(LML) Nerve function loss after the completion of MDT

Leprosy Mailing List – May 30,  2021 

 

Ref.:  (LML) Nerve function loss after the completion of MDT 

 

From:  Wim Theuvenet, Apeldoorn, the Netherlands 

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Dear Pieter,

Would anyone on the LML have data on the progression of nerve function loss in the time after the completion of MDT??

With best regards and thanks,

Wim J.Theuvenet

Plastic, Reconstructive & Hand surgeon. 

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

LML blog link: http://leprosymailinglist.blogspot.it/ 

Contact: Dr Pieter Schreuder << editorlml@gmail.com  

Fw: Ref.: (LML) The world's most impactful intervention against HD (leprosy) transmission

 

Leprosy Mailing List – May 22,  2021

 

Ref.:  (LML) The world's most impactful intervention against HD (leprosy) transmission

From:  Joel Almeida, London and Mumbai

 

Dear Pieter and colleagues,

The measured outcomes and impact of the mass multi-drug administration with ROM (rifampicin + ofloxacin + minocycline) in FSM (Federated States of Micronesia), are the best ever achieved. An 84% decline in new HD cases was achieved within 2 years. Those who received ROM showed a 92% reduction in incidence rate of HD compared to those who did not receive ROM. The intervention was discontinued prematurely. However, when all deliberate interventions against HD (leprosy) are analysed throughout history, this ROM intervention in FSM emerges as the most impactful. No segregation was involved. We gained important clues about what is achievable..

 

What were the elements of the intervention?

a) Polar LL (lepromatous) patients received prolonged anti-microbial protection, beyond 12 months of MDT. This protected them against re-infection and very painful ENL (Erythema Nodosum Leprosum) episodes.

Prolonged anti-microbial protection (MDT beyond 12 months) was a critical component of the success. Otherwise polar LL patients are forced to accept re-infection. Simply protecting polar LL patients against reinfection (in endemic areas) is capable of achieving a sustained 16%/year to 20%/year decline in new LL and MB (multibacillary) HD cases. This was demonstrated in Karigiri (a low income population, India) and Shandong (China) in the 1980s. Karigiri then switched from prolonged anti-microbial protection to 2 year and 1 year MDT (multi-drug therapy) in the 1990s. This again allowed the polar LL patients to be reinfected after MDT. Recurrent LL HD is an important source of concentrated viable bacilli, and the near-zero incidence rate of LL HD was lost. Yunnan (China) always used only 2 years or 1 year of MDT. Despite steady increases in income levels and "HD villages", Yunnan is still achieving only about 6%/year decline in new HD cases. This is a much slower decline than Karigiri or Shandong.

Reinfection of polar LL patients allows the bacilli to cause hard-to-diagnose recurrent HD and to keep infecting children and others. It also multiplies the risk of excruciatingly painful ENL episodes among the polar LL patients, driving some of them to suicidal ideation. In FSM, the end of the project was accompanied by the switch from prolonged MDT to 1 year MDT for even LL patients. This allowed the bacilli to cause recurrent HD and so to maintain a supply of highly concentrated viable bacilli. This problem can be solved simply by prolonging MDT for polar LL patients who rely on free-of-charge MDT, or by offering monthly post-MDT chemoprophylaxis with 3 bactericidal drugs to LLp patients who can afford to pay. Sub-polar LL patients respond well to MIP vaccine, and 24 months of MDT probably suffices for them once they receive such immunoprophylaxis. But polar LL patients in an endemic area require prolonged protection against ENL and bacillary proliferation, regardless of immunoprophylaxis.


b) Polar LL patients were diagnosed during skin camps, for all skin conditions, with experienced clinicians assisting less qualified personnel. This reduced the number of missed LL patients.

Polar LL patients can shed tens of millions of viable bacilli per day, but too often show few or no visible signs of HD. Microscopy of skin smears or nasal smears shows globi packed densely with acid-fast bacilli. Expert clinicians know how to detect the subtle physical signs even while waiting and campaigning for microscopy services to be restored. Participation of an expert clinician was a critical component of the success in FSM/ROM. Otherwise, even a single missed LL patient is forced to keep spreading millions of viable bacilli per day, infecting children and others. 

