Leprosy Mailing List Blog

Give the leprosy workers a voice

2011-12-27T07:16:00.002-08:00

Leprosy Mailing List – December 26^th, 2011

Ref.: Give the leprosy workers a voice
From: P A M Schreuder, Maastricht, The Netherlands

Dear Salvatore,

It is Christmas time. Let’s us reconsider our differences. The final goal of everyone is a world without leprosy. The first step is elimination, the absence of a disease from an area; the second step will be eradication, the disappearance of a disease from the entire world (like what happened with smallpox). There are not that many tools, interventions, available to reach that final goal. Too little is known about transmission and the step from contamination to infection to disease. Yes, leprosy has (almost) disappeared from the developed world. Why transmission had halted we do not know, but it is assumed that improved living conditions (hygiene, living space, nutrition, etc.) have played an important role (but what and how, we do not know). BCG is widely applied in the world and certainly has caused a dent in the incidence of leprosy. Prophylactic treatment of contacts is still in the research stage, but very promising. There are no tests yet which can predict if a person infected will actually develop the disease. Everybody agrees with the present strategy of early (soon after the appearance of the disease) diagnosis and prompt treatment with MDT. If this indeed will interrupt the transmission cycle is not clear. To be able to apply a strategy, a well-organized basic health service, supported by a well-defined system of training, supervision and referral services, is needed. We do not only want a patient to become rapidly non-infectious, we also want the patient to be free and stayed free of nerve function impairments. And if impairments develop to prevent further worsening, and further disabilities and handicaps. The recent WHO Global Strategies spell this out very clearly (WHO Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities 2006 – 2010 and the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy 2011 – 2015).

The WHO elimination policy, although based on a faulty definition and lacking any scientific justification, has been highly successful in gathering political support and organizing leprosy control programmes in many countries. The policy based on early case finding through active and passive case detection, MDT treatment, and organizing and integrating the basic health services resulted in many new patients being diagnosed and a rapid decline in known prevalence. If the leprosy countries would implement WHO Global Strategies, including POD and setting up rehabilitation services, and if new approaches for leprosy control in less endemic areas, would be developed, the leprosy control situation would continue to improve.

However, as soon as the WHO declared its elimination policy it became hijacked by health authorities and politicians. Its target “setting of a prevalence rate of less than 1 per 10,000” suggested that by reaching this target the leprosy reproduction rate would become less than 1 and as such leprosy would further decline and eventually disappear from an area. Once more, there was no scientific support for these suppositions and the “elimination of leprosy”, the disappearance of leprosy from previously endemic areas, has not materialized so far. What is even more, if the original definition of a leprosy case, the duration of treatment and the duration on the patient register had not changed, than many countries, where leprosy has been so-called eliminated, would not even have reached a target of less than 1 per 10,000 by now. Changes of case definitions, ascertainment procedures, and diagnostic and registration conventions have impacted more on reductions in prevalence (1) than a decline in incidence in many countries.

Because the quality and coverage of control programmes had increased remarkably, many new patients were diagnosed and successfully completed treatment. Still the postulated decline in detection rates in many endemic countries did not materialize even after the so-called elimination target was reached. Even though new leprosy patients continued to present themselves, some countries started to dismantle the leprosy services leading to extra suffering of patients (late diagnosis, difficulties in finding treatment). Why should we be apologetic about this?

Instead of accepting that the present policy did not necessarily resulted in a rapid decline in detection rates and that the target setting of a prevalence rate of 1 per 10,000 did not show to reflect the real leprosy situation in the field, not the target and prevalence were discarded but the detection figures and the leprosy workers were made the culprit. Administrative steps were taken in several endemic countries to hide the real situation that many more new patients were found than was politically convenient. Many authors (and many leprosy workers), like Paul Fine in Leprosy Review, have pointed this out, but with as only result that the proponents of this misguided target setting have become even more intransigent. The video message at the Brazilian Leprosy Congress is a prime example of this, blaming the highly dedicated and hardworking leprosy workers, instead of realizing that the world has gone on and that WHO has set new policies and strategies. That is why we want to pay so much attention to this in the LML.

Yours sincerely,

Pieter

References:

Anjan Gosh. A Health Policy Report “How could changes of case definitions, ascertainment procedures, and diagnostic and registration conventions have impacted on reductions in the prevalence of leprosy in India, reported over the last decade (taking the state of Jharkland as a case study)? LSHTM, 2008

International training announcement

2011-12-27T07:16:00.000-08:00

Leprosy Mailing List – December 26^th, 2011

Ref.: International training announcement
From: G Gurung, Pokhara, Nepal

Dear Dr Salvatore,

Greetings from Nepal! This is just a quick check if our international training announcements have been forwarded to all LML readers. I am attaching those files for your convenience.

Many thanks for your support,

Wishing you and all LML readers a Merry Christmas and Happy New Year 2012!

Gopal

Gopal Gurung

Program Manager

BIKASH Nepal

Pokhara

Nepal

P: 00977 61 430562

F: 00977 61 430940

W: www.bikashnepal.org.np

Training courses

1: Rehabilitation and Prevention of Disability (RPOD): 20 February-02 March 2012

2: Community Based Rehabilitation (CBR): 05-16 March 2012

3: Communication, Advocacy and Training Skills (CATS): 25-30 March 2012

4: Leprosy Training for Medical Doctors: 15-20 April 2012

Christmas [Portuguese]

2011-12-27T07:15:00.000-08:00

Leprosy Mailing List – December 26^th, 2011

Ref.: Christmas [Portuguese]
From: W Nogueira, SP, Brazil

Meus queridos amigos,

Já faz alguns meses que estou para mandar notícias a todos, mas alguns fatos muito tristes que tomei conhecimento ao longo deste ano me fizeram aguardar uma boa oportunidade, e nada mais favorável que o bom astral das Festas de Natal e Ano Novo para comunicar a todos que continuo por aqui, cada dia um pouco mais forte e com muita esperança de dias ainda melhores. Acabei de realizar todos os exames e mais uma vez foram todos negativos e os colegas médicos que me acompanham pediram para retornar para controle em seis meses, aumentando um pouquinho mais o espaço dos retornos. Neste ano, eu mesmo constatei que estou bem melhor fisicamente. A queles que me visitaram no Hospital Santa Catarina e se assustaram com os 30 kilos que tinha perdido podem se tranquilizar porque já recuperei 25 e nem quero engordar mais pra não voltar a ter sobrepeso.

Este também foi um ano mais produtivo, e junto com uma amiga, Assistente Social do Espírito Santo, escrevemos um livro – “A Fundação Paulista Contra a Hanseníase e o processo de transformação dos antigos hospitais – colônia do Estado de São Paulo”, editado por esta mesma Fundação onde voluntariamente ainda mantenho algumas atividades de trabalho. Neste livro, além de registrar as mudanças institucionais nas últimas décadas no controle desta endemia, apresentamos os trabalhos que estamos desenvolvendo nesta Fundação para o resgate da cidadania daqueles antigos doentes que foram isolados compulsoriamente no passado. Se alguém que receber este e-mail ainda não recebeu este livro e tem interesse em conhecer este trabalho, basta mandar o endereço residencial para o e-mail << contato@fundacaohanseniase.org.br >> que eu enviarei pelo correio.

Para finalizar desejo a todos um Natal com muita paz e alegria e um Ano Novo sempre muito melhor que aquele que se encerra.

Um grande abraço

Wagner Nogueira

What should be the correct strategy to diminishing the burden of leprosy?

2011-12-27T07:14:00.001-08:00

Leprosy Mailing List – December 24^th, 2011

Ref.: What should be the correct strategy to diminishing the burden of leprosy?
From: J. A. Barreto, Bauru, SP, Brazil

Dear Salvatore,

Concerning the letters of Dr N. Cardona Castro and Dr W Nogueira [Dec 8th and Dec 19th, 2011], we must remember that the decision to eliminate leprosy was based on the fact that MDT cured leprosy patients, or at least that the release from treatment is higher after 24 doses of MDT-MB than after 10 years of dapsone monotherapy. Unfortunately, this strategy does not act to prevent - infected and thus susceptible peoples to develop leprosy. There is no vaccine, incubation time is long and asymptomatic, and the people affected are usually poor and have a low cultural status.

In my PhD thesis, in 2008, I reevaluated lepromatous leprosy patients treated with MDT 24 doses, as well as their household contacts in the state of Santa Catarina, were leprosy was eliminated since 1997. With a median time interval of 11 years after treatment, more than 90% of them did not have clinical evidences of disease activity, though the presence of M. leprae in environment did not change. Once I found 6 new cases among 187 contacts evaluated. Also, IgM for PGL1 and or the detection of M. leprae DNA in nasal mucosa were found in 20 to 30% from contacts of healed patients. The disease development rate among household contacts was the same as observed by Doull in the Phillipines 80 years ago, i.e., more than 6 cases per year per 1000 exposed, i.e., even with 100% of BCG vaccination in the household contacts, susceptible individuals developed the disease as in the past.

Why this happened? Because the diagnosis leprosy is still centralized in reference centers, and thus the access to it is difficult. A fact that is typical for areas where leprosy is not a public health problem, which explains the gap in time of more than 8 years between the diagnosis of leprosy in the contact and the diagnosis of the index case (lepromatous). What should be the correct strategy to diminishing the burden of leprosy?

We, certainly, must keep the goal of elimination, since this put leprosy in focus. The following steps must be reinforced:

First: recognition that the disease is a problem. This must be linked to several other factors, from which bacilli are only one. The Brazilian government surely diminished poverty and improved education, but eradication of misery is a long journey to go.

Second: teaching leprosy in Universities, since most of health professionals (like me in the past) think it does not exist, or that it is rare. Many are afraid to became sick too when attending the patients due to ignorance about the disease.

Finally, improvement of the capability of health professionals who are in the field, with a strategy of in service training, like DAHW is doing in the states of Mato Grosso and Mato Grosso do Sul.

Regards,

Jaison

J. A. Barreto, Leprologist and Dermatologist, PhD, Bauru, Brazil

Dr A Ghosh’s contribution

2011-12-27T07:13:00.001-08:00

Leprosy Mailing List – December 24^th, 2011

Ref.: Dr A Ghosh’s contribution.
From: H K Kar, New Delhi, India

Dear Dr Noto,

This is my first letter after our meet in Brazil for Brazil Congress and ILA regional leprosy congress for Americans. However, I was keenly going through all your mails.

I am not agreeing with many aspects mailed by A Ghosh [LML Dec. 17th, 2011]. Introduction of MDT by WHO has a tremendous impact on reduction of case load in the world. The word elimination no doubt has created a false impression of eradication particularly among the politicians and non-medical administrators. As leprologists it is our duty to clarify ourselves first and clear the doubts of nonmedical administrators and politicians the difference between eradication and elimination.

Leprosy is neither highly infectious nor M. leprae remains alive outside the human being for more than few days as stated by A Ghosh. No doubt, a few pockets (municipalities, districts) in all endemic countries are having hidden cases of leprosy which needs to be detected at the earliest by certain active mechanism like conducting SKIN CAMPS periodically after adequate IEC programme for voluntary reporting in the camp for early detections and treatment. Due to long incubation period as well as persistence some hidden untreated cases, new cases of leprosy continue to surface for some more years. As rightly targeted by WHO for reduction of deformities by 35 % depends on how early we are detecting our new cases. Increase number of new cases among children in certain parts of the glove is not a healthy sign. We all have to be serious on intra familial and extra-familial contact tracing and if possible regular school survey for early detection of cases within the existing setup of integrated programme. We must be optimistic and work hard towards for ultimate eradication.

Regards,

Dr (Prof.) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001

Dr A Ghosh’s contribution. Community Dermatology

2011-12-27T07:12:00.002-08:00

Leprosy Mailing List – December 20^th, 2011

Ref.: Dr A Ghosh’s contribution. Community Dermatology
From: T. Ryan, Oxford, UK

Dear Salvatore,

Anjan Ghosh [LML Dec. 17^th 2011] has made a lucid and informative contribution which everyone with an interest in the future of leprosy should read. I am disappointed that there is no mention and discussion of the contribution the profession of dermatology should make to the future. Of course the majority of Dermatologists in private practice do not want to be part of an outreach of a new elimination programme. However all will be willing to be part of its advocacy and that could be helpful.

What the old brigade and that includes Ghosh's supervisors, do not realise is that there is a developing branch of Dermatology named Community Dermatology. Ryan Tj (2011) The International Society of Dermatology's Task force for Skin care for ALL: Community Dermatology. International Journal of Dermatology 50: 548-551. Nine articles under this heading follow. There is a CD with 41 accounts of successful practice. Leprosy is included as a topic in both.

Leprosy is predominantly a skin disease and unless those who supervise the future have an expectation that Dermatology will make a significant contribution in the future and invite them to the forums that discuss the future it will be difficult for Community Dermatology to plan to be part of that future. I recognise that there are Dermatologists playing a leadership role but sadly such involvement most frequently sees them drop the title of Dermatologist.

Terence Ryan

Email: userry282(at)aol.com

What strategy should be applied for leprosy control?

2011-12-27T07:12:00.000-08:00

Leprosy Mailing List – December 20^th, 2011

Ref.: What strategy should be applied for leprosy control?
From: V. Pannikar, India

Dear Dr Noto,

I am fascinated by the on-going discussion on the Brazilian leprosy programme. I have always admired Brazil for their honesty in providing us with the "true" leprosy situation in the country. They are ready to accept their shortcomings gracefully and correct them. The country is vast; the population still on the move, the infrastructure is still trying to reach the unreached areas/populations.

If anybody knows the leprosy situation well, it is the Brazilian scientists, dermatologists and experts, who have dedicated their lives for controlling this disease. In doing so they have contributed richly to the global fight against leprosy and improved our scientific knowledge in many fields. In this I will particularly single out the dermatologists and their organizations, who unlike in other countries, have been at the front of fight against leprosy. In my opinion, Brazil is one of the rare countries where leprosy work is highly respected; taught and young people are still willing to dedicate their lives for.

Regarding the issue of what strategy should be applied for leprosy control? There is no correct answer, elimination had its own goal and purpose and now we are moving to next steps. This does not mean that elimination strategy was wrong, if properly understood, in the context of period and situation in 1990's, it was the best. Today in the second decade of 2000's, the context has changed and new challenges are appearing. We are seriously looking at other issues like prevention of disabilities (PoD), rehabilitation, stigma etc because we were able to reduce the burden of leprosy prevalence, reduce the cost MDT - free now. To me the strategies evolved during the last 2-3 decades were a continuum, one benefitting from the previous and still retaining essentials.

The ultimate choice must remain with the national programmes, as long as the essentials are followed, things will work out for the best. I would fully support the right of the programme to choose and we must support their efforts.

With kind regards,

V. Pannikar

Brazilian Hansen's Disease Congress and "Elimination" Goal

2011-12-27T07:11:00.001-08:00

Leprosy Mailing List – December 19^th, 2011

Ref.: Brazilian Hansen's Disease Congress and "Elimination" Goal
From: W Nogueira, S Paulo, Brazil

Dear Salvatore,

I am the member of the Brasilian Society of Hansenology (SBH) who did not agree with the video-message of the Ministry of Health [see letter of Dra. Maria Leide, LML Dec. 9th, 2011] and I requested, during the SBH assembly, to register in the record of the proceedings my disagreement. Regrettably the meeting was against, stating that this was not the moment to set itself against the Ministry of Health, with which I did not agree. I am also a member of the board of Directors of the Fundação Paulista Contra a Hanseníase and, in our meeting after the congress, which took place on 9-12-2011 it was decided that the Foundation will send a letter declaring itself against what was declared at the SBH congress about: "the wrong strategies implemented by the country the past decades". As soon as this letter is written and sent to the Ministry of Health and the SBH, I will send you a copy.

Regards,

Wagner Nogueira

<< “Prezado Salvatore,

Eu sou este membro desta sociedade que não concordou com o discurso e solicitei, na assembleia da SBH, um registro em Ata do meu desagrado. Lamentavelmente a Sociedade foi contra, afirmando que não era momento de se insdispor com o Ministerio da Saúde, com o que não concordei. Faço parte também da diretoria da Fundação Paulista Contra a Hanseníase e, em nossa reunião pós congresso, realizada em 9/12/2011 ficou decidido que a Fundação vai enviar uma carta manifestando-se contraria ao que foi declarado neste congresso sobre "as estratégias equivocadas adotadas pelo país nas últimas décadas". Tão logo esta carta seja escrita e encaminhada para o Ministério da Saúde e Sociedade Brasileira de Hansenologia, envio uma copia para você.

