Forecasting the number of zoonotic cutaneous leishmaniasis cases in south of Fars province, Iran using seasonal ARIMA time series method

Objective: To predict the trend of cutaneous leishmaniasis and assess the relationship between the disease trend and weather variables in south of Fars province using Seasonal Autoregressive Integrated Moving Average(SARIMA) model,Methods: The trend of cutaneous leishmaniasis was predicted using Mini tab software and SARIMA model,Besides,information about the disease and weather conditions was collected monthly based on time series design during January 2010 to March 2016,Moreover,various SARIMA models were assessed and the best one was selected,Then,the model's fitness was evaluated based on normality of the residuals' distribution,correspondence between the fitted and real amounts,and calculation of Akaike Information Criteria(AIC) and Bayesian Information Criteria(BIC),Results: The study results indicated that SARIMA model(4,1,4)(0,1,0)(12) in general and SARIMA model(4,1,4)(0,1,1)(12) in below and above 15 years age groups could appropriately predict the disease trend in the study area,Moreover,temperature with a three-month delay(lag3) increased the disease trend,rainfall with a four-month delay(lag4) decreased the disease trend,and rainfall with a nine-month delay(lag9) increased the disease trend,Conclusions: Based on the results,leishmaniasis follows a descending trend in the study area in case drought condition continues,SARIMA models can suitably measure the disease trend,and the disease follows a seasonal trend.

Climate change and potential distribution of zoonotic cutaneous leishmaniasis in Central Iran: Horizon 2030 and 2050

Objective: To investigate and predict the effects of climate change on the potential distribution of the main vector and reservoir hosts of the disease in Yazd province in the future.Methods: Distribution data for vector and reservoir hosts of zoonotic cutaneous leishmaniasis in Yazd province were obtained from earlier studies conducted in the area.MaxEnt ecological niche modeling was used to predict environmental suitability.BCC-CSM1-1(m) model and two climate change scenarios, RCP 4.5 and RCP 8.5 were used for horizons 2030 and 2050 climate projections.Future projections were based on data of a regional climate change model.Results: With both scenarios in 2030 and 2050, the results of jackknife test indicated that the mean temperature of wettest quarter and temperature annual range had the greatest effect on the model for the vector and the reservoir hosts, respectively.Conclusions: The climate conditions are the major determinants of zoonotic cutaneous leishmaniasis incidence rate in Yazd Province.These climate conditions provide favorable habitats for ease transmission of zoonotic cutaneous leishmaniasis in this endemic area.Habitats suitability for the vector and reservoir will be expanding in the coming years compared with the current conditions, such that, in horizon 2030 & 2050, the probability of the presence of the vector and reservoir within 38 580 and 37 949 km^2, respectively, from Yazd province is above 60%.Moreover, an increase is predicted in the presence of the vector in the western parts and the reservoir in the northern and central parts of the province in the future.Understanding the role of environmental and bioclimatic factors in zoonotic cutaneous leishmaniasis occurrence can provide a guide for policy-makers in the creation and implementation of more effective policies for prevention and control.

Disseminated cutaneous leishmaniasis due to Leishmania(Leishmania) amazonensis in human immunodeficiency virus(HIV)-infected patients: A report of two cases

Rationale: Co-infection of human immunodeficiency virus(HIV) and Leishmania spp. has impact on clinical and therapeutic outcomes of leishmaniases. Most studies do not present the identification of Leishmania species causing American tegumentary leishmaniasis in co-infections. In the Americas, Leishmania(L.) Viannia(V.) braziliensis and L.(V.) guyanensis have been identified. Patient concerns: In this study, two cases of American tegumentary leishmaniasis in patients infected with HIV are described. Patients presented several lesions with rapid dissemination and mucosal involvement. Diagnosis: Disseminated cutaneous leishmaniasis caused by L. amazonensis was identified by molecular test. Interventions: The patients were treated with conventional therapies for HIV infection and American tegumentary leishmaniasis. Outcomes: In co-infection, the clinical manifestations are atypical and the treatment response can be impaired. Lessons: These cases show that HIV infection impacts L. amazonensis infection and point to the relevance of identifying Leishmania species, which can lead to a better patient management.

