Monday, November 30, 2015

(LML) to identify the extent of declining knowledge among clinicians and maintenance of clinical knowledge in diagnosing leprosy by general practitioner

Leprosy Mailing List – November 30,  2015

Ref.:    (LML) to identify the extent of declining knowledge among clinicians and maintenance of clinical knowledge in diagnosing leprosy by general practitioner

From:  Pranab Kumar  Das, Birmingham, UK


Dear Pieter, Ben and Dipak,


I would like to carry out a questionnaire based study as stated below:

 "The occurrence of poly-neuropathy due to various infectious agents is well recognized in literature. Among them nerve damage in leprosy leading to permanent disability still represent an important global health problem.  In relation to leprosy it should be firmly stated that although the disease has declined to the level of being “eliminated”, it still remains a threat in the Europe due to the flow of migration from the developing and emerging countries as well as frequent travel. In this respect, we would like to conduct a questionnaire based study in collaboration with the immigrant population and GPS/dermatologists for finding cases of suspected cases leprosy and patients with relevant mycobacterial infection. The strategy of the study will aim to identify the extent of declining knowledge among clinicians and maintenance of clinical knowledge in diagnosing leprosy by general practitioner." 

The relevant back ground work for this study can be found in the following references:

1. Teasdale K, De Wildt G, Das Pranab Kumar et al (2015) The Patient Perspective od diagnostic for leprosy in Brazil. An Exploratory study.  Lepr. Rev. 86, 21-36.

2. Mary Henry, GalaAn Noemi, Teasdale Katherine............Virmond Marcos and Das Pranab Kumar(2015): Factors Contributing to Delay in Diagnosis and Continued Transmission of Leprosy-A Quatitative Questionaire Based Study from Instituto Lauro de Souza Lima, Sao Paulo, Brazil: Submitted and under revision , Plos Neglected Tropical Disease.

I shall appreciate help from you three and if you have any other suggestion. Like to base the study firstly in Holland (because, Ben can be instrumental, and in France [again Ben can be instumental] , may be in Italy or Spain.

Thank you.  Kind regards.

Pran


LML - S Deepak, B Naafs, S Noto and P Schreuder

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(LML) Draft WHO Leprosy Strategy 2016-2020

Leprosy Mailing List – November 30,  2015

Ref.:    (LML) Draft WHO Leprosy Strategy 2016-2020

From:  Pranab Kumar Das, Birmingham, UK


 

Dear Pieter,


This letter is in reference to Dr Shetty's communication on 25th November 2015 concerning on the application of U-MDT vs R-MDT. It seems that the cardinal debate has been long surrounding relapse, progressive silent nerve damage, re-infection and reactions etc. sounding the disease almost "mission impossible" in terms of continuous transmission and unpreventable episodic reactions. All of the world famous leprosy experts seem to go round and round these cardinal problems.


Following all these arguments, my naive conclusion is that U-MDT may be a rational alternative in a mass programme and indeed that needs to be superimposed with timely examination of NFI, symptoms of reactions and the expert management, that are suitable for mass programme. I wonder whether such strategy is being adopted anywhere probably in Brazil.


Personally, I feel that declining knowledge in clinical expertise in leprosy needs to be revitalised in Medical curricula.


Regards,


Pran 


LML - S Deepak, B Naafs, S Noto and P Schreuder

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Friday, November 27, 2015

(LML) Draft WHO Leprosy Strategy 2016-2020

Leprosy Mailing List – November 27,  2015

Ref.:    (LML) Draft WHO Leprosy Strategy 2016-2020

From:  Hemanta Kumar Kar, Delhi, India


Dear Pieter,


I fully agree with Sunil (LML, 20-11-2015). Around 2 lacks and odd new leprosy patients are being detected every year around the world, the majority from India, with slow reduction of new cases from year to year. Uniform MDT is a viable option to implement if it is given for 1year instead of 6 months for the obvious reasons discussed from time to time.

Number one is the problem of missing many MB cases because lack of complete examination of whole body area leading to missing of some lesions, both skin and nerve. That leads to under diagnosis of MB cases as PB. This could be solved with U-MDT.

Secondly there are cases of LL being missed frequently because of stoppage of doing SSS examination by National Program managers. Many of them are remained undiagnosed until they develop certain complications like reaction, neuritis leading to deformity and landed directly in tertiary care set up in late stage. That is one of the reasons of slow reduction of new cases.

