Epidemiology of Cutaneous
Leishmaniasis
SIDNEY N. KLAUS, MD
SHOSHANA FRANKENBURG, PhD
ARIEH INGBER, MD
L
eishmaniasis refers to an infection caused by pro-
tozoan parasites of the genus Leishmania. Of the
three clinical expressions of the disease— cutane-
ous, visceral, and mucocutaneous—the cutaneous form
(CL) is the most abundant. It is important to recognize
that CL does not refer to a single disease. At least 12
species of the genus Leishmania are known to cause CL,
and each parasite species has its own characteristic
vectors and reservoirs. Bradley has pointed out that in
no other parasitic genus infecting man is there such a
“diversity of species and strains, variety of pathogenic
manifestations, and ecologic richness of transmission
patterns.”1 It is now clear that only by recognizing the
complexity of this group of diseases—including the
intricate patterns of interaction between hosts, reser-
voirs, and vectors— can progress be made in formulat-
ing effective methods of control.
Distribution of Leishmaniasis
CL is found in all countries of the tropical and sub-
tropical regions of the world, except New Zealand,
Australia, and the island nations of the Pacific. Within
the geographic limits of CL, the extent and severity of
the problem differs widely. For example, in countries in
the south and west of Africa, CL occurs only sporadi-
cally,2– 4 while in the northern and eastern parts of the
continent the disease is endemic.5– 8 This irregularity in
the worldwide distribution of CL is emphasized by the
fact that, although CL has been reported from more
than 80 countries of the world, 90% of all cases occur in
just six: Afghanistan, Brazil, Iran, Peru, Saudi Arabia,
and Syria.9
Importance of Environmental Factors
In those regions where two or more species of leishma-
nia are known to overlap, the likelihood of infection by
From the Department of Dermatology, Hadassah University Hospital;
and The Kuvin Centre for the Study of Infectious and Tropical Diseases, The
Hebrew University, Jerusalem, Israel.
Address correspondence to Dr. S.N. Klaus, The Hebrew University,
Hadassah Medical School, Department of Dermatology, P.O. Box 12272,
91120 Jerusalem, Israel.
© 1999 by Elsevier Science Inc. All rights reserved.
655 Avenue of the Americas, New York, NY 10010
one species rather than another is related to several
local factors. For example in parts of the Middle East,
where CL is caused by either Leishmania major or Leish-
mania tropica, topographic features appear to be impor-
tant. In low-lying desert regions the disease is usually
caused by Leishmania major, spread zoonotically from
desert rodents to man by the sandfly Phlebotomus pa-
patasi. In urban centers, located at higher altitudes, CL is
caused by L. tropica, spread anthroponotically, from
human to human by another species of sandfly, Phle-
botomus sergenti. Recently a third pattern of CL has
emerged that differs from both previous patterns. In
small villages and settlements CL is caused by L. tropica
but is spread zoonotically to man from as yet uniden-
tified animal reservoirs.10,11
It should be emphasized that the distinction between
CL caused by different species of Leishmania cannot be
made on clinical grounds. Although early classifiers
insisted that L. major was “wet” appearing, and L.
tropica “dry,” these distinctions are no longer consid-
ered valid, and today identification of the species of
Leishmania causing a CL lesion is made using biochem-
ical or molecular techniques (such as isoenzyme analy-
sis or PCR).
Micro-environmental Factors
Even within a single endemic zone, “micro”-environ-
mental factors may influence spread of the disease, and
slight topographical differences are known to affect
morbidity rates within a confined geographic setting.
After an outbreak of CL among Israeli soldiers at an
outpost in the Negev Desert, a comparison was made
between the encampment site of those who became
infected and the site of those who remained disease
free. Of 99 soldiers encamped near a dry river bed, 32
became infected (32.3%), while of 46 soldiers quartered
on a ridge 500 meters away, only one (2.2%) became
infected. The authors of this study concluded that dur-
ing an outbreak even minor differences in the physical
location of an encampment could significantly affect
morbidity.12
0738-081X/99/$–see front matter
PII S0738-081X(99)00043-7
258 KLAUS ET AL.
Demographic Aspects
Overall, the total number of new cases of CL occurring
throughout the world each year is estimated at 1.5
million,13 but only about 300,000 are officially declared
infected because of widespread underreporting.14
In those areas where CL is prevalent, the disease
occurs commonly among children and in some hyper-
endemic areas a history of CL is almost universal by
teen-age. In a study conducted in the town of Jericho,
located in a hyperendemic region in the Jordan Valley,
more than 80% of children, ages 12 and 13, were found
to have evidence of past infection, as shown by a pos-
itive Montenegro skin test or a lymphocyte prolifera-
tion microtest.15 In many areas where the prevalence of
CL is high, CL cases are rarely reported to public health
authorities because the disease is considered as a nor-
mal part of “growing up.”
Among people who live in areas that are near to, but
not within, foci of infection, it is usually adult males
who enter into the endemic areas for purposes of work
who are most at risk. In Brazil in the 1940s a major
epidemic occurred during the building of a railroad in
the state of Sao Paulo; 9000 of the workers were treated
for CL and an estimated 30,000 became infected.16
Individuals who reside in completely leishmania-
free areas can also become infected if they enter into
endemic zones, even for short periods of time. These
individuals appear to be at greater risk of contracting
the disease than are the “locals.” An outbreak of CL at
a construction site in an endemic region in Saudi Arabia
involved foreign workers at a rate more than six times
that of the Saudi workers.17 An outbreak of CL under
similar circumstances was reported recently from Jor-
dan. Eighty soldiers, who usually resided in a CL-free
zone in the northern part of the country, were posted to
a camp located in an endemic zone in the south. After a
stay of only five and one-half months, 45% of the newly
arrived contingent developed CL.18
Tourists from America and Europe are also at risk for
CL. Of 269 patients who presented with travel-associ-
ated dermatoses to a tropical disease unit in Paris, 8%
were found to have CL.19 In our own experience, “ad-
venture” tourists—those taking long evening walks and
sleeping “under the stars” without the protection of bed
nets—are most likely to contract the disease.20 The risk of
infection is also increased by eating out of doors (especial-
ly the evening meal, because sandflies are usually evening-
and night-biters), or during other outdoor recreational activ-
ities, such as fishing, rock-climbing, or hiking. Most travel
clinics today provide information about insect repellents and
advice on how to reduce exposure to insect vectors.
