Thursday, December 31, 2020

Fw: (LML) The Brazilian Public Health System (SUS) will offer clarithromycin for the treatment of resistant leprosy



Leprosy Mailing List – December 31,  2020

 

Ref.:  (LML) The Brazilian Public Health System (SUS) will offer clarithromycin for the treatment of resistant leprosy

From:  Rodrigo Sena, Brasília, Brazil

_____________________________________________________________________________________________________________________________________________


Dear Pieter,

I am writing to disclose that Brazil will adopt clarithromycin for the treatment of drug-resistant leprosy.

I made a brief summary of the scientific and economic evidence studies, which supported the decision of the public health system in Brazil (SUS).
(attached file).

We are honored to contribute.



Greetings
,


Rodrigo Sena

 

National Leprosy Program of Brazil.

_________________________________________________________________________________________________________________________________________________

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

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

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

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Fw: (LML) Previously treated but neglected persons multiply the risk of HD in a household




From: leprosymailinglist@googlegroups.com <leprosymailinglist@googlegroups.com> on behalf of Pieter Schreuder <editorlml@gmail.com>
Sent: 31 December 2020 18:04
To: Leprosy Mailing List <leprosymailinglist@googlegroups.com>
Subject: (LML) Previously treated but neglected persons multiply the risk of HD in a household
 

 

Leprosy Mailing List – December 31,  2020

 

Ref.:  (LML) Previously treated but neglected persons multiply the risk of HD in a household

 

From:  Joel Almeida, London and Mumbai

______________________________________________________________________________________

 

Dear Pieter and colleagues,

 

Meticulous observational and analytical studies at the frontlines can unearth important clues. Unexpected clues tend to be the most valuable, because they can make the difference between harm and benefit. 

 

Joel Almeida

 

= = = = =

 

Previously treated but neglected persons multiply the risk of HD in a household

 

Methods

 

The methods used were described by Vijayakumaran et al.(1) In summary, during the 11 years ending December 1994, all consecutively diagnosed skin-smear positive and previously untreated "index" patients living in a defined geographical area were started on 24 months of MDT. Every household contact of every such "index" patient was physically examined for HD. The physical examinations were repeated at annual intervals. New arrivals into each such household, who joined after the start of MDT in the "index" patient, likewise were examined. These new arrivals will be referred to below as "newcomers". Further, the presence or absence of "co-prevalent" persons was noted. These "co-prevalent" persons consisted of those previously started on anti-microbial treatment, including those who had already completed treatment prior to enrollment of the "index" patient.

The incidence rate of all types of HD in this defined area with a well-established control programme, estimated from sample surveys, was about 900 new patients/million population/year.

 

Results among "newcomer" children

 

The incidence rate of HD among "newcomer" children is shown in Figure 1.

 

Figure 1.  (see attached file) Presence of a previously treated patient multiplied the risk of HD among "newcomer" children in a household, despite prior start of treatment in a newly diagnosed "index" patient.(1) Excess risk to "newcomer" children in household endured for as long as observation continued - up to 9 years

 

The presence of a previously treated patient in the household apparently increased the risk of HD among "newcomer" children to over 25 times that in the general population of the area, during the initial three years after the start of MDT in the "index" patient. When a previously treated patient was present in the household, treatment of the index patient alone did not suffice to reduce the risk to the "background" population level. Even seven to nine years after the start of 24 month MDT in the "index" patient, "newcomer" children showed a greatly elevated risk of HD if a previously treated (but since neglected) patient was present in the same household. 

 

Discussion

 

Prolonged anti-microbial protection of previously treated but genomically anergic (2-5) persons  in endemic areas is likely to reduce dramatically the risk of HD in their household contacts. It also would help protect the individuals from reactions,(6-9) which can be painful, distressing, and aggravate nerve damage. Reinfection in previously treated anergic patients remains a sustained threat in endemic areas.(10)

 

Preventive antimicrobials among contacts of such neglected previously treated but anergic patients would need to continue for over nine years, to cope with the sustained duration of risk. It seems wiser to rely on prolonged anti-microbial protection of the anergic patients.

 

Prolonged anti-microbial protection of patients with possible anergy (eg., LL patients) can be achieved by

a) prolonged MDT, after the usual duration. At least until smear negativity.

 

or

 

b) prolonged anti-microbials after the usual duration of MDT, with a combination of 3 bactericidal drugs. Some enlightened private practitioners and centres of excellence in endemic areas of India and Brazil already protect LL patients with combinations of bactericidal drugs after MDT. 

 

This HD control area, served by the Schieffelin Centre in Karigiri (India) had earlier produced one of the world's great successes in rapidly reducing the incidence rate of LL HD (16%/year). As long as prolonged anti-microbial protection was ensured for persons with anergy, the exemplary success continued (as discussed here previously). Resurgence in LL HD occurred only after fixed-duration MDT replaced prolonged anti-microbial protection in even LL patients. Since the introduction of fixed duration MDT (in place of MDT till smear negativity) the world too has experienced stagnation in the number of new MB HD patients per year. This is evidenced in Weekly Epidemiological Records. MB types of HD rarely self-heal. Therefore sooner or later they come to the attention of health services and form a more reliable epidemiological indicator than most other indicators.

As the best young local talent is invited and encouraged to participate in HD work, we can expect increasingly astute investigations and openness to front-line clues. The evidence so far indicates that, in endemic areas, it is neither safe nor fair to exclude persons with anergy (mostly LL) from prolonged anti-microbial protection.

 

References

 

1.     Vijayakumaran P, Jesudasan K, Mozhi NM, Samuel JD. Does MDT arrest transmission of leprosy to household contacts? Int J Lep 1998; Jun;66(2):125-30.

