Leprosy Mailing List – February 16, 2019
Ref.: (LML) Early detection is the critical part
From: Joel Almeida, London and Mumbai
Dear Pieter,
Dr. Zijp in Chad wrote (LML, January 18, 2019):
"carries out nerve assessments so as to detect and treat leprosy reaction early"
"We are having the same vision: early detection and treatment and we add: early detection of leprosy reaction and treatment."
Dr. Zijp apparently considers these patients as members of her own family. That is probably because she is right there living among them, caring for them, doing her best for them. More power to her.
Preventing permanent deformity depends on
a) anti-microbial treatment (MDT) and
b) nerve function assessment with anti-inflammatory treatment
What is the relative contribution of each?
We know that 25% to 40% of MB patients show worsening of disability despite MDT (1). With regular nerve assessment and prompt anti-inflammatory treatment this can be greatly reduced. Prednisolone was so effective in a randomised controlled trial that at the end of a 4-month treatment phase those on placebo had a 158% increase in risk of deterioration in sensory scores compared to those given prednisolone.(2) Further, most nerve damage occurs without symptoms of reaction (quiet nerve paralysis or silent neuropathy). (3) This makes regular nerve function assessment even more important.
How about the contribution of earlier diagnosis? About 5% to 8% of patients have visible deformity at diagnosis, in the large endemic countries. Earlier diagnosis could, at best, reduce this to zero.
Therefore, earlier diagnosis could, at best, help avert permanent deformity in 5% to 8% of patients. Nerve function assessment and prompt steroid treatment could help avert deformity in as many as 30% of patients. The evidence therefore supports Dr. Zijp's compassionate plea for nerve function assessments.
Many parts of India in the 1990s had mobile nerve function assessment and rehabilitation services visiting patients near their homes. These have been destroyed since the early 2000s, on the pretext that leprosy was being eliminated. How was it being eliminated? By withdrawing services and removing patients from registers. In reality, such unjustified boasts had the effect of eliminating the nerve assessment services on which depend the nerves, limbs, eyes, minds, livelihoods and relationships of vulnerable and trusting people in endemic countries.
As a result of dismantling nerve function assessment services, it can be estimated that over 250,000 Indians with MB disease (over 20% of 1.2 million since 2000) have unnecessarily suffered avoidable deformity. Meanwhile, life in affluent countries has continued to be good.
We need to continue speaking out loudly on behalf of the vulnerable and trusting people of endemic countries, so that normal standards of science and human rights can be respected in the battle against the bacillus. The people at risk are part of our family. The human family.
It is no accident that Hanseniasis patients had to go to the Indian Supreme Court because of exaggerated claims and empty boasts. More power to them.
We need to hold ourselves to a better quality of technical advice in Hanseniasis, better informed by science, front-line experience and compassion. And we need to restore competent services for regular nerve function assessment.
Joel Almeida
References
1) 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
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.
3) Srinivasan H, Gupte MD. Experiences from Studies on Quiet Nerve Paralysis in Leprosy Patients. Indian J Lepr 2017, 89 : 203-215.
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
No comments:
Post a Comment