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LTC Peter Weina response - 1,178 Leishmaniasis cases in November 2004

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  • Kirt Love
    ... From: Weina, Peter J LTC WRAIR-Wash DC To: Kirt Love ; Magill, Alan J COL WRAIR-Wash DC ; mcevoy@afip.osd.mil ; EPI@nehc.mar.med.navy.mil ;
    Message 1 of 1 , Dec 29 10:13 AM
      ----- Original Message -----
      Sent: Thursday, December 29, 2005 11:41 AM
      Subject: RE: 1,178 Leishmaniasis cases in November 2004

      Dear Sir;
          I understand your frustration with the variability in reported cases for leishmania, but my explanation below is still valid in the face of your most recent questions.  The simple, most direct answer to your question is that there is no "accurate" "true" number to the question as stated: "the total number of soldiers coming back with Leishmaniasis".  The question is too broad and vague.  If you ask how many laboratory confirmed cases of cutaneous leishmania are there, we can give you a number which is one answer.  If you ask how many cases have been treated for cutaneous leishmania from Iraq, we can give you a number which is another answer.  If you ask how many cases are reported to the reportable disease database, we can give you a number which is yet another answer.  None of them are going to be the same.  There are many types of leishmania (clinically), there are different ways of diagnosing leishmania (clinically or laboratory confirmed), and as stated below, there are different ways of physicians (both military and civilian) to report officially the number of cases to a database.
          I have given you my personal perspective, but it is just that, a personal perspective not backed by science and does not necessarily reflect the position of the U.S. Army.  The Office of the Surgeon General of the Army is the official source of the number of cases of leishmania in soldiers returning.  Also, the AMSA MSMR report at CHPPM is the number that is most available to you and frankly is no better or worse than data I have available to me.  In the absence of solid data to dispute those numbers, it is the best we have.

      Peter J. Weina, PhD, MD 
      LTC (P), MC, USA 
      Director, Leishmania Diagnostics Laboratory
      Walter Reed Army Institute of Research
      503 Robert Grant Avenue
      Silver Spring, MD 20910
      Phone: 301-319-9956
      Fax: 301-319-7360

      From: Kirt Love [mailto:DSBR@...]
      Sent: Wednesday, December 28, 2005 6:10 PM
      To: Magill, Alan J COL WRAIR-Wash DC; mcevoy@...; EPI@...; special.assistant@...; Weina, Peter J LTC WRAIR-Wash DC; wriisc.dc@...
      Cc: Gulflink
      Subject: 1,178 Leishmaniasis cases in November 2004

      Dear LTC Peter Weina
      I had asked about case reporting of total number of soldiers
      coming back with Leishmaniasis. Jay Price of the "News &
      Observer" had posted a conservative estimate he got from
      Walter Reed of more than 800 cases.
      Posted on Wed, Dec. 21, 2005
      Skin ulcers plague men from N.C. unit
      JAY PRICE - The (Raleigh) News & Observer
      You go on the record April 15th 2005 saying you suspect
      there are 1,500 cases. When Army Surgeon General's Office
      is saying 830 cases.
      * Rare parasite infection afflicts U.S. troops in Iraq

      The Gazette
      I found that the AMSA MSMR report at CHPPM says total
      number of Leishmaniasis case for the Armed Forces in
      November 2004 was 1,178.
      Leishmaniasis among U.S. Armed Forces, January 2003-November 2004
      Which means that Mr. Price had been very conservative by about
      378 cases from the November 2004 total. Not to mention the Dec
      2005 total.
      So when you wrote saying:
              "as well as overambitious reporting of suspected cases that
              have not been confirmed by laboratory methods"
      I find that these reporters have every reason to be suspicious of
      the totals as they go up, and down. Who can we rely on to get the
      totals right when it seems there is a conflict here on that total.
      So my question to you, Army Surgeon General, CHPPM, AFIP,
      DHCC, DHSD, CDC, NIH, CENTCOM, and others that apply is:
      What are the actual total of American military Leishmaniasis
      cases for December 2005?
                                                              Kirt P. Love
                                                              Director, DSBR

      ----- Original Message -----
      Sent: Tuesday, December 27, 2005 7:47 AM
      Subject: RE: DOD under reporting Leishmaniaisis cases

