Asian Pacific Journal of Tropical Medicine

384-396

Authors: Alzeir M. Rodrigues, Victor Emanuel P. Martins, Selene M. Morais

The Aedes (Ae.) aegypti and Ae. albopictus mosquitoes are vectors of epidemiologically relevant arboviruses in the public health context, such as the dengue, Zika and chikungunya viruses. Among the alternatives to synthetic insecticides for the control of these vectors, the use of natural plant products deserves attention. This review summarizes findings on the larvicidal potential of plant extracts on Ae. aegypti and Ae. albopictus, as well as the potential of isolated compounds from plants of the Annonaceae and Piperaceae families against these vectors. Descriptors related to larvicidal activity of plant extracts and isolated compounds in Aedes spp. in the Web of Science database were used, for plant extracts considering publications between 2000 and 2019. A total of 859 articles were analyzed for plant extracts and estimates of lethal concentration values (LC50 and LC90). In the end, 95 articles that presented the larvicidal potential of 150 plant species from 52 families were analyzed. The two families most studied for this activity were Fabaceae and Asterace Aedes. The plant families with the best LC50 values against mosquitoes were Piperaceae and Annonaceae. Larvicidal activity of 50 acetogenins has already been identified on Ae. aegypti, and 29 of them presented LC50 below 10 μg/mL, as well as the larvicidal activity of 8 compounds isolated from Piperaceae. Therefore, plants of these two families are promising for the development of commercial botanical larvicides in the form of extracts and isolated substances, as well as the production via organic synthesis of the most active compounds.

402-408

Authors: Kurnia Fitri Jamil, Wira Winardi, Amanda Yufika, Samsul Anwar, Nurfanida Librianty, Nyoman Ananda Putri Prashanti, Tri Novita Wulan Sari, Prattama Santoso Utomo, Theresia Dwiamelia, Putu Pangestu Cendra Natha, Salwiyadi Salwiyadi, Febrivan Wahyu Asrizal, Ikram Ikram, Irma Wulandari, Sotianingsih Haryanto, Nice Fenobileri, Abram L. Wagner, Mudatsir Mudatsir, Harapan Harapan

Objective: To assess healthcare workers’ knowledge of novel coronavirus disease 2019 (COVID-19) in the early phase of the outbreak in Indonesia. Methods: A cross-sectional survey was conducted in 12 hospitals in Indonesia from March 6 to March 25, 2020. Healthcare workers’ knowledge on COVID-19 was assessed, and demographic data, workplace characteristics, and medical professional characteristics as well as the current local situation of COVID-19 were collected. To characterize determinants associated with knowledge, a logistic regression analysis was employed. Results: Out of 288 healthcare workers who completed the interview-assisted questionnaire, 149 (51.7%) respondents had a good knowledge. Nurses and other types of healthcare workers had lower odds of having good knowledge compared to doctors: adjusted odds ratio (aOR): 0.38; 95% CI: 0.20-0.72 and aOR: 0.31; 95% CI: 0.13-0.73, respectively. Compared to healthcare workers who had medical practice experience less than 5 years, those who had worked for more than 10 years had lower knowledge (aOR: 0.43; 95% CI: 0.20-0.90). Healthcare workers who worked in the infection department had higher knowledge compared to those in the emergency room (aOR: 14.33; 95% CI: 3.67-55.88). Conclusions: The knowledge of COVID-19 among surveyed healthcare workers was relatively low. The COVID-19 response in Indonesia will require further education and enhancement of the capacity of healthcare workers in the emergency room where COVID-19 patients may be treated the earliest.

415-422

Authors: Nattapong Maneeroth, Nawee Noonanant, Kanaphot Thongkhao, Theerakamol Pengsakul

Objective: To determine the morphological characteristics of variations in populations of female adult sand fly, Sergentomyia anodontis Quate and Fairchild, 1961 in caves in southern Thailand using morphometric analysis. Methods: A total of 107 female Sergentomyia anodontis were isolated from 651 sand flies captured by CDC light traps overnight in caves in Surat Thani, Nakhon Si Thammarat, Satun and Songkhla provinces from February to December 2017. Measurement of 23 external and internal morphological characteristics was conducted. Data were tested with preliminary statistics (Kolmogorov-Smirnov test, Levene's test and Box's test of equality of covariance matrices) and by one-way ANOVA or Kruskal-Wallis test. Measurements were analyzed using canonical discriminant analysis. Results: There were 11 morphological characteristics with high variability while two characteristics exhibited low variation. The sand fly populations from Nakhon Si Thammarat, Satun and Songkhla provinces were very similar but were separate from that in Surat Thani province based on canonical discriminant analysis data. This indicates that the morphological variation founding is a result of the diversity of habitats in each population and the geographic features of caves in each area, such as their altitude above sea level. Conclusions: There is a certain variation in the morphology of Sergentomyia anodontis sand flies at the population level which may be used for future classification of sand flies.

