Clinical and laboratory evaluation of cured and non-cured patients with cutaneous leishmaniasis treated by Glucantime.

BACKGROUND & OBJECTIVES: Insufficient treatment of cutaneous leishmaniasis (CL) by conventional drugs is a major barrier in control strategies. This study was aimed to evaluate Glucantime efficacy and the susceptibility of Glucantime unresponsive and responsive CL isolates in the field and laboratory. METHODS: Chi-square test (x[2]) was used to determine the significance of difference between proportions in Glucantime-treated patients. The inhibitory activity of various concentrations of Glucantime against Leishmenia tropica stages was evaluated by a colorimetric cell viability MTT and macrophage assays. Mixed model, t-test and ANOVA were performed to determine the significance of difference between various concentrations of Glucantime unresponsive or responsive isolates and untreated control group and p <0.05 was defined as significant level. Altogether, 89.8% of the patients were cured by Glucantime, whilst 10.2% remained non-cured. RESULTS: The overall Glucantime efficacy in different age groups and genders was similar. The IC50 values of promastigotes and amastigotes for Glucanime unresponsive isolates were 2.1 and 2.6 times higher than the equivalent rates obtained for responsive cases, respectively. The overall mean number of amastigotes within macrophages in unresponsive isolates was significantly higher (32.68 ± 1.24) than that in responsive ones (18.68 ± 1.52, p <0.001). Glucantime unresponsive and responsive field isolates of anthroponotic CL (ACL) caused by L. tropica strongly correlated to in vitro assays. INTERPRETATION & CONCLUSION: Monitoring of Glucantime unresponsiveness by the health surveillance system is extremely important, where anthroponotic transmission occurs in humans. Hence, physicians should be aware of such clinical unresponsive presentations with ACL for antimonial therapeutic failure to improve management of disease in endemic regions.

Antifungal and antibacterial activity of densely dispersed silver nanospheres with homogeneity size which synthesized using chicory: An in vitro study.

With increase in isolation of multi and extensive drug resistance hospital pathogens (MDR, XDR) in burn centers of many hospitals in the world, attempt to use nanomaterials for treatment of burn-infected patients is the focus of researches all around the world. In the present investigation silver nanospheres (Ag NSs) has been synthesized by chicory seed exudates (CSE). The various parameters influencing the mechanism of Ag NSs synthesis including temperature, concentration, pH and time were studied. Greener Ag NSs were formed when the reaction conditions were altered with respect to pH, concentration of AgNO3 and incubation temperature. Finally, we evaluated antimicrobial activity of silver nanospheres biosynthesized by chicory (Cichodrium intybus) against most prevalent burn bacteria pathogens Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter baumannii, and fungus Fusarium solani. The UV visible spectroscopy, X-Ray diffraction (XRD), dynamic light scattering (DLS) used for primary screening of physicochemical properties. The transmission electron microscopy (TEM) images showed the Ag NSs (with globular shape) with a size less than 25nm that they have the same size about 8nm (more than 97% are 8nm). Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of Ag NSs against the standard strains of A. baumannii, P. aeruginosa and K. pneumonia showed a relatively high inhibitory and bactericidal activity (MIC 1.56µg/mL and MBC 3.12µg/mL) of the nanoparticles and F. solani cultures. In antifungal tests, the lowest level of zone of inhibition was observed at a concentration of 5µg/mL synthesized silver nanospheres with the 7% inhibition of growth. Ag NSs have high antimicrobial activity against three common burn bacteria pathogens and fungus F. solani. Therefore, Ag NSs can be used to prevent burn infection and for wound healing.

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

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

Intestinal microsporidiosis in Iran: infection in immune-compromised and immunocompetent patients.

