Independent Circulation of Leishmania major and Leishmania tropica in Their Respective Sandfly Vectors for Transmission of Zoonotic and Chronic Cutaneous Leishmaniasis Co-Existing in a Mixed Focus of Central Tunisia

Zoonotic cutaneous leishmaniasis (ZCL) and chronic cutaneous leishmaniasis (CCL) are known to overlap in Central Tunisia. Sandflies were collected using sticky traps and CDC light-traps set in rodent burrows at the ecotones surrounding the village, in houses, and in animal shelters during July–October 2017, 2018, and 2019. A total of 17,175 sandflies were collected during the three sandfly seasons and identified morphologically to species level. Of a total of 18 sandfly species reported in Tunisia, 16 were identified in this mixed focus of ZCL and CCL. Except for the rocky mountainous areas, Phlebotomus papatasi was the most abundant sandfly species in all biotopes. In the mountainous areas, Phlebotomus sergenti is the most abundant sandfly species belonging to the genus Phlebotomus. Female sandflies were tested for the presence of Leishmania species by PCR. The overall infection prevalence of sandflies with Leishmania major and Leishmania tropica was 0.42% and 0.065%, respectively. The sequencing of PCR-amplified ITS1 products showed that L. major is the predominant species in all biotopes and transmitted mostly by P. papaptasi followed by Phlebotomus longicuspis and Sergentomyia species. Leishmania tropica was detected in Phlebotomus sergenti and in Phlebotomus longicuspis collected in bedrooms and in the ecotone of rocky mountainous areas. Our results provided strong evidence that the proximity of human settlements to biotopes of rodent reservoir hosts of L. major and of L. tropica resulted into the cocirculation of both Leishmania species leading to a mixed focus of ZCL and CCL. The epidemiology of leishmaniases in North Africa is highly complex by the high diversity of sandfly vectors and their associated Leishmania species, leading to a mixed form of cutaneous leishmaniasis. It is of major epidemiological importance to point to the risk of spillover from rural to urban areas leading to the anthroponization of cutaneous leishmaniasis. Therefore, efficient control to reduce the indoor abundance of sandfly vectors in order to reduce the incidence of leishmaniases is urgently needed.


Introduction
Leishmaniases are vector-borne diseases caused by Leishmania protozoan parasites and they are transmitted to humans by the bite of infected female sandflies. Leishmaniases are widespread across 98 countries and 3 territories on 5 continents, with more than 58,000 visceral leishmaniasis cases (VL) and 220,000 cutaneous leishmaniasis cases (CL)

Study Site
The study was carried out in the governorate of Sidi Bouzid situated in an arid bioclimatic zone [28] (Figure 1), a highly endemic area with multiple foci of ZCL located in Central Tunisia [19]. The average annual incidence rate of ZCL was 666.7/100,000 inhabitants in the governorate of Sidi Bouzid and the dynamics of ZCL incidence are significantly heterogenic, occurring in outbreaks and clustering in space and time [19].
The study was performed in the village of Gouleb (9 • 36 E, 34 • 48 N), located in the delegation of Souk Jedid, within the governorate of Sidi Bouzid, a highly endemic focus of ZCL with an annual incidence of 3822.8 cases per 100,000 inhabitants [29], and it is considered as an emerging focus of CCL [30]. A hypoendemic focus of CCL has been reported in the delegation of Meknassy, which is adjacent to the delegation of Souk Jedid where the village of Gouleb is located [4,26]. The village is situated at the flank of the rocky mountainous areas which is the natural habitat of C. gundi [15] (Figure 2A,D). On the other side, the village is surrounded by agricultural fields harboring jujube trees ( Figure 2B,E) and by nonagricultural fields made of chenopods, which are the natural habitat of M. shawi and P. obesus ( Figure 2C,F), respectively. Thus, in the study sites, three ecotones which are the interface between human settlements and natural ecosystems were considered [31]. The study was performed in the village of Gouleb (9° 36′ E, 34° 48′ N), located in the delegation of Souk Jedid, within the governorate of Sidi Bouzid, a highly endemic focus of ZCL with an annual incidence of 3822.8 cases per 100,000 inhabitants [29], and it is considered as an emerging focus of CCL [30]. A hypoendemic focus of CCL has been reported in the delegation of Meknassy, which is adjacent to the delegation of Souk Jedid where the village of Gouleb is located [4,26]. The village is situated at the flank of the rocky mountainous areas which is the natural habitat of C. gundi [15] (Figure 2A,D). On the other side, the village is surrounded by agricultural fields harboring jujube trees ( Figure 2B,E) and by nonagricultural fields made of chenopods, which are the natural habitat of M. shawi and P. obesus ( Figure 2C,F), respectively. Thus, in the study sites, three ecotones which are the interface between human settlements and natural ecosystems were considered [31].

