Marring leishmaniasis: the stigmatization and the impact of cutaneous leishmaniasis in Pakistan and Afghanistan

The psychosocial impacts of skin-neglected tropical diseases (SNTDs) as perceived by the affected persons: A systematic review

BACKGROUND

Neglected Tropical Diseases (NTDs) disproportionately affect marginalised groups within impoverished communities, conferring devastating physical, financial and psychosocial effects. Skin-NTDs (SNTDs) are uniquely stigmatising due to their visible nature, rendering affected individuals vulnerable to psychosocial risk and the associated decline in social participation, quality of life and mental health. In response to knowledge gaps identified by current global efforts for integrated control of SNTDs this review gathers existing evidence on the psychosocial effects of SNTDs, with consideration given to the influence of gender.

METHODS

The study protocol is registered with PROSPERO (CRD42022336676). Data was collected from Embase, Global Health, Medline and Web of Science, with additional articles identified through Google Scholar and bibliography tracking. Qualitative studies published in English between 2005 and 2024 reporting men's and women's experiences with SNTDs were searched. Appropriate data from each included study were inputted into NVivo software to facilitate thematic synthesis. Descriptive and analytic themes were generated through line-by-line coding using an inductive approach.

RESULTS

27 articles of high and moderate quality were included. They pertained to buruli ulcer, cutaneous leishmaniasis, leprosy, lymphatic filariasis, tungiasis, onchocerciasis, schistosomiasis and podoconiosis. Men and women across SNTDs and contexts reported debilitating physical symptoms which impaired their ability to work, socialise and carry out usual daily activities. Some felt (at least initially) well supported by partners and relatives, whereas most experienced avoidance, abandonment and even violence, with women incurring worse SNTD-related social consequences. Many men and most women experienced stigma, with discriminatory behaviours largely attributed to fear of infection, decreased ability to perform gender-specific daily activities, and the perceived association between SNTDs and sinfulness. Self-reported impacts of SNTDs on men's and women's mental wellbeing included low mood, anxiety, low self-esteem, and suicidal ideation. Disease-specific knowledge, early treatment, social support, and disease acceptance were mentioned as protective factors.

CONCLUSION

SNTDs cause significant psychosocial harms, particularly for women. Implementing myth-busting and contact-based educational campaigns and improving access to treatment and to livelihood opportunities and social protection schemes for men and women with a SNTD will help prevent and mitigate these.

Quality of life among adults with scabies: A community-based cross-sectional study in north-western Ethiopia

INTRODUCTION

Scabies undermines quality of life through its highly disturbing disease symptoms, by distorting self-perception, and secondary to social stigma. Knowledge of its effect on quality of life in general and on specific aspects of day-to-day life is key to addressing the health needs of individual patients and to evaluating gains from community-based disease control interventions.

OBJECTIVES

To measure the effect of scabies on the quality of life of people with the infestation.

METHODS

A community-based cross-sectional study was conducted in a scabies outbreak-affected district in north-western Ethiopia. The study involved 381 households and 86 adults with scabies. We used the ten-item Cardiff Dermatology Life Quality Index (DLQI) tool to collect data. Cronbach's alpha value was used to determine the internal consistency of the Amharic version of the scale. Overall and Dermatology Life Quality (DLQ) domain specific mean scores were calculated. The association between sociodemographic characteristics and scabies-related life quality impairment was tested using Kruskal-Wallis test.

RESULTS

Scabies moderately affected the quality of life of adults with scabies. The overall mean DLQI (mDLQI) score was 9.2 (SD = 7.6). 'Symptoms and feelings' and 'daily activity' DLQ domains had the highest mDLQI scores (3.5, SD = 1.9 and 2.2, SD = 2.5, respectively). 'Leisure activities' was the least affected domain 0.8 (SD = 1.1). In terms of severity, scabies had moderate or severe effect on DLQ of 54.7% of the participants and extremely severe effect was reported among 27% of the participants. However, no association was observed between sociodemographic characteristics and quality of life impairment.

CONCLUSION

Quality of life was moderately impaired among people affected by scabies. Refocusing attention on management of disease symptoms, using standard scabies treatment, and providing psychosocial support to improve self-perception of people affected with scabies may help reduce quality of life impairment.

Epidemiology of cutaneous leishmaniasis in children of Khyber Pakhtunkhwa, Pakistan

OBJECTIVES

In Pakistan, cutaneous leishmaniasis is an emerging tropical disease and a very high number (>70%) of children are afflicted by this marring infection. This study aimed to scrutinise the prevalence, spatial distribution and socio-demographic and behavioural risk factors associated with cutaneous leishmaniasis in children aged <5-15  years in Khyber Pakhtunkhwa.

METHODS

A total of 1, 559 clinically confirmed records of children diagnosed with cutaneous leishmaniasis (January-December) from 2020 and 2022 were obtained from selected district hospitals. In addition, a risk factors-related questionnaire was administered to 1, 011 households (400 in 2020 and 611 in 2022) in nine districts during a household survey.

RESULTS

The maximum number of cutaneous leishmaniasis cases was recorded in 2022 (n = 877, 56.25%) as compared to 2020 (n = 682, 43.75%). The hospital records showed a greater number of male patients in the 2022 cohort (n = 603, 68.76%). The highest number of cases were observed in children aged 5-9 years in 2022 (n = 282, 32.16%) and 2020 (n = 255, 37.39%). In 2020 and 2022, cutaneous leishmaniasis cases showed peak aggregation in March (n = 118, 17.3%) and January (n = 322, 36.72%). From a spatial analysis, the maximum number of cutaneous leishmaniasis cases was recorded at 59-1700 m elevation in various land-use/land-cover and climatic regions with quaternary alluvium rock formations. A multivariate logistic regression model analysis of risk factors from the households survey suggested that age group, socio-economic status, construction materials of the house, use of insect repellents, Afghan refugee camps in the village/district, knowledge and biting times of sand flies, frequent use of mosquito bed nets, presence of domestic animals in the house, knowledge of the transmission period and peak month of leishmaniasis infection increased the risk of acquiring cutaneous leishmaniasis (p  value < 0.05).

CONCLUSION

Our analysis demonstrated that cutaneous leishmaniasis in children is influenced by a variety of environmental, socio-demographic and behavioural risk factors in Khyber Pakhtunkhwa. The increase in recorded cases of cutaneous leishmaniasis in children in 2022 compared to 2020 suggests that the infection likely extended to new foci in the province.

Clinical polymorphism of zoonotic cutaneous leishmaniasis: combination of the clinical and the parasitological diagnosis

Zoonotic cutaneous leishmaniasis (ZCL) is a neglected tropical disease caused by Leishmania (L.) major. This zoonosis is characterized by a broad-spectrum clinical polymorphism and may be underestimated and poorly treated since it is a simulator of various dermatoses. The aim of our study was to analyze the clinical polymorphism of patients with ZCL. A total of 142 patients with confirmed CL based on the microscopic examination of skin lesion biopsies were included in this study. Molecular typing of Leishmania species revealed that all patients were infected with L. major. In total, 14 clinical forms were observed. Six were typical and eight were atypical. The typical ZCL forms are grouped as follows: papular (26.76%), ulcero-crusted (26.05%), ulcerated (13.38%), impetiginous (9.86%), nodular (9.15%), and papulo-nodular (5.63%) lesions. In atypical ZCL forms, we described erythematous (2.81%), erysipeloid (1.4%), sporotrichoid, (1.4%), keratotic (0.7%) lupoid (0.7%), lichenoid (0.7%), psoriasiform (0.7%), and zosteriform (0.7%) lesions. Here, the lichenoid and the keratotic forms caused by L. major were reported for the first time in Tunisia. These findings will help physicians to be aware of the unusual lesions of ZCL that could be confused with other dermatological diseases. For this reason, it will be necessary to improve the diagnosis of CL especially in endemic areas. Such large clinical polymorphism caused by L. major may be the result of a complex association between the vector microbiota, the parasite, and the host immune state, and further studies should be carried out in order to reveal the mechanisms involved in clinical polymorphism of ZCL.

Environmental and socio-demographic factors associated with cutaneous leishmaniasis in district Khyber, Pakistan; alarming spread of the disease to new foci

Cutaneous leishmaniasis (CL) is a sand fly-borne infection of significant public health concern in Pakistan (endemic for CL). This study aimed to scrutinize the environmental and socio-economic risk factors for CL in district Khyber (located on Pak-Afghan border), Pakistan. Clinically confirmed 2881 CL case records for (January-December) 2017 and 2020 were obtained from district hospital. In addition, a questionnaire for CL risk factors assessment was administered to 525 households (175 in 2017 and 350 in 2020) in 40 villages throughout the district in a household survey. Higher number of CL cases were recorded in 2020 (N = 1824 belonging to 90 villages) compared to 2017 (N = 1057 from 42 villages). Highest number of CL patient cases were recorded in tehsil Jamrud (N = 2248, 39.01 %), followed by Landi Kotal (N = 398, 6.91 %) and Bara (N = 235, 4.08 %). Records showed higher number of CL cases in males (N = 1,659, 57.58 %) compared to females (N = 1,222, 42.41 %). In 2017 and 2020 the disease burden peaked in January. GIS-based spatial analyses of hospital records revealed that CL cases were abundant at 294-1,916 m elevation, in agriculture and range lands. Univariate logistic regression model analysis of risk factors suggested that higher education, family size >15, knowledge of CL, having family member/s that suffered from CL in the past, knowledge about biting time of sand flies, use of mosquito spray, presence of Afghan refugees in the village/s and living in mud-made houses increased the risk of acquiring CL. The multivariable logistic regression model showed none of the risk factors to be statistically significant. Findings of the study are crucial towards effective and targeted control of CL in district Khyber.

