Follow-up studies on pure/primary neural leprosy patients in India

Leprosy Mailing List – January 19th, 2011

Ref.:   Follow-up studies on pure/primary neural leprosy patients in India

From: Rao P. N., Hyderabad, India

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Dear Salvatore,

This mail is in continuation to Dr Kar’s letter (Jan 11, 2011) on pure/primary neural leprosy (PNL) patients.  Although there are no methods or tests known to identify which patients of PNL develop clinical lesions, there are few follow-up studies which provide information on appearance of skin lesions.  Below mentioned are two studies on PNL, which provide contrasting information about appearance of skin lesions in PNL patients on follow-up.

1.  In a  follow-up study of 182 PNL patients by Suneetha et al., 62% of patients developed the lesions within 2 years of the onset of symptoms.  The study also mentions that 38% of patients developed a single patch and 28% developed two patches.  (Suneetha S, Sigamoni A, Kurian N, Chacko CJ. The development of cutaneous lesions during follow-up of patients of pure neuritic leprosy.  Int J Dermatol. 2005;44(3):224-9.).

2.  In a study by  Kumar B et al, of 32 PNL  patients, none of them developed any skin lesions on a follow-up of 2 years.  (Kumar B et al.  Pure Neuritic Leprosy in India: an Appraisal.  Int J  Lepr and other Mycobact Dis. 2004, 72, Number 3).

I just thought of sharing this information with our members.

With best regards,

Potharaju Narasimha Rao

Infolep choice of new (e-)publications on leprosy

Leprosy Mailing List – January 19^th, 2011

Ref.:   Infolep choice of new (e-)publications on leprosy

From: Erlings J., Amsterdam, Netherlands

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Dear Dr Noto,

Greetings!

Below you will find a selection of new publications on leprosy.  Please contact me for full text versions.  Do you have publications on leprosy to share? Please let me know! 

With kind regards,

Jiske Erlings

INFOLEP Leprosy Information Services

P.O. Box 95005 Ι 1090 HA  Amsterdam
Netherlands

Tel.: + 31 20 5950530  Fax: +31 20 6680823

E-mail:  infolep(at)leprastichting.nl

E-mail: J.Erlings(at)Leprastichting.NL

Web: http://www.ilep.org.uk/library-resources/infolep-information-services/

Web: www.leprastichting.nl

Journals

New issue of Leprosy Review, 2010, issue no.4

Download articles from: http://www.leprahealthinaction.org/lr/Dec10/Lep346-347.pdf

Articles in other journalsItems 1 - 14 of 14

1:
Bashir K, Dar NR, Sibghat Ullah Rao. Depression in adult dermatology outpatients.
J Coll Physicians Surg Pak. 2010 Dec;20(12):811-3. PubMed PMID: 21205547.

2:
Ghorpade AK. Transepidermal elimination of Mycobacterium leprae in histoid leprosy: A case report suggesting possible participation of skin in leprosy transmission.
Indian J Dermatol Venereol Leprol. 2011 Jan-Feb;77(1):59-61. PubMed PMID: 21220882.  Full text available from: http://www.ijdvl.com/

3:
Gonçalves A, Mantellini GG, Padovani CR. Leprosy control: perspectives & epidemiological and operational aspects.
Rev Inst Med Trop Sao Paulo. 2010 Dec;52(6):311-5. PubMed PMID: 21225214.

Full text available from: http://www.scielo.br/pdf/rimtsp/v52n6/a05v52n6.pdf

4:
Hendrik Richardus J, Saunderson P, Smith C. Will new tuberculosis vaccines provide protection against leprosy?
Int J Tuberc Lung Dis. 2011 Feb;15(2):143. PubMed PMID: 21219671.

5:
Horo I, Rao PS, Nanda NK, Abraham S. Childhood leprosy: profiles from a leprosy referral hospital in West Bengal, India.
Indian J Lepr. 2010 Jan-Mar;82(1):33-7. PubMed PMID: 21229845.

