Pakistan

The only option for cutaneous leishmaniasis treatment in Khyber Pakhtunkhwa

Sixteen-year-old Anas, above, is from Soor Gul – a village about 15 kilometres from Kohat city in Khyber Pakhtunkhwa province – is finally hopeful that his infection will be cured at MSF’s cutaneous leishmaniasis treatment centre in Peshawar. He is not the only one in his family to have developed a parasitic skin infection: his brother and mother were also victims of the sandfly, but they recovered. Anas did not, despite months of treatment at public and private hospitals in his area.

The lesions first appeared on his face nine months ago. His family took him to the doctor in Kohat city, where he went through different injectable and oral medications, but the infection continued to grow. Finally, a woman from his village told them about the MSF cutaneous leishmaniasis treatment centre in Peshawar. Today is his first day of treatment there.

“He now has to come for treatment for at least 21 consecutive days. It might extend depending on his progress. I’m afraid he might have developed some drug resistance as he went through different treatments during the last nine months,” said Dr Pervez, who is in charge of the MSF facility.

Anas came to the centre with his uncle, Shaur Khan, who will not be able to work for the next 21 days as someone has to accompany the young boy. “There are more than 80 patients in our village alone. We spent 7,000 rupees (US$ 100) on injections and 14,000 (US$ 200) on tablets over the last few months before reaching the MSF facility. Anas’ brother and mother are fine now, but his infection has grown badly. We don’t know why. Anas was afraid that his nose would fall away from his body,” his worried uncle said.

People with cutaneous leishmaniasis are often subject to discrimination due to the disfiguring lesions on their face. They become isolated and go through psychological trauma. Anas is brave though, maybe because he is not the only one in his village with lesions. “I can’t wash my face properly. I have to sleep straight on my back the whole night because if I do not, my nose touches the bed and it’s very painful,” explained Anas, who continued to ask his uncle to speak on his behalf.

Anas has received several injections inside his lesions. Dr Pervez pointed out that this was not good practice in Anas’ case. He also fears that Anas may be among the many patients he has met who were given antibiotics and other drugs to treat cutaneous leishmaniasis. The first-line treatment for cutaneous leishmaniasis is meglumine antimoniate; other general antibiotics do not normally work.

“For such a big lesion, especially on a sensitive area like the nose, the best practice is to give intramuscular injections. But the needle you need to administer these injections is barely available in Pakistan, and the drugs available on the open market are not of reliable quality. Use of the wrong or bad quality drugs, and treatment by untrained medical staff, are most probably factors behind Anas’ current condition,” he added.

A man leaves from the MSF treatment centre in Peshawar with his nephew who received treatment for cutaneous leishmaniasis.

A man leaves from the MSF treatment centre in Peshawar with his nephew who received treatment for cutaneous leishmaniasis.

Treating cutaneous leishmaniasis in Pakistan

A public health burden in Pakistan, cutaneous leishmaniasis (CL) cases have surged in the country’s northwestern Khyber Pakhtunkhwa province since the end of 2018. The health authorities have reported about 28,000 cases since November 2018, most of them from merged districts previously known as the Federally Administrated Tribal Areas, close to the border with Afghanistan. A recent upsurge in the province’s southernmost districts, particularly in South Waziristan, has driven people to the neighbouring district of Bannu or even to the provincial capital, Peshawar, for treatment.

Cutaneous leishmaniasis is a skin infection caused by a parasite transmitted by the bite of a phlebotomine sandfly and is endemic in Pakistan. Although not life threatening, it can cause severe stigma and psychological trauma. People with lesions and scars are often victimised and excluded from public life.

A view of the waiting area from the door at the MSF cutaneous leishmaniasis treatment centre.

Aslam* enters the MSF cutaneous leishmaniasis treatment centre to get injections.

A view of the waiting area from the door at the MSF cutaneous leishmaniasis treatment centre.

Aslam* enters the MSF cutaneous leishmaniasis treatment centre to get injections.

One treatment centre at capacity, soon to open another

Working with the Ministry of Health, Médecins Sans Frontières (MSF) opened a dedicated treatment centre in Peshawar’s Naseerullah Babar Khan memorial hospital in May 2018 and will shortly be opening another at Bannu district headquarters hospital to address the dire needs in Khyber Pakhtunkhwa’s southern districts.

The treatment centre in Peshawar admits 250 to 300 new patients every month and has treated more than 2,300 people in total since its opening in May 2018. The facility is operating at full capacity, with patient numbers continuing to increase.

“This is the only specialised CL treatment centre in the whole of Khyber Pakhtunkhwa province,” says Dr Pervez Khan, in charge of the MSF treatment centre in Peshawar. “We have a cure rate of more than 95 per cent in 2019 and are constantly seeing more and more patients, which also demonstrates the heavy needs in the province.”

MSF also treats the disease in Quetta and Kuchlak in Balochistan province, where we are the biggest provider of treatment for the disease.

Shahbaz

Shahbaz* was planning to get married in April 2019, until he was bitten by a sandfly and developed a lesion on his nose. Saddened by the incident, he postponed his wedding. Having reached MSF’s cutaneous leishmaniasis treatment centre, he now hopes to be cured and get his life back to normal.

