran in the Middle East and Germany in Europe are two major host countries to the largest populations of Afghan refugees. In both countries, several studies have been done to assess the health condition of refugees.

OBJECTIVES

To systematically review the existing literature to identify similarities and differences of health conditions of Afghan refugees living in the two countries, and to synthesize evidence on the health status and health care access of these populations.

METHODS

Related electronic databases and grey literature of Iran and Germany on the health of Afghan refugees were scanned and searched up for the period 2000-2020. Key terms were formed by combining "Afghan refugees or immigrants or populations or asylum seekers", "Physical or mental health", "Healthcare service or access or use", "Iran or Germany". Empirical studies were considered if they contained samples of Afghan refugees with particular outcomes for Afghans. Results were categorized for both countries in the three main areas of physical health, mental health, and access/use of healthcare services.

RESULTS

Nine hundred twenty-two documents were extracted, of which 75 full-texts were finally reviewed. 60 documents belonged to the health condition of Afghan refugees residing in Iran including 43 in physical health, 6 in mental health, 8 in healthcare access and use, and 3 in multiple aspects of health, and 15 belonged to Germany including 7 in physical health, 4 in mental health, 2 in healthcare access and use, and 2 in multiple aspects of health. A less explicit evaluation of the overall health condition of Afghan refugees was observable, particularly for Germany. While matches on the study subject exist for both countries, in comparison to Germany, we extracted more quantitative and qualitative health studies on Afghan refugees of the mentioned areas from Iran. German health studies were rare, less qualitative, and more on the health condition of diverse refugee groups in general.

CONCLUSIONS

Wide gaps and unanswered questions related to mental health and overall health status of the Afghan refugee population are observable, especially in Germany. Our systematic review identified the gap in evidence, which we would recommend to bridge using a wider lens to comprehensively assess the overall condition of refugees considering associations between health and socio-economic and cultural determinants instead of a one-dimensional approach. Further, within health studies on refugee populations, we recommend stratification of results by the country of origin to capture the within-group diversity among refugees with different countries of origin.

Cutaneous Leishmaniasis Based on Climate Regions in Iran (1998-2021): A Systematic Review and Meta-Analysis

Background

Climate change can facilitate the expansion of leishmaniasis and create the suitable habitat for vector and reservoir species. The objective of this study was to estimate the prevalence of cutaneous leishmaniasis (CL) at the climatic regions of Iran.

Materials and Methods

The literature search was conducted to identify all published studies reporting the prevalence or incidence of CL in humans in Iran. A total of 350 articles that reported leishmaniasis in Iran were retrieved, due to eligibility criteria, only 42 studies were selected to the final systematic review and meta-analysis procedure. Random effects meta-analysis was done with the estimate of heterogeneity being taken from an inverse-variance model. Subgroup analysis was conducted and it stratified the studies according to climatic regions. Between-study heterogeneity was assessed by using I ² and Cochran's Q method I ² value of heterogeneity. Meta regression was used to investigate factors potentially contributed the between-study heterogeneity.

Results

Individual studies showed that prevalence per 100,000 population estimated the range from 1.5 to 318.7 with the overall random pooled prevalence of 83.3 (95% confidence interval 74.5-92.1). Subgroup analysis by climatic regions showed that many studies were conducted in the desert areas and also, it has more prevalent than the other climatic regions.

Conclusions

Leishmaniasis was more prevalent in regions with dry and desert climates than the other climatic regions. One of the advantages of this work is that the majority of selected studies have been conducted on population-base. However, some of the studies have been designed poorly or have had a lack of internal validity.

Cutaneous leishmaniasis in Iran: A review of epidemiological aspects, with emphasis on molecular findings

Leishmania parasites can cause zoonotic cutaneous leishmaniasis (CL) by circulating between humans, rodents, and sandflies in Iran. In this study, published data were collected from scientific sources such as Web of Science, Scopus, PubMed, Springer, ResearchGate, Wiley Online, Ovid, Ebsco, Cochrane Library, Google scholar, and SID. Keywords searched in the articles, theses, and abstracts from 1983 to 2021 were cutaneous leishmaniasis, epidemiology, reservoir, vector, climatic factors, identification, and Iran. This review revealed that CL was prevalent in the west of Iran, while the center and south of Iran were also involved in recent years. The lack of facilities in suburban regions was an aggravating factor in the human community. Some parts of southern Iran were prominent foci of CL due the presence of potential rodent hosts in these regions. Rhombomys opimus, Meriones lybicus, and Tatera indica were well-documented species for hosting the Leishmania species in Iran. Moreover, R. opimus has been found with a coinfection of Leishmania major and L. turanica from the northeast and center of Iran. Mashhad, Kerman, Yazd, and sometimes Shiraz and Tehran foci were distinct areas for L. tropica. Molecular identifications using genomic diagnosis of kDNA and ITS1 fragments of the parasite indicated that there is heterogeneity in leishmaniasis in different parts of the country. Although cutaneous leishmaniasis has been a predicament for the health system, it is relatively under control in Iran.

Leishmania spp. infection in Rhombomys opimus and Meriones libycus as main reservoirs of zoonotic cutaneous leishmaniasis in central parts of Iran: Progress and implications in health policy

Rodents from the subfamily Gerbillinae are the principal reservoir of cutaneous leishmaniasis (CL) caused by Leishmania major in the center and northeast of Iran. This study was conducted to determine both naturally occurring Leishmania infection rates and the distribution of Leishmania species in the central parts of Iran during 2019-2020. In this regard, presence of Leishmania parasites were confirmed by microscopic examination and the species were identified by nested-PCR using the Internal Transcribed Spacer2- Ribosomal DNA (ITS2-rDNA). Finally, some samples were sequenced and, the blast analysis of L. major samples, showed a 92.45-100% homology to the L. major sequence. Of the 181 wild gerbils collected (Rhombomys opimus=157 and Meriones lybicus=24), 88 (48.6%) tested positive for Leishmania sp. by microscopic examination whereas 162 (89.5%) were positive by nested-PCR. Of the 162 infected gerbils, 103 showed single strain infections (30 L. major, 28 L. gerbilli and 45 L. turanica), 43 showed dual infections with only the non-human species (L. gerbilli and L. turanica), and 16 were mixed infections of L. major and L. turanica (n = 14) or L. gerbilli (n = 2). All single or mixed L. major infections were detected in gerbils from areas with reports of human CL during the last decade. These findings suggest that Rhombomys opimus and Meriones libycus have a potential role in the maintenance of human and non-human transmission of Leishmania species in the CL foci.

