Recent findings of Phlebotomus neglectus Tonnoir, 1921 in Italy and its western limit of distribution

During the sand fly season of 2001, sand flies were collected in two different regions of Italy to investigate the northern distribution of Phlebotomus neglectus. The study areas were two provinces of northern Italy, Ivrea and Verona, in Piedmont and Veneto regions respectively. Sticky traps and CDC miniature light traps were used both inside and outside domestic and peri-domestic environments. Sand flies were also collected in domestic resting sites with mouth and electric aspirators. Of 1,295 sand fly specimens collected, 855 were from the Veneto region and 440 were from the Piedmont region. Five species of the genera Phlebotomus and Sergentomyia were identified. S. minuta (66.3%) was the most abundant sand fly followed by P. perniciosus (22.2%), P. neglectus (10.3%) and P. papatasi (1.2%). Only one specimen of P. mascittii was caught in Piedmont region. P. neglectus was found in 9 out of 15 (60%) of the sites where sand flies were found with a prevalence of 1.5% to 45.8%; the highest value was recorded in Piedmont region. P. neglectus was mostly associated with peridomestic and domestic sites. The results confirm previous observations on the presence of P. neglectus in northern Italy and suggest that this species is probably widespread in the area. From a review of all previous published and unpublished records of P. neglectus, it appears that this species is present in only two areas of the country, namely in the regions of Friuli Venezia Giulia, Veneto and Piedmont in northern Italy and the regions of Calabria, Apulia and Sicily in southern Italy. The apparent absence of P. neglectus in Central Italy is discussed and the resulting settlement through two probable migration routes from the East is analysed.     

Canine leishmaniasis in Campania: new and old foci

Canine Leishmaniasis (CanL) is endemic in Campania Region (Italy) and is strictly related to Human Visceral Leishmaniasis. Past and present reports of the prevalence in the Region show that exist places were CanL has been known for a century (Vesuvius and Ischia Foci) and other localities where the disease appears to be recent (Caserta and Salerno provinces); moreover, the zoonosis is seen not only in endemic foci (autochthonous), but also in non-endemic areas (imported cases), for example in the Benevento and Avellino provinces. Two zymodemes have been identified in human and canine population and also in sandflies: MON 1 and MON 72. Endemic or stable CanL foci correspond with Vesuvius Area, Ischia island, Maddaloni and neighbouring Commons, other foci in the Salerno province. These foci are associated with optimal ecological condition, abundance of reservoirs and hosts, abundance of phlebotomine vectors, prevalence in canine population around 10-40%, incidence in canine population 5%, risk for human population 0.002%. Instable foci occur at the border of the stable foci: they may be the result of changes in climate with the occasional introduction of infected dogs in the areas; in the foci are registered low presence of phlebotomine vectors, prevalence around 0.5-3%, sporadic human cases. Today, in Campania region CanL undoubtedly has an increased incidence and a wider geographic distribution than before: new cases are now reported in areas that were previously non-endemic. Ecological, demographic and environmental changes, large population movements, urbanization have led to an increased incidence and to importation into suburbs with high densities of people and sand-flies. These changes include "global warming", increased number of stray dogs, dogs and population movements, changes in human population (increased number of immune-depressed and old people). Nowadays, the most important focus of CanL and Human Visceral Leishmaniasis of the Mediterranean area is located in Campania Region: during the year 2000, 143 cases of Human Visceral Leishmaniasis have been recorded in Italy, an half of them (83 cases) in Campania region.     

Transmission of visceral leishmaniasis in a previously non‐endemic region of Tunisia: Detection of Leishmania DNA in Phlebotomus perniciosus

Visceral leishmaniasis (VL) has been endemic in northern Tunisia and has occurred sporadically in the center of Tunisia. Recently, there have been several cases from areas known to be free of VL. We report in this work all human and canine cases of VL recorded between 2003 and 2011 and an entomological study of phlebotomine fauna in a previously non‐endemic region. Sixty‐three cases of VL were diagnosed and identified as L. infantum using several different methods. Eight species of 179 sand flies were caught and identified by both morphological and molecular methods. Two genera were present, Phlebotomus and Sergentomya, with an abundance of the subgenus Phlebotomus (Larrousius) spp., a classic vector of VL in Tunisia. Moreover, Leishmania DNA was detected in seven unfed Phlebotomus pernicousus and L. infantum was identified in three of them. This result confirms the establishment of a transmission cycle of VL in the studied region by the coexistence of infected vectors with infected hosts.     

