Thursday, February 16, 2017

(LML) Government of India proposes new action plan against leprosy in its parliament

Leprosy Mailing List – February 16,  2017

Ref.:  (LML)   Government of India proposes new action plan against leprosy in its parliament

From:  P. Narasimha Rao, Hyderbad, India


Dear Pieter,

It is heartening to note that this year’s annual national budget presented by  finance minister Mr Arun Jaitley on 1 February 2017 to Indian Parliament mentions about leprosy. The budget paper in its page 15 states that ‘Government of India has prepared an action plan to ‘eliminate’ leprosy by 2018. It also mentions that 150 000 health sub-centers  all over India would be transformed into Health & wellness centers. 

This is a laudable and welcome initiative. More details are awaited to bring clarity it this action plan.  However, there are couple of issues we need to take note of. The year  2018 is just a year away and  second, what the term “elimination’ actually implies in regard to leprosy in Government of India’s  new action plan, as  India has reached WHO elimination target for leprosy by the end of year 2005 itself.  If it is state and district wise elimination (local elimination) the document is referring to, India still has some distance to cover.

The National leprosy elimination programme (NLEP), India – Report of 2014 -15 reads as follows: 34 States/ Union territories (U.T) had already achieved the level of  WHO elimination target  i.e. PR < 1 case per 10,000 population.  One State (Chhattisgarh) and One U.T. (Dadra & Nagar Haveli) has remained with PR between 2 and 5 per 10,000 populations.  Four other States/UT viz. Odisha, Chandigarh, Delhi and Lakshadweep which achieved elimination earlier have shown slight increase in P.R. (1-2), for the year 2014-15.

While 532 districts in India have reached the elimination, 137 (out of 669) districts in India still have PR of leprosy of >1 indicating that local elimination is still to be reached.

In his context it would not be out place to refer to recent news report on spurt of new cases detected during active search in India. The Indian Express, Mumbai edition of November 23, 2016 published a report based on interview given by Union Health and Family Welfare Ministry’s Deputy Director General (Leprosy) Anil Kumar in which he stated that as many as 31,666 “hidden” leprosy cases were detected in a door-to-door survey held in September and October across 20 states. This included 3,755 pediatric cases

This new initiative of Government of India gives welcome hope to detect and bring down the leprosy numbers further in India. 

 

 

P. Narasimha Rao, MD, PhD

 

dermarao@gmail.com

 

p/s Note editor: in the context of this communication we like to refer to the LML letter by Joel Almeida of February 9, 2017 “ India's Supreme Court issues order”.

 


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, February 8, 2017

(LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

Leprosy Mailing List – February 9,  2017

Ref.:    (LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

From:  Tahir Dahiru. Kano/Jos, Nigeria


 

Dear LML,

 

I would like to refer to the LML article of Linda Lehman of February 5, 2017. What she describes is really true but in situation of low Leprosy endemicity the focus should be first in the referral centers where  the skills can be impacted and maintained. If staff at the peripheral clinics will be trained and supplied with MF, the skills will never be perfected as some stay for months without seeing a Leprosy patient.

 

 

Dr Tahir

 


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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(LML) India's Supreme Court issues order

Leprosy Mailing List – February 9,  2017

Ref.:   (LML)   India's Supreme Court issues order

From:  Joel Almeida, Mumbay and London


 

Dear Pieter,

 

 

The recent Indian budget singles out the "Poor and the Underprivileged" as one of the main themes. This includes strengthening the systems of health care. Leprosy is specifically targeted. This means a boost of funding. We need to switch our mindset from scarcity to effectiveness. Ms. Lehman has offered an excellent account of graded monofilament use. We could now consider ways to make the most effective methods available to all. 

 

People may be able to set their own bones after fracture, but we need to ask whether that is the most effective approach. It is the same with leprosy.  We need to focus on what is most effective. Not on how we can save money by exposing people to permanent damage. Their limbs and eyes are as important as our own.

 

Our opinions about technical questions matter. Neglect of leprosy over the past decade arose from scientifically obsolete or invalid definitions. Some of these invalid definitions still surface from time to time.

 

"Burden of disease" has a standardised definition: prevalence of sequelae x disability weight of the sequelae.  That's the definition for all diseases, and we need not treat leprosy differently. Else we disadvantage the population at risk of leprosy. 

 

"Elimination" was defined by the WHO NTD report of 2013 as the reduction to zero of the incidence rate of infection in a defined geographical area as a result of deliberate efforts.  That's the definition for all diseases. We need not disadvantage the population at risk of leprosy by condoning scientifically obsolete terms such as "elimination as a public health problem".

 

Further, over-optimistic predictions tend to encourage complacency and to hasten a premature drop in funding. So we need not ignore the rising trend in incidence rate of newly detected cases with visible deformities. Else our mathematical models tend to mislead and damage.

 

We have emerged from a dark period in leprosy control, where experts were in a mindset of premature self-congratulation and scarcity. There was a rush to destroy competent leprosy services.  But there is no substitute for the trained, mobile leprosy workers who we dismissed. They are needed again, to transform outcomes.

