Assessment of use of lavender lotion as repellent for protection against sand fly bites in endemic area with visceral leishmaniasis in Eastern Sudan

This study was an epidemiological study regarding the prevalence of visceral leishmaniaisis among first year students (as new comers) in Gadarif University, Eastern of Sudan, in 2013. It was conducted to evaluate the use, efficacy and comfortability of the use of commercial lavender lotion as vector control tool among group of 10 students from first year (5 male and 5 female). Health education regarding use of repellents and sand flies was put into operation in the end of the rainy season before the start of the study. The repellents used in this study were commercial lavender lotion which was made from the essential oil extracted from the fresh flowers of the lavender plant, also known as insect repellent. The field evaluation showed protection up to mean time for 7 h and 40 min against the species. Application of commercial lavender lotion can be safe and low-cost means of personal protection against sand fly bites in endemic areas of Gadarif, if the community is advised and encouraged to use it. Significant correlations between post leishmanin skin test results and using of repellents has been reported (p = 0.001).


INTRODUCTION
Leishmaniasis is a disease caused by protozoan parasites of the genus Leishmania.The genus Leishmania is divided into two subgenera on the basis of the development in the sand fly vector (TDR, 2005).Members of the genus Leishmania are polymorphic and are present in two forms: the amastigote form which shows a round to oval body without free flagellum, and the promastigote which is longer than the amastigote, with a central nucleus, anterior kinetoplast and a well-developed flagellum (El-Hassan and Zijlstra, 2001).Leishmaniasis is transmitted by sand flies, members of the Phylum Arthropoda and belong to the class Insecta.This class is the largest group of animals with respect to the number of species (~773,000) or individuals.Animals as reservoirs of infection includes dogs, monkeys, and ponies.It was also found that other animals such as hyenas and jackals could not be ruled out as potential reservoirs (TDR, 2005).Man-biting sand flies pose a *Corresponding author.E-mail: Mustafanag_1971@yahoo.com.Tel: 00966563009189.
Creative Commons Attribution er the terms of the Author(s) agree that this article remain permanently open access und License 4.0 International License threat to humans in different parts of the world by serving as vectors of sand fly fever, bartenollosis and Leishmaniasis (Gorgina, 2007).The last, existing in two broad categories (cutaneous and visceral Leishmaniasis), is the most widespread and serious disease in tropical and subtropical regions of the world.The disease was diagnosed for the first time in Sudan in an 8 years old boy, from Meshra-er-Req in Bahr-el-Ghazal district, southern Sudan in 1904(University of Glasgow Archives, 1996).In subsequent years several tens of cases including 2 British officials, were reported from the east of the country in the area extending from Senar to Kassala and the borders of Ethiopia (Rolleston, 2004).
The first epidemic was documented in 1940 with a death rate of 80%.From the beginning of 1984, an epidemic until 1988) devastated the Western part of Upper Nile state, ultimately causing around 100,000 deaths in a population of 280,000 over a 10-year period (University of Glasgow Archives, 1996).Passive case-detection data on kala-azar in Southern Sudan, collected by the World Health Organization (WHO) since 1989, indicated a cyclic pattern of kala-azar with considerable variation in the caseload from one year to another (El-Hassan and Zijlstra, 2001).Recurrent outbreaks of visceral leishmaniasis have been reported in Southern Sudan, with 6363 cases and 303 deaths (case fatality rate of 4.7%) recorded since outbreaks began in September, 2009.The number of cases was more than six times higher than the same period starting in 2007 (758 cases) and 2008 (582 cases).Most affected patients were children aged less than 15 years (70%).There are over 1,680 patients currently undergoing treatment in various local health facilities in the greater Upper Nile region (WHO, 2010).
Currently, the disease is confined in the state of Gedarif in East Sudan, with some sporadic cases in Kassala, Blue Nile and Senar State (Federal Ministry of Health, 2009).The control of phlebotomine sand flies (Diptera: Psychodidae), the vectors of leishmaniasis, is directed mostly against adults as larvae develop in unknown or inaccessible habitats.Depending on application techniques, timing and target species.Sandflies are known to be highly susceptible to insecticides (Theodor and Mesghali, 1964).
In Sudan, most leishmaniasis transmission appears to be extradomicilliary as in the rest of Eastern Africa, where the conventional malaria vector control tools such as long lasting insecticide treated nets (LLITNs) and indoor residual sprayings (IRSs) may be less important.With no effective means of sand fly control for exophagic and exophilic species so far in Sudan or elsewhere, the first line of defense for individuals might be the personal use of insect repellents.Use of natural or synthetic repellents, or protective clothing, may be the only preventive measures available to reduce man-vector contact in these situations (Siddig et al., 1990).
Leishmaniasis transmission is intradomicilliary and control tools such as LLITNs and/or IRS might be in place.
Repellents may still be more advantageous as most sandflies bite early (before bed time).It has been shown that use of a combination of nets and repellents greatly reduces malaria infection.Similar effects could be expected with leishmaniasis.Diethyl-3 methylbenzamide (DEET) is one of the best and most widely used synthetic insect repellent developed and has been the gold standard for public use, emergencies and military operations (Banũls et al., 1999) However, although DEET and other synthetic repellents are effective, cost is too high for daily use within poor communities in tropical Africa.Moreover, DEET is not always ideal, as few cases of side effects have been reported (WHO, 1990).For these reasons, new compounds are being screened continuously for their repellent actions.Lavender is a plant with aromatic leaves and flowers that is a member of the mint family.Oil from the flowers has been used in some cultures to treat certain medical problems, to keep insects away, and to wash in.It is also used in aromatherapy.Perillyl alcohol, a substance found in lavender, is being studied in cancer prevention and treatment.The scientific name is Lavandula angustifolia (National Institute of health, National Cancer Institute, 2010).

