RESEARCH ARTICLE
Detection of cutaneous leishmaniasis in three
communities of Oti Region, Ghana
Richard Akuffo 1,2*, Carmen Sanchez3, Carmen Chicharro 3ID ID , Eugenia Carrillo3,
Naiki Attram 4ID , Mba-Tihssommah Mosore
4, Clara Yeboah 4 5ID , Nana Konama Kotey ,
Daniel Boakye 1ID , Jose-Antonio Ruiz-Postigo
6, Javier Moreno 3ID , Michael Wilson
1
ID ,
Bismark Sarfo 2ID , Francis Anto
2
1 Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana, 2 School of Public
Health, University of Ghana, Accra, Ghana, 3 WHO Collaborating Center for Leishmaniasis, Instituto de
Salud Carlos III, Madrid, Spain, 4 U.S. Naval Medical Research Unit No. 3, Ghana Detachment, Accra,
a1111111111 Ghana, 5 National Yaws Control program, Ghana Health Service, Accra, Ghana, 6 Department of Control of
a1111111111 Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
a1111111111
a1111111111 * richard.akuffo@gmail.com, rakuffo@ug.edu.gh
a1111111111
Abstract
OPEN ACCESS
Citation: Akuffo R, Sanchez C, Chicharro C, Carrillo Background
E, Attram N, Mosore M-T, et al. (2021) Detection of
Cutaneous leishmaniasis (CL) is the most common type of leishmaniasis, a neglected tropi-
cutaneous leishmaniasis in three communities of
Oti Region, Ghana. PLoS Negl Trop Dis 15(5): cal disease caused by parasites of the genus Leishmania. In Ghana, some studies in the
e0009416. https://doi.org/10.1371/journal. Volta region have detected Leishmania parasites among persons with skin ulcers.
pntd.0009416
Editor: Henk D. F. H. Schallig, Academic Medical
Center: Amsterdam UMC Locatie AMC, Methodology/Principal findings
NETHERLANDS
Using a cross-sectional study design, the prevalence of CL in three communities of the Oti
Received: December 22, 2020
Region of Ghana was investigated. Demographic and epidemiological data were obtained
Accepted: April 27, 2021 by a structured interviewer administered questionnaire. A total of 426 (12.4%) out of 3,440
Published: May 24, 2021 participants screened had at least one skin ulcer. Of 595 skin ulcers sampled and tested by
Copyright: This is an open access article, free of all PCR for Leishmania infection, 150 (25.2%) ulcers from 136 individuals tested positive,
copyright, and may be freely reproduced, accounting for an overall CL prevalence of 31.9% among persons with skin ulcers. Individual
distributed, transmitted, modified, built upon, or community CL prevalence of 23.2%, 29.8%, and 36.8% was observed in Ashiabre, Keri,
otherwise used by anyone for any lawful purpose.
and Sibi Hilltop respectively among persons with skin ulcers.
The work is made available under the Creative
Commons CC0 public domain dedication.
Data Availability Statement: All relevant data are
within the manuscript and its Supporting Conclusions/Significance
Information files. Confirmation of CL in the study area suggests an active cycle of transmission of Leishmania
Funding: This project was funded by the post infection. The observation of skin ulcers which tested negative to Leishmania infection sug-
graduate training scheme fellowship in gests a need to test for additional causes of skin ulcers such as Treponema pallidum perte-
implementation science by the Special Programme
nue and Mycobacterium ulcerans in the study area.
for Research and Training in Tropical Diseases
(WHO/TDR) at the School of Public Health,
University of Ghana. https://publichealth.ug.edu.gh/
The grant was received by RA. The authors declare
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PLOS NEGLECTED TROPICAL DISEASES Cutaneous leishmaniasis in Oti Region, Ghana
that the funder had no role in the study design,
data collection, data analysis, data interpretation, Author summary
and in writing the manuscript.
Cutaneous leishmaniasis (CL) is a neglected tropical disease caused by parasites of the
Competing interests: The authors have declared
genus Leishmania and is transmitted by various species of female sandflies. CL usually
that no competing interests exist.
begins as painless nodules and is usually characterized by skin ulcers which may be single
or multiple. Although ulcers due to CL are often self-healing, they may become painful
and result in scarring after healing. Typically, CL occurs on exposed parts of the body
such as the neck, limbs, and face, which may be easily accessible to sandflies. Although
cases of CL had previously been reported in some parts of the Volta region of Ghana, no
previous case of CL had been reported in the Oti region. This study was initiated following
reports of skin ulcers which were suggestive of CL in some communities of the Oti region.