BACKGROUND AND PURPOSE: Gastroenteritis and the clinical profile caused by Microsporidia, an opportunistic pathogen, may be severe in immunocompromised individuals, especially in AIDS patients. Conventionally, it is necessary to detect the small infective spores in stained smears. However, due to the limitations of the microscopy-based methods, several DNA-based methods such as polymerase chain reaction (PCR) have recently been developed to enhance diagnosis sensitivity. Therefore, we sought to evaluate the rate of infection in immunocompromised patients as compared with immunocompetent patients in Kerman, Iran. MATERIALS AND METHODS: We collected stool samples of 199 human subjects (116 males and 83 females), aged 1 to 69 years old. They were divided into immunocompromised (i.e., AIDS [n=72] and cancer-positive patients [n=59]) and immunocompetent (n=68) groups. We comparatively examined the fecal materials using the microscopy and PCR methods. RESULTS: The overall prevalence rate of Microsporidia infection was 10.05% (20/199). Entrocytozoon bieneusi was the only species within the Microsporidia genus that was identified in 14.5% (19/131) of the immunocompromised patients and 1.47% (1/68) of the immunocompetent individuals. CONCLUSION: Considering the higher prevalence rate of microsporidiosis in patients with immunodeficiency (10.03%), we suggest performing sensitive and specific techniques such as PCR for the detection of these parasites in immunocompromised patients.

First report on natural Leishmania infection of Phlebotomus sergenti due Leishmania tropica by high resolution melting curve method in South-eastern Iran.

OBJECTIVE: To identify the Leishmania species in infected sand flies by Real-time PCR coupled with HRM analysis. METHODS: Real-time PCR coupled with HRM analysis targeting the first internal transcribed spacer (ITS1) of nuclear ribosomal DNA as the genetic marker was used to identify and distinguish Leishmania species in sand flies specimens. RESULTS: Three out of 115 females of Phlebotomus sergenti (P. sergenti) (2.6%) were positive to Leishmania tropica (L. tropica). CONCLUSIONS: This is the first report on P. sergenti as the main and proven vector of anthroponitic cutaneous leishmaniasis in Dehbakri County using Real-time PCR coupled with HRM analysis. This method is rapid, sensitive and specific for diagnosing of parasites in infected Sand flies and ideal for large scale genotyping projects.

Investigation of Double-Band Electrophoretic Pattern of ITS-rDNA Region in Iranian Isolates of Leishmania tropica.

BACKGROUND: Leishmania tropica is a genetically divergent species. Amplification of entire internal transcribed spacer (ITS) region of L. tropica isolates obtained from Bam district, one of the well known focus of anthroponotic cutaneous leishmaniasis (ACL) in Iran, revealed a double-band pattern in agarose gel electrophoresis. This study explains how this pattern occurs. METHODS: Twenty seven L. tropica smear preparations were collected from Bam district, south east Iran, and eight L. major and one L. infantum smear preparations were gathered from Shiraz, south west Iran. Furthermore one L. major and one L. infantum cultured standard strains were tested using entire ITS-PCR to survey their electrophoretic pattern. The ITS sequences of L. tropica, L. major, and L. infantum already deposited in GenBank were analyzed. Analysis of GenBank sequences of L. tropica revealed two groups of sequences based on length size, one group having a 100 bp gap. Therefore, a new reverse primer namely LITS-MG was designed to exclude this gap in PCR products. RESULTS: Whole ITS fragment amplification resulted in a double-band pattern in all L. tropica cases, while a sharp single band was observed for L. infantum and L. major isolates. This result was corresponding to the result obtained from in silico analysis of GenBank sequences. Use of LITS-MG primer was expectedly resulted in a single band including ITS1, 5.8s and partial ITS2 product for L. tropica which is appropriate for following molecular studies such as sequencing or restriction analysis. CONCLUSION: Sequences analysis of GenBank L. tropica sequences and following practical laboratory tests revealed at least two alleles in L. tropica which were confirmed in Bam isolates. This especial double-band pattern is because of a 100 bp fragment difference within ITS-rDNA alleles.

Spatial distribution and molecular identification of leishmania species from endemic foci of South-eastern iran.

