By Christine M. Choi, Wounds1 StaffOn January 14, 2002, the World Health Organization (WHO) reported an outbreak of the skin disease leishmaniasis (Leash-ma-NIGH-a-sis) in the Kurram Agency, an Afghan refugee- hosting agency located in Pakistan’s North West Frontier Province. At least 738 cases have erupted amongst the local Pakistani population, mostly in young children under fifteen. These are in addition to the 1500 cases reported within Afghan refugee camps. An astonishing 72% of those affected do not have access to medical treatment for their disease.
Providing treatment for these people poses a significant challenge. One difficulty is that the standard medication for treating leishmaniasis, Glucantime, is not available in Pakistan. Compounding the unavailability of medicine is the fact that local physicians are not trained in handling this disease. WHO official Dr. Faizulah Kakrar assured that his organization and UNHCR (United Nations High Commissioner for Refugees) were cooperating to make enough of the medicine available in addition to training local medical staff in handling the disease.
Approximately 2 million new cases of leishmaniasis are reported every year, although this number does not include the many cases that go unreported worldwide. Leishmaniasis is caused by a parasite that is spread by the bite of infected sandflies. There are several forms of the disease, the most common being cutaneous (cue-TAY-knee-us) leishmaniasis affecting the skin and visceral (VIS-er-al) leishmaniasis affecting the internal organs of the body. The disease is common in tropical and subtropical regions of the world, including Central and South America, southern Europe, West Asia, the Middle East, and Africa. Very rarely, people living in rural southern Texas have developed cutaneous leishmaniasis, but no cases of visceral leishmaniasis are known to have been acquired in the United States.
Patients with cutaneous leishmaniasis develop one or more open sores on their skin within a few weeks of being bitten by an infected sandfly. Usually they cannot recall being bitten. Sores vary in size and shape: they can be painless or painful and can appear as an ulcer with a raised edge or be covered by a scab. Although the lesion may be located anywhere on the body, it is usually on exposed parts of the skin. The sore may leave a permanent scar that can be disfiguring and socially stigmatizing. In contrast, visceral leishmaniasis may take months to develop after a patient is bitten and is manifested by fever, weight loss, an enlarged spleen and liver, and swollen glands. Patients usually also have decreased levels of red blood cells, white blood cells, and platelets.
Leishmaniasis is completely curable if treated appropriately in a timely fashion. The standard treatment is Glucantime, or sodium stibogluconate, administered intravenously. There are several second-line drugs available. Treatment duration depends on the severity of the disease and can range from 8 to 90 days. If not treated, a cutaneous infection can spread to the mucous membranes of the nose and mouth (‘mucocutaneous leishmaniasis’). Visceral leishmaniasis can cause death if left untreated.
How does this outbreak impact people living in the United States? Think back to the early 1990s when U.S. troops were involved in another military conflict, this time in the Middle East. By December 1991, 16 military personnel returning from Operation Desert Storm had been diagnosed with cutaneous leishmaniasis. An additional 7 cases of leishmaniasis involving internal organs (‘viscerotropic leishmaniasis’) were diagnosed at Walter Reed Army Medical Center in Washington, D.C. It is highly unlikely to acquire the infection through person- to- person contact without direct inoculation from the open wound of a patient or transfer of infected blood products. There have been rare cases of leishmaniasis spread from an infected mother to her fetus, via contaminated needles, and through blood transfusions.
If you have traveled to an area where leishmaniasis is found and have developed skin sores that are not healing, notify your health care provider. If you are planning to travel to a region where leishmaniasis is common, follow these preventive guidelines:
- Stay in well-screened and air-conditioned areas, especially from dusk to dawn when sand flies are most active.
- When outside, wear long-sleeved shirts, long pants, and socks to limit the amount of skin that is exposed.
- Apply insect repellent on exposed skin before going outside. Repellents containing 30-35% DEET (N,N-diethylmetatoluamide) are effective for about 4 hours. Use repellents with DEET concentrations £10% sparingly on children 2 to 6 years old, but do not use on children under 2 years old.
- Cover sleeping areas with fine mesh netting. Keep in mind that sand flies are much smaller than mosquitoes, so the mesh should have at least 18 holes to the inch.
- Spray clothes, living, and sleeping areas with permethrin- containing insecticides. Reapply after every five washings.
For more detailed information about leishmaniasis, visit the WHO or the CDC websites.
Sources:
World Health Organization (WHO)
Centers for Disease Control and Prevention (CDC)