426-428

Authors: Praveen D, Ranadheer Chowdary Puvvada, Vijey Aanandhi M

None.

335-349

Authors: Zhong Wang, Xuezhong Yu, Yuguo Chen, Chuanzhu Lv, Xiaodong Zhao

Sepsis is currently a major problem and challenge facing the medical community. With rapid development and progress of modern medicine, researchers have put more and more attention on sepsis; meanwhile, the morbidity and mortality of sepsis remains high despite great efforts from experts in various fields. According to updated guidelines, sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Infection is the initial step of sepsis progression, and development from infection to sepsis is a complex pathophysiological process, including pathogen invasion, cytokine release, capillary leakage, microcirculation dysfunction, etc. which finally leads to organ metabolic disorders and functional failure. According to the latest recommended international guidelines of Sepsis 3.0, the presence of infection and SOFA score ≥ 2 are considered as the diagnostic criteria for sepsis, and the “rescue” measures mainly focus on reversal of organ dysfunction. However, despite nearly two decades of efforts, the “Save Sepsis Campaign” has not achieved satisfactory results. Emergency medicine is the frontier subject of acute and severe illness which treats patients with acute infections at the earliest. If at this stage, physicians can predict the possibility of sepsis progression from demographic characteristics, localize the pathogen and infection, detect the inflammatory storms by tests of cytokines and evaluate the severity of the infection with more effective clinical scoring system, and then take effective measures to prevent infection from developing into sepsis in high-risk patients, the morbidity and mortality of sepsis in patients with acute infection will be greatly reduced. Based on this situation, Chinese emergency medicine experts proposed the concept of “preventing and blocking” sepsis, and launched the nationwide “Preventing Sepsis Campaign in China (PSCC)” nationwide. The main concept is summarized as “three early and two reduces” which includes early detection, early diagnosis and early intervention during the “pre-symptomatic” and “peri-septic” stage in order to reduce the incidence of sepsis and it proposed a new approach for diagnosis and treatment of acute severe infection. This consensus is jointly advocated, discussed and written by four academic associations in the field of emergency medicine and five scholarly publishing organizations. More than 40 experts from fields of emergency medicine, critical care medicine, infectious diseases, pharmacy and laboratory medicine have participated in several rounds of deliberation and finally reached consensus on the criteria of identifying patients with acute infection, taking anti-infective treatments, screening of high-risk patients with sepsis, detection and treatment of inflammatory storm, protection of vascular endothelial cells and the regulation of coagulation function, as well as strategies of liquid support and organ function protection etc. The consensus summarizes the commonly used clinical diagnosis criteria and treatment measures of sepsis both in Western medicine and traditional Chinese medicine for clinicians in order to provide evidence for the diagnosis and treatment of the disease.

358-365

Authors: Raghavendra Rao, Snehal Nayak, Akhilesh K Pandey, Shobha U Kamath

Objective: To determine the relationship between C-reactive protein (CRP) level and the severity of dengue and the potential use of CRP in predicting acute dengue infection. Methods: A prospective observational study was performed on dengue patients admitted to a tertiary care hospital in southern India. All patients of age above 18 years, diagnosed with dengue were included in the study. The detailed laboratory parameters pertaining to dengue were recorded. CRP levels were estimated and compared between groups i.e. severe and non-severe dengue. CRP cut-off value was detected using the receiver-operator curve. Results: Totally 98 patients with a mean age of 40 years were included. Among them, 11.2% of the patients suffered from severe dengue, 54.1% of the cases had non-severe dengue without warning signs, and 34.7% had non-severe dengue with warning signs. The median CRP was significantly higher in patients with severe dengue compared to patients with non-severe dengue (96.2 mg/dL vs. 5.3 mg/dL). Univariate logistic regression analysis showed that the odd’s ratio (OR) of CRP was 1.053 (P≤0.001, 95% CI=1.029-1.078). CRP at a cutoff value of 21.6 mg/L (0.929 AUC) had excellent sensitivity (100%) and specificity (81.6%) in predicting severe dengue infection. Multivariate logistic regression analysis showed that CRP (OR=1.089, P=0.013) and ALT (OR=1.010, P=0.034) were statistically significant independent predictors of dengue severity. Conclusions: CRP level could be used as a potential biomarker to predict severity of dengue in adults.