 

The Supreme Court of India has ordered the Indian government to show how it intends to fill vacant staff posts at the ground level. "You need people to successfully implement your policies at the ground level," the court stated. The court has got it right, and we experts need to keep up. The people of India, through the courts, have been reclaiming what we experts took away.  Now we can support the people of India in their quest to rebuild adequate leprosy services.

 

 

Regards,

 

 

Joel Almeida


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, February 7, 2017

(LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

 

Leprosy Mailing List – February 8,  2017

Ref.:    (LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

From:  José Antonio Garbino, Bauru, Brazil


 

Dear  Pieter and all,

 

Excellent article from Linda (LML, February 5, 2017)! I think that this algorithm called LOFT is the basis of the nerve function follow up, and that it should be always be remembered. SORRI and ILSL developed a Software called NervScore that transforms the serial NFI evaluations and medication doses in graphs making possible to see easily  the evolution of all nerves under the treatment: http://www.sorribauru.com.br/ email: ti@sorribauru.com.br. Attached  is a paper about nerve evaluation and a PP about the NervScore.

 

 

On the other hand, in what the more armed technology may help?

Well, we have both in current use: the nerve conduction studies (NCS) and the nerve ultrasound (US).

-       The NCS can add the understanding of the NFI underline neuropathology – demyelination acute or subacute that means nerve inflammation-, it can show the sites of entrapment precisely, the severity more accurately and based in these findings one can presume the prognosis.

-       The US is more useful to show nerve morphology, i.e. the enlargement, nerve abscess, liquid collection in the nerve abscess or not. The US with Doppler can also show nerve inflammation. The Doppler, in my point of view, can be useful to show inflammation when the NCS doesn´t show demyelination, when the picture is only axonal.

-        

Which gains the approach to the underline neuropathology will provide to the NFI follow up? These data will serve as the guideline for the steroid or other immunosuppressant treatment, and will also show if it is working effectively.  

 

 

Best regards,

 

 

Garbino

 

Jose Antonio Garbino, MD, PhD, Clinical Neurophysiology

Research Institute "Lauro de Souza Lima', Bauru/SP

 

-           José Antonio Garbino, MD, PhDa,⁎, Carlos Otto Heise, MD, PhDb,

Wilson Marques Jr., MD, PhDc. Assessing nerves in leprosy. Clinics in Dermatology (2015)

-          Garbino JA,  Bento LFM, Marques T, Quaggio CMP, Nardi SMT, Nicholl ARJ, Bentim C, Virmond M. Software for Assessing Nerves. ILSL, Bauru, São Paulo, 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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(LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

Leprosy Mailing List – February 8,  2017

Ref.:    (LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

From:  Grace Warren, Sidney, Australia


 

Dear Pieter.,

Thank you for publishing the marvellous article by  Linda Lehman (LML, February 5, 2017) on the use of MFN for testing nerve function in Leprosy.

Congratulations too to Brazil for making these seas available in all areas (I assume from her comments) and hopefully they are used correctly for as she points out their use needs to be well taught.

I have never visited S. American let alone worked in Brazil but I am experienced in Asian countries and some African, and I know that the MFN sets are certainly not available. Most of the countries in which I have worked could not afford for the workers to go out doing the villagers and the contacts.

Is there any way of gaining global financial assistance  to enable such a useful tool? In the meantime can we train the workers to use what they have got for in many countries very few workers really do  touch tests correctly and make them helpful in assessing the activity of the disease and its progress.

She has set out very well the pros and cons of their use and I would like to see them used more, which means they must be more easily available.

Yours sincerely,

Grace  Warren

Previously adviser in Leprosy and rehabilitation surgery for The Leprosy Mission in Asia


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, February 4, 2017

(LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

Leprosy Mailing List – February 5,  2017

Ref.:    (LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

From:  Linda Lehman, Belo Horizonte, Brazil


 

Dear Pieter,

 

I have been following the Leprosy Listing comments on Monofilaments (MF) and ball point pen(BP) /clip testing for the last month with comments from many experts in the field.  It always stimulates much good reflection and discussion.  It all comes down to priorities and commitment to enable early detection of Nerve Function Impairment (NFI).  I will comment on the following areas:

 

1.    Priority for Disability Prevention

2.    Using LOFT to discover Nerve Function Impairment

3.    My 40yrs Experience with MF and BP pen/clip experience in work in the Americas, Africa and Asia in the field and reference centers

4.    Share the Brazil experience adopting and using MF for sensory testing and the adoption of MF within National Leprosy Guidelines, training and monitoring activities

 

Priority for Disability Prevention

My question is, do we want to Prevent Disability?  This requires BOTH early disease detection and Early Detection of NFI along with adequate treatment for the NFI.

 

Using “LOFT” to discover Nerve Function Impairment

Whether we use MF, ball point pens, clips we must remember to think of LOFT:

LISTEN carefully to the patient’s comments;

OBSERVE for atrophies, injuries, dryness, etc.;

FEEL for sweating, temperature difference; and

TEST sensory and motor function and take ACTION when NFI  is identified. 

