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Dires A, Gedamu S, Kumar P, Yimam W, Ademe S, Dires T. Determinants of cutaneous leishmaniasis among students in Delanta district, Northeast Ethiopia: A case-control study. Health Sci Rep 2022; 5:e917. [PMID: 36324427 PMCID: PMC9621467 DOI: 10.1002/hsr2.917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/18/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Background and Aims Cutaneous leishmaniasis (CL) is the most common form of leishmaniasis that causes skin lesions on exposed parts of the body. It is endemic in over 170 districts and highly prevalent in the northern and southern parts of Ethiopia. Thus, the aim of this study was to assess the determinants of CL among students of Wegeltena secondary school in Delanta district, Northeast Ethiopia. Methods This unmatched case-control study was conducted from January 4 to 20, 2021 at Wegeltena secondary school. Cases were students who had an active lesion of CL and controls were students who had never been infected with CL (no active lesions). A simple random sampling technique was utilized to select participants in the control group. Data were collected by using a pretested, interviewer-administered structured questionnaire. Bivariable and multivariable logistic regression analyses were performed and variables were declared determinants of CL at a p value of <0.05. Results A total of 225 students (58 cases and 167 controls) participated in the study. The mean age of cases and controls was 18.6 (SD ± 0.99 years) and 18.5 years (SD ± 1.17 years), respectively. In this study, 74.1% of cases and 51.5% of controls have been living in rural areas. Furthermore, being male (adjusted odds ratio [AOR] = 4.11; 95% confidence interval [CI]: 1.94-8.69), rural residents (AOR = 2.95; 95% CI: 1.33-6.52), living in areas where caves (AOR = 3.63; 95% CI: 1.24-10.59), nearby forest (AOR = 4.04; 95% CI: 1.42-11.51), and hyrax available (AOR = 2.43; 95% CI: 1.16-5.08) were significantly associated with CL. Conclusion In our study, sociodemographic and environmental factors were found to be determinants of CL. Therefore, reducing outdoor activities, wearing protective clothes, use of insecticide-treated nets, and destruction of sand fly breeding sites shall be implemented targeting the rural population that resides in areas where forests, caves, and hyraxes are prominent.
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Affiliation(s)
- Abebe Dires
- Department of Comprehensive Nursing, School of Nursing and Midwifery, College of Medicine and Health Sciences Wollo University Dessie Ethiopia
| | - Sisay Gedamu
- Department of Comprehensive Nursing, School of Nursing and Midwifery, College of Medicine and Health Sciences Wollo University Dessie Ethiopia
| | - Prem Kumar
- Department of Comprehensive Nursing, School of Nursing and Midwifery, College of Medicine and Health Sciences Wollo University Dessie Ethiopia
| | - Wondosen Yimam
- Department of Comprehensive Nursing, School of Nursing and Midwifery, College of Medicine and Health Sciences Wollo University Dessie Ethiopia
| | - Sewunet Ademe
- Department of Comprehensive Nursing, School of Nursing and Midwifery, College of Medicine and Health Sciences Wollo University Dessie Ethiopia
| | - Tadila Dires
- Department of Nursing Debre Tabor University Debre Tabor Ethiopia
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Sawalha S, Al-Jawabreh A, Hjaija D, Ereqat S, Nasereddin A, Al-Jawabreh H, Evlampidou I. Effectiveness of insecticide thermal fogging in hyrax dens in the control of leishmaniasis vectors in rural Palestine: A prospective study. PLoS Negl Trop Dis 2022; 16:e0010628. [PMID: 36099245 PMCID: PMC9469989 DOI: 10.1371/journal.pntd.0010628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/01/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Zoonotic cutaneous leishmaniasis (ZCL) is endemic in Palestine and transmitted by Phlebotomus sand flies. They inhabit dens of hyraxes, the reservoir animal. Control measures were implemented since 1996 but cases still occur. We estimated the effect of insecticide thermal fogging inside hyrax dens on sand fly density and leishmania infection.
