Fw: Ref.: (LML) "Ping pong reinfection" of LL HD patients

 

Leprosy Mailing List – August 26,  2021

 

Ref.:  (LML) "Ping pong reinfection" of LL HD patients

From:  Joel Almeida, London and Mumbai

 

Dear Pieter & colleagues,

 

LL (lepromatous) patients with genomically related anergy to HD bacilli are central to the epidemiology of HD (leprosy). In endemic areas, children who newly join the household of a patient under treatment experience an elevated risk of developing signs of HD, if another individual with particular characteristics is present in that same household. What are the characteristics of that other individual? They were previously treated for HD.

 

What is going on? Take an illustration.

 

We can elaborate on this with an example. An LL patient with genomically related anergy to HD bacilli starts and completes treatment in an endemic area. Let's call them person A. Meanwhile, one or more family members with anergy have been incubating LL HD. Let's call them person B. Person A, after the withdrawal of anti-microbials, remains highly susceptible to reinfection. Person B sheds astronomical numbers of bacilli in nasal discharges and has enormous numbers of bacilli in nerves, bloodstream, skin and other organs. However, Person B shows no patches and few (if any) physical signs. Smear microscopy is omitted, delaying diagnosis.

Person B reinfects Person A. Meanwhile, Person B develops visible signs of HD and is started on a fixed duration of anti-microbials. Person A now starts to generate astronomical numbers of viable bacilli. However, this reinfection is not recognised promptly. Sequelae of previous infection mask the subtle physical signs of reinfection. Omission of smear microscopy does not help. 

 

Person A now sheds astronomical numbers of viable HD bacilli, unchecked. This increases the risk of infection in children who newly join the household of Person B. Person B is under treatment, and protected. But everyone else in their vicinity, including person A, is unprotected. 

 

Once Person A's reinfection becomes apparent, typically after 5 years or more, the roles of Persons A and B are reversed. In this way Persons A and B between them can keep "ping pong reinfection" going for years or even decades. These previously treated but since neglected LL patients provide a key source of concentrated viable bacilli in that area. Anti-microbial neglect of LL patients after 12 months of MDT imposes on them the role of super-spreaders. These LL patients also experience a huge increase in the risk of painful, swollen nerves of ENL neuritis. We could spare them from this easily avoidable suffering.

 

Wherever prolonged anti-microbial protection was ensured for LL patients, the incidence rate of MB or LL HD declined fairly rapidly (16% to 20% per year). This happened even when incomes in those places were conspicuously low (Karigiri, Uele, Shandong). The addition of repeated mass multi-drug administration in hyperendemic hot spots can turbo-charge such success. With annual mass multi-drug administration added to skin camps and prolonged MDT for LL patients, an 84% decline within only 2 years was demonstrated in the incidence rate of HD. The consistent use of multi-drugs for treatment or prophylaxis, instead of a single drug, delays the selection of drug resistant mutant bacilli. This helps to maintain the efficacy of MDT.

 

"Ping pong" reinfection between LL patients can be ended. We could ensure prolonged anti-microbial protection of LL patients, following 12 months of MDT. This will rapidly reduce transmission as well as the risk of excruciatingly painful ENL neuritis among previously treated LL patients. We will succeed, because we are a noble-minded community dedicated to preventing or alleviating human suffering, and we are open to learning from the dramatic front-line successes created by great colleagues.

 

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) Demise of Dr SK Noordeen

Leprosy Mailing List – August 25,  2021

 

Ref.:  (LML) Demise of Dr SK Noordeen

 

From:  Marcos Virmond, Bauru, Brazil

 

 

Dear Pieter and colleagues,

 

We are very sad to hear about the departure of Dr. S. K. Noordeen. 

 

He was a notable name in the fight against leprosy on a worldwide basis and his leading efforts in the strategy of elimination of leprosy as a public health problem will remain as a landmark in the history of leprosy. In addition, he was able to maintain a high level of political commitment on leprosy within the WHO milieu.

