A Feasibility Study on Using the Facilities of Health Centers for Developing a Laboratory Network on Vectors and Reservoir Hosts of Cutaneous Leishmaniasis in Iran http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... Review Article A Feasibility Study on Using the Facilities of Health Centers for Developing a Laboratory Network on Vectors and Reservoir Hosts of Cutaneous Leishmaniasis in Iran *Mohammad Reza Yaghoobi-Ershadi1; Amir Ahmad Akhavan1; Mohammad Reza Shirzadi2; Seyedeh Zohreh Hosseini1; Oscar Daniel Salomon3; Ahmad Ali Hanafi-Bojd1; Yavar Rassi1 1Department of Medical Entomology and Vector Control, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran 2Communicable Diseases Management Center, Iranian Ministry of Health and Medical Education, Tehran, Iran 3National Institute of Tropical Medicine, Puerto Iguazu, Misiones, Argentina *Corresponding author: Dr Mohammad Reza Yaghoobi-Ershadi, E-mail: yaghoobi.reza@gmail.com (Received 23 Jun 2020; accepted 30 Mar 2021) Copyright © 2021 The Authors. Published by Tehran University of Medical Sciences.Copyright © 2021 The Authors. Published by Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International license (https://creativecommons.org/licenses/ by- nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited.by- nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Abstract Background: Cutaneous leishmaniasis is an ancient endemic disease in Iran and continues to be a growing health threat to community development and the environment. This paper explains how to use the facilities of health centers for developing a laboratory network on vectors and reservoir hosts of cutaneous leishmaniasis in Iran. Methods: A literature search was performed of the relevant multiple databases to include studies on vectors and reservoirs of cutaneous leishmaniasis in Iran. A team of experienced experts was performed. After holding several meetings, field visits and organizing workshops, the activities of laboratories were determined at three levels. Results: Entomological studies showed that 5 species of the genus Phlebotomus and 10 species of the genus Sergentomyia are active in the south, 4 species of the genus Phlebotomus and one species of the genus Sergentomyia in the central part and 5 species of the genus Phlebotomus and 2 species of the genus Sergentomyia in the north east. Reservoir hosts were identified in the study areas. The tasks of laboratories were regulated at different levels. Conclusion: The Iranian Ministry of Health and Medical Education should prioritize the employment of capable persons in the field of Medical Entomology and Vector Control. The survival of this laboratory network depends on hiring and employing interested and persistent people. The universities of Medical Sciences that have the facilities to set up this network will be a very effective partner in the control of the disease in high risk areas. The results can be used in neighboring countries. Keywords: Laboratory network; Leishmaniasis; Vectors; Reservoirs; Iran Introduction Parasitic diseases of the genus Leishmania are a huge burden on human health and socie- ty. Their incidence is found to be prevalent in some of the poorest countries in the world, but they summon less attention than other infectious diseases like malaria, tuberculosis and AIDS (1). They are categorized as a ne- glected tropical diseases because, although they cause significant mortality, there is little effort on the part of the global community 256 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... and pharmaceutical industry to invest in research and development of better and innovative therapeutics because lack of sufficient incentives. Also, the disease is found primari ly among the poorest of the poor, who have no influence over policy- makers and little access to healthcare and the health-related market (1, 2). The disease is caused by more than 20 species/subspecies of Leishmania protozoa. They are transmitted to humans through the bites of infected Phlebotominae sand flies (3), principally belonging to two genera: Phlebotomus (in the Old World) and Lutzomy ia (in the New World). While Leishmania parasites were found in several species of a third genus Sergentomyia, which feed on hu mans, none were up to now incriminated as vectors. An estimated 31 species of Phlebotomus and 47 species of Lutzomyia are proven vectors of human leishmaniases (4). Sand flies are also known to be the vectors of other human pathogens, such as Bartonella spp. (Carrion’s disease), and a number of viral