Leprosy Mailing List, August 30th, 2009
Ref.: Be aware of the word 'cured' in LL cases.
From: Ganapati R., Mumbai, India
--------------------------------------------------------------------------------
Dear Dr Derek,
I refer to your LML message dated August 27th, 2009. Thank you for this. Your illustrious father Dr Stanley Browne who made his contributions mainly in the dapsone mono-therapy era had warned long ago about the relapses due to the “lurking bacilli”.
He continued to make observations during the early MDT period, but unfortunately did not live long enough to observe the outcome of the persistence of lurking organisms leading to relapse many years after completion of effective treatment with far more powerful bactericidal drugs.
We are encountering relapses 10 to 15 years after withdrawal of treatment in spite of satisfactory completion of universally prescribed schedules of treatment. This phenomenon reiterates the foresight of the “Mr Leprosy” who rightly advised to use the word ”cure” in LL cases with caution. Unfortunately the word is freely used particularly by some who want to underestimate relapses for public health reasons.
Relapse should be viewed from the clinical angle, as this is of concern to the affected individual. If the patient is BI and MI* positive at the time of relapse, he may be source of transmission of leprosy.
With regards,
Dr R Ganapati
*BI= bacteriological index
MI= morphological index
Pages
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Monday, August 31, 2009
Enhanced Global Strategy 2011-2015
Leprosy Mailing List, August 29th, 2009
Ref.: Enhanced Global Strategy 2011-2015 (see attachment)
From: Pannikar V., New Delhi, India
--------------------------------------------------------------------------------
Dear Dr Noto,
Please find attached the final print version (English, PDF) of the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy (2011-2015). Several hard copies of the document will be distributed to all WHO Regions, countries and partners for distribution to all health programme managers responsible for leprosy control in their area.
The purpose of these documents is to help managers of national health services to develop detailed national policies applicable to their own situation, and revise the National Manual for Leprosy Control in their respective countries.
I would like to request you to share these documents with the national programme authorities from endemic countries and other interested colleagues. In addition, I would encourage programmes to translate the document into local languages, as appropriate.
With kind regards,
V. Pannikar
Ref.: Enhanced Global Strategy 2011-2015 (see attachment)
From: Pannikar V., New Delhi, India
--------------------------------------------------------------------------------
Dear Dr Noto,
Please find attached the final print version (English, PDF) of the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy (2011-2015). Several hard copies of the document will be distributed to all WHO Regions, countries and partners for distribution to all health programme managers responsible for leprosy control in their area.
The purpose of these documents is to help managers of national health services to develop detailed national policies applicable to their own situation, and revise the National Manual for Leprosy Control in their respective countries.
I would like to request you to share these documents with the national programme authorities from endemic countries and other interested colleagues. In addition, I would encourage programmes to translate the document into local languages, as appropriate.
With kind regards,
V. Pannikar
“Leprosy eliminated? … A wake-up call from Liberia”
Leprosy Mailing List, August 27th, 2009
Ref.: “Leprosy eliminated? … A wake-up call from Liberia”
From: Vijayakumaran P., Chennai, India
--------------------------------------------------------------------------------
Dear Dr. Noto,
Greetings from Damien Foundation India Trust. This is regarding Dr Diefenhardt’s message and attachment “Leprosy eliminated? … A wake-up call from Liberia”, LML, July 7th, 2009. Thank you for sharing the observation.
I came across a similar situation in India. It was one of the backward regions in socio-economic development and communication facilities. There was no civil war but this region was highly prone for natural calamities. The leprosy situation was far behind when compared to many other regions in the country.
We had an advantage that health infra-structure existed in this region though inadequate. In that time (year 1996) there was set of health staff exclusively for leprosy control programme (called vertical programme). There was gross inadequacy of staff in vertical structure.
There was lack of guidance to health staff to implement required activities. Capacity building and on-the-job guidance were the major components of new strategy (through Technical Support Teams). The primary health care system was enabled to participate in leprosy control programme from the beginning of implementing the new strategy. When the leprosy control programme activities were regularly implemented there was a remarkable progress. Basic leprosy care services were made available in all the primary health centres. The leprosy control programme was integrated into primary health care system (year 2002). The progress was sustainable as primary health care system was involved along with vertical system. The Technical Support Teams were totally withdrawn in the year 2007. The success was mainly because of good situation analysis, application of appropriate strategy and good coordination by programme managers at different levels.
