Leprosy Mailing List – April 3, 2023
Ref.: (LML) DOCHANSEN: New Telemedicine Platform for Leprosy in Brazil
From: Joel Almeida, Mumbai, India
Dear Pieter & colleagues,
Congratulations to Dr. Laila de Laguiche for the DOCHANSEN initiative. There is no substitute for a good physical examination by a health worker. If we could clone HD experts we would. Telemedicine with local health workers receiving instructions from an expert is not the same as having an expert present physically. However, in many places telemedicine is the only realistic alternative to substandard services.
Treatment of difficult cases can certainly benefit from telemedicine. That need not be all.
The diagnosis of subtly indurated LL (lepromatous) HD (leprosy) can be challenging for even physicians, especially where smear microscopy has fallen into disuse. No skin patches, no conspicuous nerve thickening, the bacilli temporarily living in relative harmony with the patient... Most health workers and even some physicians are unlikely to suspect HD in such LL patients. These LL patients can seem healthy until an experienced clinician notices subtle alteration and pinches their skin to check for induration. Failing to recognise LL patients has serious consequences. Untreated LL patients, both before and after MDT (following reinfection), typically are a prolific source of concentrated viable bacilli. Competent examination of apparently healthy persons is important in endemic areas, as is smear microscopy to check for densely packed bacilli in nasal discharges or tissue fluids.
If LL patients are left without anti-microbial protection in endemic areas then HD will continue to affect thousands of additional children each year as well as hundreds of thousands of adults. Stopping transmission at source by prolonged anti-microbial protection of all LL patients seems wise. Even LL HD patients treated many years ago deserve anti-microbial protection. In Brazil and other places qPCR is increasingly used for highly specific diagnosis. Even in such favourable circumstances, it seems necessary in endemic areas to recognise LL HD patients by good clinical examination and smear microscopy. Then LL patients in endemic areas can receive the prolonged anti-microbial protection they need against reinfection.
Infection as well as reinfection need to be shut out among persons with polar LL genomes. We know this because we currently have trouble achieving even 7%/year decline in the incidence rate of MB (multibacillary) HD. Typically we are achieving a much slower decline than 7%/year, and in some places there is even an increase. The temporary dip in case-finding owing to the pandemic does not alter that fact. Disappointing decline in HD is observable even in places where income levels have increased markedly since the 1990s (e.g., Yunnan).
By contrast, Uele (DRCongo/Zaire), Karigiri (India) and Shandong (China) achieved well-documented 16% to 20% annual decline in MB HD at a time when they had relatively low incomes. Wherever prolonged anti-microbial protection was made available to LL patients, HD declined rapidly. Whenever LL patients are denied prolonged anti-microbial protection in endemic areas, all our other efforts including chemoprophylaxis and BCG fail to achieve the 16% to 20% annual decline in MB HD that demonstrably is achievable with prolonged anti-microbial protection of LL patients. It is not that the molecules are ineffective, although the use of a single drug for prophylaxis instead of multi-drugs steadily and stealthily increases the frequency of drug-resistant mutants especially in missed LL cases. Rather, currently fashionable treatment and control practices are ineffective because they appear to have overlooked key epidemiological facts.
People with polar LL genomes in endemic areas are being forced to walk around shedding as many as ten million viable bacilli per day, before MDT and in case of reinfection even after MDT. This increases their risk of excruciatingly painful ENL. This is not in keeping with our identity as exemplary respecters of human rights, keen on reducing the risk of ENL and demonstrating rapid decline in the incidence rate of MB HD. We could act more consistently with our noblest aspirations.
Telemedicine is an important part of our response. It is being embraced in steadily more places. In the Philippines, a mobile phone based HD teleconsultation system was introduced almost a decade ago. Indonesia too is known to have teledermatology services in at least some areas, as noted in LML. TLM Bangladesh uses video calls on mobile phones for teleconsultation about complications of HD, with active participation by persons who experienced HD. DOCHANSEN appears to be a promising combination of clinical advice together with education of inexpert health workers & strengthening of skills. In India the government's e-sanjeevani teleconsultation initiative could play an increasing role in improving the quality of health services. That could benefit HD patients and HD control.
Every HD-endemic area needs and deserves a widely available telemedicine service, well resourced by local and regional experts who speak the local languages, especially for under-served or widely scattered populations. Too many people have to make do with inexpert services. Telemedicine can bring expertise to the most remote and underserved areas. Smartphones are becoming ubiquitous and the signal coverage is constantly improving even in remote areas. Safeguarding patient privacy remains important, but that challenge can be met. Telemedicine could usefully be financed and take its rightful place as a key contributor to HD treatment and control, with the help of suitably compensated experts.
DOCHANSEN is a helpful step in the right direction.
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
--You received this message because you are subscribed to the Google Groups "Leprosy Mailing List" group.
To unsubscribe from this group and stop receiving emails from it, send an email to leprosymailinglist+unsubscribe@googlegroups.com.
To view this discussion on the web visit https://groups.google.com/d/msgid/leprosymailinglist/ef29cc98-ebf3-4f08-980f-56cae827dbc0n%40googlegroups.com.
No comments:
Post a Comment