Manual for case management of cutaneous leishmaniasis in the

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Manual for case management of cutaneous leishmaniasis in the

Transcript Of Manual for case management of cutaneous leishmaniasis in the

WHO Regional Publications, Eastern Mediterranean Series

35

Manual for case management of cutaneous leishmaniasis in the WHO Eastern Mediterranean Region

WHO Regional Publications, Eastern Mediterranean Series

35

Manual for case management of cutaneous leishmaniasis in the WHO Eastern Mediterranean Region

WHO Library Cataloguing in Publication Data World Health Organization. Regional Office for the Eastern Mediterranean
Manual for case management of cutaneous leishmaniasis in the WHO Eastern Mediterranean Region / World Health Organization. Regional Office for the Eastern Mediterranean
p. .- (WHO Regional Publications, Eastern Mediterranean Series; 35) ISBN: 978-92-9021-945-3 ISBN: 978-92-9021-946-0 (online) ISSN : 1020-041X 1. Leishmaniasis, Cutaneous - prevention & control 2. Leishmaniasis, Cutaneous – epidemiology - Eastern Mediterranean Region 3. Leishmaniasis, Cutaneous – transmission 4. Leishmaniasis, Cutaneous – therapy I.Title II. Regional Office for the Eastern Mediterranean III. Series
(NLM Classification:WR 350)
© World Health Organization 2014 All rights reserved.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Publications of the World Health Organization can be obtained from Knowledge Sharing and Production, World Health Organization, Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371, Egypt (tel: +202 2670 2535, fax: +202 2670 2492; email: [email protected] who.int). Requests for permission to reproduce, in part or in whole, or to translate publications of WHO Regional Office for the Eastern Mediterranean – whether for sale or for noncommercial distribution – should be addressed to WHO Regional Office for the Eastern Mediterranean, at the above address: email: [email protected] Design, layout and printing by WHO Regional Office for the Eastern Mediterranean, Cairo, Egypt

Contents
Foreword......................................................................................................... 5
Acknowledgements........................................................................................ 6
1. Introduction............................................................................................ 7 Cutaneous leishmaniasis: an important health problem................................................... 7 Purpose of this document....................................................................................................... 7
2. Epidemiology.......................................................................................... 9 Cutaneous leishmaniasis in the world.................................................................................. 9 Cutaneous leishmaniasis in the Region................................................................................ 9
3. Parasitology..........................................................................................10 The parasite..............................................................................................................................10 The vector................................................................................................................................10 The reservoirs.........................................................................................................................10 Transmission of leishmaniasis...............................................................................................10
4. Clinical examination to identify skin lesions suggestive of cutaneous leishmaniasis..................................................................13 Typical lesions: initial history and constant signs..............................................................13 Variable features and unusual forms...................................................................................13 Rare forms................................................................................................................................14
5. Parasitological diagnosis......................................................................16 Skin sampling............................................................................................................................17 Visualizing parasites or parasite components...................................................................17 Determination of Leishmania species..................................................................................18 Summary................................................................................................................................... 18
6. Treatment.............................................................................................19 Situation 1.................................................................................................................................21 Situation 2.................................................................................................................................22 Situation 3.................................................................................................................................23 Potential allergies and how to address them....................................................................23
7. Monitoring and evaluation..................................................................25

8. Annexes.................................................................................................27
Annex 1.WHO case definitions..........................................................................................27 Annex 2. Standard operating procedure for parasitological diagnosis.................................................................................................................................... 28 Annex 3. Standard operating procedure for cryotherapy and intralesional injection of antimony..............................................................................30 Annex 4: Standard operating procedure for thermotherapy........................................32 Annex 5. Systemic treatment of cutaneous leishmaniasis with pentavalent antimonials..........................................................................................................33 Annex 6: Leishmaniasis medical record (patient’s file)...................................................39 Annex 7. Monthly report forms...........................................................................................43

