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Journal of Pharmaceutical Policy and Practice
Together we unite: the role of the Commonwealth in achieving universal health coverage through pharmaceutical care amidst the COVID-19 pandemic
Amy Hai Yan Chan1,2,
Victoria Rutter1,
Diane Ashiru-Oredope1,
Chloe Tuck1,3 &
Zaheer-Ud-Din Babar4
Journal of Pharmaceutical Policy and Practice volume 13, Article number: 13 (2020) Cite this article
The world currently faces unprecedented health challenges as COVID-19 poses a huge threat to health systems, economies and societies as we know it. The events of the current COVID-19 pandemic have further emphasised existing issues within our health systems. There is no better time than now to come together in global solidarity to tackle these evolving threats of COVID-19 pandemic. The Commonwealth is an ideally placed network to tackle these global health challenges, with its wide-reaching networks of governmental, non-governmental and civil society organisations across all continents. Although the biennial Commonwealth Heads of Government Meeting (CHOGM) originally scheduled to take place in Kigali in Rwanda 22–27 June 2020 has been postponed in view of COVID-19, Commonwealth country discussions are continuing, centred on the CHOGM key theme of 'Delivering a Common Future: Connecting, Innovating, Transforming', and five subthemes of Information and Communications Technology (ICT) and Innovation; Trade; Environment; Governance and the Rule of Law; and Youth. The planned CHOGM and Commonwealth itself provides all members a timely platform to consider innovative ways to connect, innovate and transform healthcare to meet the needs of their populations. This commentary considers these five CHOGM subthemes and how member nations can be supported to achieve universal health coverage through optimising medicines use and outcomes, in the midst of a global pandemic in line with the global health agenda.
The year 2020 marks the beginning of a new decade, and with it a new set of challenges but also opportunities. The biennial Commonwealth Heads of Government Meeting (CHOGM) was scheduled to take place in Kigali in Rwanda 22–27 June 2020, however, has been postponed indefinitely in view of COVID-19 [1]. Despite the postponement, virtual forums and discussions centred on the key theme for CHOGM 2020 – 'Delivering a Common Future: Connecting, Innovating, Transforming' [2] – are ongoing. These discussions are particularly pertinent in the COVID-19 pandemic to ensure that the rapidly changing needs of member countries are met. When the theme for this meeting was conceived, no one imagined how relevant and timely it would be in these current times of the COVID-19 global health crisis. The events of the pandemic have only served to further emphasise existing issues within our health systems that were highlighted at the last CHOGM [3] such as substandard and falsified medication [4], and concerns about the health workforce shortages [5, 6]. Additionally, the COVID-19 pandemic has brought new, unprecedented health and ethical challenges [7] such as questions on how to ensure ongoing, equitable access to pharmaceutical care [8], and protect the safety of our current health workforce [9]. Yet, with this comes a great need and motivation to evolve innovative approaches to communicate and collaborate in response to these new pressures. There is no better time than now to bond together in global solidarity to tackle these emerging threats of COVID-19 pandemic [10].
The Commonwealth is a key multilateral organisation, comprising 54 member nations spread across Africa, Asia, the Americas, Europe and the Pacific, encompassing many lower-middle income countries (LMICs) [11]. It includes associated networks consisting of a myriad of governmental, non-governmental and civil society organisations working together to deliver collaborative actions based on shared objectives. The Commonwealth is thus a ready-made network spanning a diverse range of countries, making it ideally placed to help tackle the global challenge of COVID-19 [11]. The upcoming CHOGM meeting is a timely platform to address these issues.
Five sub-themes have been identified for discussion at CHOGM 2020: Information and Communications Technology (ICT) and Innovation; Trade; Environment; Governance and the Rule of Law; and Youth [2]. These discussions will build on the progress that was achieved since the last CHOGM 2018 in London. The discussions are expected to centre on the ways that a contemporary Commonwealth can transform societies, in line with the Commonwealth Charter values of democracy, multilateralism, sustainable development, and empowerment of women and youth, whilst considering the impact of the COVID-19 pandemic.
In these rapidly changing times, countries around the world, both within and outside of the Commonwealth, have been faced with unprecedented health system pressures and human rights challenges that have prompted the development of innovative ways to connect, innovate and transform healthcare to meet the needs of their populations [7]. High on the list of priorities to address is the issue of pharmaceutical access and quality pharmaceutical care [8]. Whilst all of the United Nations Sustainable Development Goals (SDGs) are affected by COVID-19 [10], SDG 3: Good health and wellbeing is the most directly impacted. As medicines are the most common and significant intervention in our society [12], ensuring equitable ongoing medicines access is key for achieving universal health coverage (UHC).
The Commonwealth Pharmacists Association (CPA) is an accredited organization of the Commonwealth and an active member of the Commonwealth Health Profession's Alliance (CHPA), who advocates for all aspects of health to national policy makers and Commonwealth governments. Representing the pharmacy workforce, the CPA's mission is to ensure safe and effective medicines use to improve health and well-being throughout the Commonwealth. The charity is therefore well-placed to lead essential discussions on medicines access, medicines supply and pharmaceutical care, as well as the broader ways pharmacists can support access to health and health information in their communities.
This commentary discusses the key medicine-related issues that are facing the Commonwealth today, and summarizes how the CPA can support member nations to achieve UHC and more equitably and effectively serve the health needs of their population in the midst of a pandemic, in line with the five CHOGM subthemes and the global health agenda.
Information and communications technology (ICT) and innovation
With the current restrictions on face-to-face social interactions and travel, there is an urgent need to explore the opportunities that ICT can provide in enabling more innovative and flexible models of pharmaceutical care delivery. However, we should be aware that ICT should help address and not add to existing inequities both within societies and between LMICs [13]. The use of electronic or faxed prescriptions and 'mail-order' or 'home-delivery' pharmacy models to facilitate remote healthcare are all potential solutions that can help ensure ongoing pharmaceutical supply to patients whilst minimising the need for in-person interactions [8, 14]. However, the technology required to support these models of care delivery are not fully integrated in some countries, including many LMICs. As pharmacies in other higher income Commonwealth countries such as the UK, Australia and NZ move towards these new models of delivery [15], we must ensure that LMICs are not left behind. There is reassuring evidence to suggest this will not be the case. With increasingly widespread mobile phone use, African nations have pioneered in mobile banking, which is widely used across the continent since mPesa was established in 2007 [16]. Initiatives, such as the launch of the Ghanaian COVID-19 tracker app [17] follow this trend of digital innovation.
ICT offers many opportunities to increase access to healthcare and support everyday practice by pharmacists. Low-cost innovations such as Mobidawa and WelTel mobile phone technologies to disseminate health messages, for example specific information on how to take medication, supports communication with traditional 'hard-to-reach' communities in Kenya and Cameroon [18]; increasingly African network providers are sending public health information and alerts such as reminders to use malaria nets during national prevention week.
ICT also exists to aid the detection of substandard and falsified (SF) medicines [19]. There is a large evidence base demonstrating widespread problems with poor quality antimicrobial drugs and other essential medicines in Southeast Asia and sub-Saharan Africa [20, 21]. The COVID-19 pandemic only serves to exacerbate such issues, including the risk of misinformation and false claims, for example through the use of SF medication for preventing and treating COVID-19 [22, 23]. Poor quality medicines are a significant barrier to UHC and undermine efforts to improve healthcare [24]. Consequences of using SF medicines include antimicrobial resistance, adverse drug reactions, toxicity, and treatment failure [19]. With the COVID-19 pandemic, there is an increased urgent need to fast-track the development of technologies to counter falsified claims, detect poor quality medicines and save lives, as well as share innovation in this area. For example, the MPedigree barcode scanning app has been implemented in several African countries to allow checking of the validity of medicines [25]. Additionally, new technologies such as PharmaCheck, which uses a handheld scanner to analyse medicines, offer competitive new ICT solutions [19] to build regulatory technical capacity. Medicines quality assurance requires a robust regulatory system overseen by a medicines regulatory agency, however in many LMICs this is limited by resource and capacity constraints. However, pharmacoviligance reporting apps developed by regulatory authorities in Ghana [26] and Zambia [27], highlight how digital innovation can enhance regulatory systems. Real-time 'point of sale' reporting devices or mobile apps such as 'MedSnap', a mobile phone app that is capable of identifying medications, and assist with the data collection and monitoring of SF medicines [28], is currently being trialled by the CPA in partnership with the Pharmaceutical Society of Zambia. This is intended to synergise with the pharmacoviligance reporting app developed by the FDA to build greater medicines regulatory capacity.
In tandem to regulatory strengthening, it is imperative to ensure patients have access to a quality assured supply route [29]. In Rwanda, innovative approaches using drones have been applied to increase medicines access in remote regions [30], which are now being extended to West-African regions. In Ghana, pharmacists are innovating apps to increase medicines efficiencies and patient access to vital medicines [31].
ICT also has a pivotal role to play in countering the COVID-19 'infodemic' [32]. Shared common information platforms, such as the online resource portals created by national pharmacy associations and international organisations such as the CPA and International Pharmaceutical Federation (FIP), can facilitate the timely exchange of news, alerts on outbreaks, opportunities for collaborations and support continuing professional development (CPD) between pharmacists. To facilitate this, regional and national policies and ICT linkages need to be established, as well as infrastructure to support access to stable internet and connectivity particularly in rural and deprived areas. CPD to improve pharmacist technology literacy will also need to be prioritised [33]. For example, in Zambia, there is an increasing demand for pharmacy services, with growing numbers of pharmacists keen to upskill and evolve new roles to expand the breadth of the profession. In line with a recent change to mandatory CPD, the CPA have worked closely with Zambia to explore the opportunities for delivering CPD via an online learning platform to address pharmacist training gaps. Many medicine information resources and centres are online, which can act as repositories of evidence-based information. However, in many healthcare settings, internet access can be intermittent and there is a need for easy access to key information, compiled in one place that can be made available offline. A successful example of this is the Commonwealth Partnerships for Antimicrobial Stewardship (CwPAMS) app which supports the rational use of antimicrobials, beginning with Ghana, Tanzania, Uganda, and Zambia [34].
Innovations in ICT can facilitate the better use of medicines by enabling pharmacists to provide data-informed practice, such as software to manage medicines dispensing and inventory [35] and technologies to check culture sensitivities, identify pathogens and aid diagnoses prior to the supply of antibiotics to support antimicrobial stewardship initiatives [36, 37]. Ensuring the right antimicrobials are used for secondary infections where indicated, but not inappropriately used for COVID-19, is particularly relevant; the current CwPAMS prescribing app is an example of an innovation that has developed COVID-19 specific resources to support this [34]. Indeed, the time could not be more apt to be embracing digitalisation. At the 2019 annual conference of the Pharmaceutical Society of Ghana, the Vice President of Ghana called for pharmacists to embrace digitalisation, enhancing patient recordkeeping and medicines access, noting their expanding and evolving role in supporting a health system moving towards UHC [31].
Exploring the impact of the current COVID-19 pandemic on issues of medicines shortages and ensuring ongoing access and supply of medicines is a key priority. Even prior to this global pandemic, there have been calls for a coordinated approach to address issues of medicines access and the need for reporting systems for medicines shortages. This was raised in the Report of the International Summit on Medicines Shortages in 2013 hosted by the FIP and the Canadian Pharmacists Association [38], with models and tactical options to address shortages summarised in a 2017 report by FIP [39].
With medicines being one of the most important interventions in healthcare, ensuring continuity of medicines supply with the current trade and travel restrictions in place as part of the pandemic response is key. There needs to be timely and accessible ways of monitoring and reporting on medicines access issues, with a global process to produce a list of critical or vulnerable medicines for each country. We do not yet fully know what the impact of the COVID-19 pandemic will be on trade and supply of medicines, including raw materials – there needs to be urgent research in this area to inform how we can support Commonwealth countries to deliver essential healthcare. This knowledge of the vulnerabilities in our medicines supply process will remain useful beyond the pandemic, as issues of access and affordability are relevant to any major global and political changes, such as with Brexit [40].
