(LML) Over-optimism and the antidote

Leprosy Mailing List – March 27,  2016

Ref.:   (LML)  Over-optimism and the antidote

From:  Joel Almeida, Mumbai and London

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Dear Pieter,

 

 

Every new prediction in leprosy can make us over-optimistic.

 

In 1991 we predicted the elimination of leprosy by MDT.  Instead, we merely eliminated leprosy services. Meanwhile, the incidence rate of new cases with visible deformity increased by 40% in India, between 2008/9 and 2014/15. The price is being paid by Indians who still needlessly suffer devastating permanent damage to their nerves, limbs and eyes.

 

What is the antidote to over-optimistic predictions?  A healthy "what if" analysis.  

 

What if our predictions and hopes are mistaken?  That approach can help us establish a safety net to protect trusting people from visible deformity. We can do this by appointing the skilled, mobile leprosy workers who can monitor nerve function regularly.  Then we can ensure anti-inflammatory treatment in time to prevent visible deformity.

 

Cuba has tried chemoprophylaxis of contacts and BCG, without denting the incidence rate of leprosy.  Micronesia has tried repeated mass chemoprophylaxis, but merely delayed the occurrence of new cases. The incidence rate returned to its former level. A randomised controlled trial of chemoprophylaxis among contacts showed a higher incidence rate of leprosy in the treated group 2 to 4 years later, although the numbers were too small for this difference to attain statistical significance.  

 

What if our hopes and predictions about chemoprophylaxis are over-optimistic?  What if chemoprophylaxis merely postpones the signs of leprosy?  What if the main sources of leprosy infection are, in fact, re-infected polar lepromatous patients after release from MDT?  Of course we hope for the best. However, we need to be prepared for the worst: a mere postponement of new cases instead of a dramatic reduction in the incidence rate.

 

If the worst happens, then the skilled, mobile leprosy workers will be a safety net that protects people from visible deformity. When it comes to the limbs and eyes of ordinary people, we need "safety first."  Then we can try whatever we want. 

 

It would seem ethically sound to include post-chemoprophylaxis surveillance, prompt MDT, nerve monitoring and prompt anti-inflammatory treatment in projects of chemoprophylaxis. Otherwise chemoprophylaxis might lead to the same kind of over-optimism, complacency and avoidable visible deformity as we have seen in the past.

 

Given our history of relying on over-optimistic predictions, we would do well to appoint skilled, mobile leprosy workers for nerve function monitoring. We would also do well to identify polar lepromatous patients at diagnosis, and to protect them from re-infection.

 

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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