6:
John TJ, Dandona L, Sharma VP, Kakkar M. Continuing challenge of infectious diseases in India.
Lancet. 2011 Jan 10. [Epub ahead of print] PubMed PMID: 21227500.

7:

Kamble RR, Shinde VS, Madhale SP, Jadhav RS. Study of cytokine response against panel of purified Mycobacterium leprae antigens by using whole blood assay in subjects residing in a resettlement village of cured leprosy patients.

Indian J Lepr. 2010 Jan-Mar;82(1):23-31. PubMed PMID: 21229844.

Full text available from: http://www.ijdvl.com/

8:

Martinez TS, Figueira MM, Costa AV, Gonçalves MA, Goulart LR, Goulart IM. Oral mucosa as a source for M. leprae infection and transmission, and implications of bacterial DNA detection and the immunological status.
Clin Microbiol Infect. 2010 Dec 31. [Epub ahead of print] PubMed PMID: 21199152.

9:

Raju R, Devi SK, Mehervani C, Kumar AS, Meena AK, Reddy PP, Pranay P, Jain S, Archelos-Gracia JJ, Suneetha S, Suneetha LM. Antibodies to Myelin P0 and Ceramide Perpetuate Neuropathy in Long Standing Treated Leprosy Patients.
Neurochem Res. 2011 Jan 14. [Epub ahead of print] PubMed PMID: 21234675.

10:

Rao GR, Sandhya S, Sridevi M, Amareswar A, Narayana BL; Shantisri. Lupus vulgaris and borderline tuberculoid leprosy: An interesting co-occurrence. Indian

J Dermatol Venereol Leprol. 2011 Jan-Feb;77(1):111. PubMed PMID: 21220903.

Full text available from: http://www.ijdvl.com/

11:

Salafia A, Chauhan G. Salvage surgery for severely deformed hands in leprosy.

Indian J Lepr. 2010 Jan-Mar;82(1):39-47. PubMed PMID: 21229846.

Full text available from: http://www.ijl.org.in/jan_mar_2010.html

12:

Sinha AK, Banerjee BG, Singh S. Leprosy and its socio-cultural perception in Indian religions and ancient texts.
Indian J Lepr. 2010 Jan-Mar;82(1):1-21. PubMed PMID: 21229843.

Full text available from: http://www.ijl.org.in/jan_mar_2010.html

13:

Trindade MA, Benard G, Ura S, Ghidella CC, Avelleira JC, Vianna FR, Marques AB, Naafs B, Fleury RN. Granulomatous Reactivation during the Course of a Leprosy

Infection: Reaction or Relapse. PLoS Negl Trop Dis. 2010 Dec 21;4(12):e921. PubMed PMID: 21200422; PubMed Central PMCID: PMC3006134.

Full text available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3006134/pdf/pntd.0000921.pdf

Video for leprosy training

Leprosy Mailing List – January 19^th, 2011

Ref.:   Video for leprosy training

From: Engelhard A., Amsterdam, The Netherlands

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Dear Dr Salvatore Noto,

Training large numbers health workers on a cost effective way in essential skills and knowledge is a well recognized challenge in leprosy control.

Through this message I hope to come into contact and share experiences with colleagues with experience in the (local) production and or use of film/video material. My main interest is for now, video material (not slides) meant for peripheral health workers with few or absent knowledge and skills on leprosy.

My main reference is the excellent but not so recently produced material produced by Schieffelin Institute of Health Research & Training Centre, formerly known as SLRTC Karigiri.  So far, YouTube did not produce much suitable content for me.

Thank you for your assistance!

With kind regards,

Anrik Engelhard, MD

Senior Advisor
KIT Development Policy & Practice
Leprosy & Tuberculosis Unit
Koninklijk Instituut voor de Tropen
Wibautstraat 137 [1097 DN]
Tel.: +31 (0)20 6939297
Fax: +31 (0)20 568 8444www.kit.nl /

Pure neuritic leprosy

Leprosy Mailing List – January 18^th, 2011

Ref.:   Pure neuritic leprosy

From: Warren G., Sydney, Australia

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Dear Dr Kar,

Thank you very much for your statement about primary/pure neuritis leprosy (LML Jan. 11^th, 2011.  I often wondered as to how much there was.  When you say 6% is that of the total number WHO lists or of all  leprosy affected  persons.