This problem can be solved by encouraging experienced clinicians to participate in skin camps, and having smear technicians travelling from camp to camp to collect nasal or skin smears for transport to a quality-controlled microscopy centre. Experienced clinicians have busy lives. But in India many clinicians donate some of their valuable time to this noble cause. Telemedicine allows experienced clinicians to assist in even remote, hard-to-reach areas. Perhaps more formal arrangements and reasonable compensation can be offered to experienced clinicians for participation in integrated skin camps. Skin camps deal with all skin conditions, not just HD. Therefore they also help reduce stigma.


c) ROM was offered at intervals to everyone in this high endemic area. This is now called mass multi-drug administration. It is used for many diseases, and repeated relentlessly at intervals until transmission is interrupted. 

Mass multi-drug administration was a critical component of the temporary success in FSM. Nearly all sources of concentrated viable bacilli were shut down temporarily. The impact was immediate. The use of a multiple drug combination delayed the selection of drug-resistant mutant bacilli.

When would be the right time to withdraw such an intervention? After no child case was detected for several years. Two annual rounds of ROM was too short for lasting victory.

What would be the right frequency for mass multi-drug administration? Probably more frequently than once a year. Every 9 months, and in hyperendemic "hot spots" even more frequently. Probably every 6 months.

What would be the most convenient way to administer it? Probably together with skin camps and mass drug administration (MDA) for other diseases. Many of the MDA diseases co-exist in the same populations, and campaigns of MDA are already in operation in several HD-endemic countries.

 

In summary, the components that enable 84% reduction of new HD cases within 2 years are:

1) Prolonged anti-microbial protection for polar LL patients, to interrupt transmission at source

 

2) Expert skin camps for all conditions, aided by smear microscopy, to detect even those previously undiagnosed polar LL patients who have only subtle signs of HD

 

3) Mass multi-drug administration using ROM or equivalent at intervals of less than a year, to reduce the incidence rate of HD to near-zero levels within a very short time. All the complications of HD, from disfigurement to painful ENL to social exclusion, are therefore avoided.

 

Financing

What would be the best way to raise financing for such highly impactful campaigns? Probably to do what we did for TB at WHO in the 1990s, when TB was under-financed with only about 100 million USD annual financing globally. Now TB has been adopted by the whole world as a major initiative with billions of USD in annual financing. HD is not a killer, and most people are naturally immune (unlike in TB). The investments required are correspondingly lower. 

What did we do, as the small WHO TB team in the 1990s?

We identified the most impactful intervention (which we defined as the DOTS strategy). Then we set up demonstration projects in endemic countries. When great measurable outcomes were shown repeatedly, the governments and donors all became enthusiastic about contributing finance to spread the great outcomes. Money chases great outcomes.

(In HD, by contrast, some organisations have been trying to promote demonstrably ineffective and harmful interventions that are far inferior to the FSM ROM intervention, and less effective even than MDT given till smear negativity. It would be good to avoid single drug use that can increase drug-resistance and drag us back to the days of hard-to-treat HD.)

The best outcomes are available from the Sasakawa Health Foundation (SHF)/WHO intervention in FSM. This demonstrated dramatic, rapid impact. It is the kind of success that can start a snowball of great outcomes, great impact, attracting adequate investment to spread the success everywhere.

Starting the snowball of success

Where would be a good place to demonstrate such rapid success? Perhaps former "HD colonies" are prime locations for once again demonstrating the impact of mass multi-drug administration used together with integrated skin camps and prolonged MDT for those with LL HD. Too many of these colonies suffer anti-microbial neglect and become hyperendemic "hot spots" where people still experience the excruciating pain of ENL episodes plus recurrent HD. Such settlements rapidly could become examples of "near zero transmission". No child who lives in such a colony need develop HD, and nobody here who has experienced HD need develop avoidable disability or suffer neglect. Former "HD colonies" could become beacons of "zero transmission", zero neglect, zero new sequelae, free from extreme poverty and emboldened to advance socio-economically with full participation in mainstream life. Demonstrable success is the best answer to scepticism, as we found in TB. Former "HD colonies" that have a high incidence rate of HD could become islands of success. This success can spread to hyperendemic "hot spots" across the globe.

Finance for exemplary demonstration projects is already available from some noble-minded philanthropic organisations. As dramatic successes accumulate, governments of endemic countries tend to become enthusiastic about investment. There is no reason for delay. 

