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.

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.

Individual and Community-Level Risk Factors for Giardiasis in Children under Five Years of Age in Pakistan: A Prospective Multi-Regional Study.

OBJECTIVES: This study aimed to estimate the prevalence of Giardia lamblia infection and identify associated risk factors at both individual and community levels in a pediatric population in different agroecological zones of Khyber Pakhtunkhwa, Pakistan. METHODS: A community-based cross-sectional study was conducted from March to December 2022. Using stratified sampling, 1026 households were recruited from nine agroecological zones. Stool samples were collected from 1026 children up to the age of five years and processed for detection of Giardia using a commercial ELISA kit. Data on potential risk factors were collected using a pre-structured questionnaire. A multivariable logistic regression model was used to identify risk factors associated with giardiasis. RESULTS: The study found that the prevalence of giardiasis in the study area was 3.31%. Children aged 13-24 months were found to be at higher risk for giardiasis. Illiterate mothers and fathers attending daycare institutions/kindergartens, mothers not practicing hand washing during critical times, households with companion animals, and homes where stray dogs/cats enter were identified as predictors of giardiasis at the individual level. Children living in sub-mountain valleys use un-piped water, inadequate domestic water storage vessels, drink un-boiled or unfiltered water, live near rubbish heaps or un-paved streets/pathways, and have unimproved latrine facilities were identified as risk factors of giardiasis at the community level. CONCLUSIONS: The study highlights the need for integrated intervention approaches at both individual and community levels to reduce the incidence of giardiasis in Khyber Pakhtunkhwa, Pakistan. Interventions aimed at promoting behavioral change and providing safe and adequate water sources, combined with individual-level interventions such as hand washing and awareness of giardiasis prevention methods, would be critical to addressing this health concern. Inter-sectoral collaboration between the health sector and other sectors would also be necessary to achieve meaningful progress in reducing the incidence of giardiasis in resource-limited areas.

Sand fly bionomics, geospatial investigation and risk factors associated with cutaneous leishmaniasis in district Mardan, Pakistan.

The present investigation was designed in response to the 2019 outbreak of cutaneous leishmaniasis (CL) in 34 villages of district Mardan, Pakistan. Sand flies were collected to study their bionomics, breeding sites, and seasonal prevalence from July to September 2019. In 2020, we acquired and digitized data on CL patients in the region to assess the possible spread of the disease to new foci. In the study period, a total of 1572 sand flies were collected, comprising 11 species. Phlebotomus sergenti (827, 52.61%) was the most widespread species. The soil pH in all samples was slightly alkaline (7-8.2) and potassium (K) was the richest component (59.4%). In 2020, there were 975 reported cases, which is an increase from 536 cases in 2019. Elevations of 361-588 m, agricultural land near human settlements, and quaternary alluvium formation had maximum CL cases. In univariate analysis, age between 25 and 35, nationality, family size (7-15 individuals), knowledge of leishmaniasis, site of infection, family members suffering from leishmaniasis, knowledge of sand flies, the difference between mosquitoes and sand flies, biting times of sand flies, use of mosquito spray, an Afghan refugee in the region, preachers visiting, and material of house construction have been identified risk of getting CL (p < 0.05). In stepwise multivariate analysis, nationality, vegetation, site of infection, and material of house construction were more prone to CL (p < 0.05). This study highlights the potential risk factors and sand flies associated with the outbreak of CL in Mardan. The high abundance of P. sergenti suggests their possible role as vectors for the transmission of CL in the region. The increase in reported cases in 2020 compared to 2019 suggests a possible spread of the disease to new foci. The study also revealed that certain demographic and environmental factors were significant risk factors for contracting CL in the district.

Bionomics of the unexplored sand flies fauna of District Mohmand, Khyber Pakhtunkhwa, Pakistan: assessing risk factors associated with cutaneous leishmaniasis.

