International Journal of Infectious and Tropical Diseases

Volume 2 Issue 1 January June 2015

www.ijitd.com
Beyene et al.; licensee Michael Joanna Publications

Original Article Open Access

Prevalence and clinical features of cutaneous leishmaniasis in

Dembidolo District, Western Ethiopia: A cross-sectional study
1* 2 3
Beyene HB , Alemu M , Degife M
1
Department of Microbiology, Immunology and Parasitology, College of Health Sciences, Addis Ababa
2
University, Addis Ababa, Ethiopia. Institute of Biomedical Sciences, College of Health Sciences, Mekele
3
University, Mekele, Ethiopia. Department of Medical Sciences, College of Health Sciences, Wollega
University, Nekemte, Ethiopia.
*
Corresponding author: habtish1976@gmail.com

Received: 16.03.15; Accepted: 25.05.15; Published: 02.06.15

ABSTRACT

Background: Cutaneous leishmaniasis (CL) is a skin diseases caused by Leishmania parasites

and vectored by Sand flies. The epidemiology and true burden the disease has not been fully
addressed in Ethiopia Aim: The aim of this study was to determine the prevalence of CL and its
clinical features. Methods: A community based, cross-sectional study was undertaken in
selected villages of Dembidolo District, Western Ethiopia. A house-to house survey was
conducted. A structured questionnaire was used to collect sociodemographic and clinical data.
Skin slit sample were collected from each subject. The diagnosis of CL was established by
finding amastigote stage in skin sample. Results: In 487 houses a total of 3,166 persons were
surveyed of which 1670 (52.4%) were females and 1505 (47.6%) were males. The overall
prevalence of CL in the communities was 132/3166 (4.2%). More than 80% of CL infected
patients were children. Skin ulcers were found on facial site in 72(54.5%) of subjects. In 45
(34.6%) of cases the lesions appeared on the upper extremities. The ulcers were non-itchy in
24(61.5%) of cases and were not painful in 20(54%) of cases. Lesions with 4 to 10 months age
had maximum yield of LD bodies. Conclusion: The prevalence of cutaneous leishmaniasis was
high in the study area. The diseases most frequently occurred among young children. We
suggest that clinicians should actively look for leishmania parasites among the myriad
aetiologies of skin diseases for better management of CL patients. Advocacy on utilization of
bed nets and treatment seeking habit, particularly for young children are also highly
recommended.

Key words: Prevalence, cutaneous leishmaniasis, infectious diseases, tropics, Western

Ethiopia

INTRODUCTION
Neglected tropical diseases (NTDs) are generally, a
group of 13 chronic infections commonly found in
[1]
the world's poorest regions. The leishmaniases
are among NTDs that represent a group of
diseases caused by protozoan parasites of the
genus Leishmania and are endemic in 88 countries

