A new research out on Tuesday shows leishmaniasis– one of the world’s oldest infectious diseases is a growing health threat affecting impoverished communities. The disease, which claims around 40,000 lives annually, is the second-largest parasitic killer in the world after malaria.
What is leishmaniasis?
There are three main forms of leishmaniasis; cutaneous, visceral (or Kala-azar) and mucocutaneous.
Visceral (kala-azar) is characterised by high fever, substantial weight loss, swelling of the spleen and liver, and anemia. If left untreated, the disease can have a fatality rate as high as 100% within two years.
Cutaneous is the most prevalent form, causing ulcers on exposed areas, such as the face, arms and legs. These usually heal within a few months, leaving scars. Diffuse cutaneous leishmaniasis produces disseminated and chronic skin lesions resembling those of lepromatous leprosy. It is difficult to treat.
Mucocutaneous, found mainly in South America, invades the mucous membranes of the upper respiratory tract, causing gross mutilation by destroying soft tissues in the nose, mouth and throat and surrounding tissues.
The disease is usually characterised by large outbreaks in densely populated cities, especially in war and conflicts zones, refugee camps and in settings where there are large-scale migration of populations.
Climate change is increasing the range of insect vectors including sandflies which spread the disease, while the mass movement of people in endemic areas due to conflict, famine or drought is putting increasing numbers at risk. It is therefore unsurprising that the ongoing conflicts in Afghanistan, Syria and the Horn of Africa have all seen an increased incidence of leishmaniasis among those affected. A major barrier to the treatment of leishmaniases is that it is a low priority for governments and health authorities with limited budget and resources allocated to communities in areas where it is prevalent.
Apart from the physical effects, the disease also causes psychological and social stigma from the ulcers and scarring of cutaneous leishmaniasis (CL), which can lead to exclusion from society due to the mistaken belief that the disease is directly contagious
At a time when diseases such as Zika, Ebola, MERS and influenza epidemics have created worldwide awareness of the devastating impact that infectious diseases can have on communities ill equipped to deal with outbreaks, leishmaniasis is still very much a growing, but neglected disease.
What is the situation in India?
Over 90% of visceral leishmaniasis cases occur in six countries: Bangladesh, Brazil, Ethiopia, India, South Sudan and Sudan. Visceral leishmaniasis is an entirely treatable disease but if left untreated it is almost always fatal.
In India, MSF (Doctors Without Borders/Médecins Sans Frontières) has a treatment programme for those with leishmaniasis.
A new research called Leishmaniasis Gap Analysis Report and Action Plan, which was carried out in Albania, Jordan and Pakistan in 2015, shows despite its worldwide prevalence and disastrous impact on the lives of millions, leishmaniasis is still very much a growing, neglected disease, mainly affecting impoverished communities, living in poor conditions, without adequate access to shelter, healthcare and medication.
The analysis was carried out by regional disease surveillance networks SECID/SEEHN, MECIDS and Pak One Health supported by CORDS and funded by the Bill & Melinda Gates Foundation.
Leishmaniasis, one of the world’s oldest recorded diseases dating back to the 7th century BC, is an entirely treatable parasitic disease spread by female sandflies. Around 310,000,000 people are estimated to be at risk globally, with around 1.6 million new cases each year across 98 countries. The cutaneous form of the disease can lead to distressing and disfiguring skin ulcers and scarring, while visceral leishmaniasis, which affects organs such as the liver and spleen, is invariably fatal if not treated. Over 40,000 people die from the disease every year, making it the second-largest parasitic killer in the world after malaria.
The study attempts to improve the capacity for diagnosis, treatment and control of leishmaniasis and other vector borne diseases.
The research found that:
-leishmaniasis is highly correlated with poverty, malnutrition and other diseases which affect immunity, as well as factors such as crowded living conditions and poor sanitation.
-the real health burden of leishmaniasis remains largely unknown with only 600,000 of the estimated 1.6 million cases each year being diagnosed and treated. This is because those who are most affected are from marginalised communities in rural areas or urban slums, who are unable to seek medical attention because of cost and lack of access to treatment
-in the majority of cases leishmaniasis cannot be transmitted directly from an infected person or animal to another person. Rather it requires the presence of female sandfly vectors to spread the disease. It is not therefore a disease that is likely to spread in areas such as Western Europe, which generally lack sandflies and have healthy populations with good sanitation and access to high-quality healthcare.
