If someone you know and love, or if there is anyone you know who has a loved one serving in Iraq or Afghanistan, this is a MUST READ!! Please pass this information to the soldier or soldiers whose health may surely be affected by the pesky sand flies that are prevalent in that region of the world. We need to alert our troops as to how to protect themselves from this parasite. The health risks listed here are generalized (as there are many more potential complications possible that are not cited here) and the numbers of soldiers reported to be infected is understated. The numbers continue to escalate! The best protection is prevention, so please help us to get the word out. THANK YOU!
FORT DETRICK, Md. (Army News Service, March 4, 2004) -- A little-known parasite that causes chronic, festering sores will be returning home with some of Operation Iraqi Freedom's warfighters.

Cutaneous leishmaniasis, which affects the skin, is caused by a sand fly bite that deposits the parasite that eventually causes weeping sores that don't heal as quickly as regular sores.

"The majority of these are lesions on the face or on the hands over joints. So in the short term, it's just not pleasant to have a lesion that won't heal potentially for up to a year - -and some of these get quite large," said Lt. Col. Peter Weina, a "leish" expert at the Walter Reed Army Institute of Research. "In the long term, the problem is the scarring, which can be disfiguring if it's on the face and can limit movement of the hands if it's over a joint."

Iraq's sand flies are most active during warm nights from March to October, so troops on the move during Operation Iraqi Freedom were right in the middle of "Sand fly Central."

"In the march up to Baghdad, people would literally fall asleep on their HUMVEE or out in the middle of the desert, so we had enormous amounts of exposure in the evenings in areas where there were a lot of sand flies," said Col. Alan Magill, another of Walter Reed Army Institute of Research's experts on leishmaniasis.

Leish experts suspected the disease was going to be a problem for troops, but until Weina arrived in theater to serve with the 520th Theater Army Medical Laboratory, they didn't know just how big the problem was. Initially sent to look for weapons of mass destruction, Weina's team also looked for common diseases in the area, like leish, to see what risk they posed to warfighters.

By April 2003, fears were confirmed.

"We found sand flies in the area and started testing them and found some extraordinary infection rates in the flies," he said. "We expected to find maybe one tenth of one percent of the sand flies to be infected with leishmaniasis, and we were finding two percent of the sand flies were infected in some locations."

Finding that many infected sand flies meant a huge increase in the potential number of cases, so Weina and his team went into full prevention mode.

"We went to units and talked to everyone from the commander on down to the private. They needed to know that the best thing to do with this disease was to prevent getting it in the first place," he said. "We did everything from stand-up comic routines out in an opening in the middle of tents, all the way to full briefings in conference rooms."

Though travel was hazardous, Weina's message to the audiences he reached was simple: Wear DEET insect repellent so sand flies don't bite; use permethrin, a pesticide, on uniforms to keep sand flies away; and sleep under mosquito nets that have been treated with permethrin. The discovery of the leish problem coincided with the war, so getting the word out on the disease wasn't easy, Weina said.

"I tried to get the attention of the brass above me ... but their concerns weren't about the guys sleeping under bed nets but making sure they weren't going to get killed."

He and his team also talked to the medical professionals in the area so they'd be on the lookout for leish. "The problem is that some (lesions) look like any other type of sore that you may have with a bacterial infection, but they just don't get better," Weina said. "We treated with antibiotics first. Then if the antibiotics failed, we considered leishmaniasis."

So far, more than 500 cases of leishmaniasis have been diagnosed. Magill said he hedges when he's asked how many total cases to expect.

"The simple answer is: I don't know. But if you extrapolate, you're probably looking at the 750 to 1,250 range. It could be higher."

Because the disease is difficult to diagnose without a lab and experts equipped to look for it, all leish smears are currently sent to the Walter Reed Army Institute of Research for confirmation. The institute, in fact, has the only leishmaniasis lab in the country that is accredited by the College of American Pathologist and is operated in accordance with the Clinical Laboratory Improvement Act.

The ability to deliver a diagnosis lets the lab cross the boundary that typically exists between research and health care, Magill said. "Though the (institute's leishmaniasis) research program was eliminated (in 1996), the lab was maintained for just the scenario being played out today," he said.

Many of the leish researchers, like Weina and Magill, are also caregivers at the only U.S. military hospital where the treatment for leish can be offered, the Walter Reed Army Medical Center. Because the drug of choice used to treat the most severe cases was never submitted to the Food and Drug Administration for its approval, the drug must be offered as an investigational new drug, which means following strict research protocols and keeping meticulous records when the drug is given. The drug, sodium stibogluconate (Pentostam), is hardly "new," as it's been used for over 50 years to successfully treat leish.

Treatment typically consists of an outpatient regimen of receiving the drug intravenously daily for 20 days, though the type of leish acquired in Iraq, leishmaniasis major, responds in 10 days.

The volume of patients who need treatment has overwhelmed both the institute and the hospital named after Walter Reed, Weina said.

"This is really the largest outbreak in the history of the military since World War II. I know for a fact that Colonel (Naomi) Aronson (the doctor who kept the hospital's IND current) has brought her sleeping bag to her office so she can sleep there if she needs to," he said. "We've never been set up to be able to treat this many cases."

To put the current leish outbreak into perspective, Magill said that for Operations Desert Shield and Storm, the official number of leishmaniasis cases was 32.

"When you're treating 30 to 40 cases a year at the most, it's no big deal having the patients come to Walter Reed Army Medical Center to be treated," Weina said. "But having 400 in a couple of months, now there's a problem."

Weina and Magill are traveling to posts with large numbers of returning troops -- like Fort Campbell, Ky.; Fort Hood, Texas; and Fort Carson, Colo. -- to let the troops and the medical professionals there know what to look for.

"The only problem is, like with most of tropical medicine, the expertise to make the diagnosis is not well distributed. To physicians and lab technicians at Fort Campbell, this is not something many of them have seen in their entire careers," Magill said.

The leish experts are also looking at other treatment options for patients, including freezing the lesions or using a device that uses heat to kill the parasite.

"There's a good biologic rationale for it (heat therapy) to work and some data that we've seen that says it works, but we are reluctant to recommend a treatment when there's been no experience." Fifteen patients at Walter Reed are currently enrolled in a study see if the thermal device works, and results should be available by March.

At the hospital, Magill has seen patients who have more than 30 lesions, patients with lesions up to 3 inches in diameter and patients with nodular lesions that look like tumors. The good news, he said, is the lesions do heal, even without any treatment. The bad news is healing can take up to a year without effective treatment.

"In the natural history of these lesions, if you do nothing, even for the worst lesions, they will get better, he said. "But cosmetically this is very damaging. If you're walking around with some of these big lesions on your face, psychologically there's a big impact there. This is an operationally acquired disease, and it's our job to address that."

Treating the lesions is important to the troops and their families, Weina said.

"The American public sees Johnny come marching home from the war, and Mom and Dad aren't thrilled about this nasty weeping lesion that's on his face that might be there for a year. They want it to go away," he said. "Even though it's not contagious, it's still a stigmata that they'd rather not have."

(Editor's note: Karen Fleming-Michael is a staff writer for the Fort Detrick, Md., Standard newspaper.)

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