 

2.     Chakravarti MR, Vogel F. A twin study on leprosy Georg Thieme Publishers, Stuttgart, Germany; 1973

 

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

 

4.      Gaschignard J, Grant AV, Thuc NV et al. Pauci- and Multibacillary Leprosy: Two Distinct, Genetically Neglected Diseases. PLoS Negl Trop Dis. 2016 May 24;10(5):e0004345. doi: 10.1371/journal.pntd.0004345


5.      Wang N, Wang Z, Wang C et al. Prediction of leprosy in the Chinese population based on a weighted genetic risk score. PLoS Negl Trop Dis. 2018 Sep 19;12(9):e0006789. doi: 10.1371/journal.pntd.0006789.

 

6.      Save MP, Dighe AR, Natrajan M & Shetty VP. Association of viable Mycobacterium leprae with Type 1 reaction in leprosy. Lepr Rev (2016) 87, 78–92


7.      Arora P, Sardana K, Agarwal A, Lavania M. Resistance as a cause for chronic steroid dependent ENL - a novel paradigm with potential implications in management. Lepr Rev (2019) 90, 201– 205

8.      Brito MDE F, Ximenes RA, Gallo ME, BÜhrer-SÉkula S. Association between leprosy reactions after treatment and bacterial load evaluated using anti PGL-I serology and bacilloscopy. Rev Soc Bras Med Trop. 2008;41 Suppl 2:67-72.

 

9.      FajardoT1, Villahermosa L, Eleanor F et al Comparative Clinical Trial in Multibacillary Leprosy with Long-Term Relapse Rates of Four Different Multidrug Regimens. Am. J. Trop. Med. Hyg., 2010, 83(3),  pp. 637–644

 

10.      Balagon MF, Cellona RV, dela Cruz E et al. Long-Term Relapse Risk of Multibacillary Leprosy after Completion of 2 Years of Multiple Drug Therapy (WHO-MDT) in Cebu, Philippines. American Journal of Tropical Medicine and Hygiene, 2009; 81, 5: 895-9. reviewed and analysed further in 19a. Almeida J Recurrence rate among MB patients following RFT. LML 2 June 2019.

______________________________________________________________________________________

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

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

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

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Wednesday, December 23, 2020

Fw: (LML) Factsheet Second Term Leprosy mandate


 

 

Leprosy Mailing List – December 23,  2020

 

Ref.:  (LML) Factsheet Second Term Leprosy mandate

 

From:  Alice Cruz, Quito, Ecuador

______________________________________________________________________________________

 

Dear friends and partners,


As I enter my second term as Special Rapporteur, I would like to thank all and each one of you for the precious support given to my mandate during its first term. With an added weight of responsibility and sense of duty I am deeply honored to serve our community for another three years.

I am sending you a fact-sheet (in English, Portuguese, Spanish and French) that recalls some of my working methods for your kind information. I hope this fact-sheet can facilitate our joint work. Kindly distribute it among your network.


This mandate is a people-centred mandate and its work and success reflects our collective struggle as a community.

I am looking forward to these three years ahead with great expectations that together we can make a positive difference!


With warm regards,


Alice


 

PORTUGUÊS


Carxs amigxs e parceirxs,


Ao começar o meu segundo termo como Relatora Especial, gostaria de agradecer a todxs e a cada um/a de vocês pelo precioso apoio dado ao meu mandato durante seu primeiro termo. Com um peso adicional de responsabilidade e sentido de dever, estou profundamente honrada em servir a nossa comunidade por mais três anos.

Envio-vos um folheto (em inglês, português, espanhol e francês) que relembra alguns dos meus métodos de trabalho para a vossa amável informação. Espero que este folheto possa facilitar nosso trabalho conjunto. Por favor, distribua-o em sua rede.


Este mandato é centrado nas pessoas e seu trabalho e sucesso refletem nossa luta coletiva como comunidade.

Estou ansiosa por estes três anos mais com grandes expectativas de que juntxs possamos fazer uma diferença positiva!


Atenciosamente,


Alice

 

ESPAÑOL


Queridxs amigxs y compañerxs,


Al entrar en mi segundo ciclo como Relatora Especial, quisiera agradecer a todos ya cada uno de ustedes el valioso apoyo brindado a mi mandato durante su primer ciclo. Con un peso adicional de responsabilidad y sentido del deber, me siento profundamente honrada de servir a nuestra comunidad durante otros tres años.

Le envío una hoja informativa (en inglés, portugués, español y francés) que recuerda algunos de mis métodos de trabajo para su amable información. Espero que esta ficha técnica pueda facilitar nuestro trabajo conjunto. Por favor, distribúyalo entre su red.


Este mandato es un mandato centrado en las personas y su trabajo y éxito refleja nuestra lucha colectiva como comunidad.

¡Estoy deseando que lleguen estos tres años con grandes expectativas de que juntos podamos hacer una diferencia positiva!


Con un cordial saludo,


Alice

 

FRANÇAIS


Chers amis et partenaires,


Alors que j'entre dans mon deuxième mandat de Rapporteuse spéciale, je tiens à remercier tous et chacun d'entre vous pour le précieux appui apporté à mon mandat au cours de son premier mandat. Avec un poids supplémentaire de responsabilité et de sens du devoir, je suis profondément honoré de servir notre communauté pendant encore trois ans.


Je vous envoie une fiche (en anglais, portugais, espagnol et français) qui rappelle certaines de mes méthodes de travail pour votre aimable information. J'espère que cette fiche d'information pourra faciliter notre travail commun. Veuillez le distribuer sur votre réseau.


