Neuritis, acute and chronic, in leprosy

Leprosy Mailing List – February 28^th, 2012 

Ref.:    Neuritis, acute and chronic, in leprosy

From:  H Srinivasan, Chennai, India

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Dear Dr Noto,

The following are my views regarding the queries raised about "Acute neuritis" in leprosy.  I think it will help starting from the definition of neuritis and then considering acute and chronic neuritis.  I also report some relevant aspects of histopathology.

Definition of leprosy neuritis

Leprosy neuritis is an inflammatory mononeuropathy occurring in leprosy.  In can be acute or chronic.

Acute leprosy neuritis 

Acute leprosy neuritis describes the clinical state characterized by pain occurring in an obviously thickened peripheral nerve trunk such as ulnar, median, lateral popliteal nerve etc.  It may occur in cutaneous nerve trunks also, but here there is no risk of disability and deformity, although the condition may be quite distressing to the patient.  Acute neuritis is of rapid (i.e., acute) onset, over the course of a few hours to a few days.  It may have been present for a few days to a few weeks by the time the patient is seen by the physician or paramedical worker.

It may be moderately severe or severe.  In moderately severe acute leprosy neuritis patient complains of severe pain, but the movement of adjacent joint is not restricted and sleep is not disturbed because of pain.  In severe acute leprosy neuritis patient complains of severe pain and the movement of adjacent joint is restricted due to the pain and patient admits that pain disturbs sleep. 

Often, acute neuritis occurs in a background of chronic neuritis.  Acute neuritis may occur along with cutaneous manifestations of type I or type II reaction, or as an isolated clinical manifestation of the reactional process.

The term “acute leprosy neuritis" when used in the histopathological context indicates presence of foci of polymorpho nuclear leucocyte infiltration in the nerve (micro or macro “hot abscess”).

Chronic leprosy neuritis

 “Chronic leprosy neuritis” is the clinical condition where there has been long standing ‘mild’ (patient admits to having pain in the nerve only on asking about it) to ‘moderate’ nerve pain (complains of pain even without asking about it, but says it is not severe) in one or more peripheral nerve trunks of the limb(s).   

Histologically, every case of leprosy shows some evidence of chronic neuritis at some site in the peripheral nervous system.  Leprosy is not diagnosed without such evidence.   

Clinical examination

On examination, the concerned nerve trunk is obviously thickened (swollen), and very tender (very painful on palpation), such that the patient is afraid of palpation of the nerve.  Range of active movement of the adjacent joint is restricted because of pain; and/or passively increasing the range aggravates pain in the nerve.  There may be clinical nerve function deficit relating to the affected nerve trunk, which may be pre-existing or of recent origin along with the attack of acute neuritis or, pre-existing nerve function deficit may have worsened coincident with the attack of acute neuritis or, there may not be any clinically identifiable nerve function deficit.  

Indications for Steroid therapy

Onset or worsening of clinical nerve function deficit relating to the affected nerve trunk (eg., sensory loss, muscle weakness or paralysis) along with acute neuritis or even while the condition is under treatment with other drugs is an absolute indication for immediate institution of steroid therapy in adequate dosage.  Continued severe nerve pain even in the absence of increasing nerve function deficit or in a destroyed nerve trunk (with no possibility of the nerve recovering) despite adequate analgesic therapy is often relieved by steroid therapy.

Nerve conduction studies

One does not wait for or depend on nerve conduction studies for diagnosing and treating acute neuritis.  They may be used, when available, for monitoring efficacy of therapy.  Nerve conduction velocity (NCVs) may be within normal limits when only slow conducting fibres are damaged.  Marginal improvement in NCVs without clinical improvement is of no material benefit to the patient.

Early detection of leprosy neuritis

Patient is the best person to suspect early the possibility of acute neuritis and report for treatment without delay.  So the patient should be trained to look for and suspect acute neuritis as well as onset/worsening of nerve function deficit of his or her thickened nerve trunks.  The paramedical and medical personnel must be sensitized to show concern and examine the patient very carefully and sympathetically when a patient reports for suspected acute neuritis and not play down or neglect the patient.  It goes without saying that they must know how to examine such patients.

