Epidemiology and Ecology of Leishmaniasis

*Tonay Inceboz*

### **Abstract**

Leishmaniasis is the third most important vector-borne disease after malaria and lymphatic filariasis. It is common disease in all over the world. The vector for leishmaniasis is *Phlebotomus* and there have found around 20 different types of this vector. There are different clinical forms under the name of leishmaniasis such as kala-azar, dum-dum fever, white leprosy, espundia, pian bois, chiclero's ulcer, uta. Environmental factors leading to climate changes and global warming are major risk factors for the spreading of the disease. *Leishmania* spp. to prevent the spread of the definitive host and intermediate hosts is difficult compared to *Plasmodium* spp. Therefore; leishmaniasis disease will retain its importance for many years.

**Keywords:** leishmaniasis, neglected tropical diseases, vector-borne disease, epidemiology, ecology

### **1. Introduction**

This fact is mainly due to the presence of many different species of *leishmania*, its vectors and hosts in different parts of the world. More than 20 pathologic species of *leishmania* and over 30 species of *Phlebotomus*—the vector- are known worldwide (**Figure 1**, **Table 1**).

On the other hand, deterioration of the eco-systems by human beings also contribute to the spread of the disease in the world.

Leishmaniasis has four clinical forms. These are cutaneous leishmaniasis (CL, local—LCL or diffuse—DCL), mucocutaneous leishmaniasis (MCL), visceral leishmaniasis (VL), post-kala-azar dermal leishmaniasis (PKDL), (**Table 1**).

**Figure 1.** *Taxonomy of* leishmania *family [1].*


*b Taxonomic position is under discussion.*

#### **Table 1.**

Leishmania *found in humans [1].*

In this section we aimed to reveal the epidemiologic analysis of different types of leishmaniasis in all over the world in every aspect.

#### **2. Geographic distribution and incidence**

Leishmaniasis, as being one of the world's most neglected diseases, affects mainly the poor, developing countries; 350 million people are thought to be at risk of contracting leishmaniasis. It is estimated that approximately 12 million men are ill and 2 million new cases occur annually [1, 2].

With new epidemics occurring in endemic areas and the spread of leishmaniasis to previously free areas because of migration, tourism, and military activities. Leishmaniasis is a disease of the poor, occurring mostly in remote rural villages with poor housing and little or no access to modern health-care facilities. In endemic areas, diagnosis of any form of leishmaniasis puts a huge financial strain on an already meagre financial resource at both the individual and community levels [3].

Visceral leishmaniasis: approximately 90% of new cases occur in the world's cases of India, Bangladesh, Nepal, Ethiopia, Sudan and Brazil are seen. The annual number of cases worldwide has been estimated to be visceral leishmaniasis, between 200,000 and 400,000. The two important causative agents of visceral leishmaniasis (VL), namely *Leishmania* (L) *donovani* and *L. infantum*, cause significant health problems [1, 4].

Visceral leishmaniasis (VL), also known as "kala azar," is caused by parasites of the *L. donovani* complex in some parts of the world. The *L. donovani* complex can be found throughout Asia, North Africa, Latin America and Southern Europe, affecting mostly vulnerable and uncared populations. As being the most severe form, VL is almost always fatal if left untreated. It is characterized by undulating fever, loss

**137**

or more [11].

*Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

Africa and West and Central Asia [1, 5].

respectively [1, 6].

of weight, splenomegaly, hepatomegaly and/or lymphadenopathies and anemia *L. infantum*, the other causative agent of VL, is found in Southern Europe, North

Cutaneous leishmaniasis: approximately 90% of the world's cases of Afghanistan, Pakistan, Sudan, Syria, Saudi Arabia, Algeria, Iran, Iraq, is seen in Brazil and Peru. The annual number of cases worldwide has been estimated to be visceral leishmaniasis, cutaneous leishmaniasis: between 700,000 and 1.2 million [1]. Old World species: *L. major*, *L. infantum*, and *L. tropica*, New World species, such as, *L. amazonensis*, *L. chagasi*, *L. mexicana*, *L. viannia* (V) *naiffi*, *L.* (V.) *braziliensis*, and *L.* (V.) *guyanensis* [6, 7]. Antroponotic cutaneous leishmaniasis (ACL) is caused by most *Leishmania* species, occur in most subtropical and tropical regions (for example, *L. major* from Africa and Asia, and *L. mexicana* from Central and South America), and by many species in the subgenus *Viannia*, which are

limited to Latin America (for example, *L. (V) brasiliensis*) [6].

are found in 98 countries around the world [7].

subside without scarring in 9–12 months [8].

affecting buccal and nasal mucosa [13].

sion. It is rare in humans [8].

Post-kala-azar dermal leishmaniasis (PKDL) is another clinical composition of kala azar and it is seen in all areas endemic for *L. donovani*. It especially comments in East Africa and on the Indian subcontinent with a prevalence of 50 and 10%,

Old World cutaneous leishmaniasis caused by *L. tropica* (seen particularly in the Mediterranean Basin, the Middle East, Pakistan and India) and *L. infantum*, (found sporadically in the Middle East, South Russia, and rural regions of Africa). New World cutaneous leishmaniasis, caused by *L. brazilensis* and *L. mexicana* is seen in Mexica and South America. Leishmaniasis exists on every continent except Australia, the Pacific Islands and Antarctica. The parasites that cause leishmaniasis

*L. tropica*, *L. major*, *L. aethiopica* and *L. infantum* causes Old World cutaneous leishmaniasis. *Leishmania tropica* is mainly seen in urban areas and causes ACL. Related vectors are *Phlebotomus sergenti* and *Phlebotomus papatasii*. Lesions are generally dry and remain without ulceration. During the course lesions change to papules [1, 8]. *L. tropica* is found in urban areas. It causes ACL via the vectors *Phlebotomus sergenti* and *Phlebotomus papatasii*. The lesions are dry and stay for a long period of time without ulceration. Thereafter, painless lesions as papules, tubercles or nodules