 

Marcos Virmond 

 

former ILA president

former Brazilian Society of Hansen's Disease president

 

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

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

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

Fw: Ref.: (LML) Demise of Dr SK Noordeen

 

Leprosy Mailing List – August 25,  2021

 

Ref.:  (LML) Demise of Dr SK Noordeen

 

From:  R. Vijayaraghavan, Tamil Nadu, India

 

 

Dear Friends,

 

It is sad to see the news. I met him in his office last year and due to lockdown I could not go and meet him in person although I live only few Kilometers away from his Office.   I will keep doing leprosy research as he encouraged me  to do leprosy research in addition to my existing research.  His encouragement and concerns towards leprosy and poor leprosy afflicted will ever remained by us.  It is a big loss for the entire leprosy society.

 

 

Dr. R. Vijayaraghavan. Ph.D (Leprosy)., 

Formerly Central Leprosy Teaching and Research Institute

Chengalpattu.

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) Dr Noordeen and Leprosy elimination strategy

 

Leprosy Mailing List – August 25,  2021

 

Ref.:  (LML) Dr Noordeen and Leprosy elimination strategy

From:  Sunil Deepak, Schio, Italy

 

Dear Pieter,

 

I am saddened by the news of passing away of Dr Noordeen. As Dr Narsimha has written he was a visionary and was passionately involved in pursuing the global goal of leprosy elimination envisaged in the year1990. As part of ILEP medical/technical commission for more than a decade and later as ILEP president, I had interacted with him many times and had many passionate discussions with him regarding the elimination strategy.

 

Over the past couple of weeks, some of us have written about the impacts of the leprosy elimination goal, especially about the negative impacts. While remembering Dr Noordeen, I think that it will also be useful for our discussions, to also think of the other side of this story - the positive impacts of the elimination strategy. The following are 3 things which come to my mind -

 

(1) Greater responsibility of the Governments in the leprosy programmes: Till early 1990s, with a few exceptions, the leprosy related activities were fragmented in geographically limited areas and were under NGOs and Christian missions, while the national programmes were mostly on paper and governments played a limited role. After the elimination strategy, gradually governments took more responsibility, even if a lot of funding was still coming from NGOs.

 

(2) Better data about leprosy: During the 1980s, university of Louvain in Belgium was collecting global leprosy data with support from ILEP but it was patchy and limited. Availability and quality of data about new cases of leprosy changed completely within a few years after the launching of the elimination strategy. Some of the epidemiological analysis which we take for granted today, would have been impossible till early 1990s.

 

(3) MDT implementation received a huge boost: During the leprosy meeting in Brazzaville in 1990, 8 years after WHO had been recommending MDT, the number of people being treated with MDT were very low - in many countries, less than 10% of the new cases. Even in the AIFO/Italy projects, which I was coordinating, they were less than 15%.

 

I remember a lot of discussions from that period with doctors working in the AIFO supported leprosy programmes and with other ILEP associations - almost all of them had big doubts about starting MDT. Most felt that they had to directly supervise the monthly dose and many of them preferred to admit patients for the whole duration of the treatment. In terms of attention given to it, the public health dimension of leprosy control was a poor cousin of clinical aspects of leprosy diagnosis and treatment.

 

Within a few years after the elimination strategy, MDT implementation had increased exponentially. In some countries like India and to a certain level, in Brazil, reaching 100% MDT implementation had taken much longer. For example, in India, the northern part of the country had few NGOs and government services were poor, and we used to think that there the leprosy incidence was very low. Starting leprosy services and treating everyone with MDT was an enormous effort. The push from elimination strategy had found hundreds of thousands of undetected new cases in states like UP and Bihar and by 1998-99, all were being treated with MDT. The kind of effort that had gone into it is difficult to imagine today.

 

Over a period of about two decades, at least a few million persons were diagnosed early and treated with MDT, most of whom would have otherwise waited for years for diagnosis and developed disabilities. This was the biggest achievement of the elimination strategy. 

 

Warm regards,

 

Dr Sunil Deepak

Schio (VI), Italy

 

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) Demise of Dr SK Noordeen

 
Leprosy Mailing List – August 24,  2021

 

Ref.:  (LML) Demise of Dr SK Noordeen

From:  P. Narasimha Rao, Hyderabad, India

 

 

Dear Pieter,

 

On behalf of the Indian Association of Leprologists (IAL) and leprosy workers of India, I am very sorry to inform LML group the sad news of the demise of Dr SK Noordeen on 17th August 2021. His son Mr Mohideen informed us of this great loss.  

