Systematic Review: Re-emergence of human leishmaniasis in the Balkans

Phlebotomine sand flies (Diptera: Psychodidae) of Bosnia and Herzegovina: distribution, ecology and environmental preferences

Sand flies (Diptera: Phlebotominae) are the principal vectors for the protozoan parasites Leishmania spp. and for phleboviruses. The sand fly fauna on the Balkan Peninsula, including Bosnia and Herzegovina (BIH), is diverse and the circulation of Leishmania infantum as well as phleboviruses has been proven. However, recent data on the sand fly fauna in BIH are scarce. In this study, we surveyed understudied regions in central and northeastern BIH to update the sand fly distribution and gain insights into the ecological and environmental factors shaping their appearance. CDC light trapping was conducted in 2022 and 2023 and a combination of morphological and molecular methods (cytochrome oxidase I barcoding) was performed for species identifications. We mapped the currently known distribution, modelled climatic suitability patterns and performed environmental analyses by applying machine learning methods. In addition, we analyzed blood meals by host gene sequencing and MALDI-TOF peptide mass mapping and screened for Leishmania spp. DNA and Phlebovirus RNA. Altogether, 591 sand flies of four species were trapped, predominantly Phlebotomus neglectus (97 %), but also Ph. balcanicus, Ph. mascittii, and Ph. papatasi. Records of seven sand fly species known to be endemic were plotted onto distribution maps based on 101 datapoints, identifying Ph. neglectus as the overall predominant species. The environmental analyses of sand fly species indicated variation in altitudinal, thermal, and precipitation conditions across the sand fly-positive sites. Phlebotomus simici, Phlebotomus tobbi, and Sergentomyia minuta are typically found exclusively in Mediterranean and subtropical climate zones, whereas other species typically inhabit continental regions. The Inverse Distance Weighted (IDW) interpolation of sand fly species numbers and Shannon entropy values suggested the southeastern coastal region of BIH as a primary focus for sand fly occurrence. This finding was corroborated by modeled average climatic suitability patterns for sand flies, depicting four distinct meso-regions for sand fly occurrence. The results of the ensemble method highlight the importance of annual precipitation to distinguish between positive and negative sand fly trapping sites in BIH. In total, 55 blood meals of two sand fly species, Ph. neglectus and Ph. balcanicus, were analyzed and five host species identified. Our comprehensive assessment of ecological and environmental preferences of sand flies in BIH may support further entomological surveys and help to better understand and evaluate potential hot spots of disease transmission in the country.

A cross-sectional study on phlebotomine sand flies in relation to disease transmission in the Republic of Kosovo

Sand flies (Diptera: Psychodidae: Phlebotominae) are blood-feeding insects that transmit the protozoan parasites Leishmania spp. and various arboviruses. The Balkan region, including the Republic of Kosovo, harbours a diverse sand fly fauna. Vector species of Leishmania infantum as well as phleboviruses are endemic; however, recent data are scarce. We performed a cross-sectional study to update the current sand fly distribution in Kosovo and assess biological as well as environmental factors associated with sand fly presence. CDC light trapping was conducted at 46 locations in 2022 and 2023, specifically targeting understudied regions in Kosovo. Individual morphological species identification was supported by molecular barcoding. The occurrence data of sand flies was used to create distribution maps and perform environmental analyses, taking elevation, wind speed and climate-related factors into account. In addition, PCR-based blood meal analysis and pathogen screening were conducted. Overall, 303 specimens of six sand fly species were trapped, predominated by Phlebotomus neglectus (97%). Barcodes from eight of nine known endemic sand fly species were obtained. Combining our data with previous surveys, we mapped the currently known sand fly distribution based on more than 4000 specimens at 177 data points, identifying Ph. neglectus and Ph. perfiliewi as the predominant species. Environmental analyses depicted two geographical groups of sand flies in Kosovo, with notable differences between the species. In total, 223 blood meals of five sand fly species were analysed. Of seven identified host species, the predominant blood meal source was observed to be cattle, but the DNA of dogs and humans, among others, was also detected. This study assessed biological as well as ecological factors of sand fly occurrence, which should help better understand and evaluate potential hot spots of disease transmission in Kosovo.