H Srinivasan, FRCS
Surgeon (Retd)
25 First Seaward Road
Chennai - 600 041
INDIA

Disability Grading Survey Results

Leprosy Mailing List – February 25^th, 2012 

Ref.:    Disability Grading Survey Results

From:  C Smith, Aberdeen, Scotland, UK

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Dear Salvatore,

I would be grateful if you could post the results of the Disability Grading Survey on the LML.  I have attached versions in English and Portuguese kindly translated by Duane Hinders. 

Cairns

Cairns Smith

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith@abdn.ac.uk 

Periodical assessment of the patient by a combination of: - always look, palpate, compare and test

Leprosy Mailing List – February 15^th, 2012 

Ref.:    Periodical assessment of the patient by a combination of: - always look, palpate, compare and test.

From:  F Ross, UK

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Dear Salvatore,

Thanks for your publication of this excellent response from Drs Naafs and Schreuder to the question of acute neuropathy (LML Feb. 14^th 2012 [enclosed]).  If applied it will save a lot of pain and disability.

Best regards.

Felton Ross.

----- Original Message -----

From: Salvatore Noto

To: Salvatore Noto

Sent: Tuesday, February 14, 2012 10:26 AM

Subject: (LML) Proposal for "Guidelines for the management of acute neuritis in leprosy" - Part I. Definition, clinical signs and electrophysiology

Leprosy Mailing List – February 14^th, 2012

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

From:  B Naafs, Munnekeburen;  P A M Schreuder, Maastricht, The Netherlands

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Dear Salvatore,

Very much, “thank you” to Dr Antoine Mahé (LML January 18^th, 2012) and to colleagues contributing to the topic about “acute leprosy neuritis”.  It is difficult to answer all Dr Mahé’s questions because one is always subjective!  Herewith are our answers:-

1) What is your definition of 'acute leprosy neuritis’?

<< Definition of acute neuritis:-  Acute neuritis in leprosy is the occurrence within a few days of increase in pain, or tenderness, decrease in voluntary muscle test (VMT) and sensory testing (ST) scores, severely diminished motor nerve conduction or nerve block in peripheral nerves serving the eye lids, face, hands and feet.  Since patients are not seen every day, “acute” goes up to 3 months.  >>

2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

<<. >>

2a Presence of pain: spontaneous? Provoked by palpation?  Or by movement?

<< All of them are important and justify therapy but, especially tenderness at palpation. >>

2b Recent occurrence of neurological dysfunction (sensory, motor, autonomic)?

<< All of them are important but, most decrease in VMT and ST scores, because these are easy to measure. >>

2c Definition of "recent"?  With or without pain?

<< We would consider “recent” when within 3 months. >>

 3) Relevance of electromyography and nerve conduction studies?

<< Nerve conduction studies are relevant but, they are not widely available. >>

4) Strategies for early detection of incipient neuritis during follow-up of known patients?

<< Periodical assessment of the patient by a combination of: - always look, palpate, compare and test.  Look at the face and eyes: do the eyes blink?  Any degree of lagophthalmos?  Any deviation of the mouth?  Look at hands and feet:- any dryness, atrophy or wounds?  Palpate* the peripheral nerves of predilection of leprosy.  Comparealways the two sides.  Test by performing the voluntary muscle test and sensory test on eyes, hands and feet.

We hope these answers help. 

Best regards,

Ben Naafs and Pieter Schreuder

* Description of the palpation of the peripheral nerves of predilection of leprosy is available on line at: - The Diagnosis of Leprosy – text and slides <<http://atlasofleprosy.hsanmartino.it/ >>

Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

Leprosy Mailing List – February 14^th, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

From:  B Naafs, Munnekeburen;  P A M Schreuder, Maastricht, The Netherlands

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Dear Salvatore,

Very much, “thank you” to Dr Antoine Mahé (LML January 18^th, 2012) and to colleagues contributing to the topic about “acute leprosy neuritis”.  It is difficult to answer all Dr Mahé’s questions because one is always subjective!  Herewith are our answers:-

1) What is your definition of 'acute leprosy neuritis’?