 

Dr Noordeen was a visionary who translated the concept of global leprosy control into a successful programme in all countries endemic for leprosy ensuring a decline in the disease. Through his work he left an indelible mark in the field of leprosy. His contributions at World Health Organization (WHO) as the head of the leprosy programme are highly significant. He was part of the WHO team which introduced MDT and the expansion of the programme globally which resulted in the reduction in leprosy across the world. He was passionately involved in pursuing the global goal of leprosy elimination envisaged in the year1990.  

 

Dr Noordeen was an epidemiologist par excellence. Early in his career he carried out studies in pure neural leprosy (PNL) which still remains a benchmark for epidemiological data on this unique form of leprosy. He was particularly very encouraging towards young medical graduates and post graduate students to take up a career in leprosy. Many of us have personal recollections of time spent and thought-provoking interactions we had with him. Those memories still inspire us. Dr Noordeen served as the President of IAL; was a key member of the IAL Central Council of our association for many years and contributed significantly to its growth. He also served as president of the International leprosy association. (ILA).  He headed CLTRI, Chengalpattu, Tamil Nadu, India during its formative years. 

 

Dr Noordeen was not keeping well for the past few years. Even during the time, he was indisposed due to health reasons he made it a point to encourage the activities of the association. The Indian Association of Leprologists (IAL) expresses its sincere sympathies to the family members of Dr SK Noordeen and we place on record our deep appreciation of the tremendous contributions he made to the association and to the field of leprosy. 

 

 

P. Narasimha Rao, MD, D.D, PhD

President, Indian Association of Leprologists (IAL) 

Past President, National IADVL- 2019

Coordinator, SIG-NTD, IADVL 2021-23

 

Professor of Dermatology, 

Bhaskar medical college,

Hyderabad, India

. 

Mobile-+91-9849044898

Email: dermarao@gmail.com

www.ial-leprosy.org

 

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) Smear positivity after one year course of MB MDT

 
Leprosy Mailing List – August 24,  2021 

 

Ref.:  (LML) Smear positivity after one year course of MB MDT 

From:  P. Narasimha Rao, Hyderabad, India 

---

  

 

Dear Pieter, 

 

 

Dr Rao wanted to know the management of a case of LL who completed a one-year course of MB MDT but continues to be smear positive. Wanted to know specifically whether to continue the treatment till smear negative or stop.  

 

It all depends on whether we are looking at patients as a part of the larger 'leprosy programme' perspective or as an individual.  Each individual leprosy patient deserves the best possible treatment.  What WHO / NLEP programme recommends is a minimum duration of treatment to bring down the prevalence of leprosy.  At the same time, NELP also supports extension of treatment beyond 1 year if the treating clinician, who is a competent leprosy specialist,  considers it necessary.  In other words, it is perfectly fine if it is extended beyond one year, if the signs and symptoms of the disease are still active in this patient.   

 

While skin smears are not being practiced in NLEP / globally as part of the leprosy programme, it is heartening that Dr Rao is able to get these services for this patient. Please note that before the skin smears were abandoned/ discouraged in the year 1998, during the first 15 years of introduction of MDT for leprosy,-post 1983, the recommendation for smear positive patients was to treat them till smear negativity or up to 2 years. 

 

Unfortunately, there are no directives / guidelines on how long one may treat beyond one year such smear positive patients.  One way would be to treat them till all clinical activity abates, as the smears may continue to be positive for many years (>5 years) in a patient with a high initial bacillary index.  In my opinion, the morphological index (MI) of skin smear, while good in theory, is difficult to practice as a basis for deciding the duration of treatment.   

 

Treating leprosy patients beyond one year with MDT or rarely till smear negativity is alright. It is not unethical at all and was done previously.  And many clinicians, dermatologists and country programme managers (e.g.; Japan, UK, US)  still practice it in various forms.  However, it has to be done with the consent and concurrence of the patient. And at the discretion and full understanding of the treatment leprologist. Only motive should be to help and benefit the patient IMHO.  

 

 

Regards  

 

P. Narasimha Rao, MD, D.D, PhD 

President, Indian Association of Leprologists (IAL)  

Past President, National IADVL- 2019 

Coordinator, SIG-NTD, IADVL 2021-23 

 

Professor of Dermatology,  

Bhaskar medical college, 

Hyderabad, India 

.  

