Friday, February 28, 2014

(LML) Leprosy in Colombia: Post Elimination Stage?

Leprosy Mailing List – February 28,  2014 

Ref.:    (LML) Leprosy in Colombia: Post Elimination Stage?

From:  Paul Saunderson


 

Dear Pieter,

For clarity, the reference to Dr Nora Cardona-Castro's paper about leprosy in Columbia (LML February 27, 2014) is as follows:
Leprosy in Colombia: Post Elimination Stage?  Leprosy Review (2013): 84 (3), pages 238-247.


Paul Saunderson MD
Editor, Leprosy Review.


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(LML) Leprosy patient with foot ulcer

Leprosy Mailing List – February 28,  2014 

Ref.:    (LML) Leprosy patient with foot ulcer

From:  Wim Theuvenet, Apeldoorn, the Netherlands


 

Dear Salvatore,

 

 

Thank you for the Bangladesh case study of January 27, 2014 (clinical leprosy, case report, BL-LL leprosy in ENL reaction) and of the same patient the presentation of February 27 (leprosy patient with foot ulcer)

 

It is puzzling  why the ulcer re-occurs at this side. Some questions:

 

1. have you checked the footwear that he used after discharge, perhaps ill fitting at the side of the ulcer?

2. can there be a corpus alienum / exostosis/ bursitis in the deep that is playing up again? Ultrasound and X-ray done?

3. there seems to be a rather dry skin with hyperkeratosis? Has he soaked, scraped and oiled?

4. what is his residency status, any gain from being admitted?

 

Warm regards,

 

Willem Theuvenet

 


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Thursday, February 27, 2014

LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 27,  2014 

Ref.:   (LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Nora Cardona Castro, Sabaneta, Columbia


 

Dear Pieter,

The leprosy situation in Colombia reflects the situation as described in the manuscript of Dr. Lockwood et al (Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign). The article "Leprosy in Colombia: Post Elimination Stage?" (see the summary below) shows this particular situation, although Colombia is considered to be in the post elimination stage according to the prevalence.

"Summary:

Leprosy in Colombia is not considering as a public health problem since a prevalence rate less than 1/10000 was achieved more than ten years ago. Nevertheless, reports of 2012 from 11 of 27 departments (48%) showed incidence rates from 0.12 to 4.73 cases per 100000 inhabitants. The Ministry of Health and the National Institute of Health direct and organize the National Leprosy Program (NLP), which plan the activities for prevention, surveillance, and control at national level.

 

The operational activities are delegated to the regional levels (municipalities, districts, departments) however in many areas poor hospital infrastructure, high costs, lack of health personnel trained, difficult access to the health services are some of the barriers that impede the development and access to the activities that the NLP publishes in guides. The above mentioned facts have as consequence late case detection with 30% of disability rates (grade 1 and 2) at the time of diagnosis.

 

Also, there is not awareness in general population neither in health professionals about the existence of leprosy cases in Colombia. This is a review of the situation of leprosy in Colombia, taking into account not only statistical data, but also some aspects that inuence late diagnosis and disability found in patients at the time of diagnosis. In this review may appear author's personal perceptions that may differ from others." (Nora Cardona Castro. Leprosy in Colombia: Post Elimination Stage? Lepr Rev (2013) 84, 1–10).

 

Best regards,

 

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.icmt.org.co


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LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 27,  2014 

Ref.:   LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Sinésio Talhari and Carolina C. Talhari-Cortez, Manaus, Brazil


 

Dear Pieter,

 

I fully agree with Dr. Salvatore Noto Bergamo,

Most of leprosy endemic countries will need to restart their leprosy control programmes in order to really understand the real situation of leprosy.

