Friday, April 12, 2019

(LML) Zero Disability

Leprosy Mailing List – February 17,  2019
Ref.:   (LML) Zero Disability
From:  Linda Lehman, Belo Horizonte, Brazil

Dear Pieter,

I appreciated very much Joel Almeida emphasis on the need for the following two things if we want to prevent impairments and reach the GLOBAL GOAL of Zero Disability:
  1. Early Disease detection and treatment with MDT
  2. Early detection an adequate treatment of reactions and nerve function impairment
I hear on my field visits health workers saying that MDT it is going to help the nerve impairment so they do not need to intervene even if they see mild nerve function impairments at diagnosis.  We have emphasized so much about early disease detection preventing disabilities (this is true) but people and health workers are shocked when impairments arise during and after MDT even with early disease diagnosis.

Ultrasound of the nerve helps us to see the nerve size and helpful for early diagnosis of the disease but it may be limited in quantifying nerve function to see if it is getting better or worse.  We have had the S-W monofilaments around for a long time and there have been studies by Manoel Villarroel, Jose Antonio Garbino and others demonstrating the S-W monofilaments are a good tool for the field to detect and monitor nerve impairments early if lighter filaments are used and not only one or two filaments (10g) or two (4g and 10g) for protective sensory loss.  Protective sensory loss is NOT early nerve function impairment, it is late and usually by the time there is a protective sensory loss, motor fibers are involved indicating even more severe nerve impairment.  Is the limited nerve function impairment improvement because we waited until there was protective loss (10g or touch with ball point pen)? 

I remember Job's work showed us by the time we see "clinical evidence (sensory and motor changes) 30% of the nerve fibers are already involved, so imagine how many nerve fibers are involved if we wait and only treat with anti-inflammatory when there is a big loss of 4 or 10g.  Looking back on my supervision documents and other records, I see that even 2g is late, as motor function impairment is frequently present by this time. 

I would like to see a real collaboration to promote and implement a much more proactive and timely nerve function assessment with interventions.  It would use lighter filaments and be a more frequent routine task within leprosy control activities. Using multiple filaments and lighter filaments (lighter than 2g) would permit for early detection of nerve function impairment before motor function is involved. 

Yes, it takes time but it can be done if there is TRUE COMMITMENT to ZERO disability.  One very good example is the Brazil National Leprosy program who has been committed to early detection of nerve function impairment and treatment for more than 20 years.  It is not easy, nor is it perfect but the commitment to both early disease detection and treatment and early nerve function impairment and treatment (at diagnosis, during treatment and after MDT) has moved this national program forward on the path to reaching the Global Leprosy Goal of Zero Disability.  I presented about Brazil's 20-year experience of using S-W monofilaments at the China Leprosy Congress.  It is important to have National Guidelines, a standard high quality multi filament tool available in country, forms, training and supervision.  NFI Assessment is done at primary health care facilities as well as reference services throughout all 27 Brazilian states. 

Early disease detection & MDT + Early detection nerve function impairment & prednisolone = ZERO DISABILITY


Linda F. Lehman, OTR/L MPH C.Ped
Senior Advisor for Morbidity Management & Disability Prevention
American Leprosy Missions
One ALM Way, Greenville, South Carolina 29601 USA
R. Castelo de Alenquer 390 Apt 302  Belo Horizonte, MG 31330-050 BRASIL
Brasil Cell (only when Brasil): +55 31 99637 5576
WhatsApp (always available) & USA Cell (only when in USA):  +1 505 504 8749

LML - S Deepak, B Naafs, S Noto and P Schreuder
Contact: Dr Pieter Schreuder <<

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