Twelve million persons have leishmaniasis, and 500,000 new cases of VL occur each year. More than 50,000 die of this disease each year. The disease is spreading because of several risk factors, climate being only one. Humanmade changes to the environment and population movements (for economic or political reasons) may lead to alterations in the range and densities of the vectors and reservoirs, increasing human exposure to infected sand flies. Urbanization of leishmaniasis becomes more common and in conjunction with the ruralization of HIV/AIDS, it contributes to increase the problem of co-infections in contexts where access to highly active antiretroviral therapy is not the same as in industrialized countries. Leishmania spp. have already become resistant to antimonial drugs (the first-line drug in many developing countries) in some regions and may soon become resistant to miltefosine (23). Despite this increasing resistance, leishmaniasis is one of the most neglected diseases in developing countries, along with others like sleeping sickness or Chagas disease. Leishmaniasis is a disease for which we lack effective, affordable, and easy to use drugs, and the pharmaceutical industry has had few incentives to engage in their development. In addition, leishmaniasis surveillance and control are also neglected. One of the main reasons for this neglect is that in developing countries, leishmaniasis is a disease of the poor. Risk for infection and clinical development are mediated by poverty, while leishmaniasis diagnosis and treatment are expensive and may lead to further impoverishment and reinforcement of the vicious cycle of disease and poverty (31).

In Europe, physicians are sometimes ill-informed on the diagnosis and treatment of leishmaniasis. In France, a telephone advice line was created in 2006 by the National Reference Centre of Leishmania to help physicians in their therapeutic diagnosis. A study in Germany, a non–disease-endemic country, showed that the median time between symptom onset and correct diagnosis was 85 and 61 days in case-patients of VL and CL, respectively (32). This value was lower in a leishmaniasis-endemic area, such as southern Italy (35 days, [33]). VL, which was initially a pediatric disease in Europe (hence the name of L. infantum), only began to gain attention when the co-infection of HIV/AIDS was documented. Between the late 1980s and early 2001, >1,900 cases were reported in southwestern Europe (16). Even though it was reported that both pathogens could be transmitted through sharing of needles among intravenous drug users (34), in many cases of co-infection, the parasite was already present at the time of HIV infection, which indicates that HIV infection would have an unmasking effect on the true endemicity of Leishmania infection. In other words, the wave of Leishmania/HIV co-infection showed that L. infantum could behave as an opportunistic parasite, with many asymptomatic carriers (12), and with the clinical syndromes being only the tip of the iceberg. Because of the highly active antiretroviral therapy, cases of co-infection generally decreased in the region, with the exception of Portugal (35).

Notification of VL varies according to the country. It does not belong to the list of 30 notifiable diseases in France. However, notification is compulsory in Greece, Italy, and Portugal, though only obligatory in 12 of 17 autonomous communities of Spain. Underreporting is common. In Portugal, for instance, 76 cases of autochthonous VL were officially reported at the country level from 2000 through 2005. During the same period, 127 cases (+67%) were observed in the Institute of Tropical Medicine of Lisboa (Table). In the case of autochthonous cutaneous leishmaniasis, consolidated data are lacking, but this clinical form is definitely underreported because of its benign nature and the fact that it usually does not require hospitalization. Nonetheless, leishmaniasis is not a disease placed under public health surveillance at the European level. It does not even belong to the package of rare diseases considered as a priority in the Public Health Programme 2003–2008. (Rare diseases, including those of genetic origin, are life-threatening or chronically debilitating diseases that are of such low prevalence [<5/10,000 persons] that special combined efforts are needed to address them so as to prevent significant illness or perinatal or early deaths or a considerable reduction in a person’s quality of life or socioeconomic potential.) At the regional level, the only dedicated network of surveillance was the one launched by the World Health Organization and the Joint United Nations Programme on HIV/AIDS in 1993 for the surveillance of Leishmania/HIV co-infections, which essentially involved European countries as well as some developing countries.

The low-profile perception seen for human leishmaniasis differs dramatically from the veterinary world’s perception. The high incidence of canine leishmaniasis in southern Europe makes Leishmania one of the main dog killers in the region, and private veterinarians are well aware of it. Dogs are treated individually to protect from sand fly bites, and those diagnosed as infected are considered extremely difficult to treat. Specific web sites are available for owners of infected dogs to discuss and compare treatment regimens and pose questions to veterinarians. Several pharmaceutical companies are investing in research and development of vaccines, drugs, and topical insecticides for specific cure and prevention of canine leishmaniasis. This high-profile perception, however, drops when dogs must be treated as the reservoir of human leishmaniasis. For instance, the issue of notification is treated differently in various leishmaniasis–endemic countries, but even where notification is compulsory (i.e., Italy and Spain), it is not a common practice. In Italy, the network Leishmap is currently monitoring the spread of canine leishmaniasis and vectors in northern Italy. Leishmap is a scientific network, supported by a private company (36). Furthermore, private interests are sometimes at odds with public health goals. Drugs for leishmaniasis are not regulated in the veterinary market, and medications intended for use in humans, such as Ambisome, are used in domestic pets, with the potential risk that they might be a source for the emergence and spreading of resistant strains.

Since 2001, several research consortia gathered scientists from Euro-Mediterranean countries (www.leishrisk.net). These consortia and other research groups generated knowledge, tools, and education packages and led to a solid European research network dedicated to the study of leishmaniasis. Bridging research with surveillance and control is an issue of dialogue and advocacy. On one hand, health professionals need to be in close contact with scientists to help translate basic research into relevant and applicable tools. For instance, sequencing the whole genome of Leishmania represented a technologic challenge, but the next challenge is to exploit this sequencing for the benefit of the patient (www.leishrisk.net). On the other hand, scientists must market their results to influence health policy. Changes in health policy are being made; during manuscript revision, we were informed of the selection of leishmaniasis among the priority zoonoses addressed by the Episouth network (www.leishrisk.net).

Deciding health policy is a complex social, economic, and political interrelationship that is much broader than leishmaniasis alone (or even infectious diseases generally). However, if Europe justifiably wants to invest more in surveillance of vector-borne diseases, the time has come to recognize its real impact on both animal and human health and include leishmaniasis as one of these diseases.