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Potential risk factors for acquiring cutaneous leishmaniasis in a hijra in AI-Majmaah

During 1994, the director of 52% had one or more CL cases compared MOH). Majrnaah General Hospital noticed an to 8% of 12 houses with no cracked walls Because it is a zoonotic disease, ZCL increase in the number of reported cases (p-<0.05, Yates corrected Chi-square spreads easily and is extremely difficult of cutaneous leishmaniasis (CL) and test). In the 12 houses adjacent to to control. Studies done elsewhere in requested an epidemiologic investigation. abandoned houses, one case or more of Saudi Arabia have shown that CL occurs AI-Majmaah district is located 200 km to CL were found in nine (75%), whereas of more frequently in males than in the north west of Riyadh, with a 46 the houses not standing adjacent to females; it is associated with working in population of more than 41000. It has abandoned houses, only 16 houses farming areas with peak incidence in one general hospital and 17 primary (34.8%) had one case or more ofCL (p- children below the age of 10 years. 4 In health care centers (PHCCs). <0.05, Yates corrected Chi-square test) . contrast in Omrajown, there were no

There were 377 CLcases in Al- Screened windows, the presence of associations of CL with age, sex, Majmaah district in 1994, with an animal enclosures attached to or nearby nationality or occupation. In addition the overall attack rate (AR) of 9.15 per 1000 the house, or the presence of rodents associations between the CL and cracks population. Omrajowm had 44 cases with indoors or outdoors were not statistically in the walls of houses and abandoned an AR of llO per 1000 population, which associated with the transmission of the houses adjacent to the cases-houses, was the highest among Al-Majmaah sub- disease. Questioning about knowledge of suggest that CL in Omrajown was districts. Omrajowm is a hijra or bedouin leishmaniasis revealed that 94.8% of the recently introduced and that the village of 400 persons living in 58 single adult residents did not know how the transmission is domestic or peridomestic. floor houses. It was founded about 27 disease occurs, or about the role ofthe The only control measure that had years ago and located 120 kIn east of Al- sandfly and rodents in transmission. been applied was fogging with Majmaah city at the western border of . Reported by Dr. Ali AI-Zahrani, Dr. insecticides. However, new CL continued the AI-Dahana desert. It has no farms. Nasser AI-Hamdan, Field Epidemiology to appear. The spraying may be The hijra has minimal population Training Program and Dr. fasser AI- ineffective because a) it is frequently movement. We visited all ofOmrajowm's Ghamdi, Majmaah Hospital done at midday, a time when the households and determined Editorial note: Leishmaniasis is a sandflies are in protected resting sites; b) demographic information, clinical group of infections of the viscera, skin, respraying is not done frequently giving presentation of CL lesions and possible and mucous membranes caused by the sandflies a chance to recover, and c) risk factors for CL through interviews. intracellular protozoan parasites of the the abandoned houses are not sprayed. The case definition for CL was any genus transmitted by sandflies of the Another consideration is the lack of person who had cutaneous lesion(s) that genus Phlebotomous in the Old World knowledge by the community about the had been clinically diagnosed as a CL at Zoonotic (ZCL) caused by Leishmania disease and its way of transmission. The any time in hislher life. major is an increasing public health appropriate method to control the .

The first case of CL acquired in problem in the Old World, from Senegal transmission of the disease in Omrajown Omrajowm appeared in July 1992 in a 40 in West Africa to the western parts of will be to educate the people about the year old Saudi woman followed by 54 India. 1

•2 Anthroponotic CL (ACL) is disease; to spray insecticides at short

cases through July 1994 (Figure 1). caused by L. tropica and occurs in urban intervals and at the appropriate time; do Mean age for the CL cases ranged centers in southwest Asia. something about the abandoned houses,

from 1 to 70 years (mean 19.7), and 54% Both ZCL and ACL occur in Saudi and to close any cracks in the walls of of cases were in women. Forty cases Arabia, particularly in the Al-Hassa houses. (74%) were Saudis, 3 (5.5%) were region in the east, in the Asir region in Palestinians, another three were the south-west and in the Riyadh region Egyptians and eight (14.8%) were of . in the central part of the country. 2,3 P. other nationalities. CL is not statistically papatasi is the vector for ZCL and P. associated with occupati9n. The sergenti for ACL. 2,3

commonest site of lesions was the l()wer In the Riyadh region, L. major, extremities (40.6%) followed by the Montpellier zymodeme 26 (MON 26), upper extremities (39 .1%), the face has been isolated from several human CL (17.2%), and the trunk (3.1 %). More cases, P.papatasi and from the rodent than one lesion occurred in 28 cases Meriones libycus. 3

(51.9%). Permanent scars were present Reported cases ofCL in the Riyadh in 98.4% of cases. Forty-nine patients region have gradually decreased from (90.7%) had received chemotherapy, 1987 to 1991, when they began to local healers treated two with increase through 1994. The same cauterization and three persons denied resurgent pattern has been found in the receiving any type of treatment. Al-Majmaah district which is a part of