*L. major* infections generally cause wet lesions in habitants of rural areas. Incubation period is less than 4 months. Lesions are usually seen on the legs. They start as acute papillary infection in the bite area and advances into pustular ulcers in 1–3 weeks. The infection is categorized as "zoonotic cutaneous leishmaniasis (ZCL)" due to the transmission to rodents, dogs via *Phlebotomus papatasi* [9]. *L. infantum* often causes small (0.5–1 cm), solitary ulcers on the face [10]. *L. aetropica* lesions are seen in the mouth and nose with local or wide spread dermal involvement. Lesions rarely become ulcerated. Healing may take 1–3 years

*L. braziliensis*, *L. mexicana*, *L. amazoensis*, *L. guyanensis*, *L. panamensis* and *L.* 

The disease caused by *L. braziliensis* is named "espundia." The infection leads to metastatic lesions, damages and deformation of the cartilage and soft tissues by

*L. mexicana* causes usually solitary, painless lesions in the pinna. It leads to

*L. guyanensis* infection is consisted of flat ulcerative plaques with leakage in whole body. The lesion is called "pianbois" in Uruguay and Venezuella [15].

*L. amazonensis* causes solitary or multiple lesions with rarely spontaneous remis-

*peruviana* cause New World cutaneous leishmaniasis [8, 12].

chronic lesions in the pinna called "chiclero's ulcer" [14].

*Current Topics in Neglected Tropical Diseases*

**Old World** *L. donovani L. major*

*L. infantum L. tropica*

In this section we aimed to reveal the epidemiologic analysis of different types of

Principal tropism Viscerotropic Dermotropic Dermotropic Mucotropic

**Subgenus** *L.* **(***Leishmania***)** *L.* **(***Leishmania***)** *L.* **(***Viannia***)** *L.* **(***Viannia***)**

*L. killicki*<sup>a</sup> *L. aethiopica L. infantum* **New World** *L. infantum L. infantum L. braziliensis L. braziliensis*

*L. mexicana L. guyanensis L. panamensis*

*L. lindenbergi L. peruviana L. colombiensis*<sup>b</sup>

*L. pifanoi*<sup>a</sup> *L. panamensis L. venezuelensis L. shawi L. garnhami*<sup>a</sup> *L. naïffi L. amazonensis L. lainsoni*

Leishmaniasis, as being one of the world's most neglected diseases, affects mainly the poor, developing countries; 350 million people are thought to be at risk of contracting leishmaniasis. It is estimated that approximately 12 million men are

With new epidemics occurring in endemic areas and the spread of leishmaniasis to previously free areas because of migration, tourism, and military activities. Leishmaniasis is a disease of the poor, occurring mostly in remote rural villages with poor housing and little or no access to modern health-care facilities. In endemic areas, diagnosis of any form of leishmaniasis puts a huge financial strain on an already meagre financial resource at both the individual and community levels [3]. Visceral leishmaniasis: approximately 90% of new cases occur in the world's cases of India, Bangladesh, Nepal, Ethiopia, Sudan and Brazil are seen. The annual number of cases worldwide has been estimated to be visceral leishmaniasis, between 200,000 and 400,000. The two important causative agents of visceral leishmaniasis (VL), namely *Leishmania* (L) *donovani* and *L. infantum*, cause signifi-

Visceral leishmaniasis (VL), also known as "kala azar," is caused by parasites of the *L. donovani* complex in some parts of the world. The *L. donovani* complex can be found throughout Asia, North Africa, Latin America and Southern Europe, affecting mostly vulnerable and uncared populations. As being the most severe form, VL is almost always fatal if left untreated. It is characterized by undulating fever, loss

leishmaniasis in all over the world in every aspect.

**2. Geographic distribution and incidence**

ill and 2 million new cases occur annually [1, 2].

**136**

*a*

*b*

**Table 1.**

*Species status is under discussion.*

Leishmania *found in humans [1].*

*Taxonomic position is under discussion.*

cant health problems [1, 4].

of weight, splenomegaly, hepatomegaly and/or lymphadenopathies and anemia *L. infantum*, the other causative agent of VL, is found in Southern Europe, North Africa and West and Central Asia [1, 5].

Post-kala-azar dermal leishmaniasis (PKDL) is another clinical composition of kala azar and it is seen in all areas endemic for *L. donovani*. It especially comments in East Africa and on the Indian subcontinent with a prevalence of 50 and 10%, respectively [1, 6].

Cutaneous leishmaniasis: approximately 90% of the world's cases of Afghanistan, Pakistan, Sudan, Syria, Saudi Arabia, Algeria, Iran, Iraq, is seen in Brazil and Peru. The annual number of cases worldwide has been estimated to be visceral leishmaniasis, cutaneous leishmaniasis: between 700,000 and 1.2 million [1]. Old World species: *L. major*, *L. infantum*, and *L. tropica*, New World species, such as, *L. amazonensis*, *L. chagasi*, *L. mexicana*, *L. viannia* (V) *naiffi*, *L.* (V.) *braziliensis*, and *L.* (V.) *guyanensis* [6, 7]. Antroponotic cutaneous leishmaniasis (ACL) is caused by most *Leishmania* species, occur in most subtropical and tropical regions (for example, *L. major* from Africa and Asia, and *L. mexicana* from Central and South America), and by many species in the subgenus *Viannia*, which are limited to Latin America (for example, *L. (V) brasiliensis*) [6].

Old World cutaneous leishmaniasis caused by *L. tropica* (seen particularly in the Mediterranean Basin, the Middle East, Pakistan and India) and *L. infantum*, (found sporadically in the Middle East, South Russia, and rural regions of Africa). New World cutaneous leishmaniasis, caused by *L. brazilensis* and *L. mexicana* is seen in Mexica and South America. Leishmaniasis exists on every continent except Australia, the Pacific Islands and Antarctica. The parasites that cause leishmaniasis are found in 98 countries around the world [7].

*L. tropica*, *L. major*, *L. aethiopica* and *L. infantum* causes Old World cutaneous leishmaniasis. *Leishmania tropica* is mainly seen in urban areas and causes ACL. Related vectors are *Phlebotomus sergenti* and *Phlebotomus papatasii*. Lesions are generally dry and remain without ulceration. During the course lesions change to papules [1, 8].