Perceived Social Stigma of Cutaneous Leishmaniasis in Hubuna, Saudi Arabia

Background

Cutaneous Leishmaniasis (CL) is a vector-borne skin infection that remains prevalent in regions with poor socioeconomic conditions. Stigmatization occurs when individuals with physical or psychological disorders interact with societal stereotypes. The aim of this study was to explore the perceived social stigma surrounding CL among people residing in Hubuna, Saudi Arabia.

Methods

This cross-sectional community-based survey recruited 618 individuals aged 18 years and above using the snowball sampling technique to reach hidden cases within the target population. Data was collected using a self-administered questionnaire and the Explanatory Model Interview Catalogue for Perceived Social Stigma (EMIC-SS-12) was used to assess the level of perceived social stigma. It includes questions on demographic variables, behaviors, and experiences. The analysis was performed using SPSS.

Results

The study included 618 participants, the majority of whom were women and girls (54.2%), with a mean age of 28 ± 12.7 years. The median score for perceived social stigma was 26.0. Only 2.1% (n = 13) of participants had the highest EMIC-SS-12 score of 36, while 7.6% (n = 47) scored zero. The mean score for overall perceived social stigma was 1.89 ± 0.91, while the mean score for experienced stigma was 1.99 ± 1.02. Univariate analysis showed that sex, employment, location of lesions, and number of lesions were insignificantly associated with stigmatization (P-value < 0.05), because these associations were uncertain because the CI includes or very close to 1.

Conclusion

The study reveals insights into stigmatization associated with CL in the Habuna area of Saudi Arabia. It found that the median of perceived social stigma was 26. Factors such as sex, employment status, and location of the lesion are uncertainly associated with stigma. It is crucial to explore negative behaviors and perceptions and develop suitable health education programs.

A prospective longitudinal study on the elimination trend of rural cutaneous leishmaniasis in southeastern Iran: Climate change, population displacement, and agricultural transition from 1991 to 2021

Leishmaniasis is a complex disease. Any change in weather conditions affects the humans' social and agricultural expansion and, consequently, the parasite's life cycle in terms of ecology, biodiversity, social stigma, and exclusion. This population-based prospective longitudinal investigation was conducted between 1991 and 2021 in a well-defined CL (cutaneous leishmaniasis) focus in Bam County, southeastern Iran. A robust health clinic and health surveillance system were responsible for the ongoing systematic documentation, detection, identification, and management of CL cases. The exponential smoothing method via the state space model was used in the univariate time series. The TTR, smooth, and forecast packages were used in R software. Landsat satellite images from 1991, 2001, 2011, and 2021 were employed in the physical development. During this period, the temperature increased while the rainfall and humidity decreased. The findings showed a downward trend in the standardized drought index. Also, the results showed that climate warming and ecological changes profoundly affected the area's agricultural patterns and topographical features. Furthermore, the last three decades witnessed an elimination trend for zoonotic CL (ZCL) and the predominance of anthroponotic CL (ACL). The present findings showed that the critical factors in the predominance of ACL and elimination of ZCL were rising temperature, drought, migration, unplanned urbanization, earthquake, and agrarian reform. The wall-enclosed palm tree gardens excluded the primary ZCL reservoir host. They controlled the disease while providing suitable conditions for the emergence/re-emergence of ACL in the newly established settlements and the unplanned ecozone. Therefore, robust health infrastructures, sustained financial support, and evidence-based research studies are crucial to facilitating the necessary surveillance, monitoring, and evaluation to control and eliminate the disease.

Looking through the lens of social science approaches: A scoping review of leishmaniases and Chagas disease research

Scholars have called for increased attention to sociocultural, economic, historical, and political processes shaping Neglected Tropical Diseases (NTDs) ecology. We conducted a scoping review to identify major research themes and the knowledge gaps in social science literature in leishmaniases or Chagas disease (CD). Following the scoping review protocol, we first determined the focus of the review to be centered on identifying research that approaches leishmaniases and CD from social science perspective and was indexed by large, biomedically focused databases. We then searched PubMed and Web of Science using "Leishmaniasis" and "Chagas disease" with "social science" or "anthropology" as search terms. We analyzed 199 articles (123 on leishmaniases and 76 on CD), categorizing them into three main research themes. Sociocultural dimensions of the diseases (leishmaniases=60.2 %; CD=68.4 %) primarily focused on individuals' knowledge, practices, and behaviors, barriers to accessing healthcare (especially in endemic regions), psychosocial effects, stigma, and traditional treatments. Research focused on socioeconomic dimensions of the diseases (leishmaniases=29.3 %; CD=19.7 %) included topics like household characteristics, social capital, and infrastructure access. A final theme, the historical and political contexts of the diseases (Leishmaniases=10.5 %; CD=11.9 %) was less common than other themes. Here, studies consider civil war and the (re)emergence of leishmaniasis, as well as the significance of CD discovery for scientific and public health in Brazil, which is the most common country for research on both leishmaniases and CD that draws on social science approaches. Future directions for research include focusing on how social institutions and economic factors shape diseases education, control measures, healthcare access, and quality of life of people affected by NTDs. Greater attention to social sciences can help mitigate and undo the ways that structural biases have infiltrated biomedicine.

Characterizing cutaneous leishmaniasis in a conflict-affected region: a study from North Waziristan, Pakistan

Background/aim

Cutaneous leishmaniasis is an emerging tropical disease that remains a serious public health issue in Pakistan, particularly in North Waziristan. The current research was carried out to investigate the presence of cutaneous leishmaniasis in this region.

Materials and methods

This prospective observational study was conducted from October 2018 to December 2020 at District Head Quarter Hospital Miranshah in North Waziristan with the collaboration of the Pathology Department of Gomal Medical College Dera Ismail Khan, Khyber Pakhtunkhwa. Needle aspirates were used for the microscopic Giemsa-stained slides. SPSS was used for data analysis.

Results

Of the 5406 clinically-suspected cases, 2603(48.2%) were positive by microscopic examination. Of these 2603 patients, 1474 (57%) were male and 1129 (43%) were female. Most of the lesions were on the face, followed by upper and lower limbs. The 5-10-year age group had the highest percentage of 1167 (45%). A single lesion affected 96.6% of the patients, while 2.7% had double lesions and 0.7% had triple lesions. A high number of cutaneous leishmaniasis were seen from April to August, while the lowest number was seen November to December.

Conclusion

This study provides extensive information in relation to the existence of cutaneous leishmaniasis in the North Waziristan district of Pakistan, as well as the detailed demographic features of those affected by the disease.

Impetiginous Cutaneous Leishmaniasis after COVID-19 Infection in a Patient with Poor Cardiac Profile: A Case Report and Literature Review

Cutaneous leishmaniasis incidence has been rising in the past couple of decades. Standard therapy often includes antileishmanial drugs; however, due to their low safety and toxicity threshold, alternative treatments are being investigated. The association between COVID-19 and cutaneous leishmaniasis remains unclear and exploring this connection may offer crucial insights into the pathophysiology of and treatment strategies for infected patients. In this article, we describe a case of a male patient with a history of cardiac and other comorbidities who presented with cutaneous leishmaniasis in the form of impetigo-like skin lesions after being infected with COVID-19. Due to the patient's poor cardiac profile, sodium stibogluconate was not used and an alternative therapeutic approach was employed. The patient was treated with oral terbinafine, cryotherapy on specific lesions, and a course of cephalexin. Following the course of treatment and subsequent follow-up, the patient exhibited complete resolution and healing of the lesions with scarring, and no active lesions or recurrence were observed. This case highlights the potential for alternative treatment strategies for cutaneous leishmaniasis in patients with comorbidities and emphasizes the importance of further research to better understand the link between COVID-19 and cutaneous leishmaniasis.

In vitro evaluation of herbal based Lesh Nat B cream against Leishmania tropica

Pentavalent antimonials continue to be the standard treatment for cutaneous leishmaniasis. But their use is retarded owing to highly-priced, prolonged hospitalization, noxious and poor solubility. Therefore, there is a dire need to characterize new potential compounds possessing anti-leishmanial activity. Topical therapies that are more successful are an essential alternative therapeutic option for the localized self-limiting form of this disease. We tested the herbal-based topical cream Lesh Nat B against Leishmania tropica KWH23 promastigotes and axenic amastigotes in vitro. The anti-leishmanial activity of Lesh Nat B cream was evaluated using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay against promastigotes and axenic amastigotes. The results of Lesh Nat B cream were concentration and incubation time-dependent. After 72 h of incubation, Lesh Nat B cream efficiently suppresses the promastigote form of the parasite, followed by 48 h and 24 h. At 72 h, the lowest and highest levels of activity were 37% and 90%. Amastigotes had a minimum activity of 34% and a maximum activity of 78.5%, respectively. This formulation was more cytotoxic against promastigote form than amastigotes form at 72 h incubation periods. All the experiments were carried out in triplicates. Half-maximal inhibitory concentration (IC50) values were determined to be (66 ug/ml) and (70 ug/ml) against promastigote and amastigote forms, respectively. Moreover, 1.63% hemolytic activity was observed in Lesh Nat B cream at (10 µg/ml) while 3% hemolytic activity was observed at (37 µg/ml). It can be concluded that Lesh Nat B cream demonstrated effective Leishmanicidal and less hemolytic activity and can be used as an alternative therapeutic option for the treatment of cutaneous leishmaniasis; however, more studies are expected to justify its effectiveness in treating cutaneous leishmaniasis in both humans and animals.

