Assessment Report of CL Karak

1

Assessment Report of Cutaneous Leishmaniasis Outbreak in Khurram Village, District Karak, NWFP, March 2010

1

2

Name and positions of assessors:

Mohammad Kamal Project Manager (MLCP) Dr Farooq Resource Technical Officer Leishmaniasis (MLCP) Dr Ishaq Assistant Manager (Health) Sajid Kamal Resource Technical Officer Vector Control (MLCP) Nasim Khan Senior Microscopist (MLCP)

Maximum level of intervention: Short term

Date of assessment: 24-26 March 2010

Duration of assessment: One day

Acronyms and abbreviations

BHU Basic Health UnitCL Cutaneous LeishmaniasisDCO District Coordination OfficerDEWS Disease Early Warning SystemDG-H Director General HealthDSM District Support ManagerDHQ District Head QuarterDSU District Support UnitEDO-H Executive District OfficerFATA Federally Administered Tribal Agency IL Intra-lesionalIM Intra-muscular IRC International Rescue CommitteeITN Insecticide Treated NetMLCP Malaria and Leishmaniasis Control ProjectMO Medical OfficerNWFP North West Frontier ProvincePPHI Peoples, Primary Healthcare InitiativeWHO World Health Organization

2

3

Purpose of the assessment

To verify the reported Cutaneous Leishmaniasis (CL) cases in Khurram village and to determine the need for assistance to the affected people.

Scope of the assessment

The focus of the assessment was on magnitude of CL cases and their management.

Objectives of the assessment

To verify the reports of the outbreak of CL in Khurram village. To look at the capacity of local health staff with reference to the diagnosis and treatment

of CL and identify needs in building diagnosis, treatment and preventive capacity. To determine CL lesions with respect to treatment i.e. intra-lesional (IL), intramuscular

(IM), thermotherapy or no need for treatment and on spot theoretical training to Medical Officer (MO) and Paramedical staff of Khurram Basic Health Unit (BHU).

To visit the hot spot areas of CL patients seeking their treatment from Khurram BHU and the favorability of sites for vectors breading and resting.

Methodology and source of information used

Meetings with Executive District Officer Health (EDO-H) Karak, District Support Manager-Peoples, Primary Health Initiative DSM-PPHI, and Medical Officer (MO) and Paramedical staff of Khurram BHU were conducted in District Head Quarter Hospital, PPHI-DSU Office, Karak and BHU Khurram respectively to obtain the required information. All persons were very cooperative and provided the required information in detail with no hesitation.

Back ground

1. Cutaneous Leishmaniasis

Cutaneous Leishmaniasis (CL) is caused by the protozoa leishmania, which is transmitted by the bite of an infected female sand fly. There are about 1.5 million new cases of CL each year in the 88 countries where the disease is endemic, of which over 90% occur in Afghanistan, Iran, Iraq, Saudi Arabia, Syria, Brazil and Peru.However, CL often occurs in specific pockets – not only of place but also in time – for example Delhi boil affected 40,000 people in the early 1940s but is rarely seen in Delhi today.The geographical distribution of CL is mainly determined by the sand fly vectors (Phlebotomus sp and Lutzomyia sp). They live in dark, damp places, and are relatively weak flyers, with a range of only 50 meters from their breeding site. They are most active in the evening and at

3

4

night. Sand fly numbers are related to natural factors such as topography of the area and the environmental conditions like temperature, humidity, wind speed and rainfall.

Since the investigation of the first CL epidemic during 1997 in Taimergara, Afghan refugee camp of district Dir, North West Frontier Province where around 38% of the 9,200 Afghan refugee inhabitants bore active lesion and was associated with cross border movement between Afghanistan and Pakistan (Rowland et al., 1999), now CL is the major public health problem both, among Afghan refugees and local Pakistani population (Bhutto et al., 2003). Refugee camps in NWFP Pakistan are reporting cases of CL for the first time (UNHCR report, 1998). Similar outbreaks of CL were reported in the NWFP local population of Upper and Lower Dir (2008) and Nowshera districts (2009) where team of Malaria and Leishmaniasis Control Project (MLCP) of International Rescue Committee (IRC) made excellent job to control the diseases.

2. District Karak

District of the NWFP, Pakistan, situated to the south of Kohat and on the north side of Bannu and Lakki Marwat districts on the man Indus highway between Peshawar and Karachi. It is 123 Km from the provincial capital Peshawar. Since 1982 it has been an independent district with Karak its capital. District is predominately populated by Khattak tribe, one of the hard working and famous tribes of Pakistan. The district has total population of 536,000, of this 281,244 (52%) are male and 254,756 are female (48%). Growth rate is 4.26%. The population is mainly rural (86%). (Constituencies and MPAs- website of the provincial Assembly of the NWFP, 2002-2007).