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 Beyene et al.: Cutaneous leishmaniasis in Dembidolo District, Western Ethiopia
of the world with an estimated 350 million people at
risk of infection.[2] Globally, the overall prevalence of
the leishmaniases is estimated at 12 million cases
[3]
per annum. From this a 1.01.5 million new
cases occurring per year are cutaneous
[3]
leishmaniasis. In Ethiopia, the disease presents in
three clinical forms: localized cutaneous
leishmaniasis (LCL), mucocutaneous (MCL) and
diffuse cutaneous leishmaniasis (DCL) with
L.aethiopica as a major causative agent across
the country.[4]
Cutaneous leishmaniasis was first described in
Ethiopia by Martoglio in 1913 who noted a
vernacular name for the disease, indicating its
[5]
familiarity to the people. This highly neglected
disease in Ethiopia is most common among
children, with the highest prevalence occurring
[6]
between 10 and 15 years of age. Although
cutaneous leishmaniasis is widely distributed in the
highlands of Ethiopia, the true burden of the
[7]
disease and its distribution is not well known. In
some documents, it is shown that about 20-50,000
[6]
cases of CL reported per annum.
Disfigurement, disability, and social and
psychological stigma are severe consequences of
7]
the disease.[ The epidemiological information of
CL in many localities across the country is
incomplete so far. According to one study done in
Ochollo destrict, South west Ethiopia, the overall
prevalence of cutaneous leishmaniasis was 3.6-
[9]
4.0%. According to this study the peak prevalence
of 8.55% was reported in the 0-10 years old age
[9]
group. A prevalence of 4.8% was reported in Silti
woreda, Southern Ethiopia that has occurred as an
outbreak with 11-20 years old being highly infected
class.[10] Yet, the situation of cutaneous
leishmaniasis has not been well investigated in
most parts of rural Ethiopia. Currently patients
presenting with characteristic skin lesions were
observed in Dembidolo district, Western Ethiopia.
These growing reports have initiated us to conduct
this study. Therefore the main objective of this
study was to determine the prevalence of the skin
lesions and undergo clinical characterization of CL
in selected villages.
METHODOLOGY
Study area and design
A cross sectional study was conducted in three
local villages named Arere, Gerjela and Gayi in
Dembidolo area, Western Ethiopia. Dembidolo
district is located 652Kms away from Addis Ababa
(capital city of Ethiopia) with a total of about
Int J Infect Trop Dis 2015;2(1):31-38
32
940,054 population. Over, 84% of the population
lives in rural areas. It is bounded by the West
wollega zone to the east-north, Gambella regional
state and Sudan to the West and Illu-Ababora zone
to the South. The areas altitude ranges from 1000
to 3335m above sea level, where Woinadega zone
(Altitude, 1500-2500) constitutes 25.6% Qolla
(Altitude below 1500m) 30.5% and Dega zone
(altitude above 2500m) about 16.90%.
Sample size and sampling technique
By taking the prevalence of cutaneous
leishmaniasis to be 48% (0.48) from previous report
[11]
in Ethiopia, a marginal error of 5% and 95%
confidence interval, the following single population
proportion formula was applied to obtain the
required sample size of households.
2 2 2 [12]
n= (Z pq/d2) = [(1.96) (0.48*0.52)/0.05 ] = 384
Then adding a 26% contingency we obtained n =
(384+103) = 487
where, n= minimum sample size
Z= confidence interval= 95 % (1.96)
P= the prevalence of CL = 0.5
q=complementary probability (1-p) =0.5
d=precision/error tolerated (5%)
Three villages were first selected randomly. The
number of households to be surveyed from each
village was assigned proportionally to each village
of interest. Accordingly 196 houses from Gayi, 70
from Arere and 221 from Gergella and in total 487
houses were reached randomly.
Data collection
A house- to -house survey was conducted among
each village. Ultimately, 487 houses with a total
population of 3,166 were surveyed. In 487 houses
132 persons were identified as CL patients. Active
cutaneous leishmaniasis was diagnosed clinically
during the survey based on criteria set forth below.
Confirmation was further made by standard
microscopic examinations. A structured
questionnaire was used to collect
sociodemographic and clinical data of CL patients.
A team of health professionals including one
Medical doctor, two public health specialists and
one medical parasitologist were involved in the
survey. Prior to data collection the questionnaire
was checked for any inconsistency and
incompleteness by the principal investigator.
Clinical diagnosis
If patients met at least five of the following criteria,
they were identified as clinical suspects:[18] has
 Beyene et al.: Cutaneous leishmaniasis in Dembidolo District, Western Ethiopia
resided for at least 6 months in the area or
