Social Impact of Leishmaniasis, Afghanistan by uij90909



occurred for 19 years. From 1959 to        shows that after years of negative                Address for correspondence: Emil C. Reisinger,
1983, numerous TBEV foci existed in        tickborne encephalitis test results in            Division of Tropical Medicine and Infectious
northeastern Germany (3). From 1960        ticks, old tickborne encephalitis foci            Diseases, Department of Medicine, University
to 1985, a total of 4 human cases were     may retain activity. Thus, tickborne              of    Rostock     Medical    School     Ernst
seen 10 km east of Neustrelitz. From       encephalitis should be included in the            Heydemannstr. 6 18055, Rostock, Germany;
1983 to 1989, numerous attempts to         differential diagnosis of meningoen-              fax: 49-381-494-7509; email: emil.reisinger@
cultivate TBEV from ticks or small         cephalitis in northeastern Germany,     
mammals failed (3). In 1992, TBEV          even if the patient has not been in
genome was detected by PCR in 3 tick       tickborne encephalitis–endemic areas.
pools from the island of Usedom, and
in 2 pools from the Darss peninsula,       Acknowledgments
100 km northeast of Neustrelitz. From           We thank G. Dobler for performing
1993 to July 2004, TBEV genome             antibody tests against flaviviruses, J.
was not detected in 16,098 ticks col-      Suess for sequencing PCR amplificates, F.            Social Impact of
lected from 275 regions of northeast-
ern Germany, including the county
                                           Ruhnau and J. Reimann for patient care,
                                           and Chiron Vaccines, Germany, for sup-
where Lake Woblitz is situated, as         port collecting ticks.                                 Afghanistan
part of a statewide surveillance pro-
                                                                                                 To the Editor: For almost a
gram (State Health Services, unpub.             Christoph J. Hemmer,*                        decade, Kabul, Afghanistan, has had
data). However, during 2004, this                  Martina Littmann,†                        the highest incidence of cutaneous
county reported 24 cases of Lyme dis-             Micha Löbermann,*                          leishmaniasis in the world, with an
ease (2003: 10 cases; 2002: 8 cases;       Michael Lafrenz,* Tobias Böttcher,*               estimated 67,500 to 200,000 cases
2001: 1 case). Therefore, our tick-             and Emil C. Reisinger*                       each year (1–3). Because of sandfly
borne encephalitis case might repre-       *University of Rostock Medical School,            vector exposure, most leishmaniasis
sent intensified amplification cycles      Rostock,    Germany;     and   †Health
                                                                                             lesions occur on the face; anecdotal
of tickborne infectious agents in 2004.    Department of the State of Mecklenburg-
                                           West Pomerania, Rostock, Germany                  reports of severe stigma are associat-
    The absence of tickborne
                                                                                             ed with the disease (3). To prioritize
encephalitis cases for 20 years does       References                                        aspects of operational activities and
not likely represent a lack of data
                                            1. Csángó PA, Blakstad E, Kirtz GE, Pedersen     before developing a disease-specific
before or a lack of interest after the
                                               JE, Czettel B. Tick borne encephalitis in     health education strategy, we collect-
