By Adeel Saeed
PESHAWAR, Nov 21 (APP): Hanzala Hamzullah, a middle-aged businessman with bulky appearance, considered an itching skin rash on toes of his right foot as a routine reaction to a mosquito bite, but extra swelling, severe pain and conversion of infected site into a fully blown up septic lesion, made him concerned about the affliction.
“Initially, I did self-medication by applying different skin ointments for treatment of the lesion, but the infection keeps on aggravating forcing me to consult a specialist dermatologist,” recalls Hanzala while speaking to APP at his shop in Peepal Mandi, city’s busiest market named after an oldest Banyan tree that was revered in past for its mythological connection with Lord Buddha.
Laboratory tests diagnosed cause of the painful lesion as Cutaneous Leshmanisis (CL) infection, a parasitic skin disease transmitted through the bite of sand fly. With face expression clearly reflecting ache he is enduring while removing blood stained gauze to uncover coin size skin ulcer, Hanzala complained that the infection started on August 5, 2021, and to date he has not recovered from this extremely agonizing illness, disallowing him to walk and even sleep properly.
Like Hanzala, thousands of victims pass through same critical phase of pain, sever stigma and psychological trauma due to this infectious disease which is registering surge in Northwestern region of the country near bordering areas with Afghanistan.
Zakia, 25, from Peshawar’s peripheries was also found very much concerned about permanent scare she has been faced with due to five months delay in treatment of infection because of her pregnancy. Holding a new born infant in her lap at Naseerullah Khan Memorial Hospital in Peshawar, the only specialized treatment center for Cutaneous Leishmenisis, Zakia told the news agency that she has shifted to her sister’s home located in proximity of the hospital for getting proper treatment to avoid lifelong disfigurement.
“Zakia got infected twice at hand and ankle in fourth month of her pregnancy and have to wait till delivery to start taking meglumine antimoniate, first line treatment for CL, but not suitable for pregnant women and people with cardiac issues,” informed Faqeer Hussain, Supervisor Leishmenisis treatment centre.
“Treatment for Zakia will continue for 28 days, but the lesions are likely to leave big scars probably physical disfigurement for which she would require to see a plastic surgeon,” whispered Faqeer Hussain to avoid hearing of his assessment by the patient. “Cutaneous Leishmanisis is a skin disease ranging from self-healing lesions to large skin ulcers and is caused by protozoan parasite of genus Leishmania transmitted through sand-fly, ” apprises Dr Akram Shah, a PhD scholar on Parasitology.
Based on epidemiology of the disease, it is divided into two forms, cutaneous leishmanisis which is both zoonotic including animal reservoir host in transmission and anthroponotic which is solely transmitted through infected humans. While the second and dangerous form is Visceral Leishmaniasis which is fatal but fortunately not widespread in the region, explains Dr. Akram.
He said that Lesishmanisis was earlier reported mostly in bordering areas of Pakistan and Afghanistan within proximity of refugees’ settlements. However, now it has become endemic in Pakistan due to mass movement and frequent border crossing, expanding infection range to other localities. In case of refugees influx due to changing political dynamics in Afghanistan can cause an impetus to already existing infectious diseases and raise public health concerns in Pakistan, he added.
Experts believed that increase in movement of people, climatic change, urbanization and deforestation are causing spread and surge in zoonotic and vector borne diseases like CL, Dengue, malaria, chikungunya, congo etc.
To substantiate this they gave example of dengue infection which within 27 years period since 1994 when the first case was reported is now occurring like an epidemic regularly on annual basis in three provinces except Baluchistan, affecting thousands of people.
“Pakistan is hosting 1.4 million registered Afghan refugees for the last four decades while an additional number of 850,000 of Afghan nationals are staying here as Afghan Citizens,” informed Qaiser Khan Afridi, Spokesman of UNHCR. “If restrictions lifted and refugees are allowed to cross border, a large influx is expected to arrive here due to economic hardship and harsh winter,” he added.