originated from known endemic area; discrete
nodules or non-healing ulcers; largely painless and
non-itchy lesions; few(often one to three lesions);
duration of several days or weeks; history of similar
lesions in the household; resistance to conventional
antibiotics; type of any more morphological features
such as satellite papules, subcutaneous nodules,
paired or clustered nodules, volcanic nodules and
[18]
ice berg nodules. The anatomical location of
skin lesion, duration, number of lesion per
individual, type of lesion, size of lesion in mm, if the
lesion was itching, painful, painless, wet, dry,
nodular, ulcerative, popular was carefully examined
and recorded.
Parasitological examination
Identification of leishmania parasites and diagnosis
of Leishmaniasis was established by microscopic
examination of stained slides. The standardized
diagnostic procedure described below was
undertaken by senior laboratory technologists for
the identification of Leishmania Donovan (LD)
[2]
bodies in skin sample. More briefly, the raised
border of an infected skin area was cleansed with a
swab soaked in 70% v/v alcohol. Using previous
[2]
method as described by Bb et al., a sterile
scalpel blade, a small cut into the dermis was made
and blotted away any blood. The cut surface
scraped in an outward direction to obtain tissue
[2]
juice and cells. The material was spread on a
clean slide using a circular motion and working
outwards to avoid damaging parasites in those
[2]
parts of the smear that have started to dry. When
dry, the smear was fixed by covering it with a few
[2]
drops of absolute methanol. Fixation was made
for 3 minutes. The smear was stained using the
Giemsa technique.[2] When the smear was dry, a
drop of immersion oil spread on it and examined
with 100X oil immersion objective to identify the
) [2]
Leishman Donovan bodies (LD .
Inclusion and exclusion criteria
The participants were permanent residents in the
community. Persons who were unable to
communicate and mentally handicapped were
excluded.
Ethical consideration/clearance
Prior to the study, ethical clearance was obtained
from Ethics Committee of the institution, and written
informed consent was obtained from each subject.
When the study subjects were children, informed
consent was obtained from their parents/guardians.
Int J Infect Trop Dis 2015;2(1):31-38
33
Statistical analysis
Data were initially entered into Excel 2007
worksheet and imported into SPSS version 20.0
software package for Windows. Descriptive
statistics were employed to generate frequencies,
tables and figures. Data were analyzed using two-
tailed t-test. P-value less than 0.05 was considered
as statistically significant.
RESULTS
Prevalence of cutaneous leishmaniasis
In 487 houses surveyed, a total of 3,166 persons
constituting 1670 (52.4%) females and 1505
(47.6%) males were found. A total of 49 subjects
with active lesions were identified .Out of this
37(1.2%) presented with laboratory confirmed
cases and 95(3%) with scars indicative of past
exposure. The overall prevalence of CL was thus
132/3166 (4.2%) (table 2). The infected subjects
age ranged from 1 to 64 years with a mean of 24
years old. Over 80% of CL patients were under or
otherwise equal to 24 years old, and most of whom
were students. As age increased the prevalence
rate dropped substantially (figure 1). Outdoor
sleeping behavior at least once a week was
reported by 58 (44%) of the CL victims which was
significantly associated with skin lesion (P=0.001).
Most of the CL patients (n= 46) reported they have
intermittently or never used bed net or any personal
protection and this was identified as a significant
factor for CL. Almost all (n=47) had not seen
medical treatment in the past 12 months.
Clinical characteristics
In this study we evaluated the clinical features of
skin lesions and observed that the lesions were
found on face in 27(52%) and in 18 (34.6%) of
cases lesions appeared on the upper of extremities
uncovered by clothing such as the arms, the backs
of the hands. Lesions had also appeared on the
cheeks, lips, earlobes, chin, forehead and nose. In
few cases the lesions were also found on the trunk
and legs as well (figure 3). The number of lesions
per subject ranged from 1 to 13. In 64(48) of CL
infected patients, the mean number of lesion was
two. Only 7% of patients had multiple skin ulcers
(figure 2). The size of lesions ranged from 10 to
45mm in diameter. The ulcers were non-itchy with
indurated margins and necrotic base in 40(82%) of
cases and were often covered by a firmly adherent
crust (table 1). The lesions were not painful in
42(86%) of CL cases. The age of lesions ranged
from 2 to 20 months with a mean duration of about
8 months. Lesion with an age of 4 to 10 months
yielded maximum LD positivity.
 Beyene et al.: Cutaneous leishmaniasis in Dembidolo District, Western Ethiopia