I am not aware of the situation and health infra-structure in Liberia. The data discussed in the communication seemed to be from a referral hospital. Generally data from such sources may not reflect the actual situation. Hence it may not be appropriate to directly interpolate to the region. The term incidence was mentioned several times. The data referred to in the communication was actually case detection rate. Patchy coverage or spurts of activities may present a situation described in the communication. New case reporting in a referral centre increases when basic care in the general health system is deficient or inaccessible due to various reasons.
There is a clear indication for a complete situation analysis in this region.
With regards.
Dr.Vijayakumaran.P
Director (Prog),
Damien Foundation India Trust,
Chennai, India.
References for the information cited:
1. Trends in new case-detection leprosy in Bihar, India. Vijayakumaran P, Prasad B, Krishnamurthy P. Indian J Lepr. 2006 Apr-Jun;78(2):145-51.
2. "Instant" new leprosy case-detection: an experience in Bihar State in India. Rao TP, Krishnamurthy P, Vijayakumaran P, Mishra RK, Samy MS. Indian J Lepr. 2003 Jan-Mar;75(1):9-15.
3. Pace of leprosy elimination and support teams in Bihar state, India. Vijayakumaran P, Rao TP, Krishnamurthy P. Lepr Rev. 1999 Dec;70(4):452-8.
4. Utilizing primary health care workers for case detection. Vijayakumaran P, Reddy NB, Krishnamurthy P, Ramanujam R. Indian J Lepr. 1998 Apr-Jun;70(2):203-10.
Ref.: “Leprosy eliminated? … A wake-up call from Liberia”
From: Vijayakumaran P., Chennai, India
--------------------------------------------------------------------------------
Dear Dr. Noto,
Greetings from Damien Foundation India Trust. This is regarding Dr Diefenhardt’s message and attachment “Leprosy eliminated? … A wake-up call from Liberia”, LML, July 7th, 2009. Thank you for sharing the observation.
I came across a similar situation in India. It was one of the backward regions in socio-economic development and communication facilities. There was no civil war but this region was highly prone for natural calamities. The leprosy situation was far behind when compared to many other regions in the country.
We had an advantage that health infra-structure existed in this region though inadequate. In that time (year 1996) there was set of health staff exclusively for leprosy control programme (called vertical programme). There was gross inadequacy of staff in vertical structure.
There was lack of guidance to health staff to implement required activities. Capacity building and on-the-job guidance were the major components of new strategy (through Technical Support Teams). The primary health care system was enabled to participate in leprosy control programme from the beginning of implementing the new strategy. When the leprosy control programme activities were regularly implemented there was a remarkable progress. Basic leprosy care services were made available in all the primary health centres. The leprosy control programme was integrated into primary health care system (year 2002). The progress was sustainable as primary health care system was involved along with vertical system. The Technical Support Teams were totally withdrawn in the year 2007. The success was mainly because of good situation analysis, application of appropriate strategy and good coordination by programme managers at different levels.
I am not aware of the situation and health infra-structure in Liberia. The data discussed in the communication seemed to be from a referral hospital. Generally data from such sources may not reflect the actual situation. Hence it may not be appropriate to directly interpolate to the region. The term incidence was mentioned several times. The data referred to in the communication was actually case detection rate. Patchy coverage or spurts of activities may present a situation described in the communication. New case reporting in a referral centre increases when basic care in the general health system is deficient or inaccessible due to various reasons.
There is a clear indication for a complete situation analysis in this region.
With regards.
Dr.Vijayakumaran.P
Director (Prog),
Damien Foundation India Trust,
Chennai, India.
References for the information cited:
1. Trends in new case-detection leprosy in Bihar, India. Vijayakumaran P, Prasad B, Krishnamurthy P. Indian J Lepr. 2006 Apr-Jun;78(2):145-51.
2. "Instant" new leprosy case-detection: an experience in Bihar State in India. Rao TP, Krishnamurthy P, Vijayakumaran P, Mishra RK, Samy MS. Indian J Lepr. 2003 Jan-Mar;75(1):9-15.