BACKGROUND: Sand flies are of considerable public health importance in Pakistan because these insects are vectors of leishmaniasis. The current study explores the bionomics of sand flies, their spatial distribution pattern and cutaneous leishmaniasis-associated risk factors in District Mohmand, Khyber Pakhtunkhwa, Pakistan. METHODS: Sand flies were collected from indoor and outdoor habitats in 69 villages of five tehsils in Mohmand during July-October 2019. Risk factor data were recorded for 829 households in 94 villages. RESULTS: In total, 2065 sand flies were captured. Phlebotomus (Paraphlebotbmus) sergenti was the most abundant species. Relative density for P. sergenti and Phlebotomus papatasi was highest in Prang Ghar and lowest in Safi. Sand flies abundance peaked in August and September, corresponding to maximum relative humidity, temperature and rainfall. Relative density for P. sergenti and P. papatasi was highest in combined dwellings (indoor) and cattle corrals (outdoor). Phlebotomus sergenti and P. papatasi were abundant at an elevation of 283-1140 m on agricultural land and rangelands. Both species were recorded abundantly on Carbontites, Mesozoic and Indus suture Melange rock formations. Presence of domestic animals, ownership of pet dogs, presence of muddy dunes in the village, knowledge of sandflies and use of mosquitoes spray remained significant risk factors. CONCLUSIONS: The study reports sand fly bionomics in District Mohmand. Risk identified for cutaneous leishmaniasis are significant in strategising control methods for Health authorities can allocate localized control means to high-risk areas using these findings.

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.

Spatial Distribution, Seasonal Abundance and Physio-Chemical Assessment of Mosquito Larval Breeding Sites in Mardan District, Khyber Pakhtunkhwa, Pakistan.

Background: Mosquitoes (Diptera: Culicidae) are haemotophagus insects and are vectors of many arthropod-borne diseases. Present study aimed to explore species composition, seasonal abundance, spatial distribution and physio-chemical properties of larval breeding sites of mosquitoes in District Mardan, Khyber Pakhtunkhwa, Pakistan. Methods: Both adults and larvae of mosquitoes were collected through light traps, insecticide spray, mouth aspirator and larval standard dipping method in District Mardan from May to November 2017. Water samples from larval sites were physio-chemically analysed. Results: 5078 (3704 adults and 1374 larvae) mosquito specimens were collected in Mardan, Katlang and Takhtbhai tehsils. Six species in four genera were reported. Culex pipiens (89.80%) and Armigeres subalbatus (9.20%) were the most abundant species. Diversity was high in Takhtbhai (0.29) followed by Katlang (0.28) and Mardan (0.25). Greater number of specimens were recorded in peridomestic sites (93.97%) as compared to domestic habitats (6.03%). Culex pipiens larval abundance had negative correlation with pH whereas it correlated positively with electric conductivity, salinity, and TDS (total dissolved sulphur). Mosquito abundance peaked in August and July while the lowest was in May. Their monthly abundance had positive correlation with rainfall (r= 0.5069), relative humidity (r= 0.4439) and mean minimum temperature (r= 0.2866). Number of mosquitoes was highest at low elevation < 347m asl (above sea level) in agriculture land and near to water bodies (streams). Conclusion: Culex pipiens being the most abundant species, was susceptible to high pH. Mosquitoes preferred habitats were at low elevation in agriculture land.

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.

Heavy Metals Accumulation in Dragonflies (Odonata) and Their Habitats in District Swabi, Khyber Pakhtunkhwa, Pakistan: Assessing Dragonfly Bionomics in the Region.

The current study aimed to examine the bionomics of dragonflies and heavy metal accumulation in their bodies and environment (sediments and water) from district Swabi, Khyber Pakhtunkhwa, Pakistan. A total of 1683 dragonflies were collected from May to September, 2018 in 4 tehsils (administrative subdivisions) of district. Orthetrum pruinosum neglectum was the most abundant species followed by O. anceps and O. chrysostigma luzonicum. Highest abundance was observed in July and August corresponding to maximum temperature and rainfall. Dragonflies displayed preferable abundance within agricultural lands and on elevation ranging from 206 to 506 m. Heavy metal analysis of sediments and water samples from 4 tehsils showed significant differences in mean concentrations of Pb, Zn, Cu, and Fe. Abundance among districts was negatively associated with Fe levels in water while the species diversity had a significant positive relationship with Fe in sediments. Accumulation of metals in each body part significantly varied among species. N. tullia tullia and O. anceps specifically demonstrated their tolerance to high concentrations of heavy metals.