Comparative Assessment of Topical Glucantime® Injection Plus Cryotherapy and Cryotherapy Alone for Treatment of Anthroponotic Cutaneous Leishmaniasis

Background: Cutaneous leishmaniasis is a worldwide health problem due to the complications in the transmission cycle, treatment failure, and post-healing problems. Objectives: Infected humans are the parasite reservoirs in the transmission cycle of anthroponotic cutaneous leishmaniasis (ACL); thus, the lack of efficient treatment increases the risk of the disease outbreak. The gold standard treatment for CL is mainly the topical or systematic use of antimonial compounds. Much research has been done on the development of topical therapy alone or in combination with cryotherapy. Therefore, this study was conducted to comparatively evaluate the current treatment protocol, cryotherapy, versus combined cryotherapy (Cryo) and intralesional Glucantime® (IG). Methods: This quasi-experimental study was performed on 476 patients with cutaneous leishmaniasis lesions referred to the health centers of a CL endemic area in southern Iran (Bam County, Kerman Province) during 2013 - 2019. A total of 200 cases with 301 lesions received Cryo using liquid nitrogen once every two weeks, and 276 cases with 406 lesions received weekly IG combined with Cryo, once every two weeks. The lesion size was recorded before and after the treatment. At seven and 12 weeks after the treatment, the lesion healing rate was monitored. Healing was defined as complete re-epithelialization. The obtained data were assessed using logistic regression to calculate the relative risk and therapeutic effects. Results: Out of 476 CL patients with 709 lesions, 200 cases with 221 lesions received Cryo, and 276 patients with 292 lesions received Cryo plus IG. At the seventh week after the treatment, complete healing was observed in 100 out of 221 cases (50%) in the group that received biweekly Cryo only and 225 out of 276 cases (81.5%) in the group that received biweekly Cryo plus weekly IG (P = 0.001). Conclusions: This study found that the use of cryotherapy plus intralesional Glucantime® increases the chance of healing for patients by 4.4 times compared to the use of cryotherapy alone.

Epidemiological features of cutaneous leishmaniasis in diagnosed patients from an endemic area (central Morocco)

Cutaneous leishmaniasis represents the most neglected tropical disease across the world. In Morocco, this disease is endemic and constitutes a major public health problem, with a national control program been implemented. The current study aimed to determine the pattern and epidemiological features of cutaneous leishmaniasis in affected patients in an area covered by the CL control and prevention program (Central Morocco). A total of 161 patients suspected for cutaneous leishmaniasis were diagnosed according to WHO laboratory methods, and 82 cases were confirmed positive for CL. The reports were analysed by patients' socio-geographic status, gender and age. The number and distribution of CL lesions by location, gender and age were investigated. Overall the confirmed cases, 89 % were infected by Leishmania tropica versus 21 % for Leishmania major. Females were significantly more affected than males (p < 0.01). Children (0-15 years), especially those ≤ 7 years of age, were the most affected. For the distribution of lesions, single lesion cases were largely preponderant (70.7 %) compared to multiple lesions. Face location was significantly more frequent (62.2 %) compared to limbs (26.8 %). Face lesions were found more prevalent in children than in adults while limb lesions were highly observed in adults. The pattern of the disease is affected by many factors (e.g. environment, gender, age, etc.) and has specifics to be considered in prevention and control programs in endemic areas.

Epidemiological features of cutaneous leishmaniasis and distribution of sand flies in an endemic area in southeast of Iran

Introduction

Cutaneous leishmaniasis (CL) is a widespread tropical infectious disease in the world. It is one of the most important health problem in Iran which is endemic in different parts of country. This study was conducted to determine epidemiological features of CL and distribution of sand flies in Hajiabad County, one of the important CL foci in southeast of Iran.

Methods

This descriptive cross-sectional study was conducted from March 2019 to March 2020.

All of the suspected CL cases with skin lesions who referred to Hajiabad County health centers and all actively detected patients were clinically and parasitologically examined for CL. Demographic and clinical data of all patients were recorded. Moreover, in this study, sand flies were collected monthly from four typical plain and foothill villages during their active season (May–November) using sticky trap. Sand flies were mounted as permanent microscopic slides, using Puri's medium, and identified by taxonomic keys. Data were analyzed using SPSS.21 software and descriptive statistics.

Results and discussion

A total of 70 confirmed cases of CL were recorded; the incidence rate of the disease was 101 per 100,000 people. The most infected age group was 0–10 years, with a rate of 64.3%. Males were infected more than females and the majority of cases (85.7%) were recorded from rural areas. Most of the cases had 1 lesion (51.4%) and the most lesions (55.8%) were in upper extremities. During the study period, 832 sand fly specimens comprised of ten species of Sergentomyia and seven of Phlebotomus were collected and identified. The most prevalent species was P. papatasi (47.12%), followed by P. alexandri (8.41%) and P. salehi (6.25%). Among the collected Phlebotomus species, P. papatasi and P. sergenti are known as the primary vectors of CL and P. alexandri, P. salehi, and P. caucasicus, play the main role as the secondary vectors of CL in Iran.

Conclusion

This study has revealed that CL is endemic in Hajiabad County and there are five CL vectors that are distributed in this County and some of them are more prevalent in plain areas. These findings can be used as a basis for implementation of interventions toward vector control, which may help in suppression of vector density, and consequently, control of CL in the study area.

Clinical, epidemiological and climatic factors related to the occurrence of cutaneous leishmaniasis in an endemic area in northeastern Brazil

Cutaneous leishmaniasis (CL) is a neglected tropical disease with a wide distribution in the Americas. Brazil is an endemic country and present cases in all states. This study aimed to describe the occurrence, the underlying clinical and epidemiological factors, and the correlation of climatic variables with the frequency of reported CL cases in the municipality of Caxias, state of Maranhão, Brazil. This is a retrospective and descriptive epidemiological study based on data extracted from the Brazilian Information System of Diseases Notification, from 2007 to 2017. Maximum and minimum temperature, precipitation, and relative air humidity data were provided by the Brazilian National Institute of Meteorology. A total of 201 reported autochthonous CL cases were analyzed. The predominance of cases was observed in males (70.1%). The age range between 31 and 60 years old was the most affected, with 96 cases (47.9%). Of the total number of registered cases, 38.8% of the affected individuals were engaged in agriculture-related activities. The georeferenced distribution revealed the heterogeneity of disease occurrence, with cases concentrated in the Western and Southern regions of the municipality. An association was detected between relative air humidity (monthly mean) and the number of CL cases per month (p = 0.04). CL continues to be a concerning public health issue in Caxias. In this context, there is a pressing need to strengthen measures of prevention and control of the disease through the network of health services of the municipality, considering local and regional particularities.