BACKGROUND: Cutaneous leishmaniasis constitutes a major public health problem in many parts of the world including Iran. The primary objective of this study was to identify Leishmania species in endemic districts of Kerman Province, south-eastern Iran. METHODS: This study was conducted by random sampling as cross- sectional descriptive between 2008 and 2010. Overall, 203 skin scraping smears were taken from the patients. Nested -PCR was performed to amplify variable minicircle fragments of Leishmania kDNA. RESULTS: Bam was the most infected district (71.1%), followed by Kerman (14.7%), Jiroft (5.4%), Baft (2.7%), Sirjan (1.6%), Shahr-e Babak (1.5%) and others (3.0%). L. tropica was the most common species identified (194 cases, 95.6%), while L. major was found in only 9 cases (4.4%). Of 203 identified patients, all species in Bam (l07 cases), Kerman (32 cases), Jiroft (l6 cases) and Shahr-e- Babak (l1 cases) were detected as L. tropica, whereas infected subjects in Baft and Sirjan showed L. tropica or L. major. Characterization of Leishmania species resulted in generation of 750 bp and 560 bp fragments, corresponding to those of L. tropica and L. major, respectively. CONCLUSION: L. tropica is the main species (95.6%) caused ACL in endemic areas of Kerman Province; however L. major is present in low level (4.4%).

Fatal Case of Plasmodium vivax Malaria in a Splenectomized Patient.

Malaria is a major problem in tropical and sub-tropical countries, with high morbidity and mortality. Splenectomy makes patients more susceptible to serious bacterial and parasitic infections. We report for the first time in Iran a fatal case of Plasmodium vivax malaria, confirmed by microscopic and molecular (Semi-nested multiplex PCR) tests in a patient who had undergone splenectomy due to hemolytic anemia.

Sonographical and serological survey of human cystic echinococcosis and analysis of risk factors associated with seroconversion in rural communities of Kerman, Iran.

Cystic echinococcosis (CE) caused by larval stage of Echinococcus granulosus, is an endemic zoonosis in Iran particularly in rural regions. The objective of this study was to determine the prevalence of CE among rural communities in Kerman using ultrasonography (US) and serology. Kerman Province, in southeastern Iran, is the largest province, with 2.9 million inhabitants. A sample of 1140 individuals (200 males and 940 females) was selected by randomized cluster sampling in 2006-2008. After acquiring informed consent for each participant a questionnaire was filled, complete abdominal US in supine position was carried out and 5 ml blood was collected for ELISA test. Two hydatid cases (0.2%) were detected by ultrasound. Serological results showed 7.3% seropositivity, and females (8.3%) were significantly more positive than males (2.1%). There were significant difference between CE seropositivity and sex, age and occupation. Residents of desert regions (Shahdad, Andouhjerd and Golbaf) were 2.5 times more likely to be seropositive than mountainous regions with better socioeconomic status (OR = 2.5; 95% CI = 1.09-5.95). Dog ownership does not appear to be a significant risk factor for CE in the region. Only about 10% of households own dogs, usually only one dog. However, the stray dog population of Kerman province is estimated at 145 000-480 000 (3.5-11.5 times the owned dog population). Infection in humans and animals would appear to come mostly from infected stray dogs. Management of stray dog population could make major progress in control of hydatid disease. In addition, proper washing of vegetables decreased probability of infection by 53% (OR = 0.47; 95% CI = 0.26-0.84). The serological study showed that many people, especially women, had been exposed to Echinococcus eggs and had seroconverted but were not infected.

Cutaneous leishmaniasis in bam: a comparative evaluation of pre- and post-earthquake years (1999-2008).

