In the midst of a devastating civil war, the people of Syria are now facing the spread of the serious but non-lethal skin infection, cutaneous leishmaniasis. The disease is considered a neglected disease, but is now spreading at a high speed throughout Syria and neighbouring Middle East countries that are affected by the ongoing refugee crisis. Cutaneous leishmaniasis is caused by a single-celled parasite transmitted by phlebotomine sandflies, and can be transmitted from people as well as infected livestock and animals.

Historically, leishmaniasis has been endemic in Syria. However, the situation is now enormously complicated given that the country’s healthcare services are struggling to maintain even basic services during the civil war. It is estimated, for example, that in 2015 more than half of public hospitals in the country were closed or operated with severely reduced services. As a result, the disease is now spreading through refugee camps and conflict zones and is being compounded by the migration of refugees to neighbouring countries, according to the Public Library of Science (PLOS) journal.

Some 4.2 million Syrian refugees have fled to neighbouring countries (most notably Turkey, Lebanon and Jordan). Data produced by the World Health Organisation (WHO) show that leishmaniasis was previously under control, but that the military conflict, particularly in ISIS controlled-territories, has caused a sharp rise in the disease prevalence. Hundreds of new cases have been reported to the WHO in Turkey and Lebanon in recent months. Eastern Libya has also reported increasing numbers of cases, while in Yemen an estimated 10,000 new cases are reported per year. With Yemini nationals in turn migrating to Saudi Arabia, concerns have been raised that the disease may spread further.

The health implications from leishmaniasis include open sores and disfiguring scars. Detection of the disease is made more difficult by the fact that patients with the skin condition may not experience obvious symptoms until between four and six months after the initial infection. The disease will typically show itself in patients with weak immune systems (including malnutrition). The WHO reported that in 2014 there were 399 million individuals at risk of cutaneous leishmaniasis globally.

Cutaneous leishmaniosis is not considered a healthcare priority by international organisations. This is despite a laudable United Nations goal to end endemic neglected tropical diseases and a commitment by the WHO to implement a disease control programme (including training experts in the collection and analysis of data across 25 countries where the disease burden from cutaneous leishmaniosis is high). The reality on the ground in Syria is that the disease is likely to spread further and faster.

Even as cutaneous leishmaniasis continues to increase throughout the Middle East region, it is highly unlikely that the non-lethal disease will spread to Western European countries, which in any case have the operational capacity to cope with isolated cases that do arise. That said, some Southern European countries such as Spain, Italy and the south of France, are preparing to use insecticides to kill the phlebotomine sandflies. In addition, in order to control the spread of the disease through refugee camps, European countries will need to prioritise training programmes for larger numbers of clinicians and dermatologists to diagnose and treat the condition in refugee camps and along migrant routes. Longer term, the development of a vaccine programme for cutaneous leishmaniasis is rising in importance. Evidence for this can be seen in the decision of the government of Saudi Arabia, with cooperation from the Sabin Vaccine Institute in the United States, to send a number of healthcare professionals to the latter country to study vaccine development for neglected and infectious diseases, with cutaneous leishmaniasis among the main targets for vaccine discover and development.

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