Anthroponotic cutaneous leishmaniasis in Kabul, Afghanistan: the high susceptibility of Phlebotomus sergenti to Leishmania tropica

Evaluation of Household Preparedness and Risk Factors for Cutaneous Leishmaniasis (CL) Using the Community Assessment for Public Health Emergency Response (CASPER) Method in Pakistan

(1) Background: In endemic areas of Pakistan, local community knowledge and attitudes towards cutaneous leishmaniasis (CL) are critical elements in the effective control and management of the disease. A cross-sectional epidemiologic design was used to assess the disease concern, preparedness, practices, and preventive behavior of the households and to assist the personnel and health care professionals in strengthening their planning efforts and awareness of CL. (2) Methods: A two-stage cluster sampling process, i.e., Community Assessment for Public Health Emergency Response (CASPER) was conducted from September 2020 to March 2021 on present household-level information about community needs and health status regarding CL in a cost-effective, timely, and representative manner. (3) Results: In the current study, 67% of the respondents were aware of CL and its causative agent and showed a low level of pandemic preparedness. The majority (74%) of the respondents mentioned that they did not avoid sandfly exposure areas. The majority (84%) of respondents had unsatisfactory behavior towards using bed nets, sprays, or repellents. (4) Conclusion: In endemic areas of Pakistan, the inadequate concern and low preparedness of the local community toward CL are critical aspects in efficient control and management of the disease.

Effects of time-lagged meteorological variables on attributable risk of leishmaniasis in central region of Afghanistan

BACKGROUND

Leishmaniasis remains one of the world's most neglected vector-borne diseases, affecting predominantly poor communities mainly in developing countries. Previous studies have shown that the distribution and dynamics of leishmaniasis infections are sensitive to environmental factors, however, there are no studies on the burden of leishmaniasis attributable to time-varying meteorological variables.

METHODS

This study used data from 3 major leishmaniosis afflicted provinces of Afghanistan, between 2003 and 2009, to provide empirical analysis of change in heat/cold-leishmaniosis association. Non-linear and delayed exposure-lag-response relationship between meteorological variables and leishmaniasis were fitted with a distributed lag non-linear model applying a spline function which describes the dependency along the range of values with a lag of up to 12 months. We estimated the risk of leishmaniasis attributable to high and low temperature.

RESULTS

The median monthly mean temperature and rainfall were 16.1 °C and 0.6 in., respectively. Seasonal variations of leishmaniasis were consistent between males and females, however significant differences were observed among different age groups. Temperature effects were immediate and persistent (lag 0-12 months). The cumulative risks were highest at cold temperatures. The cumulative relative risks (logRR) for leishmaniasis were 6.16 (95% CI: 5.74-6.58) and 1.15 (95% CI: 1.32-1.31) associated with the 10th percentile temperature (2.16 °C) and the 90th percentile temperature (28.46 °C). The subgroup analysis showed increased risk for males as well as young and middle aged people at cold temperatures, however, higher risk was observed for the elderly in heat. The overall leishmaniasis-temperature attributable fractions was estimated to be 7.6% (95% CI: 7.5%-7.7%) and mostly due to cold.

CONCLUSION

Findings in this study highlight the non-linearity, delay of effects and magnitude of leishmaniasis risk associated with temperature. The disparity of risk between different subgroups can hopefully advise policy makers and assist in leishmaniasis control program.

Laboratory transmission of an Asian strain of Leishmania tropica by the bite of the southern European sand fly Phlebotomus perniciosus

Imported cases of anthroponotic cutaneous leishmaniasis due to Leishmania tropica are increasingly documented in Europe. We investigated the ability of Phlebotomus perniciosus, a competent vector of Leishmania infantum widespread in southwestern Europe, to support the growth and transmissibility of an Asian strain of L. tropica recently isolated from a refugee. Parasite growth behavior was investigated in laboratory-reared sand flies fed artificially with promastigotes as well as in sand flies infected after biting on footpad lesions induced in hamsters by promastigote inoculation. The evolution of infection was checked by gut microscopy and quantitative real-time PCR, and it was found to be similar between promastigote- and amastigote-initiated infections. In 80% of infected sand flies, despite survival and flourishing growth of promastigotes after blood digestion and defecation, either the parasites died, or failed to migrate to the foregut and/or to mature into infective forms. However, in the remaining 20% L. tropica developed into abundant metacyclic promastigotes. The quantitative real-time PCR assay detected variable loads of gut promastigotes irrespective of morphological evidence of viability or progressive/final death. Parasite transmissibility was investigated by exposing naive hamsters to P. perniciosus previously infected on chronic lesions induced in hamsters which survived to take a second blood meal. Two months post exposure, lesions developed in skin sites bitten by sand flies confirmed to harbor metacyclic promastigotes; in the following months, the presence of viable and transmissible L. tropica parasites in lesions was demonstrated by xenodiagnosis assays. Our findings support the hypothesis that, in particular epidemiological situations, P. perniciosus may play the role of an occasional L. tropica vector.

Epidemic outbreak of anthroponotic cutaneous leishmaniasis in Kohat District, Khyber Pakhtunkhwa, Pakistan

An epidemiological and molecular study was carried out for the first time in Kohat District of Khyber Pakhtunkhwa (KP) province, Pakistan from April 2015 to May 2016 to determine the prevalence of Cutaneous Leishmaniasis (CL) in local population and Internally Displaced People (IDPs). In 13 different villages, a total of 1359 (out of 26,250 individuals belonging to local population) and 140 (out of 3615 IDPs residing in these villages) cases were recorded and 300 samples were collected. The total prevalence of CL in local population was 5.17% with active lesions and scar prevalence of 3.91% and 1.26% respectively. Similarly a prevalence of 3.86% for CL was recorded in IDPs. Highest number of IDPs having CL active lesions and scars were recorded in villages Sherkot, Surgul, and Jarma and their presence was positively correlated with CL in local population. Age wise prevalence was highest in young children of age group 1-15 years. The microscopic examination showed 64.33% (193/300) positive samples while kinteoplastic PCR showed 84.66% (254/300) positive. For the first time in KP province, 2/784 sandflies trapped from the study villages was found positive for Leishmania by PCR. Restriction Fragment Length Polymorphism of patients and sandflies samples revealed L. tropica as the prevalent Leishmania species in this district. The results of sequencing and RFLP identified L. tropica in Phlebotomus sergenti. This is the first ever report of molecular identification of L. tropica from sandflies of genus P. sergenti in Khyber Pakhtunkhwa province. This data can be helpful for health authorities in finding out new CL foci and to plan effective strategies for the provision of health facilities to poor people of this area.

