LETTERS

Cutaneous cutaneous leishmaniasis lesions or lence of scars, compared to the high scars, number of lesions, date of prevalence of disease, shows that Leishmaniasis, lesion onset) in household members cutaneous leishmaniasis has been Northern and interviewed them to collect introduced into Faizabad only recent- Afghanistan demographic data (gender, age). ly (1,4). Local Ministry of Health Because of logistic constraints, para- records show that the disease was vir- To the Editor: In Afghanistan, sitologic diagnosis of cutaneous leish- tually absent (<50 annual cases) in most cutaneous leishmaniasis cases maniasis lesions (i.e., microscopic Badakhshan 3 years ago; this infor- are caused by Leishmania tropica, examination or parasite culture) was mation is corroborated by the obser- which is transmitted anthroponotical- not conducted. However, in vation that the mean time since the ly by the sandfly Phlebotomus sergen- Afghanistan, skin lesions attributed to recovery of surveyed people with ti (1). Cutaneous leishmaniasis can causes other than cutaneous leishma- cutaneous leishmaniasis scars was 1.5 have devastating effects on local com- niasis are rare, and experience has years (range 0.3–15). Although no munities because of its clinical symp- shown that clinical diagnosis has a attempts were made to identify circu- toms, i.e., large, multiple, or both, dis- sensitivity and specificity of >80% lating Leishmania sp., the current epi- figuring lesions, that can lead to social and >90%, respectively (Reithinger et demic is likely caused by L. tropica ostracism of affected persons (e.g., al., unpub. data). Written approval to because both men and women are women are often deemed unsuitable conduct the study was obtained from equally affected and younger age for marriage or to raise children) (2). the Ministry of Health. Informed con- groups are at higher risk for cutaneous Cutaneous leishmaniasis is consid- sent was obtained from study partici- leishmaniasis than older age groups ered a low priority disease by interna- pants; all study participants with (1,4). Current analyses are under way tional donor agencies because treat- active cases of the disease were to establish risk factors (e.g., presence ment costs are high and the disease offered free anti-leishmanial treat- or absence of animals, type of house does not cause death (3). ment at the HealthNet International construction) for contracting the dis- Data on the effects of cutaneous leishmaniasis clinic. ease. leishmaniasis in Afghanistan previ- We surveyed 1,832 people from With support from HealthNet ously have been available only for 200 households; 8.3% (152/1,832) International, three leishmaniasis clin- Kabul city; recent studies have report- and 7.8% (142/1,832) had active cuta- ics have been established in Faizabad ed an estimated 67,500 cases (4). neous leishmaniasis lesions or scars, to increase the total number of Because of the migration of an esti- respectively. Of those persons with patients whose illness is diagnosed mated 4.5 million infected Afghan cutaneous leishmaniasis lesions, the and treated; to reduce the risk to sus- refugees returning home from other mean lesion number was 2.4 (range ceptible persons through the subsi- countries, the sporadic treatment of 1–14), the mean lesion size was 2.4 dized sale of insecticide-impregnated patients infected with cutaneous leish- cm (range 1–5.5), and the mean lesion bed nets; to train and supervise the maniasis, and limited control of the duration (to survey date) was 5.6 Ministry of Health staff in diagnosis, sandfly vector, L. tropica has spread months (range 1–11). Active preva- treatment, and prevention of the dis- to areas that were previously nonen- lence was not associated with gender ease; and to implement health educa- demic for the disease, e.g., northeast- (Yates-corrected χ2 = 2.16, p = 0.14); tion campaigns for patients attending ern Afghanistan. 85/152 (56%) of the cutaneous leish- the clinics and the community at A survey in Faizabad city, maniasis case-patients were women, large. Hopefully, these activities will Badakhshan Province, was conducted and 67/152 (44%) of cutaneous leish- prevent the current cutaneous leish- in June 2003 by HealthNet maniasis case-patients were men. maniasis outbreak from becoming an International to collect data on the Data showed that persons aged ≤15 epidemic, as it has been in Kabul over impact of cutaneous leishmaniasis. years were at higher risk of contract- the past 15 years (4,5). Leishmaniasis in this region is trans- ing the disease than were persons mitted from April to October. The city aged >15 years (odds ratio = 2.23, Acknowledgments was divided into 10 districts, and 20 95% CI 1.54 to 3.24, Yates-corrected We thank the Afghan Ministry of households were surveyed along a χ2 = 19.44, p < 0.001). Health and the HealthNet International randomly chosen transect drawn from Based on population estimates of survey team staff for logistical support. the center of each district. A team of 65,000 people and observed preva- This study was supported by the experienced medical staff clinically lence, approximately 5,395 cutaneous United Nations Mission to Afghanistan. diagnosed cutaneous leishmaniasis leishmaniasis case-patients would be (based on the presence or absence of found in Faizabad. The low preva-

966 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 10, No. 5, May 2004 LETTERS