Self-reported depression and anxiety rates among females with cutaneous leishmaniasis in Hubuna, Saudi Arabia

Background

Cutaneous leishmaniasis (CL) is a parasitic disease transmitted through the bite of infected sandflies, causing disfiguring skin lesions and a range of physical symptoms. However, the psychological impact of CL is often overlooked despite the significant burden it imposes on the affected individuals and communities. This is especially true in Saudi Arabia, where limited research exists on the psychological consequences of CL, particularly among females. This study aimed to address this knowledge gap by investigating the perceived psychological problems associated with CL among females living in the Hubuna area of Saudi Arabia.

Methods

This cross-sectional study recruited 213 females with CL in the Hubuna area of Saudi Arabia using purposive sampling. Data was collected using a self-administered electronic questionnaire that included socio-demographic characteristics and measures of depression and anxiety using the BDI and GAD-7 tools. Descriptive analysis was used to determine the psychological impact of CL, including means and standard deviations for the BDI and GAD-7 scores, as well as frequencies and percentages for other variables of interest. Logistic regression was performed to identify independent predictors of anxiety and depression, including variables such as age, marital status, education, occupation, number and location of lesions. The significance level for all statistical tests was set at p < 0.05. The study was carried out between September and December of 2022.

Results

The study found that the mean Beck Depression Inventory (BDI) and Generalized Anxiety Disorder-7 (GAD-7) scores among the participants were 8.67 ± 4.82 out of 63 and 8.20 ± 7.08 out of 21, respectively. Furthermore, the prevalence of depression and anxiety was 55.9% and 68.1%, respectively, indicating a significant psychological burden associated with CL in the study population. The results of the logistic regression analysis showed that anxiety and depression were significantly associated with age, marital status, number of lesions, and location of the lesions on the body, highlighting the importance of considering these factors when designing interventions aimed at improving the mental health of CL patients.

Conclusions

In conclusion, this study highlights the significant psychological impact of CL among females in the Hubuna area of Saudi Arabia, calling for urgent action to address this neglected aspect of the disease. By integrating mental health considerations into CL prevention and management efforts, healthcare providers can improve the overall well-being of affected individuals and contribute to the broader goal of eliminating CL as a public health concern.

Versatile anti-infective properties of pyrido- and dihydropyrido[2,3-d]pyrimidine-based compounds

A series of 1H-indeno[2',1':5,6]dihydropyrido[2,3-d]pyrimidine and 1H-indeno[2',1':5,6]pyrido[2,3-d]pyrimidine derivatives was prepared and screened for antiparasitic and viral RNase H inhibitory activity. Several compounds showed considerable activity against Toxoplasma gondii parasites and Leishmania major amastigotes, which warrants further investigation. Based on the structural similarities of certain derivatives with common viral RNase H inhibitors, a HIV-1 RNase H assay was used to study the RNase H inhibition by selected test compounds. Docking of active derivatives into the active site of the HIV-1 RNase H enzyme was carried out. The new compound 2a, inactive in the antiparasitic tests, showed distinct HIV-1 RNase H inhibition. Thus, ring substitution determines antiparasitic or HIV-1 RNase H inhibitory activity of this promising compound class.

Evaluation of the Antiparasitic and Antifungal Activities of Synthetic Piperlongumine-Type Cinnamide Derivatives: Booster Effect by Halogen Substituents

A series of synthetic N-acylpyrrolidone and -piperidone derivatives of the natural alkaloid piperlongumine were prepared and tested for their activities against Leishmania major and Toxoplasma gondii parasites. Replacement of one of the aryl meta-methoxy groups by halogens such as chlorine, bromine and iodine led to distinctly increased antiparasitic activities. For instance, the new bromo- and iodo-substituted compounds 3 b/c and 4 b/c showed strong activity against L. major promastigotes (IC50 =4.5-5.8 μM). Their activities against L. major amastigotes were moderate. In addition, the new compounds 3 b, 3 c, and 4 a-c exhibited high activity against T. gondii parasites (IC50 =2.0-3.5 μM) with considerable selectivities when taking their effects on non-malignant Vero cells into account. Notable antitrypanosomal activity against Trypanosoma brucei was also found for 4 b. Antifungal activity against Madurella mycetomatis was observed for compound 4 c at higher doses. Quantitative structure-activity relationship (QSAR) studies were carried out, and docking calculations of test compounds bound to tubulin revealed binding differences between the 2-pyrrolidone and 2-piperidone derivatives. Microtubules-destabilizing effects were observed for 4 b in T. b. brucei cells.

Prevalence of cutaneous Leishmaniasis in the Middle East: a systematic review and meta-analysis

Cutaneous leishmaniasis (CL), caused by an obligate intracellular protozoan parasite from the genus Leishmania, imposing a significant burden on underdeveloped countries especially those located in the Middle East. Four electronic databases were searched to evaluate the prevalence of CL in the Middle East. The random effects model (95% confidence intervals (CI)) were applied to determine the overall and subgroup pooled prevalence. Heterogeneity was assessed by Cochran's Q test and I2 statistics. Among 2424 peer-reviewed papers, 37 datasets from 34 studies were included in the current meta-analysis. 285560 individuals were assessed across 9 Middle Eastern countries. The pooled prevalence of CL was estimated at 12% (95% CI 9-15 %; 10718/285560). The highest prevalence rate was observed in Syria (39%, 37-42%), and the lowest one was found in Iraq and Lebanon (0%, 0-1%). The prevalence of CL in studies that applied LST assays had the highest rate (48%, 17-80%). The infection rate in males was similar to females (7%, 4-10%). The prevalence of infection in individuals living in urban areas was higher than in rural areas (14%, 10-19%). The prevalence of CL in the age group 0-15 years was higher than in individuals 16-40 and >40 years (9%, 6-13%). Most of the lesions were found on the face, and single lesions were more prevalent than two and three ones. In conclusion, the occurrence of CL was considerable in Middle Eastern countries. Therefore, more efforts should be made to precisely report the CL in this region for developing appropriate preventive and controlling strategies.  .

Distribution and Risk of Cutaneous Leishmaniasis in Khyber Pakhtunkhwa, Pakistan

Cutaneous leishmaniasis (CL) is a zoonotic infection caused by obligate intracellular protozoa of the genus Leishmania. This study aimed to investigate CL in Khyber Pakhtunkhwa, Pakistan and to estimate the risk of epidemics. Clinico-epidemiological data of 3188 CL patients were collected from health facilities in 2021. Risk factors were analyzed using the chi-square test. ArcGIS V.10.7.1 was applied for spatial analysis. The association between CL occurrence and climatic variables was examined by Bayesian geostatistical analysis. The clinical data revealed males or individuals younger than 20 years old were more affected. Most patients presented with a single lesion, and the face was the most attacked body part. CL was prevalent in the southern region in winter. A proportional symbol map, a choropleth map, and a digital elevation model map were built to show the distribution of CL. Focal transmission was predicted by inverse distance weighting interpolation. Cluster and outlier analysis identified clusters in Bannu, Dir Lower, and Mardan, and hotspot analysis suggested Bannu as a high-risk foci. Bayesian geostatistical analysis indicated that increasing precipitation and temperature as well as low altitudes were associated with CL infection. The study has provided important information for public health sectors to develop intervention strategies for future CL epidemics.

Antiparasitic Activity of Fluorophenyl-Substituted Pyrimido[1,2-a]benzimidazoles

A series of fourteen pyrimido[1,2-a]benzimidazole compounds was prepared by straightforward heterocyclic chemistry and oxidation methods. The new pyrimidobenzimidazole derivative 2a with a 3-fluorophenyl substituent was identified as a new antiparasitic compound showing excellent activities against Leishmania major parasites. 2a was highly active against L. major promastigotes and amastigotes with EC₅₀ values in the nanomolar concentration range. Compound 3b was less active than 2a against L. major, but more active against Toxoplasma gondii with considerable selectivity. Hence, two promising and selective antiparasitic drug candidates 2a and 3b for the treatment of two parasitic diseases were identified, which can be prepared by green chemistry methods using simple one-pot reactions and oxidation procedures, respectively.

Exploring the cultural effects of gender on perceptions of cutaneous leishmaniasis: a systematic literature review

BACKGROUND

More than one million people each year become infected by parasites that cause the disease cutaneous leishmaniasis (CL). This disease manifests as one or more skin lesions or ulcers that are slow to heal with variable response rates to drug treatments. Thus far, little attention has been paid to how the cultural effects of gender shape perceptions and experiences of CL. This review aims to bring together and analyse existing studies which use qualitative data to explore these differences. These studies offered insights into our specific research questions.

METHODS

We conducted a systematic review of the literature pertaining to either CL or muco-cutaneous leishmaniasis (MCL) through EBSCO, EMBASE, Medline, Scopus and Web of Science databases. To meet inclusion criteria, articles had to be either qualitative or mixed-method with a qualitative component. They also had to include a reflection on how the gender of participants impacted the findings and addressed the lived experiences of CL. We did not exclude articles based on the language they were published in or in which country the study took place.

RESULTS

From a total of 1589 potential articles, we found that thirteen met the inclusion criteria. These articles were published in English, Spanish or Portuguese and reported on studies carried out in various countries in Africa, Asia and South America. After using the principles of a meta-ethnography to analyse these studies, we generated several key themes. We found that health-seeking behaviours, treatment choices, stigma and the impact of scarring are shaped by gender in a variety of contexts.

CONCLUSIONS

Gender impacts on an individual's experience of CL. In particular, women are more constricted in their health-seeking behaviours and experience more stigma both from the active lesions and from scarring than men. In many contexts, however, men are more at risk of becoming infected by the parasite that causes CL and may turn to more harmful or aggressive self-treatments. We recommend that future research on CL should consider the impact of gender as this can create very different experiences for individuals.