375-377

Authors: Rooh Ullah, Muhammad Suleman Rana, Mehmood Qadir, Muhammad Usman

Rationale: Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has been recognized as highly pathogenic. The current pandemic of SARS-CoV-2 has been spread globally and infected more than 200 countries. Patient concerns: We report the first confirmed fatal case of COVID-19 in Pakistan. A 50-year-old man returned from Saudi Arabia on March 09, 2020 and presented with cough, fever, malaise, poor appetite and difficulty in breathing to the Pulmonologist at District Headquarter Hospital Mardan. Diagnosis: The patient was initially diagnosed as COVID-19 suspected case. A oropharyngeal swab sample was positive by realtime RT-PCR tests. Lessons: This report highlights the importance of close coordination between clinicians and public health authorities as well as the importance of early laboratory-based confirmation of COVID-19 cases.

288-294

Authors: Muthu Thiruvengadam, Baskar Venkidasamy, Ill-Min Chung, Prabhu Thirupathi, Umadevi Subramanian

Diabetes mellitus, an endocrine disorder, has a wider reach among most of the world population. The incidence of diabetes is high not only among adults but wider-age groups are also becoming susceptible to this disease because of modified food habits and lifestyle changes that are alien to the physiological system. The control of blood glucose level would be the prime focus of all the therapeutic targets, which is achieved through drugs, modified lifestyle, and paleo-based diets. To find a solution to these problems, earlier humans have revolutionized the science with the discovery of insulin from the porcine pancreatic crude extract. Later, developments have been made with artificial recombinant insulin and even insulin analogs that would mimic the physiological basal insulin in controlling the blood sugar levels. Various factors such as cost and logistics for quality delivery to the end-user at various corners of the world have impeded the reach of the original product. Hence, biosimilar insulins that are original insulin analogs were designed to execute similar physiological functions. In the current situation, the use of biosimilars has been approved in various clinical conditions that are very promising in its functions. In the present review, the various developmental phases of biosimilar preparations and the regulations enforced ensuring a quality product in the market through the Food and Drug Administration and the European Medicines Agency have been discussed.

301-307

Authors: Tsung-Hang Kuo, Chia-Chang Chuang, Chin-Chung Tseng, Ming-Yuan Hong, Sheng-Hsiang Lin

Objective: To identify the febrile characteristics and clinical presentations associated with fatality in hospitalized adult patients with dengue virus (DENV) infections. Methods: A total of 289 adult hospitalized patients with laboratoryconfirmed DENV infections were examined, of which 22 were fatal and 267 were non-fatal. A comparison of the clinical and laboratory characteristics was retrospectively conducted of the deceased and surviving individuals. Multivariate logistic regression and receiver operating characteristic curve analysis were performed to identify predictors of fatality. Results: Fatal patients exhibited significantly more comorbidities, particularly renal and cardiac comorbidities, and they were, in general, older than control individuals (P<0.000 1). The results of logistic regression analysis showed that febrile duration of less than four days before arriving in the Emergency Department (OR=5.34; 95% CI: 1.39–20.6), episode of hypotension in the Emergency Department (OR=6.95; 95% CI: 2.40–20.1), and comorbidity with congestive heart failure (OR=11.26; 95% CI: 2.31–54.79) were all significantly associated with inpatient fatality due to DENV infection. The ROC curve analysis indicated that the final prognostic model yielded an area under the curve of 0.87 (95% CI: 0.79–0.97) for fatality. Conclusions: The aforementioned clinical findings may help clinicians predict fatality among adult inpatients with DENV infection.

