Impact of Modifiable Risk Factors on the Occurrence of Cutaneous Leishmaniasis in Diyala, Iraq: Case-Control Study
Authors: Lehlewa Asaad Mahdi , Khaleel Hanan Abdulghafoor , Lami Faris , Hasan Saif Aldeen Falah , Malick Hasanain Asmail , Mohammed Razzaq Hashim , Abdulmottaleb Qais Abdulazziz 
Published: May 2021

Background
In 2018, an outbreak of cutaneous leishmaniasis (CL) occurred in Diyala Province in Iraq. Several risk factors of CL were identified in a prior study; however, the impact of removing modifiable risk factors on the occurrence of the disease was not measured.

Objective
The aim of this study is to measure the impact of removing modifiable risk factors of CL on the occurrence of the disease.

Methods
We conducted a population-based unmatched case-control study in two conveniently selected districts in Diyala Province. All cases of CL were included. Controls were chosen preferentially according to the site where the cases occurred. A structured questionnaire was used to collect data. The unadjusted odds ratios (ORs) and 95% confidence intervals for each risk factor were calculated using binary logistic regression. We also calculated the attributable fractions and 95% confidence intervals of the modifiable risk factors. A P value <.05 was considered statistically significant.

Results
Data from 844 persons (432 cases, 51.2%) were analyzed. Cases were more likely than controls to report a history of previous displacement (OR 5.18, 95% CI 3.84-6.98), electricity supply for less than 12 hours per day (OR 1.94, 95% CI 1.47-2.55), living in a rural area (OR 1.91, 95% CI 1.45-2.51), living in a clay house (OR 2.41, 95% CI 1.59-3.66), having an unpainted indoor living space (OR 2.14, 95% CI 1.51-3.02), having rodents inside the house (OR 5.15, 95% CI 3.56-7.47), having chickens, sheep, or both (OR 3.44, 95% CI 2.48-4.75), having a mixture of dogs and sheep or of dogs and chickens within a distance of less than 100 meters (OR 3.92, 95% CI 2.59-5.94), fogging (OR 2.11, 95% CI 1.40-3.19), bed net use (OR 1.72, 95% CI 1.08-2.72), and sleeping outside or a mixture of inside and outside (OR 4.01, 95% CI 1.32-12.19). The data show that the exposure of approximately 70% to 80% of cases was associated with displacement, the presence of rodents inside the house, the presence of animals within 100 meters of the house, the presence of animals (chickens/sheep/both or a mixture of dogs and sheep or of dogs and chickens), and sleeping outside. Approximately 40%-50% of the cases reported living in a clay house, living in a rural area, having an unpainted indoor space, having an electricity supply for less than 12 hours, and using a bed net.

Conclusions
Prevention and control of CL requires a multifaceted approach that relies on changing environmental conditions, housing conditions, and human behavior. Fogging and bed net use were not effective because the underlying housing characteristics and human behavior provided a good culture for the disease. We recommend conducting a study to identify the species, reservoirs, and vectors of CL in Iraq; studying vector behaviors before applying environmental control measures; and educating the public on how and when to use bed nets as well as how to accompany their use with behavioral changes.