LeishmaniasisLeishmaniasis

December 11th, 2003December 11th, 2003

Kirt P. LoveKirt P. Love

Director, DSBRDirector, DSBR

Contamination of AmericanContamination of American

Blood supply, Gulf War I & II.Blood supply, Gulf War I & II.

                                                           

                     

IntroductionIntroduction

The 1990 -1991 Gulf War conflict was fought primarily during the winter season, so the issueof Sand Fly exposure was minimal. Still, whathas been overlooked by the military medical monitoring was that Leishmaniasis also flourishesin wet pools, and then burrows into the feet oftheir host.

DHSD – WRAMC - DHSD – WRAMC - DHCCDHCC

Our organization met with the Our organization met with the

Pentagons Deployment Health Pentagons Deployment Health

Support Directorate on the Support Directorate on the

medical fate or troops medical fate or troops

Deploying to Iraq in 2002.Deploying to Iraq in 2002.

September – December 2002

DHSD – WRAMC - DHSD – WRAMC - DHCCDHCC

Mike Kilpatrick of DHSDMike Kilpatrick of DHSD

stated that the indecisive stated that the indecisive PCRPCR

test for Leishmaniasis stilltest for Leishmaniasis still

needed work, and wasn’tneeded work, and wasn’t

reliable.reliable.

September – December 2002

Cutaneous vs L. Cutaneous vs L. TropicaTropica

Even though a directive was sent outEven though a directive was sent out

by the by the Army Surgeon GeneralArmy Surgeon General on on

December 23December 23rdrd, 2002 to monitor, 2002 to monitor

Leishmaniasis during the present War.Leishmaniasis during the present War.

Diagnosis in the feild was exclusively Diagnosis in the feild was exclusively visualvisual

observation for lesions. PCR labs or observation for lesions. PCR labs or SplenicSplenic

asparate / Bone marrow were not asparate / Bone marrow were not availableavailable

in the desert for non-visual symptoms.in the desert for non-visual symptoms.

UNICEF - UNICEF - OutbreakOutbreak

Outbreak of Kala-Azar (Visceral Leishmaniasis) in IraqOutbreak of Kala-Azar (Visceral Leishmaniasis) in Iraq

UNICEF has announced an outbreak of Kala-Azar (Visceral Leishmaniasis) inUNICEF has announced an outbreak of Kala-Azar (Visceral Leishmaniasis) inIraq. Though there have been outbreaks of the disease in Iraq in the pastIraq. Though there have been outbreaks of the disease in Iraq in the past around this time of year, it is particularly severe this time.around this time of year, it is particularly severe this time.

There are now more than 200 cases of Kala-Azar reported in Iraq. TheThere are now more than 200 cases of Kala-Azar reported in Iraq. The country does see regular outbreaks of the disease.country does see regular outbreaks of the disease. UNICEF has warned that this time the outbreak could be severe.UNICEF has warned that this time the outbreak could be severe.

Kala-Azar is spread mainly by sand flies and causes malnutrition andKala-Azar is spread mainly by sand flies and causes malnutrition and anaemia. When left untreated, the disease is fatal within 4 to 6 weeks.anaemia. When left untreated, the disease is fatal within 4 to 6 weeks.

[Byline: Kamini Sawhney (Baghdad)][Byline: Kamini Sawhney (Baghdad)]

Thu 29 May 2003

                                             

PL 105-85, & PL 105-85, & monitoringmonitoring

Pre and Post deployment medical tracking ofPre and Post deployment medical tracking of

the troops in Afghanistan and Iraq were the troops in Afghanistan and Iraq were hastilyhastily

done. So many did not give blood samplesdone. So many did not give blood samples

before leaving, stored by the AFIP.before leaving, stored by the AFIP.

PL 105-85, & PL 105-85, & monitoringmonitoring

That blood taken before and after is strictly That blood taken before and after is strictly HIVHIV

testing, and is not used for other test. Thetesting, and is not used for other test. The

Naval Research Medical Center, and othersNaval Research Medical Center, and others

have used it for limited recent studies, but it ishave used it for limited recent studies, but it is

still strictly a military medical operation. still strictly a military medical operation.

