Leprosy Mailing List – February 19, 2020
Ref.: (LML) The importance of undiagnosed LL patients in spreading HD
From: Joel Almeida, London and Mumbai
Dear Pieter and colleagues,
We have discussed Salaunikhurd village (India) here previously. Careful observations there by the Indian HD program and local professionals offer critical clues about why HD continues to spread and disable so many people.
Now details are reported by a journalist:
https://www.theweek.in/health/more/2020/02/10/a-deformed-system.html
Undiagnosed persons with LL disease can sometimes show no signs of disease. In this illustration, the only sign apart from possible madarosis (loss of eyebrows) is an absence of wrinkles in a 70 year old, although that is not a specific sign. A nasal speculum and a torch might reveal nodules on the nasal mucosa. Skin smears and nasal discharges, however, tend to be almost invariably full of acid-fast globi (dense agglomerations of bacilli) in such patients. Missing such patients and giving them a single dose of a single drug is a recipe for selection of drug-resistant mutant bacilli. That could put HD control out of our reach for decades.
A positive skin smear can be the only clue to LL HD. The failure to use skin smears is allowing HD to spread. It is a devastating problem with a simple solution. It seems wise to restore reliable skin smear services widely in India.
The primary health care centre nearest to this village is 50 km away, in an area with poor public transport. Apparently, MDT is not stocked there. Patients have to make a three-hour 200 km journey by a twice-daily bus service just to get access to MDT. That is if they have enough money left over after buying the essentials of life. The situation might improve with the new health and wellness centres that each serve about 10,000 people, but only if these centres stock MDT.
The Kewat family in Salaunikhurd demonstrate multiple patients with de novo LL disease (LLp, polar LL) within one family. Since the frequency of LLp genomes in the population is probably about 25/100,000, the probability of multiple de novo LL (LLp) patients occurring in one family based on a non-genetic random distribution alone is vanishingly small. Accordingly, genetic predisposition to de novo LL disease appears to play a critical role in the continuing spread of HD.
The bacillus has evolved to leave those patients unharmed for relatively long periods, who shed astronomical numbers of viable bacilli in nasal discharges. They remain with few or no obvious signs of disease. Meanwhile, the majority of patients in door-to-door surveys by expert examiners are non-infectious even before treatment, but are saddled with the same label as the highly infectious few. Worse, health services have been focusing largely on self-healing patients with well defined skin patches, while overlooking LL patients who tend to have only subtle signs. It seems wise to help the many non-infectious and self-healing patients to escape any and all stigma, by more careful and accurate education of the public and professionals.
There is no substitute for consistent, reliable diagnosis of highly bacillated de novo LL patients, followed by adequately prolonged anti-microbial treatment for them. It is the only tried and tested method so far that produces a 20% decline/year in new cases leading to near-zero transmission. Let's allow the people of endemic countries to benefit from it.
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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