Topography of Karak is the series of high and low mountains of salt range enter into Karak from Punjab. It is mostly arid and main source of crop is wheat. Source of irrigation is mostly rain and tube wells. Agriculture is the main source of living of people; gas has been recently discovered in Shakardara, Gurguri Makori and Nospa Banda areas. Seasonal River is present in tehsil Banda Daud Shah providing water to the nearby fields. It leaves stagnant water at the edges, full of green algae and vegetation, providing source of possible breading sites for malaria vectors. Administratively district Karak is subdivided into three tehsils, namely; Banda Daud Shah, Karak and Takht-e-Nasrati. Climate is very hot during the summer and sand storms are very common.

Findings of the assessment

Steps taken by other organizations before the assessment by MLCP-IRC

According to the report of PPHI-DSU on March 24, 2010 regarding the current CL outbreak and coordination meeting of MLCP-IRC technical experts with EDO-H and DSM-PPHI Karak, it was pointed out that the concerned MO (PPHI) declared an outbreak situation as total of 68 CL cases were registered at Khurram BHU, tehsil Banda Daud Shah on that date. Immediate correspondences were made by the PSU PPHI-NWFP/FATA with health department government of NWFP, District Coordination Officer (DCO) Karak, and Director General Health (DG) for

4

5

their collective efforts to cope with situation. Media also highlighted the case on 17 th of March. By the direction of EDO-H, DSM DSU PPHI arranged training on Disease Early Warning System (DEWS) for BHU staff. EDO-H arranged 250 Long Lasting Insecticide Nets (LLIN) for the affected people of the area. 119 bed nets were issued, one bed net /infected person till the visiting date. WHO recommended aerial spray (Fogging) for which PPHI provided 120 liters of fuel and insecticide was provided by provincial health department to start immediate action for vector control. One round of aerial spray was conducted in the affected area. (See picture No.6)

Steps taken by MLCP-IRC technical experts during assessment

Health Coordinator of IRC communicated EDO-H Karak for coordination meeting at DHQ hospital for 25 March 2010. During the meeting of MLCP-IRC technical team with EDO-H Karak and DSM-PPHI Karak, the EDO-H demanded for immediate help especially for the technical assistance like; training on case management and preventive measures to government health staff. He also strongly emphasized for arrangement of anti Leishmaniasis drugs as the district health department is lack of resources to arrange the medicines.

The technical team from MLCP-IRC, accompanied by Malaria Superintendent of DHQ Karak visited the affected village, Khurram and confirmed the reported cases through clinical diagnosis in BHU (see attached pictures). The village has a scattered population of about 15,000 of whom approximately 300 individuals are affected by CL till the reporting date. 140 cases of CL were registered in BHU Khurram, while according to the MO of concerned BHU about 160 cases left unregistered during the months of January and February. It was noticed that CL cases are not confined to that reported village but also prevail in the catchment population of RHC Sore Dag (about 15-20 Km south of Khurram), where 4-5 cases were also reported during last few days.

The MO in charge of the Khurram BHU was directed by EDO-H Karak to inform the affected people of the area to visit BHU for cases confirmation and relevant health massages by MLCP-IRC technical team. MLCP team was divided by the Project Manager, giving the relevant technical tasks to the concerned persons to ensure quick and effective assessment while the Project Manager supervises the whole processes.

1) Diagnosis and confirmation of CL Cases

The Leishmaniasis expert doctor diagnosed and confirmed the cases while Assistant Manager-Health recorded the cases by using the well designed proforma. MO and paramedical staff also attended the diagnosis and cases confirmation session, theoretical presentation of treatment procedures was also given on spot. The health staff was not aware of the proper treatment procedures. 32 patients of different ages and both the sexes were available in BHU for diagnosis and confirmation. Information was analyzed to see the different aspects of case load. It is interesting that 23 out of 32 (71.9%) were female while the rest 09 (28.1%) were male. This high

5

6

proportion of female’s patients presence may be attributed to the social stigma caused by CL and their reluctance to the unpleasant appearance (Table1). As out of total 140 cases registered at BHU, the proportion of female infection 80 (57%) was higher than male 60 (43%).

(Table.1) Age and sex wise CL cases attended Khurram BHU on 25/3/2010Age Groups (Years) Gender

Male Female Total1-4 2 (6.25) 1 (3.13) 3 (9.37)5-14 5 (15.63) 9 (28.13) 14 (43.75)>14 2 (6.25) 13 (40.63) 15 (46.88)

Total 9 (28.12) 23 (71.88) 32 (100)Note: Figures in parenthesis shows the percentage.

