Eurosurveillance - Volume 18, Issue 29, 18 July 2013

An increased number of autochthonous visceral leishmaniasis (VL) cases has recently been reported in Bologna Province in northern Italy. Over six months from November 2012 to May 2013, 14 cases occurred, whereas the average number of cases per year was 2.6 (range: 0-8) in 2008 to 2012. VL was diagnosed in a median of 40 days (range: 15-120) from disease onset. This delay in diagnosis shows the need for heightened awareness of clinicians for autochthonous VL in Europe. .

Visceral leishmaniasis is a sporadic illness in Bulgaria. However, cases in humans are registered nearly every year. This study describes the geographical distribution of the disease in Bulgaria from 1988 to 2012, over a period of 25 years. Cases were analysed according to age, sex, and place of residence. A total of 122 cases were registered in 25 years, 118 of which were autochthonous and four of which were imported from endemic countries in southern Europe. The average annual incidence for the study period was 0.06 per 100,000 population, or an average of five cases per year (maximum 15 in 1989; no cases notified in 1991, 1995, 1996 and 2008). Cases of visceral leishmaniasis were recorded in 13 out of 28 regions in Bulgaria, mainly in the southern part of the country. The highest number of cases were registered in the regions of Blagoevgrad (n=36) and Stara Zagora (n=34). Data presented in this study show that there is ongoing transmission of visceral leishmaniasis in Bulgaria with a high mortality rate (1:7), affecting mostly children.

Leishmaniasis is endemic and mandatorily notifiable in Greece. Epidemiological surveillance data for leishmaniasis in Greece between 1981 and 2011 are presented. In 1998, the notification system began distinguishing between visceral and cutaneous leishmaniasis. The mean annual incidence of reported leishmaniasis cases between 1998 and 2011 was 0.36 per 100,000 population. Of a total 563 leishmaniasis cases reported after 1998, 523 (93%) were visceral leishmaniasis cases. Incidence of reported visceral leishmaniasis cases fluctuated during this period, generally decreasing after 2007, with a small re-increase in 2011. The mean annual incidence rate of reported visceral leishmaniasis cases was significantly higher in less than four year-olds (p <0.001). Leishmaniasis cases occurred both in the country mainland and islands. Between 1998 and 2011, Attica concentrated almost half of the reported visceral leishmaniasis cases, with incidence rates in western Attica and western Athens above 12.00 per 100,000 population. Compared to visceral leishmaniasis, cutaneous leishmaniasis had a rather sporadic distribution, with many prefectures appearing free of cases. From 2004, the notification also included risk factors and of 287 cases with known immune status, 44 (15%) were immunocompromised. Moreover having a dog at home was reported by 209 of 312 leishmaniasis cases (67%), whereas 229 of 307 cases (75%) reported the presence of stray dogs near their residence. Linking clinical surveillance data with laboratory data and improving collaboration with the veterinary public health sector are some of the future challenges for leishmaniasis surveillance in Greece.

The prevalence of asymptomatic leishmaniasis in the general population of Croatia has not been studied to date. To assess the prevalence of Leishmania infantum specific IgG antibodies among immunocompetent residents of Croatia, sera from 2,035 persons (eastern coast of Adriatic Sea, n=1,186; Adriatic islands, n=653; mainland, n=196), were tested by an enzyme immunoassay. A total of 231 (11.4%) persons had anti-Leishmania antibodies. Multivariate analysis revealed that seropositivity was associated with geographic location and age. Residents of coastal areas and islands were significantly more seropositive than mainland residents (odds ratios (OR) 20.37 to 28.51). Moderate to high anti-Leishmania seroprevalence was found throughout the eastern Adriatic coast and islands (4.0% to 22.2%) including the sites previously considered non-endemic. A highly endemic focus was identified in central coastal Dalmatia (seroprevalence 22.2%; OR: 1.72; 95% confidence interval (CI): 1.33-2.22). Regarding age, children aged 0-9 years were the most vulnerable group for asymptomatic Leishmania infection (OR: 2.19; 95% CI: 1.16-4.14).

Starting from 1989 Italy experienced an increase of visceral leishmaniasis (VL) cases over a baseline of 10 to 30 cases reported annually. The number of cases peaked in 2000 and 2004 with more than 200 cases/year, and subsequently declined to reach on average one third of the 2000 peak value in the period after 2010. A retrospective analysis from 1982 to 2012 showed that the multi-annual epidemic consisted of major components including (i) an outbreak involving infants and immunocompetent adults in parts of the Campania region (southern peninsular Italy) and that appears to have declined naturally, (ii) a second outbreak affecting human immunodeficiency virus (HIV)-infected individuals throughout the country, that declined owing to the use of highly active antiretroviral therapies (HAART), (iii) a generalised increase of VL cases in immunocompetent individuals and patients affected by associated conditions other than HIV from endemic regions of peninsular and insular Italy (other than Campania), which was due to a geographical spreading of VL foci, with no major case-clusters or outbreak features. A minor component consisted in the appearance of a few autochthonous cases in formerly non-endemic areas, starting from the early 1990s. Epidemic determinants and reasons for VL decline in the Campania region remain largely unexplained, despite the information available on canine reservoir and phlebotomine vectors in Italy.

Leishmaniasis is endemic in the south of France, where autochthonous disease is caused by Leishmania infantum, and affects both humans and dogs. The prevalence of canine leishmaniasis is between 3 and 66% depending on the region and the methods used. Human leishmaniases are also imported into France, mainly from French Guiana and North Africa. The surveillance of autochthonous and imported human leishmaniases is based on passive notification to the National Reference Centre for Leishmaniases (NRCL) created in 1998. Between 1999 and 2012, 317 autochthonous and 1,154 imported cases were notified to the NRCL. The average number of autochthonous cases notified per year was 22.6, mainly cases of visceral leishmaniasis (84.5%). All cases were infected in the south of France. Leishmaniasis incidence is 0.22 per 100,000 inhabitants in the endemic area. Imported cases were more frequent (annual mean of 82.4 cases) and consisted predominantly in cutaneous leishmaniasis (CL) cases (91%), essentially L. major CL imported from Maghreb and Sub-Saharan Africa, and L. guyanensis CL from French Guiana. This national notification system allowed a better understanding of the incidence and distribution of the disease; it is also useful to assess the temporal-spatial evolution of the disease in France, which appears relatively stable.