agents causing sand fly fever, summer menin gitis, vesicular stomatitis and Chandipura vi rus encephalitis(4). Both cutaneous and vis- ceral forms of leishmaniasis are present in the Eastern Mediterranean Region, making a significant neglected tropical disease there. Re garding cutaneous leishmaniasis, both the anthroponotic form, caused by Leishmania tropica, and the zoonotic form, caused by L. major with animal reservoir hosts, are endem ic in the region. Cutaneous leishmaniasis is one of the pri- orities in the WHO Eastern Mediterranean Region as it carries a large portion of the global burden. According to data reported in the Global Health Observatory, the Eastern Mediterranean Region reported 69.6% of the total number of cutaneous leishmaniasis cases detected worldwide in 2016 (followed by the Region of the Americas with 28.5% and the European Region with 1.6%). Of the total cases in the Region, over 90% were reported from three countries: the Syrian Arab Repub lic, Afghanistan and Pakistan, each of which reported more than 10 000 cases. Most of the cases are due to the anthroponotic form of the disease. Regarding visceral leishmaniasis, the Eastern Mediterranean Region carries about 19% of the global burden, with the highest number of cases reported from Sudan and Somalia (5). Cutaneous and visceral leish- maniasis are ancient endemic diseases in Iran and continue to be a growing health threat to community development and the environment in the country. Cutaneous leishmaniasis is endemic in two forms, Anthroponotic Cuta neous Leishmaniasis (ACL) and Zoonotic Cutaneous Leishmaniasis (ZCL). About 20000 cases of leishmaniasis (including ACL, ZCL and Zoonotic Visceral Leishmaniasis) are reported annually but the real figures could be 4–5 folds higher due to underreport ing, because of misdiagnosis, lack of active case detection and overlooking the im portance of the disease due to the lack of mor tality (6) Anthroponotic cutaneous leishmani asis is still a neglected tropical disease in many parts of the country, while it was great ly reduced in many foci by malaria control measures, many foci remained active in some large and medium sized cities such as Tehran, Mashhad, Neishabur and Sabzevar in the north-east, Shiraz in the south, Kerman and Bam in the southeast, Yazd, Kashan and parts of the city of Esfahan in the central region (7, 8, 9). The parasite is Leishmania tropica and the suspected vector is Phlebotomus (Paraph­ lebotomus) sergenti Parrot 1917. The main reservoir host is the human, but dogs have a role as animal reservoir host and active le- sions in dogs have been reported in Tehran, Mashhad, Shiraz and Neishabur (8, 9). Zo- onotic cutaneous leishmaniasisis is endemic in many rural areas of 17 out of 31 provinces and is a great health problem in Iran. More than 85% of cases reported in the coun try are of ZCL form (9, 10). Rhombomys opi mus, the great gerbil, is the main animal res ervoir in foci in the northeast and central part of the country, Meriones libycus, the Libyan jird, is considered the principal reservoir host in some parts of the central and south of the coun try. Tatera indica, the Indian gerbil, is 257 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... the main reservoir host in the southeast and Meri ones hurrianae, the desert gerbil, is the reser voir in the southeastern part of Iranian Balu chistan, neighboring Pakistan (11, 12, 13) Phlebotomus papatasi Scopoli 1786, the most prevalent among Phlebotomus genus, is the only known vector (14, 15, 16, 17). In 2019, totally 13055 cases of Cutaneous leishmaniasis were reported in the country, 12567 (96.5 %) of which from 18 endemic provinces and 488 (3.5 %) from non-endemic provinces. Most of the cases were from Isfahan Province in the central part of the country with 3127 cases and 59.1 incidence per 100000. But the highest incidence rate was in Semnan Province with 95.9 per 100000 populations (CDC, Iranian Ministry of Health and Medi cal Education, unpublished data). Fig. 1 shows the trend of reported cases of cutane ous leishmaniasis in Iran in the last 36 years. The incidence of the disease varies between 48/100000 and 15.8/100000 population dur ing 1983–2019 respectively. Whether the in cidence has been reduced between these years but, the burden of the disease is still high in some regions. It should be mentioned that the reduction has been due to the implementation of active rodent control operations in ZCL foci and improvement of surveillance and timely treatment of the patients in ACL foci. Iran is facing many