3. Pace of leprosy elimination and support teams in Bihar state, India. Vijayakumaran P, Rao TP, Krishnamurthy P. Lepr Rev. 1999 Dec;70(4):452-8.
4. Utilizing primary health care workers for case detection. Vijayakumaran P, Reddy NB, Krishnamurthy P, Ramanujam R. Indian J Lepr. 1998 Apr-Jun;70(2):203-10.
Be aware of the word 'cured' in LL cases
Leprosy Mailing List, August 27th, 2009
Ref.: Be aware of the word 'cured' in LL cases.
From: Browne D., Brockenhurst, Hampshire , UK
--------------------------------------------------------------------------------
Dear Salvatore,
Grace Warren's contribution (LML 20th August, 2009) was a brave reflection on the actual 'current' leprosy problem now and possible future explosion of reactivated cases worldwide.
My father the late Dr Stanley Browne (Mr Leprosy) often told me to be aware of the word 'cured' in LL cases, ' you never know what's going to happen to the bacilli lurking dormant in the dartos muscles waiting for the right conditions to reactivate'
Thank you Grace for your contribution.
Derek Browne
Ref.: Be aware of the word 'cured' in LL cases.
From: Browne D., Brockenhurst, Hampshire , UK
--------------------------------------------------------------------------------
Dear Salvatore,
Grace Warren's contribution (LML 20th August, 2009) was a brave reflection on the actual 'current' leprosy problem now and possible future explosion of reactivated cases worldwide.
My father the late Dr Stanley Browne (Mr Leprosy) often told me to be aware of the word 'cured' in LL cases, ' you never know what's going to happen to the bacilli lurking dormant in the dartos muscles waiting for the right conditions to reactivate'
Thank you Grace for your contribution.
Derek Browne
We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
Leprosy Mailing List, August 24th, 2009
Ref.: We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
From: Palande D. D., Pondicherry, India
--------------------------------------------------------------------------------
Dear Salvatore,
I fully agree with Grace Warren (LML, August 20, 2009). May be we are the older generation with less patience and belief in epidemiological projections based on available information from registers and better vision in spite of our age. In both India and China the priority for Leprosy in particular and health in general is rather low- very pragmatic countries as is WHO.
However I do believe that Nature is great. Something will happen, who knows? The Hansen’s Disease Bacillus may mutate into a harmless one!
Best regards,
Dinkar D. Palande
Ref.: We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
From: Palande D. D., Pondicherry, India
--------------------------------------------------------------------------------
Dear Salvatore,
I fully agree with Grace Warren (LML, August 20, 2009). May be we are the older generation with less patience and belief in epidemiological projections based on available information from registers and better vision in spite of our age. In both India and China the priority for Leprosy in particular and health in general is rather low- very pragmatic countries as is WHO.
However I do believe that Nature is great. Something will happen, who knows? The Hansen’s Disease Bacillus may mutate into a harmless one!
Best regards,
Dinkar D. Palande
We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
Leprosy Mailing List, August 24th, 2009
Ref.: We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
From: Ganapati R., Munbay, India
--------------------------------------------------------------------------------
Dear Dr Warren,
Many knowledgeable clinicians will definitely like to join your cry in the wilderness (ref LML, August 20, 2009). Your views on “reservoir cases” representing the very basis of leprosy transmission have been deliberately ignored by the guardians of public health since the advent of MDT. In their attempt to over- simply the complex clinical facets of the disease, they devised a “made easy” solution for collecting statistics and have painted a rosy picture. Many are still gloating over the success of reaching the goal of 1 case per 10,000 population. Over this long period the science of clinical leprology unfortunately has been sidelined.
In our experience in Bombay, true relapses in multibacillary leprosy with bacterial positivity are encountered as late as 10 to 15 years after stopping treatment (irrespective of the treatment regimens and duration of therapy) raising the possibility of recycling of transmission of the disease. Poorly managed type 1 and 2 reactions with uncontrolled neuritis are thronging our referral centres.
It is a paradox that donors are made to believe that leprosy is eradicated. NGOs solely depending upon public donations are virtually deprived of money and manpower.