BACKGROUND: The recent devastating earthquake of December 26 in Bam, 2003 created various risk factors; caused a sharp increase in incidence of anthroponotic cutaneous leishmaniasis (ACL) cases and reached to an epidemic proportion. The objective of this study was to evaluate the status of ACL cases five years before the earthquake compared to the cases occurred five years after the earthquake (1999-2008). METHODS: Status of disease was assessed retrospectively for the five years before the earthquake and prospectively for the five years after the earthquake. Identification was confirmed by smear and polymerase chain reaction (PCR). RESULTS: The mean annual incidence of ACL for the period from 1999 to 2003 was 1.9 per 1000 comparing to post earthquake period, which was 7.6 per 1000. Most of the infection was in individuals of <20 years, more frequently in females before the earthquake, whilst in contrast, there was a progressive rise in the number of cases, significantly in male individuals of >20 years (P< 0.0001) in post earthquake era. The anatomical distribution of lesions considerably changed during the two periods. Most of the cases were limited to three zones within the city prior to the earthquake, whereas it was spread throughout different zones after the earthquake. PCR indicated that the CL was due to Leishmania tropica in the city. CONCLUSION: The results strongly suggest that in natural disasters such as earthquakes various precipitating factors in favor of disease will be created, which in turn provide a suitable condition for propagation of the vector and the transmission of the parasite.

Susceptibility Status of Phlebotomus papatasi and P. sergenti (Diptera: Psychodidae) to DDT and Deltamethrin in a Focus of Cutaneous Leishmaniasis after Earthquake Strike in Bam, Iran.

BACKGROUND: The cutaneous leishmaniasis (CL) has been occurred in Dehbakri County, located 46 km of Bam District, Kerman Province since 2004-2005. Phlebotomus papatasi is an important vector of zoonotic cutaneous leishmanisis (ZCL) as well as sand fly fever and P. sergenti is considered as main vector of anthroponotic cutaneous leishmaniasis (ACL) in Iran. There are several measures for vector control with emphasizing on insecticides. The objective of this study was to determine the baseline susceptibility of leishmaniasis vectors to the DDT and deltamethrin in an endemic focus of CL in southern Iran. METHODS: Baseline susceptibility tests were carried out on field collected strains of P. papatasi and P. sergenti and tested with WHO impregnated papers with DDT 4.0% and deltamethrin 0.05% in the focus of disease in Dehbakri County during summer 2010. The values of LT(50) and LT(90) were determined using probit analysis and regression lines. RESULTS: The LT(50) value of DDT 4.0% and deltamethrin 0.05% against P. papatasi was 20.6 and 13.6 minutes respectively. The same data for P. sergenti were ranged between 21.8 and 17.7 minutes. CONCLUSION: The results of tests will provide a guideline for implementation of vector control using pesticides such as impregnated bed nets, indoor residual spraying and fogging.

Epidemiological aspects of visceral leishmaniasis in baft district, kerman province, southeast of iran.

BACKGROUND: Visceral leishmaniasis (kala-azar) is an endemic disease in some areas of Iran. A cross- sectional study was conducted for sero-epidemiological survey of visceral leishmaniasis (VL) in Baft district from Kerman Province, southeast of Iran. METHODS: Blood samples were collected from children up to 12 years old and 10% of adult population from Baft villages with a multi-stage randomized cluster sampling. In addition, blood samples were collected from 30 domestic dogs from the same areas. All the collected blood samples were tested by direct agglutination test (DAT) for the detection of anti-Leishmania antibodies in both human and dog using the cut-off value of ≥1:3200 and ≥1:320, respectively. Parasitological, molecular, and pathological were performed on infected dogs. Chi-square and Fisher exact tests were used to compare sero-prevalence values. RESULTS: From 1476 collected human serum samples, 23 (1.55%) showed anti-Leishmania antibodies at titers of 1:800 and 1:1600 whereas 14 (0.95%) showed anti-Leishmania infantum antibodies at titers of ≥1:3200. No statistically significant difference was found between male (1.18%) and female (0.69%) sero-prevalence (P=0.330). Children of 5-8 years showed the highest sero-prevalence rate (3.22%). Seven out of 30 domestic dogs (23%) showed anti-Leishmania antibodies at titers ≥1:320. Leishmania infantum was identified in five infected dogs by nested - PCR assay. CONCLUSION: It seems that visceral leishmaniasis is being endemic in southern villages of Baft district, southeast of Iran.

Emergence of cutaneous leishmaniasis in a border area at south-east of Iran: an epidemiological survey.

