Fw: Ref.: (LML) WHO Goodwill Ambassador's Leprosy Bulletin NO. 116, August 2023

                                                Leprosy Mailing List – August 24,  2023

 

Ref.:  (LML) WHO Goodwill Ambassador's Leprosy Bulletin NO. 116, August 2023

From:  Takahiro Nanri, Tokyo, Japan

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Dear Dr. Schreuder and Friends,  

 

Warm greetings from Sasakawa Health Foundation/ Sasakawa Leprosy (Hansen's Disease) Initiative in Tokyo.

 

We have issued WHO Goodwill Ambassador's Leprosy Bulletin NO.116 August 2023 "Regaining momentum for a leprosy-free world".

 

In this issue, we feature: 

 

MESSAGE FROM THE AMBASSADOR
This year marks the 150th anniversary of the discovery of the leprosy bacillus by Dr. Gerhard Armauer Hansen in Bergen, Norway. To prompt reflection on the past and build momentum for a zero leprosy future, the Sasakawa Leprosy (Hansen's Disease) Initiative and the University of Bergen co-hosted an international conference on June 21–22. Read More 

 

REPORT
Japan's efforts to eliminate discrimination against persons affected by Hansen's disease and their family members

Yoshinori Takazawa, Director, Human Rights and Humanitarian Affairs Division, Foreign Policy Bureau, Ministry of Foreign Affairs, Japan

The protection of human rights and fundamental freedoms is a basic responsibility of all countries and a matter of legitimate concern for the international community. Japan, based on the premise that human rights are universal values, puts efforts into improving human rights situations through bilateral dialogue, taking into account the historical and cultural background of each country. Read more 

 

REPORT
Discriminatory law repealed in Senegal

Papa Mamadou Diagne, President, Association Sénégalaise Contre la Lèpre et les Maladies Tropicales Négligées (ASCL/MTN)

For 47 years, Senegal has had nine villages de reclassement social (VRS), created by the authorities and governed by Law 76-03 of 1976. At the time that they were established, the VRS were intended to isolate persons affected by leprosy and block transmission of the disease. Read more 

 

REPORT
Report on Bergen International Conference on Hansen's Disease, June 21–22

On June 21–22, 2023, the Sasakawa Leprosy (Hansen's Disease) Initiative and University of Bergen co-hosted an international conference in Bergen, Norway, to commemorate the 150th anniversary of the discovery of the leprosy bacillus Mycobacterium leprae by Dr. Gerhard Armauer Hansen. Read more 

 

VIEWPOINT
Reflections on my first months as MORHAN's national coordinator

Faustino Pinto, National Coordinator, Movement for the Reintegration of Persons Affected by Hansen's Disease (MORHAN)

On June 1, 2023, Brazil's Movement for the Reintegration of Persons Affected by Hansen's Disease (MORHAN) held a live online event to honor and say farewell to Artur Custódio, who served as our national coordinator for many years. I have been challenged to step up and take over his role. Read more 

 

INITIATIVE NEWS
Sasakawa Leprosy (Hansen's Disease) Initiative welcomes new program advisors

The Sasakawa Leprosy (Hansen's Disease) Initiative is a strategic alliance that coordinates the activities of the WHO Goodwill Ambassador for Leprosy Elimination, Sasakawa Health Foundation, and The Nippon Foundation for the purpose of achieving a leprosy-free world. Read more 

 

AMBASSADOR'S JOURNAL

Goodwill Ambassador Sasakawa attends Bergen International Conference on Hansen's Disease
WHO Goodwill Ambassador for Leprosy Elimination Yohei Sasakawa visited Norway, June 21–22, to attend the Bergen International Conference on Hansen's Disease. The event was co-sponsored by the Sasakawa Leprosy (Hansen's Disease) Initiative and the University of Bergen.  Read more 

 

INITIATIVE NEWS
Sasakawa Leprosy (Hansen's Disease) Initiative launches cooperative relationship with the Miss Supranational Organization

Miss Supranational is an international beauty pageant that emphasizes natural grace and community service. In 2020, the Miss Supranational Organization launched "From the Ground Up," an initiative meant to encourage grassroots projects that address local needs.  Read more 

 

BACK ISSUES 

 

 

We hope that you would enjoy reading the latest Leprosy Bulletin. 