Mobile-+91-9849044898 

Email: dermarao@gmail.com 

www.ial-leprosy.org 

---

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) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 24,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

From:  David Scollard, Baton Rouge, USA

 

 

Dear Pieter, 

 

In response to Dr. Rao's concern about visible bacilli after 1 year of MDT, I agree with Wim and others. For a convincing visual demonstration of this I recommend that he look at the Pathology chapter of the International Textbook of Leprosy, (internationaltextbookofleprosy.org), where he can see a series of photomicrographs of annual biopsies from an LL patient receiving MDT. 

 

Only a small decline in number was seen after one year. MDT was continued for another year and still many bacilli were present. MDT was stopped at that time, on the understanding that all bacilli were dead.  The number of bacilli continued to decline slowly over the next few years. 

 

MDT kills M leprae effectively, but the body has great difficulty in eliminating the dead bacterial carcasses. 

Best wishes, 

 David Scollard 

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) Slit-skin smear positive leprosy

 

Leprosy Mailing List – August 24,  2021

 

Ref.:  (LML) Slit-skin smear positive leprosy

 

From:  Salvatore Noto, Bergamo, Italy

 

 

Dear Pieter, 

Thank you to Dr Rao for his message (LML 20-08-2021).  Slit-skin smear result should report about bacteriological index (BI) and morphological index (MI).  

BI is about the total number of bacilli, that is to say:- "solids", "fragmented" and "granular" and, takes years to decrease down to zero; roughly it decreases of one degree of positivity per year.  For example a BI 4+ will take four years to become zero. 

MI indicates the percentage of the so called "solids" bacilli.  These are considered viable bacilli and, they disappear a few months after a successful anti-leprosy treatment.  

In the case of Dr Rao's patient, we do not have this information.  If he can discuss further with the microscopist, it will be good , if not he should rely on clinical data only.  If the patient has a form leprosy that by definition has a high bacterial load like borderline lepromatous or lepromatous leprosy, I suggest continuing treatment for one year more. 

Best regards,

S. Noto
Bergamo, Italy

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) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 23,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

From:  Jaison Barreto, Bauru, Brazil

 

Dear Pieter,

 

We evaluate and we have done histopathology and inoculation in mouse foot pads for all patients with no good response to MDT. As many as 40% of BL and LL patients have a positive inoculation in mouse foot pads, and almost all have well stained bacilli or viable bacilli, or bacilli inside endothelial cells, which means recent bacillaemia.

 

The mean time interval to see a relapse bacteriologically is 8 years for patients in lepromatous range after MDT 12 doses, and 13 years for those treated with MDT 24 doses. Almost all patients show an initial improvement after 12 doses, but most of them still had viable bacilli that continued to grow, sometimes with reaction, mostly type 2, and after a enough time, we showed that, unfortunately, the patient was not cured.

 

We also have the problem of reinfection, once household contacts are usually not evaluated or followed. As many as 50% of my patients with relapse have family members with active disease. In this case, I think that these relapses are resulting from a mix of reinfection plus not enough treatment.

 

Leprosy is an ancient and complex disease. Doull found in Philippines, and published in 1942, a 0.6% per year rate of attack of leprosy in family members. The M.leprae know how to stay dormant and alive in family members. Dr Opromolla always said that who keep the endemic is the lepromatous patient.

 

It is very difficult to diagnose them. Most young LL patients do not show signs or symptoms of peripheral neuropathy. Most have signs and symptoms of rheumatism, or vascular disease. The expertise to stain the M.leprae in slit skin smear or biopsy slides was lost. Every month I see patients with reports of misdiagnosis due to a mix of lack of suspicion or/and mistakes in laboratorial examination.

 

Most physician continues to believe that leprosy is a question of patches, like vitiligo. Leprosy is a primary disease of Schwann cells, with or WITHOUT patches, as well as syphilis is a primary disease of endothelial cells, with or WITHOUT patches. Of course, as there are thousands of Schwann cells and endothelial cells in skin, these diseases usually have visible skin inflammation, but not always.

 

We also have the question of number of lesions, the Apocalypses of Leprosy. If the patient has 1 single visible leproma, is this patient a PB? Or should we call LL leprosy only with 6 lepromas? At the same way, should we consider Primary Syphilis with 1 lesion, secondary with 2 lesions, and tertiary with 3 or more?