Reemergence of zoonotic cutaneous leishmaniasis in an endemic focus, northeastern Iran

Zoonotic cutaneous leishmaniasis (ZCL) is a form of disease, which is mostly caused by Leishmania major (L.major) in the Old World with high incidence through early life. Recently, the high incidence of CL has been reported in Jajarm County, northeastern Iran. The aim of the present study was to investigate the epidemiological aspects of CL and to identify Leishmania spp. in the area. Between 2012 and 2018, patients with active lesions suspected of CL were examined. Diagnosis was performed by methods of clinical examination and direct smears. Conventional kDNA polymerase chain reaction (PCR) was used to identify species of Leishmania. During the seven-year study period, 629 subjects were diagnosed as CL cases by clinical and microscopic examination. Considering the population of the study area, the average incidence rate was 237.8 per 100,000 population. Most (29.4%) of the subjects with ZCL were aged <10 years. Most of the patients (58.7%) were male and the rest were female. Most ulcers were observed on the face (32.2%) and hands (23.7%), respectively. Most patients (90%) had two or more ulcers on their body. The highest incidence was in the autumn in October (32%). Our data revealed that an ongoing reemergence of ZCL focus caused by L.major has arisen in the study area. Moreover, direct PCR on the smears for identifying Leishmania showed 100% specificity, and the species was identified as L. major using species -specific kDNA PCR. The use of conventional PCR on skin smears seems to provide a valuable method for confirming the clinical diagnosis of ZCL, which is very specific and sensitive particularly for clinical correlative studies. Further investigations are needed to improve planning strategies of vectors and reservoirs populations.

Major risk factors and histopathological profile of treatment failure, relapse and chronic patients with anthroponotic cutaneous leishmaniasis: A prospective case-control study on treatment outcome and their medical importance

Over the last years, there has been a remarkable increase in the number of unresponsive patients with anthroponotic cutaneous leishmaniasis (ACL) reported worldwide. The primary objective of this study was to explore the role of demographic, clinical and environmental risk related-factors in the development of treatment failure, relapse and chronic cases compared to responsive patients with ACL. Moreover, molecular, histopathological and immunohistochemical (IHC) findings between these forms were explored. This work was undertaken as a prospective and case-control study in southeastern Iran. Culture media and nested PCR were used to identify the causative agent. Univariate multinomial and multiple multinomial logistic regression models and the backward elimination stepwise method were applied to analyze the data. A P<0.05 was defined as significant. Also, for different groups, skin punch biopsies were used to study the histopathological and immunohistochemical (IHC) profile. All samples showed that L. tropica was the only etiological agent in all unresponsive and responsive patients with ACL. Data analysis represented that 8 major risk factors including nationality, age groups, occupation, marital status, history of chronic diseases, duration of the lesion, the lesion on face and presence of domestic animals in the house were significantly associated with the induction of unresponsive forms. The histopathological and immunohistochemical findings were different from one form to another. The present findings clearly demonstrated a positive relation between ACL and distinct demographic, clinical and environmental risk determinants. Knowledge of the main risk factors for ACL infection is crucial in improving clinical and public health strategies and monitor such perplexing factors.

Negligible data are present related to anthroponotic cutaneous leishmaniasis (ACL) treatment outcome and resultant unresponsiveness risk determinants. The role of demographic, clinical, and environmental risk associated-factors in the development of treatment failure, relapse, and chronic forms of ACL has not been studied. We carried out a case-control study for a period of 4 years (2015–2019) using culture media and nested PCR to identify the causative agent. Afterward, we analyzed the data by univariate multinomial and multiple multinomial logistic regression models and the backward elimination stepwise method. Also, we examined skin punch biopsies to study the histopathological and immunohistochemical (IHC) profile for different comparative groups. The findings identified 8 major risk factors were significantly associated with the creation of unresponsive forms. Clinical practitioners and health surveillance systems should be aware of and monitor such perplexing factors. Awareness of the major determinants for unresponsiveness to the treatment of ACL is critical to improving clinical strategies and public health measures. These multidisciplinary approaches need to address specific barriers that directly affect the treatment outcome.

Vector-borne diseases in Iran: epidemiology and key challenges

Vector-borne diseases have become a global health concern in recent decades as a result of global warming, globalization, growth in international trade and travel, use of insecticide and drug resistance. This review study addressed the key vector-borne diseases and their current status in Iran to emphasize the requirements for further research on vector-borne diseases. The dispersion patterns of these diseases differ in various regions. Some of them such as Crimean-Congo hemorrhagic fever, and Q fever are distributed all across Iran, whereas some others such as plague, leishmaniasis, tularemia, and malaria are restricted to specific areas. The high prevalence of vectors throughout the country necessitates enhancing the monitoring and surveillance of emerging and reemerging vector-borne diseases and their potential vectors.

Cutaneous leishmaniasis in male schoolchildren in the upper and lower Dir districts of Khyber Pakhtunkhwa, and a review of previous record in Pakistan

Documented reports are limited, showing cutaneous leishmaniasis (CL) as a severe threat to schoolchildren in Pakistan. The present study aimed to investigate the clinico-epidemiology and associated risk factors of CL in local and Afghan male schoolchildren between 6 and 16 years of age. The experimental strategy involved a questionnaire for the collection of information and clinical diagnosis (microscopy and semi-nested PCR) of 113 CL symptomatic schoolchildren out of 8,833 schoolchildren (7,175 local and 1,658 Afghan refugees) studying in nineteen schools of the Upper and Lower Dir Districts, Khyber Pakhtunkhwa, Pakistan. Previous records of CL in Pakistan was studied, and spatial analysis was performed on elevation and agro-ecological maps using Arc-GIS v10.3.1. Active lesions were found predominant (n=113, 1.2%: cutaneous lesions, 97, 86%, and lesions with mucosal involvement, 16, 14%) than scars (20, 0.25%). Active lesions of both local (100, 88%) and Afghan refugees (13, 12%), and infected age groups were found significantly different. Majority of the lesions were dry crusted (98, 86.7%), single (83, 73%), and frequently infecting facial region (59, 52%). Avoiding bed nets, living in mud houses and animal shelters were highly associated with CL infection. Temergara (30, 26.5%) and Rabath (14, 12.3%) were hyperendemic CL foci. Microscopically, 71 (63%) cases were positive, while the PCR assay revealed Leishmania tropica in 110 (97.3%) cases. Previous record revealed that L. tropica is dominant throughout Pakistan, and dry mountains and plateaus of northwestern and southwestern regions are spatially at high-risk. Measures should be taken to reduce CL infection by eliminating the associated risk factors, promoting PCR-based diagnosis and basic medical facilities.