 

 

Takahiro NANRI, Ph.D.
Executive Director, Sasakawa Health Foundation

*********************************************************
Sasakawa Leprosy (Hansen's Disease) Initiative
Sasakawa Health Foundation
Tel：81-3-6229-5377, Fax：81-33-6229-5388
email: hansen@shf.or.jp

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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) Fixed duration multidrug therapy (12 months) in leprosy patients with high bacillary load – Need to look beyond

 

Leprosy Mailing List – August 10,  2023

 

Ref.: (LML) Fixed duration multidrug therapy (12 months) in leprosy patients with high bacillary load – Need to look beyond

From:  Sunil Dogra, Chandigarh, India

 

 

Dear Pieter and colleagues,

 

 

We would like to thank Dr. Sinésio Talhari (LML, August 8, 2023) and Dr. Sandra Durães (LML, August 3, 2023) for their interest in our publication  (Narang T, Almeida JG, Kumar B, Rao PN, Frade MAC, et al. Fixed duration multidrug therapy (12 months) in Hansen's disease patients with high bacillary load – need to look beyond. Indian J Dermatol Venereol Leprol  doi: 10.25259/IJDVL_278_2023).

 

 

In response to their inquiry regarding the statement presented in the published paper on FDT in leprosy, which indicated a sevenfold increase in relapses in the 6-month regimen (U-MDT) compared to the 12-month treatment (FD-MDT), we would like to reference the data provided in the paper authored by Penna GO, et al. and published in PLoS Neglected Tropical Diseases (Volume 11, Issue 7, Article e0005725).

 

The authors of this paper have documented the following information regarding relapse rates: During the active follow-up period, four patients within the U-MDT group experienced relapse, resulting in a relapse rate of 2.6 per 1000 patients per year of active follow-up. Additionally, during the passive follow-up phase, three patients from the U-MDT group relapsed, along with one patient from the R-MDT group. This leads to a total of seven relapsed patients within the U-MDT group in comparison to one patient within the 12-month R-MDT group.

 

The authors have also indicated that the estimated relapse rate for the U-MDT group was 4.46 per 1000 people per year, while for the R-MDT group, it was 0.44 per 1000 people per year. However, it should be noted that the statistical significance of this difference was not established.

 

 

We have cited these figures from the aforementioned paper without delving into the intricate statistical calculations or the specifics of relapse rate determination.

 

As far treatment option of high BI multibacillary leprosy patients is concerned – we have suggested extending MDT MB beyond 12 months as only one of the strategies since it is likely to be logistically easy than other options as listed in our viewpoint.

 

Best Wishes & Regards,

 

 

Sunil Droga

 

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) Fixed duration multidrug therapy (12 months) in leprosy patients with high bacillary load – Need to look beyond

 

Leprosy Mailing List – August 8,  2023

 

Ref.: (LML) Fixed duration multidrug therapy (12 months) in leprosy patients with high bacillary load – Need to look beyond

From:  Sinésio Talhari, Manaus, Brazil

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Dear colleagues,

I fully agree with Dr. Sandra Duraes (LML, August 3, 2023) and, mainly with what was highlighted in relation to the article in question: "the U-MDT study from Brazil showed seven times more relapses in the 6-month regimen (U-MDT) compared to 12 months of treatment (FD-MDT )". I also ask the authors to explain how they arrived at this conclusion based on the results and methodological and statistical analyzes of the research. I participated in this study and this recurrence rate is not included in the published articles.

Yours sincerely,

Prof. Dr. Sinésio Talhari 

Fundaçao de Dermatologia Tropical e Venereologia "Alfredo da Matt

Manaus, Amazonas, Brasil

 

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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) Are we opposed to success?

 

 

 
Leprosy Mailing List – August 7,  2023

Ref.:  (LML) Are we opposed to success?

From:  Joel Almeida, Mumbai, India

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Dear Pieter and colleagues,

 

Are we opposed to stopping reinfection of those patients who remain susceptible to reinfection after 12 months of MDT? Must they incur an increased risk of ENL and unwitting transmission to others? 