314-321

Authors: Kingston Rajiah, Mari Kannan Maharajan, May Yee Woo, Yew Wing Yee, Shi Mun Cheah, Mai Ya Zhe

Objective: To identify the predicting factors that contribute to knowledge, attitude and practices relating to Zika virus infection among the general public in Malaysia. Methods: A cross-sectional study was conducted using a validated self-administered questionnaire. Descriptive analysis was done for participants' socio-demographic profile. Contingency table analysis was done to analyse the associations between knowledge, attitudes, and practices (KAP) scores and socio-demographic profile. A Bonferroni-corrected P-value was used to find the significance of the associations and multiple comparisons were performed in a single data set. To determine the linear relationship between each independent variable and the dependent variable, Spearman rank correlation was performed. Cohen’s correlation coefficient was evaluated to determine the strength of the effect size. Multiple correlations and regression analyses were performed to identify independent variables that predicts the dependent variable. Results: Multiple correlation analyses were conducted between respondents’ KAP score and independent variables (Age >60 years; Female gender; Selangor state; At least 1 pregnant woman per household). The independent variables such as ‘Female gender’, ‘Selangor state’ and ‘At least 1 pregnant woman per household’ were positively and significantly correlated with KAP score whereas, age >60 years was negatively and significantly correlated with the KAP scores. Conclusions: There were associations between four independent factors and the KAP scores, while only three factors contributed to changes in KAP scores among the public. Among these contributing factors, respondents’ age group was the strongest predictor.

328-330

Authors: Vahid Rahmanian, Mohammad Hasan Rabiee, Hamid Sharifi

None.

242-246

Authors: Chiranjib Chakraborty, Ashish Ranjan Sharma, Manojit Bhattacharya, Garima Sharma, Sang-Soo Lee

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus (CoV), has recently emerged as a significant pathogen for humans and the cause for the recent outbreak of the 2019 novel coronavirus disease (COVID-19) throughout the globe. For developing any preventive measure, an understanding of the zoonotic pattern for this virus is a necessity. We should have a clear knowledge of its reservoir host, its distribution pattern and spreading routes. Information about zoonotic reservoirs and its transmission among them can help to understand the COVID-19 outbreaks. In this article, we discuss about the bats as the zoonotic reservoir of several CoV strains, co-existence of bats and CoV/viruses, the sequence similarity of SARS-CoV-2 with bat SARS-like CoV, the probable source of the origin of SARS-CoV-2 strain and COVID-19 outbreak, intermediate host of CoVs and SARS-CoV-2, human to human transmission and the possibility to maintain the zoonotic barriers. Our knowledge about the zoonotic reservoir of SARS-CoV-2 and its transmission ability may help develop the preventive measures and control for the future outbreak of CoV.

252-259

Authors: Hong-juan Jiang, Jiang Nan, Zhi-yue Lv, Juan Yang

Objective: To examine the effects of coronavirus disease-2019 (COVID-19) exposure, expressive suppression/cognitive reappraisal, and demographic variables on post-traumatic stress symptoms (PTS) among Chinese. Methods: Participants were recruited by social media through WeChat and 6 049 Chinese (aged from 17 to 63 years; median=24) from 31 provinces were included in the study. PTS symptoms, expressive suppression, and cognitive reappraisal were assessed after the outbreak of COVID-19. A regression mixture analysis was conducted in Mplus 7. Results: A regression mixture model identified three latent classes that were primarily distinguished by differential effects of COVID- 19 exposures on PTS symptoms: (1) Class 1 (mildly PTS symptoms, 80.9%), (2) Class 2 (moderate PTS symptoms, 13.0%), and (3) Class 3 (high PTS symptoms, 6.1%). The results demonstrated that the young, women and people with responsibilities and concerns for others were more vulnerable to PTS symptoms; and they had more expression inhibition and less cognitive reappraisal in three latent classes. Conclusions: The findings suggest that more attention needs to be paid to vulnerable groups such as the young, women and people with responsibilities and concerns for others. Therapies to encourage emotional expression and increase cognitive reappraisal may also be helpful for trauma survivors.