Working in Burma in the 1970/80s I diagnosed and treated many patients we saw with primary persistent neuritic leprosy, who developed  paralysis but NEVER had a skin lesion.  Many we could operate upon and correct the deformity.

In the 1990s I saw a large  number in Thailand / Cambodia.  A number of these has previously been seen by WHO consultants who stated that because there was no skin lesion they did not have leprosy in spite of large firm poorly functioning nerves at typical sites.  Because of this statement they had not been given multi-drug therapy (MDT) and since the WHO statement many had gone on to develop further deformity.  In one patient with many large nerves but no skin lesions we were able to biopsy a nerve and the biopsy indicated that the patient was definitely Borderline, tending to Lepromatous so he certainly needed full MDT and one wonders how many  others he may have infected by coughing and sneezing.

In endemic areas, when these primary neuritic patients present with affected typical nerves it would be worth treating them with standard full MDT, even if it is not possible to do a biopsy to prove it is leprosy.

One of the problems I encounter is that the general doctors do not always examine all the affected nerves; some do not even know how to examine for leprosy, and which ones are commonly affected, in Leprosy.   I have met several patients in whom the diagnosis was only made because a helpful surgeon, while decreasing the disability, took a biopsy of the nerve!  Surely these facts should encourage better education in medical schools.  I have been asked to lecture in Medical colleges where my lecture was the first time there had ever been a lecture on leprosy as such!

Can I ask if that 6% get included in the WHO figures of affected patients as they do not fulfil the WHO definition as there may never be any skin lesions.  Yes there may be anaesthesia and deformity but technically no skin lesion in the primary persistent neuritis cases.  I know that there are lots of these  primary persistent  neuritis  leprosy patients in S.E.  Asia and hopefully they are not going to be the nidus of a sudden increase in numbers of patients in the next 20 years.

Yours sincerely,

Grace  Warren

Previously Adviser in Leprosy and Reconstructive Surgery for The Leprosy Mission in Asia ( 1975-1995)

Priorities for future of leprosy control

Leprosy Mailing List

(LML) Priorities for future of leprosy control: communication

18 January 2011

Dear All,

Please find herewith enclosed a LML message in Word format from Dr Pongtiku, from Indonesia, about the above mentioned subject.

Best regards,

S. Noto

Pure neuritic leprosy

Leprosy Mailing List – January 18^th, 2011

Ref.:   Pure neuritic leprosy

From: Warren G., Sydney, Australia

---

Dear Dr Kar,

Thank you very much for your statement about primary/pure neuritis leprosy (LML Jan. 11^th, 2011.  I often wondered as to how much there was.  When you say 6% is that of the total number WHO lists or of all  leprosy affected  persons.

Working in Burma in the 1970/80s I diagnosed and treated many patients we saw with primary persistent neuritic leprosy, who developed  paralysis but NEVER had a skin lesion.  Many we could operate upon and correct the deformity.

In the 1990s I saw a large  number in Thailand / Cambodia.  A number of these has previously been seen by WHO consultants who stated that because there was no skin lesion they did not have leprosy in spite of large firm poorly functioning nerves at typical sites.  Because of this statement they had not been given multi-drug therapy (MDT) and since the WHO statement many had gone on to develop further deformity.  In one patient with many large nerves but no skin lesions we were able to biopsy a nerve and the biopsy indicated that the patient was definitely Borderline, tending to Lepromatous so he certainly needed full MDT and one wonders how many  others he may have infected by coughing and sneezing.

In endemic areas, when these primary neuritic patients present with affected typical nerves it would be worth treating them with standard full MDT, even if it is not possible to do a biopsy to prove it is leprosy.