Foreword
Cutaneous leishmaniasis is a complex entity representing a major public health problem in the WHO Eastern Mediterranean Region. Several epidemiological, parasitological and clinical aspects pose a challenge for the management and control of the disease. The Manual for case management of cutaneous leishmaniasis in the WHO Eastern Mediterranean Region addresses a crucial and sensitive aspect of the control of the disease: the treatment of patients. At the global and regional level, resolutions were endorsed in 2007 on the control of leishmaniasis by the World Health Assembly (WHA60.13) and on neglected tropical diseases by the WHO Regional Committee for the Eastern Mediterranean (EM/RC54/R.3). These resolutions called for necessary guidelines on prevention and management to support Member States in establishing systems for surveillance, data collection and analysis, as well as strengthening active detection and treatment of cases. This publication represents a key step forward in translating Control of the leishmaniases (WHO Technical Report Series, No. 949) into a more practical tool for health personnel directly involved in the case management of cutaneous leishmaniasis. With this manual, countries will have, for the first time, standardized diagnosis and treatment protocols, case definitions and indicators to enable them to easily track progress on cutaneous leishmaniasis case management across the Region. It will provide support to professionals in charge of cutaneous leishmaniasis, in order to alleviate the suffering of affected populations from this appalling disfiguring and stigmatizing neglected tropical disease.
Ala Alwan WHO Regional Director for the Eastern Mediterranean
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Manual for case management of cutaneous leishmaniasis
Acknowledgements
This manual was prepared by Pierre Buffet and Gloria Morizot, Pasteur Institute, France, Lama Jalouk, consultant, Syrian Arab Republic and Mourad Mokni, consultant, Tunisia. Badderedin Annajar, Ministry of Health, Libya and Reza Shirzadi, Ministry of Health, Islamic Republic of Iran, reviewed the document and provided comments and insight. Jose A. Ruiz-Postigo and Riadh Ben-Ismail, WHO Regional Office for the Eastern Mediterranean, Cairo, provided technical input and comments. Daniel Argaw and Jorge Alvar, WHO headquarters, Geneva, provided comments and insight. The manual was developed within the framework of the partnership signed between WHO and Sanofi-Aventis to fight some of the most neglected tropical diseases, including cutaneous leishmaniasis.1
1 http://www.who.int/neglected_diseases/WHO_sanofi_partnership_2011/en/
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Introduction

Introduction

Cutaneous leishmaniasis: an important health problem
Cutaneous leishmaniasis is a potentially severe and disfiguring disease. People with cutaneous leishmaniasis have one or several long-lasting lesions on the skin, usually without fever or general symptoms. The impact that cutaneous leishmaniasis has on propagating poverty is important, since treatment is expensive and is therefore either unaffordable or involves a great loss of wages. The cost of treatment and implementation of prevention strategies needs sizeable financial and human resource investment.
Cutaneous leishmaniasis is a major public health problem in the WHO Eastern Mediterranean Region. New cases are emerging in areas previously free of the disease. Over 100 000 new cases of cutaneous leishmaniasis are reported annually to WHO by countries in the Region, but the actual incidence is estimated to be three to five times higher since many patients never seek medical attention and not all patients with a diagnosis of cutaneous leishmaniasis are reported to health authorities.
Purpose of this document
The scientific and medical communities have learnt a lot about cutaneous leishmaniasis during the 20th and early 21st centuries. However, the management and control of the disease remains a difficult task. This manual provides essential information on the parasite, on the way it is transmitted and spreads, on how to make the diagnosis and how to treat patients. Annex 1 provides case definitions, Annexes 2–5 provide standard operating procedures for parasitological diagnosis and different treatments, Annex 6 provides a patient’s file form to register all the necessary epidemiological, diagnostic and treatment information and Annex 7 provides monthly report forms on diagnostic and treatment activities.
Most lesions of cutaneous leishmaniasis display the following features (Fig. 1):
• there is some degree of infiltration of the skin (the skin on or around the lesion appears thicker than normal, either by eye or by touch);
• the evolution is slow, i.e. it takes over 1 week for the lesion to reach its final size;
• the shape of the lesion is broadly reminiscent of a disk or an oval; • skin colour on the lesion and borders is abnormal (most often red or dark);

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Manual for case management of cutaneous leishmaniasis
• the lesion’s limits are usually well demarcated (i.e. except those with many peripheral papules).

(a)

(b)

(c)

Fig. 1. Skin lesions in patients with cutaneous leishmaniasis: (a) ulcerated crusted nodule; (b) ulcerated lesion; (c) verrucous lesion

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Epidemiology

Epidemiology

Cutaneous leishmaniasis in the world
Cutaneous leishmaniasis is currently endemic in 87 countries worldwide. The disease is present in 20 countries in the New World (South and Central America) and in 67 countries in the Old World (Europe, Africa, Middle East, central Asia and the Indian subcontinent). An estimated 500 000–1 000 000 new cases occur annually but only a small fraction of cases, 19%–37%, are actually reported to health authorities. Cutaneous leishmaniasis principally affects poor populations. Outbreaks can occur anywhere, in both urban and rural areas, and is sometimes seen in refugee camps or among internally displaced populations.
Cutaneous leishmaniasis in the Region
The disease burden in the Region is 57% of the cutaneous leishmaniasis burden worldwide. Cutaneous leishmaniasis due to Leishmania tropica and L. major is endemic in 18 countries/territories in the Region: Afghanistan, Egypt, Iraq, Islamic Republic of Iran, Jordan, Kuwait, Libya, Morocco, Oman, Pakistan, Saudi Arabia, Sudan, Syrian Arab Republic, Tunisia, West Bank and Gaza Strip , and Yemen. In Djibouti, the parasite species causing cutaneous leishmaniasis are unknown and in Lebanon only cutaneous leishmaniasis cases due to L. infantum are reported.
In each country, some areas may be free of cutaneous leishmaniasis while the disease may be very frequent in other areas. New foci appear in addition to well-known zones of transmission.

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