Canine leishmaniasis: evolution of the chemotherapeutic protocols

Dogs are the domestic reservoir for Leishmania infantum (syn.: L. chagasi), the parasite causing zoonotic visceral leishmaniasis (ZVL) in both the Old and New Worlds. In foci of canine leishmaniasis (CanL), symptomatic disease occurs in less than 50% of infected dogs, and is characterized by chronic evolution of viscero-cutaneous signs. Among strategies recommended to control ZVL, detection and drug treatment of infected dogs are usually employed in the endemic countries of southern Europe. However, the conventional antileishmanial drugs successfully used in human therapy, such as pentavalent antimonials, amphotericin B, pentamidine or miltefosine, have low efficacy in the treatment of CanL. In dogs, these drugs induce only temporary remission of clinical signs, do not prevent occurrence of relapses, and often cause severe side effects. Leishmaniotic dogs may be classified into 4 groups: 1) Asymptomatic resistant dogs ("contacted dogs"), 2) Asymptomatic dogs (preclinical), 3) Dogs with minimal signs of leishmaniasis (oligosymptomatic dogs? Chronic form of leishmaniasis?), 4) Dogs suffering from different forms of clinical leishmaniasis (symptomatic dogs). The dog's immunological status and the associated clinical signs may influence the efficacy of antileishmanial drugs. Subjects belonging to groups 2, 3 and 4 should be always treated, in order to reduce their parasite load. Parameters that must be considered before starting the antileishmanial treatment are hemogram, renal and hepatic functions, electrophoretic protein pattern, antileishmania antibody titres, and bone marrow and lymph node parasite load. The most common antileishmanial drugs currently used in Italy to treat CanL are pentavalent antimonials (meglumine antimoniate) and allopurinol, alone or in combination. Other used drugs are aminosidine (syn.: paromomycin), pentamidine, metronidazole and spyramicin. Each drug regimen has different duration, from a few weeks (aminosidine), to a few months (meglumine antimoniate) or several months (allopurinol). One of the most recent drug used in human VL is liposomal amphotericin B (AmBisome--L-AMB), a powerful antileishmanial drug in both experimental murine models and in VL patients. In Italy, L-AMB is now considered the drug of choice for the treatment of human cases. However, in HIV co-infected patients high doses of L-AMB are ineffective in obtaining a radical cure. In dogs, L-AMB treatment rapidly leads to clinical recovery but is uneffective to eliminate the parasites. Drugs containing amphotericin B should not be used in veterinary practice in order to avoid selection of parasites resistant to the drug, as it already occurred for the pentavalent antimonials. Currently, there is not a standard protocol for CanL treatment in Italy, as there is an extreme variability of proposed dosages. Clinical studies on immunotherapeutics and new antileishmanial drugs, such as miltefosine and its derivates, are in progress.     

Leishmania infection and host-blood feeding preferences of phlebotomine sandflies and canine leishmaniasis in an endemic European area,the Algarve Region in Portugal