Molecular detection of Cryptosporidium: an emerging parasite in different water sources of 2010 flood-affected district Nowshera, Pakistan.

Cryptosporidium is a water-borne zoonotic parasite worldwide, usually found in lakes and rivers contaminated with sewage and animal wastes, causing outbreaks of cryptosporidiosis. In this study, 300 water samples were collected from four designated places of flood-affected district Nowshera consist of different water sources to find out the prevalence of Cryptosporidium via polymerase chain reaction (PCR). The overall prevalence of Cryptosporidium was 30.33% (91/300) with more prevalent 44% in drain water and low 5% in bore/tube well water. The prevalence in open well and tap water was recorded 33% and 20%, respectively. The highest prevalence was recorded in summer (June-September). The result of this study ensures enormous contamination of drinking water that requires appropriate treatment, cleaning and filtration to provide safe drinking water. Preventing water-borne disease and proper treatment of water supplies is essential to public health.

Sand Fly (Diptera: Psychodidae) Species Diversity, Habitat Preferences, and Ecological Aspects of Distribution in Bajaur District, Khyber Pakhtunkhwa, Pakistan.

The species composition, distribution, and bionomics of sand flies was investigated from January to December 2017 in four tehsils (20 villages) of district Bajaur (formally Bajaur agency), Khyber Pakhtunkhwa, Pakistan. In total, 4,173 adult specimens comprising of seven species of Phlebotomus (Diptera: Psychodidae) and three species of Sergentomyia (Diptera: Psychodidae) were collected by oral aspirator, insecticide spray, and sticky traps from June to October. Highest numbers of flies were collected indoors in July and August when relative humidity and temperature were highest. Phlebotomus sergenti Parrot (Diptera: Psychodidae) was the most abundant species from all the collection sites, making approximately 70% of the total capture. Combined dwellings and chicken cages harbored the highest number of adult and immature flies (unrotated external genitalia). Abundance of P. sergenti had a significant (P ≤ 0.05) positive correlation with monthly average temperature, relative humidity, and average rainfall in indoor collections. On the other hand, P. papatasi Scopoli displayed similar correlation in the indoor and nighttime collections. Both the species were apparently abundant in the elevation range ≤ 419 m above sea level and on rangelands. Phlebotomus papatasi, however, also occurred on agricultural lands. The number of cutaneous leishmaniasis (CL) cases did not significantly correlate with the abundance of sand fly vectors across the villages surveyed. The results reported herein can serve as a baseline for an all-extensive future work in Bajaur. Our investigations will benefit the public health experts and medical entomologists for improved control and surveillance vectors of leishmaniasis.

Habitat characterization of sand fly vectors of leishmaniasis in Khyber Pakhtunkhwa, Pakistan.

Leishmaniasis is currently prevalent in 98 countries including Pakistan, where its wide-spread. Phlebotomus papatasi Scopoli and Phlebotomus sergenti Parrot are suspected vectors of cutaneous leishmaniasis (CL) while P. Phlebotomus major Yakimoff and Phlebotomus hindustanicus Theodor are vectors of visceral leishmaniasis (VL) in the Khyber Pakhtunkhwa (KP) province of Pakistan. The present study identifies the complexity of environmental factors affecting the distribution of these vector sand fly species in KP. Sand fly habitats in the province were characterized from relevant published sources and analyzed using geographic information system (GIS) tools. Specific spatial analysis indicated that P. sergenti and P. papatasi were ecological generalists, found in diverse ecological settings, while P. major and P. hindustanicus were less frequent and had restricted foci in Khyber Pakhtunkhwa. We specifically observed a close association between elevation and existance of several sand fly species. P. sergenti primarily presented at high elevation while P. papatasi had distribution at low altitudinal ranges. P. major and P. hindustanicus were apparently limited to high altitudes in the northern areas of the province. This GIS-based spatial investigation of Phlebotomine vectors of leishmaniasis aims to provide a beneficial tools to medical entomologists, epidemiologists and public health workers for regional control of leishmaniasis. Outcomes from such spatial studies can be utilized in planning vector control initiatives so as to ensure proper allocation of funds for the region's integrated vector control program budget.