This study confirmed Leishmania infection in 150(25.5%) out of 595 skin ulcer samples
obtained from 426 study participants. Given that 445(74,8%) of the skin ulcers tested neg-
ative for Leishmania parasite suggests a need for investigation of additional causes of skin
ulcers such as yaws and Buruli ulcer in the study area.
Introduction
Cutaneous leishmaniasis (CL) is an important neglected tropical skin disease (skin NTD) of
public health importance and is the commonest form of leishmaniasis, characterized by skin
lesions which may result in ulcers, scars, disability and stigma [1,2]. Globally, it is estimated
that between 0.7 to 1.3 million new cases of CL are reported annually [3].
A localized outbreak of skin ulcers suspected to be cases of CL was first reported in
Ghana from the Ho municipality of the Volta Region in 1999 based on the identification of
Leishmania amastigotes in some skin lesion biopsies [4]. Subsequent studies have identified
L. major, uncharacterized Leishmania species, and recently, members of the Leishmania
enriettii complex from suspected CL cases in the Ho municipality, suggesting a complex epide-
miology of CL in the region [5–7].
Although the Oti region has been part of the Volta region until the year 2019, no previous
confirmation of CL cases had been made there. This study was therefore initiated following
reports of skin ulcers which were suggestive of CL in some communities of the Oti region,
after leishmanin skin test (LST) had been conducted to establish Leishmania infection
(reported elsewhere).
Materials and methods
Ethics statement
Ethical approval to conduct this study was obtained from the ethics review committee of the
Ghana Health Service (GHS-ERC006/08/18). Written informed consent was obtained from all
study participants. For participants under 18 years, written consent was obtained from a par-
ent or guardian.
Study design
This study was based on a cross-sectional study design approach. The study was conducted
from October to December 2018 in three communities of the Oti region of Ghana having at
least three suspected cases of active CL (ACL). A suspected ACL lesion was defined clinically
as any open ulcer with diameter bigger than 5mm. Prevalence of CL among study participants
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PLOS NEGLECTED TROPICAL DISEASES Cutaneous leishmaniasis in Oti Region, Ghana
with skin ulcers was investigated. Demographic and epidemiological data were obtained by a
structured interviewer administered questionnaire.
Study area
This study was conducted in the following three communities of the Oti region of Ghana:
Ashiabre, Keri, and Sibi Hilltop. Ashiabre is in the Tutukpene sub-district of the Nkwanta
South municipality while Keri is in the Keri sub-district of the municipality. Sibi Hilltop is in
the Sibi sub-district of the Nkwanta North district of the region.
The population of Nkwanta South municipality is estimated to be 117,878 with males con-
stituting 49.6% of the population. Covering a land area of approximately 2733 km2, the
Nkwanta South municipality is located between latitudes 7o 30’ and 8o 45’ North and longitude
0o 10’ and 0o 45’East [8].
The population of the Nkwanta North district is estimated to be 64,553 with males consti-
tuting 50.2% of the population. The district is located between Latitude 7˚30’N and 8˚45’N and
Longitude 0˚10’W and 045’E. It shares boundaries with Nkwanta South municipality to the
south, Nanumba South to the north, Republic of Togo to the east, and Kpandai District to the
west [9].
Inclusion criteria
Eligible study participants were residents in the study community for� 12 months, aged
between 2 to 65 years (inclusive).
Sample size considerations
For active case detection, assuming a current CL prevalence (P) of 22.1% [4,10], Z2 = (1.96)2
for 95% confidence interval D2 = maximum 0.05, a minimum sample size (N) of 265 individu-
als was required for screening for active case detection using the formula:
N = ((Z)2P/D2) �(1-P)
Selection of households for study inclusion
Using a sorted list of households, 200 households (with an average of 5–7 persons per house-
hold) were selected for study inclusion in each study community using a systematic sampling
approach. For this study, a household was defined as a person or a group of persons, who live
together in the same house or compound and share the same house-keeping arrangements.