Saudações

Wagner Nogueira”>>

What can we do Dr Noto?

2011-12-27T07:10:00.001-08:00

Leprosy Mailing List – December 19^th, 2011

Ref.: What can we do Dr Noto?
From: S. Noto, Genoa, Italy

Dear Dr Nora Cardona Castro,

Thank you very much for your message in LML dated Dec. 8th, 2011 about ”Why Brazil is doing this?” and for sharing important information about the leprosy situation in Bolivia. At the end of your message you kindly asked:- << ”What can we do Dr Noto?” >>.

I think we should carry out anti-leprosy activities using the proper tools. If we use the proper tools we can only do better. But probably your important question is too big for me and others have to answer. I can try to understand who is advising Brazil in doing the right thing with the wrong tools and why? After this, one may discuss with these persons and get explanations on why it should be “elimination” instead of “control”? Why registered point prevalence rate instead of incidence related indicators? And what will change after we reach the 1 in 10,000 benchmark?

The more I think about the National Congress of the Brasilian Society of Hansenology and the Regional Congress of the International Leprosy Association held in Maceio’, Brazil, from the 23 to 26 November 2011,the more hypotheses I get. The congress days were excellent. I met many friends and colleagues all discussing about leprosy, its complexity, its sequelae and how to address the many unresolved questions. None, among the great number of health workers present was talking about the so called “elimination strategy”, with two exceptions. Just at the welcome session two speakers, mentioned this strategy. Might it be (hypothesis) that somebody from Brazil or from outside is advising the use of this strategy against the opinion of most people working in this field?

If that were that case it is a nightmare, we are back to square one. There has been no learning from the past. Should wait we again for somebody like Dr Sansarricq who honestly reported: << “ … Noteworthy, too, is that the elimination initiative was recommended by the WHO Executive Board and the World Health Assembly without a WHO Expert Committee meeting, Study Group, or other preparatory step. It may have been felt that a technical meeting was likely to express some reservations about the elimination concept …” > >?

Not to mention about who is going to organize the next International Leprosy Congress about a disease that was already eliminated in the year 2000, then with a final push it was eliminated again in the year 2005, then the same disease went into the post elimination era [incredible, the post-elimination era!] and, then Brazil starts all over again and, then India pays money to “volunteer” health workers per each leprosy patient detected.

It is not a matter of words, it is a matter of tools or weapons in the armamentarium against leprosy, we should use the right ones. It is like we were using the wrong drugs and giving away MDT. If instead, we use the right tools we can only do better.

Best regards,

S. Noto

“Why Brazil is doing this?”

2011-12-27T07:08:00.001-08:00

Leprosy Mailing List – December 17^th, 2011

Ref.: “Why Brazil is doing this?”
From: A Ghosh, London, UK

Dear Salvatore,

Thank you for your LML message “Why Brazil is doing this?” dated December 4^th, 2011. It is an interesting area of discussion. In fact my dissertation for my Master in Public Health at the London School of Hygiene and Public Health in 2008 was about this. The title of the dissertation was: -
“A Health Policy Report - How could changes of case definitions, ascertainment procedures, and diagnostic and registration conventions have impacted on reductions inthe prevalence of leprosy in India, reported over the last decade (taking the state of Jharkhand as a case study)?”.

Herewith are my conclusions (and in attachment the full paper). Thank you for circulating it on the leprosy mailing list. Any comment will be appreciated.

Best regards.

Anjan Ghosh
Specialty Registrar Public Health

Department of Health Services Research & Policy

London School of Hygiene & Tropical Medicine

15-17 Tavistock Place

London WC1H 9SH

<< 7.1 Conclusions

Declaring a disease eliminated from a country has very serious implications. Despite more than 20 years of multi-drug therapy (MDT), leprosy has not been eradicated. Leprosy patients are highly infectious and M. leprae can remain viable outside the human host for many months. The mean incubation period of lepromatous disease is 10 years. These factors make it difficult to completely eradicate the disease and there is no evidence that the global initiative has lead to the disappearance of infection or disease from any population.

Perhaps we are failing to understand some important aspect of the disease’s natural history. With elimination declared, resources are becoming scarce for the continued efforts necessary to keep this enigmatic disease at bay.

Integration has resulted in the loss of skilled and experienced leprosy workers and the lack of training to general health staff has further compounded the situation. Cessation of active case detection will continue to contribute to a rise in hidden cases. In the absence of effective IEC, campaigning and public awareness initiatives, voluntary reporting will not be effective in new case detection.

Social stigma in relation to leprosy is ingrained in society. Fear of social ostracism and discrimination discourage patients from accessing services or even being diagnosed. Socio-economic rehabilitation of leprosy cases is greatly hampered by this. Ignoring the reality of the problem will not make it go away. Declarations of elimination on paper do not magically rid a country of a disease. Much to the contrary, it is possible the leprosy will re-emerge as a major health issue unless it is addressed according to the ground realities. >>

Request of address of Doctor with experience in leprosy in Cuba

2011-12-27T07:07:00.001-08:00

Leprosy Mailing List – December 15^th, 2011

Ref.: Request of address of Doctor with experience in leprosy in Cuba

From: S. Noto, Genoa, Italy

Dear All,

We have here in Genoa a patient of leprosy that has been treated for ENL reaction. He is going back home to “Jsla del la Juventud”, Cuba. I am looking for the address or contact numbers of a Doctor with experience in leprosy in Cuba to whom referring the patient.

Thank you very much in advance,

Best regards,

S. Noto

Brazil

2011-12-27T07:06:00.002-08:00

Leprosy Mailing List – December 14^th, 2011

Ref.: Brazil

From: J A Barreto, Bauru, SP, Brazil

Dear Dr Noto,

The last International Leprosy Congress, in Maceio’, Brazil, was an important moment to discuss the question of leprosy in America, as well as in the World. For WHO, nowadays, we are the last country where leprosy was not "eliminated", and though we all know that this is not true, Brazil became in a bad situation: are we so incompetent, more than all other countries, like Ethiopia, Sudan, etc?

The fact is only one, and WHO should change the way how this issue has being understood. Having an elimination target is good, and important, at least once the detection rate decreases when leprosy is not in focus, and not like what happened after 2005 in Brazil (The reporting was only on ¾ of the year). Nevertheless, to reach elimination, many efforts must be done, and the foolish strategy, which is in progress today, i.e., the making up of statistics, will have a high price.

Monitoring of “elimination”, as well as the quality of assistance, is also extremely important, and since 2005 nothing was done in Brazil about this. When I went to the state of Rio Grande do Sul, in 2003 and 2005, as monitor of Leprosy Elimination Monitoring, I observed that the goal of elimination, achieved in 1997 in that state, was only operational: an extremely centralized model of leprosy assistance, i.e., made by dermatologists in regional references, without evaluation of household contacts, associated with a high degree of stigma and prejudice. This led to the progressive decreasing from the detection rate due to gradual retirement of these professionals, whose were not substituted. Today, like the other 2 states that also achieved elimination (on paper), i.e., São Paulo and Santa Catarina, the rule is late diagnosis in referral centers, like the same problem reported by Dra. Nora Cardona Castro from Colombia.

I had published a paper about the leprosy cases diagnosed in our Institute from 2003 to 2007, with the profile of leprosy patients from the state of São Paulo. Almost two thirds had grade of disability higher than zero, and one third had grade 2; median time interval from the start of symptoms to diagnosis in a referral center was one year. Half of the patients came to our services without the suspicion of leprosy, i.e., among the other dermatologic diseases, since we have a Residence in Dermatology.

Today, like Dra. Nora, we are diagnosing 1 new case almost every day in our routine. During the last Skin Cancer Campaign in our city, fifteen days ago, 2 new cases were found, one of them was an advanced lepromatous case, with several lepromas. Finally, my opinion is that having an “elimination” target is important, but epidemiological vigilance must be kept, as well as monitoring the achievement, like what we are doing now.

Jaison A. Barreto

Instituto Lauro de Souza Lima

Bauru, SP, Brazil

CALL FOR PAPERS - For a special issue of Leprosy Review on Chemotherapy

2011-12-27T07:06:00.000-08:00

Leprosy Mailing List – December 13^th, 2011

Ref.: CALL FOR PAPERS - For a special issue of Leprosy Review on Chemotherapy

From: I Allen, Colchester, Essex, UK

Dear Salvatore,

Would you be kind enough to put the attached CALL FOR PAPERS on the Leprosy Mailing List please?

Thanks very much

All best wishes

Irene

Mrs. Irene Allen

Assistant Editor

Leprosy Review

28 Middleborough

Colchester

Essex CO1 1TG

Tel: 01206 216730

Fax: 01206 762151

28th Biennial Conference of Indian Association of Leprologists

2011-12-27T07:05:00.000-08:00

Leprosy Mailing List – December 13^th, 2011

Ref.: 28^th Biennial Conference of Indian Association of Leprologists

From: Swapan K Samanta, West Bengal, India

Dear Dr Noto,

Thank you very much for your excellent mailing list. Please be kind enough to circulate this attached Brochure of the ensuing 28^th Biennial Conference of Indian Association of Leprologists to be held in Mumbai, India on 27, 28 & 29^th January, 2012 and also inform the interested participants to have a look on our Website:www.indianleprologists.org for any last minute information.

Looking forward for your urgent necessary action.

Regards,

Swapan K Samanta

Dr Swapan Kumar Samanta, MBBS (Hons), MS, CCEH(ICEH,London), West Bengal Medical Education Service
Hony. Secretary, Indian Association of Leprologists
Hony. General Secretary, Association of Community Ophthalmologists of India
Councillor, SAARC Academy of Ophthalmology
Associate Prof. & Visiting Eye Surgeon
Dept. of Ophthalmology, Calcutta National Medical College ,Kolkata 700014, West Bengal
Visiting Eye Surgeon, Brandt Ocular Leprosy Clinic
Haldia Lions Eye Hospital, Haldia Port City, West Bengal, India)
Mailing Address:
657 Abasbari, TAMLUK,Dist. Purva Medinipore, West Bengal, PIN : 721636
Tel: 03228266101, 09434023759, Email : swapansamanta53(at)gmail.com

Attachments: Brochure and Registration form

Why Brazil is doing this?

2011-12-27T07:04:00.000-08:00

Leprosy Mailing List – December 12^th, 2011

Ref.: Why Brazil is doing this?
From: W H van Brakel, Amsterdam, Netherlands

Dear Salvatore,

I would like to add that I agree for 100% with the view expressed so well by Prof. Cairns Smith (LML, Dec. 10^th, 2011)!

With best wishes,

Wim van Brakel

Wim H. van Brakel, MD MSc PhD

Head, Leprosy Unit

Royal Tropical Institute (KIT)

Amsterdam

Netherlands

Brazilian Hansen’s disease Congress and “Elimination” Goal

2011-12-27T07:03:00.001-08:00

Leprosy Mailing List – December 12^th, 2011

Ref: Brazilian Hansen’s disease Congress and “Elimination” Goal
From: D D, Palande, Pondicherry, India

Dear Salvatore,

I find this letter [M L Wan-Del-Rey de Oliveira, LML Dec. 9^th, 2011] and the action proposed and taken very interesting and wonder how many of us in India would strongly advocate such an approach. My appreciation and thanks Dr Maria Leide for this way of approach and its pragmatism.

Dinkar

Dinkar D. Palande

Why Brazil is doing this?

2011-12-27T07:02:00.002-08:00

Leprosy Mailing List – December 10^th, 2011

Ref.: Why Brazil is doing this?
From: W C S Smith, Aberdeen, Scotland, UK

Dear Salvatore,

Can I respond to your message (LML Dec. 4th, 2011) from a personal perspective? Much of what you say about incidence, prevalence and elimination is correct, and is re-visiting old debates. I am very aware of the debates and misgivings about the term elimination. Correctly the ‘elimination strategy’ was defined in the World Health Assembly 1991 resolution as elimination as a public health problem to a registered prevalence of less than 1 in 10,000 population at a global level by the year 2000. The elimination strategy was highly successful in providing a focus for leprosy and in securing political and financial commitment leading to a dramatic reduction in registered prevalence by the end of 2000. Since then the global strategies have focused more on reducing the burden of disease, new case detection, improving quality of leprosy services and reducing disabilities.

Public health strategies and policies with targets are developed, based on many factors as well as the epidemiology. Many of the weaknesses of prevalence you have mentioned also apply to new case detection which limit its validity as an indicator of ‘incidence’. Prevalence can be a useful indicator of treatment workload for programme managers. Now that treatment duration is 6 or 12 months, the prevalence approximates to new case detection. Indeed where the duration of MDT is fixed, and it is efficiently delivered with good completion rates, new case detection is the main determinant of prevalence according to the mathematic formula.

As to the situation in Brazil – this is a country that, according to the Weekly Epidemiological Record, is in the rather unique position of not yet achieving a registered prevalence below 1 in 10,000. If the government wants to develop an ‘elimination strategy’ that would improve the quality and coverage of the national programme that should be welcomed – the name is of less importance and I am very aware of the problems with that word. If the multidrug therapy (MDT) programme in Brazil is efficient (the prevalence/new case detection ratio is less one in Brazil which suggests the MDT programme is efficient) then the only way to reduce registered prevalence will be by reducing new case detection. I would hope that the strategy would also include the key components of the WHO ‘Enhanced Global Strategy’ which includes a focus on new case detection, reduction in disabilities, participation of people affected by leprosy, and addresses issues of human rights and discrimination. The heart of the issue is not the title but whether this policy is going to have a positive effect on the health and wellbeing of people affected by leprosy? If yes, then we should work together to support the efforts of the Brazilian leprosy programme.

With best wishes,

Cairns

W Cairns S Smith OBE, MD, MPH, PhD

Emeritus Professor of Public Health,

School of Medicine and Dentistry,

University of Aberdeen,

Polwarth Building,

Foresterhill,

Aberdeen AB25 2ZD,

Scotland, UK

Telephone - (44) 1224 437266

Email: w.c.s.smith(at)abdn.ac.uk

Brazilian Hansen’s Disease Congress and “Elimination” Goal

2011-12-27T07:02:00.000-08:00

Leprosy Mailing List – December 9^th, 2011

Ref: Brazilian Hansen’s Disease Congress and “Elimination” Goal
From: M L Wan-Del-Rey de Oliveira, Rio de Janeiro, Brazil

Dear Salvatore,

To the surprise of all foreign (and Brazilian) hansenologists invited for the recent Brazilian Hansen´s Disease Congress the video-message from Ministry of Health (MOH) reintroduced and emphasized the old elimination goal based on the period prevalence rate of the disease. Such decision was not discussed with the Brazilian hansenologists.

In fact, this elimination goal is an anachronism after the consensus of the most important hansenologists worldwide, regarding the new focus on case detection and grade 2 of physical disability among new cases (WHO Global Strategy for Further Reducing the Leprosy Burden and Sustaining Leprosy Control Activities 2006 – 2010 and the Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy 2011 – 2015). But for the Brazilian technicians the most provocative declaration showed in the same video was “Brazil did not eliminate leprosy due to incorrect strategies done in the recent decades”.

During the Assembly of Hansenology Society at the congress, one member manifested the need of a note from the Society, against such type of communication. But another said that this kind of speech is nothing new among new managers and politicians referring to previous administrations. So the conclusion was that we must be complacent with this.

Of course, the responsible for this video-message knows that this non-achievement of the elimination goal in Brazil was related to the fact that the new cases comprise a number so high that it is impossible to have less than one per 10,000 inhabitants up to now. But it also can be neutralized if not all new cases detected during the year be included or if no priority for cases detection was done.

The strategies triggered by MOH/Brazil, since the MDT implementation in 1986 was the same: early diagnosis, promptly MDT treatment, contacts surveillance and the reinforcement of decentralizing through the Primary Health Care/SUS. Therefore, the results depend upon the effectiveness of these services in performing these actions. It is also influenced by the improvement of economic and social situation of the poorest and most endemic regions.

Recently, MOH announced the funds transference to the 160 most endemic municipalities. I want to remind this MOH representative that the same strategy was done in 1997/98 under his previous direction, comprising 280 most endemic municipalities. I had a high regard of him at that time, because Tuberculosis, Dengue and Malaria (also neglected diseases) received a budget for this program. So we presented a plan to him asking five millions to do the same for Hansen´s Disease and he so authorized. Later this plan was given greater potential by the following plan with the participation of Novartis and CONASEMS (Council of Municipal Secretariat of Health) in 1998-2002.