*L. tropica* is found in urban areas. It causes ACL via the vectors *Phlebotomus sergenti* and *Phlebotomus papatasii*. The lesions are dry and stay for a long period of time without ulceration. Thereafter, painless lesions as papules, tubercles or nodules subside without scarring in 9–12 months [8].

*L. major* infections generally cause wet lesions in habitants of rural areas. Incubation period is less than 4 months. Lesions are usually seen on the legs. They start as acute papillary infection in the bite area and advances into pustular ulcers in 1–3 weeks. The infection is categorized as "zoonotic cutaneous leishmaniasis (ZCL)" due to the transmission to rodents, dogs via *Phlebotomus papatasi* [9].

*L. infantum* often causes small (0.5–1 cm), solitary ulcers on the face [10].

*L. aetropica* lesions are seen in the mouth and nose with local or wide spread dermal involvement. Lesions rarely become ulcerated. Healing may take 1–3 years or more [11].

*L. braziliensis*, *L. mexicana*, *L. amazoensis*, *L. guyanensis*, *L. panamensis* and *L. peruviana* cause New World cutaneous leishmaniasis [8, 12].

The disease caused by *L. braziliensis* is named "espundia." The infection leads to metastatic lesions, damages and deformation of the cartilage and soft tissues by affecting buccal and nasal mucosa [13].

*L. mexicana* causes usually solitary, painless lesions in the pinna. It leads to chronic lesions in the pinna called "chiclero's ulcer" [14].

*L. guyanensis* infection is consisted of flat ulcerative plaques with leakage in whole body. The lesion is called "pianbois" in Uruguay and Venezuella [15].

*L. amazonensis* causes solitary or multiple lesions with rarely spontaneous remission. It is rare in humans [8].

*L. peruviana* infection causes solitary or multiple painless dermal lesions they usually subsided spontaneously in 4–5 months. This infection is called uta [16].

Lesions of *L. panamensis* are ulcers without spontaneous improvement the reservoirs are dogs and monkeys [12].

*L. venezuelensis* generally causes solitary painless nodular lesion. [12, 17].

*L. garnhami* usually causes solitary or multiple lesions and may spontaneously be healed in 6 months [12].

The Eastern Hemisphere (Old World): leishmaniasis is found in some parts of Asia, the Middle East, Africa (especially in the tropical region and North Africa), and Southern Europe.

The Western Hemisphere (New World), leishmaniasis is found in some parts of Mexico, Central America, and South America. It is not found in Chile or Uruguay.

Leishmaniasis is seen in most tropical and subtropical regions with climate, mainly in South and Central America, Africa, Asia, and Southern Europe. The leishmaniasis is considered as one of the neglected tropical diseases (NTD) (**Figures 2** and **3**) [18].

**Figure 2.** *World VL distribution in the last 10 years [19].*

**139**

*Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

b.*Lutzomyia* spp. (New World).

resting [6].

**4. Host**

**4.1 Human**

stick injuries in the labs [25–27].

create a tendency towards an increase of vectors [27–29].

patients with VL and PKDL when treated with MIL [37].

**3. Epidemiology of leishmaniasis according to vector**

Humidity and moisture, whether from rainfall or in the soil, have often been identified as important for the sandfly, with humidity influencing breeding and

Sandflies belonging to either *Phlebotomus* spp. (Old World) or *Lutzomyia* spp. (New World) are the primary vectors; domestic dogs, rodents, sloths, and opossums are amongst a long list of mammals that are either incriminated or suspected reservoir hosts [1, 21, 22]. Most of its foci in the Old World have a Mediterranean climate and sand fly vectors, usually *Phlebotomus* (Larroussius) species, *Phlebotomus* species (*P. papatasi*, *P. sergenti*, *Phlebotomus alexandri*, *P. tobbi*, *Phlebotomus syriacus*, *Phlebotomus neglectus*, *Phlebotomus perfiliewi*, *Phlebotomus galilaeus*, *Phlebotomus transcaucasicus*, and *Phlebotomus halepensis*) two *Sergentomyia* species (*Sergentomyia theodori* and *Sergentomyia dentata*), (*Phlebotomus ariasi* and *Phlebotomus perniciosus*, *Phlebotomus longicuspis*) can diapauses for human visceral leishmaniasis [21–24]. In contrast to malaria, there is little evidence for the effect of vector control in

leishmaniasis because terrestrial habitat of *Phlebotomus* is mostly unknown.

*Leishmania* species are transmitted to human via vectors, blood transfusion, organ transplantation or vertically via transplacental route. Other factors that cause the transmission of the disease are contact with contaminated materials or needle

*Leishmania*-infected humans especially in poor socioeconomic conditions play a pivotal role as a reservoir in transmission of the agent to vectors or to other hosts. In another words, one can say that human beings contribute the disease transmission by themselves [26, 27]. Poor living conditions in adobe, wooden houses, barns

In all three clinical types of *Leishmania* spp., antimonials (sodium stibogluconate [SSG]), miltefosin (MIL), amfoterisin B (AmB) veparomomisin (PMM)) are being used [30]. Children and people with immune suppression, HIV infection or malignant diseases cause rapid spread of leishmaniasis. Apart from these, undiagnosed or untreated infected people create an important risk factor. Especially drug resistance and high expense of the medication cause insufficient treatment [27–29]. The first drug resistance was reported in VL treatment against SSG and against MIL, in India and Nepal, respectively [31–33]. Later, resistance against MIL was also reported in

Verma et al. showed that the effectiveness of PMM was decreased by 6 times for the promastigote forms of *L. donavani* [36]. Invasion of macrophages by PMM-R parasites led to increased nitric oxide (NO), whereas the levels of reactive oxygen species (ROS) remained unchanged. This finding shows resistance of *Leishmania* spp. against PMM [36]. Similarly, Deep et al., reported high recurrence rates in

In conclusion, due to immune problems of the patient, co-existence of other diseases, inappropriate use of the drugs during the medical treatment of leishmaniasis, "drug resistance" may occur via gene over-expression, deletion, single nucleotide

one patient with HIV and another two patients with Indian origin [34, 35].

a.*Phlebotomus* spp. (sandfly). (Old World).