Sandfly Trapping and Identification
Our entomological investigation was carried out in the village of Gouleb during three consecutive years (2017-2019). In Tunisia, the phenology of P. papatasi is characterized by two main peaks of activity: one in June-July and a second, larger peak in September-October [18]. Each season, sandflies were collected during July-October by using CDC light traps (LT) and by sticky traps (ST) placed inside houses, animal shelters located in peridomestic areas, between rocks in the mountainous areas, in burrows of M. shawi and of P.

Sandfly Trapping and Identification
Our entomological investigation was carried out in the village of Gouleb during three consecutive years (2017-2019). In Tunisia, the phenology of P. papatasi is characterized by two main peaks of activity: one in June-July and a second, larger peak in September-October [18]. Each season, sandflies were collected during July-October by using CDC light traps (LT) and by sticky traps (ST) placed inside houses, animal shelters located in peridomestic areas, between rocks in the mountainous areas, in burrows of M. shawi and of P. obesus. Traps were placed from dusk to dawn and brought back the following morning to the laboratory. The collected sandflies were dissected to remove the head and the genitalia for species identification and the rest of the body was placed in a 1.5 mL microfuge tube to be examined for the presence of Leishmania DNA. Sandflies were identified at the species level by using the identification keys of Croset et al. [32] with special attention given to the atypical form of female P. perniciosus that could be confused with P. longicuspis [33,34]. Following identification, unfed female sandflies were pooled with up to a maximum of 30 specimens per pool based on the date of collection, species, and biotype and then stored in phosphate-buffered saline (PBS) for molecular analysis.

Detection of Leishmania DNA in Female Sandflies
Because this study deals with the circulation of two forms of cutaneous leishmaniasis in one focus, we used two different methods to detect Leishmania infection. Firstly, we used a nested-PCR-based schizodeme method targeting the partially conserved region of the kinetoplast minicircle DNA, enabling Leishmania species discrimination on the basis of PCR amplicon size, where L. tropica generated a 750 bp product, L. infantum produced a 680 bp product, whereas the product size of L. major was 560 bps [35]. Secondly, we used a nested PCR of a partial region of ITS-rDNA gene allowing the sequencing of detected Leishmania DNA as described by Parvizi et al. [36][37][38].
Female sandflies in pools were homogenized in 200 µL of PBS through high-speed shaking using the automated Tissue Lyser LT (Qiagen, Hilden, Germany) with glass beads. The mixture was clarified by centrifugation at 6000× g for 2 min for use in DNA extraction with a Qiagen DNA Mini Kit (Qiagen, Hilden, Germany) according to the manufacturer's instructions. Extracted DNA from female sandflies was screened for infections with Leishmania species by a nested PCR based on the schizodeme method targeting the partial conserved region of the kinetoplast minicircle DNA as previously described [35]. This method allows the discrimination of Leishmania species originating from North Africa based on the PCR amplicon size. The nested PCR product sizes for L. tropica, L. major and L. infantum were 750, 560 bp and 680 bp, respectively [35]. The first PCR was performed using the Taq DNA recombinant polymerase kit (Invitrogen, Waltham, MA, USA) in 25 µL containing: 2.5 µL 10X buffer, 1.5 µL MgCl2 (50 mM), 1 µL dNTP mix (10 mM), 1 µL of each reverse and forward primers CSB2xF/CSB1xR (10 µM), 0.25 µL Taq DNA polymerase (5 U/µL), 12.75 µL nuclease-free water and 5 µL of extracted DNA. The nested PCR was carried out in 50 µL containing 3 µL of the first PCR step DNA product and 47 µL of a mixture containing: 5 µL 10X buffer, 3 µL MgCl2 (50 mM), 2 µL dNTP mix (10 mM), 2 µL of each reverse and forward internal primers 13Z/LIR (10 µM), 0.5 µL of Taq DNA polymerase (5 U/µL) (Invitrogen, Waltham, MA, USA), and 32.5 µL of RNase and DNase-free H 2 O. Optimized cycling conditions for the first and second PCR steps were performed as follows: 94 • C for 5 min followed by 35 cycles, repeating denaturation at 94 • C for 30 s, annealing at 55 • C for 60 s and elongation at 72 • C for 90 s, and an extension step at 72 • C for 10 min. Previously extracted L. tropica (MHOM/TN/88/TAT3) and L. major (MHOM/TN/97/LPN162) DNA were used as a positive control for Leishmania detection. Cross-contamination was monitored by negative controls for sample extraction and PCR assay. Amplification products of the nested PCR were then visualized by electrophoresis in 1.5% agarose gel supplemented with ethidium bromide under UV-light transillumination. Positive PCR product sizes were estimated In this study, the infection of sandfly species by Leishmania species is reported using the minimum infection rate (MIR) which is calculated by: ([number of positive pools/total number of tested sandflies] × 100) [39].