Thirdly, both type 1 and type 2 reactions develop in more number cases beyond 6 months of treatment particularly  in MB cases. It will be inappropriate to stop multidrug treatment after 6 months while steroid administration is going on  beyond that period to control reactions/ neuritis without MDT.

Therefore, at this crucial juncture implementation of 6 months U-MDT regimen will be too early and may be suicidal for the program. I am sure WHO/ Novartis can afford MDT for few more years for 1 year regimen rather than 6 months. We all hope that the WHO will take care of these problems and take an appropriate decision for ultimate eradication of leprosy from the world.

Warm Regards,


Kar

Dr Hemanta Kumar Kar
Professor in Dermatology,North Delhi Municipal Corporation Medical College Delhi -110007
Former Director, Dean and Med. Superintendent
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001


LML - S Deepak, B Naafs, S Noto and P Schreuder

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(LML) ILA Congress, Beijing, 2016

Leprosy Mailing List – November 27,  2015

Ref.:    (LML) ILA Congress, Beijing, 2016

From:  Chandrakant Revankar, New Jersey, USA


 

Dear Pieter,

 

I would like to refer to the letter addressed to Marcos Virmond regarding the coming ILA Congress in Beijing, 2016, in LML, 16-11-2015.

 

Since morbidity management and disability prevention (MMDP) in leprosy and other NTDs (e.g. Buruli ulcer, lymphatic filariasis) for integrated management is being discussed and advocated more and more, ILA congress 2016 may give some time to discuss on this important topic.

 

This will open up opportunities to participate not only leprosy but also other experts working on other neglected tropical diseases and WASH strategy.

Regards

CR Revankar

Dr.CR Revankar

Consultant

Leprosy and other NTDs

NewJersey.USA

revankarcr@gmail.com


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Wednesday, November 25, 2015

(LML) Working your fingers to the bone. An interdisciplinary conference on identifying occupation from the skeleton

Leprosy Mailing List – November 25,  2015

Ref.:     (LML) Working your fingers to the bone. An interdisciplinary conference on identifying occupation from the skeleton

From:  Ana Luisa Santos, Coimbra, Portugal


Dear colleagues,


We would like to announce a forthcoming conference which may interest you.

Next July the University of Coimbra will host the meeting
Working your fingers to the bone. An interdisciplinary conference on identifying occupation from the skeleton.


Hope that you have new research to present. The abstract deadline is the end of February.

More information will be available soon at
http://www.uc.pt/en/cia/events/Occupation_Conference_2016

Please share this information widely.

Looking forward to welcome you in Coimbra.

From the Organizers,

 

Ana Luisa Santos

CIAS – Centro de Investigação em Antropologia e Saúde / Research Centre for Anthropology and Health

Departamento de Ciências da Vida/ Department of Life Sciences, University of Coimbra

Apartado 3046

P- 3001 401 Coimbra, Portugal

 

http://www.uc.pt/fctuc/dcv/

http://www.uc.pt/en/cia/people/cvana

Telef / Phone + 351 239 240 718 (interno 262218)

Fax +351 239 854 129

http://www.uc.pt/fctuc/dcv/ensino/dou_antrop

https://estudogeral.sib.uc.pt/handle/10316/14637


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(LML) Draft WHO Leprosy Strategy 2016-2020

 

Leprosy Mailing List – November 25,  2015

Ref.:    (LML) Draft WHO Leprosy Strategy 2016-2020

From:  VP Shetty FMR, Mumbai Maharashtra, India


Dear Pieter,

 

I would like to contribute to this very important ongoing debate. I agree that in principle, Uniform MDT regimen for all leprosy patients is a very logical and a practical approach in a mass programme for;  

This will reduce the task and level of confusion in the minds of service providers as well as patients. Service provider, because he usually determines the treatment regime without even touching the patient. Patients, because often he/she fails to understand the discrimination.

We have come across patients who internally share their experience as well as medicine or seek private treatment, as they are a dissatisfied lot. This aspect remains unchecked in mass programme.

My main concern however is we have no proof what so ever to say that 6 months of MDT is good enough for all patients.