 

 

Avoiding drug resistance

It seems important, however, to avoid drug resistance. It has compromised efforts in TB greatly. We need not let drug resistance derail our victory in HD. We aim for the mountain-top of zero HD transmission, but we walk along the cliff-edge of drug resistance. It is easy to push endemic countries over the edge by using or promoting single drug use (e.g., promoting SDR PEP instead of the highly impactful SHF/WHO ROM intervention). We are all life-long students, open to learning from unexpected disappointments and unexpected successes alike. It would be good if all of us could learn from this impactful and world-leading SHF/WHO ROM intervention. 

 

 

Conclusion

It seems sensible to use multi-drugs invariably, instead of single drugs, whether for prophylaxis or treatment. The SHF/WHO ROM project in FSM shows that we can succeed, and rapidly, while delaying drug resistance. We too can achieve 84% decline of new HD cases within 2 years. We could implement this mass multi-drug intervention relentlessly in hot spots, until every child is free from the threat of HD transmission. In other areas a 20% annual decline in the incidence rate of MB HD is available by ensuring prolonged anti-microbial protection for polar LL patients. 

 

A world with near-zero HD transmission is within our reach, providing we avoid drug resistance. Let's open our minds, learn from programmes with huge epidemiological impact, and reach for success.

 

Joel Almeida

 

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

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

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Ref.: (LML) Global Leprosy Strategy 2021-2030

 

Leprosy Mailing List – May 18,  2021 

 

Ref.:  (LML) Global Leprosy Strategy 2021-2030 

 

From:  Sunil Deepak, Schio, Italy 

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Dear Pieter, 

 

I think that the situation of leprosy programmes around the world has changed significantly over the past few years. The leprosy programmes in countries are generally even more neglected than ever before. The continuing Covid-19 devastation, especially in countries like India and Brazil,  would probably weaken them even more. As the new leprosy strategy 2021-2030 acknowledges, the number of trained leprologists around the world is decreasing. 

 

The goal of the new leprosy strategy is focused on decreasing the total number of cases by chemo-prophylaxis of the contacts with SDR. There is little in this strategy about the quality of the services for the individuals who have leprosy though it does mention about diminishing laboratory services and importance of disability prevention. 

 

The new Global Leprosy Strategy 2021-2030 can be downloaded from the following link: 

https://www.who.int/publications/i/item/9789290228509 

 

I think that it might be interesting to hear from LML members about the quality of leprosy services in their countries in the present scenario and about the Global Leprosy Strategy. 

 

Sunil 

 

Dr Sunil Deepak 

Consultant AIFO, Italy  

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

LML blog link: http://leprosymailinglist.blogspot.it/ 

Contact: Dr Pieter Schreuder << editorlml@gmail.com  

Re: LML Leprosy Cure

Leprosy Mailing List – May 15,  2021

 

Ref.:  (LML) Leprosy Cure

 

From:  Diana Lockwood, London, UK

 

 

Dear Pieter,

 

I thank Dr L Laila de Laquiche for her question about leprosy cure (LML, May 7, 2021). She has asked a complicated question that has generated some thoughtful responses. Henk Eggens captured the problems of leprosy patients with neuropathic complications who do not feel cured (LML 8.5.21).

 

For the key point with treating leprosy patients is that this is both a mycobacterial and an immunological disease. Cure means having treated both aspects of the disease, the infection and the immune response. Leprosy is further complicated by individual responses that patients have in terms of the bacterial load that develops which ranges from the low in tuberculoid to very high in lepromatous leprosy patients.  Superimposed on this are leprosy reactions and nerve damage which affect people mainly in the borderline part of the spectrum except for ENL which affects patients with LL disease. 

 

I would like to add the following parameters to the ones mentioned by Dr Narasimha Rao's posting 12 may 2021:

1. Completed treatment for reactions and complications requiring immune-suppressive therapy

2. Stable neuropathic complications

3. Psychological ease post leprosy

 

This would give us a 6 point assessment for cure and takes in the different aspects of leprosy. Narasimha Rao's first 3 points were 1. clinical cure 2. Bacteriological cure, 3. Histopathological cure. Point 4, Serological cure, was rightly discarded.

 

The real problem is that patients with nerve damage and reactions have on going inflammation and do not feel cured when they have completed their MDT. About 50% of MB patients will have significant inflammation requiring steroids.(1) Patients who have reactions in their skin and nerves or ENL reactions require long courses of steroids which makes them anxious and depressed and they do not feel "cured". Patients with ENL sometimes commit suicide. I have discussed these chronic aspects of leprosy.(2)

 

The neuropathic complications of leprosy take in many different aspects of disease management and need multidisciplinary teamwork.

