1. Cutaneous leishmaniasis in Syria

2. Leishmaniasis Introduction zInfectious disease caused by intracellular protozoan parasites of the genus Leishmania zvisceral, cutaneous, and mucocutaneous

3. Visceral Leishmaniasis zKnown as kala azar zCharacterized by ychronic recurrent fever ysplenomegaly ypancytopenia yweight loss yhigh mortality

4. Cutaneous leishmaniasis (CL) zmost abundant zCL is caused by at least 12 different species of Leishmania, and each of them has its own characteristic, vectors, and reservoirs

5. (CL) Presentation zSingle or multiple chronic skin ulcers zDestructive mucocutaneous lesions, or zDisseminated infection

8. Mode of Transmission zAt least 70 different species of sandflies, small insects of the genus Phlebotomus zThe primary sandfly vectors of the Southwestern Asia region include yPhlebotomus papatasi yPhlebotomus sergenti

9. CL Occurrence zCL is found in most countries of the tropical and subtropical regions of the world z90% of all cases occur in only six countries: Afghanistan, Brazil, Iran, Peru, Saudi Arabia, and Syria

11. CL Incidence Incidence fluctuates due to: znew agricultural projects zweather variability zchanges in reservoir densities, and zannual sandfly patterns

12. CL Incidence The annual incidence of CL throughout the world is 1 to 1.5 million cases with 350 million people at risk of getting the disease, only 300,000 cases are officially reported

13. Most Important Infectious Agents zOld World: yLeishmania major yLeishmania tropica yLeishmania aethiopica zNew World: yLeishmania braziliensis yLeishmania mexicana

14. Leishmania major zAlso known as the rural type zCauses moist cutaneous lesions zOccurs in southern districts of Syria zReservoir host is the rodent Psammomys obesus (Fat Sand Rat) zSpreads zoonotically from desert rodents to man by sand fly Phlebotomus papatasi

15. Leishmania major zIncubation period is week to months zUlcers appear on the extremities zSpontaneous healing occurs within 3 to 6 months, leaving a depigmented pitted scar

16. RodentSandflyHuman Leishmania major Mode of Transmission

17. Leishmania major Occurrence zSemi-arid climates yhot dry season lasting 6 or more months ytemperature exceeding 35-40 o C yRainfalls vary from 100mm- 600mm annually. zFound in low-lying desert regions zSoils are deep and friable but sufficiently cohesive for the construction of deep, durable, rodent burrows

22. Leishmania tropica zKnown as urban CL, or “anthroponotic CL” zCauses dry lesion zTransmitted from person-to-person zHumans and the domestic dogs serve as the reservoirs of infection zCausative parasite in northern districts zTransmitted by the sandfly Plebotomus sergenti

23. Leishmania tropica Occurrence Spreads in areas of zurban centers zhigher altitudes ztemperate climate zarid, cold and warm weather

24. Leishmania tropica zIncubation period 2 months > a year zLesion is usually facial and begins as a pruritic, purplish nodule (the Aleppo button) then slowly enlarges and finally breaks down after 3 or 4 months zHealing of the ulcers may require a year or more

26. Leishmania tropica Mode of Transmission SandflyHuman

28. Climate in Syria zTwo seasons: ydry and hot summer (July hottest month) ywet and cold winter (January coldest month) yspring and fall mild with some rainfall zTemperature declines from south to north (average annual temperature is 19.7 o C in the south,and 17.2 o in the north) zThe average annual precipitation is 100mm-1500mm

29. Purpose of the Study zTo describe temporal and spatial patterns of disease and to characterize risk factors for exposure.

30. CL Case Data Used in the Study

31. Preliminary Results

32. Incidence Rate per 1000 in each district between 1990-1997

34. IR/1000 in Damascus Suburbs b/w 1994-1997 according to sex

35. IR/1000 in Aleppo b/w 1994-1997 according to sex

36. IR/100 in Damascus Suburbs b/w 1994-1997 according to age groups

37. IR/100 in Aleppo b/w 1994-1997 according to age groups

38. Damascus Suburbs Total Incidence Rates

39. Damascus Suburbs Male Incidence Rates

40. Damascus Suburbs Female Incidence Rates

41. Aleppo Total Incidence Rates

42. Aleppo Male Incidence Rates

43. Aleppo Female Incidence Rates

44. Conclusion zThere are few studies of the CL status in Syria despite the high rates zMore research is needed to identify the epidemiological relationship between vector, reservoir and host and to limit the spread of the disease.