**2. Current situation of leishmaniasis in Tunisia**

Tunisia is located in Northern Africa, bordering the Mediterranean sea between Algeria and Libya. Its climate is of the hot temperate Mediterranean type. Bioclimatic zones range from humid in the north to saharian in the extreme south (Figure 1).

The country is divided into 24 governorates, each composed of a variable number of "delegations"; and each delegation is subdivided into localities also named "imadas" (Figure 2). Four forms of leishmaniasis are known to occur in Tunisia: i) the sporadic cutaneous leishmaniasis (SCL); ii) the chronic cutaneous leishmaniasis (CCL); iii) the zoonotic cutaneous leishmaniasis (ZCL); iv) the visceral leishmaniasis (VL).

#### **2.1 The sporadic cutaneous leishmaniasis (SCL)**

This form is caused by dermotropic zymodemes of *Leishmania infantum*, mainly the zymodeme MON 24 and to a lesser extent MON 1 (Aoun et al., 2000, 2008; Ben Ismail et al, 1986, 1992; Gramiccia et al., 1991; Haouas et al., 2007; Kallel et al., 2005, 2008b). The dog is supposed to be the reservoir as it is the case for the viscerotropic zymodemes and *Phlebotomus perfiliewi* as the phletotomine vector. But other vectors can not be excluded; following an outbreak of SCL in the locality of Oued Souani, le Kef governorate, *P. langeroni* was found infected by *L. infantum* (Guerbouj et al., 2007).

Retrospective Analysis of Leishmaniasis in

composed of 4 governorates).

Central Tunisia: An Update on Emerging Epidemiological Trends 229

Fig. 2. Map of Tunisia showing its subdivision into 24 governorates (Grand Tunis is

Table 1. Number of recorded sporadic cutaneous leishmaniasis cases since 1945.

Clinically, SCL is characterized in more than 90 % of patients by a small single ulcerated or lupoid lesion of the face that often lasts longer than one year and up to three years (Bel Hadj et al., 1996; Ben Ismail & Ben Rachid, 1989; Chaffai et al, 1988; Masmoudi et al., 2007). On a parasitological level, amastigotes of *L. infantum* are smaller than those of *L. major*, usually

**Years Nb of cases Median**  1945-55 10 1.0 1956-67 17 1.4 1968-78 84 8.4 1979-89 151 15.1 1990-99 217 21.7 2000-10 652 59.3 Total 1131 17.1

Fig. 1. Map of Tunisia showing the distribution of bioclimatic zones.

SCL was first described in 1917 in a patient from Sakiet Sidi Youssef (Le Kef governorate) located next to the Algerian frontier (Nicolle & Blanc, 1917), and again in 1945 (Chadli et al., 1968; Vermeil, 1956). Since 1945, the disease has sporadically been reported with, however, an incidence that gradually increased from a median of one case /year between 1945 and 1955 to 22 cases /year in the 1990s and 59 cases/year in the 2000s (Table 1; Anonymous ; Ben Abda et al., 2009; Ben Said et al., 2006; Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1983, 1992; Chadli et al., 1968 ; Chaffai et al., 1988; Ladjimi & Lakhoua, 1955 ; Vermeil, 1956). SCL has long been supposed to be confined to the humid and subhumid bioclimatic areas north to the "dorsale" or "tunisian Ridge" (the eastern extension of the Atlas mountains), in rural areas where its distribution overlaps with that of VL (Ben Ismail et al., 1989; Ben Rachid et al., 1983; Ben Rachid & Ben Ismail, 1989; Chadli et al., 1986 ; Vermeil, 1956). However, over the last three decades, many cases originating from central Tunisia governorates (Monastir, Sousse, Mahdia and Kairouan) and referred to our laboratory were found to be very suggestive of SCL on the basis of epidemiological, clinical and parasitological criteria. Typed strains obtained from some of these patients proved indeed to be *L. infantum* (Ben Said et al., 2006). These data were very indicative of SCL spread towards the south of the country. These findings were further confirmed by additional reports (Aoun et al, 2000, 2008; Ben Abda et al., 2009; Kallel et al., 2008a, 2008b). The revised SCL distribution is shown in figure 3. SCL usually occurs sporadically within no particular season. However, over the last few years, local outbreaks were reported like that of Sidi Bourouis in Siliana governorate, which involved more than 30 patients over a short period (Bel Hadj et al., 2003).