Detection of Leishmania DNA, DNA Sequencing and Phylogenetic Analysis
Extracted DNA was screened for infections of Leishmania species by a nested PCR of a partial region of the ITS-rDNA gene as previously described [36,37]. The first amplification steps were performed using the Taq DNA recombinant polymerase kit (Invitrogen, Waltham, MA, USA) in 50 µL reaction containing: 5 µL 10X buffer, 3 µL MgCl 2 (50 mM), 2 µL dNTP mix (10 mM), 1 µL of each reverse and forward primers IR1/IR2 (10 µM), 0.5 µL Taq DNA polymerase enzyme and 10 µL of total extracted DNA. The nested PCR was carried out in 50 µL containing 2 µL of the first PCR step DNA product and 48 µL of mixture containing: 5 µL 10X buffer, 3 µL MgCl 2 (50 mM), 2 µL dNTP mix (10 mM), 1 µL of each reverse and forward internal primers ITS1F/ITS2R4 (10 µM) and 0.5 µL of Taq DNA polymerase (Invitrogen, Waltham, MA, USA). Optimized cycling conditions for the first and second PCR step were performed as follows: (i) 94 • C for 3 min followed by 40 cycles of 94 • C for 60 s, 58 • C for 60 s and 72 • C for 90 s, followed by a final extension step (72 • C) for 10 min; (ii) nested PCR with 94 • C for 3 min followed by 5 cycles of 94 • C for 60 s, 55 • C for 60 s and 72 • C for 60 s, and 35 cycles of incubation at 94 • C, 59 • C and 72 • C for 60 s each. The extension step was continued for 10 min at 72 • C. Cross-contamination was monitored by negative controls for sample extraction and PCR solutions for the PCR test. Amplification products of the nested PCR were separated in 2% agarose gel stained with ethidium bromide and visualized under UV-light illumination. Positive PCR products were directly sequenced to identify sandfly-associated Leishmania species.
The 462bp nested PCR products were purified by the ExoSAP-IT method using the Exonuclease-I and the Shrimp Alkaline Phosphatase were sequenced in both directions using a Big Dye Terminator ready reaction cycle sequencing v3.1 kit (Applied Biosystems, Waltham, MA, USA) with forward and reverse nested PCR primers (ITS1F/ITS2R4) [38]. The resulting consensus sequences were deduced by aligning the respective forward and reverse sequences using CLUSTAL_W 1.4 implemented in MEGA v.5.22 [40]. In addition to the studied sequences, several Leishmania species sequences, including 1 L. brazeliensis, 13 L. tropica, and 33 L. major, were selected from the GenBank database. Phylogenetic analysis was performed using the maximum likelihood analysis method and the Tamura-3 parameter model. The tree topology was supported by 1000 bootstrap replicates.

