Leprosy Mailing List – December 30, 2018
Ref.: (LML) Why M.leprae defeates us
From: Joel Almeida, Mumbai and London
Dear Pieter,
We don't know everything about M. leprae and its interaction with us. However, we probably know enough to protect people much more reliably than at present.
1. We need to identify people with anergy, polar LL patients, so that we can keep protecting them against M. leprae.
M. leprae currently spreads, in important part, because we withdraw anti-microbial treatment prematurely from such patients with anergy. M. leprae that pass from one person with anergy, to another with anergy, are sufficient to defeat our leprosy control efforts. No amount of early detection and treatment of non-infectious patients can compensate for that error among polar LL patients.
Unfortunately, we discouraged skin smear services, and they are now in need of rebuilding. That makes it difficult for us to recognise patients with anergy. As a result, we continue to withdraw anti-microbial treatment prematurely from such patients. This means that M. leprae continue to spread, while continuing to damage these patients. This mistake can be corrected.
We need to rebuild skin smear services, urgently, and to provide prolonged anti-microbial protection to patients with polar LL leprosy. It is probably the lowest-hanging fruit in leprosy treatment and control, with one of the biggest payoffs.
2. We need to monitor nerve function regularly and competently, because most nerve damage in south Asia occurs without signs or symptoms of reaction (1). Then we can intervene with anti-inflammatory treatment promptly enough to prevent and reverse nerve damage.
A randomized controlled trial (2) compared corticosteroids - 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%). We need to keep reminding ourselves of this randomised controlled trial. And we need to act on this RCT so that we protect the limbs, eyes and lives of the vulnerable people who trust us.
This, too, requires the rebuilding of formerly available services. This time, for nerve function testing.
Otherwise, as a recently reported RCT in Brazil showed (3), about 30% of patients will suffer worsening of disability despite MDT. That equates to over 400,000 people in India newly suffering worsening of disability over the coming decade. We can do better than that. However, it does require us to rebuild the mobile nerve monitoring services that formerly visited patients near their homes at regular intervals.
3. We need to do sample surveys every few years, perhaps every 5 years, relying on highly skilled personnel. Otherwise we are reduced to guesswork about the endemic.
The national sample survey in India, using reliable personnel and methods, demonstrated that for every 4 recognised patients there were about 6 unrecognised patients (4). The Supreme Court of India was sensible in ordering that such sample surveys be repeated regularly.
Persons affected by leprosy had approached parliamentarians in India's upper house, expressing doubts about the claimed decline of leprosy. That's how the sample survey came to be done.
People whose eyes or limbs were damaged by leprosy obviously remained clear-sighted when it came to the magnitude of leprosy. Such persons have an important role to play in defeating M. leprae because they don't underestimate the problem. A coalition between them and reliable experts is likely to yield good outcomes.
4. We need accurately to depict the weight of disability that is experienced by people affected by leprosy. That is the real burden of leprosy. Closing our eyes to their situation does not help them. Nor do subjective descriptions of the magnitude of leprosy.
Experts in every disease, except leprosy, do this correctly. It is a simple formula, used by the Institute for Health Metrics and Evaluation in describing the burden of morbidity from a disease:
Prevalence of disability x weight of disability
It is used for other diseases and their sequelae. We need to start using it for leprosy too. People affected by leprosy have enough disadvantages without us experts misrepresenting and underestimating the magnitude of the disease relative to other diseases.
Otherwise, leprosy will continue to be neglected because of our failure to observe established practices that are used in every other disease.
Conclusions
We experts have sometimes been inexpert. Worse, our inexpertise and propensity to imagine victories has led us to destroy competent leprosy services. The sooner we recognise this, the more quickly we can transform the situation.
The good news is that we can now correct our mistakes. We owe this to the vulnerable people who trust us. We can become builders of competent services once again.
We have no shortage of compassionate people with strong scientific skills and front-line implementation experience. Let's join together, invite a new generation to join us, and do it.
Let's make 2019 much worse for M. leprae, and much better for human beings at risk of leprosy and its consequences.
Joel Almeida
References
(1) Srinivasan H, Gupte MD. Experiences from Studies on Quiet Nerve Paralysis in Leprosy Patients. Indian J Lepr 2017, 89 : 203-215.
(2) 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 controlled trial (TRIPOD 2). Leprosy Review 2003;74(4):300‐10.
(2) Penna GO, Bu¨hrer-Se´kula S, Kerr LRS,
Stefani MMdA, Rodrigues LC, de Arau´jo MG, et al.
Uniform multidrug therapy for leprosy
patients in Brazil (U-MDT/CT-BR): Results of an
open label, randomized and controlled clinical trial,
among multibacillary patients. PLoS Negl Trop Dis
2017; 11(7): e0005725. https://doi.org/10.1371/journal.
pntd.0005725
(3) Kiran Katoch, Abha Aggarwal, Virendra Singh Yadav, Arvind Pandey. National sample survey to assess the new case disease burden of leprosy in India. Indian Journal of Medical Research, 2017; 146(5): 585-605.
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
