Leishmaniasis

"The various clinical forms of leishmaniasis are also on the rise; the number of reported cases has tripled over the last 10 years."  I read this in a 2008 Pan American Health Organization (PAHO) report on Healthcare in Nicaragua. 


Leishmaniasis, I thought.
I don't know anything about leishmaniasis.  


So, learning about leishmaniasis became a learning project. Below is a summary of my reading.  

Leishmaniasis is caused by a protozoa transmitted to mammals via the bite of the female sandfly of the genus Phlebotomus in the Old World and Lutzomyia in the New World.

Female Sandfly

For most species of Leishmania, an animal reservoir is required for endemic conditions to persist. Common New World hosts include sloths, anteaters, opossums, and rodents. Humans are considered incidental hosts.

Leishmaniasis can be divided into cutaneous, mucocutaneous, visceral, and viscerotropic forms.

Parasites exist in the promastigote stage in sandflies and transform to the amastigote form in animal and human hosts.

Female sandflies can transmit the parasite 7-10 days after feeding on an infected host. The promastigotes migrate from the gut to the proboscis and are regurgitated during the next meal into the new host's tissue.

After inoculation, parasites infect the reticuloendothelial system and live in the intracellular lysosomal organelles of macrophages.

Parasites may incubate for weeks to months before presenting as skin lesions or as a disseminated systemic infection involving the liver, spleen, and bone marrow.

Pathogenesis appears related to T-cell cytotoxicity. The extent and presentation of disease depend on several factors, including the humoral and cell-mediated immune response of the host, the virulence of the infecting species, and the parasite burden.

Infections might heal spontaneously or might progress to chronic disease, often resulting in death from secondary infection.

New World leishmaniasis exists throughout the Americas, with the exception of Canada, Chile, and Uruguay.

        

Cutaneous Leishmaniasis

      Inoculation occurs after a sandfly bites an exposed part of the body, usually the legs, arms, neck, or face.

      Incubation occurs over weeks to months followed by the appearance of a solitary erythematous papule, which can evolve into a plaque or ulcer.

      The skin lesion begins as a nontender, firm, red papule several centimeters in size at the site of the sandfly bite.

      In time, the lesion widens with central ulceration, serous crusting, and granuloma formation.

      The border often has a raised erythematous rim known as the volcano sign.

      Lesions can be wet or dry and become fibrotic or hyperkeratotic with healing.

      Satellite lesions might be present.

      Wound progression occurs over time and might exhibit localized lymphangitic spread.

      Lesions are usually without pain or pruritus, although secondary bacterial infection can complicate the wound.

      Systemic symptoms are absent.

      Healing can occur spontaneously over 2-12 months and is followed by scarring and changes in pigmentation.

      New World disease can progress to mucocutaneous leishmaniasis.

Mucocutaneous Leishmaniasis

  Most commonly caused by New World species.

  Can arise after inadequate treatment of certain Leishmania species.

      Initial infection is characterized by a persistent cutaneous lesion that eventually heals, although as many as 30% of patients report no prior evidence of leishmaniasis.

      The initial skin lesion is often notable for its prolonged healing time and large size. In most cases, a healed scar can be identified based on careful examination.

      Oral and respiratory mucosal involvement occurs months to years later and causes inflammation and mutilation of the nose, mouth, oropharynx, and trachea.

      Patients develop rhinorrhea, epistaxis, and nasal congestion.

      Examination reveals excessive tissue that obstructs the nares, septal granulation, and perforation.

      Nose cartilage might be involved, giving rise to external changes known as parrot's beak or camel's nose.

      The palate, uvula, lips, pharynx, and larynx might exhibit granulation, erosion, and ulceration with sparing of the bony structures.

      Hoarseness might be a sign of laryngeal involvement.

      With prolonged infection, death occurs from respiratory compromise, malnutrition due to dysphagia, and secondary infection.

  

Visceral Leishmaniasis

      The most devastating and fatal form, classically known as kala-azar or black fever.

      The incubation period varies after infection and might depend on the patient's age and immune status and the species of Leishmania.

      Results from systemic infection of the liver, spleen, and bone marrow.

      Pentad of fever, weight loss, hepatosplenomegaly, pancytopenia, and hypergammaglobulinemia.

      Patients present with recurrent high fevers, wasting, anorexia, night sweats, diarrhea, and malaise.

      Patient is thin and cachetic with abdominal distension and protuberance due to massive hepatosplenomegaly.

      Epistaxis and petechiae from severe thrombocytopenia.

