Leishmaniasis epidemic

Researchers warn of leishmaniasis epidemic in Middle East


The Syrian refugee crisis has precipitated a catastrophic outbreak of Old World cutaneous leishmaniasis now affecting hundreds of thousands of people living in refugee camps or trapped in confl ict zones. A similar situation may also be unfolding in eastern Libya, Iraq and Yemen, say the authors of a recently published report on the crisis.

They warn that “we may be witnessing an epidemic of historic and unprecedented proportions, but it has largely been hidden due to lack of specifi c information”.

The report: “Old World Cutaneous Leishmaniasis and Refugee Crises in the Middle East and North Africa” published 26 May 2016 in PLoS Neglected Tropical Diseases – doi: 10.1371/journal. pntd.0004545 – notes that leishmaniasis has been endemic in Syria for over two centuries, with the fi rst case ever reported being as early as 1745, when it was known as the “Aleppo boil”. Old World cutaneous leishmaniasis (CL) is characterized most notably by disfi guring skin lesions, nodules, or papules, and in the Middle East and North Africa (MENA) region it is primarily caused either by the parasite Leishmania tropica (anthroponotic) or L. major (zoonotic).

Although Leishmaniasis is generally not fatal, clinical symptoms can lead to disfi guring scars that result in social stigmatization with psychological consequences, such as anxiety, depression, and decreased quality of life.

The authors say that while CL is by no means new to Syria, the war in Syria has greatly increased the risk for CL and reports have indicated sharp increases in the number of CL cases in Syria and in surrounding areas of the Middle East.

Within Syria, a 2013 study published by the Ministry of Health reported an incidence rate more than twice as high as the incidence rate reported in Syria between 2004 and 2008 by the WHO. The annual incidence of CL in Syria between 2004 and 2008 was estimated to be 23,000 cases per year. In 2012, 53,000 cases were reported, and in the fi rst half of 2013 alone, 41,000 cases were reported.

The authors state that the number of cases of CL has most likely been severely underreported; the WHO estimated that the actual incidence of CL in Syria between 2004 and 2008 was three to fi ve times higher than the reported incidence. The true number of annual incident and prevalent cases in Syria may therefore exceed 100,000. They highlight that few countries have mandated reporting of CL, and the resultant weak reporting system promotes a lack of disease awareness and public policies for treatment and prevention. Compounding this problem is the absence of rapid diagnostics and the requirement to have highly skilled dermatologists and pathologists establish a diagnosis on the basis of clinical presentation and confi rmatory microscopy.

They say that with the influx of Syrian refugees into Turkey, Lebanon and Jordan all these countries have shown indications of increased prevalence of CL. They point out that in the countries that have observed new cases of CL, younger age groups, due to their lack of previous exposure to the disease, have been the most affected.

“Knowledge of Old World CL in Syria and among its refugees is limited; however, we know even less about the situation in areas of Libya now controlled by the selfproclaimed Islamic State,” the authors say. They add: “Leishmaniasis is a hidden NTD in Yemen as well. Approximately 10,000 new cases are reported annually.

Among a number of recommendations, they say “a multifaceted, collaborative approach must be taken to control the incidence of CL, with priority given to initiatives that will not only aid in the prevention and control of CL but also improve the living conditions and survival of refugee populations”.


What is leishmaniasis

Leishmaniasis is caused by a protozoa parasite from over 20 Leishmania species and is transmitted to humans by the bite of infected female phlebotomine sandfl ies. Over 90 sandfl y species are known to transmit Leishmania parasites. There are 3 main forms of the disease: 

  • Visceral leishmaniasis (VL), also known as kala-azar is fatal if left untreated in over 95% of cases. It is characterized by irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia. It is highly endemic in the Indian subcontinent and in East Africa. An estimated 200,000 to 400,000 new cases of VL occur worldwide each year. Over 90% of new cases occur in 6 countries: Bangladesh, Brazil, Ethiopia, India, South Sudan and Sudan. 
  • Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis and causes skin lesions, mainly ulcers, on exposed parts of the body, leaving life-long scars and serious disability. About 95% of CL cases occur in the Americas, the Mediterranean basin, the Middle East and Central Asia. Over two thirds of new CL cases occur in 6 countries: Afghanistan, Algeria, Brazil, Colombia, Iran (Islamic Republic of) and the Syrian Arab Republic. An estimated 0.7 million to 1.3 million new cases occur worldwide annually.
  • Mucocutaneous leishmaniasis leads to partial or total destruction of mucous membranes of the nose, mouth and throat. Almost 90% of mucocutaneous leishmaniasis cases occur in Bolivia, Brazil and Peru. WHO


Date of upload: 13th July 2016

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