Leprosy Mailing List – June 11, 2019
Ref.: (LML) Recurrence rate among MB patients following RFT
From: Joel Almeida, London and Mumbai
Dear Pieter,
Thanks to Dr. Kawuma for describing the situation in Africa.
I would like to share encouragement regarding finances. Once there is a demonstrably effective intervention, money tends to start flowing more freely. Financial backers, whether governments or foundations or lotteries or even noble individual philanthropists etc., like to have a clear picture of what we are proposing, and why it is likely to work. They are moved by compassion and would love for transmission to be interrupted, so that no more lives unnecessarily are blighted by visible deformity and the consequent ostracism, destitution, homelessness, psychological problems and worse.
We, too, are compassionate. We, too, want to avert human suffering. We have the advantage of using our scientific skills to identify what works and what does not.
Shandong achieved a 15% annual decline in new MB patients using prolonged anti-microbial treatment. Post-MDT chemoprophylaxis for LL patients using 2 or 3 bactericidal drugs monthly is as effective as the treatment used in Shandong, and probably even more effective. Shandong achieved near-zero transmission, and so can we.
Shandong ensured anti-microbial protection for LL patients for 5 years after "clinical cure" followed by 5 years of annual observation. (1)
"Criteria for cure were as follows:
a) complete disappearance of lesions,
b) no nerve tenderness and/or leprosy reactions for at least one year,
c) six consecutive negative smears within one year for multibacillary patients and negative smears before and after therapy for paucibacillary patients, and
d) only nonspecific inflammation in biopsies taken from formerly active lesions."
Recurrences were treated according to the regimen for new patients.
We can tweak such criteria for use in our own areas, bearing in mind what facilities are available. More facilities can eventually be made available as financing grows. As the endemicity declines, the risk of re-infection also declines. In non-endemic areas the risk of re-infection is near zero.
Shandong persisted with prolonged anti-microbial protection even in the MDT era, ignoring the global fashion for fixed-duration MDT.(2) That local practice protected LL patients against recurrence and allowed Shandong to achieve near-zero transmission. It is one of the great success stories in the history of public health. Zero transmission is a highly attractive proposition to governments and other investors.
We know how Shandong achieved near-zero transmission. We intend to match that achievement. That's why we need more money. This can be our clear message to all the governments, taxpayers, individual donors, philanthropists, foundations, organisations etc. Our call for increased financing is founded on demonstrable success.
Besides, post-MDT chemoprophylaxis is part of competent case management for LL patients. They are the most prone to visible deformity. It is unwise to neglect them. We would like to reduce the cumulative recurrence rate among LLp patients from as high as 75% to 0%, by using post-MDT chemoprophylaxis for all LL patients. It is how we propose to match Shandong's victory.
We have a clear offer to the world: interruption of transmission at source, through improved long-term case management of LL patients.
Finding money is usually not the problem once a demonstrably effective intervention is available. I speak from first-hand experience, having served as the policy specialist and global media spokesperson for WHO HQ's Global TB Programme. Global financing for TB went from about USD100 million per year to several billion USD per year. Even low-income country governments chipped in. It is important to have a demonstrably effective intervention. We can all take courage, because the efficacy of post-MDT chemoprophylaxis is likely to be nearly 100%, matching the efficacy of Shandong's prolonged anti-microbial treatment.
Post-MDT chemoprophylaxis can start with LL patients who are already known to us and accessible. It seems wise to include probably-LL patients too, instead of leaving them out in areas with very limited facilities. This intervention requires far less than billions of USD. We can make a start and create new success stories to match Shandong's victory.
Dr. Styblo, one of my biggest heroes, developed and demonstrated an effective TB management system in Tanzania. He just went ahead and did it, on a shoestring budget relying on quarterly donations. That started the ball rolling for TB. Fortunately Dr. Kochi at WHO HQ identified this system as the key transformative intervention in TB. Then we, at WHO, kept evolving and tweaking the effective management system and adapting it to various situations around the globe with the input of local communities. Step by step, it was adopted across the world, forming a life-saving global cocoon. I myself travelled to the frontlines in several countries, reviewing practices and training people. There was no shortage of scepticism ("just another Sheraton programme") but I saw how that changed to delight once outcomes were demonstrated. When President Clinton visited India, he was taken to only one health project. It was the public-private mix TB project, the very first pilot project of an intervention that I designed at WHO and then launched with local partners in Hyderabad. Only a few years earlier, sceptics had assured us that it would not work. Instead, we produced better outcomes than most other approaches. Demonstration is the best answer to scepticism. I mention all this only to encourage the doers here as we move forward. We can dare to dream based on careful analysis of the evidence, and we know how to make this particular dream of near-zero transmission come true.