Considered as `Poor’s affliction’ because of its occurrence in rural and mostly slum dwellings, CL remained neglected by Health teams till 2018 when an outbreak of the disease causing large scale infection brought it into highlight. In 2018 around 28000 people got infected from CL in tribal region and adjacent southern districts of Khyber Pakhtunkhwa province.
The outbreak triggered preventive measures that helped in containing the disease by dropping cases of infection in Khyber Pakhtunkhwa gradually to 24,131 in 2019, 18,652 in 2020 and and 11,390 in ten months of 2021. In Baluchistan which is also affected from infection, cases are contained from 18,495 in 2019 to 13,457 in 2020. While in the current year a total of 9978 cases were registered till October 2021.
According to WHO’s Country Profile for Leishmenisis, Pakistan has registered about 16,648 cases in year 2015. While at global level, around 700,000 to one million cases occur annually. Medecines Sans Frontier (MSF), an international medical humanitarian association, which come for help of patients after outbreak of CL in 2018, has treated around 4946 patients during the year 2020 at its three centers established at Peshawar, Bannu and Quetta cities,” says Zahra Shoukat, Communication Officer MSF Pakistan. “MSF is offering free of cost services to the patients from southern districts of KP and Baluchistan where the disease is endemic,” Zahra added.
“In Pakistan, both Visceral and Cutaneous Leishmanisis are prevalent but the high burden of CL is found in the south-western province of Baluchistan and Khyber Pakhtunkhwa, located along the 2,600 kilometer long porous border with Afghanistan,” reveals a study published in Journal of Parasitology on August 6, 2021, titled `Systematic Review of Leishmenisis in Pakistan’.
“Leishmenisis is widening its horizons from endemic to non-endemic sites due to rapid urbanization, deforestation and large scale dispersion of the human population,” concurs Dr Nazma Habib Khan, a PhD on Leishminia Diagnostics from London School of Hygiene and Tropical Medicine who was also part of the three members’ team that conducted this study.
According to Dr. Qaiser Khan, Assistant Professor Zoology Department Peshawar University, Leishmenisis has become prevalent in the country after spreading from its pocketed ranges in bordering region. “We have around 17 to 18 species of sand fly and when it bites an infected person, the transmission cycle starts jumping from one human to another.”
Leishmenisis needs to be given due consideration by conducting research on breeding cycle of sand flies, vector biology, infection control measures and drugs used in treatment which are around 70 years old, he suggested.
He also recommended adopting `One Health’ approach, involving multiple sectors to work together to achieve better public health outcomes, for finding out all the characteristics of the disease through the involvement of epidemiologist, entomologists, microbiologists and ecologists as well.
Burden of disease is increasing in Baluchistan as Leishmenisis is reported in 17 out of total 33 districts, comments Dr Khalid Qumbarani, Programme Manager Vector Control Programme Baluchistan.
In an interview with APP, Dr. Khalid said our dependency is on WHO (World Health Organization) in obtaining injections which provides 5000 vials on yearly basis while we need 300,000 vials for treating 12000 registered and unregistered patients.
The Khyber Pakhtunkhwa government has purchased 170,000 vials from WHO for treatment of CL patients who are getting treatment in 71 centers set up in the province, informed Dr Rehman Afridi, Programme Manager, Integrated Vector Control Programme KP.
“WHO is providing injections for treatment of CL infection free of cost but in limited number due to its non availability in open market,” says Dr. Muhammad Babar Alam, Head WHO Sub-Office. He appreciated decision taken by the Khyber Pakhtunkhwa government of purchasing injection as per the increasing number of patients.
Dr. Babar agrees that refugees’ influx can raise risk of increase in infectious diseases because population density is major source of spillover of contagion.
The Integrated Disease Surveillance and Response System (IDSRS) has intensified vigilance at entry points after the outbreak of Covid-19 virus, informed Dr Bilal Ahmad, Programme Manager, (IDSRS) KP.
CL is included in the list of `Priority Diseases’ prepared by the IDSRS for keeping a vigil on its occurrence based on reports received on weekly basis from 1500 health units.
Public Health Department has realization that when migration takes place, it can bring different diseases along with them, but we are prepared to cope with any such situation, if the government allows entry of refugees to Pakistan, Dr Bilal added.