Shahbaz is a 27-year-old agricultural worker living in a rural area on the outskirts of Peshawar, the capital of Pakistan’s Khyber Pakhtunkhwa province. The disease has badly disrupted his life and caused him severe psychological trauma. He has intentionally isolated himself to avoid stigmatising remarks about his looks.

“I wear this mask to hide my nose. I do not go out or play cricket with my friends anymore. My friends joke about my nose. I feel upset. I can’t describe how difficult the past months have been for me,” says Shahbaz. “I didn’t know about this disease at all. I tried different things to treat it during the last few months, but everything failed.”

A doctor in a private hospital gave him oral medication, saying that he would be fine after three doses. He spent about 13,000 rupees (US$ 187) on drugs that actually worsened the lesion. Another local doctor then told him he would need 60 injections to treat the lesion, for which he would have pay 42,000 rupees (US$ 600). Shahbaz could not afford that.

He was eventually advised by a village fellow to visit Naseerullah Khan Babar memorial hospital in Peshawar. Faqeer Hussain, the supervisor of MSF’s cutaneous leishmaniasis treatment centre there, says that Shahbaz came for treatment just in time. “His skin is still intact so I’m hopeful he will not have a scar on his nose.”

Shahbaz has delayed his wedding until at least August, and he is hopeful that he will be cured by then. He has received support from an MSF health promoter and has been reassured by talking to other patients – one of whom has already suggested he inform his future in-laws that he will be fine in a couple of months, so they should start preparing for the wedding.

*Name changed

Mohammad Jannat

Bahadur Khel village, in the Karak district of Khyber Pakhtunkhwa province, is home to sandflies. According to one resident, Mohammad Jannat, every household has at least five or six people with cutaneous leishmaniasis. Some have as many as 10 to 12.

Jannat and two of his sons, 17-year-old Nasir Usman and 13-year-old Muhammad Wahab, are all being treated for cutaneous leishmaniasis at the MSF treatment centre in Peshawar. He travels two to three hours twice a week from his workplace to get the injections, while his sons, who need the drugs every day, stay in the hospital.

“Nine out of 10 members of my family were bitten by sandflies. Only one of my sons is safe, because he does not live in the village. We have no idea why they are so prevalent. Some people say they are caused by a fly or a dengue mosquito. A few think it is due to the weather conditions,” said Jannat.

The two children are given intramuscular injections, but Jannat himself gets them into his lesions. He has six separate lesions on his body and getting injections in all six places is extremely painful.

Cutaneous leishmaniasis is not life threatening, so it is not very often that patients need to be admitted to hospital. But Nasir Usman and Muhammad Wahab stay there as they can’t travel to the hospital from their village and back every day. It costs 1,400 rupees (US$ 20) each time they travel to Peshawar, so Jannat is thankful that the Naseerullah Khan Babar memorial hospital administration let the children stay. He is satisfied that his children are safe at a government hospital.

“There are high needs in my area. There should be a medical facility there as well. A poor person can’t reach here,” Jannat added.

The treatment centre supervisor, Faqeer Hussain, has multiple examples of people from the same family affected by the sandfly. “Most of these families are poor. They sit or sleep on the ground. They live in unsanitary conditions. It is hard for them to protect themselves,” he explained.

While Muhammad Jannat was waiting for his turn at the treatment centre, he met another person from his village. Four of his family members have already been treated at the centre; he will bring two more for treatment once Nasir Usman and Muhammad Wahab are cured.

“My friends tell me, ‘You were bitten by the mosquito’. I did not know this disease before, but I now I know what it is,” 13-year-old Mohammad Wahab adds, who spends all day in the hospital together with his brother.

Shahbaz

Shahbaz

Mohammad Jannat

Mohammad Jannat

Baby Ayesha

Baby Ayesha

Faiza Bibi

Faiza Bibi

Baby Ayesha

Baby Ayesha* was bitten by a sandfly on her chest and hands. She has henna on her hands but the lesion remains clearly visible. Just like many other children the MSF team treats, Ayesha is afraid of injections. Her father tries his best to calm her down, telling her it won’t hurt much, but Ayesha’s loud cries suggest otherwise. At least her lesions are not big, so they can be treated easily.

The bigger worry for the family is Ayesha’s mother, who is also suffering from cutaneous leishmaniasis. She can’t be treated currently as she is pregnant and the drug used could damage the health of the foetus and increases the chance of miscarriage.

“When we inject the medication intramuscularly, it goes to the entire body of the patient and can cause bleeding resulting in spontaneous abortion. It is also very dangerous to inject meglumine antimoniate into the lesion of pregnant women; if the body doesn’t recognise the drug and reacts, it may start expelling the foetus,” explains Suzette Kämink, an MSF expert on tropical diseases who is conducting a clinicalstudy to find alternative treatment methods.

Neither meglumine antimoniate – currently the only choice for patients in Pakistan – nor any other drug used to treat cutaneous leishmaniasis elsewhere can be prescribed to pregnant women. This means a woman has to put up with the pain and worsening of her lesions throughout her pregnancy. “

A woman’s immunity is already low during pregnancy. If her body does not react effectively to the infections, the lesions can get bigger and worse than in other people. There is certainly a need for research to look for options to treat pregnant women,” Suzette adds.