Once we start acting and the incidence rate of new MB patients starts declining, money will start to chase us instead of the reverse. We don't need to have everything perfect before we start, we need just to make a start and then keep tweaking the intervention. That's how effective programmes are developed, from tiny seeds, into great life-giving trees. Effective action attracts money which attracts more action and so on. One willing leader in one place and one compassionate, enlightened donor suffice to start this revolution against the bacilli. Victory is highly likely, given Shandong's measurable success.
What about adverse effects? The consequences of unchecked bacilli tend to be more frequent and severe than the unintended adverse effects of monthly drugs. Even in low-income settings, and especially there. However, we can certainly stay alert to any symptoms and signs reported by patients, and keep tweaking our post-MDT chemoprophylaxis regimens to minimise any unintended adverse effects. Prof. Frankel would probably appreciate that.
Mahatma Gandhi graces the front page of the Indian national programme's website. This quote from Gandhi expresses what many of us practice: "Recall the face of the poorest and weakest man you have seen, and ask yourself if this step you contemplate is going to be any use to him." We can continue to follow Gandhi's noble example, recalling the faces of women, children and men disfigured unnecessarily, as we strive to protect human limbs, eyes, minds, relationships, educations and livelihoods from the unnecessary ravages of the bacilli. Each of us has an inner Mahatma (great soul). Let's draw on that to accelerate our success. Shandong showed us the way to success. Now we too can do it.
Joel Almeida
Translations
हम जानते हैं कि शांडोंग ने शून्य संचरण कैसे प्राप्त किया। हम भी ऐसा करना चाहते हैं। इसलिए हमें अधिक वित्तपोषण की आवश्यकता है। यह सभी सरकारों, करदाताओं, व्यक्तिगत दाताओं, परोपकारी, नींव, संगठनों आदि के लिए हमारा स्पष्ट संदेश हो सकता है। पर्याप्त धन के लिए हमारा अनुरोध शांडोंग में प्रदर्शनकारी सफलता पर आधारित है।
हम भी एलएल रोगियों के लिए एमडीटी के बाद कीमोप्रोफिलैक्सिस का उपयोग करके शांडोंग की तरह शून्य संचरण प्राप्त कर सकते हैं। एमडीटी के बाद मासिक अंतराल पर एलएल मरीजों को 3 जीवाणुनाशक दवाएं देकर हम शांडोंग की तरह सफल हो सकते हैं।
Nós sabemos como Shandong conseguiu quase zero transmissão. Nós também queremos fazer isso. É por isso que precisamos de mais financiamento. Esta pode ser a nossa mensagem clara para todos os governos, contribuintes, doadores individuais, filantropos, fundações, organizações, etc. O nosso pedido de financiamento adequado baseia-se num sucesso demonstrável em Shandong.
Podemos alcançar quase zero transmissão usando quimioprofilaxia após MDT para pacientes com LL. 3 drogas bactericidas mensais são tão eficazes quanto o tratamento longo usado em Shandong. Shandong conseguiu quase zero transmissão dessa maneira. Nós também podemos fazer isso.
Nous savons comment le Shandong a atteint une transmission presque nulle. Nous voulons le faire aussi. C'est pourquoi nous avons besoin de plus de financement. Cela peut être notre message clair à tous les gouvernements, contribuables, donateurs individuels, philanthropes, fondations, organisations, etc. Notre demande de financement adéquat est basée sur le succès démontrable du Shandong.
En donnant la chimioprophylaxie après PCT aux patients LL, nous pouvons atteindre une transmission presque nulle. Trois médicaments bactéricides par mois sont aussi efficaces que le traitement de longue durée utilisé dans le Shandong. Le Shandong a réalisé une transmission presque nulle de cette manière. Nous aussi pouvons le faire.
References
1. Li HY, Pan YL, Wang Y. Leprosy control in Shandong Province, China, 1955-1983; some epidemiological features. Int J Lepr Other Mycobact Dis. 1985 Mar;53(1):79-85
2.2. Li HY, Weng XM, Li T et al. Long-Term Effect of Leprosy Control in Two Prefectures of China, 1955-1993. Int J Lepr Other Mycobact Dis. 1995 Jun;63(2):213-221.
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
