Ref.: (LML) Bhilwara, India: lessons for defeating HD
From: Joel Almeida, London and Mumbai
Dear Pieter and colleagues,
You might be interested in this effort in an Indian COVID-19 hotspot that is successfully containing transmission. No new cases for a week. About one per million population COVID-19 related deaths in the district. That is a comfortingly low number, in these troubled times.
https://youtu.be/UFSuxQhURuU?t=251
In a country with limited availability of expensive (and sometimes unreliable) tests, screening relied largely on upper respiratory symptoms/signs and temperature monitoring. Temperature was monitored more than once per day for contacts considered at risk.
India can hope to interrupt transmission of even highly contagious diseases in hot spots, with locally devised appropriate actions. Hopefully this COVID-19 success can be spread across the country, as the lockdown progressively is relaxed. Time will tell. However, the local success is like a lighthouse indicating a safe harbour to the rest of the country (and perhaps beyond).
The current least fortunate 10 countries by COVID-19 related mortality rate (deaths per million population) are shown in the table.
The Table. The 10 countries with the highest deaths/million from SARS-CoV-2.
(source: Worldometer, 10 April 2020)
Deaths have occurred in the hundreds per million population. That is a tragedy. San Marino, Spain, Andorra, Italy, Belgium, France, Sint Maarten, Netherlands, UK, Switzerland. These are not names that would be predicted by most people. Hopefully these countries will be open to learning from successes elsewhere. The virus ruthlessly exposes the (in)efficacy of efforts. Pragmatic action often works. Untested assumptions in mathematical models can bring on unintended and unnecessary death or disability. Nobody deserves that.
The whole world benefits when we respect and enable talent in endemic countries. The flow of front-line knowledge, research capacity and public health competence can be from HD-endemic countries to affluent countries too, although that goes contrary to past habit. The death rates from SARS-CoV-2 are a wake-up call to affluent countries. Shandong, with its rapid achievement of zero transmission in HD, illustrates what can happen when local experts are given elbow room to do their best instead of being pressured to follow ineffective or harmful practices. There is no substitute for the brains, knowledge and dedication of local experts in HD-endemic countries.
India hopefully will interrupt transmission of HD too. Super-spreading events, droplet transmission, clustering, a spectrum of immunological response, self-healing in most infected persons, some degree of environmental survival, animal hosts, are all relevant to the epidemiology of HD too. There are, of course, big differences from SARS-CoV-2. These include the availability of effective treatment for HD, its slower course, and its low mortality rate.
Further, most persons with only a single well-demarcated anaesthetic skin patch and no other signs of HD, are non-infectious even before treatment. There is no reason to inflict stigma on such persons, who form the vast majority of newly detected patients in active case-finding campaigns. They are almost invariably completely harmless even before treatment.
At the other end of the spectrum, evidence strongly suggests genetically-related high susceptibility to HD and its recurrence.(1) Easy-to-miss LLp recurrence is demonstrably frequent among neglected formerly treated patients.(2) Like easy-to-miss "de novo LL" HD, it is probably an important cause of super-spreading events that maintain transmission despite active case-finding. (3)
The Figure. Super-spreading events of HD transmission were observed in Salaunikhurd village, India. (3)
The annual new case detection rate, in the Block, which had hovered around 30 per 10000 persons/yr until 2015 has risen to over 100 per 10000 persons/yr since then.
Therefore, prolonged anti-microbial protection of LLp (genetically anergic) patients is critical to zero transmission, as well as the welfare of individual patients. There is no substitute for the wealth of clues available at the frontlines.
The LML approach of online rapid publication and scientific discussion has been widely adopted for fighting COVID-19. Such open discussion tends to be more effective and safe than the "country club" approach of invitation-only meetings. On LML, everyone has a voice. Thanks to LML, we can be optimistic about learning from successes, avoiding harmful interventions, and defeating HD together.
Wishing health and wellbeing to all. Please keep your distance from others so that we can all survive to defeat HD, once SARS-coronavirus-2 abates.
Joel Almeida
References
1. Sartori PVU, Penna GO, Bührer-Sékula S. Human Genetic Susceptibility of Leprosy Recurrence. Sci Rep, 10 (1), 1284 2020 Jan 28. DOI: 10.1038/s41598-020-58079-3
2. Rao PS, Mozhi NM, Thomas MV. Leprosy affected beggars as a hidden source for transmission of leprosy. Indian J Med Res. 2000 Aug;112:52-5.
3. Central Leprosy Division, India. Epidemiological investigation of multiple cases occurring in one family in village Salaunikhurd. NLEP newsletter Vol III, Issue 3, July – Sept 2018
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