266-271

Authors: Sahapat Barusrux, Napatrupron Koomdee, Rattanaporn Sukprasong, Weerawat Manosuthi4, Monpat Chamnanphon2,3,5, Apichaya Puangpetch, Chonlaphat Sukasem, Veeranoot Nissapatorn, Maria de Lourdes Pereira

Objective: To investigate the influence of ABCB1 polymorphisms on the plasma level of efavirenz in Thai adult cases infected with HIV-1. Methods: A single nucleotide polymorphism of ABCB1 3435C>T (rs1045642) in the gene encoding ABCB1 was genotyped using real-time PCR-based alleles in 149 HIV-infected Thai adults receiving efavirenz treatment. Plasma concentrations of efavirenz were measured by high-performance liquid chromatography 12 hr after administration. The relationship between plasma efavirenz concentrations and ABCB1 3435C>T polymorphisms was analyzed. Results: Logistic regression analysis showed no significant predictors of high plasma efavirenz concentration in relation to age, gender, body weight, CD4 count and plasma HIV-1 RNA, blood biochemical parameters, antiretroviral duration or ABCB1 3435C>T polymorphisms, except for height (OR=0.902, 95% CI: 0.835-0.973) (P<0.05). The minor allele frequency of ABCB1 3435C>T was 0.446. The frequency of the heterozygous mutant ABCB1 3435C/ T was 53.02% (n=79), ABCB1 3435T/T homozygous mutant was 18.12% (n=27) and the wild type ABCB1 3435C/C genotype was 28.86% (n=43). The overall median plasma concentration of efavirenz in 149 HIV-infected Thai cases was 2.41 mg/L [IQR: (1.46-4.12) mg/L]. The plasma concentration of efavirenz was higher in cases with ABCB1 3435T/T homozygous mutant [2.73 mg/L, IQR: (2.02-4.19) mg/L] and ABCB1 3435C/T heterozygous mutant [2.29 mg/L, IQR: (1.41-4.28) mg/L] genotypes compared to the wild type ABCB1 3435C/C homozygous [2.1 mg/L, IQR: (1.37-3.53) mg/L]. However, there was no statistically significant difference in the efavirenz concentration between the different genotypes (P>0.05). Conclusions: There is no statistical significance for a tendency toward higher plasma efavirenz concentration in the ABCB1 3435T/T and ABCB1 3435C/T genotypes. No parameters of physiological characteristics in this study except for height were found to be predictors of high plasma efavirenz concentration in Thai HIV-1 infected cases.

278-280

Authors: Peng Zhang, Zhenghai Yang, Jie Li, Xiaoning Li

Rationale: Trichosporon, an anamorphic fungus, proliferates under high humidity, causing serious opportunistic infections collectively called trichosporonosis. Among the Trichosporon species causing trichosporonosis are Trichosporon (T.) asahii, T. asteroides, T. cutaneum etc. Patient concerns: A 38-year-old Chinese male with severe aplastic anemia was admitted due to multiple joints pain, poor appetite, and right ankle swelling. One year earlier he had undergone allogeneic hematopoietic stem cell transplantation. Diagnosis: T. asahii infection and severe aplastic anemia. Interventions: Combined treatment of amphotericin B liposomes (55 mg/24 h) and voriconazole (200 mg/12 h) for 8 days. Outcomes: The symptoms of the patient’s ankle were relieved and effusion cultures showed no T. asahii. Lessons: To the best of our knowledge, T. asahii ankle cavity effusion infections are rare. Trichosporon infections may be attributed to risk factors such as improper long-term use of antimicrobials for an underlying disease (e.g., anemia, hypoalbuminemia). Attention should be paid to prevent and control Trichosporon infections in order to avoid comorbidities.

283-284

Authors: Dhanasekaran Sivaraman

None.

193-196

Authors: Marli C Cupertino, Graziela A Cupertino, Andréia P Gomes, Nicholas AJ Mayers, R Siqueira-Batista

None.