Ecological setting of phlebotomine sand flies in the Republic of Kosovo

Sand flies (Diptera, Psychodidae) are the principal vectors of Leishmania spp., the causative agents of leishmaniasis, as well as phleboviruses. In the Balkans, the endemicity and spreading of sand fly-borne diseases are evident, particularly in the Republic of Kosovo, a country with a predominantly humid continental climate. To date, understanding the drivers behind the spatial structure and diversity patterns of sand fly communities in humid continental regions remains limited. Therefore, elucidating the geographical and ecological factors contributing to the presence of potential vector species in the country is crucial. We aimed to enhance our understanding of factors influencing sand fly occurrence in cool and wet wintering humid continental areas, which could serve as a model for other countries with similar climatic conditions. Therefore, we assessed the currently known sand fly fauna through detailed environmental analyses, including Voronoi tessellation patterns, entropy calculations, Principal Coordinate and Component Analyses, Hierarchical Clustering, Random Trees, and climatic suitability patterns. Notable differences in the ecological tolerance of the species were detected, and the most important climatic features limiting sand fly presence were wind speed and temperature seasonality. Sand flies were observed to prefer topographical environments with little roughness, and the modelled climatic suitability values indicated that, dominantly, the western plain regions of Kosovo harbour the most diverse sand fly fauna; and are the most threatened by sand fly-borne diseases. Phlebotomus neglectus and P. perfiliewi, both confirmed vectors for L. infantum and phleboviruses, were identified as two main species with vast distribution in Kosovo. Contrary to this, most other present species are relatively sparse and restricted to temperate rather than humid continental regions. Our findings reveal a diverse potential sand fly fauna in Kosovo, indicating the need for tailored strategies to address varying risks across the country's western and eastern regions in relation to leishmaniasis control amidst changing environmental conditions.

The changing epidemiology of human leishmaniasis in the non-endemic country of Austria between 2000 to 2021, including a congenital case

BACKGROUND

Leishmaniasis is caused by infection with intracellular protozoans of the genus Leishmania. Transmission occurs predominantly by the bite of phlebotomine sandflies, other routes, including congenital transmission, are rare. The disease manifests as either cutaneous, visceral or mucosal/mucocutaneous leishmaniasis. In recent years, changes in the epidemiological pattern have been reported from Europe.

PRINCIPAL FINDINGS

A total of 311 new and 29 published leishmaniasis cases occurring between 01/01/2000 and 12/31/2021 in Austria were collected and analyzed. These encompassed 146 cutaneous (CL), 14 visceral (VL), 4 mucosal, and 3 cases with concurrent VL and CL. In addition, asymptomatic infections, comprising 11 unspecified cases with Leishmania DNA detectable only in the blood and 162 cases with anti-Leishmania antibodies were reported. Particularly since 2016, the incidence of leishmaniasis has steadily risen, mainly attributable to increasing numbers of CL and cases with positive serology against Leishmania species, whereas the incidence of VL has slowly decreased. Analysis revealed that a shift in the causative species spectrum had occurred and that a substantial number of CL cases were caused by members of the Leishmania donovani/infantum complex. Simultaneous occurrence of VL and CL was identified in immunocompromised individuals, but also in a not yet reported case of an immunocompetent child after vertical transmission.

CONCLUSIONS

The incidence of leishmaniasis has risen in the recent years. The numbers are anticipated to keep rising due to increasing human mobility, including travel and forced migration, growing reservoir host populations as well as expansion and dispersal of vector species caused by climate and habitat changes, urbanization and globalization. Hence, elevated awareness for the disease, including possible transmission in previously non-endemic regions and non-vector transmission modes, support of sandfly surveillance efforts and implementation and establishment of public health interventions in a One Health approach are pivotal in the global efforts to control and reduce leishmaniasis.

First Detection and Molecular Analysis of Leishmania infantum DNA in Sand Flies of Kosovo

Phlebotomine sand flies (Diptera: Psychodidae) are the principal vectors of phleboviruses and Leishmania spp., the causative agents of leishmaniases. The Mediterranean sand fly fauna is diverse, and leishmaniasis, mainly caused by Leishmania infantum, is endemic in the Balkan countries. Despite recent entomological surveys, only some districts of Kosovo have been sampled for sand flies, with no proof/confirmation of L. infantum. This study aimed to gain further insights into the species composition of natural sand fly populations in previously unsampled districts and areas in Kosovo without reports of leishmaniasis and to detect Leishmania DNA in sand flies. A sand fly survey was conducted in 2022 in all seven districts of Kosovo. Collected females were screened for Leishmania DNA by PCR. Positive samples were sequenced and subjected to maximum likelihood analysis with reference sequences for further molecular characterization. The trapping activities at 114 different localities resulted in 3272 caught specimens, comprising seven sand fly species of two genera, namely Phlebotomus neglectus, Ph. perfiliewi, Ph. tobbi, Ph. papatasi, Ph. simici, Ph. balcanicus and Sergentomyia minuta. Leishmania infantum DNA was detected in three individual sand flies of Ph. neglectus and Ph. perfiliewi. This study provides the most extensive sand fly survey in Kosovo and reports the first record of L. infantum DNA in sand flies, indicating autochthonous circulation of L. infantum.

Current Status of Vector-Borne Diseases in Croatia: Challenges and Future Prospects

Different vector-borne pathogens are present or have (re-)emerged in Croatia. Flaviviruses tick-borne encephalitis (TBEV), West Nile (WNV), and Usutu (USUV) are widely distributed in continental regions, while Toscana virus (TOSV) and sandfly fever viruses are detected at the Croatian littoral. Recently, sporadic clinical cases of Tahyna orthobunyavirus (TAHV) and Bhanja bandavirus infection and seropositive individuals have been reported in continental Croatia. Acute infections and serologic evidence of WNV, TBEV, USUV, and TAHV were also confirmed in sentinel animals and vectors. Autochthonous dengue was reported in 2010 at the Croatian littoral. Lyme borreliosis is the most widely distributed vector-borne bacterial infection. The incidence is very high in northwestern and eastern regions, which correlates with numerous records of Ixodes ricinus ticks. Acute human Anaplasma phagocytophilum infections are reported sporadically, but there are many records of serologic evidence of anaplasmosis in animals. Mediterranean spotted fever (Rickettsia conorii) and murine typhus (Rickettsia typhi) are the main rickettsial infections in Croatia. Human leishmaniasis is notified sporadically, while serologic evidence of leishmaniasis was found in 11.4% of the Croatian population. After the official eradication of malaria in 1964, only imported cases were reported in Croatia. Since vector-borne diseases show a growing trend, continuous monitoring of vectors is required to protect the population from these infections.

