Leprosy Mailing List – August 19, 2021
Ref.: (LML) Spreading success
From: Joel Almeida, London and Mumbai
Dear Pieter and colleagues,
We are a noble-minded community keen on preventing or alleviating human suffering and affirming human dignity. In order to move forward and achieve our aims it seems helpful to ask constructive questions, such as::
What have been the most impactful interventions against HD (leprosy)?
and
How do we spread such success to more places, while continuously improving the efficacy of our efforts?
The most impactful intervention against HD transmission by far was demonstrated in FSM (Micronesia). It combined
a) Integrated skin camps, for all conditions, using expert clinicians
b) Anti-microbial protection, including prolonged anti-microbial protection for highly bacillated patients
c) Mass multi-drug administration, repeated at intervals
An 84% decline in the incidence rate of HD cases was demonstrated within only 2 years. Therefore 40% annual decline in incidence rate is demonstrably achievable. The use of multi-drugs instead of single drugs helps to delay drug resistance. Otherwise MDT (multi-drug therapy), the backbone of HD control, could lose its effectiveness.
a) and b) can be used everywhere, aided by telemedicine if necessary. a) and b) can enable a 16% to 20% annual decline in new MB (multibacillary) or LL (lepromatous) cases, as was demonstrated in even low income areas such as Karigiri (India) and Uele (DR Congo). In hyperendemic hot spots, such as self-settled HD colonies in endemic countries, mass multi-drug administration can be added. That can enable a 40% annual decline in the incidence rate of HD in hyperendemic hot spots.
WHO (World Health Organisation) in 2013 defined elimination as interruption of transmission. We have set our sights on real impact now, not being satisfied with relative stagnation in incidence rates. How can we measure progress reliably? The case detection rate of MB HD is probably the most reliable measure, because MB HD rarely self-heals. Sooner or later persons with MB HD come to the attention of health professionals. The 3-year or 5-year moving average of the case detection rate of MB HD allows us reliably to monitor epidemiological trends. Other measures tend to be less reliable because they can be raised or lowered rapidly and at will, regardless of underlying transmission. In addition, the accumulated prevalences of people with HD-related visible deformity or social exclusion, respectively, are important measures. Periodic sample surveys, such as India's National Sample Survey or local door-to-door surveys, help to establish facts.
Interruption of transmission is not the only priority. Many people have already experienced HD. Prevention of new deformity among ever-diagnosed persons is important. Further, if people slip through our safety net and suffer deformity or social exclusion and its consequences, then they require and deserve rehabilitation, inclusion and opportunity.
How frequently does new deformity occur during or after MDT? Fewer than 5% of patients in one part of India had visible deformity at diagnosis, but 15% to 33% of persons who had received MDT showed visible deformity. Recording the deformity status of every newly diagnosed patient at the start and end of MDT is therefore very important. Brazil sets a good example in this respect. Similarly, it is important to discover the prevalence in the population of HD-related deformity. Sample surveys, or total population surveys in defined populations, are uniquely useful for this purpose.
How can we prevent new deformity from occurring during and after MDT? Over 80% of nerve damage during or after MDT occurs without any physical sign of inflammation (variously labelled silent neuritis / silent neuropathy / quiet nerve paralysis). Therefore quarterly nerve function assessment, with prompt steroid treatment when needed, is indispensable during at least the first two years after the start of MDT. Brazil and Dadra Nagar Haveli (DNH in India) are among the endemic areas that already monitor nerve function regularly. DNH has paramedical workers trained in HD, equipped with transport so that they can serve all HD patients across a wide area. This enlightened approach reflects respect for patients, and for their right to competent services. It can be replicated in other endemic areas. Then nerve damage can be detected early, and the risk of new deformity during or after MDT can be reduced greatly.
Rehabilitation, inclusion and opportunity have been promoted in exemplary projects serving persons who have experienced HD. Too many are still experiencing deformity, destitution or exclusion. Increasingly, they are speaking out against inhumane neglect and exclusion, while demanding the respect and services to which they are entitled. Successful projects are like lighthouses showing us how to help more people reach the safe harbour of wellbeing, empowerment and inclusion.
As we create and celebrate successes, support will grow. We can nurture a broad popular movement against HD and its too-often terrible consequences. Other disease control efforts have benefited from such popular movements, where everyone is invited and empowered to contribute according to their unique strengths. It can happen in HD too, especially because exemplary projects have achieved dramatic successes. Effective action with demonstrable impact is the best answer to lingering doubts. Let's spread success..
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
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