**Author details**

around the town where *P. Obesus* was very dense, deep plowings of colonies of the rodent and their poisoning. These interventions led to a significant reduction in the incidence among

Consequently, in 2000, the Tunisian National Control of Parasitic Diseases Program (PDP) introduced ecological surveillance of areas at risk for ZCL before the occurrence of the epi‐ demics based on the surveillance of the emergence of rodent colonies, such as *P. obesus.* Despite this significant effort, and the analysis of transmission dynamics of the disease in other regions, control strategies remain unsatisfactory, as indicated by the number of annual cases [5]. In fact, such actions are demanding and expensive, and consequently are often partially and intermittently performed. As such, it was therefore not possible to reduce the

Thereby, the national strategy for Leishmaniasis prevention and control has mainly focused on passive case detection and free diagnosis and treatment rather than on the reservoir and

Since ZCL is polymorph in terms of disease severity (number and size of lesions, duration for healing), we can hypothesize that some immune factors, depending on their intensity, will not protect against the development of the disease but rather against the severe forms. Their identification could help the development of a vaccine that protect against a severe disease, which could constitute an interesting option. The rationale for vaccine development is provided by the evidence that most individuals that had leishmaniasis or symptomless infection are resistant to subsequent clinical infections. The only proven CL vaccine (prac‐ ticed for centuries) is the deliberate inoculation of virulent Leishmania parasites, so‐called

In order to decrease the CL incidence in Tunisia during future years, some points are recom‐ mended and should be considered such as health education and awareness about disease, traffic control of immigrants and travelers to endemic regions, personal protection from sand‐ fly biting by curtains and bed nets, eliminating and destroying habitats of the reservoir rodent and spraying insecticides in habitats of sandflies [38]. Therefore, the high awareness among the community, health decision and policy makers were key elements for sustainability of surveillance and control measures in Tunisia. Constructing a risk map of geographical spread of ZCL across Tunisian regions is also important to guide such programs [39]. Indeed finding areas with high probability of presence for both vectors and reservoirs of ZCL will be benefi‐

The prevalence and the incidence of ZCL infection are increasing, which may reflect the higher endemicity of ZCL transmission in Tunisia over time and across geographic space. This suggests that the control strategy was not effective enough to reduce man vector contacts in endemic regions. The lack of efficacy of the control tools available is partly explained by the complexity of the transmission cycle and the insufficient knowledge of the epidemiology and the natural history of the disease. Due to its limited health resources, prioritization of

cial to prevent human infection by planning relevant activities [28].

humans with a prevention fraction of disease exceeding 90%.

temporal and spatial spread of the disease [4].

86 The Epidemiology and Ecology of Leishmaniasis

sandfly control.

leishmanization [37].

**6. Conclusions**

Bettaieb Jihène\* and Nouira Meriam

\*Address all correspondence to: bettaiebjihene@yahoo.fr

Laboratory of Transmission Control and Immunobiology of Infections, Pasteur Institute of Tunis, Tunisia