Spatially Correlated Time Series and Ecological Niche Analysis of Cutaneous Leishmaniasis in Afghanistan

Leishmaniasis is the third most common vector-borne disease and a very important protozoan infection. Cutaneous leishmaniasis is one of the most common types of leishmaniasis infectious diseases with up to 1.2 million occurrences of new cases each year worldwide. A dynamic transmission multivariate time series model was applied to the data to account for overdispersion and evaluate the effects of three environmental layers as well as seasonality in the data. Furthermore, ecological niche modeling was used to study the geographically suitable conditions for cutaneous leishmaniasis using temperature, precipitation and altitude as environmental layers, together with the leishmaniasis presence data. A retrospective analysis of the cutaneous leishmaniasis spatial data in Afghanistan between 2003 and 2009 indicates a steady increase from 2003 to 2007, a small decrease in 2008, and then another increase in 2009. An upward trend and regularly repeating patterns of highs and lows were observed related to the months of the year, which suggests seasonality effect in the data. Two peaks were observed in the disease occurrence—January to March and September to December—which coincide with the cold period. Ecological niche modelling indicates that precipitation has the greatest contribution to the potential distribution of leishmaniasis.

Joint spatial time-series epidemiological analysis of malaria and cutaneous leishmaniasis infection

Malaria and leishmaniasis are among the two most important health problems of many developing countries especially in the Middle East and North Africa. It is common for vector-borne infectious diseases to have similar hotspots which may be attributed to the overlapping ecological distribution of the vector. Hotspot analyses were conducted to simultaneously detect the location of local hotspots and test their statistical significance. Spatial scan statistics were used to detect and test hotspots of malaria and cutaneous leishmaniasis (CL) in Afghanistan in 2009. A multivariate negative binomial model was used to simultaneously assess the effects of environmental variables on malaria and CL. In addition to the dependency between malaria and CL disease counts, spatial and temporal information were also incorporated in the model. Results indicated that malaria and CL incidence peaked at the same periods. Two hotspots were detected for malaria and three for CL. The findings in the current study show an association between the incidence of malaria and CL in the studied areas of Afghanistan. The incidence of CL disease in a given month is linked with the incidence of malaria in the previous month. Co-existence of malaria and CL within the same geographical area was supported by this study, highlighting the presence and effects of environmental variables such as temperature and precipitation. People living in areas with malaria are at increased risk for leishmaniasis infection. Local healthcare authorities should consider the co-infection problem by recommending systematic malaria screening for all CL patients.

Distribution, species composition and relative abundances of sandflies in North Waziristan Agency, Pakistan

This study was conducted to investigate the diversity of sandflies (Psychodidae: Phlebotominae) and the incidence of leishmaniasis in three villages of North Waziristan Agency, Pakistan. Sandflies were sampled monthly during 2012, at dusk and dawn, in selected indoor habitats including both bedrooms and animal sheds using a knock-down spray catch method. A total of 3687 sandflies were collected, including 1444 individuals in Drezanda, 1193 in Damdil and 1050 in Dattakhel. This study revealed 14 species of two genera, Phlebotomus (Phlebotomus sergenti, Phlebotomus papatasi, Phlebotomus caucasicus, Phlebotomus kazeruni, Phlebotomus alexandri and Phlebotomus salehi) and Sergentomyia (Sergentomyia dentate, Sergentomyia baghdadis, Sergentomyia babu, Sergentomyia theodori, Sergentomyia sumbarica, Sergentomyia dreyfussitur kestanica, Sergentomyia hogsoni pawlowskyi and Sergentomyia fallax afghanica) (both: Diptera: Psychodidae). Phlebotomus sergenti was the most abundant species (42.1%), followed by S. dentata (17.7%) and S. baghdadis (17.4%). The number of males collected represented about twice that of female flies, and the maximum number was collected in July, followed by August. The determination of the species composition of sandfly populations, seasonal variations, relative abundances and estimations of infection in the vector population may provide information about the dynamics of leishmaniasis transmission that is useful in planning vector control activities.

Estimation of canine Leishmania infection prevalence in six cities of the Algerian littoral zone using a Bayesian approach

A large-scale study on canine Leishmania infection (CanL) was conducted in six localities along a west-east transect in the Algerian littoral zone (Tlemcen, Mostaganem, Tipaza, Boumerdes, Bejaia, Jijel) and covering two sampling periods. In total 2,184 dogs were tested with an indirect fluorescent antibody test (IFAT) and a direct agglutination test (DAT). Combined multiple-testing and several statistical methods were compared to estimate the CanL true prevalence and tests characteristics (sensitivity and specificity). The Bayesian full model showed the best fit and yielded prevalence estimates between 11% (Mostaganem, first period) and 38% (Bejaia, second period). Sensitivity of IFAT varied (in function of locality) between 86% and 88% while its specificity varied between 65% and 87%. DAT was less sensitive than IFAT but showed a higher specificity (between 80% and 95% in function of locality or/and season). A general increasing trend of the CanL prevalence was noted from west to east. A concordance between the present results and the incidence of human cases of visceral leishmaniasis was observed, where also a maximum was recorded for Bejaia. The results of the present study highlight the dangers when using IFAT as a gold standard.

Epidemiological study on sand flies in an endemic focus of cutaneous leishmaniasis, bushehr city, southwestern iran

Cutaneous leishmaniasis is the most important health problem in the city of Bushehr, southwestern Iran. The objective of the study was to determine some ecological aspects of sand flies in the city during 2010–2011. Sand flies were collected monthly from outdoors and indoors by sticky traps at four selected districts of the city. They were also dissected and examined by nested-PCR for identification of the parasite during August–September of 2011. A total of 1234 adult sand flies were collected and 6 species including 3 of Genus Phlebotomus and 3 of Genus Sergentomyia were identified. Four species including P. papatasi (3.98%), P. sergenti (1.14%), S. tiberiadis (87.18%), and S. baghdadis (7.7%) were found indoors. Six species including P. papatasi (3.47%), P. sergenti (3.17%), P. alexandri (0.1%), S. tiberiadis (77.74%), S. baghdadis (15.41%), and one female of S. clydei (0.11%) were collected from outdoors. Sand flies started to appear from March and disappear at the end of January. There was only one peak in the density curve in July. The study revealed that S. tiberiadis and S. baghdadis could enter indoors which 89 and 81.8% of them were found blood-fed, respectively. Moreover, P. papatasi, S. tiberiadis, and S. baghdadis were active indoors and outdoors in most months of the year. Nested-PCR of P. papatasi females was positive against kinetoplast DNA of L. major and L. turanica and also mixed natural infections were found by L. gerbilli and L. turanica. Moreover, mixed infections by L. major and L. turanica were observed in this species. Sergentomyia clydei and S. tiberiadis were found to be negative to any DNA of Leishmania species. Phlebotomus sergenti females were found infected with DNA of L. turanica and this is the first report of natural infection and detection of the parasite from this sand fly species in worldwide.