There is great potential for local production of medicines to allow tighter regulatory control and support better quality assurance and supply of essential medicines, as a result of a more efficient use of resources, and efficiency of time and supply, particularly of temperature sensitive medicines such as vaccines. Local manufacturing can support the provision of more cost-effective quality treatments, such as has been recognised by several member countries. The Commonwealth can achieve this by promoting local manufacturing capacity through supporting local companies to become Good Manufacturing Practices (GMP) compliant, establishing bioequivalence centres to support the local industry, providing financial support (e.g. long-term, low-interest patient capital), and linking to other countries with strong local manufacturing capacity (e.g. India, Malaysia, Bangladesh, Kenya, Ghana), which can help increase global competitiveness. For example, in Ghana, initiatives to foster a manufacturing 'hub' are anticipated to foster economic growth in the pharmaceutical sector and improve access to quality assured medicines. This includes tax exemption on raw materials and essential medicines produced locally and a 15% local price preferment strategy [41]. In tandem, the Ghana pharmaceutical sector development strategy includes capital loans to incentivise producing medicines on the national health insurance list [42].
Current barriers to exporting locally manufactured generics relate to the risk of SF medicines; training to identify these low-quality medicines such use of serialisation to trace and track and regulation to streamline trade, needs to be prioritised. Calls for regional harmonisation and initiatives to pool regulatory efforts, such as through the African Medicines Regulatory Agency [43], have highlighted significant progress [44]. Yet, further work is also needed to implement the Continental Free Trade Agreement to iron out modalities of free trade in pharmaceuticals amongst African countries. This is particularly pertinent in areas such as cancer, where intellectual property and the expertise required to develop complex medicines remains with few manufacturers [45].
Linking in with ICT, the sharing of information on product innovation can facilitate discussions on how to tackle the challenges of different trade policies, currency, language/cultural barriers; and allow a common platform for free information exchange. Use of a pooled procurement strategy to facilitate shared access to pharmaceuticals can also increase medicines accessibility by improving the efficiency and affordability of their procurement [46].
With an increasing global population, the notion of 'Green pharmacy practice' is an essential topic for discussion. Considering how pharmaceuticals impact on the environment at both the manufacturer and individual level is important [47] – for example, ensuring responsible use of medicines to reduce wastage, managing the safe disposal of unused / unwanted / expired medicines, and the use of plastic-free packaging options. This helps to safeguard sustainable practice and overall responsibility to uptake methods to reduce the environmental impact of medicines [48]. Disposal of medicines is also costly with some countries facing fees charged by regulators to dispose medicines, or high costs to use incinerators to safely dispose pharmaceuticals [49]. Countries need to move towards free disposals to encourage more responsible disposal, for example by developing guidelines and allocating funding to provide the needed infrastructure to support safe disposal of medicines, green and eco-friendly manufacturing, and campaigns to promote public awareness [50]. Of particular importance is the need to consider safe disposal of antimicrobials, as inappropriate disposal, for example of antibiotics into waste water [51], can worsen antimicrobial resistance.
Good governance and the rule of law
The significance of pharmacies and pharmacists has been brought to the forefront in the recent pandemic, with many pharmacy services around the world overwhelmed [52]. Never has the world seen such a focus on pharmacy service provision; the advantages of the dual-role of community pharmacists as retailer and health provider have emerged [53] as countries have gone into lockdown and pharmacists are named as a 'vital' part of the healthcare system as one of the few essential services that can remain open to the public. Beyond the pandemic, we need to ensure that this significance of pharmacists as an essential health provider is not diminished. There needs to be ongoing support at the national and global level for pharmacy services to be implemented in their full potential. This is particularly important when considering the shortfall of 18 million health workers by 2030 that is projected by WHO and the amplification of this problem in LMICs [6]. Pharmacists are skilled worldwide to provide more extensive public-facing services – such as family planning, HIV testing, screening, and vaccination. These extended pharmacy services – particularly vaccination services – will be key for achieving population vaccination coverage when a COVID-19 vaccine becomes available, especially as pharmacies are one of the most accessible health providers in the community [54]. The effectiveness of utilising pharmacists for public health interventions has been highlighted through Commonwealth initiatives led by female pharmacist groups to set-up clinical breast screening and raise awareness to reach the most vulnerable communities. This would help with healthcare access for the public yet policy-level barriers need to be overcome to enable full utilisation of the pharmacy workforce globally, as well as cold-chain issues.
New policies may be needed to support the evolution of pharmacy practice, for example the establishment of senior pharmacist roles at the government level, and involvement of national pharmacy associations in the creation and implementation of health policies. Pharmacists should be key stakeholders on all discussions involving medicines if systems and policies are to be well thought out and effective. Governments need pharmacist skillsets, but steps need to be taken to strengthen the profession and ensure they are appropriately regulated and recognised. This good governance facilitates better regulation of medicines, pharmacists and pharmacies. Without legislation or governance that specifically defines pharmacist roles and pharmacy practice, it is difficult to advocate for the expanding role of pharmacists. For example, in Zambia, the pharmacy profession is not currently self-regulated despite 60% of budget being spent on pharmaceuticals. There is a need for pharmacists to have their own pharmacy council to clarify roles and functions of regulatory agencies, whilst preventing overlap in functions leading to over-regulation and associated financial burdens. Pharmacy councils are needed to address issues at a national level collectively via implementation of regulations. For example, the Pharmacy Council and Pharmaceutical Society of Ghana, together with Management Sciences for Health (MSH), conducted a pharmaceutical service mapping exercise of a rural region in Ghana to highlight gaps to improve access to quality assured medicines. Other examples of issues where collaborative actions are required include SF medicines and its contribution to AMR, ensuring honest and corruption-free systems, and reviewing licencing systems so licenses to practice are based on a minimum required level of skill and knowledge to ensure public safety. For example, community unregulated sale of medicines, such as at markets and stores, in particular antibiotics, are of high concern in many LMICs [55]. The CwPAMS has brought together practitioners and policy makers and raised these issues leading to acknowledgment and action by pharmacy councils to work with unlicensed sellers of antibiotics to address these issues [34]. There is potential for the CPA to support this by creating online knowledge sharing symposia, webinars or online workshops.
Encouraging youth to be the next generation of health professionals needs to be high on the Commonwealth agenda as the numbers seeking to study medicine, nursing and pharmacy begin to decline whilst the public health needs increase. In the UK, the undergraduate university courses for medicine, pharmacy and nursing have been undersubscribed; there is a need to understand the drivers of this to increase enrolment and ensure ongoing workforce development, equity and diversity. Engaging with the youth in policy development and stakeholder representation – for example through establishing local and national Young Pharmacists Groups and linking with the Commonwealth Youth Network, WHO Global Health Workforce Network (Youth Hub) – are key first steps. The different mindset and priorities of the youth generation needs to be considered – innovative ways to entice young people in key health professional roles are needed. Many youth enjoy portfolio working and travel opportunities – knowledge and skill exchanges such as twinning and health partnership programmes between LMICs and other countries, for example the CwPAMS scheme [34], may be particularly attractive to youth. Public education, campaigns and mentorship programmes to support youth development as future health leaders are needed.
Simultaneously, many countries across the Commonwealth have young populations and the pharmacy workforce is dynamically evolving and rapidly expanding [11]. At the national and global level, governments and health organisations need to ensure that any increase in number in the pharmacy workforce is matched by an increase in pharmacy roles and job vacancies. For example, in Zambia, there are nearly 200–300 new pharmacists each year, in Rwanda the number of pharmacists has grown rapidly after the establishment of the Rwanda Community Pharmacists' Union in 2016 [56], and in Tanzania, there are over 1900 pharmacists, including 500 hospital pharmacists; with such rapid growth in the pharmacy profession, there is a need to ensure jobs and roles for new graduates. This will include in clinical settings in hospitals, where pharmacists have key roles in ensuring rational medicines use as part of multidisciplinary team. In many LMICs, pharmacists still hold a traditional supply role and clinical pharmacy is at a nascent stage [5]. Skill sharing initiatives such as CwPAMS with settings where clinical pharmacy has been well-established have led to expanding pharmacists' roles and cultivating a culture of clinical pharmacy, gain policy-leader interest. The CPA are currently exploring approaches to expand and sustain this through sharing education and skills to meet the demands of the growing workforce and population health priorities. However, in certain countries, there is a current lack of employment in the public sector, and the lack of funds available to pharmacists to support the establishment of businesses are perceived as barriers. It is critical the momentum and energy behind the growing pharmacy profession is capitalised on to support progress towards SDG 3 and beyond.
The current global crisis that the world is facing lends itself to new challenges and opportunities for the pharmacy profession. The time is now for the Commonwealth to capitalise on the diversity within its network to work together to respond to these challenges and consider how the pharmaceutical workforce can be positioned to support the global COVID-19 pandemic response, and beyond that post-pandemic, to progress towards UHC. The CHOGM 2020 themes provide a timely and useful framework to consider our global response. The pandemic has highlighted the crucial role of pharmacists in essential healthcare delivery; the significance of the pharmacy workforce in healthcare needs to be continually recognised beyond the pandemic as global health needs increase and change. Together we must unite in the fight against this and future global health crises and ensure equal health outcomes for all.
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Commonwealth Pharmacists Association, London, UK
Amy Hai Yan Chan, Victoria Rutter, Diane Ashiru-Oredope & Chloe Tuck
School of Pharmacy, Faculty of Medical and Health Sciences, University of Auckland, Level 3, Building 505, 85 Pard Road, Grafton, Auckland, 1023, New Zealand
Amy Hai Yan Chan
School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
Chloe Tuck
University of Huddersfield, Huddersfield, UK
Zaheer-Ud-Din Babar
Victoria Rutter
Diane Ashiru-Oredope
All authors participated in the conceptualisation, drafting and revision of the manuscript. All authors have read and approved the final manuscript.
Authors' information
Amy Chan, PhD is the Professional Development and Research Lead with the Commonwealth Pharmacists Association, and a Senior Clinical Research Fellow with the School of Pharmacy, University of Auckland.
Victoria Rutter, MPharm is Executive Director at The Commonwealth Pharmacists Association.
Diane Ashiru-Oredope, PhD is Global AMR Lead and Programme Lead for CwPAMS with the Commonwealth Pharmacists Association.
Chloe Tuck, MBiochem is a Health Policy Advisor with The Commonwealth Pharmacists Association and PhD Candidate at the School of Health and Research, University of Sheffield.
Zaheer-Ud-Din Babar, PhD is a trustee for the Commonwealth Pharmacists Association, and Professor in Medicines and Healthcare at the Department of Pharmacy, University of Huddersfield.
Correspondence to Amy Hai Yan Chan.
All authors approved the manuscript.
AC has received consultancy fees from Janssen-Cilag and Spoonful of Sugar Ltd., a UCL-Business spinout company, for work unrelated to this submitted piece. AC is the Associate Editor of Journal of Pharmaceutical Policy and Practice.
CT's role at the University of Sheffield is supported by funding from Wellcome Trust (108903/B/15/Z) and the University of Sheffield, for work unrelated to this submitted piece.
ZUDB is the Editor in Chief of Journal of Pharmaceutical Policy and Practice.
All other authors declare no conflicts of interest.
Chan, A.H.Y., Rutter, V., Ashiru-Oredope, D. et al. Together we unite: the role of the Commonwealth in achieving universal health coverage through pharmaceutical care amidst the COVID-19 pandemic. J of Pharm Policy and Pract 13, 13 (2020). https://doi.org/10.1186/s40545-020-00214-6
CHOGM
Pharmacists and the COVID-19 Pandemic
Submission enquiries: Access here and click Contact Us