The head of each household was defined as a male or female member of the household recog-
nised as such by the other household members. The head of a particular household is generally
the person with economic and social responsibility for the household. As a result, household
relationships were defined with reference the household head [11]. The community household
list was obtained for each study community based on a household census. The number of
households per study community determined by household census was 945, 795, and 1184 in
Ashiabre, Keri, and Sibi Hilltop respectively.
A sampling interval I was determined, where I = N/n with N being the sum of individual
households in the study community while n was the number of households to be selected. The
I was rounded to 2 decimal places.
Using Microsoft excel, the RANDBETWEEN command was used to generate a random
decimal integer R between 0 and 1 rounded up to two decimal points. The sequence of
households that were selected in each study community were R�I, R�I + I, R�I +2�I,
R�I +3�I,. . ..R�I + (n-1)�I, each rounded up to the next highest whole number [12]. With the
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PLOS NEGLECTED TROPICAL DISEASES Cutaneous leishmaniasis in Oti Region, Ghana
assistance of community-based volunteers, the selected households were identified after which
all members of the selected households aged 2 to 65 years were invited to participate in the
study, using a door-to-door invitation approach. Because the invitation to participate in the
study was extended to households, a household was not included in the study if the household
head declined to allow his or her household to participate in the study. However, the agree-
ment of the household head did not make it compulsory for every household member of age 2
to 65 years to participate in the study. Each household member was given the opportunity to
go through the informed consent process to decide whether they wish to participate or not.
Sampling of suspected active cutaneous leishmaniasis (ACL) lesions
(ulcers)
Each study participant was asked to disclose the occurrence of any skin ulcer(s) on their body.
Interviewers also examined the exposed parts of participants body such as legs, arms, neck,
and face to identify any suspected active CL (ACL) lesion(s). The location, size, and duration
of each suspected ACL was documented. For each suspected ACL lesion, a non-invasive diag-
nostic sampling technique using sequential tape strips with a diameter of 22 mm (D-Squame,
CuDerm Corporation, Texas, USA) was used to obtain samples for subsequent DNA isolation
[13].
For the non-invasive skin sampling, one tape disc was placed on each suspected skin lesion
after which even pressure was applied to the disc on the lesion using a plunger which was
gently held on the disc and pressed for approximately 20 seconds. The tape disc was then
detached and transferred into a sterile 1.5ml Eppendorf vial and stored at 4˚C for transporta-
tion to the laboratory for further analysis (Fig 1). Participants received standard wound care
after sample collection.
DNA isolation from tape strip disc and PCR amplification of Leishmania
species
DNA extraction was performed using SpeedTools Tissue DNA Extraction Kit (Biotools, Inc).
A nested polymerase chain reaction (Ln-PCR) approach was used to amplify DNA of Leish-
mania species from the human skin lesions following an adaptation of the protocol by Cruz
et al., 2002 [14], with the target being the small subunit ribosomal ribonucleic acid (SSU
rRNA) gene. Positive control used was Leishmania infantum (JPC strain) with distilled water
as negative control.
Data management
Data was managed using Microsoft Access software version 2013 and analyzed using STATA
software version 14. Association between nominal variables was assessed using Pearson’s chi
square test of association and Fishers exact test. All statistical tests were performed at a 95%
confidence level.
Results
Of 600 households (200 in each study community) invited to participate in this study, a total of
587 households comprising 189 (32.2%), 200 (34.1%), and 198 (33.7%) from Ashiabre, Keri
and Sibi Hilltop respectively, were included in this study. The study households had a total of
3718 members out of which 3,440 (92.5%) consisting of 1,194, 941, 1305 from Ashiabre, Keri,
and Sibi Hilltop respectively were enrolled in the study.
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Fig 1. Non-invasive sampling of skin lesions.
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The average household size was 6.3 with a range of 1 to 18 household members. Ashiabre
and Sibi Hilltop had an average household size of 7 while Keri had an average household size
of 5.
Out of 3440 persons physically examined for ulcers, a total of 595 skin ulcers were observed
on 426 (12.4%) (Table 1). Of the 426 persons, 314 (73.7%) were within the age group 5–15
years while those under five constituted 13.6%. The number of skin ulcers observed on the par-
ticipants ranged from 1 to 7 with those having one ulcer (47.1%) and two ulcers (27.6%) being
the majority. Although skin ulcers were observed on various parts of the participants’ body,
majority occurred on the lower legs (71.3%) and feet (17.1%). In Ashiabre, Keri, and Sibi Hill-
top, 65.2%, 70.1%, and 74.3% of persons with skin ulcers had the ulcer on their lower legs
respectively (Table 1).
