A NEGLECTED STIGMATISING DISEASE: Cutaneous leishmaniasis in ,

Chenery Ann E. Lim, MSF Quetta, Pakistan Cecilio L. Tan, MSF , Pakistan Maryam Urazgani, Benazir Bhutto Hosp in Quetta, Pakistan Koert Ritmeijer, MSF Amsterdam, The Netherlands Balochistan, Pakistan

 Volatile & unpredictable security context  Presence of vulnerable, marginalized & displaced populations  Decentralized Ministry of Health (MoH)  High morbidity & mortality especially in rural areas amongst women, infants & young children

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan CL: MSF in Quetta

Maternal and Child Health Clinic  Serves nomads and Afghan communities that have no access to health care

 Mariabad Hospital, OPD  Predominantly Hazara (Shia) population  Minority & persecuted group

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan Cutaneous leishmaniasis: “year-long blister”  Parasitic skin ulcerating disease  Two modes transmission:  Zoonotic - Leishmania major (rural areas)  Antrophonotic - Leishmania tropical  Vector: phlebotomous sandflies  Animal reservoir: rodents  Skin lesions usually located on the face & extremities  Lesions can cause scarring & deformities

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan Cutaneous leishmaniasis

 Self-limiting disease  Treatment indication:  Only 2% develop lesions  on the face  Most common in children  multiple lesions  over the joint  growing larger  more than 5-6 months

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan Methods: Program Description

Analysis of routinely collected program data (approved by MSF ethics review committee) Laboratory diagnosis by microscopic smear of skin lesion aspiration using G 19-22 needle (at times skin scrapings) Antimonial (glucantime) injection given intra-lesionally for single lesion Intramuscular injection given for multiple lesion, lesions on critical areas (near the eye, near the joints)

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan RESULTS: OVERALL

2013 2014

# Suspects diagnostically screened 525 1492

% suspects confirmed diagnosis 36.9% (194/525) 42.6% (636/1492)

# Patients started treatment 213 671

# Patients Discharged 200 560

Cure rates 97.5% (195/200) 97% (544/560)

Defaulter rates 2.5% (5/200) 2.9% (16/560)

Relapse rate ---- 4.2% (23/544)

ALL relapsed patients were re-started on treatment and discharged as cured.

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan Staff giving Intralesional Injection Ulcerative lesions on children

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan RESULTS: MARIABAD

 Duration of lesions BEFORE treatment: (n=450)  > 6-months = 40.2% (181)  3-5 months = 26.2% (118)  < 3-months = 33.6% (151)

 Type of lesions:  Multiple papular lesions = 45.6% (205)  Ulcerative & Nodular lesions = 54.4% (127 + 118)

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan MSF’s LIMITATIONS

 Drug importation: long admin process (6-months lead time) AND with possible further delays (customs regulations, new importation requirements, frequent changes of personnel, etc)  MSF is the only organization giving free treatment to C.L. patients in the country  ACCESS: by patients and/or MSF is limited due to security constraints (including sectarian violence)

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan MoH’s CHALLENGES

 CL SURVEILLANCE: no proper reporting  WHO Disease Early Warning System (DEWS): stopped due to funding constraints  POLITICAL WILL: low prioritization!!!  Local drug: expensive, also from black market – NO quality assurance  POOR CL AWARENESS

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan CONCLUSIONS

 CL data: Continue analyzing program data and share achievements & constraints  CL treatment can be integrated in OPD  MoH can lobby for CL treatment in region  Good collaboration with MoH is possible  Available treatment still effective: LOBBY to increase priority and budget allocations  Need to improve public awareness of CL in community

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan Acknowledgements: “SHUKRIA”

 Benazir Bhutto Hospital, Mariabad: Medical Superintendent & Staff  Kuchlak Maternal and Child Health Clinic  WHO Disease Early Warning System (DEWS) in Quetta  Ministry of Planning and Development

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan She is the “tree lady” - Child almost very happy with her finishing her Treatment as she can treatment now SMILE and have Confidence.

Chenery Ann Lim, MSF; A neglected stigmatising disease: cutaneous leishmaniasis in Pakistan, Balochistan