-leishmaniasis has been ignored largely because of its association with poverty and the limited capacity of governments and aid agencies to deal with its complex epidemiology.
-it has also been a low priority for multinational pharmaceutical companies to invest in research to develop effective vaccines and therapies.
Prof Nigel Lightfoot CBE, Executive Director of CORDS Network said, "Our goal is to raise awareness about the millions of people suffering from leishmaniasis, and address barriers to its treatment and prevention. We need more action, more funding and a stronger political commitment to end the needless suffering of millions.
We believe a rapidly changing world demands a pro-active and systematic approach to addressing the various contributing factors to disease proliferation. Therefore, we advocate and support a co-ordinated One Health approach to interventions."
Social and psychological impact
Mothers with CL may refrain, or be prohibited, from touching their children; young women with disfiguring facial scars are often considered unsuitable for marriage and the disease may provide the pretext for a husband to abandon a wife. Children with the condition can miss out on their education because of concerns that they may infect others at their schools.
Key findings by country
Albania
In Albania, visceral leishmaniasis (VL) remains predominantly a paediatric disease in impoverished rural communities. 80% of new cases are detected in children under 10. The incidence of VL in Albania remains the highest in Europe.
Between 2000 – 2014 there have been a total of 1368 cases, 956 of whom are children from 1-14 years.
In Albania, VL is a zoonotic disease with dogs acting as reservoir hosts in infected areas. Breaking the cycle of human infection therefore requires effective control of the disease in dogs.
Jordan
Zoonotic CL (ZCL) is the predominant form of the disease and is mostly confined to the Jordan Valley where rodents act as a wildlife reservoir. Patients often initially resort to ineffective traditional remedies leading to delays in seeking medical treatment. This results in an increased risk of residual scarring and disfigurement.
Jordan, like Lebanon and Turkey, which also host large numbers of Syrian refugees, is at significant risk of anthroponotic cutaneous leishmaniasis (ACL) becoming established, firstly among the impoverished refugee populations and subsequently in host communities. ACL does not require a reservoir host and can therefore become established in urban environments.
Pakistan
There are an estimated 50,000 new cases of cutaneous leishmaniasis (CL), the predominant form of leishmaniasis in Pakistan, each year. It is an emerging disease, initially prevalent in refugee communities from Afghanistan, which has also become established in host communities in Balochistan and elsewhere in north-west Pakistan.
A key problem in Pakistan is a lack of access to low cost, quality assured drugs to treat the condition, particularly in deprived communities. This has resulted in a market for counterfeit and smuggled drugs of dubious quality, which can have harmful impacts on those being treated.
A One Health Approach
Co-ordinated efforts are needed to raise awareness and interest, as a critical step in addressing the major gaps identified in the treatment and prevention of this and similar vector-borne diseases.
One area that urgently needs to be addressed is for governments in Albania, Pakistan, Jordan and other affected countries to change their regulations to enable the registration and importation of anti-leishmanial drugs into their countries.
In Pakistan there is also an urgent need to build corresponding capacities (skills, services, equipment and drug supplies) to improve detection and response to vector-borne diseases.
In Albania, we will focus on the prevalence of leishmaniasis in children in poor, rural areas and the need to develop programmes that both treat carriers (dogs) as well as treating those with the condition.
In Jordan, the focus should be on the significant risk of ACL (anthroponotic cutaneous leishmaniasis) becoming established in refugee and host communities and innovative approaches working with schools to spread awareness and identify those needing treatment
We need a One Health Framework that delivers:
-increased awareness of the various forms of leishmaniasis (amongst governments, health organisations and the public in affected areas)
-better co-ordination between governments, animal and human health organisations and NGO’s
-better and more sustainable access to diagnostics, treatment and medication
-more affordable treatment available in communities where leishmaniasis is most prevalent
-a proactive programme for vectors and reservoir hosts carrying leishmaniasis in affected areas
-funding and government buy in is needed to implement the report recommendations
to help halt the spread of this treatable condition which has such a terrible impact on the health of marginalised populations in affected countries.
"We have set out what the countries would like to happen and are prepared to do to alleviate the suffering. However, the policy changes and initiatives highlighted will need more funding and government commitment for this to happen. This is the beginning of our journey to tackling this growing infectious disease, which has had such a disastrous impact on the lives of so many. The time for action is now," Prof Nigel added.