[Leish-l] Fwd: PRO/AH/EDR> Leishmaniasis, visceral - Uganda: (Karamoja)

[jeffreyj at usp.br]

LEISHMANIASIS, VISCERAL - UGANDA: (KARAMOJA) 

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> Date: Wed 16 Dec 2015
> Source: AllAfrica, Daily Monitor report [edited]
> < http://allafrica.com/stories/201512161626.html >

> With an emaciated body, [a 13-year-old] turns uneasily on his mat,
> grimacing from the pain he is going through. He has lost weight due
> to
> loss of appetite. With his prominent cheekbones and sunken eyes, he
> appears badly undernourished.

> During a visit to his home in Akorkeya village, Abilibyeyi parish in
> Loro Sub-county in Amudat [district in Karamoja sub-region], his
> father claims his son has been bewitched at the anthill.

> When children start to lose weight and become sickly in this area, it
> is believed that the children will not heal because they are
> suffering
> from the disease of the anthill.

> Three days after Daily Monitor's visit to his home village, [the
> patient] died at the Kala Azar [visceral leishmaniasis] Treament
> Centre in Amudat.

> [This patient's] is not an isolated case. Many children who look
> after
> goats and cattle in Amudat, Nakapiripirit, Napak, Kotido, Kaabong
> [districts in Karamoja sub-region] and parts of Katakwi and Amuria
> [districts in Teso sub-region; cattle corridor], especially those who
> live in mud and wattle houses are suffering from the same disease.

> According to Patricia Namohe, an LC I secretary for women affairs in
> Amudat Town, who lost 2 children to the same disease, most children
> who suffer from this disease usually die before making 15 years.

> This is the reason why many sick children are kept indoors, where
> herbs are prepared and administered to heal them.

> Namohe says, "There are times we have tried to take children to
> hospitals in Kenya and Uganda but most of them die and those who
> survive, are still weak due to the disease."

> In the case of [the 13-year-old male patient], Dr Patrick Sagaki
> in-charge of Amudat hospital, made a diagnosis of kala azar [visceral
> leishmaniasis]. According to Dr Sagaki, kala azar is the most deadly
> parasitic disease after malaria and it is classified by the World
> Health Organisation (WHO) as a Neglected Tropical Disease (NTD).

> Kala azar (visceral leishmaniasis) is a deadly disease caused by
> parasitic protozoa _Leishmania donovani_, transmitted to humans by
> the
> bite of infected female sandfly, _Phlebotomus argentipes_ [Simulial].
> The parasite is hard to detect with the naked eye. "The vector
> thrives
> in cracks and crevices of mud-plastered houses, other poor housing,
> heaps of cow dung, in rat burrows, bushes and vegetation around the
> houses and near anthill[s]," says Dr Sagaki.

> World Health Organisation [WHO] health reports by Dr Parasittisuk
> Chusuk on the disease reveal that a peculiar feature of Indian kala
> azar is darkening of the patient's skin, from which the name kala
> (blackening) azar (fever) is derived.

> Reports at the new Amudat district health office indicate that the
> sub-region [Karamoja] has long battled several animal diseases; goat
> plague PPR (peste des petits ruminants), bovine pleural pneumonia --
> an infectious livestock disease -- and bovine tuberculosis which
> infects a variety of hosts including wildlife, domestic livestock and
> humans. And now the region is fighting kala azar, another neglected
> tropical disease.

> Dr Patrick Sagaki who doubles as the medical superintendent at Drugs
> for Neglected Diseases [DNDi], the only Ugandan Kala Azar Research
> and
> Treatment Centre in Amudat, says although kala azar disease has been
> around for many years, the recent attacks have thrown residents into
> panic.

> "We have so far admitted a cumulative number of about 226 since
> August
> 2008, admitting an average of 15 patients every month. Most of these
> cases come not only from Amudat but also as far as Rupa, Katikekile
> in
> Moroto and Kacheliba in Kenya within the cattle corridor," says Dr
> Sagaki.

> Kala azar is a chronic and potentially fatal parasitic disease of the
> viscera (the internal organs) affecting the liver, spleen, bones and
> the lymph nodes due to infection by the parasite called _Leishmania
> donovani_, which is commonly associated with semi-arid regions and is
> widespread in Karamoja [sub-]region, particularly Nakapiripirit,
> Abim,
> Napak, Moroto, Kotido, parts of Teso [sub-region] and the new Amudat
> districts in Uganda.