Data Analysis Sandfly Species Diversity
Biological diversity was quantified by measuring richness and evenness for a better understanding of community structure [41]. To assess the sandfly fauna structure, the following ecological parameters and diversity indexes were calculated: Relative abundance (ni): Number of sandfly species/Total number of sandflies in the sample.
Specific richness (S): number of species in the sample [41]. Specific diversity was also measured by the Shannon-Wiener index (H ) that takes into consideration the probability of encountering a specific species in a stand. To better discuss this Shannon index, it is often accompanied by the Piélou equitability index (J), or equirepartition index (E). Its formula corresponds to the ratio between H and Hmax: E = H /Hmax. This index varies between 0 and 1. If it tends towards E = 1, then the species Statistical analysis was performed using python Jupiter notebook. Fisher's exact test was applied to a 2 × 2 contingency table to compare the relative abundance of sandfly species in different habitats and their distribution within infected sandflies. The significance level was set at 5%.

Sandfly Fauna
In the focus on Gouleb, 16 sandfly species were identified, belonging to two genera, Phlebotomus (ten species) and Sergentomyia (six species). Among sandfly species of the genus Phlebotomus, Phlebotomus (Phlebotomus) papatasi was the most abundant species followed by P.  (Table 1). Of the total collected sandflies in all biotopes during the three sandfly seasons, P.  The relative abundance of predominant sandfly species varied significantly among biotopes (Table 2). Among sandfly species of the genus Phlebotomus, P. sergenti was the predominant sandfly in the mountainous areas, the natural habitat of the gundi, compared to other biotopes (p < 0.05). Phlebotomus papatasi was less prevalent in gundi's biotope, predominant in bedrooms, animal shelters located in the peridomestic areas, and rabbit holes, and highly abundant in burrows of M. shawi and P. obesus (p < 0.05). Phlebotomus longicuspis was abundant in animal shelters located in the peridomestic areas, bedrooms, and to a lesser extent, in gundi's biotope. Sergentomyia fallax and S. minuta had the same patterns of distribution, being the most abundant in gundi's biotope followed by bedrooms, and animal shelters located in the peridomestic areas ( Table 2).

Leishmania Detection
A total of 957 pools of unfed female sandflies were screened for Leishmania infection by the nested-PCR-based schizodeme method targeting the partially conserved region of the kinetoplast minicircle DNA. Thirty pools were found to be positive for Leishmania DNA. Hence, the overall minimum infection rate of sandflies with Leishmania DNA was 0.5% (30/6187). Sandflies forming positive pools were collected from bedrooms, animal shelters located in the peridomestic areas, gundi's biotope, and rodents' burrows ( Table 3).
rows of M. shawi and/or P. obesus was positive for L. major DNA (Figure 3). Despite the fact that L. major was detected in Sergentomyia species, P. sergenti, and P. longicuspis, it remained highly associated with P. papatasi (p < 0.05). In the rocky mountainous areas, which are the natural biotope of C. gundi, in addition to two pools of P. sergenti positive for L. tropica DNA (50%), two pools (one S. fallax and one P. sergenti) were positive for L. major DNA. Statistically, an association was shown between P. sergenti and P. longicuspis towards L. tropica (p < 0.05).

Leishmania DNA Sequencing and Phylogenetic Analysis
From the 30 PCR-positive products for Leishmania DNA which were sequenced, only 18 were readable. The alignment of ITS sequences obtained confirmed that samples corresponded to 3 L. tropica and 15 L. major. Three sequences corresponding to three L. tropica (from two P. sergenti and one P. longicuspis) were selected and deposited in GenBank under accession numbers OK338429, OK354361, and ON243921. Fifteen sequences
A phylogenetic analysis was performed to observe the phylogenetic relationships of ITS among species. The identified Leishmania DNA sequences are closely related to the reference sequence of L. major and L. tropica with (96.8-99%) and (99-100%) of identity, respectively.
The evolutionary history was inferred by using the maximum likelihood method based on the Tamura three-parameter model. The 1000 bootstrap pseudo-replication values were reported at nodes. The scale bar represents 0.05% divergence with branch lengths measured in the number of substitutions per site. The analysis involved 47 nucleotide sequences aligned using the CLUSTAL algorithm. All positions containing gaps and missing data were eliminated. There was a total of 155 positions in the final dataset. Evolutionary analysis was conducted in MEGA7. The sequences obtained are marked with a pink triangle and a green diamond. Leishmania braziliensis was used as the outgroup. Pathogens 2022, 11, x FOR PEER REVIEW 11 of 17