Rapid healing of cutaneous leishmaniasis by high-frequency electrocauterization and hydrogel wound care with or without DAC N-055: a randomized controlled phase IIa trial in Kabul

Background

Anthroponotic cutaneous leishmaniasis (CL) due to Leishmania (L.) tropica infection is a chronic, frequently disfiguring skin disease with limited therapeutic options. In endemic countries healing of ulcerative lesions is often delayed by bacterial and/or fungal infections. Here, we studied a novel therapeutic concept to prevent superinfections, accelerate wound closure, and improve the cosmetic outcome of ACL.

Methodology/Principal Findings

From 2004 to 2008 we performed a two-armed, randomized, double-blinded, phase IIa trial in Kabul, Afghanistan, with patients suffering from L. tropica CL. The skin lesions were treated with bipolar high-frequency electrocauterization (EC) followed by daily moist-wound-treatment (MWT) with polyacrylate hydrogel with (group I) or without (group II) pharmaceutical sodium chlorite (DAC N-055). Patients below age 5, with facial lesions, pregnancy, or serious comorbidities were excluded. The primary, photodocumented outcome was the time needed for complete lesion epithelialization. Biopsies for parasitological and (immuno)histopathological analyses were taken prior to EC (1^st), after wound closure (2^nd) and after 6 months (3^rd). The mean duration for complete wound closure was short and indifferent in group I (59 patients, 43.1 d) and II (54 patients, 42 d; p = 0.83). In patients with Leishmania-positive 2^nd biopsies DAC N-055 caused a more rapid wound epithelialization (37.2 d vs. 58.3 d; p = 0.08). Superinfections occurred in both groups at the same rate (8.8%). Except for one patient, reulcerations (10.2% in group I, 18.5% in group II; p = 0.158) were confined to cases with persistent high parasite loads after healing. In vitro, DAC N-055 showed a leishmanicidal effect on pro- and amastigotes.

Conclusions/Significance

Compared to previous results with intralesional antimony injections, the EC plus MWT protocol led to more rapid wound closure. The tentatively lower rate of relapses and the acceleration of wound closure in a subgroup of patients with parasite persistence warrant future studies on the activity of DAC N-055.

Trial Registration

ClinicalTrails.gov NCT00947362

In many countries of the Middle East such as Afghanistan, cutaneous leishmaniasis is a highly prevalent, chronic and stigmatizing skin disease. Poor hygiene conditions frequently aggravate the lesions due to bacterial and fungal superinfections. Classical treatments with injections of pentavalent antimony are hampered by costs, side effects, resistance development, supply and manufactural quality problems. In the present study on Afghan patients with Leishmania tropica-induced skin lesions we evaluated the clinical effect of an initial removal of lesion tissue by electrocoagulation using a bipolar high-frequency electrosurgery instrument, followed by daily moist wound treatment with or without a preparation of pharmaceutical sodium chlorite (DAC N-055). DAC N-055 is a compound with anti-infective, immunomodulatory and tissue repair-promoting effects. Our analysis revealed that the carefully performed moist wound treatment led to a rapid healing of the wounds within an average period of 6 weeks, even in the absence of the sodium chlorite preparation. This is considerably faster than the time spans previously reported for local or systemic antimony treatment. We believe that the current standard for local care of chronic wounds should also be applied to Leishmania skin lesions. If combined with an initial single high-frequency electrocoagulation, it is a highly effective, inexpensive and well-tolerated treatment option for cutaneous leishmaniasis.

Epidemiologic study and molecular detection of Leishmania and sand fly species responsible of cutaneous leishmaniasis in Foum Jamâa (Azilal, Atlas of Morocco)

The region of Foum Jamâa (province of Azilal) has become endemic for cutaneous leishmaniasis (CL) since 2006. The objective of this study was to investigate molecular identification of the etiological agent of CL in this region; we also carried out an entomological survey of Phlebotomine sand flies (Diptera: Psychodidae) in this focus to study the sand fly fauna, species composition, and the monthly prevalence of sand flies during 1 year. In the period between 2009 and 2010, skin scrapings spotted on glass slides were collected from 119 patients, aged from 9 months to 70 years old, who came from 43 localities distributed in 3 sectors in Foum Jamâa (FJ). The ITS1 PCR-RFLP was used to identify the Leishmania parasite responsible for the recent cases of CL in FJ. Our results revealed that the disease is caused by L. tropica. No significant association was observed between gender and the rate of CL in presenting patients, while the highest rate of positive lesions was found in the age group of 9 years old or under (86.67%). In this study, we found also that L. tropica infection mostly caused single lesions (67.90%) that were located in the face (96.30%). Morphological identification was performed on a total of 1152 sand flies (23% females and 77% males) collected by sticky paper traps. 57% of the total collected flies were identified as Phlebotomus (Paraphlebotomus) sergenti (Parrot).

Effect of large-scale installation of deltamethrin-impregnated screens and curtains in Bam, a major focus of anthroponotic cutaneous leishmaniasis in Iran

INTRODUCTION

Installation of deltamethrin-impregnated screens and curtains was assessed as a preventive measure against transmission of anthroponotic cutaneous leishmaniasis (ACL) by Phlebotomus sergenti in Bam, a well-known focus of ACL in Iran with a population of nearly 100,000.

METHODS

This was a quasi-experiment based on official data from an ACL control program in which one section of the city with about one-quarter of the population received the intervention. In the analysis, the rest of the city was used as control. Data covered June 2007 through October 2010.

RESULTS

Comparison of cumulative incidence between the intervention and control areas before and after installation indicate a significant differential reduction in the cumulative ACL incidence in the intervention area and a reversal of the relative risk, beginning four months after the completion of installation, from RR = 1.14 (95% CI:1.05-1.23) to RR = 0.84 (95% CI:0.72-0.98). Results also indicate a return to a higher cumulative relative risk, RR = 1.51 (95% CI:1.30-1.77), several months after the loss of the preventive effect.