> Dr Sagaki says although medical reports in Amudat have long
> acknowledged the existence of the disease, the rates of infection in
> both people and domestic animals is poorly documented, let alone
> controlled.

> Although many people in Karamoja regard kala azar as a strange,
> mysterious disease, research has shown that cases of the disease have
> been recorded in Nakapiripirit, Amudat, Western parts of Kenya,
> Ethiopia and Sudan for close to 50 years.

> "Through DNDi we have admitted and treated many kala azar patients.
> We
> admit about 15 patients every month, usually boys of between 6 to 15
> years because they are exposed and the rates of infection are still
> going up because it has now stretched from Amudat to Katakwi in
> Teso,"
> says Dr Sagaki.

> Information availed to Daily Monitor at the DNDi indicates that the
> disease has claimed lives of at least 46 people in the last 2 years
> and is likely to claim more if the ministry of health does not
> intervene to put in place measures to contain the situation.

> The DHO [District health Officer] Nakapiripirit, Dr John Anguzo,
> affirmed that many cases of kala azar have been detected at
> Nakapiripirit but they are transferred to Amudat hospital and
> admitted
> at the treatment centre.

> Dr Lawrence Okello of WHO, also working with DNDi says whereas the
> disease is usually dormant during the scanty rainy season, it flares
> up during dry weather when the pastoralists travel long distances in
> search of water.

> Dr Okello says that an enlarged spleen and liver are the main
> symptoms
> of the disease and that at primary level, the disease manifests in
> form of weight loss due to loss of appetite (anorexia), fever, cough,
> high body temperatures, anaemia, fatigue and epistasis (bleeding
> through the nose).

> Ministry of Health says
> -----------------------
> Dr Thomson Lakwo, an assistant commissioner, at the national
> Entomologist for Onchocerciasis Control programme, NTD programme,
> Ministry of Health, says there are no confirmed statistics yet about
> the burden of disease in Uganda, but that the disease has been
> endemic
> to Amudat district and increasingly people from other districts such
> as Kotido, Moroto, Abim, Kaabon, Napak, Nakapiripirit [all in
> Karamoja
> sub-region], Katakwi [Teso sub-region], and presently Amuria,
> Kaberamaido and Serere [Teso sub-region] are presenting with it. "We
> have not mapped so we do not know the extent of the disease in the
> country but more people from other districts are presenting with it,"
> says Dr. Lakwo.

> Scientists working on neglected tropical diseases at the ministry of
> health in Uganda say the increased cases of kala azar could be due to
> increased awareness because many cases were not reported in the past.

> "Also the Ugandan health system is getting more sensitive and picks
> disease problems that were previously not picked, says Dr Lakwo.

> Local authorities
> -----------------
> The LCV chairman, Mr William Bwatum says the strange disease could
> have been imported from neighbouring Kenya, particularly Turkana and
> Pokot, through cross border cattle raids by the warriors.

> The District Health report for 2015 seen by Daily Monitor indicates
> that the strange disease has claimed lives of about 46 people in the
> last 2 years and is likely to claim more if the ministry of health
> does not intervene to put in place measures to contain the situation.

> Records at the district also indicate that over 1000 domestic animals
> have died of the disease in the last 5 years and that the disease
> mainly affects the children between the ages of 5 to 16 years who
> look
> after goats.

> Prof Joseph Olobo, a lecturer at the Immunology Department, College
> of
> Health Sciences, Makerere University, says they are training more
> health workers to treat the disease. He says kala azar is treatable
> but fatal if left untreated.

> The disease also affects mainly the world's poorest populations, who
> live in arid or semi-arid regions of the world. Eastern Africa is the
> most affected region in Africa with an estimated annual incidence
> rate
> of 29 000 to 56 000 cases. "70 per cent of kala azar patients are
> children and it affects more men than women because they spend more
> time outside looking after animals in the fields," says Prof Olobo.

> Treatment
> ---------
> Dr Okello says the disease attacks the poor living in mud and wattle
> houses, in the cattle-keeping semi-arid sub-region of Karamoja, where
> heaps of dung are dumped, near anthills. It is an expensive disease
> which the poor can't afford to manage financially. We usually give a
> combination of 2 drugs, sodium stibogluconate [SSG] which is
> administered for 21 days with a balanced diet because the drug is
> very
> toxic.

> Dr Okello says Leishmaniasis East Africa Platform (LEAP) has
> developed
> a new combination therapy (SSG&PM) which is cheaper and nearly brings
> the length of treatment from a 21-day course of injections to 17
> days,
> but that it is yet to be used in Uganda.