Includes AT8418 instrument mount for brass, reeds, drums, etc.
Designed for sax, toms, brass and percussion, the PRO35cW excels in high-SPL applications and is ideal for active stage performances. Its extended frequency response captures subtle nuances of the performance. The included UniMount® clip permits accurate positioning and provides shock resistance while protecting the element. The microphone's cardioid polar pattern reduces pickup of sounds from the sides and rear, improving isolation of the desired sound source.
Register your PRO35CW for the latest product information, warranty repairs, and easy access to all your Audio-Technica products.
The PRO35CW Cardioid Condenser Clip-on Instrument Microphone for A-T Wireless System is covered by Audio-Technica's European Warranty. This covers your product to be free of defects in materials and workmanship.


Edward de Bono is one of the leading thinkers on thinking and creativity. And, of all his books, ideas, and methodologies, the Six Thinking Hats idea is definitely his best.
So, what are the Six Thinking Hats?
Project Management in Under 5: Video. What are the Six Thinking Hats? Click To Tweet Please: subscribe to our YouTube Channel by clicking here.


Vestfold is renowned for it's coast line, but please sample some of our other attractions!
Vestfold holds family parks and activity parks for the whole family! Please check out Children's Vestfold.
Between April and the end of September, Vestfold is the perfect setting for cycling holiday. The landscape is easy to cycle in, and you can choose what you want to see.
Walking on the skerries is a great feeling, among the rushes and along the beaches of Vestfold's wonderful archipelago. The coastal paths in Vestfold are a fantastic experience. The coastal path from Stavern has 35 kilometres signposted trails.


text:
Q: Not able to show spinner until mediaplayer is prepared I tried various approaches but nothing is solving my problem. Hope someone here can help me.
Simple requirement is I want to show a spinner until media player window is shown. It sounds easy enough but it is not.
I am calling my mediaplayer class on "Listen" click of alertDialog. Here it is:
alertBox.setCancelable(false)
  .setNegativeButton("Listen", new DialogInterface.OnClickListener(){
   public void onClick(DialogInterface dialog,int id){
dialog.dismiss();
emp = new EasyMediaPlayer(mp3PopupLayout,buttonPlayPause,seekBarProgress,tv_mp3,downloadURL);
emp.startPlayingMP3();
}
}).show();

