J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 234 http://jad.tums.ac.ir Published Online: September 30, 2019 Review Article Conducting International Diploma Course on Leishmaniasis and its Control in the Islamic Republic of Iran *Mohammad Reza Yaghoobi-Ershadi1; Amir Ahmad Akhavan1,3; Mohammad Reza Shirzadi2; Yavar Rassi1; Ali Khamesipour4; Ahmad Ali Hanafi-Bojd1; *Hassan Vatandoost1,3 1Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 2Zoonosis Control Department, Ministry of Health and Medical Education, Tehran, Iran 3Department of Chemical Pollutants and Pesticides, Institute for Environmental Research Tehran University of Medical Sciences, Tehran, Iran 4Center for Research and Training in Skin Diseases and Leprosy (CRTSDL), Tehran University of Medical Sciences, Tehran, Iran (Received 26 May 2019; accepted 21 Sep 2019) Abstract Background: Leishmaniasis represents the important public health problem in the world. One of the main objectives of World Health organization is capacity building of managers and authorities who are involved with diseases control ac- tivities. Methods: The course was conducted in Esfahan Health Research and Training Center (E.H.R.T.C) in summer 2005 and 2009. The course carried out jointly by the Ministry of Health and Medical Education (MOH) of Iran, World Health Or- ganization-Eastern Mediterranean Regional Office (WHO-EMRO) and School of Public health, Tehran University of Med- ical Sciences (SPH-TUMS) and designed for medical officers, senior technicians and managers involved in leishmania- sis control. Prior to initiate the course, pre-test evaluations including different subjects on leishmaniasis and its control were carried out. The examinations include multiple choice questions. The duration of the course was 3 weeks. A total of 206 contact hours were taught. The main subjects were Basic epidemiology, Leishmaniasis parasitology, Leishmaniasis en- tomology, control of vectors and reservoirs, principles of integrated pest management, Field work and Planning. Dif- ferent methods of teaching including lecture, laboratory, workshop, team work, field exercise and presentation were used. Requirement for achievement of the course was to have at least 60% of the total mark for awarding the diploma certificate. Results: A total of 45 participants from Iraq, Afghanistan and Iran graduated from this course. Conclusion: The course is providing the skill for managers, how to combat against disease in their country and is paral- lel to the policy of the leishmaniasis control for capacity building in endemic areas of their countries. Keywords: Leishmaniasis; Diploma course; Disease control; Iran Introduction Human leishmaniasis with a wide clinical spectrum is the neglected form of neglected trop- ical diseases with a wide variety of parasite spe- cies, reservoirs and vectors which are involved in transmission. The causative agent is more than 20 species of the protozoa Leishmania and is transmitted to animals and humans through the bite of certain species of female sand flies (1). Out of about 1000 species of sand flies, 93 of them spread leishmaniasis. They are usually 2 millimeter large and can tear the skin in feeding of blood (2). The disease is extended in 100 countries in the world with a global prevalence of 12 mil- lion people and 2 million new cases are reported each year (3, 1). Cases mostly occur in devel- oping countries around the subtropical regions and its incidence is rising significantly. The pres- ence of the disease is linked directly to poverty, but the factors such as social, poor housing, en- *Corresponding authors: Prof Mohammad Reza Yaghoobi-Ershadi, Email: yaghoobia@tums.ac.ir, Prof Hassan Vatandoost, Email: vatando@tums.ac.ir http://jad.tums.ac.ir/ mailto:yaghoobia@tums.ac.ir mailto:vatando@tums.ac.ir J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 235 http://jad.tums.ac.ir Published Online: September 30, 2019 vironmental and climate change influence the epidemiology of the disease. More than half of the world's population lives in endemic areas and is at risk of infection (1). Available tools for prevention and control are limited in the world, which means that exposed individuals should take steps to reduce contact with the vector. Fur- thermore, the health authorities should imple- ment surveillance actions and carry out public health interventions when necessary. Early di- agnosis and proper treatment are essential for halting this disease (4). Cutaneous