Methodology/Principal findings
During July-September 2019, we conducted a 12-week controlled interrupted time series study in two control and one intervention sites containing three hyrax dens each. We implemented Permethrin thermal fogging in the intervention site at week 6. We measured weekly and 36hrs post-intervention sand fly abundance inside dens using CDC light traps. We performed Next-Generation Sequencing to identify sand fly Leishmania spp. infection. We calculated the abundance reduction (AR) using Mulla’s formula and negative binomial regression. Among 11427 collected sand flies, 7339 (64%) were females and 1786 (16%) were Phlebotomus spp. comprising ten species; P. sergenti was the dominant (n = 773, 43%). We report P. arabicus (n = 6) for the first time in Palestine. After fogging, Phlebotomus spp. AR was 93% at 36hrs, 18% and 38% at two and five weeks respectively and 41% during the complete post-intervention period. In the regression models, Phlebotomus spp. density in the intervention site decreased by 74% (IRR: 0.26, 95%CI: 0.11–0.57) at two weeks, 34% (IRR: 0.66, 95%CI: 0.48–0.90) at five weeks and 74% (IRR: 0.26, 95%CI: 0.12–0.59) during the complete period. The density of Leishmania infected sand flies decreased by 65% (IRR: 0.35, 95%CI: 0.26–0.48) at five weeks and 82% (IRR: 0.18, 95%CI: 0.07–0.42) for the complete period (zero infections until week two). Leishmania infection prevalence in the intervention site was 14% pre-intervention and 3.9% post-intervention.
Conclusions/Significance
Fogging hyrax dens reduced sand fly abundance and leishmania infection during the 5-week post-intervention period and especially the first two weeks suggesting it could be an effective source-reduction measure for ZCL vectors. Future randomized controlled trials are needed to confirm the effectiveness of fogging hyrax dens on decreasing ZCL incidence.
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Affiliation(s)
- Samer Sawalha
- Vector Control Unit, Environmental Health Department, Ministry of Health, Ramallah, Palestine
- Mediterranean and Black Sea Field Epidemiology Training Programme—MediPIET, Madrid, Spain
| | - Amer Al-Jawabreh
- Leishmaniases Research Unit, Jericho, Palestine
- Arab American University, Jenin, Palestine
- * E-mail:
| | - Dea Hjaija
- Preventive Medicine Department, Ministry of Health, Ramallah, Palestine
| | - Suheir Ereqat
- Biochemistry and Molecular Biology Department, Faculty of Medicine, Al-Quds University, East Jerusalem, Palestine
| | - Abdelmajeed Nasereddin
- Biochemistry and Molecular Biology Department, Faculty of Medicine, Al-Quds University, East Jerusalem, Palestine
| | | | - Iro Evlampidou
- Mediterranean and Black Sea Field Epidemiology Training Programme—MediPIET, Madrid, Spain
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Borges MS, Niero LB, da Rosa LDS, Citadini-Zanette V, Elias GA, Amaral PDA. Factors associated with the expansion of leishmaniasis in urban areas: a systematic and bibliometric review (1959–2021). J Public Health Res 2022; 11:22799036221115775. [PMID: 36062236 PMCID: PMC9434684 DOI: 10.1177/22799036221115775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/09/2022] [Indexed: 11/15/2022] Open
Abstract
This work describes a systematic and bibliometric review of the factors that contribute to the expansion of leishmaniasis in urban areas. Three scientific databases were used: Scientific Electronic Library (Sci ELO), Scopus and Web of Science, encompassing all original and review articles between 1959 and 2021. Three descriptors were used: “leishmaniasis” AND “urban” AND “rural.” Planning, execution, summarization, and selection processes were performed using StArt ( State of the Art through Systematic Review) software. We obtained a total of 304 articles, 60 of which concerned canine leishmaniasis. The factors associated with the expansion of leishmaniasis in urban areas are interrelated, including socioenvironmental and economic complexity, the type of leishmaniasis, the reservoirs, vectors, deforestation, disorderly occupation of space, poor sanitary conditions, and human migration trends. A lack of diagnosis and underreporting of cases in some regions may reflect the increase of cases seen in urban areas. A majority ( n = 121) of studies were conducted in Brazil, followed by Iran ( n = 43). In relation to publications; in general, output has increased over the years, particularly in 2021. The majority of published studies were in the area of epidemiology ( n = 158).
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Affiliation(s)
- Marília Schutz Borges
- Mestra em Ciências Ambientais, Programa
de Pós-Graduação em Ciências Ambientais, Universidade do Extremo Sul Catarinense
(UNESC), Criciúma, Santa Catarina, Brasil
- Marília Schutz Borges, Programa de
Pós-Graduação em Ciências Ambientais, Universidade do Extremo Sul Catarinense
(UNESC), Av. Universitária, 1105 - Bairro Universitário CEP: 88806-000 Criciúma,
Santa Catarina, Brasil.