**Figure 3.** *World CL distribution in the last 10 years [19].*

## **3. Epidemiology of leishmaniasis according to vector**

a.*Phlebotomus* spp. (sandfly). (Old World).

b.*Lutzomyia* spp. (New World).

Humidity and moisture, whether from rainfall or in the soil, have often been identified as important for the sandfly, with humidity influencing breeding and resting [6].

Sandflies belonging to either *Phlebotomus* spp. (Old World) or *Lutzomyia* spp. (New World) are the primary vectors; domestic dogs, rodents, sloths, and opossums are amongst a long list of mammals that are either incriminated or suspected reservoir hosts [1, 21, 22]. Most of its foci in the Old World have a Mediterranean climate and sand fly vectors, usually *Phlebotomus* (Larroussius) species, *Phlebotomus* species (*P. papatasi*, *P. sergenti*, *Phlebotomus alexandri*, *P. tobbi*, *Phlebotomus syriacus*, *Phlebotomus neglectus*, *Phlebotomus perfiliewi*, *Phlebotomus galilaeus*, *Phlebotomus transcaucasicus*, and *Phlebotomus halepensis*) two *Sergentomyia* species (*Sergentomyia theodori* and *Sergentomyia dentata*), (*Phlebotomus ariasi* and *Phlebotomus perniciosus*, *Phlebotomus longicuspis*) can diapauses for human visceral leishmaniasis [21–24].

In contrast to malaria, there is little evidence for the effect of vector control in leishmaniasis because terrestrial habitat of *Phlebotomus* is mostly unknown.

### **4. Host**

*Current Topics in Neglected Tropical Diseases*

reservoirs are dogs and monkeys [12].

healed in 6 months [12].

and Southern Europe.

(**Figures 2** and **3**) [18].

*L. peruviana* infection causes solitary or multiple painless dermal lesions they usually subsided spontaneously in 4–5 months. This infection is called uta [16]. Lesions of *L. panamensis* are ulcers without spontaneous improvement the

*L. garnhami* usually causes solitary or multiple lesions and may spontaneously be

The Eastern Hemisphere (Old World): leishmaniasis is found in some parts of Asia, the Middle East, Africa (especially in the tropical region and North Africa),

The Western Hemisphere (New World), leishmaniasis is found in some parts of Mexico, Central America, and South America. It is not found in Chile or Uruguay. Leishmaniasis is seen in most tropical and subtropical regions with climate, mainly in South and Central America, Africa, Asia, and Southern Europe. The leishmaniasis is considered as one of the neglected tropical diseases (NTD)

*L. venezuelensis* generally causes solitary painless nodular lesion. [12, 17].

**138**

**Figure 3.**

**Figure 2.**

*World CL distribution in the last 10 years [19].*

*World VL distribution in the last 10 years [19].*

#### **4.1 Human**

*Leishmania* species are transmitted to human via vectors, blood transfusion, organ transplantation or vertically via transplacental route. Other factors that cause the transmission of the disease are contact with contaminated materials or needle stick injuries in the labs [25–27].

*Leishmania*-infected humans especially in poor socioeconomic conditions play a pivotal role as a reservoir in transmission of the agent to vectors or to other hosts. In another words, one can say that human beings contribute the disease transmission by themselves [26, 27]. Poor living conditions in adobe, wooden houses, barns create a tendency towards an increase of vectors [27–29].

In all three clinical types of *Leishmania* spp., antimonials (sodium stibogluconate [SSG]), miltefosin (MIL), amfoterisin B (AmB) veparomomisin (PMM)) are being used [30]. Children and people with immune suppression, HIV infection or malignant diseases cause rapid spread of leishmaniasis. Apart from these, undiagnosed or untreated infected people create an important risk factor. Especially drug resistance and high expense of the medication cause insufficient treatment [27–29]. The first drug resistance was reported in VL treatment against SSG and against MIL, in India and Nepal, respectively [31–33]. Later, resistance against MIL was also reported in one patient with HIV and another two patients with Indian origin [34, 35].

Verma et al. showed that the effectiveness of PMM was decreased by 6 times for the promastigote forms of *L. donavani* [36]. Invasion of macrophages by PMM-R parasites led to increased nitric oxide (NO), whereas the levels of reactive oxygen species (ROS) remained unchanged. This finding shows resistance of *Leishmania* spp. against PMM [36]. Similarly, Deep et al., reported high recurrence rates in patients with VL and PKDL when treated with MIL [37].

In conclusion, due to immune problems of the patient, co-existence of other diseases, inappropriate use of the drugs during the medical treatment of leishmaniasis, "drug resistance" may occur via gene over-expression, deletion, single nucleotide


**141**

*Leishmanias***pecies**

*Le.* (*V.*) *braziliensis*

*Le.* (*V.*) *peruviana*

*Le.* (*V.*) *guyanensis*

*Le.* (*V.*) *panamensis*

*Le.* (*V.*) *shawi* *Le.* (*V.*) *lainsoni*

*Le.* (*V.*) *colombiensis*

*Le.* (*V.*) *naiffi* *Le.* (*Le.*) *amazonensis*

*Le.* (*Le.*) *mexicana*

*Le.* (*Le.*) *venezuelensis*

*Synphlebotomus La., Larroussius; Lu., Lutzomyia.*

**Table 2.**

*Disease types and transmission cycles of leishmaniasis worldwide [6, 20, 21].*

ZCL, DCL

Northern Venezuela

ZCL, DCL,

West of Andes, southern United States: not

ML

Peru

ZCL, DCL

East of Andes: not Guyana, Paraguay

Silvatic, non-climax

Terrestrial rodents,

Marsupials

forest

Silvatic, non-climax

Terrestrial rodents,

*L.* (*Ny.*) *olmecaolmeca*

Marsupials

Unknown

*L.* (*Ny.*) *olmecabicolor*

forest

Silvatic *Abbreviations: TC, transmission cycle; A, anthroponotic; Z, zoonotic; V, visceral; C, cutaneous; M, mucosal; D, diffuse; L, leishmaniasis. P., Phlebotomus; Pa., Paraphlebotomus; Pf., Pifanomyia; Sy.,* 

