Travel Health Information Sheets
- Risk for travellers
- Signs and symptoms
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Leishmaniasis is an infection caused by a protozoan parasite of the genus Leishmania, of which there are more than 20
sub-species. Leishmaniasis is transmitted by the bite of the
female sand fly. The organism is found in regions of tropical
Africa, Central and South America, the Mediterranean, central
and East Asia and southern Europe.
Clinical syndromes in humans are cutaneous and visceral
leishmaniasis. Cutaneous leishmaniasis is usually caused by
L. tropica and L. major and by members of the L. mexicana
complex and the Viannia subgenus. Visceral leishmaniasis
(also known as Kala-Azar) is usually caused by L. donovani,
L. infantum and L. chagasi.
Leishmaniasis is endemic to more than 80 countries and is an
important public health concern with a global incidence of
1.5 – 2 million cases each year .
More than 90% of the cases of cutaneous leishmaniasis (CL)
occur in Afghanistan, Algeria, Brazil, Iran, Pakistan, Peru, Saudi
Arabia, and Syria; 90% of visceral leishmaniasis (VL) occurs in
Bangladesh, Brazil, India, Nepal, and Sudan . An increase in
leishmaniasis has been observed; for example, the annual
number of cases of CL reported in Brazil increased from 21,800 in 1998, to 40,000 in 2002 . An important factor in this increase has been population migration. In Manaus, Brazil, urbanisation has resulted in suburbs being built on the edge of the rainforest, placing human populations in close proximity to animal reservoirs of leishmaniasis that include opossums, sloths, and anteaters .
In the poorer suburbs of Middle Eastern countries such as
Afghanistan, Iran, Turkey and Syria, population density is high
and sanitary conditions are poor, providing ideal breeding
grounds for sandflies. As a result there has been a progressive
increase in the number of cases of CL reported from Aleppo in
Syria. It is estimated that approximately 270,000 persons are
currently infected in Kabul, Afghanistan .
Leishmaniasis in travellers from England, Wales, and Northern
In 2004, there were 50 laboratory reports of leishmaniasis, the
highest annual number reported since 1990  and an increase
of 32% compared to 2003 (38 reports). In 2005, there was a
further increase of 16% (58 reports) . Since 1996, the annual
number of reported cases, although small, has increased by an average of 28% every year, as illustrated in the figure. In 2004 and 2005, there was also an increase in reports where the Leishmania organism was not identified and, therefore, it is not possible to say whether they were cutaneous or visceral
Figure. Laboratory reports of leishmaniasis by clinical
expression, England, Wales, and Northern Ireland: 1996 - 2005
Data from the Health Protection Agency, Centre for Infections
It is presumed that all cases of leishmaniasis reported in the
United Kingdom (UK) are acquired abroad, as leishmaniasis
does not occur naturally in the UK.
In 2005, of the 26 reports of CL, 21 had travel information; nine
stated travel to Central America (seven to Belize, one to
Guatemala, and one to Costa Rica and Nicaragua), seven
travelled to Afghanistan, four to South America (one each to
Bolivia, Colombia, Guatemala, and Guyana), and one to
Pakistan. Of the six reports of VL, five had travel information; one each travelled to Afghanistan, the Balkans and Spain,
Mediterranean basin, Pakistan, and Turkey. Of the 26 unknown leishmaniasis reports, four had travel information; one each
travelled to Afghanistan, India, Belize, and Portugal .
Between July 2004 and June 2005, 33 cases in military
personnel were laboratory confirmed as Leishmania major .
Twenty cases had served in northern Afghanistan, 19 were on
exercise in Belize and four had returned from Iraq. It is likely that some personnel had served in all three places prior to their diagnosis so it is not possible to say exactly where their
infections were acquired. Similarly, between August 2002 and February 2004, 522 confirmed cases of CL were reported in
United States’ military personnel, the majority of whom had
returned from Iraq .
Adventure travellers, missionaries, and soldiers who travel to
areas of risk, particularly to rural or jungle areas are at risk of cutaneous disease . A review of 42 patients with CL at the
Hospital for Tropical Diseases in London, found that jungle
travel was one of the main factors for transmission .
VL is rare in travellers; however imported cases in the UK have occurred following travel to the Mediterranean . The risk of
clinical illness with VL is greater in those with HIV infection.
Cases of VL and HIV co-infection are well-documented in
southern European countries including Spain, Italy, and France
Leishmaniasis is a zoonosis in which humans are accidentally infected, although during epidemics, humans may play a part in maintaining the transmission cycle . Mammals, including
dogs, foxes, and rodents, are the usual reservoirs for
Leishmania and the female phlebotomine sand fly is the vector.
Sand flies, contrary to what their name suggests, are not found
on beaches. They are usually found in forests, the cracks of
stone or mud walls, or animal burrows. The sand fly
predominantly bites between dusk and dawn and usually stays
close to the ground. Approximately 800 species of sand fly have
been described, of which 70 belonging to the genus
Phlebotomus or Lutzomyia are known to transmit leishmaniasis
A female sand fly requires a blood meal in order for her eggs to develop and mature. She transmits the promastigote form of the protozoa (carried in the salivary glands) to a human during
In rare cases, VL has been transmitted congenitally and via
CL presents as skin lesions that develop weeks or months after infection. They can vary in appearance from a classic round ulcer
with a beefy red granulating base and raised margin, to nodules or papular scaling lesions. Regional lymphadenopathy may be present. Untreated, these lesions persist for several weeks.
Diagnosis is made by slit skin smear of the lesion, with Giesma staining and microscopy. A specialist parasitology laboratory may also be able to culture and speciate the organism.
Many cases of VL are sub-clinical. Those causing clinical
symptoms follow an acute, sub-acute, or chronic course after an incubation period of weeks or months; life-threatening disease may develop with symptoms of fever, hepatosplenomegaly, anaemia, thrombocytopenia, and hypogammaglobulinaemia. Diagnosis is made by detecting Leishmania parasites in stained slides or cultures of a biopsy sample or tissue aspirate.
Patients should be referred to a specialist tropical disease unit
for diagnosis and treatment of all forms of leishmaniasis
depending upon the form of the disease. There are several drug treatments available including oral, parenteral, and topical medications. These are chosen based on the form of
leishmaniasis and the infecting species and after careful
There is no vaccine available for leishmaniasis. Travellers
should be advised on the need for insect bite avoidance
measures, particularly between dusk and dawn.
Sand flies are small enough to pass through a standard
mosquito net; however, if the net is impregnated with permethrin it will usually be effective in preventing the flies from going
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World Health Organization leishmaniasis website.
Special Programme for Research and Training in Tropical Diseases
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