reunification of Germany. Tickborne            southern Norway. Emerg Infect Dis.            ed data on knowledge, attitudes, and
encephalitis was a reportable disease          2004;10:534–5.
                                                                                             perceptions regarding leishmaniasis.
under East German regulations, and          2. Lindgren E, Gustafson R. Tick borne
                                               encephalitis in Sweden and climate change.        In October 2002, we randomly
tickborne encephalitis surveillance
                                               Lancet. 2001;358:16–8.                        chose 5 of Kabul’s 14 administrative
was intensified after reunification (3).    3. Süss J, Sinnecker H, Sinnecker R, Berndt      districts to carry out a house-to-house
    Eight weeks after our patient’s tick       D, Zilske E, Dedek G, et al. Epidemiology
                                                                                             survey (HHS) as well as 13 focus
bite, 160 Ixodes ricinus ticks were            and ecology of tick-borne encephalitis in
                                               the eastern part of Germany between 1960      group discussions (FGDs) with
collected from 10 pools near Lake
                                               and 1990 and studies on the dynamics of a     women. The 5 districts chosen were
Woblitz. RNA was isolated in 5 mol/L           natural focus of tick-borne encephalitis.     Karti-Seh (HHS) and Dasht-e-Barchi
guanidium isothiocyanate solution,             Zentralbl Bakteriol. 1992;277:224–35.
                                                                                             (4 FGDs), Karti-Now (3 FGDs),
extracted by phenolchloroform, and          4. Robert Koch Institute. Risikogebiete der
                                               Frühsommer-Meningoenzephalitis (FSME)         Arzam Qemat (3 FGDs), and Rahman
precipitated with ethanol. cDNA was
                                               in Deutschland (Risk Areas of TBE in          Mena (3 FGDs). The survey was con-
amplified by nested reverse transcrip-         Germany). Epidemiol Bull. 2004;21:            ducted by using a standardized, multi-
tion–PCR and detected by elec-                 169–73.
                                                                                             ple-choice questionnaire. The most
trophoresis (6). In 2 of these pools,       5. Lademann M, Gabelin P, Lafrenz M,
                                               Wernitz C, Ehmke H, Schmitz H, et al.         senior, available family member in
PCR directed towards the 5′ terminal
                                               Acute disseminated encephalitis (ADEM)        252 neighboring households was
noncoding region of the TBEV                   following P. falciparum malaria caused by     interviewed, after the first household
genome yielded a 104-bp fragment,              varicella zoster virus reactivation. Am J
                                                                                             was randomly selected (2). We
but the sequence was not specific for          Trop Med Hyg. In press 2005.
                                            6. Ramelow Ch, Süss, J, Berndt D,                focused on women in FGDs because
                                               Roggendorf M, Schreier E. Detection of        they have greater risk for leishmania-
    This case does not prove a north-          tick-borne encephalitis virus. RNA in ticks   sis than men (2,3) and are often the
bound spread of tickborne encephali-           (Ixodes ricinus) by the polymerase chain
                                                                                             primary caregivers in Afghan culture
tis in northeastern Germany. Rather, it        reaction. J Virol Methods. 1993;45:115–9.