Performance of a universal PCR assay to identify different Leishmania species causative of Old World cutaneous leishmaniasis

BACKGROUND

The characterization of Leishmania species is important for clinical management of the diseases and the epidemiological control of the parasite distribution. Most of the published polymerase chain reaction (PCR) amplification methods lack the ability to identify all species complexes, have low performance and usually need post-PCR procedures. There is a need for improving the diagnosis of CL by development of an accurate affordable PCR method to identify all Leishmania species in clinical specimens.

METHODS

We designed an optimized a PCR amplifying the internal transcribed spacer 2 sequence of the ribosomal RNA gene (ITS2) aligned from different strains of CL-causing Leishmania species in the Old World. The performance of the method was evaluated on lesion samples from several CL suspected patients and the limit of detection (LOD) was determined on DNA of promastigotes from reference strains.

RESULTS

The universal PCR enabled simultaneous discrimination of L. major, L. tropica and L. infantum using one primer pair in one reaction. Stained smear microscopy and Novy-MacNeal-Nicolle (NNN) medium culture alone detected 77.27% (17/22) and 72.73% (16/22) of the positive CL samples, respectively. The PCR assay showed 100% sensitivity (22/22) (95% CI: 84.56-100%) and 100% specificity (3/3) (95% CI: 29.24-100%) for species identification on isolates from lesion scraping/exudate and 100% sensitivity (13/13) (95% CI: 75.29-100%) and 100% specificity (11/11) (95% CI: 71.51-100%) for species identification on biopsy samples of CL patients, while being capable to successfully amplify as little as 0.01-0.1 pg of Leishmania DNA from cultured promastigotes.

CONCLUSIONS

We present a validated easy-to-use affordable universal PCR assay to identify the most common Old World Leishmania species causing CL. This PCR assay could be used as a sensitive/specific technique to diagnose CL-causing Leishmania species in clinical samples with high accuracy.

Outwitting an Old Neglected Nemesis: A Review on Leveraging Integrated Data-Driven Approaches to Aid in Unraveling of Leishmanicides of Therapeutic Potential

The global prevalence of leishmaniasis has increased with skyrocketed mortality in the past decade. The causative agent of leishmaniasis is Leishmania species, which infects populations in almost all the continents. Prevailing treatment regimens are consistently inefficient with reported side effects, toxicity and drug resistance. This review complements existing ones by discussing the current state of treatment options, therapeutic bottlenecks including chemoresistance and toxicity, as well as drug targets. It further highlights innovative applications of nanotherapeutics-based formulations, inhibitory potential of leishmanicides, anti-microbial peptides and organometallic compounds on leishmanial species. Moreover, it provides essential insights into recent machine learning-based models that have been used to predict novel leishmanicides and also discusses other new models that could be adopted to develop fast, efficient, robust and novel algorithms to aid in unraveling the next generation of anti-leishmanial drugs. A plethora of enriched functional genomic, proteomic, structural biology, high throughput bioassay and drug-related datasets are currently warehoused in both general and leishmania-specific databases. The warehoused datasets are essential inputs for training and testing algorithms to augment the prediction of biotherapeutic entities. In addition, we demonstrate how pharmacoinformatics techniques including ligand-, structure- and pharmacophore-based virtual screening approaches have been utilized to screen ligand libraries against both modeled and experimentally solved 3D structures of essential drug targets. In the era of data-driven decision-making, we believe that highlighting intricately linked topical issues relevant to leishmanial drug discovery offers a one-stop-shop opportunity to decipher critical literature with the potential to unlock implicit breakthroughs.

Epidemiological aspects of cutaneous leishmaniasis in Southwest of Iran

Background and Aim: Zoonotic rodents (Rodentia: Muridae: Gerbillinae) and Phlebotominae sand flies are the major reservoir hosts and vectors of Leishmania major causing zoonotic cutaneous leishmaniasis, respectively. This study was carried out to evaluate the epidemiological aspects of cutaneous leishmaniasis (CL) in Tangestan County, Southwest Iran. Materials and Methods: This descriptive cross-sectional study was carried out on human cases, probable reservoirs, and vectors of CL at Tangestan County in 2017. The data of patients were taken on health centers and analyzed. To determination faunistic of sand flies, they were collected using sticky paper traps and identified using identification keys. The rodent samples were captured using Sherman live traps and determined for amastigote infection. Results: A total of 436 cases occurred during 2005-2017 and the incidence rate of disease was 0.2-12/100,000 people. Six species of sand flies including three species of Phlebotomus and three species of Sergentomyia including Phlebotomus papatasi, Phlebotomus sergenti, Phlebotomus alexandri, Sergentomyia tiberiadis, Sergentomyia baghdadis, and Sergentomyia clydei were identified. From 185 trapped rodents, 9 species were identified. We founded, 2 out of 132 Tatera indica (1.53%) were positive with Leishmania spp. using the microscopic method. Conclusion: According to the existence of human leishmaniasis cases as a host, T. indica with high abundance and infected to Leishmania as a reservoir, and existence of P. papatasi with high abundance as a suspected vector of disease; there is a potential for transmission of disease in the area. Design of exact control and prevention strategies is highly recommended.

Arab world's growing contribution to global leishmaniasis research (1998-2017): a bibliometric study

BACKGROUND

Leishmaniasis is a parasitic disease caused by a protozoan of the Leishmania genus, and is considered a neglected tropical disease. It still remains a main public health concern at global level and in Arab world mainly in low-income countries. Therefore, this study was designed to evaluate the Arab world's growing contribution to global leishmaniasis research.

METHODS

This study describes a bibliometric review of all leishmaniasis research publications published between January 1998 and December 2017 indexed on the Scopus database.

