Sunday, January 6, 2019

(LML) Missed lepromatous cases

Leprosy Mailing List – January 6,  2019
Ref.:  (LML) Missed lepromatous cases
From:  Joel Almeida, London and Mumbai

Dear Pieter,

Congratulations to the Indian Central Leprosy Division for a careful investigation of missed cases in Salaunikhurd village, Bilaigarh Block, Chhattisgarh state. (1) 
The annual new case detection rate, in the Block, which had hovered around 30 per 10000 persons/yr until 2015 has risen to over 100 per 10000 persons/yr since then.
Multiple cases in one family, all with infiltrated skin and even some nodules, escaped detection during case detection campaigns. A careful investigation was carried out to understand what led to this. A team of experts visited the village.

It turns out that the symptoms were not worrisome and the patients hoped for self-cure. The duration of symptoms before diagnosis was between about 1 to 2 years. The patients are described as having "de novo MB" leprosy. Presumably, no patches ever appeared.Neither the patients nor the village health personnel were aware that this was leprosy, and stigma was not a clear explanation for the delay in seeking diagnosis. The family had a low income and family members had to migrate as seasons changed (presumably in order to survive by finding some income). The knowledge about leprosy among the village health personnel and those at the primary health centre was found to require improvement.

What can we conclude from this excellent investigation, apart from the fact that the Central Leprosy Division deserves congratulations for its meticulous approach to continuous improvement at the frontlines?

1) We are teaching health personnel to detect every kind of leprosy except lepromatous leprosy, the kind that is most responsible for the spread of M. leprae. Denying skin smear services to front-line personnel is like sending firemen to fight fires but with blindfolds on.
We need urgently to rebuild skin smear services, otherwise we will keep failing to detect lepromatous cases. Then we will have steadily more examples of the annual new case detection rate rising to over 100 per 10000 persons/yr despite all our worthy efforts.

2) Low income forces people to move around in search of work. Persons with anergy are fertile soil for M. leprae. One person with anergy can harbour more M. leprae than tens of thousands of patients with well-defined patches. A patient with anergy remains susceptible to reinfection if treatment is prematurely withdrawn. This is particularly important in villages such as Salaunikhurd, where sources of M. leprae are abundant. 
Then, through no fault of their own, unprotected patients with anergy tend to spread as many M. leprae as do tens of thousands of untreated persons with self-limiting forms of leprosy. Withdrawing treatment prematurely from patients with anergy is like sending the fire brigade home before the fire is extinguished.
Infectious diseases are like a fire. M. leprae are particularly dangerous because they cause few symptoms or signs in persons with anergy. The fire is hidden.  
Our failure reliably to detect patients with lepromatous leprosy and then to protect them against reinfection is like a huge but avoidable hole in our fire barrier. We can do better.

3) Well defined skin patches are often a sign that the infection has been contained. By contrast, the barely perceptible diffuse infiltration of early lepromatous leprosy easily can be missed.
Health personnel naturally gravitate to clearly visible patches, especially if they are denied the skin smear services that can confirm subtle signs of early lepromatous leprosy. It is like firemen focusing largely on smoke because subtle smouldering flames are hidden.
Since the early 2000s we have been discouraging skin smear services. That is why M. leprae continue to flourish in places like Salaunikhurd village, unnecessarily damaging human limbs, eyes and lives. The damage is avoidable, but we have to become builders of competent skin smear services once again.
The more quickly we detect hidden lepromatous leprosy, and the more we ensure protection against reinfection, for patients with anergy, the smaller the risk of the endemic flaring up as happened in Salaunikhurd village.

4) There is no substitute for continuous improvement at the frontlines. We have grown somewhat isolated from the realities of leprosy, and the clues that are continually available at the frontlines. That's why it's so important to invite in a new generation of leprosy workers in the endemic countries. 
We need to enlarge our horizons beyond past habits and past errors by understanding more clearly what is really happening between M. leprae, anergic patients, other patients, the community and the environment. Our minds need to be open to improved approaches.

The Indian Central Leprosy Division shows how important it is to open our eyes especially to unexpected failures (and unexpected successes, where reliable investigation confirms that). Then we can make continuous improvement a reality at the frontlines. Congratulations to the Indian CLD for this exemplary investigation.
I intend to compliment the relevant leaders in India for this exemplary work.

Joel Almeida

1) Central Leprosy Division, India. Epidemiological investigation of multiple cases occurring in one family in village Salaunikhurd. NLEP newsletter Vol III, Issue 3, July – Sept 2018

LML - S Deepak, B Naafs, S Noto and P Schreuder
Contact: Dr Pieter Schreuder <<

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