Discussion
Despite the high annual prevalence of ZCL in the delegation of Souk Jedid where the village of Gouleb is located [18][19][20]29], little is known regarding the epidemiological aspects of the coexistence of ZCL and CCL in this area. Species identification of the sandfly vectors and etiological-agent typing in these vectors represent steps forward in understanding the epidemiology of leishmaniasis, which should lead to the implementation of improved disease control programs. Taking into account the coexistence of ZCL and CCL, in a nearby focus of CCL [26], the focus of Gouleb is of particular epidemiological importance. The present study aimed: (1) to clarify the diversity and the abundance of sandflies, and (2) to identify the Leishmania species infecting sandfly species in this emerging CCL within a focus of a predominantly ZCL.
Following this biological approach, we quantified the species diversity of sandfly populations in and around houses of CL cases due to L. major and in biotopes of the reservoir host Meriones. Species diversity was low in all habitats. As previously reported in ZCL foci, the proven vector of L. major in Tunisia, P. papatasi, was the dominant species [31]. Other species were probably insufficiently abundant in the Meriones habitat to be easily captured in and around the houses. In these recently established settlements, P. papatasi is probably the first species, or the only species, to invade new houses, because of its specific behavior.
Of a total of 18 sandfly species reported from Tunisia [42,43], 16 species were collected from the site of Gouleb, representing 88.8% of the sandfly fauna reported from Tunisia. Except in the mountainous areas, P. papatasi was the predominant sandfly species in all biotopes including bedrooms, peridomestic areas, and agricultural fields surrounding the village harboring burrows of rodents which are reservoir hosts of L. major.
In addition, P. papatasi was the most prevalent L. major-infected sandfly species in all biotopes including rodents' burrows. Recently, it was shown that ZCL incidence is significantly higher in the ecotones of M. shawi compared to ecotones of P. obesus [31]. This finding could be explained by the high infection prevalence of M. shawi with L. major reaching 53% in autumn compared to the infection prevalence of P. obesus (41%) [11], and by its migratory behavior leading to the dispersal of ZCL [44]. Considering that the flight range of P. papatasi is around 0.75 km [45], increases in densities of L. major-infected P. papatasi in the ecotone of M. shawi expand the overlap of the infected ZCL vector with human habitations and communities contributing to the emergence of epidemics among naïve human populations [46]. Taking into account that P. papatasi (i) is highly associated with burrows of M. shawi at the ecotone level [31] and (ii) is the most abundant sandfly species indoors and is highly endophilic with a trophic preference for humans and rodents [46], consequently, ZCL is the predominant form of CL in the focus of Gouleb [19,29].
Phlebotomus sergenti is the predominant sandfly species belonging to the genus Phlebotomus in the mountainous areas of the village of Gouleb, a natural biotope of the gundi [15]. Indoors, P. sergenti is endophilic but it may take longer for this sandfly species to invade houses compared to the most abundant species P. papaptasi, as has been reported by Jaouadi et al. [47] in the same area and by Tabbabi et al. [23] in a mixed focus of ZCL and CCL in Southeastern Tunisia. Previous studies reported the detection of L. tropica in P. sergenti collected from bedrooms [47,48]. In the present work, we reported for the first time the detection of L. tropica in P. sergenti collected from the rocky mountainous areas of the village, a natural biotope of the gundi. In addition, L. tropica was detected in gundi [49], and also in P. sergenti trapped from a bedroom in a site near to the village of Gouleb [47], and isolated from a human in the same region [27]. The aforementioned findings provide strong evidence to incriminate P. sergenti and C. gundi as the vector and the reservoir of L. tropica, respectively, in Central Tunisia, as has been reported from the Southeast of Tunisia [24,48].
In the present study, we showed that P. sergenti is totally absent from burrows of M. shawi and P. obesus; therefore, this sandfly species is not cavernicolous compared to P. papatasi. Thus, it is expected that P. sergenti will not be involved in the transmission of L. major between M. shawi and/or P. obesus. However, we reported for the first time the natural infection of unfed female P. sergenti collected from the rocky mountainous areas with L. major. Concomitantly, a high infection prevalence of gundi with L. major (30%, N = 23) trapped in a nearby site named Khabina was reported [15]. The detection of L. major DNA in P. sergenti does not mean necessarily that this sandfly species is permissive for L. major. Phlebotomus sergenti was described as specific vector only for L. tropica and not for L. major [50,51]. Kamhawi et al. [50] highlighted the role of sandfly midgut lipophosphoglycan (LPG) receptors in Leishmania attachment and the impact of LPG on the vectorial competence of P. sergenti for only L. tropica and, consequently, this sandfly species is not permissive for other Leishmania species such as L. major and/or L. donovani. Since P. sergenti may not have the genetic characteristics of a single species [52], it is of major epidemiological importance to study the vectorial competence and the vectorial capacity of the North Africa strain of P. sergenti in the transmission of L. major.
