Leishmaniases in Greece

Species-specific variation in predicted distribution and habitat suitability of phlebotomine sand flies in Italy under different climate change scenarios

The incidence of human and canine leishmaniasis in Europe is increasing and is a key indicator in the Lancet Countdown report on health and climate change 2024. While the potential distribution of the disease on a continental scale has been assessed under climate change scenarios, local analyses of vector species distribution are crucial for effective prevention strategies. Italy is endemic for Leishmania infantum, and expansions in the latitudinal and altitudinal distribution of canine cases and vector species have been recorded. This study evaluated the potential distribution of six phlebotomine sand fly species, known or suspected vectors of L. infantum, under climate change scenarios using ecological niche modeling and the maximum entropy (MaxEnt v. 3.4.1) modeling algorithm. We analyzed 410 records from 1979 to 2013 and projected future distributions for 2041-2060 and 2061-2080 using five CMIP5 models and two representative concentration pathways. Historical data from 1968 to 1972 were also examined to confirm suitable areas. The predictions indicate suitable habitats for sand flies throughout Italy, and variations among the different scenarios evaluated. All species show potential for expansion, such as the main vector, P. perniciosus, which shows an increase in the percentage of suitable habitat over time. On the other hand, predictions for P. perfiliewi don't show a clear pattern, with an initial decrease and subsequent increase in suitable areas. Shifts in the distribution of insect vectors may affect the dynamics of Leishmania transmission, highlighting the need for improved surveillance strategies.

Leishmaniasis in Greece: Prospects of transitioning to a One Health surveillance system

Leishmaniasis is a high burden neglected disease in the Mediterranean ecoregion, lacking surveillance attention. We aimed to provide an overview of the state of leishmaniasis surveillance in Greece, investigating the prospect of transitioning to a One Health surveillance system. We conducted a narrative review describing human and animal leishmaniasis data from Greece, including entomological findings. Through a separate review process, we describe the current leishmaniasis surveillance system pertaining to humans, animals, vectors and the environment. Additionally, we distributed likert-scale questionnaires to key informants, capturing expert-view on the necessity, existing levels and barriers of OH leishmaniasis surveillance in Greece. We identified key system strengths, weaknesses, opportunities and threats respective to a OH transition through SWOT analysis. Greece is endemic for zoonotic visceral leishmaniasis (VL) and canine leishmaniasis (CanL), displaying an increasing VL trend in recent years and high national Leishmania seroprevalence rates in dogs (range: 13.8-23.4 %). Mandatory leishmaniasis notification in humans and animals, human case-based investigations, and active case finding activities in stray dogs, comprise valuable system components of high OH operational relevance. Conversely, the existing CanL surveillance governance and the lack of systematic entomological surveillance constitute important drawbacks. Moreover, the current context of public health and animal health financial constraints in Greece may impede a strategic OH transition in leishmaniasis surveillance. On the contrary, Greece's OH experience in West Nile Virus surveillance in conjunction with leishmaniasis-expert consensus on the necessity of OH surveillance and key barriers to its realization, compose important transition opportunities. Despite shortfalls in human, animal and vector surveillance, existing system characteristics, structures and practices comprise a promising basis for developing OH cross-sectoral leishmaniasis surveillance activities in Greece.

A Retrospective Study of Genetic Characterization in Suspected Visceral Leishmaniasis Cases in Greece, 2005 to 2020

Leishmania infantum is considered the predominant Leishmania species responsible for visceral leishmaniasis (VL) in Greece but limited molecular-typing-based studies have been performed so far. We retrospectively analyzed data and serum samples collected from 3661 individuals suspected for VL in a sixteen-year period, from 2005 to 2020, to study the seasonality and demographic characteristics of VL cases and to define the L. infantum genotypes circulating in the country. Serum samples were tested with immunofluorescence assay and/or molecular assay. qPCR Leishmania-positive samples were subjected to genotypic analysis based on polymorphisms in 12 microsatellite regions of the internal transcribed spacers (ITSs) 1 and 2. We diagnosed 219 definite (6%, sample with a positive molecular assay and/or antibody titer ≥ 1:400) and 230 probable (6.3%, sample with antibody titer between 1:100 and 1:200) VL cases. Data analysis revealed that amongst VL-definite cases, the age group (≥65) constitutes the most affected factor, since 36.9% of the VL cases belonged to this age group. Amongst the VL definite cases, the most frequently reported symptoms were fever (83%), splenomegaly (49%), and hepatomegaly (40%), but this was not the case for immunocompromised patients that developed non-typical symptoms of leishmaniasis. Although no statistically significant differences in the overall seasonality of VL cases were observed, February and June showed a significantly higher proportion of VL cases compared to August and December. Genotyping of ITS1 and ITS2 regions revealed that all VL cases belong to ITS type A of L. infantum. Our study provides epidemiological information on VL and demonstrates for the first time, providing genotypic data, the circulation of ITS type A L. infantum in Greece.

Global Distribution of Canine Visceral Leishmaniasis and the Role of the Dog in the Epidemiology of the Disease

Visceral leishmaniasis is a disease caused by protozoa of the species Leishmania (Leishmania) infantum (syn = Leishmania chagasi) and Leishmania (Leishmania) donovani, which are transmitted by hematophagous insects of the genera Lutzomyia and Phlebotomus. The domestic dog (Canis familiaris) is considered the main urban reservoir of the parasite due to the high parasite load on its skin, serving as a source of infection for sandfly vectors and, consequently, perpetuating the disease in the urban environment. Some factors are considered important in the perpetuation and spread of canine visceral leishmaniasis (CVL) in urban areas, such as stray dogs, with their errant behavior, and houses that have backyards with trees, shade, and organic materials, creating an attractive environment for sandfly vectors. CVL is found in approximately 50 countries, with the number of infected dogs reaching millions. However, due to the difficulty of controlling and diagnosing the disease, the number of infected animals could be even greater. In the four continents endemic for CVL, there are reports of disease expansion in endemic countries such as Brazil, Italy, Morocco, and Tunisia, as well as in areas where CVL is not endemic, for example, Uruguay. Socio-environmental factors, such as migration, drought, deforestation, and global warming, have been pointed out as reasons for the expansion into areas where it had been absent. Thus, the objective of this review is to address (i) the distribution of CVL in endemic areas, (ii) the role of the dog in the visceral leishmaniasis epidemiology and the factors that influence dog infection and the spread of the disease, and (iii) the challenges faced in the control of CVL.

Analysis of the current risk of Leishmania infantum transmission for domestic dogs in Spain and Portugal and its future projection in climate change scenarios

Canine leishmaniosis, caused by the protozoan parasite Leishmania infantum, is a cosmopolitan vector-borne zoonosis, transmitted principally by Phlebotomus perniciosus in Spain and Portugal, where it is considered an endemic disease. Ecoinformatics tools such as ecological niche models (ENM) have been successfully tested to model the distribution of the risk of infection of different parasitosis as they take into account environmental variables vital for their survival. The risk map proposed in this study combines the potential distribution of Ph. perniciosus in the Iberian Peninsula and the calculation of the infection rate of the parasite in the vector to model the risk of contracting the disease in a more realistic way. In fact, this weighting strategy improves the predictive power of the resulting model (R2 = 0.42, p = < 0.01) compared to the Ph. perniciosus ENM model alone (R2 = 0.13, p > 0.05). The places with the highest risk of transmission are the southwest and central peninsular area, as well as the Mediterranean coast, the Balearic Islands and the Ebro basin, places where the ideal habitat of Ph. perniciosus and the infection rate is also high. In the case of future projections under climate change scenarios, an increase in the risk of infection by L. infantum can be observed in most of the territory (4.5% in 2040, 71.6% in 2060 and 63% in 2080), mainly in the northern part of the peninsula. The use of ENMs and their weighting with the infection rate in Ph. perniciosus is a useful tool in predicting the risk of infection for L. infantum in dogs for a given area. In this way, a more complete model can be obtained to facilitate prevention and control.

Prevalence and factors associated with Leishmania spp. and Toxoplasma gondii infections in apparently healthy horses in Eastern Spain

Leishmaniasis and toxoplasmosis are two of the most common parasitic zoonoses. Leishmaniasis is endemic to 98 countries around the world, whereas toxoplasmosis is widely distributed throughout the world, causing significant health expenditure. Horses can play a relevant role in the transmission of the disease, being a silent reservoir, as clinical signs are not common. Serum samples from 166 horses living in eastern Spain (Mediterranean basin) were analysed to determine the presence of antibodies against Leishmania spp. and T. gondii by ELISA (Enzyme-linked Immunosorbent Assay.) The risk factors evaluated were the geographical area and the relative humidity and average temperature, and epidemiological factors such as sex, reproductive status, age, breed, morphotype, living with other domestic animals, use and access to the outdoors. Seroprevalence of Leishmania spp. and T. gondii infection was found 28.92%, and 16.27% respectively, whereas co-infection of the two parasites was found only in two males. Leishmania seroprevalence was high in castrated males and several mesodolichomorphic equine breeds used for teaching, as well as in outdoor animals. The most elevated seroprevalence was found in winter with higher levels of rainfall, whereas high seroprevalence of T. gondii was found in crossbreeding animals and those used for breeding. High seroprevalence of Leishmania spp. and T. gondii was found in horses of the Mediterranean basin. These data suggest that horses can act as a silent reservoir and that this species has high potential for transmission to humans, outdoor animals and in geographical areas with high average rainfall.

