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Letter
Cutaneous Leishmaniasis, Northern
Afghanistan
Richard Reithinger,*†
Khoksar Aadil,† Samad Hami,† and Jan Kolaczinski*†
*London School of Hygiene and Tropical Medicine, London, United Kingdom;
and †HealthNet International, Peshawar, Pakistan
Suggested citation
for this article:
Reithinger R, Aadil K, Hami S, Kolaczinski J. Cutaneous leishmaniasis,
northern Afghanistan. Emerg Infect Dis [serial on the Internet]. 2004
May [date cited]. Available from: http://www.cdc.gov/ncidod/EID/vol10no5/03-0894.htm
To the Editor: In Afghanistan, most cutaneous leishmaniasis cases
are caused by Leishmania tropica, which is transmitted anthroponotically
by the sandfly Phlebotomus sergenti (1). Cutaneous
leishmaniasis can have devastating effects on local communities because
of its clinical symptoms, i.e., large, multiple, or both, disfiguring
lesions, that can lead to social ostracism of affected persons (e.g.,
women are often deemed unsuitable for marriage or to raise children) (2).
Cutaneous leishmaniasis is considered a low priority disease by international
donor agencies because treatment costs are high and the disease does not
cause death (3).
Data on the effects of cutaneous leishmaniasis in Afghanistan previously
have been available only for Kabul city; recent studies have reported
an estimated 67,500 cases (4). Because of the migration
of an estimated 4.5 million infected Afghan refugees returning home from
other countries, the sporadic treatment of patients infected with cutaneous
leishmaniasis, and limited control of the sandfly vector, L. tropica
has spread to areas that were previously nonendemic for the disease, e.g.,
northeastern Afghanistan.
A survey in Faizabad city, Badakhshan Province, was conducted in June
2003 by HealthNet International to collect data on the impact of cutaneous
leishmaniasis. Leishmaniasis in this region is transmitted from April
to October. The city was divided into 10 districts, and 20 households
were surveyed along a randomly chosen transect drawn from the center of
each district. A team of experienced medical staff clinically diagnosed
cutaneous leishmaniasis (based on the presence or absence of cutaneous
leishmaniasis lesions or scars, number of lesions, date of lesion onset)
in household members and interviewed them to collect demographic data
(gender, age). Because of logistic constraints, parasitologic diagnosis
of cutaneous leishmaniasis lesions (i.e., microscopic examination or parasite
culture) was not conducted. However, in Afghanistan, skin lesions attributed
to causes other than cutaneous leishmaniasis are rare, and experience
has shown that clinical diagnosis has a sensitivity and specificity of
>80% and >90%, respectively (Reithinger et al., unpub. data). Written
approval to conduct the study was obtained from the Ministry of Health.
Informed consent was obtained from study participants; all study participants
with active cases of the disease were offered free anti-leishmanial treatment
at the HealthNet International leishmaniasis clinic.
We surveyed 1,832 people from 200 households; 8.3% (152/1,832) and 7.8%
(142/1,832) had active cutaneous leishmaniasis lesions or scars, respectively.
Of those persons with cutaneous leishmaniasis lesions, the mean lesion
number was 2.4 (range 1–14), the mean lesion size was 2.4 cm (range 1–5.5),
and the mean lesion duration (to survey date) was 5.6 months (range 1–11).
Active prevalence was not associated with gender (Yates-corrected c2
= 2.16, p = 0.14); 85/152 (56%) of the cutaneous leishmaniasis case-patients
were women, and 67/152 (44%) of cutaneous leishmaniasis case-patients
were men. Data showed that persons aged <15 years were at higher
risk of contracting the disease than were persons aged >15 years (odds
ratio = 2.23, 95% CI 1.54 to 3.24, Yates-corrected c2 = 19.44,
p<0.001).
Based on population estimates of 65,000 people and observed prevalence,
approximately 5,395 cutaneous leishmaniasis case-patients would be found
in Faizabad. The low prevalence of scars, compared to the high prevalence
of disease, shows that cutaneous leishmaniasis has been introduced into
Faizabad only recently (1,4). Local Ministry of Health
records show that the disease was virtually absent (<50 annual cases)
in Badakhshan 3 years ago; this information is corroborated by the observation
that the mean time since the recovery of surveyed people with cutaneous
leishmaniasis scars was 1.5 years (range 0.3–15). Although no attempts
were made to identify circulating Leishmania sp., the current epidemic
is likely caused by L. tropica because both men and women are equally
affected and younger age groups are at higher risk for cutaneous leishmaniasis
than older age groups (1,4). Current analyses are under
way to establish risk factors (e.g., presence or absence of animals, type
of house construction) for contracting the disease.
With support from HealthNet International, three leishmaniasis clinics
have been established in Faizabad to increase the total number of patients
whose illness is diagnosed and treated; to reduce the risk to susceptible
persons through the subsidized sale of insecticide-impregnated bed nets;
to train and supervise the Ministry of Health staff in diagnosis, treatment,
and prevention of the disease; and to implement health education campaigns
for patients attending the clinics and the community at large. Hopefully,
these activities will prevent the current cutaneous leishmaniasis outbreak
from becoming an epidemic, as it has been in Kabul over the past 15 years
(4,5).
Acknowledgments
We thank the Afghan
Ministry of Health and the HealthNet International survey team staff
for logistical support.
This study was supported
by the United Nations Mission to Afghanistan.
References
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leishmaniasis in Kabul: observations on a prolonged epidemic. Ann
Trop Med Parasitol 1992;86:361–71.
- Griffiths WDA. Old World cutaneous leishmaniasis. In: Peters W, Killick-Kendrick
R, editors. The leishmaniases in biology and medicine. London: Academic
Press; 1987. p. 617–43.
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Anthroponotic
cutaneous leishmaniasis, Kabul, Afghanistan. Emerg Infect Dis 2003;9:727–9.
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