RESULTS

The total number of publications published at global level was 17,570 papers, which achieves an average annual productivity of 878.50 papers publications. Brazil was responsible for the greatest output with the total number of publications of 3865 followed by the Unites States (n = 2729), India (n = 2119), the United Kingdom (n = 1363), and Spain (n = 1274). By limiting the analysis to the publications that have been published by Arab world, the research productivity was 993 papers, which represents 5.65% of total research output at global level in research regarding leishmaniasis. Tunisia was responsible for the greatest output from Arab world with the total number of publications of 297 followed by Sudan (n = 192), Saudi Arabia (n = 131), Morocco (n = 119) and Egypt (n = 67). Since 1998, the growth of publications on leishmaniasis fluctuates, overall showing a rising trend in both global and Arab world. There is a highly significant correlation between publication productivity related to leishmaniasis at global level and the Arab world (r = 0.936; p-value< 0.001). Leishmaniasis treatment, intracellular mechanism of infection, and lifecycle of leishmania are the major current hot topics for the research in this subject at global level and the Arab world.

CONCLUSIONS

The current study presents a novel review of the current Arab leishmaniasis-related research, and how these results are related to worldwide output. In comparison to the global research output, the Arab world produced less leishmaniasis research. The data presented in the current study by this innovative approach may serve relevant researchers to direct the global leishmaniasis research to Arab counties in which leishmaniasis is endemic.

Expansion of urban cutaneous leishmaniasis into rural areas of southeastern Iran: Clinical, epidemiological and phylogenetic profiles explored using 7SL high resolution melting-PCR analysis

Cutaneous leishmaniasis (CL) has increased remarkably in Iran and has expanded into new areas. The present study aimed to assess the emerging CL outbreak in southeastern Iran using high resolution melting-polymerase chain reaction (HRM-PCR) and phylogenetic analysis using the 7SL RNA gene marker. A cross-sectional and analytical survey was conducted during a house-to-house census of 11,021 inhabitants in Narmashir County in southeastern Iran in 2016. The cases were detected by direct smear microscopic examination and sequencing and were characterized using the 7SL RNA gene. All age groups and sexes were equally affected. Most were single lesions (70.7%). The hands (55.2%) and face (37.9%) were the main sites of involvement. The disease was more common among illiterate persons. Sequencing and HRM-PCR revealed that Leishmania tropica (accession no. MH632168 Qale-Shahid) was the principal causative agent of anthroponotic CL (ACL) in new areas of expansion. This is the first emergence of ACL in rural areas of Narmashir County. Based on the molecular data, the causative parasite species confirmed to be L. tropica. Sequencing and phylogenetic analysis indicated that a single clone of the organism derived from a single source has spread into the affected villages. Construction of a main road, population movement and recent urbanization in the area are likely the major factors associated with the establishment of this new outbreak. This study was essential to enable the planning of effective therapeutic and prophylactic measures to control the disease.

Cutaneous leishmaniasis: an epidemiological study in southwest of Iran

The current study was aimed to evaluate the frequency and epidemiological aspects of cutaneous leishmaniasis (CL) in the southwest of Iran, an endemic focus for the leishmaniasis from 2014 to 2017. In the present retrospective cross-sectional study, all suspicious CL persons who were referred to health centers affiliated to Abadan School of Medical Sciences (Abadan and Khorramshahr cities) were tested. In this regard, both clinical and parasitological (staining with Giemsa) verifications were performed to diagnose a case. Furthermore, a structured questionnaire containing some demographic details was applied for each positive patient. In total, 151 and 132 positive CL cases were identified in Abadan and Khorramshahr cities, respectively. More frequency of CL was observed during the Winter season, among male subjects, and in urban inhabitants in both cities. The incidence of CL based on age distribution was higher in the age range of 20-30 years than others. Besides, the hands and feet were the most involved organs. Although the frequency of CL has declined in the region, CL is still a public health problem. More appropriate control strategies are required to limit and eliminate the infection in the future.

Cutaneous leishmaniasis in Qasr-e Shirin, a border area in the west of Iran

Aim:

The prevalence of cutaneous leishmaniasis (CL) is growing in Iran, and new sources of the disease have been found in the country. The purpose of this study was to describe the epidemiology of CL in Qasr-e Shirin County, Kermanshah Province, West of Iran. Qasr-e Shirin is located near the Iran-Iraq border, and several million pilgrims pass through this area to Iraq every year.

Materials and Methods:

A descriptive cross-sectional study was carried out for active case detection from April 1, 2014, to March 31, 2015. All individuals with suspicious lesions were identified through house-to-house visits in the aforementioned area. A questionnaire was filled out for everyone with clinical suspicion of CL. A diagnosis was made based on parasitological examination of the lesion exudate. The annual incidence and prevalence of CL were estimated.

Results:

In total, 5277 individuals were randomly screened for the presence of active lesions or scars suspected of CL. The overall prevalence of CL in the County was 4.8% (60 cases had active lesions and 194 cases had scars). All age groups were affected, but the highest incidence of CL was seen in the age group 20-29 years (1.9%). The incidence and prevalence were higher in women than men (5.5% vs. 4%). Most cases (45.6%) had a single lesion or scar and 44 (17.4%) patients had five or more lesions or scars.

Conclusion:

The incidence of CL in Qasr-e Shirin County is high. There is a need for further studies on reservoirs and vectors of leishmaniasis in this area. The results of such studies help to perform more efficient and timely spraying against phlebotomine sandfly or detect and decrease the animal reservoir population.

Isolation of Crithidia spp. from lesions of immunocompetent patients with suspected cutaneous leishmaniasis in Iran

OBJECTIVE

Leishmania major has been considered as the main aetiological agent of cutaneous leishmaniasis in Iran. However, there are recent reports about the existence of Crithidia spp in cutaneous lesions in southern Iran. Therefore, this study was designed to decipher some morphological, biological and molecular aspects of this phenomenon.

METHODS

Clinical isolates were obtained from 167 patients with cutaneous ulcers. A set of specific primers based on GAPDH (Glyceraldehyde-3-Phosphate Dehydrogenase) gene were used to distinguish between Crithidia and Leishmania genera. For molecular analysis, Pulsed Field Gel Electrophoresis and Mi-Seq Illumina platform were applied. Then, morphological analysis and some biological features (including potential growth at 37 °C and the ability of infecting mammalian macrophages) were studied.

RESULTS

In 92.8% of clinical cases, L. major was the only causative microorganism isolated; in 5.4% of cases, co-infection of L. major and Crithidia spp. was identified; and in 1.8% of lesions, only Crithidia spp. were found.

