Leprosy Mailing List – December 23, 2013
Ref.: (LML) Duration of MDT MB, relapses and re-infection
From: Jaison Barreto, ILSL Bauru, São Paulo, Brazil
Dear Pieter,
The problems I have seen and described are occuring every day, whether I’m in the field or at the national reference centre where I work. Details about situation of the leprosy in the field can be seen at the site of Brazilian DAHW (www.dahwmt.org.br).
Physicians do not know about leprosy, and, many times, do not want to learn about it, because if they do, they will have to attend the patients from their municipalities. Of course, there are still good willing professionals, but they are diminishing in number.
For the few physicians whose are still fighting against leprosy, it is a hard life: we have to fight against the disease, the problems the patients have, and also against the politicians from the area we live and work.
Ignorance, stigma and prejudice are still the rule, mainly at the Brazilian states where leprosy is proclaimed "eliminated". The concept that leprosy is eliminated in a municipality or in a state worsens this vicious circle and leads to neglecting leprosy. Health managers do not want to spend money on a disease they believe does not exist
The weakness of the WHO classification (only the number of skin lesions, while the number of nerves involved is not important), also worsens this problem. Ridley, 40 years ago, showed that borderline patients tend to downgrading: most BL comes from BT, and most LL comes from BB/BL.
Is it right to treat a patient, who has many bacilli inside his nerves and few in the skin and who has not the capacity of elimination of M. leprae from the nerves, with daily dapsone and monthly rifampin for 6 months only? We, clinicians and leprologists, see, today, that many high BI leprosy (LL/BL) patients are not cured with 12 doses. So, what can we say about regimens of 6 months for these patients?
The most recent and best cohort study was published by Katoch et al in 2008, who described that 70 patients with BB, BL and LL leprosy that were treated with MDT 12 doses plus Ofloxacin and Minocycline, still had a relapse rate of 5,7% (follow up 8-10 years). In my recent (2011) PhD thesis, in a 11 years follow-up cohort study of 46 LL patients, treated with 24 doses MDT, 91% were found clinically healed,9% was still clinically active. Of the 46 patients 27% still had laboratory signs of disease (positive bacilloscopy, serology or bacilli inside the nose)..
Of course, household contacts must be evaluated, or the number of doses does not matter at all because of reinfection. I remember a patient I saw, from the state of Mato Grosso: a married woman, treated with 24 doses, who "relapsed" 2 times in 10 years. She said that her husband had no problems: no complains, no patches, no lepromas, but also no eyebrows and no eyelashes and never diagnosed.
Fortunately, in Brazil, we are working hard, and try to change this situation, since the making-up of statistics, as well as centralization of diagnosis and treatment, used to be done in many countries, does not solve the problem. The Brazilian Ministry of Health stimulates activities at municipalities, in order to evaluate household contacts locally, in order to detect the problem at younger ages and early (eg children with indeterminate leprosy).
Best regards
Jaison
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
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