First evidence for two independent and different leishmaniasis transmission foci in Sri Lanka: recent introduction or long-term existence?
Cutaneous leishmaniasis caused by a genetic variant of L. donovani is being reported from Sri Lanka since year 2001. Patients presented from different geographical locations (600 patients from North or South and a minority of cases from other foci, 2001-2013) were studied. Analysis revealed two different sociodemographic and clinical profiles of leishmaniasis in Northern and Southern Sri Lanka. Also, the same different profiles were present in these foci since the onset of the recent outbreak and had independently propagated within each focus over the time. A profile of 14 parameters identified in the Northern focus was further examined with regard to other locations. Northwestern (10/14) and Central parts (9/14) of the island were more similar to Northern focus (14/14). Infection would have originated in one focus and spread to other 2 in Northern Sri Lanka. Southern focus was different from and appeared older than all others (2/14). Western focus that accommodates a large transient population had a mixed picture of North and South features (4/14). Lesions in North showed a slow progression and a nonulcerative nature (128/185, 69.2%), while those in South showed a rapid progression and less nonulcerative lesions (193/415, 46.5%). Clinical analysis favoured a parasite aetiology (considerable strain differences) rather than a host aetiology (age, gender, or genetics). Both foci demonstrated a biannual seasonal variation since the onset of the epidemic. Two peaks were observed during the early and latter parts of the year. Furthermore, long-term existence and recent spatiotemporal expansion and detection of leishmaniasis in this country rather than a recent introduction and establishment were indicated by these findings. Vigorous antimalarial activities that existed in Sri Lanka until few decades ago, lack of professional awareness, and more recent military activities that brought human population in close contact with a sylvatic cycle would have played a role in silent propagation of Leishmania parasites and subsequent increment in human cases, respectively, in this country.