**2. Leishmaniasis in Iraq**

Leishmaniasis is known to be endemic in Iraq since 3000–2000 B.C. and has been described for the first time by Abu Bakr Muhammad ibn Zakariya' al-Razi, one of

#### *Geopolitical and Geospatial Conflicts Affecting Cutaneous Leishmaniasis: Iraqi Cases, 2014-2015 DOI: http://dx.doi.org/10.5772/intechopen.101147*

the greatest names in medieval medicine, in 1500 A.D. [15, 16]. A common name of CL in Iraq is Baghdad boil, which suggests the disease has a long history in Iraq [17].

Two types of CL were reported in Iraq, a zoonotic type caused by *Leishmania major* and an anthroponotic type caused by *Leishmania tropica* [18]. Rural areas in Iraq are described as source of infection and endemicity because of the presence of animal reservoirs (rodents, dogs, and foxes) for ZCL and the use of clay to build some of the houses in villages in these areas [19, 20]. Underdeveloped clay buildings facilitate sand-fly breeding because they maintain a sufficient level of moisture which is important for the sand-fly a larval habitat. The human population in these regions more exposed to a sandfly bite due to their work mainly in the farms [18, 21, 22].

The incidence rate of disease is higher among males than females nearly in all age groups [23, 24]. Males were found to be more vulnerable to CL infection due to the nature of the Iraqi culture that they are mainly responsible for family finance and support, thus making them more exposed to the infectious agents and young males playing outdoors without clothes and swimming in the rivers or lakes due to constant power outage.

CL manifestations increase in October, peak in January, and then gradually decline, reaching their lowest level in August. Two-thirds of the cases were reported between December and March [25]. The difference in seasonal peak can be attributed to the presence of different types of reservoirs widespread in these areas, in particular for the ZCL, and to the activity of sandflies, which extends from April to November and reaches its peak in September to October [26].

Iraq has been exposed to wars, civil wars, widespread violence, and terrorism. Internal displacement of population, unlawful housing, shortage of municipal services, constant power outage, accumulation of waste, and uncontrolled stray dogs and animals in the cities since 2003 contributed to many CL outbreaks [9, 27] (**Figure 2**). In 2009, the Baghdad governorate reported CL outbreak with a high incidence of 45.5/100,000 population (**Figure 2**) [26, 28].

In 2014, the ISIS seized large areas of Iraqi lands that caused large internal displacement of the residents; they were mostly nonimmune and malnourished who moved to live in an endemic area with poor housing camps, lack of sanitation and water supply, and increased waste and garbage around their camps (**Figure 3**).

**Figure 2.** *Predisposing factors for CL occurrence.*

**Figure 4.** *Underdeveloped mud houses.*

In addition, living in illegal underdeveloped mud houses with cracked walls, low socioeconomic status, and constant power outage may be playing as a risk factor for Leishmaniasis outbreak (**Figure 4**) [13, 29].

Sleeping without an insecticide-treated bed net outside the house due to a constant power outage and keeping domestic animals inside or around their houses are another risk factors for the transmission of the disease to human (**Figure 5**) [14, 30].

The conflicts had a negative impact on the health system in Iraq; many health programs were including the prevention and control measures of Leishmaniasis were affected. Eventually, an outbreak of Cutaneous Leishmaniasiss occurred in 2015 [9, 31].

Geopolitical conflicts and geospatial health deterioration contributed to an increase in various dominant reservoir species in Iraq, particularly for ZCL, and the activity of the sand flies [8]. There was a sudden, sharp increase in CL cases from 2671 cases in 2014 to 17,264 cases observed in 2015, and an outbreak was reported (**Figure 6**) [31].

*Geopolitical and Geospatial Conflicts Affecting Cutaneous Leishmaniasis: Iraqi Cases, 2014-2015 DOI: http://dx.doi.org/10.5772/intechopen.101147*

**Figure 5.** *Human behaviors.*

**Figure 6.**

All Iraqi governorates reported CL cases during the CL outbreak in 2015, and the incidence rate was 49/100,000 population. The majority of cases, 4460 (25.8%), was observed in the Diyala governorate. Therefore, violence and conflicts had a negative impact on CL occurrence [11, 32].