The technicians presenting at the Maceió Congress know very well the field situation of Hansen´s Disease, as well as the partners in the field of Hansen’s Disease Control like universities, state Foundations and ILEP members working in Brazil. Many scientific presentations corroborate that the later strategies are helping in controlling the disease and the decrease observed in a country was a result of their continuous and intensive work. And it is in accordance with the disease behavior and dependent of the quality of actions performance in a Brazilian SUS scenario. Many presentations at the Congress showed that the strategic spotlight on child rate and household contacts examination results in a better disease surveillance in the field.

There are many dedicated technicians who should be stimulated to continuing their work in order to reduce and further “eliminate” the Hansen´s Disease transmission focus. MORHAN could also collaborate with this doing a real social control at municipal level. The many young doctors, nurses, physiotherapist, social assistants and basic, social and operational researchers among others at the Congress bring a comfortable assurance that the strategic spotlight on child rate and household contacts examination aggregated all these people in the common objective of a world without Hansen’s Disease. This is most important than any ephemeral, authoritarian and political speech.

Best regards,

Dr. Maria Leide Wan-Del-Rey de Oliveira

Rio de Janeiro, Brazil

Why Brazil is doing this?

2011-12-27T07:01:00.000-08:00

Leprosy Mailing List – December 8^th, 2011

Ref.: Why Brazil is doing this?
From: K Cardoso Rodrigues, Governador Valadares, Brazil

Good afternoon Dr Noto,

I'd like to subscribe the Leprosy Mailing List. I'm a family and community physician who works in leprosy in Brasil at municipality level, in Governador Valadares, an hyper-endemic city with 260,000 inhabitants and around 130 new leprosy cases per year (of those, 10% are children).

Thanks and congratulations about your recent message about why "Brazil" is doing this mistake of backing public politics in the "elimination paradigm". Sure I'll spread it to health care workers and other interested people.
Katiuscia Cardoso Rodrigues
(33) 88470432

Why Brazil is doing this? – Leprosy in Colombia

2011-12-27T07:00:00.001-08:00

Leprosy Mailing List – December 8^th, 2011

Ref.: Why Brazil is doing this? – Leprosy in Colombia
From: N. Cardona Castro, Sabaneta, Colombia

Dear Dr. Noto,

Thank you for your message “Why Brazil is doing this?” dated LML Dec. 4^th, 2011. Your words about “elimination” of leprosy are remarkable important.

I would like to share some information about the leprosy situation in Colombia, a country with prevalence of leprosy less than 1/10,000 since 2000 year. Colombia is still considered an endemic country where leprosy is not a public health problem because its prevalence, but there are about 200-400 new cases per year. This means that the transmission continues, which has not been impacted by the multi-drug therapy (MDT) as expected.

Nevertheless, the reduction in prevalence is not a real reflection of the problem with respect to population distribution. For instance, Colombia has some regions where the actual prevalence is 1 to 3/10,000 and other regions where prevalence is 0 to 0, 5/10,000.

When Colombia reached the prevalence of <1/10,000, the leprosy control programme suffered devastating consequences. After reaching this figure health officials let down their guard and control programmes and control activities were under budget because "leprosy in Colombia is in the post-elimination phase."

I am MD and work in leprosy research, fact that is considering by my colleges as foolishness, because leprosy in Colombia does not exist, this is the interpretation of ELIMINATION, not only for general people, this is the interpretation for scientific and health authorities that have the responsibility to budget the public health policies.

Every week at least one patient with disability 2 or 3 is diagnosed as a NEW patient in Colombia. The devastating consequences of “elimination” were not only for budget or leprosy control measures, these consequences affected the medicine school programmes, and leprosy is studied in Colombia as other mycobacterial diseases in a class that is forgot very easy for medical students.

I attach some epidemiological studies that we have performed to improve the early diagnosis in household contacts of leprosy patients, but where are the non-diagnosed patients and their household contacts?

What can we do Dr. Noto?

Nora Cardona Castro | MD MSc Investigadora Prof Asociada

Instituto Colombiano de Medicina Tropical - Universidad CES

Carrera 43A # 52 Sur 99 Sabaneta

Colombia

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

ncardona@ces.edu.co | www.ces.edu.co

Leprosy in Colombia (PDF): Attachment 1 Attachment 2 Attachment 3

Commemoration of the Civil Servant Day in Brazil. FIOCRUZ initiative to honor its workers

2011-12-27T06:59:00.001-08:00

Leprosy Mailing List – December 5^th, 2011

Ref.: Commemoration of the Civil Servant Day in Brazil. FIOCRUZ initiative to honor its workers.From: P A M Schreuder, Maastricht, The Netherlands

Maastricht, 30-10-2011

José Augusto da Costa Nery, MD, PhD - Professor of Dermatology, University Gama Filho, FIOCRUZ and Santa Casa, Rio de Janeiro

José Augusto was born and studied medicine in Belém, Pará, Brazil. In 1982, he came to Rio de Janeiro to do a 2-years post-graduate course in dermatology. He always was interested in the public health side of dermatology and became involved through Prof. Dr. Maria Leide W. de Oliveira in the Hanseníasis programme of Caxias, Rio de Janeiro. When Dr. Maria Leide became National Hanseníasis Coordinator at the Ministry of Health of Brazil in 1986, she invited Prof. Dr. Euzenir Sarno to set up a Leprosy National Referral Centre at FIOCRUZ (Fundação Oswaldo Cruz, Rio de Janeiro, Brazil) and to start research in Hanseníasis. José Augusto was then invited to help to re-start and give new life to the Hanseníasis Outpatient Department of FIOCRUZ. He has many scientific publications to his name.

José Augusto is one of the few dermatologists interested in public health, and his two main areas of interest are Hanseníasis (FIOCRUZ and Santa Casa) and Sexual Transmitted Diseases (Santa Casa). He must be one of the very few dermatologists who do not have a private practice. He is Professor of Dermatology, University Gama Filho and supervises residents in dermatology and medical students at FIOCRUZ and Santa Casa. He is a very dedicated Doctor to his patients and an excellent and compassionate teacher, and has a very gentle personality.

With great respect we would like to praise this initiative of FIOCRUZ, an international well-known research Centre in many fields of medicine, to honor its workers. We, readers of LML, we are very pleased to extend our congratulations to José Augusto.

Attachment (in Portoguese).

Ben Naafs

Salvatore Noto

Pieter AM Schreuder

Maharogi Sewa Samiti (MSS), Leprosy Rehabilitation Foundation, India

2011-12-27T06:58:00.000-08:00

Leprosy Mailing List – December 5^th, 2011

Ref.: Maharogi Sewa Samiti (MSS), Leprosy Rehabilitation Foundation, India.

From: S. Amte, Warora, Maharashtra, India

Dear Dr. Noto,

Maharogi Sewa Samiti is a non-profit organisation in Maharashtra State of India. MSS was founded by my grandfather, world renowned leprosy activist, humanitarian and peacemaker late ‘BABA AMTE, way back in 1949 for helping leprosy afflicted people to enhance their livelihood capabilities through self-discovery and empowering them to contribute back to the society. My grandfather Baba was the only person to receive UN Human Rights Award for the cause of leprosy. He has also received several prestigious honors, like The Damian Dutton Award, Ramon Magsaysay Award and the Templeton Prize.

MSS has a firm belief in giving a 'Chance' and not just charity to the socially outcasts who have lost sense of self-respect. It gives them opportunities to self-discover the worth of their hidden ability and thus eliminate their dependence on others.

MSS has been a pioneer in medical treatment and rehabilitation of leprosy patients in India. We are proud to inform you that in June 2011, our organization has crossed a mark of benefitting 2.3 million marginalized people like the leprosy afflicted, people with disabilities and tribal populace through our constructive programmes.

Due to the qualitative enhancement in the lives of leprosy afflicted people with disabilities, MSS has been increasingly getting recognized internationally as an apex referral centre for leprosy rehabilitation. This is evident with the fact that MSS received over one new leprosy patient each day at Anandwan, the headquarters, from various parts of the country and sometimes, the world.

Anandwan is perhaps the only experiment in the country where leprosy patients help others help themselves. Leprosy patients produce various goods worth Rs. 40 million every year through various productive activities. With the help of our cured leprosy patients, MSS now arranges various medical and surgical camps which benefit over 60,000 poor people from surrounding poverty stricken areas every year. Anandwan dairy project has been able to generate 700 litres of milk every day. Because of the relentless efforts of our people afflicted by leprosy, is been looked at as one of the most promising social businesses in the district. It is a matter of pride that the non-exploitative, non-bureaucratic management system of MSS is being studied by various apex educational institutes that include civil services, IIMs, IITs, social science institutes, environmental science and agricultural institutes from all over the world.

We would like to be a part of LML and receive information about more such organisations in the world and explore the possibility of constructive association. We would also like to explore the possibility of partnering with ILEP for livelihood promotion programmes with leprosy patients. We cordially invite you to visit ANANDWAN sometime, our “Paradise of, for & by the Underprivileged” to see our inmates celebrate the birth of new life with great enthusiasm.

With warm regards,

Dr. Sheetal Amte

Development Officer
Maharogi Sewa Samiti

Warora

Maharashtra, India

Why Brazil is doing this?

2011-12-27T06:57:00.000-08:00

Leprosy Mailing List – December 4^th, 2011

Ref.: Why Brazil is doing this?
From: S. Noto, Genoa, Italy

Dear All,

In 1991 the World Health Assembly (WHA) approved the resolution “Elimination of leprosy as public health problem by the year 2000”. Elimination was defined as a prevalence rate of less than one case per 10,000 population. That was a sad experience of how Ministries of Health can be misled and, strategies without sound scientific basis can be approved.

For years leprosy workers were asking how that happened? In 2004 Dr Sansarricq, ex head of the leprosy division at WHO gave the explanation. In his publication (Multidrug therapy against leprosy: development and implementation over the past 25 years / [editor]: H Sansarricq) he explained that the authors of the “elimination” strategy (no names are given) “felt” that the strategy had no scientific basis and instead of correcting it, they decided to bypass the requested procedures.

Herewith are reported Sansarricq’ s words: << “ … Noteworthy, too, is that the elimination initiative was recommended by the WHO Executive Board and the World Health Assembly without a WHO Expert Committee meeting, Study Group, or other preparatory step. It may have been felt that a technical meeting was likely to express some reservations about the elimination concept …”> >

The major points of the “Elimination” resolution are wrong. The Table 1. shows the components, namely: the goal, “elimination”; the indicator, “ register prevalence rate” and; the benchmark, “one in 10,000” and, alternatives are suggested.

The word “elimination” is inappropriate. It signifies elimination of the disease (i.e. the disappearance of that disease from a region). Even when the so-called elimination goal is reached we are still left with enormous numbers of patients. For example in countries like India and Brazil the numbers would still be about 120,000 and 20,000 cases per year respectively. How such numbers of cases of a serious and complex disease like leprosy can be called “elimination”?

Prevalence in an area consists of the known prevalence, those patients on register, and the patients not yet diagnosed. The real prevalence is often more than twice the known prevalence. For the elimination strategy only the known prevalence, defined as the number of patients on multi-drug therapy treatment, was taken into account. Apparently the patients not yet diagnosed and living in the community were not considered to take part in the transmission of the infection.

There is a mathematic formula that correlates prevalence and incidence. Prevalence is equal to incidence times duration of the disease. If treatment shortens the duration of disease, the prevalence goes down but, this does not necessarily influences incidence and the persistence of the transmission in the community.

The Figure 1. shows the global trend of the registered point prevalence (in red) and new case detection (in blue) of leprosy from 1985 to 2010. The source of the data is the Weekly Epidemiologically Record (WER). The red line is misleading. In the studied period the duration of the treatment of leprosy has changed and consequently the prevalence too but, is the blue line that is nearer to core of the problem.

An indicator related to incidence, like new case detection is more appropriate to monitor the trend of leprosy and gives better information about the risk of contracting the infection in a given community.

The benchmark used, “one in 10,000 population” has no meaning. The biology and the epidemiology of the disease have no relation with it. The endemic foci of leprosy will continue to produce new cases above and below this benchmark. Nobody knows who “invented” it.

Many colleagues have reported these and, other problems of the so called “elimination” strategy. Dr Sansarricq from WHO has honestly explained what happened. The new WHO strategies (2006-2010) have adopted the necessary changes.

Some days ago, on November 23^rd, 2011 at the national congress of the Brazilian Society of Hansenology and regional congress of the International Leprosy Association, in Maceio’, Brazil, the Brazilian Ministry of Health announced, via video-message, that his country will adopt the so called “Elimination” strategy. As discussed above such a policy would not have any scientific significance.

S. Noto

Demise of Dr R Ganapati

2011-11-24T07:09:00.001-08:00

Leprosy Mailing List – November 19th, 2011

Ref.: Demise of Dr R Ganapati

From: Pranab K Das, UK; J Watson, …

Dear all,

Dear Dr Pai,

With sadness we have received the news. Our heartfelt condolence is to be conveyed to his family and friends and most importantly to he committed team.

Professor Pranab K Das

Dear Friends,

I am so sorry to hear of the death of the wonderful Dr. Ganapati. His dedication to the cause of helping the leprosy affected has been phenomenal. His manner was always gracious and patient in the extreme. The world will be a poorer place without him. My thoughts and prayers are with those who now mourn him.

Kind Regards,

Jean

Jean Watson OBE, Leprosy Gandhi Award recipient.

Demise of Dr R Ganapati

2011-11-24T07:08:00.001-08:00

Leprosy Mailing List – November 19th, 2011

Ref.: Demise of Dr R Ganapati

From: H Srinivasan, Chennai, India; G Oehler, Nigeria; R Jerskey, Los Angeles, USA

Dear all,

The Leprosy World lost an eminent son and I have lost another good friend in the death of Dr R Ganapati, who tirelessly worked for the well- being of the leprosy-afflicted, all his life and almost till his last breath. Just three weeks ago he, in a mail to me, said he "tries to work as much as his heart allows" him to. Even his heart, large as it was, could not, I suppose, cope with the workload and had to call it a day at last.

Dr Ganapati's name was synonymous with "Urban leprosy control" and whenever Bombay (now Mumbai) was mentioned in connection with leprosy, it often referred to Dr Ganapati and his work. He was the father of the well-known Bombay Leprosy Project and in setting that up and running it he showed that good quality leprosy work could be done successfully in the urban metropolitan milieu and how that could be done. That was not an easy task as anybody with experience in field work would avow. Before Ganapati, it was thought an almost impossible task, and lo, there was Dr Ganapati and the impossible was shown to be successfully possible, giving a fillip to setting up other urban leprosy control projects. Unlike many others in the field, his interest was not confined to "making the leprosy patients safe for the community by rendering them 'smear negative' "; he was interested in their total welfare and in that I feel he served as a model leprosy worker. His work in Dharavi, reputed to be the largest slum of Asia located in Bombay, is a glorious chapter in the annals of leprosy work in India.

He was a personal friend of mine and I will always remember his endearing smile and the way he came forward and offered his help to my daughter when she had to spend a year in Bombay as a student. My heartfelt condolences to Mrs Ganapati and his two daughters and to the staff of Bombay Leprosy Project for their great loss. In the face of death, we are helpless and can only share their sorrow.

H Srinivasan

Dear all,

Everyone at GLRA Nigeria was very sorry indeed to receive the news of the passing of Dr. Ganapati. His tireless work at the Bombay Leprosy Project brought hope and comfort to many, and will remain an inspiration to everyone involved in the fight against leprosy. The management and staff of GLRA Nigeria wish to convey our heartfelt condolences to colleagues, friends and Ganapati family, while we pray for God to grant his soul perfect peace.

Yours sincerely,

Gerhard Oehler

GLRA Country Representative

on behalf of German Leprosy and TB Relief Association Nigeria

Greetings from East Godavari Dt., Andhra Pradesh, India, Salvatore, and greetings to all who read the LML....

My wife Vikerunuo ["Aruno"] and I are visiting projects in urban and rural India these weeks and we had the joy and privilege of meeting with Dr. Ramaswamy Ganapati during our sojourn in Mumbai just this past week, including at the Bombay Leprosy Project.