 

Best regards,

 

Dr. Sinésio Talhari

Dr. Carolina C. Talhari-Cortez

Fundaçao Alfredo da Matta

Manaus, Am, Brazil


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(LML) Leprosy patient with foot ulcer

Leprosy Mailing List – February 27,  2014 

Ref.:    (LML) Leprosy patient with foot ulcer

From:  P Forgione, Naples and S. Noto, Bergamo, Italy


Dear Pieter

 

Thank you very much for the question from Robert S. Jerskey, LML February 4, 2014. He asked about the footwear used by the patient. Excuse me for the delay in this answer.

 

It was about the case of a leprosy patient from Bangladesh seen in Naples, Italy, suffering from borderline lepromatous - lepromatous (BL-LL) leprosy, recurrent erytehma nodosum leprosum (ENL) reaction and foot ulcer. The slit-skin smear examination reported: bacteriological index (BI) 4+, morphologic index (MI) 0.8% and globi.

 

The patient arrived in hospital with severe ENL reaction and an ulcer on the border of the right heel (see attached slides 2-4). The plantar weight-bearing surface of the sole is dry but with no ulcer. The ulcer healed in about 6 months (slide 5). The treatment was rest in bed and, when he was better he went around in the ward on cheap open sandals. When he was released from hospital no special footwear were provided. The ulcer relapsed and this time it was deeper and larger. It slowly closed again with rest during his further long admission to hospital; again no special shoes where used.

 

Best regards,

 

 

Salvatore


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Sunday, February 23, 2014

LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 23,  2014 

Ref.:    LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Grace Warren, Sidney, Australia


 

Dear Pieter,


Thank you for publishing all these letters. It is very interesting to note the various comments, and opinions, especially in view of the facts that I personally have seen how different countries have interpreted and put into action the  various WHO statements.


Yes I will agree that the WHO aim to eliminate leprosy has certainly resulted in a big increase in attempt to find and treat the disease  and the numbers of new cases diagnosed each  year in the last decade has decreased.  One big problem now is that  some countries which are said to have eliminated leprosy now no longer give the grants to help doing surveys and to run clinics.   Having worked in many Asian countries doing leprosy for over 50 years I know the differences that  have occurred in many areas.  I also appreciate that many countries did not give realistic figures of the numbers of leprosy. This was a real problem in the middle of last century as it was considered a disgrace to have a high incidence of leprosy.  One country I know of gave the number admitted to the Government hospital as the official number for the country and did not include the hundreds( and there were) of patients who were being treated by NGOs in small clinics scattered  round the country.


But a major effect today , is that the Medical Colleges in many countries are reducing the  amount of teaching  that they are giving on Leprosy and many of the younger doctors have little idea now of what leprosy really is and of what to do to look for leprosy and to diagnose it and even more to  treat it effectively.  I am really concerned when I am told in some places  that" there is no leprosy in this country". And it is often mirrored by the attitude of the doctors who do not consider it a possibility - What one does not look for, or think about one will never find.


Combined with this is the WHO statement that a patient to be diagnosed as leprosy must have  " a skin patch or patches with a definite loss of sensation and has not completed a full course of treatment with multidrug therapy"   (first edition of the WHO Booklet  "A guide to Eliminate Leprosy as a public health problem",  2000)  Yes it adds that " other signs  include:  reddish or skin coloured  nodules or  smooth, shiny diffuse thickening of the skin without loss of sensation”. These statements virtually eliminate diagnosis of leprosy in Indeterminate leprosy which has no sensory loss  and although the diffused thickening of the skin is common in some skin colours it is often NOT shiny and can often only be appreciated by palpation and there are  no edges and no alteration in sensory perception.


