Leprosy Mailing List – December 20, 2021
Ref.: (LML) Food for thought - what about leprosy in 2022?
From: Pieter Schreuder, Maastricht, the Netherlands
Dear colleagues,
As you may know, leprosy disappeared from many countries before antibiotics were available. Nowadays, in many counties, leprosy does not behave like a contagious disease, especially in those countries where leprosy is an import disease (Dr. Bracken, 1898). We do not know what is the magic pump handle from John Snow in leprosy. Yes, we assume that better housing, hygiene and socio-economic conditions play an important role in diminishing the spread of leprosy, like it is the case with tuberculosis. What I want to say is: be careful not to claim what is not yours.
We still do not know how a person gets infected, through direct contact or indirect through for example the environment. What we know is that M.leprae enters the body (mainly) through the nose. We know that the incubation period can be many years. The diagnosis of early leprosy is not always easy, especially since skin smears are not routinely applied anymore. Clinical skills are disappearing. A proportion of disability grade 2 among newly diagnosed patients of more than 20% is not acceptable (but is any action taken, by whom?). To see again children with severe disabilities should ring all alarms – does it, does it lead to any action? In a well-run program 5% could be achieved (also depending on the PB/MB ratio). Treatment is important to relieve the suffering of the patient (early case detection, adequate chemotherapy and appropriate management of complications to prevent disabilities). It still happens that necessary drugs are not always available at basic health services level, especially prednisolone.
Theoretically, one could argue that by timely diagnosing and treating a patient (and applying PEP to contacts) the chain of infection could be interrupted. However, a lepromatous patient can be infectious before any clear clinical signs appear. Resistance to essential anti-leprosy drugs is on the rise. A LL polar patient, after MDT, could become infectious again, if he/she is not closely followed up or does not receive post-treatment prophylaxis. Would it not be better to calculate relapse rates for MB patients separately for patients with an original BI of 3 or more? What happens with defaulters which were skin smear positive at diagnosis or do they just disappear from the register? Should the proportion of defaulters not always be mentioned when publishing relapse rates?
Most leprosy control programs have been integrated in basic health services. Regular supervision and support should be an important aspect of any integrated program. Once a while organising a training course, but forgetting regular supervision, does not make any sense. And is a functioning referral system available and can the patient afford to be referred?
What we also have to question is in how far official statistics represent the real situation in the field? Corona has disrupted many programs; leprosy control is one of them. Most likely, poor programs suffer more than well-organised programs. Again, one cannot claim that incidence rates are falling. Yes, detection rates for sure, but nothing to be happy about. Leprosy comes in clusters. To use total population figures to calculate rates distorts the reality on the ground.
What we learned from recent LML letters for example from Jason Barreto and Joel Almeida, the article of Utpal Sengupta about drug resistance, the discussion about the detection of nerve damage and timely treatment, is that in many countries the leprosy control program is not up to its tasks.
LML is an open forum; everyone is invited to take part in the discussion. This year 2021, many new persons subscribed to LML, but the number of people taking part in discussions is still very small. Speak out your thoughts (as I do in this letter – of course, not everyone will agree).
As you may know, Christmas is a celebration of light and peace, and a family gathering. Christians celebrate the birth of Christ. It does not matter so much what one believes, each of us has its own celebration of light and peace with the family during the year.
Elif Shafak: "No one can survive alone – except the Almighty God. And remember, in the desert of life, the fool travels alone and the wise by caravan."
On behalf of the editorial board of LML, we wish you Happy Holidays, Merry Christmas and a Prosperous New Year. All the best for 2022.
Pieter Schreuder
List of abbreviations:
BI : bacteriological index
LL : lepromatous
LML : leprosy mailing list
MB : multi bacillary
MDT : multi-drug therapy
PEP : post exposure prophylaxis
LML - S Deepak, B Naafs, S Noto and P Schreuder
LML blog link: http://leprosymailinglist.blogspot.it/
Contact: Dr Pieter Schreuder << editorlml@gmail.com