Civilian monitoringCivilian monitoring

American Physicians are not ready for this Exotic American Physicians are not ready for this Exotic Endemic disorder, and will miss cases having little Endemic disorder, and will miss cases having little previous experience.previous experience.

September 12th 2003, September 12th 2003, William WinkenwerderWilliam Winkenwerder::Under Secretary for Health, Veteran AffairsUnder Secretary for Health, Veteran AffairsMemorandum to Joint Chiefs of Staff, LeishmaniasisMemorandum to Joint Chiefs of Staff, Leishmaniasis

“It is also possible that deployed personnel may re-deploy without knowing they are infected”

MonitoringMonitoring

USA TODAY December 4, 2003

Coleman and Army Lt. Col. Peter Weina, a leishmaniasisColeman and Army Lt. Col. Peter Weina, a leishmaniasis

expert still in Iraq, predicted in April that there would be 400expert still in Iraq, predicted in April that there would be 400

cases, based on the number of bites seen and tests that showcases, based on the number of bites seen and tests that show

about one out of 70 sand flies carries the bug.about one out of 70 sand flies carries the bug.

New York Times - December 6, 2003

Dr. Coleman found soldiers who got Dr. Coleman found soldiers who got more than 200 bites in a single night.more than 200 bites in a single night.

Major vs TropicaMajor vs Tropica

L Major - 1,500,00 cases world wide each year

L Tropica - 500,00 cases world wide each year

L. donovani L. mexicana L. tropica L. major L. aethiopeca

The Pentagon recognizes 12 cases of L. Tropica from the 1991 Gulf War, and 20 cases of L. Major.

The Pentagon is also trying to say there is almost no L. Tropica present in Iraq. WRAMC goes as far as to imply the Iraqi L. Tropica is less virulent.

ELISA / PCRELISA / PCR

Current ELISA accuracy is still between 32%Current ELISA accuracy is still between 32%to 67% with 3 part control under ideal conditions.to 67% with 3 part control under ideal conditions.Visceral tissue biopsies are only good after infectionVisceral tissue biopsies are only good after infectionis severe to terminal. is severe to terminal.

Institute of Microbiology and Hygiene, Humboldt University, Charite, Berlin, Germany.

113 cases (69.7%) were positive by PCR

Sept 2003Sept 2003

Visceral Visceral untreateduntreated

Office of Clinical and Regulatory Affairs,Office of Clinical and Regulatory Affairs,

National Center For Complementary andNational Center For Complementary and

Alternative Medicine, National Institutes ofAlternative Medicine, National Institutes of

HealthHealth

““visceral disease is incurable if untreated.”visceral disease is incurable if untreated.”

TreatmentsTreatments

Drug of Choice:

Amphotericin B,Streptomyces nodosus (photo sensitive – 4 to 6times a day ) $48.60 500mg

Not as effective withVisceral:Pentostam - Diflucan

100 MG 50 TAB $300.00

Alternatives:

Fluconazole

100 MG 50 TAB $300.00

Miltefosine (Impavido®)

$32.00 100 mg

Too Expensive!!

IncubationIncubation

With no compulsary reporting of Leishmaniasis around the world, It is still undetermined what long term incubations could remain in remission until turning visceral. One case at WRAMC showed 43 years after a old cutaneous scar was irritated, the case developed to visceral.

SummarySummary

With DOD unable to track this, or unwilling to pay for expensive advanced labs – there is no way of knowing for sure how many troops coming home will be infected or with what strain.

Until the lab detection procedures are 100% conclusive,and species specific – isnt the risk of Leishmaniasis to the general public from the troops too high.

RecommendatioRecommendationsns

With undetermined long term latency for Leishmaniasis( Tropica )and the uncertainty of today’s labs, we at DSBR recommend to the FDA a permanent blood ban on all troops coming home From Iraq, Afghanistan from 1990 to present.

At a minimum the soldiers blood should not be used inVat blood products, or plasma serum based products.