I was  fascinated  when I first encountered,  back in the 1980s,   Persistent Primary Neuritic Leprosy in S E Asia, where it certainly is  not uncommon. More recently in about 2002 I was visiting a centre where a new program was being set up and was asked to examine some problem patients and how to manage them?   One of them was a young man with a clawed hand. He had no other complaints,  no skin lesions and the WHO consultant who had visited a few weeks earlier had said he did not have leprosy. However the man came from an area where leprosy was common so they referred him to me. On careful examination he had  a very definite  and  enlarged very firm ulna nerve at the elbow and on the hand as well as firm easily felt radial nerves on the back of the affected hand and some alteration in sensory perception - mostly mis-reference.  I could not find any other large nerves and no skin lesions but am sure he was leprosy. I have seen many of these in SE Asia who if seen early,  soon after the paralysis starts, can be completely reversed by MDT and 3 months of carefully controlled steroids with treatment of any other metabolic problems that may be playing a part in the process.


Another teenager was brought to me because he has unusual lumps on neck and groin.  These were obviously lymph nodes. Checking his past history was very interesting as he had been recently discharged from an psychiatric hospital where he had been confined for several years because he complained of funny feelings in the Index and adjacent finger of the right hand. When I checked the hand the radial and ulna nerves were very large and firm  but it was very hard to determine the size of the median ( it often is) . He had definite areas of sensory  abnormality with some complete anaesthesia and mis-reference, but fortunately no paralysis.   I biopsied one lymph node from the neck (he would not let me touch the one in the groin as he was afraid it may affect his bike riding !).  The well experienced pathologist, to which it was sent,  was thrilled to receive such a definite leprosy affected lymph node and in his mind that was the complete cause of the problem. 


I am afraid Indeterminate leprosy often gets excluded.  I wonder how many have been diagnosed later with  full blown leprosy- we will never know.  And I have seen a goodly number of diffuse lepromatosis with large areas of palpably infiltrated skin that does not appear affected and to which there is no definite edge -  but slit skin smears give the answer. Unfortunately the places where  reliable slit skin  smear reporting occurs is getting  harder to find and so this method of confirmation  is not so easy these days. Back in the 1960/70s many of our Chinese patients were diagnosed because they had positive slit skin smears with very few other signs.


Leprosy is certainly a fascinating disease to have treated for so long. I suspect that it will remain around for quite a time yet and could well flare up again if the current trainees and medical officers  consider it is gone and so do not even consider it as a possibility, and do not look for it. Well publication of the increases in annual diagnosis is good. Is there somehow that we can remind people that it is still present and needs to be looked for. The WHO statement was " "Eliminate leprosy as a Public health problem",   not complete elimination!


Congratulations on sharing every ones experiences so we  can all help each other.


 Yours sincerely,


Grace  Warren.
was MS Hong Kong Leprosarium 1960-1975 and Adviser in leprosy and reconstructive surgery for the Leprosy Mission in Asia from 1975-1995, still doing consulting at present

 


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(LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 23,  2014 

Ref.:     (LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Aguinaldo Gonçalves, Campinas, Brazil


 

Dear Dr. Schreuder,



Considering the recent communication by Diana Lookwood et al  about lessons from the leprosy elimination campaign,  I am sending herewith the article (in English, as it was published) as an attached file. The web link of Braz. J. of Epidemiology is http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1415-790X2013000300611&lng=pt&nrm=iso&tlng=en

 

 

“In the light of successive therapeutical difficulties for leprosy control, the application of drug therapy combination over the last decades has brought about an expectation of cure for leprosy patients and also for the elimination of this illness as a Public Health problem. However, there has been a progressive reduction in the prevalence of leprosy, but without any apparent impact on transmission, which has led to recognized need for solid assessment of respective epidemiological evidence as grounds for interventions to solve the problem. In this regard, here we present a retroanalytical qualitative and quantitative study. The conclusions that have been reached indicate, mainly, that the reality of leprosy control with the use of combination drug therapy, still needs to be handled with care, even more so as this is just a fragment of the set of people once under medical attention, which also correspond to a parcel of the set of people affected by the ailment” (Gonçalves A. Realities of leprosy control: updating scenarios. Rev. bras. epidemiol. vol.16 no.3 São Paulo set. 2013).

 

Other research about this matter, see the references 1,2 and 3.

