Qom University of Medical Sciences Journal

Leishmaniasis is one of the most important infectious diseases in the world, which is caused by obligate intracellular protozoa of the genus Leishmania. It is transmitted to humans by female sandflies. Leishmaniasis can be seen in four forms: Cutaneous, visceral, mucocutaneous, and diffuse cutaneous [1].
Cutaneous leishmaniasis (CL) is one of the most prominent and common diseases in Iran, which is seen in both urban and rural areas with an annual number of about 25000 cases in different parts of the country. The causes of urban-type and rural-type leishmaniasis (dry and wet types) are leishmania tropica and leishmania major, respectively [2, 3].
There is no any drugs for CL prevention, and the use of vaccine for its prevention is still in the study and testing phase. The carrier control can only be done in some special epidemic conditions. On the other hand, medication therapy has different effects. Although the mortality rate of this disease is low, it can create skin lesions, secondary infection, and heavy cost burden on the society with a long treatment process and side effects due to the use of drugs [4].
The most common drug used for treatment of CL are pentavalent compounds such as sodium stibogluconate. Not all patients need treatment, because many lesions heal by themselves [5]. Since leishmaniasis is a serious health problem in some countries, it is necessary to carry out more studies to better understand the disease cycle.
In Qom city, one of the main health problems of people in rural areas is CL [6]. Currently, the control of CL has been the focus of officials in this region, and accurate related information are needed for health planning [7]. Repeated referrals of local residents with CL to health centers in recent years in this region  and the declaration of no history of traveling outside the region during infection indicate that CL has become endemic, which has created concerns among health officials in the province [8]. This study aims to investigate epidemiological factors in patients with CL referred to health centers in Qom, Iran.
Methods
In this descriptive-analytical study, the epidemiological data was collected from 1084 people who had visited health centers in Qom city for the diagnosis of CL from March 2016 to February 2022 (6 years). The information such as age, sex, place of residence, occupation, and affected organ were extracted from the patients’ medical files.
Data analysis was done in SPSS software using descriptive and inferential statistics. Mean and standard deviation were used to describe quantitative variables and frequency and percentage were used for qualitative variables. Chi-square test and Fisher’s exact test were used for data analysis.
Results
Of 1084 people, 781 were male (32%) and were female (28%). Of 1084 people, 719 were infected with CL, of whom 539 were male (75%) and 179 were female (24.9%). A statistically significant difference was observed between patients in terms of gender, where males were infected more than females (P=0.03). Moreover, 88.3% of the infected patients were from urban areas and the rest from rural areas. No significant difference was observed between patients in terms of the place of residence (P=0.23). Self-employed patients were more infected with CL (Table 1). The most common age group with CL was >20 years (Figure. 1). There was a significant difference between patients in terms of age (P<0.001) (Table 2). Based on the year of infection, the highest frequency of infection was related to 2019 (n=202, 18%) and the lowest frequency was seen in 2013 (n=34, 3.1%) (Table 3).
It was found out that 87.3% (n=628) of patients had a history of traveling to disease endemic areas, most of which were to Isfahan province. Furthermore, 29.4% (n=320) were infected with CL in October and November, and 13.5% (n=97) had a previous history of infection with CL (Table 4). Moreover, 45.9% had skin lesions on the hand (Table 5) and 32.2% of them had more than three skin lesions.

Discussion
The results of this study revealed that the incidence of CL in Qom city was higher in males (75.1%) than in females. In the study by Barati et al., in Khatam county, Yazd, Iran during 2004-2013, 61% of patients with CL were male and 39% were female [9]. In Abbasi et al.’s study, 31.4% of patients were female and 68.6% were male [10].
In the study by Mokhtari et al. in Mashhad, Iran, it was shown that during 2008-2013, 236 (54%) of CL patients were male and 202 (46%) were female [11]. The higher rate of infection among men in other parts of Iran can be due to higher number of men in the areas where there is a possibility of being bitten by infected sandflies, such as abandoned places, construction sites, desert, and agricultural and livestock areas, and women are less exposed to infected sandflies due to more and appropriate coverage of the body [12, 13].
In the study by Dehghani et al. in Bushehr province, it was reported that 422 (63.7%) patients were from urban areas and 241 (36.3%) were from rural areas [14]. In our study, there were also more urban-type CL.