<< Definition of acute neuritis:-  Acute neuritis in leprosy is the occurrence within a few days of increase in pain, or tenderness, decrease in voluntary muscle test (VMT) and sensory testing (ST) scores, severely diminished motor nerve conduction or nerve block in peripheral nerves serving the eye lids, face, hands and feet.  Since patients are not seen every day, “acute” goes up to 3 months.  >>

2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

<<. >>

2a Presence of pain: spontaneous? Provoked by palpation?  Or by movement?

<< All of them are important and justify therapy but, especially tenderness at palpation. >>

2b Recent occurrence of neurological dysfunction (sensory, motor, autonomic)?

<< All of them are important but, most decrease in VMT and ST scores, because these are easy to measure. >>

2c Definition of "recent"?  With or without pain?

<< We would consider “recent” when within 3 months. >>

 3) Relevance of electromyography and nerve conduction studies?

<< Nerve conduction studies are relevant but, they are not widely available. >>

4) Strategies for early detection of incipient neuritis during follow-up of known patients?

<< Periodical assessment of the patient by a combination of: - always look, palpate, compare and test.  Look at the face and eyes: do the eyes blink?  Any degree of lagophthalmos?  Any deviation of the mouth?  Look at hands and feet:- any dryness, atrophy or wounds?  Palpate* the peripheral nerves of predilection of leprosy.  Comparealways the two sides.  Test by performing the voluntary muscle test and sensory test on eyes, hands and feet.

We hope these answers help. 

Best regards,

Ben Naafs and Pieter Schreuder

* Description of the palpation of the peripheral nerves of predilection of leprosy is available on line at: - The Diagnosis of Leprosy – text and slides <<http://atlasofleprosy.hsanmartino.it/ >>

Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

Leprosy Mailing List – February 11^th, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition, clinical signs and electrophysiology

From:  L Reni, Genoa, Italy

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Dear Salvatore,

Thank you very much to Dr Antoine Mahé for introducing such an important topic (LML January 18^th, 2012).  Herewith are my answers:-

1) What is your definition of 'acute leprosy neuritis' ?

<< "Acute leprosy neuritis", my definition:-

It is an acute inflammatory mononeuropathy presenting with pain spreading, from a point of entrapment (for example at the ulnar groove or in the cubital tunnel), along the nerve.

There is tenderness and/or swelling of the nerve; its palpation evokes a typical “electric shock” along the nerve with paraesthesia in the area of its cutaneous distribution (Tinel's sign).

The pain may be isolated or accompanied by neurological dysfunctions (sensitive and/or motor and/or autonomic).  The neuritis may be considered acute if symptomatology and/or signs have arisen within a few weeks.  >>

2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

<< The implementation of a specific therapy is necessary whenever a peripheral nerve lesion is suspected. >>

 2a Presence of pain: spontaneous? Provoked by palpation?  Or by movement?

<< The pain may be absent.  If present, it may be spontaneous, provoked by palpation or by movement. >>

2b Recent occurrence of neurological dysfunction (sensory, motor, autonomic)?

<< Neurologic dysfunction may be sensory (sensory deficit or paraesthesia) and/or motor and/or autonomic. >>

 2c Definition of "recent"?  With or without pain?

<< "Recent" means within a few weeks.  Pain may be absent. >>

3) Relevance of electromyography and nerve conduction studies?

<< Electromyography is useless.  Nerve conduction studies are useful; it allows the diagnosis in dubious cases, detecting the nervous lesion, while waiting echography and surgical approach.  Nerve conduction has proved to be useful in our experience demonstrating focal modifications in quite modest or dubious cases and previous to the appearance of clinical symptoms. >>

4) Strategies for early detection of incipient neuritis during follow-up of known patients?