First report on molecular characterization of Leishmania species from cutaneous leishmaniasis patients in southern Khyber Pakhtunkhwa province of Pakistan

Objective: To report presence of Leishmania major in Khyber Pakhtunkhwa of Pakistan, where cutaneous leishmaniasis(CL) is endemic and was thought to be caused by Leishmania tropica only. Methods: Biopsy samples from 432 CL suspected patients were collected from 3 southern districts of Khyber Pakhtunkhwa during years 2011–2016. Microscopy on Giemsa stained slides were done followed by amplification of the ribosomal internal transcribed spacer 1 gene. Results: Leishmania amastigotes were detected by microscopy in 308 of 432 samples(71.3%) while 374 out of 432 samples(86.6%) were positive by ribosomal internal transcribed spacer 1 PCR. Subsequent restriction fragment length polymorphism confirmed Leishmania tropica in 351 and Leishmania major in 6 biopsy samples. Conclusions: This study is the first molecular characterization of Leishmania species in southern Khyber Pakhtunkhwa. It confirmed the previous assumptions that anthroponotic CL is the major CL form present in Khyber Pakhtunkhwa province. Furthermore, this is the first report of Leishmania major from a classical anthroponotic CL endemic focus identified in rural areas of Kohat district in southern Khyber Pakhtunkhwa.

Therapeutic response and safety of different treatments for cutaneous leishmaniasis in patients: A retrospective cross-sectional study

Objective:To analyze the therapeutic response and safety of different treatments for cutaneous leishmaniasis,received by patients in the Program for the Study and Control of Tropical Diseases-PECET-Medellín-Colombia.Methods:This is a retrospective cross-sectional study of patients attended at PECET Research Center during 2016-2021.Relevant information regarding sociodemographic characteristics,history of leishmaniasis,characterization of current infection,treatment received,follow-up of therapeutic response and safety was collected from the medical records.Data were analyzed with Pearson's Chi-square association tests and Mann-Whitney U test using statistical software.Results:A total of 486 clinical records of patients were analyzed,and 356 received treatment.Eight different therapeutic alternatives(systemic,local and in combination)were analyzed.The therapeutic response of the different alternatives used(except thermotherapy)was higher than 50%.Most frequent adverse events were myalgias,arthralgias and headache,and vesicles for systemic and local treatment,respectively.Conclusions:Safety profile and performance of local therapeutic alternatives and combined schemes for the treatment of uncomplicated cutaneous leishmaniasis are an interesting option for the management of the disease.

Spatiotemporal clustering of cutaneous leishmaniasis in Fars province,Iran

Objective: To assess the spatiotemporal trait of cutaneous leishmaniasis(CL) in Fars province, Iran.Methods: Spatiotemporal cluster analysis was conducted retrospectively to find spatiotemporal clusters of CL cases. Time-series data were recorded from 29 201 cases in Fars province, Iran from 2010 to 2015, which were used to verify if the cases were distributed randomly over time and place. Then, subgroup analysis was applied to find significant sub-clusters within large clusters. Spatiotemporal permutation scans statistics in addition to subgroup analysis were implemented using Sa TScan software.Results: This study resulted in statistically significant spatiotemporal clusters of CL(P < 0.05). The most likely cluster contained 350 cases from 1 July 2010 to 30 November2010. Besides, 5 secondary clusters were detected in different periods of time. Finally,statistically significant sub-clusters were found within the three large clusters(P < 0.05).Conclusions: Transmission of CL followed spatiotemporal pattern in Fars province,Iran. This can have an important effect on future studies on prediction and prevention of CL.

Treatment of Acute Cutaneous Leishmaniasis by Oral Zinc Sulfate and Oral Ketocanazole Singly and in Combination