199-203

Authors: AbdulAzeez A. Anjorin

Objective: To assess the proportion of caregivers of children and patients who received malaria prevention counseling from their healthcare provider at the time of outpatient malaria treatment. Methods: This was a descriptive cross-sectional study involving 353 randomly selected adult patients and caregivers of children attending the general and paediatric outpatient clinics of a Nigerian hospital. An interviewer-administered questionnaire was used to collect data on participants’ sociodemographics and last malaria-episode characteristics. Chi square test and logistic regression analysis were used to determine factors associated with and predictors of receiving malaria-prevention counseling, respectively. Results: The mean age of the respondents was (33.6±9.6) years; they were predominantly females (257, 72.8%). Most had at least secondary-level education (304, 86.1%); the family size was mostly 1-6 persons in 202 (57.2%) respondents. They were treated mostly by doctors 256 (72.5%), but only 132 (37.4%) received malaria prevention counseling. Educational-level (χ2=5.42, P=0.02), family size (Fisher’s exact, P=0.01), place of treatment (Fisher’s exact, P=0.0002), pretreatment malaria test (χ2=9.48, P=0.002), who prescribed treatment (Fisher’s exact P=0.001), consultation time (χ2=22.09, P＜0.001), and previous demand for malaria prevention counseling (χ2=36.59, P＜0.001) were associated with receiving malaria prevention counseling. However, consultation time [Odd ratio (OR)=2.38, 95% confidence interval (CI): 1.28, 4.40, P=0.006] and previous demand for malaria prevention counseling (OR=3.62, 95% CI: 2.15, 6.10, P＜0.001) were independent predictors of receiving counseling. Conclusions: The proportion of respondents that received malaria prevention counseling was surprisingly low. This offers opportunity for policy review towards improving the quality of outpatient malaria care through alternative strategies for giving malaria prevention information, especially in busy clinics where consultation time is constrained.

214-220

Authors: Godpower Chinedu Michael, Bukar Alhaji Grema, Ibrahim Aliyu, Muhammad Baba Usman, Zainab Abdulazeez Umar

Objective: To assess the proportion of caregivers of children and patients who received malaria prevention counseling from their healthcare provider at the time of outpatient malaria treatment. Methods: This was a descriptive cross-sectional study involving 353 randomly selected adult patients and caregivers of children attending the general and paediatric outpatient clinics of a Nigerian hospital. An interviewer-administered questionnaire was used to collect data on participants’ sociodemographics and last malaria-episode characteristics. Chi square test and logistic regression analysis were used to determine factors associated with and predictors of receiving malaria-prevention counseling, respectively. Results: The mean age of the respondents was (33.6±9.6) years; they were predominantly females (257, 72.8%). Most had at least secondary-level education (304, 86.1%); the family size was mostly 1-6 persons in 202 (57.2%) respondents. They were treated mostly by doctors 256 (72.5%), but only 132 (37.4%) received malaria prevention counseling. Educational-level (Χ2=5.42, P=0.02), family size (Fisher’s exact, P=0.01), place of treatment (Fisher’s exact, P=0.0002), pretreatment malaria test (Χ2=9.48, P=0.002), who prescribed treatment (Fisher’s exact P=0.001), consultation time (Χ2=22.09, P＜0.001), and previous demand for malaria prevention counseling (Χ2=36.59, P＜0.001) were associated with receiving malaria prevention counseling. However, consultation time [Odd ratio (OR)=2.38, 95% confidence interval (CI): 1.28, 4.40, P=0.006] and previous demand for malaria prevention counseling (OR=3.62, 95% CI: 2.15, 6.10, P＜0.001) were independent predictors of receiving counseling. Conclusions: The proportion of respondents that received malaria prevention counseling was surprisingly low. This offers opportunity for policy review towards improving the quality of outpatient malaria care through alternative strategies for giving malaria prevention information, especially in busy clinics where consultation time is constrained.

227-234

Authors: Ebrahim Ghaderi, Behzad Mohsenpour, Ghobad Moradi, Mohammad Karimi, Fatemeh Najafi, Seiran Nili, Samaneh Rouhi

Objective: To explore the spatial accumulation of diseases and their aggravating factors are essential in all public health. This study attempts to use geographic information system (GIS) to provide more information about the incidence and future of anthrax. Methods: Patients were diagnosed with anthrax in Kurdistan Province from 2009 to 2016. Data was then exported into ArcGIS software version 9 and the required layers for years and areas were added.Final map for each year was drawn up, pointing out the hot spots and predicting its future pattern. Results: Most cases were reported in females (57 cases, 54.80 %), and the lower body limbs were most affected (63 cases, 60.57%). The highest numbers of incidences were related to the cities of Marivan, Saqez and Divandareh, with more concentration in the central parts of the province, rather than borderline areas. The highest percentage of the probable incidence of the disease was in Sanandaj (57.74%) with a potential susceptible area of 1 729.12 km2 and then in Saqez (54.36%) with a potential area of 2 422.4 km2. Conclusions: A vast area of Kurdistan Province is high risk for new cases of anthrax. Therefore, it is important to scale up the surveillance system in the province.

237-238

Authors: Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava

None.