One of the problems I encounter is that the general doctors do not always examine all the affected nerves; some do not even know how to examine for leprosy, and which ones are commonly affected, in Leprosy.   I have met several patients in whom the diagnosis was only made because a helpful surgeon, while decreasing the disability, took a biopsy of the nerve!  Surely these facts should encourage better education in medical schools.  I have been asked to lecture in Medical colleges where my lecture was the first time there had ever been a lecture on leprosy as such!

Can I ask if that 6% get included in the WHO figures of affected patients as they do not fulfil the WHO definition as there may never be any skin lesions.  Yes there may be anaesthesia and deformity but technically no skin lesion in the primary persistent neuritis cases.  I know that there are lots of these  primary persistent  neuritis  leprosy patients in S.E.  Asia and hopefully they are not going to be the nidus of a sudden increase in numbers of patients in the next 20 years.

Yours sincerely,

Grace  Warren

Previously Adviser in Leprosy and Reconstructive Surgery for The Leprosy Mission in Asia ( 1975-1995)

Primary neuritic leprosy in India

Leprosy Mailing List – January 11^th, 2011

Ref.:    Primary neuritic leprosy in India

From:  Kar H K, New Delhi, India

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Dear Dr Watson,

Thanks for a valid question (LML Jan. 8^th 2011).  About 6% of cases of leprosy are diagnosed as primary neuritic leprosy in India.  There is no study to identify  how many of them develop clinical lesion in the skin late.  During the initial phase they may land in neurology department for diagnosis.  Where-ever awareness exists among neurologists they refer the case to Dermatology department to exclude leprosy.  In India, the referral is common in tertiary care hospital because of awareness among neurologists about the possibility of having leprosy.

Regards,
 

Dr (Prof.) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001  

Selection of new publications on leprosy

Leprosy Mailing List – January 11^th, 2011

Ref.:    Selection of new publications on leprosy

From:  Erlings J., Amsterdam, The Netherlands

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Dear Dr Noto,

Greetings and a Happy New Year!

Below you will find a selection of new publications on leprosy.  Please contact me for full text versions.  Do you have publications on leprosy to share? Please let me know! 

Met vriendelijke groet / With kind regards,

Jiske Erlings

INFOLEP Leprosy Information Services

Leprastichting / Netherlands Leprosy Relief (NLR)

P.O. Box 95005 Ι 1090 HA  AMSTERDAM
The Netherlands

Tel.: + 31 20 5950530

E-mail: InfoLep(at)Leprastichting.NL

Web: http://www.ilep.org.uk/library-resources/infolep-information-services/

1:

Al Aboud, D. Eponyms in leprology.
SKINmed. 2010;8:323–326

Free full text available from: http://www.skinmedjournal.com/skinmed_v8i6_l.pdf

2:

Basavaraj KH, Navya MA, Rashmi R. Relevance of psychiatry in dermatology: Present concepts.
Indian J Psychiatry. 2010 Jul;52(3):270-5. PubMed PMID: 21180416
Free full text available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990831/?tool=pubmed

3:

Diniz LM, Catabriga MD, Souza Filho JB. [Evaluation years in leprosy patients treated with single dose alternative scheme ROM (rifampin, ofloxacin, minocycline), after seven to nine.]. Rev Soc Bras Med Trop. 2010 Dec;43(6):695-699. Portuguese. PubMed PMID: 21181026.
Free full text available from: http://www.scielo.br/pdf/rsbmt/v43n6/19.pdf

4:

Duthie MS, Truman RW, Goto W, O'Donnell J, Hay MN, Spencer JS, Carter D, Reed SG. Insight Toward Early Diagnosis of Leprosy Through Analysis of the Developing Antibody Responses of M. leprae-Infected Armadillos.
Clin Vaccine Immunol. 2010 Dec 22. [Epub ahead of print] PubMed PMID: 21177914.
5:

Hali F, Latifi A, Sbai M. [Malignant transformation of plantar ulcers in leprosy: experience of National Leprosy Center in Casablanca.].
Bull Soc Pathol Exot. 2010 Dec 29. [Epub ahead of print] French. PubMed PMID: 21191827.