634                        Emerging Infectious Diseases • • Vol. 11, No. 4, April 2005

(4). The same HHS questions were           exist that the disease can be transmit-       fly vectors, i.e., screens for windows
used in the FGDs. Surveyors random-        ted by person-to-person physical con-         and doors (n = 108), nets around beds
ly chose a house in each district and      tact (of 360 respondents, the most            (n = 63), indoor insecticide spraying
explained the study’s purpose to resi-     common answers were “touching” [n             (n = 24), or other method of personal
dents. When residents agreed to host       = 86] and “sharing meals and house-           protection (n = 10); 152 (78%) of 252
an FGD, women from neighboring             hold goods” [n = 26]), affected people        HHS respondents said that they did
households were invited to join.           are excluded from communal life.              not have a net over their bed because
FGDs had a maximum of 12 partici-          This exclusion can consist of minor           it was too expensive.
pants and lasted 2 hours; answers to       domestic restrictions (40 [46%] of 89             Kabul residents are knowledgeable
questions were recorded on paper.          FGD respondents said they would not           about leishmaniasis; they are able to
FGD moderators were instructed to          share plates, cups, or towels with            describe its symptoms and the neces-
pose questions, encourage free discus-     leishmaniasis patients) or more severe        sity for professional treatment.
sion, and ask participants to empha-       measures that lead to physical and            However, we show that while many
size personal experiences. FGD data        emotional isolation. FGDs showed              FGD respondents knew that leishma-
were analyzed by thematic analysis of      that leishmaniasis caused trauma; of          niasis is transmitted by “mosquitoes,”
the transcripts. Surveys were carried      83 respondents who had children with          severe stigma and trauma are associ-
out by experienced surveyors, who          leishmaniasis, 45 (54%) said their            ated with the disease, particularly in
have been involved in previous leish-      children felt disfigured because of           children and women. Our operational
maniasis prevalence surveys or inter-      lesions or scars (n = 20), because of         experience corroborates this finding,
vention trials (2–4). Written approval     painful treatment (intralesional or           which underlines the disease’s social
for the study was obtained from the        intramuscular injections with pen-            effect on the local population and
Afghan Ministry of Health, and oral        tavalent antimony, n = 19), or because        refuting the belief that leishmaniasis
consent was given by all surveyed          they were excluded from play with             is of little health importance (5). Half
persons. Active case-patients sur-         other children (n = 6). Of 96 FGD             of the 15,983 leishmaniasis patients
veyed were offered free antileishma-       respondents, 21 (22%) said that a             treated at HNI clinics in 2003 were
nial treatment at the HealthNet            mother with leishmaniasis should not          women. Although women are at
International leishmaniasis clinics.       breast-feed her child; 48 (51%) of 94         greater risk for leishmaniasis, they do
    A total of 252 and 108 persons         FGD respondents would prevent                 not typically attend healthcare pro-
were surveyed in the HHS and FGDs,         someone with leishmaniasis from               grams in Afghanistan because of soci-
respectively, although not all respon-     touching or hugging their children; 55        ocultural constraints (e.g., husbands
dents answered every question. Our         (57%) of 96 respondents said that a           not allowing their wife or daughters to
study confirmed the prevalence of          person with leishmaniasis should not          attend) (6). In addition to diagnosing
cutaneous leishmaniasis in Kabul; 128      be allowed to cook for the family; and        and treating active cases, HealthNet
(51%) of 252 HHS respondents report-       21 (22%) of 94 respondents said that a        International will now focus on leish-
ed a family member with leishmania-        woman with a leishmaniasis lesion or          maniasis education activities in
sis. Respondents were knowledgeable        scar will have difficulty finding a hus-      Kabul, outlining aspects of disease
about leishmaniasis: of 360 total HHS      band. Severity and visibility of the          transmission and prevention, as well
and FGD respondents, 287 (80%) said        lesions as well as past experience of         as disseminating messages to reduce
that it was a disease, and 160 (44%)       leishmaniasis within the family influ-        the disease’s social impact.
said that it was acne. Of 66 FGD           enced respondents’ answers.
respondents who knew that leishmani-           The study yielded 2 other impor-          Acknowledgments
asis was a disease, 29 (44%) knew that     tant findings. First, 245 (97%) of 252             We are grateful for the logistical sup-
it was transmitted by mosquitoes. Of       HHS respondents knew that leishma-            port of the Afghan Ministry of Health in
104 FGD respondents, 41 (43%) could        niasis does not resolve without treat-        carrying out the survey and the support by
describe the clinical symptoms of          ment and that patients should seek            the European Union, the Gesellschaft für
leishmaniasis (each was asked to give      professional assistance. Of 344 HHS           Technische       Zusammenarbeit,         the
1 answer only), i.e., an open wound (n     and FGD respondents, 322 (94%) said           Norwegian Afghanistan Committee, the
= 17) that is not painful (n = 7) and      that leishmaniasis patients should            Dutch Government, Thermosurgery
takes a long time to cure (n = 17).        seek a doctor or clinic for treatment         Technologies Inc., The Leveen Family
    The principal finding of our study     (as opposed to a traditional healer or        Fund, the United Nations Aid Mission to
is that we show, for the first time, the   self-medication). Second, 205 (57%)           Afghanistan, and the World Health
extent of the disease’s social impact in   of 358 HHS and FGD respondents use            Organization for HNI’s Malaria and
Kabul. Because erroneous beliefs           methods to prevent exposure to sand-          Leishmaniasis Control Program.

                            Emerging Infectious Diseases • • Vol. 11, No. 4, April 2005                          635