CONCLUSIONS

Findings indicate the short-term effectiveness of such preventive measures but highlight the necessity of long-term, sustainable strategies. Results also suggest that shrinkage in the human reservoir pool in response to the intervention may play a significant role in prolongation of the preventive effect beyond the insecticidal life of impregnated materials in foci of anthroponotic cutaneous leishmaniasis and possibly anthroponotic visceral leishmaniasis due to L. donovani.

The role of surface glycoconjugates in Leishmania midgut attachment examined by competitive binding assays and experimental development in sand flies

Binding of promastigotes to the sand fly midgut epithelium is regarded as an essential part of the Leishmania life cycle in the vector. Among Leishmania surface molecules putatively involved in attachment to the sand fly midgut, two GPI-anchored molecules are the most prominent: lipophosphoglycan (LPG) and promastigote surface protease gp63. In this work, we examined midgut attachment of Leishmania lines mutated in GPI-anchored molecules and compared results from 2 different techniques: in vivo development in sand flies and in vitro competitive binding assays using fluorescently labelled parasites. In combination with previous studies, our data provide additional support for (1) an LPG-independent parasite-binding mechanism of Leishmania major within the midgut of the permissive vector Phlebotomus perniciosus, and provide strong support for (2) the crucial role of L. major LPG in specific vector Phlebotomus papatasi, and (3) a role for Leishmania amazonensis gp63 in Lutzomyia longipalpis midgut binding. Moreover, our results suggest a critical role for GPI-anchored proteins and gp63 in Leishmania mexicana attachment to L. longipalpis midguts, as the wild type (WT) line accounted for over 99% of bound parasites.

Experimental acquisition, development, and transmission of Leishmania tropica by Phlebotomus duboscqi

We report experimental infection and transmission of Leishmania tropica (Wright), by the blood-feeding sand fly Phlebotomus duboscqi (Neveu-Lemaire). Groups of laboratory-reared female sand flies that fed "naturally" on L. tropica-infected hamsters, or artificially, via membrane feeding device, on a suspension of L. tropica amastigotes, were dissected at progressive time points post-feeding. Acquisition, retention and development of L. tropica through procyclic, nectomonad, and leptomonad stages to the infective metacyclic promastigote stage, and anterior progression of the parasites from abdominal midgut bloodmeal to the thoracic midgut were demonstrated in both groups. Membrane feeding on the concentrated amastigote suspension led to metacyclic promastigote infections in 60% of sand flies, whereas only 3% of P. duboscqi that fed naturally on an infected hamster developed metacyclics. Sand flies from both groups re-fed on naïve hamsters, but despite infections in 25-50% of membrane-fed and 2-3.5% of naturally fed flies, no skin lesions developed in the hamsters. After four months of observation these animals were euthanized and necropsied. Screening of the organs and tissue by polymerase chain reaction (PCR) that targeted the small subunit RNA gene, amplified generic Leishmania DNA from liver, spleen, bone marrow, and blood, but only from hamsters bitten by membrane-infected P. duboscqi. These results are notable in demonstrating the ability of P. duboscqi, originating from Kenya, to acquire, retain, develop, and transmit a Turkish strain of L. tropica originally isolated from a human case of cutaneous leishmaniasis. This marks the first demonstration of complete development and transmission of L. tropica by a member of the Phlebotomus subgenus of sand flies.

The development of Psychodiella sergenti (Apicomplexa: Eugregarinorida) in Phlebotomus sergenti (Diptera: Psychodidae)

Psychodiella sergenti is a recently described specific pathogen of the sand fly Phlebotomus sergenti, the main vector of Leishmania tropica. The aim of this study was to examine the life cycle of Ps. sergenti in various developmental stages of the sand fly host. The microscopical methods used include scanning electron microscopy, transmission electron microscopy and light microscopy of native preparations and histological sections stained with periodic acid-Schiff reaction. Psychodiella sergenti oocysts were observed on the chorion of sand fly eggs. In 1st instar larvae, sporozoites were located in the ectoperitrophic space of the intestine. No intracellular stages were found. In 4th instar larvae, Ps. sergenti was mostly located in the ectoperitrophic space of the intestine of the larvae before defecation and in the intestinal lumen of the larvae after defecation. In adults, the parasite was recorded in the body cavity, where the sexual development was triggered by a bloodmeal intake. Psychodiella sergenti has several unique features. It develops sexually exclusively in sand fly females that took a bloodmeal, and its sporozoites bear a distinctive conoid (about 700 nm long), which is more than 4 times longer than conoids of the mosquito gregarines.

Characteristics of resting and breeding habitats of adult sand flies in the Judean Desert

Recently, in several areas of the Middle East, a sharp increase of cutaneous leishmaniasis was observed in suburbs of larger towns including Jerusalem. In some of these areas, poor housing conditions and unsuitable waste management was suspected to provide ideal conditions for sand fly breeding, but hard data on diurnal resting sites and breeding habitats of most sand fly species are scant. In this study, we chose 16 sites on both slopes and the bottom of a natural valley in the Judean Desert to conduct a survey of sand fly distribution with emergence traps. Altogether, 1,261 sand flies, 52%Phlebotomus syriacus, 22%P. sergenti, 14%P. papatasi and 12%P. tobbi were caught. About two thirds of the flies caught were resting, while the other third emerged from breeding sites. All four species showed clear preferences for resting and breeding sites, but generally, most sand flies were breeding in the more humid habitats, namely the bottom of the valley, the adjacent north facing slope, terraces on the north facing slope, and caves. The vegetation cover also appeared to be important for resting habitats; on the bottom of the valley more than six times as many sand flies were collected in areas covered by dense vegetation than in areas with low vegetation cover. P. sergenti seemed also to better tolerate the drier habitats, which might explain the abundance of this species in the arid Judean Desert.

The sandflies (Diptera: Psychodidae, Phlebotominae) in military camps in northern Afghanistan (2007-2009), as identified by morphology and DNA 'barcoding'

As part of a continuous, standardized programme of monitoring the Leishmania vectors in German military camps in northern Afghanistan between 2007 and 2009, a detailed taxonomic analysis of the endemic sandfly fauna, as sampled using light and odour-baited traps, was conducted. Of the 10 sandfly species that were recorded, six may serve as enzootic and/or zooanthroponotic vectors of parasites causing human leishmaniasis. The use of a simple DNA-'barcoding' technique based on the mitochondrial cyt b gene, to identify the collected sandflies to species level, revealed (1) a clear discrimination between the potential vector species, (2) clustering of species within most subgenera, and (3) particularly high heterogeneity within the subgenus Paraphlebotomus (Phlebotomus alexandri being grouped with Ph. papatasi rather than with other Paraphlebotomus species). The data also indicate a high level of genetic heterogeneity within the subgenus Sergentomyia but close similarity between Sergentomyia sintoni and Sergentomyia murgabiensis. The morphological similarity of many medically important sandflies can make species identification difficult, if not impossible. The new DNA-barcoding techniques may provide powerful discriminatory tools in the future.