PCR test of the 595 ulcer samples indicated that 150 (25.2%) of them were Leishmania posi-
tive. In the study communities, 14 (20.3%), 62 (22.1%), and 74 (30.2%) of skin ulcers tested
from Ashiabre, Keri, and Sibi Hilltop respectively were positive for Leishmania (Table 1).
Of the 595 ulcer samples tested, 365 (61.3%) were obtained from males while 90 (60.0%) of
the 150 Leishmania positive samples were also obtained from males. Also, 437 (73.4%) of the
ulcer samples tested as well as 112 (74.7%) of the Leishmania positive ulcer samples were
obtained from people within the age group 5–15 years (Table 2).
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Table 1. Individuals with skin ulcers, ulcers sampled and result of Leishmania PCR test.
Characteristic Category Ashiabre Keri Sibi Hilltop Total
n % n % n % n % P value
Age of individuals with skin ulcers
<5 years 12 21.4 22 11.7 24 13.2 58 13.6 0.141
5–15 years 35 62.5 145 77.1 134 73.6 314 73.7
16–45 years 9 16.1 19 10.1 18 9.9 46 10.8
>45 years 0 0 2 1.1 6 3.3 8 1.9
Total 56 100 188 100 182 100 426 100
Sex of individuals with skin ulcers
Male 36 64.3 109 58 110 60.4 255 59.9 0.684
Female 20 35.7 79 42 72 39.6 171 40.1
Total 56 100 188 100 182 100 426 100
Number of Skin ulcers tested
1 31 44.9 116 41.3 133 54.3 280 47.1 <0.001
2 28 40.6 84 29.9 52 21.2 164 27.6
3 8 11.6 46 16.4 37 15.1 91 15.3
4 0 0 30 10.7 11 4.5 41 6.9
5 2 2.9 5 1.8 0 0 7 1.2
6 0 0 0 0 5 2 5 0.8
7 0 0 0 0 7 2.9 7 1.2
Total 69 100 281 100 245 100 595 100
Skin ulcer locations
Face/Head 3 4.3 5 1.8 6 2.4 14 2.4 0.029
Upper arm 0 0 2 0.7 0 0 2 0.3
Lower arm 1 1.4 13 4.6 11 4.5 25 4.2
Palm/Back of palm 0 0 2 0.7 3 1.2 5 0.8
Chest 0 0 1 0.4 0 0 1 0.2
Back (upper part below neck)) 0 0 0 0 2 0.8 2 0.3
Stomach 2 2.9 0 0 0 0 2 0.3
Buttocks 1 1.4 0 0 2 0.8 3 0.5
Thighs 1 1.4 8 2.8 6 2.4 15 2.5
Lower legs(crus/cnemis) 45 65.2 197 70.1 182 74.3 424 71.3
Feet 16 23.2 53 18.9 33 13.5 102 17.1
Total 69 100 281 100 245 100 595 100
Leishmania pcr result
Negative 55 79.7 219 77.9 171 69.8 445 74.8 0.061
Positive 14 20.3 62 22.1 74 30.2 150 25.2
Total 69 100 281 100 245 100 595 100
https://doi.org/10.1371/journal.pntd.0009416.t001
The 150 Leishmania positive ulcer samples were obtained from 136 study participants of
which 123 (90.4%) had single Leishmania positive skin ulcer, 12 (8.8%) had two Leishmania
positive skin ulcers and 1 person had three Leishmania positive skin ulcers (Table 3). Majority
of individuals with Leishmania positive ulcers were within the age group of 5–15 years (73.5%)
followed by children under five (14.0%) and persons aged 16–45 years (10.3%). Across the
study sites and among males and females respectively, majority of persons with Leishmania
positive skin ulcer(s) were within the age group 5–15 years (Table 3).
The overall prevalence of cutaneous leishmaniasis (Leishmania infection observed among
those with skin ulcers) was 31.9% (136/426) with prevalence of 23.2% (13/56), 29.8% (56/188),
and 36.8% (67/182) observed in Ashiabre, Keri and Sibi Hilltop respectively.
