Leishmaniasis December 11th, 2003 Kirt P. Love Director, DSBR Contamination of American Blood supply, Gulf War I & II.

Introduction The Gulf War conflict was fought primarily during the winter season, so the issue of Sand Fly exposure was minimal. Still, what has been overlooked by the military medical monitoring was that Leishmaniasis also flourishes in wet pools, and then burrows into the feet of their host.

DHSD – WRAMC - DHCC Our organization met with the Pentagons Deployment Health Support Directorate on the medical fate or troops Deploying to Iraq in September – December 2002

DHSD – WRAMC - DHCC Mike Kilpatrick of DHSD stated that the indecisive PCR test for Leishmaniasis still needed work, and wasn’t reliable. September – December 2002

Cutaneous vs L. Tropica Even though a directive was sent out by the Army Surgeon General on December 23 rd, 2002 to monitor Leishmaniasis during the present War. Diagnosis in the feild was exclusively visual observation for lesions. PCR labs or Splenic asparate / Bone marrow were not available in the desert for non-visual symptoms.

UNICEF - Outbreak Outbreak of Kala-Azar (Visceral Leishmaniasis) in Iraq UNICEF has announced an outbreak of Kala-Azar (Visceral Leishmaniasis) in Iraq. Though there have been outbreaks of the disease in Iraq in the past around this time of year, it is particularly severe this time. around this time of year, it is particularly severe this time. There are now more than 200 cases of Kala-Azar reported in Iraq. The country does see regular outbreaks of the disease. country does see regular outbreaks of the disease. UNICEF has warned that this time the outbreak could be severe. UNICEF has warned that this time the outbreak could be severe. Kala-Azar is spread mainly by sand flies and causes malnutrition and Kala-Azar is spread mainly by sand flies and causes malnutrition and anaemia. When left untreated, the disease is fatal within 4 to 6 weeks. anaemia. When left untreated, the disease is fatal within 4 to 6 weeks. [Byline: Kamini Sawhney (Baghdad)] Thu 29 May 2003

PL , & monitoring Pre and Post deployment medical tracking of the troops in Afghanistan and Iraq were hastily done. So many did not give blood samples before leaving, stored by the AFIP.

PL , & monitoring That blood taken before and after is strictly HIV testing, and is not used for other test. The Naval Research Medical Center, and others have used it for limited recent studies, but it is still strictly a military medical operation.

Civilian monitoring American Physicians are not ready for this Exotic Endemic disorder, and will miss cases having little previous experience. September 12th 2003, William Winkenwerder: Under Secretary for Health, Veteran Affairs Memorandum to Joint Chiefs of Staff, Leishmaniasis “It is also possible that deployed personnel may re-deploy without knowing they are infected”

Monitoring USA TODAY December 4, 2003 Coleman and Army Lt. Col. Peter Weina, a leishmaniasis expert still in Iraq, predicted in April that there would be 400 cases, based on the number of bites seen and tests that show about one out of 70 sand flies carries the bug. Dr. Coleman found soldiers who got New York Times - December 6, 2003 Dr. Coleman found soldiers who got more than 200 bites in a single night.

Major vs Tropica L Major - 1,500,00 cases world wide each year L Tropica - 500,00 cases world wide each year L. donovani L. mexicana L. tropica L. major L. aethiopeca The Pentagon recognizes 12 cases of L. Tropica from the 1991 Gulf War, and 20 cases of L. Major. The Pentagon is also trying to say there is almost no L. Tropica present in Iraq. WRAMC goes as far as to imply the Iraqi L. Tropica is less virulent.

ELISA / PCR Current ELISA accuracy is still between 32% to 67% with 3 part control under ideal conditions. Visceral tissue biopsies are only good after infection is severe to terminal. Institute of Microbiology and Hygiene, Humboldt University, Charite, Berlin, Germany. 113 cases (69.7%) were positive by PCR Sept 2003

Visceral untreated Office of Clinical and Regulatory Affairs, National Center For Complementary and Alternative Medicine, National Institutes of Health “visceral disease is incurable if untreated.”

Treatments Drug of Choice: Amphotericin B, Streptomyces nodosus (photo sensitive – 4 to 6 times a day ) $ mg Not as effective with Visceral: Pentostam - Diflucan 100 MG 50 TAB $ Alternatives: Fluconazole 100 MG 50 TAB $ Miltefosine (Impavido®) $ mg Too Expensive!!

Incubation With no compulsary reporting of Leishmaniasis around the world, It is still undetermined what long term incubations could remain in remission until turning visceral. One case at WRAMC showed 43 years after a old cutaneous scar was irritated, the case developed to visceral.

Summary With DOD unable to track this, or unwilling to pay for expensive advanced labs – there is no way of knowing for sure how many troops coming home will be infected or with what strain. Until the lab detection procedures are 100% conclusive, and species specific – isnt the risk of Leishmaniasis to the general public from the troops too high.

Recommendations With undetermined long term latency for Leishmaniasis ( Tropica )and the uncertainty of today’s labs, we at DSBR recommend to the FDA a permanent blood ban on all troops coming home From Iraq, Afghanistan from 1990 to present. At a minimum the soldiers blood should not be used in Vat blood products, or plasma serum based products.