Leishmaniasis in an era of conflict in the Middle East

Leishmaniasis is endemic in the Middle East, and both cutaneous and visceral forms are reported from the region ranging from the Levant to Afghanistan. The potential and proven phlebotomine sand fly vectors and reservoir hosts of the Leishmaniases species in Afghanistan, Iran, Iraq, Israel, Jordan, Lebanon, Saudi Arabia, Syria, Turkey, and Yemen are described. This region has seen a movement of populations across the area, due to both military and civilian strife. Refugees, armed forces, and multi-national contractors are particularly at risk to acquire this disease. There has been an upsurge in Leishmaniasis research, especially as new foci are exposed and the need to protect the naïve populations moving into endemic areas becomes a public health priority. New sand fly vectors and animal reservoirs have been discovered while novel control methods are being evaluated. Modern molecular techniques are now being used more routinely and revealing some unusual findings. The aim of this review is to collate the most recent data on the burden of the disease, diagnostic applications, eco-epidemiology of vectors, and reservoir hosts, and how the control projects have been developing in the Middle East.

Risk factors for anthroponotic cutaneous Leishmaniasis at the household level in Kabul, Afghanistan

Background

Kabul, Afghanistan, is the largest focus of anthroponotic cutaneous leishmaniasis (ACL) in the world. ACL is a protozoan disease transmitted to humans by the bite of phlebotomine sand flies. Although not fatal, ACL can lead to considerable stigmatization of affected populations.

Methods

Using data from a standardized survey of 872 households in 4 wards of Kabul, Afghanistan, univariate and multivariate logistic regression analyses tested associations between presence of active ACL and ACL scars with 15 household-level variables.

Findings

Univariate analyses showed that active ACL was positively associated with household member's age, ACL prevalence, and brick wall type, but negatively associated with household number of rooms, bednet use, and proportion of windows with screens. Multivariate analysis showed a positive association between active ACL and household member's age, ACL prevalence, and brick wall type, and a negative association with household proportion of windows with screens.

Conclusion

Household-level charateristics were shown to be risk factors for ACL. Monitoring a selected number of household characteristics could assist in rapid assessments of household-level variation in risk of ACL. ACL prevention and control programs should consider improving house construction, including smoothing of walls and screening of windows.

Cutaneous leishmaniasis is a vector-borne protozoan disease that is characterized by cutaneous lesions which develop at the site of the insect bite. Lesions can vary in severity, clinical appearance, and time to cure; in a proportion of patients lesions can become chronic, leading to disfiguring mucosal leishmaniasis or leishmaniasis recidvans. Albeit not fatal, cutaneous leishmaniasis can have a significant social impact as it may lead to severe stigmatisation of affected individuals when lesions or scars occur on the face and exposed extremeties. Over the last 10–20 years there has been an increase in the number of leishmaniasis cases reported in South Asia, particularly in Afghanistan. Little is known about the household-level risk factors for infection and disease. Here we confirm previous reports that had shown the association of cutaneous leishmaniasis with age and clustering of cases at the household-level. Additionally, we show that risk of cutaneous leishmaniasis is associated with household construction (i.e. brick walls) and design (i.e. proportion of windows with screens).

Aspects of the bionomics of Phlebotomus sergenti sandflies from an endemic area of anthroponotic cutaneous leishmaniasis in Aleppo Governorate, Syria

Aspects of the bionomics of phlebotomine sandflies (Diptera: Psychodidae) were studied from June to November 2005 in three foci of anthroponotic cutaneous leishmaniasis (ACL) in Aleppo Governorate, Syria, where the agent Leishmania tropica (Wright) (Kinetoplastida: Trypanosomatidae) is transmitted by Phlebotomus sergenti Parrot. Syria has been designated by the World Health Organization as one of four countries in the Old World where cutaneous leishmaniasis is hyperendemic, but little is known about the biology of local vector populations. Standard collections by sticky traps showed two peaks in density, in June and late August. In total, 1840 sandflies were caught, comprising five species: Phlebotomus papatasi (Scopoli) (68.0%); P. sergenti (25.4%); Sergentomyia minuta (Rondani) (6.4%); Phlebotomus tobbi Adler & Theodor (0.1%), and Phlebotomus mascittii canaaniticus Adler & Theodor (0.1%). Similar numbers of P. sergenti were caught indoors (246 specimens) and outdoors (222), whereas P. papatasi was significantly more abundant indoors (1096 specimens) than outdoors (156) (chi(2) = 241, P < 0.01). In total, 212 blood-fed females were tested for host blood determination, of which 176 (83.0%) reacted with anti-species reagent. Results from 20 P. sergenti suggest that this species is an opportunistic feeder, imbibing human, ovine, avian, bovine and feline blood, although more bloodmeals were taken from humans and cattle than expected in relation to the relative proportions of potential hosts present (the forage ratio, FR). The bionomics of P. sergenti are discussed in relation to the inefficacy of control campaigns based on indoor spraying with residual insecticides that have been implemented by the Syrian Ministry of Health to control the epidemics of ACL in the Aleppo Governorate.

Control of phlebotomine sandflies in confined spaces using diffusible repellents and insecticides

The control of phlebotomine sandflies (Diptera: Psychodidae), the vectors of leishmaniasis, is directed mostly against adults as larvae develop in unknown or inaccessible habitats. In the current study we tested geraniol, a natural plant-derived product, as a space repellent and the synthetic pyrethroid prallethrin as a diffusible insecticide. Geraniol was dispersed in the air using diffusers with an electric fan and prallethrin was evaporated using electrically heated evaporators. Both substances were tested in inhabited bedrooms and in tents. Geraniol failed to effect significant reductions in the numbers of either Phlebotomus papatasi Scopoli in rooms or Phlebotomus sergenti Parrot in tents. In laboratory experiments, geraniol proved ineffective in preventing sandflies from feeding. By contrast, prallethrin was highly effective in reducing the number of sandflies in rooms as well as in tents. Exposure of sandflies to prallethrin in laboratory experiments caused 97% mortality rates. Both prallethrin and, to a lesser extent, geraniol reduced the number of Culex mosquitoes captured in tents. Electric liquid-vaporizers with 1.5% prallethrin are highly effective in protecting people from sandfly bites in confined spaces and may be useful in combating cutaneous leishmaniasis.

