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Ahead of Print -Resurgence of Cutaneous Leishmaniasis in Israel, 2001–2012 - Volume 20, Number 10—October 2014 - Emerging Infectious Disease journal - CDC

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Ahead of Print -Resurgence of Cutaneous Leishmaniasis in Israel, 2001–2012 - Volume 20, Number 10—October 2014 - Emerging Infectious Disease journal - CDC


Thumbnail of Selected localities (black dots) where cases of cutaneous leishmaniasis were reported in Israel during 2001–2012. Health districts are labeled in boldface.

Figure 2. Selected localities (black dots) where cases of cutaneous leishmaniasis were reported in Israel during 2001–2012. Health districts are labeled in boldface.


Resurgence of Cutaneous Leishmaniasis in Israel, 2001–2012

Dan Gandacu1, Yael Glazer1Comments to Author , Emilia Anis, Isabella Karakis, Bruce Warshavsky, Paul Slater, and Itamar Grotto
Author affiliations: Israel Ministry of Health, Jerusalem, Israel (Y. Glazer, D. Gandacu, E. Anis, I. Karakis, B. Warshavsky, P. Slater, I. Grotto)Hebrew University and Hadassah–Braun School of Public Health, Jerusalem (E. Anis)Ben-Gurion University of the Negev Department of Public Health, Be’er Sheva, Israel (Y. Glazer, I. Karakis, I. Grotto)


Cutaneous leishmaniasis has long been endemic in Israel. After a 15-year period of moderate illness rates, reported incidence increased from 0.4 cases per 100,000 population in 2001 to 4.4 cases per 100,000 population in 2012, and the disease emerged in areas where its presence had previously been minimal. We analyzed all cases reported to the national surveillance system and found that outbreak patterns revealed an expansion of Leishmania major infections over large areas in the southern part of the country and the occurrence of spatially focused L. tropica outbreaks in the northern part of the country. Outbreaks often followed new construction in populated areas. Further study of factors affecting the transmission of cutaneous leishmaniasis is needed in Israel, as well as the development of effective methods to control the disease, an increase in awareness among health care professionals, and intensive public education regarding control measures in areas of known leishmaniasis foci.
Leishmaniasis is a disease caused by parasites of the genus Leishmania; global incidence approaches 2 million cases annually (1,2). Cutaneous leishmaniasis (CL), the most common form of the disease (3), is endemic in most Mediterranean countries (4). Humans become hosts of the disease when the parasitic infection develops in the immune system and causes skin lesions. The lesions tend to heal spontaneously after 3–18 months (5) but often result in disfiguring scars (6,7). Functional complications are rare (8).
CL has long been endemic in Israel, and the disease is known colloquially in the region as the “Rose of Jericho.” Historically, the main source of the disease in Israel has been L. major protozoa; cases resulting from this species have been widely distributed in the Negev region in the Southern health district, the arid and semi-arid area of southern Israel that that is sparsely populated and accounts for ≈60% of the country’s land. More recently, illness caused by L. tropica parasites has been reported in several semi-arid hilly areas in Israel’s more densely populated, and less dispersed, central and northern population centers (9,10).
The recognized vector of CL in Israel is the female phlebotomine sand fly. The species predominantly responsible for CL cases in Israel have beenPhlebotomus papatasi for L. major infections and Ph. sergenti for L. tropica infections. The reservoir of L. major parasites consists of rodents (e.g.,Psamomys obeesus, Meriones crassusMicrotus guentheriMeriones tristramiGerbillus spp.), whereas the main reservoir of L. tropica parasites is the rock hyrax (Procavia capensis). L. tropica infection tends regionally to be an urban, anthroponotic phenomenon, but in Israel it is zoonotic in nature and has an incubation period that is longer than that for L. major infection and is more resistant to treatment. L. tropica infection also results in multiple lesions and, when it results in leishmaniasis recidivans, has a lower tendency to heal spontaneously (11,12).
Before 2001, a total of 3,352 cases of CL had been reported in Israel, and annual incidence ranged from 0.1 to 7.3/100,000 population. Two periods of particularly high illness rates occurred during this time, in 1967–1969 and in 1980–1982 (13). The first peak, in the late 1960s, appeared after the June 1967 War, after the exposure of naive populations to the parasite in disease-endemic areas. The second peak, in the early 1980s, was assumed to have resulted primarily from the continuing increase in the number of new settlements westward from the Jordan Valley toward Jerusalem (13). A decade and a half of relatively moderate incidence followed, and at the end of 2000, reported national incidence stood at 0.3/100,000 population. However, by 2012, reported incidence had increased to 4.4/100,000 population and CL had emerged in areas where its presence had previously been minimal. We describe these changes from an epidemiologic point of view and discuss factors that might explain the increase in CL rates and distribution from 2001 to 2012.

Dr Gandacu is a public health physician in the Division of Epidemiology of the Israel Ministry of Health. His research interest is the epidemiology of zoonotic diseases.


We thank Laor Orshan for her professional comments and suggestions on the vector and reservoirs of the disease and Zalman Kaufman for his preparation of the map.


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Suggested citation for this article: Glazer Y, Gandacu D, Anis E, Karakis I, Warshavsky B, Slater P, et al. Resurgence of cutaneous leishmaniasis in Israel, 2001–2012. Emerg Infect Dis [Internet]. 2014 Oct [date cited]. http://dx.doi.org/10.3201/eid2010.140182
DOI: 10.3201/eid2010.140182
1These authors contributed equally to this article.

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