Abstract: This thesis addresses the impact of leprosy control on the occurrence of leprosy and its associated impairments. Chapter 1 introduces leprosy, an infectious disease. Its manifestations vary widely: from mild self-healing forms to chronic and destructive disease. Knowledge regarding transmission of the leprosy bacterium Mycobacterium leprae is limited. For instance, it is unknown to what extent individuals incubating for disease contribute to transmission. Leprosy is a public health problem because it may cause nerve function impairment, leading to secondary complications of eyes, hands and feet. Disability, handicap and social stigma are ultimate consequences. Activities to prevent impairment and disability are very important. Early detection of patients followed by chemotherapy is the mainstay of leprosy control. The introduction of highly bactericidal multidrug therapy (MDT) in the 1980s was a strong impetus for control programmes. However, evidence for an impact of MDT on transmission and incidence is still lacking.

Abstract: The X-linked bleeding disorder haemophilia A is due to a deficiency or functional defect of coagulation factor VIII. The bleeding tendency can be corrected by administration of factor VIII concentrates. A serious complication of factor VIII replacement therapy is the development of anti-factor VIII antibodies (inhibitors) that neutralize factor VIII activity. In recent years, the epitope-specifities and the inhibitory mechanisms of factor VIII inhibitors have gained increasing interest. The generation of factor VIII knock-out mice has opened the possibility of studying the immunobiology of inhibitor formation in murine models of haemophilia A. In spite of these recent developments however, the immunological mechanisms underlying the anti-factor VIII immune response have remained poorly understood so far. Most of our current knowledge is based on studies on inhibitor formation in the severe form of haemophilia. However, inhibitors also occur in patients with mild haemophilia A, in particular after a period of extensive factor VIII replacement therapy. These patients differ from severe haemophiliacs in that they have low levels of circulating factor VIII activity (5-25% of normal). The presence of endogenous factor VIII may have major impact on the immune response to exogenous factor VIII during replacement therapy. The studies presented in this thesis were performed to obtain a better understanding of the immunobiology of inhibitor development in mild haemophilia A. In the introduction (chapter 1), recent studies on the immunobiology of factor VIII inhibitors in haemophilia A patients are summarized and discussed. We have characterized the anti-factor VIII antibodies in patients with mild haemophilia A employing phage display technology. In chapter 2, anti-C2 antibodies were isolated and characterized from the repertoire of a mild haemophilia A patient. Our results provide evidence for the presence of two classes of anti-C2 antibodies that recognize distinct antigenic sites in factor VIII. The characteristics of the anti-C2 antibodies were further analysed in chapter 3, and compared to the epitopes of previously described murine monoclonal antibodies. The first class of anti-C2 antibodies bind to the epitope defined by monoclonal antibody ESH4. The second class of antibodies bind to the epitope defined by monoclonal antibody CLB-CAg 117. Antibodies belonging to this second class of antibodies were also isolated from a different patient with mild haemophilia A (chapter 4). The VH gene segment usage of the antibodies directed at the epitope defined by CLB-CAg 117 is less restricted compared to the first class of anti-C2 antibodies. Based on the long CDR3 region, we argue that this second class of antibodies originates from a pool of polyreactive human antibodies. In chapter 5, we describe the inhibitor development of a patient with mild haemophilia A caused by an Arg593 to Cys mutation. We have isolated and characterized anti-A2 antibodies using phage display and we have performed epitope-mapping studies of anti-factor VIII antibodies in plasma using immunoprecipitation analysis. The data presented in chapter 5 provide a possible explanation for anamnestic responses observed in patients with a history of inhibitor development. We propose that activation of a quiescent pool of memory B cells underlies the rise in inhibitor titer observed in haemophilia A patients with a history of inhibitor development. Chapter 6 describes the epitope specificities of anti-factor VIII antibodies in another patient from our cohort of mild haemophilia A patients with the Arg593 to Cys mutation. Results from this chapter and previous studies show that high responder patients with the Arg593 to Cys substitution develop inhibitory antibodies predominantly directed at the A2 domain of factor VIII. This suggests that inhibitor formation proceeds via a common mechanism in these patients. The role of HLA class II alleles in inhibitor formation was investigated by HLA genotyping of 42 patients with the Arg593 to Cys mutation. Our data suggest a weak association between inhibitor development and HLA class II alleles in mild haemophilia A patients with the Arg593 to Cys mutation. In Chapter 7, we present the characteristics of a mouse transgenic for human factor VIII with the Arg593 to Cys mutation (hufVIII-R593C mouse). The anti-factor VIII immune response was analysed in transgenic hufVIII-R593C mice crossed with factor VIII-deficient mice (exon 16 knock out, or E-16 KO mice). Serial intravenous injections of human factor VIII do not evoke an immune response in hufVIII-R593C/E-16 KO mice. The introduction of the human factor VIII–R593C transgene renders the mice tolerant to human factor VIII. However, when hufVIII-R593C/E-16 KO mice were subcutaneously injected with factor VIII in the presence of an adjuvant, loss of tolerance to factor VIII was observed. The results of chapter 7 demonstrate that hufVIII-R593C/E-16 KO mice provide a valuable model for studies directed at the mechanisms underlying inhibitor development in haemophilia A. Finally, chapter 8 provides a general overview that discusses the implications of our findings.

Abstract: This thesis explores the demand for family planning (FP) in the region and demonstrates that just at the time that demand takes off the brain drain and economic situation make it unlikely that the required services will be provided. This, increasingly, results in unsafe abortions. FP in Zimbabwe is overwhelmingly based on the pill (little effort of health workers needed) with huge failure rates. In South Africa injectables are the mainstay of FP with less failures but with many discontinuations because of side effects. Furthermore women between 40-50 years of age using this method do not know when they can safely stop. The dissertation discusses the role of the Roman Catholic Church in sabotaging proper access to and information about FP. Also teenagers do not get the proper education they need to protect themselves against HIV, another result of the attitude of the above church that only believes in the abstinence message and not in factual information. Another chapter is about bourgeois women from the First World who succeed in undermining trust in injections and implants and hence adding to the problems of their African sisters by limiting their choice. FP and HIV is discussed extensively. The author demonstrates with fake patients that health workers are unfriendly and incompetent when the morning-after pill" is needed. The author presents two studies the results of which will make it easier in view of the restraints in staff availability to offer women a sterilisation. One study shows that at follow up months later women do not remember a sterilisation under local anaesthesia as much more painful than an operation under GA. Another study shows that it is ethically acceptable to ask if a sterilisation is wanted together with a (emergency) caesarean section (CS) in high parity women. Those asked are 6x as often satisfied as those not asked. Regret is seen 22 times as often in those not sterilised in this situation as those who are. It is claimed that for some women it is more likely that they will die of the next pregnancy (with a scar in the uterus) than that they will regret giving permission for a sterilisation in a stressed situation. Of course it would be even better to discuss the possibility of a CS and the inherent option of a sterilisation with all higher parity women during the antenatal period and document their wish. A pre-printed text on the antenatal card would be best. One other large study follows-up with success 2000 sterilised women and 1000 controls. The regret rate is very low in those sterilised and high in the other group. The same applies to depression and loss of libido. If the facilities, staff and motivation would be available voluntary sterilisation would be an excellent option for many woman in Africa. For example in the Netherlands in 1970 there were an estimated combined total of 1700 women and men sterilised (the total of all sterilisations in the past 20 years) in the year 1983 there were 63.000 of such operations performed in one year. In the US 50% of women between 40-45 are sterilised in Zimbabwe 6.9% while Zimbabwe has the highest figures for southern-Africa excluding South Africa."