 

Chaterjee wrote a very good concept of leprosy - in potentially a malign and a benign group. And Ridley found that only 10% of patients will develop self-limited disease. In these more than 20 years of Leprosy, I saw less than 10 cases of TT or Indeterminate (initial) disease. Most TT are, indeed, BT, when is possible to follow up, and they relapse due to insufficient treatment (PB with reaction) after 7 years. And most adults with Indeterminate Leprosy are, indeed, macular borderline, developing neuritis during or after treatment and relapses bacteriologically visible after 8 years. 

 

Finally, let's try to understand better this disease, and teach health professionals about the concept of spectral leprosy. 

 

 

Regards, 

 

Jaison

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) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 23,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

From:  Arry Pongtiku, Papua, Indonesia

 

Dear Pieter,

 

A letter from Dr.Rao and comments from Dr.Wim. One year treatment of MDT for MB (LL) is enough.  if skin smear is taken for such these cases, the bacteria will still appear for some years but not intact (death bodies only). We should check Morphological Index if there are solid bacteria or not . Leprosy reactions may happen after one year treatment particularly ENL type. This makes us doubtful.

 

Supervised dose (monthly dose) is very important to kill bacteria, continued with dose taken at home. In some cases , patients did not take medicine regularly particularly if treated in hospital than health center.

 

Thank you very much,

 

salam,

 

Arry Pongtiku, in Papua,Indonesia

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

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

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Fw: Ref.: (LML) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 23,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

From:  Joel Almeida, London and Mumbai

 

 

Dear Pieter & colleagues,

 

Dr. Suryanarayan Rao, a colleague from India, has asked for advice about a patient

with LL HD - lepromatous leprosy (ref LML - 20 Aug 2021) Esteemed colleagues will be well placed to advise further, but the following approach is likely to be in the patient's best interests.

Presuming this patient is an adult with LL HD and lives in an area that is still endemic, the main threats to them following 1 year of MDT come from ENL episodes and reinfection. How can an independent private practitioner best protect this patient?

A dose of MIP vaccine (also known as Mycobacterium w) can be given. It is likely to evoke a favourable immune response if the patient downgraded from BL to LL. This can be gauged from a positive lepromin test. If the response to MIP vaccine is disappointing, the patient might be considered to have LLp (polar lepromatous) HD with genomically related anergy to HD bacilli. Then, further precautions seem wise for such patients living in endemic areas. 

A combination of 3 bactericidal drugs given monthly under supervision will significantly reduce the risk of ENL as well as reinfection in endemic areas. It will also help ensure regular drug ingestion and allow regular monitoring of nerve function for sensory or motor deterioration. There will also be a regular opportunity to counsel, reassure and encourage the patient and, when helpful, the family too (if the patient permits). Periodic tests of hepatic and renal function, blood counts, as well as clinical examination will help rule out serious adverse effects. Monthly examination can help rule out any physical signs of inflammation or deterioration.

ROM (rifampicin + ofloxacin + minocycline) is the combination first promoted and used by WHO in the 1990s, with good outcomes. Moxifloxacin, however, is more bactericidal than ofloxacin. Therefore, moxifloxacin is better able than ofloxacin to balance the anti-microbial efficacy of rifampicin. Antimicrobial imbalance otherwise allows the selection of mutant bacilli resistant to the most potent drug in a combination.

Rifampicin 600mg +

Minocycline 100mg +
Moxifloxacin 400 mg

taken faithfully at least once a month offers robust anti-microbial prophylaxis. Clarithromycin, favoured by Brazil in some circumstances, is also included for exceptional use in the US national HD program guide. 

 

Many colleagues would prefer to include daily administration of potent antimicrobials to LL patients for at least 2 years after the start of treatment. This may be because of the report that patients treated with 1 year of MDT yielded bacilli that grew in mouse footpads. In the USA the national HD program guide encourages 2 years of MDT including daily rifampicin, for (multibacillary) MB HD patients. 

Once LL patients in an area are skilfully diagnosed, treated and consistently protected against reinfection, transmission in that area tends to decline fairly rapidly. Prophylaxis against reinfection in polar LL patients becomes steadily less necessary as transmission declines. Prolonged anti-microbial protection not only maintains the polar LL patient in a non-infectious state, but it also greatly reduces their risk of developing ENL neuritis with painful, swollen nerves.