6:

Ledermann W. [Sir Arthur Conan Doyle, Sherlock Holmes and infectious diseases].
Rev Chilena Infectol. 2010 Oct;27(5):429-34. Spanish. PubMed PMID: 21186510.

7:

Opromolla PA, Laurenti R. [Hansen's disease control in the State of São Paulo: a historical analysis.].
Rev Saude Publica. 2011 Feb;45(1):195-203. Portuguese. PubMed PMID: 21181057.
Free full text available from: http://www.scielosp.org/pdf/rsp/v45n1/en_1764.pdf

8:

Ramos JM, Reyes F, Lemma D, Belinchón I, Gomez JR. Disability profile in leprosy patients' diagnoses in a rural reference leprosy centre in Ethiopia during 1999-2009.
Trop Doct. 2011 Jan;41(1):51-3. PubMed PMID: 21172905.

9:

Shen J, Liu M, Zhou M, Li W. Causes of death among active leprosy patients in China.
Int J Dermatol. 2011 Jan;50(1):57-60. PubMed PMID: 21182503.

10:

Silva AR, Matos WB, Silva CC, Gonçalves ED. [Leprosy in Buriticupu, State of Maranhão: active search for cases in the adult population.].
Rev Soc Bras Med Trop. 2010 Dec;43(6):691-694. Portuguese. PubMed PMID: 21181025.
Free full text available from: http://www.scielo.br/pdf/rsbmt/v43n6/18.pdf

11:

Singh P, Cole ST. Mycobacterium leprae: genes, pseudogenes and genetic

diversity. Future Microbiol. 2011 Jan;6:57-71. PubMed PMID: 21162636.

12:

Singh RK. Granulomatous abscess of the ulnar nerve in a case of paucibacillary leprosy given multidrug therapy.
Ann Trop Med Parasitol. 2010 Dec;104(8):673-4. PubMed PMID: 21144186.

13:

Souza LW. [Leprosy reactions in discharged patients following cure by multidrug therapy.].
Rev Soc Bras Med Trop. 2010 Dec;43(6):737-739. Portuguese. PubMed PMID: 21181036.
Free full text available from: http://www.scielo.br/pdf/rsbmt/v43n6/29.pdf

14:

Spencer JS, Kim HJ, Wheat WH, Chatterjee D, Balagon MV, Cellona RV, Tan EV, Gelber R, Saunderson P, Duthie MS, Reece ST, Burman W, Belknap R, Mac Kenzie WR, Geluk A, Oskam L, Dockrell HM, Brennan PJ; on behalf of the IDEAL Consortium. Analysis of Antibody Responses to Mycobacterium leprae Phenolic Glycolipid-I, Lipoarabinomannan and Recombinant Proteins to Define Disease-Subtype Specific Antigenic Profiles in Leprosy.
Clin Vaccine Immunol. 2010 Dec 22. [Epub ahead of print] PubMed PMID: 21177913.

15:

van Veen NH, Hemo DA, Bowers RL, Pahan D, Negrini JF, Velema JP, Richardus JH. Evaluation of activity limitation and social participation, and the effects of reconstructive surgery in people with disability due to leprosy: a prospective cohort study.
Disabil Rehabil. 2010 Aug 13. [Epub ahead of print] PubMed PMID: 20707596.

16:

 Yaghoobi R, Feily A, Ranjbari N, Lotfi J, Yaghoobi E. Lepromatous leprosy: a commonly misdiagnosed disease.
ScientificWorldJournal. 2010 Dec 14;10:2348-9. PubMed PMID: 21170484.

17:

Yu MW, Yan LB, Shen JP, Sun YM, Zhang GC. [Epidemiological analysis on leprosy in China, 2009.].
Zhonghua Liu Xing Bing Xue Za Zhi. 2010 Oct;31(10):1155-1157. Chinese. PubMed PMID: 21162820.

