New Leprosy Patients at ALERT, 2009/2010

Leprosy Mailing List – January 7^th, 2012

Ref.:    New Leprosy Patients at ALERT, 2009/2010

From:  Shimelis N. Doni, Addis Ababa, Ethiopia

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Dear Dr Noto,

Re:  New Leprosy Patients at ALERT - All Africa Leprosy and TB Education, Rehabilitation and Training Center, Addis ABABA, Ethiopia.

Method: A retrospective analysis was conducted from October 2009 to October 2010. The data were collected from the new patient registration book of the ALERT Center Leprosy Clinic.     

Objective: To analyze new patients detected at ALERT Center, Addis Ababa, Ethiopia.

Result and Discussion

Leprosy notification rate in Ethiopia remained relatively stable over the past five years, between 4000 and 5000 new patients per year according to the Ministry of Health.  A total of 429 new leprosy patients were diagnosed at ALERT (October 2009/2010); most of them, 415 (97%), were classified as Multibacillary and 9 (3%) as Paucibacillary; and 5 patients were present as pure neural leprosy.  Of the new patients 293 (68%) were males.  This male predominance reflects the difficulty of women to travel to health institutions.   A significant number of children 14 (4%) children were among the new patients, the youngest was 2 years old.  This is slightly lower than of the 7% children among new patients in Ethiopia in 2010 (Ministry of Health report).  This indicates that there is active and recent leprosy transmission in the community.  About 132 (31%) patients had a bacteriological index (BI) greater than 3.  This indicates that a significant proportion of leprosy patients are highly infectious.  Unfortunately, we do not have a contact tracing programme and depend on the patients to check his family contacts and bring in cases.

A significant proportion of patients presented with leprosy reaction, among them 175 (41%) patients were diagnosed with reversal reaction and 26 (6%) patients with an erythema nodosum leprosum (ENL) reaction at the time of first presentation.  The patients were referred from the health centers where primary health care workers have difficulties treating reactions and monitoring progress.  A significant number of patients were found to have nerve damage of which Grade 1 disability stands at 181 (42%) patients and Grade 2 at 77(18%) patients; which is much higher than the Ministry of Health leprosy report of 9% grade 2 disabilities among new patients in 2010.  Disability grade 2 is a sign of late detection (late diagnosis and treatment) which is due to fear of stigma, spending time at the holy water and lack of knowledge as well as delay in diagnosis/treatment at the health institutions.

Conclusion and Recommendation

The best cost effective strategy for leprosy prevention and control is by designing a new national leprosy training program for all health professionals for early diagnosis, treatment and   management of reactions and disability; Improve and  maintain  MDT drug delivery to all  health  institutions; thalidomide which is a treatment of choice for ENL reaction should be available to  ALERT Center which is  the only specialized dermatology center in Ethiopia; Develop a contact tracing programme; Strengthen the self-care programme; Increase community awareness and  involvement in leprosy prevention  and control; Improve the socioeconomic status of the leprosy patients.

Yours sincerely,

Dr Shimelis N Doni

Medical Director

ALERT, Addis Ababa, Ethiopia

Give the leprosy workers a voice

Leprosy Mailing List – December 26^th, 2011

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

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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:

1. 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

Leprosy Mailing List – December 26^th, 2011

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

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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]

Leprosy Mailing List – December 26^th, 2011

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

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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?

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

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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

Leprosy Mailing List – December 24^th, 2011

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

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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

Leprosy Mailing List – December 20^th, 2011

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

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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