Cutaneous Leishmaniasis, Northern Afghanistan

To the Editor: In Afghanistan, most cutaneous leishmaniasis cases are caused by Leishmania tropica, which is transmitted anthroponotical-ly by the sandfly Phlebotomus sergen-ti (1). Cutaneous leishmaniasis can have devastating effects on local communities because of its clinical symptoms , i.e., large, multiple, or both, disfiguring lesions, that can lead to social ostracism of affected persons (e.g., women are often deemed unsuitable for marriage or to raise children) (2). Cutaneous leishmaniasis is considered a low priority disease by international donor agencies because treatment costs are high and the disease does not cause death (3). Data on the effects of cutaneous leishmaniasis in Afghanistan previously have been available only for Kabul city; recent studies have reported an estimated 67,500 cases (4). Because of the migration of an estimated 4.5 million infected Afghan refugees returning home from other countries, the sporadic treatment of patients infected with cutaneous leish-maniasis, and limited control of the sandfly vector, L. tropica has spread to areas that were previously nonen-demic for the disease, e.g., northeastern Afghanistan. A survey in Faizabad city, Badakhshan Province, was conducted in June 2003 by HealthNet International to collect data on the impact of cutaneous leishmaniasis. Leishmaniasis in this region is transmitted from April to October. The city was divided into 10 districts, and 20 households were surveyed along a randomly chosen transect drawn from the center of each district. A team of experienced medical staff clinically diagnosed cutaneous leishmaniasis (based on the presence or absence of cutaneous leishmaniasis lesions or scars, number of lesions, date of lesion onset) in household members and interviewed them to collect demographic data (gender, age). Because of logistic constraints, para-sitologic diagnosis of cutaneous leish-maniasis lesions (i.e., microscopic examination or parasite culture) was not conducted. However, in Afghanistan, skin lesions attributed to causes other than cutaneous leishma-niasis are rare, and experience has shown that clinical diagnosis has a sensitivity and specificity of >80% and >90%, respectively (Reithinger et al., unpub. data). Written approval to conduct the study was obtained from the Ministry of Health. Informed consent was obtained from study participants ; all study participants with active cases of the disease were offered free anti-leishmanial treatment at the HealthNet International leishmaniasis clinic. had active cuta-neous leishmaniasis lesions or scars, respectively. Of those persons with cutaneous leishmaniasis lesions, the mean lesion number was 2.4 (range 1–14), the mean lesion size was 2.4 cm (range 1–5.5), and the mean lesion duration …