[Overview on utility of in-house tests for detection of systemic infectious diseases in dogs]

For detection of infectious diseases, several point-of-care (POC) tests are on the market in addition to methods performed in commercial laboratories. These POC tests are based on enzyme-linked immunosorbent assay (ELISA) or other immunochromatographic technologies and present results within few minutes in veterinary practice. This article gives an overview of the utility of numerous POC tests of different manufacturers for detection of parvovirus antigen in feces, Dirofilaria (D.) immitis antigen in blood as well as antibodies against Borrelia (B.) burgdorferi, Anaplasma (A.) spp., Ehrlichia (E.) spp., Leptospira (L.) spp. and Leishmania (L.) infantum in blood (single or in different combinations). Sensitivity and specificity of these tests are important for their usefulness in veterinary practice. Furthermore, presence of antibodies or detection of antigen has to correlate with the presence of clinical signs. POC tests for detection of canine parvovirus antigen have a very high specificity, the sensitivity of all evaluated POC tests, however, is very low. POC tests for detection of D. immitis antigen have a very high sensitivity and specificity. As they detect antigen from the uterus of female adult parasites, test results are negative when only very few female or only male adults are present. POC tests for detection of antibodies against B. burgdorferi only indicate contact with Borrelia spp. and do not prove clinical Lyme disease, as the infection only extremely rarely causes clinical signs. POC tests for detection of antibodies against A. phagocytophilum are also not suitable for diagnosis of clinical anaplasmosis. Infections with A. phagocytophilum only lead to clinical disease in very rare cases and in these, clinical signs occur before the development of antibodies. POC tests for detection of antibodies against E. canis have a very high sensitivity as well as specificity. POC tests for detection of antibodies against L. infantum and Leptospira species (spp.) show a very high specificity and a high sensitivity. However, Leptospira spp. antibody-positive results may occur following vaccination, as the POC tests cannot distinguish between field and vaccination strains.

Sand fly-borne diseases in Europe: epidemiological overview and potential triggers for their emergence and re-emergence

Phlebotomine sand flies (Diptera: Phlebotominae) are vectors of human and animal pathogens, including Leishmania species protozoan parasites and viruses of the genus Phlebovirus. In Europe, visceral zoonotic leishmaniasis caused by Leishmania infantum, a deadly disease when left untreated, is endemic in southern countries, and dogs are the main reservoir hosts for human infection. Most phleboviruses cause asymptomatic infections or flu-like syndromes in humans, but Toscana phlebovirus can cause meningitis and encephalitis. These diseases are likely to re-emerge, posing a growing threat to public and animal health. Potential triggers include the movement of humans and dogs, increasing numbers of immunosuppressive conditions, climate change and other human-mediated environmental changes. An overview of the main epidemiological characteristics of the pathogens transmitted by sand flies in Europe and the potential triggers involved in their emergence and re-emergence are reviewed here. There is a need to implement mandatory notification of human and canine leishmaniases and human phleboviruses and coordinated epidemiological surveillance programmes at a European level, and to raise awareness among healthcare professionals and citizens about sand fly-borne diseases, following a One Health approach.

Co-Circulation of Leishmania Parasites and Phleboviruses in a Population of Sand Flies Collected in the South of Portugal

In the Old World, phlebotomine sand flies from the genus Phlebotomus are implicated in the transmission of Leishmania spp. parasites (Kinetoplastida: Trypanosomatidae) and viruses belonging to the genus Phlebovirus (Bunyavirales: Phenuiviridae). Two of the five sand fly species known to occur in Portugal, Phlebotomus perniciosus and Ph. ariasi, the former being the most ubiquitous, are recognized vectors of Leishmania infantum, which causes visceral leishmaniasis, the most prevalent form of leishmaniasis in the country. Phlebotomus perniciosus is also the vector of the neurotropic Toscana virus, which can cause aseptic meningitis. Entomological surveillance is essential to provide fundamental data about the presence of vectors and the pathogens they can carry. As such, and given the lack of data in Portugal, an entomological survey took place in the Algarve, the southernmost region of the country, from May to October 2018. Polymerase chain reaction assays were performed in order to detect the presence of the above-mentioned pathogens in sand fly pools. Not only were both Leishmania parasites and phleboviruses detected during this study, but more importantly, it was the first time their co-circulation was verified in the same sand fly population collected in Portugal.

The estimated distribution of autochthonous leishmaniasis by Leishmania infantum in Europe in 2005-2020

BACKGROUND

This study describes the spatial and temporal distribution between 2005 and 2020 of human and animal leishmaniasis by Leishmania infantum in European countries reporting autochthonous cases, and highlights potential activities to improve disease control.

METHODOLOGY/PRINCIPAL FINDINGS

It was based on a review of the scientific literature and data reported by the World Health Organization (WHO), the World Organization for Animal Health (WOAH) and the Ministries of Health, including hospital discharges in some countries. Autochthonous infections were reported in the scientific literature from 22 countries, including 13 and 21 countries reporting human and animal infections, respectively. In contrast, only 17 countries reported autochthonous human leishmaniasis cases to the WHO and 8 countries animal infections to the WOAH. The number of WOAH reported cases were 4,203, comprising 4,183 canine cases and 20 cases in wildlife. Of 8,367 WHO reported human cases, 69% were visceral leishmaniasis cases-of which 94% were autochthonous-and 31% cutaneous leishmaniasis cases-of which 53% were imported and mostly in France. The resulting cumulative incidence per 100,000 population of visceral leishmaniasis between 2005-2020, was highest in Albania (2.15 cases), followed by Montenegro, Malta, Greece, Spain and North Macedonia (0.53-0.42), Italy (0.16), Portugal (0.09) and lower in other endemic countries (0.07-0.002). However, according to hospital discharges, the estimated human leishmaniasis incidence was 0.70 in Italy and visceral leishmaniasis incidences were 0.67 in Spain and 0.41 in Portugal.

CONCLUSIONS/SIGNIFICANCE

Overall, there was no evidence of widespread increased incidence of autochthonous human leishmaniasis by L. infantum in European countries. Visceral leishmaniasis incidence followed a decreasing trend in Albania, Italy and Portugal, and peaked in Greece in 2013, 2014 and 2017, and in Spain in 2006-2007 and 2011-2013. Animal and human cutaneous leishmaniasis remain highly underreported. In humans, hospital discharge databases provide the most accurate information on visceral leishmaniasis and may be a valuable indirect source of information to identify hotspots of animal leishmaniasis. Integrated leishmaniasis surveillance and reporting following the One Health approach, needs to be enhanced in order to improve disease control.

Leishmaniosis in Greece: The Veterinary Perspective

Leishmaniosis caused by the protozoon Leishmania infantum that is transmitted through the bites of infected phlebotomine sandflies is of major veterinary concern in Greece. The country is endemic with particularly favourable environmental conditions for the spread of this infection. Moreover, Greece remains a popular touristic destination, and the continuous travel of pets raises concern regarding the possible dissemination of infection from endemic to non-endemic areas. Dogs are the main reservoir host, although other animal species, including humans, may also be infected. Canine leishmaniosis manifests as a visceral disease that can result in death if left untreated. Serological and molecular epizootiological studies have confirmed circulation of the parasite in Greek canine and feline populations as well as in other mammals. As a result, constant surveillance and identification of high-risk localities are necessary to establish chemoprophylactic protocols for travelling animals to safeguard animal and public health.

Leishmania (Sauroleishmania) tarentolae isolation and sympatric occurrence with Leishmania (Leishmania) infantum in geckoes, dogs and sand flies

The trypanosomatid protist Leishmania tarentolae is a saurian-associated parasite vectored by the Sergentomyia minuta sand fly. This study aimed to confirm the circulation of L. infantum and L. tarentolae in sand flies, reptiles and dogs and to isolate new strains of these protists. Reptilian and sheltered dog blood samples were collected, and sand flies were captured. Samples were tested for Leishmania spp. using duplex real-time PCR (dqPCR) and real-time PCR (qPCR); the origin of blood meal was identified in engorged sand flies by conventional PCR. The reptilian blood and intestinal content of sand fly females were cultured. Dog sera were tested by IFAT using both Leishmania species. Four Tarentola mauritanica geckoes were molecularly positive for L. infantum or L. tarentolae, with no co-infections; moreover, amastigote-like forms of L. infantum were observed in the bone marrow. 24/294 sand flies scored positive for Leishmania spp. by dqPCR, 21 S. minuta and two Phlebotomus perniciosus were positive for L. tarentolae, while only a single Ph. perniciosus was positive for L. infantum. Blood meal analysis confirmed reptile and dog in S. minuta, dog and human in Ph. perniciosus and dog in Phlebotomus neglectus. Two axenic strains of L. tarentolae were obtained. Twelve of 19 dogs scored positive for L. infantum and L. tarentolae by IFAT and three of them also for L. infantum by dqPCR, and six by qPCR. These data confirm the sympatric circulation of L. infantum and L. tarentolae in geckoes, sand flies, and dogs, and suggest that geckoes may be infected with L. infantum.

Leishmania tarentolae is a saurian-associated parasite recently reported in geographical areas where Leishmania infantum is endemic. To confirm the circulation of both protists in sand flies, reptiles and dogs and to isolate new Leishmania spp. strains, reptilian and sheltered dog blood samples were collected and sand flies captured. Samples were molecularly tested for Leishmania spp. and sandflies for origin of blood meal. Dog sera were tested by IFAT for both Leishmania species and reptilian blood and intestine of sand flies were cultured. Four Tarentola mauritanica geckoes were positive for L. infantum or L. tarentolae; moreover, amastigote-like forms of L. infantum were observed in the bone marrow. 24/294 sand flies scored PCR positive for Leishmania spp. Reptile and dog blood were found in S. minuta, dog and human in Ph. perniciosus and dog in Phlebotomus neglectus. Two axenic strains of L. tarentolae were obtained. Twelve of 19 dogs scored positive for L. infantum and L. tarentolae by IFAT and three of them also for L. infantum by PCR, and six by qPCR. Data confirm the sympatric circulation of L. infantum and L. tarentolae in geckoes, sand flies, and dogs, and suggest that geckoes may be infected with L. infantum.