Ce mandat est un mandat centré sur les personnes et son travail et son succès reflètent notre lutte collective en tant que communauté.

J'attends avec impatience ces trois années à venir avec de grandes espérances qu'ensemble, nous pouvons faire une différence positive!


En vous remerciant chaleureusement,


Alice


______________________________________________________________________________________

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

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

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

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Tuesday, December 22, 2020

Epidemiology of HD

 Leprosy Mailing List – December 21 ,  2020 

 

Ref.:  (LML) Epidemiology of HD 

 

From:  Joel Almeida, London and Mumbai 


 Dear Pieter and colleagues, 

Understanding unexpected successes and unexpected failures is very helpful in achieving major epidemiological impact. Some field programmes achieved 16% to 90% real annual decline in new cases, while others showed a disappointing impact (0% to 3% real annual decline). The underlying epidemiology can be summarised as below. This might encourage great colleagues in endemic countries to implement increasingly effective interventions. 


Fig. 1 The neglected multitude of previously treated anergic patients maintains transmission despite all other efforts. 16% to 20% / year real decline in new cases is available from repeated skin camps with competent clinicians to diagnose subtle LL signs + MDT (prolonged for high BI patients to prevent reinfection/recurrence).(1-3)  90% / year real decline in new cases is available by adding repeated mass multi-drug administration to suppress bacilli in sub-clinical disease or missed cases, alongside skin camps and MDT.(4) By contrast, fixed duration MDT for LL patients failed to sustain a rapid decline,(5) with patients who had a high initial BI showing a significant risk of recurrent disease after even 24 months of MDT.(6) 

 


 

Fig. 2 Only a very small fraction of the population has genetically linked(7-10) anergy to HD bacilli, with consequently low ID50s. ID50 is the dose of bacilli sufficient to infect 50% of individuals of a given description. 

  


Fig. 3 Nearly all HD patients are non-infectious, for practical purposes. Transmission is almost exclusively by unrecognised LL or previously treated LL patients with recurrent disease, whose nasal discharge can contain up to tens of millions of viable bacilli per day.(11) 

Reliable epidemiology is like a reliable map. It is better than driving blindfolded. Further, our understanding keeps improving as clues from the front-lines are unearthed by great colleagues. Endemic countries need the elbow room to sustain and spread the successes they have demonstrated in exemplary programmes. 

 

Joel Almeida 

 

References 

 

1.    Tonglet R, Pattyn SR, Nsansi BN et al. The reduction of the leprosy endemicity in northeastern Zaire 1975/1989 J.Eur J Epidemiol. 1990 Dec;6(4):404-6 reviewed in: 23a. Almeida J. Reducing transmission in poor hyperendemic areas - evidence from Uele (DRC). LML 29 Nov 2019  

2.      Norman G, Bhushanam JDRS, Samuel P. Trends in leprosy over 50 years in Gudiyatham Taluk, Vellore, Tamil Nadu. Ind J Lepr 2006. 78(2): 167-185. reviewed and analysed further in: 20a Almeida J. Karigiri, India: How transmission rapidly was reduced in a low-income population LML 29 October 2020 

3.        Li HY, Weng XM, Li T et al. Long-Term Effect of Leprosy Control in Two Prefectures of China, 1955-1993. Int J Lepr Other Mycobact Dis. 1995 Jun;63(2):213-221. reviewed & analysed further in: 22a. Almeida J. What really happened in Shandong? LML 16 Nov 2019 

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

 5.         Scheelbeek PFD, Balagon MVF, Orcullo FM et al. A retrospective study of the epidemiology of leprosy in Cebu: an eleven-year profile. PLoS Negl Trop Dis. 2013 Sep 19;7(9):e2444. doi: 10.1371/journal.pntd.0002444. eCollection 2013. 

6.         Balagon MF, Cellona RV, dela Cruz E et al. Long-Term Relapse Risk of Multibacillary Leprosy after Completion of 2 Years of Multiple Drug Therapy (WHO-MDT) in Cebu, Philippines. American Journal of Tropical Medicine and Hygiene, 2009; 81, 5: 895-9. reviewed and analysed further in 19a. Almeida J Recurrence rate among MB patients following RFT. LML 2 June 2019.  

7.         Gaschignard J, Grant AV, Thuc NV, Orlova M, Cobat A, Huong NT, et al. Pauci- and Multibacillary Leprosy: Two Distinct, Genetically Neglected Diseases. PLoS Negl Trop Dis 2016; 10(5): e0004345. https://doi.org/10.1371/journal.pntd.0004345 

8.         Chakravarti MR, Vogel F. A twin study on leprosy Georg Thieme Publishers, Stuttgart, Germany; 1973.

9.          Cambri G, Mira MT. Genetic Susceptibility to Leprosy—From Classic Immune-Related Candidate Genes to Hypothesis-Free, Whole Genome Approaches. Front. Immunol., 20 July 2018 | 
https://doi.org/10.3389/fimmu.2018.01674

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

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

PS. In medical exams someone from our college was asked, "What is the function of the muscle spindle?" The classmate replied "Sir, that is not well understood." 
The examiner shot back, "By whom, Sir? By the world at large or just by you?" 

In the epidemiology of HD, despite whatever might remain to be discovered, it seems wise to recognise and apply the knowledge already available. 