<< The patient needs instructions about the possible symptoms leading to a dramatic evolution.  Sensory testing and voluntary muscle test are performed periodically.  Nerve conduction study is useful. >>

Best regards,

Lizia

Dr Lizia Reni

Department of Neurology

University of Genoa,

Genoa, Italy

Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition

Leprosy Mailing List – February 2^nd, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy” – Part I. Definition

From:  H K Kar, New Delhi, India

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Dear Dr Noto,

Thank you very much to Dr Mahé and to the Association of the French speaking leprologists for this initiative (LML 18^th Jan. 2012).  Herewith I am trying to give my opinion on the first question:

1) What is your definition of 'acute leprosy neuritis' ?

My definition:-

<< Sudden onset of acute inflammation of the nerve presenting with acute pain in peripheral nerve or nerve tenderness and/or swelling due to nerve abscess with or without recent onset of neurological deficit of usually 6 months duration in a leprosy patient is called as “acute leprosy neuritis”.

Best 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

Disability Grading Survey – available in English, French and Portuguese - deadline extended to 17th February

Leprosy Mailing List – February 9^th, 2012 

Ref.:    Disability Grading Survey – available in English, French and Portuguese - deadline extended to 17^th February

From:  C Smith, Aberdeen, Scotland, UK

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Salvatore,

We have had an excellent response to the Survey on disability grading – so far 237 people have completed it.  I would like to extend the deadline to 17^th February for anyone who has still to complete the survey – it is available in English, French and Portuguese.

http://www.abdn.ac.uk/~sme577/Leprosy  (English)

http://www.abdn.ac.uk/~sme577/Leprosy%20French/

http://www.abdn.ac.uk/~sme577/Leprosy%20Portuguese/

I have asked a panel of experts to give their answers and I will circulate this with the survey finding on 24^th February.

Many thanks,

Cairns Smith.

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith(at)abdn.ac.uk

Further information

Accurate assessment of disability due to leprosy using the WHO Disability Grading is important.  It is used to monitor diagnosis (it indicates whether diagnosis is early or late) and it is used as an indicator of the effectiveness of treatment (the progress of patients during MDT is monitored using the WHO disability grading).   

The WHO disability grade is a simple method to assess impairments in the Hands, Eyes and Feet of patients taking MDT.  It is described in the Operational Guidelines for the Enhanced Global Strategy (2011-2015) – see page 22 – 25.  The overall WHO Disability Grade (the WHO maximum Disability Grade) should be recorded for each patient, but it is also recommended that a patient’s progress through treatment should be assessed using the EHF score. The EHF score is when the grading for both eyes, both hands and both feet are added together.  

It is important that the WHO Disability Grades are accurate and reliable.  There is wide variation in the disability grading between and within countries.  This may be due to real differences or due to differences in the way the Grading is implemented.   We would like to check to see if disability assessments are conducted and recorded in the same way everywhere. To help assess this situation, we would like as many people as possible to complete the following 20 questions (your answers will be completely anonymous).  We will circulate the answers on the LML

Original English:  http://www.abdn.ac.uk/~sme577/Leprosy 

Disability Grading in Colombia

Leprosy Mailing List – January 31^st, 2012 

Ref.:    Disability Grading in Colombia

From:  N Cardona Castro, Sabaneta, Colombia

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Dear Dr. Salvatore,

Thank you for posting Prof. Smith’s survey on W.H.O. disability grading on the leprosy mailing list. (Jan. 13^th and 28^th, 2012).  I would like sharing the disability classification used in Colombia.

We do not use the eye, hand and feet (EHF) score, and the grades are 0, I and II but, there are other characteristics that can be interpreted like there are patients grade II+ or III.  Herewith I copy the parameters for disability classification used in Colombia.  They are included in the guidelines of our Leprosy Control Programme which is available on line at the following internet address: -http://www.nacer.udea.edu.co/pdf/libros/guiamps/guias18.pdf.  They are in Spanish and their English translation follows between brackets.