Canine Leishmaniasis: Update on Epidemiology, Diagnosis, Treatment, and Prevention

Dog are the main reservoir of Leishmania infantum, causing canine leishmaniasis, an incurable multisystemic disease that leads to death in symptomatic dogs, when not treated. This parasite causes visceral, cutaneous, and mucosal leishmaniasis in people in the Mediterranean Basin, North Africa, South America, and West Asia. This disease is mostly unknown by veterinarians outside the endemic areas, but the disease is expanding in the Northern Hemisphere due to travel and climate change. New methodologies to study the epidemiology of the disease have found new hosts of leishmaniasis and drawn a completely new picture of the parasite biological cycle. Canine leishmaniasis diagnosis has evolved over the years through the analysis of new samples using novel molecular techniques. Given the neglected nature of leishmaniasis, progress in drug discovery is slow, and the few drugs that reach clinical stages in humans are unlikely to be commercialised for dogs, but several approaches have been developed to support chemotherapy. New-generation vaccines developed during the last decade are now widely used, along with novel prevention strategies. The implications of the epidemiology, diagnosis, treatment, and prevention of canine leishmaniasis are fundamental to public health.

Detection of Leishmania spp. in Chronic Dermatitis: Retrospective Study in Exposed Horse Populations

Leishmania infantum is a protozoan causing human zoonotic visceral leishmaniasis (ZVL) and visceral–cutaneous canine leishmaniosis (CanL) in the Mediterranean Basin. L. infantum is able to infect a large number of wild and domestic species, including cats, dogs, and horses. Since the 1990s, clinical cases of equine leishmaniasis (EL), typically characterized by cutaneous forms, have been increasingly diagnosed worldwide. The aim of the present study was to evaluate the presence of clinical forms of EL in CanL-endemic areas in Italy, where exposure of equine populations was ascertained from recent serological surveys. For this purpose, formalin-fixed and paraffin-embedded skin biopsies of 47 horses presenting chronic dermatitis compatible with EL were retrospectively selected for the study and subjected to conventional and q-PCR. A singular positivity for L. infantum was found; BLAST analysis of sequence amplicons revealed a 99–100% homology with L. infantum sequences. The histological examination revealed a nodular lymphoplasmacytic and histiocytic infiltrate; immunohistochemistry showed rare macrophages containing numerous positive amastigotes. The present retrospective study reports, for the first time, a case of a cutaneous lesion by L. infantum occurring in an Italian horse. Pathological and healthy skin samples should be investigated on a larger scale to provide information on the potential clinical impact of EL in the practice, and to define the role of horses in epidemiological ZVL and CanL scenarios.

Molecular Survey of Dirofilaria and Leishmania Species in Dogs from Central Balkan

Dirofilariosis and leishmaniosis are severe parasitic diseases in dogs, and their causative agents can also be pathogenic to humans. In this study, we conducted a multicentric survey in the regions of Serbia and North Macedonia with the goal to establish an epidemiological scenario of dirofilariosis and leishmaniosis in the territory of Central Balkan. Using molecular analyses, a total of 535 dogs from Northern Serbia (NS), Southern Serbia (SS) and North Macedonia (NM) were screened for the presence of Dirofilaria spp. and Leishmania spp. We confirmed that Central Balkan is an endemic region for Dirofilaria (D.) immitis, as it was found to be the dominant species in this area, with the highest prevalence of 8.75% in NM, followed by NS (6.68%) and a significantly lower prevalence in SS (1.51%). Two dogs (2.5%) from NM were positive for Leishmania (L.) infantum infection. None of the dogs from Serbia tested positive for Leishmania spp. High prevalence and dominance of D. immitis species, and the rising threat of L. infantum spread to the territory of Serbia, suggest that preventive measures are of a great necessity to combat the spread of these vector-borne zoonoses.

Fauna, Seasonal Activity, and Altitudinal Distribution of Phlebotomine Sand Flies (Diptera: Psychodidae) in Leishmaniasis Endemic Area, Aydın Mountains, and Surroundings in Western Turkey

OBJECTIVE

Human and canine leishmaniasis (CanL) are endemic in Turkey, and cutaneous leishmaniasis (CL) is a primary public health problem among vector-borne diseases, with 1500-2000 autochthonous cases per year. In this study, we aimed to perform a comprehensive entomological survey, including the detection of sand fly fauna, seasonal activity, and altitudinal distribution, together with the ecological features of Aydın Mountains and their surroundings that are endemic areas for CL caused by Leishmania tropica and CanL caused by L. infantum MON-1.

METHODS

The survey was carried out from June 2009 to July 2010. Ten localities with different altitudes were selected. Sand fly collection was done every 15 days in July and August when sand flies are most active and every 30 days between September and June (14 months, 16 samplings) using CDC light traps and sticky traps. During the collection, the temperature, humidity, and ecological and environmental features were recorded. Sand fly specimens were dissected and identified at species level using written keys.

RESULTS

A total of 6712 sand fly specimens (3268 females and 3444 males) were collected from 10 localities throughout all study periods. Species identification revealed that nine and three species belonging to Phlebotomus (P. major s.l. 30.38%, P. tobbi 22.93%, P. papatasi 5.88%, P. sergenti s.l. 4.51%, P. alexandri 4.26%, P. simici 3.50%, P. burneyi 0.63%, P. brevis 0.45%, and Transphlebotomus spp. 0.28%) and Sergentomyia (S. dentata 23.17%, S. minuta 2.43%, and S. antennata 1.58%) were found, respectively. The seasonal activities of these 12 sand fly species were determined, and P. major s.l. and P. tobbi, which were probable vectors of VL and CanL, were present in the study area. P. sergenti s.l., a probable vector of CL, was also found in the region and was active for seven months between April and October. P. sergenti s.l. was found in the 400-600 m altitude in July, while P. major and P. tobbi were found in high densities in the 200-400 m altitude in September.

CONCLUSION

Our results showed that leishmaniasis vectors are present in different altitudes in the Aydın mountains and surroundings. The findings revealed the time intervals of parasite transmission in the area and the period of applying protective measures, such as insecticide application.

Canine Leishmaniosis in Greece: An Updated Countrywide Serological Study and Associated Risk Factors

Canine leishmaniosis (Leishmania infantum) is a zoonotic disease that affects dogs worldwide. Greece is enzootic for this disease, and updated data for its current distribution are of major importance. The aim of this cross-sectional serological study was primarily to update the current knowledge of Leishmania infantum seropositivity status within the asymptomatic Greek canine population and, furthermore, to assess the possible climatological and other risk factors. In total, sera of 1265 asymptomatic dogs were collected from all prefectures of the country. A questionnaire that included all individual dog information was completed for all animals. The Speed Leish K^® canine Leishmania antibody test kit (BVT Groupe Virbac, France) was employed. Potential risk factors were evaluated utilizing logistic regression models. Overall, 13.8% (n = 175) of the sampled dogs were seropositive to Leishmania infantum originating from all geographical departments of the country, whereas most prefectures had at least one seropositive animal. Outdoor living, high mean humidity, low mean wind speed and high total annual rainfall were found to increase the seropositivity status against the parasite. Conclusively, Leishmania infantum remains a common parasite challenge in the asymptomatic canine population of Greece, and therefore, its early diagnosis and effective prevention are significant in the country.

Surveillance data for human leishmaniasis indicate the need for a sustainable action plan for its management and control, Greece, 2004 to 2018

Background

The World Health Organization (WHO) lists human leishmaniasis as a neglected tropical disease; it is not under surveillance at European level.

Aim

We present surveillance data for visceral (VL) and cutaneous (CL) leishmaniasis for the period 2004 to 2018 in Greece to assess their public health importance.

Methods

We extracted data from the mandatory notification system to analyse separately imported and domestic cases of VL and CL. A case was defined by clinical manifestations compatible with VL or CL and laboratory confirmation.

Results

Between 2004 and 2018, 881 VL (862 domestic, 19 imported) and 58 CL cases (24 domestic, 34 imported) were recorded. The mean annual notification rate of domestic VL was 0.5 per 100,000 (range: 0.12–1.43/100,000) with a statistically significant increasing trend (p = 0.013). Cases were reported by all regions. The highest notification rate occurred in the age group 0–4 years (1.3/100,000). Overall 24% (164/680) of the cases were immunocompromised and their proportion increased after 2010 (p < 0.001). The mean annual notification rate of domestic CL was 0.05 per 100,000 (range: 0.01–0.19/100,000) with the highest rate in the age group 5–14 years (0.03/100,000). Cases were recorded in six of the 13 regions. Among 34 imported CL cases, 29 were foreign nationals.

Conclusion

VL is endemic in Greece, with an increasing trend and a considerable burden of severe disease and young children being most affected. CL is rarely reported. A sustainable action plan is needed to reduce the burden of VL and prevent local transmission of CL.

Sand Fly (Diptera: Psychodidae: Phlebotominae) Population Dynamics and Natural Leishmania Infections in Attica Region, Greece

A 2-yr sand fly (Diptera: Psychodidae) seasonality study was performed in Attica Region, Greece, from June 2017 until November 2018, aiming also to detect the presence of Leishmania infection in the collected sand flies. In total, 701 sand flies were collected from urban areas within the Attica Region using BG-Sentinel traps, set weekly in eight fixed sites. Five species were identified morphologically and molecularly, namely Phlebotomus tobbi (Adler and Theodor), which was most the most commonly collected species, followed by P. Neglectus (Tonnoir), P. papatasi (Scopoli), P. simici (Theodor), and Sergentomyia minuta (Rondani). During both survey years sand fly populations peaked in late August to early September. Fifty-nine monospecific pools were examined for Leishmania detection by analyzing the ITS1 nuclear region using both RFLPs and sequencing, seven of which were found positive. Leishmania DNA was identified as L. infantum in six pools (five P. papatasi and one P. tobbi), whereas in one P. papatasi pool Leishmania DNA was identified as L. tropica. This is the first time that L. tropica has been detected in naturally infected sand flies from the Attica Region as well as in central Greece, while previously it has only been detected in sand flies collected from Central Macedonia (Northern Greece).

