Journal of School of Public Health and

Visceral leishmaniasis (VL) has been found as an endemic disease in some areas in northwest and south parts of Iran during recent two decades. The species of the Leishmania has been characterized as L.infantum and the main sources of human infection in the endemic areas is dog. The majority of kala-azar cases are found among children in the age group of 1-4 years. As the delay in diagnosis and treatment of kala-azar cause high mortality in the patients, serological surveillance, using direct agglutination test (DAT), and treatment of seropositive cases who have clinical symptoms are carrying out with cooperation of Provincial Health Services in the endemic foci of Ardebil and East Azerbaijan Provinces in the northwest and Bushehr in the south parts of Iran since 1997.
DAT Leishmania antigen is made in the Protozoology Unit of the School of Public Health with the strain of L.infantum isolated from an infected dog in Iran. The finger prick blood samples are collected by trained Health Workers (Behwarz) from suspected kala-azar patients in the Rural Health Houses. The collected samples are transferred to the near district kala-azar laboratory and tested (using DAT) by the trained technicians. The sero -positive patients are referred to pediatricains or trained general physicians in district hospital or health center for clinical examination and treatment of the seropositive cases (DAT titers of 1:3200 or higher) with kala-azar clinical symptos. For the treatment, usually, meglomine antimongtc (Glucantime) is used via intra-muscular in dosss of 20mg/kg/day for 20 days.
In kala-azar case finding in the serological surveyed areas of Ardebil, East-Azerbaijan and Bushehr provinces during 1997-2001, altogether, 19693 blood samples were collected from suspected kala-azar patients and tested by DAT. Totally , 1274 cases (6.74%) were seropositive in titers of 1:3200 or higher. In the clinical examination of seropositive cases 690 patients (54.16% of sero-positive cases and 3.50% of the total samples) had kala-azar clinical symptoms and therefore they were treated.
This seroloeical surveillance of kala-azar in the endemic area as have detected high number of kala-azar patients among children up to 12 years old, who were subsequently treated on time . This ptoject has prevented the mortality of the disease in the studied areas.

Malaria has been prevalent for a long time in Iran. About 1000 years ago, the Iranian physicians such as Avicenna (979-1037) were acquainted to the clinical feature of the disease. The scientific study of malaria in Iran was started by Latycheve in 1921. Later on up to 1944, malaria have been studied by some Iranian and foreign investigators and it was found hyper-endemic in some littoral parts of Caspian Sea in the north and Persian Golf in the south and hypo-or meso-endemic in the central parts of the country. From 1941 to 1948 the anti-malaria campaign were using quinine for chemotherapy and chemoprophylaxis as well as anti-larval measures for vector control. From 1949 DDT was used for the control of the Anopheles vectors which were determined at that time as A.maculipennis and A.superpictus in the north and some central parts of Iran, A. sacharovi in the west and A.stephensi and A. culicifacies in the south parts of the country. At the present time A.d&aposthali and A.fluviatilis are also considered as malaria vectors and A.pulcherrimus as a suspected vector in the south parts of Iran.
Spraying (using DDT) and malaria surveillance (case finding and treatment) caused a great reduction in malaria incidence in the malarious areas, particularly in the north and central parts of the country. The Institute of Malariology was established in the Department of Medical Parasitology, Medical School of Tehran University for training and research works on malaria in 1952.Malaria Eradication Programme (MEP) was recommended by the World Health Organization in 1956 and actually started in 1957 in Iran under General Office of Malaria Eradication (GOME) in the Ministry of Health.
Anti-malaria campaign in MEP during 1957-1971 caused interruption of transmission of malaria in the north parts of Zagross mountains, approximately, half north parts of Iran, and reduced, greatly, the incidence of the disease in the south parts of Iran which were considered as problem or refractory areas.
In 1973, GOME became a division of CDC in Ministry of Health and this integration caused some standstill in the activities of MEP. Thus, the incidence of malaria increased in the refractory areas in the south as well as in consolidation areas in the north parts of the country and the total diagnosed cases of malaria in Iran raised from less than 35,000 to approximately 100,000 cases per year. Therefore, the Ministry of Health strengthened the MEP again. Actually, from 1980 the anti-malaria campaign from MEP changed to malaria control programme , because in the refractory areas due to some behaviors or resistance of vectors to insecticides and, partly, due to the resistance of P.falciparum to chloroquine at RI & RII levels, the interruption of transmission was not possible. However, there was about 80% reduction of annual malaria incidence as well as percentage of P.falciparum during the recent decade. The prevalent species of Plasmodia are P.vivax & P.falciparum in the malarious areas of south and P.vivax in the north parts of Iran. P.malariae is rarely found at present time.

