Leprosy Mailing List – March 13, 2021
Ref.: (LML) Highly effective interventions do not stigmatise newly diagnosed patients
From: Joel Almeida, London and Mumbai
Dear Pieter & colleagues,
Fear of HD (leprosy) still causes people to impose a life sentence on persons newly diagnosed, in too many places. This barbaric practice occurs even when the affected persons have types of HD that almost never shed significant numbers of bacilli. HD has even been called a "living death". This is owing to the frequently devastating social and economic consequences imposed on those affected.
What does a more informed view suggest?
Only persons with LL (lepromatous) HD have been shown to shed high concentrations of viable bacilli in nasal discharges. Anti-microbial protection rapidly switches that off. When LL patients were protected against reinfection, by continuing anti-microbial treatment till smear negativity, transmission declined rapidly (16%/year or more) in even low-income areas. However, when such protection was withdrawn at 12 or even 24 months, transmission continued or resumed. Within households, the presence of a previously treated but since unprotected LL patient greatly multiplied the risk of transmission to children. This suggests the overwhelming importance of protecting LL patients against (re)infection beyond just 12 months of MDT. Other patients, even before starting treatment, have not been shown to shed significant concentrations of viable bacilli, although they require anti-microbial treatment (MDT) for their own protection.
In due course, a diagnosis of any type of HD will come to be regarded as unremarkable. That is our dream. However, dreams are not always current reality. In too many places, that happy day is still some way off. HD continues to spread because LL patients suffer anti-microbial and wider neglect after 12 months of MDT. It continues to disfigure people despite MDT because nerve function is not regularly tested. Newly diagnosed patients cannot close their eyes and rely on dreams. They are forced to face harsh reality.
Civilised society requires evidence before a life sentence is imposed on anyone. What is the evidence that persons with HD (other than unprotected LL patients) shed viable bacilli in any significant concentration? The evidence is absent, scarce, or contrary to stigmatising claims. For example, full treatment of PB patients made no dent in the risk of HD among their household contacts, suggesting that the PB patients posed no threat to their contacts to begin with. Yet harmless human beings too frequently are condemned to a living death. The harsh treatment is completely disproportionate to the trivial or often zero public health risk. Unprotected LL patients, who have been known to shed viable bacilli in high concentrations, can be identified and protected. Nearly all other HD patients typically are harmless from the outset. These distinctions are important.
Some interventions explicitly or implicitly portray and expose all newly diagnosed persons as a threat to family and neighbours. However, the demonstrably effective interventions do not single out and publicly expose newly diagnosed patients. Many newly diagnosed patients are poor and illiterate. They are not well placed to defend their own best interests in the face of careless advice. All the more reason to protect their best interests. "Outing" them is unnecessary for epidemiological impact.
The privacy and dignity of every person in high endemic areas can be preserved even when prophylaxis is used. That is by sticking to mass multi-drug administration. Further, mass multi-drug administration showed far greater epidemiological impact, with far lower microbiological risk (of drug resistance), than any other approaches. A 16% to 20% annual decline in incidence rate of HD had been demonstrated earlier wherever regularly ingested MDT was continued till smear negativity. The Sasakawa Health Foundation, along with WHO, then sponsored the addition of mass multi-drug administration. This resulted in a greater than 90% decline in new cases of HD within only 2 years. This was preceded by an immediate 92% reduction in risk among those who received a single dose of rifampicin + ofloxacin + minocycline compared to those who did not. Fewer than 15% of new cases occur among household contacts in an endemic area (1), but mass multi-drug administration reaches beyond household contacts and instantly shuts down nearly all sources of concentrated bacilli. If such exemplary campaigns had been repeated relentlessly in that high-endemic population, bacilli likely would have become as scarce as they are now in Shandong. Shandong has near-zero transmission.
Great colleagues at the frontlines have demonstrated what really works, even in low income populations such as in the Karigiri area. Stigmatising interventions that select drug resistant bacilli and demonstrably increase the risk of MB HD in persons exposed to cultivable mycobacteria need not be promoted in endemic countries. Instead, highly successful interventions can be promoted vigorously. 90% reduction of new HD cases within 2 years is the achievable benchmark to which we can aspire. LL patients can receive the prolonged anti-microbial protection they require, and bacilli can be attacked relentlessly until they become as scarce as in Shandong. We know how to succeed using specific interventions..
1) Competent diagnosis, especially of LL HD, including by wider use of reliable nasal and skin smears
2) MDT, including MDT continued till smear negativity for LL patients
3) In high endemic zones, mass multi-drug administration repeated every 6 to 9 months
4) Quarterly monitoring for MB patients, to detect and treat early impairment of nerve function
5) Demonstrating not just by words but by effective interventions that HD is easily treatable and preventable, there is no need for fear
Only first class, highly effective interventions will suffice for the people of endemic countries, because endemic countries too have only first class human beings.
Joel Almeida
References
1. Butlin CR, NIcholls P, Bowers B. Outcome of late healthy household contact examinations in leprosy-affected households in Bangladesh. Lepr Rev (2019) 90, 305 – 320
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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