Leishmania infantum Seroprevalence in Cats From Touristic Areas of Italy and Greece

Leishmaniosis by Leishmania infantum is a major zoonotic Vector-Borne Disease (VBD) in terms of geographic distribution, pathogenicity and zoonotic potential. While dogs are the main reservoir of L. infantum, the infection in cats is poorly understood although increasingly reported from enzootic and non-enzootic areas. The Mediterranean basin is a key area for leishmaniosis and includes touristic spots that require continuous surveillance for VBDs in consideration of the growing tendency of tourists to travel with their pets. This study evaluated L. infantum seroprevalence in cats living in selected touristic localities of Italy and Greece. A total of 269 cat serum samples from three Sites i.e., 76, 40, and 153 from Adriatic Coast of Abruzzo, Italy (Site A), Giglio Island, Tuscany, Italy (Site B), and Mykonos Island, Greece (Site C), respectively, were included in the survey. Sera samples were subjected to an indirect immunofluorescence antibody assay for the detection of anti-L. infantum specific IgG. Associations between possible risk factors and seropositivity to L. infantum were statistically evaluated. Antibodies against L. infantum were detected in eight out of 269 (3.0%) cats tested i.e., 4/76 (5.3%), 1/40 (2.5%), and 3/153 (2.0%), from sites A, B, and C, respectively. A statistical association between anti-L. infantum antibodies and cohabitation with dogs was shown. This study indicates that feline populations living in the examined Italian and Greek touristic areas are exposed to L. infantum and that they may contribute to the circulation of L. infantum, enhancing the risk of infection for dogs and humans.

Sandfly surveillance and investigation of Leishmania spp. DNA in sandflies in Kosovo

In the past decade, leishmaniasis seems to be re-emerging in Balkan countries. There are serious implications that Kosovo is a visceral leishmaniasis endemic region with autochthonous transmission; nevertheless, surveillance of vectors, reservoirs or the disease is not yet established. Gaining knowledge about sandfly vector species is a prerequisite for the development of a monitoring and control plan in the future. After a long gap in research of over 70 years, sandfly studies in Kosovo were resumed in 2014. During this presence/absence study, nine sandfly species were detected: Phlebotomus papatasi, Ph. perfiliewi, Ph. tobbi, Ph. neglectus, Ph. simici, Ph. balcanicus, Ph. alexandri, Ph. mascittii and Sergentomyia minuta. Three species are new with regard to the fauna of Kosovo - Ph. alexandri, Ph. balcanicus and Ph. mascittii. Besides increased diversity, changes in the number of collected specimens and distribution range of species were recorded, with Ph. neglectus being the most dominant species with the widest distribution. Testing of randomly chosen females for Leishmania spp. DNA resulted the in detection of L. tropica in a specimen of Ph. neglectus. The presence of numerous vector species in the sandfly fauna of Kosovo pose a threat for the re-emergence of vector-borne diseases. Therefore, continuous surveillance is recommended with regular updates on vector distribution and abundance.

Cercopithifilaria species in dogs and ticks from Greece

Filarioids of the genus Cercopithifilaria (Spirurida, Onchocercidae) are parasites of wild and domestic animals in tropical and subtropical regions being transmitted by ixodid ticks. Though this filarioid species have been studied in canine and tick populations in Europe, data on their species diversity and geographical distribution in Greece is scant. Thus, the aims of this study were to investigate the presence of Cercopithifilaria spp. in dogs and ticks across Greece and to assess the possible risk factors. A total of 500 skin biopsies were collected from dogs, while 508 ticks were collected from 180 infested animals and examined. Sediments from skin biopsies were microscopically screened for detection of dermal microfilaria (mfs). Skin samples (n = 115) and tick specimens (n = 153) were molecularly subjected by PCR. Overall, 70 samples (14%) scored positive for mfs. Specifically, 68 samples (13.6%) were positive for Cercopithifilaria bainae and two (0.4%) were co-infected with C. bainae and Cercopithifilaria sp. II. Molecular analyses revealed that all sequences obtained belong to C. bainae. Haplotype I was the most frequent (92.6%), followed by haplotype XVIII (3%) and haplotypes II and IX (1.5%). Three new haplotypes of C. bainae, named XIX, XX, and XXI, were also identified. Among the risk factors examined, habitat, dog use, body weight, tick infestation history, and the use of acaricides were associated with the presence of C. bainae. The estimated prevalence of Cercopithifilaria spp. demonstrates that these filarioids are common in dogs and ticks in Greece. Finally, the identification of 7 haplotypes for C. bainae confirms their genetic variability.

Mapping the canine vector-borne disease risk in a Mediterranean area

Background

The aim of this study was to determine exposure to vector-borne pathogens (VBPs) in populations of dogs living on Greek islands in the Ionian and Aegean seas.

Methods

In total, 1154 dogs with different lifestyles and of varying ages and breeds were randomly sampled and examined for the presence of clinical signs compatible with canine vector-borne diseases (CVBDs). Blood was collected from each individual animal. For the detection of antibodies against Leishmania spp., the WITNESS® Leishmania test was performed, and positive samples were further examined with indirect enzymatic immunoassay (ELISA). Antibodies to Borrelia burgdorferi, Ehrlichia canis or E. ewingii, as well as Anaplasma phagocytophilum or A. platys were investigated using the Snap® 4Dx® Plus test. Positive Ehrlichia spp. and Anaplasma spp. samples were further examined using an indirect ELISA for further identification of the species.

Results

In total, 25.6% of dogs were exposed to at least one of the pathogens investigated, with seroprevalences varying regionally. Of these seropositive dogs, 27.4% displayed clinical signs suggestive of CVBDs, such as cutaneous lesions, enlarged lymph nodes, pale mucous membranes, onychogryphosis and weight loss. The overall seroprevalence detected using the rapid tests was 15.3% for Leishmania spp., whereas 2.3% of the examined dogs were found to be positive for Anaplasma spp. and 7.5% for Ehrlichia spp. while B. burgdorferi was not detected. Twenty-four samples positive to A. phagocytophilum by ELISA were analysed by PCR for the presence of Anaplasma DNA. PCR and sequencing results showed the presence of A. platys DNA in 4 samples and E. canis DNA in 4 samples. The remaining samples (66.7%) were negative.

Conclusions

In the present study, exposure of dogs to VBPs was shown in the geographical areas investigated. Results confirm that on Greek islands VBPs represent a constant health risk for both native and visiting dogs, suggesting the presence of distinct “hot-spots” of VBP infections on different islands. In order to reduce the risk of transmission and the spread to non-endemic regions, the protection of dogs through use of repellents and vaccines, together with owner education, seem to be of paramount importance.

Experimental assessment of permethrin-fipronil combination in preventing Leishmania infantum transmission to dogs under natural exposures

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Controlled experimental field study allowing natural exposure to sandflies.

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Two groups of 20 dogs each in two close sub-unit kennels.

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7/20 dogs infected by L. infantum in the untreated group.

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0/20 dogs infected by L. infantum in the fipronil-permethrin monthly treated group.

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100 % protection obtained during this one-year study.

Canine vector-borne disease transmission can be reduced with regular use of repellent insecticides. The objective of this year-long experimental study was to assess the efficacy of a topical formulation of fipronil/permethrin (Frontline Tri-Act®) in preventing transmission of Leishmania infantum by sandflies. This clinical field trial was conducted in Xanthi (Northern Greece), an area highly endemic for canine leishmaniosis, from April 2018 to March 2019. Forty purpose-bred Beagle dogs, testing negative for L. infantum prior to study initiation, were enrolled in the study, which consisted of three phases: Phase 1 (field exposure phase) took place from Day 0–196. The dogs were randomly allocated to two groups, group 1 (sham-treated topically with sterile water) and group 2 (treated topically with Frontline Tri-Act®). Dogs in both groups were housed in two subunits of an open-air kennel for a period of 7 months, spanning the Leishmania transmission season. All dogs were treated or sham-treated on Days 0, 28, 56, 84, 112, 140 and 168. Clinical examinations, PCR analysis of conjunctival swabs, and serological tests were performed on a monthly basis. Sandflies were collected every 2 weeks, during a 12 -h period overnight using light traps. Each collection was placed in a container and kept refrigerated until speciation and PCR analysis could be performed. In the second phase of the study, from Day 197 to 252, the dogs were moved into a protected environment (insect-proof protected environment phase). CDC light traps were activated every 2 weeks inside and outside the kennels to ensure the vector-free status of the facility. Monthly clinical examinations, including PCR analysis of conjunctival swabs, and serological tests continued. At the end of the phase 2, bone marrow samples were collected on all dogs. Phase 3 (the final post-winter check) took place from Day 253 to 350. Dogs were released and adopted by individual private owners on Day 253. Follow up analyses included blood collection for SNAP tests and conjunctival swaps for PCR analysis on Days 304 and 350. Additionally, bone marrow collections were also performed on Day 350.

Presence of sandflies was observed only in the phase 1 exposure period, and 1714 sandflies were collected (1427 females and 287 males). Two species were identified, Phlebotomus perniciosus var. tobbi and Phlebotomus neglectus. Out of the 62 pooled samples of sandflies assessed by PCR, three were considered positive (4.8 %). By the end of the study, 35 % of the Group 1 dogs (7/20) became positive based on PCR (conjunctival swab and bone marrow) and 30 % (6/20) based on SNAP/IFAT and ELISA tests, while all the dogs in the Frontline Tri-Act® treated group 2 remained negative for all tests (G1 vs G2, p = 0.008). All tests identified the same positive animals, and PCR allowed the detection of one additional infected dog. This clinical field trial demonstrated that monthly administration of Frontline Tri-Act® to dogs exposed to Leishsmania infection in a high endemic area provided 100 % preventive efficacy against transmission of L. infantum.