> He says there are other drugs which are expensive to use and these
> include pentamidine isethionate (imported), miltefosine (imported)
> and
> liposomal amphotericin B (local but expensive). He adds, "Kala azar
> treatment is painful and the treatment is fairly undignified
> involving
> a 30-day course of injections on the buttocks."

> Challenges
> ----------
> Dr Sagaki and Dr Anguzo say most people are ignorant about the
> disease
> and usually leave their children in the homes to die. "Amudat is the
> only treatment centre for kala azar and given the remoteness of the
> place and the long distance, most people usually shy away," says Dr
> Sagaki, adding, "And the numbers we talk about are the only ones that
> access the hospital yet there are many more who die of the disease in
> the villages after the treatment with herbs fails."

> One complete dose of treatment for 21 days of miltefosine [oral]
> drugs
> costs Shs 200 000 [about USD 600]. Given that those frequently
> infected are the poorest of the poor, they can't afford the treatment
> let alone the feeding of their children. He reveals that DNDi, a
> Geneva-based project with the African headquarters in Nairobi started
> technical trials for kala azar treatment at Amudat centre, but that
> few doctors are well-versed with the disease.

> Children admitted at the ward for kala azar told Daily Monitor: "We
> get breakfast, lunch, dinner and supper throughout the day. We take
> milk, bread, beans, meat, rice, Irish potatoes, matooke, blueband and
> posho." "We actually feed well at times we don't even think about
> going back home," says [a 12-year-old] who is admitted at the DNDi
> centre.

> [Byline: David Mafabi]

> --
> Communicated by:
> ProMED-mail
> < promed at promedmail.org >

> [Karamoja is located in northeast Uganda
> (< https://en.wikipedia.org/wiki/Karamoja >) bordering Kenya and
> South
> Sudan. There has been civil unrest in the region with displacement
> for
> the past 10 years.

> The report strongly suggests that visceral leishmaniasis (VL, kala
> azar) is increasing in Karamoja, and indeed it is highly endemic in
> neighboring South Sudan. The report emphasizes that children are
> particularly hit and that contact with domestic animals, especially
> goats, seems to be a risk factor.

> The known reservoirs for _Leishmania_ in the region are rodents and
> to
> a lesser extent humans. Humans could play a role in transmission if
> the HIV infection rate in the area is high, as HIV infected persons
> cannot control the _Leishmania_ infection and thus will be more
> infective to the sandflies.

> There are few data on domestic animals other than dogs as reservoirs
> for _Leishmania_, but a recent study from Ethiopia (Rohousova et al.
> Exposure to _Leishmania_ spp. and sand flies in domestic animals in
> northwestern Ethiopia. Parasites & Vectors 2015;8:360) found
> _Leishmania_ in the blood of cows (1 percent), dogs (2.9 percent),
> goats (1.3 percent) and sheep (2.7 percent) using PCR. The results
> suggest that there may be reservoirs other than dogs, humans and
> rodents, and studies of the animal reservoirs are needed to develop a
> rational control strategy. - Mod.EP

> A HealthMap/ProMED-mail map can be accessed at:
> < http://healthmap.org/promed/p/97 >.]

> [See Also:
> Leishmaniasis, visceral - South Sudan (02): corr
> http://promedmail.org/post/20151126.3820915
> Leishmaniasis, visceral - South Sudan (02)
> http://promedmail.org/post/20151028.3749052
> Leishmaniasis, visceral - South Sudan: (JG)
> http://promedmail.org/post/20150118.3100799
> 2014
> ----
> Leishmaniasis, visceral - South Sudan (03)
> http://promedmail.org/post/20141031.2918104
> Leishmaniasis, visceral - South Sudan (02)
> http://promedmail.org/post/20141006.2836861
> Leishmaniasis, visceral - South Sudan: (JG)
> http://promedmail.org/post/20140909.2760146
> 2012
> ----
> Leishmaniasis, visceral - South Sudan (03): (JG)
> http://promedmail.org/post/20121015.1343672
> Leishmaniasis, visceral - South Sudan (02): (UY)
> http://promedmail.org/post/20120916.1295988
> Leishmaniasis, visceral - South Sudan
> http://promedmail.org/post/20120421.1109078
> 2011
> ----
> Leishmaniasis, visceral - South Sudan (JO, UN)
> http://promedmail.org/post/20111111.3346
> Leishmaniasis, visceral - Sudan: (southern)
> http://promedmail.org/post/20110313.0810 ]
> .................................................sb/ep/je/dk
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