Molecular approaches for a better understanding of the epidemiology and population genetics of Leishmania

Molecular approaches are being used increasingly for epidemiological studies of visceral and cutaneous leishmaniases. Several molecular markers resolving genetic differences between Leishmania parasites at species and strain levels have been developed to address key epidemiological and population genetic questions. The current gold standard, multilocus enzyme typing (MLEE), needs cultured parasites and lacks discriminatory power. PCR assays identifying species directly with clinical samples have proven useful in numerous field studies. Multilocus sequence typing (MLST) is potentially the most powerful phylogenetic approach and will, most probably, replace MLEE in the future. Multilocus microsatellite typing (MLMT) is able to discriminate below the zymodeme level and seems to be the best candidate for becoming the gold standard for distinction of strains. Population genetic studies by MLMT revealed geographical and hierarchic population structure in L. tropica, L. major and the L. donovani complex. The existence of hybrids and gene flow between Leishmania populations suggests that sexual recombination is more frequent than previously thought. However, typing and analytical tools need to be further improved. Accessible databases should be created and sustained for integrating data obtained by different researchers. This would allow for global analyses and help to avoid biases in analyses due to small sample sizes.     

The current status of zoonotic leishmaniases and approaches to disease control

Leishmaniases are a complex of world-wide diseases with a range of clinical and epidemiological features caused by Leishmania spp. of protozoan parasites. Among 15 well-recognised Leishmania species known to infect humans, 13 have zoonotic nature, which include agents of visceral, cutaneous and mucocutaneous forms of the disease in both the Old and New Worlds. Currently, leishmaniases show a wider geographic distribution and increased global incidence of human disease than previously known. Environmental, demographic and human behavioural factors contribute to the changing landscape of leishmaniasis, which includes increasing risk factors for zoonotic cutaneous leishmaniases and new scenarios associated with the zoonotic visceral leishmaniases. The latter consist of the northward spread of Leishmania infantum transmission in Europe and America, the identification of unusual mammal hosts, and the decline of HIV-Leishmania co-infections in southern Europe following the introduction of the highly active antiretroviral therapy. Few advances have been made in the surveillance and control of the zoonotic leishmaniasis, however a number of tools have been developed for the control of the canine reservoir of L. infantum. These include: (i) several canine vaccine candidates, in particular an FML Leishmania enriched fraction showing good clinical protection, has been registered in Brazil for veterinary use; (ii) a number of insecticide-based preparations have been specifically registered for dog protection against sand fly bites. Laboratory and field studies have shown improved efficacy of these preparations for both individual and mass protection.     

Strain variation in Mediterranean and Red Sea Mycobacterium marinum isolates

Four different PCR fingerprinting techniques were tested to distinguish possible strain variations in fourteen Mycobacterium marinum isolates, thirteen from Mediterranean and Red Sea fishes and one from a patient in Sardinia, Italy. PCR ribotyping and ERIC (enterobacterial repetitive consensus sequences)-PCR were found to be non-discriminative, whereas IS (insertion sequences)-PCR and GTG (GTG sequences repeats)-PCR could distinguish the clinical isolate from the piscine isolates, two Italian piscine isolates from all other isolates, but not the Greek isolates from the Israeli isolates. Our results indicate that GTG-PCR and IS-PCR have superior discriminative properties and are thus useful molecular tools for epidemiological studies of M. marinum.     

Parasite identification in the surveillance of imported leishmaniasis cases in Italy