 

 


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

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

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

Friday, December 18, 2020

Fw: (LML) Leprosy case finding should contain as many contacts as possible

 

 


Leprosy Mailing List – December 18,  2020

 

Ref.:  (LML) Leprosy case finding should contain as many contacts as possible

 

From:  Diana Lockwood, London, UK

---------------------------------------------------------------------------------------------------------------------------------------


Dear Pieter,

 

We would like to thank Paul Saunderson et al for their post on LML (10.12.2020) about our paper in Plos neglected Tropical Diseases.(1)  We have also replied to Saunderson's comments on the PLOS NTD website. Our paper reported a large cohort study with a 21-year follow up period and we found a single, dominant risk factor for leprosy development amongst household (HH) contacts – smear positivity. We are excited about this significant finding which helps to understand leprosy transmission risk factors. We are sorry that our colleagues are not more enthusiastic about this major piece of work on leprosy transmission that followed a large cohort of patients for 21 years.

 

We agree with Saunderson et al that ideally all contacts of all newly diagnosed leprosy cases should be examined. Our findings endorse the importance of conducting HH contact examinations for case detection and control. However, there is a cost associated with HH contact examinations. Economic and human resources for leprosy control are scarce and where leprosy control is integrated into general health services, comprehensive coverage of household contacts has not been possible.

 

We did not say that it was unnecessary to examine all contacts of all new cases as Saunderson et al suggested, but recommended that when leprosy resources are scarce, a prioritisation based on the probability of finding more new cases per household should be considered by leprosy control programmes, but only if slit-skin smears are available in the assessment of the index case . This is possible through our finding of a single, dominant risk factor for developing leprosy. This is similar to using the clinical prediction rule for nerve function impairment (2) to determine which patients need more attention for nerve function monitoring. In our other COCOA (Contact Cohort Analysis) paper that Saunderson et al cites, we concluded (3) "where resources are severely limited and observed  prevalence rate is low.. managers could direct staff to give first priority to undertaking an initial HCE of MB/ smear positive index HHs. Then, as second priority, to undertake one more examination of MB HHs after 12 or 24 months, and only as third priority to do a single HH contact examination soon after diagnosis for each PB index case".

 

We agree that finding leprosy patients in settings beyond the household is important, but our study did not include neighbour or social contacts, which we carefully discussed, (1) so did not comment on these categories. "Extended contact surveys" will become more important as leprosy rates decline.

 

According to stepwise pr analysis (and as explained in the results below Table 4) the hazard ratio for HH contacts of index cases who are smear low positive is 1.57. The smear variable was grouped into 3 groups. Smear negative, smear low positive (bacterial index 1-3) and smear high positive (BI 4-6). The risk of their associated contacts developing leprosy increases by 1.57 times for each increase in smear grouping. HH contacts of smear high positive index cases are at 3.14 times increased risk of developing leprosy compared to contacts of smear negative patients. 

 

Of 608 new cases detected throughout the follow-up, 405 (67%) were associated with index cases who were skin smear negative. So 33% of new cases detected amongst contacts were from HHs with smear positive index cases, comprising only 6.55% households examined. When looking at the absolute number of new cases one should consider the population they come from, especially when assessing relative risk. NW-Bangladesh has a high paucibacillary (PB) rate of leprosy cases compared to the rest of the country, maybe because of the active leprosy control unit work there by a specialist NGO for over 20 years.

 

Of the HH contacts of index cases with high positive smear leprosy (1480), 11.69% of them were diagnosed with leprosy throughout the follow up. This is compared to the HH contacts of smear negative index cases (32582), where 1.24% were diagnosed with leprosy (405). So the highest hazard ratio is being associated with high smear positive index case. Where smear services are lacking, multibacillary (MB) classification can be used as a proxy for identifying the HHs at higher risk of new case development.

 

We are pleased that Saunderson quickly changed his position on the value of slit-skin smears from initially stating in the PLOS NTD comment that it 'seems counter-productive to spend scarce resources on reviving skin smear services which have no added value for treatment decisions' (1) to acknowledging that 'the skin smear test is a useful test for other reasons'. (Saunderson et al post on LML (10.12.2020)). The presence of acid fast bacilli is a cardinal sign of leprosy so we need to be able to detect them in index cases. They are also needed to detect relapse of multi-bacillary leprosy.  Slit-skin smears can predict the development of Erythema nodosum leprosum (ENL), BL/ LL patients with a BI of 4 or higher at greatest risk of ENL. (4)

 

This study highlights a single, dominant risk factor for leprosy development, skin smear positivity. Where skin smear services are available, and resources are scarce, the identification of this single risk factor enables the prioritisation of HH contact examination to those HHs at greatest risk.  Performing slit-skin smears in this circumstance would be used for risk stratification and works in conjunction with contact examination. We are not pitching "two good interventions " against each other; slit-skin smears and HH contact examinations, both are needed. Conversely, our results could increase the effectiveness of leprosy control by using skin smears in conjunction with HH contact examinations. This is another piece of compelling evidence for the leprosy community as a whole to advocate, to revive and improve skin smear services. 

 

 

 

Diana NJ Lockwood

Emeritus Professor of Tropical Medicine

London School of Hygiene and Tropical Medicine

Keppel Street

London WC1E 7HT

 

Emily Quilter

Department of Infectious and Tropical Diseases

London School of Hygiene and Tropical Medicine

Keppel Street

London WC1E 7HT

 

Steve L Walker

Associate professor

Department of Infectious and Tropical Diseases

London School of Hygiene and Tropical Medicine

Keppel Street

London WC1E 7HT

 

Peter Nicholls

Independent statistician

 

Ruth Butlin

The Leprosy Mission England and Wales

Peterborough

United Kingdom

 

References:

1.    Quilter EEV, Butlin CR, Singh S, Alam K, Lockwood DNJ (2020) Patients with skin smear positive leprosy in Bangladesh are the main risk factor for leprosy development: 21-year follow-up in the household contact study (COCOA). PLoS Negl Trop Dis 14(10): e0008687. doi.org/10.1371/journal.pntd.0008687

 

2.    R P Croft P G NichollsE W SteyerbergJ H RichardusW CairnsS Smith. A clinical prediction rule for nerve-function impairment in leprosy patients. Lancet. 2000 May 6;355(9215):1603-6. doi.org/10.1016/s0140-6736(00)02216-9.

