jerusalem is located atop the judean hills , on the edge of the judean desert . the desert drops off steeply to the east , falling 1,200 m over a course of 20 km to a nadir of 400 m on the shores of the dead sea , the lowest point on land on earth . on the edge of this region the town is built along narrow ridges that fall away to deep ravines inhabited by wildlife . houses on the periphery are often just meters from desert crags and crevices ; none is more than 500 m from the wilderness . all cases of leishmaniasis in israel are required to be reported to the district health office , and a weekly national report is published by the department of epidemiology , israeli ministry of health ( 7 ) . cases were plotted on the ministry of health geographic information system ( environmental systems research institute , redlands , ca , usa ) , adapted specifically for the informatics and computation division of the ministry of health ( systematics technologies ltd . , local population data were supplied by the town municipality , and neighborhood incidence rates were derived and averaged for 20042005 . a total of 161 cases of cl were reported in the jerusalem district in 2004 ( n = 71 ) and 2005 ( n = 90 ) compared with 1 or 2 cases in each previous year . of the cases reported in 2005 , forty - eight ( 53% ) had positive cultures ; 20 ( 41.6% ) of these were serologically positive for l. tropica , and none was positive for l. major . average annual incidence of cl in israel ( excluding the jerusalem district ) increased from 0.95/100,000 in 19992003 to 1.61/100,000 in 20042005 ( rr  1.63 ) . over the same period , however , rates for the jerusalem district increased from 0.13 to 9.7/100,000 ( rr  74.7 ) . rates for the jerusalem district were lower than those for the rest of israel during 19992003 ( rr  0.14 ) but substantially higher during 20042005 ( rr  6.1 ) . in 2006 , rates for the jerusalem district decreased , and national incidence continued to increase ; 2007 showed a trend to an increased incidence in the jerusalem district ( figure 1 ) . of the case - patients in the jerusalem district , 54 ( 76% ) in 2004 and 73 ( 81% ) in 2005 occurred in maale adumim , where the incidence was 214/100,000 in 20042005 , compared with an annual average of 2/100,000 in preceding years . the epicenter of the outbreak was a small neighborhood of 1,040 residents ( a in figure 2 ) in which 52 cases occurred over the 2-year period ( attack rate 50/1,000 ) ; this attack rate was greater than in any other neighborhood . the second most affected neighborhood had 24 cases among 2,251 residents ( attack rate 10.7/1000 for the 2-year period ) . all but 6 case - patients lived within 200 m of the ravines that encompass the town , and 3 of these case - patients had occupational exposure . in 2006 and 2007 , 13 and 29 cases , respectively , were reported in the jerusalem district ; 5 ( 38% ) and 9 ( 31% ) of these case - patients , respectively , were infected in maale adumim . wilderness ravines ( white areas ) reach within meters of houses at the periphery of the neighborhood in all directions . age distribution of patients was not different from that of uninfected persons in the town ( table ) . more than one third of the patients ( 37.5% ) reported a family member who was infected with cl in the same period . most patients ( 62.2% ) had > 1 lesion , 70% reported having a private garden , 57.1% lived adjacent to public parks , 52.7% had a home that faced a wilderness area , 45.8% reported a construction site near their home , and 65.1% had intact insect screens on their windows . eight patients ( 14% ) ( 6 in neighborhood a and 2 in neighborhood b ) reported seeing hyraxes near their homes ( figure 2 ) . we report a large outbreak of cl in israel caused by l. tropica that was centered on a town just outside jerusalem . this outbreak was observed in the context of increasing rates of cl in israel . during the outbreak , highly visible environmental intervention and active surveillance were undertaken , which may have introduced detection bias , but it is unlikely that these alone could explain the dramatic increase in incidence . the association between cl outbreaks and urban development has been noted repeatedly , and construction waste and soil humidity are considered intermediaries ( 8,9 ) . a study in colombia found that habitat degradation negatively affected phlebotomine populations but that medically important sandfly species were able to exploit modified environments ( 10 ) . maale adumim has undergone rapid development and expansion over the past decade , and sandflies are abundant in the area . a 2005 study collected 80,000 sandflies near the town , of which 85% were ph . although environmental investigation is ongoing , we suspect that hyraxes infesting building sites were the source of this outbreak . this hypothesis is in accordance with current knowledge that associates l. tropica with urban outbreaks and hilly terrain . however , the pattern of this outbreak supports a zoonotic rather than anthroponotic source . in 2006 , chaves and pascual reported that climate was a valuable covariate in predicting incidence of cl ( 12 ) . a 1996 computerized model examined the effect of warming of 1c , 3c , and 5c on the likelihood of cl transmission at 115 southwest asian sites . sandflies are not known to reproduce in jerusalem , but cross and hyams suggest that jerusalem could support endemic transmission if the average temperature increased by 1c ( 13 ) . since that model was proposed , the average temperature in jerusalem has increased by 1c ( 14 ) . the spate of recent outbreaks suggests that l. tropica is no longer an emerging pathogen but rather that it is an established pathogen in israel . the proximity of the outbreak to jerusalem , in light of the trend toward global warming ( 15 ) , makes an outbreak of cl in jerusalem a real and disturbing prospect .
a total of 161 cases of cutaneous leishmaniasis caused by leishmania tropica occurred in the jerusalem district during 20042005 ; 127 ( 79% ) cases were in a town just outside jerusalem . 
 environmental models suggest that in the context of global warming , this outbreak has the potential to extend into jerusalem .