By Dr Santosh Rath, Visiting Professor, Institute of Global Health Innovation, Imperial College London
The past three decades have witnessed impressive results in leprosy control through global effort. Early detection of disease through door-to-door survey and treatment by multi-drug therapy (MDT) in domiciliary setting ensured high rates of cure (WHO). The focus was to identify and manage high-risk patients prone to complication likes reactions and peripheral nerve function impairment (NFI).
The ulnar, median, common peroneal, posterior tibial and facial nerves are commonly affected in the disease and are the cause of the deformities, which are the visible hallmark of leprosy. Visible impairments occurs in 2% of patients and are categorised as grade 2 deformities. The NFI, if detected early, can be treated effectively with steroids. However, NFIs more than six months are irreversible and resulting deformities can be corrected by tendon transfer surgery. The sensory loss is permanent and is the cause of foot and hand ulcers. Repeated infection in insensate parts leads to scarring and grotesque deformities and many a time to amputations. The physical disfigurement in Leprosy is a consequence of poor management of the disease and is preventable by adopting evidence-based care-pathways. The global effort through the prevention of disabilities (POD) programme has significantly reduced the deformities and secondary consequences from NFI, though a lot is yet to be done for people with long-standing deformities and sensory loss.
The earlier practice of isolation and treatment in a leprasorium stigmatised the disease. A paradigm shift to domiciliary care with MDT had phenomenal social impact. In the current protocol of care, majority continue to live in their own homes and carry-on with daily activities. People with residual deformities after cure of the disease are offered free surgical treatment.
There are many systems challenges in the provision of corrective surgery in resource-constrained regions. The backlog of deformities requiring surgical correction after release from leprosy treatment is enormous and the demand –supply gap is huge. Financial incentive and innovation like ‘camp surgery’ is being tested to deal with the burden of deformities.
Another challenge for self-employed people and women with young children are access to surgical care. Prior to MDT, patients lived in leprosariums and time was not an issue. The domiciliary care model in communities without social security and work loss compensation, time and work loss is a major barrier to access surgery. The average treatment time for each procedure is 10-12 weeks. The current protocols for successful tendon transfer surgery included three to four weeks post-operative plaster immobilisation. An innovation for immediate post-operative active mobilisation of tendon transfer was tested in trials by the author [Rath] and demonstrated 40% reduction in treatment time. There are early adopters of this protocol [Wangdell] and the evidence from leprosy can be used as ‘reverse innovation’ in advanced economies.
The lesson learned from Leprosy POD programs can be widely applied to other contemporary global health challenges that contribute to significant burden of disabilities. Diabetic foot, stroke and geriatric disabilities can benefit from the primary care POD approach. Similarly the new protocol for tendon transfer can reduce treatment time and opportunity cost.