One of the main problems in malaria control is the resistance of Plasmodium falciparum to chloroquine and some other antimalarial drugs. This resistance is now quite common in most regions where falciparum malaria is endemic. Between 1968 and 1976, two in-vivo studies were carried out in endemic areas in the south of Iran and they showed P. falciparum to be chloroquine-sensitive. In 1983, the Department of Protozoology in the School of Public Health undertook in vivo and in vitro studies on the response of P. falciparum to chloroquine and other antimalarials. In the Iran-Shahr region a few cases of in vivo resistance to chloroquine were found in 1983, and the rate of resistance was 5.7% at RI level. Between 1994 and 1996, resistance in this region gradually increased to 51.2% at RI, RII and RIII. In Bandar-Abbas and Kahnoudj areas, prevalence of chloroquine-resistant P. falciparum infection was 32.5% at RI and RII from 1986 to 1987 it increased to 64.8% at RI,RII and RIII levels from1994 to1996 and then altered between 68% and 84% at RI and RII levels in the 1997-2001 period. 88 chloroquine-resistant patients were treated with standard doses of sulfadoxine-pyrimethmine (Fansidar) alone or in combination with amodiaquine and then examined with 28-day in-vivo tests. In 13.6% of them resistance was observed at RI and RII levels. In micro in-vitro tests, using WHO standard kits, the rates of resistance of P. falciparum to chloroquine, amodiaquine, sulfadoxine-pyrimethamine, mefloquine and quinine were 33.4%, 15.2%, 17.9%, 2.2% and 0.0% in 281, 72, 39, 44 and 72 cases respectively. As mefloquine has never been used in the studied areas, the sporadic cases of in-vitro mefloquine resistance may be considered as cases of innate and/or imported resistance. Primary resistant casese was seen mostly among Afghan and Pakistani immigrants/passengers. Hence these individuals are likely to have introduced chloroquine–resistant malaria into this country. The in vivo response of Plasmodium vivax to chloroquine was also studied in 827 patients was also studied in the endemic areas of the South-East between 1995 and 2001. The mean parasite clearance time (MPCT) was 2.78 and no resistant cases were found. Most cases in these studies had been referred by the local Malaria Control Laboratories to the research facilities at Health Training and Research Centers in Bandar-Abbas and Iran-Shahr. Some had received chloroquine, and those with a good response had not been referred. Therefore, the high rates of chloroquine resistance found in these studies probably do not reflect overall resistance rates at population level. To determine true resistance levels in these areas, all eligible patients must undergo WHO’s simplified in-vivo tests performed by trained malaria microscopists or laboratory technicians.

Background and Aim: Visceral leishmaniasis is a systemic parasitic disease with a high fatality rate in under-5-year-old children. The disease is endemic in some parts of Iran, particularly in the north-west region. In 2001 a visceral leishmaniasis (VL) surveillance system was established for children aged ≤ 12 years in the primary health system in Meshkin-Shahr District, Ardebil Province, situated in the north-west of Islamic Republic of Iran.

Materials and Methods: All cases with clinical signs and symptoms of VL and confirmed positive by the direct agglutination test (DAT) were referred for physical examination and treatment.

Results: The mean annual incidence of VL decreased significantly from 1.88 per 1000 children before (1985-2000), to 0.77 per 1000 child population after (2001-07), the intervention. In the control area with no surveillance, it increased from 0.11 to 0.23 per 1000.

Conclusion: Early detection of VL using serological tests and timely treatment of cases can decrease the mortality and morbidity rates of VL in endemic areas.