 

3.    Butlin CR, Nicholls P, Bowers B, Quilter E, Singh S AK. Outcome of late healthy household contact examinations in leprosy-affected households in Bangladesh. Lepr Rev. 2019;90: 305–320

 

4.    Pocaterra L,  Jain S, Reddy R, et al. Clinical course of Erythema Nodosum Leprosum: an 11-year cohort study in Hyderabad, India. Am. J. Trop. Med. Hyg. 74(5), 2006, pp. 868–879

 

 --------------------------------------------------------------------------------------------------------------------------------------------

 

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

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

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

 

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Tuesday, December 15, 2020

Fw: (LML) WHO Goodwill Ambassador's Leprosy Bulletin NO. 101 DECEMBER 2020

 

 

Leprosy Mailing List – December 15,  2020

 

Ref.:  (LML) WHO Goodwill Ambassador's Leprosy Bulletin NO. 101 DECEMBER 2020

 

From:  Takahiro NANRI, Tokyo, Japan

 

 

Dear Dr. Schreuder and Friends,   

 

 

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

 

In this issue, we feature:

 

MESSAGE FROM THE AMBASSADOR

Welcome to the Leprosy Bulletin, a new version of the newsletter that I have been publishing since 2003.  Read More 


ANNOUNCEMENT

Introducing the Sasakawa Leprosy (Hansen's Disease) Initiative

In April 2020, the WHO Goodwill Ambassador for Leprosy Elimination, The Nippon Foundation (TNF), and the Sasakawa Health Foundation (SHF) completed a two-year reorganization project to leverage knowledge, networks, and resources more effectively.  Read more


INTERVIEW

New Secretariat Director aims to maintain consensus as GPZL moves forward

In October, Leprosy Bulletin interviewed Bill Gallo, the new Secretariat Director of the Global Partnership for Zero Leprosy (GPZL). Amid the COVID-19 pandemic, he shared the way that GPZL is staying focused on zero leprosy so that both short-term needs and long-term goals can be met.  Read more


NEXT GENERATION

If I don't do something, who will?

"When I was first diagnosed with leprosy in 2012, I felt my life had been destroyed and there was no hope. I thought about committing suicide," recalls Yuliati, Head of PerMaTa South Sulawesi, Indonesia.  Read more


REPORT

Taking responsibility for our own safety and the safety of those we serve

Artur Custodio, National Coordinator of MORHAN, describes how members of the Brazilian social movement "are learning to smile and kiss with our eyes and shake hands with our elbows" under "new normal" conditions.  Read more


DATA BOX

WHO's latest global leprosy update (2019 data)

Every year, the World Health Organization (WHO) receives official data on leprosy from national programs in member states worldwide. For the calendar year 2019, WHO received data from 160 countries. WHO released a report on this data in September 2020.  Read more


WISH LIST

Ramesh Kumar Choudhary, who works at Lalgadh Leprosy Hospital & Services Centre in Nepal, shares his list of wishes, beginning with "a joyful society where persons affected by leprosy can participate freely."  Read more


UPCOMING EVENTS

Webinar series: Issues in leprosy amid the COVID-19 pandemic

In October, Sasakawa Leprosy (Hansen's Disease) Initiative began hosting a webinar series on social, medical, and historical aspects of leprosy in the context of the COVID-19 pandemic.  Read more

 

BACK ISSUES

 

Takahiro NANRI, Ph.D.

Executive Director, Sasakawa Health Foundation

*********************************************************

Sasakawa Leprosy (Hansen's Disease) Initiative

Sasakawa Health Foundation

Tel81-3-6229-5377, Fax81-33-6229-5388

email: hansen@shf.or.jp

visit our website at https://www.shf.or.jp

*********************************************************

 

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

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

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

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Saturday, December 12, 2020

Fw: (LML) Replacing opinions with evidence

 


Leprosy Mailing List – December 12,  2020

 

Ref.:  (LML) Replacing opinions with evidence

 

From:  Joel Almeida, London and Mumbai

_______________________________________________________________________________

 

Dear Pieter and colleagues,

 

Several perspectives have been shared by esteemed colleagues. The heart of the matter is a contrast in epidemiological impact between front-line programs such as Karigiri, Uele and Shandong that demonstrated a 16% to 20% annual decline in new cases of HD (leprosy), and global practices that yield stagnation in the annual number of new cases (about 200,000 newly detected cases per year, disappointing annual decline of 0% to 3%). What explains this vast difference in outcomes/impact?

 

The acceptance of a 1% "relapse" rate appears to be at the root of this difference. How so? Fewer than 1% of cases newly detected by vigorous case-finding have anergy to the bacilli. Yet this small minority of newly detected cases, if left unprotected in endemic areas, is highly susceptible to reinfection and uniquely capable of shedding tens of millions of viable bacilli per day. A 100% cumulative recurrence rate among this tiny minority of newly detected patients would remain well within a 1% overall "relapse" rate. Yet it is this sub-1% rate of relapse that can result in 200,000 persons/year newly being detected with signs of HD.

 

Remarkable successes were created by inventive people at the front lines striving simply to do their best for their patients and their people. They were more closely associated with the grassroots than the ivory tower. Can we learn anything from their successes? 

