[Leprosy outpatient clinic in Aichi Prefecture, Japan].

Until the Japanese Leprosy Prevention Law was abolished in 1996, leprosy patients, regardless of their severity, had to be treated by accredited doctors. The majority of them had to be confined in a sanatorium to be treated, since only few hospitals/sanatoria had outpatient clinics for leprosy patients. This de facto confinement limited their occupational, social, financial, and family options, but no clear criteria/guidelines allowing discharge existed. The importance of leprosy outpatient clinics was almost never debated until 1962, when Tofu Association (a foundation established in 1952 to support the confined patients) and the National Suruga Sanatorium planned the opening of the clinic. This clinic looked after total of 4,977 patients until the abolishment of the Law. Since 1996, 349 persons consulted the clinic as of 2010. The importance of the continuation of these clinics is beyond dispute, even in low-endemic countries. However, the diminishing number of patients and demands in this country makes the management difficult. Thus, coordination with the local clinics and dermatologists is inevitable.

[Future strategies for global leprosy control, 2011-2015].

The main principles of leprosy control, based on timely detection of new cases and their treatment with effective chemotherapy in the form of multidrug therapy, will not change over the coming years. The emphasis will remain on sustaining the provisions for quality patient care that are equitably distributed, affordable and easily accessible. The Enhanced Global Strategy for Further Reducing the Disease Burden due to Leprosy: 2011-2015 together with the updated Operational Guidelines of the Enhanced Global Strategy. The Strategy will require endorsement and commitment from everyone working towards the common goal of reducing the disease burden due to leprosy and its detrimental physical, social and economic consequences in order to move closer to achieving the common dream of "world without leprosy".

[Children born to Hansen's disease patients in Amami-Oshima, Kagoshima, Japan].

In the Japanese leprosaria, it was very difficult or almost impossible for leprosy patients to give birth to their children. There were various reasons for this situation. Leprosy in the women mostly worsened in pregnancy and some of the children developed leprosy. Because of the chronic nature of the disease, marriage was encouraged in Japanese leprosaria, so that vasectomy was usually enforced in men who were wed, while artificial abortion was enforced in pregnant women. The only one exception was the situation of the Amami Wako-en Leprosarium. The Wako-en Leprosarium was started in 1943, and between 1946 and 1953, it was under American rule. Later it was transferred to Japanese rule. Religions such as Buddhism, Christianity and other religions greatly helped with leprosy patients, and in the Wakoen, it was Catholicism which prevailed. Catholic believer Joan Matsubara (later the secretary of Wako-en), Father Patrick Finn, Kaoru Ohira (director) outlined how children born to Hansen's disease patients would be grown up and made the internal rules of the couples' dormitory, while this was impossible in other leprosaria. Between 1953 and 1954, children were brought up by Matsubara's family or nurses. And since November 1954, children were brought up at nurseries (firstly named "Children's House" and later at "Naze Engel House" and children between 2 and 3 years went to "White Lily House". The children could meet their parents at times and now they are full-fledged grown-up citizens.

[Report of the Ninth meeting of the WHO Technical Advisory Group of Leprosy Control].

The Ninth meeting of the WHO Technical Advisory Group (TAG) on Leprosy Control was held in Cairo, Egypt on 6th and 7th March 2008. The meeting was chaired by Professor W.C.S. Smith and attended by national leprosy programme managers from Brazil, the Democratic Republic of Congo, Cambodia, Egypt, Iran, India, Nigeria and Thailand. In addition, several experts and members of the Technical Commission of the International Federation ofAnti-Leprosy Associations (ILEP) also attended the meeting.

[Leprosy and medicine II--progress and establishment of an absolute isolation policy].