The highest rate of CL in our study was seen in 2019 (n=202, 18.6%) and the lowest rate was in 2013 (n=34, 3.1%).The disease was observed in all seasons, mostly in autumn (n=159, 14.7%) and less in spring (n=26, 2.4%). In the study by Mahdavi et al. in Golestan city in 2018, the most cases were in October, November, and December, while the least cases were in April and May [15].
In the study by Mokhtari et al., there were 106 cases (24.2%) in spring, 70 cases (16%) in summer, 161 cases (36.8%) in autumn, and 101 cases (23.1%) in winter [16]. which is consistent with our results.
In the study by Mohammadi et al. in Marovdasht city in 2016 [17], the most cases of CL patients had age 20-30 years (17.7 %), which is consistent with the results of our study.
In our study, infected people were mostly self-employed men (38.2%) and housewives (20.8%), while farmers and children with no occupation had the lowest frequency of CL. Among the people with cutaneous leishmaniasis, 627 people (87.4%) had a history of traveling to disease endemic areas and 90 (12.6%) had no history of traveling and got infected in Qom city. Of 718 patients, 97 people (13.5%) had a history of previous infection, and 612 people (86.5%) had no history. In the study by Rasa et al. in Dashte Azadegan county, the highest number of CL cases was observed in people aged 0-19 years (23.78%) and 20-29 years (23.63%). A statistically significant difference was observed between patients in terms of the place of residence, occupation and season of infection. About 59.54% of the patients had one skin lesion and the most affected organ was the hand (28.78%) [18].
Hatami et al. in a study in Shiraz in 2018 showed that the incidence of CL increased from 109 per 100000 people in 2005 to 218 cases in 2008 and then decreased to 110 cases in 2014. The age group of 0-9 years was the most vulnerable age group and housewives were the most involved occupational group. Most patients had wet lesions. Hands were the most affected part. The highest incidence of CL was seen in autumn season. Zoonotic CL was the dominant type [19].
In the study by Lotfi et al. in Yazd province in 2017, the highest prevalence (7.18%) was among patients aged 21-30 years. Housewives had the highest rate of CL (6.22%). Most of the cases were reported in autumn. Skin lesions were mostly seen in legs (18.7%). In more than half of the cases (7.52%), and 82 patients (7.54%) had only one skin lesion [20].
In our study, the majority of skin lesions were seen in the hand (n= 329, 45.8%) and legs (n=217, 30.2%), while it was less frequent in the neck (0.6%), ears (3.5%) and face (8.9%).
In other studies, the hand was also the most common site of Leishmania lesions [21].
Saqafipour et al. showed that, of 1812 patients with CL in Qom province, 1047 were male (57.78%) and 765 were female (42.22%). The mean prevalence rate was 25.8 per 100,000 people. The most common age group was >15 years (74.5%) and 50.39% of patients were from urban areas. Moreover, 52.65% had no history of traveling to disease endemic areas and 24.5% had three or more skin lesions. In 49.08% of cases, the location of skin lesions was the hand [22].
In the study by Zahir Nia et al. in Hamadan province, most of the lesions were seen in uncovered areas of the body, including hands and legs. The incidence was much higher in men [23]. Their results are consistent with the results of our study.
The present study, similar to studies by Dehghan et al. in Lorestan [16], Hashemi et al. in Hamedan province [24], Hamzoi et al. in Bushehr province [25], Abbasi et al. in Gorgan province [26] and Saqfipour et al. in Qom province [15], showed that more than 45% of patients had more than one wound in their body.
The CL in Qom city is more prevalent in people aged 20-30 years and those living in urban areas. Due to the increasing rate of CL in Qom, it is necessity to educate and inform people about this disease. In addition, since the disease creates skin lesions that can remain for a long time and cause mental health problems, it seems necessary to take action for prevention, controlling and prompt treatment of people suffering from this disease in Qom.
Ethical Considerations
Compliance with ethical guidelines
This study has an ethical approval from Qom University of Medical Sciences (Code: IR.MUQ.REC.1399.261).
Funding
This article is based on the dissertation of Fatemeh Badri, a medical student, and the Deputy Director of Research and Technology of Qom University of Medical Sciences has been a sponsor of this study.
Authors contributions
Study concept and design: Seyed Jafar Adnani Sadati; analysis and interpretation of data: Babake Aghili; drafting of the manuscript: Fatemhe Badri; statistical analysis: Mostafa Vahedian.
Conflicts of interest
The authors declared no conflict of interest.
Acknowledgements
The authors would like to thank the Vice-Chancellor for Research of Qom University of Medical Sciences for financial support.