BACKGROUND & OBJECTIVES: Cutaneous leishmaniasis (CL) has been recently emerged in new foci, posing a public health problem. Increasing cases of CL have been reported during recent years from a border area between Iran and Pakistan, a previously non-endemic area. The present study was designed for epidemiological and parasitological characterization of the disease for the first time in this area. METHODS: A total of 3100 individuals from the city of Mirjaveh and its four rural districts were randomly selected and surveyed from March 2005 to February 2006. Microscopic examination, in vitro culture, mouse inoculations and species-specific kDNA-PCR assay were carried out for Leishmania detection and species identification. RESULTS: CL was endemic in an important rural district of Mirjaveh, presenting active lesions and scars in 6.6 and 9.5%, respectively. The highest rates of both active lesions and scars were found in the age group of 10 years or under with significant differences (p < 0.05) comparing to the older age groups. No association between genders and the rate of leishmaniasis was observed (p > 0.05). The most affected location was upper limb, 39.2% of ulcers and 41.7% of scars. Inoculation of the clinical isolates on Balb/c mice, led to the development of ulcers in the animals, implying that the causative parasite is Leishmania major. The PCR amplification also generated amplicons specific to L. major. CONCLUSION: It can be concluded that Mirjaveh is an endemic region of cutaneous leishmaniasis as a new focus due to the recent emergence in this border area of south-east of Iran with a major contribution of L. major, as the causative parasite species.

Bacterial infections in children with visceral leishmaniasis: observations made in Kerman province, southern Iran, between 1997 and 2007.

Cases of human visceral leishmaniasis (VL) are often found to have bacterial infections. Between 1997 and 2007, 60 cases of VL were admitted to the paediatric ward of the Afzalipour Medical Centre, which forms part of the Kerman University of Medical Sciences, in southern Iran. On admission, the 60 cases (39 boys and 21 girls), each of which was confirmed by the demonstration of amastigotes in a bone-marrow aspirate, had a mean (S.D.) age of 48.8 (44.4) months and a mean (S.D.) erythrocyte sedimentation rate of 53.2 (34.2) mm/h. Twenty-five (42%) of the cases (14 boys and 11 girls) were found to have bacterial infections. Urinary infections (seen in 36% of the cases with bacterial infection) were the most common, followed by blood (28%), respiratory (16%), gastro-intestinal (12%) and skin infections (8%). Despite treatment of all the VL cases with meglumine antimoniate, four (7%) died on the paediatric ward, all four having concurrent bacterial infections. The leucopenia and immunosuppression associated with VL probably facilitate the development of fatal bacterial co-infections. The prompt diagnosis and treatment of both the VL and any bacterial co-infections should therefore reduce mortality among VL cases.

Monitoring of insecticides resistance in main malaria vectors in a malarious area of Kahnooj district, Kerman province, southeastern Iran.

BACKGROUND AND OBJECTIVES: Kahnooj district in south of Iran is an endemic area for malaria where Anopheles stephensi (Liston) is a main malaria vector and An. dthali (Patton) a secondary vector. According to the national strategy plan on monitoring of insecticides resistance, this study was performed on susceptibility and irritability levels of An. stephensi and An. dthali to different insecticides in the district. METHODS: The susceptibility and irritability levels of field strains of An. stephensi and An. dthali at the adult and larval stages to discriminative dose of different imagicides was determined as recommended by WHO. RESULTS: Using discriminative dose and WHO criteria it was found that An. stephensi is resistant to DDT and dieldrin with 36.1 +/- 2.3 and 62.2 +/- 1.95 mortality rates, respectively; but susceptible to other insecticides. An. dthali was found to susceptible to all tested insecticides. The larvae of An. stephensi, exhibited 100% mortality for temephos and malathion, but 44 +/- 4.32 for discriminative dose of fenitrothion. The results of irritability level for DDT and pyrethroids showed that permethrin had the most irritancy effect on An. stephensi and An. dthali. DDT and deltamethrin showed the least irritancy effect against An. stephensi with 0.42 +/- 0.08 and 0.77 +/- 0.12 take-offs/min/adult, respectively, however, lambdacyhalothrin had the least irritancy effect against An. dthali with 0.096 +/- 0.02 take-offs/min/ adult. The mean number of take-offs/min/adult with permethrin showed significant difference to DDT, lambdacyhalothrin, cyfluthrin and deltamethrin. INTERPRETATION AND CONCLUSION: Pyrethroid insecticides are being used as indoor residual sprays in Iran. Based on our results, the main malaria vectors in the region are still susceptible to pyrethroid insecticides. Therefore, we propose the use of pyrethroids with low irritancy effect in rotation with carbamate insecticides in two interval seasonal peaks of malaria transmission. Biological control including larvivorous fishes, using of local made Bacillus thuringiensis and larvicides such as chlorpyrifos-methyl are the main larval control in the region. Result on larval test exhibited the susceptibility of main vectors to some larvicides, although the 100% mortality was not obtained using fenitrothion and this is postulated the use of this insecticide in agriculture pest control. Monitoring and evaluation of insecticides resistance in malaria vectors in the region could provide an essential clue for judicious use of insecticides.

