Epidemiological study of Visceral Leishmaniasis in Diyala Province , Iraq

The study has been done in the Al-Batool hospital in Baqubah Town, Diyala province on the patients admitted to hospital in the period from January-2015 till January-2016. The aim of the study, is to study the epidemiology and the source with pathogenesis of the visceral Leishmaniasis also the variations about the distribution of the disease between all districts of diyala province. Data were collected from (280) subjects infected with by Visceral Leishmaniasis in the hospital, the study reveal that the highest incidence of disease among the children less than one year of age (43%) and the children in less than two years of age (42%).the incidence was higher in females than in male (female to male ratio is about (1.14: 1). The highest incidence of the disease appeared in patients admitted to the hospital during the period from (January to April) of the (81.3%). In addition the highest incidence of infections was in patients living in Al khalis district (28.9%). The results of the present study showed that the death rate was (7.85%), (4.28% among males and 3.57% among females), but the percentage according to death is (10.8%) in age bellow (12 years). The best accurate method of diagnosis is by using Immune Fluorescent Assay Test (IFAT). (69.6%).


Introduction
Leishmanaisis is a group of the protozoa zoonosis caused by various species of genus Leishmanial of (500) known Phelbotomies species, (30) of them have been positively identified as a vectors of the disease, the female sand fly transmitted the protozoa, the geographical distribution of disease is limited by depend on the distribution of sand fly and the area who Leishmaniasis currently threaten (350) millions of men, women and children in (88) countries around the world.The fatality rate can be as high (100%) if left untreated, over the last 10 years endemic region have spreading further and there has been a sharp increase in number of recorded cases of disease as notification is obligatory in only (33)of (88) countries affected by Leishmaniasis, a substantial number of cases are never recorded as reported in (1).
In fact of two million new cases estimated to occur annually, only (600,000) are officially reported in addition deadly epidemics of visceral Leishmaniasis which also known as Kala-Azar.(2)In Iraq, there are fifteen species of sand fly, but the Phlebotominous paptassi is responsible for transmission of the disease to the human as reported in (3).
Transmission of infection depend on the presence of a suitable reservoir and vector with susceptible human population.Large number of cases of V.L are due to Leishmanial donavani, which are reported from eastern India and Bangladesh.The children and young adults are the most frequently affected.( 4) In regarding to pathogenesis, including, the promastigotes convert to amastigote in the macrophage, then multiply and eventually disseminate to mononuclear phagocytes through the reticuloendothelial system (6) Increased number of mononuclear phagocytes in the liver and spleen result in progressive hypertrophy, the spleen in particular becomes massively enlarge as splenic lymphoid follicles are replaced parasitized mononuclear cell, in the liver there is marked increase in the number of Kupffers cells, many of which are filled with amastigotes.Infected mononuclear phagocytes also found in bone marrow, lymph nodes.(5).

Clinical manifestations
The clinical features of the visceral Leishmaniasis are remarkably similar in different areas of world.The incubation period ranged (3-8) months as reported in (6)The onset of symptoms may be gradual or sudden, subacute or chronic cases, victims experience the insidious on set of abdominal enlargement due to hepatosplenomegaly, fever, weakness, loss of weight, pallor, loss of appetite with sweeting and chills.

Aim of the study:
To demonstrate some epidemiological characteristics and the source with pathogenesis of visceral Leishmaniasis in Diyala province.Also to know the variations about the distribution of the disease between all districts of the Diyala province

Patients and methods
All case sheets of patients with Visceral Leishmaniasis whose admitted to Al-Batool hospital in Baqubah during the period from (January-2015 till January-2016).Data were collected using a simple form, this form contains the following information's (name, age, resident according to health districts, clinical finding as fever, anemia and hepatosplenomegaly).Outcome of the patient (cure, death) .Method of the diagnosis (clinical, I.F.A.T, bone marrow), Method of treatment (Na-stiboglucanate) were used in all cases.This information's are obtained separately from the preventive section in Diyala health directorate.

Results and Discussion
Among the (280) patients was found that about 43% of cases less than one year and about 42%aged less than two year.So about 84.4% of aged two years and less.The female to male ratio is about 1.14:1.The majority of male aged 13-24 months (49%) while the majority of female aged ≤ 12 months (Table1).By using the (Chi -Square test) about the relation between the disease and the sex, the calculated value is (6.759), and this is less than the tableted value (9.488) at the level of significant (p=0.05).This is mean the infection is independent on the sex.Concerning month of admission in 2015 found 71.9% patient admitted in the first 4 months (January to April) and about 43% admitted in first two months (Table 2).By using the percentage, the incidence value according to months is (22.1 in January (2015), and the less value in the August month.Regarding the method of diagnosis we found the majority of cases diagnosed by IFAT test (69.6%)followed by clinical diagnosis (24.3%).

Months of admission
Diagnosis by bone marrow were done in (6.1%)Table 3.

P=0.05
The calculated value is (0.0115) which is less than the table value (19.00) at the level of (p=0.05) and this is supported by the coefficient association value (0.16).Concerning the outcome of disease found that that (22) patients died about (7.85%).This proportion was (4.28%) between the male, and (3.57%) among the female.There is no significant Percentage found between the outcome and sex (Table 4).By using (Chi-Square test) and contingency table (2×2), the calculated value is (0.577) and this is less than the tableted value (3.841) at the level of significance ( P=0.05).This is mean no major effect of the sex on the percentage of the cure or death.Regarding the outcome according the age, found that the more patients in `age of (1-24) months was cured in percentage between (89.2%-93%) while the percentage of death is between (7%-10.2%).There is no percent of death among the ages between (25-48) months, but there is less percent of death at the ages (49 -60) months (16.7%).Table (5).By use of the percentage, the death percent is (7.8%), and the high percent is between the age group of (1-12) months (10.8%).Regarding the distribution of cases by health district found the majority of cases from Al-Khalis district (28.9%), followed by those from Baladrose district (25.4%) and Baqubah (23.6%).Table (6).By use the percentage, the highest percent of infection (28.9%) in Al-Khalis district and (5.5%) in Jalawlaa district.2. The incidence of infection was more in between the children bellow (1 year) age while the second degree of infection appear in the age bellow (2 years).

3.
The more incidence of infection among the females sex.

4.
High incidence of out com of patients admit to hospital are cured while the less percent was died.
5. the percentage of the males died are more than in the females.