| | - Luana Budny Niero
- Farmacêutica e mestranda do Programa de
Pós-Graduação em Ciências Ambientais, Universidade do Extremo Sul Catarinense
(UNESC), Criciúma, Santa Catarina, Brasil
| | - Laíse Dimer Sant’ana da Rosa
- Acadêmica do curso de farmácia da
Universidade do Extremo Sul Catarinense (UNESC), Criciúma, Santa Catarina,
Brasil
| | - Vanilde Citadini-Zanette
- Doutora em Ecologia e Recursos
Naturais, Programa de Pós-Graduação em Ciências Ambientais, Universidade do Extremo
Sul Catarinense (UNESC), Criciúma, Santa Catarina, Brasil
| | - Guilherme Alves Elias
- Doutor em Ciências Ambientais, Programa
de Pós-Graduação em Ciências Ambientais, Universidade do Extremo Sul Catarinense
(UNESC), Criciúma, Santa Catarina, Brasil
| | - Patrícia de Aguiar Amaral
- Doutora em Ciências Farmacêuticas,
Programa de Pós-Graduação em Ciências Ambientais, Universidade do Extremo Sul
Catarinense (UNESC), Criciúma, Santa Catarina, Brasil
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El Idrissi Saik I, Benlabsir C, Fellah H, Lemrani M, Riyad M. Transmission patterns of Leishmania tropica around the Mediterranean basin: Could Morocco be impacted by a zoonotic spillover? PLoS Negl Trop Dis 2022; 16:e0010009. [PMID: 35025884 PMCID: PMC8757988 DOI: 10.1371/journal.pntd.0010009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Cutaneous leishmaniasis (CL) due to Leishmania tropica is a neglected tropical disease characterized by a wide geographical distribution in the Mediterranean basin and is endemic in several of its countries. In addition, the vector Phlebotomus sergenti is abundantly present all around the basin. Its transmission cycle is still subject to debate. In some countries, the presence of an animal reservoir has been confirmed. In Morocco, CL due to L. tropica has risen since the 1980s and has spread widely to become the most abundant form of leishmaniasis in the territory. However, the anthroponotic transmission is so far the only recognized mode, despite recordings of L. tropica infection in animal hosts. In this review article, we assess the situation of CL due to L. tropica in the Mediterranean basin with a focus on Morocco and gather knowledge about any potential zoonotic transmission in the country. A concomitant zoonotic transmission could explain the persistence of the disease in areas where human protective measures combined with vector management did not help reduce the disease burden. Cutaneous leishmaniasis (CL) due to Leishmania tropica is a neglected tropical disease still considered to be anthroponotic in Morocco despite evidence of zoonotic transmission in other endemic countries of the Mediterranean basin. Its high incidence in the country makes it necessary to investigate whether or not a potential concomitant zoonotic transmission exists alongside the anthroponotic one. Moreover, several reports of natural animal infection have been noted in the country. In this paper, we review how CL due to L. tropica is present around the Mediterranean basin, with a particular focus on the Moroccan foci, and try to unveil the existence of a zoonotic transmission in the area. A deep understanding of the transmission patterns of L. tropica in the region is necessary for the implementation of effective control measures and a better assessment of the disease burden. In addition, the complexity of this neglected disease requires more fundamental and applied research to unveil potential factors involved in its spread.
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Affiliation(s)
- Imane El Idrissi Saik
- Laboratory of Cellular and Molecular Pathology, Research Team on Immunopathology of Infectious and Systemic Diseases, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
- Laboratory of Parasitology and Vector-Borne-Diseases, Institut Pasteur du Maroc, Casablanca, Morocco
| | - Chaimaa Benlabsir
- Laboratory of Cellular and Molecular Pathology, Research Team on Immunopathology of Infectious and Systemic Diseases, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
| | - Hassan Fellah
- Laboratory of Cellular and Molecular Pathology, Research Team on Immunopathology of Infectious and Systemic Diseases, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
| | - Meryem Lemrani
- Laboratory of Parasitology and Vector-Borne-Diseases, Institut Pasteur du Maroc, Casablanca, Morocco
| | - Myriam Riyad
- Laboratory of Cellular and Molecular Pathology, Research Team on Immunopathology of Infectious and Systemic Diseases, Faculty of Medicine and Pharmacy, Hassan II University of Casablanca, Casablanca, Morocco
- * E-mail:
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Paz S, Majeed A, Christophides GK. Climate change impacts on infectious diseases in the Eastern Mediterranean and the Middle East (EMME)-risks and recommendations. CLIMATIC CHANGE 2021; 169:40. [PMID: 34980932 PMCID: PMC8716574 DOI: 10.1007/s10584-021-03300-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/18/2021] [Indexed: 06/14/2023]
Abstract
The Eastern Mediterranean and Middle East (EMME) region has rapid population growth, large differences in socio-economic levels between developed and developing countries, migration, increased water demand, and ecosystems degradation. The region is experiencing a significant warming trend with longer and warmer summers, increased frequency and severity of heat waves, and a drier climate. While climate change plays an important role in contributing to political instability in the region through displacement of people, food insecurity, and increased violence, it also increases the risks of vector-, water-, and food-borne diseases. Poorer and less educated people, young children and the elderly, migrants, and those with long-term health problems are at highest risk. A result of the inequalities among EMME countries is an inconsistency in the availability of reliable evidence about the impacts on infectious diseases. To help address this gap, a search of the literature was conducted as a basis for related recommended responses and suggested actions for preparedness and prevention. Since climate change already impacts the health of vulnerable populations in the EMME and will have a greater impact in future years, risk assessment and timely design and implementation of health preparedness and adaptation strategies are essential. Joint national and cross-border infectious diseases management systems for more effective preparedness and prevention are needed, supported by interventions that improve the environment. Without such cooperation and effective interventions, climate change will lead to an increasing morbidity and mortality in the EMME from infectious diseases, with a higher risk for the most vulnerable populations.