Potential of Triterpenic Natural Compound Betulinic Acid for Neglected Tropical Diseases New Treatments

Neglected tropical diseases are one of the most important public health problems in many countries around the world. Among them are leishmaniasis, Chagas disease, and malaria, which contribute to more than 250 million infections worldwide. There is no validated vaccine to prevent these infections and the treatments available are obsolete, highly toxic, and non-effective due to parasitic drug resistance. Additionally, there is a high incidence of these diseases, and they may require hospitalization, which is expensive to the public health systems. Therefore, there is an urgent need to develop new treatments to improve the management of infected people, control the spread of resistant strains, and reduce health costs. Betulinic acid (BA) is a triterpene natural product which has shown antiparasitic activity against Leishmania, Trypanosoma cruzi, and Plasmodium. Here, we review the main results regarding the in vitro and in vivo pharmacological activity of BA and its derivatives against these parasites. Some chemical modifications of BA have been shown to improve its activities against the parasites. Further improvement on studies of drug-derived, as well as structure–activity relationship, are necessary for the development of new betulinic acid-based treatments.

Positivity, diagnosis and treatment follow-up of cutaneous leishmaniasis in war-affected areas of Bajaur, Pakistan

This study was conducted to explore the frequency of positivity of cutaneous leishmaniasis (CL) in the tribal district Bajaur located near the Pak-Afghan border. The present study was conducted at the Leishmaniasis Center of Headquarter Hospital Khar District Bajaur, Pakistan. In total, 646 patients were recruited and included in the study after ethical approval and consent from the patients. CL was confirmed by taking blood samples from the sides of the lesion and observing them under a microscope using Giemsa staining. Information about demographic factors was collected from the study participants with a questionnaire and analyzed by SPSS. It was found that 73.8% of suspected patients were positive and 26.2% were negative for CL. There were 51.9% male and 48.1% female patients. The most frequently affected site was the face (42.6%), and most of the patients (85.8%) had only one lesion. The positivity of CL was higher among those under age 15 years. The area of most positivity, with 45.2% of the cases, was Tehsil Mamund. Most of the patients (46.6%) lived in stone houses, with 98.6% of patients having domestic animals in their houses. Approximately 198 patients were treated with intramuscular and intralesional injections of meglumine antimoniate, and their weekly follow-up revealed that 48% of patients recovered, while the remaining patients left the course of treatment at different stages of therapy. The positivity of CL is high in this area and is confirmed by the detection of Leishmania amastigotes in the blood collected from their lesions. Socioeconomic factors are the main underlying causes of the rapid spread of this disease and meglumine antimoniate is an effective drug.

Diagnosis of visceral and cutaneous leishmaniasis using loop-mediated isothermal amplification (LAMP) protocols: a systematic review and meta-analysis

Sensitive, reliable and fast diagnostic tools that are applicable in low-resource settings, at the point of care (PoC), are seen as crucial in the fight against visceral leishmaniasis (VL) and cutaneous leishmaniasis (CL). Addressing the need for a PoC test, several diagnostic tests, including serological and molecular methods, have been developed and evaluated in the past. One promising molecular method, already implemented for diagnosis of a range of diseases, is the loop-mediated isothermal amplification (LAMP) protocol. In this systematic review and meta-analysis, using a comprehensive search strategy, we focus on studies evaluating the performance of LAMP for the diagnosis of leishmaniasis in humans and other mammals such as dogs, compared with microscopy and/or any other molecular diagnostic method. A meta-analysis, pooling sensitivity and specificity rates and calculating areas under the curve (AUCs) in summary receiver operating characteristic (SROC) plots, was conducted on datasets extracted from studies, grouped by clinical condition and sample type. We found high sensitivity and specificity for LAMP when compared with microscopy and PCR using blood samples, with pooled estimate values of > 90% for all subgroups, corresponding to calculated AUC values > 0.96, except for LAMP compared to microscopy for diagnosis of CL. However, only a limited number of studies were truly comparable. Most of the observed heterogeneity is likely based on true differences between the studies rather than sampling error only. Due to simple readout methods and low laboratory equipment requirements for sample preparation compared to other molecular methods, LAMP is a promising candidate for a molecular (near-)PoC diagnostic method for VL and CL.

Photodynamic therapy for leishmaniasis: Recent advances and future trends

Leishmaniasis has infected more than 12 million people worldwide. This neglected tropical disease, causing 20,000-30,000 deaths per year, is a global health problem. The emergence of resistant parasites and serious side effects of conventional therapies has led to the search for less toxic and non-invasive alternative treatments. Photodynamic therapy is a promising therapeutic strategy to produce reactive oxygen species for the treatment of leishmaniasis. In this regard, natural and synthetic photosensitizers such as curcumin, hypericin, 5-aminolevulinic acid, phthalocyanines, phenothiazines, porphyrins, chlorins and nanoparticles have been applied. In this review, the recent advances on using photodynamic therapy for treating Leishmania species have been reviewed.

Clinical diversity and treatment results in Tegumentary Leishmaniasis: A European clinical report in 459 patients

BACKGROUND

Cutaneous leishmaniasis (CL) is frequent in travellers and can involve oro-nasal mucosae. Clinical presentation impacts therapeutic management.

METHODOLOGY

Demographic and clinical data from 459 travellers infected in 47 different countries were collected by members of the European LeishMan consortium. The infecting Leishmania species was identified in 198 patients.

PRINCIPAL FINDINGS

Compared to Old World CL, New World CL was more frequently ulcerative (75% vs 47%), larger (3 vs 2cm), less frequently facial (17% vs 38%) and less frequently associated with mucosal involvement (2.7% vs 5.3%). Patients with mucosal lesions were older (58 vs 30 years) and more frequently immunocompromised (37% vs 3.5%) compared to patients with only skin lesions. Young adults infected in Latin America with L. braziliensis or L. guyanensis complex typically had an ulcer of the lower limbs with mucosal involvement in 5.8% of cases. Typically, infections with L. major and L. tropica acquired in Africa or the Middle East were not associated with mucosal lesions, while infections with L. infantum, acquired in Southern Europe resulted in slowly evolving facial lesions with mucosal involvement in 22% of cases. Local or systemic treatments were used in patients with different clinical presentations but resulted in similarly high cure rates (89% vs 86%).

CONCLUSION/SIGNIFICANCE

CL acquired in L. infantum-endemic European and Mediterranean areas displays unexpected high rates of mucosal involvement comparable to those of CL acquired in Latin America, especially in immunocompromised patients. When used as per recommendations, local therapy is associated with high cure rates.

Characterization of sand fly breeding sites in district Malakand, Khyber Pakhtunkhwa, Pakistan, and evaluation of risk factors for cutaneous leishmaniasis in the region

Present study was carried to determine the sand fly species composition, breeding sites ecology, seasonal abundance, and spatial distribution in district Malakand, Khyber Pakhtunkhwa, Pakistan. In addition, risk factors associated with cutaneous leishmaniasis (CL) were also evaluated. Survey of indoor and outdoor habitats was carried out using sticky traps in 31 villages of Dargai and Batkhela tehsils of Malakand. Soil from habitats of adult and immature sand flies was analysed. Questionnaire-based household survey was also performed in these villages to assess risk factors associated with CL. Soil samples from selected CL positive households were analysed for its contents. Additionally, clinicoepidemiological data from local health centres was examined for the year 2019. Total of 3,140 sand flies belonging to 18 species were collected. Phlebotomus sergenti was the most abundant species (38.16%). Its abundance had a strong positive correlation with mean monthly relative humidity and negative correlation with average temperature. Phlebotomus sergenti and Phlebotomus papatasi were abundant at an elevation ranging from 320 to 1,120 m above sea level and in agricultural lands near human settlements. Flight height preference apparatus collected maximum sand flies at 30 cm (1ft) above the ground and all species associated negatively with height. Soil analysis from habitats of adult and immature flies showed that highest mean number of adults and immatures were recorded from silt loam which carried highest concentrations of K₂ O, Mg, Ca, and Zn. Number of immature sand flies correlated moderately (r = .7, p < .05) with K₂ O soil concentrations. There was significant similarity between organic matter contents in soil samples from positive breeding sites and CL households (Wilcoxon rank-sum test, p = .1976). In multivariate analysis model for CL risk factors, age (26-35 and >35 years), knowledge of leishmaniasis, living in a middle and upper class, preachers visit to villages, and assumption that Afghan refugees are more prone to CL were significant. CL patient's archived data from health centres showed that majority of patients had lesions on face and hands. Patient's influx was highest in February and March.

Molecular characterization and genetic diversity of cutaneous leishmaniasis from North Eastern Pakistan

The genetic diversity of Leishmania spp. in North Eastern Pakistan remains undetermined despite increased cases of cutaneous leishmaniasis (CL). This study was designed to decipher the molecular characterization and genetic diversity of Leishmania spp. in North Eastern Pakistan. Out of 13761 CL suspected cases, 567 cases were microscopically positive and confirmed as Leishmania spp. by internal transcribed spacer (ITS) gene amplification through the PCR- RFLP technique. Further, isolates were directly sequenced to conduct phylogenetic analysis for genetic diversity. Among suspected CL cases, Mirpur showed the highest proportion of CL infection with 4.85% (118/2431) of the cases, while the Neelum district showed the lowest percentage at 3.29% (9/273). The slide positivity rate, annual blood examination rate, and annual parasite incidence rate were 3.84, 0.27, and 0.01% respectively, and the incidence of CL in the age group 1-20 years old was higher in males (50.92%) than females (25.75%). The RFLP analysis and sequencing confirmed the occurrence of Leishmania tropica, Leishmania major, and Leishmania infantum. Leishmania tropica (p = 0.02) confirmed significantly higher nucleotides variation than L. major (p = 0.05). Current findings confirmed the prior assumption that anthroponotic CL is the primary CL form present in North Eastern Pakistan. Moreover, this is the first report based on molecular identification of L. major, and L. infantum from North Eastern Pakistan. This remarkable heterogeneity in the Leishmania spp. is the leading cause of treatment failure and emergence of new haplotypes. Therefore more extensive investigations are recommended from all geographical regions of North Eastern Pakistan, especially those using a large sample size.