Population dynamics, pathogen detection and insecticide resistance of mosquito and sand fly in refugee camps, Greece

BACKGROUND

As of 2015 thousands of refugees are being hosted in temporary refugee camps in Greece. Displaced populations, travelling and living under poor conditions with limited access to healthcare are at a high risk of exposure to vector borne disease (VBD). This study sought to evaluate the risk for VBD transmission within refugee camps in Greece by analyzing the mosquito and sand fly populations present, in light of designing effective and efficient context specific vector and disease control programs.

METHODS

A vector/pathogen surveillance network targeting mosquitoes and sand flies was deployed in four temporary refugee camps in Greece. Sample collections were conducted bi-weekly during June-September 2017 with the use of Centers for Disease Control (CDC) light traps and oviposition traps. Using conventional and molecular diagnostic tools we investigated the mosquito/sand fly species composition, population dynamics, pathogen infection rates, and insecticide resistance status in the major vector species.

RESULTS

Important disease vectors including Anopheles sacharovi, Culex pipiens, Aedes albopictus and the Leishmania vectors Phlebotomus neglectus, P. perfiliewi and P. tobbi were recorded in the study refugee camps. No mosquito pathogens (Plasmodium parasites, flaviviruses) were detected in the analysed samples yet high sand fly Leishmania infection rates are reported. Culex pipiens mosquitoes displayed relatively high knock down resistance (kdr) mutation allelic frequencies (ranging from 41.0 to 63.3%) while kdr mutations were also detected in Ae. albopictus populations, but not in Anopheles and sand fly specimens. No diflubenzuron (DFB) mutations were detected in any of the mosquito species analysed.

CONCLUSIONS

Important disease vectors and pathogens in vectors (Leishmania spp.) were recorded in the refugee camps indicating a situational risk factor for disease transmission. The Cx. pipiens and Ae. albopictus kdr mutation frequencies recorded pose a potential threat against the effectiveness of pyrethroid insecticides in these settings. In contrast, pyrethroids appear suitable for the control of Anopheles mosquitoes and sand flies and DFB for Cx. pipiens and Ae. albopictus larvicide applications. Targeted actions ensuring adequate living conditions and the establishment of integrated vector-borne disease surveillance programs in refugee settlements are essential for protecting refugee populations against VBDs.

Place of Serology in the Diagnosis of Zoonotic Leishmaniases With a Focus on Visceral Leishmaniasis Due to Leishmania infantum

Leishmaniases are a group of parasitic diseases transmitted through the bite of female phlebotomine sandflies. Depending on the Leishmania species, the reservoirs can be humans (anthroponosis) or different animals (zoonosis). Zoonotic leishmaniasis present several clinical forms in function of the species involved: visceral leishmaniasis (VL), cutaneous leishmaniasis (CL), and muco-cutaneous leishmaniasis (MCL). The biological diagnosis is of utmost importance because the clinical features are not specific. In addition to parasitological and molecular biology (polymerase chain reaction, PCR) assays, serology is routinely used for the diagnosis of leishmaniasis. Indeed, although PCR is more sensitive than serological assays, its implementation is limited to referral laboratories and research centers. Therefore, serology is still a key element for their diagnosis. Here, we discuss the different serological assays available for the diagnosis of zoonotic leishmaniasis. We will review the enzyme-linked immunosorbent assay, immunofluorescence antibody test, immunochromatography test (ICT), direct agglutination test, and western blot as well as the different diagnostic strategies in function of the clinical form (VL, CL, and MCL). We will also discuss the place of serology for detecting asymptomatic carriers and for the follow-up of VL. Depending on the laboratory, different assays can be used, from ICT, which is appropriate for field testing, to a combination of serological tests to improve the sensitivity.

Antileishmanial effect of rapamycin as an alternative approach to control Leishmania tropica infection

Cutaneous leishmaniosis (CL) is a parasitic disease in animals and human with no satisfactory treatments and vaccination. Rapamycin is a potent inhibitor of mammalian target of rapamycin (mTOR) with various applications. Here, the effect of rapamycin alone or in combination with two other drugs, namely amphotericin B (AmB) and glucantime, was investigated against Leishmania tropica infection. In vitro viability and electron microscopy evaluation of the parasites showed detrimental changes in their appearance and viability. Treatment with clinically relevant dose of rapamycin (10.2 μg/dose) is able to control the parasite load in BALB/c mice infected with L. tropica. Furthermore, the cytokine profiles showed significant polarization towards Th1 immune response. Surprisingly, combination therapy with either AmB or glucantime was not efficient. Rapamycin is showed an effective alternative therapy against leishmaniosis caused by L. tropica.

Serological and molecular investigation of selected parasitic pathogens in European brown hare (Lepus europaeus) in Greece: inferring the ecological niche of Toxoplasma gondii and Leishmania infantum in hares

The occurrence of infection or exposure to Toxoplasma gondii, Neospora caninum, and Leishmania infantum was investigated in European brown hares (Lepus europaeus, EBH) hunter-harvested over two consecutive hunting seasons in northern and central Greece. Geographical information system was used along with the ecological niche model to define the geographical distribution of seropositive hares relative to environmental parameters and to identify high-risk areas for hare exposure. Molecular analysis showed that 3.8% and 9.6% of the examined hares were infected with N. caninum and L. infantum, respectively, while, 5.7%, 0.95%, and 12.4% of the hares tested positive for the presence of antibodies against T. gondii, N. caninum, and L. infantum respectively. None of the examined hares was polymerase chain reaction-positive for T. gondii. Mixed exposure against both T. gondii and L. infantum was found in 2.9% of the hares examined. Rainfall indices and land uses significantly influenced the exposure of hares to T. gondii and L. infantum. This is the first molecular and serological survey of protozoan pathogens in EBH in Greece. Furthermore, we report the environmental parameters related to hare seropositivity and present a risk map for hare exposure to T. gondii and L. infantum in northern and central Greece. The ecological niches of T. gondii and L. infantum in the hares presented herein could be applied to other regions with similar environmental and climatic conditions.

Endoparasites and vector-borne pathogens in dogs from Greek islands: Pathogen distribution and zoonotic implications

The present study investigated the presence of endo- and ecto-parasites, and vector-borne pathogens, in dogs from four islands of Greece. A total of 200 (123 owned and 77 sheltered) dogs were examined with different microscopic, serological and molecular methods.

Of the examined dogs, 130 (65%) were positive for one or more parasites and/or vector-borne pathogens. The most common zoonotic intestinal helminths recorded were Ancylostomatidae (12.5%) and Toxocara canis (3.5%). Ninety-three dogs (46.5%) seroreacted to Rickettsia conorii. Twenty-two (11%) of them were also PCR positive and 7 (3.5%) showed corpuscles suggestive of Rickettsia spp. on the blood smears. Nineteen dogs (9.5%) were seropositive for Ehrlichia canis, three of them being also PCR positive. Dogs positive for Anaplasma phagocytophilum-Anaplasma platys (1%), Dirofilaria immitis (0.5%) and Babesia canis (0.5%) were also found. Fleas and ticks were recorded in 53 (26.5%) and 50 (25%) dogs, respectively, and all specimens were identified as Ctenocephalides felis felis and Rhipicephalus sanguineus sensu lato. Binary multiple univariate Generalized Linear Models were used to investigate factors and clinical signs related to the recorded positivity, while the association of specific signs with the pathogens was evaluated using tests of independence. Knowledge of occurrence and impact of zoonotic parasites and vector-borne pathogens in dog populations is crucial to prevent the infection in animals and people, and to control the risk of spreading of these pathogens in endemic and non-endemic areas.

Both owned and sheltered dogs can harbor a variety of intestinal and extra-intestinal endoparasites, as well as vector-borne pathogens and ectoparasites, of zoonotic concern. Dog shelters and stray dogs are present in several touristic areas of Greece, including Sporades and Cyclades islands, where tourists often bring their pets with them, likely travelling from non-endemic to endemic areas. The present study has been carried out with the aim to evaluate the occurrence of the aforementioned pathogens. Data obtained showed that they are present in canine populations of Greece, with possibilities of infection for travelling dogs, which can also contribute to the spreading of zoonotic vector-borne diseases, introducing new pathogens in previously non-endemic areas. For these reasons, a constant monitoring of the epidemiological situation, improving control measures and correct diagnostic approaches are of primary importance for the prevention of canine and human infections, decreasing the spreading of potentially deadly pathogens.

Vector-borne pathogens affecting shelter dogs in eastern Crete, Greece

Canine pathogens transmitted by blood-sucking arthropods are of significant importance for veterinary and, in some cases, human health. However, they are still underestimated and rarely investigated in many parts of the Mediterranean region, mostly due to financial reasons. Therefore, in the present paper, we investigated the occurrence of blood-associated pathogens affecting dogs in Crete, Greece. For this purpose, blood samples from 103 shelter dogs were screened for the pathogens by PCR and serological tests. Overall, samples from 43 dogs scored positive for at least one pathogen (41.8%). In particular, antibodies to Leishmania infantum were detected in 26 dogs (25.2%), and 15 and 11 animals were positive for Hepatozoon canis (14.6%) and Mycoplasma haemocanis (10.7%) by PCR, respectively. Co-infections were recorded in nine animals. Clinical signs indicative of infection (alterations of skin or coat or reduced body condition) were detected in 10 animals, four of which were infected with one pathogen, three with two pathogens. Based on the results obtained, dogs from Crete appear to be frequently exposed to several blood-borne pathogens, including agents of zoonotic concern. Given that some of the pathogens were reported for the first time in this area, results presented in our study should improve the awareness of the local veterinarians and of dog rescue organisations in order to reduce disease burden on stray and owned dogs and to control the spread of canine vector-borne diseases from Greece to non-endemic areas by travelling or exported infected dogs.

