The Relationship between Socio-economic Risk Factors and Contracting of Zoonotic Cutaneous Leishmaniasis in Al-Hasa Region of Kingdom of Saudi Arabia

 

A dissertation submitted

By Bandar Saleh

 

Liverpool School of Tropical Medicine

 

This dissertation has been submitted in partial fulfilment of the
requirements for the award MASTER IN MOLECULAR BIOLOGY OF PARASITE DISEASES AND VECTORS

 

Word count

 

Acknowledgements

I would like to dedicate this research study to special supporters whose continuous support has ensured the materialization of determining the influence of socio-economic risk factors on contracting zoonotic CL infection in the Al-Hasa region of KSA.

I sincerely express my heartfelt gratitude to Dr., my chair Dr.Alvaro Acosta, Dr. James Lacourse, Dr. Martyn Stewart, Prof. Asif Fatani, and Prof. Mohammed Afifi.and Prof..Mahmoud Foaad. Your consistent guidance and patience with me has helped me understand the seriousness of NTDs in KSA.

I would also like to extend my heartfelt thanks to King Abdul-Aziz University, Liverpool School of Tropical Medicine, and Ministry of Health of Saudi Arabia and Ministry of Education of Saudi Arabia. Your open support towards mitigating and eradicating NTDs, especially cutaneous leishmaniasis is commendable. I thank you once again for your open support.

Last but not the least, dear father, Hasan Saleh, dear mother, Madeehah Al-Siyami, and my gorgeous your beautiful presence in my life has made me understand the importance of education and I sincerely thank my God, my Allah, for blessing me with such parents and teachers.

May god bless each one of you!

 

 

 

abstract

Background: Cutaneous leishmaniasis (CL) is endemic in Al-Hasa region of KSA and periodic studies identifying the risk factors are essential to mitigate the NTD through relevant control measures.

Objective: To determine the influence of socio-economic risk factors associated with contracting zoonotic CL infection in the Al-Hasa region of KSA.

Design, setting and participants: Mixed-methods approach was used and primary data was collected from Ministry of Health (MoH) database collected by Dr. Waleed Al-Salem. Data constituted of 236 patients representing various nationalities across various outpatient clinics in Al-Hasa region, KSA, in separate visits for the period of 2014-2016.

Results: Using grounded theory approach the literature review identified direct measure of relationship between socio-economic and other risk factors and contracting CL infection. Using SPSS statistical analytical methods, quantitative analysis was conducted where socio-economic and other risk factors functioned as independent variables (IV) in the current study, and their influence on contracting CL infection, measured through three dependent variables (DV) – kinds of lesion, number of lesion and lesion location was relatively obtained through the quantitative analysis.

Conclusion and relevance: The endemic nature of CL infection in Al-Hasa requires relevant control measures through vector-based mechanisms. Further studies could use the risk factors for each of the DV categories to draw relevant control measures across the population

 

 

 

 

list of abbreviations

American cutaneous leishmaniasis                ACL

Cutaneous leishmaniasis                                CL

Diffuse cutaneous leishmaniasis                    DCL

Direct agglutination test                                  DAT

Immunofluorescence antibody test                IFAT

Kinetoplast DNA                                             kDNA

Kingdom of Saudi Arabia                                KSA

Localized cutaneous leishmaniasis                 LCL

Ministry of health                                            MOH

Neglected tropical diseases                            NTD

Restriction fragment length polymorphism    RFLP

World Health Organization                              WHO

Zoonotic cutaneous leishmaniasis                  ZCL

 

Table of Contents

Acknowledgements. ii

abstract. iii

list of abbreviations. iv

Table of Contents. v

LIST OF TABLES. vii

List OF FIGURES. viii

1        INTRODUCTION. 1

1.1          Background. 1

1.2          Statement of Problem. 4

1.3          Rationale of the Study. 6

2        LITERATURE REVIEW.. 7

2.1          What is Leishmaniasis?. 7

2.2          Types of Leishmaniasis. 7

2.3          Lifecycle of Leishmania parasite. 8

2.4          Epidemiology of Cutaneous Leishmaniasis. 10

2.5          Clinical manifestations of Cutaneous Leishmaniasis. 12

2.6          Diagnosis of Cutaneous Leishmaniasis. 13

2.7          Risk factors associated with Cutaneous Leishmaniasis. 13

3        Aims and Objectives. 17

3.1          Conceptual Framework. 17

4        METHODOLOGY. 19

4.1          Methodology Selected. 19

4.1.1      Research Design. 20

4.2          Research Hypotheses. 21

4.3          Data Collection and analysis. 22

4.3.1      Objective 1. 22

4.3.2      Objective 2. 24

4.3.3      Objective 3. 25

4.4          Quality Assurance. 26

4.5          Ethical Considerations. 26

5        FINDINGS and analysis. 28

5.1          Descriptive analysis of the MOH dataset. 28

5.1.1      Key summary descriptive statistics. 28

5.1.2      Normality tests. 31

5.1.3      Correlations and inter-correlations associations among the socio-economic and other risk factors  34

5.2          Direct measure of relationship between socio-economic and other risk factors and contracting zoonotic CL infection. 36