And startPlaying function calls chooseToStart(true) which in-turn runs the media player. This class is:
public class EasyMediaPlayer implements OnClickListener, OnTouchListener, OnCompletionListener, OnBufferingUpdateListener{
EasyMediaPlayer(View mp3PopupLayout,ImageView buttonPlayPause,SeekBar seekBarProgress,TextView tv_mp3, String MP3URL){
        this.mp3PopupLayout = mp3PopupLayout;
        this.buttonPlayPause = buttonPlayPause;
        this.seekBarProgress = seekBarProgress;
        this.tv_mp3 = tv_mp3;
        this.MP3URL = MP3URL;
        seekBarProgress.setOnTouchListener(this);
        buttonPlayPause.setOnClickListener(this);
    }

    public void startPlayingMP3(){
        mediaFileLengthInMilliseconds = 1;
        tv_mp3.setText("");
        buttonPlayPause.setImageResource(R.drawable.button_play);
        buttonPlayPause.setVisibility(View.GONE);
        seekBarProgress.setProgress(0);
        seekBarProgress.setSecondaryProgress(0);
        mediaPlayer = new MediaPlayer();
        mediaPlayer.setOnBufferingUpdateListener(this);
        mediaPlayer.setOnCompletionListener(this);
        mediaPlayer.setOnErrorListener(new OnErrorListener() {
            public boolean onError(MediaPlayer mp, int what, int extra) {
                tv_mp3.setText("Error in playing file !!");
                return true;
            }
        });
        mp3DownloadWindow = new PopupWindow(mp3PopupLayout, LayoutParams.MATCH_PARENT,LayoutParams.WRAP_CONTENT, true);
        mp3DownloadWindow.showAtLocation(mp3PopupLayout, Gravity.BOTTOM, 30, 0);
        chooseToStart(true);
    }

    public void chooseToStart(boolean startFlag){
        if(startFlag){
            try {
                mediaPlayer.setDataSource(this.MP3URL);
                mediaPlayer.prepare(); // you must call this method after setup the datasource in setDataSource method. After calling prepare() the instance of MediaPlayer starts load data from URL to internal buffer.
                mediaFileLengthInMilliseconds = mediaPlayer.getDuration(); // gets the song length in milliseconds from URL
            } catch (Exception e) {
                tv_mp3.setText(e.toString() + "\nClose it");
            }

            if(!mediaPlayer.isPlaying()){
                spinner.cancel();
                mediaPlayer.start();
                buttonPlayPause.setImageResource(R.drawable.button_pause);
            }else {
                mediaPlayer.pause();
                buttonPlayPause.setImageResource(R.drawable.button_play);
            }
            primarySeekBarProgressUpdater();
        }
    }
//other stuff
}

I need to know where and how I can use spinner so it will be shown until media player starts playing.
Any help will be appreciated. Thanks

A: Use prepareAsync() and setOnPreparedListener() instead of prepare().
mediaPlayer.setDataSource(this.MP3URL);
mediaPlayer.setOnPreparedListener(new OnPreparedListener() {
    @Override
    public void onPrepared(MediaPlayer mp) {
       // Hide whatever you need, mediaPlayer is prepared
       mp.start();
    }
});
// Show whatever you need, mediaPlayer is preparing
mediaPlayer.prepareAsync();

redpajama_set_name: RedPajamaStackExchange


Warm Spring weather led to excellent fruit-set. The warmer than average Summer was thankfully without major heat spikes. Warm and dry weather continued through to a record early harvest.
Block C Pinot Noir - Willowlake Vineyard. Woori Yallock, Upper Yarra Valley.
Clay loam soil. Southerly aspect. MV6 clone Pinot Noir planted in 1991. Hand-picked on 29th February 2016.
This website is owned and run by The Jack Russell Wine Company Pty Ltd ABN 84 140 044 239.


text:
<resources>

    <!-- Base application theme. -->
    <!-- Default screen margins, per the Android Design guidelines. -->
    <dimen name="activity_horizontal_margin">16dp</dimen>
    <dimen name="activity_vertical_margin">16dp</dimen>

    <dimen name="button_height">30dp</dimen>
    <dimen name="button_width">50dp</dimen>
    <dimen name="votes_icon_height">40dp</dimen>
    <dimen name="votes_icon_width">60dp</dimen>
    <dimen name="video_item_height">300dp</dimen>

</resources>

redpajama_set_name: RedPajamaGithub


text:
«Электроника Г9.04» — настольные электронные кварцевые часы с питанием от сети, производившиеся под торговой маркой «Электроника» в СССР в 80-х.

Конструкция и принципы работы
Корпус пластиковый и имеет форму скругленного параллелепипеда бежевого цвета, фронтальная рамка черная, индикаторы прикрыты темно-зеленым прозрачным пластиком. Время отображается в 24-часовом формате при помощи пяти вакуумных люминесцентных индикаторов: имеются четыре ИВ-12 для отображения цифр и один ИВ-1 для отображения разделителя в виде точки и подчеркивания. Точка мигает, отмеряя секунды.

Часы имеют отсек для батареи типа «Крона». Энергия батареи используется для поддержания хода при отсутствии сетевого питания, индикаторы при этом не светятся.

Возможен выбор между двумя степенями яркости свечения индикаторов.

Часы построены на восьми микросхемах серии К176 и кварцевом резонаторе. Имеется подстроечный конденсатор для регулировки хода, доступен без вскрытия корпуса.

Технические характеристики
Параметры питания: 220 В переменного тока, 0,25 А.

Габариты: 125 × 165 × 112 мм.

Индекс модели: Г9.04.

Стоимость на момент выпуска: 35 рублей.

Интересные факты
 В момент перехода на ноль часов в течение полсекунды на индикаторе отображается время 24:00.
 При первом включении (или при перебое в питании) часы начинают отсчет с 00:11.
 Кнопки, служащие для настройки значения часов и минут, имеют следующий эффект: пока кнопка нажата, соответствующее значение увеличивается на 1 каждую секунду. Таким образом, для установки значения "59 минут" потребуется минута.
 Для маркировки кнопок не используются текст или буквы. Вместо подписей нанесены значки: круг, квадрат, треугольник и треугольник с линией под ним ("значок Eject").
 Принципиальная схема

Примечания

Марки часов
Часы СССР

redpajama_set_name: RedPajamaWikipedia


As a reminder, I am out of town until next week - please contact @CaGregorio or @VinasSol if you need anything. Thanks!
Is it bad when you're still at work, yet debating whether or not you're going to call out of work tomorrow. .