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Affiliation(s)
- Shlomit Paz
- Department of Geography and Environmental Studies, University of Haifa, 199 Aba Khoushy Ave., Mount Carmel, 3498838 Haifa, Israel
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - George K. Christophides
- Department of Life Sciences, Imperial College London, London, UK
- Climate and Atmosphere Research Centre,, The Cyprus Institute, Nicosia, Cyprus
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Valdivia HO, Zorrilla VO, Espada LJ, Perez JG, Razuri HR, Vera H, Fernandez R, Tong C, Ghersi BM, Vasquez GM, Burrus RG, Lescano AG, Montgomery JM. Diversity, distribution and natural Leishmania infection of sand flies from communities along the Interoceanic Highway in the Southeastern Peruvian Amazon. PLoS Negl Trop Dis 2021; 15:e0009000. [PMID: 33566811 PMCID: PMC7875382 DOI: 10.1371/journal.pntd.0009000] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 11/20/2020] [Indexed: 01/24/2023] Open
Abstract
The Peruvian-Brazilian border is a highly endemic tegumentary leishmaniasis region in South America. The interoceanic highway is a commercial route that connects Peru and Brazil through Madre de Dios and has raised concerns about its impact on previously undisturbed areas. In order to assess leishmaniasis transmission risk along this highway, we conducted a surveillance study of the sand fly populations in this area. Sand flies were collected between 2009 and 2010 along transects at 200 m, 600 m and 1000 m from six study sites located along the highway (Iberia, La Novia, Alto Libertad, El Carmen, Florida Baja, Mazuko and Mavila) and an undisturbed area (Malinowski). Collected specimens were identified based on morphology and non-engorged females of each species were pooled and screened by kinetoplast PCR to detect natural Leishmania infections. A total of 9,023 specimens were collected belonging to 54 different Lutzomyia species including the first report of Lu. gantieri in Peru. Four species accounted for 50% of all specimens (Lutzomyia carrerai carrerai, Lu. davisi, Lu. shawi and Lu. richardwardi). El Carmen, Alto Libertad, Florida Baja and Malinowski presented higher Shannon diversity indexes (H = 2.36, 2.30, 2.17 and 2.13, respectively) than the most human disturbed sites of Mazuko and La Novia (H = 1.53 and 1.06, respectively). PCR detected 10 positive pools belonging to Lu. carrerai carrerai, Lu. yuilli yuilli, Lu. hirsuta hirsuta, Lu. (Trichophoromyia) spp., and Lu. (Lutzomyia) spp. Positive pools from 1,000 m transects had higher infectivity rates than those from 600 m and 200 m transects (9/169 = 5.3% vs 0/79 = 0% and 1/127 = 0.8%, p = 0.018). El Carmen, accounted for eight out of ten positives whereas one positive was collected in Florida Baja and Mazuko each. Our study has shown differences in sand fly diversity, abundance and species composition across and within sites. Multiple clustered Lutzomyia pools with natural Leishmania infection suggest a complex, diverse and spotty role in leishmaniasis transmission in Madre de Dios, with increased risk farther from the highway.