Leishmaniasis is a parasitic tropical infectious disease caused by the bite of a sandfly. The two main forms of leishmaniasis are visceral and cutaneous. Visceral leishmaniasis, also known as kala azar, can be fatal. If a pregnant woman suffers from visceral leishmaniasis, doctors sometimes have to take the risk of giving her drugs. Otherwise, she might lose her life anyway due to this disease.

*Child’s name changed

Faiza Bibi

Six-year-old Faiza Bibi is one of hundreds of patients who have travelled to MSF’s cutaneous leishmaniasis treatment centre in Peshawar from Tilla Band, an area on the outskirts of Peshawar district known to be highly affected by sandflies. Faiza Bibi’s father, Khalid, is an agricultural worker and has three children; he is clearly not surprised that one of them has caught this parasitic skin infection.

“I have four uncles and many of their children have these lesions. There are about 125 people in my extended family living in the area, and 20 to 25 of them have the disease,” says Khalid.

MSF’s cutaneous leishmaniasis outreach team visits southern parts of Peshawar district on a regular basis, to conduct awareness-raising sessions. That is how Faiza Bibi’s farther came to know about the MSF treatment centre, where he has brought his daughter.

Like many, they came to the hospital only when the lesions had got really bad. Faiza Bibi has had the disease for eight months already. Delayed arrival and severe lesions automatically make the treatment longer and more difficult, with greater likelihood of scarring.

Expensive or unavailable – difficult access to treatment

Many people are unable to access medical treatment because it is too expensive, if available at all. Most government hospitals have limited drugs and no specialised staff, leaving people to buy the drugs themselves or pay to travel long distances to access free treatment in big cities – something many cannot afford to do.

Nine out of 10 members of Muhammad Jannat’s family from Karak district have cutaneous leishmaniasis. Two of his sons are receiving treatment, which means injections for at least 21 consecutive days, at Naseerullah Babar Khan memorial hospital in Peshawar.

Each trip from their village to Peshawar costs 1,400 rupees (US$ 9). Jannat asked the hospital administration to let his children stay there because he can’t bear the expense. He will bring two more members of his family for treatment after his sons complete theirs.

“There are high needs in my area,” says Jannat. “There should be a medical facility there as well. A poor person can’t reach here.”

Limited drug options

Meglumine antimoniate, the first-line treatment for cutaneous leishmaniasis, is not produced locally in Pakistan. The health authorities therefore rely largely on imports by international organisations such as the World Health Organization and MSF. In many settings the doses each patient receives are insufficient, because of the drug’s limited availability and the lack of suitably trained medical staff.

“Meglumine antimoniate is the only option for people with CL in Pakistan,” says Suzette Kämink, an MSF tropical diseases expert currently supervising clinical study into alternative treatments for cutaneous leishmaniasis in Pakistan. “We have no evidence of any other drug or treatment method that is effective against leishmania tropica, the form of CL prevalent in Balochistan and Khyber Pakhtunkhwa provinces. There is certainly a need to look for other treatment options.”

Mohammad Jannat tries to resist the pain as he receives an injection into his lesion at the MSF cutaneous leishmaniasis treatment centre in Peshawar. He was bitten by the sandfly on six different spots on his body.

Mohammad Jannat tries to resist the pain as he receives an injection into his lesion at the MSF cutaneous leishmaniasis treatment centre in Peshawar. He was bitten by the sandfly on six different spots on his body.

A view of the slides with blood samples chemically treated to test for cutaneous leishmaniasis at the MSF treatment facility in Naseerullah Khan Babar memorial hospital, Peshawar.

A view of the slides with blood samples chemically treated to test for cutaneous leishmaniasis at the MSF treatment facility in Naseerullah Khan Babar memorial hospital, Peshawar.

Subhan calms his daughter Afia as she receives injection for cutaneous leishmaniasis lesion at the MSF treatment centre in Naseerullah Khan Babar Memorial hospital, Peshawar.

Subhan calms his daughter Afia as she receives injection for cutaneous leishmaniasis lesion at the MSF treatment centre in Naseerullah Khan Babar Memorial hospital, Peshawar.

Outreach to increase awareness

We have also started outreach activities to address the lack of awareness in communities about the disease and how to prevent it. The treatment centre in Peshawar has so far been the only option for thousands of people with cutaneous leishmaniasis in Khyber Pakhtunkhwa.

The new centre in Bannu will go some way to improving access to treatment for people in southern districts, but it is essential that more patients have access to quality drugs at affordable prices where they live in order to properly tackle the high prevalence of cutaneous leishmaniasis in the region.

“We have achieved far more than expected with the new cutaneous leishmaniasis services over the last year,” says Dr Siraj Muhammad, medical superintendent of Naseerullah Khan Babar memorial hospital in Peshawar. “Patients from 25 different districts seek services from this centre. We are satisfied with its progress. We are thankful to MSF for its services and support to the provincial department to deal with this medical issue.”