Leprosy
mailing list – August 21st, 2006
Ref.: ILEP
Technical Commission request for feedback on the need for a new text
on leprosy
From: Warren G., Sydney, Australia
NB. Still problems with my e-mail. Your feedback about quality of
reception will be appreciated.
Dear
Salvatore Noto,
Once
again your correspondents have hit a jackpot. Dr Ahmad L. of Karachi LML (July
25th, 2006) suggests that as there is a decline of
leprosy in endemic areas there is no need for a new textbook. Let us be frank. The decline is in the number of
patients technically on the WHO ”Leprosy patients List” and as yet
there is not a great decrease in the total numbers of new patients
diagnosed in many countries. And there is certainly, as result
of the publicity, a decrease in the training of doctors to be
able to diagnose and treat leprosy.
One
South African country achieved its goal of less than 1 per 10,000 of
population some 15-20 years ago, but as yet there is really no
decrease in the number of new patients diagnosed every year! Do not suffer from delusions
that leprosy is going!
The
main problem as I see it is that there may well be, in the not too
distant future, many relapsed patients who were given only 12 doses of
MDT and some time later they relapse.
They state they have had treatment so the local GPs will not
think seriously of leprosy as a diagnosis.
There
is also the problem of the patient who having had the WHO MDT for
a borderline type leprosy has, after MDT is completed, developed an
upgrading reaction with acute neuritis. These are often poorly
treated, often given only prednisolone and not another full course of
MDT. In the last 3 months,
I have received queries about two such patients in Pakistan, where I
assume Dr Ahmed is working. In
each case the patient is very distressed but was not getting adequate
MDT for obviously active leprosy until I interfered!
Yes
those methods for treatment, may not appear in WHO recommendations,
but having worked in the Chinese racial group for 50 years I know that
in some racial groups there are very few BB/BL or LL patients who even
with full 3 drug MDT will completely recover with less that 3-4
years of treatment (not including the months in which they need
steroids for nerve problems). Yes
it sounds a long time. The
number of relapses one sees over the next ten years will indicate the
efficiency of any programme.
IN a
number of counties in Asia, where I still work, I am witnessing
patients relapsing with florid LL / BL leprosy after having been given
so called full MDT for 12 -24 months and told they “were cured”.
This was completed up to 5 years pre my seeing them with very
high bacillary index in skin smear.
No please someone do not tell me one does not use skin smears
to diagnoses leprosy! Some
of the WHO papers say that “It is not necessary”. It gives a positive diagnosis
in many of the diffuse lepromatous patients when there are no definite
skin lesions but the patient is highly infectious! This is far more common in the
Chinese and lighter skinned people with LL/BL leprosy, than in the
dark skinned and many from the Indian sub continent in whom
leprosy is more often on the TT / BT end of the spectrum) and, if
these lepromatous patients were treated at once the patient may
recover without any permanent disability.
Please
consider the whole patient. There are many who definitely have
leprosy but do not satisfy the WHO criteria for registration. They NEED TREATMENT NOW not in
a couple of years when they have become a real problem.
We need
a good practical book such as the Yawalkar book (originally a CIBA publication)
that is small enough and cheap enough and has plenty of good coloured
illustrations, of all skin colours, to spread widely to those
learning leprosy now, and even more important to stimulate the younger
generation to think leprosy when confronted with possible cases in the
future in any area of the world. Leprosy
travels by air and in countries like Australia there are very few
doctors who would even think of the possibility of leprosy for someone
with dermatological rings!
There
was a recommendation by Virmond M. (July 25th, 206), that
each country ought to be responsible for putting relevant material
into the various languages- excellent!
Please
do not let us loose the experience we have gained over the last 40
years. By suffering from
the delusion that leprosy is on a serious decline. Beware Leprosy is probably the
cleverest organism we try to get rid of!
It will come back! We
cannot let everyone forget how to treat leprosy and to look for
it early. What can we do
to try and improve the diagnosis of this disease for the next twenty
years? It will not be gone
in that time! We need a
simple, small book that does give the essentials without a lot of
hot air!
Grace Warren