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Affiliation(s)
- Hugo O. Valdivia
- Department of Parasitology, U.S. Naval Medical Research Unit 6, Lima, Peru
- * E-mail:
| | - Victor O. Zorrilla
- Department of Entomology, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Liz. J. Espada
- Department of Entomology, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Jocelyn G. Perez
- Department of Parasitology, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Hugo R. Razuri
- Department of Emerging Infections, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Hubert Vera
- Dirección Regional de Salud de Madre de Dios, Puerto Maldonado, Peru
| | - Roberto Fernandez
- Department of Entomology, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Carlos Tong
- Department of Entomology, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Bruno M. Ghersi
- Department of Emerging Infections, U.S. Naval Medical Research Unit 6, Lima, Peru
| | | | - Roxanne G. Burrus
- Department of Entomology, U.S. Naval Medical Research Unit 6, Lima, Peru
| | - Andres G. Lescano
- Emerge, Emerging Diseases and Climate Change Research Unit, and Clima, Latin American Center of Excellence for Climate Change and Health, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Joel M. Montgomery
- Department of Emerging Infections, U.S. Naval Medical Research Unit 6, Lima, Peru
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Hess J, Boodram LLG, Paz S, Stewart Ibarra AM, Wasserheit JN, Lowe R. Strengthening the global response to climate change and infectious disease threats. BMJ 2020; 371:m3081. [PMID: 33106244 PMCID: PMC7594144 DOI: 10.1136/bmj.m3081] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Jeremy Hess
- Departments of Emergency Medicine, Environmental and Occupational Health Sciences, and Global Health, and Center for Health and the Global Environment, Schools of Medicine and Public Health, University of Washington, Seattle, WA USA
| | | | - Shlomit Paz
- Department of Geography and Environmental Studies, University of Haifa, Haifa, Israel
| | - Anna M Stewart Ibarra
- Inter-American Institute for Global Change Research (IAI), Montevideo, Department of Montevideo, Uruguay
| | - Judith N Wasserheit
- Departments of Global Health and Medicine, Schools of Medicine and Public Health, University of Washington, Seattle, WA USA
| | - Rachel Lowe
- Centre on Climate Change & Planetary Health and Centre for Mathematical Modelling of Infectious Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Barcelona Institute for Global Health (ISGlobal), Spain
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Salloum T, Moussa R, Rahy R, Al Deek J, Khalifeh I, El Hajj R, Hall N, Hirt RP, Tokajian S. Expanded genome-wide comparisons give novel insights into population structure and genetic heterogeneity of Leishmania tropica complex. PLoS Negl Trop Dis 2020; 14:e0008684. [PMID: 32946436 PMCID: PMC7526921 DOI: 10.1371/journal.pntd.0008684] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 09/30/2020] [Accepted: 08/06/2020] [Indexed: 12/18/2022] Open
Abstract
Leishmania tropica is one of the main causative agents of cutaneous leishmaniasis (CL). Population structures of L. tropica appear to be genetically highly diverse. However, the relationship between L. tropica strains genomic diversity, protein coding gene evolution and biogeography are still poorly understood. In this study, we sequenced the genomes of three new clinical L. tropica isolates, two derived from a recent outbreak of CL in camps hosting Syrian refugees in Lebanon and one historical isolate from Azerbaijan to further refine comparative genome analyses. In silico multilocus microsatellite typing (MLMT) was performed to integrate the current diversity of genome sequence data in the wider available MLMT genetic population framework. Single nucleotide polymorphism (SNPs), gene copy number variations (CNVs) and chromosome ploidy were investigated across the available 18 L. tropica genomes with a main focus on protein coding genes. MLMT divided the strains in three populations that broadly correlated with their geographical distribution but not populations defined by SNPs. Unique SNPs profiles divided the 18 strains into five populations based on principal component analysis. Gene ontology enrichment analysis of the protein coding genes with population specific SNPs profiles revealed various biological processes, including iron acquisition, sterols synthesis and drug resistance. This study further highlights the complex links between L. tropica important genomic heterogeneity and the parasite broad geographic distribution. Unique sequence features in protein coding genes identified in distinct populations reveal potential novel markers that could be exploited for the development of more accurate typing schemes to further improve our knowledge of the evolution and epidemiology of the parasite as well as highlighting protein variants of potential functional importance underlying L. tropica specific biology.
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Affiliation(s)
- Tamara Salloum
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Byblos, Lebanon
| | - Rim Moussa
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Byblos, Lebanon
| | - Ryan Rahy
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Byblos, Lebanon
| | - Jospin Al Deek
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Byblos, Lebanon
| | - Ibrahim Khalifeh
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - Rana El Hajj
- Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - Neil Hall
- Earlham Institute, Norwich research Park, University of East Anglia, Norwich, United Kingdom
| | - Robert P. Hirt
- Biosciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom
- * E-mail: (RPH); (ST)
| | - Sima Tokajian
- Department of Natural Sciences, School of Arts and Sciences, Lebanese American University, Byblos, Lebanon
- * E-mail: (RPH); (ST)
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