Fig. 1. Map of Tunisia showing the distribution of bioclimatic zones.

more than 30 patients over a short period (Bel Hadj et al., 2003).

SCL was first described in 1917 in a patient from Sakiet Sidi Youssef (Le Kef governorate) located next to the Algerian frontier (Nicolle & Blanc, 1917), and again in 1945 (Chadli et al., 1968; Vermeil, 1956). Since 1945, the disease has sporadically been reported with, however, an incidence that gradually increased from a median of one case /year between 1945 and 1955 to 22 cases /year in the 1990s and 59 cases/year in the 2000s (Table 1; Anonymous ; Ben Abda et al., 2009; Ben Said et al., 2006; Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1983, 1992; Chadli et al., 1968 ; Chaffai et al., 1988; Ladjimi & Lakhoua, 1955 ; Vermeil, 1956). SCL has long been supposed to be confined to the humid and subhumid bioclimatic areas north to the "dorsale" or "tunisian Ridge" (the eastern extension of the Atlas mountains), in rural areas where its distribution overlaps with that of VL (Ben Ismail et al., 1989; Ben Rachid et al., 1983; Ben Rachid & Ben Ismail, 1989; Chadli et al., 1986 ; Vermeil, 1956). However, over the last three decades, many cases originating from central Tunisia governorates (Monastir, Sousse, Mahdia and Kairouan) and referred to our laboratory were found to be very suggestive of SCL on the basis of epidemiological, clinical and parasitological criteria. Typed strains obtained from some of these patients proved indeed to be *L. infantum* (Ben Said et al., 2006). These data were very indicative of SCL spread towards the south of the country. These findings were further confirmed by additional reports (Aoun et al, 2000, 2008; Ben Abda et al., 2009; Kallel et al., 2008a, 2008b). The revised SCL distribution is shown in figure 3. SCL usually occurs sporadically within no particular season. However, over the last few years, local outbreaks were reported like that of Sidi Bourouis in Siliana governorate, which involved

Fig. 2. Map of Tunisia showing its subdivision into 24 governorates (Grand Tunis is composed of 4 governorates).


Table 1. Number of recorded sporadic cutaneous leishmaniasis cases since 1945.

Clinically, SCL is characterized in more than 90 % of patients by a small single ulcerated or lupoid lesion of the face that often lasts longer than one year and up to three years (Bel Hadj et al., 1996; Ben Ismail & Ben Rachid, 1989; Chaffai et al, 1988; Masmoudi et al., 2007). On a parasitological level, amastigotes of *L. infantum* are smaller than those of *L. major*, usually

Retrospective Analysis of Leishmaniasis in

Fig. 4. Actual distribution of chronic cutaneous leishmaniasis.

Surprisingly, over the last decade, cases of CCL were reported in patients originating from areas where this form has never been previously reported, the first case being in a child from Meknassy in Sidi Bouzid governorate (Haouas et al., 2005). Later, additional cases were reported from Kairouan, Gafsa and Siliana governorates, very far from the classical foci of Tataouine (Aoun et al., 2008; Ben Abda et al., 2009; Bouratbine et al., 2005).

1986; Sang et al., 1994).

Central Tunisia: An Update on Emerging Epidemiological Trends 231

annual incidence of 10 cases /year (Figure 4; Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1983, 1992; Chadli et al., 1968). CCL was first reported in 1957 and nearly nothing was known about the disease before this date. In 1979, an outbreak involving 47 individuals arose in Tataouine; and the epidemiological investigation, which included the isoenzymatic typing of strains isolated from the patients, led to the identification of the parasite as the MON 8 zymodeme of *L. tropica*, named *L*. *killicki,* a species previously described in Kenya, Namibia, Yemen and, more recently in Algeria and Libya (Harrat et al., 2009; Rioux et al.,

less than 3 , and promastigotes are difficult to maintain on NNN medium (Aoun et al., 2000, 2003).

: corresponds to the classical distribution of the cases; : illustrates the emerging distribution of cases. Fig. 3. Updated distribution of sporadic cutaneous leishmaniasis in Tunisia.

