Leishmaniasis – an old disease opening new wounds across the Middle East

by Stephen Stocks, Marketing & Communications Manager at NRS International

The Syrian refugee crisis has prompted a widespread outbreak of cutaneous leishmaniasis across swathes of the Middle East. This tropical disease, which causes life-changing disfigurement, is now threatening hundreds of thousands of people living in refugee camps or trapped in conflict zones. The breakdown of health care in these areas is exacerbating the already serious situation.

The World Health Organization (WHO) has identified long-lasting insecticidal nets (LLINs) as a key vector control tool in the fight against leishmaniasis. As one of the world’s leading manufacturers of LLINs, our subsidiary TANA Netting is using its expertise as part of the ongoing response to this outbreak.

World Refugee Day

A neglected tropical disease

Cutaneous leishmaniasis has been present in Syria for many hundreds of years and was once commonly known as the ‘Aleppo evil’ or ‘Aleppo boil’. Until the 1960s, the disease’s prevalence in Syria was clustered around the cities of Aleppo and Damascus. This skin infection is caused by a single-cell organism that is transmitted by sand flies, resulting in open sores and skin lesions if left untreated. Whilst this form of leishmaniasis is generally not fatal, studies show that the social stigmatisation caused by scars leads to anxiety, depression, decreased quality of life and a narrowing of job opportunities. The World Health Organization includes leishmaniasis as one of the 17 ‘neglected tropical diseases’ (NTDs), and like many other such diseases it amplifies poverty, which in turn increases incidences of the disease. A vicious circle of disease is the result.

Disease spread caused by multiple factors

Leishmaniasis-02 As Syria’s civil war continues, the ensuing refugee crisis has triggered a disastrous outbreak of the disease, particularly in those regions under Daesh control. Around four million Syrians have been displaced into neighbouring countries and most of these refugees have gone to Turkey, Lebanon and Jordan. As a result, cutaneous leishmaniasis has begun to emerge in such areas where displaced Syrians and disease reservoirs such as the sand fly exist side by side.

The situation is being exacerbated by a combination of factors. The ongoing conflict within Syria has degraded the country’s health care system. More than 50% of the public hospitals in Syria have been destroyed by military action and the health care infrastructure is bordering on nonexistent. The availability of drugs has been severely curtailed. Furthermore, many of the temporary refugee settlements suffer from poor sanitation and hygiene, low quality housing and rubbish accumulation. Bombed out buildings, disrupted insecticide control, and poor water and sanitation services create the perfect breeding environment for sand flies.

A ripple effect across the region

Before the Syrian civil war, the incidence of Leishmaniasis in the country was around 23,000 cases each year. However, since then, annual cases have soared to more than 40,000 each year, with the most affected areas being Ar-Raqqah, Diyar Al-Zour, and Hasakah, all of which have spent long periods under Daesh control. Yet, even worse, these figures are just the reported ones…because health care surveillance procedures are severely disrupted, the actual scale of the problem is likely to be much greater.

The movement of millions of refugees to neighbouring countries is permitting the disease to spread outwards across the region. In Lebanon, cases rose to 1,033 in 2013 from just six in the previous 12 years. Hundreds of cases have also been recorded in Turkey and Jordan. Eastern Libya has seen increasing numbers of leishmaniasis and in Yemen, an estimated 10,000 new cases are seen every year. With Yeminis migrating to Saudi Arabia, there is the danger that the disease may spread further.

Sand flies, not people, transmit the disease, and as sand flies are unable to survive in colder climates, leishmaniasis poses no threat to northern European countries. However, the disease is already present in parts of southern Europe including Spain, Italy and the south of France. In these prosperous regions, where people have nutrition and general good health, the disease will usually only affect those with compromised immune systems.

Using LLINs as a key tool to interrupt disease spread

sandflyNo vaccines or drugs are available to prevent infection. The Centers for Disease Control and Prevention (CDC) recommends that the best way for people living in affected areas to prevent infection is to protect themselves from sand fly bites.

Sand flies are most active between dusk and dawn. So if outdoors, it is a good idea to limit the amount of bare skin exposed. Insect repellent containing DEET can be applied to any exposed skin and under the ends of sleeves and trouser legs.

When indoors, the CDC recommends that long-lasting insecticidal nets be used as the primary method of defence, particularly in the form of bed nets. TANA Netting’s DawaPlus® Sandfly Net is specifically designed to control and prevent leishmaniasis, and its deltamethrin-coated polyester netting has a fine mesh of 230 holes per square inch to prevent bites from sand flies and phlebotomes. Public education campaigns have a major role to play, as it is sometimes falsely perceived that the smaller holes reduce ventilation and result in higher temperatures under the net.

The World Health Organization has also identified LLINs as a key tool, describing them as ‘an effective, relatively cheap, sustainable method for sand fly control’. Its trials of nets in Syria have shown that they can provide an effective protection against cutaneous leishmaniasis.  Screening of windows with insecticide-treated curtains, such as the DawaPlus® Curtain, has also been proven to significantly reduce the numbers of sand flies entering houses in studies conducted in Burkina Faso, Italy, Sudan and Latin American.

Combining tools for a strong response

Vector control programme efficiency can be further enhanced if more than one method is used to reduce or interrupt transmission of disease. This relies on a full understanding of the local epidemiology of leishmaniasis, and of the sand fly and its habitats. The planning of such an integrated programme requires a detailed assessment of the ecology of the area, definition of operational targets, selection of proper methods and a monitoring and evaluation scheme.


In addition to the use of LLINs, indoor residual spraying could further help as a vector control tool. Environmental management could also be used, whereby human settlements such as camps could be relocated away from sand fly habitats. The vector’s habitats themselves could also be physically modified, with actual or potential sand fly breeding sites, such as rubble and rubbish tips, being eliminated in sanitation programmes involving the local community.

Ready to respond

TANA Netting is ready to respond to this public health emergency. H. Sheikh Noor-ud-Din & Sons, our family-run factory in Lahore, Pakistan, has an annual capacity of more than 50 million long-lasting insecticidal nets. By working hand-in-hand with governments and NGOs we are committed to do whatever it takes to win the fight against leishmaniasis wherever it may occur.

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