Leprosy Mailing List – February 11, 2016
Ref.: (LML) Time scale of payoffs
From: Joel Almeida, Mumbai and London
Dear Pieter,
It may be useful to think of the time-scale of payoffs, when fighting M. leprae and its devastating consequences.
1) Payoffs in decades
a) Secular trends in incidence rate, owing to socio-economic development, sanitation, deforestation, urbanization etc.
b) Lasting changes in incidence rate attributable to deliberate efforts (treatment, prophylaxis etc.)
2) Payoffs in years
a) Suppression of M. leprae in patients with very low specific immunity (that subset of lepromatous patients who respond slowly and may require prolonged anti-microbial treatment).
b) Prevention of further disability among leprosy-affected persons who have already suffered permanent nerve damage.
c) Rehabilitation and integration of leprosy-affected persons who have already suffered permanent nerve damage and disfigurement.
3) Payoffs in months
a) Suppression of M. leprae in newly diagnosed patients, by case-finding and MDT.
b) Prevention of nerve damage among leprosy-affected persons during the first 2 years after starting MDT, by monthly monitoring of nerve function and prompt anti-inflammatory treatment where required.
The shortage of funds for leprosy control is a temporary blip, brought about by premature self-congratulation. TB control went through this phase in the 1980s. But time is a great teacher.
The funds for leprosy control will expand greatly, just as the funds for TB control expanded from about $100 million/year in the early 1990s to several billion dollars per year now. This is because M. leprae remains infective for months outside the human body, replicates in amoebae, and is relentless in triggering inflammatory responses leading to nerve damage and visible deformity. We can turn a blind eye to the newly developed visible deformities and child cases for only so long. Eventually the world finds out.
As the cake of funding expands, we can enlarge efforts to pursue more distant pay-offs. Meanwhile, it would seem wise to pluck the low-hanging fruit: those payoffs which are available within months. Mass chemoprophylaxis, once evaluated in a suitable demonstration site, might also yield payoffs within months (suppression of M. leprae with delay or prevention of clinical signs).
We cannot allow people newly to develop deformity just because we were busy pretending to eliminate leprosy. We need to expand the funding cake for leprosy so that we can pursue all the payoffs vigorously. Our narrative needs to be transformed, just as happened with TB in the 1990s. Then our outcomes will be transformed. This process has already begun.
Regards,
Joel Almeida
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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