The Algarve Region (AR) in southern Portugal, which is an international tourist destination, has been considered an endemic region of zoonotic leishmaniasis caused by Leishmania infantum since the 1980s. In the present study, phlebotomine and canine surveys were conducted to identify sandfly blood meal sources and to update the occurrence of Leishmania infection in vectors and dogs. Four sandfly species were captured: Phlebotomus perniciosus, Phlebotomus ariasi, Phlebotomus sergenti and Sergentomyia minuta. In one P. perniciosus female, L. infantum DNA was detected. Blood meal tests showed that this species had no host preferences and was an opportunistic feeder. An overall canine leishmaniasis (CanL) seroprevalence of 16.06% was found; the seroprevalence was 3.88% in dogs housed in kennels and 40.63% in dogs that attended veterinary clinics. The simultaneous occurrence of dogs and P. perniciosus infected with L. infantum in the AR indicates that the region continues to be an endemic area for CanL. Our results reinforce the need for the systematic spatial distribution of phlebotomine populations and their Leishmania infection rates and the need to simultaneously perform pathogen monitoring in both invertebrate and vertebrate hosts to investigate the transmission, distribution and spreading of Leishmania infection.     

Faunistic study of sandflies in Greece

A faunistic study of phlebotomine sandflies was carried out on the mainland and on four islands in Greece between 1999 and 2004. Sandflies were collected in 18 areas, and the population structure was observed and recorded. A total of 10 species were identified; their distribution is presented here. Of these, the species Phlebotomus neglectus Tonnoir and P. perfiliewi Parrot (Diptera: Psychodidae), epidemiologically the most important vectors of leishmaniases and sandfly fever in Greece, were shown to be present in the main endemic foci of the country.     

Focus: Zoonotic Disease: Eco-epidemiological Aspects of Visceral Leishmaniasis in the Municipality of Diamantina,Jequitinhonha Valley (Minas Gerais State, Brazil)

Background: The present study was carried out in the rural and urban area of Diamantina/Minas Gerais (MG), an endemic municipality for visceral leishmaniasis (VL) in Brazil. Methods: Patient notification records, canine prevalence, and phlebotomine fauna were evaluated. Results: In the period from 2016 to 2018, eight human cases were confirmed, with three deaths, predominantly in males. In the same period, a total of 1,388 dogs resided in the rural and urban area of the municipality were submitted to the DPP® and ELISA, with a percentage of confirmed canine cases of 29.9% and 29.4%, respectively. The entomological study conducted in the municipality revealed the presence of 10 species of sand flies, with a predominance of Lutzomyia longipalpis (55.75%), mainly in the rural area. Conclusions: Unlike what is happening in urban centers, the results of this study suggest that the VL in Diamantina is in the process of urbanization, given the high percentage of confirmed canine cases and the high density of Lu. longipalpis in the rural area of the municipality. These risk factors warn about the need for continuous surveillance and the need to control actions of VL in this area.     

Evidence for an impact on the incidence of canine leishmaniasis by the mass use of deltamethrin-impregnated dog collars in southern Italy

Dogs are the domestic reservoir of Leishmania infantum Nicolle (Kinetoplastida: Trypanosomatidae), the agent of zoonotic human visceral leishmaniasis. In southern Europe, where canine leishmaniasis (CanL) is widespread due to L. infantum, killing seropositive dogs is considered unacceptable and drug treatment has low efficacy in preventing transmission. We made a field evaluation of the efficacy of deltamethrin dog collars in a CanL focus of southern Italy, Mount Vesuvius area of Campania region, where the vector is Phlebotomus perniciosus Newstead (Diptera: Psychodidae), by assessing their impact on the incidence of CanL in an intervention town, compared to that in dogs of control towns where no collars were fitted. During two consecutive transmission seasons, collars were fitted to 350 (1998) and 354 (1999) dogs from San Sebastiano al Vesuvio (70% of the canine population). Control dogs (371 and 264 in the 2 years, respectively) were from four towns of the same area. Before each transmission season, the CanL seroprevalence in the intervention and control towns was evaluated by cross-sectional surveys and found to be similar (about 15% in 1998 and 10% in 1999, respectively). After each transmission period, incidence rates of seroconversions were determined in adult dogs that were serologically negative before the season under evaluation, and in puppies. After the 1998 season, 2.7% of the dogs in the intervention town seroconverted compared to 5.4% in the control towns (50% protection, P = 0.15). After the 1999 season, 3.5% of collared dogs seroconverted compared to 25.8% of control dogs (86% protection, P < 0.001). The increase in seroconversion rates recorded in control dogs suggests an increase in the Leishmania force of infection in the canine reservoir during the 1999 sandfly season, as supported by the concomitant increase of human cases in control towns and in the whole Campania region. Our results suggest that the impact of mass use of deltamethrin-impregnated dog collars on the incidence of CanL may be negligible during low transmission seasons, or probably in low endemic foci, but can be very strong when the force of transmission is high.     