 

Psychological peace. Many patients are anxious and depressed during and after their treatment. This contributes to the feeling of stigma. One needs to assess this part of their being to assess a cure post leprosy.

 

Narasimha Rao discussed the different aspects and shortcomings of bacteriological cure that we can measure. Since having acid fast bacilli in slit skin smears are one of the cardinal signs of leprosy it is a great shame that many programmes stopped doing slit skin smears.  This means that one cannot encourage patients by telling them that their skin smears are improved. It is difficult to assess possible relapse cases without having access to slit skin smear services. I agree with him that we should be doing all we can to promote the availability of slit skins smears through national programmes.

Butlin et al did a prospective observational study of patients in Bangladesh given 6 months  or 12 months MDT. (4)  Of the patients who were smear positive at the beginning of the study the proportion becoming smear negative was 21% at 24 months, 80% at 60 months and 100% at 96 months post treatment.

 

Clinical improvement of skin lesions is variable.  This is partly due to the ongoing inflammation in the lesions which is part of the clinical disease. Some patients' skin lesions resolve completely, others often with borderline tuberculoid leprosy can have persisting lesions with hypopigmentation.  The lesions in lepromatous leprosy patients may take years to improve. These variations in patient skin lesions improvement have been documented by Manickam (5)  in their prospective open study of Uniform Multidrug therapy (U-MDT) 6 months of standard triple therapy (dapsone and clofazimine daily and rifampicin monthly) regimens in India and China (2091 PB and 1298 MB patients).  They classified skin lesions using a scale into inactive, improved and static and followed up for five years, the rates for the MB patients were 10.4%. 84.9%, and 4.7% at treatment completion; 72.4%, 26.8%, and 0.8% at three years; and 80.7%, 18.2%, and 1.1% at five years. Patients can be reassured that their skin lesions will improve over 4 years, but some will have persisting lesions. This is an important clinical message and patients can be given hope that their skin will improve. The relapse rate was low, four MB patients relapsed giving a rate of 0.07/100 person years.

 

We should work to formalise the scale that was used by Manickam in their study so we have a better scale for measuring improvement.

 

The challenge is that new leprosy patients need to be given a message of hope but this has to be tempered with a message that they may have complications requiring further treatment with steroids. This is a difficult concept to transmit.

 

These factors also feed into the stigma associated with leprosy.

 

I told my patients that were bacteriologically cured once they had completed their multidrug therapy. I think this helped them even when they were having reactions because they knew that that at least part of the disease was treated. 

 

The cure needs to embrace these different aspects of leprosy management. One needs a long time frame for leprosy cure.  

 

Diana NJ Lockwood

Emeritus professor of Tropical Medicine

London School of Hygiene & Tropical Medicine

Keppel St

London WC1E 7HT

 

 

1.         Walker S, L. Leprosy Reactions.  The International Textbook of Leprosy American leprosy Mission; 2019.

2.         Lockwood DNJ. Chronic aspects of leprosy-neglected but important. Trans R Soc Trop Med Hyg. 2019;113(12):813-7.

3.         Lasry-Levy E, Hietaharju A, Pai V, Ganapati R, Rice AS, Haanpaa M, et al. Neuropathic pain and psychological morbidity in patients with treated leprosy: a cross-sectional prevalence study in Mumbai. PLoS Negl Trop Dis. 2011;5(3):e981.

4.         Butlin CR, Pahan D, Maug AKJ, Withington S, Nicholls P, Alam K, et al. Outcome of 6 months MBMDT in MB patients in Bangladesh- preliminary results. Leprosy Review. 2016;87(2):171-82.

5.         Manickam P, Mehendale SM, Nagaraju B, Katoch K, Jamesh A, Kutaiyan R, et al. International open trial of uniform multidrug therapy regimen for leprosy patients: Findings & implications for national leprosy programmes. Indian J Med Res. 2016;144(4):525-35.

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

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

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Fw: Ref.: (LML) Infolep monthly overview of new publications on leprosy - May '21

 

 

Leprosy Mailing List – May 12,  2021

 

Ref.:  (LML) Infolep monthly overview of new publications on leprosy - May '21

 

From:  Anniek Akerboom, Amsterdam, the netherlands

 

 

Dear colleagues,

The new WHO Global Leprosy Strategy 2021-2030, entitled 'Towards zero leprosy', was released on April 15th. The document presents the basic direction, goals, challenges and strategic pillars for the next ten years at a global level. ILEP's response to the Global Leprosy Strategy: "National NTD and leprosy programmes are urged to adopt it and to adapt its strategic pillars to their country context."

