Interest in leprosy is alive among young dermatologists: An account of IADVL CME and workshop on leprosy held in Hyderabad, India

Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) special interest group (SIG) on leprosy and IADVL Academy of Dermatology, with the support of non-governmental organization “Codewel Nireekshana-Acet” and Department of Dermatology, Gandhi Medical College (GMC) organized a one and half day continuing medical education (CME) and workshop, titled “update on leprosy-for PGs to practitioners” on the 14^th and 15^th September, 2013 in the campus of GMC, Hyderabad, India.

The emphasis of CME was to inform and update delegates on the present status and newer developments in leprosy. The workshop was planned in such a way to demonstrate essential clinical and basic laboratory techniques to all delegates apart from showcasing few advances in management options of leprosy.

The CME took off on the morning of 14^th September 2013 at 9 am in the “Alumni hall” of GMC. More than 200 delegates registered for it, and about 2/3^rd of them were post graduate (PG) students. Delegates and PG students from (Maharashtra, Karnataka, Kerala, Tamil Nadu, Odisha, New Delhi, Jharkhand etc.,) various part of India attended the meeting, even on a very short notice. After very brief introductory messages by Prof. Putta Srinivas, Prof. Geeta Kiran and Prof. Udaya Kumar, the conference was inaugurated by lighting of lamp by Dr. TSS. Lakshmi and Dr. R Patnaik, revered senior Dermatologists of this region. Before start of main programme, two of the leprosy workers who served leprosy with distinction and no more with us, Dr. V.V. Gurunatha Babu, a renowned Leprologist and great teacher of leprosy and Mr. Mohd Ismail, who was a Leprosy histopathology technician par excellence, were remembered and respects paid.

In the first session of CME, Dr. Sudhavani, faculty of GMC, spoke on classification of leprosy and their appropriateness to therapy. Dr. Sujai Suneetha spoke on the relevance of skin smear and skin biopsy vis-a-vis clinical diagnosis and how they complement each other. He emphasized that skin smear is a must in all suspected cases of leprosy. He also stated that skin biopsy can give clear info on reactions, which histologically can sometimes precede clinical reaction. The granuloma fraction can be a guide to activity, especially if follow up biopsies are done. Bacterial index of granuloma especially when it is high (4+ or more) should alert the clinician on continuation of multidrug therapy (MDT). 
He highlighted that skin biopsy can help in taking decisions on continuing or stopping treatment, treating reactions and detecting relapse. He argued for the judicious use of biopsy as a tool in leprosy management in all tertiary centers.

In the session on therapy of leprosy, I spoke on various fixed duration therapies (FDT) and their modified versions available for Leprosy. Rifampicin, Ofloxacin and Minocycline (ROM) therapy is not advocated any more by WHO for single skin lesion cases. Uniform-MDT for all patients of leprosy is still an unproven therapy. World Health Organization (WHO) MDT is the only approved and proven FDT for leprosy. Any modification or extensions of therapy should have WHO MDT as lattice to improve upon it. Dr. IC. Reddy spoke about newer drugs available for leprosy and on their relevance and advised that they should not be used empirically and in unproved or un-tested regimen. He also suggested that short regimens with new drugs are not much value in leprosy, with no studies to support such claim. Dr. Hemant Kar in his talk on management of suspected MDR/non-responding leprosy, emphasized that in such cases consider the option to extend the MDT for 12 more months, which is accepted by authorities. If reactivation is confirmed in few months of release from treatment (RFT), restart the full course as though it is a new case. He strongly advised against use of newer drugs in case of leprosy empirically and advocated use of WHO MDT only, as it is robust in routine practice. He mentioned about the proposed multi-centre trial with inclusion of Moxifloxacin, an initiative of IADVL-SIG leprosy. Dr. Udaya Kiran spoke on algorithmic approach for type 1 reaction treatment. Emphasized that dose of prednisolone should be full dose (1 mg/kg) in cases of when multiple nerves are involved, patient is obese and neuritis is severe. Duration should be longer than 4 months, up to 6 months and withdrawal step wise. Dr. Aparna Palit spoke on approach to patient with persistent and recurring clinical activity, and divided it into three categories. One, those due to incomplete treatment as in defaulters, second, those due to post RFT reactions and a third small group due to true reactivation/relapse or re-infection. Dr. H. Kar in his second lecture presented a step wise approach to type 2 reactions of leprosy based on it is severity. Info on use of Methotrexate, azathioprine and others was presented. Dr. Ananth Reddy, an experienced leprosy reconstructive surgeon, spoke on role of pre and post of physiotherapy and scope of reconstructive surgery in leprosy and emphasized on the role of identifying nerve function impairment (NFI) and its management early to avoid surgery later. Dr. Raghunatha Reddy, a trained dermato-surgeon spoke on how to examine nerves and the role of fine-needle aspiration cytology and biopsy on peripheral nerves. He kept it crisp as he had a live demo of nerve biopsy next day. Dr. Suman Jain in her talk on use of ultrasonography (USG) in nerve imaging informed about its application in deciphering structural changes, such as fascicular shadows etc., for its integrity. Also spoke about accentuated blood flow signals during phases of reactions. Dr. Vijaya Lakshmi, a PhD researcher from blue peter research centre, LEPRA, Hyderabad spoke on T cell responses in leprosy and their advances in research and gave glimpses of research on genes and other factors in identifying susceptible members in family of leprosy patient. Dr. Udaya Kiran gave a very brief talk on a novel approach, the use of camouflage on skin patches in leprosy patients and its impact on ‘qualify of life index’. Before the close of the CME, there was a session ‘meet the experts’ where members asked questions to expert panel of faculty. There was interesting discussion on iris phenomenon in leprosy and whether it is different from type reaction. Also the rare complication of acute renal shut down to rifampicin and an interesting case of so called ‘auto aggressive hansaniasis’ was discussed. The CME ended at 5.15 pm.