ZCL ZCL

Panama, Colombia, Venezuela

Brazil, French Guiana, Panama

Silvatic Silvatic

*Choloepushoffmanni*

*Dasypusnovemcinctus*

ZCL

Bolivia, Peru, Brazil, French Guiana, Suriname

Silvatic

Rodent *Agouti paca*

ZCL

Brazil

Silvatic

Arboreal

ZCL, ML

ZCL, ML

East of Andes: not Paraguay

West of Andes, northern Venezuela: not Mexico, Belize, El Salvador

Silvatic Silvatic

Arboreal edentates, others

Arboreal edentates, others

*L.* (*Ny.*) *umbratilis*

*L.* (*Ny.*) *trapidoi L.* (*Ny.*) *ylephiletor L.* (*Ny.*) *edentula L.* (*Tricholateralis*) *gomezi*

*L.* (*Trichophoromyia*) *ubiquitalis L.*

(*Pf.*) *nuneztovari*

*L.* (*Trichophoromyia*) *ubiquitalis L.*

(*Pf.*) *nuneztovari*

*L.* (*He.*) *hartmanni*

*L.* (*Ps.*) *ayrozai* and other species *L.*

(*Ny.*) *trapidoi*c

*L.* (*Ny.*) *flaviscutellata*

ZCL, ML

Peru

ZCL, ML

**Disease**

**Countries (suspected)**

West of Andes, northern Venezuela: not El Salvador

**Landscapes** Peridomestic, silvatic Peridomestic, silvatic

Rodents, marsupials, dog

*L.* (*He.*) *peruensis*s.l. *L.* (*Pf.*) *verrucarum*s.l.

**Reservoir hosts**

Rodents, marsupials, dog

*L.* (*Pifanomyia*) *ovallesi*

**Vector**

*Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

#### *Current Topics in Neglected Tropical Diseases*


### *Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

*Current Topics in Neglected Tropical Diseases*

*P. (Pa.) alexandri*, *P. (Ad.)* species

*P.* (*Larroussius*) *orientalis*

**140**

*Leishmanias***pecies**

**Old World**

*L. donovani* *L. donovani* *L. donovanib* (*L.* 

AVL, ZVL,

ML

*archibaldi*)

*L. donovanib* (*L.* 

AVL, DCL

Sudan, Ethiopia, Kenya, (Uganda)

Rural,

Human anthroponosis

*P. (Sy.) martini*

savannatermite

mounds

Rural, peri-domestic

Domestic dog, wild

*P. (La.) ariasi*, *perniciosus*

canids, domestic cat

*archibaldi*)

*L. infantum* *L. infantumc* (*L. chagasi*)

*L. major* *Le.* (*Le.*) *tropica*

*Le.* (*Le.*) *tropicac (Le.*

ZCL

North Africa, MiddleEast, Sub-Saharan Africa

Rural Rural, Rocky

Hyraxes

highlands

(*Le.*) *killicki*)

*Le.* (*Le.*) *aethiopica*;

**New World**

*Leishmania* (*Leishmania*)

ZVL, ZCL

Latin America: not Peru, Guianas

Peridomestic,

Domestic dog

*Lutzomyia* (*Lutzomyia*) *longipalpis*s.l.

including suburbs

Peridomestic,

Rodents, marsupials, dog

*L.* (*Psychodopygus*) *wellcomei L.*

(*Nyssomyia*) *neivai L.* (*Ny.*) *whitmani*

silvatic

*infantum*

*Leishmania*(*Viannia*)

ZCL, ML

East of Andes: not Guyana, Suriname

*braziliensis*

ZCL,DCL,

Ethiopia, Kenya

ML

ACL

North Africa, Middle East, Iran, Afghanistan

Urban

Peridomestic, including

*P.* (*Paraphlebotomus*) *sergenti*

suburbs; human

Rockyarid; hyraxes,

*P.* (*Adlerius*) *arabicus P.* (*La.*)

*guggisbergi*

*P.* (*La.*) *longipes P.* (*La.*) *pedifer*

Rodents

VL, CL

ZCL

ZVL, ZCL

Med Europe, North Africa, Southwest Asia,

People's Republic of China

Latin America: not Peru or Guianas

North Africa, Ethiopia, Kenya, Sudan, Meadle

Asia India

Rural, peri-domestic

Peri-domestic

Domestic dog, wild canids

Human anthroponosis

*Lu. (L.) longipalpis*

*P. papatasi*, *P. duboscqi*

AVL

AVL, DCL,

Northeast India, Nepal, Bangladesh, (Bhutan),

Rural, peri-domestic

Human anthroponosis

*P. (Eu.) argentipes, P. (La.) orientalis*,

*P. (Sy.) martini*

Sri Lanka, Republic of China, Sudan, Ethiopia,

(Chad), (Yemen), Kenya

People's Republic of China

Sudan, Ethiopia, (Chad), (Yemen)

Rural, peri-domestic

Rural, *Acacia—*

Human anthroponosis

*Balanites* forest

Unknown

CL

**Disease**

**Countries (suspected)**

**Landscapes**

**Reservoir hosts**

**Vector**

*Synphlebotomus La., Larroussius; Lu., Lutzomyia.*

## **Table 2.**

*Disease types and transmission cycles of leishmaniasis worldwide [6, 20, 21].*

polymorphisms generating stop codons or amplification of sets of genes [38–40]. This very important for epidemiological standpoint and thus proper use of drugs when needed should be stressed, and also new drug formulations and/or vaccine should be investigated.

Technological advances let the people travel all over the world. This may cause vectored spread or spread directly by infected people [41].

