Skin disfiguring neglected disease surging in Pakistan: Cutaneous leishmaniasis (CL)

Médecins Sans Frontières is concerned by an increase in the number of cutaneous leishmaniasis (CL) cases registered at its facilities across Pakistan. Balochistan and Kyber Pakhtunkhwa are the worst affected provinces, but this treatable neglected tropical disease, that is endemic in Pakistan, is also found in Sindh, Kashmir, and central and southern areas of Punjab.   

“The number of patients visiting MSF clinics across Pakistan has steadily increased over the years,” said Suzette Kämink, MSF cutaneous leishmaniasis expert. “However, the increase in incidence in 2022 to 2023 has been exceptional with twice as many patients registered in our Khyber Pakhtunkhwa (KP) facilities: while a 95.0% increase was recorded in Bannu and a 75.5% rise in Peshawar. A similar trend is seen in Balochistan, for example in Kuchlak, one of three CL clinics that MSF is supporting, we registered 69.9% more cases than the previous year, as well as CL being reported in areas where the disease was not normally present,” she added.

The skin disease is caused by a parasite, transmitted by the bite of phlebotomine sandfly.  Although it is not life-threatening it causes ulcers on the face and open areas of the body, which can evolve into severe scarring and disfigurement, often leading to social stigmatization, discrimination, and emotional distress.   

Major factors in the spread of the disease are poor living conditions; poor hygiene and housing, no proper waste management, and a general lack of awareness about the disease, combined with population movement, and changes in the climate. “The increase in cases highlights the lack of knowledge about the disease and its prevention such as proper environmental waste disposal, reducing potential sandfly breeding and resting places, and the correct use of long-lasting impregnated nets (LLINs),” said Suzette Kämink.

“Early diagnosis and access to effective treatment is another way to control this neglected disease. CL is curable with the mainstay treatment of pentavalent antimonial drugs: meglumine antimoniate or sodium stibogluconate. Treatment is painful and consists of daily injections for 20 to 28 days. However, access to this treatment is a challenge,” she added.  

In Pakistan, these drugs are often not available in public health centers and when found on the private market, they are expensive and generally unaffordable.  Besides ensuring a steady supply of medication, encouraging early healthcare-seeking behaviour, and increasing awareness through health education, better data collection and surveillance of CL would help provide a more meaningful oversight of the disease.

In an effort to improve access to treatment, since 2022, MSF has been carrying out a clinical trial in Pakistan to look for other options besides the pentavalent antimonial drugs. So far, 386 patients have enrolled in the CL clinical trial in the two centres in Quetta. Another clinical trial site was authorized in Quetta in January 2024 and MSF is presently waiting for further approval from the Drug Regulatory Authorities Pakistan for an additional site in Peshawar.  

With five dedicated CL centres and one satellite treatment clinic, MSF is one of the main providers of free-of-charge CL diagnostic and treatment services in collaboration with Balochistan and Khyber Pakhtunkhwa’s ministry of health. In Dadu, Sindh province, in early 2022, MSF supported the MoH in controlling a reported CL outbreak, by providing the necessary CL health care services, and training in CL management. In December 2023, MSF handed over all CL services to the local health authorities including the donation of drugs.   

Besides providing free medical care, in Balochistan the centres are also providing mental health support and carrying out outreach activities to increase awareness about treatment and prevention. In 2023, MSF treated close to 12,000 CL patients across the five dedicated CL centres. Since starting the CL programmes in 2008, over 51,000 patients have received services in MSF CL facilities. 

MSF has been offering CL services in Pakistan since 2008. Presently it runs five CL diagnostic and treatment centres in collaboration with the health authorities: three in Quetta district of Balochistan: Kuchlak health centre, Mohtarma Shaheed Benazir Bhutto General Hospital and Bolan Medical Complex Hospital and two in Khyber Pakhtunkhwa: in Bannu's Khalifa Nawaz Gul teaching hospital, and in Peshawar Governmental Naseer Ullah Khan Babar Memorial Hospital with a satellite treatment centre in Rural Health Unit in Badaber.