Leishmania infection in lagomorphs and minks in Greece

Greece is an endemic country for human and canine leishmaniosis. Studies about the role of lagomorphs and minks in the epidemiology of the diseases are, so far, limited. The aim of the present study was to investigate the prevalence of Leishmania infection in these animals, in different areas of the country. Samples from 393 domestic and wild rabbits, 90 hares and 200 minks were collected and examined by cytology (spleen imprints) and serology (ELISA), while spleen samples of 116, 56 and 95 of the rabbits, hares and minks, respectively, were examined by a PCR assay targeting the ITS1 region. For every animal examined a form was created, recording information like date, area, animal species, sex, etc. All imprint smears examined were negative, while serology revealed infection in 7.6% (C.I. 5.0-10.3%) rabbits, 6.7% (C.I. 1.5-11.8%) hares and 20% (C.I. 14.5-25.5%) minks. Infection was confirmed by molecular methods in 2.6% (C.I. 0.0-5.5%), 3.6% (C.I. 0.0-8.4%) and 2.1% (C.I. 0.0-5.0%) of the animals, respectively. The statistical analysis showed that minks are most likely to be seropositive and that in rabbits, the breeding method (i.e. homestead reared animals) was associated with infection. Because of the proximity of lagomorphs and minks to humans and dogs it is necessary to further elucidate their role in the epidemiology of leishmaniosis.

Identification of Leishmania Species in Naturally Infected Sand Flies from Refugee Camps, Greece

High infection rates of Leishmania donovani and L. tropica were detected in Phlebotomus spp. sand flies collected from refugee camps in Greece, indicating increased risk of infection among local populations. Detection and treatment of leishmaniasis, community education, and vector control are essential measures to prevent pathogen transmission and protect public health.

Imported cutaneous leishmaniasis: a 13-year experience of a Polish tertiary center

INTRODUCTION

Leishmaniasis is a vector-borne infection endemic in 98 countries. Its cutaneous form (CL) causes skin lesions on exposed parts of the body and may lead to scarring. The numbers of imported cases of CL are increasing in Europe but the incidence of CL importation in Poland is unknown.

MATERIAL AND METHODS

A list of all patients diagnosed with CL at the Department in the years 2005-2017 was obtained. The study presents their data including age, sex, areas visited, purpose of travel, time from the onset of symptoms to correct diagnosis, appearance of lesions, results of impression smears and PCR, and superinfection, if detected, as well as treatment methods and their outcomes.

RESULTS

Altogether, 14 cases of cutaneous leishmaniasis were identified. The study demonstrates an increase in the number of cases of imported CL at our center over the last 5 years. The time to correct diagnosis was long in spite of the fact that the lesions had usually an appearance typical of CL.

CONCLUSIONS

Intensified education of physicians and travelers, as well as improvement in the access to travel medicine services and to the diagnosis and treatment methods appropriate for CL, are needed in our country. In our opinion, surveillance of leishmaniasis should be introduced in Poland.

Seroprevalence of canine Leishmania infantum infection in the Mediterranean region and identification of risk factors: The example of North-Eastern and Pyrenean areas of Spain

The Mediterranean basin is an endemic region for canine leishmaniosis (CanL), where it represents a major veterinary problem and raises human health concerns. However, the distribution of the disease is heterogeneous and not all countries and locations have been equally studied and characterized. This work describes the situation of CanL in Girona province (Catalonia, Spain), for which no data has been previously reported, and presents a relevant study to exemplify other areas with similar characteristics across the region. Four cross-sectional seroprevalence surveys were performed from 2012 to 2016 throughout the province, including 36 sampling stations in 26 localities and a total of 593 dogs. For each animal, individual and location variables were also collected. Additionally, each dog owner answered a questionnaire about their knowledge of CanL and preventive methods used. Blood samples were analysed by an in-house ELISA and a mixed logistic regression model was used to assess the relationship between pre-determined variables and dog seropositivity. A Spearman's correlation was used to assess the association between dog owners' perceived risk of CanL and Leishmania infantum seropositivity in dogs at a given location. The overall true seroprevalence estimated for Girona province was 19.5% (95%CI: 15.5-23.5), of which only 6.8% (10/146) were considered symptomatic. Age of the dog [OR = 1.21 (95%CI: 1.11-1.31); p < 0.001] and altitude [OR = 0.02 (95%CI: 0.001-0.19); p = 0.001] were identified as risk factors for the infection. The results obtained in this study are expected to aid in the implementation of directed control programmes in CanL endemic areas throughout Europe, as well as to provide suitable data for the design of better risk assessment maps of the disease.

Detection of Pyrethroid Resistance Mutations in the Major Leishmaniasis Vector Phlebotomus papatasi

Phlebotomine sand flies (Diptera: Psychodidae) are primary vectors of leishmaniasis. Greece and Turkey are both endemic for visceral and cutaneous leishmaniasis and are widely affected by the disease. Measures commonly applied for controlling sand flies rely on the use of insecticides, predominantly pyrethroids. A worldwide problem associated with the intensive use of insecticides is the development of resistance. Scarce information is available regarding the resistance status in sand fly populations. Sand flies were collected from Greece (Thessaloniki, Peloponnese, Chios island) and Turkey (Sanliurfa) and analyzed for the presence and frequency of target-site knockdown resistance mutations on the voltage-gated sodium channel (Vgsc) gene. Five sand fly species were included in the analysis: Phlebotomus perfiliewi Parrot, Phlebotomus neglectus Tonnoir, Phlebotomus simici Nitzulescu, Phlebotomus tobbi Adler and Theodor, and Phlebotomus papatasi Scopoli. Their Vgsc gene-domain II was analyzed for the presence of known pyrethroid resistance mutations. The mutation 1014F, associated with pyrethroid-resistant phenotypes, was detected in P. papatasi sand flies from Sanliurfa at an allele frequency of 48%. Homozygotes for the wild type allele 1014L (Leu/Leu) represented 36% of the population, while homozygotes for the resistant allele 1014F (Phe/Phe) and heterozygotes encompassing both alleles (Leu/Phe) each had a frequency of 32%. In all other sand fly species, only the wild type allele 1014L was detected. This is the first report for the detection of resistance mutations in the major leishmaniasis vector P. papatasi and is of major concern regarding leishmaniasis control.

Childhood Visceral Leishmaniasis: Distinctive Features and Diagnosis of a Re-emerging Disease. An 11-year Experience From a Tertiary Referral Center in Athens, Greece

BACKGROUND

Visceral leishmaniasis (VL) remains a public health issue in Greece. The aim of this study was to describe the clinical and epidemiologic characteristics of pediatric VL in our region as well as to evaluate the laboratory findings and the diagnostic techniques that are applied.

METHODS

We retrospectively reviewed the medical records of all children diagnosed with VL in an 11-year period at a tertiary public hospital in the region of Athens. Demographic features, clinical information and laboratory findings were accessed.

RESULTS

A total of 43 cases were recorded during 2005-2015. Median age of the patients was 3.7 years. Pallor (100%), fever (98%), hepatosplenomegaly (55.8%) and appetite loss (32.6%) were the most common presentations of the disease. The predominant laboratory abnormalities were anemia (100%), thrombocytopenia (90.7%), elevated inflammatory markers (86.1%) and decreased albumin/globulin (A/G) ratio (72.1%). Four patients developed secondary hemophagocytic lymphohistiocytosis syndrome, whereas in 3 others abdominal ultrasound showed splenic nodules. Bone marrow aspiration detected Leishmania parasites in 92.7% of cases and the rapid rK39 strip test indicated anti-Leishmania antibodies in 97.1% of children. In addition, all patients in whom indirect immunofluorescent antibody test was implemented had positive results.

CONCLUSIONS

VL still affects children in our area. Fever, splenomegaly, anemia and appetite loss are the typical findings in children. Noninvasive techniques (immunofluorescent antibody test, rK39) in combination with bone marrow microscopy are useful in the diagnosis of pediatric VL.

Phlebotomine sand flies (Diptera: Psychodidae) in the Greek Aegean Islands: ecological approaches

BACKGROUND

Blood-sucking phlebotomine sand flies are the vectors of the protozoan parasites Leishmania spp. Different Phlebotomus species transmit different Leishmania species causing leishmaniases which are neglected diseases emerging/reemerging in new regions. Thirteen sand fly species, ten belonging to the medically important genus Phlebotomus and three belonging to Sergentomyia are known in Greece. An increasing number of human and dog cases are reported each year from all parts of the country including the Aegean Islands. However, no previous study has been conducted on the sand fly fauna on the islands, except for Rhodes and Samos. The aim of this study was to investigate sand fly species in eleven small Aegean islands; to understand species-specific relationships with environmental and climatic factors and to compare sand fly community parameters among islands. A risk analysis was carried out for each species using climatic and environmental variables.

RESULTS

Nine sand fly species: Phlebotomus neglectus, P. tobbi, P. similis, P. simici, P. perfiliewi, P. alexandri, P. papatasi, Sergentomyia minuta and S. dentata, were collected from the islands studied. Phlebotomus (Adlerius) sp. and Sergentomyia sp. specimens were also collected but not identified to the species level. There was a positive effect of distance from the sea on the abundance of P. neglectus, S. minuta and S. dentata, and a negative effect on the abundance of P. tobbi, P. simici and P. similis. In general, temperature preferences of sand fly populations were between 21 and 29 °C. Nevertheless, there were significant differences in terms of temperature and relative humidity preference ranges among species. The most important species found, P. neglectus, was indisputably the most adapted species in the study area with a very high reaction norm, favoring even the lower temperature and humidity ranges. Overall, the sand fly fauna in the islands was very rich but there were differences in species diversity, as indicated by the values of the Shannon-Wiener index, along with evenness and richness of the sand fly fauna between the islands and altitude ranges in the islands.