CONCLUSION

We isolated Crithidia spp. from clinical samples of patients suspected of cutaneous leishmaniasis in Iran, indicating that Crithidia spp. are capable of surviving at human body temperature and infecting macrophage cells. This raises questions on the influence of this phenomenon on pathogenicity, therapeutic outcome and disease control strategies.

Differential expression of TLRs 2, 4, 9, iNOS and TNF-α and arginase activity in peripheral blood monocytes from glucantime unresponsive and responsive patients with anthroponotic cutaneous leishmaniasis caused by Leishmania tropica

BACKGROUND

Detection of the mechanism of host/parasite interactions in unresponsive forms of anthroponotic cutaneous leishmaniasis (ACL) caused by Leishmania tropica is helpful for immunotherapy and vaccine development. In the present study, the gene expression of toll-like receptors (TLRs), TNF-α, iNOS and also arginase (ARG) activity in monocytes from Glucantime unresponsive in comparison to responsive patients infected with L. tropica was investigated.

METHODS

In this case-control study, patients with unresponsive (n = 10) and responsive (n = 10) ACL were recruited. Gene expression of TLR2, TLR4, TLR9, TNF-α and iNOS was analyzed in L. tropica-exposed monocytes. The level of ARG activity in both isolated promastigotes and the lysates of monocytes was also determined.

RESULTS

L. tropica-exposed monocytes represented higher expression of all three TLRs and TNF-α and lower expression of iNOS compared to unexposed ones in both groups of patients. Results revealed a significant down-regulation of TLR2 and TNF-α and up-regulation of TLR9 expression in unresponsive isolates in comparison to responsive ones. Besides, ARG level showed a significant increase in L. tropica-stimulated monocytes and cultured promastigotes from unresponsive isolates versus responsive ones.

CONCLUSIONS

The decreased TLR2, TLR4, TNF-α and iNOS and the increased level of TLR9 expression in L. tropica-exposed monocytes from unresponsive isolates and also the increment in ARG activity in their promastigotes and monocytes, might possibly be involved in the severity of the disease and leading to Glucantime unresponsiveness.

Unresponsiveness to meglumine antimoniate in anthroponotic cutaneous leishmaniasis field isolates: analysis of resistance biomarkers by gene expression profiling

BACKGROUND

Resistance to antimonials is a fundamental determinant of treatment failure in anthroponotic cutaneous leishmaniasis (ACL). Detection of reliable molecular markers to distinguish unresponsive and responsive parasites is critical for consolidating strategies to monitor drug efficacy.

METHODS

We analysed the expression of five major antimony resistance-associated genes that is aquaglyceroporin1 (AQP1), γ-glutamylcysteine synthetase (γ-GCS), multidrug resistance protein A (MRPA), trypanothione reductase (TR) and thiol-dependent reductase 1 (TDR1), in unresponsive and responsive Leishmania tropica field isolates by quantitative real-time PCR in comparison with sensitive and resistant reference strains.

RESULTS

Gene expression analysis showed the down-regulation of AQP1, γ-GCS and TDR1 by a factor of 1.9, 1.7 and 3.55, respectively, in unresponsive isolates vs. responsive ones. The average RNA expression level of MRPA increased by a factor of 1.9 in the unresponsive group. Isolates exhibited a strong positive linear correlation between gene expression of AQP1 and γ-GCS. A negative correlation between the AQP1 and γ-GCS expression level and lesion duration in responsive patients indicated the potential role in diagnosing drug-unresponsive parasites in endemic areas of ACL.

CONCLUSION

In cases of inconclusive outcomes of resistance tests in clinical isolates, expression analysis of a set of influential genes can be beneficial to identify distinctive biomarkers between antimony-unresponsive and responsive parasites.

A newly emerged focus of zoonotic cutaneous leishmaniasis in South-western Iran

Leishmaniasis is rising in many countries, including Iran, due to climate change, refugee crises, urbanization and etc. The aim of this study was to explore the epidemiology, extent and identity of Leishmania species in a newly emerged focus in Abdanan County, Ilam Province, South-western Iran. This study was performed as a descriptive cross-sectional study by a systematic house-to-house approach. The Leishmania species was identified by RFLP-PCR and sequencing. Altogether, 46799 individuals consisting of 22907 (48.9) female and 23892 (51.1%) male were interviewed and physically examined for the presence of skin lesions. Overall, the incidence rate was 0.34% (n = 160). All age groups were affected and the incidence rate was the highest in <10 years of age group (0.49%) and the lowest in >50 years old individuals (0.15%), although there was no significant difference regarding the sex and age. The majority of patients had one lesion (47.5%) on hands (56%) and most of the cases occurred in Abdanan city (%54) in summer. Based on the RFLP-PCR analysis, all the Leishmania isolates were L. major of single genotype. A newly emerged focus of zoonotic CL caused by L. major occurred in South-western of Iran. Multiple risk factors created this epidemic area. Further studies on the vector and reservoir are crucial needed to provide evidences to select the prophylactic and therapeutic measures for future control strategies.

Geographical distribution and molecular characterization for cutaneous leishmaniasis species by sequencing and phylogenetic analyses of kDNA and ITS1 loci markers in south-eastern Iran

This study aimed to explore geographic distribution and molecular characterization of cutaneous leishmaniasis (CL) species by amplifying two popular markers in kinetoplast DNA and internal transcribed spacer 1 loci by nested-PCR, and characterized by sequencing and phylogenetic analyses. Findings demonstrated that two species co-existed in the province: L. tropica (88.5%) and L. major (11.5%). All gender and age groups were equally infected, although males, 21-30 years old, exhibited a significantly higher infection. Sequencing and phylogenetic analyses of 34 randomly selected samples showed that L. tropica isolates exhibited some degree of heterogeneity. Both anthroponotic CL and zoonotic CL are present in south-eastern Iran with predominance of L. tropica species. Some level of heterogeneity was observed in L. tropica isolates which possibly reflects different colonies in the area. Implementation of diagnostic tools directly from clinical samples could be an important strategic approach for exploration of spatial distribution, molecular characterization and phylogenetic analyses.