Microsatellite analysis reveals genetic structure of Leishmania tropica

The current rapid spread of leishmaniases caused by Leishmania tropica and the complexity of its clinical spectrum call for this parasite's epidemiological and evolutionary investigation. Evaluation of its population structure by isoenzyme electrophoresis and previous molecular biological analysis has proved difficult. In this study, we used 21 microsatellite loci to type 117 strains from different African and Asian locations. Eighty-one different genotypes were found. A genetic bottleneck supported by a gradient in the number of alleles and consistent with the geographical structure of the Middle East suggests an African origin of this species. A Bayesian approach identified 10 genetic clusters that correlated predominantly with geographical origin. The strains in the 'Asia' cluster form a very heterogeneous sub-population, with a varied but inter-related genotype that is geographically very widely dispersed and consistent with anthroponotic transmission of the parasite. The other nine clusters were more homogenous. The propagation of L. tropica appears to be predominantly clonal. In Africa and the Middle East, anthroponotic and zoonotic systems of distribution may contribute to the development of overlapping, genetically distinct populations of L. tropica.

Entomological investigations in Chichaoua: an emerging epidemic focus of cutaneous leishmaniasis in Morocco

Cutaneous leishmaniasis due to Leishmania tropica Wright seems to be an emerging disease in Chichaoua, a province located in southwestern Morocco. In this study, sand flies (Diptera: Psychodidae) were collected from 12 stations. Sticky traps were placed in domestic, peridomestic, and sylvatic sites. In total, 3,787 specimens consisting of 10 species (seven Phlebotomus and three Sergentomiya) were identified. Phlebotomus perniciosus Newstead, the predominant species, was abundant, especially in mountainous areas. Phlebotomus sergenti Parrot (12%) was found in all studied villages where it was associated with domestic and peridomestic habitats. On the basis of its abundance, distribution, and notable anthropophily, P. sergenti, a proven vector of L. tropica elsewhere, is considered the cutaneous leishmaniasis vector in this emerging focus.

Altitudinal variation in morphometric and molecular characteristics of Phlebotomus papatasi populations

Four populations of the phlebotomine sandfly Phlebotomus (Phlebotomus) papatasi (Scopoli) (Diptera: Psychodidae), in different ecoregions at altitudes between 368 and 1117 m in the Sanliurfa Province of Turkey, were compared using morphometric and isoenzyme analyses. A similarity phenogram obtained from allozyme data showed that heterozygosity was extremely low, particularly for the alleles which were found to be completely fixed in populations at Hamdun (HMD) and Alitas (ALT). Populations at Akcakale (AKL) and ALT branched as a separate group from populations at Hayatiharrani (HHR) and HMD. The ALT population at the highest altitude (1117 m), and the HHR population (488 m) were clustered distinctly when linear measurements of 46 morphological characteristics were examined. A UPGMA (unweighted pair-group method using arithmetic averages) phenogram also showed that ALT and HHR clustered separately, whereas AKL and HMD formed another group.

Bionomics of phlebotomine sandflies in the Galilee focus of cutaneous leishmaniasis in northern Israel

The bionomics of phlebotomine sandflies (Diptera: Psychodidae) were studied for three years (2001-2003) in the Galilee focus of cutaneous leishmaniasis in northern Israel, where the causative Leishmania tropica (Kinetoplastida: Trypanosomatidae) is transmitted by Phlebotomus (Adlerius) arabicus Theodor and Phlebotomus (Paraphlebotomus) sergenti Parrot, comprising 22% and 8%, respectively, of the local sandfly fauna sampled by light traps. The predominant species overall was Phlebotomus (Larroussius) tobbi Adler & Theodor (51%) with lesser numbers of Phlebotomus (Adlerius) simici Theodor (11%), Phlebotomus (Larroussius) syriacus Adler & Theodor (5%), Phlebotomus (Larroussius) perfiliewi Perfil'ev (3%) and Phlebotomus (Phlebotomus) papatasi Scopoli (0.05%). Sandfly adult populations were prevalent from April to November and peaked between June and August, being more abundant through the summer in irrigated habitats, such as gardens and orchards, than in open grassland. Of the two cutaneous leishmaniasis vectors, P. sergenti preferred boulder mounds located at the outskirts of settlements, whereas P. arabicus was more abundant overall and near houses in particular. Females of all these sandfly species displayed a peak of activity after sunset (20.00-22.00 hours), whereas activity of males persisted longer through the night. Another slight increase in activity was noted before dawn (02.00-04.00 hours). Phlebotomus arabicus appears to be the main vector of L. tropica in the Galilee focus, due to its denser populations, more endophily and preference for peridomestic habitats than shown by P. sergenti in northern Israel.

Phlebotomus (Adlerius) halepensis vector competence for Leishmania major and Le. tropica

In Eurasia, phlebotomine sandflies of the subgenus Adlerius (Diptera: Psychodidae) comprise about 20 known species. Some are suspected vectors of visceral leishmaniasis (VL) and at least one species has been implicated as a vector of cutaneous leishmaniasis (CL). We tested Phlebotomus (Adlerius) halepensis Theodor (Jordan strain) for CL vector competence, compared with three standard vectors: Phlebotomus (Phlebotomus) duboscqi N-L. from Senegal, Phlebotomus (Paraphlebotomus) sergenti Parrot from Turkey and the Neotropical Lutzomyia longipalpis (L. & N) (Jacobina strain). Sandfly females were membrane-fed on amastigote suspensions of Leishmania major Y. & S. and Le. tropica (Wright) (Kinetoplastida: Trypanosomatidae) and examined for parasite development 3, 6 and 10 days post-infection. Phlebotomus halepensis showed high susceptibility to both leishmanias, supporting typical suprapylarian parasite development similar to the other vectors. Phlebotomus halepensis infection rates were approximately 90% for Le. major and approximately 80% for Le. tropica, with high parasite densities. Development of infections was relatively fast, colonizing the thoracic midgut by 6 days post-bloodmeal in every case and reaching the stomodeal valve in >80% of flies. In late-stage infections, 10 days post-bloodmeal, nearly all P. halepensis females had cardia and stomodeal valve filled with very high numbers of parasites and some Le. tropica-infected females had promastigotes in the pharynx and proboscis. Host choice experiments in the laboratory showed that P. halepensis females fed readily on rat or rabbit and preferred the human forearm. In view of its vector competence and partial anthropophily, we infer that P. halepensis is a potential vector of cutaneous as well as visceral leishmaniases.