      Melanocyte stimulation and xerosis causes characteristic skin hyperpigmentation.

      A progressive disease with the mortality rate ranging from 75-95% if untreated. With appropriate therapy and supportive care, the mortality rate is 5%.

      Death usually occurs from malnutrition, immunosuppression, and secondary infection.

Always treat visceral, mucocutaneous, and severe forms of cutaneous leishmaniasis. Given its potential to progress into mucocutaneous leishmaniasis, treat New World cutaneous leishmaniasis.

Therapies available are limited.

The mainstays are the pentavalent antimony compounds, sodium stibogluconate (Pentostam) and meglumine antimonate (Glucantime), which have similar efficacy. Cure rates of 80-100% have been reported.

                                     

Other therapies include amphotericin B (AmBisome) and pentamidine.

Orally administered ketoconazole, itraconazole, fluconazole, allopurinol, and dapsone have been examined internationally, but none is as effective as the pentavalent antimony compounds. However, given their minimal adverse effect profile, these agents might be useful to accelerate the cure in patients with cutaneous leishmaniasis that does not progress to mucosal disease and tends to self-resolve.

The recent discovery of an affordable, orally administered, and well-tolerated therapy for visceral leishmaniasis has made mass treatment in the developing world a reality. Miltefosine is a phosphocholine analogue originally developed as an antineoplastic agent that interacts with membrane synthesis and signal production.

                 

Insect repellent, protective clothing, and permethrin-impregnated mosquito nets offer some protection for visitors to endemic areas. The female sandfly is small enough to pass through standard mosquito nets, thus requiring specially designed netting.

Wages in Nicaragua

The Nicaraguan Gross Domestic Product in 2005 was $4.9 billion dollars, or about $860 dollars per person.
This modest amount implies that wages must be very low and this is the case. 


According to WHO data, the average monthly minimum wage (Nicaraguan Cordobas converted to Canadian Dollars) in 2006 was $45 for an agricultural worker and $101 for a fisherman. This information supports other data that I have read that a substantial percent of the population earns less than $500 a year. The WHO also reports that the average cost to meet the basic nutritional needs of a person is $133 a month. Therefore those individuals who are paid the minimum wage are starving.  



The child labor market includes an estimated 240,000 children and adolescents of whom 61.4% do not receive any remuneration at all. 


Many Nicaraguan men work in Costa Rica, where the wages are much higher. The economy in Costa Rica has blossomed in the last few decades courtesy of tourism and foreign investment. The Nicaraguan government has actively encouraged tourism and foreign investment since 2006. Americans, Canadians, Australians, and Europeans are traveling to Nicaragua in record numbers. American Airlines recently started a non-stop flight to Managua from Miami.


The clinic where I help out is located in Limon, a community on the north-south Pacific coastal road. The clinic is only about five km inland from the coast. The region has a lot of tourist potential. San Juan del Sur, a coastal community further to the south has boomed over the last decade and now has cruise ships that stop every week.


The low cost of land and labor are attractive for foreign investors. I have talked to numerous Americans who have built or who are building in Nicaragua. The current wage for an unskilled worker at a building site is $150 a month. Doesn't sound like much, but this is at least more than the cost of the basic nutritional needs for an individual. However, what if this person is the sole wage earner for a family of 4. That means the family is still starving. 


Tourism and foreign investment imports much needed dollars into Nicaragua and increases employment at higher than the minimum wage. Is this good? The money and employment is good, but there is always a cost. The Nicaraguan people are selling their prime real estate to improve their standard of living.

Blue Crab, Callinectes sapidus, watched me carefully for a moment,

then disappeared into the sand within a few seconds.   

Pan American Health Organization (PAHO) Data 2008

Health Systems Profile - Nicaragua

Monitoring and Analyzing Health Systems Change

Pan American Health Organization/World Health

Organization PAHO/WHO

May 2008

MINSA is the Department of Health in Nicaragua. MINSA targets primary and secondary levels of care in Nicaragua. This makes sense. When the resources are limited, the best approach is to focus on the basics. However, this implies that tertiary level care is not available to the public, unless this is provided by a private physician, clinic, or hospital. This means for instance, that dialysis would not be available for a child with kidney failure.

The table below outlines who pays for the health care in Nicaragua. MINSA pays for the majority. The total does not add up to 100%, which implies that no one pays for the missing 20%. This actually might imply that one fifth of the population does not receive any care! I suspect that these are the individuals who are not registered with MINSA. Unless you have a number you do not exist. This is a real concern because without a MINSA registration, an individual cannot access care, and individuals are actually turned down in this situation. Ridiculous bureaucratic obstacles exist in every jurisdiction. 

