A rapid intervention by the World Health Organization and its partners, the Massoud Foundation and HealthNet International, in Kabul, Afghanistan, made possible by a donation from the Belgian government, should dramatically reduce the incidence of leishmaniasis in less than two years.
Without immediate action, the current epidemic threatens to escalate into an uncontrollable situation. This emergency initiative aims not only to treat those currently affected in the acute phase of the epidemic, but to prevent further transmission of the disease.
Kabul is the largest centre of cutaneous leishmaniasis in the world, with an estimated 67,500 cases. The figure accounts for a third of the 200,000 cases in all of Afghanistan. Cutaneous leishmaniasis is a disabling disease transmitted by the bite of the sand fly. The disease leads to disfigurement usually on the face and hands, and social stigma, particularly for women and children. As an immediate measure, WHO and partners expect to begin distributing insecticide treated bednets soon to protect more than 30,000 people from sand flies.
"This is a unique opportunity to stop a debilitating disease in its tracks, and make gains in a country where people so deserve to see improvements to their health," says Dr Philippe Desjeux, head of WHO's leishmaniasis control programme. The initiative also reflects WHO's commitment to ensuring that diseases of neglected populations are addressed with a sense of urgency.
While effective control programmes for leishmaniasis once existed in Afghanistan, the past two decades of ongoing conflict has gravely weakened much of the health infrastructure. Environmental damage and poor sanitary conditions have resulted in the proliferation of sand flies' breeding sites. At the same time, the influx of large numbers of displaced people threatens to increase the disease's already epidemic levels. With little immunity to leishmaniasis, displaced people, or in this case, people returning from neighbouring Pakistan, are typically more susceptible to the disease.
"We must act now if we are going to have any chance of controlling the situation," says Desjeux.
Leishmaniasis is a parasitic disease transmitted by the bite of some species of sand flies. It is an obligate intracellular protozoan. The disease most commonly manifests either in a cutaneous (skin) form or in a visceral (internal organ) form.
Leishmaniasis is found in approximately 90 tropical and subtropical countries around the world and in southern Europe. More than 90% of the world's cases of cutaneous leishmaniasis are in Afghanistan, Algeria, Brazil, Iran, Iraq, Peru, Saudi Arabia, and Syria. However, approximately 75% of the cases that are evaluated in the United States were acquired in Latin America, where leishmaniasis occurs from northern Mexico (rarely in rural southern Texas) to northern Argentina. More than 90% of the world's cases of visceral leishmaniasis occur in Bangladesh, Brazil, India, Nepal, and Sudan. Leishmaniasis is not found in Australia or the South Pacific.
Travelers of all ages are at risk for leishmaniasis if they live in or travel to these areas. Leishmaniasis usually is more common in rural than urban areas, but it is found in the outskirts of some cities. Risk is highest between dusk and dawn. Adventure travelers, Peace Corps volunteers, missionaries, ornithologists, other persons who do research outdoors at night, and soldiers are examples of those who might have an increased risk for leishmaniasis, especially the cutaneous form. Even persons with short stays in leishmaniasis-endemic areas can become infected.
Cutaneous leishmaniasis is characterized by one or more skin sores (either painful or painless, with or without a scab) that develop weeks to months after a person is bitten by infected sand flies. If untreated, the sores can last from weeks to years and often eventually develop raised edges and a central crater. The manifestations of visceral leishmaniasis, such as fever, weight loss, enlargement of the spleen and liver, and anemia, typically develop months, but sometimes years, after a person becomes infected. If untreated, symptomatic visceral leishmaniasis typically is fatal.