[leish-l] Leishmaniasis - Pakistan (Balochistan, Sindh)

[Fred R. Opperdoes]

At 2:49 PM -0500 1/14/05, ProMED Digest wrote:
>
>Date: Thu, 13 Jan 2005 09:55:04 -0500 (EST)
>From: ProMED-mail <promed at promed.isid.harvard.edu>
>Subject: PRO/AH/EDR> Leishmaniasis - Pakistan (Balochistan, Sindh)
>
>LEISHMANIASIS - PAKISTAN (BALOCHISTAN, SINDH)
>*********************************************
>A ProMED-mail post
><http://www.promedmail.org>
>ProMED-mail is a program of the
>International Society for Infectious Diseases
><http://www.isid.org>
>
>Date: Wed 12 Jan 2005
>From: ProMED-mail <promed at promedmail.org>
>Source: IRIN News [edited]
><http://www.alertnet.org/thenews/newsdesk/IRIN/cfd70ac2815ada5ae770fd63a8bd064b.htm>
>
>
>Leishmaniasis outbreak in parts of Balochistan and Sindh
>- --------------------------------------------------------
>An outbreak of leishmaniasis, a skin disease caused by the bite of a sand
>fly, has been reported in parts of the southern Pakistani provinces of
>Sindh and Balochistan. "The number of cases reported to health authorities
>has gone up from 402 to more than 1200 in just 2 days. And we are receiving
>similar reports from the adjoining districts of Sukkur, Jacobabad, Larkana
>and Naushero Feroze," said Dr Hadi Bux Jatoi, director-general (DG) of
>health services in Sindh. He was talking to IRIN from Sukkur district, some
>480 km from the Sindh capital, Karachi, on Friday [7 Jan 2005].
>
>Leishmaniasis is endemic in the provinces of Balochistan, North West
>Frontier Province (NWFP) and Federally Administered Tribal Areas (FA-TA).
>It was reported in Sindh for the 1st time in 2000 and since then the cases
>have been mounting, according to health officials.
>
>Dr Jatoi said that 4 mobile health teams had been deployed in Dadu. "During
>the last season [2004], some 4000 cases were reported across the province,
>but this year [2005], it is spreading [even more] rapidly." 7 districts of
>Balochistan -- those of Qilla Sai-fullah, Loralai, Zhob, Barkhan, Musa
>Khel, Ziarat and Quetta -- have been reported as having a high prevalence
>of leishmaniasis.
>
>"We've had reports from the health authorities of these districts about the
>occurrence of cases, and they've been asked to submit the [detailed] data
>so that we can plan effective interventions," Dr Sher Ahmed, a WHO medical
>officer in the Balochistan capital, Quetta, told IRIN. He said that WHO had
>been trying to introduce weekly reporting on the actual incidence of the
>disease as part of the Disease Early Warning System. "For that, the WHO has
>trained the medical staff at the primary, secondary and tertiary level
>health facilities," Ahmed added. Leishmaniasis, a skin disease, is caused
>by the bite of a sand fly. A pimple appears on the skin after the bite,
>which grows with time, becomes very ugly, and persists for a long time.
>"Sometimes, the period lasts as long as a year... It is called "Saldana" in
>Afghanistan and Iran, where it is widely prevalent," Dr Faizullah Kakar,
>epidemiologist at the WHO country branch, told IRIN in the Pakistani
>capital, Islamabad.
>
>The DG health services, Sindh has proposed aerial spraying against the sand
>fly in areas of Sindh and Balochistan to contain the disease. "If it
>continues to occur, then we'd need huge resources to treat the patients
>every year, which is practically impossible. So, we must address the root
>cause of the disease, that is to eliminate the sand fly," Dr Jatoi said.
>
>Nevertheless, WHO officials have stressed the need to focus on a prevention
>and control strategy, rejecting the idea of aerial spraying. "Spraying
>won't work. Practically it's not possible on such a large scale, as it
>would involve a huge cost. Secondly, it's not a permanent solution, as the
>situation would be the same again after 2 months," Dr Ghulam Nabi Qazi, WHO
>provincial operational officer for Sindh, told IRIN from Karachi. "We need
>to focus on effective interventions, such as community awareness, proper
>health education, personal hygiene, and improving the disease monitoring
>system," Ahmed said. Another reason the idea of spraying wouldn't work is
>that there are continuous migrations of the sand fly from Afghanistan,
>where its prevalence is far higher, so the host and vector would always be
>present, the WHO medical officer said.
>
>However, the health authorities in Sindh maintain that community awareness
>for preventive care won't work in the areas, "where the majority is
>illiterate, and the area has been severely hit by drought over the years;
>where people have no [clean] water to drink; so how can they be trained in
>personal hygiene?" asked Dr. Jatoi. "The district of Dadu alone is 300
>miles [500 km] long, and the population is scattered, so it's not possible
>to run community awareness programs in the area," he added. The DG for
>health said the root cause of the disease needed to be focused on, and for
>that, technical assistance should be sought. "The treatment of the disease
>is costly, unbearable for the poor masses. At the moment, we are dealing
>with the situation, but if the cases continue to grow like this, then what
>will happen?" he wondered.
>
>- --
>ProMED-mail
><promed at promedmail.org>
>
>[The outbreak in Sindh was reported by ProMED-mail in 2004 (see references
>below) and thoroughly discussed by Dr Philippe Desjeux -- Medical Officer
>Disease Control, Prevention and Eradication (CDS/CPE) TDR Leishmaniasis
>Research Coordinator -- in our posting from 1 Feb 2004. In brief, all cases
>are cutaneous with a probable animal reservoir in small rodents. The sand
>fly vector breeds outside, and the outbreak is due either to increased
>human or to rodent migration. The discussion of different control
>strategies favored by the Pakistani authorities and the WHO is interesting
>but, with the background data provided, it seems that spraying is an
>expensive and short term measure which will not eliminate the vector for
>long and will not affect the zoonotic reservoir. - Mod.EP
>
>I think it is generally agreed that in most cases, compulsory treatment of
>those infected with _Leishmania major_ (ZCL) is the best strategy to
>control outbreaks. However, if the vector proves to be _Phlebotomus
>papatasi_ (see 20040201.0392), then it may be appropriate to spray the
>internal surfaces of houses and outhouses with residual insecticides. In
>fact, spraying was believed to have greatly reduced leishmaniasis in India
>when used to kill the indoor-resting anopheline vectors of malaria.
>However, such an approach will not kill sandfly adults resting outside
>homes, such as in rodent borrows. Although it might be argued that aerial
>spraying is more appropriate, this approach has rarely (if ever) been
>successful in controlling sandfly populations; even when used against
>mosquito vectors of malaria and dengue, aerial spraying has often failed.
>Moreover, it requires considerable organization and high costs, which most
>would consider totally unjustified, especially as the actual sandfly vector
>and their habits (such as resting places) have not actually been
>identified. Furthermore, outdoor spraying does not usually remain effective
>for more than 2 to 3 months.
>
>I would be surprised if there were "continuous migration" of sandflies from
>Afghanistan into the Sindh or other areas of Pakistan, as suggested in the
>report. Although they have been known to fly up to 2.2 km over a few days
>and might be dispersed considerable distances with the wind, sandflies
>generally fly very short distances. Nevertheless, I would think that human
>population movements, such as migration of labour forces and/or changes in
>rodent populations are more likely to have aided the reported increases in
>leishmaniasis. - Mod.MS]