and visceral leishmaniasis are endemic in Iran and continue to be a growing health threat to community development and in the environment. Cutaneous leishmaniasis (CL) occurs in two forms, Anthroponothic Cutaneous Leishmaniasis (ACL) and Zoonotic Cutaneous Leishmaniasis (ZCL) (5). The incidence of CL has been reported between 36–49 cases per 100 000 population during 1983–2017 but in recent years it has had a decreasing trend (Fig. 1). The number of reported CL cases in 2017 was 12491, with minimum of 443 in July and maximum of 1661 in November (Fig. 2). Fig. 3 shows the frequency of cutaneous leishmania- sis cases by province in the country in 2017. The most affected province was Ilam with incidence rate of 135/1000 and the lowest incidence rate (0-11) has been reported from the northwest and southwest areas. A total of 60 cases of VL have been reported from Iran in 2017, the most af- fected area was Meshkin-Shahr District in the northwest (Fig. 4). The trend of visceral leish- maniasis cases shows a sharp reduction during 1998–2017 (Fig. 5). The main elements of cutaneous and viscer- al leishmaniasis control programs in the Islamic Republic of Iran have focused on the establish- ment of a national committee for leishmania- sis control, are as follows: Strengthening the leishmaniasis surveillance system and establishing a laboratory network from the national to peripheral level, establish- ment of standard diagnosis and treatment centers, provision of educational programs for different social levels and revision of the national guide- line, standardization of case definition and treat- ment results, early diagnosis and rapid treatment of patients accompanied by dressing wounds to prevent sand fly bites, reservoir control pro- grammes, collecting the rubble and rubbish tips and vector control programs, applying direct ag- glutination test in periphery levels for visceral leishmaniasis diagnosis, identification and col- lection of infected owned and stray dogs in vis- ceral leishmaniasis endemic foci, intersectional coordination with related organizations and in- stitutions (6). Leishmaniasis and its control has been a matter of interest by different research- ers at School of Public Health, Tehran Uni- versity of Medical Sciences (TUMS), in coin- cidence with the beginning of epidemiological studies on CL in 1965 and have been contin- ued by scientists and young researchers so far. Some of their several publications on different aspects of leishmaniasis is worthy of mention in recent years (7-21). Course contributors The course was organized jointly by the Ministry of Health and Medical Education, Is- lamic Republic of Iran, The School of Public Health and National Institute of Health Re- search, Tehran University of Medical Scienc- es, World Health Organization, Eastern Medi- terranean Region (EMRO). It provided the par- ticipants with the knowledge and skills in dif- ferent aspects of leishmaniasis and its control, through small group work, field exercises, ex- change of experiences and discussions with qual- ified specialists. Contents of the course Epidemiological trends of Leishmaniasis Description, history and geographical distri- bution of leishmaniasis in the world and East- ern Mediterranean Regional Office (EMRO), Ep- idemiology of leishmaniasis in Iran and neigh- boring countries, effects of climate change and disaster on leishmaniasis situation. http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 236 http://jad.tums.ac.ir Published Online: September 30, 2019 Treatment Clinical manifestation and treatment of old world cutaneous and visceral leishmaniasis: physical systematic, interleisonal, oral drugs, management of visceral leishmaniasis Immunology of leishmaniasis Natural immunity and Acquired immunity, Experience of vaccination in leishmaniasis, se- rological surveillance of asymptomatic viscer- al leishmaniasis and case detection, leishman- iasis surveillance in Iran. Human disease Methods of studies on human disease: rates, ratios, proportions, prevalence and incidence of leishmaniasis, data presentation: common sta- tistical tests, tables, graphs, charts. Leishmaniasis entomology An overview of vectors and reservoirs of leishmaniasis, biology and ecology of sand flies, Taxonomy of sand flies, identification criteria, explaining of identification keys. Identification of sand fly genera: different sub-genera of Phlebotomus genus. Sampling methods of sand flies: sucking tube, CDC light traps, funnel