Background: Cutaneous Leishmaniasis (CL) is an endemic disease in many countries and caused by different species of Leishmania parasite. It results in a deformed scar after a relatively long period. Many therapies have been tried in treatment of this disease. Objective: To compare the effect of oral zinc sulfate and oral ketoconazole singly and in combination in the treatment of acute cutaneous leishmaniasis. Patients and Methods: This single, blinded, therapeutic, controlled study was conducted in the Department of Dermatology, Baghdad Teaching Hospital, Baghdad, Iraq, during the period, January 2015 to July 2015. Seventy-five patients with acute CL were enrolled in this study. The total numbers of lesions were 327, and the duration of lesions ranged from 4 to 12 (6.9 ± 0.7) weeks. The diagnosis was confirmed by smear and histopathology. Patients were divided into three groups: 24 patients in Group A were treated with oral zinc sulfate capsules 10 mg/kg/day for 6 weeks;24 patients in Group B were treated with ketoconazole tablets 200 mg twice daily for 6 weeks and 27 patients in Group C were treated orally with a combination of zinc sulfate and ketoconazole for 6 weeks. All patients were seen regularly every 2 weeks for 6 weeks of treatment period, then monthly for the next three months as follow up period. Healing of the lesions was assessed by using Sharquie’s modified Leishmania score to assess the objective response to the topical or systemic therapy. Results:After six weeks, 75 patients have completed the treatment, 24patients received zinc sulfate capsule, 24 patients received oral ketoconazole and 27 patients received a combination of both treatments. The cure rate was (60%) in the group receiving oral zinc sulfate capsuleand (50%) in the one receiving oral ketoconazole tablet (P = 0.146) and (96%) in the combination group (P ? 0.04). Conclusion: The combination therapy using oral zinc sulfate and oral ketoconazole gave a high cure rate. The combination therapy is a new mode of therapy as both drugs act in a synergistic way.

Molecular detection of Leishmania species in human and animals from cutaneous leishmaniasis endemic areas of Waziristan, Khyber Pakhtunkhwa, Pakistan

Objectives: To detect Leishmania species in human patients, animal reservoirs and Phlebotomus sandflies in Waziristan, Pakistan. Methods: Tissue smears and aspirates from 448 cutaneous leishmaniasis(CL) suspected patients were analyzed. To sort out role of the reservoir hosts, skin scrapings, spleen and liver samples from 104 rodents were collected. Furthermore, buffy coat samples were obtained from 60 domestic animals. Sandflies were also trapped. All human, animals and sandfly samples were tested by microscopy, kinetoplastic PCR and internal transcribed spacer 1(ITS1) PCR followed by restriction fragment length polymorphism for detection of Leishmania species. Results: An overall prevalence of 3.83% and 5.21% through microscopy and ITS1 PCR respectively was found. However, the statistically non-significant correlation was found between area, gender, and number of lesions. The presence of rodents, sandflies, domestic animals and internally displaced people increased the risk of CL. Using ITS1-PCR-RFLP, Leishmania tropica(L. tropica) was confirmed in 106 samples while 25 of the isolates were diagnosed as Leishmania major(L. major). Similarly, 3/104 rodents were positive for L. major and 14 pools of DNA samples containing Phlebotomus sergenti sandflies were positive for L. tropica. None of samples from domestic animals were positive for leishmaniasis. Conclusions: In the present study, L. tropica and L. major are found to be the main causative agents of CL in study area. Movement of internally displaced people from CL endemic areas presents a risk for nearby CL free areas. To the best of our knowledge, we report for the first time L. major infection in rodents(Rattus rattus) and L. tropica in Phlebotomus sergenti sandflies trapped in Waziristan, Pakistan.

Identification of climatic and environmental factors associated with incidence of cutaneous leishmaniasis in Central Iran using satellite imagery

Objective:To determine the effect of climatic and environmental factors on the incidence of cutaneous leishmaniasis in Qom province in 2018.Methods:In this cross-sectional study,the data on cutaneous leishmaniasis incidence were collected from the Disease Control and Prevention Center in Qom province.Climatic and environmental data including Normalized Difference Vegetation Index(NDVI),Land Surface Temperature(LST),and soil moisture were extracted using satellite images.Data of altitude and sunny hours were provided based on shuttle radar topography mission digital elevation model and hemispherical viewshed algorithm,respectively.The associations of climatic and environmental variables with the incidence of the disease were analyzed by Pearson correlation method.The Arc GIS 10.3 software was used to determine the geographical distribution of these factors.Results:There were positive correlations between cutaneous leishmaniasis incidence and the two climatic factors:LST and sunny hours per day(P=0.041,P=0.016),and it had weak negative correlations with the digital elevation model(P=0.27),soil moisture(P=0.54),and NDVI(P=0.62).The time delay analysis showed that in one-,two-,and three month periods,the correlations increased with a 95%confidence interval.Accordingly,the correlation with the three-month time delay was positive and relatively strong between the cutaneous leishmaniasis incidence and LST and sunny hours(P=0.027,P=0.02);nevertheless,there were negative correlations between the cutaneous leishmaniasis incidence and the soil moisture(P=0.27)and NDVI(P=0.62).Conclusions:As Qom is located in one of the semi-arid climate zones,topography and solar energy are important factors affecting the incidence of cutaneous leishmaniasis in autumn.Therefore,appropriate disease control programs are recommended.