 

Is there some endemic area where rapid decline in the incidence rate of MB (multibacillary) HD (leprosy) was achieved without protecting highly bacillated patients against reinfection? No such area is easy to recall.

 

Exemplary projects in low income endemic areas achieved 16% to 20% per year decline in the incidence rate of MB and LL (lepromatous) HD  [1-3] Such impactful projects invariably protected anergic patients against reinfection. This was achieved, mostly inadvertently, through prolonged anti-microbial protection for highly bacillated patients. Inadvertently, because there was not yet direct evidence of reinfection. Eventually, studies in Brazil provided direct evidence of reinfection in HD [4] and other studies in Brazil even suggested human genetic predisposition to recurrent HD.[5]  Are we opposed to incorporating this knowledge into highly effective action? 

 

Would it be a bad idea for India, Brazil and Indonesia to achieve 16 to 20% annual decline in the incidence rate of MB HD, as demonstrated by exemplary projects in low-income endemic areas? [1-3] Nearly 80% of all new cases occur in those 3 countries. 

There is also a documented association between the risk of recurrent HD and new HD cases among children, as reported from an endemic area of Brazil.[6] This too points to reinfection rather than exclusively endogenous relapse as an explanation for recurrent HD in endemic areas. Are we against weakening this association? Are we determined to expose children and others to transmission from reinfected anergic LL patients? A single nose blow from a highly bacillated HD patient who is unprotected can contain millions of viable bacilli.[7] How are we supposed to reduce transmission if we allow such a tsunami of viable bacilli from reinfected patients to continue?

 

Further, would it be a bad idea to reduce the risk of the swollen, painful nerves of ENL? The risk of painful neuritis during months 13 to 24 after the start of anti-microbials was boosted by 600% when anti-microbials were withdrawn from LL patients after only 12 months. [8]  

 

Based on the accumulating evidence, neglect of anergic previously treated patients in endemic areas can maintain transmission in even well-run programmes. It is transmission that opens the door to infection, disease, reactions, ENL, nerve damage, deformity etc. 

 

We have effective options. Anti-microbial protection demonstrably reduces the risk of reinfection. In India, a recurrence rate of only 1.27/100 patient-years of follow-up was found in a prolonged MDT group compared to 4.29/100 patient-years in a fixed 24 months MDT group (p<0.01), among patients with an initial BI (log bacillary index) of 4+ or more.[9] Further, nearly half of the recurrences in that study relied on regular skin smear microscopy for detection, but reliable skin smear microscopy is not available everywhere. Elsewhere, expert clinicians were reported to detect signs of recurrence five times more frequently than well trained but non-expert health workers.[10] But expert clinicians are not available everywhere. Given all this, must anergic LL patients after 12 months of MDT be excluded from anti-microbial protection in endemic areas? 

 

The world's most impactful intervention against HD transmission, in FS Micronesia, included prolonged anti-microbial protection, alongside expert skin camps and mass multiple drug administration (Rifampicin + Ofloxacin + Minocycline). [11, 12] In armadillo territory the further precaution of avoiding contact with armadillos or armadillo-contaminated soil is probably wise. But every endemic hot spot can aim for, and achieve, much greater than 20%/year decline in the incidence rate of MB HD, by emulating the FSM strategy. There is no need to regress to single drug use for prophylaxis, or to depict HD patients who shed zero bacilli as being dangerous to their contacts.

 

Highly bacillated patients in endemic areas are known to often show conversion of lepromin status upon receiving MIP vaccine/Mw [13] It is the remaining 10 to 30% of highly bacillated LL patients who remain in need of anti-microbial protection even if they receive MIP vaccine. They have a disproportionate impact on transmission because of the astronomical numbers of viable bacilli that they are capable of developing and shedding.

 

Given all this, must anergic LL patients after 12 months of MDT be excluded from anti-microbial protection in endemic areas? They are already excluded from many important things. Must they alone be banished to the pre-antimicrobial era? Are we opposed to protecting them against reinfection in endemic areas? Available options include either post-MDT chemoprophylaxis (e.g. fully supervised Rifampicin or Rifapentine  + Ofloxacin or Moxifloxacin  +  Minocycline) or the more affordable option of simply prolonging MDT.

