As if the beleaguered people of civil war torn Syria didn’t already have more than enough to contend with, they’re being further tormented by a pestilential parasitic skin disease that causes disfiguring facial sores and boils that is reportedly quickly spreading in the besieged city of Aleppo, adding further to the misery there — the number of estimated cases ranging into the thousands or possibly even the hundreds of thousands with children and young people disproportionately affected.
According to a report posted by the James A. Baker III Institute for Public Policy at Rice University in Houston, Cutaneous leishmaniasis (CL) is not a new disease, having been an endemic health threat for hundreds of years in the Middle East, with its nexus in Syria’s ancient second city Aleppo, where it is popularly referred to as the “Aleppo evil,” “Aleppo ulcer,” or “Aleppo boil,” writes Baker Institute Fellow in Disease and Poverty fellow Dr. Peter J. Hotez, a professor of molecular virology and microbiology at Baylor College of Medicine at Houston, writing in a June 5, 2013, edition PLOS Blog posting entitled “‘Aleppo Evil’: The Ulcer, the Boil, the Sandfly, and the Conflict.”
“It should come as no surprise that this disease would re-emerge with a vengeance as a result of a horrific civil war” and a breakdown in infrastructure and public health control measures,” says Dr. Hotez, who is director of the Sabin Vaccine Institute and Texas Children’s Hospital’s Center for Vaccine Development, operated in partnership with Baylor College of Medicine’s pediatrics department. He is also the Texas Children’s Hospital Endowed Chair of Tropical Pediatrics and serves as chief of the Section of Pediatric Tropical Medicine, Professor of Pediatrics and Molecular Virology & Microbiology, as well as the founding dean of the new National School of Tropical Medicine at Baylor College of Medicine, Co-Editor in Chief of PLOS Neglected Tropical Diseases, and the author of Forgotten People, Forgotten Diseases (ASM Press), Second Edition, which will be published this month.
“Even in the best of times the Syrian Arab Republic (Syria) has struggled with cutaneous leishmaniasis (CL),” writes Dr. Hotez, noting that that old world or anthroponotic CL caused by the microorganism Leishmania tropica is endemic to Syria and elsewhere in the Middle East, North Africa, and Central Asia, and in Aleppo CL has been present for hundreds of years (if not longer).
A June 21 report by Foreign Policy’s Erin Banco notes that According to the WHO, which has early-warning systems in place to monitor CL in all 14 of Syria’s governorates, 1,047 cases of cutaneous leishmaniasis were reported between April 14 and May 18 of this year, with the majority of those cases occurring in Aleppo. However, with 1.6 million refugees having fled Syria and 7,000 more daily pouring across Syria’s borders seeking refuge in neighboring states, the disease will spread and take hold in areas well beyond its traditional range. Ms. Banco notes that the WHO has already received some 1,300 reports of leishmaniasis cases in Lebanon, Jordan, Turkey, and Iraq over the past year. with in all likelihood many more cases going unreported.
Aleppo evil is a disfiguring condition that disproportionately occurs on the face, especially of young people. CL lesions typically persist for one or two years before healing spontaneously, and are often referred to locally as “one-year sore”. However, Dr. Hotez affirms that in many cases specific anti-parasitic chemotherapy can hasten the healing process and improve clinical and cosmetic outcomes.
Aside from the immediate misery they cause, Dr. Hotez notes that scars left by CL lesions even after the infection heals can result in permanent facial disfigurement leading to social stigmatization and isolation, particularly among girls and young women who can be rendered unmarriageable, while mothers with CL may not be allowed to touch their children, even though human to human contact does not transmit the infection.
CL’s actual transmission vector is the Phlebotomus sandfly, whose numbers had been suppressed in periodic anti-malarial insecticide campaigns since the 1950s, with one clinical trial conducted prior to the current civil conflict finding that use of insecticide-treated bednets (ITNs) could prevent CL in Aleppo. However, with municipal garbage and sewage disposal infrastructure in Syria having been gradually deteriorating since the early 1990s, and virtually stopped since open civil conflict there erupted in 2011, mountains of garbage and buildups of raw sewage — ideal breeding habitats of Phlebotomus sandflies — have proliferated.
Dr. Hotez cites effective sanitation, insecticidal spraying, expanded use of Insecticide-Treated Net(s), case detection, and access to anti-parasitic therapies as the first line of defense against CL proliferation, noting that leishmaniasis vaccines are under development but still years away, and unfortunately, the history of conflict and its links with neglected tropical diseases (NTDs) over the last few decades portend continued public health inaction as long as hostilities continue. He suggests that in the realm of the doable, at minimum the international community for now needs to focus on refugees and refugee encampments to ensure local control and patient access to treatments.