Two recent but temporally distinct outbreaks of cutaneous leishmaniasis among foreign workers in the Dead-Sea area of Jordan.

Two temporally distinct outbreaks of human cutaneous leishmaniasis (CL), as well as scattered cases of the disease, have recently been observed close to the Dead Sea, in Jordan. Each of the two outbreaks, which occurred in 2004/2005 and 2007/2008, involved a group of foreign workers who were deployed within otherwise uninhabited locations. During each outbreak, about 20% of the workers were found infected with the causative parasite. In the earlier outbreak, 61 workers were found to have skin lesions like those of CL and all but three were confirmed by culture and/or the examination of smears (40 cases) or, in the case of 18 (86%) of the 21 suspected cases found smear- and culture-negative, by PCR. In the second outbreak, the cases were only identified from their clinical manifestations and their response to antileishmanial treatment (cryotherapy). Leishmania major was identified as the cause of the 2004/2005 outbreak and some sporadic cases that occurred, in 2004, along the shores of the Dead Sea. The burrows of potential reservoir hosts were found close to the outbreak locations, frequently under the chenopod Seidlitzia rosmarinus. The two outbreaks emphasise the continuing problem posed by the CL focus in the Mid Jordan Valley and its impact on humans who move into the area. Curiously, an investigation on the socio-economic conditions of the workers during the outbreaks identified a group of 48 workers who were living in air-conditioned rooms during the 2007/2008 outbreak, among whom no CL cases were found. In contrast, 26 of a neighbouring group of 124 workers, who were all living in non-air-conditioned rooms, developed CL lesions. The role of air conditioning, and of other factors and measures, in the prevention of the transmission of the causative parasites of CL merits further investigation and the attention of the local health authorities.