#### **2.2 The chronic cutaneous leishmaniasis (CCL)**

Formerly known as anthroponotic CL, CCL sporadically occurs in micro-foci located in the south-eastern presaharian and saharian areas of Tunisia. Its distribution is rural, sub-urban and urban; and cases are reported from houses, farms, and even from troglodytes of Tataouine (Tataouine governorate) and Matmata (Gabès governorate), with a median

less than 3 , and promastigotes are difficult to maintain on NNN medium (Aoun et al.,

: corresponds to the classical distribution of the cases; : illustrates the emerging distribution of cases.

Formerly known as anthroponotic CL, CCL sporadically occurs in micro-foci located in the south-eastern presaharian and saharian areas of Tunisia. Its distribution is rural, sub-urban and urban; and cases are reported from houses, farms, and even from troglodytes of Tataouine (Tataouine governorate) and Matmata (Gabès governorate), with a median

Fig. 3. Updated distribution of sporadic cutaneous leishmaniasis in Tunisia.

**2.2 The chronic cutaneous leishmaniasis (CCL)** 

2000, 2003).

annual incidence of 10 cases /year (Figure 4; Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1983, 1992; Chadli et al., 1968). CCL was first reported in 1957 and nearly nothing was known about the disease before this date. In 1979, an outbreak involving 47 individuals arose in Tataouine; and the epidemiological investigation, which included the isoenzymatic typing of strains isolated from the patients, led to the identification of the parasite as the MON 8 zymodeme of *L. tropica*, named *L*. *killicki,* a species previously described in Kenya, Namibia, Yemen and, more recently in Algeria and Libya (Harrat et al., 2009; Rioux et al., 1986; Sang et al., 1994).

Fig. 4. Actual distribution of chronic cutaneous leishmaniasis.

Surprisingly, over the last decade, cases of CCL were reported in patients originating from areas where this form has never been previously reported, the first case being in a child from Meknassy in Sidi Bouzid governorate (Haouas et al., 2005). Later, additional cases were reported from Kairouan, Gafsa and Siliana governorates, very far from the classical foci of Tataouine (Aoun et al., 2008; Ben Abda et al., 2009; Bouratbine et al., 2005).

Retrospective Analysis of Leishmaniasis in

as 0/00 000).

Central Tunisia: An Update on Emerging Epidemiological Trends 233

Fig. 5. Distribution of zoonotic cutaneous leishmaniasis according to incidence ( expressed

with an average of 4700 cases/year (Figure 7). The annual incidence showed the same fluctuations. It ranged between 3 0/00 000 in the less affected areas and > 500 in Kairouan, and > 1000 in Gafsa and Sidi Bouzid in 2004 (Anonymous). These fluctuations are at least in part related to the dynamics of rodents' populations. It was demonstrated that the distribution of *P. obesus* is of paramount importance in the epidemiology of the human disease (Ben Ismail et al., 1987a; Ben Ismail & Ben Rachid, 1989; Ben Salah et al., 2007; Fichet-Calvet et al., 2003). On the other hand, control programmes are undoubtedly very effective and beneficial in terms of incidence. Indeed, a rodent control project, consisting of ploughing lands with growing chenopods and reafforestation with acacia and other plants was launched in 1992 in Sidi Bouzid city and suburbs that resulted in a dramatic decrease in the incidence of the disease in the area; but the intensity of the epidemic grew again as soon as the control programme stopped (Figure 7). From the mid 2000s, similar control measures have been carried out again in Sidi Bouzid and then in Sidi El Heni

Hence the actual distribution and incidence of CCL need further investigations and obviously should be revised.

*L. killicki* is transmitted by *Phlebotomus sergenti*, but the reservoir is still debated. Median age of patients suffering of CCL is 21 years (Ben Abda et al., 2009; Ben Ismail & Ben Rachid, 1989). Clinically, CCL most often presents as single or very few lesions on the face or limbs, that are dry, extensive, and chronic, lasting for up to six years (Ben Abda et al., 2009; Ben Ismail & Ben Rachid., 1989; Chaffai et al., 1988; Masmoudi et al., 2007).