His warmth, passion for serving those affected by leprosy and encyclopaedic knowledge in the field of leprosy will be greatly missed. The twinkle in his eyes, his smile, and generosity of sharing from his extensive reservoir of anecdotes and research....undiminished since we first met, when he graciously welcomed me nearly 20 years ago to the day at the conference on "Relapses and Reactions" in Hyderabad.

In Memorium and Gratitude,

Robert Jerskey

LOTR, POD consultant

National Hansen's Disease Program

Los Angeles and San Diego

Recently approved ILEP Leprosy Research strategy

2011-11-24T07:07:00.003-08:00

Leprosy Mailing List – November 18th, 2011

Ref.: Recently approved ILEP Leprosy Research strategy

From: D Soutar, London, UK

Dear Salvatore,
I would be grateful if you could post the following news item and link regarding the recently approved ILEP Leprosy Research strategy. Further research in all aspects of leprosy control will still be needed if we are to have the appropriate, sustainable tools with which to continue towards our goal of a world without leprosy. I very much hope the sharing of this ambitious ILEP Strategy will stimulate some fresh debate and motivation to address and reverse the declining focus on important leprosy research. We welcome your readers’ thoughts and responses on this topic.
Regards,
Douglas Soutar

Ambitious Research Strategy for ILEP Federation See link: ILEP Research Strategy

At their meeting in October, 2011 the ILEP Board approved an ambitious Research Strategy for the ILEP Federation. This had been formulated by the outgoing ILEP Technical Commission and its promotion and follow-up will now be a priority for the new ILEP Technical Commission whose eight members were selected by the ILEP Board during the same meeting.

Summary: A research strategy to develop new tools to prevent leprosy, improve patient care and reduce the consequences of leprosy

The ImportanceThe Global Leprosy Programme has had a dramatic impact on the prevalence of registered cases of leprosy over the last 20 years through the implementation of short course multi-drug therapy (MDT) treatment. However, further advances in the field of leprosy are hindered by the lack of new tools to address the challenge of apparent persistence in transmission and incidence, and the long term consequences of the disease.

The StrategyThis strategy was developed by the Technical Commission of ILEP to provide a framework to prioritise research, to identify the steps needed to develop and implement new tools, and to identify funding gaps. The strategy focuses on applied research, either technology transfer or research to evaluate effectiveness of interventions where there is already proof of principle. More basic research and proof of principle are important but are outside the scope of this five-year strategy.

The PrinciplesThe strategy is composed of eight themes but research in these themes should be fully integrated mainly through the use of common field sites. The integration of research with other Neglected Tropical Diseases and diseases of poverty, and multi-disciplinary approaches are strongly advocated. Millennium Development Goal (MDG) 6 targets the reduction in the burden of disease but tackling poverty (MDG1), education (MDG2), gender equality (MDG3), child health (MDG4), maternal health (MDG5) and partnerships (MDG8) are all important for leprosy. The key research themes are as follows:

1. Prevention of leprosy
2. Early detection
3. Chemotherapy
4. Nerve function impairment and reactions
5. Prevention of disability
6. Community Based Rehabilitation
7. Stigma reduction and advocacy
8. Health and social care integration

The LogisticsThis strategy is based on the achievement of deliverables within five years at an estimated cost of £24 million. A number of the projects are already in progress, some are developed and requiring funding, while other areas are gaps representing urgent priorities.

ILEP Board Members, in approving this strategy, highlighted the importance of strengthening the links between research and field operations. Research into chemoprophylaxis for example, ties in with the recommendation of the WHO’s Enhanced Global Strategy to Further Reduce the Disease Burden Due to Leprosy 2011 – 2015 to examine contacts of persons diagnosed with leprosy. Such links are given prominence within the Research Strategy since combining such elements more effectively could have a big impact on leprosy control. Success in the other research areas could have an even more significant impact on leprosy around the world.

The General Secretary of ILEP, Mr Douglas Soutar, welcomed this clear identification of research priorities in leprosy and expressed his optimism that the declining interest in leprosy research can be reversed if ILEP Members and others can garner support for these vitally important fields of investigation. “Only with a sound evidence base and new tools will we be able to achieve our ultimate goal of a world without leprosy.”

ILEP Research Strategy

Douglas Soutar
General Secretary
International Federation of Anti-Leprosy Associations
Tel: 44 (0) 207 602 69 25 – Fax: 44 (0) 207 371 16 21 – Website: www.ilep.org.uk
E-mail: doug.soutar(at)ilep.org.uk

Survey on INFOLEP information services

2011-11-24T07:07:00.001-08:00

Leprosy Mailing List – November 18th, 2011

Ref.: Survey on INFOLEP information services

From: C Voorend, Amsterdam, The Netherlands

Dear Salvatore Noto,

With regards to a survey on INFOLEP information services, I would kindly like to ask you to forward the herewith enclosed text to your readers. Since I need to finish this evaluation by Wednesday already, I need to kindly ask you for passing this through as soon as possible. May it be possible to notify them before the weekend? Then I hope in 3 days time many people will be able to respond.

With many thanks in advance.

Best regards,

Carlijn Voorend

Dear Dr. Noto,

Infolep/Netherlands Leprosy Relief would like to invite your readers for a short user-survey on Infolep's services. We are currently evaluating the services of Infolep and the (future) information needs of the leprosy community. We would highly appreciate the LML-subscribers (users and non-users) to fill in this short questionnaire before November 22nd. This takes about 10-15 minutes and is accessible viahttps://www.surveymonkey.com/s/XJ3X5HX.

Infolep is the international knowledge centre for leprosy and related subjects (www.leprosy-information.org; www.infolep.org). Infolep facilitates global access to many e-resources through the integrated ILEP / Infolep website. Infolep is available for anyone involved in leprosy from researchers and students, to programme managers and field workers. The library is based in the Netherlands. Future strategic directions focus on becoming a decentralized multilingual, dynamic online portal (database with one interface) built up from Infolep’s collections and the collections of partners.

Questions or a request for a word-version of this survey can be pointed out to (c.voorend[at]leprastichting.nl , infolep@leprastichting.nl, or +31 20 59 50 530).

With many thanks in advance.

Yours sincerely,

Carlijn Voorend

Netherlands Leprosy Relief

Leprastichting / Netherlands Leprosy Relief (NLR)

Postbus / P.O. Box 95005

1090 HA Amsterdam

The Netherlands

Tel: +31 20 5950500

E-mail: C.Voorend(at)Leprastichting.NL

Web: www.leprastichting.nl

Demise of Dr R Ganapati

2011-11-16T07:26:00.001-08:00

Leprosy Mailing List – November 15th, 2011

Ref.: Demise of Dr R Ganapati

From: VV Pai, Mumbai, India

Dear All,

We deeply regret to announce the sad and sudden demise of Dr R Ganapati, Founder and Director Emeritus, Bombay Leprosy Project (BLP), on Sunday 13.11.2011. He passed away after a brief illness and hospitalization subsequent to his earlier longstanding cardiac ailment on 13^th Nov 2011.

Dr R Ganapati passing away is a great loss to the nation particularly to the Research and Medical fraternity including social workers and leprosy patients. His vision and mission of Leprosy Free World will be kept going by his committed team. He is survived by wife and two daughters. His death is deeply mourned by the Staff of BLP, Management, Well Wishers and Patients.

With kind regards,

Dr V V Pai
Director BLP

Early diagnosis and treatment is the key in the fight against leprosy

2011-11-16T07:25:00.001-08:00

Leprosy Mailing List – November 13th, 2011

Ref.: Early diagnosis and treatment is the key in the fight against leprosy.

From: H K Kar, New Delhi, India

Dear Dr Noto,

Thank you very much for circulating Dr Saunderson’s message and the Final Report of the “Leprosy Vaccine Summit” (LML Nov. 08th, 2011).

Rethinking of leprosy vaccine research is a positive approach in the direction of leprosy eradication from the globe. It should be cost effective even for vaccination of contacts. In India we were all involved in vaccine trial using various atypical mycobacterial antigens like Mw, ICRC, BCG etc. in last three decades with some success. However, it could not be implemented in the field due to lack of cost effectiveness. Chemoprophylaxis has shown some success. Ultimately it is the early diagnosis and treatment, the key to eradication.

Regards,

Dr (Prof.) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001

Many clinicians are not taught to really examine the nerves

2011-11-16T07:24:00.001-08:00

Leprosy Mailing List – November 12th, 2011

Ref.: Many clinicians are not taught to really examine the nerves.
From: G. Warren, Sydney, Australia

Dear Dr Noto,

Thank you very much for publishing the photos and thank you Dr Barreto for sending them in (LML Nov. 7^th, 2011).

It is so good to see good photos of typical cases and, I especially appreciate the photos of the nerves. Many clinicians are not taught to really examine the nerves and I frequently have been able to make a final diagnosis by finding an altered radial or ulnar nerve on the back of a hand. One horse jockey had no feeling in some toes and no one could diagnose till I showed them the large superficial peroneal nerve!

One teenager, in Asia, complained of numbness and parasthesia, of index and long fingers and had no other obvious symptoms or signs so the general doctor, to whom he went, sent him to a psychiatric hospital for many months. Eventually they got him out and when I saw him he had a very large hard radial nerve on the back of that hand and large lymph nodes in neck and groin. A Biopsy of one of them showed classical leprosy that even the experienced professor was thrilled at finding- he was not often sent biopsies of lymph nodes! Poor boy fortunately he did not develop any further major deformity. Certainly not the classical case- but something to be aware of.

Thank you for the picture of the sural nerve abscess. I must confess that although I have felt many nerve abscesses and seen many large sural nerves I have never seen one abscess in that manner in the middle of the calf. It all goes to show that what we do not look for we will never see! I wonder what I have missed? Thank you for that.

Grace Warren.

Castle Hill, Sydney Aust.

Prev. Advisor for Leprosy for the Leprosy Mission in Asia 1975-1995.

What is in paucibacillary (PB) leprosy?

2011-11-16T07:23:00.001-08:00

Leprosy Mailing List – November 12th, 2011

Ref.: What is in paucibacillary (PB) leprosy? From: J Barreto, Bauru, S. Paulo, Brazil

Dear Dr Noto,

Thank you very much to my friend Dr Ben Naafs, and also to Dr Pieter Schreuder for their comments (please see LML 9^th Sept., 2011).

1. Yes, there is a spectrum in leprosy classification, and low resistant tuberculoid is a fact, even though I have seen only less than 10 cases in more than 10 years, and in more than 15.000 slides of leprosy cases which I saw during 8 years as dermatopathologist at the Instituto Lauro de Souza Lima (ILSL).

2. According to 1971 Ridley’s Classification (Five from seven groups), there is a group called TI (Indefinite Tuberculoid), who develops type 1 reaction, but this group is not the same of tuberculoid reactional described by Wade and Lauro de Souza Lima in the beginning of the 20 century. The name reactional tuberculoid leprosy, grouped later with BT patients in R&J Classification 1962/1966, should be deserved to patients with usually a lesion clinically and histopathologically indeterminate (early), whose developed, in most cases, a reaction in the first or second month of therapy, usually with few or no nerve symptoms, and the normal evolution was to cure. These patients had a Mitsuda reaction of 2+, i.e., 6 to 10mm diameter, different from TT patients (>10mm or ulcerated). Ridley, in his paper "Skin biopsy on Leprosy", 1987, second edition, pointed that TI is not the same as TR, though both undergone reactions. At the ILSL we recognize 2 groups of low resistant tuberculoids: "T in reaction", which in turn are really BT patients, i.e., annular tuberculoid lesions with satellite lesions and erythema after the beginning of treatment, and "reactional tuberculoid", described above.

3. It is also important to know that is very difficult to distinguish, even histopathologically, true TT from BT cases. Dr Fleury published a paper about this, in Hansenologia Internationalis. Ridley (1974) pointed some clues, as the lower destruction of epidermis and dermal nerve branches, as well as the presence of more Langhans giant cells in granuloma, but the main clue is the bacilloscopy (slit-skin smear examination), and sometimes only the evolution over long term follow up.

4. About bacilloscopy, as many as 90% of smears are made with bad quality in Brazil, and I believe that few technicians in the world, as well, are able to perform it correctly. I performed a study in 2010, in the state of Mato Grosso do Sul, Brazil, that I am going to present on the next International Leprosy Congress in Brazil. Why I made a study in this state? Because the quality of smears, on indirect evaluation, was said more than 99% good, and for this reason, it was the model for the country. Nevertheless, when we went to the field, and on direct evaluation, less than 10% of the smears were made in good conditions, i.e. good collection, fixation, staining and reading. This is the likely reason which explains why patients with less than 5 lesions are said PB: the smear collection from the lesions needs a good technics, and usually it is not possible to make it with tools other than the fingers, and for this reason almost all technicians DO NOT COLLECT from lesions. This is a fact. Once in cases of initial borderline leprosy the bacilli are found only in lesions, of course, index points will show no bacilli, and patients will be considered wrongly PB.

5. How long must we wait to say the patient is healed? 5yrs? 10yrs? How many long term follow up of PB patients, with good methodology, are described on literature? On my recent review of literature for my PhD thesis, ALL of them had less than 10yrs, and ALL the relapsed cases in these studies were diagnosed only by spontaneous demand. If we wonder that M. leprae can stay dormant in Schwann cells as many as 10yrs, and duplication time is almost 2 weeks, how many time must we wait to find and show viable bacilli on skin biopsies, or even on smears (which have lower accuracy), in order to distinguish between reversal reaction and relapse, after a short course of treatment in a borderline patient?

6. Finally, if, in a normal distribution of cases in the spectrum, only 10% have Mitsuda reaction positive (Ridley, 1974), and only these patients are able to destroy dormant bacilli inside nerve fibers, once metabolic inactive M. leprae will not be destroyed by MDT, what will be the real percentage of good prognosis MDT PB treated patients?

These are only some questions, which I still do not have answers.

Regards,

Jaison

What is in paucibacillary (PB) leprosy?

2011-11-16T07:22:00.001-08:00

Leprosy Mailing List – November 9th, 2011

Ref.: What is in paucibacillary (PB) leprosy?

From: B Naafs and P A M Schreuder, The Netherlands

Dear Salvatore,

We thank Dr. Jaison for his message “What is paucibacillary (PB) leprosy?” (LML Oct. 15^th, 2011). We just want to make a few observations to add to the discussion.

1. Dr. Leiker recognised that there existed a classification between tuberculoid (TT) and borderline tuberculoid (BT) leprosy. He called that LRT = Low Resistant Tuberculoid. It presents one or a few lesions (not symmetrically distributed) with a few satellites. Skin smears are mostly negative. It was a group of patients who hardly had problems or went into reaction. It is a pity this was never taken up by the international leprosy community.

2. In the old times BT with a max. smear bacteriological index (BI) of 1+ were indeed treated as PB. It later on turned out that especially BT with multiple lesions relapsed. In those cases were nerve biopsies were taken, many of those had a positive RC nerve biopsy (Dr. Ben Naafs). To reduce the PB relapse rate to a lower level a new clinical classification system was put in place: those patients with less than 6 lesions or with not more than 1 nerve involved were called PB. That indeed had the intended result.

3. Indeed, when smears would be taken in PB patients, 2 - 4% will be positive (ref. 1). Sometimes even a single lesion turns out to be positive. In case of nerve biopsies in PB patients even more will be positive. Nevertheless, we do not find a relapse rate of 2 - 4% in PB patients, much less so. Even in the old times, not all BT smear positives or with many lesions relapsed.

4. The first result of the Uniform MDT schedule shows that the PB relapse rate has become even lower than the MB relapse rate. Which could have been expected.

5. We are aware of Opromolla’s hypothesis, but which is not shared by many. In Thailand we saw and treated (with steroids) successfully many patients with a late reaction. The big majority of these patients improved and never relapsed (Dr. Pieter Schreuder).

May we also refer to the article by Maria Angela Bianconcini Trindade et al (reference 2): The histopathological changes in 167 biopsies from 66 leprosy patients were studied. The patients were selected when their sequential biopsies demonstrated either different patterns or maintained the same pattern of granulomatous reaction over more than two years during or after the treatment of leprosy. In 57 of the patients studied, a reactivation was seen which coincided with a decrease in the BI, suggesting that this reactivation (reversal reaction or type 1 leprosy reaction) coincides with an effective capacity for bacteriological clearance. In nine patients, an increase of the BI or persistence of solid bacilli occurred during the reactivation, indicating proliferative activity, suggestive of a relapse. The histopathological aspects of the granulomas were similar in both groups. CONCLUSION: bacteriology (slit-skin smear examination) provided the only means to differentiate a reversal reaction from a relapse in patients with granulomatous reactivation. The type 1 leprosy reaction may be considered as a partly effective immune reconstitution (reversal, upgrading reaction) or as a mere hypersensitivity reaction (downgrading reaction) in a relapse.