CONCLUSIONS

The study indicated that the Greek Aegean Islands, however small, maintain a rich sand fly fauna. This includes important vectors of Leishmania spp. representing a risk for parasite transmission to humans and dogs along with the danger of maintaining new Leishmania spp. if introduced to the area.

Identification of wild-caught phlebotomine sand flies from Crete and Cyprus using DNA barcoding

Background

Phlebotomine sand flies (Diptera: Psychodidae) are vectors of Leishmania spp., protozoan parasites responsible for a group of neglected diseases called leishmaniases. Two sand fly genera, Phlebotomus and Sergentomyia, contain species that are present in the Mediterranean islands of Crete and Cyprus where the visceral (VL), cutaneous (CL) and canine (CanLei) leishmaniases are a public health concern. The risk of transmission of different Leishmania species can be studied in an area by monitoring their vectors. Sand fly species are traditionally identified using morphological characteristics but minute differences between individuals or populations could be overlooked leading to wrong epidemiological predictions. Molecular identification of these important vectors has become, therefore, an essential tool for research tasks concerning their geographical distribution which directly relates to leishmaniasis control efforts. DNA barcoding is a widely used molecular identification method for cataloguing animal species by sequencing a fragment of the mitochondrial gene encoding cytochrome oxidase I.

Results

DNA barcoding was used to identify individuals of five sand fly species (Phlebotomus papatasi, P. similis, P. killicki, Sergentomyia minuta, S. dentata) circulating in the islands of Crete and Cyprus during the years 2011–2014. Phlebotomus papatasi is a known vector of zoonotic CL in the Middle East and it is found in both islands. Phlebotomus similis is the suspected vector of Leishmania tropica in Greece causing anthroponotic CL. Phlebotomus killicki was collected in Cyprus for the first time. Sergentomyia minuta, found to present intraspecific diversity, is discussed for its potential as a Leishmania vector. Molecular identification was consistent with the morphological identification. It successfully identified males and females, which is difficult when using only morphological characters. A phylogenetic tree was constructed based on the barcodes acquired, representing their genetic relationships along with other species from the area studied. All individuals identified were clustered according to their species and subgenus.

Conclusions

Molecular identification of sand flies via DNA barcoding can accurately identify these medically important insects assisting traditional morphological tools, thus helping to assess their implication in Leishmania transmission.

Phlebotomine sand fly-borne pathogens in the Mediterranean Basin: Human leishmaniasis and phlebovirus infections

Pathogens transmitted to humans by phlebotomine sand flies are neglected, as they cause infectious diseases that are not on the priority list of national and international public health systems. However, the infections caused by protozoa of the Leishmania genus and viruses belonging to the Phlebovirus genus (family Phenuiviridae)—the most significant group of viruses transmitted by sand flies—have a relevant role for human pathology. These infections are emerging in the Mediterranean region and will likely spread in forthcoming decades, posing a complex threat to human health. Four species and 2 hybrid strains of Leishmania are pathogenic for humans in the Mediterranean Basin, with an estimated annual incidence of 239,500–393,600 cases of cutaneous leishmaniasis and 1,200–2,000 cases of visceral leishmaniasis. Among the phleboviruses, Toscana virus can cause neuroinvasive infections, while other phleboviruses are responsible for a typical “3-day fever”; the actual incidence of Phlebovirus infections in the Mediterranean area is unknown, although at least 250 million people are exposed. Here, we reviewed the current literature on epidemiology of sand fly–borne infections in the Mediterranean Basin, with a focus on humans. Our analysis indicates the need for increased public health activities directed to determine the disease burden of these infections as well as to improve their surveillance. Among the emerging challenges concerning sand fly–borne pathogens, the relationships between sand fly–borne protozoa and viruses should be considered in future studies, including epidemiological links between Leishmania and phleboviruses as well as the conditional capacity for these pathogens to be involved in interactions that may evolve towards increased virulence.

Canine leishmaniosis caused by Leishmania major and Leishmania tropica: comparative findings and serology

BACKGROUND

Infection and clinical disease associated with Leishmania major and Leishmania tropica, two common agents of human cutaneous leishmaniosis, have rarely been reported in dogs. This study describes dogs infected with these Leishmania spp. prevalent in the Middle East and North Africa, and compares the serological response of dogs infected with Leishmania infantum, L. major or L. tropica to whole promastigote antigen enzyme-linked immunosorbent assay (ELISA) of each species and to rK39 dipstick.

RESULTS

Leishmania major infection in a 5-month-old male dog was associated with alopecic and ulcerative periocular and limb skin lesions which responded to allopurinol treatment. Infection was detected by skin and blood polymerase chain reaction (PCR) and confirmed by DNA sequencing but the dog was seronegative. Leishmania tropica infection was detected in a 3-month-old female dog co-infected with Babesia vogeli and Anaplasma platys and with no skin lesions. PCR and DNA sequencing of the blood and parasite culture were positive for L. tropica. Sera from 11 dogs infected with L. infantum, L. major or L. tropica were reactive with all three Leishmania spp. antigens except for sera from a dog with L. major infection. No significant differences were found between reactivity of dog sera to the antigen of the infecting species, or to the other Leishmania spp. antigens. Sera from dogs infected with L. infantum and L. tropica were positive with the rK39 antigen kit, while dogs with L. major infection were seronegative.

CONCLUSIONS

Skin lesions in L. major infected dogs from this study and previous reports (n = 2) were ulcerative and located on the muzzle, feet and foot pads and not associated with generalized lymphadenomegaly and splenomegaly. In previous L. tropica infections, skin lesions were proliferative mucocutaneous in young dogs (n = 2), or associated with widespread dermatitis, lymphadenomegaly and splenomegaly in older dogs with similarity to L. infantum infection (n = 2). This study suggests that ELISA serology with whole promastigote antigen is not distinctive between L. infantum, L. major and L. tropica canine infections and that some L. major infections are not seropositive. PCR with DNA sequencing should be used to discriminate between canine infections with these three species.

Intestinal parasites and vector-borne pathogens in stray and free-roaming cats living in continental and insular Greece

This survey investigated the distribution of various intestinal parasites and vector-borne pathogens in stray and free-roaming cats living in four regions of Greece. A total number of one hundred and fifty cats living in three Islands (Crete, Mykonos and Skopelos) and in Athens municipality was established as a realistic aim to be accomplished in the study areas. All cats were examined with different microscopic, serological and molecular assays aiming at evaluating the occurrence of intestinal parasites, and exposure to or presence of vector-borne infections. A total of 135 cats (90%) was positive for one or more parasites and/or pathogens transmitted by ectoparasites. Forty-four (29.3%) cats were positive for one single infection, while 91 (60.7%) for more than one pathogen. A high number of (n. 53) multiple infections caused by feline intestinal and vector-borne agents including at least one zoonotic pathogen was detected. Among them, the most frequently recorded helminths were roundworms (Toxocara cati, 24%) and Dipylidium caninum (2%), while a high number of examined animals (58.8%) had seroreaction for Bartonella spp., followed by Rickettsia spp. (43.2%) and Leishmania infantum (6.1%). DNA-based assays revealed the zoonotic arthropod-borne organisms Bartonella henselae, Bartonella clarridgeiae, Rickettsia spp., and L. infantum. These results show that free-ranging cats living in areas of Greece under examination may be exposed to a plethora of internal parasites and vector-borne pathogens, some of them potentially able to infect humans. Therefore, epidemiological vigilance and appropriate control measures are crucial for the prevention and control of these infections and to minimize the risk of infection for people.

Several intestinal parasites and vector-borne pathogens, some of that with zoonotic potential, often occur in free-ranging cat populations. Stray cats are abundant in touristic areas of Greece, where they live in free colonies. With the aim to enhance our knowledge on the hazard posed by cats living in Greek touristic spots, the present research has evaluated the presence of intestinal parasites and vector-borne pathogens in stray cats living in selected areas. The study demonstrates that these pathogens are present in Greece and that appropriate control measures should be implemented to minimize the risk for cats and people.

Five-month serological monitoring to assess the effectiveness of permethrin/fipronil (Frontline Tri-Act®) spot-on in reducing the transmission of Leishmania infantum in dogs

Canine vector-borne diseases are highly endemic in European countries of the Mediterranean basin. The use of repellent insecticides aids to reduce the risk of pathogen transmission. The primary objective of this 5-month serological field study conducted in a highly endemic area of canine leishmaniosis in Greece was to comparatively assess the effectiveness of a topical formulation of fipronil/permethrin (Frontline Tri-Act®/Frontect®) and of a deltamethrin collar (Scalibor®) for the prevention of Leishmania infantum transmission. Initially, 72 clinically healthy owned dogs were sampled for inclusion. Ten out of the 72 (13.8%) were seropositive according to the Snap Leish® ELISA test and removed. Ultimately, a total of 56 dogs were followed from May to October 2015 with monthly blood samples and serological tests based on Snap Leish® and Snap 4Dx® ELISA tests. Twenty-five dogs were treated with deltamethrin collar (Scalibor®) (Group 1) and 31 were treated monthly with the topical fipronil/permethrin formulation (Group 2). In group 1, three dogs out of 25 (12%) seroconverted for Leishmania whereas none of the dogs (0/31) seroconverted in group 2. In addition, this trial provided means to serological assess the transmission of other vector-borne pathogens. Regarding Anaplasma spp., one dog in each group was seropositive at the beginning of the study and no dogs became positive during the study. For Ehrlichia canis, 9/25 (36%) dogs in group 1 and 5/31 (16.1%) in group 2 were seropositive at inclusion time. Two out of 16 (11.8%) and 3/26 (11.5%) dogs became positive for E. canis after 3months in groups 1 and 2, respectively. No Borrelia burgdorferi sensu lato seropositive dog was found during the study. In regard to Dirofilaria immitis, 7/25 (28%) dogs and 12/31 (38.7%) were antigen-positive in groups 1 and 2, respectively, at inclusion. There was no significant difference between groups 1 and 2 in regard to new seroconversions during the trial. This study, conducted in a highly endemic area for vector-borne pathogen transmission, confirmed that the use of deltamethrin and permethrin is a suitable approach to reduce the risk of L. infantum infection by sandflies.