14.3 Evaluación de la discapacidad (evaluation of disabilities)

Para dicha valoración se asume la clasificación de la OMS (This evaluation uses the W.H.O. guides)

Ojos:  (Eyes)

• Grado 0: sin discapacidad (Grade 0: no disabilities)

• Grado I: anestesia, conjuntivitis (Grade I: anaesthesia, conjuntivitis)

• Grado II: lagoftalmos (Grade II: lagophthalmos)

• Iritis o queratitis: opacidad de córnea (iritis, keratitis: corneal opacity)

• Catarata: pérdida avanzada de la visión (cataract, loss of vision)

• Ceguera (blindness)

Manos: (Hands)

• Grado 0: sin discapacidad (Grade 0: no disabilities)

• Grado I: anestesia (Grade I: anaesthesia)

• Grado II: úlceras y heridas (Grade II: ulcers and wounds)

• Dedos en garra móviles: (mobile claw fingers)
• Reabsorción de 1 ó más falanges: (Reabsorption of 1 or more phalanges)
• Parálisis radial anquilosis: (Paralysis radial ankylosis)

 Pies: (Feet)

• Grado 0: sin discapacidad (Grade 0: no disabilities)

• Grado I: anestesia (Grade I: anaesthesia)

• Grado II: perforante plantar: (Grade II: plantar ulcer)
• Dedos en martillo: pie paralítico (Hammer toes: paralytic foot)
• Reabsorciones: (resorptions)
• Anquilosis de la articulación del cuello del pie (Ankylosis of the ankle joint)

Best wishes,

Nora Cardona Castro

MD MSc Investigadora Prof Asociada

Instituto Colombiano de Medicina Tropical - Universidad CES

Carrera 43A # 52 Sur 99  Sabaneta, Colombia

Tel: (57) (4) 3053500 ext 2297 | Fax: (57) (4) 3014258

ncardona(at)ces.edu.co | www.ces.edu.co

Disability Grading Survey – available in French and Portuguese

Leprosy Mailing List – January 28^th, 2012

Ref.:    Disability Grading Survey – available in French and Portuguese

From:  C Smith, Aberdeen, Scotland, UK

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Dear Salvatore,

We have now translated the disability survey into French and Portuguese.  Could you post it on the LML please?

http://www.abdn.ac.uk/~sme577/Leprosy%20French/

http://www.abdn.ac.uk/~sme577/Leprosy%20Portuguese/

Cairns Smith

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith@abdn.ac.uk

Further information

Accurate assessment of disability due to leprosy using the WHO Disability Grading is important.  It is used to monitor diagnosis (it indicates whether diagnosis is early or late) and it is used as an indicator of the effectiveness of treatment (the progress of patients during MDT is monitored using the WHO disability grading).   

The WHO disability grade is a simple method to assess impairments in the Hands, Eyes and Feet of patients taking MDT.  It is described in the Operational Guidelines for the Enhanced Global Strategy (2011-2015) – see page 22 – 25.  The overall WHO Disability Grade (the WHO maximum Disability Grade) should be recorded for each patient, but it is also recommended that a patient’s progress through treatment should be assessed using the EHF score. The EHF score is when the grading for both eyes, both hands and both feet are added together. 

It is important that the WHO Disability Grades are accurate and reliable.  There is wide variation in the disability grading between and within countries.  This may be due to real differences or due to differences in the way the Grading is implemented.   We would like to check to see if disability assessments are conducted and recorded in the same way everywhere. To help assess this situation, we would like as many people as possible to complete the following 20 questions (your answers will be completely anonymous).  We will circulate the answers on the LML

Original English:  http://www.abdn.ac.uk/~sme577/Leprosy

LL patients may have no obvious skin lesions and no changes in sensation for years

Leprosy Mailing List – January 24^th, 2012 

Ref.:    LL patients may have no obvious skin lesions and no changes in sensation for years
From:  G. Warren, Sidney, Australia

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Dear Dr Noto,

It was good to see Dr Lockwood’s letter (LML Jan. 20^th, 2012) regarding the “Elimination” in Brazil, and her acknowledgement that recognition of leprosy cases will continue for many decades.