      Richard Reithinger,*                         (MRSA) strains has been found              United States, Japan, and Europe, has
 Khoksar Aadil,* Jan Kolaczinski,*                 extensively in Japan (1), rarely in the    been found in 12% of Belgian hospi-
      Mohammad Mohsen,*                            United States (2), and, thus far, not in   tals during a national survey conduct-
       and Samad Hami*                             Europe.                                    ed in 2001 (6).
*HealthNet      International,     Peshawar,           We report a case of TSS due to an          The treatment included aggressive
Pakistan                                           MRSA strain that produced a TSS            intravenous fluid resuscitation,
                                                   toxin 1 (TSST-1). A 54-year-old            administration of dopamine, and
References                                         woman was admitted to the emer-            antimicrobial agent therapy with
 1. World Health Organization. Cutaneous           gency ward of Brugmann University          teicoplamin and clindamycin. The
    leishmaniasis, Afghanistan. Wkly Epidemiol     Hospital, Brussels, with a 2-day histo-    treatment outcome was favorable. On
    Rec. 2002;77:246.                              ry of myalgia, diarrhea, and vomiting.     the second day, a diffuse cutaneous
 2. Reithinger R, Mohsen M, Aadil K, Sidiqi
                                                   She had undergone surgery for a            macular rash appeared. The acute
    M, Erasmus P, Coleman PG. Anthroponotic
    cutaneous leishmaniasis, Kabul, Afghan-        palate neoplasia 2 months earlier, and     renal failure and the biological abnor-
    istan. Emerg Infect Dis. 2003;9:727–9.         again 2 weeks earlier, in another hos-     malities resolved. On the fifth day, the
 3. Reyburn H, Rowland M, Mohsen M, Khan           pital. After the second operation, she     patient was transferred back to the
    B, Davies CR. The prolonged epidemic of
                                                   had been treated for a local scar infec-   hospital where she had undergone sur-
    anthroponotic cutaneous leishmaniasis in
    Kabul, Afghanistan: “bringing down the         tion with amoxicillin–clavulanic acid      gery; extensive peeling then devel-
    neighbourhood.” Trans R Soc Trop Med           for 1 week.                                oped on both of the patient’s hands.
    Hyg. 2003;97:170–6.                                On physical examination, the               Our patient met the criteria of TSS:
 4. Rasekh Z, Bauer HM, Manos MM,
                                                   patient was conscious, tachypneic,         she had fever, rash, desquamation,
    Iacopino V. Women’s health and human
    rights in Afghanistan. JAMA. 1998;280:         pale, and sweating. Her temperature        hypotension, vomiting, diarrhea,
    449–55.                                        was 38.2°C and her blood pressure          myalgias, elevated creatine kinase,
 5. Trouiller P, Olliaro P, Torreele E, Orbinski   was 70/50 mm Hg. Abdominal exami-          acute renal failure, and thrombocy-
    J, Laing R, Ford N. Drug development for
                                                   nation findings were normal. The cuta-     topenia. The diagnosis of staphylo-
    neglected diseases: a deficient market and a
    public-health policy failure. Lancet.          neous operative wound was red and          coccal TSS was confirmed by bacteri-
    2002;359:2188–94.                              swollen. Laboratory results included       ologic results.
 6. van Egmond K, Naeem AJ, Verstraelen H,         the following: leukocyte count                 Although TSST-1 production by
    Bosmans M, Claeys P, Temmerman M.
                                                   19,830/mm³ with 97% polynuclear            MRSA strains has been described in
    Reproductive health in Afghanistan: results
    of a knowledge, attitudes and practices sur-   neutrophils, platelets 90,000/mm³, cre-    Europe (7), this case is the first of TSS
    vey among Afghan women in Kabul.               atinine 2.1 mg/dL, bicarbonate 13          due to TSST-1–producing MRSA in
    Disasters. 2004;28:269–82.                     mEq/L, cyclic AMP receptor protein         Europe. Recently Nathalie van der
                                                   43.7 ng/mL, creatine kinase 514 U/L.       Mee-Marquet et al. (8) described the
Address for correspondence: Richard
                                                   Cultures of blood, stool, and urine        first case of neonatal TSS–like exan-
Reithinger, 807 S Overlook Dr, Alexandria, VA
                                                   samples were negative for microbial        thematous disease due to a MRSA
22305, USA; email:
                                                   agents. Puncture of the wound              strain containing the TSST-1 gene in
                                                   released 12 mL of pus; culture of the      Europe. They emphasized the risk of
                                                   pus sample yielded an MRSA strain          emergence of neonatal toxic shock
                                                   harboring a TSST-1 gene, detected by       syndrome–like exanthematous dis-
                                                   multiplex polymerase chain reaction        ease outside Japan.
Methicillin-resistant                              as previously described (3).                   We would also like to emphasize
                                                       By molecular typing, the strain        the rising risk of TSS due to virulent
                                                   belonged to the epidemic MRSA              MRSA strains outside Japan and par-
aureus Toxic Shock                                 pulsed-field gel electrophoresis clone     ticularly in Europe. The usual recom-
     Syndrome                                      G10 and carried the staphylococcal         mendations for the treatment of
                                                   chromosome cassette mec (SCCmec)           staphylococcal TSS do not consider
   To the Editor: Toxic shock syn-                 type II. This clone belongs to the         this possibility and consist of a β-lac-
drome (TSS), which can be life threat-             sequence type (ST) 5-SCCmec II             tamase–resistant anti-staphylococcal
ening, is defined by clinical and labo-            clone, formerly named “New-                agent and clindamycin in some cases
ratory evidence of fever, rash, desqua-            York/Japan clone,” which has been          (to decrease the synthesis of TSST-1)
mation, hypotension, and multiple                  associated with neonatal TSS–like          (9–11).
organ failure caused by Staphylococ-               exanthematous disease in Japanese              We immediately treated our patient
cus aureus toxins. TSS caused                      hospitals (4–6). This epidemic clone,      with teicoplanin and clindamycin
by methicillin-resistant S. aureus                 which is widely disseminated in the        because we suspected a nosocomial

636                              Emerging Infectious Diseases • • Vol. 11, No. 4, April 2005

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