Leprosy Mailing List – March 27, 2016
Ref.: (LML) Over-optimism and the antidote
From: Joel Almeida, Mumbai and London
Dear Pieter,
Every new prediction in leprosy can make us over-optimistic.
In 1991 we predicted the elimination of leprosy by MDT. Instead, we merely eliminated leprosy services. Meanwhile, the incidence rate of new cases with visible deformity increased by 40% in India, between 2008/9 and 2014/15. The price is being paid by Indians who still needlessly suffer devastating permanent damage to their nerves, limbs and eyes.
What is the antidote to over-optimistic predictions? A healthy "what if" analysis.
What if our predictions and hopes are mistaken? That approach can help us establish a safety net to protect trusting people from visible deformity. We can do this by appointing the skilled, mobile leprosy workers who can monitor nerve function regularly. Then we can ensure anti-inflammatory treatment in time to prevent visible deformity.
Cuba has tried chemoprophylaxis of contacts and BCG, without denting the incidence rate of leprosy. Micronesia has tried repeated mass chemoprophylaxis, but merely delayed the occurrence of new cases. The incidence rate returned to its former level. A randomised controlled trial of chemoprophylaxis among contacts showed a higher incidence rate of leprosy in the treated group 2 to 4 years later, although the numbers were too small for this difference to attain statistical significance.
What if our hopes and predictions about chemoprophylaxis are over-optimistic? What if chemoprophylaxis merely postpones the signs of leprosy? What if the main sources of leprosy infection are, in fact, re-infected polar lepromatous patients after release from MDT? Of course we hope for the best. However, we need to be prepared for the worst: a mere postponement of new cases instead of a dramatic reduction in the incidence rate.
If the worst happens, then the skilled, mobile leprosy workers will be a safety net that protects people from visible deformity. When it comes to the limbs and eyes of ordinary people, we need "safety first." Then we can try whatever we want.
It would seem ethically sound to include post-chemoprophylaxis surveillance, prompt MDT, nerve monitoring and prompt anti-inflammatory treatment in projects of chemoprophylaxis. Otherwise chemoprophylaxis might lead to the same kind of over-optimism, complacency and avoidable visible deformity as we have seen in the past.
Given our history of relying on over-optimistic predictions, we would do well to appoint skilled, mobile leprosy workers for nerve function monitoring. We would also do well to identify polar lepromatous patients at diagnosis, and to protect them from re-infection.
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
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Tuesday, March 29, 2016
Re: (LML) Over-optimism and the antidote
Sunday, March 27, 2016
(LML) Over-optimism and the antidote
Leprosy Mailing List – March 27, 2016
Ref.: (LML) Over-optimism and the antidote
From: Joel Almeida, Mumbai and London
Dear Pieter,
Every new prediction in leprosy can make us over-optimistic.
In 1991 we predicted the elimination of leprosy by MDT. Instead, we merely eliminated leprosy services. Meanwhile, the incidence rate of new cases with visible deformity increased by 40% in India, between 2008/9 and 2014/15. The price is being paid by Indians who still needlessly suffer devastating permanent damage to their nerves, limbs and eyes.
What is the antidote to over-optimistic predictions? A healthy "what if" analysis.
What if our predictions and hopes are mistaken? That approach can help us establish a safety net to protect trusting people from visible deformity. We can do this by appointing the skilled, mobile leprosy workers who can monitor nerve function regularly. Then we can ensure anti-inflammatory treatment in time to prevent visible deformity.
Cuba has tried chemoprophylaxis of contacts and BCG, without denting the incidence rate of leprosy. Micronesia has tried repeated mass chemoprophylaxis, but merely delayed the occurrence of new cases. The incidence rate returned to its former level. A randomised controlled trial of chemoprophylaxis among contacts showed a higher incidence rate of leprosy in the treated group 2 to 4 years later, although the numbers were too small for this difference to attain statistical significance.
What if our hopes and predictions about chemoprophylaxis are over-optimistic? What if chemoprophylaxis merely postpones the signs of leprosy? What if the main sources of leprosy infection are, in fact, re-infected polar lepromatous patients after release from MDT? Of course we hope for the best. However, we need to be prepared for the worst: a mere postponement of new cases instead of a dramatic reduction in the incidence rate.
If the worst happens, then the skilled, mobile leprosy workers will be a safety net that protects people from visible deformity. When it comes to the limbs and eyes of ordinary people, we need "safety first." Then we can try whatever we want.