Addressing vulnerability, building resilience: community-based adaptation to vector-borne diseases in the context of global change

Background

The threat of a rapidly changing planet – of coupled social, environmental and climatic change – pose new conceptual and practical challenges in responding to vector-borne diseases. These include non-linear and uncertain spatial-temporal change dynamics associated with climate, animals, land, water, food, settlement, conflict, ecology and human socio-cultural, economic and political-institutional systems. To date, research efforts have been dominated by disease modeling, which has provided limited practical advice to policymakers and practitioners in developing policies and programmes on the ground.

Main body

In this paper, we provide an alternative biosocial perspective grounded in social science insights, drawing upon concepts of vulnerability, resilience, participation and community-based adaptation. Our analysis was informed by a realist review (provided in the Additional file 2) focused on seven major climate-sensitive vector-borne diseases: malaria, schistosomiasis, dengue, leishmaniasis, sleeping sickness, chagas disease, and rift valley fever. Here, we situate our analysis of existing community-based interventions within the context of global change processes and the wider social science literature. We identify and discuss best practices and conceptual principles that should guide future community-based efforts to mitigate human vulnerability to vector-borne diseases. We argue that more focused attention and investments are needed in meaningful public participation, appropriate technologies, the strengthening of health systems, sustainable development, wider institutional changes and attention to the social determinants of health, including the drivers of co-infection.

Conclusion

In order to respond effectively to uncertain future scenarios for vector-borne disease in a changing world, more attention needs to be given to building resilient and equitable systems in the present.

Electronic supplementary material

The online version of this article (doi: 10.1186/s40249-017-0375-2) contains supplementary material, which is available to authorized users.

Molecular identification of Leishmania spp. isolates causes cutaneous leishmaniasis (CL) in Sanliurfa Province, Turkey, where CL is highly endemic

Cutaneous leishmaniasis (CL) is an important public health problem in Turkey. CL has been most frequently seen in Sanliurfa. There is an expectation of increase in the population of leishmaniasis cases with the influence of Syrian refugees arriving in Turkey. In this study we aimed to diagnosis of CL and identifying of parasite from Leishmania isolates by using ITS 1 PCR RFLP. Samples were collected from 135 CL patients in Sanliurfa. After the specimens were inoculated in medium NNN, the ones which were cultures positive were cultivated in RPMI 1640 followed by PCR-RFLP. Genomic DNA was extracted phenol-chloroform procedure. Samples were examined by using ITS 1 PCR followed by RFLP analysis. Our results indicated that two species, L. tropica (132 samples) and L. major (3 samples), are responsible for cutaneous leishmaniasis in Sanlıurfa. Our study is the first scientific study in which it is reported molecular analyses of cutaneous leishmaniasis cases caused by L. major in Sanliurfa in Southestern Anatolia Region. Because CL cases caused by L.major are detected in our study, it is considered that genotyping is important for diagnosis of Leishmania and following change of epidemiology.

Geographic and ecological features of phlebotomine sand flies (Diptera: Psychodidae) as leishmaniasis in Central Iran

Phlebotomine sand flies occur throughout the tropics and subtropics, as well as in temperate regions of the world. They are vectors of human and canine leishmaniasis and sand fly fevers caused by phleboviruses. This study was aimed to determine the geographic and ecological characteristics of phlebotomine sand flies as vectors of leishmaniasis and to prepare a checklist of phlebotomine sand flies. The study was conducted in Qom province, central Iran, between April and November 2016. Qom is located in latitude 34.6399°N and longitude 50.8759°E with average annual minimum and maximum temperatures of 16.5 and 49 °C, annual rainfall of 150 mm and relative humidity of 84 and 28%, respectively. Sand flies were collected by sticky paper traps from Qom city and its six districts. The sand flies collected were separated from the sticky paper traps using an insulin syringe and kept in 70% ethanol for species identification using taxonomic keys. Also, a literature review was performed using all published reports on phlebotomine sand flies in this province during 1999-2015. A total of 28,410 sand flies from two genera and 14 species were collected. Phlebotomus papatasi, the main vector of zoonotic cutaneous leishmaniasis and arboviruses, and Phlebotomus sergenti, the vector of anthroponotic cutaneous leishmaniasis, were the predominant species followed by Phlebotomus kandelakii, P. major and P. alexandri. Fourteen species from two genera mostly from wet and mountainous areas were identified in the study area. Kahak and Markazi districts were identified as high-risk foci with numerous leishmaniasis vectors species; we recommend intensifying and strengthening of vector control programme in the area of study.

Control of zoonotic cutaneous leishmaniasis vector, Phlebotomus papatasi, using attractive toxic sugar baits (ATSB)

Introduction

Attractive Toxic Sugar Baits (ATSB) is a new vector control method that meets Integrated Vector Management (IVM) goals. In an experimental design, this study aimed to determine effects of ATSB on control of Phlebotomus papatasi, as a main vector of Zoonotic Cutaneous Leishmaniasis (ZCL), in Qom Province, center of Iran.

Methods

In a cross-sectional design, boric acid was mixed with brown sugar solution and tested as toxic baits for P. papatasi. Two methods were utilized to use the baits: (a) spraying ATSB on vegetation, bushes, and shrubs; and (b) setting ATSB-treated barrier fences in front of colonies at 500 m distance from the houses in outskirts of villages. In order to examine the residual efficacy rate of ATSB-treated barrier fences, the bioassay test was used. Density of P. papatasi sandflies was measured using sticky and light traps biweekly. For data analysis, Mann-Whitney U Test and Kruskal-Wallis were used. Results ATSB-treated barrier fences led to 3 times reduction in P. papatasi population. Besides that, ATSB spraying on plants led to more than 5 times reduction in P. papatasi population.

Conclusions

Comparing the incidence of leishmaniasis in treated villages before and after the study showed that the incidence was statistically reduced. Therefore, ATSB is an effective method to control vectors and prevent leishmaniasis.

Incidence and Disability-Adjusted Life Years (Dalys) Attributable to Leishmaniasis In Iran, 2013

Background

Leishmaniasis covers a range of clinical manifestations. Estimation of the burden of leishmaniasis may help guide healthcare management personnel and policy-makers in applying effective interventions. The present study aimed to calculate the incidence and burden of cutaneous and visceral leishmaniasis in Iran in 2013.

Methods

To evaluate the epidemiological aspects of the disease in Iran, published studies over the past 20 years were searched and the viewpoints of relevant specialists in Iran were obtained. Data were collected from the Ministry of Health and from the Tehran University of Medical Sciences. To calculate years of life lost due to premature death, standard expected years of life lost was used. Standard life table of Global Burden of Disease (GBD) 2010 with the life expectancy of 86.02 years for both sexes was used to calculate the remaining potential years of life at any age from death.