One report states that in at least one country there is an incidence of 50% of graded 2 disability in new cases at diagnosis.  This surely means that the clinicians just do not know early leprosy. Unfortunately as, I have often said before, I believe that this is largely due to the WHO statement that to be diagnosed as leprosy the patient needs an anaesthetic skin patch!  I have worked in many countries (27) and find so many variants in early presentation, partly racial but, in some groups the highly infectious LL patients may have no obvious skin lesions and may have no changes in sensation for twenty years and, even then many of them do not have any anaesthesia; though they may have altered sensory perception.  In the same way as Most diabetics do not have anaesthetic feet; they feel each step as it hits the ground but they may not feel a cut or even a broken bone causes no pain.  Yes, I have seen WHO consultants refuse to register patients with positive skin smears because they had no anaesthesia.  Also I have seen many “Primary persistent neuritic” leprosy patients not registered because they have no skin patch.

Surely we need to somehow get these recognised so that we do get  more accurate figures.  The present statements that leprosy Elimination is progressing is causing reduction in available funds.  The present figures really do not give any idea of how much leprosy is spreading.  In India there are hundreds of children being diagnosed now.  Is it really changing or just that people are now looking and revising their strategies, for which I am very thankful.

Can these new Statistics from India inspire others to try and do something similar?  What can be done to modify that Definition of leprosy as published in the WHO guide to Elimination.  That definition is certainly not the one in most reliable Text books on Leprosy which state the patient needs at least one of three clinical signs, which are patches, nerve involvement or positive skin smears.  While that definition stands many early patients will not be diagnosed at a time when it is possible and easy to eliminate the disease before serious deformity has been caused.

Keep it up Brazil and may others follow your lead and may we proceed to a more practical approach to the control of this disease.  The use of that word elimination makes Governments try and forget that it is still a problem and can easily flare up again to a major problem unless constantly looked for.  I teach my students “What you do not look for you will never see”.  Let’s try and get everyone looking for leprosy again.

Grace Warren,

Previously advisor for the Leprosy Mission in Asia. (1975-1995)

Leprosy Elimination in Brazil

Leprosy Mailing List – January 24^th, 2012 

Ref.:    Leprosy Elimination in BrazilFrom:  Ryan T, Oxford, UK

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Dear Salvatore,

Diana Lockwood’s useful comments (LML Jan. 20^th, 2012) illustrate the point I have made.  She refers to Brazilian Leprologists and the reader might not be aware that most of these are Dermatologists.  Especially in India where it should be Dermatologists who do more to conquer leprosy, some might read this and think that those who are global leaders, and actually leprologists, like Diana, have no expectation that they should play a part.

Best regards,

Terence Ryan

E-mail: userry282(at)aol.com

Leprosy Elimination in Brazil

Leprosy Mailing List – January 20^th, 2012

Ref.:    Leprosy Elimination in BrazilFrom:  D Lockwood, London, UK

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Dear Salvatore,

Apologies for making a late contribution to this debate and a Happy New Year to all LML readers.  I would like to thank Piet for making a range of useful comments about the elimination strategy.  It is important that we should discuss the elimination strategy and its strengths and weaknesses because we can then use the parts that worked and develop alternatives for the aspects that did not work. 

The lack of an evidence base for the policy of elimination has been critical in the campaign and modelling by Jan Richardus [1] shows that leprosy cases will continue to present for decades yet.  Studies in Bangladesh [2] and India [3] have shown that there are still many undetected cases of leprosy in the community.  India reached the elimination level partly through the application of changes in case finding and registration.  India has now had a national sample survey to estimate how many leprosy patients there are.  This has revealed many undiagnosed patients and a substantial burden of disability.  India is thus after an apparently successful elimination strategy having to work out a way of acknowledging that in some states the strategy was not successful.  It is important to understand the reasons why elimination has not worked in the most endemic areas and develop new ways of detecting and treating patients rather than striving to reach a target of fewer patients.