An accurate Leishmania classification was defined since 1980s by the use of isoenzyme analysis. To date, this procedure still represents the reference identification technique, despite the increasing use of molecular approaches. Studies and surveillance methods on leishmaniases are strongly conditioned by the knowledge and mapping of all the parameters characterizing each nosogeographical entity. On this respect, the identification of parasites from all the actors of the natural life cycle plays a key role. With the increasing population movements and climate changes, novel risk factors could be identified associated to Leishmania geographical distribution and spreading: a) the introduction into Italy of new populations of L. infantum from other countries; b) the introduction of new Leishmania species that may find a suitable milieau to support their life cycle in our country. The objective of this report is to present the surveillance activity on imported leishmaniases by the Leishmania Identification Reference Centre, ISS. Two different methodologies were routinely applied: a) isoenzyme electrophoretic analysis, which requires parasite culture, and b) a number of molecular techniques, used for both diagnosis and parasite identification, differently applied according to the geographical origin of the suspected leishmaniasis case. When possible, both types of methodologies were applied. From 1986 to June 2002, 38 imported cases of leishmaniases were identified: 9 visceral (VL) and 29 cutaneous (CL) cases, of which 22 from the Old and 7 from the New World. Pathology, Leishmania species/zymodeme and geographical origin features are reported in the paper. Seven out of 9 VL patients were HIV positive, of whom 5 detected in the period 1993-1995. This high importation rate can be associated to the general increase in Mediterranean Leishmania/HIV coinfections in that period. Following HAART treatment, VL imported cases became occasional; no introduction of new L. infantum populations has been detected. On the other hand, our findings show an increase of CL imported cases from different areas of the Old and New Worlds. This phenomenon, however, is so far limited to new Leishmania species that could hardly be introduced in our country, because of their strict biological requirements (i.e. vectors and/or natural reservoir hosts). Since June 2002, 10 further suspected imported cases were recorded. For these patients--whose Leishmania identification is still in course--the origin/visited geographical areas were only slight different from the previous. However, the characteristics of the patients are changing: there are more immigrants that occasionally visited their place of origin, and Italian military staff.     

Risk zones of human Leishmaniases in the Western Mediterranean basin: correlations between vector sand flies,bioclimatology and phytosociology

Correspondence analysis was applied to sand fly sampling in 865 stations from the Western Mediterranean basin. The position of each of 24 species was determined with respect to the bioclimatic belts. Thus, the multidimensional analyses manifest clear correlations between bioclimatic belts and their expression in the area, the phytosociological groupings, and vector species of visceral and cutaneous leishmaniases. The transfer of these data to usual maps allows to delimit the geographical distribution of these diseases in the Western Mediterranean basin and contributes to the determination, in a rational manner, of the high risk zones.     

Risk factors in the spread of leishmaniases: towards integrated monitoring?

Environmental changes, immune status and treatment failure constitute the three major risk factors for the (re-)emergence and spread of leishmaniases. Except for Leishmania-HIV co-infection, these risk factors are not systematically monitored and their interaction is poorly studied and understood. Recently, the multidisciplinary network Leish-Med was launched to document this issue around the Mediterranean and to promote transborder control strategies.     

Ecological interactions in the transmission of the leishmaniases

Epidemiological studies on the leishmaniases are disclosing a multiplicity of Leishmania species infecting a wide range of wild mammalian hosts, from marsupials to monkeys. In the primitive, silvatic habitat these parasites are transmitted by an equally wide variety of phlebotomine sandfly species (Diptera: Psychodidae: Phlebotominae). Transmission is not haphazard, however, and available evidence points to the existence of environmental barriers that normally limit the different Leishmania species to specific sandfly vectors, transmitting to certain mammalian species, within distinct ecotopes. In this situation, humans may become infected by a variety of leishmanial parasites when intruding into the different enzootics, if the sandfly vectors are anthropophilic. Many are not, however, and their parasites rarely, if ever, make contact with the human host. Natural or man-made ecological changes may result in modification of the epidemiological pattern of leishmaniasis, leading to either a reduction or an increase in the human disease.     

