Analysis of gaps in the correct diagnosis of leishmaniasis at primary care level; socio-demographic and environmental risk factors of leishmaniasis transmission in Anuradhapura

Background The leishmaniasis is an emerging health problem in dry zone of Sri Lanka. The multiplicity of factors involved in the transmission of leishmaniasis constitutes a challenge to its control. Knowledge of such factors may contribute to identify the control strategies. Although Medical officers have been given training on leishmaniasis, still patients with leishmaniasis had been diagnosed incorrectly. Aim of the study was to analysis of the diagnosis pattern of leishmaniasis patients by the primary care medical officers and to identify potential socio demographic and environmental risk factors of leishmaniasis transmission.


Introduction
Leishmaniasis is poverty related, neglected vector born disease caused by a protozoan parasite which is transmitted by the bite of an infected female phlebotomine sandflies 1, 2. The first autochthonous case of leishmaniasis was reported in 1992 from Southern province of Sri Lanka. 3 In 2003, causative species was identified as Leishmania donovani zymodeme MON-37. 4 Mucocutaneous and visceral involvements were first reported in 2005 5, 6 and 2006 7,8 respectively caused by the same species. Although occasional cases are reported from all the provinces in Sri Lanka, Southern 9 and North-Central province 10 are the endemic reporting more than 2000 cases annually. The observed gradual increase in case number annually in Anuradhapura district could be due to actual increase in cases, increase in case detection or both.
Leishmaniasis is predominantly an occupational disease, related to activities such as farming, rubber tapping, military operations and road constructions. Environmental factors that can affect the incidence of leishmaniasis include urbanization, domestication of the transmission cycle and the incursion of agricultural farms and settlements in to forested areas. 1,11 Leishmaniasis is climate sensitive and strongly affected by changes in rainfall, temperature and humidity.
The proven reservoir hosts of leishmaniasis are dogs as well as other animals. 1,11 The disease occurs in agricultural villages where houses are frequently constructed with mud walls and earthen floors, cattle and other livestock are kept close to human dwellings. Human behavior such as sleeping outside or on the ground, may increase the risk, while the use of bed nets tends to be associated with lower risk. 1,11 Multiplicity of factors involved in the transmission of leishmaniasis constitutes a challenge to its control.
In Sri Lanka, until 2007 it was known as a disease of military personnel. From 2007 to 2010 Ranawaka RR and Weerakoon HS published several research articles 10,11,12,13,14 showing that this is a disease of locals, where farmers and children who engaged in outdoor activities were the mostly affected. Leishmaniasis was not even known to most medical practitioners before 2007 and disease notification system included leishmaniasis as a notifiable disease in 2008.In 2007 awareness programs started focusing on health care workers, school children and public in Anuradhapura. Although health care workers including medical officers have been given training on leishmaniasis, continue to see many patients with leishmaniasis had been missed-diagnosed at the primary health care level. Most of the leishmaniasis patients have delayed presentation to the dermatology clinic and it may be due to missed-diagnosis or actual delayed presentation. 10 The clinically diagnosed leishmaniasis patients were confirmed by slit-skin-smear or histopathology to avoid misdiagnosis because there are several other diseases mimic cutaneous leishmaniasis clinically, such as leprosy, cutaneous tuberculosis and cutaneous sarcoidosis.
There are several risk factors involve in leishmaniasis transmission 1 but there are no published research articles involving leishmaniasis patients in Anuradhapura district regarding risk factors although highest number of patients reporting in Anuradhapura District. There was one study done by Salindra Ranasingha et al regarding risk factors but it was involve in patients and community. 15 This study was aimed to analyze the gaps in the correct clinical diagnosis of leishmaniasis by the primary care medical officers in Anuradhapura district and to identify potential socio-demographic and environmental risk factors of leishmaniasis transmission in an endemic district of Sri Lanka.

Methodology
Study setting Anuradhapura district is located in North Central Province. It has an area of 6861 Km 2 and nearly 900000 inhabitants (2016).Anuradhapura district reported the highest leishmaniasis case incidence in 2010 to 2015(Regional Epidemiology unit, Anuradhapura district and unpublished data). The altitude is generally less than 85meters above mean sea level and the climate is typically tropical but some area are humid tropical with mean annual temperature of 28 0 c and mean annual rainfall of 140mm 3 (Department of Meteorology, Sri Lanka).
People of Padaviya, Thalawa, NuwaragamPalatha Central, Nuwaragam Palatha East, Nochchiyagama, Thambuttagama and Rajanganaya areas are commonly affected with leishmaniasisin Anuradhapura district. In these areas there are numerous paddy fields, water reservoirs, water channels, scrub jungles and forest areas in this district.
Study design A descriptive cross sectional study was carried out on the leishmaniasis patients diagnosed from November 2015to November 2016.Each patient was interviewed by using a questionnaire (in Sinhala and/or Tamil) after taking written consent from the patients. The collected data, relevant to the objective one and two analyzed separately.
Sample size Study Sample included new leishmaniasis patients attending to the dermatology clinic Teaching Hospital Anuradhapura during one-year period from 1 st November 2015 to 1st November 2016.

Open Access
Anuradhapura Medical Journal 2018| Volume 12 | Issue 1 | Page 12 | Each leishmaniasis patient was interviewed using a questionnaire in Sinhala and/or Tamil, after obtaining informed consent. Questionnaire was drawn up to obtain data on the following group of variables; sociodemographic variables (ethnicity , sex, age, occupation, education, monthly income and place of stay) ; social awareness on leishmaniasis; variables relating to treatment pattern (number of medical officers visited before referral to dermatology clinic and from whom treatment was taken); variables relating to clinical aspects (duration of occurrence of disease before treatment, affected sites, number of affected sites, symptoms); variables relating to residence of the patient (whether patients is a new-comer to the area or not, the patients who stayed less than one year at their residence considered as a new-comer); variables related to household (wall, floor) and variables relating to the area surrounding the household and the environment(within 200 meters radiant paddy field , banana bushes, water channels, manna bushes ,forest area and domestic animals outside the house); variables related to domestic habits(sleeping under the mosquito net, working outside the house at dusk and dawn, working outside with cloths covering whole body, sleeping outside the house and sleeping on the floor).

