Leishmania donovani leishmaniasis in Cyprus.

76 www.thelancet.com/infection Vol 9 February 2009 Nicole Léger and Jérôme Depaquit emphasise “the importance of preventing an extension of this anthroponotic species in Europe”, a point also stressed by Dujardin et al, since leishmaniasis is not placed under public health surveillance in Europe. We certainly agree with the authors that the indigenous transmission of Leishmania donovani to Cyprus needs to be proven, since the possibility of the invasion of Cyprus by anthropophilic L donovani vectors cannot a priori be excluded—particularly if we consider the geopolitical status of the island (fi gure, A). In this scenario, imported L donovani-infected sandfl ies would need either to transmit the parasite within their short lifespan or survive and spread. While the fi rst hypothesis is contradicted by the 2–3 year observed infection period, the second is possible if the Cypriot ecosystem/microclimate is taken into account (fi gure, B). However, the fi ve reported human cases, including an additional cutaneous leishmaniasis case in Nicosia (unpublished), were found in three of the fi ve prefectures of the government-controlled area. Each prefecture belongs to a distinct, relatively distant, biogeographical region (fi gure, B). Within the context of sandfl ies’ weak fl ight, there is little chance of even a small number of infected sandfl ies having traveled and spread to these diff erent locations. This raises the question of whether the Cyprus sandfl y fauna, present since the Miocene period, can transmit L donovani. This fauna is comprised of nine closely related species of the Phlebotominae subfamily (Phlebotomus and Sergentomyia genera), which are proven or probable vectors of Mediterranean canine visceral leishmaniasis (CVL) caused by L infantum. P neglectus, a species with a wide distribution in eastern Mediterranean countries, was only recently identifi ed in the northern nongovernment-controlled area of Cyprus. Interestingly, the Larroussius species P galilaeus and P tobbi, are the most abundant in both the government-controlled and northern areas of Cyprus. Notably, P tobbi, a broadly permissive vector, has been found in high dog seropositivity areas during several fi eld surveys. As a result it is considered to be the vector of L infantum in Cyprus, and this is also the case in the eastern Mediterranean region (fi gure, A). Léger and Depaquit question the role of P tobbi as a vector of L donovani in Cyprus based simply on their observation that, unlike in the north, no human leishmaniasis cases were reported in the southern part of the island. However, in Turkey, it was recently shown through blood-meal identifi cation that P tobbi feeds preferentially on cattle and people. If we also consider the few reported cases due to L infantum, and the identifi cation of both species in a dog, the trophic preferences of local populations of P tobbi remain to be established. In addition, the host immune response depends, not only on whether sandfl ies are infected, but also on their parasite load. Pre-exposure to certain sandfl y saliva components could aff ect immune response to Leishmania spp infection, and consequently disease outcome. Therefore we consider that the conclusion reached, concerning the lack of anthropophily of P tobbi in Cyprus may be illusive and Leishmania donovani leishmaniasis in Cyprus