Phlebotominae (Diptera: Psychodidae) of human leishmaniosis sites in Tunisia

In order to identify the phlebotomine sandfly populations in Tunisian leishmaniosis foci, an entomological survey was carried out through three entomological seasons (2002-2003-2004) in 19 visceral and cutaneous leishmaniosis areas, located in six bioclimatic zones. Sandfly collections were based on light and sticky traps placed around human leishmaniosis cases. 8,722 phlebotomine sandflies belonging to 12 species were collected. The dominance of subgenus Larroussius species in northern foci, Phlebotomus papatasi in south-western foci and their co-dominance in the centre of the country is in accordance with the distribution of Leishmania infantum and L. major in Tunisia. The low density found in the historical zoonotic cutaneous leishmaniosis focus of Metlaoui in the south-west may indicate the high competence of the local populations. Studied phlebotomine settlements have showed a low specific diversity in most of the studied sites. In L. infantum areas, the dominant species were respectively: P. perfiliewi in the cutaneous leishmaniosis site of the humid bioclimatic stage, P. perniciosus in the cutaneous and visceral leishmaniosis foci of semi-arid and arid bioclimatic stages and P. longicuspis in the visceral leishmaniosis focus of saharan bioclimate. In the zoonotic cutaneous leishmaniosis foci, P. papatasi was a dominant species. In the well-known south-eastern foci of cutaneous leishmaniosis due to L. killicki, P. sergenti was a dominant species with P. perniciosus. In the central emerging foci of L. killicki, P. perniciosus was a dominant species in some sites whereas it was very rare in others. In these sites, the subgenus Paraphlebotomus was always present with a higher abundance of P. alexandri than P. sergenti.     

A stable focus of canine leishmaniosis in the Bologna Province, Italy

During an epidemiological survey carried out for two consecutive years (2001-2002), autochthonous cases of canine leishmaniosis (CanL) were reported in Communes of the Bologna Province (Emilia-Romagna Region, northern Italy), involved in the past (1971-1972) in a severe outbreak of human visceral leishmaniosis (VL). Serological controls, carried out by immunofluorescence antibody test on a sample of owned dogs, detected a mean prevalence of 2.5% in the first year in 4 Communes, and of 11.2% in the second year in only one Commune, where an incidence value of 9.3% was assessed. The autochthonous origin of the infection was confirmed in 11 out of 13 positive animals in the first year and in 5 out of 6 new cases in the second year. In one case the parasitological examinations led to the isolation of leishmaniae characterized as Leishmania infantum zymodeme MON 1. Entomological surveys carried out during two sandfly seasons in one of the areas concerned by the VL outbreak showed the presence of Phlebotomus perfiliewi and, to a lesser extent, of P perniciosus, both proven vectors of L. infantum in Italy. The results obtained seem to suggest the presence of a stable focus of CanL in the territory involved in the previous VL outbreak of 1971-1972, within which the infection in the canine population had been assessed only serologically. Such an epidemiological situation may be seen either as the persistence of an old focus or as a new imported one.     