 

My Experience with MF and BP /clip experience in work in the Americas, Africa and Asia in the field and reference centers

·         Both require good training on testing technique, interpretation and using information to make decisions on treatment interventions (corticosteroids, surgery).

·         Both require constant training and monitoring during field visits to assure NF evaluation is done, is done correctly, interpreted correctly and then that needed action is taken.  It seems to be a never-ending job!

·         BP pressures vary from 4g (rare) to over 300g depending on the person.  Getting a consistent 10g pressure touch is rare and can improve with training.  When BP not felt, motor function is usually involved, indicating advanced NFI. If not felt, we know the person is AT Risk for Injury

Caution:  Feeling BP does not mean sensation and nerve function are normal!

·         MF are not perfect and have their limitations but are more repeatable and reliable than BP and paper clips.  They can demonstrate change in NFI, if a series of filaments are used.  Using 10g does not detect NFI early, it only tells us someone is AT RISK for injury.  Feeling 10g does not mean sensation and nerve function are normal.  The greatest limitation of MF is that they are not easily accessible or available.

 

Brazil Experience with MF

·         Brazil is the 5th largest country (8,516 million km2)  in the world and has over 30,000 new cases of leprosy each year.  There are more than 5,500 municipalities in 26 states and 1 federal district.

·         At the ILA China 2016 Congress I presented on a 24-year follow-up of using MF within the national Hansen’s disease control activities after MF kits were produced and available in Brazil.  http://www.sorribauru.com.br/custom/462/uploads/English223.pdf

·         Initially in 1983 only two locations in Brazil used imported MF kits and today MF kits are produced and used in all 27 federal states and district of Brazil.

·         A Monkey Survey was done Aug 2016 with all Brazilian State HD Coordinators and the National Program.  Results of data from 13 state coordinators and National program are as follows:

 

o   MF in Leprosy: 100% in reference centers, 92% Primary Health Care, Other - Universities, private clinics and other non-leprosy services use MF (diabetes, neuropathies, research cancer, etc.).

o   Most High endemic states.  75% of municipalities who attend HD use MF.

o   All use 6 monofilament kits (0.05g, 0.2g, 2g, 4g, 10g, 300g). If only 1 filament is used, the 2g is used for both foot and hand, as oriented in Brazil National Hansen’s disease Guideline and 10g for the diabetic foot as oriented by the National Diabetic Foot program.

o   When MF are used in government health services, it is part of the routine practice in leprosy and diabetes (93%) versus only with referral.

o   MF have been a part of the Brazil National Leprosy Guidelines, training manuals and monitoring activities since 1998.

o   MF use in leprosy programs was adopted due to the following factors:

§  Beliefs and knowledge of Professionals that MF testing detects and quantifies NFI best and is important to disability prevention.

§  MF are Accessible and Available IN COUNTRY.

§  Good quality control of produced MF Kits by producer.

§  Good durable MF Kit design for the field.

§  MF is initially complex to learn but possible with training and monitoring.

§  NFI Results and changes are easy to see with color coding.

§  Political commitment of National Leprosy Control Program of Brazil in adopting MF within routine leprosy control program.

 

TAKE HOME MESSAGE:

 

MF are best for detecting and monitoring NFI in the field but MF must be made accessible and available with good quality control production at a reasonable cost.  It requires National and local political and professional commitments to include MF within guidelines, training and monitoring activities.

 

 

Linda F. Lehman, OTR/L MPH C.Ped

Senior Advisor for Morbidity Management & Disability Prevention

American Leprosy Missions

llehman@leprosy.org

 

 

 

Reference Article:

Lehman, Linda Faye, Maria Beatriz Penna Orsini, and Anthony Robert Joseph Nicholl. "The development and adaptation of the Semmes-Weinstein monofilaments in Brazil." Journal of Hand Therapy 6.4 (1993): 290-297.

 


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, January 31, 2017

(LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

 

Leprosy Mailing List – February 2,  2017 

Ref.:  (LML) Silent neuritis. Nerve damage. Disability and deformity. Prevention and management.

From:  Grace Warren, Sidney, Australia


Dear Pieter,

I would like to thank  Arry Pongtiku (LML, January 29, 2017) for these timely comments   by  someone who has been taught to use MFN and they are not easily available on his  field.,

I like his comments, very practical  especially getting the patients to try and assess themselves.  I write to remind people of the use of an opened paper clip the long oval type. If you open out one arm you have a long tool, easy to handle, that has a rough end and a smooth curved end so it ought to be easy for anyone with any sensory perception of appreciate the difference between the sharp and blunt as I call them. But even better, if the patient is asked (after the clip is removed) to point to where he was touched. It will often indicate that he does not feel the site accurately!  This may indicate that there is already some nerve damage even if the patient still feels some tough.

The Parameds can even do this out on the field- no extra costs !!!!

Grace  Warren

Previously adviser in Leprosy and Reconstructive surgery in Asia,  for the Leprosy Mission International  ( 1975-1990).

Arry Pongtiku, Papua,Indonesia


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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