SYSTEMATIC REVIEW OF LEISHMANIASIS IN PAKISTAN: EVALUATING SPATIAL DISTRIBUTION AND RISK FACTORS

Both cutaneous (zoonotic cutaneous leishmaniasis [ZCL] and anthroponotic cutaneous leishmaniasis [ACL]) and visceral leishmaniasis (VL) are prevalent in Pakistan, although the cutaneous form is comparatively more widespread. The present study aimed to spatially map different forms of leishmaniasis in Pakistan. In addition, the risk for acquiring leishmaniasis was assessed in different locations of the country. Previously published literature on leishmaniasis distribution and associated risk factors in Pakistan was obtained from PubMed/NCBI and GoogleScholar using specific keywords. Further, 50 articles that focused on geographical distribution and risk factors of the disease in Pakistan were obtained and systematically reviewed. Data regarding location (used in ArcGIS for spatial analysis), number of cases, and risk factors were identified. The present study revealed a high burden of cutaneous leishmaniasis in the northern and western foci of Pakistan. Leishmania major, chiefly a causative agent of ZCL, was observed to be prevalent in the arid and semi-arid climatic zones of the country with elevations between 45 and 2,837 m (maximum number at low elevation). Leishmania tropica cases, associated with ACL, were recorded at elevations ranging from 551 to 2,837 m (majority cases at high elevation). Visceral leishmaniasis (VL) (reportedly caused by Leishmania infantum) was sporadically distributed in the northern areas at elevations 1,432-2,873 m. For VL, particularly, mountainous communities, farming communities, and the presence of dogs were the most commonly reported risk factors. On the other hand, poor preventive measures, migration, presence of domesticated animals, presence of cattle dung, living in mud houses, and outdoor sleeping habits were the principal risk factors associated with cutaneous leishmaniasis (CL). This investigation can guide the health experts and medical entomologists toward targeted and cost-effective surveillance and control of leishmaniasis in Pakistan.

Activity of Fluorinated Curcuminoids against Leishmania major and Toxoplasma gondii Parasites

A new 3,4-difluorobenzylidene analog of curcumin, CDF, was recently reported, which demonstrated significantly enhanced bioavailability and in vivo anticancer activity compared with curcumin. For highlighting the antiparasitic behavior of CDF, we tested this compound together with its new O-methylated analog MeCDF against Leishmania major and Toxoplasma gondii parasites. Both CDF and MeCDF were tested in vitro against L. major and T. gondii. In addition, the in vitro cytotoxicity against Vero cells and macrophages was determined and selectivity indices were calculated. The DPPH radical scavenging activity assay was carried out in order to determine the antioxidant activity of the test compounds. Both compounds showed high activities against both parasite forms with EC₅₀ values in the (sub-)micromolar range (0.35 to 0.8 μM for CDF, 0.31 to 1.2 μM for MeCDF). The higher activity of CDF against L. major amastigotes when compared with MeCDF can in parts be attributed to the antioxidant activity of CDF while MeCDF lacking any antioxidant activity was more active than CDF against T. gondii parasites. In conclusion, CDF and MeCDF are promising antiparasitic drug candidates due to their high activities against L. major and T. gondii parasites.

Cutaneous Leishmaniasis in Pakistan: a neglected disease needing one health strategy

Background

Cutaneous Leishmaniasis (CL) is a neglected tropical disease, which mainly affects poor communities. It is one of the major vector-borne disease and endemic in Pakistan.

Methods

A case-control study to evaluate potential risk factors of human-CL was conducted in Khewra region, District Jhelum, Pakistan from January–April 2014. Case data about 90 cases registered during October 2012 to November 2013 was retrieved from Municipal Hospital. Controls were matched (1,1 ratio) on the date of registration with cases from same hospital. Both cases and controls were invited to participate and data was collected in a face-to-face interview. A prospective study of canine leishmaniasis (canine-CL) was also conducted at Civil Veterinary Hospital in the same area. Suspected dogs with skin ulceration signs were included in the study and blood samples were collected. Statistical analyses were conducted to determine association between various parameters and outcome of interest.

Results

The ages of cases ranged from 1 to 76 years (median = 15 years) and proved to be protective factor i.e. increase in each year in age reduced the likelihood of being infected with human-CL [Odds Ratio (OR) = 0.4, 95% Confidence Interval (CI) = 0.25–0.76]. People sleeping outsides in an open area were more likely to become a case (OR = 8.7, 95% CI = 2.90–26.37) than a control. Poor sanitary condition inside the house (OR = 3.3, 95% CI 1.03–10.56) and presence of other animals in house (livestock, poultry) (OR = 3.6, 95% CI = 1.07–12.12) also identified as risk factors of high significance. The proportion of positive dogs with canine-CL was 21.05% and was significantly associated with human-CL cases in the same area (p < 0.05).

Conclusions

We concluded that adopting self-protections measures against sand-fly, and maintaining good hygiene may lower the risk of human-CL. One-Health Strategy is suggested to control leishmaniasis in human and dog population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06327-w.

Vulnerabilities to and the Socioeconomic and Psychosocial Impacts of the Leishmaniases: A Review

The leishmaniases are a group of four vector-borne neglected tropical diseases (NTDs) with 1.6 billion people in some 100 countries at risk. They occur in certain eco-epidemiological foci that reflect manipulation by human activities, such as migration, urbanization and deforestation, of which poverty, conflict and climate change are key drivers. Given their synergistic impacts, risk factors and the vulnerabilities of poor populations and the launch of a new 2030 roadmap for NTDs in the context of the global sustainability agenda, it is warranted to update the state of knowledge of the leishmaniases and their effects. Using existing literature, we review socioeconomic and psychosocial impacts of leishmaniasis within a framework of risk factors and vulnerabilities to help inform policy interventions. Studies show that poverty is an overarching primary risk factor. Low-income status fosters inadequate housing, malnutrition and lack of sanitation, which create and exacerbate complexities in access to care and treatment outcomes as well as education and awareness. The co-occurrence of the leishmaniases with malnutrition and HIV infection further complicate diagnosis and treatment, leading to poor diagnostic outcomes and therapeutic response. Even with free treatment, households may suffer catastrophic health expenditure from direct and indirect medical costs, which compounds existing financial strain in low-income communities for households and healthcare systems. The dermatological presentations of the leishmaniases may result in long-term severe disfigurement, leading to stigmatization, reduced quality of life, discrimination and mental health issues. A substantial amount of recent literature points to the vulnerability pathways and burden of leishmaniasis on women, in particular, who disproportionately suffer from these impacts. These emerging foci demonstrate a need for continued international efforts to address key risk factors and population vulnerabilities if leishmaniasis control, and ultimately elimination, is to be achieved by 2030.

p-Trifluoromethyl- and p-pentafluorothio-substituted curcuminoids of the 2,6-di[(E)-benzylidene)]cycloalkanone type: Syntheses and activities against Leishmania major and Toxoplasma gondii parasites

A series of the title curcuminoids with structural variance in the heteroatom of the cycloalkanone and the p-substituents of the phenyl rings were tested for their activities against Leishmania major and Toxoplasma gondii parasites. The majority of them showed high activities against both parasite forms with EC₅₀ values in the sub-micromolar concentration range. Bis(p-pentafluorothio)-substituted 3,5-di[(E)-benzylidene]piperidin-4-one 1b was not just noticeable antiparasitic, but also exhibited a considerable selectivity for L. major promastigotes over normal Vero cells. While derivatives differing only in the p-phenyl substituents being CF₃ or SF₅ showed similar antiparasitic activities, the cyclic ketone hub was more decisive both for the anti-parasitic activities and the selectivities for the parasites vs. normal cells. QSAR calculations confirmed the observed structure-activity relations and suggested structural variations for a further improvement of the antiparasitic activity. Docking studies based on DFT calculations revealed L. major pteridine reductase 1 as a likely molecular target protein of the title compounds.

Epidemiological and pathological characteristics of Cutaneous Leishmaniasis from Baluchistan Province of Pakistan

Cutaneous Leishmaniasis (CL) is considered a neglected tropical disease which in Pakistan can now be considered as a growing public health problem. The exact figures on the magnitude of the disease are lacking both at the national and regional level and only a few health centres are available for diagnosis of CL. The present study was designed to identify the epidemiology of CL infection from August 2018 to December 2019 and to assess clinical aspects of CL in Baluchistan Province of Pakistan. A total of 4072 clinically suspected CL cases were analysed statistically. The highest number of CL cases were reported in May, followed by April, January and then July, February and June and the lowest number of cases were observed in March and November. The highest prevalence rate was found in males where 38% of reported cases were aged 0-9 years. The majority (24.4%) of lesions were found on the hands followed by the face in which cheeks, ears and nose were the effected organs. About 50% of the participants have single lesion while 14% of the participants had two and nearly 3% of the participants have six lesions. The atypical clinical presentations were observed in Baluchistan and common unusual presentations were lupus erythematosus. The study findings suggest that more epidemiological studies and health education campaigns are needed for the population awareness regarding CL in Baluchistan. It is recommended that risk factors should be evaluated to establish control and management strategies to prevent disease at the individual and community level.

Unveiling the Targets Involved in the Quest of Antileishmanial Leads Using In silico Methods

BACKGROUND

Leishmaniasis is a neglected tropical disease associated with several clinical manifestations, including cutaneous, mucocutaneous, and visceral forms. As currently available drugs have some limitations (toxicity, resistance, among others), the target-based identification has been an important approach to develop new leads against leishmaniasis. The present study aims to identify targets involved in the pharmacological action of potent antileishmanial compounds.