Canine leishmaniosis in Tunisia: Growing prevalence,larger zones of infection

BackgroundDiscovered by Nicolle and Comte in 1908 in Tunisia, Leishmania infantum is an intracellular protozoan responsible for zoonotic canine leishmaniosis (CanL) and zoonotic human visceral leishmaniasis (HVL). It is endemic in several regions of the world, including Tunisia, with dogs considered as the main domestic reservoir. The geographic expansion of canine leishmaniosis (CanL) has been linked to global environmental changes that have affected the density and the distribution of its sand fly vectors.Methodology/Principal findingsIn this study, a cross-sectional epidemiological survey on CanL was carried out in 8 localities in 8 bioclimatic areas of Tunisia. Blood samples were taken from 317 dogs after clinical examination. Collected sera were tested by indirect fluorescent antibody test (IFAT; 1:80) for the presence of anti-Leishmania infantum antibodies. The overall seroprevalence was 58.3% (185/317). Among positive dogs, only 16.7% showed clinical signs suggestive of leishmaniosis. Seroprevalence rates varied from 6.8% to 84.6% and from 28% to 66% by bioclimatic zone and age group, respectively. Serological positivity was not statistically associated with gender. The presence of Leishmania DNA in blood, using PCR, revealed 21.2% (64/302) prevalence in dogs, which varied by bioclimatic zone (7.3% to 31%) and age group (7% to 25%). The entomological survey carried out in the studied localities showed 16 species of the two genera (Phlebotomus and Sergentomyia). P. perniciosus, P. papatasi, and P. perfiliewi were the most dominant species with relative abundances of 34.7%, 25% and 20.4%, respectively.Conclusions/SignificanceThe present report suggests a significant increase of CanL in all bioclimatic areas in Tunisia and confirms the ongoing spread of the infection of dogs to the country’s arid zone. Such an expansion of infection in dog population could be attributed to ecological, agronomic, social and climatic factors that affect the presence and density of the phlebotomine vectors.     

A new stable focus of canine leishmaniasis in northern Italy

A new stable focus of canine leishmaniasis (CanL) was identified in a coastal Adriatic area of the Emilia-Romagna Region in Northern Italy. Following the first clinical cases observed starting from 1998, a seroepidemiological survey was carried out on owned dogs from two communes and on animals housed in dog pounds of the Rimini province. Sixteen out of 612 dogs (2.6%) resulted positive to the IFA test. The 16 positive dogs all came from the two communes, with seroprevalences of 3 and 6%, respectively. The autochthonous origin of the infection was confirmed in all the cases. The parasitological investigation led to the isolation and identification of the parasite as Leishmania infantum Zymodeme MON 1. An entomological survey showed that Phlebotomus perniciosus and P. perfiliewi are present in this area and that P. perfiliewi was very abundant in one collection site. The risk of the establishment of a permanent transmission of the infection in the area, previously considered CanL-free, must be analysed in view of further investigations to be extended also to neighbouring areas.     

Sandflies of Lebanon: faunistic inventory

An entomological study was made in order to complete the epidemiological data on leishmaniasis in Lebanon. 19 species of sandflies (13 of the genus Phlebotomus and six of the genus Sergentomyia) were found. The list includes a recently described species of the Synphlebotomus subgenus (P. saltiae) and eight other species mentioned for the first time in Lebanon: P. neglectus, P. brevis, P. langeroni, P. balcanicus, S. fallax, S. taizi, S. tiberiadis and S. christophersi. Ecological records of each species and its possible involvement in Leishmania transmission are discussed.     

Tiger mosquito control: new approaches to the issue in local context

Until recently, the control of mosquitoes has primarily focused on them as a nuisance due to their biting behaviour. This has now evolved into a significant health problem. To deal with this serious issue, a rational approach to vector control should be adopted, with clear, technically sound guidelines enforceable by legislation. The extensive outbreak of Chikungunya in the Indian Ocean during 2005-6 and the subsequent outbreak in the Emilia Romagna region of Italy in August 2007, should prompt a number of actions which must occur without delay in order to prevent any future recurrence of outbreaks. An International Symposium on Chikungunya was held in Alessandria, Italy on February 27th 2008. A number of experts from various disciplines were in attendance, the sole aim to assess the risk of this disease and other mosquito borne diseases occurring in Europe. The meeting culminated in the signing of a declaration called the "Alessandria Resolution" by the experts in attendance and members of several local authorities (see www.zanzare.eu). This act signified joint commitment of an national and international standing, to tackle the spread of the Asian Tiger mosquito and raise awareness among the general public. This paper will share the experiences of the mosquito control programmes in the Italian regions and in Alessandria and Piedmont emphasising key lessons learned.     