Phlebotomine sandflies and the spreading of leishmaniases and other diseases of public health concern

Phlebotomine sandflies transmit pathogens that affect humans and animals worldwide. We review the roles of phlebotomines in the spreading of leishmaniases, sandfly fever, summer meningitis, vesicular stomatitis, Chandipura virus encephalitis and Carrión's disease. Among over 800 species of sandfly recorded, 98 are proven or suspected vectors of human leishmaniases; these include 42 Phlebotomus species in the Old World and 56 Lutzomyia species in the New World (all: Diptera: Psychodidae). Based on incrimination criteria, we provide an updated list of proven or suspected vector species by endemic country where data are available. Increases in sandfly diffusion and density resulting from increases in breeding sites and blood sources, and the interruption of vector control activities contribute to the spreading of leishmaniasis in the settings of human migration, deforestation, urbanization and conflict. In addition, climatic changes can be expected to affect the density and dispersion of sandflies. Phlebovirus infections and diseases are present in large areas of the Old World, especially in the Mediterranean subregion, in which virus diversity has proven to be higher than initially suspected. Vesiculovirus diseases are important to livestock and humans in the southeastern U.S.A. and Latin America, and represent emerging human threats in parts of India. Carrión's disease, formerly restricted to regions of elevated altitude in Peru, Ecuador and Colombia, has shown recent expansion to non‐endemic areas of the Amazon basin.     

The leishmaniases--survival and expansion in a changing world. A mini-review

The number of cases of visceral and cutaneous leishmaniasis is increasing globally at an alarming rate irrespective of the region and the leishmaniases are amongst the top emergent diseases in spite of control measures. In the present review attention is drawn to some of the reasons for this. The leishmaniases have expanded beyond their natural ecotopes due to the ecological chaos caused by man and this in turn affects the levels of his exposure to the vectors. Examples of how different phenomana (such as war, civilian migration, immuno-suppression caused by medication and viral infections, globalization of work and leisure and transmission outside endemic areas) contribute to the spread and increase of the disease are discussed.     

Leishmaniasis: complexity at the host-pathogen interface

Leishmania is a genus of protozoan parasites that are transmitted by the bite of phlebotomine sandflies and give rise to a range of diseases (collectively known as leishmaniases) that affect over 150 million people worldwide. Cellular immune mechanisms have a major role in the control of infections with all Leishmania spp. However, as discussed in this Review, recent evidence suggests that each host-pathogen combination evokes different solutions to the problems of parasite establishment, survival and persistence. Understanding the extent of this diversity will be increasingly important in ensuring the development of broadly applicable vaccines, drugs and immunotherapeutic interventions.     

Phlebotomine fauna (Diptera: Psychodidae) and putative vectors of leishmaniases in impacted area by hydroelectric plant, State of Tocantins, Brazil

Background

Although leishmaniases are regarded as serious public health issues in the State of Tocantins, as consequence of the impact of environmental changes, small advances in taxonomic and ecological studies of Phlebotominae fauna are taking place in this state. The present study aimed to improve the knowledge about the sand flies, as well as about the aspects of the bioecology of leishmaniases vectors from Porto Nacional, a city that was directly impacted by the construction of Luís Eduardo Magalhães Hydroelectric Plant (HEP – Lajeado).

Methodology/Principal Findings

Sand flies were collected monthly using CDC light traps and Shannon traps for a period of 40 consecutive months, at different monitoring stations, where 7162 specimens were collected and 48 species were detected. Among the species found, 22 are first records in the state and seven are considered important vectors of leishmaniases. Lutzomyia longipalpis, the vector of American Visceral Leishmaniasis (AVL) showed higher frequency in urban compared to rural areas, and Nyssomyia whitmani, the vector of American Cutaneous Leishmaniasis (ACL), predominated in rural areas. The frequency and habits of sand fly vectors are discussed considering environmental characteristics and climatic factors.

Conclusions/Significance

The construction of dams requires a great amount of labor, therefore attracting people from elsewhere. Increased migration, without adequate structure, leads to bad living conditions in new and unplanned settlements. It also leads to deforestation associated with environmental impacts, which can facilitate the spread of leishmaniases.This study discusses the importance of Lu. longipalpis and Ny. whitmani on the transmission cycles of leishmaniases in Porto Nacional and the record of Bi. flaviscutellata in periurban area of the city.     

The epidemiology of hydatidosis with special reference to the Mediterranean area.