I want to share a small survey finding recently undertaken in parts of Maharashtra, India.   In a 3 year active follow-up study 54 confirmed relapse cases were detected   in a cohort of 520 patients released from treatment at the public health facility (PHC), between March 2005 and April 2010. Occurrence of relapse was 11.7% among MB treatment group (37/316) and 8.3% among PB treatment group (17/204), is by no means a negligible proportion.

It is all the more important to note that over 80% among them were BT cases receiving 12 months of MB-MDT, raising a serious concern with regard to efficacy of WHO MDT regimen.

There are several other burning issues that are being undermined by the draft WHO leprosy strategy 2016-2020.

As has been pointed out by Drs Joel Almeda, Narashima Rao, Ben Naafs, WIM van Brakel,  Dinkar Palande and others, early  detection and timely intervention of NFI, reaction and its management are as important as new cases detection. MDT alone is not going to solve the problem of Leprosy. Monthly/ three monthly screening of patients for NFI will pay a good dividend.

We note an increase in trend of Pure neural leprosy cases with a delay in diagnosis of 2-3 years. This is mainly due to depletion of expertise.

 

Regards,

 

VP Shetty.        

The Foundation for Medical Research,

84-A, R.G.Thadani Marg,

Worli, Mumbai,

Maharashtra – 400018

Phone – 022-24934989

Fax – 022-24932876

email:fmr@fmrindia.org

 

Website:www.fmrindia.org


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Tuesday, November 24, 2015

(LML) Protecting Indians from leprosy

Leprosy Mailing List – November 24,  2015

Ref.:  (LML)   Protecting Indians from leprosy

From:  Rajeev B. Dudhalkar, Mumbai, India


Dear Sir,

Here I would like to draw your attention to some of the today’s disturbing issues and concerns for leprosy and me in person (Editor: see also Joel Almeida letter, LML 25-09-2015).

1.       Are we emphasising on lepromatous / infectious case detection ? In the absence of ‘Skin Smear’ for the confirmation of diagnosis, one of the ‘Cardinal Sign’ for leprosy. Is there any alternative we have provided in the programme ? In India Revised National Tuberculosis Programmed (RNTCP) network of sputum laboratory within the General Health Care System (GHCS) can be very effectively utilised.

2.       In the absence of promoting the infectious case detection, patch orientated case detection, awareness and grouping for treatment MB/PB how it will help in true sense  control and curtail the incidence of leprosy.

3.       Trouble free signs and symptoms of leprosy is the main obstacle in voluntary reporting of the early cases of leprosy and suspects in the absence of effective and sustained leprosy awareness along with dissemination of scientific facts about leprosy though press mass media and social media / network.

4.       After integration of ‘National Leprosy Eradication Programme’ within GHCS it should have been more fruitful in terms of early case detection, treatment, management and providing timely quality leprosy services to the PAL (Person Affected by leprosy) through the well-established network of medial and paramedical staff of GHC system (Ref. Government of India LAW COMMISSION OF INDIA Report No. 256 ‘ELIMINATING DISCRIMINATION AGAINST PERSON AFFECTED BY LEPROSY (April 2015)’ 2.3.2 However, once the declaration the elimination of leprosy as a public health issue was made, the vertical health programme of Leprosy was merged into general healthcare system of the country. This transition did not happen as smoothly and in as well planned a manner as it should have, leading to gaps in the delivery including the detection of Leprosy, which continue to exist till today. … A major portion of these new cases of leprosy in India are of children, who face the threat of isolation and discrimination at  a very young age.)

5.       Instead of embedding and strengthening leprosy services with the help of effective and efficient use of existing leprosy expertise why we are still trying to withhold the verticality of the programme?  By doing so we can enhance our reach to PAL and doorstep delivery of the leprosy services in turn benefit large number and getting away ‘Stigma’ attached to leprosy.

6.       If there is assured full course of MDT made available like RNTCP. This will help in good treatment compliance and overcome the lapses in the distribution and shortage of MDT at the peripheral level. Because, making full course of MDT assured, made available at the time of case detection itself is very crucial for control / elimination of leprosy.

 

With best regards,

 

Rajeev B. Dudhalkar

 

Mumbai, India


LML - S Deepak, B Naafs, S Noto and P Schreuder

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(LML) Protecting Indians from leprosy

Leprosy Mailing List – November 24,  2015

Ref.:  (LML)   Protecting Indians from leprosy

From:  Rajeev B. Dudhalkar, Mumbai, India


Dear Sir,

Here I would like to draw your attention to some of the today’s disturbing issues and concerns for leprosy and me in person (Editor: see also Joel Almeida letter, LML 25-09-2015).