Results

The overall incidence of cutaneous and visceral leishmaniasis was calculated as 22 and 0.092 per 100000 population of Iran, respectively. The burden of leishmaniasis was 99.5 years: 95.34 and 4.16 years for cutaneous and visceral, respectively. Sensitivity was analyzed and deaths predicted by the Institute of Health Metrics and Evaluation added, the burden of visceral leishmaniasis was 726 years.

Conclusion

The share of leishmaniasis burden in Iran is lower than the global burden of the disease. GBD 2010 standard method is recommended to calculate the burden of leishmaniasis in different countries and set local priorities on the basis of these measures.

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

The aim of this study was to investigate the impact of the environmental factors on cutaneous leishmaniasis (CL) prevalence and morbidity in Ilam province, western Iran, as a known endemic area for this disease. Accurate locations of 3237 CL patients diagnosed from 2013 to 2015, their demographic information, and data of 17 potentially predictive environmental variables (PPEVs) were prepared to be used in Geographic Information System (GIS) and Land-Use Regression (LUR) analysis. The prevalence, risk, and predictive risk maps were provided using Inverse Distance Weighting (IDW) model in GIS software. Regression analysis was used to determine how environmental variables affect on CL prevalence. All maps and regression models were developed based on the annual and three-year average of the CL prevalence. The results showed that there was statistically significant relationship (P value≤0.05) between CL prevalence and 11 (64%) PPEVs which were elevation, population, rainfall, temperature, urban land use, poorland, dry farming, inceptisol and aridisol soils, and forest and irrigated lands. The highest probability of the CL prevalence was predicted in the west of the study area and frontier with Iraq. An inverse relationship was found between CL prevalence and environmental factors, including elevation, covering soil, rainfall, agricultural irrigation, and elevation while this relation was positive for temperature, urban land use, and population density. Environmental factors were found to be an important predictive variables for CL prevalence and should be considered in management strategies for CL control.

Tumour Necrosis Factor-alpha (TNF-α) and its soluble receptor type 1 (sTNFR I) in human active and healed leishmaniases

The role of tumour necrosis factor-alpha (TNF-α) is not fully understood in human leishmaniasis. We analysed the alterations in the levels of TNF-α, soluble TNF receptor type 1 (sTNFR I), IL-17 and IL-22 productions in active and healed leishmaniases. Blood samples were collected from volunteers with active cutaneous leishmaniasis (ACL), the same subjects after lesion healing (healed CL = HCL), volunteers with active visceral leishmaniasis (AVL), healed VL (HVL) and healthy controls. Levels of cytokines were titrated on Leishmania Ag-stimulated PBMC culture. The mean level of TNF-α production from stimulated cells was significantly higher in ACL than controls (P < 0·001) and significantly reduced after treatment in HCL volunteers (P < 0·05). The mean level of sTNFR I production was significantly higher in ACL than controls (P < 0·001) and significantly reduced after treatment in HCL volunteers (P < 0·05). The mean level of IL-22 production in AVL was significantly higher than controls (P < 0·05) and was significantly lower in HVL compared with AVL (P < 0·001) and controls (P < 0·05). The levels of TNF-α (P = 0·0025) and sTNFR I (P < 0·01) productions from PBMCs showed significant decreasing trend after treatment in each CL volunteer. Reduction in TNF-α is associated with clinical response to treatment and healing of CL lesions due to L. major.

Leishmaniasis revisited: Current aspects on epidemiology, diagnosis and treatment

Leishmaniasis is a vector-borne disease caused by protozoan parasites of the genus Leishmania. It is transmitted by phlebotomine female sand flies of the genera Phlebotomus and Lutzomyia in the old and new world, respectively. More than 20 well-recognized Leishmania species are known to infect humans and cause visceral (VL), cutaneous (CL) and mucocutaneous (ML) forms of the disease. Approximately 350 million people are at risk of contracting the disease and an estimated 1.6 million new cases occur annually. The disease mainly affects poor people in Africa, Asia and Latin America, and is associated with malnutrition, population migration, poor residency conditions, frail immune system and lack of resources. Previously, diagnosis of leishmaniasis relied mainly on invasive techniques of detecting parasites in splenic and bone marrow aspirates. Nevertheless, serological tests using the recombinant kinesin antigen (rK39) and molecular methods (polymerase chain reaction) are considered the best options for diagnosis today, despite problems related to varying sensitivities and specificities and field adaptability. Therapy of leishmaniasis ranges from local treatment of cutaneous lesions to systemic often toxic, therapy for disseminated CL, ML and VL. Agents with efficacy against leishmaniasis include amphotericin B, pentavalent antimonial drugs, paromomycin and miltefosine. No single therapy of VL currently offers satisfactory efficacy along with safety. This article provides a brief and updated systematic review on the epidemiology, diagnosis and treatment of this neglected disease.

Epidemiologic profile of oriental sore caused by Leishmania parasites in a new endemic focus of cutaneous leishmaniasis, southern Iran

Cutaneous leishmaniasis (CL) is the first and most important vector-borne zoonotic disease transmitted by sand flies in Iran. As a parasitic disease in the Old World, it is a complex zoonosis with multiple vertebrate hosts and arthropod vectors of pathogenic flagellate protozoan in the genus of Leishmania in different parts of its range. Phlebotomine sand flies are proven as vectors of this parasite which can be transmitted through the bite of an infected female sand fly distributed in almost all parts of Iran. This research performed on all CL patients as that were registered into special forms by physicians and experts during the study period 2006-2013 in the county town of Fasa, Iran. Data were analyzed by Chi square test using SPSS 17 statistics software. Overall, 1,908 patients (59.18 %) lived in rural and 1,316 (40.82 %) lived in urban areas. All ages were between 1 and ≥30 year. The most frequent age group was ≥20 years (54.6 %). Sex ratio of patients was almost 1:1 (1,561; 48.42 % male vs. 1,663; 51.58 % female). Most of them (66.84 %) had wet lesions and those with dry lesions were less frequent (33.16 %). There was a significant difference between the frequencies of these two groups (P < 0.05). Hand ulcers were the most prevalent part of body (43.24 %). The highest prevalence rate (35.14 %) of lesions occurred in autumn. The unstable trend of this disease in different years and its relatively high disease burden affecting all age groups in Fasa with respect to other counties in Iran showed that it was most likely an endemic disease in this region.