	Percent
MINSA	60
Nicaraguan Social Security Institute INSS	8
Government and Military	8
Private	4
Total	80

MINSA has a list of essential drugs and reviews what should be included every two years. MINSA likely only chooses generic medications. Cutting edge (read expensive) therapies are not likely considered. Every month the local MINSA physician reports data on the patients and medications dispensed and the supply for the next month is based on this data. I learned that the supplies always run out well before the end of the month. I imagine the more organized patients turn up in the first week to obtain their chronic medications. 

The inventory of equipment at the first level of care fails to meet user demand for these services. My experience certainly confirms this. 

At the second level of care serious obstacles hinder efforts to maintain existing equipment, including a lack of qualified equipment maintenance personnel. I am sure this is the case. There are no parts or personnel to fix any out-of-the-ordinary mechanical or electrical device, much less sophisticated medical equipment. For example, if I were to purchase a car in Nicaragua, there are only a few makes and models that would routinely have parts and service available. Why would anyone purchase something different?   

Physicians per 10,000 population increased from 4.0 in 2000 to 4.7 in 2007. By comparison, the number of physicians in Canada per 10,000 population is 22. 


In 2007 there were 1376 male physicians and 1231 female physicians in the public health sector. Many of these are brand new graduates. I learned that physicians who graduate from medical school in Nicaragua are obliged to serve for two years in a MINSA clinic. The physicians are posted to a clinic immediately after they graduate and the public service is therefore their postgraduate training program. I graduated from a first class medical school that included a lot of clinical experience prior to graduation but I spent 6 more years of postgraduate training before the Canadian Medical Profession let me practice my specialty without supervision. For general paediatrics at that time the minimum duration was 4 years and for family medicine the duration was 2 years. Posting brand new graduates to meet community needs sounds ridiculous, but any knowledge and help, however inexperienced, is better than no knowledge or help.

Great Egret on a windy day.
The wind is only apparent with the feathers behind the neck.
The branch was really swaying and the egret needed to
brace the legs and lean into the wind to keep steady. 

  

Community Outreach Program

This trip was far more successful than my prior efforts. Experience counts.

From the outset I decided that I wanted to find a location where I could return and continue to work as a paediatrician. I desired continuity.

I did not aspire to visit foreign places once and then move on, although this is the most common pattern for a medical volunteer. For some volunteers the destination country is the reason for the trip and each volunteer opportunity is a location on the volunteer’s bucket list. I get that. Help is help and always appreciated.

However, for me, I desired continuity. I knew that continuity would educate me and that really making a difference always requires knowledge. When a patient returns improved this is affirmation of success; when a patient returns and is not improved, this means I need to improve. Continuity is a great teacher. My ground rules are to improve the quality of my care with each subsequent visit. There is no reason why I cannot continue to improve. 

I have only seen a tiny tip of the iceberg of poor health in the region. The mothers who came to the clinic had to hear about my visit and they needed transportation. Communication and transportation are key issues that need ongoing improvement.

One way to improve transportation and communication is for me to travel to the patients. If I travel to a community, this solves the transportation problem and local communication will be simpler. As such, with my next trip I want to start a Community Outreach Program.

The Goals of the Community Outreach Program will be Paediatric Health Screening and Paediatric Health Education

Paediatric Health Screening

Check the immunization cards of the children.

Check height, weight, and head circumference and plot the data on a growth chart.

Check a stool specimen for parasites and worms.

Check a dipstick urinalysis.

Children with abnormal screening tests will be referred for follow up to the Clinic.

Paediatric Health Education

Essentials of good nutrition

How to disinfect water with SODIS

How to prevent worm disease

How to use oral rehydration solution

How to treat fever

Provide Basic Medications for Every Child

1. Multi-vitamin - two month supply

2. Acetaminophen with Spanish instructions on dosage

3. Oral rehydration solution packets sufficient to make two liters with Spanish instructions on how to prepare and use

With the approval of the mother, every child could be treated for worms with mebendazole 
and for parasites with metronidazole. 

Gaby Organized the Toys for the Children - Thank You!

Gaby is a 10 year old girl who visits my office. She is a terrific gal. The acorn doesn't fall far from the oak, and her Mom is wonderful as well. When Gaby and Mom found out I was on my way back to Nicaragua, Gaby purchased some toys for the children. The photos show children enjoying her generous gifts.  


Thank you Gaby.