METHODS

The literature information regarding molecular interactions of antileishmanial compounds studied over the past half-decade is discussed. The information was obtained from databases such as Wiley, SciFinder, Science Direct, National Library of Medicine, American Chemical Society, Scientific Electronic Library Online, Scopus, Springer, Google Scholar, Web of Science, etc. Results: Numerous in vitro antileishmanial compounds showed affinity and selective interactions with enzymes such as arginase, pteridine reductase 1, trypanothione reductase, pyruvate kinase, among others, which are crucial for the survival and virulence of the Leishmania parasite.

CONCLUSION

The in-silico activity of small molecules (enzymes, proteins, among others) might be used as pharmacological tools to develop candidate compounds for the treatment of leishmaniasis. As some pharmacologically active compounds may act on more than one target, additional studies of the mechanism (s) of action of potent antileishmanial compounds might help to better understand their pharmacological action. Also, the optimization of promising antileishmanial compounds might improve their biological activity.

Effectiveness of miltefosine in cutaneous leishmaniasis caused by Leishmania tropica in Pakistan after antimonial treatment failure or contraindications to first line therapy-A retrospective analysis

Background

Cutaneous leishmaniasis (CL) is a neglected tropical skin disease, caused by Leishmania protozoa. In Pakistan, where CL caused by L. tropica is highly endemic, therapy with pentavalent antimonials is the standard of care, but has significant toxicity when used in systemic therapy, while are no evidence-based safer alternative treatment options for L. tropica. The efficacy of oral miltefosine has not been studied in CL caused by L. tropica. We evaluated effectiveness and tolerability of miltefosine in patients with previous treatment failure or with contraindications to systemic antimonial treatment.

Methods

A retrospective review was conducted of a cohort of CL patients who were treated with a 28-day course of miltefosine between December 2017 and August 2019, in urban Quetta, Pakistan, an area endemic for L. tropica. Descriptive analyses were performed, and effectiveness was assessed by initial response after treatment, and final cure at routine follow up visits, six weeks to three months post-treatment. Tolerability was assessed by routinely reported adverse events.

Results

Of the 76 CL patients in the cohort, 42 (55%) had contraindications to systemic antimonial treatment, and 34 (45%) had failure or relapse after antimonial treatment. Twelve patients defaulted during treatment and 12 patients were lost to follow up. In the remaining 52 patients, final cure rate was 77% (40/52). In those with contraindications to systemic antimonial treatment the final cure rate was 83% (24/29) and in the failure and relapse group 70% (16/23). Twenty-eight patients (40.0%) reported 39 mild to moderate adverse events with the main complaints being nausea (41.0%), general malaise (25.6%), and stomach pain (12.8%).

Conclusion

Results indicate that miltefosine is an effective second line treatment in CL in areas endemic for L. tropica. Prospective studies with systematic follow up are needed to obtain definitive evidence of effectiveness and tolerability, including identification of risk factors for miltefosine treatment failure.

Cutaneous Leishmaniasis (CL) is a neglected tropical skin disease, which globally affects an estimated 0.6 to 1 million people. The skin disease is caused by the protozoa Leishmania and is transmitted by phlebotomine sandflies in Old World CL (OWCL). In Pakistan, CL is highly endemic, especially in the provinces Balochistan and Khyber Pashtunkwa, where L. tropica is the main causative species. In this context, untreated CL often leads to stigmatisation and severe (psycho)social suffering, due to the disfiguring ulcerating wounds and scars. The mainstay treatment is with pentavalent antimonials, and evidence for efficacy of alternative treatments for L. tropica is lacking. Médecins sans Frontières (MSF) has specialised treatment centres in Balochistan (Quetta and Kuchlak), where in December 2017 miltefosine was introduced for patients who did not respond to, or had contraindications for antimonials. In this study, we showed favourable outcomes of miltefosine as second-line treatment for these CL patients.

Psychosocial burden of neglected tropical diseases in eastern Colombia: an explorative qualitative study in persons affected by leprosy, cutaneous leishmaniasis and Chagas disease

BACKGROUND

Leprosy, cutaneous leishmaniasis (CL) and Chagas disease (CD) are neglected tropical diseases (NTDs) with a high psychosocial burden in Norte de Santander and Arauca in Colombia. This study provides insights into affected persons' feelings, perceptions and experiences to better understand the nature of this burden.

METHODS

In 2018, 34 leprosy, CD and CL patients participated in four focus groups discussing the influence of the disease on mental well-being, social participation and stigma. Additionally, 13 leprosy patients participated in semi-structured interviews to further explore the health-related stigma related to this disease. Audio recordings were transcribed verbatim, and open coding was used to identify the most relevant categories and themes.

RESULTS

Persons suffering from CD reported that their mental distress was mainly caused by impairments and stress related to the progressive and incurable nature of the disease. Persons affected by CL perceived the treatment for the disease as having the most impact on their psychosocial well-being. Persons affected by leprosy reported suffering most from anticipated and experienced stigma.

CONCLUSIONS

The findings indicate that these diseases are likely to impose a significant psychosocial burden on patients in the studied regions, even though these vary per condition. Consistent data collection on the psychosocial burden and the sharing of knowledge of effective interventions can contribute to the holistic approach needed to win the fight against NTDs.

Psycho-social impacts, experiences and perspectives of patients with Cutaneous Leishmaniasis regarding treatment options and case management: An exploratory qualitative study in Tunisia

Although non-fatal and mostly self-healing in the case of Leishmania (L.) major, cutaneous leishmaniasis (CL) is mainly treated to reduce lesion healing time. Less attention is paid to the improvement of scars, especially in aesthetically relevant areas of the body, which can dramatically affect patients' wellbeing. We explored patients' perspectives about treatment options and the social and psychological burden of disease (lesion and scar). Individual in-depth interviews were conducted with ten confirmed CL patients at two L. major endemic sites in Southern Tunisia (Sidi Bouzid and Gafsa). Participants were selected using a sampling approach along a spectrum covering e.g. age, sex, and clinical presentation. Patients' experiences, opinions and preferences were explored, and their detailed accounts gave an insight on the impact of CL on their everyday lives. The impact of CL was found to be considerable. Most patients were not satisfied with treatment performance and case management. They expected a shorter healing time and better accessibility of the health system. Tolerance of the burden of disease was variable and ranged from acceptance of hidden scars to suicidal thoughts resulting from the fear to become handicapped, and the stress caused by close relatives. Some believed CL to be a form of skin cancer. Unexpectedly, this finding shows the big gap between the perspectives of patients and assumptions of health professionals regarding this disease. This study provided valuable information for better case management emphasizing the importance of improving communication with patients, and accessibility to treatment. It generated context-specific knowledge to policy makers in Tunisia to implement effective case management in a country where access to treatment remains a challenge due to socio-economic and geographic barriers despite a long tradition in CL control.

New Pyrano-4H-benzo[g]chromene-5,10-diones with Antiparasitic and Antioxidant Activities

New pyranonaphthoquinone derivatives were synthesized and investigated for their activity against Trypanosoma brucei, Leishmania major, and Toxoplasma gondii parasites. The pentafluorophenyl derivative was efficacious against T. brucei with single digit micromolar EC₅₀ values and against T. gondii with even sub-micromolar values. The 3-chloro-4,5-dimethoxyphenyl derivative showed an activity against amastigotes of Leishmania major parasites comparable to that of amphotericin B. In addition, antioxidant activities were observed for the bromophenyl derivatives, and their redox behavior was studied by cyclovoltammetry. Anti-parasitic and antioxidative activities of the new naphthoquinone derivatives appear uncorrelated.

Cutaneous leishmaniasis in refugees from Syria: complex cases in Berlin 2015-2020

BACKGROUND

The Syrian conflict has led to a dramatic increase of Old World cutaneous leishmaniasis (CL), triggered by continuous population displacements, disrupted control programmes, poor shelter and sanitation.

METHODS

A retrospective patient record study was conducted at the Institute of Tropical Medicine and International Health in Berlin. Records of all refugees from Syria treated for CL between January 2015 and March 2020 were reviewed.

RESULTS

Twenty refugees from Syria were treated. Seventeen refugees (85%) had complex lesions, mainly due to previous therapy failure or localization on the face. A long disease duration (50% > 1 year), pronounced facial scarring (20%), recurrences (20%), or worsening of existing lesions (20%) were observed. Nine patients (45%) had been pretreated in Syria. Complete remission was achieved in 10 of 16 patients (63%) treated with perilesional antimony. Eight patients (40%) required systemic treatment, thereof four (20%) repeated systemic treatment. Eight patients (40%) reported a delay of therapy ≥3 months in Germany, thereof one patient with a delay of 12 months and one patient with a delay of 32 months.

CONCLUSION

Between 2015 and 2020, Syrian refugees presented with severe morbidities of CL frequently requiring systemic and even consecutive systemic treatments. We assume a combination of socioeconomic and environmental factors associated with the ongoing Syrian conflict and migration to be responsible for the complex clinical presentations in this case series. More attention should be drawn to the situation of Syrian refugees with CL in countries where they are displaced to.