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Table 2. Skin ulcers tested for Leishmania parasite using PCR by age and sex.
Sex Age Number of skin Leishmania positive ulcers
ulcers tested n (%)
Males < 5 years 48 8 (16.7)
5–15 years 276 70 (25.4)
16–45 years 36 10 (27.8)
>45 years 5 2 (40.0)
Subtotal 365 90 (24.7)
Females < 5 years 45 13 (28.9)
5–15 years 161 42 (26.1)
16–45 years 19 4 (21.1)
>45 years 5 1 (20.0)
Subtotal 230 60 (26.1)
Total < 5 years 93 21 (22.6)
5–15 years 437 112 (25.6)
16–45 years 55 14 (25.5)
>45 years 10 3 (30.0)
Total 595 150 (25.2)
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Table 3. Distribution of individuals with Leishmania positive skin ulcers by age, sex, and community of residence.
Characteristic Category Ashiabre Keri Sibi Hilltop Total
Male (%) Female (%) Male Female Male Female Male Female Total
Individuals with one Leishmania positive skin ulcer
<5 years 1 (25.0) 1 (12.5) 3 (9.4) 5 (27.8) 4 (9.8) 3 (15.0) 8 (10.4) 9 (19.6) 17 (13.8)
5–15 years 3 (75.0) 6 (75.0) 23 (71.9) 11 (61.1) 31 (75.6) 15 (75.0) 57 (74.0) 32 (69.6) 89 (72.4)
16–45 years 0 1 (12.5) 6 (18.8) 1 (5.6) 4 (9.8) 2 (10.0) 10 (13.0) 4 (8.7) 14 (11.4)
>45 years 0 0 0 (0) 1 (5.6) 2 (4.9) 0 2 (2.6) 1 (2.2) 3 (2.4)
Sub total 4 (100) 8 (100) 32 (100) 18 (100) 41 (100) 20 (100) 77 (100) 46 (100) 123 (100)
Individuals with two Leishmania positive skin ulcers
<5 years 0 0 0 1 (33.3) 0 1 (25.0) 0 2 (28.6) 2 (16.7)
5–15 years 1 (100) 0 3 (100) 2 (66.7) 1 (100) 3 (75.0) 5 (100) 5 (71.4) 10 (83.3)
16–45 years 0 0 0 0 0 0 0 0 0
>45 years 0 0 0 0 0 0 0 0 0
Sub total 1 (100) 0 3 (100) 3 (100) 1 (100) 4 (100) 5 (100) 7 (100) 12 (100)
Individuals with three Leishmania positive skin ulcers
<5 years 0 0 0 0 0 0 0 0 0
5–15 years 0 0 0 0 1 (100.0) 0 1 (100.0) 0 1 (100.0)
16–45 years 0 0 0 0 0 0 0 0 0
>45 years 0 0 0 0 0 0 0 0 0
Sub total 0 0 0 0 1 (100) 0 1 (100) 0 1 (100)
Individuals with Leishmania positive skin ulcer(s)
<5 years 1 (20.0) 1 (12.5) 3 (8.6) 6 (28.6) 4 (9.3) 4 (16.7) 8 (9.6) 11 (20.8) 19 (14.0)
5–15 years 4 (80.0) 6 (75.0) 26 (74.3) 13 (61.9) 33 (76.7) 18 (75.0) 63 (75.9) 37 (69.8) 100 (73.5)
16–45 years 0 1 (12.5) 6 (17.1) 1 (4.8) 4 (9.3) 2 (8.3) 10 (12.0) 4 (7.5) 14 (10.3)
>45 years 0 0 0 (0) 1 (4.8) 2 (4.7) 0 2 (2.4) 1 (1.9) 3 (2.2)
Sub total 5 (100.0) 8 (100.0) 35 (100) 21 (100) 43 (100) 24 (100) 83 (100) 53 (100) 136 (100)
https://doi.org/10.1371/journal.pntd.0009416.t003
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Fig 2. Examples of skin ulcers which tested positive for Leishmania parasite. A. Location: Left lower leg; dimension:10.1mm by
5.9mm. B. Location: Left lower arm; dimension:17.0mm by 15.1mm. C. Location: Left lower arm; dimension:17.6mm by 11.0mm. D.