Below you will find the list with new publications on leprosy and interesting events, this time including online courses. Feel free to contact me to receive full-text versions if these cannot be found through the Infolep portal. Also, I would be happy to assist you with literature searches.

Warm regards,

Anniek Akerboom

Infolep Coordinator
www.leprosy-information.org
a.akerboom@infolep.org

 

 

Highlighted

 

 

Towards zero leprosy. Global leprosy (Hansen's Disease) strategy 2021–2030
World Health Organization . 2021;
Learn more

ILEP statement of commitment to the participation of persons affected by leprosy
ILEP. 2021;
Learn more

G-FINDER - Neglected disease research and development: Where to now?
Chapman N, Doubell A, Tuttle A, et al. Policy Cures Research. 2021; 
Learn more

 

 

Leprosy & COVID-19

 

Enhanced IL-6 and IL-12B Gene Expression After SARS-CoV-2 Infection in Leprosy Patients May Increase the Risk of Neural Damage.
Junior G, Kurizky P, Cerqueira S, et al. The American journal of tropical medicine and hygiene. 2021; 
Learn more

COVID-19 and the incidence of neglected tropical diseases: reflections from pandemic times
Santos GCDA, Mariano SMB, Silva JBNF. NEPAS. ABCS Health Sciences. 2021; 
Learn more

Evidence summary: Experiences of people with disabilities during COVID19 in Asia and the Pacific
CBM, Nossal Institute for Global Health . 2021; 
Learn more

How should Indonesia consider its neglected tropical diseases in the COVID-19 era? Hopes and challenges (Review)
Fauziyah S, Putri S, Salma Z, et al. Spandidos Publications. Biomedical Reports. 2021; 
Learn more
 

 

 

New publications

 

 

Leprosy postexposure prophylaxis with single-dose rifampicin: Nepalese dermatologist's dilemma.
Parajuli N, Poudyal Y. PLoS neglected tropical diseases. 2021; 15 (4) : e0009039. 
Learn more

Leprosy Screening Based on Artificial Intelligence: Development of a Cross-Platform App
De Souza MLM, Lopes GA, Branco AC, et al. JMIR Publications Inc.. JMIR mHealth and uHealth. 2021; 9 (4) : e23718. 
Learn more

Leprosy detection rate in patients under immunosuppression for the treatment of dermatological, rheumatological, and gastroenterological diseases: a systematic review of the literature and meta-analysis.
Barroso D, Brandão J, Andrade E, et al. BMC infectious diseases. 2021; 21 (1) : 347. 
Learn more

High transmission of leprosy among inhabitants in two former isolated leprosy villages in Senegal
Diop MM, Fall L, Dioussé P, et al. Leprosy Review. Lepra. 2021; 92 (1) : 2-10. 
Learn more

Peak plantar pressure analysis using customized tactile sensory feedback system — A short report
Paul MS, Siva B. Leprosy Review. Lepra. 2021; 92 (1) : 82-87. 
Learn more

Material analysis for therapeutic insoles — A short report
Paul S, Kumar DP, Siva B. Leprosy Review. Lepra. 2021; 92 (1) : 75-81. 
Learn more

Comparing socio-economic conditions of mother and children with leprosy in endemic and non-endemic areas in east Java, Indonesia.
Prakoeswa F, Awanis G, Azizah A, et al. African journal of infectious diseases. 2021; 15 (2) : 52-58. 
Learn more

A Qualitative Study Exploring the Perceived Impact of Race on Leprosy-Affected Persons' Experiences of Diagnosis and Treatment of Leprosy in Southeast Brazil
Shyam-Sundar V, de Wildt G, Virmond MCL, et al. Indian Journal of Leprosy. 2021; 
Learn more

Activity limitations in leprosy and their association to cognition and neuropsychiatric symptoms.
Amaral L, Felippe L, Gonçalves G, et al. Revista brasileira de enfermagem. 2021; 74 (1) : e20200649. 
Learn more

LAMP Assay Targeted RLEP for Detection of Mycobacterium Leprae in leprosy patients.
Jiang H, Tsang L, Wang H, et al. International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases. 2021; 
Learn more

Clinicopathological Diagnosis of Leprosy: Comparative Evaluation of Three Staining Methods for Acid Fast bacilli in Slit Skin Smears and Biopsy Specimens
Kamle A, Awasthi P, Rawat N, et al. Indian Journal of Leprosy. 2021; 
Learn more

