Leprosy Mailing List – May 17, 2019
Ref.: (LML) Protection of cured LLp patients
From: Joel Almeida, London and Munbai
Dear Pieter,
For the purpose of matching Shandong's success in interrupting transmission, I had written:
"Provide anti-microbial protection to persons with LL disease after the standard duration of MDT, in endemic areas. Monthly doses of 2 or 3 highly bactericidal drugs in combination are likely to work well, after the standard duration of MDT."
Once we do this in endemic countries, we are likely to match Shandong's achievement of a 15% annual decline in the new case detection rate of MB disease. We, too, can ensure that this rate of decline continues relentlessly until near zero transmission. We will keep tweaking our approach and adding helpful elements to accelerate the decline. But we can start now.
The key element in Shandong's success was prolonged anti-microbial protection for LL patients. Others too received similar protection in Shandong. That is irrelevant from an epidemiological point of view. LL patients were given prolonged protection - that is what counts for interrupting transmission at source. Those are the people we most need to protect after their cure. That is currently the biggest gap in our defences against the bacillus.
Shandong also used skin smears at every stage. So could we.
Once we go to the world with this demonstrably realistic prospect of interrupting transmission within a reasonable time frame, our financing is likely to get a huge boost. There will be enough money for histopathology as a routine, and for developing even more rapid and effective tools. But we can start right away, using classification based on clinical observation backed by slit skin smears. The endemic does not wait for us. We cannot afford to drag our heels.
We will still value new tools that might help accelerate the decline beyond the impressive rate achieved in Shandong.
I had the privilege of participating in the WHO HQ team that defined game-changing interventions in TB. We also multiplied financing for TB control. That transformation of TB from a neglected disease to a well financed effort relied on careful analysis of epidemiological clues from the front lines, understanding of the underlying biology, demonstration of measurable outcomes on the ground using the newly defined interventions, and clear messages about the macroeconomics of health. We, too, can do that. Then we will no longer fight over financial crumbs or take self-serving positions. We will all have enough resources to do our job well.
Dr. Saunderson seems keen to promote Lepvax. That is a separate matter. The development of Lepvax by IDRI was financed by American Leprosy Missions (ALM) to the tune of over 5 million USD, as publicly acknowledged. Dr. Saunderson is employed by ALM. Lepvax's measured efficacy in animal models, compared to other vaccines, can be reviewed in a separate contribution at another time. However, it is not necessary to delay Shandong-type success (interruption of transmission) merely in order to promote an ALM-financed product. Nor would ALM want that, as far as I know.
We need to bring our best and most noble selves to this effort, setting aside self-serving motives. There is a moral (and possibly legal) imperative to protect cured LL patients against re-infection and other perils. The socio-economic plight of many cured LL patients can be dealt with in another contribution. Cured LL patients can increasingly be protected against destitution, homelessness, under-nutrition and ostracism too.
Protecting cured LL patients is not only the right thing to do, but also the most effective thing to do, epidemiologically. That's because it closes the major hole in our current defences against the bacillus. Monthly doses of 2 or 3 highly bactericidal drugs in combination are likely to work well in LL patients, in endemic countries, after the standard duration of MDT. Shandong achieved victory using prolonged anti-microbial protection for LL patients. So, probably, can all of us.
Regards,
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