Location: Left lower leg; dimension:14.4mm by 5.2mm.
https://doi.org/10.1371/journal.pntd.0009416.g002
The average size of the skin ulcers observed was 10.2mm by 10.3mm with 573 (96.3%) of
them reported to have started in the year 2018. Among the ulcers which started in the year
2018, 17 (3.0%) started between January to July 2018 while 13 (2.3%), 70 (12.2%), 346 (60.4%),
127 (22.2%) of them started in August, September, October and November of the year 2018
respectively. Examples of Leishmania positive skin ulcers observed is captured as Fig 2.
Of the 426 individuals with skin ulcers, 419 (98.4%) indicated that they applied some form
of treatment. Majority of them (67.5%) used herbs while 35.3%, and 14.2% of them used hot
stone and hot water respectively as treatment of their skin ulcers (Table 4).
Discussion
Cutaneous leishmaniasis among study participants
The control of CL requires an understanding of the disease epidemiology [15]. This study con-
firmed cutaneous leishmaniasis in the study communities by detecting Leishmania infection in
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Table 4. Summary of ulcer treatment methods reported by study participants.
Treatment Ashiabre Keri Sibi Hilltop Total
method No. % No. % No. % No. %
Herbs 21 40.4 117 62.6 145 80.6 283 67.5
Hot stone 3 5.8 72 38.5 73 40.6 148 35.3
Dermacot 7 13.5 31 16.6 3 1.7 41 9.8
Penicillin 7 13.5 14 7.5 8 4.4 29 8.1
Amoxycillin 5 9.6 10 5.3 2 1.1 17 4.7
Hotwater 5 9.6 19 10.2 27 15 51 14.2
Other treatment 5 9.6 4 2.1 6 3.3 15 4.2
Total 52 100 187 100 180 100 419 100
https://doi.org/10.1371/journal.pntd.0009416.t004
150 (25.2%) out of 595 ulcer biopsies tested by PCR. The overall prevalence of cutaneous
leishmaniasis among persons with skin ulcers was 31.9% (136/426) with prevalence of 23.2%
(13/56), 29.8% (56/188), and 36.8% (67/182) observed in Ashiabre, Keri and Sibi Hilltop
respectively. In Mali, a systematic review reported a prevalence of 40.3% for cutaneous leish-
maniasis among suspected CL cases[10].
Majority of the persons with CL in this study (73.5%) were in the age group of 5–15 years,
with males in this age group constituting majority of those infected among persons with
skin ulcers. A study in Mali which screened study participants with skin lesions for CL using
PCR, confirmed Leishmania infection in samples from 8 persons who were all under 18 years
[16].
A review of literature on CL suggests that although Leishmania infection and subsequent
leishmaniasis disease generally tends to be influenced by factors associated with the host, the
parasite, as well as the disease vectors, the prevalence of CL usually increases with age till about
15 years [17]. It is assumed that the prevalence of CL levels of at about 15 years because persons
exposed early on in life to Leishmania infection may have acquired some level of immunity to
the infection by then [17]. Observation of the highest prevalence of CL in 5–15 years age group
in this study suggest a need to prioritize this group in future CL control planning in the study
area.
Treatment of persons with cutaneous leishmaniasis
An important aspect of disease control is treatment of affected people. The data on treatment
of skin lesions by study participants indicate that majority of them use herbs (67.5%) followed
by those who use hot stone (33.5%) and hot water (14.2%) respectively.
In the case of cutaneous leishmaniasis, the first choice of treatment is pentavalent antimoni-
als with its attendant cost and possible adverse effects [18–22]. However, the evidence for what
can be described as optimal treatment for CL has been described as patchy and generally weak.
There is therefore a need for the development of improved guidelines for management of CL
in addition to the conduct of more robust studies to improve the existing body of evidence for
treatment of CL [18,23–25].
Furthermore, although efforts are ongoing to develop a vaccine against leishmaniasis, there
is currently no vaccine licensed for use against leishmaniasis [26,27]. Given the gaps in the
treatment of leishmaniasis and ongoing global efforts to develop vaccines, there is a need to
develop measures in the local Ghanaian context, to protect people who are affected by leish-
maniasis while research continues to provide data on critical aspects of the disease such as the
vectors and reservoirs.
