The ecoepidemiology of cutaneous leishmaniasis in Ethiopia: a systematic review and meta-analysis

BACKGROUND: Cutaneous leishmaniasis (CL) is a neglected tropical skin disease. In Ethiopia, CL is a public health concern; about 29 million people are at risk, with an estimated incidence of up to 50,000 new cases annually. In endemic communities, access to diagnosis, treatment, and prevention is crucial but often limited. Understanding the prevalence and access to care, as well as exploring its relationship to agroecological factors, is crucial to inform control strategies. OBJECTIVES: The aim of this work is to estimate the pooled prevalence, access to care service facilities, and spatial distribution and relationship to agroecological factors. METHODS: A systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) framework. The metafor and metadata packages from R Studio were used to obtain pooled prevalence and odds ratio using a random-effects model with a double arcsine transformation. The CL endemicity at the woreda level was overlaid with the locations of CL treatment centers and agroecological zones using ArcGIS. RESULTS: The pooled prevalence of CL was 6.75% (95% confidence interval (CI) 3.37-11.17). Sociodemographic factors (male gender, rural living) and environmental factors (muddy walls, outdoor sleeping, proximity to rocky habitats, and hyrax populations) were significantly associated with CL. CL cases were reported from 85 woredas with a broad spatial distribution; a higher proportion of them were from the Weyna Dega, Dega, and Upper Kola agroecological zones. Access to care is generally poor, with service centers for CL often centralized at the zone level. CONCLUSIONS: The estimated pooled prevalence likely underrepresents the true burden of CL. The identified risk factors are more related to rural livelihoods and living conditions, and most of the endemic woredas are in the most productive agrarian agroecological zones, which underlines the health and socioeconomic significance of CL in Ethiopia. Thus, decentralizing healthcare services and improving surveillance for CL are crucial steps in breaking the vicious cycle of poverty.