 

If the LL patient in an endemic area cannot afford to pay for monthly doses of 3 bactericidal drugs after a year of MDT, then MDT (free of charge) can be continued. Reliable supplies of MDT are the backbone of HD treatment and control. 

 

At the first sign of sensory loss, the patient needs to be offered prednisolone to avert further deterioration in nerve function. Such vigilance against nerve function impairment needs to be maintained for at least two years after the start of MDT. Similar treatment is indicated for signs of inflammation in lesions, nerves or organs. Anti-microbial protection greatly reduces the risk of ENL but if ENL still occurs then it requires robust treatment. Advice on self-care and prevention of permanent damage is important especially if anaesthesia has set in. If deformity has already developed, then specialist rehabilitation is indicated. If common mental disorders develop then referral to a clinical psychologist is indicated. If ostracism, job loss and social exclusion are inflicted on the patient (this is less likely for patients bearing the relatively non-emotive and easily transliterated label "HD") then counselling of the family/employer as well as referral to NGOs and patient support groups are indicated. It is important to let relevant people know that such a patient is non-infectious because MDT killed nearly all the HD bacilli and subsequently prophylaxis is preventing reinfection. 

Smear positivity is not the reason for offering polar LL patients prophylaxis after one year of MDT. The risks of reinfection and ENL are the reason. The rate of bacillary clearance from skin smears merely correlates with the specific immune response to HD bacilli, and is therefore a helpful (if only inexact) way to gauge the immune response. Polar LL patients tend to show the slowest rate of bacillary clearance from skin smears, making them the slowest of "slow responders". However, an overwhelming majority of bacilli in the skin smears of treated patients are non-viable. Prophylaxis after MDT, for polar LL patients in endemic areas, is mainly for protection against reinfection and ENL.

 

Best wishes to Dr. Suryanarayan Rao as he seeks to act in the best interests of his patient. By protecting his patient against ENL and reinfection, using anti-microbials, he is also striking a blow against transmission in his area. 

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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Fw: Ref.: (LML) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 22,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

 

From:  Aguinaldo Gonçalves, Campinas, Brazil

 

Dear Pieter,

In such cases (LML, 20-8-2021) I ask an experienced microscopist to examine morphologically the integrity of bacilli: if they are granulous I consider the patient bacteriologically controlled; if they are integral, I investigate the possible cause (relapsing, resistance, failure, not adherence, etc).

Best regards,

Prof. Dr. Aguinaldo Gonçalves, MD, MSc, PhD
Full Professor, Public Health & Physical Activity, Unicamp, Brazil
A3 Professor, Preventive and Social Medicine,  PUC Campinas, Brazil
aguinaldogon@uol.com.br
http://lattes.cnpq.br/8140651861738248

 

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) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 22,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

 

From: Wim van Brakel, Amsterdam, the Netherlands

 

Dear Pieter,

In response to Dr Rao's query, I would advise that 1 year of MB MDT is sufficient. Smear positivity at 1 year is not linked directly to treatment outcome or prognosis. Generally, the bacteria seen at 1 year are already dead, but they continue to show up in smear. The decline in smear positivity until the smear becomes negative can take years, but there is no need to continue treatment. Ample evidence shows that the decline takes place regardless of whether MDT is continued. It is advisable to follow the government guidelines on treatment of MB leprosy.

There is one caveat. A limited body of evidence suggests that patients with an initial BI of 4+ or higher have an increased risk of a (late) relapse. Some practitioners would therefore use a 2-year MB-MDT regimen for such patients. However, to my knowledge, the benefit of this has not been conclusively established.

 

With kind regards,

Wim van Brakel, MD MSc PhD

Medical Director NLR

 

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) Smear positivity after one year course of MB MDT

 

Leprosy Mailing List – August 20,  2021

 

Ref.:  (LML) Smear positivity after one year course of MB MDT

 

From:  G.Suryanarayan Rao, Andrha Pradesh, India

 

 

Dear sir,

 

I am Dr.Suryanarayan Rao dermatologist from India. I treated a case of LL with full one year course of MB MDT. At the end one year still the patient smear positive. Should I continue the treatment till smear negative or stop. Please advise.