 

A good start is to dig below the surface of reported recurrence rates after the end of anti-microbial chemotherapy. They can be underestimated. This tends to happen in several ways.. 

 

Inadequate duration of follow-up


Visible recurrences among highly bacillated patients tend to start in year 6 after the end of MDT (multi-drug therapy), and continue well beyond 10 years.(1) Therefore follow-up truncated at 7 years (or even less) underestimates the frequency of re-infection, especially among persons with genetically determined anergy. 

 

Inadequate BI criteria

 

Recognition of recurrence can be delayed by reliance on changes in average BI (bacillary index), instead of BI changes at single sites. Further, sequelae of past LL disease tend to delay the clinical suspicion of recurrence. Unavailability of skin smear facilities does not help.

 

Inappropriate populations

 

Follow-up in non-endemic areas does not reliably estimate the risk of reinfection in high-endemic areas. For example, reinfection rates in London (UK) are not expected to be very high.

 

Diluted denominators

 

Patients with a zero or low initial BI seldom suffer recurrence after MDT of any kind. Whenever included in estimates of recurrence rates, such patients dilute the denominator. This error is akin to diluting estimates of ovarian cancer risk by including boys in the denominator. That would lead to substantial under-estimates of the true risk. Similarly, if non-LL types of HD are included in the denominator then the recurrence rate among LL patients is likely to be underestimated. However, those with polar LL HD demand our special focus, as discussed further below. Recurrence rates among them need to be analysed separately.

 

Discussion

 

Prolonged anti-microbial protection of polar LL patients is important in endemic areas, for protecting individual patients against reinfection as well as to reduce transmission.   

 

Polar LL HD patients form a small fraction of all newly diagnosed patients but uniquely are highly susceptible to (re)infection and - if denied prolonged anti-microbial protection - can shed tens of millions of viable bacilli per day.(2) This allows transmission to continue unchecked during covert bacillary multiplication in LL HD patients, without their knowledge or consent. Further, recurrence exposes nerves of LL HD patients to yet more damage induced by viable bacilli, again without their consent. Transmission newly blights the lives of hundreds of thousands of additional people each year, involving important physical, psychological, social, educational and economic consequences. Children are among those afflicted. It seems wiser to emulate successful programmes than needlessly to allow further damage among LL HD patients or continued transmission.

 

In Cebu (Philippines), even 24 months of MDT failed to extinguish most human sources of infection in an endemic area.(2) However, in Karigiri (India) anti-microbial protection of LL HD patients till smear negativity reduced the incidence rate of LL HD by 16%/year, until near-zero incidence of LL HD.(3) The dramatic successes of Karigiri, Shandong and Uele (16% to 20%/year decline in incidence rate) all relied on prolonged anti-microbial protection of LL HD patients.(4-6) We could help colleagues in endemic countries to expand and accelerate such demonstrable success, or at least give them the elbow room to succeed. If we are too quick to impose our views and (too often ineffective) interventions on them, the space and respect required for front-line innovation can be constricted.

 

Many enlightened private practitioners and centres of excellence in India are already striving to improve outcomes, in the best interests of their patients. In ensuring prolonged anti-microbial protection for LL HD patients in endemic areas, they are also helping to keep these patients out of the infectious pool. Prolonged anti-microbial protection for LL HD patients is often achieved by the usual drugs used till smear negativity, or else with monthly doses of 3 bactericidal drugs given after the conventional duration of MDT.

 

We are a community with noble values and principles, unique in our pre-occupation with a highly stigmatising and misunderstood disease that is considered by many to be a non-problem. Persons affected by HD typically champion inclusion. Far be it from us to champion exclusion of LL HD patients, especially exclusion from prolonged anti-microbial protection. Instead we could work shoulder to shoulder with those affected, as champions of inclusion. These are not only good things to do, and consistent with the Universal Declaration of Human Rights, but also wise and epidemiologically effective.

 

Joel Almeida

 

References

 

1.      Balagon MF, Cellona RV, dela Cruz E et al. Long-Term Relapse Risk of Multibacillary Leprosy after Completion of 2 Years of Multiple Drug Therapy (WHO-MDT) in Cebu, Philippines. American Journal of Tropical Medicine and Hygiene, 2009; 81, 5: 895-9. reviewed and analysed further in 19a. Almeida J Recurrence rate among MB patients following RFT. LML 2 June 2019

 

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

 

3.      Scheelbeek PFD, Balagon MVF, Orcullo FM et al. A retrospective study of the epidemiology of leprosy in Cebu: an eleven-year profile. PLoS Negl Trop Dis. 2013 Sep 19;7(9):e2444. doi: 10.1371/journal.pntd.0002444. eCollection 2013.

 

4.        Norman G, Bhushanam JDRS, Samuel P. Trends in leprosy over 50 years in Gudiyatham Taluk, Vellore, Tamil Nadu. Ind J Lepr 2006. 78(2): 167-185. reviewed and analysed further in: 20a Almeida J. Karigiri, India: How transmission rapidly was reduced in a low-income population LML 29 October 2020

 

5.        Li HY, Weng XM, Li T et al. Long-Term Effect of Leprosy Control in Two Prefectures of China, 1955-1993. Int J Lepr Other Mycobact Dis. 1995 Jun;63(2):213-221. reviewed & analysed further in: 22a. Almeida J. What really happened in Shandong? LML 16 Nov 2019

 

6.      Tonglet R, Pattyn SR, Nsansi BN et al. The reduction of the leprosy endemicity in northeastern Zaire 1975/1989 J.Eur J Epidemiol. 1990 Dec;6(4):404-6 reviewed in: 23a. Almeida J. Reducing transmission in poor hyperendemic areas - evidence from Uele (DRC). LML 29 Nov 2019

 

 

= = = = =


P.S. UK policy states: "Multibacillary leprosy should be treated with a combination of rifampicin, dapsone and clofazimine for at least 2 years." Polar LL HD patients in endemic areas need at least as much anti-microbial protection as do patients in the UK. 