Richard Reithinger,*† domestic and wild animals that also products obtained by PCR with Khoksar Aadil,† Samad Hami,† feeds readily on people. Recent stud- primers for the 17-kDa protein (4), and Jan Kolaczinski*† ies have implicated the cat flea as a citrate synthase (4), and PS 120 pro- *London School of Hygiene and Tropical vector of new and emerging infectious tein (5) genes. R. felis has been estab- Medicine, London, United Kingdom; and diseases (1). To determine the lished in tissue culture (XTC-2 and †HealthNet International, Peshawar, pathogens in C. felis in New Zealand, Vero cells) (6), and serologic testing Pakistan we collected 3 cat fleas from each of has been used to diagnose infections 11 dogs and 21 cats at the Massey (5). Reports indicate that patients References University Veterinary Teaching respond rapidly to doxycycline thera- 1. Ashford R, Kohestany K, Karimzad M. Hospital from May to June 2003. The py (5), and in vitro studies have Cutaneous leishmaniasis in Kabul: observa- fleas were stored in 95% alcohol until shown the organism is susceptible to tions on a prolonged epidemic. Ann Trop Med Parasitol 1992;86:361–71. they were identified by using morpho- rifampin, thiamphenicol, and fluoro- 2. Griffiths WDA. Old World cutaneous leish- logic criteria and washed in sterile quinolones. maniasis. In: Peters W, Killick-Kendrick R, phosphate-buffered saline. The DNA B. henselae is an agent of cat- editors. The leishmaniases in biology and from each flea was extracted individ- scratch disease, bacillary angiomato- medicine. London: Academic Press; 1987. p. 617–43. ually by using the QiaAmp Tissue Kit sis, bacillary peliosis, endocarditis, 3. Trouiller P, Torreele E, Olliaro P, White N, (QIAGEN Ltd., Hilden, Germany), bacteremia, and various neurologic Foster S, Wirth D, et al. Drugs for neglect- according to the manufacturer’s and ocular conditions. Cats are the ed diseases: a failure of the market and a instructions. When polymerase chain reservoir hosts, and contact with cats public health failure? Trop Med Int Health 2001;6:945–51. reaction (PCR) was performed with and their fleas is an established risk 4. Reithinger R, Mohsen M, Aadil K, Sidiqi primers for gltA and rOmpAas factor for most infections. Although M, Erasmus P, Coleman PG. The burden of described (2), products were obtained B. henselae has been isolated from anthroponotic cutaneous leishmaniasis in with DNA from 15 (15%) of the fleas. 17% of domestic cats in New Zealand Kabul, Afghanistan. Emerg Infect Dis 2003;9:727–9. The sequences of the products were (7), only two human infections have 5. Reyburn H, Rowland M, Mohsen M, Khan identical to those of Rickettsia felis been reported in the country; neurore- B, Davies CR. The prolonged epidemic of (GenBank AF191026) with infected tinitis was diagnosed in both patients anthroponotic cutaneous leishmaniasis in fleas taken from both dogs (3/11; (8). In neighboring Australia, howev- Kabul, Afghanistan: “bringing down the neighbourhood.” Trans R Soc Trop Med 27%) and cats (7/21; 33%). When er, cat-scratch disease, bacillary Hyg 2003;97,170–6. PCR was performed with primers for angiomatosis, and endocarditis have the 16S-23S rDNA interspacer region been diagnosed in numerous patients. Address for correspondence: Richard as described (3), products were Cats are also the reservoir hosts of B. Reithinger, Disease Control and Vector Biology obtained with DNA of four fleas. The clarridgeiae which has been implicat- Unit, Department of Infectious and Tropical sequences of the products from three ed as an agent of cat-scratch disease in Medicine, London School of Hygiene and fleas (from two cats) were identical to humans and aortic valve endocarditis Tropical Medicine, Keppel Street, London that of Bartonella henselae (GenBank and hepatic disease in dogs (9). The WC1E 7HT, UK; fax: +44 207 927 2164; AF312495), and the sequence of the organism has been found in cat fleas email: [email protected] product of one flea (from a cat) was (as great as 17%) in Europe (1), and identical to that of B. clarridgeiae although we found only one flea (GenBank AF167989). infected with B. clarridgeiae in New Our study is the first to identify R. Zealand, this description is the first of felis in Oceania. The organism is a the organism in Oceania. However, B. Rickettsia felis, recently described human pathogen, clarridgeiae has been found in and infections with this spotted fever domestic cats in nearby Indonesia and Bartonella group rickettsia have already been the Philippines (10). henselae, and reported in 11 persons: 4 persons in Our findings add to the accumulat- B. clarridgeiae, the United States, 2 persons in Brazil, ing data on R. felis, B. henselae, and 4 persons in Europe, and 1 person in B. clarridgeiae and should alert med- New Zealand Thailand. The symptoms of the ical workers in New Zealand, a com- To the Editor: The cat flea patients were nonspecific and includ- mon tourist destination, to the possi- (Ctenocephalides felis felis Bouché, ed fever, headache, and rash. bility that their patients may be infect- 1935) is a ubiquitous parasite of Diagnoses were made by sequencing ed with these organisms.

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