In the Mediterranean area 2 subspecies of Echinococcus granulosus exist: E. g. equinus and E. g. granulosus. The latter is divided into sheep, cattle, pig and camel strains, the adult forms of which mainly occur in farm-dogs but sometimes in wild canidae. Some of these strains can infect man: namely, the sheep and the pig strain. The infectivity of the cattle strains for man is not certain. The epidemiological cycle is mainly a rural one, but it can become sylvatic or even urban. Thus, the epidemiological features of hydatidosis in the Mediterranean area are not basically different from the general epidemiology of the disease. But extensive rearing of sheep, combined with the carelessness and ignorance of people and with some particular habits, favours the maintenance of the infection.     

A synthesis of the biological quality elements for the implementation of the European Water Framework Directive in the Mediterranean ecoregion: The case of Saronikos Gulf

Benthic macroinvertebrates, macroalgae and phytoplankton constitute the biological quality elements proposed in the Water Framework Directive (WFD, 2000/60/EC) to be used for the classification of the ecological status of a water body. In the context of the preparation for the implementation of WFD, classification schemes for all three elements have been developed and tested for all the European ecoregions. In the present work, the classification schemes, with the corresponding metric tools and the interpretations of the class boundaries according to the normative definitions of WFD, are presented for each biological element in Saronikos Gulf, as case study in the Mediterranean ecoregion. The combination of the three biological elements into an integrated classification for coastal water bodies has been one of the major issues addressed in the context of WFD guidelines. Results are interpreted and validated, through an ecological viewpoint, on the basis of relevant environmental data. Moreover, this work presents a way to combine the EUNIS system to the typology of water bodies in the Mediterranean ecoregion.     

Molecular variation in endothelial nitric oxide synthase gene (eNOS) in western Mediterranean populations

Endothelial nitric oxide synthase (eNOS or NOS3) is the main responsible for nitric oxide (NO) production in vascular system and different polymorphisms have been identified in epidemiological studies. Trying to test the eNOS genetic variation in general populations we studied the 27-bp VNTR in intron 4 and G894T substitution in exon 7 markers in 6 Western Mediterranean populations (3 from Iberian Peninsula, 1 from North Africa, and 2 from Sardinia) and a sample from Ivory Coast. The VNTR frequencies in Western Mediterranean and Ivory Coast fit well into the ranges previously described for Europeans and Sub-Saharans respectively, and a typical African allele has been detected in polymorphic frequencies in the Berber sample. The G894T substitution presents the highest frequencies described for the T allele in the North Mediterranean populations. Linkage disequilibrium is present between both markers in all populations except in the Ivory Coast sample. The variation found for these polymorphisms indicates that they may be a useful tool for population studies even at microgeographical level.     

Visceral Leishmaniasis and HIV Coinfection in the Mediterranean Region

Visceral leishmaniasis is hypoendemic in Mediterranean countries, where it is caused by the flagellate protozoan Leishmania infantum. VL cases in this area account for 5%–6% of the global burden. Cases of Leishmania/HIV coinfection have been reported in the Mediterranean region, mainly in France, Italy, Portugal, and Spain. Since highly active antiretroviral therapy was introduced in 1997, a marked decrease in the number of coinfected cases in this region has been reported. The development of new diagnostic methods to accurately identify level of parasitemia and the risk of relapse is one of the main challenges in improving the treatment of coinfected patients. Clinical trials in the Mediterranean region are needed to determine the most adequate therapeutic options for Leishmania/HIV patients as well as the indications and regimes for secondary prophylaxis. This article reviews the epidemiological, diagnostic, clinical, and therapeutic aspects of Leishmania/HIV coinfection in the Mediterranean region.     