New developments in the treatment of cutaneous leishmaniasis

Leishmaniasis,including the cutaneous form,poses an important public health threat around the world,while no vaccine is currently available against any form of leishmaniasis.The drugs used in the first line treatment of cutaneous leishmaniasis(CL)are commonly pentavalent antimonials despite their toxicities,long-term treatment duration and increasing resistance rates.Other alternatives are amphotericin B,pentamidine,miltefosine and paromomycine.Movement of the population,especially in endemic regions,increases the spread of the parasite and affectes the distribution of causative species,which requires re-evaluation the treatment regimen.Extensive researches are carried out on the treatment of leishmaniasis.The immunotherapeutic and targeted therapeutic approaches,formulations of carrier-loaded active drugs,local thermotherapeutic applications,the combination of antileishmanial drugs/compounds,the use of new synthetic and natural products are promising therapeutic options in the future.Herein,the author reviews the potential treatment modalities of CL with a brief overview of current treatments in the light of ongoing studies around the world.

Situation analysis of cutaneous leishmaniasis in an endemic area,south of Iran

Objective: To update current situation of the cutaneous leishmaniasis(CL) in Kazerun County,southwest of Iran and to analyze the epidemiological aspects of the disease during 2005-2015,Methods: Data on CL were obtained from the Health Center of Kazerun County,and then were analyzed and mapped using SPSS and Arc GIS 10.3,Results: A total of 700 cases of CL were recorded during the study period with an overall decreasing trend from 2005 to 2015,More than 60% of the patients were inhabitants of rural areas and males were infected more than females,Although there was not a significant difference between gender,job categories,residence and CL infection(P>0.05),age groups were significantly different(P<0.05),But there was no significant correlation between monthly cases of the disease with average temperature(P>0.05),Most of the acute lesions were found to be present on the hand,leg and face,respectively,The average CL incidence in the study area was calculated as 24.9/100 000 population,A hot spot for the disease was found in southern part of the area(P<0.05),Conclusions: This study revealed that CL is present in Kazerun country,Thus,effective monitoring and sustained suveillance system is crucial in counteracting the disease,and if possible,to eliminate it.

Cutaneous leishmaniasis in Louisiana-one-year follow-up:A case report

Reports of leishmaniasis are scarce in North America.It is considered to be one of the neglected tropical diseases.It is seen in immigrants from endemic areas to United States.Treatments are not readily available in the United States.Untreated or inadequately treated cutaneous leishmaniasis not only causes localized disfigurement but can advance to more permanent and devastating mucosal disfigurement and perforation,if caused by a species that can also cause mucocutaneous leishmaniasis.CASE SUMMARY A 42-year-old human immunodeficiency virus negative male immigrant from Honduras presented to the emergency department of our facility in Louisiana with a 2-mo history of a left lower extremity ulcer.It started as a painless blister that progressed in size and developed into other smaller lesions tracking up the thigh and became tender and erythematous.Clinically looked nontoxic and healthy.He was afebrile.Blood tests,except inflammatory markers,were within normal limits.The cellulitis of the leg was treated with 6 d of vancomycin that also relieved the pain.Skin biopsy was obtained,and histopathology was suspicious for leishmania.Polymerase chain reaction/deoxyribonucleic acid sequencing done by centers for disease control and prevention confirmed the diagnosis as Leishmania panamensis.There was no involvement of nasooropharyngeal mucosa,confirmed by otolaryngology.The patient was treated with miltefosine for 28 d.Clinic follow-up after approximately 11 mo revealed a healed skin ulcer.CONCLUSION Cutaneous leishmaniasis should be in the differential diagnosis of skin ulcers of travelers from endemic areas.Awareness regarding diagnosis and treatment of leishmaniasis needs to be enhanced.