A Clinicohistopathological Correlation of Hansen's Disease in a Rural Tertiary Care Hospital of Central India.
Atram M, Ghongade P, Gangane N. Journal of global infectious diseases. 2020; 12 (4) : 191-196. 
Learn more

Comparison between fine-needle aspiration cytology and histopathology in leprosy: A cross-sectional study
Dominic S, Asokan N, Nandakumar G, et al. Journal of Skin and Sexually Transmitted Diseases. Scientific Scholar. 2021; 
Learn more

Comparison between nerve conduction study and high-resolution ultrasonography with color doppler in type 1 and type 2 leprosy reactions.
Akita J, Miller L, Mello F, et al. Clinical neurophysiology practice. 2021; 
Learn more

Strategies for drug target identification in Mycobacterium leprae.
Acebrón-García-de-Eulate M, Blundell T, Vedithi S. Drug discovery today. 2021; 
Learn more

Reverse vaccinology and subtractive genomics approaches for identifying common therapeutics against Mycobacterium leprae and Mycobacterium lepromatosis.
Jaiswal A, Tiwari S, Jamal S, et al. The journal of venomous animals and toxins including tropical diseases. 2021; 
Learn more

Reviewing the therapeutic management of leprosy in primary care: demand case series referred to a University Hospital in the Midwest region of Brazil.
de Sousa P, de Sousa A, Turchi M. Anais brasileiros de dermatologia. 2021; 
Learn more

Correlation of Plasma Level of Insulin-Like Growth Factor-1 (IGF-1) with Bacterial Index on Leprosy Patients in Bali.
Santosa C, Rusyati L, Adiguna M, et al. Annals of dermatology. 2020; 32 (5) : 370-374. 
Learn more

Trends of Leprosy Over a Period of Four Years (2016-2019) at a Tertiary Care Hospital in Uttarakhand (India) and Comparison with Last Lustrum (2011-2015)
Jindal R, Chauhan P, Roy S, et al. Indian Journal of Leprosy. 2021; 
Learn more

 

 

Interesting events

 

 

Rising to the challenge: Learning and adapting NTD programming in a changing landscape
10 Jun 2021 | Virtual
The Neglected Tropical Disease Network for NGOs (NNN) COVID working group and the Coalition for Operational Research on Neglected Tropical Diseases (COR-NTD) Research Links series is excited to announce a joint three-session series entitled: Rising to the challenge: A year of NTD programming and research during COVID. The first session of the joint NNN/COR-NTD COVID series presents ministry of health perspectives on implementing NTD activities restarted during the COVID pandemic.
Register here for the first session

Online courses from the London School of Hygiene & Tropical Medicine:

• Global Disability: Research and Evidence: Explore how to conduct and interpret findings from global disability research
• Global Health and Disability: Leaving no one behind: disability, health and wellbeing in global development

 

 

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Websites & Services

 

 

Info Hansen - A innovative hub for knowledge sharing about Hansen's Disease

ALLF - Official website of the Association des Léprologues de Langue Française

LML - Leprosy Mailing List - a free moderated email list that allows all persons interested in this theme to share ideas, information, experiences, and questions.

InfoNTD - Information on cross-cutting issues in Neglected Tropical Diseases (NTDs)

 

 

Newsletters & Journals

 

 

ILEP newsletter archive
GPZL newsletter archive
WHO Goodwill Ambassador's Leprosy Bulletin
Leprosy Review
Leprosy Review Repository (1928-2001)
Fontilles Revista de Leprología
Indian Journal of Leprosy
Hansenologia Internationalis

 

 

GDPR & the Infolep newsletter

 

 

New EU data protection regulations came into force on 25 May 2018. We have been reviewing our practices with regard to the GDPR, including our privacy statement and mailing list. Infolep sends out monthly e-mails to its subscribers with an overview of recent publications on leprosy. The purpose of this activity is to keep subscribers up to date. Infolep will only process the data we have (names, email addresses) for the purpose of sending you the newsletter. We take your security seriously and will never share your contact details with anyone else. We hope the content from the Infolep newsletter is useful to you, but you can update your preferences or unsubscribe from this list at any time.