Body location of "New World" cutaneous leishmaniasis lesions and its impact on the quality of life of patients in Suriname

Cutaneous leishmaniasis (CL) is a chronic skin infection caused by Leishmania parasites, causing single or multiple skin nodules and ulcers on the exposed body locations. Healing of lesions is followed by scar formation. Active and healed CL lesions may affect patient's health related quality of life (HRQL). The aim of this study was to determine whether the body location of the leishmaniasis lesions affects the HRQL of localized CL patients in Suriname. The HRQL of 163 patients with CL was assessed by Skindex-29 and EQ-5D/VAS questionnaires. Forty-six patients out of the total study population also participated in a qualitative anthropological study involving in depth interviews. All patients were allocated in 4 groups in the following hierarchy: head and face, upper limbs, lower limbs and trunk. Patients with lesions on the lower limbs had significantly higher Skindex-29 scores, indicating worse HRQL, in the symptom scale compared to lesions on head/face and trunk. The lower limb group was more likely to report problems in the dimensions self-care, mobility, daily activities and pain/discomfort of the EQ-5D. Little to no social stigma was reported in the in-depth interviews. The findings of this study indicate that Surinamese patients with CL lesions located on the lower limbs had more impairment in HRQL than on other body locations. Stigma related to CL seems to be virtually absent in Suriname.

Recent advances and new strategies on leishmaniasis treatment

Leishmaniasis is one of the most important tropical neglected diseases according to the World Health Organization. Even after more than a century, we still have few drugs for the disease therapy and their great toxicity and side effects put in check the treatment control program around the world. Moreover, the emergence of strains resistant to conventional drugs, co-infections such as HIV/Leishmania spp., the small therapeutic arsenal (pentavalent antimonials, amphotericin B and formulations, and miltefosine), and the low investment for the discovery/development of new drugs force researchers and world health agencies to seek new strategies to combat and control this important neglected disease. In this context, the aim of this review is to summarize new advances and new strategies used on leishmaniasis therapy addressing alternative and innovative treatment paths such as physical and local/topical therapies, combination or multi-drug uses, immunomodulation, drug repurposing, and the nanotechnology-based drug delivery systems.Key points• The treatment of leishmaniasis is a challenge for global health agencies.• Toxicity, side effects, reduced therapeutic arsenal, and drug resistance are the main problems.• New strategies and recent advances on leishmaniasis treatment are urgent.• Immunomodulators, nanotechnology, and drug repurposing are the future of leishmaniasis treatment.

Epidemiological features of cutaneous leishmaniasis endemic in hilly areas of district Karak, Khyber-Pakhtunkhwa province of Pakistan

Cutaneous leishmaniasis is a vector borne infection caused by flagellated parasitic protozoans of the genus Leishmania. This is an emergent threat and endemic in areas of tropic and sub-tropics and has a wider geographical distribution. This study was aimed to find the epidemiological aspects of cutaneous leishmaniasis during the recent epidemic in district Karak in 2018-2019. The suspected patients of leishmaniasis from different areas of district Karak were examined. We came across 803 cases during six-month period from August 2018 to January 2019. A major portion (> 37%; n = 299) of these patients were in age 11-20 years. The infection rate was higher in female (55.3%; n = 803) compared to males (44.6%; n = 803). Both gender and age showed a significant effect on the occurrence of infection. It is concluded that cutaneous leishmaniasis has appeared as a major health issue in district Karak. The current study report CL outbreak in Karak district which need immediate response from the healthcare authorities. In addition, extensive awareness campaigns are needed for timely prevention of such outbreaks.

Why does leishmaniasis result in life-long scars for women in Afghanistan?

OBJECTIVES

The main purpose of this study was to explore the reasons behind the late presentation of female patients with leishmaniasis to the clinic.

STUDY DESIGN

A descriptive study design and qualitative method were used in this study.

METHODS

For information generation, two focus group discussions and three in-depth interviews were conducted with healthcare providers.

RESULTS

Many factors, including socio-economic status, lack of knowledge about the disease (i.e. signs and symptoms, transmission, prevention and treatment), the use of traditional or local treatment methods and lack of female healthcare providers, contribute to the late presentation of patients with leishmaniasis to the clinic. This late presentation of patients with leishmaniasis, especially in women, can result in damage to the body tissue, resulting in life-long scars that carry social stigmas.

CONCLUSIONS

Leishmaniasis can result in life-long scars if it is not timely diagnosed and treated. As a result of the scars being highly stigmatised, the social life of patients with leishmaniasis can be impacted, especially for female patients.

Stigma, participation restriction and mental distress in patients affected by leprosy, cutaneous leishmaniasis and Chagas disease: a pilot study in two co-endemic regions of eastern Colombia

BACKGROUND

Leprosy, cutaneous leishmaniasis (CL) and Chagas disease (CD) are neglected tropical diseases with a high psychosocial burden (PSB). These conditions are endemic in Norte de Santander and Arauca in Colombia, but data on the related PSB are scarce. Therefore, we assessed mental distress, participation restriction and stigma among CD, CL and leprosy patients.

METHODS

In 2018, 305 leprosy, CD or CL patients were interviewed using a self-report questionnaire to assess mental distress, participation scale for participation restriction and explanatory model interview catalogue (EMIC) for stigma. Descriptive statistics and the significance of median score differences were compared.

RESULTS

Fifty percent of CD patients and 49% of leprosy patients exhibited mental distress, percentages which were significantly higher than that of CL (26%). Twenty-seven percent of leprosy patients experienced participation restriction, which was lower for CL (6%) and CD (12%). Median EMIC scores were significantly higher for leprosy patients than for CD (27%) and CL (17%) patients.

CONCLUSIONS

We found high levels of PSB among leprosy, CD and CL patients. Mental distress was highest among CD patients. Participation restriction and stigma were more prevalent in leprosy patients. Rural residence or lower educational status may impact PSB. Further investigation is needed to formulate evidence-based, holistic interventions.

Elucidating the possible mechanism of action of some pathogen box compounds against Leishmania donovani

Leishmaniasis is one of the Neglected Tropical Diseases (NTDs) which is closely associated with poverty and has gained much relevance recently due to its opportunistic coinfection with HIV. It is a protozoan zoonotic disease transmitted by a dipteran Phlebotomus, Lutzomyia/ Sergentomyia sandfly; during blood meals on its vertebrate intermediate hosts. It is a four-faceted disease with its visceral form being more deadly if left untreated. It is endemic across the tropics and sub-tropical regions of the world. It can be considered the third most important NTD after malaria and lymphatic filariasis. Currently, there are numerous drawbacks on the fight against leishmaniasis which includes: non-availability of vaccines, limited availability of drugs, high cost of mainstay drugs and parasite resistance to current treatments. In this study, we screened the antileishmanial activity, selectivity, morphological alterations, cell cycle progression and apoptotic potentials of six Pathogen box compounds from Medicine for Malaria Venture (MMV) against Leishmania donovani promastigotes and amastigotes. From this study, five of the compounds showed great promise as lead chemotherapeutics based on their high selectivity against the Leishmania donovani parasite when tested against the murine mammalian macrophage RAW 264.7 cell line (with a therapeutic index ranging between 19–914 (promastigotes) and 1–453 (amastigotes)). The cell cycle progression showed growth arrest at the G0-G1 phase of mitotic division, with an indication of apoptosis induced by two (2) of the pathogen box compounds tested. Our findings present useful information on the therapeutic potential of these compounds in leishmaniasis. We recommend further in vivo studies on these compounds to substantiate observations made in the in vitro study.

There are numerous drawbacks in the fight against leishmaniasis which includes difficulty in drug administration, lengthy time of treatment, high toxicity, adverse side effects, high cost of drugs and increasing parasite resistance to treatment. These have made the search for new antileishmanial chemotherapeutics very essential. The Medicine for Malaria Venture (MMV) with the aim of accelerating drug development for poverty-related diseases has assembled some 400 diverse, drug-like molecules active against neglected diseases called the Pathogen box compounds. Thus, in this study we explored the antileishmanial potency and elucidated some possible mechanisms of action of some of the compounds against the Leishmania donovani parasites. The six compounds studied caused a distortion in the mitochondrion morphology, loss of kinetoplastid DNA and eventual nuclear degeneration upon treatment for 72 hours. Parasites treated with two of the cytocidal compounds MMV676057 (E03C) and MMV688942 (D06A) showed no significant programmed cell death due to apoptosis when compared to the untreated parasites but rather showed a cell cycle growth arrest in the G0-G1 and S-phases.

Understanding the role of disease knowledge and risk perception in shaping preventive behavior for selected vector-borne diseases in Guyana

BACKGROUND

Individual behavior, particularly choices about prevention, plays a key role in infection transmission of vector-borne diseases (VBDs). Since the actual risk of infection is often uncertain, individual behavior is influenced by the perceived risk. A low risk perception is likely to diminish the use of preventive measures (behavior). If risk perception is a good indicator of the actual risk, then it has important implications in a context of disease elimination. However, more research is needed to improve our understanding of the role of human behavior in disease transmission. The objective of this study is to explore whether preventive behavior is responsive to risk perception, taking into account the links with disease knowledge and controlling for individuals' socioeconomic and demographic characteristics. More specifically, the study focuses on malaria, dengue fever, Zika and cutaneous leishmaniasis (CL), using primary data collected in Guyana-a key country for the control and/or elimination of VBDs, given its geographic location.

METHODS AND FINDINGS

The data were collected between August and December 2017 in four regions of the country. Questions on disease knowledge, risk perception and self-reported use of preventive measures were asked to each participant for the four diseases. A structural equation model was estimated. It focused on data collected from private households only in order to control for individuals' socioeconomic and demographic characteristics, which led to a sample size of 497 participants. The findings showed evidence of a bidirectional association between risk perception and behavior. A one-unit increase in risk perception translated into a 0.53 unit increase in self-reported preventive behavior for all diseases, while a one-unit increase in self-reported preventive behavior (i.e. the use of an additional measure) led to a 0.46 unit decrease in risk perception for all diseases (except CL). This study also showed that higher education significantly improves knowledge and that better knowledge increases the take up of preventive measures for malaria and dengue, without affecting risk perception.

CONCLUSIONS

In trying to reach elimination, it appears crucial to promote awareness of the risks and facilitate access to preventive measures, so that lower risk perception does not translate into lower preventive behavior.