The previous Brazilian leprologists were very honest in admitting that Brazil had not reached the elimination target in 2005 and the recent high numbers of leprosy patients being reported from Brazil is a testament to the strength of the programme in that it is doing what an infectious disease programme should do which is detect and treat all cases.  It is therefore most unfortunate to describe this instead as a failure to reach elimination.

The perception of elimination has reduced research and innovation in leprosy.  The recent ILEP review highlighted several important research areas that need studies to provide evidence for our treatments and policies.[4]

The other problem of elimination as a public health problem is that it creates the perception that leprosy is really eliminated and that future training is not needed.  This is an important consequence when leprosy cases in future will have to be diagnosed by a range of health workers.

Best wishes,

Diana Lockwood

Professor of Tropical Medicine

London School of Hygiene & Tropical Medicine
Keppel St London WC1E 7HT, UK

References

1. Fischer EA, de Vlas SJ, Habbema JD, Richardus JH (2011) The long-term effect of current and new interventions on the new case detection of leprosy: a modeling study. PLoS Negl Trop Dis 5: e1330.

2. Moet FJ, Schuring RP, Pahan D, Oskam L, Richardus JH (2008) The prevalence of previously undiagnosed leprosy in the general population of northwest bangladesh. PLoS Negl Trop Dis 2:e198.

3. Shetty VP, Thakar UH, D'Souza E, Ghate SD, Arora S, et al. (2009) Detection of previously undetected leprosy cases in a defined rural and urban area of Maharashtra, Western India. Lepr Rev 80: 22-33.

4. van Brakel W, Cross H, Declercq E, Deepak S, Lockwood D, et al. (2010) Review of leprosy research evidence (2002-2009) and implications for current policy and practice. Lepr Rev 81:228-275.

Proposal for "Guidelines for the management of acute neuritis in leprosy” - Definition, symptoms and signs

Leprosy Mailing List – January 18^th, 2012 

Ref.:    Proposal for "Guidelines for the management of acute neuritis in leprosy”

            Definition, symptoms and signs

From:  A Mahé, Paris, France

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Dear Dr Noto,

With the ongoing transfer of the leprosy control activities to the general health services, the Bulletin of the French-speaking leprologists (BALLF) aims at providing to health personnel clear and understandable outlines of some of the conditions related to leprosy they may encounter.  The diffusion of the Bulletin is covering francophone Africa, South East Asia and the Caribbean area. Proposals of all LML affiliates are welcome.

Therefore, we would like to propose in our journal standardized "Guidelines for the management of acute neuritis in leprosy".  In that perspective, and owing to the relatively high variability of practices in that specific field, it seemed to us interesting to question the affiliates of the leprosy mailing list about their practices in their institutions.

We would be very grateful for those who would let us know those practices.  A synthesis will then be performed, and communicated to the leprosy mailing list.

We have selected the following questions about definition, clinical signs and electromyography (Part I.);

1) What is your definition of 'acute leprosy neuritis' ?

 2) Which are the clinical symptoms and signs to be taken into account for justifying the implementation of a specific therapy of acute neuritis (i.e., systemic steroids):

2a - presence of pain : spontaneous ? Provoked by palpation ? Or by movement ?

2b - recent occurrence of neurological dysfunction (sensory, motor, autonomic) ?

2c Definition of "recent" ? With or without pain ?

3) Relevance of electromyography and nerve conduction studies ?

4) Strategies for early detection of incipient neuritis during follow-up of known patients ?

Thank you so much for your answers and comments,

Dr Antoine Mahé

Editor of the Bulletin of the French-speaking leprologists (BALLF)

Dr Antoine Mahé

Dermatologie

Hôpital Pasteur

39, avenue de la Liberté

68024 Colmar Cedex

Secrétariat (+33) 03 89 12 44 65 / 41 58

Fax (+33) 03 89 12 47 69

Portable (+33) 06 31 27 68 71

NB Part II Medical and surgical therapy will follow.