DNA sequencing confirms PCR-RFLP identification of wild caught Larroussius sand flies from Crete and Cyprus

Many Phlebotomine sand fly species (Diptera, Psychodidae) are vectors of the protozoan parasite Leishmania causing a group of diseases called the leishmaniases. The subgenus Larroussius includes sand fly vectors found in South East Mediterranean Basin responsible for Visceral (VL) and Cutaneous human leishmaniasis (CL). It is important to monitor these medically important insects in order to safely predict possible Leishmania transmission cycles. Leishmania infantum is endemic in the islands of Crete and Cyprus with increasing VL cases in humans and dogs and in Cyprus the newly introduced Leishmania donovani causes both VL and CL in humans. The morphological identification of the females of the subgenus Larroussius often presents difficulties. Morphology and COI PCR - RFLP were used to identify wild caught Larroussius sand flies belonging to Phlebotomus tobbi, P. perfiliewi, and P. neglectus species from Crete and Cyprus. The identification results were further confirmed by sequencing (DNA barcoding) and Bayesian phylogenetic analysis. COI PCR - RFLP, when correctly optimized and with respect to geographical origin, can serve as an initial patterning identification tool when large sand fly numbers need to be identified. It could accurately assign Larroussius females and males to their taxa overcoming the difficulties of morphological identification. Finally, DNA barcoding will contribute to a molecular identification database to be used for in-depth species studies.

Leishmania infantum and Dirofilaria immitis coinfection in dogs in Greece

Leishmaniasis and dirofilariasis are parasitic diseases of humans and dogs, worldwide, and they are often found as coinfections in endemic areas. Cases of human and canine dirofilariasis have being reported in Greece and leishmaniasis is endemic in most prefectures in humans and dogs. In most cases, dirofilariasis is established by parasitological (the modified Knott's test) and/or immunological methods, whilst for leishmaniasis molecular techniques and culture are also used. During an epidemiological study in Greece, 22·1% of the 5772 dogs studied were found positive by serology forLeishmania.Blood cultures of 165 (12·94%) of these animals producedLeishmaniapromastigotes and 26 (2·03%)Dirofilariamicrofilariae (L1), whilst only in two (0·16%) bothLeishmaniaandDirofilariaL1 appeared. The aim was to assess coinfections by the two parasites in dogs in Greece, the isolation and survival ofDirofilariamicrofilariae andLeishmaniapromastigotes using clotted blood (a fast, simple and low-cost method) and the survival potential of the two parasites in coexistence,in vitro.

Pediatric Visceral Leishmaniasis Caused by Leishmania infantum in Northern Cyprus

Visceral leishmaniasis (VL) is a vector-borne disease widespread in the Mediterranean basin, including Cyprus. During the last decades no cases were notified from northern Cyprus, but herein three cases of VL (female: 2, male: 1, median age: 24.6 months) diagnosed during their hospital admission between January 2011 and December 2012 are reported. Diagnosis was based on clinical findings; 1 ≥ 1/64 titer positivity of immunofluorescence antibodies, Leishmania amastigotes in Giemsa-stained slides of bone marrow, as well as molecular identification confirmed that in all three the infecting pathogen was Leishmania infantum Fever, splenomegaly, and hepatomegaly were the typical clinical findings. First-line treatment with liposomal amphotericin B (AmBisome^®; intravenous, 3 mg/kg) on days 1-5, followed by the same on days 10 and 21 yielded a successful outcome with no relapse in all cases. These confirmed VL cases found within 2 years demonstrate the presence of VL on the island.

Evaluation of Immunofluorescence Antibody Test Used for the Diagnosis of Canine Leishmaniasis in the Mediterranean Basin: A Systematic Review and Meta-Analysis

With an expected sensitivity (Se) of 96% and specificity (Sp) of 98%, the immunofluorescence antibody test (IFAT) is frequently used as a reference test to validate new diagnostic methods and estimate the canine leihmaniasis (CanL) true prevalence in the Mediterranean basin. To review the diagnostic accuracy of IFAT to diagnose CanL in this area with reference to its Se and Sp and elucidate the potential causes of their variations, a systematic review was conducted (31 studies for the 26-year period). Three IFAT validation methods stood out: the classical contingency table method, methods based on statistical models and those based on experimental studies. A variation in the IFAT Se and Sp values and cut-off values was observed. For the classical validation method based on a meta-analysis, the Se of IFAT was estimated in this area as 89.86% and 31.25% in symptomatic and asymptomatic dogs, respectively. The Sp of IFAT was estimated in non-endemic and endemic areas as 98.12% and 96.57%, respectively. IFAT can be considered as a good standard test in non-endemic areas for CanL, but its accuracy declines in endemic areas due to the complexity of the disease. Indeed, the accuracy of IFAT is due to the negative results obtained in non-infected dogs from non-endemic areas and to the positive results obtained in sera of symptomatic dogs living in endemic areas. But IFAT results are not unequivocal when it comes to determining CanL infection on asymptomatic dogs living in endemic areas. Statistical methods might be a solution to overcome the lack of gold standard, to better categorize groups of animals investigated, to assess optimal cut-off values and to allow a better estimate of the true prevalence aiming information on preventive/control measures for CanL.

Species composition, activity patterns and blood meal analysis of sand fly populations (Diptera: Psychodidae) in the metropolitan region of Thessaloniki, an endemic focus of canine leishmaniasis

Species composition, activity patterns and blood meal analysis of sand fly populations were investigated in the metropolitan region of Thessaloniki, North Greece from May to October 2011. Sampling was conducted weekly in 3 different environments (animal facilities, open fields, residential areas) along the outskirts of the city in areas of increased canine leishmania transmission. Six sand fly species (Phlebotomus perfiliewi, Phlebotomus tobbi, Phlebotomus simici, Plebotomus papatasi, Sergentomya minuta and Sergentomya dentata) were identified using both classical and molecular techniques. DNA barcodes were characterized for the first time for two (P. simici and S. dentata) of the six recorded species. Phylogenetic analysis based on the COI gene sequences confirmed the grouping of P. tobbi, P. perniciosus and P. perfiliewi (subgenus Larrousius) and the monophyly of P. simici (subgenus Adlerius). By far the most prevalent species was P. perfiliewi, followed by P. simici and P. tobbi. The largest populations of sand flies were collected from animal facilities, followed by residential areas and open agricultural fields. Peak activity of sand flies overall occurred mid-August to mid-September and then declined sharply in October. Blood meal analysis showed that P. perfiliewi and P. simici feed preferentially on humans (88% & 95%, respectively) but also feed on chickens and goats. When designing a control strategy to alleviate sand fly nuisance in the region of Thessaloniki the following conclusions can be reached from this study: a) August and September are high risk months due to increased sand fly activity levels, b) animal facilities within or adjacent to urban settlements are high risk areas and may act as a maintenance and amplification foci for the vector as well as the parasite, and c) the abundance, ubiquity and feeding behavior of P. perfiliewi and P. simici establishes them as potentially important vectors of Leishmania in the region.

Environmental parameters as risk factors for human and canine Leishmania infection in Thessaly, Central Greece

Thessaly, Central Greece, is an endemic area for leishmaniasis with higher incidence rate during the last years. We herein investigated the geographical distribution of human leishmaniasis cases and Leishmania infected dogs in relation to environmental parameters to identify high-risk areas. All the human leishmaniasis cases (n = 82) reported to Hellenic Centre for Disease Control and Prevention from 2007 to 2014 and 85 Leishmania polymerase chain reaction positive dogs were included in this study. To analyse the data geographical information system (GIS) together with the Ecological Niche Model (ENM) were used. The most important findings of the study were: (i) Central plain of Thessaly together with the coast line and the western and eastern lowlands were identified as high-risk geographical areas. (ii) The highest percentage of the high-risk areas was found in low altitude (<200 m above sea level) and in irrigated and cultivated agricultural areas. (iii) A total of 20% of the human settlements was found in high-risk areas. (iv) The maximum temperature of the warmest month contributes the highest per cent to define both environmental niche profiles for humans and dogs. (v) The ENM could be a useful tool for the epidemiological study of leishmaniasis. Spatial analysis may allow the design of entomological studies and identify target population in order to implement preventive measures.

Tumor lysis-like syndrome in a child during treatment for visceral leishmaniasis

A 2.5-year-old girl was admitted due to splenomegaly and pancytopenia. Laboratory analysis revealed pancytopenia and hypergammaglobulinemia, and due to the absence of fever and the relevant clinical and hematological presentation the child was initially suspected for acute lymphoblastic leukemia. Bone marrow aspiration displayed macrophages and extracellular space containing Leishmania amastigotes. Visceral leishmaniasis diagnosis due to Leishmania infantum was confirmed by the presence of high titers of Leishmania antibodies and by PCR. The patient was successfully treated with liposomal amphotericin B but during the third post-treatment day significant increases in the levels of serum uric acid, blood urea nitrogen, and phosphate were registered. The child was successfully treated with hydration and urine alkalization and resulted in full recovery of the metabolic abnormalities.