#### **2.3 The zoonotic cutaneous leishmaniasis (ZCL)**

ZCL is by far the most frequent and the most widely distributed form of CL in Tunisia where it constitutes a major public health problem. It is endemo-epidemic in extended areas of central and southern Tunisia (Figure 5). It is caused by *L. major* and transmitted by the zoo-anthropophilic *Phlebotomus papatasi* sandfly which is mainly encountered and caught in and around the rodent burrows, and less in and around human habitations (Ben Ismail et al., 1987b, 1987c; Ben Rachid et al., 1992; Ghrab et al., 2006; Helal et al., 1987). The reservoirs are rodents of the *Psammomys* and *Meriones* genera. The main one is *P. obesus*, a prolific diurnal rodent that is very abundant in arid and subsaharian areas. Its feeding requirements consist exclusively of chenopodiaceae (*Salicornia*, *Salsola*, *Atriplex*) that mainly grow in sandy, humid and salty soils unsuitable for agricultural purposes (Ben Ismail et al., 1987a; Ben Rachid et al., 1992; Fichet-Calvet et al., 2003). *Psammonys* infection rate may reach 100 %. The hygrophilic nocturnal rodents, *Meriones shawi* and *Meriones libycus* act as secondary reservoirs and are responsible of the spread of the disease because of their migratory habits. *Meriones* are granivorous and build their burrows in jujube trees (*Zizyphus*) surrounding cereal fields and often cause important agricultural damage (Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1992). All *Leishmania* strains isolated so far from humans, rodents and phlebotomine vectors are of the zymodeme MON 25 (Aoun et al., 2008; Ben Abda et al., 2009; Ben Ismail et al., 1986; Haouas et al., 2007).

ZCL was first described in 1882 in and around Gafsa oases, and termed "clou de Gafsa" (Deperet & Bobinet, 1884). From this date and up to the beginning of the 20th century, many additional outbreaks were reported in the same area. Then, the disease continued to occur on a very sporadic mode, and nearly disappeared (Chadli et al., 1968; Vermeil, 1956).

In 1982, a large outbreak arose in Nasrallah delegation (Kairouan governorate), near to the recently completed Sidi-Saad dam (Ben Ammar et al., 1984). From there, the disease rapidly spread to cover large rural and sub-urban parts of the central and south-western neighbouring governorates, so that, by 1986, 10 governorates were involved (Figure 6). In season 1991-1992, ZCL extended further south-east to Medenine and Tataouine governorates. All along the outbreak, Sidi Bouzid, Gafsa and Kairouan governorates have remained the leading areas in terms of incidence (Anonymous). However, from the early 1990s and up to date, Tataouine, Tozeur, Médenine, Kébili, Gabès, Sfax and Kasserine have emerged as active and stable foci (Figure 5). In the last few years, some level of ZCL spread towards the north (Siliana, Béja, Le Kef, Tunis and Zaghouan governorates) was registered, which is somewhat surprising (Ben Abda et al., 2009).

The number of annual recorded cases rapidly grew from 182 cases in 1982 to > 18000 cases by 1987, > 65000 cases by 1999. Up to date, > 120000 cases were reported and the epidemic is still going on. It should be mentioned however, that the actual number of cases is supposed to be underestimated and would exceed 150000 cases (Chahed et al., 2002). The number of annual recorded cases greatly varied and ranged from 1129 cases in 1995 to > 15000 in 2004,

Hence the actual distribution and incidence of CCL need further investigations and

*L. killicki* is transmitted by *Phlebotomus sergenti*, but the reservoir is still debated. Median age of patients suffering of CCL is 21 years (Ben Abda et al., 2009; Ben Ismail & Ben Rachid, 1989). Clinically, CCL most often presents as single or very few lesions on the face or limbs, that are dry, extensive, and chronic, lasting for up to six years (Ben Abda et al., 2009; Ben

ZCL is by far the most frequent and the most widely distributed form of CL in Tunisia where it constitutes a major public health problem. It is endemo-epidemic in extended areas of central and southern Tunisia (Figure 5). It is caused by *L. major* and transmitted by the zoo-anthropophilic *Phlebotomus papatasi* sandfly which is mainly encountered and caught in and around the rodent burrows, and less in and around human habitations (Ben Ismail et al., 1987b, 1987c; Ben Rachid et al., 1992; Ghrab et al., 2006; Helal et al., 1987). The reservoirs are rodents of the *Psammomys* and *Meriones* genera. The main one is *P. obesus*, a prolific diurnal rodent that is very abundant in arid and subsaharian areas. Its feeding requirements consist exclusively of chenopodiaceae (*Salicornia*, *Salsola*, *Atriplex*) that mainly grow in sandy, humid and salty soils unsuitable for agricultural purposes (Ben Ismail et al., 1987a; Ben Rachid et al., 1992; Fichet-Calvet et al., 2003). *Psammonys* infection rate may reach 100 %. The hygrophilic nocturnal rodents, *Meriones shawi* and *Meriones libycus* act as secondary reservoirs and are responsible of the spread of the disease because of their migratory habits. *Meriones* are granivorous and build their burrows in jujube trees (*Zizyphus*) surrounding cereal fields and often cause important agricultural damage (Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1992). All *Leishmania* strains isolated so far from humans, rodents and phlebotomine vectors are of the zymodeme MON 25 (Aoun et al., 2008; Ben Abda et al.,