In Central Tunisia, ZCL is the predominant form of CL caused by L. major due to the predominance of the sandfly vector P. papatasi in the peridomestic areas and its high infection prevalence with the parasite. However, the occurrence of sporadic human cases of CCL in Central Tunisia located at the flank of rocky, arid, mountainous areas is most probably due to the involvement of P. sergenti and the gundi in the transmission of L. tropica, and, subsequently, leading to the coexistence of ZCL and CCL. In Morocco, several studies conducted in historical foci of CL, due to L. major being close to mountainous areas where P. sergenti is the most commonly collected sandfly species, have shown the emergence of L. tropica in these foci [53][54][55]. The North African form of L. tropica tends to be zoonotic and endemic in rural areas compared to the Middle East form which is anthroponotic and endemic in urban cities [56]. Recently, several epidemics with hundreds of cases of L. tropica CL have been reported in several Moroccan cities [57,58]. It is of major epidemiological importance to point to the risk of spillover of CCL from rural settlements to urban areas in Tunisia [59], added to the risk of anthroponization which may lead to major outbreaks of cutaneous leishmaniasis due to L. tropica in major cities located in Central and Southern Tunisia. Further studies are needed to assess the risk of urbanization of CCL in Central Tunisia.
Among sandfly species belonging to the genus Phlebotomus, P. longicuspis is the second most dominant species in bedrooms and in animal shelters located in the peridomestic areas and are rare in the rocky mountainous areas as well as in burrows of M. shawi and P. obesus. The infection of P. longicuspis collected from animal shelters with L. tropica point to the potential role of this sandfly species in the transmission of CCL in Central Tunisia. Similar results were reported by Remadi et al. [60] from arid Central Tunisia. Phlebotomus longicuspis is abundant in the Saharan and arid bioclimatic zones with a relative abundance of 60% and 40%, respectively [61]. Recently, we showed the involvement of P. longicuspis in the transmission of L. infantum in highly irrigated areas of Central Tunisia [39]. Similar results were reported by Remadi et al. [60], and it is suspected to be the main vector of L. infantum in Southern Tunisia [61]. In Morocco, P. longicuspis is considered a vector of L. infantum in a CL focus where P. sergenti is confirmed as the main vector of L. tropica [62,63]. In Northern Algeria, P. longicuspis is suspected to be a competent vector of zoonotic visceral leishmaniasis in these areas [64]. As for P. perniciosus, P. longicuspis appears to be a permissive vector for Leishmania species.
Sandflies of the genus Sergentomyia, mainly S. fallax, S. antennata, and S. minuta, are predominant mainly in the rocky mountainous areas, indoors, animal shelters, and rodents' burrows. Indoors, L. major was detected in S. fallax and S. antennata. In the rocky mountainous areas, S. fallax was shown to be infected with L. major. In animal shelters, L. major was detected in S. fallax, S. antennata, and S. minuta. It is important to point out that no L. tropica was detected in S. fallax, S. antennata, and S. minuta trapped in the rocky mountainous areas, the natural biotope of gundi. In an old emerging ZCL focus of Southern Tunisia (Gafsa), L. major was detected in S. minuta trapped in the peridomestic areas [65]. Here, we reported for the first time the detection of L. major in S. fallax and S. antennata. Our findings strongly suggest that S. fallax, S. antennata, and S. minuta are suspected vectors of L. major and the gundi is considered a potential reservoir host in the rocky mountainous areas close to communities, and may play a significant role in the transmission of ZCL.
In conclusion, the epidemiology of leishmaniases in North Africa is highly complex due to the high diversity of sandfly vectors and their associated Leishmania species, leading to a mixed form of CL caused by different pathogens, with the risk of spillover from rural to urban areas. Therefore, efficient control to reduce the indoor abundance of sandfly vectors to reduce the incidence of leishmaniases is urgently needed.