Table 1: Sociodemographic characterstics and LD body positivity among leishmania infected subjects,
Western Ethiopia

Characteristics Active CL (%) LD positive (%) P-value

Age in years
1-20 25(51) 20(54) 0.012
21-30 16(22) 8(23)
31-45 3(16) 6(15)
>45 5(10) 3(8)
Sex
Male 28(57) 20(54)
Female 21(43) 17(46)
Use of bed net
Yes 3(6) 0(0)
No 46(94) 37(100) P=0.03
Medical treatment
Yes 2(6) 0(0)
No 47(94) 37(100)
LD body =leishman Donovan body

Table 2: Proportion of cutaneous leishmanisis in selected villages, Western Ethiopia

Village
Variable
Gayi (n %) Arere (n %) Gerjella (n %) Total
No. of Households 196(40) 70(14) 221(45) 487(100)
Population 1220(38) 700(22) 1246(40) 3,166(100)
LD positive 14(0.4) 6(0.2) 17(0.5) 37(4.2)
n= total number of suspected subjects with active skin lesion

Table 3: Clinical characterstics of Cutaneous leishmanisis , Dembidolo district, West Ethiopia

Clinical feature Frequency (%)
Itching
Yes 9 18
No 40 82
Painful
Yes 7 14
No 42 86
Size (mm)
10-20 26 54
20 - 40 17 34
>40mm 6 12
Age of infection
2-6 months 30 61
7-12 months 7 14
12-15 months 10 20
16-20months 2 5
Gross appearance
Nodular lesion 9 19
Open/ulcerated 40 81

Int J Infect Trop Dis 2015;2(1):31-38

34
 Beyene et al.: Cutaneous leishmaniasis in Dembidolo District, Western Ethiopia

Figure 1: Prevalence of CL in relation to age, Western Ethiopia

Figure 2: Number of lesions per individual CL infected subjects, Western Ethiopia

Figure 3: Distribution of skin ulcers over the body of CL patients, Western Ethiopia