Characterization of Leishmania isolated in Iran: 1. Serotyping with species specific monoclonal antibodies.

A total of 156 isolates of Leishmania from patients with cutaneous leishmaniasis and one isolate from gerbil were characterized using standard monoclonal antibodies (mAb) in ELISA and IFA test systems. The geographic distribution of the isolates was 30 isolates in Shiraz, 28 in Kerman and 98 in Tehran. A total of 63, 72, and three Leishmania promastigote isolates preferentially reacted with anti-Leishmania tropica mAb (A11), anti-Leishmania major mAb (T1) and anti-Leishmania infantum mAb (D2), respectively. Of the three isolates which reacted with anti-L. infantum mAb, two were dermotropic strains of L. infantum and one was the organism isolated from gerbil. Mixed reactions with the monoclonal antibodies were also observed as six isolates reacted with both anti-L. tropica and anti-L. major mAbs, five reacted with anti-L. tropica and anti-L. infantum mAbs and two with anti-L. major and anti-L. infantum mAbs. The monoclonal antibodies used did not react with five of the isolates. The present investigation has identified the organisms from the known and newly emerged foci of cutaneous leishmaniasis in Iran.

A randomised, double-blind, controlled trial of a killed L. major vaccine plus BCG against zoonotic cutaneous leishmaniasis in Iran.

Safety and efficacy of killed (autoclaved) L. major promastigotes, ALM, mixed with BCG against zoonotic cutaneous leishmaniasis was tested in healthy volunteers (n = 2453) in a randomized double blind trial vs. BCG as control. Side-effects were similar in both groups but tended to be slightly more frequent and prolonged in the ALM + BCG group. Leishmanin skin test conversion (induration > or =5 mm) was significantly greater in the ALM + BCG than in the BCG group (36.2% vs. 7.9% on day-80 and 33% vs. 19%, after 1 year, respectively). Cumulative incidence rates for 2 years, were similar in both groups (18.0% vs. 18.5%). However, LST responders on day 80 (> or =5 mm) had a significantly lower incidence (35%) of CL during the first year than non-responders. A single dose of ALM + BCG is not sufficiently immunogenic to provide a measurable response when compared to BCG alone. A single dose of this vaccine has been shown to be safe with no evidence of an exacerbating response following natural infection; hence, multiple doses or other adjuvants should be considered to increase its immunogenicity.

Cutaneous leishmaniasis in primary school children in the south-eastern Iranian city of Bam, 1994-95.