Proposal of a data collection form to record dento-alveolar features--application to two Roman skeletal samples from Italy

Bones and teeth are an important source of information about the lifestyle, health status and dietary habits of past populations. Modifications and lesions of the periodontal tissues also provide information about the health status and behavior of an individual or of an ancient population. In this paper a method to record some dento-alveolar features of both deciduous and permanent teeth is described. The forms that we propose make it easy to record the data in a Microsoft Excel sheet. The form for adults has been applied to two Roman Imperial age skeletal samples from northern Italy - Casalecchio di Reno (II-V c. AD, Bologna) and Emilia Romagna, and central Italy - Quadrella (I-IV c. AD, Isernia, Molise).     

Key factors influencing lung cancer survival in northern Italy

Aim: Lung cancer is a major cause of cancer death worldwide. The aims of this study were to analyze presentation, treatment and survival for lung cancer in northern Italy, and identify factors influencing survival. Methods: A total of 1180 lung cancer cases diagnosed in four north Italian cancer registries (Biella, Modena, Reggio Emilia, Romagna) in 2003–2005 were analyzed. Information on morphology, stage, diagnostic examinations, chemotherapy, radiotherapy, and surgical treatment was collected from clinical records. Three-year relative survival and relative excess risks of death were estimated. Results: Overall, 10% of cases were stage I, 50% stage IV, and 12% stage unknown. Romagna – where sophisticated diagnostic examinations were performed more often – had proportionately more microscopically verified cases and resected cases than Biella. Romagna had also high proportions of cases given chemotherapy and radiotherapy. Three-year survival was 14%, range 10% (Biella) to 19% (Romagna); 69% for stage I, 3% for stage IV. Stage I survival was higher in Romagna (82%) than Reggio Emilia and Biella (60–61%) but for operated stage I cases, survival was similar (88%) in Romagna and Biella. The fully adjusted model showed a higher risk of death in Biella (1.23, 95%CI 1.02–1.48) than Modena (reference). Conclusions: Stage and surgery are key factors influencing survival. Centralizing lung cancer treatment to improve diagnostic work-up may improve outcomes.     

Genetic Diversity and Population Structure of Leishmania infantum from Southeastern France: Evaluation Using Multi-Locus Microsatellite Typing

In the south of France, Leishmania infantum is responsible for numerous cases of canine leishmaniasis (CanL), sporadic cases of human visceral leishmaniasis (VL) and rare cases of cutaneous and muco-cutaneous leishmaniasis (CL and MCL, respectively). Several endemic areas have been clearly identified in the south of France including the Pyrénées-Orientales, Cévennes (CE), Provence (P), Alpes-Maritimes (AM) and Corsica (CO). Within these endemic areas, the two cities of Nice (AM) and Marseille (P), which are located 150 km apart, and their surroundings, concentrate the greatest number of French autochthonous leishmaniasis cases. In this study, 270 L. infantum isolates from an extended time period (1978–2011) from four endemic areas, AM, P, CE and CO, were assessed using Multi-Locus Microsatellite Typing (MLMT). MLMT revealed a total of 121 different genotypes with 91 unique genotypes and 30 repeated genotypes. Substantial genetic diversity was found with a strong genetic differentiation between the Leishmania populations from AM and P. However, exchanges were observed between these two endemic areas in which it seems that strains spread from AM to P. The genetic differentiations in these areas suggest strong epidemiological structuring. A model-based analysis using STRUCTURE revealed two main populations: population A (consisting of samples primarily from the P and AM endemic areas with MON-1 and non-MON-1 strains) and population B consisting of only MON-1 strains essentially from the AM endemic area. For four patients, we observed several isolates from different biological samples which provided insight into disease relapse and re-infection. These findings shed light on the transmission dynamics of parasites in humans. However, further data are required to confirm this hypothesis based on a limited sample set. This study represents the most extensive population analysis of L. infantum strains using MLMT conducted in France.     