Population Migration
Another circumstance that is known to increase mor-
bidity, or even trigger epidemics of CL, is the move-
Clinics in Dermatology Y 1999;17:257–260
ment of large numbers of people from one region to
another. Ordinarily migrants from a leishmania-free
zone are at risk when they move into an endemic
region. Occasionally, however, the migrants moving to
non-infected areas can bring the disease with them if
appropriate vectors and reservoirs are already present.
This was the situation in a major outbreak of CL in the
late 1980s in Khartoum province of the Sudan when
thousands of people moved from the west of the coun-
try to an area around Khartoum to escape a drought in
their home regions. Many of the migrants were infected
with CL and they served as the source for its spread,
first to animal reservoirs, and ultimately to more than
10,000 members of the immunologically naive local
population.21
Seasonal and Climatic Influence
In those regions of the world where the development of
adult sandflies is seasonal, the pattern of CL infection in
humans is also seasonal. CL is transmitted by the bite of
an adult female sandfly, and in areas where adult flies
develop during the spring and early summer months,
new cases of CL commonly present in the late summer
and autumn.22
In climatic zones where adult sandflies are present
year-round, the incidence of the disease may still follow
a seasonal pattern, especially if periodic rains or
drought influence the density of the sandfly popula-
tion.16
Climatic conditions can also influence vector–reser-
voir interactions. For example, in the arid Jordan Valley,
the sandflies that carry L. major tend to congregate in
cool, underground animal burrows in order to conserve
fluids and it is within these burrows where the rodents
are found which serve as the reservoirs for the parasite.
Among such sandfly-infected colonies the proportion of
infected animals was more than 90%.23
Global Warming
Global warming is potentially an important influence
on the worldwide distribution of CL. Some experts
have suggested that even a modest warming of the
mean temperature—no more than 1 or 2 degrees
C—will lead to a significant spread of the disease.24 One
researcher has warned that global warming could allow
sandfly vectors, now limited to the south of France, to
spread as far north as Britain.25
Control Programs
Programs to control CL usually are directed at reducing
the population of sandflies within a given endemic
area. In the Amazon basin, for example, forests were
cleared for 300 meters around villages to reduce the
invasion of the sylvatic sandflies and this effort resulted
in a substantially reduced morbidity.16 Another ap-
Clinics in Dermatology Y 1999;17:257–260
proach was used in Allepo, Syria, where an insecticide
spraying campaign, begun in 1991, was followed ini-
tially by a reduction in the number of CL cases. In this
case, however, despite continued spraying, the num-
bers of cases increased again in subsequent years, prob-
ably because of an increase in the number of sandfly
breeding sites. It is now recognized that breeding sites
in urban areas can be reduced through the prompt
removal of construction rubble and the patching of
cracks in the walls of buildings.26
In desert and forest environments, where sandflies
are ubiquitous, the use of insecticides or elimination of
breeding sites is not considered feasible and other strat-
egies have been sought. One approach, based on the
observation that certain plants on which the sandflies
feed will cause significant injury to leishmania parasites
within the guts of the sandflies, have led to a plan to
cultivate such plants in CL endemic areas.27 Another ap-
proach, still in the planning stage, is to introduce parasite-
resistant genes into natural sandfly populations.
Reservoir animals also have been targeted by control
programs, because these animals serve as critical
“bridges” to carry the parasites over from one biting
season to the next. Where the number of animals can be
reduced, the rate of infection among female flies also
decreases, which in turn leads to fewer cases of human
infection. One such program was directed at Rhombo-
mys opimus, the rodent reservoirs of L. major infection in
the southern part of the former Soviet Union. A major
campaign was undertaken to eliminate these animals
using chemical poisons (zinc phosphide), anticoagu-
lants, and deep ploughing of the animals’ burrows. This
program succeeded in decreasing the reservoir popula-
tion and was followed by a significant drop in the
frequency of CL in the region.28
The control programs least hazardous to the environ-
ment are those aimed at regulating human behavior.
These programs, however, require both financial sup-
port and an educational effort to be successful. For
example, it is widely known that the use of fine-mesh
bed netting, impregnated with a residual insecticide, is
an effective means for preventing infection. But the
purchase of nets on a large scale is costly and this
measure has not come into wide use. Also, teaching
people to avoid outdoor activities in the evenings and
to use insect repellents is effective and involves less
financial outlay, but does require a significant level of
voluntary cooperation.
Conclusions
At present, hopes for the control of CL are not optimis-
tic. Twenty years ago when leishmaniasis was selected
for special attention by the World Health Organiza-
tion’s Tropical Disease Program, it was expected that
research advances would soon limit the spread of the
EPIDEMIOLOGY OF CL 259
disease, or perhaps eliminate it entirely. Unfortunately,
despite significant progress in many areas—such as the
biochemistry and molecular biology of the parasites,
the hosts’ immune response, the life cycle of the vectors
and reservoirs, and the epidemiologic relationships be-
tween vector, reservoir and host— effective control of
CL still remains a major challenge.
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