WORKSHOP

Workshop was attended by about 140 delegates which was conducted on 15^th of September at Department of Dermatology, GMC. There were five workstations. Delegates were grouped in to five batches with max of max 30 each. Members moved from station to station to cover all in 5 hours. It started at 9 am and ended at 2 pm.

Workstation-1

Skin smear–techniques of taking smear, staining and assessing bacillary index (BI): Faculty involved were Mr. Venkateswara Reddy, Mr. Shamshuddin, (senior skin smear technicians) Dr. Sujai Suneetha and Dr. Lavanya Suneetha. Participants were shown techniques and given tips on: How to take a good skin smear, how to prepare good AFB stains and how to stain for AFB, the methods & pitfalls. With the help of 6 microscopes, method of grading of BI of a skin smear (1+ to 6+) was shown.

Workstation-2

Testing for NFI: Faculty involved were; Mr. Md. Muzaffarullah, Mr. Bala Krishna (leprosy physiotherapists), Dr. K. Udaya Kiran and Dr. P. Narasimha Rao. The technique of using SW filaments on hands and feet for charting of NFI and voluntary muscle testing in leprosy, correct method of examination of peripheral nerves and their grading in a leprosy patient and assessment of disability based on WHO grading was demonstrated. In addition, the use of camouflage on facial patches and other patches on exposed parts of body to improve quality of life of patient was demonstrated.

Workstation-3

USG -its use in assessing peripheral nerves in leprosy: Faculty involved were, Dr. Suman Jain, Dr. Renuka Raju and Dr. Kavita. Basics of USG use in leprosy and methods of its use for various nerves in leprosy were demonstrated with the help of a high definition USG machine. When to refer leprosy patients for USG examination and what to expect from it were also explained.

Workstation-4

Physiotherapy and rehabilitation in leprosy: Faculty involved were, Mr. Purushottam, Mr. Ganapathi, Ms. Vimala (all trained physiotherapists) and Dr. Anantha Reddy. Basic exercises for small muscles of hand and feet, essential supports for hands and feet for use during reactions were shown. Methods of nerve stimulation, active and passive exercises, and do's and don’ts in physiotherapy were also explained.

Workstation-5

Nerve biopsy station: Faculty involved were, Dr. Raghunatha Reddy, Dr. Narasimha Rao Netha and Dr. Rajya Lakshmi. A short power-point presentation on technique of nerve biopsy, was followed by the live video demonstration of nerve biopsy on radial cutaneous nerve and sural nerve.

Adequate time was given for answering questions of the participants in all workstations. Delegates participated with vigor and discipline. During the workshop the Semmes-Weinstein (SW) filament set of five, specially fabricated by mounting on needle hubs were sold for a very small price and more than 150 sets were sold. All the delegates were very keen to put them to use in their clinics and hospitals.

During the conference, there was no official dinner. Only working lunch was served. Participation of Pharma was meager, as expected for a leprosy conference. Nonetheless, it did not seem to matter at all for anyone involved, neither to delegates nor to faculty. Audio recording of whole CME proceedings and video recording of nerve biopsy workshop procedure was done. We are planning to come out with an e-booklet of edited transcripts of proceedings of this CME.

Overall, it was very pleasing to see the enthusiasm of all the delegates, especially in the PGs. They were all ears and with bright eyes and intelligent questions. It was a very gratifying experience for the faculty who took part in this effort voluntarily, without any financial benefit or support. At the end of the conference, we were gratified to note that interest to get updated in leprosy is alive in Dermatologists and surely in young post graduate students, provided one finds the right way to enthuse and make it interesting.