 

 

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

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

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Fw: Ref.: (LML) Leprosy Cure

Leprosy Mailing List – ,  2021

 

Ref.:  (LML) Leprosy Cure

 

From:  Narasimba Rao, Hyderabad, India

 

 

Dear Pieter,

Ref to the mail of Dr Laila LML dated 7th May 2021

 

It is not the answer that enlightens, but the question." – Eugene Ionesco

 

Dr Laila wanted to know where one can find more information about the criteria for clinical cure, laboratory cure of the disease. It is an important question.  Every leprosy worker need to ponder over it, as it pertains each and every PAL, for whom the programme is designed. . I would like to put forward my views

 

Cure can be A. clinical cure B. Bacteriological cure C. Histological cure D. Serological cure. Of these, I would like to disregard the last one and elaborate on the first three. 

 

Clinical cure  – in theory could be observed in all types of patients, if looked for carefully, when it occurs. (Now,  it should be  very simple! but it is not. Because it depends on the initial clinical features noted and vary for each type of leprosy.  For example neither hypoesthesia (its sequels) nor hypopigmentation/ nerve thickening/ disability regress completely in years after completion of prescribed MDT.  Hence, cessation of activity  of disease is considered as clinical cure.  However, there is no accepted list/ consensus to define signs are activity. But they are there. 

 

Bacteriological cure:  First of all, skin smear  (SS) services should be available, which were abandoned, globally. Hence, the discussion below pertains to those centers that have SS facility.   

  

A definition in the programme states that Increase in BI  by 2 logs is considered as relapse after therapy.  But fall by 2 logs is not bacteriological cure.  Only a BI of zero can be cure.  But researchers haggle over  morphology of AFB  when observed; solid, fragmented, granular; to decide on their viability vis a vis cure/non-infectivity of the patient. And to be fair it could be the right method, but practically deciphering MI is not an easy job. 

 

To top it, SS is positive only in  some percentage of  MB patients and always negative in PB group (who are about 50% of leprosy patients world over). Hence SS values cannot be a basis for cure in  PB group and some part of MB group who happen to be smear negative, if it is performed at all.  

 

Histological Cure:  Based on Skin biopsy

Good news is that it can help to some extent in all types of leprosy, except in pure neuritic leprosy, wherein nerve biopsy is needed.  Bad news is that WHO/ most national leprosy programmes are  yet to give skin histopathology  a status, either in defining  relapse or cure or for deciding on type of MDT needed for the patient.  On the whole, it is a neglected parameter. Reason..? Ummm…  It is complicated!!    

There is a need  for initial and  follow-up skin/nerve biopsy records to decide cure. And anyway, very few biopsies are performed in field in general. Moreover, special stains for AFB and trained pathologist, nay, a leprosy pathologist is needed to study and decipher them. Only possible in few tertiary-care centers. 

 

In Conclusion, of all the above mentioned methods, skin smear bacteriology (bacilloscopy) is the most dependable, as many country-specific programmes rely on them. Even WHO depended on it in 1982 to 1998, with great success. 

 

Even today, countries like US, japan, England among others, do perform skin smears and  as per their programme guidelines, and provide treatment based on skin smear status, sometimes up to smear negativity, indicating that it is the most followed parameter to define cure. 

 

On the whole, about 1/4th to  1/3rd of all leprosy patients are smear positive and they are the most important reservoir of M leprae globally and  the cause of transmission in the community.  And it is sad that SS is not part of global  programme anymore! Even the latest Global strategy 2021-2030 does not mention to re-start it globally. Only talks of strengthening it, whatever that means!   

 

With best regards 

 

P Narasimha Rao MD PhD

President, Indian Association of leprologists.

 

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

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

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Fw: Ref.: (LML) Leprosy Cure

 

 

Leprosy Mailing List – ,  2021

 

Ref.:  (LML) Leprosy Cure

 

From:  Joel Almeida, London and Mumbai

 

 

Dear Pieter and colleagues,

Dr. Laila Laguiche has asked a very important question. She specified clinical and laboratory criteria. Esteemed colleagues can do it better. But her thoughtful question invites answers. 

 

In HD (leprosy), perhaps we could consider something along the following lines, to minimise harm and maximise legitimate entitlements for persons who have experienced HD.

Cure is restoration to a state of health and wellbeing, such that special and specific interventions are no longer required. That is, they can be withdrawn without risk of serious harm to the person or others.

