Environmental and social determinants and risk factors for Cutaneous Leishmaniasis in Palestine: A case- control study in Hebron and Bethlehem Governorates
مرام المخارزة, ياسر عيسى
كلية الصحة العامة-جامعة القدس · فلسطين
Cutaneous leishmaniasis is a persistent public health challenge in Palestine, particularly within the Hebron and Bethlehem governorates. This study aims to analyze the epidemiological characteristics of cutaneous leishmaniasis (CL) cases by person, place, and time in Hebron and Bethlehem Districts. Through statistical analysis, it seeks to identify the sociodemographic and environmental risk factors associated with CL transmission in these endemic areas. Additionally, it assesses the relationship between climate factors, particularly rainfall, and CL occurrence over recent years. Finally, the study evaluates the effectiveness of recent preventive measures implemented by municipalities and health authorities in these districts to combat the disease. Methods: A case-control study was conducted with 207 confirmed cases of cutaneous leishmaniasis and 414 controls (1:2 ratio) matched by age, sex, and residential area. Data were gathered through structured interviews and validated questionnaires covering socioeconomic status, housing conditions, environmental exposures, and behavioral factors. Statistical analyses, including chi-square tests, t-tests, and multivariate logistic regression, were used to identify significant risk factors. Results: The spatial distribution of cases revealed that 29.9% were concentrated in Za'atara, A'rab Rashayida, and Al-Dirat, with notable clusters in Wadi Araba, Dimona, Beer Sheba, and Eilat (16.4%), as well as Massafer Bani Na'im (14.5%). Multivariate logistic regression identified several key risk factors for cutaneous leishmaniasis. Household crowding was a significant predictor, with those in overcrowded conditions showing increased odds of infection (OR = 2.10, 95% CI: 1.45–3.05). Poor housing quality, characterized by inadequate sanitation and proximity to areas with high vector activity, further elevated the risk (OR = 2.35, 95% CI: 1.50–3.70). Lower socioeconomic status was strongly associated with higher incidence rates, disproportionately affecting individuals in the lowest income brackets (p < 0.05). Environmental factors, including rainfall and topography, were also significant. The study found that areas with lower annual rainfall (<300 mm) had a higher incidence of cutaneous leishmaniasis, possibly due to the drier conditions favoring the breeding and survival of sandfly vectors (p < 0.05). Topographical analysis revealed that cases were more common in low-lying areas and valleys, which provide suitable microhabitats for sandflies. These areas often have higher humidity levels and vegetation, which can support vector proliferation and increase human exposure risk (OR = 1.90, 95% CI: 1.30–2.80). Behavioral factors, particularly outdoor sleeping habits and insufficient use of protective measures during peak vector activity at night, were significantly correlated with higher infection rates (p < 0.01). Proximity to animal shelters and unprotected agricultural areas increased the likelihood of exposure to sandfly bites, the primary vector for leishmaniasis (OR = 1.85, 95% CI: 1.20–2.85). Educational programs aimed at improving knowledge and practices related to vector protection showed potential as an intervention, indicating that public awareness is critical in mitigating the spread of the disease. Conclusions: The findings underscore the importance of improving socioeconomic conditions, enhancing housing and environmental sanitation, and promoting awareness about leishmaniasis to mitigate the disease's spread. Targeted interventions, including the use of insecticide-treated bed nets and better waste management, are recommended to reduce infection rates. Continued surveillance and tailored public health strategies are essential to address the ongoing challenge of leishmaniasis in Palestine.