Wing size and shape variation of Phlebotomus papatasi (Diptera: Psychodidae) populations from the south and north slopes of the Atlas Mountains in Morocco

The wing shape and size morphology of populations of the medically important phlebotomine sand fly, Phlebotomus papatasi, were examined in two endemic (south of the Atlas Mountains) and nonendemic (north of the Atlas Mountains) foci of cutaneous leishmaniasis by using geometric morphometrics in Morocco. Although it is present in all of Morocco, P. papatasi is the main vector of Leishmania major in only southern part of the Atlas Mountains. There are four major mountain ranges that serve as geographical barriers for species distribution in the study area and at least four gaps were recognized among these barriers. We found statistically significant differences in wing shape morphology between southern and northern populations. Analysis clearly recognized two main groups of populations on both sides of the mountains. The graphical depiction of Principal Component Analysis (PCA) and Canonical Variates Analysis (CVA) confirmed our morphometric study suggesting that the difference in wing morphology between the populations indicates that the population of P. papatasi shows phenotypic plasticity in the study area. According to centroid size analyses, which were used as measures of wing size differences among different sites, the north population of P. papatasi had relatively larger wings than the south population.     

Visceral leishmaniasis: what are the needs for diagnosis, treatment and control?

Visceral leishmaniasis (VL) is a systemic protozoan disease that is transmitted by phlebotomine sandflies. Poor and neglected populations in East Africa and the Indian sub-continent are particularly affected. Early and accurate diagnosis and treatment remain key components of VL control. In addition to improved diagnostic tests, accurate and simple tests are needed to identify treatment failures. Miltefosine, paromomycin and liposomal amphotericin B are gradually replacing pentavalent antimonials and conventional amphotericin B as the preferred treatments in some regions, but in other areas these drugs are still being evaluated in both mono- and combination therapies. New diagnostic tools and new treatment strategies will only have an impact if they are made widely available to patients.     

Epidemiology of Imported Leishmaniasis in Italy: Implications for a European Endemic Country

In the past decade, the number of imported leishmaniasis cases has increased in countries of Western Europe. The trend is associated with increasing travels, ecotourism activity, military operations and immigration. While in endemic countries leishmaniasis is usually well diagnosed, accurate patient history and parasite identification are necessary to distinguish between autochthonous and imported cases. This is particularly important, as new Leishmania species/genotypes may be introduced and transmitted by local phlebotomine vectors without appropriate surveillance, with unpredictable consequences. We report on the surveillance of imported leishmaniasis performed by the Leishmania Identification Reference Centre of Rome from 1986 through 2012, involving health care centres from 16/20 Italian regions. Suspected imported cases were analyzed and conclusions were based on clinical, epidemiological and diagnostic findings. Over the years, different parasite identification methods were employed, including MultiLocus Enzyme Electrophoresis and molecular techniques combining disease diagnosis (SSU rDNA nested-PCR) and Leishmania typing (nuclear repetitive sequence and ITS-1 PCR-RFLPs). A total of 105 imported cases were recorded (annual range: 0-20) of which 36 were visceral (VL) (16 HIV-coinfections) and 69 cutaneous (CL) cases; 85 cases (52 CL) were from the Old World and 20 (17 CL) from the New World. Eight Leishmania species were identified, of which 7 were exotic to Italy. VL importation until 1995 was associated with the spread of Mediterranean Leishmania-HIV co-infections in early 1990s. Following the introduction of HAART treatment, such cases became occasional in Italians but relatively frequent among immigrants. In contrast, a steady increase of CL cases was observed from different areas of the Old and New Worlds, that in recent years included mainly immigrants ‘visiting friends and relatives’ and Italian tourists. This positive trend likely depends on better diagnosis and reporting; however, we suspect that many CL cases remained unrecognized. Given the relatively low incidence of leishmaniasis importation, the risk of introduction of exotic parasites appears limited, although the detection of anthroponotic species requires attention.