The following report is an analysis of the infectious diseases in Afghanistan, designed for use by humanitarian relief workers. The author is the GDIN Infectious Disease Working Group. Questions and suggestions for improvement of the data is encouraged. Send to firstname.lastname@example.org. Other information on GDIN, the Global Disaster Information Network (GDIN) and its Infectious Disease Working Group can be found at www.gdin.org.
GDIN's Infectious Disease Working Group functions independently but in concert with official infectious disease reporting and verification systems. Its objective is to serve as a resource multiplier and a facilitator of efficient, rapid, cost-effective infectious disease management by the international community and individual governments through improved communication and information support.
Food-borne and water-borne diseases
Sanitation is extremely poor throughout the country. Local food and water sources (including ice) are heavily contaminated with pathogenic bacteria, parasites, and viruses. Risk is year-round and countrywide, including in major urban areas.
- Bacterial and protozoal diarrhea: In general, bacterial agents such as enterotoxigenic Escherishia coli, Campylobacter, Shigella, and Salmonella are the most common causes of acute bacterial diarrhea. Resistance to the standard therapeutic agent sulfamethoxazole/trimethoprim (SMZ/TMP) has been reported. Endemic protozoa such as Cryptosporidium spp., Giardia lamblia, and Entamoeba histolytica often are associated with more chronic infections, but can cause acute diarrhea. Amoebiasis infection rates up to 3 percent have been estimated for the general Afghan population. Giardiasis has been found in up to 11 percent of surveyed children.
- Cholera: as of March 2000, the World Health Organization considered the following provinces cholera endemic: Badakhshan, Baghlan, Balkh, Bamian, Helmand, Herat, Kabol, Kandahar, Kapisa, Kondoz, Lowgar, Nangarhar, and Zabol.
- Hepatitis A and E: Most Afghans contract hepatitis A virus (HAV) infection during childhood, indicating active transmission of the virus both person-toperson and through contact with contaminated water. Hepatitis E virus (HEV) infection has been reported, but levels are unclear.
- Typhoid and paratyphoid fever: outbreaks have been reported in rural and urban areas.
During the warmer months of May to November, the climate and ecological habitat support large populations of arthropod vectors, including mosquitoes, ticks, and sand flies. Significant disease transmission is sustained countrywide, including in urban areas. Malaria is the major vector-borne risk in Afghanistan. In addition, many other serious diseases may not be recognized or reported due to the lack of surveillance and diagnostic capability.
- Crimean-Congo hemorrhagic fever: Tick-borne (Amblyomma variegatum and Hyalomma marginatum). Infection also may be transmitted through contact with blood and body fluids of infected patients, and during slaughter of infected animals. Risk is year-round (peak transmission in warmer months) and primarily in rural areas.
- Cutaneous-mucosal Leishmaniasis: Seasonal (Apr to Oct) associated with the period of greatest sand fly activity. Risk is limited to focal areas in rural and periurban areas in the northern plains of Baghlan, Balkh, Faryab, Jowzjan, Kondoz, Samangan, and Takhar Provinces, and in the southwestern lowlands. Foci of L. tropica have been reported from most towns and cities of Badakhshtan, Ghazni, Herat, Kabol, Kandahar, Kapisa, and Parvan Provinces.
- Malaria: Seasonal (May to Nov), transmission generally is limited to the warmer months with seasonal variations dependent on elevation. Risk exits countrywide (including urban areas) below 2,000 meters elevation. Plasmodium vivax predominates countrywide, but P. falciparumz also occurs. Cholorquine resistance has been reported.
- Relapsing fever: Tick-borne (Ornithodoros papillipes). Identified in Alpine regions of central Afghanistan.
- Sand fly fever: Seasonal (Apr to Oct) associated with periods of greatest sand fly activity. Focally endemic, based on regional occurrence and on virus isolation (Sicilian and Naples viruses) in Paravan Province in central-eastern Afghanistan.
- Typhus (louse-borne): Risk is year-round and countrywide (Up to 13 percent of surveyed adults have been seropositive).
- Typhus (mite-borne): foci likely exist countrywide up to 3,200 meters elevation in areas of scrub brush and secondary growth vegetation favorable for vector mite populations.
Overcrowding associated with cold conditions and use of temporary shelter is highly conducive to the transmission of measles, diphtheria, meningitis, influenza, tuberculosis, and acute respiratory infections. The biggest concern is high mortality among the 5 and under age group, with some relief organizations estimating mortality of 5.9 per 10,000. High mortality is almost inevitable when vaccination rates are low; measles vaccination rates are estimated to be as low as 35 percent of the population. Complicating low measles vaccination rates is the fact that children are undernourished and vitamin A deficient. In addition, displacement of the Afghan people is disrupting ongoing tuberculosis treatment, contributing to further spread of infections. Although the immediate impact of disrupted tuberculosis control is minimal, this will eventually influence longer-term health status.
- Measles: Outbreaks have been reported, with Measles vaccine has been a priority of ongoing relief efforts, but many children likely remain susceptible.
- Meningococcal meningitis: Transmitted by direct contact, including exposure to respiratory droplets from nose and throat of infected people. Disease may occur countrywide and year-round (peak transmission period Nov to Feb); risk may be elevated during cooler months.
- Tuberculosis: Afghanistan is one of the highest burden countries for tuberculosis in the world; nearly 35 percent of the population reportedly is infected. The World Health Organization estimated that in 1999 there were 325 new tuberculosis cases per 100,000 population.
- Poliomyelitis: Transmitted via the fecal-oral route, polio is a serious health threat to Afghan children. Polio control has been an ongoing relief priority, at times prompting cease-fires to conduct vaccination campaigns.
- Anthrax: Cutaneous anthrax (transmitted through direct contact with infected animals or carcasses, including hides) and gastrointestinal anthrax (contracted through eating infected meat) occur year-round, primarily in rural areas. (see appendix on Anthrax)
- Leptospirosis: Lakes, rivers, streams or other surface water in the northern and eastern plains may be contaminated with leptospirosis.
- Rabies: human and animal cases occur annually.