text:
iMovie '11
By Jeff Carlson
Contributor, Macworld | PT
The new Movie Trailer feature of iMovie '11 is a great way to demo the program because it packs all the strengths of the video editor into a compact, visually arresting package. But like a real movie, there is more to iMovie '11 than the trailer—and thankfully, all of the best scenes aren't given away in the teaser.
iMovie '11 is an interesting mix of old and new. Audio editing is an old feature from iMovie HD 6 that's finally making its appearance in the new version, but with a new, easy approach. There are features such as One-Step Effects, which build upon the editing foundation of iMovie '08 and '09. But Apple is also putting serious effort into iMovie's development with a new fix for rolling shutter artifacts, and a People Finder feature which can help immensely when you're trying to locate clips of family members or friends amid hours of raw footage.
Although not the most important addition to iMovie '11, the Movie Trailers feature gets top billing because it's fun. Even if you don't know what a medium shot is, the placeholder animatics provided in the Storyboard tab of the Project browser make it easy to determine which kind of clip to add. (If anything, it reminds me that I need to vary the types of shots I capture, so I'm interspersing closeups with lots of wide shots or groups.)
The trailers are also somewhat editable, with controls in each thumbnail for un-muting the clip, removing it, and choosing which section of the overall clip to use. Also, you can apply effects and other controls within iMovie's inspectors (such as adjusting the color or making footage look weathered).
The big question about trailers is whether people will continue to create them after the novelty wears off. Or, will users create trailers and then never get around to cutting together a longer movie? Fortunately, the Movie Trailer is a gateway to other features.
After building a trailer, it can be converted to a regular project. (Be sure to duplicate the trailer project first, or you'll lose it as a trailer.) All the edits that went into the trailer are exposed and can be changed at will.
Deleting text in a Movie Trailer text field doesn't remove the text from the project.
Or, if you're planning an upcoming video shoot, create a new Movie Trailer project, click the Shot List tab, and build a list of scenes you need using the animatic placeholders found in the Maps, Backgrounds, and Animatics panel. Then, print the shot list (or save it as a PDF that you can take on location on an iPad, iPod, or laptop).
I did run into one behavior that seems like a bug, but isn't, according to Apple: When editing the title text, it's not possible to leave a text field blank to delete it. If I wanted to write "This Christmas" instead of "This Holiday Season" in the Holiday trailer, deleting the word "Season" or replacing it with a space reverts back to the default, therefore reading "This Christmas Season". It may be a feature, but it's certainly clunky.
iMovie's audio effects range the gamut from fun to occasionally useful.
I'm happy to see that, after three years of Apple insisting that editing audio within a clip isn't important to casual users, iMovie's designers have finally added the capability in this edition. Clicking a button in the Project browser makes audio waveforms visible at the bottom of every clip.
Adjusting audio levels takes a very iMovie-like approach: select a range of audio you'd like to edit, then drag the volume bar up or down to change the level. You don't need to first add keyframe markers—they appear automatically and can be fine-tuned (if, say, you want the audio to drop off sharply and then fade back in slowly).
The new collection of audio effects does a fine job of applying broad filters. I can't remember the last time I wanted a clip to sound like it came from a robot, but I could anticipate using the Telephone effect on a voiceover, or the room size simulators to make a space feel larger or smaller.
The Multi-Tune effect (Apple's name for the auto-tune effect overused in a lot of pop music) is amusing but offers no fine control; similarly, the pitch effects offer increases or decreases in four large steps. If you want more control over adjustments like these, as opposed to just having fun, use GarageBand ( ) to process the audio separately.
One-Step Effects and additional edits
One of the difficulties of editing video is that it's time-consuming. Apple has attempted to make common edits easier by introducing One-Step Effects. To make a clip fade to black and white, for example, you select a portion of the clip and choose Clip -> Fade to -> Black and White. To do that manually you would make the selection, split the clip, open the Clip inspector, apply the Black and White video effect, close the inspector, and add a Cross Dissolve transition.
These effects are cool and helpful, but here's the best part: Since the building blocks of each effect are features that already exist in iMovie (you could do them yourself), the edits are left in place to tweak later, if you choose. And if you don't like the effect, choosing Undo once restores the clip to its pre-effect state.
iMovie '11 has a few new editing capabilities. For example, it's now possible to add footage shot against a blue background and choose Blue Screen to knock out the background; previously, Green Screen was the only option, which made green items disappear. A new Side by Side effect is similar to the Picture-in-Picture option, letting two clips share the screen vertically; the clips are cropped automatically, but with some clever adjustment with the Crop tool you can gain some control over what appears in each side.
This version also includes a Transition Overlap control, something that existed in iMovie '09, but as an option that appeared only when you added or removed transitions for an entire project. The setting controls how two clips overlap: whether iMovie attempts to keep the visible portion of a clip intact when changing the duration of the transition, or grabs footage from surrounding clips to maintain the project's overall duration. This is important if you're synchronizing video with music (like a music video) or an additional audio track.
The new Side by Side edit lets two clips share a bisected screen.
Back to the timeline
One significant change is the new Single-Row View, accessible by clicking a button in the Project browser. Instead of running the project in multiple rows like a paragraph of text, the view maintains one row that scrolls horizontally. Wait, that looks familiar! It's just like a traditional video editing timeline, the lack of which was one of the main reasons iMovie HD users shunned the new incarnation. Click the Swap Events and Projects button in the toolbar, and you've got the timeline in its familiar place at the bottom of the screen.
It's important to point out that the new People Finder feature uses face-detection technology, which notices when a human is in the shot, and not face-recognition, which identifies specific people. Even so, it's helpful to be able to quickly view all footage containing people when you're searching through hours of footage—but keep in mind that analysis can take some time; and analyzing just for people is faster than for stabilization. (iMovie's clip thumbnails are especially ill-suited to this task, because someone could appear in 10 seconds of footage that is otherwise dominated by scenery; unless you've expanded the icon view to display more frames, you may not see that section without scrubbing through the entire clip.)
I had no troubles with People Finder, and even noticed that it correctly ignored a plastic action figure. The feature takes advantage of the under-utilized keyword tagging capabilities of iMovie (which appear when Show Advanced Tools is enabled in the application's preferences). With a little time and patience, you could create keywords for people who appear in your movies, use the People Finder to narrow the footage, then tag the person-specific keywords to the appropriate sections.
Formats and performance
If there's any portion of iMovie '11 that might disappoint longtime iMovie users, it's the fact that not much has changed with the program's core engine. Video shot as interlaced (such as 1080i, where the camera records every other horizontal line in every frame) can display combing artifacts.
Also, iMovie does not edit AVCHD video natively, but still transcodes imported footage into AIC (Apple Intermediate Codec) format for easier editing. This is presumably in order to maintain smooth interactivity when editing. (AVCHD manages to fit a lot of high-definition video into a relatively small space due to the way it compresses the video: after capturing a full image frame, many subsequent frames include only the pixels that have changed. Editing the footage in real time requires more computational power to fill in the rest of the frames, which can lead to sluggish performance. I encountered this when reviewing Adobe Premiere Elements 9 ( ), which does handle AVCHD natively.) So, as with previous versions of iMovie, importing AVCHD video requires transcoding time before editing, rather than slowdowns during editing.
iMovie also does not import raw AVCHD files, except when connected to a camera, or when you've used iMovie's archive feature to offload the contents of a camera to the hard drive for import later. To import the native compressed files directly, you'd need to run them through a conversion utility such as VoltaicHD.
With the Rolling Shutter fix at its highest setting, the wobbly effect caused by moving a CMOS camera while shooting can be dramatically minimized.
On the other hand, iMovie '11 does now support video shot at 24p (24 progressive frames per second) without converting the rate, as the previous version did. The exception is when you're mixing video of different frame rates within a project, in which case the first clip added to the project determines the frame rate used. When clips in the Event browser have different frame rates than the current project, a yellow indicator badge appears with the rate. In practical terms, the badge is for informational purposes only, but it can help you choose footage with the same frame rate from multiple events, such as when you want a project to be entirely 24p.
One intriguing addition to iMovie '11 is a Rolling Shutter fix option. Here's the problem: cameras that record to a CMOS sensor capture each frame in horizontal bands starting at the top of the frame and moving to the bottom. Although each frame is captured quickly, camera motion can often cause a "jelly" effect, where objects seem rubbery.
After a clip is analyzed for image stabilization or to identify whether people are in the frame, iMovie can apply a rolling shutter fix in the Clip inspector. It can apply four levels of correction (Low, Medium, High, and Extra High), and in this case results will vary depending on the footage. But if you encounter footage that's particularly "bendy," it's worth letting iMovie take a crack at fixing it. The fix is mathematical, so iMovie doesn't need to re-analyze or render the clip. Below is an example of the Rolling Shutter fix on a video I shot. Another simple but useful feature is the Mark Camera Pans option, which makes it easier to identify sections of stable video or changes in subject matter.
Macworld's buying advice
iMovie '11 has a few standout features that show off its capabilities, like Movie Trailers, long-awaited sound editing, and One-Step Effects. But there are also plenty of other enhancements indicating that this release has depth and character, like the return of a traditional timeline in Single-Row View, a fix for rolling shutter artifacts, the People Finder feature, audio effects, and even little things like the Side by Side and Blue Screen edits.
Although iMovie doesn't edit AVCHD natively, I'm inclined to consider it only a partial negative; I'd much rather give up transcoding time at the import stage and edit with few interruptions, than have to stop and render portions of the movie (an aspect of iMovie HD that I'm happy to leave behind). It is unfortunate that people working with interlaced footage still run into problems, and need to either encode outside the application or consider moving to Final Cut Express ( ) or other editors to get the best quality.
However, other additions, such as exporting movies directly to Vimeo and Facebook, make iMovie '11 a solid upgrade, especially given the lower $49 price of iLife '11, compared to previous releases.
Jeff Carlson is the author of iMovie '09 & iDVD for Mac OS X: Visual QuickStart Guide (Peachpit Press; 2009) and the managing editor of TidBits .
Apple iMovie '11
Improved audio editing
Fun Movie Trailers, which can be converted to projects
Support for 24p footage
One-Step Effects automate repetitive edits
Side-by-Side and Blue Screen edit options
Rolling Shutter fix (results vary depending on footage)
Single-Row View brings back traditional timeline
Interlaced video still hampered by single-field processing
No native AVCHD editing or direct import
Pre-processing and import transcoding can be time-consuming

redpajama_set_name: RedPajamaCommonCrawl


Appeal from McCracken Circuit Court.
ROY G. GARRISON and JACK E. FISHER for appellants.
J.W. CAMMACK, Attorney General, and S.H. BROWN, Assistant Attorney General, for appellee.
The appellants, Louis Schuster and Clyde Chambers, have been convicted of the crime of robbery, and their punishment fixed at two years in the penitentiary. Their counsel claim the right to a reversal on the ground of misconduct of one of the jurors in failing to take his seat with the other members of the panel and sitting among the spectators, and also because this juror had expressed the opinion of defendants' guilt before being accepted as a member of the panel. They also contend that the verdict is contrary to the law and flagrantly against the evidence.
Concerning the first-mentioned ground, it may be said that there is no bill of exceptions in this record except the transcript of the evidence, and that does not disclose the conditions about which appellants complain. The ground does appear in the motion for a new trial, and there comes to us a transcript of evidence heard by the trial judge respecting that matter. This point cannot be considered for the reasons stated in Voils v. Commonwealth, 229 Ky. 305, 17 S.W.2d 238.
The only witness introduced by the commonwealth was L. Waltman, who testified that he was the driver of a street bus in the city of Paducah, and that about 11 o'clock on the night of March 7, 1929, two men boarded his bus as though to take passage. They drew their pistols and forced him to surrender his money and to lie flat on the floor while they escaped. The witness positively identified the appellants as the men who robbed him. He testified that he recognized the voice of one of them, the faces of both, and identified the clothing produced as that worn by the culprits.
The appellants deny that they had anything to do with the robbery, and testified that at the time of its commission they were in the Palmer Hotel talking to two other men. These two men corroborated them. Two or three other witnesses say that they had seen the defendants and the two men mentioned by them in or around the Palmer Hotel on some night about this time, but are unable to fix it definitely as being the night of the robbery. They also show by several witnesses that one of the defendants since infancy had been unable to speak clearly and without stuttering, while the prosecuting witness had stated that neither of the men who robbed him disclosed any such impediment in his speech.
It must be admitted that the preponderance of the evidence is in favor of appellants. But it was the province of the jury as to whether or not they would accept the testimony of these witnesses or that of the victim of the robbery. This rule is so well established as to justify no citation of authority.