The genus Leishmania in Italy

Seventy-four Leishmania isolates collected in Italy from six different Regions where leishmaniases are endemic, have been typed. Parasites have been isolated from: man (VL and CL), dog, black rat (Rattus rattus), fox (Vulpes vulpes) and geckoes (Tarentola mauritanica and Cyrtodactylus kotschyi). The isolates have been characterized by starch-gel electrophoresis for 9-16 enzymes whose mobility was compared with that of international reference strains for L. infantum, L. tropica, L. major, L. donovani, L. aethiopica and L. tarentolae. The results obtained have shown that the genus Leishmania in Italy is represented by five zymodemes which may be grouped into two taxa: L. infantum s.l. (L. infantum s.st., L. infantum NH130 variant, L. infantum NH140 variant and L. infantum GOT, MDH, NH variant), agent of mammalian leishmaniases (including human leishmaniases), and L. tarentolae, parasite of geckoes. At the moment, the absence of L. tropica in Italy as agent of CL has been revealed. Through the analysis of epidemiological data obtained from the foci where Leishmania parasites were isolated two zymodemes only, L. infantum s.st. and L. infantum NH140 variant, show to be widely distributed. However, L. infantum s.st. appears to be prevalent in Thyrrenean foci which are characterized by VL cases and by high density of Phlebotomus perniciosus, and L. infantum NH140 variant is present in Adriatic areas where CL is diffuse and P. perfiliewi is the probable vector.     

Characterization of the sand fly fauna in Barbalha,one of the municipalities with the highest leishmaniasis rates in Brazil

Leishmaniases are a complex of sand fly-borne diseases that are considered a public health issue in several countries. Brazil presents high leishmaniases rates. The South of Ceará State, known as Cariri region, shows worrying statistics mainly on American tegumentary leishmaniasis. In Barbalha, which is one of the municipalities in this region, there is still a lack of studies regarding the local phlebotomine (Diptera: Psychodidae) fauna in order to help clarify the high rates. This study aimed to characterize such fauna by capturing sand flies with light traps during a four-year period. A total of 3730 sand flies were captured, of which 37.8% were females. Fourteen species were found: 13 of the Lutzomyia genus and one of the Brumptomyia genus. Of the Lutzomyia species, four were proven and five had potential involvement in leishmaniasis transmission. Lutzomyia longipalpis was the most common species (66.97%). This predominance, especially in the urban area, indicates its epidemiological importance and adaptation to environmental conditions modified by human activity. In fact, further studies are still required to accurately determine the behavioral features of these vectors in order to guide public health measurements towards its control and prevention.     

Challenges and perspectives in vaccination against leishmaniasis

The leishmaniases are a group of diseases caused by protozoa of the genus Leishmania and affect millions of people worldwide. The leishmaniases are transmitted to vertebrate hosts by phlebotomine sand flies. In this review, we focus on several issues that have been poorly addressed in ongoing efforts to develop a vaccine against Leishmania, namely: vaccination with antigens present in sand fly saliva, vaccines based on intracellular Leishmania antigens, and use of recombinant BCG as a vehicle for vaccination. Additionally, we address the differences between L. major and L. braziliensis and the impact that these differences may have on strategies for immunoprophylaxis.     

State‐of‐the‐art CRISPR/Cas9 Technology for Genome Editing in Trypanosomatids

CRISPR/Cas9 technology has revolutionized biology. This prokaryotic defense system against foreign DNA has been repurposed for genome editing in a broad range of cell tissues and organisms. Trypanosomatids are flagellated protozoa belonging to the order Kinetoplastida. Some of its most representative members cause important human diseases affecting millions of people worldwide, such as Chagas disease, sleeping sickness and different forms of leishmaniases. Trypanosomatid infections represent an enormous burden for public health and there are no effective treatments for most of the diseases they cause. Since the emergence of the CRISPR/Cas9 technology, the genetic manipulation of these parasites has notably improved. As a consequence, genome editing is now playing a key role in the functional study of proteins, in the characterization of metabolic pathways, in the validation of alternative targets for antiparasitic interventions, and in the study of parasite biology and pathogenesis. In this work we review the different strategies that have been used to adapt the CRISPR/Cas9 system to Trypanosoma cruzi, Trypanosoma brucei, and Leishmania spp., as well as the research progress achieved using these approaches. Thereby, we will present the state‐of‐the‐art molecular tools available for genome editing in trypanosomatids to finally point out the future perspectives in the field.