Results
Study included 300 leishmaniasis patients.
All of the study participants were Sinhalese except one Muslim. Most were males with sex ratio of nearly 2:1. Most (64%)were in the age group of 21 to 50 years and there were less proportion of cases below 10 years (2.1%) and above 70 years (5.0%) of age. The youngest patient was 3 years and the oldest was 83 years. Most (46.4%) were educated up to ordinary level. Local civilians were more (79.3%) affected than armed forces personals in this study. One third of patients (36.1%) had no permanent family income and were dependent on daily wages and 8.2% of them had monthly income within SLR 10000 to 20000.Only 1.1% of patients had more than SLR 60000 income per month. Thalawa Medical Officer of Health (MOH) area was the highest (18.5%) affected than other MOH areas. (Table 1) Regarding social awareness on leishmaniasis, most (63.9%) of the patients had never heard about leishmaniasis before diagnosing the disease.
Majority (73.9%, n=207) of the patients were timely referred to the dermatology clinic for treatment after seeking medical advice but 26.1% (n=73) were not referred for treatment timely and warranted repeat treatment.      (Table 6).

Discussion
Leishmaniasis is now considered as an endemic disease in Sri Lanka. 17,18 . It is an emerging health problem in dry zone of Sri Lanka. 10 Leishmaniasis is overtaking previously common public health problems such as malaria in Anuradhapura. Leishmaniasis and the environment are linked together by human behavioral factors, vector habits and their interaction with the environment. This study was mainly aimed at determining the risk factors for leishmaniasis. The multiplicity of risk factors involved in the transmission of the leishmaniasis constitutes a challenge to its control. The diversity of etiologic agents, variety of vector species, existence of both wild and domestic reservoirs, differences in environmental conditions and differences in human factors could play a role in transmission. Knowledge of such factors may contribute to identify the control strategies.
Our study population was Sinhalese except one Muslim patient. There was high chance to get leishmaniasis in Sinhala population in our study and it was same as another study. 16 In our study the affected youngest child was 3years and the oldest was 83 years. It showed that the leishmaniasis can affect at any age. Field work or work near the forest area was a risk factor for acquiring leishmaniasis. 1 In our study also there was an association because most of our patients had worked related to the forest area; military personal, farmers, laborers and fieldworkers. It had been reported that outdoor occupation is a risk factor for cutaneous leishmaniasis in the Northern area of Sri Lanka favoring our asociation. 19 But it was not shown in other studies . 15, 20 In these two studies showed that there was no association between occupation and favors peridomestic transmission of leishmaniasis.
Leishmaniasis is a neglected tropical disease that affects poor and marginalized communities. In our study also most (36.1%) of them had no permanent income and 10.7% patents had less than 20000 Sri Lankan Rupees family incomes per month. But it was same as in study done at Alogoas, Brazil. 20 It was observed that people living in small towns or in rural area mostly affected. 20 In our study also most affected patients were from rural areas. The study population had poor awareness on leishmaniasis although highest number of leishmaniasis patients reporting from Anuradhapura since 2010.
In our study nearly one forth (26.1%)of leishmaniasis patients warrant repeat consultation from medical personal and it showed that there was a gap in correct diagnosis of leishmaniasis at primary care level. This needs to be address by health authorities because the only method of control of leishmaniasis practiced in Sri Lanka is early detection of cases and early treatment. Still there is no vector control methods established in Sri Lanka although leishmaniasis is an endemic disease in Sri Lanka.
The clinical profile of cutaneous leishmaniasis patients was similar to those reported in Anuradhapura in 2007 and 2010 10, 12 . Leishmaniasis was more prevalent in villages where houses were frequently constructed with mud walls and earthen floors. 1`I n another study done at Alagoas ,Brasil 20 reported that non-durable wall materials in the houses increases the chance of acquiring leishmaniasis but our study most of them had durable walls in study group.
One study done by Salindra et al mentioned that living near paddy field is associated with increased risk for transmission of leishmaniasis 15 . In our study also 67.1% of patients had paddy fields near their residence favoring that observation. Data in the literature suggested that some crops are more favor of transmission of leishmaniasis 1  They become reservoirs of the parasites thus participating in the transmission chain and increasing the risk of leishmaniasis. Sometimes it would perform a protective role such that humans would avoid being bitten. The role of domestic dogs as a reservoir for leishmaniasis transmission has been recognized ins several studies. 21,22 Most (74.3%) of the leishmaniasis patients have lived close with dogs or cats as pets in our study favoring some association. Some countries does not recognize that domestic animals are participants in the trans mission chain even when infected with leishmaniasis. 20 Although domestic habits like sleeping outside or on the ground may increase risk and the use of bed nets tends to be associated with lower risk. 1,11 But in our study most of the patients has not slept outside or on the ground and use bed nets showing it was not increase the risk for transmission of leishmaniasis or due to variation of vector habits .
In conclusion we would like to draw the attention to recognize the multiplicity of factors involved in the transmission of leishmaniasis and its challenge to control. Knowledge of such factors among general community and health care workers may contribute to identify the control strategies. 23 Therefore it is necessary to do further research on risk factors for leishmaniasis transmission. From this research we recommend that to consider about presence of environmental risk factors for leishmaniasis transmission like banana and manna cultivations and paddy fields near community residential areas. .