Leprosy Mailing List – July 13, 2018
Ref.: (LML) Improving the quality of leprosy treatment
From: Joel Almeida, London and Mumbai
Dear Pieter,
Several important points are being made in recent discussions by esteemed colleagues: Leprosy spreads, and Leprosy disfigures.
If we take care of those two problems, we will protect people adequately.
Slit skin smears
In recent decades we have discouraged and discontinued slit skin smears. Even though we know that an inadequately treated person with polar lepromatous leprosy can spread up to one million times the number of M. leprae as a person with TT leprosy. This error is highly favourable to M. leprae and highly unfavourable to human beings. It would be good to correct this error. How?
First by reminding ourselves that one inadequately treated polar LL patient is equivalent, epidemiologically, to one million TT patients.
It is not the patient's fault. It is our fault for discontinuing slit skin smears as a routine. Consequently, inadequate anti-microbial treatment for polar LL leprosy has become widespread. In effect, these patients remain susceptible to relapse or re-infection but are left without anti-microbial protection. Such a situation would probably not be tolerated in any other disease. Every human being deserves an adequate quality of care. The human rights of people with leprosy do not begin only after they suffer disfigurement.
It would be good to resume slit skin smears that were a routine part of leprosy control programs. It is important for the individual and for society. We need to scale up training and supplies to achieve this.
Nerve monitoring
Leprosy disfigures, largely by damaging nerves. MDT or any other anti-microbial treatment helps, but it does not suffice to protect against nerve damage. Despite exaggerated claims to the contrary.
A randomized controlled trial (van Brakel at al 2003) compared prednisolone, given for 4 months, with placebo. During these 4 months, the placebo group had a 158% higher risk of deterioration in sensory scores between the start and end of treatment (confidence interval 19% to 460%).
Regular monitoring of nerve function during and after anti-microbial treatment is necessary to reduce the risk of disfigurement. Especially since as much as 85% of new nerve damage in South Asians with leprosy occurs without any signs of inflammation ("silent neuritis").
We have an opportunity to restore science to leprosy treatment, so that people at risk of leprosy are treated no less humanely and competently than other human beings.
Once we improve the quality of treatment for leprosy we can hope to
a) reduce the spread of leprosy;
b) reduce the risk of disfigurement among those infected with M. Leprae.
We tried propaganda, for many years. It harmed leprosy work, harmed patients and drove young talent away from leprosy. It may be time for new faces and new thinking to take us forward.
Joel Almeida
Reference:
Van Brakel WH, Anderson AM, Withington SG, Croft RP, Nicholls PG, Richardus JH, et al. The prognostic importance of detecting mild sensory impairment in leprosy: a randomized control
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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