Int J Infect Trop Dis 2015;2(1):31-38

35
 Beyene et al.: Cutaneous leishmaniasis in Dembidolo District, Western Ethiopia
DISCUSSION
Cutaneous leishmaniasis is the commonest form of
leishmaniasis. There are about 214,000 cases
reported each year and the estimated annual CL
incidence ranges from 691,000 to 1.2 million cases
[18].
worldwide Though, it has been neglected as a
major public health problem probably because it is
not lethal, it has become an important disease of
[11]
development. The increase in the number of
cases has been associated with socioeconomic,
[11]
political and environmental factors.
The prevalence of CL rises with age up to 15 years,
[17]
then declines due to the acquisition of immunity.
The infection can cluster within households, which
is indicative of the short flight range of sand flies.[17]
Gender, age, household design and construction
material, and presence of domestic animals are
[17]
common predisposing factors. CL is a serious
public health problem with the majority of old world
CL caused by one of two species of parasites; L.
tropica which often results in benign (dry) ulcers
and L. major which can cause a skin ulcer that
usually develops larger and more destructive (wet)
ulcers.[16]
Cutaneous leishmaniasis is widely distributed in the
highlands of Ethiopia, but the true burden of the
[14]
disease and its distribution is not well known.
Most of CL cases are caused by L. aethiopica
[16]
which is found in Ethiopia and Kenya. Lack of
evidence on CL treatment recommendation is one
[14]
of the challenges to control the infection. It is
known that, Public health control measures are
strongly dependent on the information coming from
[11]
the surveillance systems. Because this system is
in its infancy in Ethiopia, the prevalence and
epidemiologic information regarding CL is not fully
understood in many localities. In the present study
an attempt has been made in place to determine
the prevalence and clinical characteristics of CL in
Western part of Ethiopia. It was also meant to
present preliminary data, to facilitate further studies
and surveillance for better understanding of the
epidemiology and clinical features of the diseases.
In this study, the overall prevalence of cutaneous
leishmaniasis in relation to the total population
studied was 132/3166(4.2%). This was by far larger
[19, 20]
than community based reports elsewhere. This
could be due to the difference in methods
employed, target study subjects, time frame of
Int J Infect Trop Dis 2015;2(1):31-38
36
study and endemicity of the diseases. In the
present study the proportion of active skin lesions
confirmed microscopically were slightly greater
compared to community-based studies. The
prevalence of skin lesions between males and
females were not significantly different, although
some studies reported that the incidence of
cutaneous leishmaniasis to be higher in men than
[21]
women.
The most frequent cases of CL were observed
significantly in young subjects between 1- 25years
old. This finding was in line with reports from other
[4, 20-22]
studies. The fact that prevalence rates of CL
are higher in children and young adults could be
attributable to immature immunity and minimal
exposure status to the parasite in such population
segments. Moreover it is suggested that young
people are more likely engaged in outdoor activities
where they become bitten by sand flies more
frequently than elderly population.
With regard to number of lesions, the majority had
two localized skin lesion (LCL) per subject. This
was contrasting finding compared to the study done
in Pakistan, where majority had a single skin
[23]
lesion. This could have been due to a potential
variation in the level of exposure to sand flies in
different ecological settings, frequency of bite and
variant of causative agent. In our set up, lesions
were typically 1 or two in number and were
localized (LCL), that is, with no evidence of
mutilation or dissemination. Skin lesions were most
frequently seen on unprotected body parts such as
facial areas and upper extremities (hands and arm).
It is suggested that uncovered body parts are where
[23, 24]
the sand fly has access to bare skin and bite.
In our study, skin ulcers were reported to be
painless in 80% of the cases, and this was similar
[25]
with a study done in Peshawar, Pakistan. It is
believed that the lesion would become painful only
or if secondary bacterial infection is present
concurrently which it thought to exacerbate the
[26]
infection. In 40(80%) of cases the skin lesions
were wet and ulcerative type. It is known that the
appearance of lesions depends on the age of ulcer.
In case of L.major infection, CL self heal within 2-6
[26]
months leaving a scar. In this study, lesion with 4
to 10 months on average gave highest yield of LD
bodies. This suggests that the rate of recovery of
parasites in skin sample is higher in the early stage
of the lesion.
 Beyene et al.: Cutaneous leishmaniasis in Dembidolo District, Western Ethiopia
CONCLUSION
In this study we have reported a significant number
of confirmed CL cases which can be rated as high.
The clinical manifestations were diverse and are
often seen in exposed body parts of particularly
young children. In order to reduce the prevalence of
CL in such remote rural villages, Community Health
Workers/CHW should be trained in identification of
skin problems, as the people in remote rural
settings do not have access to specialist
Dermatologists. Clinicians should be also
suspicious about leshmania parasites for early
detection and treatment of CL patients. Advocacy
on bed net use, early treatment seeking particularly
for young children should be there. Finally we
suggest further studies to be undertaken
incorporating entomological and reservoir host
interactions to come up with more rigorous results.
ACKNOWLEDGEMENTS
We thank all study subjects that participated in the
study for their kindness and availability. We are also
grateful to the officials of Dembidolo health
department for their cooperation and permission to
conduct this study.
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doi: http://dx.doi.org/10.14194/ijitd.2.1.4

How to cite this article: Beyene HB,

Alemu M, Degife M. Prevalence and
clinical features of cutaneous
leishmaniasis in Dembidolo District,
Western Ethiopia: A cross-sectional
study. Int J Infect Trop Dis 2015;2(1):31-
38.

Int J Infect Trop Dis 2015;2(1):31-38

38