 

 

Best regards,



Prof. Dr. Aguinaldo Gonçalves, MD, MSc, PhD


A2 Researcher Professor of Dermatology, PUC Campinas, Brazil
Formerly Director of Leprosy National Division, Ministry  of Health, Brazil
aguinaldogon@uol.com.br
http://lattes.cnpq.br/8140651861738248


1 - GONÇALVES, A. & GONÇALVES, N.N.S. – Multdrugtherapy in Leprosy, with special reference to Brazil.  Bras. Med.  23(1-4): 5-10, 1986.

2- GONÇALVES, A.; MANTELLINI, G. G.; PADOVANI, C. R. Leprosy Control: perspectives & epidemiological and operational aspects. Rev Inst Méd Trop S.Paulo 52(6): 311-322, 2010.

3- MANTELLINI, G.G.; GONÇALVES, A.; PADOVANI, C.R.   Leprosy dual paradigm control or elimination: the critical period 2000-2005.
Hansenol Internat 36(2): 17-23, 2011

 


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Saturday, February 22, 2014

LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 22,  2014 

Ref.:    LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Salvatore Noto, Bergamo, Italy


Dear Pieter,

 

Thank you to Dr Daumerie for his message (LML  February 21, 2014) and attached paper but, it is impossible  to agree with him.  He actually uses his authority to try to convince others of his ideas.  He has been involved in implementing the WHO leprosy policy and he says it is good.   The opposite is true; clinical skills have been forgotten in the field, where they are needed.  Leprosy patients suffering of reactions, neuritis, nerve damage and their sequelae are given blister packs and sent home with no attention to their eyes, hands,  feet and peripheral nerves; in other words with no proper clinical management.

The 1991 WHO elimination strategy was scientifically wrong.  They were wrong with the definition, the indicator and the bench mark (1 in 10,000).  We now use incidence or new cases as indicator.  The increasing first and, the decline of the leprosy cases later on, was due to the enormous commitment of all involved in leprosy activities.

 

The "WHO target set for 2020 of reducing the number of new leprosy cases with grade-2 disability to less than one case per million population" is one more sign that he has the power and force of impose his wrong ideas.  

 

Early detection and timely treatment of leprosy and its complications was and, still is the target.

 

Yours sincerely,

 

Salvatore
Bergamo, Italy

 


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(LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 22,  2014 

Ref.:   (LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Jaison Barreto, ILSL, Bauru, São Paulo, Brazil


 

Dear Pieter

 

In the past, I was strongly against the concept of leprosy elimination, once elimination is reached grants are reduced. However, today, after several years working in the field, I think that the idea to reach a target is hopeful. Every time we state a target, and, of course, when we work hard to reach it, more and more patients suffering from NTD are diagnosed and cured, diminishing the burden of the disease.

 

Will leprosy be, really, eliminated from the world easily? Personally, I do not think so, cause it is dependent on several factors, and among them, mainly ignorance and poverty, which are quite difficult to eliminate. But this does not mean that we shall give up to reach it.

 

Nobody can deny the importance of MDT implementation on the reduction of the burden of leprosy. Traveling in several other countries, I have noticed that the decentralized Brazilian system of notification/treatment/management is, although not perfect, much better than several other countries. I am also sure that we have so many cases diagnosed every year because we do not hide the statistics, our system of notification is robust and believable, and also because we work hard looking for early diagnosis. The efforts to look for leprosy among school children which we use to do in Brazil is one of the best examples, of how to create new methodologies, in order to make possible diagnosis in silent areas. Who is also doing this, in other countries were leprosy is said eliminated?    

 

With the support of governmental institutions, like Instituto Lauro de Souza Lima, and NGOs like DAHW, we work together training health professionals in the field. Research projects on NTD have more and more funds. The most difficult problem to solve I have found is how to sensitize the physician who works in the field, and also the health managers in municipalities/states for the problem of leprosy. This is quite difficult, as well.