Study design
This is a community based-experimental study, among first year students in University of Gadarif, Sudan, 2013.

Study area
Gadarif state is situated in the Eastern part of the Sudan 413 km from Khartoum, between longitudes 34 and 36 East, and latitudes 12 and 17 North.

Study population
Ten students in the age group 15 to 25 years of age from first year, coming from outside the study area and with no history of Leishmaniasis were voluntarily recruited to participate in the experiment and were given appropriate training.

Data collection
A questionnaire was designed to collect information needed in the study.It consisted of dependent variables as duration of using repellent, sleeping habits and so on and independent variables such as sex, ages and comfortable in using repellents.

Repellents
The repellent used in this study was commercial lavender lotion which was made from the essential oil extracted from the fresh flowers of the lavender plant by steam distillation and yielded 1.4 to 1.6%.The main chemical composition of lavender oil are a-pinene, limonene, 1, 8cineole, cis-ocimene, trans-ocimene, 3-octanone, camphor, linalool, linalyl acetate, caryophyllene, terpinen-4-ol and lavendulyl acetate.Two packages consisting of 48 refills were given to each student.The  duration of the study was 5 days then the mean was calculated.The volunteers applied the lotion on arms and legs, then exposed the whole nights (18:00 to 05:00) and collected sand flies landing on the arms and legs (with about 5 to 10 min break each hour) using aspirator and small test tubes.

Night visits
Three night visits to student's settlements were done by the team to ensure that the students were applying the repellents properly and collecting the sand flies.

RESULTS
The results showed full protection for up to 4 h, extended to a mean time of 7 h, and 20 to 40 min with less protection.Most of the members in the study said the use of the lotion was comfortable

DISCUSSION
The repellent activities of lavender lotion evaluated against sand fly in the field conditions show full protection for up to 4 hours, extended to a mean time of 7 h, and 20 to 40 min with less protection (Table 1).In fact there are no much studies conducted to evaluate the effectiveness of lavender lotion or lavender oil as personal protection methods against sand fly, but some studies conducted to evaluate the efficacy of neem (Azadirachta indica A. Juss.) and Chinaberry (Melia azedarach) linseed oils as repellents against laboratory and field populations of some sand flies in Ethiopia, 2009, provided protection up to a mean time of 7 h and 20 min (Kebede et al., 2010).
Another study conducted in town of Ma'ale Adumim situated approximately 10 km east of Jerusalem in the Judean Desert of Palestine in 2008, evaluated the efficacy of geraniol, a natural plant-derived product, as a space repellent and the synthetic pyrethroid prallethrin as a diffusible insecticide to control phlebotomine sandflies (Diptera: Psychodidae), the vectors of Leishmaniasis revealed that geraniol proved ineffective in preventing sandflies from feeding (Sirak-Wizeman et al., 2008).Only one study used lavender oil in compound with eucalyptus oil done as field trial in 2012 in Bundaberg, Queensland in tidal mangrove forest against natural population of sand fly (Culicoides spp).The target pest was coastal sand flies in their natural habitat.The time of each landings and bite post-application was recorded for each individual bite up to 10 bites per body part per person.This study demonstrated an effective control against sand fly (Sirak-Wizeman et al., 2008;Ridley et al., 2012).Most of the members in the study said the use of the lotion was comfortable with P value = 0.003 and no itching or unpleasant smell (Table 2).
Our study revealed that there was significant relationship between gender and the use of the lotion that all females were satisfied on the use of the lotion with P value = 0.001 (Table 3).

Table 1 .
Total of sand flies landed/night/five volunteers.

Table 2 .
Students evaluation for the use of lavender lotion.

Table 3 .
Evaluation for the use of lavender lotion and gender.
1. National Fund for the student's welfare in collaboration with National program for Leishmaniasis Eradication must provide repellents and other preventive measures.2. Establishment of health education program addressing leishmaniasis control and prevention in community base in Gadarif State.Regarding the ethical consideration, agreement was obtained from Gadaref University, Ministry of Health, and National Program for Leishmaniasis Eradication and the Students involved in the study.