                      

Thank you. 

  

Yours sincerely,

Dr.G.Suryanarayan Rao.              

 

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: (LML) Spreading success

 

 

Leprosy Mailing List – August 19,  2021

 

Ref.:  (LML) Spreading success

From:  Joel Almeida, London and Mumbai

 

 

Dear Pieter and colleagues,

 

We are a noble-minded community keen on preventing or alleviating human suffering and affirming human dignity. In order to move forward and achieve our aims it seems helpful to ask constructive questions, such as::

What have been the most impactful interventions against HD (leprosy)?

 

and

 

How do we spread such success to more places, while continuously improving the efficacy of our efforts?

 

The most impactful intervention against HD transmission by far was demonstrated in FSM (Micronesia). It combined

a) Integrated skin camps, for all conditions, using expert clinicians

b) Anti-microbial protection, including prolonged anti-microbial protection for highly bacillated patients
c) Mass multi-drug administration, repeated at intervals

 

An 84% decline in the incidence rate of HD cases was demonstrated within only 2 years. Therefore 40% annual decline in incidence rate is demonstrably achievable. The use of multi-drugs instead of single drugs helps to delay drug resistance. Otherwise MDT (multi-drug therapy), the backbone of HD control, could lose its effectiveness. 

 

a) and b) can be used everywhere, aided by telemedicine if necessary. a) and b) can enable a 16% to 20% annual decline in new MB (multibacillary) or LL (lepromatous) cases, as was demonstrated in even low income areas such as Karigiri (India) and Uele (DR Congo). In hyperendemic hot spots, such as self-settled HD colonies in endemic countries, mass multi-drug administration can be added. That can enable a 40% annual decline in the incidence rate of HD in hyperendemic hot spots.

 

WHO (World Health Organisation) in 2013 defined elimination as interruption of transmission. We have set our sights on real impact now, not being satisfied with relative stagnation in incidence rates. How can we measure progress reliably? The case detection rate of MB HD is probably the most reliable measure, because MB HD rarely self-heals. Sooner or later persons with MB HD come to the attention of health professionals. The 3-year or 5-year moving average of the case detection rate of MB HD allows us reliably to monitor epidemiological trends. Other measures tend to be less reliable because they can be raised or lowered rapidly and at will, regardless of underlying transmission. In addition, the accumulated prevalences of people with HD-related visible deformity or social exclusion, respectively, are important measures. Periodic sample surveys, such as India's National Sample Survey or local door-to-door surveys, help to establish facts.

 

Interruption of transmission is not the only priority. Many people have already experienced HD. Prevention of new deformity among ever-diagnosed persons is important. Further, if people slip through our safety net and suffer deformity or social exclusion and its consequences, then they require and deserve rehabilitation, inclusion and opportunity. 

How frequently does new deformity occur during or after MDT? Fewer than 5% of patients in one part of India had visible deformity at diagnosis, but 15% to 33% of persons who had received MDT showed visible deformity. Recording the deformity status of every newly diagnosed patient at the start and end of MDT is therefore very important. Brazil sets a good example in this respect. Similarly, it is important to discover the prevalence in the population of HD-related deformity. Sample surveys, or total population surveys in defined populations, are uniquely useful for this purpose. 

How can we prevent new deformity from occurring during and after MDT? Over 80% of nerve damage during or after MDT occurs without any physical sign of inflammation (variously labelled silent neuritis / silent neuropathy / quiet nerve paralysis). Therefore quarterly nerve function assessment, with prompt steroid treatment when needed, is indispensable during at least the first two years after the start of MDT. Brazil and Dadra Nagar Haveli (DNH in India) are among the endemic areas that already monitor nerve function regularly. DNH has paramedical workers trained in HD, equipped with transport so that they can serve all HD patients across a wide area. This enlightened approach reflects respect for patients, and for their right to competent services. It can be replicated in other endemic areas. Then nerve damage can be detected early, and the risk of new deformity during or after MDT can be reduced greatly.

Rehabilitation, inclusion and opportunity have been promoted in exemplary projects serving persons who have experienced HD. Too many are still experiencing deformity, destitution or exclusion. Increasingly, they are speaking out against inhumane neglect and exclusion, while demanding the respect and services to which they are entitled. Successful projects are like lighthouses showing us how to help more people reach the safe harbour of wellbeing, empowerment and inclusion.