To what extent are the peripheral nerve lesions that may complicate leprosy given space in neurology curricula?

Leprosy Mailing List – January 8^th, 2011

Ref.:    To what extent are the peripheral nerve lesions that may complicate leprosy given space in neurology curricula? 

From:  Watson J., China

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Dear Dr Noto,

I refer to Prof. Ryan message (LML (Dec. 31^st, 2010).  To what extent are the facial and peripheral nerve lesions that may complicate leprosy given space in neurology curricula?  These are usually not the first signs of leprosy but, in my recent Far East experience, even signs of such nerve lesions do not consistently trigger thoughts of leprosy in neurology departments during differential diagnosis.  Hence even further delays in leprosy diagnosis and treatment.  One patient was operated on by tendon transfer in a major city hospital after ulnar paralysis but before leprosy was identified as the cause of the nerve lesion.

Kind regards,

Jean Watson 

Present fear is relapse of leprosy

Leprosy Mailing List – January 7^th, 2011

Ref.:   Present fear is relapse of leprosy

From: Warren G., Sydney, Australia

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Dear Dr Noto,

I would like to compliment Dr Porichhas on his  comments on fear of relapse (LML Dec. 31st 2010).

Yes persisters are, I feel, very much to blame and, have been shown to be able to cause relapse after the patients has had 5 years of effective drug therapy and apparent “cure” of obvious lesions.  In one official trial at the end of five years of supervised daily rifampicin (supervised so we could not blame non compliance!).  Far more than we normally give, normal M. leprae, fully sensitive  to rifampicin could be cultured from  selected nerves!

However I would be interested to know if anyone has seen a patient on MDT, who had not been given rifampicin alone previously,  who has developed rifampicin resistance.    One presented with rifampicin resistant relapse?  Most of us have no facilities to do these sensitivity  tests whether by mouse foot pads or CPR.  Congratulations of India getting some centres organised in this field.

We all know dapsone resistance is common but, with due respect to some earlier correspondence, I would be interested to know if any research laboratory has identified clofazimine resistance developing in a human patient on treatment, whether monotherapy or in multidrug therapy.  Yes I know resistance to clofazimine has been developed in a laboratory but that was in mouse foot pads and, as  was a said in the 1960s  “a mouse even if he is a mighty mouse is still a mouse” and  what can be done in the laboratory will not of necessity produce the same effects in a human.

Greetings to all for the New year,

Grace  Warren

Adviser in Leprosy and Reconstructive surgery for The Leprosy Mission in Asia ( 1975-1994).

Shifting of leprosy management to peripheral health staff

Leprosy Mailing List – January 3^rd, 2011

Ref.:   Shifting of leprosy management to peripheral health staff

From: Kar H K, New Delhi, India

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Dear all leprosy fraternity,

When merging of the vertical organised leprosy control programme with the general health services, there was a hue and cry among leprosy workers and a lot of apprehension regarding early detection of cases and their appropriate management.  But it does not so happen.  WHO has taken a wise decision motivating all endemic countries to do so at the appropriate time for shifting of leprosy management to peripheral health staff with assistance from higher centres for management of difficult cases and their complications.

I would like to complement Dr Noordeen and Dr Pannikar and the whole WHO team for the above decision.  We must go forward and improve our strategy and activities depending on the need of the hour rather than looking back and pretending to repent. We have a sizable population having leprosy clinically and potential number of subclinical infected population.  The new clinical cases will continue to come for few more years including child cases and with Grade 2 deformities.

  

There is no shortage of clinical teaching material and specialists in the field of leprosy. In India there are many registered dermatologists, ortho surgeons, plastic surgeons, pathologists, microbiologists, and eye surgeons etc.  Only motivation is lacking, so far as leprosy is concerned. It is the same situation in Brazil and Africa.