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Need for investigation of skin ulcers which were negative for Leishmania
infection
Given that not all skin ulcers observed in the study communities were infected with Leish-
mania parasites, there is a need for continuous diagnoses of skin ulcers observed in the study
communities in order to identify the ulcers infected by Leishmania parasite for the appropriate
treatment to be applied [28–30].
Some studies have reported occurrence of other skin ulcers such as buruli ulcer, and yaws
in Ghana [31–34]. A pilot study aimed at using azithromycin as treatment for yaws in some
communities of the West Akim district of Ghana for instance, used sero-positivity based on a
point of care dual treponemal and non-treponemal test as the primary outcome in addition to
presentation with clinically active yaws like lesions (as secondary outcome) to select yaws cases
[35].
As a result, future studies aimed at screening a larger sample of persons in the study area
for yaws and other skin ulcer causing diseases such as buruli ulcer, incorporating more sophis-
ticated laboratory diagnostic approaches may help to better characterize the causes of skin
ulcers in the study area.
Conclusions
Out of 426 individuals observed with various numbers of skin ulcers in the study communities,
136 (31.9%) individuals had various numbers of confirmed Leishmania positive skin ulcers.
The observation of skin ulcers which tested negative to Leishmania infection suggests a need
to test for additional causes of skin ulcers such as Treponema pallidum pertenue and Mycobac-
terium ulcerans in the study area.
Limitations of the study
Molecular characterization of the ulcer samples for agents of other skin ulcer causing diseases
reported in Ghana such as yaws, and buruli ulcer would have enriched the data.
Inclusion of a household in the study depended on the consent of the household head. This
may have led to the exclusion of a few households, given that 587 households were included
out of 600 households invited.
Supporting information
S1 STROBE checklist. Checklist according to The Strengthening the Reporting of Observa-
tional studies in Epidemiology (STROBE) guidelines.
(DOCX)
Acknowledgments
The authors wish to thank the Department of Neglected Tropical Diseases of the World Health
Organization for technical support. We also thank the WHO Collaborating Center for Leish-
maniasis at the Instituto de Salud Carlos III, Spain for providing laboratory and technical sup-
port for the conduct of this study.
We are grateful to Prof. Richard Adanu, Dr. Phyllis Darko-Gyekye, and all the administra-
tors of the WHO/TDR PhD Fellowship for their roles in Coordinating the program.
The assistance of field workers from the Nkwanta South and North District Health director-
ates is also appreciated. The authors are also grateful for the support from Mr. Emmanuel
Agbodogli of the Nkwanta South District hospital and Dr. Laud Boateng, the Nkwanta South
PLOS Neglected Tropical Diseases | https://doi.org/10.1371/journal.pntd.0009416 May 24, 2021 10 / 13
PLOS NEGLECTED TROPICAL DISEASES Cutaneous leishmaniasis in Oti Region, Ghana
District Director during the field component of this study. Technical advice from Mr. Thomas
Azurago of the Ghana Health Service and Dr. Kinsley Asiedu of the Department of Neglected
Tropical Diseases of the World Health Organization is also appreciated.
Author Contributions
Conceptualization: Richard Akuffo.
Data curation: Richard Akuffo, Mba-Tihssommah Mosore, Clara Yeboah.
Formal analysis: Richard Akuffo.
Investigation: Mba-Tihssommah Mosore, Javier Moreno.
Methodology: Richard Akuffo, Jose-Antonio Ruiz-Postigo.
Project administration: Richard Akuffo.
Resources: Naiki Attram, Jose-Antonio Ruiz-Postigo.
Software: Richard Akuffo.
Supervision: Michael Wilson, Bismark Sarfo, Francis Anto.
Validation: Javier Moreno.
Visualization: Richard Akuffo.
Writing – original draft: Richard Akuffo.
Writing – review & editing: Richard Akuffo, Carmen Sanchez, Carmen Chicharro, Eugenia
Carrillo, Naiki Attram, Mba-Tihssommah Mosore, Clara Yeboah, Nana Konama Kotey,
Daniel Boakye, Jose-Antonio Ruiz-Postigo, Javier Moreno, Michael Wilson, Bismark Sarfo,
Francis Anto.
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