 

About drug resistance, I have seen, in the field or at the national reference I work, that this is quite uncommon, and most relapses are, in fact, under-treatment (borderline patients treated as having PB leprosy), or probable reinfection due to lack of evaluation of household contacts.

 

Regards

 

Jaison  

 


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(LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 22,  2014 

Ref.:  (LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From:  Krishnan Vijay, Hyderabad, India


Dear Dr. Schreuder,

More and more people started recognising the fact that something went wrong in leprosy work. In all endemic countries, the ‘elimination’ achievement did huge losses to humanity by breaking down the attack on leprosy – and not leprosy itself. The “political commitment” happening in global conferences as described by Dr Denis Daumerie, does not have any flavour of or impact on the grassroots realities. People in remote villages and those living in difficult terrains and even those in poor urban slums are never equipped to report voluntarily at general health centres with cardinal signs of leprosy – which is the reason why the new cases detected around ‘elimination years’ fell dramatically. Leprosy work included committed grassroots level activities covering information education, rehabilitation and case detection and treatment – all of which were stopped untimely – imagining that “leprosy is eliminated’.

Surely elimination declaration made an impression among decision makers and the general public that the “prevalence rate” and other figures around leprosy, represented actual situation – grossly underestimating the reality. In the year 2013 (from 1st April 2012 to 31st March 2013) 13,387 children were reported as new cases in India. 4,650 of them were reported with Grade II disability. It does not mean that only this much children were the existing child cases – so many of them would get detected with further delay in later years. Is it not a tragedy that with so much concern on “scientific evidences” and possession of all knowledge and know-how, children of our modern era are at risk of leprosy disability? Or is it because we do not value human lives when they are poor?

It is unfortunate that we still bother about clean registers and over-diagnosis rather than ensuring timely diagnosis and treatment.

The evidence from Malawi study of 2012 (http://www.biomedcentral.com/1472-698X/12/12) suggests the folly of elimination in a country which “achieved” elimination as early as 1994. Indonesia, after ‘achieving’ elimination in 2000, stands another testimony with increasing number of child cases and disabilities. India instead of learning from others’ experiences is waiting for our own.

If we didn’t have this twisted explanation of the word ‘elimination’ in 1981, perhaps we would have been much more practical.

Regards,

Vijay

Fontilles India

 


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Friday, February 21, 2014

(LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 21,  2014 

Ref.:   (LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

From: Denis Daumerie, WHO, Geneva, Switserland


Dear Dr. Schreuder,

 

By attached file our response to the analysis by Diana Lookwood published in the BMJ on Feb 15th

The response will be published in the BMJ as soon as possible.

 

Best wishes,

 

Dr Denis Daumerie
WHO/HTM/NTD
Project Manager Neglected Tropical Diseases
Neglected Tropical Diseases Control
HIV/AIDS, TB, Malaria and Neglected Tropical Diseases (HTM)
World Health Organization
1211 Geneva 27 Switzerland

Tel. direct: +41 22 791 3919
Fax direct:
+41 22 791 4850
Mobile:
+41 79 596 5719
Mail:
daumeried@who.int

Visit WHO at
www.who.int/neglected_diseases


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Wednesday, February 19, 2014

(LML) Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign

Leprosy Mailing List – February 19,  2014 

Ref.:    (LML) Hazards of setting targets to eliminate disease: lessons  from the leprosy elimination campaign

From:  Diana Lockwood, LSHTM, London, UK


Dear Pieter,

 

 

“Elimination of a disease sounds attractive, but as the recent re-emergence of polio has shown, it is difficult to accomplish. As part of its roadmap for reducing the burden of neglected tropical diseases, the World Health Organization has identified five diseases for elimination by 2015 and a further eight by 2020. Although setting these ambitious targets has the potential to focus money and resources, unless the targets are realistic they can have unforeseen consequences. We use the experience of the 1991 campaign to eliminate leprosy to show how targets can end up causing harm to patients” (Lockwood DNJ, Shetty V, Penna GO. Hazards of setting targets to eliminate disease: lessons from the leprosy elimination campaign. BMJ 2014;348: g1136 doi: 10.1136/bmj.g1136).