 

As we create and celebrate successes, support will grow. We can nurture a broad popular movement against HD and its too-often terrible consequences. Other disease control efforts have benefited from such popular movements, where everyone is invited and empowered to contribute according to their unique strengths. It can happen in HD too, especially because exemplary projects have achieved dramatic successes. Effective action with demonstrable impact is the best answer to lingering doubts. Let's spread 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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Fw: Ref.: (LML) Leprosy elimination policy (1990 -2005)

 
Leprosy Mailing List – August 17,  2021

 

Ref.:  (LML) Leprosy elimination policy (1990 -2005)

 

From:  Salvatore Noto, Bergamo, Italy

 

 

Dear Pieter,

Thank you very much to Doctors Sunil Deepak, Jaison Barreto, Wim Theuvenet and M.S. Raju for their messages (LML, August 8, 9 and 10, 2021)  Please note that I have changed the title of the subject to "Leprosy elimination policy (1990-2005)".   

The WHO leprosy staff in the past decades imposed the inappropriate anti-leprosy strategy we are talking about.  There was no real debate; the WHO leprosy staff powerfully acted, paying  no attention to all criticism coming from so many colleagues.  A group of WHO indoctrinated staff acted directly onto national Ministry of Health personnel and imposed the, then, new anti-leprosy policy.

The list of colleagues disappointed by the imposed WHO anti-leprosy policy was very long.  Leprosy doctors from all five continents expressed their disappointment.   The use of the wrong indicator (prevalence) and the risk of losing leprosy knowledge were among the important topics mentioned but, all comments were dismissed.  The colleagues in the field, in all leprosy fields (not only the clinicians) were powerless.

 

Yours sincerely,

S. Noto

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) Behavioural immune system

 

Leprosy Mailing List – August 15,  2021

 

 

Ref.:  (LML) Behavioural immune system

 

From:  Ajit P, Maharashtra, India

 

 

 

Respected Pieter,

 

 

Here is the open access link for the original behavioural immune system articles by Mark Schaller (see LML, August 7, 2021).

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3189350/

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4410372/

 

 

 

My article which I had mentioned in my earlier post,  describes the behavioural immune system in brief and mentions its possible implications for dermatologists,  e.g. value of camouflage creams, why camouflage creams should be essential medicines etc. 

 

Thanks,

Dr Ajit

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

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

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Fw: Ref.: (LML) Cell phone Reminder ' Nudge ' to prevent leprosy related disability

 

Leprosy Mailing List – August 15,  2021

 

Ref.:  (LML) Cell phone Reminder ' Nudge ' to prevent leprosy related disability

From:  Ajit P, Maharashtra, India

 

Respected Pieter,

 

Policymakers often resort to rules, mandates, regulations etc. to ensure a certain type of public  behaviour. Typically this is for the greater good of the people e.g. banning alcohol, tobacco etc. 

 

At the other extreme, is the leave alone policy, people know what is best for them and need not be told.

 

In between these two approaches lie  ' nudges ' e.g. health warning symbols on cigarette packages, reminders etc. That is instead of simply banning cigarettes (rules - which often are impractical to enforce) or leave alone policy (wrong when we know tobacco causes cancer), we use health warnings to make the dangers of cigarette smoking salient ( apparent ) to people to modify behaviour. 

 

Prof Richard Thaler, Nobel laureate, and a leading behavioural economist has mentioned these in detail in a book: Nudge: The Final Edition. 

 

Reminders are also  ' nudges '.

 

Reminders to prevent leprosy related foot ulcers .

 

It is imperative, that at the time of diagnosis of leprosy itself, we should tell patients to set up reminders in their cell phones for checking (under a bright tube light) if there are injuries on their feet.

 

We can explain that since leprosy affects nerves, sensations are impaired and hence you do not feel pain from minor injuries which over time enlarge. It is important to tell the patients that this nerve impairment often persists even after successful treatment. 

 

My advice is to make the patient set up a reminder in the cell phone right in front of us. 

 

Patients often cannot understand the importance of this simple intervention and hence it is necessary to stress this again  in follow up visits .

 

 

Dr Ajit

 

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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