Each physician is empowered and even required to act in the best interests of patients. That may be partly why so many colleagues in endemic areas, including some who themselves have experienced HD, are looking beyond 12 months of MDT for highly bacillated patients. They are ensuring prolonged anti-microbial protection for their highly bacillated patients in endemic areas. In doing so, they are not only reducing the risk of painful ENL neuritis but also helping to reduce transmission. This is the nucleus of success in efforts to stop transmission. Success is unstoppable partly because every bit of new evidence points more clearly to the underlying realities; and partly because the easily avoidable suffering of people experiencing HD is not a comforting sight. 

 

Are we opposed to success?

 

Joel Almeida

 

References

 

1.     Norman G, Bhushanam JDRS, Samuel P. Trends in leprosy over 50 years in Gudiyatham Taluk, Vellore, Tamil Nadu. Ind J Lepr 2006. 78(2): 167-185. reviewed and analysed further in: 1a. Almeida J. Karigiri, India: How transmission rapidly was reduced in a low-income population.  LML 29 Oct 2020

2.     Tonglet R, Pattyn SR, Nsansi BN et al. The reduction of the leprosy endemicity in northeastern Zaire 1975/1989 J.Eur J Epidemiol. 1990 Dec;6(4):404-6 reviewed in: 2a. Almeida J. Reducing transmission in poor hyperendemic areas - evidence from Uele (DRC). LML 29 Nov 2019

3.      Li HY, Weng XM, Li T et al. Long-Term Effect of Leprosy Control in Two Prefectures of China, 1955-1993. Int J Lepr Other Mycobact Dis. 1995 Jun;63(2):213-221. reviewed & analysed further in: 3a. Almeida J. What really happened in Shandong? LML 16 Nov 2019

4.      Stefani MMA, Avanzi C, Buhrer-Sekula S, Benjak A, Loiseau C, Singh P Whole genome sequencing distinguishes between relapse and reinfection in recurrent HD cases. PLoS Negl Trop Dis 2017; 11: e0005598

5.      Sartori PVU, Penna GO, Bührer-Sékula S et al. Human Genetic Susceptibility of Leprosy Recurrence. Scientific Reports 2020 volume 10, Article number: 1284    

6.    Gonçalves FG, Belone AFF, Rosa PS, Laporta GZ. Underlying mechanisms of leprosy  recurrence in the Western Amazon . BMC Infectious Diseases (2019) 19:460

7.     Davey TF, Rees RJ. The nasal dicharge in leprosy: clinical and bacteriological aspects. Lepr Rev. 1974 Jun;45(2):121-34

8      Balagon MV, Gelber RH, Abalos RM, Cellona RV. Reactions following completion of 1 and 2 year multidrug therapy (MDT). Am J Trop Med Hyg 2010;83:637–44. Analysed further in 8a. Almeida J, LML 24 Mar 2023

9.     Girdhar BK, Girdhar A, Kumar A. Relapses in multibacillary leprosy patients: effect of length of therapy. Lepr Rev 2000;71:144–53.

10.     Balagon MF, Cellona RV, Cruz E, Burgos JA, Abalos RM, Walsh GP, et al. 2009. Long-term relapse risk in multibacillary leprosy after completion of 2 years of multiple drug therapy (WHO-MDT) in Cebu, Philipplines.  Am. J Trop. Med. Hyg. 81(5), 895-899.

 

11.     WORKSHOP ON THE PREVENTION OF LEPROSY, POHNPEI, FEDERATED STATES OF MICRONESIA. 25-27 MAY 1999 sponsored by the Sasakawa Memorial Health Foundation Tokyo, Japan and the Western Pacific Regional Office of the World Health Organization. Int J Lepr, 67 (4) (SUPPLEMENT)

 12.     Diletto C, Blanc L, Levy L. Leprosy chemoprophylaxis in Micronesia. Lepr Rev. 2000;71(Suppl):S21–3.

 

13.    Sharma P, Misra RS, Kar HK et al. Mycobacterium w. vaccine, a useful adjuvant to multidrug therapy in multibacillary leprosy: A report on hospital based immunotherapeutic clinical trials with a follow up of 1-7 years after treatment. Lepr Rev 2000; 71 : 179-92.

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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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