 

For medical cure, it is restoration to a state of health and wellbeing that outlives the withdrawal of medical interventions. In most self-healing persons with HD, who escaped permanent sequelae, cure might be attained rapidly, within days or weeks. For the fastidious, viability PCR of tissue biopsies, with appropriate negative controls, probably offers the best sensitivity and specificity. However, it is important to recognise the other patients, especially the subset of LL patients who remain anergic and vulnerable to reinfection even after MDT and MIP immunoprophylaxis. They start MDT with an astronomical number of bacilli. In endemic areas they need ongoing protection against re-infection and ENL episodes. 

 

For epidemiological cure, it is restoration to a state of health and wellbeing sufficient to pose no risk to the health and wellbeing of others even if specific interventions are withdrawn. This might take more than 12 months in persons with genomic anergy who live in an endemic area. This holds true even if the most potent anti-microbials are used, since sources of concentrated viable bacilli remain available for reinfection. However, mass multi-drug administration tends to shut down nearly all sources of highly concentrated viable bacilli almost instantly, in even hyperendemic hot spots. This is effective alongside integrated skin camps (with expert clinicians in person or by telemedicine) and MDT for newly diagnosed patients. Only armadillos (in the Americas) have highly concentrated viable bacilli that easily escape mass multi-drug administration. People in the Americas might need to keep a safe distance from armadillos and their haunts.

 

If mass multi-drug campaigns in hot spots are repeated relentlessly at intervals of less than a year, until no child case of HD can be found for a few years, then even genomically anergic patients are likely to enjoy epidemiological cure. Otherwise it is necessary to  protect genomically anergic patients well beyond 12 months of MDT. Then the incidence rate of recurrent highly bacillated HD in that population is likely to remain less than the incidence rate of new highly bacillated HD. Otherwise, difficult-to-diagnose recurrent HD can become the main source of concentrated viable bacilli in a population. This has been happening too often in recent decades, leading to stagnation (or worse) in new MB cases/year despite all other efforts.

 

Socio-economic cure might consist of establishing a state of health, wellbeing and inclusion that outlasts the withdrawal of special financial or other extraordinary socio-economic assistance. For a person who has lost eyesight, limbs, schooling, training, family and community, such special assistance might need to last longer than a few years. Possibly until their last breath. In areas where persons who experienced HD are discriminated against (e.g., by denial of land ownership and various entitlements available to others, or by social exclusion), socio-economic cure might require sustained public education. Winning the hearts and minds of the public and legislators might take much more than a few days or weeks or months.

 

Psychological cure might consist of establishing a state of health, wellbeing, inclusion and meaningful activity that survives the withdrawal of special psychological or related interventions. Emotional wellbeing is sometimes achievable despite horrendous adverse circumstances, such as extreme poverty, hunger and exclusion. However, emotional wellbeing can be facilitated by preventing or alleviating the excruciating pain of ENL, or of social exclusion, or incapacitating wounds, or extreme poverty. Spiritual practices too, alongside amelioration of adverse circumstances, have been known to help many individuals.

 

Legal cure might consist of enforcing rights that are open to litigation under national and international laws that are consistent with, or are newly legislated to be consistent with, the Universal Declaration of Human Rights. Legal settlements or judgments might be easier to achieve with legal aid for those who have experienced HD. Public education and political activism might be necessary, to influence legislation. To the extent that courts and politicians find us persuasive, all persons who have experienced HD and inhumane neglect or denial of rights will enjoy legal cure. Eventually.

 

Inhumane neglect currently is inflicted on too many persons who have experienced HD. This sadly includes widely enforced anti-microbial neglect of persons with polar LL HD who have completed 12 months of MDT. In the past two decades we have allowed them to suffer excruciatingly painful ENL episodes, pushing them deeper into extreme poverty. Some of them, in poorer areas of endemic countries, are forced to survive on only a few US cents per day. Prolonged anti-microbial protection can make a big difference to them, helping to break the downward spiral of ill health and extreme poverty. They need not be denied prolonged anti-microbial protection..

 

I hope esteemed colleagues will contribute answers to Dr. Laila Laguiche. She specified clinical and laboratory criteria. I have not been able to pinpoint those. Nevertheless, it is truly a privilege to be part of this thoughtful and noble-minded community brought together by LML. We can all keep helping one another to improve our understanding so that we achieve great outcomes and impact for the people we seek to serve. There are not many greater fulfillments in life than preventing or alleviating avoidable human suffering.

 

Best,

 

Joel Almeida

 

 

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

LML blog link: http://leprosymailinglist.blogspot.it/

Contact: Dr Pieter Schreuder << editorlml@gmail.com

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