Middle East DVEP - Armed Forces Pest Management Board

produce large numbers of refugees. In Sudan, between the years 1991 and 1996, therewere reports of 10,000 treated cases and 100,000 deaths from VL. Surveys suggest adeath rate of 38 to 57% for the period 1984 to 1996.Military Impact and Historical Perspective. Although not a war stopper, leishmaniasisis a persistent health threat to U.S. military personnel because troops deploy or conductmilitary exercises in locations where the disease is endemic. The overall potential forthis disease to compromise mission objectives is significant. CL is highly endemic in theMiddle East, and in some areas 80-90% of the people bear leishmanial scars. Soldiersexposed to sand fly bites while deployed to the region are highly susceptible to infectionwith Leishmania. Immunity among US military personnel is essentially nonexistent, andrecovery from CL does not confer immunity to VL. In the Karum River Valley of Iraq,US forces suffered 630 cases of the disease in a 3-month period during WWII. Duringthe 1967 "Six Day War," Israeli soldiers camped near Jericho in the Jordan Valleysuffered a 50% attack rate of Le. major. In the northern Sinai desert, 113 cases of Le.major were reported from Multinational Forces and observers from 1973 through 1991.In 1990-91, twenty cases of CL due mainly to Le. major and 12 cases of VL due to Le.tropica were diagnosed when 697,000 allied soldiers were deployed to the ArabianPeninsula during Operations Desert Shield and Storm. Even though no fatalities wereassociated with leishmaniasis in this deployment, new lessons were learned that couldaffect future military deployments. Before the Persian Gulf War, eastern Saudi Arabiawas not known to be endemic for visceral leishmaniasis and L. tropica was notconvincingly shown to produce visceral disease. More importantly, the potential forleishmaniasis to cause intransigent post-deployment diagnostic problems and threatenblood supplies had not been anticipated. Returnees from the Persian Gulf War werebarred from donating blood for up to two years, severely impacting blood supplies.Infection with Leishmania was even listed as one of the causative agents of Persian GulfWar syndrome, but scientific evidence for this association is lacking.Diagnosis of leishmaniasis is difficult at best, and providing proper care for servicemembers who may have been exposed or infected is a long, costly and complex process.Treatment usually requires 20 or more days and consists of injections with pentavalentantimony (Pentostam). Because this drug is not registered for use in the US, it must beadministered under an experimental protocol at an approved medical treatment facility.Estimated leishmaniasis-related costs can exceed US $17,000 per patient, with an averageof 92 lost duty days per patient. Other important but less quantifiable costs include lossto the unit, personal distress, and delay of career progression.Disease Distribution. CL due to Le. major (“wet sore”) occurs in the Old Worldthroughout the Mediterranean basin countries of North Africa, the Middle East andsouthern Europe, parts of sub-Saharan Africa, southern Asia, the western part of theIndian subcontinent, and China. In the Middle East it is common in Israel, Jordan,Lebanon, Syria, Iraq, Iran, southern Turkey, northern and southern Saudi Arabia, andYemen (Figure 8). Localities of Le. major share a semi-arid to arid climate with a hotdry season lasting six or more months, in which air temperatures regularly exceed 35ºCand frequently exceed 40ºC. All these localities are in areas of low relief, mostly almostflat, and share soils sufficiently deep and friable yet sufficiently cohesive for the108