It would seem ethically sound to include post-chemoprophylaxis surveillance, prompt MDT, nerve monitoring and prompt anti-inflammatory treatment in projects of chemoprophylaxis. Otherwise chemoprophylaxis might lead to the same kind of over-optimism, complacency and avoidable visible deformity as we have seen in the past.
Given our history of relying on over-optimistic predictions, we would do well to appoint skilled, mobile leprosy workers for nerve function monitoring. We would also do well to identify polar lepromatous patients at diagnosis, and to protect them from re-infection.
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
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Sunday, March 13, 2016
(LML) Basic Dermatology Course for Medical Doctors
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Thursday, March 10, 2016
Re: (LML) 19th International Leprosy Congress Beijing 2016
Leprosy Mailing List – March 8, 2016
Ref.: (LML) 19th International Leprosy Congress Beijing 2016
From: Tahir Dahiru, India
Dear Schreuder,
As per the question by Geeske Zip (LML, March 6, 2016), in clinical Leprosy you classify base on skin lesions and major nerve trunk involvement. If an individual patient has 5 skin lesions or less with only one major nerve trunk involvement or none you classify as PB. If an individual has more than five skin lesions you classify as MB or if he has more than one nerve involvement even if he has less than 6 skin lesions you classify as MB as per the WHO guideline.
Dr Tahir Dahiru
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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(LML) 19th International Leprosy Congress Beijing 2016
Leprosy Mailing List – March 10, 2016
Ref.: (LML) 19th International Leprosy Congress Beijing 2016
From: Indropo Agusni, Surabaya, Indonesia
Dear Pieter,
I am of the same opinion as Dr. Jaison Barreto (LML, March 9, 2016)). During reversal reaction many leprosy cases develop some new small skin lesions (" flare up”) at sites that previously looked like normal skin. It indicates that actually some of leprosy bacilli or antigen are already present in the tissue, without any previous sign or symptom. Soon after the start of MDT or type 1 reaction, the immune system detects the invaders, immune cells are recruited and inflammation occurs, manifested as “flare up" of skin lesions.
Leprosy bacilli seems to be “tolerated " by human body or having a "mask" in their face, so the immune system does not recognized the enemy. They live happily and multiply in human body without any opponent. That is why leprosy should be treated early and not to wait until the presence of skin lesions.
Best regards,
Indropo Agusni
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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(LML) 19th International Leprosy Congress Beijing 2016
Leprosy Mailing List – March 10, 2016
Ref.: (LML) 19th International Leprosy Congress Beijing 2016
From: Marco Andrey Cipriani Frade, Ribeirão Preto, Brazil
Dear Pieter,
Dr Jaison (LML, March 9, 2016) touched exactly an uncomfortable point about leprosy classification and he has my complete agreement.
According the simple scheme, considering just the number of lesions and neglecting the nerve impairment, we are losing the chance to do an early diagnosis and the correct treatment of leprosy and really cure these patients before disabilities and incapacity.
Nowadays, the number of patients with borderline profile and with small number of skin lesions, many almost imperceptible, but with restrict neural branches impairment with islet of sensitivity alteration(s) (tactile, pain and/or hot), and/or sympathetic alteration. Sympathetic alteration defined as restricted areas (islet) with no vasomotor reflex to endogenous or exogenous histamine stimulus and/or sweat dysfunction defined by (the absence of) natural beads of sweat or using lugol test. None of these details and detailed peripheral nerve clinical exam are described in routine protocols.
With MDT leprosy became a simple disease to treat, but its diagnosis continues or became more complex. Sure, we should think strongly about it and propose a more elaborated continuous educational program in leprosy clinic mainly in these early neural signs preventing the advance and the consequent notoriety of stigmas that both committed leprosy patients.
Best regards
Marco Andrey C. Frade
President of Brazilian Society of Leprology
Prof. Dr. Marco Andrey Cipriani Frade
Professor Associado (Livre Docente)
Coordenador Residência Médica de Dermatologia HCFMRP-USP
Coordenador Centro de Referência em Dermatologia Sanitária - HansenÃase - HCFMRP-USP
[(http://lattes.cnpq.br/9103136155056414)]
Divisão de Dermatologia - Departamento de ClÃnica Médica
Faculdade de Medicina de Ribeirão Preto - Universidade de São Paulo
Av. Bandeirantes, 3900 - Monte Alegre - Ribeirão Preto -SP - Brasil
CEP: 14.049.900 - Tel: 55-16-36022441 (Sala) - 36022447 (Sec.) - FAX: 55-16-36021522
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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Wednesday, March 9, 2016
(LML) 19th International Leprosy Congress Beijing 2016
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