Geospatial and Climatic Patterns Associated With the Distribution of Sand Fly (Diptera: Psychodidae) Vectors of Leishmaniasis in Pakistan.

We provide a comprehensive and updated review on the effects of elevation and climatic factors on distribution of sand fly (Diptera: Psychodidae) vectors of cutaneous leishmaniasis (CL) and visceral leishmaniasis (VL) across Pakistan. Our study was undertaken in view of the increasing risk of leishmaniasis, particularly resulting from climatic deviations and political instability in the region. Literature (published and unpublished) on suspected vectors of CL (Phlebotomus sergenti Parrot and Phlebotomus papatasi Scopoli) and VL (Phlebotomus major Yakimoff and Schokhor and Phlebotomus hindustanicus Theodor) was collected, sorted, and utilized in geospatial analysis. P. papatasi and P. sergenti co-occurred in majority of the referenced localities and were generally distributed toward the western and southern parts across a wide range of elevation, whereas P. major and P. hindustanicus were limited to high elevation in cool and humid northern areas of Pakistan. Conversely P. papatasi and P. sergenti exploited diverse ecological settings across the country, being particularly abundant in warm/hot and arid regions.

Potential Resting and Breeding Sites of Sand Flies (Diptera: Psychodidae) and Their Habitat Characteristics in Leishmaniasis Foci of Dir Districts, Khyber Pakhtunkhwa, Pakistan.

Despite their medical importance, natural breeding sites of sand flies have been poorly explored. Detecting such sites is imperative in vector control strategies. This study aimed to identify potential breeding and resting microhabitats of sand flies and household risk factors associated with cutaneous leishmaniasis transmission in Dir districts, Khyber Pakhtunkhwa, Pakistan. Survey of indoor and outdoor habitats in four tehsils (subdistricts) of upper and lower Dir districts was carried out using sticky traps, flit method, and aspirator. To assess risk factors associated with cutaneous leishmaniasis (CL), questionnaires were administered to household heads. Mud houses and plants belonging to Cucurbitaceae family sheltered highest number of sand flies. Excessive number of flies were collected from indoor sites (common rooms used for both people and animals) compared to outdoor habitats (cattle dungs). Phlebotomus salangensis Artemiev, 1978 and Phlebotomus sergenti were the most widely distributed species, while Sergentomyia bailyi peaked in caves with high organic content in soil. Roof material and ownership of fans were associated with significant risk of CL. Findings of this study present a list of potential breeding sites for sand flies and CL risk factors that can be targeted and implemented in control programs for CL. Further studies are required to elucidate the breeding behavior and preferences of these medically important vectors.

Species composition and activity patterns of sand flies (Psycodidae: Phlebotomine) in four tehsils of Dir Districts, Khyber Pakhtunkhwa, Pakistan.

The present study reports sand flies species composition, fauna diversity and seasonal variations from four tehsils of Dir Districts, Khyber Pakhtunkhwa, Pakistan. Collection was made using sticky traps, flit method and aspiration where highest number of sand flies was captured through sticky traps. Digitalized sand flies distribution maps were produced using geographic information system ArcGIS. A total of 7292 specimens were captured between January to December 2014, comprised of 11 Sergentomyia and 9 Phlebotomus. Phlebotomus salengensis was the most abundant species followed by Phlebotomus sergenti. Overall, male to female ratio observed was 3:1 and species diversity varied among the studied tehsils. Highest abundance was recorded in July and August, whereas the flies disappeared in the colder months (November-April) of the year. Information about insect vector behaviour in natural setting is required to understand the status of disease caused by them. This study is a thorough account of biodiversity of sand flies in the region and provides a useful insight in to identifying potential breeding preferences of sand flies and recognition of active and potential vector species in the Dir districts. Further large scale studies are needed to determine the behaviour, infection rate, and the natural reservoir hosts of sand fly vectors in the region.