      Dear Kirt P. Love;
          You raise some very important issues and have identified a true Achilles' heel of epidemiology and disease surveillance that has plagued the military since its inception.  The issues are complex to say the least involving both perceived and real issues that are complicated by the political atmosphere, interagency efforts that do not always mesh, and a waxing and waning of attention by both the medical community and patient population.
          Currently, reporting of leishmania cases to the reportable disease database by practitioners who see cases is probably the most robust and best way to track the number of cases.  Unfortunately, this is complicated by the knowledge of practitioners that they are supposed to report this disease, the knowledge of where to report this disease to, and the desire to report this (all of these contribute to underreporting), as well as overambitious reporting of suspected cases that have not been confirmed by laboratory methods (contributing to over reporting).  The hope is that these two opposing errors in the system will balance themselves.  Unfortunately this balance is all too often influenced by some of the problems I pointed out in the second line of my message above.
          We track the number of cases that are submitted to us for laboratory confirmation and have a very good tracking since the beginning of the war in Iraq, but only of the laboratory confirmed cases.  We report these numbers to requests for information to OTSG and others on a regular basis. 
          I can give a personal perspective on this though having spent the first year of the war in Iraq as the commander of the 520th TAML who was tasked to do endemic disease surveillance for the theater.  During that year, we identified the potential problem and did active disease surveillance.  We captured a large percentage of the actual cases since we did an extensive education program with both the commanders on the ground as well as the vast majority of the medical personnel present in the theater.  At that time, we did not know what species of leishmania we were dealing with and as such we very proactive in identifying as many cases as possible.  Over time we discovered that the majority of the cases (>99%) of all cutaneous disease in Iraq from leishmania were caused by Leishmania major and was of a MON type that produced only mild disease in the majority of the cases.  Many cases of leishmania caused by this species was self-healing and posed little to no health threat to the soldier.  This was a good thing and a bad thing as the attention of most practitioners then turned to more immediately threatening issues for the patients that they saw both in Iraq and in the returning troops.  Surveillance became passive rather than active and many of the cases were viewed as needing a tincture of time rather than the sometimes difficult to administer Pentostam treatment originally recommended.
          It is my personal belief that while the numbers of new cases have dramatically dropped as compared to the first year of the war, principally due to better living conditions rather than better preventive measures such as permethrin and DEET, it is not as low as surveillance data would suggest.  I personally believe the true numbers to be an order of magnitude higher than currently reported for several reasons (underreporting from practitioners who see the disease - either through not recognizing the disease or not reporting the cases they do see; troops not reporting the lesions for many reasons - sometimes they have more important things to worry about while in theater and downplay the lesions and therefore are not seen until they return to be seen as a local VA, military facility, or personal physician).
          One last important issue to consider is that the press reporting leishmania in troops returning are not always accurate.  Unless the disease is laboratory confirmed, it may not be leishmania.  I can tell you from personal experience of seeing hundreds of leishmania cases just during the first year of the war, the number of skin lesions that look like leishmania is much higher than the number of lesions that are really leishmania.  I found in active surveillance of probable cases, that there were probably one true leishmania case for very 6 or more lesions I looked at that looked like leishmania (the majority turned out to be complicated bacterial infections that cleared with appropriate antibiotic therapy... and Keflex, most often prescribed for these lesions, was not appropriate).
          I know that this long discourse does not fix the problem, but may contribute to understanding the problem and may lead to a solution.  I would be happy to discuss this further at any time and continue to work on our end in the accurate diagnostics of this disease.

      Peter J. Weina, PhD, MD 
      LTC (P), MC, USA 
      Director, Leishmania Diagnostics Laboratory
      Walter Reed Army Institute of Research
      503 Robert Grant Avenue
      Silver Spring, MD 20910
      Phone: 301-319-9956
      Fax: 301-319-7360

      From: Kirt Love [mailto:kirt@...]
      Sent: Saturday, December 24, 2005 4:21 PM
      To: EPI@...; special.assistant@...; mcevoy@...; Weina, Peter J LTC WRAIR-Wash DC; Magill, Alan J COL WRAIR-Wash DC; wriisc.dc@...
      Cc: Gulflink
      Subject: DOD under reporting Leishmaniaisis cases