Consider the number of CL lesions, ranges from 1-5 per person. Among 32 patients 21 persons (65.62%) having single lesion, followed by 07 patients (21.88%) having two lesions, three persons having 03 (9.37%) lesions, while only one patient with 05 lesions (3.13%) on their body. (Table.2)

(Table.2) Number of CL lesions per personS.No. No. of Persons No. of CL lesions Percentage1 21 01 65.622 7 02 21.883 3 03 9.375 1 05 3.13Total 32 100.0

Considering the lesions duration, only one patient having lesion more than one year while rest of (31) patients having lesions with duration less than one year. Not a single patient slept under bed net during night when interviewed.

2) Community awareness session regarding preventive measures

A full session regarding the self prevention methods was conducted by the Senior Microscopist and Resource Vector Control Officer to the people visited the BHU (see photographs). It was emphasized that the disease is preventable and curable and the infected person should sleep under bed net during night to stop further transmission. All the persons (majority was women and children) took active participation during the session and showed well discipline.

3) Survey of disease hot spot

MLCP team also visited that portion of the village from where high case load was reported. Houses of the village are situated on the slope of mountain. Houses made of mud or breaks, with cracks in the walls, providing favorable resting sites for sand flies. Burrow pits and holes were also observed in the mountains of the area, which are dark, humid and provide suitable resting

6

7

sites for the vectors. Waste organic materials scatter in the village, providing breading sites for the vectors.

4) Cross checking of CL slides

Laboratory technician of DHQ hospital already took slides from four CL patients, but only one slide was available for cross checking. Senior Microscopist (MLCP) cross checked the slide, but the smear was taken from the blood while it should be taken from the serum or tissues.

Recommendation and Conclusion

To reduce the suffering of the affected population and minimize the risk of further transmission sufficient quantity of anti Leishmaniasis drug should be provided to the EDO-H Karak, because all the government health facilities lacking the anti- leishmanicide drug and full course treatment is too expensive for the poorest community to afford. The Leishmaniasis affects the world's poorest populations and it is estimated that 80% of CL patients earn less than $2 a day.

As Insecticide Treated Nets (ITNs) play a significant role in control of Leishmaniasis it would be better if more ITNs provided to the people of affected village because the case load is high and the community has received just 250 nets. Disease epidemiology shows distinct clustering of cases, so members of a household with one infected individual should be under bed net during night to prevent further transmission. The household trial in Kabul showed that permethrin treated nets reducing Cutaneous Leishmaniasis risk by 65% (Reyburn et al., 2000)

Prevention of spread of disease focuses on early treatment, personal protection and Public Health Awareness. Campaigns should be conducted in a coordinated fashion using a variety of media by enforcing the key messages like:

Leishmaniasis is transmitted by insects (Sand flies). Leishmaniasis is NOT transferable between people by the direct contact with

the diseased person and do not need to be isolated, kept away from school, or stigmatized.

The earlier treatment is sought the better – identify to the public what early stage lesions look like and advise to seek treatment.

Those with the disease should sleep under an ITN. Use of insect repellents.

Capacity of local health staff need to build up through workshops and trainings of various categories of the health staff which will help to resolve the problem in the long term. Training of health workers is the first step to be taken. Training should cover: Basic

7

8

leishmaniasis (i.e. disease etiology, epidemiology and transmission), diagnosis and treatment, prevention and control and public health awareness.

As majority of the patients have single or two lesions and can easily be treated by thermotherapy. It will be better if a thermotherapy machine is taken by loan from EDO-H Nowshera or FATA directorate by EDO-H Karak for at least one month and the Leishmaniasis Resource Technical officer (MLCP-IRC) conduct two days practical training on thermotherapy, intra-lesional and intramuscular treatment to the health staff of Karak. It is also estimated that anti Leishmaniasis drugs i.e. about 4000 ampoules of Glucantime OR 660 vials of Pentostam will be required to treat the patients of the affected area. (estimated cost for Glucantime ampoules = Rs One million)

At least three rounds of aerial spray at weekly intervals are needed to be conducted, as it has no residual effect and new emergence of adult vectors will become a problem.

For long term treatment one thermotherapy machine is required for Karak district which will be rotated within the district on need basis. (estimated cost of one thermotherapy machine is about Rs 250,0000

At last but very important; TECHNICAL SUPPORT SHOULD PROVIDED BY MLCP-IRC TECHNICAL EXPERTS AND ARRANGEMENT OF NECESSARY RESOURCES BY OTHER HEALTH RELATED ORGANIZATIONS TO COPE WITH THIS ALARMING SITUATION TO FULFILL THE MENDATE OF WHO- ALMATA DECLARATION 1978, AS HEALTH FOR ALL.

8

9

(Picture.1) Location of hot spot of CL cases in Khurram village.

9

10

(Picture.2) CL lesion on right leg of a male patient aged about 30 years.

10

11

(Picture.3) District Karak health staff conducting aerial spray in Khurram village.

11