The leprosy policy of Japan began from when the government enacted "law No. 11 (The leprosy prevention act)" in 1907 (Meiji 40) and several leprosy sanatoriums were built to receive previously homeless patients. Then, with the rise of totalitarianism, the isolation policy of Japan gained national support under the slogan "Patient Relief", which would become a major factor behind the enactment of "Leprosy Prevention Law" in 1931 (Showa 6) by which the leprosy policy was changed to one of absolute isolation aimed at the internment of all leprosy patients. From recent research on the leprosy policy of Japan, the internment of all leprosy patients, isolation for life, social defense, and neglect of patients' human-rights had tragic results in many cases. However, there is little research which can reply clearly to the question of whether the leprosy policy of Japan was really original and what factors led to the formation of the absolute isolation policy. This paper focuses on the relation between leprosy policy and treatment, and from this, I make clear the similarities, or peculiarities, of the isolation policy between Japan and the rest of the world, while clarifying the factors associated with the progress of the absolute isolation policy. The processes involved were historical and medical historical in that the relation between the formation of a national health system and the progress of the isolation policy of Meiji Era, the proposal of the isolation policy by Dr. Keizo Dohi, Dr. Shibasaburo Kitasato, and Dr. Masatsugu Yamane; the practical application of this policy by Dr. Kensuke Mitsuda, and the decision to enact this policy and its support by the Health and Medical Bureau and the Department of the Interior, as well as many other factors, all contributed to the final implementation of the absolute isolation policy.

[Leprosy and medicine I--proposal of an isolation policy and its background].

The leprosy policy of Japan began from when the government enacted "law No. 11 (The leprosy prevention act)" in 1907 (Meiji 40) and several leprosy sanatoriums were built and the patient who wanders about was received. Then, in rise of totalitarianism, the isolation policy of Japan gained national support under a slogan "Patient Relief", and it would become the big factor to which enactment of "Leprosy Prevention Law" in 1931 (Showa 6) and leprosy policy changed to segregation which aimed at internment of all leprosy patients. From today's research on the leprosy policy of Japan, it is internment of all leprosy patients, whole life isolation, social defense and neglect of patients' human-rights and led to many tragedy of patient. However, there is little research which can reply clearly to the question of whether the leprosy policy of Japan was really original and what the factors of led to the formation of the segregation policy. This paper focuses on the relation between leprosy policy and medicine, and from this, I make clear the similarity, or peculiarity of the isolation policy between Japan and the vest of the world, and clarify the factors of progress of the absolute isolation policy. The processes are historical and medical historical the verification of the relation between the formation of the national medicine and the progress of the isolation policy of Meiji Era, the proposal of the isolation policy by Dr. Keizo Dohi, Dr. Shibasaburo Kitasato, and Dr. Masatsugu Yamane, and the application by Dr. Kensuke Mitsuda, the decision to enact this policy and its support by the Health and Medical Bureau and the Department of the Interior, as well as many factors.

[Future strategies for global leprosy control].

WHO has recently proposed a 5-year strategy plan for leprosy control beginning from 2006 to 2010. Even though currently there are still nine countries which have yet to achieve the goal of eliminating leprosy, it is considered to be accomplished in the near future. It is expected that the number of newly detected cases are expected to decline in the future by early detection, accurate diagnosis, early treatment, preventing disabilities and by further continuing the leprosy control activities.

[Situation of global leprosy].

The epidemiological situation of leprosy is reported by the health division of each country to WHO. The reported data is collected by WHO and is immediately run on the Weekly Epidemiological Record. On this latest edition, data from the beginning of 2005 was reported. According to this edition, the importance of the fact that nine countries in the world has yet to achieve the WHO goal of eliminating leprosy, early detection and constantly providing drugs free of charge, and continuing to carry out the leprosy control activities within the general health services.

[Leprosy situation in Myanmar before and after multidrug therapy].