Spatiotemporal Distribution of Phlebotomine Sand Flies （Diptera： Psychodidae） in a Focus of Cutaneous Leishmaniasis in Foum Jamaa （Azilal, Atlas of Morocco）

An entomological survey of Phlebotomine sand flies （Diptera： Psychodidae） was carried out in three sectors of Foum Jamgta region （province of Azilal, Morocco） during the year 2010. Morphological identification was performed on a total of 1,152 sand flies （23% females and 77% males） collected by sticky paper traps. 80% of the total collected flies were identified as Phlebotomus （Paraphlebotomus） sergenti （Parrot） （57%） and Phlebotomus （Larroussius） longicuspis （Nitzulescu） （23%）. In addition to these dominant species, four other species were found, Phlebotomus （Phlebotomus） papatasi （Scopoli）, Sergentomyia （Sergentomyia） minuta （Rondani）, Phlebotomus （Larroussius） perniciosus （Newstead） and Phlebotomus （Paraphlebotomus） chabaudi （Croset）. Overall, the population dynamics show a yearly bimodal pattern related to rainfall and temperature, and with high density around human dwellings. The spatiotemporal distribution of sand fly species was helpful to discuss strategies that might be useful in controlling cutaneous leishmaniasis transmission in this endemic focus.

Atypical Cutaneous Leishmaniasis by Leishmania Mexicana: A Case Report with Dermoscopic, Histopathological and Molecular Study

Cutaneous leishmaniasis is a neglected tropical skin endemic disease, with worldwide distribution. By 2020 in the Americas, Mexico was in 12th place with 11 states reporting new cases. Molecular biology with different targets for diagnosis and species identification has been used for decades, also dermoscopy, a non-invasive diagnostic tool has shown its usefulness. We present the first case of cutaneous leishmaniasis in non-endemic place (Guerrero, Mexico) identifying Leishmania mexicana with molecular biology, and treated with itraconazole.

Spatial and temporal distribution of American cutaneous leishmaniasis in Acre state,Brazil

Background:Acre has reported the highest incidence of American cutaneous leishmaniasis(ACL)in Brazil in recent years.The present study seeks to identify high and low risk agglomerations of ACL in space and space-time during the period from 2007 to 2013 in Acre,and also to characterize the occurrence of the disease in time and according to sociodemographic variables.Methods:This is an ecological study,the study population of which consisted of autochthonous ACL cases notified in the municipalities of Acre by an epidemiological surveillance system.Scan statistics of SaTScan^(TM)software were used to identify spatial and space-time clusters.In addition,the cases were characterized by sex,age,home situation(in a rural or urban area),and temporal tendency.Results:Acre reported an incidence rate of 12.4 cases per 10000 inhabitant-years in the study period,with the rates varied greatly(standard deviation of 21.8)among their 22 municipalities.One agglomeration of high risk and three of low risk were detected in space and space-time.Four of the five micro-regions of Acre presented a stationary temporal tendency.The profile of transmission varied according to the micro-region.Generally speaking,the disease occurred more often among young people,those of male gender,and those living in rural areas.Conclusions:Acre has stood out within the Brazilian national context due to its high rates of ACL incidence in the central region of the Acre Valley.The high rates in the micro-region of Brasileia are related to the disease’s intra/peridomiciliary occurrence,and it would seem that the municipality of Sena Madureira is approaching a transmission pattern similar to that of Brasileia.In other micro-regions,the profile of the disease’s transmission is mainly related to the forest/sylvatic cycle of ACL.