Abraços,

Ben Naafs

Pieter AM Schreuder

References
1.Rao PS, Ekambaram V, Reddy BN, Krishnamoorthy P, Kumar SK, Dutta A.Is bacteriological examination by skin smear necessary in all paucibacillary leprosy patients in mass control programmes? Lepr Rev. 1991;62:303-309
2.Trinade MA, Benard G, Ura S, Ghidella CC, AVelleira JC, Vianna FR, Marques AB, Naafs B, Fleury RN. “Granulomatous reactivation during the course of a leprosy infection: reaction or relapse. PLoS Negl Trop Dis. 2010 Dec 21;4(12):e921

Indian Council of Medical Research (ICMR) calls for proposals to evaluate Leprosy Eradication Programme

2011-11-16T07:20:00.001-08:00

Leprosy Mailing List – November 8th, 2011

Ref.: Indian Council of Medical Research (ICMR) calls for proposals to evaluate Leprosy Eradication Programme

From: S. R. Narahari, Kasaragod, Kerala, India

Dear Dr Noto,

Can you please circulate the enclosed “ICMR Proposal”? I think many leprosy mailing list readers might be interested.

ICMR calls for proposals to evaluate Leprosy Eradication Programme

The Indian Council of Medical Research (ICMR) has called for research proposals to evaluate the National Leprosy Eradication Programme (NLEP). The deadline for scientists and doctors to submit proposals is December 15.

India achieved leprosy elimination as a public health problem in December 2005, however there are pockets of endemicity where the number of new case detection is still high and the community is at higher risk of being infected with M. leprae. Over 200 districts of India, in parts of Bihar, Madhya Pradesh, Maharashtra and Tamil Nadu recorded more numbers last year.

Therefore, to address these issues, Secretary, DHR and DG, ICMR has taken steps to promote research by funding projects on the Priority Areas of research in leprosy given below:-

Health Systems Research & Operational Research on integration issues.
.
Studies evaluating current IEC strategies in increasing community awareness.

Studies addressing psychosocial issues for formulation of newer approaches to reduce the stigma, for encouraging early detection and completion of MDT.

Studies for encouraging early detection (through self-reporting) and completion of MDT.

Development of indicators for stigma at community level and evaluation of participation scale for wider use.
.
Nerve Damage and Care of the Disabled at the Community level and impact of field interventions.

Epidemiological studies
.
Estimating trends/prevalence/incidence in India with special emphasis on biological reasons and genetics.
.
Behavioural and social factors influencing the epidemiology of disease.
.
Transmission dynamics of leprosy to identify sources/genotypes, its presence in soil and water and establish chain of transmission in endemic pockets.
.
Study addressing issues related to changing profile of disease.
.
Precise epidemiological data on pooled grade-2 disabilities in rural communities.
.
Leprosy in Children / dynamics of childhood leprosy

Clinical – Research
.
Clinical - Laboratory studies on complications of leprosy and its management.
.
Evaluating effect of newer anti-leprosy drugs/molecules.
.
Studies addressing leprosy relapse and reactions.
.
Detection of early bacteriologically positive Multibacillary Bacillary leprosy and its early management.
.
Use of immunomodulators in relation to leprosy and tuberculosis in children.
.
Use of chemoprophylaxis in household contacts.

Operational Research.
Effect of inclusion of leprosy in a community based integrated rehabilitation disability care programme.
.
Research on disability prevention and identification of predictors of early nerve damage in leprosy.
.
Varying distribution pattern of patients with nerve damage, acute, chronic or "silent".
.
Identification of pre-clinical disease markers like nerve conduction tests etc.

Basic Research
.
Studies using genomics, proteomics and other approaches to understand the host-parasite interaction and pathogenesis of the disease.

Basic Immunology
.
Translational research including newer technology such for detection of M. leprae from environment.
.
Tools to identify leprosy susceptibility

Drug resistance studies
.
Resistance to anti-leprosy drugs.
.
Studies on use of second line newer drugs for resistant and relapse cases.

Surgical aspects
.
Trials on immediate post-operative active mobilization of hand following deformity correction and to investigate if the benefits of tendon transfers can be improved with early mobilization.
.
Effects of early mobilization to reduce dependence on therapist to attain a satisfactory result.
.
Investigation of economic and social impact of this technique in varied patient groups.
.
Trials regarding the safety of immediate active mobilization protocol (IAMP) to other tendon transfers.
.
Assessment of economic impact of earlier return to work by RCS patients and also the cost of care.
.
Understanding the neurobiology of tendon transfer rehabilitation.
.
Standard of ulcer care in leprosy

Concept proposals (limited to 5 pages) are invited from scientists of various recognized Research Institutions, Universities, Medical Colleges etc. in India. The concept proposals should include the following details.

1) Title of the concept
2) Name, address, telephone number including the mobile no. and e-mail ID of PI & Co-PI
3) Participating Institutions
4) Need for the study
5) Type of study: Hospital based (clinical), Field based (epidemiological), Lab. Based (Basic)
6) Major objectives and milestones
7) Research focus, short term goals, long term goals and scientific strategies to achieve this
8) Research Plan: Including sample size statistically calculated, place and methods of collection of samples, detailed methodology, etc.
9) Expected deliverables/Outcomes
10) Relevance/Applicability in the national interest.
11) The main strength(s) which merit(s) this support should be described in less than 200 words.
12) A brief biodata of PI and Co-PI (along with proof of expertise in form of publications).

After review the investigators of the selected proposals would be invited to submit the full proposals. The concept proposal (one electronic copy and 15 hard copies) is to be sent on or before December 15th 2011. The project proposals may be sent to, `
Dr. Manjula Singh,
Scientist `C',
Division of ECD,
ICMR, V. Ramalingaswami Bhawan, New Delhi 110-029

Best regards,

Dr. S. R. Narahari MD; DVD (dermatology)
Director
Institute of Applied Dermatology
6/1665, Nayaks Road, Kasaragod, Kerala, India
Phone: +91-4994-223687 & 230116; Res +914994223625
www.iad.org.in

Leprosy Vaccine Summit – Final Report

2011-11-16T07:19:00.001-08:00

Leprosy Mailing List – November 8th, 2011

Ref.: Leprosy Vaccine Summit – Final Report

From: P Saunderson, Greenville, SC, USA

Dear Salvatore,

As you may know, ALM has been funding work for some years on the development of a new leprosy vaccine. We recently had a workshop to discuss progress and prospects. I’ve attached the final report of the meeting, which may be of interest to some of your readers.

With kind regards,

Paul Saunderson MD, MRCP

Medical Director, American Leprosy Missions

Short user-survey on INFOLEP's services

2011-11-16T07:18:00.001-08:00

Leprosy Mailing List – November 8th, 2011

Ref.: Short user-survey on INFOLEP's services

From: C Voorend, Amsterdam, The Netherlands

Dear Dr. Noto,

Infolep/Netherlands Leprosy Relief would like to invite the leprosy mailing list (LML) readers for a short user-survey on Infolep's services. We are currently evaluating the services of Infolep and the (future) information needs of the leprosy community. We would highly appreciate the LML-subscribers (users and non-users) to fill in this short questionnairebefore November 15th. This takes about 10-15 minutes and is accessible via:- https://www.surveymonkey.com/s/B6M9WKZ.

Infolep is the international knowledge centre for leprosy and related subjects (www.leprosy-information.org; www.infolep.org). Infolep facilitates global access to many e-resources through the integrated ILEP / Infolep website. Infolep is available for anyone involved in leprosy from researchers and students, to program managers and field workers. The library is based in the Netherlands. Future strategic directions focus on becoming a decentralized multilingual, dynamic online portal (database with one interface) built up from Infolep’s collections and the collections of partners.

Questions or a request for a word-version of this survey can be pointed out to (c.voorend[at]leprastichting.nl or +31 20 59 50 530).

With many thanks in advance.

Yours sincerely,

Carlijn Voorend

Netherlands Leprosy Relief

Carlijn Voorend

Leprastichting / Netherlands Leprosy Relief (NLR)

Postbus / P.O. Box 95005

1090 HA Amsterdam

The Netherlands

Tel: +31 20 5950500

E-mail: C.Voorend(at)Leprastichting.NL

Web: www.leprastichting.nl

Community care of the physically disabled due to leprosy

2011-11-16T07:17:00.001-08:00

Leprosy Mailing List – November 7th, 2011

Ref.: “Community care of the physically disabled due to leprosy”

From: R. Ganapati, BLP Mumbai India

Dear Dr Deepak,

Thank you for your comments (LML November 7^th, 2011). I am extremely glad that you have taken interest in this piece of study. This crucial community based investigation has evoked no response from any dermatologist or specialists in community medicine. (Pardon my not using the words "persons affected by leprosy" throughout the text of the article).

(1) The study aims at POWD (Prevention of Worsening Disability) rather than POD. The work is totally carried out by village level youth including a few young cured leprosy patients. They are a part and parcel of the villages where the patients are derived from and they are familiar with the local logistics. Recently a donation of 2 to 3 motorcycles has greatly facilitated their mobility and has brought down the cost of commuting to remote corners of the taluka.

After simple training they surveyed the villages and identified visible disabilities under the supervision of experienced paramedical workers mostly retired from govt service. Diagnosis was confirmed by the staff of Bombay Leprosy Project. As detection of grade I disabilities will involve eliciting history and physical examination, this was not given the priority. As the prevalence of frank, uncared for mutilated limbs were rampant (prevalence rate of grade 2 disabilities alone being about 25 per 10,000) and needed doorstep services, we limited the object of the study to care of the already disabled (POWD) rather than identifying and diagnosing grade 1 which is too much to expect from the volunteers. However, whatever cases came to our knowledge during surveys were examined by senior staff and handed over to the PHC with due advice on how to manage the patients. The follow up of such cases was beyond the scope of this part of the study. Now that some volunteers are motivated and experienced we may take this up as a separate investigation provided we get donor support.

(2) Almost all patients had completed the course of MDT. The list of patients released from treatment (RFT) was obtained from the PHCs. It was difficult to identify from the rudimentary details obtained from old records. This list had very few patients, whereas surveys by the volunteers were the main source of patients. Very few patients under active treatment did have grade 2 disabilities. As they were expected to attend PHCs we could only "advice" the govt staff on care of limbs (which was mostly not followed) and our staff had to offer domiciliary care. Offering MDT was not the aim of the study as PHCs were expected to take care of this.

(3) All the grass root level work was carried out by rural workers receiving remuneration on the days they worked. Physiotherapists and trained staff specializing in ulcer dressing were used for offering training to volunteers in the local language. Demonstration of the techniques like dressing and, simple exercises, usage of MCR footwear and wax therapy by the expert team was easily picked up and practiced. Plantar ulcer is the biggest problem and most of the simple ulcers are attended to by the volunteers. Physiotherapist and dresser are needed for refractory ulcers needing minor surgery under aseptic conditions. This is also practiced at the door step to the maximum extent possible. Occasionally plaster casts have also been applied. Patients beyond the scope of domiciliary service are brought to Bombay in the vehicles for special footwear and amputation etc.

(4) As for "home self care", among young, motivated, health conscious patients we have found this is practised after proper counselling. Most of the elderly patients (many of whom are alcoholics) hardly care for their limb protection if left alone. There were instances where family members offered care after counselling. I believe attitude towards self-care is a special subject and in the areas adopted it is possible to study this.

(5) I fully share Dr Sunil , your apprehensions about the PHC staff taking over these activities. At present they are passive observers from a distance. However if the health planners among the govt officials study the "Shahapur Model" as it is now called and adopt it seriously, this may be a break through and will benefit the community in the distant future.

(6) This is just a preliminary venture in a deprived tribal population living in inaccessible hilly terrains. We have started an independent assessment by a social scientist through a questionnaire method in a total of 656 disabled patients in Shahapur taluka, though donors do not seem to be interested in evaluation. A sample has been selected consisting of patients, household relatives, nearby community members, volunteers etc. and the interview is in progress. The impact of the physical care from a medical angle on deformity status is also in progress. As the cost of every item is carefully recorded, cost analysis is also contemplated. A Research Committee of experts has been formed to offer guidance. It is also possible that the service after some months may have to be abruptly withdrawn for want of donor support. Research in this neglected aspect of the care of the disabled hardly has any glamour attached to it.

I don't claim that we have carried all the technical knowledge available in institutions into the community. This is just an attempt to understand the implications of grass root level work by local village youth in the back ground of the Utopian concepts of CBR as enshrined in the definition.We have shown that penetration of technology into the remote areas is possible to some extent and it is cost effective.

If there are any further clarification is needed by LML readers, I will be pleased to answer.

With best wishes

Dr R Ganapati

Bombay Leprosy Project

Community care of the physically disabled due to leprosy

2011-11-16T07:15:00.001-08:00

Leprosy Mailing List – November 7th, 2011

Ref.: “Community care of the physically disabled due to leprosy”

From: S Deepak, Bologna, Italy

Dear Salvatore,

I would like to thank Dr Ganapati for sharing the interesting paper about “community care for large number of persons with disabilities due to leprosy in Thane district of India” (LML Nov. 2^nd, 2011). I have a few questions to him for a better understanding of this paper:

(1) The first phase of the project identified around 3000 persons with disabilities due to leprosy – does that include persons with WHO grade 1 disabilities (loss of sensation without visible disabilities)?

(2) In the second phase and third phase of the project, Dr Ganapati mentions identification of “500 patients” and “140 patients” – are these persons with disabilities due to leprosy or they also persons who need anti-leprosy treatment?

(3) In phase 3, what kind of staff was used for door-to-door delivery of home care? Were they professionals like physiotherapists or specialized staff? These were employed specifically by the project?

In their activities, the paper mentions different interventions but does not say anything on self-care. Was teaching self-care part of the activities?

I understand that the paper is providing an overview but it will be interesting to understand the role played by persons affected with leprosy themselves, their families and communities in these activities.

I have some doubts about the feasibility of such level of activities being carried out by PHC staff as part of their routine work and opinion of Dr Ganapati on this issue will be useful.

Finally, were there activities related to other problems faced by persons affected with leprosy in this project such as related to social exclusion, poverty, etc.?

With best wishes,

Sunil

Dr. Sunil Deepak

AIFO, Bologna, Italy

Tuberculoid (TT) leprosy

2011-11-16T07:14:00.001-08:00

Leprosy Mailing List – November 7th, 2011

Ref.: Tuberculoid (TT) leprosy
From: Barreto J, Bauru, S. Paulo, Brazil

Dear Dr Noto,

Please find herewith enclosed, clinical and histopathology pictures of cases of tuberculoid leprosy. All comments from the LML readers will be welcome.

Regards,

Jaison A. Barreto
Instituto Lauro de Souza Lima (ILSL)

Acute abdomen in lepromatous (LL) leprosy

2011-11-09T08:25:00.000-08:00

Leprosy Mailing List – November 3^rd, 2011

Ref.: Acute abdomen in lepromatous (LL) leprosy.
From: Barreto J, Bauru, S. Paulo, Brazil

Dear Salvatore,

The questions that must be made about this case:

1. Is this patient with active (non treated) lepromatous leprosy? If the answer is yes, Lucio's fenomenon must be ruled out; once it is not uncommom deep vascular trombosis in this type of leprosy.

2. Is this patient in erythema nodosum leprosum (ENL or type 2) reaction? As well as in Lucio's fenomenon, deep trombosis also can occur during this reaction. Dr Opromolla and Dr Raul Fleury published cases of deep vascular trombosis during type 2 reaction, in the past, in Hansenologia Internationalis (www.ilsl.br). Some cases developed even myocardial infarction.

If the answer to both questions is no, other causes must be involved.

Regards,

Jaison

“We changed and gave the clofazimine with a meal”

2011-11-09T08:24:00.000-08:00

Leprosy Mailing List – November 3^rd, 2011

Ref.: “We changed and gave the clofazimine with a meal”.