What to wear in Charlotte?
What to wear in Charlotte? This page provides information about appropriate clothes in Charlotte when you travel.
5 day clothes forecast and weather forecast in Charlotte are as follows, and these are updated daily.
Monthly clothes forecast in Charlotte is as follows.
Our focus is on Charlotte, the city in North Carolina-US. Lucky for those planning a trip over there because they won't get stuck on what to wear. Since our dressing culture is centered on the weather patterns, it's good to be in the light. Charlotte is known for its extremity in each weather change. For instance, during the winter, it is usually very cold and wet. Same case applies to the summer which is extremely hot.
If you are traveling to Charlotte between May and September, the appropriate clothes should be light. This is due to the high temperatures which are rather unforgiving. It can be quite a torture if you are clueless about these facts. Once you get used to it, your trip will be a smooth breeze. You will even want to do it all over again.
You might be asking when is the right time for you to wear that cute coat you bought months ago? Not to worry, the cold season lasts a bit shorter than the hot one. Temperatures begin to cool down from the end of November all the way towards the end of February. A fun fact to know about Charlotte's climatic change is that its coldest day is on the 17th of January. This is the best time to get your cutest boots, coats and scarfs.
The weather conditions should never cause you to lose your sense of fashion. On the contrary, you should be more keen on your taste for fashion than you have ever been. Since we have known that the better part of the year in Charlotte is centered on high temperatures,wear some light clothing. This is where all the tank tops and booty shorts come in handy. As for the men, some beach shorts and muscle tees would do you a lot of good. Not only does it feel good to dress according to the pattern, it makes you look good.
If you want to avoid hefty baggage during your trip, put on something that you can peel off easily. In case your body temperature is something to go by, you may want to put on something light on the inside and some warm clothing on top. This way, you can lose the warm toppings with so much ease. Charlotte is the land of the wild and free. Jump right into the vast ocean and swim with the free fish.
As the weather patterns change, your skin has a hard time trying to adjust. This should never bar you from releasing your wild, adventurous self. Instead, you should take all precautions to safeguard your skin from the harsh effects. For example, carrying all the genuine lotions will curb all side effects that the climate might have on your skin. At the same time, you shouldn't expose yourself to the weather effects directly. For instance, the sun does have some precarious effects on your bare skin. Avoid it at all costs unless you have a sunscreen that will prevent the harmful UV rays.
Since your trip to Charlotte is supposed to be pure fun and leisure, you should take things easy. This is not an adventure in the wild that should get you all worked up and tense. Go with the flow and you will leave this great city with precious memories.


We all need a vibrant summer dress one to slip on and make the most of a sunny day or liven up your holiday look and this vibrant orange Ruba dress is just the one, it's easy to wear, a bold colour and can be worn any time.
The Dressing Room has a superb edit of summer dresses which cover everything from long figure fitting special occasions to a light floaty, flirty dress for a hot summer day.
Bursting full of colour and print, this Samsoe & Samsoe Jayla Dress was made for the Summer time and features a yellow and blue floral print with neat short capped sleeves and a wrap across skirt with gathered at the waist with frills.


text:
STOCKADE CAPTURES CONFERENCE TITLE WITH WIN OVER HARTFORD CITY
It was a long road to glory, but in the end it was well worth it for all involved.
Kingston Stockade FC triumphed over Hartford City FC, 2-1, on Saturday evening in the Atlantic White Conference Championship. The match, which went to extra time, was played at Dietz Stadium in front of a club-record 1,393 fans.
The win gave Stockade its first trophy in the club's second season.
Just as they did upon their first visit to Kingston, Hartford opened the scoring early. Sebastian Stezewski slotted home from close range after a Stockade defensive miscue in the fifth minute to give the visitors an early 1-0 lead.
Stockade FC responded relatively quickly, however, as Bruce Jeter managed to nod home a long cross in the 15th minute to level the score at 1-1.
The remainder of the first half was played without either side asking too much of the other.
The game livened up in the second half, however, as both sides stepped up the pace, intensity, and skill. Despite numerous chances going both ways — including a lovely strike from distance by Stockade midfielder Ross Macklin that was skillfully saved by Hartford goalkeeper Hami Kara — neither team was able to break through.
Until the 94th minute, that is.
In the first stanza of extra time, Stockade forward Michael Creswick, who was subbed on in the 69th minute, collected the ball on the right side of the field and struck a lovely, spinning half-volley from some distance. The ball struck the far post and found its way into the back of the net, giving the thousand-plus fans a moment to celebrate.
With the win, Stockade advances to the regional semifinals against the Clarkstown SC Eagles. The match will take place on Saturday, July 22 at 7:30 p.m. in Madison, New Jersey.
2017 northeast
CLARKSTOWN EAGLES SECURE THIRD STRAIGHT KEYSTONE CONFERENCE TITLE WITH 3-1 WIN OVER NEW JERSEY COPA FC
MIAMI FUSION DEFEAT MIAMI UNITED TO FINISH REGULAR SEASON