#### **4.2 Dogs**

Dogs are very important in terms of the epidemiology of leishmaniasis. All forms of leishmaniasis namely cutaneous, mucocutaneous and visceral types may be found in dogs. Since the infected dogs are important reservoir of the disease, their controls and treatments are mandatory for the disease control. Dogs as pets are being controlled by vets however stray or wild dogs, fox species like *Lycalopex vetulus* [42], *Cerdocyonthous* [43] may cause outbreaks. Dogs are natural hosts for *L. infantum*, *L. chagasi*, *L. tropica* and *L. peruviana* as well as being infected by them. Especially they are endemic in dogs in Mediterranean region, Asia and Latin America. *Leishmania infantum* is the causative agent of visceral leishmaniasis and it is prevalent especially in Mediterranean region. Vectors for this type are *Phlebotomus ariasi*, *P. major*, *P. perniciosus*, *P. longicuspis*, *P. chiensis*, *P. mongolensis*, *P. papatasi* [44, 45]. In the same region, the causative agent of zoonotic cutaneous leishmaniasis is *L. tropica* and the vectors are *P. perfilievi*, *P. papatasi* and *P. sergenti* [1, 46]. In South America, the causative agent of canine cutaneous leishmaniasis is *L. chagasi* and the vectors are *Lu. longipalpalis*, *Lu. evansi*, *Lu. gomezi* [1].

#### **4.3 Rodents**

Comparing to dogs, eradication of the infectious agent of leishmaniasis from the rodents is more difficult and even sometimes impossible.

Different rodents such as *Didelphis albiventris* (opossum), *Mus musculus* (domestic mouse), *Microtus socialis*, *Rattusrattus* (black rat), *Cercomys cunicularius* (wild rat), *Mesocricetus auratus* (Syrian hamsters) in America, Africa and Asia lead to spread of leishmaniasis [47–51].

*Phlebotomus papatasi*, vector of *L. tropica*, transmitted cutaneous leishmaniasis to small rodents such as *Psammomys obesus* (Israel), *Meriones crassus* (Israel), *Meriones libycus* (Iran), *Rhombomys opimus* (Iran), *Rhombomys opimus* (Iran), *Meriones sacramenti* (Egypt) [9].

*Rattus rattus* and *Rattus norvegicus* have been found naturally infected with *L. infantum* in the Mediterranean and in Next Orient endemic areas (**Table 2**) [49, 52, 53].

## **5. Transmission cycle**

There are two different types of transmission;

1.In many geographic areas, infected people are not needed to sustain the transmission cycle of the parasite in nature; transmission cycle continue via the infected animals (rodents or dogs, felines). *Leishmania* infection in reservoir animals are specifically named; if it is in dogs, it is named as canine leishmaniasis whereas in cats, it is called feline leishmaniasis dogs species of *Leishmania* species in the reservoir in animals, canine leishmaniasis, which is in feline called leishmaniasis. *L. infantum* is the most common and important cause of canine leishmaniasis worldwide. The **zoonotic transmission** of *L.* 

**143**

leishmaniasis.

**7. Summary**

*Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

**transmission**.

prevention of leishmaniasis [54, 55].

*infantum*, from canine to humans, is not only in the Mediterranean region where it may have originated, but also it may be found in many of the drier regions of Latin America. *Leishmania* species reported from dogs include *L. mexicana*, *L. donovani*, and *L. braziliensis*. These *Leishmania* species are occasionally reported from the cats. Cats are at risk of infection especially in

2.In some parts of the world, infected people are needed to sustain the cycle; this kind of transmission (human—*Phlebotomus*—human) is called **anthroponotic** 

Full knowledge on these two transmission cycles is very important in effective

Unlike other parasites, it is extremely difficult to eradicate whole kinds of species of *Leishmania* in nature. This is contrary to some other parasites. As example *Plasmodium vivax* is specific to human, thus it can be eradicated by vector control.

There are many check points to establish the control of the disease. Firstly, all patients with leishmaniasis should be properly treated. *Leishmania* transmission is dependent on the togetherness of contaminated sandflies with the reservoir hosts, and humans. Additionally, climatic and environment factors are important, too. As the development of chemical insecticides use such as dichlorodiphenyltrichloroethane (DDT) against mosquito was a key component of the eradication, similarly they were proposed to have an effect on the sandflies, vectors of visceral leishmaniasis [56–58]. Since DDT use is found to be harmful to the environment and people, its use is prohibited by the World Health Organization [59]. At the moment there isn't any strategy to control *Phlebotomine* by using insecticides by governments [60, 61]. Preliminary experiments for developing a vaccine against *Leishmania* spp. was reported [62]. However, the vaccine did not appear to protect against visceral leishmaniasis [63]. fucose-mannose ligand from an extract of *L. donovani* has been used in conjunction with a saponin adjuvant in attempts to vaccine [64]. Further studies are needed to develop an effective vaccine against

Leishmaniasis is still an important parasite disease in all over the world. The reasons are presence of many different species of *Leishmania*, and their ability to survive in many different organisms, such as vectors, dogs, rodents, humans. *Leishmania* spp. may cause different clinical scenarios by affecting different tissues and organs. As eukaryotic cells, *Leishmania* spp. can survive in the immune system of the most advanced organism, human. Presence of amastigote forms even in the

Leishmaniasis is an important public health problem. Thus, relevant public health policies such as education of the people especially in endemic areas, multidisciplinary approach, diagnosis, treatment will be helpful in the elimination of the disease. Additionally, further epidemiological studies as well as vaccination studies

**6. Effect of deteriorated eco-system on spread of leishmaniasis**

areas where these parasites are endemic [6, 54, 55].

However, this is not the case for *Leishmania* spp. [54, 55].

hosts' defensive cells shows the strength of the parasite.

will continue to strive for eradication.

*Current Topics in Neglected Tropical Diseases*

should be investigated.

**4.2 Dogs**

**4.3 Rodents**

spread of leishmaniasis [47–51].

*Meriones sacramenti* (Egypt) [9].