Between August 1994 and July 1995, 11,517 primary school children aged 6-11 years in the south-eastern Iranian city of Bam, comprising 5560 (48.3%) girls and 5957 (51.7%) boys, were examined for the presence of active lesions or scars of cutaneous leishmaniasis (CL). There was a trend towards increasing prevalence with age, the prevalence being 10.7% in 6-year-old and 20% in > or = 11-year-old children. Overall, 1.3% of the children had active lesions and 14.3% had scars. There was no significant difference between the sexes in the prevalence of active lesions and/or scars. Of the children examined, 54 (0.5%) had leishmaniasis recidivans: 19 girls (35.2%) and 35 boys (64.8%). The number of active lesions or scars per child ranged from 1 to 10. The majority (82.3%) had 1 lesion, 12.4% had 2 lesions, and 5.3% had > or = 3. The average number of lesions was 1.08 (1.03 in girls and 1.18 in boys). The face was the part of the body most commonly involved (63.6%), followed by the hands (20.9%), legs (12.8%) and other parts of the body (2.7%). Examination of isolates from 14 children revealed that in 13 (92.9%) the causal organism was Leishmania tropica and in the other (7.1%) L. major. The survey indicates that the geographical distribution of CL is far wider than previously thought. It also shows that Bam is a suitable areas for a vaccine field trial.

PIP: Cutaneous leishmaniasis, caused by Leishmania tropica, is endemic in southeastern Iran's Kerman Province, including the city of Bam. As a first step toward selecting different arms of a vaccine field trial, all 11,517 primary school students 6-11 years old from Bam were examined between August 1994 and July 1995 for the presence of active lesions or scars of cutaneous leishmaniasis. Overall, 1.3% of children had active lesions and 14.3% had scars. Prevalence tended to increase with age, but there was no difference on the basis of sex. 54 children (0.5%) had leishmaniasis recidivans. The number of active lesions or scars per child ranged from 1 to 10 (average, 1.08). Body parts most frequently affected were the face (63.6%), hands (20.9%), and legs (12.8%). Examinations of isolates from 14 children revealed that L. tropica was the causal organism in 13 (92.9%). These findings indicate that cutaneous leishmaniasis is even more widely distributed throughout Iran than previously thought, probably as a result of agricultural and unplanned urban development. They further confirm that Bam is a suitable location for a vaccine field trial.

Randomised vaccine trial of single dose of killed Leishmania major plus BCG against anthroponotic cutaneous leishmaniasis in Bam, Iran.

BACKGROUND: A vaccine consisting of a single dose of whole-cell autoclave-killed Leishmania major (ALM) mixed with BCG was assessed in comparison with BCG alone against anthroponotic (human to human transmission) cutaneous leishmaniasis in a randomised double-blind trial in Bam, Iran. METHODS: 3637 schoolchildren, aged 6-15 years, with no history of cutaneous leishmaniasis and no response to a leishmanin skin test, were randomly assigned to receive 1 mg ALM mixed with BCG (n = 1839), or BCG alone (n = 1798). Safety of the vaccine and the incidence of confirmed cases of cutaneous leishmaniasis were followed up for 2 years. FINDINGS: Side-effects were those usually associated with BCG vaccination, but tended to persist longer in the ALM + BCG group. After exclusion of four cases occurring within 80 days of vaccination (one in the ALM + BCG group and three in the BCG group), the 2-year incidence of cutaneous leishmaniasis did not differ significantly between vaccine and BCG groups: 2.8% vs 3.3%, respectively (total cases 112). A sex-stratified analysis showed that in boys the vaccine conferred a protective efficacy of 18% and 78% for the first and second years, respectively--a crude 2-year overall protection of 55% (95% CI 19-75%, p < 0.01). In the first 9 months after vaccination, there was a non-significant excess of cases in the ALM + BCG group (25 vs 16), whereas the incidence of cutaneous leishmaniasis thereafter was significantly reduced in the ALM + BCG group (27 vs 44, p < 0.05). INTERPRETATION: A single dose of ALM + BCG was safe and more immunogenic than BCG alone, as measured by leishmanin skin test. The exact reason for the apparent protective effect of the vaccine in boys is unknown, and may be a chance finding. However, since boys are more exposed to the infection, which is indicated by higher disease prevalence in boys in this study population, the preferential protective effect in boys may have resulted from a greater booster effect produced by repeated exposure to infected sandflies. Booster injections or alternative adjuvants should be tried to improve the potential efficacy of this vaccine.