From: G Warren, Sydney, Australia

Dear Dr Noto,

Thank you for publishing that letter and picture by Dr Peton. He does not mention what antileprosy medication the patient was on. - was it multi-drug therapy (MDT)? Was the patient on clofazimine – at what dose and for how long?

My comments are that in the early days we often used to use clofazimine as monotherapy (when doing the initial drug trials) and we used to give a dose of oil with each dose as initially recommended. But we often gave it in 200 or 300m mgms daily. Yes, it did produce a very dark skin in the Chinese patients. A few of the patients did complain of abdominal discomfort if they did not take the oil.

One patient was actually admitted to the major govt hospital and operated on for a suspected abdominal problem as he complained of persistent gastric discomfort. From Memory (this was about 1970) they found very heavy pigmentation with clofazimine in the mucosa of the ileum and colon which were apparently very dark in colour (No I did not see it nor do I have a photo- good on you for getting the record). But no evidence of gastric ulceration or other regular cause of gastric discomfort. From that incident we changed and gave the clofazimine with a meal and had no further similar complaints.

Sometime in the 1980s an article appeared stating that clofazimine caused diarrhoea and similar problems but the case written up also had amoebic dysentery! No we (treating literally hundreds of patients and doing regular path testing) found that clofazimine causes very few if any complications other than the discolouration of skin that fades within about a year of discontinuation. But we did find that many of the biochemical abnormalities present (eg poor liver and kidney function) initially were corrected within the first year.- oh yes we treated any obvious abnormalities such as anaemia and parasites!

I am sorry I cannot quote the publications concerned now- but would be interested as to the symptoms of the patient he speaks about and recommend the clofazimine be given with his meals and or oil, in future.

Yours sincerely,

Grace Warren

Previously superintendent Hong Kong leprosarium 1960-75 and

Adviser for The Leprosy Mission In Asia for 1975-1994.

Unnecessary laparotomy for abdominal pain and fever due to clofazimine

2011-11-09T08:23:00.001-08:00

Leprosy Mailing List – November 3^rd, 2011

Ref.: Unnecessary laparotomy for abdominal pain and fever due to clofazimine

From: Bryceson A, London, UK

Dear Salvatore

I wonder if the patient was taking clofazimine. If so, the red coloration might be due to clofazimine. Clofazimine can cause abdominal pain, sometimes mimicking an acute abdomen. The pain is thought to be due to an inflammatory reaction to crystals of the drug deposited in the small bowel mucosa and mesenteric lymph nodes. For this reason the high starting dose (300 mg) of clofazimine that is used to control ENL (Type 2) reactions, should be reduced after 2 or 3 weeks. References go back a long way, but here are some recent ones.

Jadhav MV, Sathe AG, Deore SS, et al. Tissue concentration, systemic distribution and toxicity of clofazimine--an autopsy study. Indian J Pathol Microbiol. 2004;47:281-283.

Mathew BS, Pulimood AB, Prasanna CG, et al. Clofazimine induced enteropathy--a case highlighting the importance of drug induced disease in differential diagnosis. Trop Gastroenterol. 2006;27:87-88.

Sukpanichnant S, Hargrove NS, Kachintorn U, et al. Clofazimine-induced crystal-storing histiocytosis producing chronic abdominal pain in a leprosy patient. Am J Surg Pathol. 2000;24:129-135.

I made the same mistake in 1979

Bryceson A. Unnecessary laparotomy for abdominal pain and fever due to clofazimine. Lepr Rev. 1979 Sep;50(3):258-9.

Best wishes,

Anthony Bryceson

Abdominal complication of clofazimine

2011-11-09T08:22:00.001-08:00

Leprosy Mailing List – November 3^rd, 2011

Ref.: Abdominal complication of clofazimine

From: W S C Smith, Aberdeen, UK

Dear Dr Peton,

Thank you for circulating this photograph. Had the patient been taking clofazimine – if so at what dose and for how long?

There are a few case reports in the literature of acute abdomen/abdominal pain associated with crystal formation due to clofazimine – I have attached reports from India, Thailand and Singapore – there are probably a few more.

Cairns Smith

http://informahealthcare.com/doi/abs/10.3109/00313029309068897

“PB-ish” leprosy in the paler skins

2011-11-09T08:21:00.001-08:00

Leprosy Mailing List – November 2^nd, 2011

Ref.: “PB-ish” leprosy in the paler skins

From: G Warren, Sydney, Australia

Dear Dr Noto.,

Thank you very much for circulating the TEXT and SLIDES of “The Diagnosis of Leprosy”. Of course, last year, when the original version was produces I was carefully following and participating the discussions together with you, Drs Schreuder and Naafs. With pleasure, I also offered some contributions, to help the newer workers to learn the tricks we have learnt, by often bitter experience, over many years. -

There seemed to be a number of letters in the week ending 16^th October and some excellent pictures on dark skin. However, last weekend I wrote to you a letter that some how seems to have slipped through the cracks, that I think would help especially those workers faced with the PB-ish [paucibacillary] leprosy in the paler skins but, I have seen no evidence of it so, I send again (after this note) in the hope that you will be able to circulate it. I feel it makes some important points about the diagnosis and management of PB-ish leprosy

Sunday 16^th October.

Dear Dr Noto,

Thank you for publishing Dr Barreto’s letter [LML Oct. 15th, 2011 “What is paucibacillary (PB) leprosy?”]. I have seen many patients who were initially treated as paucibacillary leprosy according to the WHO guidelines who have returned 3-10 years later with obviously mid borderline/borderline lepromatous (BB/BL) type lesions. On careful history taking one can realise that initially the patients was never properly classified. According to WHO the PB leprosy is less than 5 lesions, but in their guide book there is no other specific requirement. PB implies few bacilli and in true tuberculoid (TT) leprosy the lesions are usually well defined and on one area of the body implying that the bacilli are not wide spread. However bacilli can well be in nerves in other parts of the body and they do not produce skin lesions. As Dr Barreto implies patients may well be multibacillary (MB) with marked neural leprosy but very few skin lesions.

In Teaching in Asia I used to stipulate that to be treated as PB the patients’ lesions must be all in one area of the body; this unfortunately, is not according to WHO classification. We often had no possibility of doing a slit-skin smear examination and so deemed it preferable to give the MB treatment and prevent “relapses”. In the last 10 years I have treated a number of immigrants to Australia who have previously been treated in an endemic country for PB leprosy and have represented 3-7 years later, in Australia, with definite BB-ish leprosy! One almost pure lepromatous (LL) type of disease and the lesions were hardly visible even on the relapse. Yes I call it relapse not reinfection.

As Dr Barreto states the bacilli live in the nerves, and may be in very high concentration in the nerves while there are few in the skin, and it has been shown that the bacilli can survive, for many years, in the nerves in spite of heavy doses of rifampicin, and can emerge later, still fully sensitive to rifampicin, to continue the Infection. So, I would plead with clinicians if there is any possibility of having less that excellent natural resistance, that the patient be given MB treatment rather than PB.

Also treat intercurrent medical conditions that could reduce the patient ability to deal with the leprosy infection. Also do not just brush aside the possibility of relapse. It turns up more frequently than appears in the statistics because there is now no continuous registrar and as Dr Rao states (in LML 15^th Oct) it is difficult to convince the authorities that a patient has a relapse when he represents with new lesions. He was previously stated to be cured when he finished the WHO stated duration of medication. WHO official statement of relapse is very low so makes the present policy (of PB and MB drug routines) seem effective. I know that most of the real LL, and BL patients I treat have much more anti-leprosy medication that the stated 12 months. We do not want relapses in our clinics.

Hence I agree - - What is paucibacillary leprosy?- - by definition it is those with few bacilli - - therefore those in whom the bacilli have not yet been able to multiply frequently because of the short duration of infection eg. as in Indeterminate (I) leprosy- or those who have enough natural resistance to have been able to produce effective T lymphocytes to control the infection so the numbers cannot become great. In both of these situations I feel we need to follow up the patient at least for several years to make sure that they really are cured, if we give the 6 months double drug therapy.

Let’s really control the infection by ensuring that those we do diagnose are fully treated to eliminate their infection. Let’s over-treat not under-treat.

Yours sincerely,

Grace Warren

Sydney, Australia

Previously Adviser for The Leprosy Mission In Asia (1975-95)

“Community care of the physically disabled due to leprosy”

2011-11-09T08:20:00.000-08:00

Leprosy Mailing List – November 2^nd, 2011

Ref.: “Community care of the physically disabled due to leprosy”

From: R Ganapati, Mumbay, India

Dear Dr Noto,

Please find herewith enclosed the paper “Community care of the physically disabled due to leprosy”. This article is specially published in the leading dermatology journal in the background of emerging interest among the clinicians to understand the epidemiology of skin diseases and offer services at the community level. The study is particularly designed to create a cost effective door-step service model aiming at the target group of leprosy patients with visible disabilities (grade 2, WHO), which is the most uncared-for and difficult component of the most neglected disease. This is just a preliminary communication of an ongoing study aimed to record the cost of services as well as the impact of the community care on the patient, the family and the people around.

Without continued donor support, this part of this unprecedented investigation may have to be compromised. I, however hope that the donors will realize how important it is to continue the observations to a logical conclusion. I invite your comments.

Thanks.

With Regards,

Dr R Ganapati, Bombay Leprosy Project

Acute abdomen in lepromatous (LL) leprosy. Request of information

2011-11-09T08:18:00.000-08:00

Leprosy Mailing List – November 2^nd, 2011

Ref.: Acute abdomen in lepromatous (LL) leprosy. Request of information.

From: E Peton, Capital Federal, Argentina

Dear Dr Noto,

I am a resident physician from an hospital in Argentina. The last week a lepromatous patient was operated by an acute abdomen. Nothing was found in the surgery, except a reddish discoloration of the colon (see attached picture). I would like knowing if you have information about similar cases?
I hope in your answer. Thanks a lot in advance.

Best regards,

E Peton

Durand Hospital

Capital Federal

Argentina

Histoid leprosy. Clinical case

2011-11-09T08:16:00.001-08:00

Leprosy Mailing List – October 30^th, 2011

Ref.: Histoid leprosy. Clinical case

From: A G Barminus, Garkida, Adamawa State, Nigeria

Dear Dr Noto,

I wish to thank Dr Salafia (and also Drs Verduga and Barreto) for sharing with us their clinical experience in the field of leprosy. I think that Dr Salafia’s case No 10 is histoid leprosy. I would like contributing to this discussion by sending some clinical pictures of histoid leprosy for readers to see and advise (optimal length of treatment?). They are hereby attached. The pictures are mine and with the consent of the patient.

The patient is a new case of leprosy. He never had any form of treatment for leprosy. There was no nerve tenderness and the disability grade at diagnosis was zero. No evidence of type 2 reaction. Bacteriological index (BI) was 5+; the morphological index (MI) was 20 %. Histology was not done as there is no facility for this in the area. As for treatment, the patient was placed on normal multi-drug therapy (MDT) and he is still on it. He is presently on the 6th month of MDT and there is just some improvement in the clinical picture. How long will it take for these lesions to disappear? Any experience?

Thank you very much in advance for your comments.

Dr Augustine Barminus

Chief Medical Officer

State dermatology hospital

Garkida

Adamawa state

Nigeria

The diagnosis of leprosy – SLIDES Part III. “Diagnosis and the clinical spectrum”

2011-11-09T08:15:00.003-08:00

Leprosy Mailing List – October 28^th, 2011

Ref.: The diagnosis of leprosy – SLIDES Part III. “Diagnosis and the clinical spectrum”

From: S. Noto, Genoa, Italy

Dear Dr Dayanghirang,

Kindly, find in attachment the last section of the SLIDES of “The Diagnosis of Leprosy”. Herewith are the slides relevant to Part III. “Diagnosis and the clinical spectrum of leprosy”.

Best regards,

S. Noto

The diagnosis of leprosy – SLIDES Part II. “The third cardinal sign”

2011-11-09T08:15:00.001-08:00

Leprosy Mailing List – October 28^th, 2011

Ref.: The diagnosis of leprosy – SLIDES Part II. “The third cardinal sign”

From: S. Noto, Genoa, Italy

Dear Dr Dayanghirang,

Kindly, find in attachment the section of the SLIDES of “The Diagnosis of Leprosy”relevant to “The third cardinal sign of leprosy”.

Best regards,

S. Noto

RIP Dr E P Fritschi

2011-11-09T08:14:00.001-08:00

Leprosy Mailing List – October 27^th, 2011

Ref.: RIP Dr E P Fritschi

From: P K Das, UK; D D Palande, India.

Dear Dr. Noto,

Dr, Fritchi, Ernest as I knew him, has been my friend since I came to work in Leprosy. I continued in this field because of him who introduced and guided me to start work in rehabilitation and surgical reconstruction. I have lost a close friend even though our contact in recent years was restricted to occasional phone calls. Through this note i would like to convey my condolences and share in a sense of loss with all common friends.

Dinkar D. Palande

To All,

In the growing academician world without leprosy, one more light goes out. With sincere and heart-felt condolence to the family and friends of Dr. E.P. Fritschi, let his soul rest in peace and tranquillity in the midst of infinity.

Pranab K Das

RIP Dr E P Fritschi

2011-11-09T08:13:00.002-08:00

Leprosy Mailing List – October 27^th, 2011

Ref.: RIP Dr E P Fritschi

From: H Srinivasan, Chennai, South India

To all,

I am really sad to hear of the passing away of Dr Ernest Fritschi, a good friend of mine.

I have known him from his medical student days at Madras Medical College, where he was two years senior to me. I came to know him, to some extent, in 1949 when I was in my third year (1st year in clinical medicine) and he was in his final year, when we were posted in the same medical unit for three months. Even then one was struck by his cheerful personality and ready with combined at the same time a compassionate approach to patients and their problems. It was not at all surprising for us to learn subsequently that he had taken to leprosy surgery as his life mission.

I later came to be in frequent contact with him, since 1962, as our professional interests coincided from then on till we retired. The Schieffelin Leprosy Research & Training Centre, (SLRTC), at Karigiri is the glowing monument to his memory and is the concrete expression of his creativity and all round personality. Luckily for the leprosy world, he was the right person at the right time in the right place when that institution was started in the 1950s and he made barren rocks bloom and put out beautiful flowers.

For nearly two decades his book on corrective surgery in leprosy was the sole guide and inspiration to people who aspired to learn and practice this super specialty. While he was guided in his ideas, especially in the early days, by Dr Paul Brand, Ernest was not a blind follower of his Guru; he could stand on his own and argue differently, a not very easy feat for those who have experienced the authoritative and at the same time highly persuasive eloquence of Dr Brand.

Dr Ernest Fritschi was a simple, cheerful, humane and lovable soul with no pompous pretensions and I am proud to have known him. Long live his memory!

Dr H Srinivasan

Leprosy Reconstructive Surgeon (Retired)
25, First Seaward Road Chennai

600 041 South India

RIP Dr E P Fritschi

2011-11-09T08:13:00.000-08:00

Leprosy Mailing List – October 26^th, 2011

Ref.: RIP Dr E P Fritschi

From: N Manimozhi, India

To all,
In attachment is a picture of Dr E P Fritschi while praying for his soul resting in peace – the great legend.

Best regards,

Dr Natarajan Manimozhi

RIP Dr E P Fritschi

2011-11-09T08:12:00.000-08:00

Leprosy Mailing List – October 25^th, 2011

Ref.: RIP Dr E P Fritschi

From: H K Kar, New Delhi, India

To all,

It is a sad moment for the Global Leprosy Family on the sad demise of Dr E P Fritschi. We lost a great leprologist and a noble person for the cause of leprosy patients. We convey our deepest condolence to the family of Dr E P Fritschi. Let this great great soul rest in peace.

Regards

Dr (Prof.) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001

The diagnosis of leprosy – SLIDES Part II. The second cardinal sign

2011-11-09T08:11:00.000-08:00

Leprosy Mailing List – October 24^th, 2011

Ref.: The diagnosis of leprosy – SLIDES Part II. The second cardinal sign

From: S. Noto, Genoa, Italy

Dear Dr Dayanghirang,

Kindly, find in attachment the SLIDES of “The Diagnosis of Leprosy”. Herewith are those relevant to “The second cardinal sign of leprosy”. The other slides will follow.