**5. Transmission cycle**

polymorphisms generating stop codons or amplification of sets of genes [38–40]. This very important for epidemiological standpoint and thus proper use of drugs when needed should be stressed, and also new drug formulations and/or vaccine

Technological advances let the people travel all over the world. This may cause

Dogs are very important in terms of the epidemiology of leishmaniasis. All forms of leishmaniasis namely cutaneous, mucocutaneous and visceral types may be found in dogs. Since the infected dogs are important reservoir of the disease, their controls and treatments are mandatory for the disease control. Dogs as pets are being controlled by vets however stray or wild dogs, fox species like *Lycalopex vetulus* [42], *Cerdocyonthous* [43] may cause outbreaks. Dogs are natural hosts for *L. infantum*, *L. chagasi*, *L. tropica* and *L. peruviana* as well as being infected by them. Especially they are endemic in dogs in Mediterranean region, Asia and Latin America. *Leishmania infantum* is the causative agent of visceral leishmaniasis and it is prevalent especially in Mediterranean region. Vectors for this type are *Phlebotomus ariasi*, *P. major*, *P. perniciosus*, *P. longicuspis*, *P. chiensis*, *P. mongolensis*, *P. papatasi* [44, 45]. In the same region, the causative agent of zoonotic cutaneous leishmaniasis is *L. tropica* and the vectors are *P. perfilievi*, *P. papatasi* and *P. sergenti* [1, 46]. In South America, the causative agent of canine cutaneous leishmaniasis is

*L. chagasi* and the vectors are *Lu. longipalpalis*, *Lu. evansi*, *Lu. gomezi* [1].

rodents is more difficult and even sometimes impossible.

There are two different types of transmission;

Comparing to dogs, eradication of the infectious agent of leishmaniasis from the

Different rodents such as *Didelphis albiventris* (opossum), *Mus musculus* (domestic mouse), *Microtus socialis*, *Rattusrattus* (black rat), *Cercomys cunicularius* (wild rat), *Mesocricetus auratus* (Syrian hamsters) in America, Africa and Asia lead to

*Phlebotomus papatasi*, vector of *L. tropica*, transmitted cutaneous leishmaniasis to small rodents such as *Psammomys obesus* (Israel), *Meriones crassus* (Israel), *Meriones libycus* (Iran), *Rhombomys opimus* (Iran), *Rhombomys opimus* (Iran),

*Rattus rattus* and *Rattus norvegicus* have been found naturally infected with *L. infantum* in the Mediterranean and in Next Orient endemic areas (**Table 2**) [49, 52, 53].

1.In many geographic areas, infected people are not needed to sustain the transmission cycle of the parasite in nature; transmission cycle continue via the infected animals (rodents or dogs, felines). *Leishmania* infection in reservoir animals are specifically named; if it is in dogs, it is named as canine leishmaniasis whereas in cats, it is called feline leishmaniasis dogs species of *Leishmania* species in the reservoir in animals, canine leishmaniasis, which is in feline called leishmaniasis. *L. infantum* is the most common and important cause of canine leishmaniasis worldwide. The **zoonotic transmission** of *L.* 

vectored spread or spread directly by infected people [41].

**142**

*infantum*, from canine to humans, is not only in the Mediterranean region where it may have originated, but also it may be found in many of the drier regions of Latin America. *Leishmania* species reported from dogs include *L. mexicana*, *L. donovani*, and *L. braziliensis*. These *Leishmania* species are occasionally reported from the cats. Cats are at risk of infection especially in areas where these parasites are endemic [6, 54, 55].

2.In some parts of the world, infected people are needed to sustain the cycle; this kind of transmission (human—*Phlebotomus*—human) is called **anthroponotic transmission**.

Full knowledge on these two transmission cycles is very important in effective prevention of leishmaniasis [54, 55].

## **6. Effect of deteriorated eco-system on spread of leishmaniasis**

Unlike other parasites, it is extremely difficult to eradicate whole kinds of species of *Leishmania* in nature. This is contrary to some other parasites. As example *Plasmodium vivax* is specific to human, thus it can be eradicated by vector control. However, this is not the case for *Leishmania* spp. [54, 55].

There are many check points to establish the control of the disease. Firstly, all patients with leishmaniasis should be properly treated. *Leishmania* transmission is dependent on the togetherness of contaminated sandflies with the reservoir hosts, and humans. Additionally, climatic and environment factors are important, too.

As the development of chemical insecticides use such as dichlorodiphenyltrichloroethane (DDT) against mosquito was a key component of the eradication, similarly they were proposed to have an effect on the sandflies, vectors of visceral leishmaniasis [56–58]. Since DDT use is found to be harmful to the environment and people, its use is prohibited by the World Health Organization [59]. At the moment there isn't any strategy to control *Phlebotomine* by using insecticides by governments [60, 61]. Preliminary experiments for developing a vaccine against *Leishmania* spp. was reported [62]. However, the vaccine did not appear to protect against visceral leishmaniasis [63]. fucose-mannose ligand from an extract of *L. donovani* has been used in conjunction with a saponin adjuvant in attempts to vaccine [64]. Further studies are needed to develop an effective vaccine against leishmaniasis.

## **7. Summary**

Leishmaniasis is still an important parasite disease in all over the world. The reasons are presence of many different species of *Leishmania*, and their ability to survive in many different organisms, such as vectors, dogs, rodents, humans. *Leishmania* spp. may cause different clinical scenarios by affecting different tissues and organs. As eukaryotic cells, *Leishmania* spp. can survive in the immune system of the most advanced organism, human. Presence of amastigote forms even in the hosts' defensive cells shows the strength of the parasite.

Leishmaniasis is an important public health problem. Thus, relevant public health policies such as education of the people especially in endemic areas, multidisciplinary approach, diagnosis, treatment will be helpful in the elimination of the disease. Additionally, further epidemiological studies as well as vaccination studies will continue to strive for eradication.