Your emphatic reference to the prevailing poor knowledge about relapses and nerve damage due to reaction should be an eye opener to the public health experts and make them devise a fresh mass strategy to eradicate the disease before it is too late.
With regards,
Dr R Ganapati,
Director Emeritus,
Bombay Leprosy Project
Ref.: We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
From: Ganapati R., Munbay, India
--------------------------------------------------------------------------------
Dear Dr Warren,
Many knowledgeable clinicians will definitely like to join your cry in the wilderness (ref LML, August 20, 2009). Your views on “reservoir cases” representing the very basis of leprosy transmission have been deliberately ignored by the guardians of public health since the advent of MDT. In their attempt to over- simply the complex clinical facets of the disease, they devised a “made easy” solution for collecting statistics and have painted a rosy picture. Many are still gloating over the success of reaching the goal of 1 case per 10,000 population. Over this long period the science of clinical leprology unfortunately has been sidelined.
In our experience in Bombay, true relapses in multibacillary leprosy with bacterial positivity are encountered as late as 10 to 15 years after stopping treatment (irrespective of the treatment regimens and duration of therapy) raising the possibility of recycling of transmission of the disease. Poorly managed type 1 and 2 reactions with uncontrolled neuritis are thronging our referral centres.
It is a paradox that donors are made to believe that leprosy is eradicated. NGOs solely depending upon public donations are virtually deprived of money and manpower.
Your emphatic reference to the prevailing poor knowledge about relapses and nerve damage due to reaction should be an eye opener to the public health experts and make them devise a fresh mass strategy to eradicate the disease before it is too late.
With regards,
Dr R Ganapati,
Director Emeritus,
Bombay Leprosy Project
We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
Leprosy Mailing List, August 20th, 2009
Ref.: We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
From: Warren G., Sidney, Australia
--------------------------------------------------------------------------------
Dear Salvatore,
Thank to Dr Pannikar for the latest in WHO statistics (LML Aug. 18th , 2009). I used to get them direct but that seems to have ceased. I much preferred to read the ones from India showing how many cases they are finding which somehow do not get on the register.
Is there anyway we can get WHO to be more realistic? One of my objections is that their figures do not come from every country. Yes, I know that is the choice of the country to send in or not, but some countries not there do have considerable case loads, and many do not want to acknowledge that!
Another objection is that they record so few relapsed cases. Yes, easy when the patient I removed from the register when he has completed the WHO MDT! If he reappears with new lesions he is a new case! WHO say very few relapses! I hate to think of the number I personally have seen in the last 20 years. Patient who have officially completed the WHO MDT.
Next is that applying the WHO definition eliminates a lot of the early LL type patients we see on east Asia (especially in Chinese skins). With over 15 years resident in Hong Kong I know that many LL patients do not develop sensory abnormalities for 10-20 years during which time they can be highly infectious, and in a large proportion there is no obvious skin lesion though if you are very astute you may realises the skin is infiltrated in very large patches! The use of slit-skin smears or even nose blows will show these people with high Bacillary Index. Once our main proof and very useful is recording progress!
Am I a voice crying in the wilderness? One problem is that the general public read the WHO statements and believing them say that leprosy work no longer requires extra funding!
Another is that Countries that use WHO free MDT often do not finish treatment. Very few true well established LL patients will be completely "cured" in 12 months, especially if they have had steroids with the MDT. Many continue with ENL and get progressive nerve involvement, but the local medicos say: - Oh They have finished MDT- No they are not on it specific anti-leprotics-
Please can there be some way of getting this rectified. We are not going to eliminate leprosy while we do not treat these reservoir cases adequately!
Grace Warren.
Ref.: We are not going to eliminate leprosy while we do not treat reservoir cases adequately!
From: Warren G., Sidney, Australia
--------------------------------------------------------------------------------
Dear Salvatore,
Thank to Dr Pannikar for the latest in WHO statistics (LML Aug. 18th , 2009). I used to get them direct but that seems to have ceased. I much preferred to read the ones from India showing how many cases they are finding which somehow do not get on the register.
Is there anyway we can get WHO to be more realistic? One of my objections is that their figures do not come from every country. Yes, I know that is the choice of the country to send in or not, but some countries not there do have considerable case loads, and many do not want to acknowledge that!