text:
Year : 2019 | Volume : 8 | Issue : 11 | Page : 3689-3694
Oral manifestation in leprosy: A cross-sectional study of 100 cases with literature review
Puneeta Vohra1, Md Siraj UR Rahman2, B Subhada3, Rahul Vinay Chandra Tiwari4, MS Nabeel Althaf5, Monika Gahlawat6
1 Department of Oral Medicine and Radiology, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
2 Department of Prosthodontics, Govt Dental College and Hospital, Afzal Gunj Hyderabad, Telangana, India
3 Department of Periodontics, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
4 Department of Oral and Maxillofacial Surgery, Sri Sai College of Dental Surgery, Vikarabad, Telangana, India
5 Consultant Periodontist, Kavil's Smiley Multi Specialty Dental Clinic, Uppala, Kasaragod, India
6 Department of OMFS, Maharaja Ganga Singh Dental College and Research Centre, 11 L.N.P, Hanumangarh Rd, Sri Ganganagar, Rajasthan, India
Date of Acceptance 23-Sep-2019
Date of Web Publication 15-Nov-2019
Dr. Puneeta Vohra
Department of Oral Medicine and Radiology, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana
Background: Leprosy is a chronic granulomatous disease of the peripheral nerve and muscle of upper respiratory tract. Consequence to the neighboring primary site, oral lesions have been seen in 20--60% of patient with leprosy mainly lepromatous leprosy. The lepromatous nodules may be infective and may lead to the spread of disease and hence require proper diagnosis. Aim: To assess oral lesion in leprosy patients. To assess the disease and the occurrence of oral lesion according to age and gender. To detect any primary lesion in oral cavity and compare these lesions in duration to study. Materials and Methods: A total of 100 patients with leprosy were examined and there oral manifestations were recorded. Results: It was found that 70 (70%) leprosy patients showed oral manifestations. And 18 (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, and 4 (5.71%) smokers palate, oral submucous fibrosis, and fissured tongue. Conclusion: Our clinical findings are in conjugation with previous studies; however, as per the review of literature this is the first study worldwide where we have examined 100 cases of leprosy which has not been documented till date. We suggest that the lesser incidence of oral lesions observed recently compared to older reports because of more effective present treatment which is initiated earlier.
Keywords: Leprosy, mouth, oral manifestations
Vohra P, Rahman MS, Subhada B, Tiwari RV, Nabeel Althaf M S, Gahlawat M. Oral manifestation in leprosy: A cross-sectional study of 100 cases with literature review. J Family Med Prim Care 2019;8:3689-94
Vohra P, Rahman MS, Subhada B, Tiwari RV, Nabeel Althaf M S, Gahlawat M. Oral manifestation in leprosy: A cross-sectional study of 100 cases with literature review. J Family Med Prim Care [serial online] 2019 [cited 2020 Jan 22];8:3689-94. Available from: http://www.jfmpc.com/text.asp?2019/8/11/3689/270954
Leprosy (from the Greek word lepi, meaning scales on a fish), or Hansen's disease (HD), was first described in the ancient Indian texts from the 6th century BC, as a nonfatal, chronic infectious disease which was caused by Mycobacterium leprae, whose clinical manifestation was largely confined to the skin, the peripheral nervous system, the upper respiratory tract, the eyes, and the testis. It is a chronic disease caused by the bacteria M. leprae and Mycobacterium lepromatosis. For long a general misconception has prevailed as to the nature of leprosy. It was once considered as a mutilating highly contagious disease with no cure which in turn led to public hysteria prompting mass segregation of leprosy patients to isolated colonies. Although in the past the prevalence of leprosy was worldwide, at present its presence is largely reduced to the following five countries in descending order of being a progressively debilitating disease, most patients suffer from some form of permanent prevalence: India, Brazil, Mozambique, Nepal, and Madagascar.[1] Despite the epidemiological confinement, the severe debilitating nature of leprosy has prompted the World Health Organization (WHO) to consider leprosy as a major health issue, especially in the above-mentioned developing countries. The advent of multidrug therapy recommended by the WHO is considered to be a major reason for effectively curbing the prevalence of leprosy. Despite effective treatment modality, the main concern in leprosy remains to be the associated morbidity. Apart from neural and cutaneous manifestations, leprosy can also affect mucosa and internal disability post-treatment,[2] most commonly involved oral mucosal surfaces include the tongue, lips, soft palate, uvula, organs. Several studies have shown the presence of orofacial manifestations in all the variants (indeterminate, tuberculoid, borderline, and lepromatous) of leprosy. Although orofacial manifestations may occur in any variant of leprosy, it is relatively more common (60% cases) in the lepromatous variant. The oral lesions in these cases are generally asymptomatic and are insidious in nature. In most cases, nasal manifestations preceded oral manifestations as the M. leprae prefers mucosa with lower temperature (nasal mucosa) for multiplication, the periodontium, and the gingiva. The presentation of lepromatous lesions varies largely ranging from sessile to pedunculated nodules to ulcerations and even perforation of the mucosa in advanced stages. Manifestations in tongue include loss of papilla and development of longitudinal fissures. Fibrosis, scarring, and loss of uvula are not uncommon. Patients may also present with chronic inflammation of the gingiva, periodontium. Periodontoclasia has also been reported. The global burden of leprosy has declined dramatically, from 5.2 million cases in 1985 to 204,800 cases at the end of 2009, having a prevalent rate which is <1 per 10,000 [1]. In India, after the introduction of multiple drug therapy (MDT), the leprosy case load came down from 57.6 cases per 10,000 population in 1985 to less than one case per 10,000 population in 2005.3 Leprosy is primarily a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract (skin lesions are the primary external symptom).[1],[2] Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs, and eyes. Infection with M. leprae remains endemic in many tropical countries.[2],[3] A proportion of infected individuals develop characteristic lesions (primarily on the skin and extremities) that are referred to as tuberculoid, lepromatous, and borderline or reactional, depending on the stage of the infection.
Tuberculoid leprosy appears clinically as macular lesions of the skin which are found to overlie subepidermal tuberculoid granulomas containing small numbers of acid-fast bacilli under microscope. Patients with tuberculoid leprosy give positive delayed hypersensitivity responses (referred to as Fernandez or Mitsuda reactions) to intradermal injections of extracts of the organism (lepromin test).[4],[5],[6]
The patient with lepromatous leprosy displays little evidence of immunity to the organism and develops multiple granulomatous masses (lepromas) affecting the face, nose, and ears (leonine facies) and the skin over the wrists, elbows, knees, and buttocks. Peripheral nerve tissue is also extensively involved, with both lepromatous nodules and apparently unaffected patches of skin often exhibiting hypoanesthesia or anesthesia. Patients with lepromatous leprosy are infectious and usually have progressive disease requiring antimycobacterial therapy. Borderline or reactional leprosy [4] represents an intermediate stage between the tuberculoid and lepromatous types. Cell-mediated immunity is considered to be the crucial defense against the disease and the magnitude of this immunity defines the extent of the disease.[2],[3] Oral mucosal lesions are seen in about 20--60% cases of lepromatous leprosy, while they are quite rare in the tuberculoid and the borderline forms. The lesions are proportional to the duration of the disease, indicating that these are late manifestations.[3],[4],[5] The propensity of the disease, when untreated, results in characteristic deformities and the recognition in most of the cultures that the disease is communicable from person to person, has resulted historically in a profound social stigma.
The literature contains few descriptions of oral lesions in cases of tuberculoid leprosy. Lepromatous nodules of the tongue, palate, lips, and pharynx are reported more frequently, as reddish yellow or brown sessile or pedunculated mucosal nodules [2] and destructive lesions of the palate and nasal bones can lead to deformities that are traditionally associated with this disease. Oral lesions have been reported in 20% to 60% of patients with Hansen's disease, the majority of these being lepromatous nodules. With the institution of appropriate and effective antimicrobial therapy, the patients can lead productive lives in the community, and deformities and other visible manifestations can largely be prevented. We emphasize here the importance of the evaluation of the oral mucosa by an oral health professional during patient care, since the oral lesions may act as a source of infection.[2],[3],[4],[5] The data from the study could provide valuable insight into the manifestation of lepromatous leprosy in the 21st century in the presence of the WHO's multidrug therapy.
The present study was carried out in the Department of Oral Medicine and Radiology, K.M Shah Dental College, Piparia, Vadodara, Gujarat. The study was approved by Ethical Committee of Sumandeep Vidyapeeth, Vadodara. SVUEC/ON/84/2009 The total of 100 subjects suffering from leprosy was randomly selected for the study from the OPD of Dhiraj General Hospital and K M Shah Dental College and Hospital Piperia, Vadodara and Ansuya Hospital, a Governmental organizations working for leprosy patients, Vadodara. Written consent was obtained from each participant. Chi square test was applied for statistical analysis to access the disease and find the correlation between age and gender.
The personal and medical history along with the findings of oral examination and Investigations were recorded in the proforma specially designed for this study. All the patients with either of clinical form having confirmed diagnosis taking MDT for leprosy according to WHO criteria were included irrespective of age and sex. Patients who were fully treated by antileprotic drugs or with history of any other systemic condition were not included in the study.
The study population comprised of 100 leprosy patients 60 males and 40 females and age range from 10 years to 82 years with mean age of 37.40 ± 13.31 In study population, there were 4 males and 1 females below 20 years of age, 13 males and 11 females in age group of 21-30 years, 23 males and 14 females in age range of 31 to 40 years, 12 males and 10 females in age range of 41-50 years, 5 males and 0 females in age group of 50--60 years, 2 males and 1 females in age group of 61--70, 0 males and 1 females in age group of 71--80 and1 male and 2 females in age group of 80 and above. Chi-square test was applied for statistical analysis to access the disease and find the correlation between age and gender P value <0.05.
[Table 1] In study population of 100 infected leprosy patients 75% patients had poor oral hygiene and periodontal status, 22% had fair oral hygiene and periodontal status, whereas 3% had good oral hygiene and periodontal status P value <0.05 (Chi-square test) [Figure 1].
Table 1: Age group distribution in study population
Figure 1: Oral manifestations of leprosy *CGP-Chronic generalized periodontitis Note- One patient may have more than one type of lesion