1.       Are we emphasising on lepromatous / infectious case detection ? In the absence of ‘Skin Smear’ for the confirmation of diagnosis, one of the ‘Cardinal Sign’ for leprosy. Is there any alternative we have provided in the programme ? In India Revised National Tuberculosis Programmed (RNTCP) network of sputum laboratory within the General Health Care System (GHCS) can be very effectively utilised.

2.       In the absence of promoting the infectious case detection, patch orientated case detection, awareness and grouping for treatment MB/PB how it will help in true sense  control and curtail the incidence of leprosy.

3.       Trouble free signs and symptoms of leprosy is the main obstacle in voluntary reporting of the early cases of leprosy and suspects in the absence of effective and sustained leprosy awareness along with dissemination of scientific facts about leprosy though press mass media and social media / network.

4.       After integration of ‘National Leprosy Eradication Programme’ within GHCS it should have been more fruitful in terms of early case detection, treatment, management and providing timely quality leprosy services to the PAL (Person Affected by leprosy) through the well-established network of medial and paramedical staff of GHC system (Ref. Government of India LAW COMMISSION OF INDIA Report No. 256 ‘ELIMINATING DISCRIMINATION AGAINST PERSON AFFECTED BY LEPROSY (April 2015)’ 2.3.2 However, once the declaration the elimination of leprosy as a public health issue was made, the vertical health programme of Leprosy was merged into general healthcare system of the country. This transition did not happen as smoothly and in as well planned a manner as it should have, leading to gaps in the delivery including the detection of Leprosy, which continue to exist till today. … A major portion of these new cases of leprosy in India are of children, who face the threat of isolation and discrimination at  a very young age.)

5.       Instead of embedding and strengthening leprosy services with the help of effective and efficient use of existing leprosy expertise why we are still trying to withhold the verticality of the programme?  By doing so we can enhance our reach to PAL and doorstep delivery of the leprosy services in turn benefit large number and getting away ‘Stigma’ attached to leprosy.

6.       If there is assured full course of MDT made available like RNTCP. This will help in good treatment compliance and overcome the lapses in the distribution and shortage of MDT at the peripheral level. Because, making full course of MDT assured, made available at the time of case detection itself is very crucial for control / elimination of leprosy.

 

With best regards,

 

Rajeev B. Dudhalkar

 

Mumbai, India


LML - S Deepak, B Naafs, S Noto and P Schreuder

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(LML) Draft WHO Leprosy Strategy 2016-2020

Leprosy Mailing List – November 25,  2015

Ref.:    (LML) Draft WHO Leprosy Strategy 2016-2020

 From:  Isabela Goulart, Uberlândia, Brazil


Dear Pieter,

Follow below my contribution to the LML debate about the Draft WHO Leprosy Strategy 2016-2020.

- Why do we need to use and discover new antimicrobials and regimens to treat leprosy?

To replace current drugs when unacceptable side effects / toxicities occur; to obtain a more “reliable” cure and to shorten the duration of treatment.

Currently it is generally recommended the same 2 or 3 drugs regimen to treat every patient with leprosy.  Adverse effects of each pharmaceutical limit their utilization in a significant number of patients; leprosy is no exception; however, alternative agents and regimens have not been recommended.

The key component of the current WHO MDT treatment for the most severe cases of leprosy includes only rifampin as bactericidal agent, and the regimen with monthly administration is generally successful. The potential for intermittency with rifampin monthly doses for the treatment of leprosy may be due to the long generation time demonstrated for M. leprae, 2 weeks in vivo.

Relapse and treatment failure in MB patients, especially those with a high BI, are unacceptably high. In the National Reference Centre for Sanitary Dermatology and Leprosy, Clinics Hospital, Federal University of Uberlandia/MG-Brazil, the relapse has progressively increased from 2010. According to WHO, all MB relapse cases included in the surveillance should immediately be put on treatment with standard MB-MDT, without waiting for the results from the reference laboratory on the status for drug resistance. If the result comes back as susceptible to rifampin, MB-MDT treatment is to be continued. For patients with resistance reported only to dapsone, standard MB-MDT can be continued. In case of a patient harbouring rifampin resistant M. leprae, the following treatment should be given: administration of 50 mg of clofazimine, together with 400 mg of ofloxacin and 100 mg of minocycline, daily for six months; and 50 mg of clofazimine, together with 100 mg of minocycline or 400 mg of ofloxacin daily for an additional 18 months. This above mentioned treatment regimen is also to be used for patients reported as harbouring both rifampin and dapsone resistant M. leprae.