Visceral leishmaniasis in Kosovo: A case of misdiagnosis and diagnostic challenges

Introduction

Visceral leishmaniasis (VL) is a parasitic disease caused by various Leishmania species and is a potentially life-threatening condition. The disease is highly endemic in several regions, including the Balkans, yet information regarding its prevalence in Kosovo is limited.

Case presentation

In this case presentation, a 62-year-old man was admitted to a hospital in Kosovo due to a persistent high fever, and after extensive evaluations and treatments, he was diagnosed with fever of unknown origin (FUO) and transferred to a hospital in Turkey. An abscess of the psoas muscle caused by MRSA was found, however, pancytopenia persisted despite antibiotic treatment. Six months later, the patient was hospitalized again due to fever, chills, and night sweats. Microscopic examination and serological tests revealed the presence of Leishmania infantum in the bone marrow. Liposomal amphotericin B treatment resulted in a significant improvement in the patient's condition.

Discussion

The diagnosis of VL can be challenging, and it can easily be misdiagnosed as other diseases, resulting in diagnostic delays and potentially fatal outcomes. In endemic regions such as the Balkans, it is crucial for physicians to be aware of this infection to avoid misdiagnosis or diagnostic delay. Early diagnosis and prompt treatment of VL are essential in preventing morbidity and mortality.

Conclusion

This case highlights the significance of considering VL as a possible diagnosis in patients presenting with febrile illnesses accompanied by pancytopenia and splenomegaly, especially in endemic regions.

High-throughput microfluidic real-time PCR for the simultaneous detection of selected vector-borne pathogens in dogs in Bosnia and Herzegovina

A scarcity of information on the occurrence of zoonotic vector-borne pathogens (VBPs), alongside a lack of human and animal health authorities' awareness of pre-existing data, augment the risk of VBP infection for local people and limit our ability to establish control programs. This holds especially true in low-middle income countries such as Bosnia and Herzegovina (BiH). This dearth of information on zoonotic VBPs is bolstered by the inability of previously used diagnostic tests, including conventional molecular diagnostic methods, to detect the full spectrum of relevant pathogens. Considering this, we set out to apply a microfluidic qPCR assay capable of detecting 43 bacterial and protozoan pathogens from blood to accrue critical baseline data for VBPs occurrence in BiH. A total of 408 dogs were tested of which half were infected with at least one VBP of zoonotic or veterinary importance. Leishmania infantum was found in 18% of dogs, reaching a prevalence as high as 38% in urbanized areas of Sarajevo. These data highlight substantially higher levels of L. infantum prevalence when compared to that previously reported using conventional methods using the same samples. Additionally, this high-throughput microfluidic qPCR assay was able to detect pathogens rarely or never reported in canines in BiH, including Anaplasma phagocytophilum (3%), Anaplasma platys (0.2%), haemotropic Mycoplasma (1%) and Hepatozoon canis (26%). Our report of the endemicity of important zoonotic pathogens and those of clinical significance to dogs emphasizes the need for urgent implementation of surveillance and control for VBPs in BiH, targeting both animal and human infections within the country.

Epidemiological Aspects and High Magnitude of Human Visceral Leishmaniasis in Ceará, Northeast of Brazil, 2007-2021

BACKGROUND

Human visceral leishmaniasis HVL is endemic to 75 countries. The state of Ceará, the Northeast region of Brazil, is of great sanitary importance for the transmission of HVL, and it stands out as an area of interest for epidemiological aspects and control strategies. This study aimed to characterize HVL in relation to epidemiological aspects, composite incidence, and mortality rates in the state of Ceará, Brazil, from 2007 to 2021.

METHODS

This ecological study used temporal and spatial cuts of HVL data from the notifiable diseases information system. Epidemiological indicators such as incidence, mortality, and composite indices of incidence and mortality were calculated according to the Ministry of Health standardization.

RESULTS

There were 6,775 confirmed cases, with high incidence coefficients in 2009 6.96 cases/100,000 inhabitants and 2011 9.83 cases/100,000 inhabitants, and the highest mortality rate in 2011 6.96 deaths/100,000 inhabitants. The composite index of incidence and mortality identified municipalities in the Northern, Northwestern, and Southern regions of Ceará as having the highest risk of HVL.

CONCLUSIONS

HVL remained endemic throughout the study period, with epidemiological indicators and risk of transmission expressing high magnitude, mainly in the Northeast, Northwest, and South regions of Ceará.