To: Leprosy Mailing List <leprosymailinglist@googlegroups.com>
Subject: Ref.: (LML) Improved care for LL patients is critical
Leprosy Mailing List – April 14, 2022
Ref.: (LML) Improved care for LL patients is critical
From: Joel Almeida, London and Mumbai
Dear Pieter & colleagues,
Recurrence rates after MDT are low among regularly treated HD patients in endemic areas but not so among polar LL patients. Further, the absence of skin smear monitoring during treatment tends to delay diagnosis of recurrence until over 5 years from the withdrawal of anti-microbials. LL patients form fewer than 1% of actively detected new cases. But this 1% of new cases accumulates over the years, gets reinfected, and is an important source of transmission. Other patients are not as susceptible to reinfection.
Genomically anergic LL patients with viable bacilli accumulate after MDT (or are re-registered eventually as relapses/other retreatment). In places such as Comoros, they form an important proportion of the currently bacillated cases. That is how transmission to children and others has continued for the past 20 years, despite vigorous active case finding and fixed-duration treatment. By contrast, in places where LL patients were allowed prolonged anti-microbial protection, transmission declined rapidly. This was true in even places that had low incomes at the time (e.g., Uele DRC, Karigiri India, Weifang Shandong China).
Recurrence rates among LL patients (including recurrences belatedly diagnosed 15 years or more after withdrawal of anti-microbial protection) can be underestimated greatly by
a) Mixing LL patients with other MB patients in the analysis (just as breast cancer rates among females can be seriously underestimated by mixing them with males in the analysis)
b) Stopping follow-up within <5 years after withdrawal of anti-microbials while omitting skin smear monitoring of LL/highly bacillated patients.(In the absence of skin smears recurrences are generally not diagnosed until >5 years after withdrawing anti-microbials).
c) Mixing the first five years of follow-up with later years of follow-up in the analysis of recurrence rates. Most recurrences are not diagnosed until >5 years after withdrawal of anti-microbials. Many are diagnosed 10 to 20 years later.
Competent & prolonged care for LL patients, including protection against reinfection, is critical to stopping transmission. It is also an important way to reduce suffering, disability and social exclusion of highly bacillated patients. There is no good reason to deny LL patients the respect and care they deserve.
Best,
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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