As the COVID-19 pandemic response underlines,(7) the most effective public health measures can originate in any part of the globe. The front-line is where knowledge is turned into good outcomes and impact. An ounce of demonstration is worth a ton of promises. LML is inclusive rather than exclusive. This allows notable front-line successes in endemic countries to become more visible. Important claims are scrutinised here by nearly all of the world's most knowledgeable experts. That's why LML is so uniquely valuable. It helps in separating what works at the front-lines from what does not. It also provides informed answers to queries of various sorts. Every disease needs an LML. More importantly, the patients, professionals and populations of endemic countries need LML.Thank you to LML, its team, and all esteemed members in our unique community. We have one common enemy - the bacillus - and we are well on our way to defeating it.

 

Reference

 

  7.       Sridhar, D. COVID-19: what health experts could and could not predict. Nature Med 26, 1812 (2020). https://doi.org/10.1038/s41591-020-01170-z

 __________________________________________________________________________________

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

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

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

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Friday, December 11, 2020

Fw: (LML) Infolep monthly overview of new publications on leprosy - December 2020

 


Leprosy Mailing List – December 11,  2020

 

Ref.:  (LML) Infolep monthly overview of new publications on leprosy - December 2020

 

From:  Anniek Akerboom, Amsterdam, the Netherlands

 

 


Dear colleagues,


Below the list of new publications you will find a section with interesting events. This time it also includes recordings of the GPZL & WHO webinar on persons affected and SDR-PEP and The Leprosy Mission and DPI's COSP13 side event on the rights of women affected by leprosy.

Are you a researcher looking for funding? Leprosy Research Initiative (LRI) is pleased to announce a call for proposals for research projects starting  in 2021. LRI funds research with a focus on leprosy – including research applications combining leprosy with other neglected tropical diseases (NTDs) or other diseases that share cross-cutting issues with leprosy. Proposals addressing any of the five research priorities are eligible to apply for funding in this call. Researchers are invited to complete and submit a Letter of Intent (LoI) through an online application portal. Deadline to submit LoI: January 29th, 2021 at 23:59 CET. More information on the call criteria and application procedure: see leprosyresearch.org/funding/apply-for-funding

We are happy to share that the Leprosy Review volumes from 2002 - 2020 are back online and can be found at leprosyreview.org/volumes. We are collaborating with Leprosy Review to ensure that the publications will again be accessible through the Infolep portal as soon as possible. 

This monthly review includes important WHO documents on contract tracing and PEP, the Global Leprosy Strategy and the NTD Roadmap. Furthermore, it provides the GPZL research agenda for zero leprosy and many other interesting publications. Feel free to contact me to receive full-text versions if these cannot be found through the Infolep portal. Also, I would be happy to assist you with literature searches.

Warm regards,

Anniek Akerboom

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




 

 



 



Highlighted

 



 



Leprosy/Hansen disease: Contact tracing and post-exposure prophylaxis
World Health Organization. 2020; 
Learn more

Global consultation of National Leprosy Programme managers, partners and affected persons on Global Leprosy Strategy 2021–2030: Report of the virtual meeting 26-30 October 2020
World Health Organization. 2020; 
Learn more

Ending the neglect to attain the sustainable development goals - A road map for neglected tropical diseases 2021–2030: 8-page summary
World Health Organization. 2020; 
Learn more

A comprehensive research agenda for zero leprosy
Steinmann P, Dusenbury C, Addiss D, et al. Infectious Diseases of Poverty. Springer Science and Business Media LLC. 2020;
Learn more

 



 



Leprosy & COVID-19

 



 



Early impact of COVID-19: Observations from an integrated WASH and NTD project in two south-eastern states in India
Anand S, Mamidi R, Biswas P. Leprosy Review. Lepra. 2020; 91 (3) : 295-298. 
Learn more

 



 



New publications

 



 



Accelerating towards a Leprosy Free India through innovative approaches in the National Leprosy Eradication Programme (NLEP), India
Kumar A, Karotia D. Leprosy review. Lepra. 2020; 91 (2) : 145-154. 
Learn more

An assessment of women's empowerment in mixed Self-Help Groups in Dhanusha District of Nepal
Jha K, Choudhary R, Shrestha M, et al. Leprosy review. Lepra. 2020; 91 (2) : 155-172. 
Learn more
 
"We are not afraid anymore…" Capturing the most significant change of the Leprosy Friendly Village approach in North Sulawesi, Indonesia
Budiawan T, Ferdiana A, Daendel S, et al. Leprosy review. Lepra. 2020; 91 (2) : 173-189. 
Learn more
 
An exploration of family quality of life in persons with leprosy-, lymphatic filariasis- and podoconiosis-related disabilities and their family members in Ethiopia.
Noordende A, Aycheh M, Schippers A. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2020;
Learn more

Socio-medical perspectives on leprosy in Indian religions
M. S, Rao P, G. K. Leprosy review. Lepra. 2020; 91 (2) : 190-199. 
Learn more

Geospatial Epidemiology of Leprosy in Northwest Bangladesh: A 20-year Retrospective Observational Study
Bulstra C, Blok DJ, Alam K, et al. Research Square. 2020; 
Learn more