93 (93%) leprosy patients had systemic manifestations out of which 40 (43%) had loss of digits, 20 (21.5%) had fever and body ache, 12 (12.9%) had loss of sensation, 9 (9.6%) had ulceration, 6 (6.4%) had erythema, 2 (2.1%) had nasal congestion and discharge, 1 (1.07%) each had depigmentation and in melanin pigmentation each. [Figure 2] Out of total 60 males all had systemic manifestations 10 (16.6%) cases had fever and body aches, followed by 30 (50%) cases of loss of digits, 8 (13.3%) cases of loss of sensation, 5 (8.3%) cases of ulceration, 4 (6.6%) cases of erythema, 1 (1.6%) had nasal congestion and discharge. Out of total 40 females, 33 (82.5%) had systemic manifestations 12 (36.3%) cases had fever and body aches, followed by 10 (30.3%) cases of loss of digits, 4 (12.1%) cases each of loss of sensation and ulceration, 2 (6%) cases of erythema and 1 (3%) cases of nasal congestion and discharge [Table 2]. The oral manifestations were seen in 70% of leprosy patients, 18 (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, 4 (5.71) smokers palate, oral submucous fibrosis (OSMF) and fissured tongue. [Figure 1] Out of total 60 males 41 (68.3%) had oral manifestations 10 (24.3%) had chronic generalized periodontitis followed by 5 (12.1%) cases of each of atrophy of papillae, melanosis and loss of taste sensation, 3 (7.3%) cases of aphthous, 4 (9.7%) cases of candidiasis, 3 (7.3%) cases of depigmentation, 2 (4.8%) cases each of fissured tongue, OSMF, and smokers palate. Out of total 40 females, 29 (72.5%) had oral manifestations 8 (27.5%) had chronic generalized periodontitis followed by 3 (10.3%) cases of aphthous and 2 (6.8%) cases each of atrophy of paillae, loss of taste sensation, oral and submucous fibrosis (OSMF), candidiasis, melanosis, smokers palate, depigmentation and fissured tongue. [Table 3] In study population out of 100 infected leprosy patients 86% patients had normal salivary flow, 11% had decreased salivary flow whereas 3% had increased salivary flow. The results were not statistically significant (P value >0.05) to comment that patient suffered from xerostomia or ptylisum. [Table 4] Most common systemic manifestation in both males and females was fever and body aches (P value <0.05) followed by loss of digits (P value <0.05) Chi-square test was applied and results were statically significant. [Table 3].
Figure 2: Systemic manifestations of leprosy Note- One patient may have more than one type of lesion
Table 2: Systemic manifestations in males and females of study population
Table 3: Oral manifestations in males and females of study population
Table 4: Salivary flow in leprosy patients (p<0.05)
Oral health is general health. Screening and diagnosis is crucial to understand the disease and obtain a certain diagnosis. Family medication masters and therapeutic officials is the foundation of medical services. Family medication pros in the essential consideration level assume an indispensable job being taken care of by the overall population, especially the individuals who could not bear the cost of private care. Patients with sickness are generally from the lower financial gathering who will look for treatment in government hospitals. Assessing the learning and certainty of family medication, masters in diagnosing and overseeing patients with sickness is significant these days on account of the expanding pattern of diseases. In any case, the learning and certainty among these essential consideration specialists is obscure.[7] In view of their constrained preparing and instruction, it is speculated that the learning and certainty would be low. Misdiagnosis of sickness as cutaneous illnesses is not exceptional. Understanding the oral manifestations present in leprosy will same way help the health professionals to understand the disease better and provide primary and effective care.
In the present study, we have attempted to access oral manifestations in leprosy patients. The sequence of pathological alterations follows the pattern described by Pinkerton in 1932 in the nasal and oral mucous membranes: congestion, infiltration, and formation of nodules, possible ulceration, atrophies, and fibrosis.[3],[5],[6],[8] Important medical and odontological complications may follow the involvement of the oral and nasal mucous membrane and the bones of the face in leprosy.[9] The upper airway is the main point of entry for the bacillus and a route for bacillary elimination in leprosy.[10],[11],[12],[14] For this reason, the control of the mucosal lesions is very important. The mucosal involvement is particularly outstanding in the nose, probably due to the preference of M. leprae for cooler sites. The oral lesions of leprosy occur more frequently in areas of the mouth which have a lower surface temperature. The oral lesions usually appear as ulcerations on the hard or soft palates as was observed in our case. The main oral cavity sites of leprosy include the gingiva in the anterior portion of the maxilla, the hard and soft palates, the uvula, and the tongue. In advanced leprosy, the mouth can acquire the characteristics of a reservoir of bacilli, and it may thus act as an important risk factor for the transmission of the illness. M. leprae favors temperatures which are a little below the body temperature, for its multiplication.[10],[14] Based on this fact, a pathophysiological mechanism has been postulated for the oral involvement: a nasal lesion with obstruction of the air flow leads to oral breathing (mouth breathing), which is very common in lepromatous leprosy. This causes a decrease in the intraoral temperature, mainly in sites near the air intake and in the anterior areas, thus facilitating the harboring of the bacillus. General aspects: The extremely wide spectrum of clinical manifestations of leprosy may be considered a reflection of different cellular responses to M. leprae. There is a relation between dominant cytokine profiles and clinical presentation of leprosy; interleukin-2 (IL-2) and interferon γ markedly dominate in tuberculoid lesions, while interleukin (IL)-4, IL-5, and IL-10 are common in the lepromatous forms of leprosy.[6],[8],[10],[12],[13]
In our study population, 75% of patients had poor oral hygiene and periodontal status, 22% had fair oral hygiene and periodontal status, whereas 3% had good oral hygiene and periodontal status. These results were consistent with previous findings by Costa et al. in 2003[10] who had also insisted the maintenance of good oral hygiene to prevent further spread of infection and incidence of oral lesions.
Out of total 100 leprosy patients, it was found that 70 (70%) had oral manifestations. The oral lesions in leprosy develop insidiously are generally asymptomatic and are secondary to nasal changes. 8,12 18 (25%) had chronic generalized periodontitis, 9 (12.8%) cases of oral melanosis, 7 (10%) atrophy of papillae and loss of taste sensation each, 6 (8.5%) complained of aphthous and candidiasis each, 5 (7.14%) depigmentation, 4 (5.71%) smokers palate, OSMF and fissured tongue these results were in conjugation with previous study done by Costa et al. in 2003. Out of total 60 males 41 (68.3%) had oral manifestations, 10 (24.3%) had chronic generalized periodontitis followed by 5 (12.1%) cases of each of atrophy of papillae, melanosis and loss of taste sensation, 3 (7.3%) cases of aphthous, 4 (9.7%) cases of candidiasis, 3 (7.3%) cases of depigmentation, 2 (4.8%) cases each of fissured tongue, OSMF, and smokers palate. Out of total 40 females 29 (72.5%) had oral manifestations 8 (27.5%) had chronic generalized periodontitis followed by 3 (10.3%) cases of aphthous and 2 (6.8%) cases each of atrophy of paillae, loss of taste sensation, OSMF, candidiasis, melanosis, smokers palate, depigmentation and fissured tongue. A similar results were found by previous studies reported in literature.[10],[15],[16]
Most common oral manifestation in both genders was chronic generalized periodontitis these findings could not be correlated with any other study done by various authors in past although a higher prevalence of oral manifestations in males then females was found like previous studies.[5],[6],[8],[10],[14] The greater prevalence in men could be explained by the fact that women seek doctor's advice earlier, perhaps for esthetical reasons.[5]
In study population of 100 leprosy patients 86% patients had normal salivary flow, 11% had decreased salivary flow whereas 3% had increased salivary flow which has not been estimated in any of the previous studies.
Out of 100 leprosy patients 93 (93%) had systemic manifestations out of which 40 (43%) had loss of digits, 20 (21.5%) had fever and body ache, 12 (12.9%) had loss of sensation, 9 (9.6%) had ulceration of digits, 6 (6.4%) had generalized erythema and eczema, 2 (2.1%) had nasal congestion and discharge, 1 (1.07%) each had depigmentation and increase in melanin pigmentation each. These figures are almost similar to earlier studies reported.[5],[6],[8],[14] Out of total 60 males all had systemic manifestations, 10 (16.6%) cases had fever and body aches, followed by 30 (50%) cases of loss of digits, 8 (13.3%) cases of loss of sensation, 5 (8.3%) cases of ulceration of digits, 4 (6.6%) cases of generalized erythema and eczema, 1 (1.6%) had nasal congestion and discharge. Out of total 40 females, 33 (82.5%) had systemic manifestations 12 (36.3%) cases had fever and body aches, followed by 10 (30.3%) cases of loss of digits, 4 (12.1%) cases each of loss of sensation and ulceration of digits, 2 (6%) cases of generalized erythema, eczema and 1 (3%) cases of nasal congestion and discharge. The most common systemic manifestation in both genders was fever and body aches which could not be correlated with any other reports given by various authors in their previous studies.
Since there are many important complications of involvement of the oral and nasal mucosa and bones of the face by leprosy, patients should be examined carefully and informed regarding improvement of their oral hygiene.[17],[18],[19],[20],[21] With the idea of other authors, it is believed that oral mucosal lesions are sources of infection in leprosy patients who expel great numbers of bacilli when they spit, sneeze, cough, or speak, once released into the environment, the bacilli could be viable for up to nine days or even longer.[6],[8],[10],[11] The lesser incidence of oral lesions observed recently compared to older report could be because the present treatment is more effective and is initiated earlier, and probably because of improvement in oral hygiene.[12] Still oral features in leprosy were noticed in hard palate and premaxilla including case of bilateral seventh nerve palsy is noted.[22],[23],[24] To conclude, the oral cavity must be examined in cases where leprosy is suspected. With the institution of appropriate and effective antimicrobial therapy, the patients can lead productive lives in the community, and deformities and other visible manifestations can largely be prevented. Three major strategic components of leprosy control include: early detection of the disease, adequate treatment, and comprehensive care for prevention of disabilities and rehabilitation.[1],[17],[18],[19],[25]
Oral leprosy lesions are nonspecific in their presentation and are often over looked by clinicians or misdiagnosed. The role of dental profession and especially the oral medicine specialist is of great importance in early diagnosis of oral lesions. A thorough knowledge of this chronic infection is hence necessary to provide optimum level of health care.
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Ethical clearance
Taken from institutional ethical committee.
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Vohra P
Rahman MS
Subhada B
Tiwari RV
Nabeel Althaf M S
Gahlawat M
oral manifestations


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