Of the 46 houses with cracked walls, the region (Leishmaniasis department,

References: 1. Peters W, Bryceson'A, Evans DA, et al. Leishmania infecting man and wild animals in Saudi Arabia. The influence of prior infection with. Leishmania arabica on challenge with L. major in man. Trans R Soc Trop Med and Hyg. 1990; 84: 681-689. 2. AI-Zahrani MA, Peters W, Evans DA, Smith V, I CC. Leishmania infecting man and animals in Saudi Arabia. Cutaneous leishmaniasis of man in the southwest Trans R Soc Trop Med Hyg 1989; 83: 621-628. 3. Ibrahim EA, Mustafa MB, AI Amri SA, AI~Seghayer SM, Hussein SM, Gradoni L. Mariones libycus

(Continued on page 5)

TUBERCULOSIS IN A PRISON, JEDDAH, SAUDI ARABIA, JULY 1993-MARCH 1995

Page 5

After recognizing four extra were interviewed in the prison or Chest mellitus (Odds ratio [OR)=16, 95% pulmonary tuberculosis cases among Hospital. Confidence Interval [CI)7-37) and prisoners hospitalized in a Jeddah From July 1993 to February 1995,53 smokers (OR=2.9, 95% CI 1.1-7.9) had a hospital, an additional 40 prisoners with cases of pulmonary (49 cases) and extra greater risk ofTB. pulmonary TB were identified from TB pulmonary (4 cases) TB were diagnosed We screened 297 prisoners using chest surveillance between July 1993 to among prisoners (incidence rate= 456 film sputum smears and tuberculin skin December 1994. An epidemiologic per 100,000 per year). TB cases had been testing. Prisoners were selected because investigation was begun to determine the detected in the correctional institute since they were in a ward with known TB reasons for the large number ofTB cases the beginning (July 1993) of the study cases or because they had a risk factor for among prisoners in a prison in Jeddah. period and the first seven cases had onset TB (HIV positive, diabetes mellitus,

The prison has two sections: a of illness more than one month after im chronic renal failure, hematological correctional institute and a general prisonment (prison-acquired). In disorder). Twenty-six previously prison according to the crime. One contrast, no TB cases had been undetected TB cases were identified clinic serves both sections of the prisons. discovered in the general prison during (8754 per 100,000). The mean PPD prisoners with suspect TB are referred to the first five months of the case review reaction was 7 mm with a range from 0-the Jeddah TB Center for chest x ray, . and one of the first three cases had onset 20 mm among all screened prisoners. tuberculin skin testing, and sputum less than one month after imprisonment The rate of tuberculin positively examination. Those with acid fast bacilli (community-acquired). For all TB cases increased with increasing months of on sputum examinatiol! or time between imprisonment and onset of imprisonment (R= 0.27,95% confidence Mycobacterium tuberculosis o.n c~ture. symptoms ranged from 0 to 1162 days limits 0.08-0.44). Screening of guards are referred to the Chest Hospitals 10 Taif (median 216) and 87% were prison- and social workers (18) detected one for treatment. New prisoners had not acquired. guard and one social worker from the been screened for TB. Referral from the prison clinic for TB Correctional Institute with pulmonary

To find cases we reviewed patients' diagnosis was delayed from 31 to 65 days TB. . records of the two hospitals used by the (mean 54) after onset of cough. The risk -- Reported by Dr. Nadir Hassan AI prison and the Jeddah TB Center. A ofTB increased with crowding in the Shareef, Dr. Robert Fontaine, Field pulmonary TB case was defined a~ a ward (Chi square for trend = 5.1, p< Epidemiology Training Program and prisoner who developed ~.coug~ Ill~ess 0.05) and time spent in prison (p< 0.01, I1ham Qattan,Diseases Control with a sputum smear positive for aCid ANOVA). When compared to control Department, Jeddah fast bacilli and extra pulmonary TB cases prisoners selected at random from all Editorial note: Prisons throughout the as an illness with TB granuloma prisoners, prisoners with diabetes world represent a situation where risk demonstrated by histology from July (Continued onpage 7) 1993 to March 1995. Prisoners with TB

LEISHMANIASIS

(Continuedfrom page 4) (Rodentia:Gerbillidae), a possible reservoir host of zoonotic cutaneous leishmaniasis in Riyadh province, Saudi Arabia. Trans R Soc Trop Med and Hyg 1994; 88:39. 4. AI-Gindan Y, Abdul-Aziz 0, Kubba R. Some clinical aspects of cutaneous leishmaniasis in AI-Hassa, Saudi Arabia. Proceedings of the medical symposium on leishmaniasis, 1980 Mar 22-24; . Dammam, Kingdom of Saudi Arabia. College of Medicine and Medical Sciences, King Faisal University, and Ministry of Health, 57-72.

Distribution of CL cases by month of onset Omrajown town, Al Majmaah, Riyadh region, KSA

1992-1994

Cases

"

15

,.

1992 1993 1994