Failure of an Innovative Low-Cost, Noninvasive Thermotherapy Device for Treating Cutaneous Leishmaniasis Caused by Leishmania tropica in Pakistan

Cutaneous leishmaniasis (CL), a neglected parasitic skin disease, is endemic in Pakistan, where Leishmania tropica and Leishmania major are the causative protozoan species. Standard treatment with antimonial injections is long, painful, and costly; has toxic side effects; and is not always available in public hospitals. Small pilot studies have previously evaluated a low-cost and noninvasive hand-held exothermic crystallization thermotherapy for cutaneous leishmaniasis (HECT-CL) device. We aimed to further establish the effectiveness, safety, and feasibility of HECT-CL in L. tropica. In a prospective observational study, patients with parasitological confirmation of CL were treated using the HECT-CL heat pack for 3 minutes with an initial temperature of 52–53°C for 7 consecutive days. Dried blood spot samples were taken for species identification by polymerase chain reaction (PCR). Effectiveness was assessed by using medical photographs and measurements of the lesion size at baseline and subsequent follow-up visits, for up to 180 days. We intended to enroll 317 patients. The HECT-CL treatment was easy to apply and well tolerated. Species identification demonstrated the presence of L. tropica. Interim analysis of 56 patients showed a failure rate of 91% at follow-up (median 45 days after treatment, interquartile range 30–60 days). Enrollment of patients was prematurely suspended because of futility. This study showed a high failure rate for HECT-CL thermotherapy in this setting. Leishmania tropica is known to be less sensitive to antileishmanial drugs, more temperature-resistant, and spontaneous healing is slower than that in L. major. More research is needed to identify low-cost, effective, and more patient-friendly treatment for L. tropica.

Microscopic and molecular evidence in support of rodent as a reservoir for dissemination of Leishmaniasis

Leishmaniasis is a worldwide public health problem and vector-borne disease. It is caused by a diverse group of protozoan parasites that belong to the genus Leishmania and transmitted to humans through a bite of an infected female sand fly. Leishmaniasis has attained epidemic proportion in Khyber Pakhtunkhwa and raises serious concern over its management. The present research work was conducted in cutaneous leishmaniasis (CL) prevalent village named Surgul of district Kohat, Khyber Pakhtunkhwa with a focus to investigate whether rodent can act as a source for dissemination of leishmanial species or not. In this context, rodent samples were analyzed via morphological and molecular approaches to unveil prevalence of CL. It was reported that 12.5% of samples were positive for signs of leishmaniasis through microscopy and 18.75% through polymerase chain reaction (PCR). Supporting the findings further, the color character of rodents was also taken into consideration, which shows that light dark colored rodents were more infected (13.3%) compared to brown colored rodents (11.43%). Based on our findings, we speculate that small rodents are a possible reservoir of various leishmanial parasites and play a significant role in zoonosis and maintenance of their species.

Novel benzoxaborole, nitroimidazole and aminopyrazoles with activity against experimental cutaneous leishmaniasis

OBJECTIVES

Drugs for Neglected Diseases initiative (DNDi) has identified three chemical lead series, the nitroimidazoles, benzoxaboroles and aminopyrazoles, as innovative treatments for visceral leishmaniasis. The leads discovered using phenotypic screening, were optimised following disease- and compound-specific criteria. Several leads of each series were progressed and preclinical drug candidates have been nominated. Here we evaluate the efficacy of the lead compounds of each of these three chemical classes in in vitro and in vivo models of cutaneous leishmaniasis.

METHODS

The in vitro activity of fifty-five compounds was evaluated against the intracellular amastigotes of L. major, L. aethiopica, L. amazonensis, L. panamensis, L. mexicana and L. tropica. The drugs demonstrating potent activity (EC50 < 5 μM) against at least 4 of 6 species were subsequently evaluated in vivo in different L. major - BALB/c mouse models using a 5 or 10-day treatment with either the oral or topical formulations. Efficacy was expressed as lesion size (measured daily using callipers), parasite load (by quantitative PCR - DNA) and bioluminescence signal reduction relative to the untreated controls.

RESULTS

The selected drug compounds (3 nitroimidazoles, 1 benzoxaborole and 3 aminopyrazoles) showed consistent and potent activity across a range of Leishmania species that are known to cause CL with EC50 values ranging from 0.29 to 18.3 μM. In all cases, this potent in vitro antileishmanial activity translated into high levels of efficacy with a linear dose-response against murine CL. When administered at 50 mg/kg/day, DNDI-0690 (nitroimidazole), DNDI-1047 (aminopyrazole) and DNDI-6148 (benzoxaborole) all resulted in a significant lesion size reduction (no visible nodule) and an approximate 2-log-fold reduction of the parasite load as measured by qPCR compared to the untreated control.

CONCLUSIONS

The lead compounds DNDI-0690, DNDI-1047 and DNDI-6148 showed excellent activity across a range of Leishmania species in vitro and against L. major in mice. These compounds offer novel potential drugs for the treatment of CL.

The impact of leishmaniasis on mental health and psychosocial well-being: A systematic review

BACKGROUND

Leishmaniasis is a neglected tropical parasitic disease endemic in South Asia, East Africa, Latin America and the Middle East. It is associated with low socioeconomic status (SES) and responsible for considerable mortality and morbidity. Reports suggest that patients with leishmaniasis may have a higher risk of mental illness (MI), psychosocial morbidity (PM) and reduced quality of life (QoL), but this is not well characterised. The aim of this study was to conduct a systematic review to assess the reported impact of leishmaniasis on mental health and psychosocial wellbeing.

METHODS

A systematic review of the literature was carried out. Pre-specified criteria were applied to identify publications including observational quantitative studies or systematic reviews. Two reviewers screened all of the titles, abstracts and full-studies and a third reviewer was consulted for disagreements. Data was extracted from papers meeting the criteria and quality appraisal of the methods was performed using the Newcastle-Ottawa Scale or the Risk of Bias in Systematic Review tool.

RESULTS

A total of 14 studies were identified from 12,517 records. Nine cross-sectional, three case-control, one cohort study and one systematic review were included. Eleven assessed MI outcomes and were measured with tools specifically designed for this; nine measured PM and 12 measured QoL using validated measurement tools. Quality appraisal of the studies showed that six were of good quality. Cutaneous leishmaniasis and post kala-azar dermal leishmaniasis showed evidence of associated MI and PM including depression, anxiety and stigma, while all forms of disease showed decreased QoL. The findings were used to inform a proposed model and conceptual framework to show the possible links between leishmaniasis and mental health outcomes.

CONCLUSION

There is evidence that leishmaniasis has an impact on MI, PM or QoL of patients and their families and this occurs in all the main subtypes of the disease. There are however large gaps in the evidence. Further research is required to understand the full extent of this problem and its mechanistic basis.

Effects of time-lagged meteorological variables on attributable risk of leishmaniasis in central region of Afghanistan

BACKGROUND

Leishmaniasis remains one of the world's most neglected vector-borne diseases, affecting predominantly poor communities mainly in developing countries. Previous studies have shown that the distribution and dynamics of leishmaniasis infections are sensitive to environmental factors, however, there are no studies on the burden of leishmaniasis attributable to time-varying meteorological variables.

METHODS

This study used data from 3 major leishmaniosis afflicted provinces of Afghanistan, between 2003 and 2009, to provide empirical analysis of change in heat/cold-leishmaniosis association. Non-linear and delayed exposure-lag-response relationship between meteorological variables and leishmaniasis were fitted with a distributed lag non-linear model applying a spline function which describes the dependency along the range of values with a lag of up to 12 months. We estimated the risk of leishmaniasis attributable to high and low temperature.

RESULTS

The median monthly mean temperature and rainfall were 16.1 °C and 0.6 in., respectively. Seasonal variations of leishmaniasis were consistent between males and females, however significant differences were observed among different age groups. Temperature effects were immediate and persistent (lag 0-12 months). The cumulative risks were highest at cold temperatures. The cumulative relative risks (logRR) for leishmaniasis were 6.16 (95% CI: 5.74-6.58) and 1.15 (95% CI: 1.32-1.31) associated with the 10th percentile temperature (2.16 °C) and the 90th percentile temperature (28.46 °C). The subgroup analysis showed increased risk for males as well as young and middle aged people at cold temperatures, however, higher risk was observed for the elderly in heat. The overall leishmaniasis-temperature attributable fractions was estimated to be 7.6% (95% CI: 7.5%-7.7%) and mostly due to cold.

CONCLUSION

Findings in this study highlight the non-linearity, delay of effects and magnitude of leishmaniasis risk associated with temperature. The disparity of risk between different subgroups can hopefully advise policy makers and assist in leishmaniasis control program.

The stigma of skin disease

PURPOSE OF REVIEW

The effects of skin disease on stigmatization are important but understudied in the pediatric population. Given the highly visible nature of dermatologic conditions, stigmatization is a common problem that requires significant attention in patients with skin diseases. In this review, we examine the recent literature addressing stigmatization of patients suffering from common dermatologic diseases with the goal to increase clinician awareness of these issues and identify new avenues for future research.

RECENT FINDINGS

A number of studies have examined the impact of skin disease on psychosocial well being and quality of life. Although some skin diseases are often overlooked medically and considered to be primarily cosmetic issues, the long-term consequences of skin diseases on psychosocial health, especially in pediatric patients, can be profound.

SUMMARY

The precipitating factors for stigma vary widely depending on age, sex, and culture. In order to effectively reduce the impact of pediatric skin diseases on psychosocial health, physicians should be able to identify specific characteristics that may increase risks for stigmatization in chidlren. Carefully monitoring psychosocial development in pediatric patients with dermatological conditions in addition to proactively guiding patients and families to appropriate resources can benefit the child's development and overall long-term well being.