Spatial-temporal pattern of cutaneous leishmaniasis in Brazil

Background:Cutaneous leishmaniasis(CL)is a vector-borne disease classified by the World Health Organization as one ofthe most neglected tropical diseases.Brazil has the highest incidence of CL in America and is one of the ten countries in the world with the highest number of cases.Understanding the spatiotemporal dynamics of CL is essential to provide guidelines for public health policies in Brazil.In the present study we used a spatial and temporal statistical approach to evaluate the dynamics ofCL in Brazil.Methods:We used data of cutaneous leishmaniasis cases provided by the Ministry of Health of Brazil from 2001 to 2017.We calculated incidence rates and used the Mann-Kendall trend test to evaluate the temporal trend of CL in each municipality.In addition,we used Kuldorff scan method to identify spatiotemporal clusters and emerging hotspots test to evaluate hotspot areas and their temporal trends.Results:We found a general decrease in the number of CL cases in Brazil(from 15.3 to 8.4 cases per 100000 habitants),although 3.2%of municipalities still have an increasing tendency of CL incidence and 72.5%showed no tendency at all.The scan analysis identified a primary cluster in northern and central regions and 21 secondary clusters located mainly in south and southeast regions.The emerging hotspots analysis detected a high spatial and temporal variability of hotspots inside the main cluster area,diminishing hotspots in eastern Amazon and permanent,emerging,and new hotspots in the states of Amapa and parts of Para,Roraima,Acre and Mato Grosso.The central coast the state of Bahia is one of the most critical areas due to the detection of a cluster of the highest rank in a secondary cluster,and because it is the only area identified as an intensifying hotspot.Conclusions:Using a combination of statistical methods we were able to detect areas of higher incidence of CL and understand how it changed over time.We suggest that these areas,especially those identified as permanent,new,emerging and intensifying hotspots,should be targeted for future research,surveillance,and implementation of vector control measures.

Health economic evaluation of moist wound care in chronic cutaneous leishmaniasis ulcers in Afghanistan

Background:The present health economic evaluation in Afghanistan aims to support public health decision makers and health care managers to allocate resources efficiently to appropriate treatments for cutaneous leishmaniasis(CL)elicited by Leishmania tropica or Leishmania major.Methods:A decision tree was used to analyse the cost and the effectiveness of two wound care regimens versus intra-lesional antimony in CL patients in Afghanistan.Costs were collected from a societal perspective.Effectiveness was measured in wound free days.The incremental cost-effectiveness ratio(ICER)and incremental net monetary benefit(NMB)were calculated.The model was parameterized with baseline parameters,sensitivity ranges,and parameter distributions.Finally,the model was simulated and results were evaluated with deterministic and probability sensitivity analyses.Final outcomes were the efficiency of the regimens and a budget impact analysis in the context of Afghanistan.Results:Average costs per patients were US$11(SE=0.016)(Group I:Intra-dermal Sodium Stibogluconate[IL SSG]),US$16(SE=7.58)(Group II:Electro-thermo-debridement[ETD]+Moist wound treatment[MWT])and US$25(SE=0.48)(Group III:MWT)in patients with a single chronic CL ulcer.From a societal perspective the budget impact analysis shows that the regimens’drug costs are lower than indirect disease cost.Average effectiveness in wound free days are 177(SE=0.36)in Group II,147(SE=0.33)in Group III,and 129(SE=0.27)in Group I.The ICER of Group II versus Group I was US$0.09 and Group III versus Group I US$0.77,which is very costeffective with a willingness-to-pay threshold of US$2 per wound free day.Within a Monte-Carlo probabilistic sensitivity analysis Group II was cost-effective in 80%of the cases starting at a willingness-to-pay of 80 cent per wound free day.Conclusions:Group II provided the most cost-effective treatment.The non-treatment alternative is not an option in the management of chronic CL ulcers.MWT of Group III should at least be practiced.The costeffectiveness of Group III depends on the number of dressings necessary until complete wound closure.

High-risk spatiotemporal patterns of cutaneous leishmaniasis:a nationwide study in Iran from 2011 to 2020

Background Cutaneous leishmaniasis(CL)is a wide-reaching infection of major public health concern.Iran is one of the six most endemic countries in the world.This study aims to provide a spatiotemporal visualization of CL cases in Iran at the county level from 2011 to 2020,detecting high-risk zones,while also noting the movement of high-risk clusters.Methods On the basis of clinical observations and parasitological tests,data of 154,378 diagnosed patients were obtained from the Iran Ministry of Health and Medical Education.Utilizing spatial scan statistics,we investigated the disease’s purely temporal,purely spatial,spatial variation in temporal trends and spatiotemporal patterns.At P=0.05 level,the null hypothesis was rejected in every instance.Results In general,the number of new CL cases decreased over the course of the 9-year research period.From 2011 to 2020,a regular seasonal pattern,with peaks in the fall and troughs in the spring,was found.The period of September–February of 2014–2015 was found to hold the highest risk in terms of CL incidence rate in the whole country[relative risk(RR)=2.24,P<0.001)].In terms of location,six signifcant high-risk CL clusters covering 40.6%of the total area of the country were observed,with the RR ranging from 1.87 to 9.69.In addition,spatial variation in the temporal trend analysis found 11 clusters as potential high-risk areas that highlighted certain regions with an increasing tendency.Finally,fve space-time clusters were found.The geographical displacement and spread of the disease followed a moving pattern over the 9-year study period afecting many regions of the country.Conclusions Our study has revealed signifcant regional,temporal,and spatiotemporal patterns of CL distribution in Iran.Over the years,there have been multiple shifts in spatiotemporal clusters,encompassing many diferent parts of the country from 2011 to 2020.The results reveal the formation of clusters across counties that cover certain parts of provinces,indicating the importance of conducting spatiotemporal analyses at the county level for studies that encompass entire countries.Such analyses,at a fner geographical scale,such as county level,might provide more precise results than analyses at the scale of the province.

Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province,Morocco

Background:In Morocco,cutaneous leishmaniasis(CL)is usually known to be a slowly healing localized skin disease,but in some cases,it can lead to mutilating scars.The outbreak of CL due to Leishmania major in the Errachidia province in southeastern Morocco between 2008 and 2010 left many adolescents with permanent scar tissue on the face or other exposed body parts.We studied the psychosocial impact of CL on these young people.Methods:In 2015 we conducted a cross-sectional survey among high-school students living in boarding schools in two CL-endemic areas of Errachidia:Rissani and Tinejdad.A self-administered questionnaire elicited responses about general knowledge of CL and related scars.An open-ended question focused on the possible psychosocial effects associated with these scars.The quantitative data were analyzed with Epi Info^(TM)and the text data with NVivo software.Results:Almost 20%of 448 respondents reported they had experienced a CL lesion and 87%said it could possibly or definitely lead to psychological consequences.The text analysis showed that girls more often than boys expanded on the negative psychological effects of CL.The students considered CL as“dangerous”,“serious”,and“deathly”,and said it sometimes led to extreme suicidal ideations.Conclusions:The burden of CL in this age group is not negligible.The indelible CL scars lead to self-stigma and social stigma,and the emergence of negative psychological effects in this age group.While some students accepted their CL scars and related suffering as their“destiny”,others were eagerly demanding protective measures against CL and treatment for the scars.

Cutaneous leishmaniasis control in Alta Verapaz (northern Guatemala): evaluating current efforts through stakeholders' experiences

Background:Cutaneous leishmaniasis(CL),endemic in Guatemala,mostly affects poor people living in the northern region.A national control program that ineludes surveillanee,diagnose,and treatment offered free of cost by the Ministry of Health(MoH)has been in place since 2003.However,the incidence is increasing and treatment rates are not optimal,suggesting that current efforts are not being effective.This study aimed to understand barriers and facilitators of CL control in Guatemala as experienced and perceived by key stakeholders in order to comprehend what works well and does not and suggest evidence-informed interventions.Methods:The study was conducted in the Coban municipality,the most endemic of Guatemala,situated in the Department of Alta Verapaz.Data were collected during May and June 2019 via focus groups and semi-structured interviews with key stakeholders,including local and national health personnel and residents of four communities of the endemic region.Thematic and content analysis of the collected data was conducted using NVIVO.Results:Three overarching issues hamper the effectiveness of current CL efforts:resource scarcity,treatment challenges,and knowledge-action gaps.Scarce economic resources from the MoH and community residents negatively impact incidence,detection of cases and treatment rates in that preventive action is insufficient and healthcare access is low.In addition,local health workers often lack specialized CL training and access to the national CL control guidelines.With regards to the population living in the study area,misunderstanding of disease causation,shame associated with CL lesions,treatment pain fear,and long(often uncertain)waiting times for diagnose and treatment negatively affect people's willingness to seek help,treatment adherence,and their trust on the healthcare provided.Conclusions:Culturally sensitive CL preventive action must be developed.Given the scarce economic resources available for CL control in the country,the involvement of trained community health workers and the inelusion of thermotherapy as a treatment option is also advised.Other cost-effective actions include:ensuring all health workers receive CL training and have access to national CL control guidelines,improving national procurement system to avoid treatment shortages,and provision of motorized vehicles to increase active surveillance and treatment rates.