   

Teaching/training in leprosy, particularly at medical under graduate level should be given top priority. The Indian Association of Dermatologists, Venereologists and Leprologists are coming out with a dedicated under graduate level  text book in dermatology  giving special  importance to leprosy.  We are increasing the hours of teaching in leprosy (both theoretical and clinical/practical) for better understanding of the disease, so that they can diagnose the disease while working at primary health care (PHC) level or practising at peripheral level helping in private public partnership in management of leprosy cases.

The core strategy of the National Rural Health Mission (NRHM) of the Government of India includes decentralisation of villages and district level Rural Planning and Management and to appoint ASHA - trained community volunteers - for creation of awareness, to counsel women and for the mobilisation of community facilities for accessing health related services.  In the NRHM programme ASHA suspect/detect new cases and bringing them to PHC level for diagnosis and treatment with multi-drug therapy (MDT).  It is an assuring sign of future success.

   

No doubt, we have practical difficulties for detecting hidden cases in difficult areas, where innovative techniques can be introduced like skin camp approach, utilising ASHA forces for detection of cases and supplying accompanied MDT regimen for the whole course treatment with effective counselling.  We have to strengthening our Deformity Prevention and Medical Rehabilitation (DPMR) approach for disabilities prevention and management and IEC program.  Research in leprosy must not be neglected. The Indian Council of Medical Research (ICMR), particularly after Dr V M Katoch, an eminent leprologist took over as DG ICMR, recently is giving much more importance to leprosy research.  Other countries health authority should behave in same way including WHO till we could eradicate this disease from the globe.

We should be optimistic.  One day we will win the race in eradicating this disease from the globe with the present strategy with minor modification from time to time.

Dr (Prof) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001

Leprosy in the teaching curricula

Leprosy Mailing List – December 31st, 2010

Ref.:   Leprosy in the teaching curricula

From:  Ryan T., Oxford, UK

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Dear Salvatore,

Pran's dagger goes straight to the heart (LML Dec. 18^th, 2010).  Unfortunately Dermatology gets too little space in the Oxford curriculum.  All medical students attending for a short course see first of all a large (updated by myself) poster on Leprosy and that is all.  That is why I emphasise the elective period when visits to India, S America, and Nepal attract them to look for a subject to study and none better than leprosy.  I invite students to accompany me on my regular trips to India.

Getting Leprosy into the general curriculum, sadly, is unlikely to compete with all the very common problems they must be expert on when they become family practitioners in the UK.  They will not see leprosy in Oxford clinics.  If in India and Nepal for example those centres regularly accepting students were to upgrade the teaching so leprosy was seen as part of Dermatology and at the same time financial help with travel was facilitated then we might recruit future leaders of the field.

I am directing my energies in that direction but will copy Pran's mail to those who plan the Oxford curriculum.

Terence

resent fear is relapse of leprosy

Leprosy Mailing List – December 31st, 2010

Ref.:   Present fear is relapse of leprosy

From: Porichha D., Bhubaneswar, Orissa, India

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Dear Dr Noto,

I refer to Dr Pannikar’s message dated LML Dec. 5^th, 2010.  Present fear is relapse of leprosy.  Relapse can be due to reactivation of “persisters“ which are sensitive to the multi-drug therapy (MDT) and respond well to the 12-dose (12 months) treatment of the presently used schedule.  Most of the relapses belong to this category.  We are much bothered for emergence of bacteria not responding to rifampicin, which is the major component of MDT.  Hence for any case of relapse suspected clinically, skin smear is tested to know whether the bacilli in the smear are sensitive to rifampicin (can be killed by the drug) or resistant. 

Earlier sensitivity testing was done in mouse foot pad; now through molecular biological technique or amplification of bacterial deoxyribonucleic acid (DNA) by polymerase chain reaction (PCR).  The surveillance for drug resistance is being undertaken in 12 states in India as per WHO protocol.  Skin smear  samples from suspected cases  from the field sentinel surveillance sites are sent along with  past (when initially treated) and present (the relapsed) clinical detail to one of the 4 accredited laboratories in the country.

