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“Aleppo Evil” قرحة حلب : The Ulcer, the Boil, the Sandfly, and the Conflict

News Reports out of Syria indicate the emergence of epidemic cutaneous leishmaniasis in the besieged city of Aleppo, adding further to the misery there.

Modern Aleppo as viewed from the the ancient Citadel. Image credit: watchsmart, via Flickr
Modern Aleppo as viewed from the the ancient Citadel.
Image credit: watchsmart, via Flickr

Even in the best of times the Syrian Arab Republic (Syria) has struggled with cutaneous leishmaniasis (CL). We reported previously in PLOS Neglected Tropical Diseases that old world or anthroponotic CL caused by Leishmania tropica is endemic to Syria and elsewhere in the Middle East, North Africa, and Central Asia. In the ancient northern Syrian city of Aleppo CL has been present for hundreds of years (if not longer), where it is known as the “Aleppo Evil”, “Aleppo ulcer”, “Aleppo Boil”, or “Aleppo Button”. Aleppo evil is a disfiguring condition that disproportionately occurs on the face, especially of young people. It typically lasts one or two years before the lesion heals spontaneously, and is often known locally as “one-year sore”. However, in many cases specific anti-parasitic chemotherapy can hasten the healing process and improve clinical and cosmetic outcomes.

A major problem with one-year sore is that the scar can produce permanent disfigurement of the face.  According to some experts working in Afghanistan old world CL is a cause of social isolation and stigma particularly among girls and young women who can be rendered unmarriageable. Mothers with CL may not be allowed to touch their children even though human to human contact does not transmit the infection.

Experts working on CL in Syria have written about the rise and fall and then a rise again in the incidence of the disease in the city of Aleppo. During the 1950s the number of cases of CL fell after an insecticide campaign aimed at controlling malaria, but it then rose again during the 1960s. However, CL was mostly controlled during the 1980s. There was a subsequent increase after 1992, which has been attributed in part to inadequate garbage disposal and construction waste in areas undergoing development outside of the ancient city center. Garbage collection, open sewage, and poverty are notorious for promoting the habitats of Phlebotomus sandflies that transmit old world CL. Interestingly, a clinical trial conducted prior to the current civil conflict found that use of insecticide-treated bednets (ITNs) could prevent CL in Aleppo.

Image credit: Freedom House, via Flickr
Image credit: Freedom House, via Flickr

Many neglected tropical diseases (‘NTDs’), especially kinetoplastid infections such as human African trypanosomiasis (sleeping sickness) and leishmaniasis, often emerge or re-emerge during times of war and conflict when there is a breakdown in infrastructure or failure to implement public health control measures. Human migrations and urbanization in forested areas are also important factors that link conflict to these NTDs. For instance, in Colombia new world CL has been linked to political violence, narcotics trafficking, and guerilla warfare, as kidnapped and incarcerated individuals are exposed to sandflies and high rates of infection, and denied access to treatment. Similarly in Afghanistan, old world CL became hyperendemic in Kabul.

Given that CL has been a public health threat in Aleppo and presumably elsewhere in Syria for decades it should come as no surprise that this disease would re-emerge with a vengeance as a result of a horrific civil war. While there are few if any official public health reports, several news accounts mostly among refugees fleeing the violence and entering Lebanon and Turkey point to widespread CL in Aleppo and surrounding areas. The number of estimated cases range into the thousands or possibly even the hundreds of thousands with children disproportionately affected.

In times of peace, the global public health community has employed the knowledge base and tools to control CL with an emphasis on surveillance, multisectoral collaboration, and international cooperation. Sanitation, insecticidal spraying, expanded use of ITNs, case detection and access to anti-parasitic therapies are priority measures, each intervention that the Eastern Mediterranean Office of the World Health Organization would ideally help to implement. Meanwhile, leishmaniasis vaccines are also under development but still years away. Unfortunately, the history of conflict and its links with NTDs over the last few decades portend continued public health inaction in the face of ongoing hostilities.  Perhaps at a minimum the international community for now needs to focus on refugees and refugee encampments to ensure local control and patient access to treatments.

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