Disability Grading Survey

Leprosy Mailing List – January 13^th, 2012

Ref.:    Disability Grading Survey

From:  C Smith, Aberdeen, Scotland, UK

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Dear Salvatore,

Could you please post this survey on WHO disability grading on the LML and ask as many people as possible to complete the survey.  It is simple and will only take 5 minutes to complete.  Once it has been completed click the SUBMIT button at the bottom and an acknowledgement will be sent. 

Can everyone please complete the survey in the next couple of weeks and we will circulate the responses and answers on the LML.

http://www.abdn.ac.uk/~sme577/Leprosy

Cairns Smith

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith(at)abdn.ac.uk

Further information

Accurate assessment of disability due to leprosy using the WHO Disability Grading is important.  It is used to monitor diagnosis (it indicates whether diagnosis is early or late) and it is used as an indicator of the effectiveness of treatment (the progress of patients during MDT is monitored using the WHO disability grading).   

The WHO disability grade is a simple method to assess impairments in the Hands, Eyes and Feet of patients taking MDT.  It is described in the Operational Guidelines for the Enhanced Global Strategy (2011-2015) – see page 22 – 25.  The overall WHO Disability Grade (the WHO maximum Disability Grade) should be recorded for each patient, but it is also recommended that a patient’s progress through treatment should be assessed using the EHF score. The EHF score is when the grading for both eyes, both hands and both feet are added together. 

It is important that the WHO Disability Grades are accurate and reliable.  There is wide variation in the disability grading between and within countries.  This may be due to real differences or due to differences in the way the Grading is implemented.   We would like to check to see if disability assessments are conducted and recorded in the same way everywhere. To help assess this situation, we would like as many people as possible to complete the following 20 questions (your answers will be completely anonymous).  We will circulate the answers on the LML

Heiser Program for Research in Leprosy

Leprosy Mailing List – January 12^th, 2012

Ref.:    Heiser Program for Research in Leprosy

From:  P Brennan, Colorado, U.S.A.  

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Dear Salvatore,

I would be very grateful if you would announce the 2012 Request for Proposals from the Heiser Program (attached).  Full details and access to application forms are on The New York Community Trust  website (nycommunitytrust.org); it is in the Grant making section under Requests for Proposals, Heiser.  The deadline for applications is March 20, 2012. The major difference in 2012 is that the Heiser Program is funding only leprosy research and will not support postdoctoral fellowships in tuberculosis research.

Thank you,

Patrick Brennan on behalf of: 

Len McNally, Director,

The Heiser Program for Research in Leprosy, The New York Community Trust,

909 Third Avenue, New York, New York 10022, U.S.A.  

Tel: (212) 686-0010, ext. 556; FAX: (212) 532-8528; e-mail: lm(at)nyct-cfi.org

To reaffirm the need for more leprosy referral centres

Leprosy Mailing List – January 10^th, 2012

Ref.:    To reaffirm the need for more leprosy referral centres

From:  Vijayakrishnan B, Secunderabad, Andhra Pradesh, India.

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Dear Dr Noto,

I thank Dr Shimelis N Doni (LML Jan. 7^th, 2012 - New Leprosy Patients at ALERT, 2009/2010) for the very useful information, which should be another warning for leprosy programmes in all countries.  It may be wiser to learn from others’ experience than to wait to have the experience to one-self.

The recommendations on training and drug supplies may be appropriate in the context of Ethiopia.  But how much the general health staff would absorb the training and make it useful for the people needing care and management of reactions, diagnosis of neural leprosy etc., is difficult to predict.  This is not to discourage training to the general health staff, but only to reaffirm the need for more referral centres where people are given high quality services in leprosy.  The staff skilled in leprosy in such centres find more meaning and respect to their skills than in general hospitals.  

I also think the recommendation of developing a contact tracing programme very important.  In fact active case finding wherever relevant and possible should be promoted – even if it causes some deformity to the monitoring graphs.

Yours sincerely,

Vijay

Vijayakrishnan B

India Representative, Fontilles

201, Royal Heights, J J Nagar Colony, Alwal

Secunderabad, Andhra Pradesh

India.