Yours sincerely,

D Porichha

Medical Coordinator, LEPRA Society, Bhubaneswar

Nippon Foundation stops funding WHO initiative on surveillance of drug resistance in leprosy

Leprosy Mailing List – December 31^st, 2010

Ref.:   Nippon Foundation stops funding WHO initiative on surveillance of drug resistance in leprosy 

From: Narasimha Rao P., Hyderabad, India

---

Dear Salvatore,

The message from Dr Pannikar (LML 5th Dec. 2010) informing about Nippon foundation deciding not to continue to fund the WHO initiative on surveillance of drug resistance in leprosy (which I gathered form the correspondence on this issue) is definitely a set back in fight against leprosy.  But it would be relevant to analyze the reasons for such a decision by the very consistent and generous funding agency.

Only reason I can think of immediately is the shrinking numbers of leprosy being reported widely all over the world, especially India.  As any programme donor or manager takes in to consideration the number of beneficiaries, (which is the number of patients in this case / prevalence rate), the less numbers of leprosy patients projected  in world leprosy statistics, makes it less attractive to fund the programme.

However, there are good numbers of missing leprosy patients from NLEP/govt of India registers, which influence world leprosy figures greatly.  It is a fact that numbers of leprosy reported from India by government/NGO leprosy agencies do not take into consideration a significant group of leprosy patients seen and treated by Dermatologists all over India as these patients are not enrolled/registered  in government/NLEP registers.  And there are more than 9,000 actively practicing dermatologist all over India as of now.

Just to estimate on how big this missing number could be,…I have  conducted a email questionnaire, in year 2007, on how may leprosy patients a popular dermatologist sees per year.  E-mails were sent to about 120 dermatologists all over India.  Responses were obtained for the request from 26 Dermatologists all over India in a 4-week period. The 26 responders were from 7 different states (Andhra Pradesh, Tamil Nadu, Karnataka, West Bengal, Gujarat, Rajasthan and New Delhi).  Of these 10 Dermatologists have, both hospital practice and private practice.  Only one of the responders had a full time hospital attachment.  Rest of the 15 were full time private practitioners.  The approximate number of leprosy patients seen by 26 Dermatologists in one year is given in the table below:

	At hospitals	At clinics	Total	Average
New patients	1169	466	1635	62.8
Partially treated patients	464	95	559	21.5
Old patients with disabilities	226	117	343	13.1

The average number of new leprosy patients seen by Dermatologists under study per year was 62.  This is a approximate figure.  Considering that only 6000 (of 9000) dermatologists are in private practice, even if we consider 10 new leprosy cases per dermatologist per year, the number would be 60,000 unregistered cases.  This could be a conservative estimate.  In an endemic areas the numbers could be more as patients going to primary care physician and other specialists (neurologist orthopedician) are not taken into consideration at all.  

Significance of these observations: Although the number of Dermatologists included in this study does not meet the sample size requirements, the results of the study cannot be ignored.  The direct result of these missing numbers could  be...

1. Inability for the Government and leprosy agencies to assess the exact number of leprosy patient load in a community, which leads to improper planning and budgeting for leprosy;
2. which could lead to an inadequate availability of resources (men and material and even MDT blister packs) where and when required;
3. finally, it leads to improper planning and inability to convince and attract donors about the seriousness of the requirements and problem of leprosy.  

I being a dermatologist my self and involved in leprosy, can vouch that most dermatologists can diagnose leprosy and administer WHO MDT very well and correctly.  But I am not sure that they are very good managers of reactions of leprosy, nerve damage and its prevention, ulcer care or management of disabilities of leprosy. Hence, there continues to be a need for an agency or programme to manage these requirements which I presume only NLEP or WHO leprosy programme is capable of.  With funds drying up, as reported by Dr Pannikar, I foresee a very bleak future for care of leprosy patient’s problems in near future, even from these agencies.  

I also take this opportunity to appeal to all who matter, not to emphasize on bringing down the numbers of leprosy and equate it to success of the programme; which I am sure has resulted in migration of so many patients to private dermatologists for the want of care and therapy.

With best regards,

P. Narasimha Rao MD., PhD.