Anthroponotic cutaneous leishmaniasis, Kabul, Afghanistan

A prevalence survey in Kabul City showed that 2.7% and 21.9% of persons have active leishmaniasis lesions or scars, respectively. Incidence of disease was estimated to be 2.9% (29 cases/1,000 persons per year; 95% confidence interval 0.018 to 0.031). Disease was associated with age and gender; logistic regression analyses showed significant clustering of cases.

Experimental transmission of Leishmania tropica to hamsters and mice by the bite of Phlebotomus sergenti

Phlebotomus sergenti is a natural vector of Leishmania tropica. However, the ability of P. sergenti to transmit L. tropica by bite has not been proven experimentally yet. We have transmitted L. tropica to golden hamsters and BALB/c mice by the bite of P. sergenti. Sand flies and Leishmania both originated from an anthroponotic cutaneous leishmaniasis focus in Urfa, Turkey. P. sergenti females from a laboratory colony were infected by feeding on lesions of needle-inoculated hamsters or mice. Gravid females were allowed to refeed on uninfected hosts 9-15 d after the infective feeding. At the second feeding, some infected females took a full blood meal, while others only a partial one; some females failed to feed at all. The ability of infected females to take a blood meal did not correlate with the parasite transmissibility. In four BALB/c mice, lesions developed after 1-6 months. In two albino hamsters (Mesocricetus auratus), lesions developed 1 month after the infective feeding, and Leishmania could be reisolated from these sites. Another hamster did not develop a lesion; however, the feeding site and the adjacent ear were PCR positive 1 year after infective feeding. Our results show that dissemination to other parts of host body occurs in L. tropica after sand fly bite. Experimental transmission of the parasite confirms that P. sergenti is a natural vector of L. tropica.

The prolonged epidemic of anthroponotic cutaneous leishmaniasis in Kabul, Afghanistan: ‘bringing down the neighbourhood’

In order to investigate the distribution and causes of the spread of anthroponotic cutaneous leishmaniasis (ACL) in Kabul, Afghanistan, a cross-sectional study was conducted during 1997-98 amongst 75,787 residents in the 13 central districts of the city. Using data on active lesions and scars with their times of onset, migration patterns and age of subjects, 2 independent methods were used to estimate, retrospectively, the annual incidence of ACL in recent years. Results indicated a rapid increase in incidence from 1987, peaking in 1996 when an estimated 12% of the population had active disease. Active prevalence was lowest in infants (aged < 2 years), and while risk was gender-independent in children and adolescents, active prevalence in those aged > 20 years was significantly higher amongst females than males (odds ratio [OR] = 1.51, 95% CI 1.34-1.70). About 44% of lesions were located on the head, 38% on upper limbs, 16% on lower limbs and 2% elsewhere. The relative frequency of head lesions dropped with age (P < 0.001), and amongst adults was lowest amongst males (P < 0.001), possibly due to the protective effect of a beard. Within the study population, 32% reported that they had immigrated from outside Kabul, 34% that they had been born in Kabul but had since migrated to another district of the city, and 34% that they had been born in the district of their present residence. Active prevalence amongst those born in their current district of residence was positively associated with the percentage of immigrants in their district (P = 0.027), indicating that a 1% increase in the percentage of immigrants increased the odds of an active lesion by 12% (OR = 1.12, 95% CI 1.01-1.24), but there was no association with the percentage of migrants from other districts in Kabul (P = 0.65) or with war damage (P = 0.33). As active prevalence was not significantly greater in immigrants than local Kabulis, these results support the hypothesis that the epidemic in Kabul has been maintained by a steady influx of susceptible immigrants. It is important that the new opportunities for social development that now exist in Kabul are not hampered by this unpleasant and stigmatizing disease. As population movement is clearly a contributing factor to its transmission, this threat is very real.

ITS 2 sequences heterogeneity in Phlebotomus sergenti and Phlebotomus similis (Diptera, Psychodidae): possible consequences in their ability to transmit Leishmania tropica

An intraspecific study on Phlebotomus sergenti, the main and only proven vector of Leishmania tropica among the members of the subgenus Paraphlebotomus was performed. The internal transcribed spacer 2 (ITS2) sequences of 12 populations from 10 countries (Cyprus, Egypt, Italy, Lebanon, Morocco, Pakistan, Portugal, Spain, Syria, and Turkey) were compared. Samples also included three species closely related to P. sergenti: Phlebotomus similis (three populations from Greece and Malta), Phlebotomus jacusieli and Phlebotomus kazeruni. Our results confirm the validity of the taxa morphologically characterised, and imply the revision of their distribution areas, which are explained through biogeographical events. At the Miocene time, a migration route, north of the Paratethys sea would have been followed by P. similis to colonise the north of the Caucasus, Crimea, Balkans including Greece and its islands, and western Turkey. Phlebotomus sergenti would have followed an Asiatic dispersion as well as a western migration route south of the Tethys sea to colonise North Africa and western Europe. This hypothesis seems to be well supported by high degree of variation observed in the present study, which is not related to colonisation or to intra-populational variation. Two groups can be individualised, one oriental and one western in connection with ecology, host preferences and distribution of L. tropica. We hypothesise that they could be correlated with differences in vectorial capacities.

Endemic infectious diseases of Afghanistan

The current crisis in Afghanistan has resulted in an influx of Western military personnel, peacekeepers, humanitarian workers, and journalists. At the same time, unprecedented numbers of internally displaced persons and refugees have overwhelmed much of the already fragile infrastructure, setting the stage for outbreaks of infectious diseases among both foreigners and local populations. This review surveys the literature concerning the infectious diseases of Afghanistan and south-central Asia, with particular emphasis on diseases not typically seen in the Western world.

Sand flies (Diptera: Phlebotominae) in Sanliurfa, Turkey: relationship of Phlebotomus sergenti with the epidemic of anthroponotic cutaneous leishmaniasis

Sand fly (Diptera: Phlebotominae) fauna were surveyed in various districts of Sanliurfa in southeast Turkey for 3 yr immediately after an epidemic of cutaneous leishmaniasis (Leishmania tropica). Sticky papers and CDC light traps collected a total of 10,937 sand flies, of which 10,919 (4,158 females and 6,761 males) were identified as Phlebotomus and 18 (11 females and seven males) as Sergentomyia (S. theodori Parrot; S. adleri Theodor). Eight Phlebotomus spp. were identified: P. sergenti Parrot (72.3%), P. papatasi (Scopoli) (27.2%), P. brevis Theodor & Mesghali (0.20%), P. neglectus Leger & Pesson (0.13%), P. perfiliewi Parrot (0.05%), P. mascitti Grassi, P. halepensisTheodor, and P. alexandri Sinton (0.01%). Phlebotomus mascitti and P. neglectus, along with both Sergentomyia sp., have not been previously described from the study area. Similar results were obtained when both trapping methods were applied in the same houses, indicating that local P. sergenti and P. papatasi populations were equally attracted to the light. P. sergenti was consistently abundant, agreeing with the general view that this species is the vector of leishmaniasis in the region. There was no apparent decrease in the relative abundance of this vector versus the other species, suggesting that factor (s) other than a change in the dynamics of sand fly populations precipitated the decline of the human leishmaniasis epidemic in Sanliurfa.