      Dear Sir or Mam
      Ive been trying to follow the Cutaneous Leishmaniasis cases
      coming back from Iraq, and sources like the CHPPM MSMR
      as well as other sources have not been very helpful.
      If I follow the Leishmaniasis ICD 9 bar graph it looks like its
      saying there were 7 cases for September 2005 for the Army.
      That through May there have been virtually little outbreaks
      military wide.
      Yet, in this Raleigh Observer newspaper we have 13 cases
      of Cutaneous Leishmaniasis from one unit in West Virginia.
      The 30th Heavy Separate Brigade. That happened this summer.
      During what the MSMR seems to report as the low part of
      this outbreak. Based on your stats, this would be the only
      people infect during that period. Which doesnt seem very
      realistic given how many cases Ive bumped into at the
      Washington DC VAMC.
      I was told by one returned soldier there that the F Co, 425th Infantry,
      Long Range Surveillance, Michigan Army National Guard had
      a horrendous outbreak up by Tal A'far. As well as other units
      at Mosul, where in one instance the sand bags used to reinforce
      the perimeters turned out full of sand fly larva that swarmed the
      camps. In his discussion with me, he said that those with small
      bites were ignored - that the medics only focused on big sores.
      More than 10 in his own unit alone.
      Its appears the cases are being under reported, or that medical
      observation is being limited to noticable draining wounds.
      What is being done to truly monitor the current amount of CL infections,
      and where can we find a up to date location to monitor the troops
      infected from Iraq.
                                                              Kirt P. Love
                                                              Director, DSBR 

      Posted on Wed, Dec. 21, 2005
      Skin ulcers plague men from N.C. unit
      13 suffer from `Baghdad boil,' likely contracted during volleyball games
      The (Raleigh) News & Observer

      RALEIGH - In addition to the combat casualties suffered during a tour of duty in Iraq last year, an N.C. National Guard brigade also had to medevac 13 men back to a U.S. hospital after volleyball games left them vulnerable to one of the Iraq war's most exotic hazards -- an outbreak of skin ulcers that can grow for years.

      The victims, all men from the same small unit, contracted cutaneous leishmaniasis, characterized by weeping sores that refuse to heal, said Lt. Col Tim Mauldin, the brigade's top medical officer.

      "No matter what you do, it just keeps getting bigger and bigger," he said.

      Leishmaniasis is spread by the bite of tiny sandflies, which deposit microscopic parasites that cause the sores. It is endemic along the Iranian border where some of the North Carolina troops served. Another version of the disease is fatal, but the main dangers for victims of this strain are permanent scarring (the ulcers often occur on the face) and loss of motion if the sores appear over a joint.

      The illness is nicknamed "Baghdad Boil." At the time the guardsmen contracted it last year, the only way to treat it was to fly them back to Walter Reed Army Medical Center for up to three weeks of intravenous treatments with a drug called Pentostam. It is not approved for use in the United States. The Army was able to administer the treatment because it had gotten the drug approved for experimental use.

      The victims were all members of an armor unit based in West Virginia. The unit is permanently attached to the 30th Heavy Separate Brigade, based in Clinton, said Spc. Robert Jordan, a Guard spokesman in Raleigh.

      None of the victims was immediately available for comment. A Guard spokesman in West Virginia said last week he was having trouble locating them.

      All recovered, said Mauldin, the brigade medical officer.

      He said most of the victims had played volleyball games in a court set up in sand that was infested with the flies. Like the rest of the brigade's soldiers in Iraq, they had used high-powered insect repellent. Apparently, though, they had sweated it off as they played in the searing heat of the Iraqi summer.

      It was early in the deployment, and their camp was still crude, so many were also sleeping outdoors without insect nets.

      It's possible that other troops and U.S. contractors have the illness and don't know it yet. Symptoms can take months to appear, and in rare cases more than a year. Because of the disease, federal health officials declared in 2003 that troops who served in Iraq would not be allowed to give blood for a year after returning home.

      Mauldin said the other soldiers of the brigade had been told to get regular exams at U.S. Department of Veterans Affairs hospitals and clinics once they returned to North Carolina. They have full access to VA treatment after coming home, he said.

      The disease can be hard to diagnose, because few U.S. medical professionals have seen it.

      Leishmaniasis experts from Walter Reed have traveled to large bases across the country to spread the word about what to look for. Early in the war, they moved from camp to camp in Iraq, raising awareness.

      The sores start as little more than bumps. The wounds gradually grow, in some cases to the size of a quarter or even larger. Army doctors reportedly saw one lesion 3 inches in diameter.

      Typically, each Guard victim had just one sore, though some soldiers treated for leishmaniasis reportedly have had more than 30. Others developed knobby lesions that looked like tumors.

      For the Guard victims, the outbreak could have been worse. More than 800 U.S. service members have contracted the disease since the Iraq War began in early 2003, most of them in Iraq, though some also in Afghanistan.

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