The institutional review board of the American University of Beirut approved this study. In November 2012, one of us (I.K.) began documenting the epidemic during trips to multiple refugee camps in eastern Lebanon (the Bekaa Valley [Baalbek, Zahle, and Ersaal]); the epidemic later expanded to camps throughout the country. During the study, 1,275 patients from 213 displaced families were triaged into 3 groups: l) leishmaniasis diagnosed, confirmed, and partially treated; 2) leishmaniasis diagnosed, confirmed, but not treated; and 3) leishmaniasis not diagnosed. The first 2 groups comprised 55 families; the remaining 158 families (948 persons) were triaged for diagnosis confirmation and are included in the subsequent statistical analyses. Data were collected at the refugee camps and included punch biopsy specimens for 1 patient/family. We used punch biopsy for microscopic confirmation and for molecular analysis by PCR using a previously published protocol (9). The anatomic sites for biopsy were selected on the basis of appropriate recommendations for sampling (10).

The average age of patients was 17.6 years; most (80%) patients were <18 years of age. Each family comprised 3–13 members (mean 6), and the percentage of family members infected ranged from 8% to 100% (mean 52%). The refugees had fled from areas to which leishmaniasis is endemic and nonendemic. Most of the refugees we encountered had migrated from Aleppo (74 [67.3%] patients), followed by Homos (30 [27.3%] patients) and Damascus (6 [5.4%] patients). Only 1 Lebanese resident with no history of travel during the past 5 years had leishmaniasis. Our sample population was scattered predominately among 4 regions of Lebanon (Figure 1).

The refugees in our study had been in Lebanon for 1–24 months (mean 5 months) and reported that the first time they saw a cutaneous lesions was 1–27 months (mean 5 months) before being examined. Most (77%) patients reported the appearance of the first lesion after being in Lebanon for >2 months, and 53% of patients recalled history of an antecedent insect bite. The head and neck were the most common locations for the cutaneous lesion (43% of patients), followed by the upper extremities (26%) and lower extremities (11%). Patients had 1–15 lesions (mean 3). Lesion size ranged from 1 cm to 15 cm (average 2.6 cm). Verrucous lesions, with or without ulceration, were the most common lesion type (56%), followed by plaque/nodular lesions (43%) and papular lesions (2%). Most patients (83%) had dry lesions; 7 persons (4%) had primary wet lesions, and 12 (8%) had both. All patients had active lesions without evidence of healing or scarring. Speciation by PCR yielded L. tropica in 85% of patients and L. major in 15%.

Fifty-nine percent of patients had >1 of the following: disease compromising the function of vital sensory organs (eye, ear, nose, and mouth) (27%); lesions >5 cm in diameter (49%); disfiguring facial lesions (37%); special forms, such as sporotrichoid or lymphangietic with satellite lesions (9%); and lesions present for >12 months’ duration (9%) (Figure 2). The above parameters were more prevalent among children (age range 3 months–16 years; median 9 years vs. 21 years; p = 0.002) and more frequently observed on the face and lower extremities (p = 0.002).

In May 2013, the World Health Organization (WHO) donated 10,000 doses of megulamine antimonate (85 mg/mL; 5-mL ampoules). As of April 2013, 5,091 ampoules of intralesional or intramuscular medication had been used to initiate or continue treatment of all 1,275 patients triaged. Eighty percent received intralesional therapy, and 20% received intramuscular therapy in accordance with WHO recommendations (4).

Systemic therapy can have serious side effects. To provide adequate and humane medical care to this impoverished population, healthcare personnel administered local anesthetic with the intramuscular injections and conducted complete blood counts, liver function tests, analysis of creatinine levels, and electrocardiograms every 2 weeks for all patients on systemic therapy. No complications occurred.

Our data are based on the analysis of leishmaniasis in Syrian refugees in camps in rural areas of Lebanon. The camps were mainly makeshift houses of rubble and tents, plagued by inadequate sanitation, waste disposal, and insulation (online Technical Appendix Figure, http://wwwnc.cdc.gov/EID/article/20/10/14-0288-Techapp1.pdf). Poverty, malnutrition, population displacement, weakened immunity, and poor housing are all risk factors for cutaneous leishmaniasis (11). Such conditions are ideal for vectors of L. tropica and enable leishmaniasis to flourish as an anthroponotic disease, as seen in outbreaks in Kabul, Afghanistan (12).

Although Lebanon remains hypoendemic for cutaneous leishmaniasis, experience has suggested that rates within Lebanon were previously low and restricted to areas bordering Syria (13). The WHO leishmaniasis control team reported no cases in Lebanon during 2004–2008, compared with 22,882 cases in Syria during the same period (14). Furthermore, 85% of cases studied were caused by L. tropica, a species endemic to the Aleppo region in Syria. This finding might explain why most of the patients we encountered had aggressive (large, multiple, and disfiguring facial lesions) and prolonged disease courses necessitating treatment with intramuscular rather than intralesional medication. Local collaboration, early detection, and diagnosis, along with speciation of the parasite, were of paramount importance to ensure the effective delivery of treatment and successful control of the epidemic.

Syrian refugees in temporary, unsanitary, resource-poor settlements, which are breeding grounds for disease and disease vectors, Beirut, Lebanon, 2012.