*Current Topics in Neglected Tropical Diseases*

## **Author details**

Tonay Inceboz Department of Parasitology, Medical Faculty, Dokuz Eylul University, Izmir, Turkey

\*Address all correspondence to: tonay.inceboz@gmail.com

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**145**

*Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

[1] WHO Expert Committee. Control of the leishmaniasis: Report of a

[2] Ghaffar A. Microbiology and Immunology Online, Parasıtology— Chapter Two Blood and Tıssue Protozoa Part 1 Trypanosomiasıs and Leishmaniasis. 2013. Available from: http://www.microbiologybook.org/ parasitology/blood-proto.htm

[3] Okwor I, Uzonna J. Social and economic burden of human leishmaniasis. The American Journal of Tropical Medicine and Hygiene. 2016;**94**(3):489-493. DOI: 10.4269/

meeting of the WHO Expert Committee on the Control of Leishmaniases, Geneva, 2010; 22-26 March. WHO Technical Report Series; 949:1-186. Available from: http://apps.who.int/ iris/bitstream/10665/44412/1/WHO\_

[8] Krotoski MJ. Medical Parasitology. 8th ed. London: W.B. Saunders Company; 1999. pp. 147-154

[9] Klaus SN, Frankenburg H, Ingber A. Epidemiology of cutaneous leishmaniosis. Clinical Dermatology. 1999;**17**:257-260. DOI: 10.1016/ S0738-081X(99)00043-7

[10] Bensaid M, Guerbouj S, Saghrouni

[11] Özbel Y, Töz ÖS. Leishmaniosis. In: Özcel MA, editor. Tıbbi Parazit Hastalıkları. 1.Baskı ed. İzmir: Meta Basım Matbacılık Hizmetleri; 2007.

[12] Achtman JC, Ellis DL, Saylors B, Boh EE. Cutaneous leishmaniasis caused by *Leishmania* (Viannia) panamensis in 2 travelers. JAAD Case Reports. 2016;**2**:95-97. DOI: 10.1016/j.

pp. 198-230

jdcr.2015.11.018

[13] Marsden PD. Mucosal

[14] Calvopiña M, Martinez L,

DOI: 10.4269/ajtmh.12-0690

[15] Lainson R, Shaw JJ, Ready PD, Miles MA, Póvoa M. Leishmaniasis in Brazil: XVI. Isolation and identification of *Leishmania* species from sandflies, wild mammals and man in north Para

Hashiguchi Y. Cutaneous leishmaniasis "chiclero's ulcer" in subtropical Ecuador. The American Journal of Tropical Medicine and Hygiene. 2013;**89**:195-196.

leishmaniasis ("espundia" Escomel, 1911). Transactions of the Royal Society of Tropical Medicine and Hygiene. 1986;**80**:859-876. DOI: 10.1016/0035-9203(86)90243-9

F, Fathallah-Mili A, Guizani I. Occurrence of *Leishmania infantum* cutaneous leishmaniasis in Central Tunisia. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2006;**100**:521-526. DOI: 10.1016/j.trstmh.2005.08.012

**References**

TRS\_949\_eng.pdf

ajtmh.15-0408

[4] Zijlstra EE. Visceral

2016;**101**(6):561-567

leishmaniasis: A forgotten epidemic. Archives of Disease in Childhood.

[6] Ready PD. Biology of phlebotomine sand flies as vectors of disease agents. Annual Review of Entomology. 2013;**58**:227-250. DOI: 10.1146/ annurev-ento-120811-153557

[7] de Vries HJ, Reedijk SH, Schallig HD. Cutaneous leishmaniasis: Recent developments in diagnosis and management. American Journal of Clinical Dermatology. 2015;**16**:99-109. DOI: 10.1007/s40257-015-0114-z

[5] Gouzelou E, Haralambous C, Antoniou M, Christodoulou V, Martinković F, Živičnjak T, et al. Genetic diversity and structure in *Leishmania infantum* populations from southeastern Europe revealed by microsatellite analysis. Parasites & Vectors. 2013;**6**:342. DOI: 10.1186/1756-3305-6-342

*Epidemiology and Ecology of Leishmaniasis DOI: http://dx.doi.org/10.5772/intechopen.86359*

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[2] Ghaffar A. Microbiology and Immunology Online, Parasıtology— Chapter Two Blood and Tıssue Protozoa Part 1 Trypanosomiasıs and Leishmaniasis. 2013. Available from: http://www.microbiologybook.org/ parasitology/blood-proto.htm

[3] Okwor I, Uzonna J. Social and economic burden of human leishmaniasis. The American Journal of Tropical Medicine and Hygiene. 2016;**94**(3):489-493. DOI: 10.4269/ ajtmh.15-0408

[4] Zijlstra EE. Visceral leishmaniasis: A forgotten epidemic. Archives of Disease in Childhood. 2016;**101**(6):561-567

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[15] Lainson R, Shaw JJ, Ready PD, Miles MA, Póvoa M. Leishmaniasis in Brazil: XVI. Isolation and identification of *Leishmania* species from sandflies, wild mammals and man in north Para

**144**

**Author details**

Tonay Inceboz

Turkey

provided the original work is properly cited.

*Current Topics in Neglected Tropical Diseases*

© 2019 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Parasitology, Medical Faculty, Dokuz Eylul University, Izmir,

\*Address all correspondence to: tonay.inceboz@gmail.com

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## *Edited by Alfonso J. Rodriguez-Morales*

Neglected tropical diseases (NTDs) is a diverse group of communicable diseases that prevail in tropical and subtropical conditions in 149 countries. NTDs affect more than one billion people and cost developing economies billions of dollars every year. According to the World Health Organization (WHO), NTDs mainly affect populations living in poverty, without adequate sanitation, and in close contact with infectious vectors, domestic animals, and livestock. Migration, as well as climate change and variability, are key factors in NTD prevalence. Therefore, NTDs deserve more study. Recently, viruses transmitted by vectors (arboviruses) that affect not only people living in the tropics, but also travelers and migrating populations, have been causing epidemics. Examples of these viruses include Dengue, Chikungunya, Zika, Mayaro, and encephalitis viruses. These viruses emerge and reemerge in multiple regions of the world, as occurred in the Americas recently (2013-2017) with Chikungunya and Zika. This book aims to update the significant epidemiological and clinical research of NTDs in many aspects with a multinational perspective.

Published in London, UK © 2019 IntechOpen © ConstantinCornel / iStock

Current Topics in Neglected Tropical Diseases

IntechOpen Book Series

Infectious Diseases, Volume 3

Current Topics in Neglected

Tropical Diseases

*Edited by Alfonso J. Rodriguez-Morales*