Can ofloxacin or minociclin replace rifampin? No. Why? Because the relative potency of active agents against LL leprosy is best judged by the time taken to clear viable M. leprae: ofloxacin and minociclin take 1-2months and rifampin takes a few days; and whether single dose regularly kill M. leprae: ofloxacin and minociclin = no; rifampin = yes. An urgent review of the recommended scheme is necessary in the light of current knowledge.

 About U-MDT:  paper of reference from Dr. Robert Gelber - Leonard Wood Memorial, Cebu, Philippines (Gelber et al., 2009)

 The successful short-course treatment for tuberculosis requires two or more bactericidal agents (rifampin and pyrazinamide). Only rifampin is bactericidal for M. leprae and not dapsone and clofazimine.

Again, it is important to emphasize that the relative potency of active agents against LL leprosy is given by the time taken to clear viable M. leprae: rifampin takes few days; dapsone and clofazimine take 3-6 months; and also whether single dose regularly kill M. leprae: rifampin = yes; dapsone and clofazimine = no.

Considering  this scientific evidence and the experience with short-course treatment for tuberculosis, how can we accept, as competent researchers, to prescribe U-MDT during 6 months for every leprosy patients, with a single bactericidal drug (rifampin) and two bacteriostatic drugs (dapsone and clofazimine), that take up to 6 months to eliminate skin bacilli in LL patients? This question has to be raised in this crucial moment.

Ideal antimicrobials to treat leprosy : 1- Bactericidal in patients (single dose kill and clear detectable viable M. leprae in days to few weeks); 2- Effective against dormant M. tuberculosis; 3- Active against M. leprae when administered intermittently.

The recent demonstration that in leprosy patients’ moxifloxacin is as bactericidal for M. leprae as is rifampin, brings into leprosy chemotherapy, for the first time, the possibility for combination of two truly bactericidal drugs (Pardillo et al., 2008). It is urgent to add moxifloxacin to leprosy therapeutic arsenal.

From the earlier results of Ji et al., 2006 and from the study of Gelber et al., 2009 with murine leprosy, the authors have demonstrated that bedaquiline (dyarilquinoline/ R207910) is bactericidal against M. leprae, not only when given once weekly, but also once monthly. All treatments were found to be bactericidal, suggesting that both low dosage and intermittent treatment with R207910 holds promise for leprosy patients . Furthermore, in 2012, The U.S. FDA, based on efficacy and safety, has approved bedaquiline for the treatment of MDR-TB. Based on these results, bedaquiline is a promising candidate for trials with leprosy patients.

I think that Dr. Gelber's team is already developing a protocol with this new drug, as was shown at the International Leprosy Congress in Brussels- Belgium in 2013. He said in his presentation that if bedaquiline proves similar bactericidal activity for M. leprae in patients and safety for long-term administration, a three drug regimen with rifamicin (rifampin) and moxifloxacin holds the best potential for leprosy treatment with an intermittent, perhaps monthly, supervised regimen, with a shorter duration than the currently required one year.

There should be an innovative approach to the leprosy treatment of the twenty-first century.

MDT, as is currently recommended by WHO, is a worn out strategy.

Furthermore, I am absolutely convinced by the scientific evidences, that U-MDT will be a mistaken strategy for the control of leprosy disease.

Best regards,

 

Isabela Goulart

 

Dr. Isabela Maria Bernardes Goulart, MD, PhD
Associate Professor – School of Medicine
Universidade Federal de Uberlândia  - UFU
Coordinator and Head of the National Reference Center for Sanitary Dermatology and Leprosy - Clinics Hospital – UFU, Uberlândia - MG, Brazil
www.credesh.hc.ufu.br; credsh@hc.ufu.brimbgoulart@gmail.com
Phone/Fax: +55 34 3216 7872;
(34) 3210-3545


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Friday, November 20, 2015

(LML) Draft WHO Leprosy Strategy 2016-2020

Leprosy Mailing List – November 20,  2015

 

Ref.:    (LML) Draft WHO Leprosy Strategy 2016-2020

 

From:  Sunil Dogra, Chandigarh, India


 

 

 

Dear Colleagues,

 

Please go through a very recent publication on the issue of U-MDT in Indian Dermatology Online Journal .