 

 

This paper was published in the BMJ on Feb 15th (see attached file). I hope that it will help leprosy work in India and Brazil.

 

 

Best wishes,

 

 

Diana Lockwood


Professor of Tropical Medicine
London School of Hygiene & Tropical Medicine
Keppel St
London WC1E 7HT
diana.lockwood@lshtm.ac.uk
Tel: 020 7927 2457
Fax: 020 7637 4314


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Monday, February 17, 2014

(LML) Obituary Dr. Raul N. Fleury

Leprosy Mailing List – February 17,  2014 

Ref.:    (LML) Obituary Dr. Raul N. Fleury

From:  Marcos Virmond, ILSL, Bauru, São Paulo, Brazil


Dear Dr. Schreuder,

 

It is with deep regret that we inform that Dr Raul N. Fleury died on 7th February 2014 in Bauru, Brazil, at 79 y., after a long struggle with a brain cancer. Dr Fleury was a devote worker in leprosy pathology serving for a lifelong in the Instituto Lauro de Souza Lima. The contributions of Dr Fleury to the understanding of leprosy reactions from the pathological point of view were both brilliant and controversial.

The funeral was held on 8th February with an impressive attendance of friends and colleagues, including the President of the Brazilian Society of Hansenology, Prof. Marco A. Frade, the former president of the Society, Prof. Norma T. Foss and representatives of the Brazilian Society of Dermatology, Prof. Joel Lastoria and Prof. Silvio Marques.

 

Regards,

 

M. Virmond

Instituto Lauro de Souza Lima (ILSL), Bauru


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(LML) Announcement Leprosy Research Initiative : deadline for submission of Letter of Intent

Leprosy Mailing List – February 17,  2014 

Ref.:   (LML)  Announcement Leprosy Research Initiative : deadline for submission of Letter of Intent

From: Ilse Egers, INFOLEP, NLR, Amsterdam, the Netherland


 

Dear Pieter,

 

 

The Leprosy Research Initiative (LRI) is a combined venture of the Netherlands Leprosy Relief (NLR), American Leprosy Missions (ALM), German Leprosy and Tuberculosis Relief Association (GLRA) and The Leprosy Mission Canada (TLMC). Guided by an allied policy with clearly defined research priorities, the four partners have established a joint fund to support leprosy research.

 

The joint fund will be reserved for research that is exclusively or strongly related to leprosy. Additional resources will be actively sought for research in the field of general disabilities and for research aimed at different diseases (e.g. other NTDs, TB and diabetes) in combination with leprosy.

 

Researchers interested to apply for funding by the LRI are invited to complete and submit a Letter of Intent (LoI), giving an outline of the intended research. The LoI should use the format provided on the LRI website (www.leprosyresearch.org ). Applications that do not follow this format will not be considered.

 

A Letter of Intent may be submitted at any time during the year. However, to be considered for the budget round 2015, LoIs should be submitted by April 1st, 2014 by e-mail to the LRI Secretariat, c/o Ms. Nicole Dinnissen (info@leprosyresearch.org ). This letter will be screened by the LRI Steering Committee (SC). If the feedback by the SC is positive, the applicants will be invited to submit a full proposal before the next deadline (June 1st).

 

Best Regards,

 

Ilse Egers

Medewerker InfoLep / Information Officer

 

Infolep Leprosy Information Services

 

Postbus / P.O. Box 95005

1090 HA Amsterdam

The Netherlands

Tel: +31 20 5950500

Mob:

E-mail: I.Egers@Leprastichting.NL

Web: www.leprosy-information.org


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