challenges- emergencies, crises situations, outbreaks, population dis placement, limited funding and weak surveil lance, lack of proper management in some provinces, lack of community awareness and some managers- all which may have led to the rising trend in cutaneous leishmaniasis cases in some regions. Even if leishmaniasis was the main public health priority of Iranian Min istry of Health, unfortunately there is not a standard method for the different aspects to study the leishmaniasis, insect vectors in the country, so in this research project the infor mation required on the matter for surveillance and control of sand flies, in order to provide to health authorities in Iran the basis for a program, that could be replicated in the re- gion. This program requires immediate in- strumentation because, during the last two decades, the reported cases of leishmaniasis especially that of cutaneous leishmaniasis due to Leishmania major have increased in Iran, and it has spread into sites where it did not previously exist, so properly Phlebotomine sand flies have received considerable atten- tion by health authorities in recent years (9). However, the disease needs special ento- mological surveillance, and to achieve this goal developing a strong laboratory network is required. At the moment, laboratories in many health centers do not have facilities for entomological activities on sand flies and res ervoir hosts of cutaneous leishmaniasis, the staffs of health centers are unaware of the matter in different endemic foci of the coun try, and their duties do not involve clearly the surveillance and control of the disease. Physi cians and senior technicians are needed to be trained on leishmaniasis entomology and their awareness on the matter should be increased. Therefore, by conducting this research, the main aspects for developing a laboratory net work are stated to support the structuration of this initiative. To obtain a feasible program based on evidences, a search of worldwide information about the topic was performed, followed by consensual workshops with diff erent levels of technical and academic health agents, and visits to the field to assess the actual conditions and capabilities. Materials and Methods This study was carried out in five high risk provinces during 2019–2020 in Iran. 1) Databases including PubMed, Web of Science, Literature Retrieval System of the Armed Forces, Pest Management Board and also at least more than 40 eligible journal arti cles on vectors and reservoirs of cutaneous leishmaniasis and its control which are in dexed in electronic databases (ISI and Med line) were selected for this review. 1a) Goal: To summarize the experience on surveillance and control program organization on leishmaniasis worldwide; 258 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... 2) A team of experienced experts consist of key people from the Tehran University of Med ical Sciences and Ministry of Health and Medical Education (MOH) was formed. 2a) Goal: to develop the first blueprint of a program of surveillance and control of leish maniasis in Iran. The members of the expert team were as follows: - Four academic members (including Profes sors and Associate professors of Medical En tomology and Vector Control from Tehran University of Medical Sciences with personal knowledge of participants after more than 40 years of field mission on leishmaniases in Iran. - Manager of the Zoonotic Department at MOH - Two senior technicians on leishmaniasis Measures were carried out by the special ized team as follows: - Holding a special meeting for analysis of the current situation of leishmaniasis cases. - Holding more than 10 meetings with the presence of team members on determining the duties of experts at different levels and having a de tailed discussion and exchange of views. 2b) To collect relevant information on the current capabilities in the high risk are as - Field visits to the high risk areas (Provinces of Esfahan, Ilam, Khuzestan, Sistan and Ba luchestan and Northern Khorasan. Each one visited once during the months of June-November, 2019– 2020 - Holding meetings with the assistant direc tors of health, disease control managers and zoonotic experts in high risk provinces - Field visits to the facilities of laboratories at health centers in the provinces under study. 