Best regards,

S. Noto

DVD on nerve involvement in leprosy

2011-11-09T08:10:00.001-08:00

Leprosy Mailing List – October 24^th, 2011

Ref.: DVD on nerve involvement in leprosy

From: A Salafia, Mumbai, India

Dear Salvatore,

I have a few thousand photos of nerves, clinical nerve, operated nerves (about 2700 so far) and I would like to make a DVD of some of the most interesting cases - even for teaching purpose. The DVD will be divided into sections: clinical, ulnar nerve, median nerve, cutaneous nerve of the arm and forearm, cutaneous nerves of the legs..... Further they will be sections of what we see on the operation table: oedema, fibrosis, organized abscess, frank abscess, cutaneous nerve pressing over nerve trunk, normal muscles and anomalous muscles pressing over nerve trunk, bands...

Is there anybody interested in such DVD? This is not meant to be a commercial proposition, however, the cost of the DVD and the postage (registered book post) have to be born by those who want to have such DVD. One request; whoever makes use of my photos should mention the source of the same.

I do not know what is the cost, now, of a DVD; the registered book post, within India should be around Rs. 100; so, the total cost, should not exceed Rs.200 per DVD. But registered book post outside India is between Rs. 400-500 (I have sent my book abroad and the cost - given the weight of the book- is more that Rs.500 per piece); but i will make further inquiries.

Only if colleagues are interested I will start the whole process, which will take quite some time.

Best wishes to you,

Antonio

E-mail: salafia90(at)hotmail.com

The diagnosis of leprosy – SLIDES Part II. 1st cardinal sign

2011-11-09T08:09:00.001-08:00

Leprosy Mailing List – October 23rd, 2011

Ref.: The diagnosis of leprosy – SLIDES Part II. 1^st cardinal sign

From: S. Noto, Genoa, Italy

Dear Dr Dayanghirang,

Kindly, find in attachment the SLIDES relevant to Part II. (the first cardinal sign of leprosy) of the “The diagnosis of leprosy”. The other slides will follow.

Best regards,

S. Noto

The diagnosis of leprosy. Request of translation in French

2011-11-09T08:08:00.001-08:00

Leprosy Mailing List – October 23^rd, 2011

Ref.: The diagnosis of leprosy. Request of translation in French.

From: Louis Paluku Sabuni, Kinshasa, Democratic Republic of Congo

Dear Salvatore,

Thank you very much for running the leprosy mailing list. I am learning about leprosy and its complications (particularly reactions). I appreciated a lot “The diagnosis of leprosy” (full text and part 1 slides [up to know]). Do you have and, possibly could circulate its French version? I am fine with English but, the French version would be better for staff project in the rural areas.

Once more thank you and keep connected.

Louis

Country leader

TLM/RD Congo

Kinshasa Gombe

RD Congo

The diagnosis of leprosy – SLIDES Part I

2011-11-09T08:07:00.002-08:00

Leprosy Mailing List – October 19^th, 2011

Ref.: The diagnosis of leprosy – SLIDES Part I

From: S. Noto, Genoa, Italy

Dear Dr Dayanghirang,

Kindly, find in attachment the SLIDES relevant to Part I (Introduction) of the “The diagnosis of leprosy”. The other slides will follow.

Best regards,

S. Noto

The diagnosis of leprosy

2011-11-09T08:07:00.000-08:00

Leprosy Mailing List – October 18^th, 2011

Ref.: The diagnosis of leprosy

From: S. Noto, Genoa, Italy

Dear Dr Dayanghirang,

Thank you very much for your message (LML Oct. 17^th, 2011). Kindly, find inattachment the text of the revised version of “The diagnosis of leprosy”. The slides will follow.

Best regards,

S. Noto

The diagnosis of leprosy

2011-11-09T08:06:00.001-08:00

Leprosy Mailing List – October 17^th, 2011

Ref.: The diagnosis of leprosy

From: N Dayanghirang, Manila, Philippines

Hi Dr S. Noto

I was browsing the internet and chanced upon the following paper:

http://www.ncbi.nlm.nih.gov/pubmed/21404597

The abstract (below) talks about an atlas for diagnosing Hansen's disease (made by you and your colleagues). I would like to request a copy. It would be very helpful in my work (to assist Federated States of Micronesia in achieving the WHO Elimination of leprosy as a public health problem).

Thank you.

Abstract

“The Leprosy Mailing List (LML) is an e-mailing list open to whoever interested in the field from all over the world. It acts as a forum for exchanging information related to Hansen's disease. It was established in February 2001 in Italy, and the present moderator of the LML is Dr Salvatore Noto. He and his colleagues have recently introduced an atlas for diagnosing Hansen's disease. The atlas is divided into three sections, (1) Introduction, (2) Cardinal signs, and (3) Diagnosis and the clinical spectrum of leprosy, and they are all accompanied with relevant photos. This time, Dr Noto kindly permitted us to translate the atlas into Japanese to be published in the Japanese Journal of Leprosy and posted in the Japanese Leprosy Association homepage. This article includes the translation and some of the most informative photos. For more information, please refer to the homepage where you will find all photos in the atlas.”

Nihon Hansenbyo Gakkai Zasshi. 2011 Feb;80(1):59-70.

[Diagnosis of Hansen's disease].

[Article in Japanese]

Yotsu RR, Suzuki K, Mori S, Ishii N.

Source: Department of Dermatology, National Center for Global Health and Medicine, Tokyo, Japan

Best regards,

Nino

Nino Dayanghirang, MD, MBA

Special Fellow

Health Leadership and Development Initiative

Stop Tuberculosis and Leprosy Elimination Team (STB)

Division of Combating Communicable Diseases (DCC)

Regional Office of the Western Pacific (WPRO)

Relapse in paucibacillary (PB) leprosy

2011-11-09T08:05:00.000-08:00

Leprosy Mailing List – October 16^th, 2011

Ref.: Relapse in paucibacillary (PB) leprosy

From: S Noto, Genoa, Italy

Dear Jaison,

Thank you very much for your message (LML Oct. 15^th, 2011 - “What is paucibacillary (PB) leprosy?) Kindly, see in attachment the pictures of a case from Genoa. The young patient was treated as paucibacillary leprosy in Senegal. Then he migrated and in Italy he relapsed. The slit-skin smear examination was negative; actually we found 1 (one) fragmented bacillus.

Best regards,

S. Noto

“… on whether the case is histoid or not …”

2011-11-09T08:04:00.000-08:00

Leprosy Mailing List – October 16^th, 2011

Ref.: “… on whether the case is histoid or not …”

From: K Al Aboud, Makkah, Saudi Arabia

Dear Dr Noto,

Greetings, I would like to thank you for your continuous efforts in maintaining the LML as an important resource for health care providers interested in leprosy. I want also, to thank , Dr P. Narasimha Rao, for his posting. However, I want to comment about the importance of identifying the cases of histoid leprosy.

This unique type of leprosy has a peculiar clinical, pathological and therapeutic response. It is well-known this type of leprosy is resistance to treatment. A possible explanation for that, is decreased bioavailability of the anti-leprosy medications in the tissue. The reason for this might be the conversion which occurs in the tissue from cellular (histiocytic) toward a more fibrous (spindle-like cells), in the histoid type and hence, the concentration of the drugs is less in the histoid type. This plus others immunological, microbial , and host factors make this type difficult to treat.

The observations and future researches on this type will for sure increase our understanding to the pathogenesis of leprosy in general. I may refer Dr Rao, and our colleagues in LML to 2 good reviews on this type of leprosy in the following papers:-

1. Mendiratta V, Jain A, Chander R, Khan A, Barara M. A nine-year clinico-epidemiological study of Histoid Hansen in India. J Infect Dev Ctries. 2011 Mar 2;5(2):128-31

2. Sehgal VN, Srivastava G, Singh N, Prasad PV. Histoid leprosy: the impact of the entity on the post-global leprosy elimination era. Int J Dermatol. 2009 Jun;48(6):603-10

With my best regards,

Yours sincerely,

Dr Khalid Al Aboud

Consultant Dermatologist

King Faisal Hospital ,

P.O Box 5440

Makkah21955

Saudi Arabia

Tel 0096625566411 ext 1110

“… on whether the case is histoid or not …”

2011-11-09T08:03:00.000-08:00

Leprosy Mailing List – October 16^th, 2011

Ref.: “… on whether the case is histoid or not …”

From: T Ryan, Oxford, UK

Dear Salvatore,

The letter from P. Narasimha Rao shattered the pleasure I have had enjoying reading "discussions we used to have among teachers and students of Dermatology". This discussion, he states "is purely academic and has no therapeutic value". This is at a time when this disease is staging a come back and the untrained troops are diminished in knowledge and quantity. Dermatology has the capacity to make a contribution and will not be able to do so unless it gets more recognition and a better welcome than this.

Histoid leprosy is far removed from the anaesthetic hypopigmented patch that is perhaps the most easy to recognise and most likely to be diagnosed presentation of leprosy. The pictures we have been looking at and the subtleties discussed are necessary. The fact that we still do not have a full understanding of the enemy remains an advantage for the M leprae allowing it to present with these multibacillary forms. Histoid leprosy by being small nests of clinically difficult to recognise lesions, which clearly is an environment that the M leprae enjoy, is calling out for a more academic approach. I believe it was a Cypriot patient of mine that Colin MacDougal diagnosed as histoid, and with Dick Rees demonstrated dapsone resistance.

We had many academic discussions, and those discussions need to continue because they may contain clues to pathogenesis and ultimately be of enormous therapeutic value. We may need new approaches to conquer this resurging disease and, the refined academic approach illustrated by the last few letters from Dermatologists are not an irrelevance.

Best regards,

Terence Ryan

“… on whether the case is histoid or not …”

2011-11-09T08:02:00.000-08:00

Leprosy Mailing List – October 15^th, 2011

Ref.: “… on whether the case is histoid or not …”

From: P. Narasimha Rao, Hyderabad, India

Dear all,

Not long ago, we used to have such discussions among teachers and students of Dermatology on suspected histoid cases and lesions, their histo-pathology etc., but used to feel very awkward when its treatment is to be discussed. After all, they have to be treated like any other leprosy case with more than 5 skin lesions, is it not? What is the big deal?! Now, many workers don't fret over such changes when seen!

I am not saying this with pessimism but stating the fact. The discussion on whether the case is histoid or not, is purely academic and has no therapeutic value, as the treatment is same for all multibacillary patients as per WHO guidelines. Or else, prove that it is a relapse (ie if you want extra drugs), which is a very difficult task officially, as one has to convince a large group of administrators.

With best regards,

P. Narasimha Rao
Hyderabad, India

What is paucibacillary (PB) leprosy?

2011-11-09T08:01:00.000-08:00

Leprosy Mailing List – October 15^th, 2011

Ref.: What is paucibacillary (PB) leprosy?

From: Barreto J., Bauru, SP, Brazil

Dear Dr Noto

I have seen many cases of "relapsed" borderline tuberculoid patients, 6 to 7 years after discharge by cure, and usually when they were treated as PB leprosy. I am sending a note to the LML in order to listen to others colleagues opinion.

Regards,

Jaison

WHAT IS PAUCIBACILLARY (PB) LEPROSY? CONSIDERATIONS ABOUT TRUE RELAPSES AND INSUFFICIENT TREATMENT

I don't understand why most borderline tuberculoid (BT) leprosy patients are still located in the same operational classification like polar tuberculoid (TT) patients, i.e., as "PB" leprosy, based only on skin smears.

What is PB leprosy? Since 1962, when Ridley & Jopling defined the spectrum, and in 1971, when Ridley revised and published the "5 of 7 groups Classification" (Ridley, 1972), it became clear that most BT leprosy patients tend to downgrade to BL, and this is the reason why most BL patients arise from downgrading of BT (Ridley, 1987).

Why? Because BT patients are usually Mitsuda negative (less than 5mm of diameter, or 0 to 1+ in Madrid classification); therefore, they clearly differ from Mitsuda positive patients (higher than 5mm of diameter). This means that they do not develop well defined tuberculoid reaction, that is to say, full epitelioid transformation of macrophages with elimination of antigens (Michalany&Michalany, 1983).

This lack (or gap) of immunity, which differs from TT patients, is the likely reason which explains why the BT patients usually show many bacilli inside dermal nerve branches on Faraco-Fite stain, as well as more false "relapses" (due to insufficient treatment) and, recurrent reactions with neuritis when treated as PB (Nilsen, 1989; Revankar, 1989).

It is also important to say that slit-skin smears are positive only if there are, at least, 10 000 bacilli per gram of tissue (Bang, 2009). In a 70kg adult, 14 kg (20% of the body weight) are represented by skin. So, in an attempt to find a positive smear, at least bacteriological index (BI) 1+, the patient should have a total load of 140 million of bacilli inside his skin. This does not seem “few”, i.e., “PB”, in my opinion.

BT patients may have BI of 1+ to 3+ in biopsy skin slides, this would represent a total skin load ranging from 140 million to 14 billion of bacilli. It is assumed that at least 1 bacillus, in a million of M. leprae, will be naturally resistant to any single drug of the multi-drug therapy protocol (Hastings, 1998). So, a total of 140 to 14 000 bacilli should be destroyed every month by the supervised rifampicin, but this drug destroys only metabolically active bacteria. Once the duplication time of M. leprae is almost 14 days, every month, these dapsone resistant bacilli would have time to duplicate twice, at least. Therefore, recurrent reactions and neuritis are foreseeable, probably due to continuing replication of bacilli not killed by dapsone during the lag phase (Opromolla, 2000). There are evidences for this in a few cases. I personally believe more in the role of autoimmunity.

Finally, leprosy is a primarily neural disease and, as Schwann cells are bad antigen presenting cells, it is understandable that these patients could have as many as 4+ of bacilli inside nerve trunks which have undergone biopsy, even if the skin smears and biopsy indexes are negative (Barreto, 2007).

Jaison A. Barreto

Dermatologist and Leprologist

Instituto Lauro de Souza Lima

Bauru, SP, Brazil

Ziehl-Neelsen or Fite-Faraco staining

2011-11-09T08:00:00.001-08:00

Leprosy Mailing List – October 13th, 2011

Ref.: Ziehl-Neelsen or Fite-Faraco staining

From: Clapasson A., Genoa, Italy

Dear Salvatore,

Thank you very much to Dr Barreto for his important message (LML Oct. 2^nd, 2011). I agree with his conclusions and, I would like adding my comments.

The most important factors, to have a good Ziehl-Neelsen’s or Fite-Faraco’s staining, is the concentration of the primary dye. The staining technique is simple but, there are some pitfalls that should not be underestimated. There are two important factors that each laboratory technician should value remember; they are:

1. The concentration of carbol-fuchsin and phenol: About this please see the attached paper: “Comparison of variants of carbol-fuchsin solution in Ziehl-Neelsen for detection of acid-fast bacilli”. Selvakumar N, Sekar MG, Rahman F, Syamsunder A, Duraipandian M, Wares F, Narayanan PR. Int J Tuberc Lung Dis. 2005 Feb;9(2):226-9.

2. The duration of the discoloration: False negatives increase with excessive time of decoloration. In Genoa I decolorize each slide separately with 2,5 ml of solution of hydrochloric acid (95ml ethanol 96° and 1ml hydrochloric acid 37% (fuming)), but if it is difficult the acquisition of “alcohol absolute” it is possible to use an aqueous solution of 23,75% sulphuric acid and 3% alcohol.

Best regards,

Andrea

BL, LL or histoid leprosy?

2011-11-09T07:59:00.001-08:00

Leprosy Mailing List – October 13th, 2011

Ref.: BL, LL or histoid leprosy?

From: M Virmond, Bauru, Brazil

Dear Salvatore,

Another feature that supports the opinion of Prof. Talhari (LML Oct. 12^th, 2011) is that lesions in histoid leprosy usually appear in non-common sites for lepromatous lesions, what is not the case of the ear rim. Certainly, the histopathology should give more details on this case (attachment), as well to explore the possibility of a relapse case.

Greetings,

Marcos Virmond

ILSL

Usually the typical histoid lesions have a slight depression in the central area

2011-11-09T07:58:00.002-08:00

Leprosy Mailing List – October 12th, 2011

Ref.: Usually the typical histoid lesions have a slight depression in the central area

From: S Talhari, Manaus, Am, Brazil

Dear Salvatore,

I think it (case number 10) is a classical leproma (attachment). Usually the typical histoid lesions have a slight depression in the central area. Of course the histopathology is very important in diagnosing this type of leprosy.