ZCL was first described in 1882 in and around Gafsa oases, and termed "clou de Gafsa" (Deperet & Bobinet, 1884). From this date and up to the beginning of the 20th century, many additional outbreaks were reported in the same area. Then, the disease continued to occur

In 1982, a large outbreak arose in Nasrallah delegation (Kairouan governorate), near to the recently completed Sidi-Saad dam (Ben Ammar et al., 1984). From there, the disease rapidly spread to cover large rural and sub-urban parts of the central and south-western neighbouring governorates, so that, by 1986, 10 governorates were involved (Figure 6). In season 1991-1992, ZCL extended further south-east to Medenine and Tataouine governorates. All along the outbreak, Sidi Bouzid, Gafsa and Kairouan governorates have remained the leading areas in terms of incidence (Anonymous). However, from the early 1990s and up to date, Tataouine, Tozeur, Médenine, Kébili, Gabès, Sfax and Kasserine have emerged as active and stable foci (Figure 5). In the last few years, some level of ZCL spread towards the north (Siliana, Béja, Le Kef, Tunis and Zaghouan governorates) was registered,

The number of annual recorded cases rapidly grew from 182 cases in 1982 to > 18000 cases by 1987, > 65000 cases by 1999. Up to date, > 120000 cases were reported and the epidemic is still going on. It should be mentioned however, that the actual number of cases is supposed to be underestimated and would exceed 150000 cases (Chahed et al., 2002). The number of annual recorded cases greatly varied and ranged from 1129 cases in 1995 to > 15000 in 2004,

on a very sporadic mode, and nearly disappeared (Chadli et al., 1968; Vermeil, 1956).

Ismail & Ben Rachid., 1989; Chaffai et al., 1988; Masmoudi et al., 2007).

**2.3 The zoonotic cutaneous leishmaniasis (ZCL)** 

2009; Ben Ismail et al., 1986; Haouas et al., 2007).

which is somewhat surprising (Ben Abda et al., 2009).

obviously should be revised.

Fig. 5. Distribution of zoonotic cutaneous leishmaniasis according to incidence ( expressed as 0/00 000).

with an average of 4700 cases/year (Figure 7). The annual incidence showed the same fluctuations. It ranged between 3 0/00 000 in the less affected areas and > 500 in Kairouan, and > 1000 in Gafsa and Sidi Bouzid in 2004 (Anonymous). These fluctuations are at least in part related to the dynamics of rodents' populations. It was demonstrated that the distribution of *P. obesus* is of paramount importance in the epidemiology of the human disease (Ben Ismail et al., 1987a; Ben Ismail & Ben Rachid, 1989; Ben Salah et al., 2007; Fichet-Calvet et al., 2003). On the other hand, control programmes are undoubtedly very effective and beneficial in terms of incidence. Indeed, a rodent control project, consisting of ploughing lands with growing chenopods and reafforestation with acacia and other plants was launched in 1992 in Sidi Bouzid city and suburbs that resulted in a dramatic decrease in the incidence of the disease in the area; but the intensity of the epidemic grew again as soon as the control programme stopped (Figure 7). From the mid 2000s, similar control measures have been carried out again in Sidi Bouzid and then in Sidi El Heni

Retrospective Analysis of Leishmaniasis in

2007; Zakraoui et al., 1995).

Bouratbine et al., 1998).

1903-1956 1957-1967 1968-1981 1982-1989 1990-2000 2001-2010

Since 1903, 2449 VL cases were reported in Tunisia (Table 2).