2c) To adapt the blue print to a feasible con- sensual program to be implemented - Preparation a list of equipment required for laboratories of cutaneous leishmaniasis vec tors and reservoir hosts. - Determination of duties for entomology senior technicians of health centers in order to detect and reveal the abundance of sand flies and rodent reservoir hosts. - To identify the collection methods of sand flies and reservoir hosts, mounting and moni toring - The platform of recording and flowchart of information - The needs and ways of capacitation “in practice” at different levels of responsibility from professionals to field technicians in the methods of monitoring of surveillance - The capacitation of decision takers, health, zoonosis and vector agents in outbreak control and integrated vector- borne diseases man agement. Results and Program proposal The results of literature review of the arti- cles on the vectors and reservoir hosts of cu- taneous leishmaniasis showed that there is not any network on this issue in the world except for South America. Many studies have been carried out on the control of vectors in differ ent countries with various results (use of re sidual spraying, spraying rodent burrows, the use of impregnated bed nets and cur tains, etc). Although many molecular stud ies have been conducted on Leishmania para site, unfortunately, studies on reservoir control are very limited and very few. Due to the fact that there is no effective vaccine against cuta neous leishmaniasis, so the control of vectors and reservoirs along with health education by the relevant specialists and allocating suffi cient funds, raising awareness of authorities and the community can prevent the spread of the disease. Results of entomological and reservoir studies in different provinces are as follows: Khuzestan Province A total of 4335 sand flies, 23.63% in doors, 76.37% outdoors, collected from Shush County in September 2019. Eight species in- cluding P. papatasi, P. alexandri, S. sintoni, S. squamipleuris, S. iranica, S. tiberiadis, S. 259 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... dentata and S. baghdadis were collected from indoors. Eleven species collected from out- doors comprising P. papatasi, P. alexandri, S. sintoni, S. tiberiadis, S. dentata, S. iranica, S. baghdadis, S. clydei, S. squamipleuris, S. the odori and S. christophersi. Out of 22 rodents which were collected in the mentioned county, 8(36.4%), 12(54.5%), and 2(9.1%) were identified as Nesokia indica, Tatera indica and Rattus Rattus, respectively. Isfahan Province A total of 3200 sand flies (35.81%) indoors, (64.19%) outdoors were collected from 6 villages in July 2019 around the city of Isfahan. Phlebotomus papatasi, P. sergenti and S. sin toni were found indoors and 5 species includ ing P. papatasi, P. segenti, P. ansarii, P. mongolensis, and S. sintoni were found outdoors. Phlebotomus papatasi was the dom inant species indoors and outdoors. Totally, 19 rodents were captured using 25 Sherman traps baited with cucumber and dates near gerbil colonies. The great majority were 16(84.2%) Rhombomys opimus and 3(15.8%) Meriones libycus. Ilam Province In total, 1071 sand flies were collected from 4 villages around the city of Mehran in June 2019. Phlebotomus papatasi, P. alexan­ dri, S. sintoni and S. dentata, were found in doors and species including P. papatasi, P. caucasicus, S. squamipleuris, S. clydei, S. the odori, S. dentata and S. tiberiadis found outdoors. Phlebotomus papatasi was a predom inant species in both outdoors and indoors. Out of 24 rodents that were caught in three villag es, 8(72/7%) and 3(27.3%) were identified as T. indica and N. indica, respectively. Sistan and Baluchestan Province In October of 2019, 644 sand flies collect- ed outdoors and indoors. Three species: P. papatasi, P. sergenti and S. sintoni were collected indoors and 6 species comprising P. papatasi, P. alexandri, P. salehi, S. clydei, S. christophersi and S. sintoni collected outdoors. The most predominant species was P. papatasi in both places. Eight reservoir hosts were captured by Sherman traps around Chabahar and Konarak, identified as M. hurrianae (75%) and T. indi ca (25%). Northern Khorasan Province An overall 1346 sand flies were collected from 4 villages in Esferayen and Bojnord in August 2019. Four species including P. papatasi, P. alexandri, P. sergenti, and S. sintoni collected indoors and 6 species comprising P. papatasi, P. sergenti, P. neglectus, P. adlerius group, S. sintoni and S. sumbarica collected outdoors. The predominant species in the indoors and outdoors were P. papatasi and S. sintoni, respectively. Out of 14 rodents, 6(42.9%), 5(35.7%) and 3 (21.4%) identified as R. opimus, N. in­ dica and M. libycus respectively. The tasks and activities of