Leprosy in Israel: an imported disease--the support of histopathological examination for its detection.

Leprosy is rare and non-endemic in Israel. Cases of leprosy are invariably imported by immigrants or foreign workers arriving from endemic areas. In view of the relative rarity of the disease, clinicians and pathologists are not always alert to the possibility of the disease or recognize potential symptoms. A case history is presented of a 31-year-old immigrant presenting symptoms of skin lesions and nodules on the hands and facial region, especially the ear lobe. Confirmation of the infection was provided by histopathology of suspected lesions stained for acid-fast bacilli (modified Fite-Faraco staining).

In sickness or in health: TDR's partners. 8. Kenya Medical Research Institute (KEMRI).

PIP: Since its establishment in 1979, the Kenya Medical Research Institute (KEMRI) has been one of the partner agencies working with the UN Development Program/World Bank/World Health Organization Special Program for Research and Training in Tropical Diseases (TDR). KEMRI consists of a secretariat and eight separate research centers devoted to alupe leprosy and skin diseases; biomedical, clinical, virus, microbiology, and medical research; vector biology and control; and traditional medicines and drugs. KEMRI also has a model clinic, an animal house, a library, a conference area, and a computer center serving 250 technical staff and 600 administrative staff. TDR has supported about 30 trainees, and KEMRI conducts research programs on all TDR diseases except trypanosomiasis, which is the responsibility of a sister institution. KEMRI's malaria research focuses on the vector, on control through the use of bednets impregnated with insecticide, and on clinical management. KEMRI is currently researching development of hard-wearing and cheaper bednets and alternatives to chloroquine. TDR has provided funding for KEMRI studies that focus on schistosomiasis treatment, prevention, and control; the distribution and impact of filariasis as well as treatment with ivermectin and anthelminthics; and control and treatment of leishmaniasis. Research into leprosy is seeking better drugs, better diagnostic tools, and ways to increase patient treatment compliance.^ieng

Risk analysis. HIV / AIDS country profile: Zambia.

PIP: The World Health Organization (WHO) estimates that, as of the end of 1994, 17% of adults in Zambia had been infected with HIV. The Ministry of Health's National AIDS/STD/TB and Leprosy Program's (NASTLP) prevalence estimates concur with those of the WHO. NASTLP surveillance covers women attending antenatal clinics, outpatients, and blood donors. Although available HIV prevalence data for the country are less than reliable, it is clear that HIV prevalence has increased over time to presently high levels and that prevalence is higher in urban areas than in rural areas. Very high levels of HIV prevalence have been found among some health care professionals tested at Lusaka University Teaching Hospital. The data on AIDS cases are of poor quality. 42% of urban and 33% of rural households in 1993 contained orphans. Projections of the course of the epidemic are presented along with discussion of the potential impact upon the economy, the agricultural sector, and the private sector. Zambia's background is outlined. Vulnerability is then considered with regard to sexually transmitted diseases, poverty, the loss of formal sector employment and structural adjustment programs, mobility within society, urbanization, social pressure upon girls to have sexual intercourse, and the traditional practice of cleansing surviving spouses through sexual intercourse with an in-law. Government and private sector responses and external assistance from the European Commission are noted.^ieng

Tuberculosis prevention: where do we go from here?

PIP: The Karonga (Malawi) Prevention Trial revealed that repeat BCG vaccinations did not protect against pulmonary tuberculosis (TB) but appeared to provide some protection against glandular TB. They increased protection against leprosy. In fact, a single BCG vaccination conferred 50% protection against leprosy and a repeat BCG vaccination increased protection by another 50%. This trial's findings confirm the need for maintaining BCG vaccination programs in countries where leprosy is a public health problem, for individuals at high risk of leprosy (i.e., contacts of leprosy cases), and because BCG provides some protection against severe forms of TB (i.e., miliary disease and TB meningitis). An alternative TB vaccine needs to be developed, however. The protective efficacy of BCG against pulmonary TB is higher at latitudes far from the equator (80% in northern Europe vs. 0% in India and Malawi). It appears that the immunologic effects of environmental mycobacteria compromise BCG's protective effect against pulmonary TB. There is heterologous immunity between various mycobacterial infections. Low-level delayed-type hypersensitivity (DTH) to tuberculin in non-BCG vaccinated people reflects exposure to environmental mycobacteria. These people are at lower risk of TB than are people with either no DTH or strong DTH to tuberculin. Intradermal exposure to different mycobacteria provides varying degrees of protection against TB in guinea pigs. The warmer and the wetter the environment, the more widespread is colonization by mycobacteria. An area of future research is mapping the distribution of environmental mycobacteria, correlating it with the pattern of DTH responses to tuberculin, and then laboratory work to isolate relevant antigens of the mycobacteria. Another approach is identifying mycobacterial antigens that elicit protective immune responses in vitro so researchers can then identify which antigens and responses are associated with patterns of DTH known to reflect low risk of TB and which response patterns are elicited by BCG against leprosy but not TB antigens. New vaccines are not on the imminent horizon, however.^ieng

Leprosy care. The impact of multiple drug therapy.