traps, sticky oil traps and other techniques, preservation, mount- ing and identification of sand flies, collection of sand flies on human and animal baits, dissec- tion of sand flies for detection and isolation of Leishmania parasites, molecular entomology of leishmaniasis vectors. Reservoir hosts Rodent leishmaniasis, biosystematics of ro- dents, identification of main reservoir hosts, bi- ology, ecology, distribution and behavior of ro- dents, criteria for incriminating rodents as res- ervoirs, methods of field and laboratory studies of reservoirs of cutaneous and visceral leish- maniasis, canine visceral leishmaniasis, molec- ular epizootiology of rodent leishmaniasis. Control of leishmaniasis Different methods of prevention and control of cutaneous and visceral leishmaniasis, meth- ods for evaluation of leishmaniasis control, dif- ferent methods for elimination of stray dogs, Leishmanization and its effectiveness in the con- trol of CL in Iran, Vaccine for visceral leishman- iasis, principals of integrated pest management (IPM planning), rodenticides and environmen- tal management and sanitation, destroying of chenopods, different methods of rodent control, insecticide susceptibility tests on sand flies, cal- culation of LT50 and LT90 using Probit analysis, insecticides recommended by WHO against leishmaniasis vectors, formulation of insecti- cides for residual spraying, measurement and calculation of insecticides for impregnation of bed nets and curtains, safe use and judicious use of insecticides and precaution measures, insec- ticide storage (condition of safe storage), space spraying, Ultra Low Volume (ULV), thermal fog. Fieldwork and practical demonstrations Collection of sand flies by different meth- ods from outdoors and indoors in a rural district (field work) around Esfahan, carrying of traps from the field to laboratory, preservation and mounting of collected sand flies, identification of sand fly genera: different sub-genera of Phlebotomus genus (laboratory practice), col- lection of sand flies by different methods (from rodent burrows, on human and animal bait, field work), carrying of traps from the field to labor- atory, dissection of collected sand flies for de- tection and isolation of Leishmania parasites, mounting, identification of collected sand flies, collection of rodents by Sherman traps in the field and carrying of them to the laboratory, identification of collected rodent reservoirs, prep- arations of smears from the ear of each rodent, fixation of slides, staining with Giemsa micro- scopic examination of slides, isolation of par- asites from infected rodents, measurement of rodenticides for application in the field circum- stances, preparing of poisoned bait, education of workers, domestic dog examination and con- http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 237 http://jad.tums.ac.ir Published Online: September 30, 2019 trol, field application of rodenticides, its mon- itoring and evaluation impact, visiting house- holds in 3 villages for case finding , examination of people for the presence of ulcers or scars, re- cording the necessary information on the related forms, preparing smears from ulcers, fixation of slides, staining with Giemsa, microscopically examination of slides, visiting health centers for examination and treatment of patients of CL in Esfahan, different methods of preven- tion and control of cutaneous and visceral leishmaniasis, methods for evaluation of leish- maniasis control, principals of integrated pest management, Integrated Pets Management (IPM) planning, different methods of rodent control, insecticide susceptibility tests on sand flies, calculation of LT50 and LT90 using probit analysis, insecticides recommended by WHO against leishmaniasis vectors, formulation of insecticides for residual spraying, measurement and calculation of insecticides for preparation of bed nets and curtains, safe use and judicious use of in insecticides and precaution measures, space spraying, ULV, thermal fog, different parts and function of Hudson pump and ther- mal fog, measurement and calculation of in- secticides for impregnation of bed nets and curtains (practical work), practical work for in- door residual spraying at the station, collection of sand flies by aspirator from the villages, car- rying out insecticide susceptibility tests by WHO standard method on collected sand flies, re- sults of susceptibility tests on sand flies: record- ing and analysis, suggestion of a control pro- gram for an Anthroponetic Cutaneous Leish- maniasis (ACL) focus, suggestion of a control program for a Zoonotic Cutaneous Leishman- iasis (ZCL) focus, suggestion of a control pro- gram for a Visceral leishmaniasis (VL) focus. 