laboratories at each level were determined as follows: a. Periphery levels (County health center la- boratory) b. Province and university levels (Provincial health center laboratory) c. Country level (National reference labora- tory on vectors and reservoirs of cutaneous leishmaniasis) Peripheral level The number of peripheral level labs de- pends on the number of counties in each prov ince. There are 452 counties in Iran (Statisti cal Center of Iran) and each of them needs one peripheral level lab. The laboratory of the county health center requires an entomology expert and two field technicians who can play an important role in collection of sand flies and rodents. Peripheral level tasks are as follows: In order to have the necessary infor- mation, at least 3–4 suitable villages will be selected under the supervision of the provin cial health center laboratory for entomology (where they could have the capability to keep sand flies colonies) in infected foci of the plain region and the 260 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... same number in the mountain ous region of the county. So that the villages are considered as the real representative of the county. Then, from the beginning to the end of each active season, once every two weeks, at sunset, 30 sticky traps (castor oil coated white papers, 20× 35cm) will be installed in fixed indoor places, including bedrooms, liv ing rooms, stables, barns and toilets, and 30 sticky paper traps will be installed in fixed outdoor areas, including on the base of walls, under boulders, caves and rodent burrows. They are collected the next morning, before sunrise and then preserved in 70% ethanol, in which form they are transferred to the laboratory of the county. Indoor locations should be in cluded in three houses, one in the middle of the village, another in the outskirts of the vil- lage and the third between the previous two houses to show the actual activity of sand flies. - Mounting of sand flies in Puri’s medium according to the relevant instructions. - Preparing samples from sand flies blood content in the gut to determine the host blood preference of vectors according to the relevant instructions and sending them to the laborato ry of the province. - Collection of rodents with at least 50 Sherman traps up to a radius of 500 meters from the center of the village, once a season in infected foci, preparing two slides from each rodent earlobe, staining the slides and diagnosing Leishmania parasites according to the relevant instructions. - Separation of skin and skull of collected rodents according to the relevant instructions and sending to the middle level (Provincial centers). - Record the results on the relevant forms and send it to the coordinator of cutaneous leishmaniasis of the county. - Sending monthly performance reports regularly to the province level. Middle level (Provincial level) The provincial health center laboratory is the University Reference Laboratory. There are 31 provinces in Iran, and each must have one lab at this level. - The provincial health center must have a leishmaniasis entomology Lab. With the nec essary facilities and equipment. The responsi bilities of this level are as follows: - Identification of mounted sand flies at the species level. - Calculating the species composition of sandflies and their abundance by species. - Drawing diagrams related to the monthly activity of sand flies by species in the indoors and outdoors. - Preparing the distribution map of sand flies by species in the province as reported by rural district and county. - Dissection of sand flies in order to deter- mine the natural promastigote infection rate during the months of August and September as stated in instructions in county level. - Computer registration of the results on sandflies and reservoir hosts information based on the relevant instructions and sending it to the national level. - Technical supervision and quality control of all entomological laboratories of the affili ated counties by examining the mounted sam ples of sand flies and slides prepared from rodent earlobes and sending feedback. - Training of the laboratory staff working at leishmaniasis entomology laboratories at the county level. - Evaluation of vector control operations us ing standard scientific methods in the event of epidemics and outbreaks. With the base-line of vector and reservoir relative and absolute abundances, their annual dynamics, and infection rates, any anomalies in the usual patterns provide an early warning system to intensify monitoring and active search of patients, and to make focus studies in order to define precisely the where and when to perform the more effective intervention for prevention or mitigation. 