**2.4 Visceral leishmanasis (VL)** 

Central Tunisia: An Update on Emerging Epidemiological Trends 235

One of the characteristics of ZCL is its marked seasonal occurence as most cases are observed

Clinically, ZCL most often presents as multiple, inflammatory ulcers on the face and the limbs that usually scar in less than 6-8 months, and affects all ages with a median of 24 years (Ben Abda et al., 2009; Ben Ismail & Ben Rachid, 1989; Chaffai et al., 1988; Masmoudi et al.,

VL has been known to sporadically occur in Tunisia, since 1903 where the first case of mediterranean VL was described in a child living in the suburbs of Tunis. The disease is caused by *Leishmania infantum*, mostly zymodeme MON 1 and to a lesser extent zymodemes MON 24 and MON 80 (Aoun et al., 2001, 2008; Bel Hadj et al., 1996, 2000, 2002; Ben Ismail et al., 1986; Haouas et al., 2005; Kallel et al., 2008b). It is transmitted by *Phlebotomus perniciosus* sandfly, and the dog is the exclusive reservoir, with an infection prevalence rate ranging from 5% to 26 % (Ben Ismail et al., 1986; Ben Rachid et al., 1992;

Period Nb cases Median/year

2.8 12.9 12.7 72.3 65.5 68.0

Total 2449 22.7

Up to 1981, incidence was low to moderate and nearly all cases were reported from Zaghouan, North-West (Le Kef, Béja, Jendouba, Siliana), Tunis and Sousse governorates, located in the humid, sub-humid and semi-arid zones (Anderson et al., 1934, 1938; Ben Ismail et al., 1986; Ben Rachid et al., 1983; Chadli et al., 1968; Khaldi et al., 1991; Nicolle, 1912; Vermeil, 1956). From the early 1980s, the incidence markedly increased and the disease progressed towards the south, mainly to Kairouan governorate and to a lesser extent to Sfax, Sidi Bouzid, Kasserine and Tozeur governorates, together with an increase in canine leishmaniasis (Ayadi et al., 1991; Bel Hadj et al., 1996; Ben Salah et al., 2000; Besbès et al., 1994; Bouratbine et al., 1998; Chargui et al., 2007; Pousse et al., 1995). Indeed, from the 1980s, the region of Kairouan emerged as a highly active VL focus, and by 1991-1992 it was

Table 2. Number of visceral leishmaniasis cases reported in Tunisia (1903-2010)

recognized as the most active one, with 30 to 55 % of reported cases (Anonymous).

The distribution of VL is given in figure 8. Highest number of cases was reported in 1922 (n = 130), 1993 and 2006 (n = 122), and 2005 (n = 120). It is worth mentioning that VL has nearly disappeared between 1974 and 1980, as a result of the anti-malaria campaign which included extensive insecticide spraying (Ben Rachid et al., 1983). The disease sporadically occurs in rural and to a lesser extent in suburban areas and mainly affects children under five years, cases in immunocompetent adults being less than 5 % (Ben Ismail & Ben Rachid, 1989; Ben Rachid et al., 1983; Besbès et al., 1994; Bouratbine et al, 1998; Hammoud et al.,

between october and january (Ben Ismail & Ben Rachid 1989; Ben Rachid et al., 1992).

delegation which is the main transmission focus in Sousse governorate, and led to an obvious decrease of incidence in both foci.

The ongoing outbreak that started in 1982 near the Sidi-Saad dam may be explained by the interruption, as a result of the construction of the dam, in the flooding that frequently occurred in the area and used to decimate a high proportion of rodents every year. In addition, the enrichment of the area's ground water helped the chenopodiaceae to grow abundantly, thereby increasing the food source of *Psammomys*. On the other hand, *Atriplex*, a plant grown in large quantities as a sheep fodder is much appreciated by *Psammomys.* Furthemore, humidity created by the dam is highly suitable for the sandflies.

Fig. 6. Spread of zoonotic cutaneous leishmaniasis during the period 1982- 1986 (Ben Ismail R., unpublished).

Fig. 7. Annual number of reported zoonotic cutaneous leishmaniasis cases at the national level from 1982 up to 2010.

One of the characteristics of ZCL is its marked seasonal occurence as most cases are observed between october and january (Ben Ismail & Ben Rachid 1989; Ben Rachid et al., 1992).

Clinically, ZCL most often presents as multiple, inflammatory ulcers on the face and the limbs that usually scar in less than 6-8 months, and affects all ages with a median of 24 years (Ben Abda et al., 2009; Ben Ismail & Ben Rachid, 1989; Chaffai et al., 1988; Masmoudi et al., 2007; Zakraoui et al., 1995).
