Fw: Ref.: (LML) Long-lasting adverse impact of chemoprophylaxis & what actually works

 

Leprosy Mailing List –  August 17,  2026

 

Ref.:  (LML) Long-lasting adverse impact of chemoprophylaxis & what actually works

From: Joel Almeida

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Dear Pieter and colleagues,

Thanks to Dr. Ben Naafs (LML 12 Aug 2026) for his inputs. He wrote: "We assigned an LL patient who would start treatment the next day to the room."  This was a person already diagnosed to have LL HD (leprosy). What about a person with zero skin or nerve signs who is shedding astronomical numbers of viable bacilli? 

Davey and Rees (1974 Lepr Rev 45(2):121-34) showed that cryptic asymptomatic and unprotected LL HD cases can shed as many as 10^7 viable bacilli/day (or even per nose blow). By contrast, zero of 208 unprotected BL HD cases showed a bacillary index (BI) of 5+ or 6+ in nasal smears, whereas many unprotected LL HD cases did so. BB, BT and TT cases are even less likely than BL HD to shed many bacilli. Unprotected LL HD seems overwhelmingly important to transmission, and to reseeding the surroundings. Even reinfected LL can show astronomical numbers of bacilli in nasal discharges. They are likely to be overlooked on the basis that they have previously completed a full course of treatment.

Think of a placid lake where a boat disturbs the surface and produces ripples. Stopping the boat stops the ripples. An unprotected LL high-shedder is like the boat.  Other types of HD are like the ripples. Cryptic asymptomatic LL are like invisible boats. Our job must include detecting the invisible boats. Only when every single boat is detected can we hope to stop all the boats. Nothing less will suffice to stop all the ripples.

This is why ALL asymptomatics in a cluster need to have nasal swabs taken for semi-quantitative mLAMP. Then no high shedder will be missed. Prompt start of full treatment will stop the flood of bacilli within days or weeks. The entire cluster can be made free from concentrated viable bacilli. The success can be sustained by periodic mop-ups. Cluster by cluster, the success can spread across districts, states, countries and continents.

Surgeons are in high demand in HD because a steady supply of deformity is being provided for their good work. Our job is to put them out of work in due course. That is why the Find Treat End strategy is critical:

FIND: Barcoded, georeferenced nasal swab screening of all asymptomatics in clusters and migratory corridors using semi-quantitative mLAMP (isothermal, no thermocycler, no cold chain, naked-eye readout of color or turbidity). This rapidly distinguishes persons with high-shedding cryptic asymptomatic LL (unique sources of concentrated viable bacilli) from casual nasal carriers of trivial numbers of bacilli. Swab collection can even be by an army of persons with lived experience after basic training. Reporting is in real time via mobile phone apps with georeferences.

·  TREAT: Prompt full anti-microbial treatment started for only high-shedders and clinical cases, combined with regular nerve function monitoring via four simple muscle weakness tests performed by trained persons with lived experience who also encourage uninterrupted completion of treatment. This eliminates concentrated viable bacilli in nasal discharges of the local human population within days/weeks. Silent nerve damage is more likely to be detected.

·  END: Periodic mop-up surveillance rounds to confirm and sustain the elimination of concentrated viable bacilli from the cluster.

There is no reason for pessimism, once we look beyond outdated and harmful approaches. The work of Zhijian Chen and his group, and de Toledo Pinto et al (J Inf Dis 2016) did not lead to hypotheses. They yielded hard facts. Concealing such hard facts from people on low incomes leads to misinformed consent and serious damage. Human eyes, hands and feet are not disposable experimental material. That is why non-human models and studies of nerve damage and deformity are vastly preferable to gambling with human eyes, hands and feet.

When we say Unite to end HD, we need to unite with the people who bear the brunt of the damage inflicted by HD: persons with lived experience and persons at risk of HD. Far from excluding science from our discussions, we need to empower as many people as possible with scientific knowledge. When a surgeon's knife slips, one person suffers. When an epidemiologist makes an error, entire populations suffer. That is why we need to get things right.

Why not unite with people who have lived experience, and help them to end the disease that has interfered with their lives?

With all sincerity,

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 << edit...@gmail.com

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