[leish-l] Troops being treated for leishmaniasis

[Peter Singfield]

High lighting:

“I don’t care how bad [the lesions] look,” he said. “It may take a year
more, but they will all heal.”

About 200 of the diagnosed servicemembers have decided to let the lesions
heal, despite the military’s offer of medical treatment, he said. 

****************************

Troops being treated for leishmaniasis 

By Lisa Burgess, Stars and Stripes
European edition, Saturday, March 20, 2004

ARLINGTON, Va. — About 500 soldiers who have served in Iraq have been
diagnosed with a skin disease caused by sand flies in the largest outbreak
of leishmaniasis faced by the U.S. military since World War II, according
to Defense Department doctors.

The disease is caused by parasites transmitted via sand fly saliva, and
comes in three forms: cutaneous, affecting the skin; mucosal, affecting the
mouth, nose and throat; and visceral, affecting internal organs, which can
be fatal if untreated.

All but two of the cases diagnosed so far have been the cutaneous form and
all but three of those were contracted in Iraq, according to Dr. Alan
Magill, a specialist in infectious diseases at Walter Reed Army Institute
of Research in Maryland.

The remaining three cases of cutaneous “leish” were contracted by U.S.
servicemembers deployed to Afghanistan, Magill said in a Thursday
interview, as were the two cases of visceral leishmaniasis.

The last time the Pentagon doctors had to cope with a leishmaniasis
outbreak was 1943, when about 1,000 U.S. soldiers stationed in what is now
Iran came down with the cutaneous version.

Significant numbers of U.S. troops also were deployed to countries where
leishmaniasis is a risk during Operation Desert Storm.

But that conflict produced just 32 confirmed cases — probably because
almost all the servicemembers were deployed in November 1990 and were sent
home before peak sand fly season, which runs from late March to late
September.

“We got lucky,” Magill said.

When it came time for Operation Iraqi Freedom, however, DOD’s core group of
about a dozen “leish” specialists were certain that luck would not hold.

“We were sending thousands of troops to an area of known disease,” Magill
said, under conditions ripe for maximum sand fly exposure.

The troops were entering Iraq just as the sand flies were beginning to
multiply. Insect control programs were limited to the sprays and salves
soldiers could apply on the move. And the troops were living “in the
rough,” bedding down atop vehicles or directly on the ground.

“So it was absolutely no surprise” when hundreds of troops were affected,
Magill said.

Experts from the 520th Theater Army Medical Laboratory began testing sand
flies for leishmaniasis in Iraq in June.

“We found an enormous amount were infected,” Magill said. “We knew right
then and there we were going to see lots of cases.”

But it wasn’t until late August that the first case was confirmed, Magill
said — in part because cutaneous leishmaniasis has a two- to eight-week
incubation period; and also because samples from all suspect lesions have
to be sent back to Walter Reed for evaluation.

By October, “we knew there were scores of cases” among Iraq-deployed
troops, Magill said. “And late November was about the time everything
really ramped up.”

Military experts believe the numbers will drop in the second Iraq rotation,
Magill said.

“I’m pretty sure we’ll see fewer cases this time around,” he said. “Troops
are moving around less,” with less makeshift billeting, and commanders have
had time to implement rodent-control programs that in turn help control the
sand flies.

Magill and his colleagues have also worked hard to educate both medical
personnel and troops, traveling both in Iraq and to bases in the United
States to spread the word.

“There certainly has been an attempt to get the message out,” Magill said.
“Ninety percent of the battle is just getting people thinking about it.”

Meanwhile, to handle the current influx of patients, DOD officials are
opening a second treatment center at Brooke Army Medical Center in San
Antonio that will be authorized by the Food and Drug Administration to
administer Pentostam, the only drug used to treat the cutaneous version.

Brooke will open to servicemembers “within weeks” for leishmaniasis and
will join Walter Reed as the only facilities in the United States with the
FDA certifications to administer the investigational drug.

Cutaneous patients receive Pentostam intravenously for 10 to 20 days. But
only the more serious cases require the often-uncomfortable regime, Magill
said.

Mild cases can be treated with liquid nitrogen, which freezes the lesions
and kills the parasites. Doctors can also carefully apply heat to stop the
infestations, Magill said.

But the best news is that cutaneous leishmaniasis heals by itself in time,
even without treatment, Magill said.

“I don’t care how bad [the lesions] look,” he said. “It may take a year
more, but they will all heal.”

About 200 of the diagnosed servicemembers have decided to let the lesions
heal, despite the military’s offer of medical treatment, he said. 

*******************************

Leishmaniasis prevention tips

There’s only one way to prevent leishmaniasis: Keep sand flies from biting.
Here are some tips:

Try to limit outdoor activity at dusk and during the evening, when sand
flies are most active.

Wear protective clothing, with uniform sleeves turned down and buttoned,
and pant legs properly bloused.

Apply insect repellent with N, N-diethylmetatoluamide (DEET) to exposed
skin and under the edges of clothing, such as under the ends of sleeves and
pant legs. Reapply according to directions (the more you sweat, the more
you may need to reapply, but check the bottle first).

Keep uniforms properly treated with permethrin. Make sure to apply after
every five washings.

Use permethrin-treated bed netting and screens on doors and windows.
Fine-mesh netting (at least 18 holes to the linear inch) is required for an
effective barrier against sand flies, which are about one-third the size of
mosquitoes.

In the field, try to get your sleeping bag off the ground. If you can’t do
that, at least use a ground pad.

If sleeping under cover, sweep all loose dust and dirt from floors. The
cleaner your quarters, the fewer the flies.

Do not wear flea collars designed for dogs and cats, even over boots,
medical experts warn. The collars are designed to repel common house fleas
and there is no evidence they work against sand flies. Meanwhile, the
chemicals in the collars have not been tested for safety with humans, and
can cause allergic reactions and sores that may become infected.

— Sources: U.S. Army, Centers for Disease Control 

http://www.estripes.com/article.asp?section=104&article=21116