Leishmania-sand fly interactions controlling species-specific vector competence

Leishmaniasis is caused by a wide range of parasites that are transmitted by an even wider range of sand fly vectors. The phlebotomine vectors of Leishmaniasis are in some cases only permissive to the complete development of the species of Leishmania that they transmit in nature. The parasite-sand fly interactions that control this specificity are related to differences in the ability of the parasite to inhibit or to resist killing by proteolytic enzymes released into the mid-gut soon after blood feeding, and/or to maintain infection in the mid-gut during excretion of the digested blood meal. In each case, surface expressed or released phosphoglycan-containing molecules appear to promote parasite survival. The evidence that the surface lipophosphoglycan (LPG) mediates promastigote attachment to the mid-gut epithelium so as to prevent their loss during blood-meal excretion is especially strong based on the comparison of development in sand flies using LPG-deficient mutants. LPG displays interspecies polymorphisms in their phosphoglycan domains that in most cases can fully account for species-specific vector competence.

A randomized controlled trial of insecticide-treated bednets and chaddars or top sheets, and residual spraying of interior rooms for the prevention of cutaneous leishmaniasis in Kabul, Afghanistan

Anthroponotic cutaneous leishmaniasis (ACL) is a significant public health problem in many towns and cities of south central Asia and the Middle East, resulting in disfigurement and disability which warrants preventive action. A randomized controlled trial was conducted in 1997/98 amongst a non-immune study population of 3666 people in Kabul, Afghanistan, to compare the efficacy of insecticide-treated nets (ITNs), insecticide-treated Islamic cloth wraps (chaddars) used to sleep in, and residual pyrethroid spraying of individual houses for the prevention of ACL. Dosages of insecticide were: ITNs with permethrin, 0.5 g/m2; chaddars with permethrin, 1 g/m2; rooms with lambdacyhalothrin, 30 mg/m2. Cases of ACL were diagnosed on clinical criteria. At the end of the trial period (15 months) the incidence of ACL amongst controls was 7.2%, amongst ITN users 2.4% (OR 0.31, 95% CI 0.2-0.5), amongst impregnated chaddar users 2.5% (OR 0.33, 95% CI 0.2-0.6) and amongst residents of sprayed houses 4.4% (OR 0.60, 95% CI 0.3-0.95). ITNs and impregnated chaddars were equally effective, providing about 65% protective efficacy, with approximately 40% protective efficacy attributable to individual house spraying. No significant differences for age or sex were found between new cases in the intervention and control groups. No serious side-effects were reported and interventions were generally popular; ITNs were the most popular, followed by residual spraying and then impregnated chaddars.

Molecular systematics of the phlebotomine sandflies of the subgenus Paraphlebotomus (diptera, psychodidae, phlebotomus) based on ITS2 rDNA sequences. Hypotheses Of dispersion and speciation

Phylogenetic Paraphlebotomus relationships are inferred by a study based on the sequences of ITS2, which has been sequenced in nine Paraphlebotomus species: P. alexandri, P. andrejevi, P. jacusieli, P. kazeruni, P. mireillae, P. mongolensis, P. saevus, P. sergenti and P. similis and in two out-groups species of the subgenus Phlebotomus: P. papatasi and P. duboscqi. Paraphlebotomus alexandri appears as the sister group of all other Paraphlebotomus sandflies. Among the other species, three groupings are clearly highlighted: andrejevi and mongolensis; mireillae and saevus; jacusieli, kazeruni, sergenti and similis. These groupings are related to speculations about the migration of Paraphlebotomus from a centre of dispersion located in the Middle East sometime from the early Eocene to the late Miocene.

An outbreak of cutaneous leishmaniasis in an Afghan refugee settlement in north-west Pakistan

Cutaneous leishmaniasis (CL) due to Leishmania tropica appears to be an emerging disease in parts of north-east Afghanistan and north-west Pakistan. Timargara, an Afghan refugee camp of 17 years' standing, in the district of Dir, North West Frontier Province of Pakistan, experienced a major outbreak of CL in 1997 for the first time. As part of the investigation, each section of the camp was surveyed for CL. Around 38% of the 9200 inhabitants bore active lesions and a further 13% had scars from earlier attacks. According to interview statements, 99% of earlier infections had healed within the previous 2 years. To confirm the diagnosis, a sample of current CL lesions was examined parasitologically. Amastigotes were detectable by microscopy in only 36% of lesions. However, 48% of slide-negative cases produced positive cultures and some cases negative to both microscopy and culture were positive by PCR. Overall detection rate was about 80%. The sandfly Phlebotomus sergenti, a known vector of L. tropica, was captured within the camp, indicating local transmission. CL has not been reported from this area of Pakistan before. Although the majority of refugees left Afghanistan 2 decades ago, cross-border movement of men is common. The Afghanistan capital, Kabul, is currently experiencing a major epidemic of CL; infected migrant carriers from Kabul are probably the source of the outbreak in Timargara.

Anthroponotic cutaneous leishmaniasis in Kabul, Afghanistan: vertical distribution of cases in apartment blocks

Owing to the civil war, the inhabitants of Kabul in Afghanistan are suffering a major epidemic of anthroponotic cutaneous leishmaniasis (ACL) caused by Leishmania tropica. Surveys conducted among children in 2 high-rise apartment blocks in the city revealed that the prevalence of active lesions was much lower on upper stories: 84% lower in one block (chi 2 = 7.13, d.f. = 1, P = 0.008) and 54% lower in the other (chi 2 = 6.17, d.f. = 1, P = 0.01). Similar trends were apparent with regard to scars from old lesions. These results suggest that in Kabul most transmission of ACL takes place in the home. In addition, the results imply that there must be limited vertical movement of the vector within apartment blocks. Together, these findings suggest that indoor spraying should be an effective means of control and that insecticidal applications could probably be restricted to lower stories.