5.3          Significant socio-economic and other risk factorial predictors for contracting CL infection in Al-Hasa region of KSA. 39

5.3.1      Lesion number 39

5.3.2      Kind of lesion. 41

5.3.3      Lesion location. 43

5.4          Implications for of the study towards control or preventive measures for containing zoonotic CL infection in the Al-Hasa region of KSA. 46

6        CONCLUSION. 47

6.1          Limitations and further studies. 48

7        REFERENCES. 49

8        AppendiX. 57

8.1          Socioeconomic codebook. 57

LIST OF TABLES

Table 1?1 Year-wise trend of CL cases reported by region, KSA.. 3

Table 4?1 Research objective, procedure for data collection and analysis for Objective 1. 22

Table 4?2 Search criteria, inclusion and exclusion criteria for conducting literature review to achieve  Objective 1  23

Table 4?3 Research objective, procedure for data collection and analysis for Objective 2. 24

Table 4?4 Research objective, procedure for data collection and analysis for Objective 3. 25

Table 5?1 The divisional calculation for skewness and kurtosis value. 29

Table 5?2 The acceptance and rejection of the null and alternate hypothesis for Kolmogorov-Smirnov (K-S) and the Shapiro-Wilk (S-W) tests. 31

Table 5?3 Table indicating Kolmogorov-Smirnov (K-S) and the Shapiro-Wilk (S-W) normality tests  31

Table 5?4 Chi-square analysis results – testing the association between socio-economic factors and lesion location, kind of lesion and number of lesions. 37

Table 5?5 The table highlights the significant socio-economic and other risk factors that influenced the CL infection for categories under lesion number. 39

Table 5?6 The table highlights the significant socio-economic and other risk factors that influenced the CL infection for categories under kind of lesion. 41

Table 5?7 The table highlights the significant socio-economic and other risk factors that influenced the CL infection for categories under lesion location. 43

 

List OF FIGURES

Figure 1?1 Endemic presence of CL worldwide, 2013. 1

Figure 1?2 Endemic presence of CL in KSA, 2013 2

Figure 1?3 Year-wise trend of new CL cases reported in KSA.. 3

Figure 1?4 Al-Hasa region of KSA which attributes to 16.77% of total cases of CL since 2006  4

Figure 2?1 Classification of Leishmaniasis based on their primary clinical symptom.. 8

Figure 2?2 Lifecycle of Leishmania parasite. 9

Figure 2?3 Vector sandfly (Phlebotomus, Intracellular Leishmania amastigote, Promastigote, Electron microscopic picture of amastigote (left to right) 10

Figure 2?4 Various Leishmania spp., the clinical pathology, transmission cycle and geographical presence  11

Figure 2?5 Cutaneous lesions of CL over left cheek and erythematous papulonodules of CL on the right arm) 12

Figure 3?1 Conceptual framework used in the current study. 18

Figure 4?1 Diagramatic representation of research methodology used in the current study. 20

Figure 5?1 Key summary statistics of the socio-economic and other risk variables in the Al-Hasa region of KSA   29

Figure 5?2 Frequency distribution for the socio-economic and other risk variables in the Al-Hasa region of KSA through histogram.. 31

Figure 5?3 Normal Q-Q plots for the socio-economic and other risk variables in the Al-Hasa region of KSA   34

Figure 5?4 Correlations and inter-correlations associations among the socio-economic and other risk factors  36

Figure 5?5 Significant socio-economic and other risk factors that influenced the CL infection for categories under lesion number 41

Figure 5?6 Significant socio-economic and other risk factors that influenced the CL infection for categories under kind of lesion. 42

Figure 5?7 Significant socio-economic and other risk factors that influenced the CL infection for categories under lesion location. 45

 

1      INTRODUCTION

1.1       Background

Leishmaniasis, one of the most neglected tropical diseases (NTD), is an infection caused by the Leishmania parasite transmitted by sandflies belonging to Phlebotomus andLutzomyia genera (Chappuis et al. 2007). Globally, about 350 million people are at the risk of contracting Leishmaniasis and each year approximately 2 million new cases are reported (Mashayekhi-Ghoyonlo et al. 2015). Spread over 70 countries, 90% of Leishmaniasis cases are reported in Algeria, Pakistan, Syria, Brazil, Afghanistan, Peru and KSA (Zakai 2014).  Reithinger et al. (2007) classify Leishmaniasis into localized cutaneous leishmaniasis (LCL), diffuse cutaneous leishmaniasis (DCL), mucosal leishmaniasis and visceral leishmaniasis based on clinical manifestations. While visceral leishmaniasis is fatal (Chappuis et al. 2007), the endemic presence of CL infection across the globe (refer fig. 1.1) poses as a concern.