Another objection is that they record so few relapsed cases. Yes, easy when the patient I removed from the register when he has completed the WHO MDT! If he reappears with new lesions he is a new case! WHO say very few relapses! I hate to think of the number I personally have seen in the last 20 years. Patient who have officially completed the WHO MDT.
Next is that applying the WHO definition eliminates a lot of the early LL type patients we see on east Asia (especially in Chinese skins). With over 15 years resident in Hong Kong I know that many LL patients do not develop sensory abnormalities for 10-20 years during which time they can be highly infectious, and in a large proportion there is no obvious skin lesion though if you are very astute you may realises the skin is infiltrated in very large patches! The use of slit-skin smears or even nose blows will show these people with high Bacillary Index. Once our main proof and very useful is recording progress!
Am I a voice crying in the wilderness? One problem is that the general public read the WHO statements and believing them say that leprosy work no longer requires extra funding!
Another is that Countries that use WHO free MDT often do not finish treatment. Very few true well established LL patients will be completely "cured" in 12 months, especially if they have had steroids with the MDT. Many continue with ENL and get progressive nerve involvement, but the local medicos say: - Oh They have finished MDT- No they are not on it specific anti-leprotics-
Please can there be some way of getting this rectified. We are not going to eliminate leprosy while we do not treat these reservoir cases adequately!
Grace Warren.
Correct dates for this year’s RPOD and CBR courses at ALERT
Leprosy Mailing List, August 18th, 2009
Ref.: Correct dates for this year’s RPOD and CBR courses at ALERT (see attachments 1 & 2)
From: Roberts A., Addis Ababa, Ethiopia
--------------------------------------------------------------------------------
Addis Ababa, 06/08/2009
Dear Salvatore,
I am sending this now, in readiness for when LML re-opens at the end of this month.
Thank you for posting ALERT and BIKASH international course announcements in May. Unfortunately the dates listed for ALERT’s courses later this year were incorrect. Could you inform members that the correct dates for this year’s RPOD and CBR courses at ALERT are:
RPOD course: October 12 – November 6th.
CBR course: November 9 – 20th.
I have attached the relevant course announcements (1 & 2) with corrected dates. We apologise for any inconvenience.
Sincerely,
Anne Roberts
Physiotherapy & Rehabilitation Co-ordinator, ALERT Hospital
for ALERT Training Division
Ref.: Correct dates for this year’s RPOD and CBR courses at ALERT (see attachments 1 & 2)
From: Roberts A., Addis Ababa, Ethiopia
--------------------------------------------------------------------------------
Addis Ababa, 06/08/2009
Dear Salvatore,
I am sending this now, in readiness for when LML re-opens at the end of this month.
Thank you for posting ALERT and BIKASH international course announcements in May. Unfortunately the dates listed for ALERT’s courses later this year were incorrect. Could you inform members that the correct dates for this year’s RPOD and CBR courses at ALERT are:
RPOD course: October 12 – November 6th.
CBR course: November 9 – 20th.
I have attached the relevant course announcements (1 & 2) with corrected dates. We apologise for any inconvenience.
Sincerely,
Anne Roberts
Physiotherapy & Rehabilitation Co-ordinator, ALERT Hospital
for ALERT Training Division
Global leprosy situation, WER n. 33, 14 August 2009
Leprosy Mailing List, August 18th, 2009
Ref.: Global leprosy situation, WER n. 33, 14 August 2009 (see attachment)
From: Pannikar V., New Delhi, India
--------------------------------------------------------------------------------
Dear Dr Noto,
Please find attached the latest Weekly Epidemiological Record on the global leprosy situation. Kindly share this with colleagues in your organization and other interested people.
Many thanks for your support to the Global Leprosy Programme.
Regards,
V. Pannikar
Ref.: Global leprosy situation, WER n. 33, 14 August 2009 (see attachment)
From: Pannikar V., New Delhi, India
--------------------------------------------------------------------------------
Dear Dr Noto,
Please find attached the latest Weekly Epidemiological Record on the global leprosy situation. Kindly share this with colleagues in your organization and other interested people.
Many thanks for your support to the Global Leprosy Programme.
Regards,
V. Pannikar