Leishmaniasis is an emerging but neglected parasitic disease caused by species of genus Leishmania which is transmitted during the bite of an infected phlebotomine sandfly. It is known to manifest in 3 main forms; cutaneous leishmaniasis, mucocutaneous leishmaniasis and visceral leishmaniasis in humans (1). About twenty species or subspecies have been identified in relation to leishmaniasis in human. Cutaneous leishmaniasis is usually caused by Leishmania tropica and Leishmania major; Leishmania braziliensis and Leishmania panamensis are responsible for mucocutaneous leishmaniasis. Visceral leishmaniasis is a result of Leishmania donovani and Leishmania infantum infections (2). Inside the reticuloendothelial system of infected individuals, organisms multiply and liberate amastigotes into the blood. These amastigotes enter into the sandfly’s gut during a bite and multiply into promastigotes which can be transmitted into a new host (3).
Cutaneous leishmaniasis is characterized by single or multiple crusted painless papules usually found in exposed areas of the body. Extensive mid facial destruction, tissue overgrowth obstructing the nares, septal granulation and gingivitis are features of mucocutaneous leishmaniasis. Kala-azar or Visceral leishmaniasis causes a systemic illness with fever, weight loss, hepatosplenomegaly and pancytopenia (4). While visceral leishmaniasis is the most fatal form of the disease, cutaneous leishmaniasis has been identified as the most prevalent form (5).
Diagnosis of leishmaniasis is mainly clinical; this can be confirmed by isolating the parasite in the skin smears or biopsies taken from the lesions. Detection of antibodies to recombinant rK 39 antigen in patients serum and polymerase chain reaction (PCR) assays can also be used in diagnostic purposes (1, 6). Intralesional, Intramuscular or Intravenous Sodium stibogluconate (SSG) injections and Cryotherapy with liquid nitrogen are the main treatment modalities for leishmaniasis (6). Nevertheless, cutaneous leishmaniasis may heal even without treatment. Applying repellents on the exposed body areas, usage of insecticide -treated bed nets and wearing long-sleeved dresses when staying outdoor are some of the measures to prevent the bite of a sandfly. Identifying infected patients and early treatment is of greater importance in ceasing the spread of the disease.
Epidemiology of the leishmaniasis depends on several factors related to the life cycle of the parasite, human behavior, and climate. The tropical climate facilitates the breeding of sand flies. Traveling to endemic countries and urbanization invading forest lands increase the chance of humans getting bitten by vectors. Poor socio-economical status increases the risk of leishmaniasis. Malnutrition compromises the immunity aggravating the self-limiting disease into full-blown systemic illness. Poor housing and sanitary conditions (such as a lack of waste management or open sewerage) may increase sand fly breeding and resting sites, as well as their access to humans. Crowded houses attract sand flies providing good sources for their blood-meals. Human behaviors, such as sleeping outside or on the ground, may increase the risk of sandfly bites (3, 7).
Around 0.7 to 1 million new cases are diagnosed every year in the world (7). Disease affected regions include Africa, America, the East Mediterranean region, Europe and South-East Asia (5). Annual death count due to leishmaniasis is 26 000 to 65 000 across the globe (7). Leishmaniasis is a notifiable disease in Sri Lanka since 2008(8). Cutaneous leishmaniasis is the most prevalent form of the disease found in Sri Lanka and the causative organism has been identified as Leishmania donovani, the organism which is mainly responsible for visceral leishmaniasis in the globe (9). The disease is highly endemic in the North Central province of the country which is a semi-urban area with a tropical climate. According to the latest annual health bulletin published by the ministry of health Sri Lanka, Anuradhapura had been reported as the second-highest rate per district; 22% (277 cases) out of all the reported cases (10). But at the time of data collection highest incident rate was from Anuradhapura district for six consecutive years from 2010 to 2015 (11).
Disease control and the notification go hand in hand. Contact tracing process and remedial measures to control the spread of the disease are taken once notifications reach the MOH (a health unit headed by Medical Officers of Health) office. The medical officers at the MOH office sends public health inspectors to trace contacts and refer them for investigations. Untreated patients are the main sources of disease spread in the community. Hence it is evident failure to notify is “opening the gate” for disease spread.
Though it is a notifiable disease and notification is a legal requirement; there are evidences for gap between actual figures and the number of cases reported. According to a survey done in Mulathiv district of the northern province between 2011 and 2013, more than 200 cases of Leishmaniasis among military recruits had been missed from the national disease surveillance reports (12). This suggests that there is a problem in the notification system of the country. Under-reporting has been identified as a major issue associated with disease notification in low and middle-income countries. In a study done among Sri Lankan medical officers, it was shown only a few doctors had notified though their awareness of notifiable diseases was good (13). Lack of time, belief of notification forms do not reach the MOH office and belief of no actions will be taken were among the reasons for notification failure (13). Except for these issues lack of clear instructions regarding notifications, unfamiliarity with the reporting system, infrastructure issues such as inadequate human resources and consideration of patient confidentiality were reported as barriers of notification in studies done in other countries (14-18).
Knowledge, attitude, and practices (KAP) of medical officers play an important role in infectious disease control in any setting. Knowledge about the disease is vital in making the right diagnosis, carrying out the relevant investigations and treating the patients. Good attitudes together with good practices such as timely notification to the relevant authorities would ensure effective control of the disease before growing into pandemic. Doctors play a vital role in educating the public on health issues. If doctors’ knowledge is deficient, public awareness inevitably becomes low. In the case of Leishmaniasis, as the skin nodules are painless, poor public awareness increases the chance of late presentation to healthcare with complications. However, there is no published data on studies done in the country regarding knowledge, attitude, and practices of medical officers related to leishmaniasis or disease notification. Knowing the KAP of medical officers related to leishmaniasis helps to identify the obstacles in controlling the disease such as under-notification and carrying out remedial measures. The main objective of this study was to assess the Knowledge, attitude, and practices of medical officers about leishmaniasis in an MOH area in Anuradhapura district.