Sincerely yours,

Prof. Sinésio Talhari
Manaus, Am, Brazil

Case number 10

2011-11-09T07:58:00.000-08:00

Leprosy Mailing List – October 12th, 2011

Ref.: Case number 10

From: Salafia A., Mumbai, India

Dear Salvatore,

The case referred to by Drs Khalid and Tahir and Prof. Kar does look like histoid leprosy; however the case is from previous year collection; I will try and find the histology reports.

Thanks for sharing your views.

Antonio

Photos from Ecuador

2011-11-09T07:57:00.000-08:00

Leprosy Mailing List – October 12th, 2011

Ref.: Photos from Ecuador

From: R Ganapati, Mumbai, India

Dear Dr Noto,

Dr Verduga's beautiful clinical photographs (LML Sept. 27^th, 2011) have indeed simulated veteran leprologists to give their comments arising from years of meticulous clinical observations. Though in India we encounter all the manifestations reported from Ecuador and much more (thank you also to Dr Salafia for sharing his cases), the clan of students keen to learn leprology is unfortunately vanishing fast in the background of prevalence rate of leprosy rising after the government decided to integrate leprosy services of the disease with the general health system.

In this context the response from clinicians through the LML forms a veritable primer in the subject covering, clinico-bacteriological aspects, skin smear investigations treatment of leprosy and complications in a nutshell.

I have prepared a file of the LMLs including the photographs to facilitate me to teach the beginners wanting to have elementary knowledge of leprosy. But where are they? "Made-easy" classification of leprosy, elimination of skin smear examination, over-simplification of treatment for mass usage, dogmatic teaching by a few teachers with little experience etc. are factors which have conspired to halt the progress of scientific approach to leprosy. Even some diseases which are much rarer than leprosy have not been dealt with in this cruel manner by the medical profession and health planners!

My compliments to you for being a pioneer in using internet medium to spread knowledge around the world.

With regards,

Dr R Ganapati,

Director Emeritus, Bombay Leprosy Project

rganapati(at)gmail.com

Case number 10: Borderline lepromatous (BL), lepromatous (LL) or histoid leprosy?

2011-11-09T07:55:00.002-08:00

Leprosy Mailing List – October 12th, 2011

Ref.: Case number 10: Borderline lepromatous (BL), lepromatous (LL) or histoid leprosy?

From: Tahir D., Plateau State, Nigeria.

Dear Dr Noto,

Thanks a lot for the interesting articles circulated in the LML. Thank you also to Drs Verduga and Salafia for sharing with us their cases. About the case number 10 presented by Dr Salafia (attachment) I share the same opinion with Dr Khalid Al Aboud. It looks more of a case of histoid type of leprosy which was seen in the past in BL or LL leprosy cases resistant to dapsone monotherapy.

Yours sincerely,

Dr Tahir D.

Nigeria

Case number 10: Borderline lepromatous, lepromatous or histoid leprosy?

2011-11-09T07:55:00.000-08:00

Leprosy Mailing List – October 12th, 2011

Ref.: Case number 10: Borderline lepromatous, lepromatous or histoid leprosy?
From: H K Kar, New Delhi, India

Dear Dr. Noto,

I agree with the comments of Dr Khalid on case 10 (attachment). These are classical histoid nodules present over the apparently normal looking skin on the pinnae of the ear. It is not possible have final conclusions from one picture but, history, slit-skin smear examination to look into bacteriological index (BI) and morphological index (MI) as well as histopathology will clinch the diagnosis of histoid leprosy.

Regards,

Dr (Prof.) H K Kar
Consultant & HOD
Department of Dermatology, STD & Leprosy
P.G.I.M.E.R. and Dr Ram Manohar Lohia Hospital
Baba Kharag Singh Marg
New Delhi-110001

Case number 10: Borderline lepromatous, lepromatous or histoid leprosy?

2011-11-09T07:54:00.001-08:00

Leprosy Mailing List – October 10th, 2011

Ref.: Case number 10: Borderline lepromatous, lepromatous or histoid leprosy?

From: K Al Aboud, Makkah, Saudi Arabia

Dear Dr. Noto,

I am referring to Dr Antonio Salafia’s recent message “Leprosy in Mumbai, clinical cases” (see attachment). Thank you very much to for sharing with us his cases. Particularly I refer to the case number 10 and, I wonder if Dr Salfia has the histopathology? It looks like the histoid type of leprosy.

With my thanks and regards,

Sincerely,

Dr Khalid Al Aboud
Consultant Dermatologist

King Faisal Hospital,

P.O. Box 5440

Makkah 21955, Saudi Arabia

Tel 0096625566411 ext 1110
Fax 0096625563523

E-mail alaboudkhalid(at)yahoo.ca
amoa65(at)hotmail.com

Choosing the decolourizer and its strength to stain Mycobacterium leprae

2011-11-09T07:53:00.001-08:00

Leprosy Mailing List – October 10th, 2011

Ref.: Choosing the decolourizer and its strength to stain Mycobacterium leprae. Does it actually matter?

Lepr Rev. 1998 Jun;69 (2):128-33 (see attachments Page 1 2 3 4 5 6)

From: R de Soldenhoff, Edinburgh, Scotland, UK

Dear Dr Noto,

It may be of interest to LML readers to review the attached article of an operational research study carried out in Indonesia. The original in Leprosy Review was published prior to all their articles being in electronic form, so my apologies for the mediocre quality scan of the article.
The reason for the study was the premise that "tuberculosis diagnosing centres with an established system of quality control, can also be responsible for leprosy microscopy. This is easier if the staining technique for both organisms is identical."
I would be very pleased if another laboratory could repeat the study, in order to confirm these findings. In addition, a comparison between the "hot method" (usually used in field laboratories for tuberculosis) and the "cold method" and between methylene blue and malachite green (occasionally used as an alternative decolouriser), would also be of interest.
With kind regards,
Dr. Richard de Soldenhoff

42 Drummond Place

Edinburgh, EH3 6NR

Scotland, UK

Home telephone: 44.131.556.7979

UK mobile: 44.777.0751578

Email: rdesoldenhoff(at)hotmail.com

Is 0.6% fucsin reagent significantly less effective?

2011-11-09T07:52:00.001-08:00

Leprosy Mailing List – October 10th, 2011

Ref.: Is 0.6% fucsin reagent significantly less effective?

From: L Gilead, Jerusalem, Israel

Dear Dr. Noto,

Thank you very much to Dr Barreto for his comments (LML Oct. 2^nd, 2011) concerning aspects of skin smears examination for leprosy and Ziehl-Neelsen (ZN) staining for acid-fast bacilli (AFB's). Following that message we re-evaluated our lab reagents and found out that the concentration of the Ziehl's fucsin reagent we are using (commercially acquired from MERK is 0.6%.

I would appreciate it if any one of the LML members could let us know if this is significantly less effective and we need to prepare our own reagent in the lab with a 1% concentration, or whether any one has a different commercial supplier that can deliver a 1% reagent?

Thank you very much and a Happy New Hebrew year from Jerusalem.

Leon

Dr. Leon Gilead

Head of The Israeli Hansen's Disease Center

24Strauss St., Jerusalem, Israel

Department of Dermatogoy

Hadasssah University Hospital

Mobile: 972-50-7874309

Leprosy in Mumbai, India, clinical pictures

2011-11-09T07:46:00.001-08:00

Leprosy Mailing List – October 6^th, 2011

Ref.: Leprosy in Mumbai, India, clinical pictures

From: A Salafia, Mumbai, India

Dear Salvatore,

Kindly, find in attachment a Power Point file with clinical pictures of some leprosy patients of mine. Thank you very much for circulating them on the LML.

Yours sincerely,

Antonio

Leprosy in Ecuador (clinical cases)

2011-11-09T07:45:00.001-08:00

Leprosy Mailing List – October 5^th, 2011

Ref.: Leprosy in Ecuador (clinical cases)

From: G. Warren, Sydney, Australia

Dear Dr Verduga,

What an excellent collection of photos (LML September 27^th, 2011), and the variety of Borderline manifestations and reactions is a lovely example for others who live in areas where natural skin colours vary.

Cases 1 and 2 (see attachment) which are on slightly darker skin and show excellently the extra erythema and swelling that so often occurs is the reactive phase.

In case 1 the central immune area can be missed on the arm but is evident on the back of the elbow.

Case 2 also shows how definite can be the inner edge of the lesions in BB. Here the true borderline rings with their central immune area can be appreciated.

The case number 3 is obviously a lighter skin initially and the leprosy lesions are not really reactive and so show a lot less than the lesions in cases 1 and 2 which are on slightly darker skin

What a lovely teaching slides. In all cases the severity of reaction needs to be watched carefully so that if there is any evidence of acute nerve involvement steroids can be given in adequate dosage. However case 3 needs to be watched as carefully as those already in reaction, when therapy is started.

I normally do not give steroids for all BB in reaction unless the lesions are on the face or there is definite evidence of nerve damage. When lesions are on the face and particularly around the eye the underline facial nerve and its branches are at risk and, I do not want to produce a facial palsy.

The beginning of the treatment with rifampicin and dapsone may well precipitate acute nerve deterioration as the drugs kill more bacilli and so cause a rapid rise in the amount of the immune response to the antigen freed from the dead bacilli. This in turn increases the swelling inside the nerve sheath and so the risk of nerve damage. This response stimulates more reaction and hence swelling in the skin lesions as well as possibly a neural deficit.

I like to give clofazimine initially as it has an anti-reaction effect as well it as bacteriostatic and bactericidal effect. It is generally taught that clofazimine is effective in preventing Type 2 ( ENL) reaction. Yes that is correct, that is where it is most used. But when doing the initial drug trials we often used it in patients with Type 1 reaction as well and it also is helpful for that. It may not be as bactericidal as some other drugs but it is adequate to prevent increasing numbers of bacilli as it is bacteriostatic. What is significant is that many BL/BB type patients develop both Type 1 and Type 2 reaction. Especially when inter-current infections and or anaemia and other metabolic diseases are dealt with. So with patients who have those unstable forms of BL/BB leprosy it is worth giving clofazimine alone till the other medical problems are dealt with so that as the Bodies natural destruction of M. leprae occurs the rise in T sensitised lymphocytes will not result in a Type 1. reaction.

In a patient with BL/BB leprosy the lesions may appear very vague initially and so it is difficult to tell if there is a borderline element. In these patients (and in some others) it is most likely that once the patient’s own ability to fight the disease rises, and the number of dead bacilli rises, so the number of leprosy antigens rises- the body will produce both “T and “B” lymphocytes. The development of clinical evidence of Type 1 or type 2 reaction will depend on, many factors. It was fascinating to see that patients with BL/BB leprosy with some evidence of Type 1 reaction would, if given an anti-smalll pox vaccination, go into Type 2 reaction! Yes that was in the late 1960s when we needed to give the smallpox but I hated doing it as so many patients of all immune levels, went into reaction. But the use of clofazimine for these patients improved their ability to cope. So this is just one of the reasons why I like any patient whom I suspect of being Reaction prone, to start on clofazimine alone for the first 6-8 weeks. It certainly reduced the problems in the lighter skinned patients with other medical problems as well.

Again commenting about the case number 3 (see attachment) it shows very well BL lesions that could well go into reaction on full MDT- the nerve damage can still occur so we need to watch but please do not give steroids for many months duration - should not be needed.

These are the patients I found did excellently on clofazimine initially and then once the tendency to reaction has settled put onto full MDT. Yes, by all means give MDT in full dose once things look more stable.

Cases number 4 and 5 have a reported smear of 3+. Case number 5 is typical, a lovely one of nodules on ear lobes, I would love to see pictures of this body or limbs as often the nodules on the ears precede obvious lesions elsewhere and are missed are being LL.

I find clofazimine the best to start treatment as rifampicin does seem to speed up the development of ENL! Patients with a high bacteriological index (BI) and especially a high morphological index (MI) need more than the 12 month multi-bacillary multi-drug therapy (MB-MDT) suggested by WHO. Sorry but the number of BL and LL patients I have seen who are still very active after 12 months MDT tells me that they are those who must have these drugs for longer than recommended if we are to prevent the disease reappearing in a few years time.

My long term experience shows that even with two or three drugs the patients with severe LL/BL leprosy need more than 12 months to be really cleared. The bacilli live in the nerves and even rifampicin cannot get at them there.

You asked for comments. Fine I do not mind and hope this helps you in your general programme. I have been treating leprosy including the reconstructive surgery since 1959 and if I can help by email please feel you can write to me.<grace.warren@levelthirteen.net>. I was Medical Superintendent of the Hong Kong leprosy Hospital from 1960 to 1975 when it closed and after that taught in many countries round the world.

With Best wishes in your programme,

Grace Warren.

BI and MI results in BB, BL and LL leprosy

2011-11-09T07:44:00.001-08:00

Leprosy Mailing List – October 4^th, 2011

Ref.: BI and MI results in BB, BL and LL leprosy

From: L Duncan, Peebles, Scotland, UK

Thanks Salvatore,

I would like commenting on Dr Verduga and Barreto’s letters dated respectively LML 27^th Sept. and 2^nd Oct. 2011. About Dr Verduga’s clinical cases (see attachment) I would agree that the last 2 slides (cases 4 and 5) should have been with a bacteriological index of 5+ and with a positive morphological index (MI) as well. The mid borderline (BB) ones are often more difficult to get as positives but again should have been positive with a positive MI.

Dr Barreto’s letter commenting on the methodology for taking the smears is well made ... as was the second point about the strength of alcohol-acid to decolourise ...

I am sure that you will find in many countries the over-simplification of methodology to diagnose and treat leprosy, together with inadequacy of follow up - so many people with leprosy are told 'Here is your treatment, 'MDT Cure' and you do not need to come back to see us for check-up'' has added to the present apparent resurgence of leprosy in many countries.

The failure to teach about the risk of pregnancy for the woman with leprosy and the need to check her during and after delivery, and to follow up for at least a year after delivery also has to be addressed.

I recently saw one such woman who did all that she was told, was not supervised after delivery and was bedridden with severe reaction and neuritis for a year after delivery. By the grace of God she was seen unofficially / accidentally (!) by someone who recognised the problem and gave her appropriate treatment and advice for the babe.

Lysbeth Duncan

lists of suitable labs for slit-skin smear examination in leprosy

2011-11-09T07:43:00.001-08:00

Leprosy Mailing List – October 3^rd, 2011

Ref.: It would be advisable to provide, lists of suitable labs for slit-skin smear examination in leprosy.From: Warren G, Sidney, Australia

Dear Dr Noto,

I am very pleased to read the comments on slit skin smears made by Dr Barreto (LML Oct. 2^nd 2011). Many times I have found that smears were reported as negative and when rechecked it was found that the stain was not correctly done.

Yes, M. leprae is difficult to stain and easily over decolourised by the use of the wrong acid-alcohol mixture. This is particularly a problem when slides are sent for acid fast bacilli (AFB) examination to a good lab that does not do M. leprae as a routine. So I must confess that if I diagnose leprosy and feel the patients ought to have a positive smear I often also send a suitable slide to an experienced lab to be sure, if it is said to be negative by the first lab.

I have had some very embarrassing experiences with laboratory personnel, whom one would think would be reliable, giving negative diagnosis on a patient who is clinically clearly positive. It is even more embarrassing when pathologists cannot diagnose from a fairly typical biopsy as happened with one patient with a definite red line (typical of BB) where the anaesthesia started – and when we looked at the stained biopsy a relatively inexperienced pathologist spotted the AFB at once but the Professor at the first institute had not seen them and had stated emphatically it was not leprosy.

It is important that we hone our ability to diagnose so that patients with leprosy are not deprived of MDT and the possibility of recovery without deformity. I have seen many “primary persistent neuritic leprosy” patients who have early ulnar nerve lesions (clawing of fingers) but NO skin lesions and are dismissed by WHO personnel as “not leprosy” because no anaesthetic skin lesion. Yet in S E Asia these are common and a biopsy of the nerve will prove AFB etc. present - but many places do not have those facilities. In fact many clinics in third world countries have no facilities to do slit skin smears and may even have no suitable place to send slides on for examination. We must hone our ability to diagnose by clinical signs and history.

Would it be advisable to provide, lists of the suitable labs who would check slit skin smears and/or biopsies for those who need it and may be make sure all the labs have full detailed instructions of the correct methods and strengths of stains to get reliable results.

Grace Warren

Previously adviser for the Leprosy Mission in Asia.