 

Figure 1?1 Endemic presence of CL worldwide, 2013 (WHOa 2015)

A closer observation of figure 1.1 also highlights the evident presence of CL infection with new case reporting in the Middle-eastern countries. Studies conducted by Salam et al.(2014) and Zakai (2014) validate the endemic nature of CL in the Middle-eastern countries. Zakai (2014) evidently establish the presence of old world CL parasitic infection in 18 out of the 23 Middle-eastern countries. Since the current study is delimited to the Al-Hasa region of Kingdom of Saudi Arabia (KSA) an insight to the endemic nature and trend of CL infection in the country is essential. According to the statistical reporting of World Health Organization (WHO) (2015b), CL infection in KSA is endemic (refer fig. 1.2).

Figure 1?2 Endemic presence of CL in KSA, 2013 (WHOb 2015)

While the trend of new CL cases in KSA shows a decreasing trend since 2005, year 2010 recorded an uncharacteristic spurge in the CL cases. Nevertheless, with a 35.79% increase in number of new CL cases for 2013 in comparison with 2012, KSA reflects volatility in the rate of CL infection.

Figure 1?3 Year-wise trend of new CL cases reported in KSA

*Data based on estimates of WHO (WHOb 2015)

A year-wise trend of CL infection in KSA (refer table 1.1) determines the high presence of CL infection (over 3000 cases) across Al-Quaseem, Al-Madinah and Al-Hasa for 2006-2014. Table 1.1 also indicates aggregate differentiation in CL prevalence across KSA’s regions. While Qurayyat, Jeddah and Hafr Al-Baten reported minimal CL cases, Qunfudah did not report any new CL cases for 2006-2014. Such regional variation in CL infection rates demands region specific studies in KSA.

Table 1?1 Year-wise trend of CL cases reported by region, KSA

	Year
Region	2006	2007	2008	2009	2010	2011	2012	2013	2014	Total
Riyadh	306	305	325	235	401	230	135	221	249	2407
Makkah	10	9	11	3	6	1	18	3	4	65
Jeddah	1	1	1	1	0	0	0	0	17	21
Ta`if	53	41	45	31	15	13	0	13	16	227
Al-Madinah	643	619	287	626	1000	405	236	591	408	4815
Al-Quaseem	981	851	758	654	1464	534	368	374	591	6575
Eastern	54	14	18	1	11	11	0	22	30	161
Al-Hasa	846	817	379	444	457	215	289	296	195	3938
Hafr Al-Baten	0	2	0	6	2	1	0	2	5	18
Aseer	143	146	130	156	261	188	139	161	126	1450
Bishah	2	2	7	25	10	16	0	10	0	72
Tabouk	149	165	90	106	159	125	97	69	68	1028
Ha`il	249	189	165	186	234	117	122	158	398	1818
Northern	0	0	0	0	1	0	0	3	0	4
Jazan	46	51	63	28	81	75	31	39	15	429
Najran	70	0	12	15	15	11	18	21	50	212
AL jouf	1	44	0	0	0	9	0	5	13	72
Al-Bahah	45	44	30	23	12	0	0	0	5	159
Qurayyat	3	0	0	0	0	0	0	0	0	3
Qunfudah	0	0	0	0	0	0	0	0	0	0
Total	3602	3300	2321	2540	4129	1951	1453	1988	2190	23474

*Data based on estimates of MOH reports (MOH 2014, 2013, 2012, 2011, 2010, 2009, 2008, 2007, 2006)

The current study focuses on CL infection in Al-Hasa region of KSA (refer fig. 1.4), since it is known to be highly endemic for ZCL (Al-Tawfig and AbuKhamsin, 2004). Although the prevalence of CL infection show cases a declining trend in Al-Hasa (refer table 1.1), the region still attributes to 16.77% of total cases of CL infection since 2006 (Ministry of health [MOH] 2013). Considering this, the context of the current study is Al-Hasa region of KSA. The region offers significant basis for collecting information and conducting analysis to design and develop effective control measures for zoonotic cutaneous leishmaniasis (ZCL).

Figure 1?4 Al-Hasa region of KSA which attributes to 16.77% of total cases of CL since 2006 (MOH 2013)

*Data based on estimates of MOH reports (MOH 2014, 2013, 2012, 2011, 2010, 2009, 2008, 2007, 2006)

1.2       Statement of Problem

Physical deformities and scarring are some of the clinical impacts of CL infection (Hunt et al. 2007). The negative attitude attached to CL infection due clinical manifestations stigmatizations ensue (Kassi et al. 2008), which result in severe psychological disorders among the infected population (Yanik et al. 2004). Disorders such as depression, severe anxiety, low-self-esteem and thoughts of suicide are prevalent among patients with unattractive lesions on visible body parts (Yanik et al. 2004). Lack of help and proper diagnosis could result in social isolation and seclusion (J. L. Johnson et al. 2007), impacting the social and economic status of the society.

Need exists in understanding or identifying the underlying causes for the origin and spread of ZCL to develop relevant measures. The problem observed in existing literature is lack of region-specific studies related to CL infection, lack of specificity in type of CL infection (zoonotic) and lack of statistical association bet