261 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... Country level (National level) The National Reference Laboratory of vectors and reservoir hosts of cutaneous leishmaniasis is responsible for management, diagnosis, supervising, laboratory, educational and re search quality review, and its tasks are as fol lows: 1- Close cooperation with the Infectious Diseases Management Center in order to better implement the national programme for the control of cutaneous leishmaniasis and the goals of the ministry of health. At any level but also at this level, the programme should also include a network with the medical coun terpart. 2- Technical supervision and quality control of all laboratories on vectors and reservoir hosts of cutaneous leishmaniasis in the coun try, by examining a given percentage of sand flies and rodents collected and identified in the province in order to confirm and send the results as feedback. 3- Climate correlation with abundances and infection rates, and land use change at differ ent space and time scales, including the na tional level monitoring of changes in the pat terns. 4- Isolation of leishmania parasites from vectors and reservoir hosts and identification by using molecular methods if necessary. An experienced senior technician will perform this goal. 5- Molecular identification of vectors and reservoirs if needed. 6- Determination the susceptibility level of the main vectors of the disease to the used insecticides by the standard method of the world health organization, if necessary. 7- Determination the host-feeding prefer- ence of vectors by advanced diagnostic meth ods. 8- Necessary recommendations regarding the time of spraying and the type of the insec- ticide during outbreaks and epidemics of cu taneous leishmaniasis. 9- Carrying out advanced research projects on the ecology of vectors and reservoir hosts and evaluation different methods of vector control and reservoirs in cooperation with the Infectious Diseases Management Center. Eco-epidemiology studies to identify exposure risk and accessibility to health care according to region, gender and age. 10- Preparation of necessary instructions for collection methods and sampling of sand flies and reservoirs and their survey techniques. 11- Launching advanced diagnostic meth ods for vectors and reservoirs of the disease in provincial laboratories. 12- Participating in analyzing the results of Fig. 1. Trend of cutaneous leishmaniasis Iran 1983–2019 Fig. 1. Trend of cutaneous leishmaniasis Iran 1983–2019 262 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... activities in preparing annual reports. 13- Establishing close relations with prestig- ious international scientific institutions abroad and inside the country. 14- Organizing of practical and applied training workshops on the control of cutane ous leishmaniasis at different levels for man agers, general practitioners, experts and tech nicians in the country. 15- Periodic visits to provinces and counties in order to monitor executive operations. 16- Organizing of practical and applied en- tomology workshops of leishmaniasis and its reservoirs at different levels. Discussion The results of the search of information indicate the fact, that there are no laboratory networks on vectors and reservoirs of cutane- ous leishmaniasis in any country. There is only one Spanish language publication from South America (18) on this issue, which can- not be generalized to our country because of the differences in the geographical and epi demiological situation of the disease between these two regions. Health education is a spe cialized issue that unfortunately is not consid ered by the authorities in Iranian health cen ters, especially since the methods of educating the community have changed in the last two decades and only experts can implement them. In view of the results of this study, it seems that the Iranian Ministry of Health and Medical Education should prioritize the em ployment of specialized and capable person nel in the field of Medical Entomology and Vector Control so that they can better serve in the field for the country’s health system. Be cause the lack of attention to the existence of a cohesive organization and experienced per sonnel can pose a serious threat in the future in endemic foci of cutaneous leishmaniasis and other neighboring provinces. It is neces- sary to set up and