Epidemiological situation of leprosy in a province in China: a long time to diagnosis and a high rate of deformity.
Zhang Q, Li G, Li C, et al. BMC public health. 2020; 20 (1) : 1790. 
Learn more

Methotrexate and prednisolone study in erythema nodosum leprosum (MaPs in ENL) protocol: a double-blind randomised clinical trial.
de Barros B, Lambert S, Shah M, et al. BMJ open. 2020; 10 (11) : e037700. 
Learn more

Intersectionality and health-related stigma: insights from experiences of people living with stigmatized health conditions in Indonesia.
Rai S, Peters R, Syurina E, et al. International journal for equity in health. 2020; 19 (1) : 206. 
Learn more

Association of MICA and HLA-B alleles with leprosy in two endemic populations in Brazil.
Jarduli L, Alves H, de Souza V, et al. International journal of immunogenetics. 2020;
Learn more

Evaluation Of Leprosy Management Program Implementation In Karang Penang Health Center, Sampang District, Madura
Nugraheni R, Wardani MK. STRADA Jurnal Ilmiah Kesehatan. Institut Ilmu Kesehatan STRADA Indonesia (STRADA Indonesia Health Sciences Institute). 2020; 9 (2) : 879-885. 
Learn more

Economic assessment of a community-based care package for people with lower limb disorder caused by lymphatic filariasis, podoconiosis and leprosy in Ethiopia.
Hounsome N, Kinfe M, Semrau M, et al. Transactions of the Royal Society of Tropical Medicine and Hygiene. 2020; 
[infolep.org/resource/economic-assessment-community-based-care-package-people-lower-limb-disorder-caused]Learn more

Leprosy - the current target in national programmes
Thangaraju P, Venkatesan N, Siddarth S, et al. Journal of Family Medicine and Primary Care. Medknow. 2020; 9 (10) : 5409. 
Learn more

The DermLep Study I: Results of Prospective Nation-Wide Survey of the Number & Profile of Leprosy Patients seen by Dermatologists in India.
Rao NP, Rathod S, Suneetha S, et al. Indian dermatology online journal. 2020; 11 (5) : 701-711. 
Learn more

Spatial analysis of epidemiological and quality indicators of health services for leprosy in hyperendemic areas in Northeastern Brazil
Barbosa CC, Bonfim CVD, Brito CMGD, et al. Revista do Instituto de Medicina Tropical de São Paulo. FapUNIFESP (SciELO). 2020; 
Learn more

Improving Treatment Outcomes for Leprosy in Pernambuco, Brazil: A Qualitative Study Exploring the Experiences and Perceptions of Retreatment Patients and their Carers
Khanna D, Wildt GD, Filho LAMDSD, et al. Research Square. 2020; 
Learn more

Prospects for new leprosy diagnostic tools, a narrative review considering ELISA and PCR assays
Gama RS, Leite LA, Colombo LT, et al. Revista da Sociedade Brasileira de Medicina Tropical. FapUNIFESP (SciELO). 2020;
Learn more

Zoonotic transmission of M. leprae in Brazil One Health Approach
Deps PD. info Hansen. 2020; 
Learn more

Leprosy, ancient scourge of humans, found to assail wild chimpanzees
Kupferschmidt K. Science. American Association for the Advancement of Science (AAAS). 2020; 
Learn more

Markets and Mycobacteria – A Comprehensive Analysis of the Infuence of Urbanization on Leprosy and Tuberculosis Prevalence in Denmark (AD 1200–1536)
Kelmelis KS, Kristensen VRL, Alexandersen M, et al. Bioarchaeology and Social Theory. Springer International Publishing. 2020;
Learn more

Crown vessels and shiny white structures in dermoscopy of histoid leprosy.
Abadías-Granado I, Navarro-Bielsa A, Gómez-Mateo CM, et al. JAAD case reports. 2020; 6 (11) : 1147-1149.
Learn more
 

 



 



Interesting events

 



 



GPZL & WHO Webinar: The Role of Persons Affected in SDR-PEP Implementation
01 Dec 2020 | Recording
Watch it here

The Leprosy Mission and DPI's COSP13 side event: The intersecting human rights challenges facing women affected by leprosy
03 Dec 2020 | Recording
Watch it here

ISNTD Connect Webinar: Hand Hygiene for All
10 Dec 2020 | Online
Register here

Sasakawa Health Foundation's Webinar Series 'Issues in Leprosy amid the Coronavirus Pandemic':

WHO NTD Webinar: The leadership needed to stimulate the battle against NTDs
16 Dec 2020 | Online
The link to register will be provided soon

 



 



 



 



Websites & Services

 



 




Info Hansen - A innovative hub for knowledge sharing about Hansen's Disease
https://www.infohansen.org/

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

https://allf.medicalistes.fr/

LML - Leprosy Mailing List - a free moderated email list that allows all persons interested in this theme to share ideas, information, experiences, and questions.
https://groups.google.com/forum/#!forum/leprosymailinglist

InfoNTD - Information on cross-cutting issues in Neglected Tropical Diseases (NTDs)
https://www.infontd.org/




 

 



 



Newsletters & Journals

 



 



ILEP newsletter archive: https://ilepfederation.org/news-events/#archive
 
GPZL newsletter archive: https://zeroleprosy.org/newsletter-archive/

Hansenologia Internationalis: http://www.ilsl.br/revista/atual.php

Indian Journal of Leprosy: http://www.ijl.org.in/index.html

Leprosy Review: https://leprosyreview.org/
Leprosy Review Repository (1928-2001): http://leprev.ilsl.br/arquivo.php

 



 



GDPR & the Infolep newsletter

 



 




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



 

 



 


 






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

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

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

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