Cutaneous and mucocutaneous leishmaniasis in travellers and migrants: a 20-year GeoSentinel Surveillance Network analysis
Authors: Boggild Andrea K , Caumes Eric , Grobusch Martin P , Schwartz Eli , Hynes Noreen A , Libman Michael , Connor Bradley A , Chakrabarti Sumontra , Parola Philippe , Keystone Jay S , Nash Theodore , Showler Adrienne J , Schunk Mirjam , Asgeirsson Hilmir , Hamer Davidson H , Kain Kevin C ,   GeoSentinel Surveillance Network, von Sonnenburg Frank , Rothe Camilla , Jordan Sabine , Vinnemeier Christof , Yansouni Cedric , McCarthy Anne , Jensenius Mogens , Goorhuis Abraham , Coyle Christina , Mockenhaupt Frank , Harms-Zwingengerger Gundel , Leung Daniel , Benson Scott , Gautret Philippe , Javelle Emilie , Chappuis Francois , Rapp Christophe , Ficko Cecile , van Genderen Perry , Glans Hedvig , Beadsworth Michael , Beeching Nicholas , Castelli Francesco , Matteelli Alberto , Plewes Katherine , Mirzanejad Yazdan , Lopez-Velez Rogelio , Chamorro Sandra , Waggoner Jesse , Wu Henry , Leder Karin , Torresi Joseph , Bottieau Emmanuel , Huits Ralph , Chen Lin , Bourque Daniel , Alpern Jonathan , Stauffer William , Cahill John , Wyler Ben , Haulman Jean , Terry Anne , Licitra Carmelo , Taylor Ashley , Perret Perez Cecilia , Weitzel Thomas , Gkrania-Klotsas Effrossyni , Warne Ben , Schlagenhauf Patricia , Weber Rainer , Schade Larsen Carsten , Wejse Christian , Barnett Elizabeth , Hochberg Natasha , Barkati Sapha , Vincelette Jean , Molina Israel , Malvy Denis , Duvignaud Alexandre , Mendelson Marc , Parker Salim , Johnston Victoria , Field Vanessa , Kuhn Susan , Piyaphanee Watcharapong , Silachamroon Udomsak , Diaz-Menendez Marta , Kelly Paul , Blumberg Lucille , de Frey Albie , Pandey Prativa , Amatya Bhawana , Mavunda Kunjana , Saio Mauro 
Published: July 2019

Abstract

Background
Cutaneous leishmaniasis (CL) may be emerging among international travellers and migrants. Limited data exist on mucocutaneous leishmaniasis (MCL) in travellers. We describe the epidemiology of travel-associated CL and MCL among international travellers and immigrants over a 20-year period through descriptive analysis of GeoSentinel data.

Methods
Demographic and travel-related data on returned international travellers diagnosed with CL or MCL at a GeoSentinel Surveillance Network site between 1 September 1997 and 31 August 2017 were analysed.

Results
A total of 955 returned travellers or migrants were diagnosed with travel-acquired CL (n = 916) or MCL during the study period, of whom 10% (n = 97) were migrants. For the 858 non-migrant travellers, common source countries were Bolivia (n = 156, 18.2%) and Costa Rica (n = 97, 11.3%), while for migrants, they were Syria (n = 34, 35%) and Afghanistan (n = 22, 22.7%). A total of 99 travellers (10%) acquired their disease on trips of ≤ 2 weeks. Of 274 cases for which species identification was available, Leishmania Viannia braziliensis was the most well-represented strain (n = 117, 42.7%), followed by L. major (n = 40, 14.6%) and L. V. panamensis (n = 38, 13.9%). Forty cases of MCL occurred, most commonly in tourists (n = 29, 72.5%) and from Bolivia (n = 18, 45%). A total of 10% of MCL cases were acquired in the Old World.

Conclusions
Among GeoSentinel reporting sites, CL is predominantly a disease of tourists travelling mostly to countries in Central and South America such as Bolivia where risk of acquiring L. V. braziliensis and subsequent MCL is high. The finding that some travellers acquired leishmaniasis on trips of short duration challenges the common notion that CL is a disease of prolonged travel. Migrants from areas of conflict and political instability, such as Afghanistan and Syria, were well represented, suggesting that as mass migration of refugees continues, CL will be increasingly encountered in intake countries.