19 83 19 84 19 85 19 86 19 87 19 88 19 89 19 90 19 91 19 92 19 93 19 94 19 95 19 96 19 97 19 98 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 INC. 36 48 32 26 42 35 28 33 25 21 23 35 27 36 39 30 30 20 22 21 32 40 32 35 32 32 31 28 26 27 22 29 25 19 15 CASE 15 21 15 12 21 18 15 19 14 11 13 20 16 22 23 18 18 12 14 13 21 27 21 24 22 23 22 21 19 20 16 22 19 14 12 0 5000 10000 15000 20000 25000 30000 0 10 20 30 40 50 60 INC/100,000 Fig. 1. Trend of cutaneous leishmaniasis in Iran, 1983–2017 http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 238 http://jad.tums.ac.ir Published Online: September 30, 2019 Fig. 2. Number of Cutaneous leishmaniasis cases by month, Iran, 2017 Fig. 3. Frequency of cutaneous leishmaniasis cases by province, Iran, 2017 http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 239 http://jad.tums.ac.ir Published Online: September 30, 2019 Fig. 4. Trend of visceral leishmaniasis in Iran 1998–2017 Fig. 5. Visceral leishmaniosis cases by province, Iran, 2017 http://jad.tums.ac.ir/ J Arthropod-Borne Dis, September 2019, 13(3): 234–242 MR Yaghoobi-Ershadi et al.: Conducting International … 240 http://jad.tums.ac.ir Published Online: September 30, 2019 Evaluation of the course and participants In evaluating the training course, almost all the training units in the module were covered during the period. There were adequate facili- ties for the delivery of lectures. These include a well-furnished spacious room for lectures with adequate audio-visual equipment. These include a white board, a slide projector and screen and a dedicated computer for the training. Each par- ticipant was provided with a copy of the relevant books and handouts. The participants were given practical field experience and laborato- ry demonstrations. The laboratory was well equipped with dissecting and compound mi- croscopes which made it possible for each par- ticipant to individually and independently do the laboratory work. There was enough reference collection of sandflies available for practical work. All the facilitators tried to make the course as participatory as possible and there was very good relationship between the facilitators and the participants. Almost all the participants through verbal communication rated the entire course as very good, delivery of lectures as excellent and practical demonstrations and fieldwork as good. The onsite accommodation for participants en- abled all the activities to be organized on time. Conclusions In general, based on the assessments and interviews, also considering the fact that most of the participants were programme managers and medical health professionals who have had very little knowledge on entomology, vector and reservoir control, the course achieved its pur- pose of providing them with basic information needed for decision making in disease control activities in their respective countries. The par- ticipants and facilitators for the first time shared experiences with regard to vector control activ- ities between different countries. We will rec- ommend that all the participants should be mon- itored and given the necessary support to ena- ble them contribute to diseases control and elim- ination activities in their respective countries. Acknowledgements The authors would like to appreciate very much for kind support of School of Public Health (TUMS), CDC of Iran (from MOH), World Health Organization, Eastern Mediter- ranean Region, and also Prof Nadim, Prof Ja- vadian, Prof Gouya, Prof Asilian, Dr Zahraei- Ramazani, Eng Abdoli, Eng Jafari, Prof Mohe- bali, Mr Arandian, Ms Shareghi, Ms Ghanei, for their contribution as course tutors and field works. References 1. Jhingran A, Chatterjee M, Madhubala R (2008) Leishmaniasis: Epidemiological trends and diagnosis in: Leishmania after the genome by: Myler PJ and Fasel N, Caister Academic Press, Norfolk, UK, pp. 1–14. 2. Maroli M, Feliciangeli MD, Bichaud L, Char- rel RN, Gradoni L (2012) Phlebotomine sand flies and the spreading of leishmani- ases and other diseases of public health concern. Med Vet Entomol. 27(2): 123– 147. 3. Choi CM, Lerner EA (2001) Leishmaniasis as an emerging infection. J Invest Der- matol Symp Proc. 6: 175–182. 4. 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