 

 

Global leprosy program: Does it need uniform-multi-drug therapy now?

p. 425

P Narasimha Rao, Sunil Dogra, Sujai Suneetha
DOI:10.4103/2229-5178.169735 

Indian Dermatol Online J [serial online] 2015 [cited 2015 Nov 18];6:425-7. Available from: http://www.idoj.in/text.asp?2015/6/6/425/169735

It highlights concerns and shortcomings of proposed U MDT which makes us think - is there any compelling REASON & EVIDENCE to implement UMDT. 

  • Are we doing it to improve compliance - we are aware of high drop out rates with 6 months ATT in TB and did cure rate in MB cases improved significantly on reducing MDT MBR from 2 year to 1 year ?
  • World Health authorities can not afford 1 year MDT MB supply for remaining few lakhs of patients ?
  • Even if results of UMDT trial are not discouraging at the moment, what are we going to lose by continuing current FDT MDT MBR (1 year) ?
  • Is present leprosy classification for treatment is difficult for general health care staff to follow - if so why not single (U) MDT MBR of 1 year duration for all cases of leprosy. ?
  • Do we have an effective and functional referral system in place in present setting of integration of leprosy services with GHS for patients who will suffer from reactions and deformities after RFT in 6 months of starting treatment ?
  • In the absence of SSS in routine practice - diagnosis of relapse and resistance will be questionable.



Are we not going to implement UMDT at the cost of risk of under treating MB cases especially with high BI. Will it not lead to possibility of secondary drug resistance in such MB cases and hence Primary in those infected later. ? High relapse rate with UMDT is very certain  on long term (>7-10 years follow up) as we had seen even when MDT was given for 2 years.  


With warm regards

 

Dr Sunil Dogra MD DNB FRCP (London)

  

Additional Professor

Department of Dermatology

Postgraduate Institute of Medical Education & Research (PGIMER)

Chandigarh, India. 

sundogra@hotmail.com 

 

 Vice President: Indian Association of Leprologists (IAL)


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(LML) Candidates for ILEP Global Policy Advisor Position

Leprosy Mailing List – November 20,  2015

 

Ref.:    (LML) Candidates for ILEP Global Policy Advisor Position

 

From:  Maria Grigore, Oxford, UK  


 

 

Dear Pieter,

 

Dr Richard de Soldenhoff has recommended to contact you, as you can see in the message below. I am working at Oxford HR and we are supporting ILEP with their search for a new Global Policy Adviser. 

 

As you may know already, ILEP was founded in 1966 as a Federation of 14 international non-governmental organisations. Members co-ordinate their work in 63 countries, where they spend some $60 million on 700 projects and around $US 2.5 million per year on leprosy research. Together they are stopping leprosy and preventing disability due to leprosy. ILEP is fighting the stigma of leprosy, which can cause people affected and their families to be shunned and excluded from everyday life, their rights ignored.


The Global Policy Advisor will provide advisory support and expertise for ILEP’s global policy process and collaborate on an assigned area of process and policy. Ultimately, you will contribute directly to developing policy that furthers ILEPs external goals.

Full details about the role can be found on the candidate pack :http://oxfordhr.co.uk/wp-content/uploads/Candidate-Pack-ILEP-GLP11112015.pdf

I would be really grateful if we could have this role posted in your group LML. 

 

Thank you for your attention and please let me know if this sounds alright.

 

All the best,

Maria


 

       

G. Maria Grigore  | Researcher and Business Development 
Tel: +44 (0) 
1865 403 298  | Direct: + 44 (0) 1865 403 266 
mgrigore@oxfordhr.co.uk  
|  Skype: maria.grigoreoxhr  
View my profile on linked 
 and connect with me!

Oxford HR Consultants Ltd  
|  Reg. Company No. 6456325   
The Old Music Hall, 106-108 Cowley Road, Oxford, OX4 1JE 
www.oxfordhr.co.uk

 


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