PIP: There are currently an estimated 10-12 million cases of leprosy in the world. Until relatively recently, dapsone was the mainstay of drug therapy against this disease, but it had to be administered for very long periods of time and began to lose effectiveness in the face of growing disease resistance. New standard, multi-drug regimens were therefore recommended by WHO in 1982 and have since become the standard minimum necessary treatment in leprosy control programs. Multiple drug therapy (MDT), if administered early enough, can cure leprosy before deformity develops. Its cost and complexity, however, impede its widespread dissemination where needed. Much of rural Africa especially suffers from a lack of MDT due to financial constraints, geographic isolation, transport difficulties, and poor healthcare infrastructure. Dr, William Philip of the United Kingdom Aberdeen Royal Infirmary describes the introduction of MDT into and throughout rural northwestern Uganda over the period 1986-90. The introduction of MDT in West Nile has made a positive impact against leprosy. Most patients have been released from treatment or will be released soon after completing their regimes, so that only new cases will be receiving drug therapy. This large drop in case load will allow greater effort to be placed upon early case detection and treatment. MDT over time will reduce the number of patients needing drug therapy and leave only few disabled patients after a few decades. In so doing, MDT seems to be the approach needed to control and eventually eradicate leprosy. It is hoped that this program experience will help guide program implementation in other areas where MDT has yet to be introduced.^ieng

Zambia's STD control programme: a model for Africa?

PIP: The annual incidence of sexually transmitted diseases (STD) in Zambia is 34 per 10,000 population with an 1.9:1 male:female ratio. Complaints related to STDs is the third most common reason for attending health establishments and constitute a significant burden upon limited financial health resources already overwhelmed by other programs such as leprosy and nutrition. STDs are therefore a major health problem in Zambia, constituting 10% of adult outpatient attendances in both hospitals and primary health care centers. Due to the enormous health, social, and economic consequences of STDs, the Zambian health ministry launched in 1980 the national STD control program, a program which is particularly important in recent years given the appearance of HIV infection and increasing evidence that concomitant STDs are significant cofactors in the sexual transmission of HIV. Program objectives are to assess the extent and nature of STDs in Zambia on the basis of existing institutional data and population sample surveys, to improve the management of STDs through the establishment of specialized STD clinics at provincial and district levels, to train in-service personnel to man STD clinics, to increase public awareness of STDs by health education and factual information, and to coordinate research, treatment, and preventive activities to reduce the incidence of STDs. Program implementation, program activities, and achievements thus far are discussed.^ieng

Leprosy treatment in Africa with the Flying Doctor Service of East Africa.

The Flying Doctor Service of East Africa and the African Medical and Research Foundation (AMREF) have been especially helpful in disseminating education along with associated primary and secondary health care to leprosy-affected regions of the Third World for over thirty years. Reconstructive surgery has helped leprosy victims both functionally and psychologically, reestablishing their courage and belief in the fact that this dreaded social stigma need not affect their ability to hold a job, maintain personal relationships and lead an otherwise normal life within the community.

AIDS in Africa--an update.

PIP: At least 1 million people in Central and East Africa are infected with HIV-1, and there are 10,000 new cases of AIDS per year. HIV-1 is spreading into the Ivory Coast, Ghana, Mozambique, Angola and southern Africa. HIV-2 is prevalent in West Africa, particularly Senegal and Guinea-Bissau. Groups at greatest risk for HIV-1 are prostitutes, their customers, and patients with a history of sexually-transmitted diseases, which cause breaches in mucosal epithelium. 24% of pregnant women in Uganda are infected, and the risk of transplacental infection is estimated to be between 17% and 79%. Blood transfusion is the 3rd most frequent mode of infection, largely due to need for blood by anemic women. Repeated pregnancy is a cofactor in the progression of AIDS, and infected infants suffer intrauterine growth retardation, premature birth, low birth weight, and high mortality in the 1st week of life. AIDS in adults is often accompanied by tuberculosis, herpes zoster, hepatitis B, herpes type 2, and leprosy. Clinical diagnosis of AIDS is made by enzyme-linked immunosorbent assay, but African patients have a high frequency of anti-p24 antibody which masks the p24 antigenemia. Some African countries have AIDS education programs, condom distribution and blood screening, but AIDS control programs need to be integrated with primary health care.^ieng