There is an enemy lurking in the grass and sands of Iraq, waiting to ambush unprotected U.S. and coalition soldiers and Marines. The weapon is biological; the delivery vehicle is the bite of a sand fly. The bite can cause open, weeping sores that can grow to the size of a half dollar. An infected sand fly spreads a fierce parasite. Doctors and scientists refer to the disease caused by the parasite as leishmaniasis. The soldiers call it "the Baghdad boil," and it poses a health risk to service members deployed there.
Leishmaniasis is a vector-borne disease that is caused by a parasite and spread by the bite of infected female phlebotomine sand flies. Most common is the skin form (cutaneous leishmaniasis), which can cause scar ring skin sores. The internal form (visceral leishmaniasis) affects internal organs, is the most serious form, and can be fatal if not treated early enough. Leishmaniasis is not the same disease as Sand fly Fever, which is also carried by sand flies.
Leishmaniasis is found in 88 tropical and subtropical countries around the world and in southern Europe. More than 90 percent of the world's cases of cutaneous leishmaniasis are in Afghanistan, Algeria, Brazil, Iran, Iraq, Peru, Saudi Arabia, and Syria. Sand fly transmission season in Iraq runs from April through November and peaks from August to October in Iraq and Afghanistan.
SIGNS AND SYMPTOMS
People with the skill form have one or more lasting skin sores where infected sand flies have fed. These sores usually form within a few weeks of a bite and can last for weeks or months. They usually do not respond to such treatments as antibiotics or creams.
The sores can change in size and appearance over time. They often end up looking a bit like a tiny volcano, with a raised edge and central crater. Scabs may develop; some have silvery scales around the outside. Some sores will heal by themselves, but may take months or even several years to heal. The sores can be painless or painful. Some people have swollen glands near the sores (for example, under the arm if sores are on the hand or arm).
People who have the internal form of leishmaniasis, a much rarer disease, usually have long-term fever, weight loss, and an enlarged spleen or liver. They usually get sick within months of the bite. The doctor may also notice abnormal lab results. Although the internal version can cause serious problems or hospitalization, it does not cause death in people with healthy immune systems who have practiced good nutrition.
As of December, DoD had reported 148 cases over the last two years among all the people who had deployed to Afghanistan and Iraq and throughout the entire Central Command area. Health officials expect these numbers to grow even higher because of the long incubation period, and because troops are headed into a new transmission season. Only one of the cases reported by DoD was the internal form, suffered by a member serving in Afghanistan. Both the skin and internal forms are found in Iraq.
Leishmaniasis is not spread from person to person. It is spread by the bite of infected sand flies. Sand flies get infected when they bite an infected animal (for example, a rat, dog or person). Sand flies do not make noise when they fly or jump, so people may not realize they are being bitten. Sand flies are very small and may be hard to see; they are only about one fourth the size of mosquitoes. Sand flies are most active from dusk to dawn. They are less active during the hottest times of the day.
The best way to prevent leishmaniasis is to prevent sand fly bites. There are no vaccines or pills to prevent it. To decrease your risk of being bitten, you should:
* Stay in air-conditioned tents from dusk to dawn when possible.
* Stay in well-screened tents if air-conditioned tents are not available.
* Wear long-sleeved shirts, long pants and socks when going outside.
* Tuck undershirts into pants and pants into boots.
* Apply insect repellent liberally on uncovered skin and under the ends of sleeves and pant legs. Repellents containing 35 percent concentrations of DEET are effective for about 4 hours. Repeat as directed.
* Spray clothing with permethrin-containing insecticides. Reapply every five washings.
* Use a fine-mesh bed net (at least 18 holes per inch) and tuck it under the mattress if sleeping in an area without air conditioned tents or proper screens. The bed net should be soaked or sprayed with permethrin because the sand flies are small enough to pass through even fine-mesh bed nets.
* Avoid dogs or rodents near sleeping areas.
* Avoid bivouacking under trees or near grasses. Sand flies find breezy, shadowy locations just as attractive as you might.
Although effective treatment is available, prevention remains the best option. Utilization of permethrin-impregnated uniforms, bednets, and topical application of Deet repellent are highly effective in reducing the risk of sand-fly bites.
While the infections caused by leishmaniasis can by cured, the parasite can persist. It is caused by obligate intracellular protozoa of the genus Leishmania. Because of this, leishmaniasis can also be spread by blood transfusions or infected needles. DoD has implemented one-year donor deferral on blood donations for military personnel having served in Iraq or Afghanistan to protect the military's blood supply. People who actually get the disease are permanently deferred.
Sources: Department of Defense Deployment Health Clinical Center; Air Force Institute for Operational Health, Risk Assessment Division (RSR); the Deployment Health Support Directorate; U.S. Army Center for Health Promotion and Preventive Medicine; Walter Reed Army Medical Center: and the Associated Press.
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