Cutaneous leishmaniasis in Mullaitivu, Sri Lanka: a missing endemic district in the leishmaniasis surveillance system

The purpose of this study was to describe the emergence of cutaneous leishmaniasis in a district of Sri Lanka, documented at the national level as having zero incidence. We analyzed data from the Sri Lanka Army (SLA) to describe reported cases of cutaneous leishmaniasis for all armed forces personnel located in all 24 districts of Sri Lanka. These data are not included in the National Surveillance System. From January 2011 through February 2013, 314 armed forces personnel were confirmed as having leishmaniasis. Of these, 223 (81.4%) were working within the district of Mullaitivu at the time of investigation and another 21 (6.5%) reported that the lesion first appeared when they were working in Mullaitivu. The reported cumulative annual incidence of leishmaniasis among the army population was 7.5 per 10000, while in the general area of Mullaitivu the incidence was 234 per 10000. Leishmaniasis is emerging in epidemic proportions in Mullaitivu and is still not detected through the public health surveillance system. Urgent attention directed at disease surveillance and control activities is needed to control this emerging public health threat.