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As per the Guidelines of National Leprosy Eradication Programme (NLEP), Government of India, new case detection (NCD) in leprosy is to be promoted by voluntary reporting through Information, Education and Communication (IEC). Accordingly, in addition to the routine IEC activities, Maharashtra Lokahita Seva Mandal (MLSM) carried out Selective Special Drive (SSD) in slum pockets in Mumbai since 2005-06. The SSD methodology prescribed under Leprosy Elimination Action Program (LEAP) of ALERT-INDIA was adopted which included selection of slum pockets, identification and training of Community Volunteers (CVs), door-to-door focused IEC through CVs using standard IEC material and referral of voluntarily reported suspected cases to nearby Health Posts under General Health Services or to Leprosy Referral Centre (LRC) established through MLSM for diagnosis and treatment. During the years, 2005-06 to 2009-10, MLSM conducted five annual SSDs in 53 slum pockets having 187,391 house-holds with the total enumerated population of 882,114 of which 563,040 (63.8%) could be covered through house-to-house IEC by 772 trained CVs/CHVs. As a result, 108 new cases (PB - 79 and MB - 29) were detected with the NCD rate ranged between 13/100,000 and 34/100,000 which is much higher than the reported NCDR in Mumbai (i.e. 6/100,000). Of the new MB cases 6 were lepromatous leprosy cases. Voluntary reporting of new cases was also found to be enhanced during the subsequent period following SSD. SSD activity encourages intensified IEC with community participation and integrates General Health Services resulting into better voluntary reporting of new cases. It is, therefore recommended that the SSD with the methodology prescribed under LEAP may be considered for incorporation in NLEP.

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With appropriate planning and preparation, a modified leprosy elimination campaign (MLEC) was undertaken in Brihan Mumbai (Bombay), which has a population of around 11 million. For the campaign, 4879 non-leprosy paramedical and non-medical personnel were trained and utilized as searchers. The MLEC revealed 1410 new leprosy cases, with a new case detection rate of 1.83/10,000. Over 80% of all cases detected were either single-lesion or paucibacillary (PB), and thus of limited significance with regard to transmission. Further efforts are required to detect and treat cases of consequence (those with more than five lesions and those with positive skin smears) and to identify reservoirs of infection.

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The sensory loss which occurs in leprosy is essentially cutaneous, resulting from centripetally ascending infection, the host cellular response and fibrosis, from dermal to certain mixed nerves. The hallmark is pain/temperature and touch/pressure loss. Muscle denervation is a byproduct of mixed nerve involvement. Leprous sensory and motor neuropathy presents a stereotyped picture, with preservation of position sense, noninvolvement of the large girdle muscles, and retained deep tendon reflexes. We report clinical and investigative details of 7 patients (3 males, 4 females) with mild-to-moderate polyneuritic leprosy who manifested severe proprioceptive loss in the upper per limbs; the lower limbs were similarly affected in 4 of them. Tendon reflexes were absent in the ataxic limbs. No other cause was found for the ataxia. Electrophysiological studies confirmed damage to large cutaneous and muscle afferents, and a normal EMG pattern in hip and shoulder muscles. Of great interest was the histology of a lumbar sensory ganglion biopsied in a severely disabled patient. There was extensive neuron loss and degeneration and reactive proliferation of capsular cells ("nodules of Nageotte"), an inflammatory focus of lymphocytes, and no bacilli. This suggests to us that the proprioceptive loss in these patients could well be the result of an unusual "leprous ganglionitis." Further clarification of the mechanism of ganglion degeneration and the frequency of inflammation could come from immunohistology of tissues from African green monkeys with experimental polyneuritic leprosy.

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A bacteriological follow-up of 16 lepromatous patients with a high initial Bacteriological Index (BI) showed that in 8 randomly selected patients who received single doses of ICRC Vaccine (C44) at the onset of multidrug therapy, the average reduction of BI was from 4.4+ to 1+ in 2 years--3 of these patients became negative and 3 showed BI 1+ or less. Comparable bacteriological assessments in 8 non-vaccinated but otherwise similar patients showed an average reduction of BI from 4.7+ to 2.6+, i.e. consistent with the expected response to MDT in lepromatous patients. Here we discuss the role of immunotherapy and the selection of a desirable antileprosy vaccine in the context of fixed-duration MDT.

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We have assessed the natural killer (NK) cell-mediated cytotoxicity and antibody-dependent cellular cytotoxicity (ADCC) in the peripheral blood lymphocytes (PBL) from untreated lepromatous leprosy (LL) patients, LL patients on multidrug therapy (MDT) with favorable responses (MDT-R), LL patients clinically classified as nonresponders to MDT (MDT-NR), treated tuberculoid leprosy (TT) patients, and healthy donors. NK cytotoxicity was modulated by treating the PBL with recombinant interferon-alpha (IFN-alpha) and recombinant interleukin-2 (IL-2). The mean percent NK cytotoxicity of untreated LL patients (15 +/- 3), treated MDT-R patients (20 +/- 4), and treated MDT-NR patients (12 +/- 4) was significantly lower than that of TT patients (39 +/- 6) and healthy donors (37 +/- 5). Treatment of effectors with IL-2 or IFN-alpha enhanced NK cytotoxicity in 5 of 6 untreated LL patients, 6 of 6 treated MDT-R LL patients, 4 of 5 and 3 of 5 treated MDT-NR LL patients, respectively, and 5 of 8 and 3 of 8 treated TT patients, respectively. Although PBL from TT patients showed initial NK activity comparable to that of healthy donors, fewer TT patients showed modulation of NK activity by IL-2, and IFN-alpha to a lesser extent. The ADCC activity was lower in untreated LL patients compared to treated patients, while TT patients had normal ADCC activity. The results indicate that although LL patients show lowered spontaneous cytotoxicity, it can be modulated favorably by lymphokines.

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Clinico-pathological features of five cases of lepromatous leprosy exhibiting "reversal" reaction with upgrading of lesions following vaccination with ICRC vaccine have been described. Two patients also developed ENL. Associated with the "reversal" reaction, the patients exhibited lepromin conversion. No evidence of fresh nerve lesions was observed in any patient. Besides lepromin conversion, occurrence of "reversal" reaction is yet another evidence of immunogenicity of the ICRC vaccine.

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