We introduced history of leprosy in Myanmar based on the book of Myanmar Academy of Medical Science published entitled "CONQUEST OF SCOURGES IN MYANMAR (Complied and Edited by Ko Ko, Kyaw and U Thaung) at 2002. "Leprosy Elimination Programme in Myanmar (Kyaw Lwin and Kyaw Nyunt Stein)" was appeared at chapter III in it. After dapsone treatment appeared, leprosy control program has started. Health system and service were developed and leprosy control program was also included in them. The integration of the elimination activities into basic health workers, such as midwives and health volunteers, has enabled the participation of a wide range of people in the community. After 1990s, multidrug therapy (MDT) was covered whole area of Myanmar, and task force for leprosy elimination was formed at Sate/Division, District and Township level. Finally Myanmar achieved the elimination of leprosy in January in 2003.

[Two cases of Hansen's disease].

We report two cases of Hansen's disease. Case 1 was 71-year old Japanese man who developed left ulnar nerve palsy since 7 years ago, multiple erythema on his body since 2-3 years ago, and erythematous nodules on his face since 3 months ago. He had no history of living outside Ibaraki prefecture. The clinical feature, the skin biopsy, laboratory data showed that he had borderline lepromatous leprosy. He was treated with multi-drug therapy which was effective and was stopped 3 years after the bacterial index showed negative. Ten months later, erythema on his body and face appeared and the therapy was restarted. Case 2 was 68-year old Japanese man who developed 5 cm of nummular erythema with slight numbness on his right forearm since 3 months ago. He had lived in Brazil since he was 24 to 64 years old. The skin biopsy showed epithelioid cell granuloma in the dermis involving vessels and nerves. Polymerase chain reaction test showed the M.leprae DNA, and he was diagnosed as indeterminate leprosy. He was treated with dapson and rifampicin and 2 months later, erythema and numbness disappeared.

[A case of multibacillary leprosy].

We report a 74-year-old Japanese man who occurred leprosy at the age of 68. He moved to Bolivia at the age of 33 as an immigrant. He complained erythematous plaques on his trunk and extremeties and dysuria. Skin biopsy specimen revealed granulomatous lesions and acid fast staining showed numerous number of positively stained bacilli. He was diagnosed as multibacillary leprosy and MDT containing DDS, RFP, and CLF was started. During the treatment, he developed borderline reaction twice presenting severe pain and marked swelling on his hand and foot. The reaction was successfully treated with daily dose of 50 mg prednisolone combined with anti-leprosy drugs. SPFX, MINO, and CAM were not able to be used due to the side effects. One year has been passed after the stop of treatment without relapse.

Recent advances in the treatment of leprosy

Leprosy, a chronic infectious disease caused by Mycobacterium leprae, was identified by G. H. A. Hansen in 1873. The different clinical presentations of the disease are determined by the quality of the host immune response. The bacteria have affinity for the peripheral nerves and are likely the cause of neuropathy, a cardinal manifestation of the disease. WHO recommends a protocol of multidrug therapy (MDT), which effectively controls the disease, hence contributing to the global elimination program. Early detection of leprosy and treatment by MDT are the most important steps in preventing deformity and disability.

Assessment of cell mediated immunogenicity of Mycobacterium leprae-derived antigens

The antigenicity of Mycobacterium leprae (M. leprae)-derived cell membrane fraction was examined using human dendritic cells (DCs). Immature DCs internalized and processed the cell membrane components, and expressed M. leprae-derived antigens (Ags) on their surface. The expression of MHC class II, CD86, and CD83 Ags on DCs and CD40 ligand (L)-associated IL-12 p70 production from DCs were up-regulated by the membrane Ags. Moreover these stimulated DCs induced significantly higher level of interferon-gamma (IFN-gamma) production by autologous CD4(+) and CD8(+) T cells than those pulsed with equivalent doses of live M. leprae or its cytosol fraction. Both subsets of T cells from tuberculoid leprosy patients also produced several fold more IFN-gamma than those from normal individuals. Furthermore, the intracellular perforin production in CD8(+) T cells was up-regulated in an Ag-dose dependent manner. These results suggest that M. leprae membrane Ags might be useful as the vaccinating agents against leprosy.