(LML) What every Indian should know about leprosy

Leprosy Mailing List – June 24,  2015

Ref.:    (LML) What every Indian should know about leprosy

From:  Joel Almeida, Kochaikanal, India

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Dear Pieter,

 

Thanks for the feedback and interesting inputs from various colleagues.

 

According to official Indian reports, about half the 130,000 leprosy cases detected in India each year, or about 65,000 per year, have disseminated (MB or multibacillary) leprosy.  Anywhere from 5% to 8% of MB patients already have visible deformities by the time of diagnosis.  This is due partly to the suppression of active case-finding.

Adverse effects of MDT (multi-drug therapy) are not prominent.  Delay in diagnosis can damage a patient for life.  Therefore “false positive” diagnoses cause less morbidity than “false negative” diagnoses.  In other words, the sensitivity of diagnosis is far more important to health than the specificity of diagnosis.  There is little excuse for suppressing active case finding.  It is more humane to do vigorous active case finding than to allow people to suffer deformity; cheaper too, once the costs and difficulty of repairing disability are taken into account.

It can be shown from the literature that a further 10% to 20% per year of newly treated MB patients are exposed to avoidable nerve damage during the first 2 years after the start of MDT: unless they are provided with regular, expert nerve monitoring.  “Silent” neuritis is a more frequent cause of nerve damage than are reactions, in South Asian populations.  Therefore monthly nerve monitoring seems crucial.  Otherwise, about 10% to 50% of a cohort of non-disabled MB patients starting MDT in India is likely to develop serious nerve damage within 2 years. That equates to 6,500 to 32,500 patients from each annual cohort in India, or as many as 300,000 newly disabled persons accumulating within 10 years.  Their disabilities will be despite MDT, all because there was nobody to monitor their nerves.  That can be changed.

India might do well to re-introduce a cadre of mobile leprosy workers.  They would be trained specially to detect leprosy-induced loss of nerve function.  They could travel around, serving the population of several health centres.   They would regularly visit MB patients near their homes, during the first 2 years after the start of MDT.  They could also hand out educational materials about various skin conditions (not just leprosy) in the neighbourhood.  This would ensure more prompt anti-inflammatory treatment for “silent” and other neuritis, but also encourage earlier diagnosis of leprosy (and other skin conditions).  ILEP (International Federation of Anti-Leprosy Organisation) members could make a huge difference here, in collaboration with the Indian government.

Potentially game-changing interventions probably require a swift demonstration project, preferably in isolated populations suffering adverse socio-economic circumstances.  If an integrated set of measures can rapidly interrupt transmission on a small island with a high incidence rate, it will probably work across India.  If it works, we win: we’ll replicate it rapidly.  If outcomes are under-whelming, we will know better.  There is no harm dreaming of a magic wand, and trying to wave it.  CDC (Centres for Disease Control) Atlanta should be encouraged to take an interest, as should Bill Gates.  They have the financial muscle to use existing tools (or develop new tools) and eliminate leprosy from a US-affiliated overseas island (or die trying).  That could help pave the way for the speedy elimination of leprosy everywhere. No harm dreaming.

It can be shown that the latest Global Burden of Disease update probably under-estimates the true DALY (disability-adjusted life year) loss from leprosy by a factor of 10 to 20 (that's 1,000% to 2,000%).  I hope to write that up and submit it to a journal.

However, we must not omit to pluck the low-hanging fruit for our beloved populations and patients, including (but not limited to):

1) Active case-finding so that MDT can be started before disability sets in.

2) Regular nerve monitoring among MB patients, by skilled mobile leprosy workers, during the first 2 years after the start of MDT.

3) Sample surveys of the population to detect the accumulation of persons disabled by leprosy (especially if cohort analysis of the outcomes of MDT is not published).

Finally, as a former WHO man (TB), I can confirm that WHO is made up of mere human beings, who generally mean well, and often learn from mistakes.  Especially now that Bill Gates has enough money to dwarf the WHO budget.  Everyone has room to exceed the standards set out in various guidelines. And to suggest improvements to the guidelines.  It's almost a duty to suggest improvements.

 

Regards,

 

Joel Almeida

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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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