use Medical Entomology laboratories in the provinces as it was pro- posed of the mentioned network as soon as possible while having sufficient facilities and equipment. The chancellors of Medical Sci ences Universities and health deputies of the provinces could have an important role in this matter and should pay special attention to setting up the discussed network. If any of the universities of medical sciences in the country have the facilities to set up this network in terms of laboratory equipment and tools and experienced specialists, it will Table 1. Cutaneous Leishmaniasis cases and Incidence Rate/ 100000 in endemic provinces of Iran, 2019 No Endemic Provinces Geographical Zones CL Number CL Incidence Rate/100000 1 Semnan Near north 719 95.9 2 Ilam West 470 78.7 3 Golestan North-east 1188 60.9 4 Isfahan Center 3127 59.1 5 Fars South-west 2002 40.0 6 North Khorasan North-east 214 24.0 7 Khorasan Razavi North-east 1581 23.4 8 Yazd Center 260 21.4 9 Qom Near central plateau 293 21.3 10 Khuzestan South-west 1013 20.7 11 Kerman South-east 565 17.1 12 Sistan and Baluchestan South-east 357 12.0 13 Hormozgan South 160 8.4 14 Kermanshah West 117 5.9 15 South Khorasan East 39 4.8 16 Lorestan West 69 3.8 17 Tehran North of central plateau 434 3.1 18 Bushehr South 28 2.3 Table 1. Cutaneous Leishmaniasis cases and Incidence Rate/ 100000 in endemic provinces of Iran, 2019 263 http://jad.tums.ac.ir Published Online: Sep 30, 2021 J Arthropod-Borne Dis, Sep 2021, 15(3): 255–264 MR Yaghoobi-Ershadi et al.: A Feasibility... undoubtedly be very effective in the control of the disease. Creating a constructive and dynamic competi tive environment in this new movement and trying to create links and interaction at differ ent levels (environment- health-social devel opment) among provinces and between juris dictional levels (from county to national level) can be useful. It should be noted that the sus tainability of this laboratory network depends entirely on hiring and employing literate, in terested and persistent people. It should be mentioned that the results of this research can be used in Afghanistan, Pakistan, Iraq, Syria, Tajikistan and Turkmenistan which have a similar problem regarding the importance of leishmaniasis as a health issue and lacking a proper national network system to perform integrated management that includes vector, reservoirs and humans. In those senses, it should be mentioned that expert manpower is important to get things done, and the adequate use of already existing or created capacities is essential. It is hoped that in the near future we will see the serious efforts of our colleagues to consolidate a network, and that all respect ed managers and experts will base their work on activities of the network according to the tasks that have been defined. Acknowledgements The authors are grateful to responsible persons and staffs of provincial health centers under study. The research reported in this publi cation was supported by Elite Researcher Grant Committee under award number 982714 from the National Institutes for Medi cal Research Development (NIMAD, Tehran, Iran.). Thank you very much for the role of this institute in the general support of research projects. The authors declare that there is no conflict of interests. References 1. Wagstaff A (2002) Poverty and health sector inequalities. Bull World Health Organ. 80(2):97- 105. 2. Yamey G, Torreele E (2002) The world’s most neglected diseases, BMJ. 325(7357):176-7. 3. Magill AJ (1995) Epidemiology of the leishmaniasis. Dermatol Clin. 13(3):505-23. 4. Maroli M, Feliciangeli MD, Bichaud L, Charrel RN, Gradoni L (2013) Phlebotomine sand flies and the spreading of leishmaniasis and other diseases of public health concern. Med Vet Entomol. 27(2):123-47. 5. 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Surveillance of leishmaniasis transmitting insects (2015) Operational manual for the community. Pictographic key for identification of Phlebotomine sand fly species. Clarification and Mounting, Red Argentina. Argentine Network for the study of leishmaniasis in Argentina. 2015 Eds. INMe T-MSAL.ISBN.978-987-29115-3-9, p. 81 (Spanish). A Feasibility Study on Using the Facilities of Health Centers for Developing a Laboratory Network on Abstract Keywords Introduction Materials and Methods Results and Program proposal Khuzestan Province Isfahan Province Ilam Province Sistan and Baluchestan Province Northern Khorasan Province Peripheral level Middle level (Provincial level) Country level (National level) Discussion Acknowledgements References