Leprosy Control
Item
- Title
- Leprosy Control
- extracted text
-
Memorandum on
Leprosy Control
Issued jointly by
Oxfam, Lepra and The Leprosy Mission
Bangalore- 5'60034
India
""
MEMORANDUM ON
LEPROSY CONTROL
by
STANLEY G. BROWNE,
O.B.E., M.D., F.R.C.P., FJR.C.S., D.T.M.
Director, Leprosy Study Centre, London
Consultant Adviser in Leprosy to the Department of Health
Medical Secretary, LEPRA
Medical Consultant, The Leprosy Mission, etc.
Secretary-Treasurer, International Leprosy Association
<7-7
If existing knowledge about leprosy were
conscientiously and persistently applied,
the disease could be controlled in our
generation and eradicated in the next.
FOREWORD
PURPOSE OF THE MEMORANDUM
by
DR. W. R. AYKROYD
This memorandum outlines in simple and largely non-technical language the modern approach to leprosy control.
Charitable agencies, missionary societies and even public
health departments are often not properly aware of the
progress achieved in control during recent decades, and
advance is unnecessarily retarded by obsolete ideas and
methods. Oxfam itself receives requests from many parts of
the world for help in leprosy work and is under an obligation
to ensure that the limited sums which it can devote to leprosy
are spent to the best advantage.
The memorandum is intended, in the first place, for the
guidance of Oxfam Field Directors, Committees and Head
quarters staff when handling requests for assistance in this
field. Further, it is intended to indicate, to those who put
forward the requests, the lines which Oxfam is attempting to
follow and the kinds of programme it will be most ready
to support. Apart from these internal purposes, the Medical
Panel believes that the memorandum will be of interest and
value to workers in different countries concerned in one way
or another with the problem of leprosy.
In 1968 Oxfam issued a booklet* on tuberculosis designed
for similar purposes. The large circulation of this booklet
suggests that a parallel one on leprosy will be greatly in
demand. Oxfam is most grateful to Dr. Browne for having
prepared this memorandum. His long and wide specialised
'Memorandum on Tuberculosis in Developing Countries by Christine
E. Cooper. Paediatrician, Department of Child Health, University
of Newcastle-upon-Tyne. Consultant Paediatrician to the Govern
ment in Sierra Leone.
3
experience indicate his suitability for the task, while his
position as Medical Secretary of LEPRA and Medical Con
sultant to The Leprosy Mission is witness to the fact that
the publication of the memorandum is in effect a joint under
taking on the part of LEPRA. The Leprosy Mission and
Oxfam.
The memorandum begins and ends with a declaration
about the eradication of leprosy. This is the first moment
in the long history of the disease that so inspiring a statement
can be made.
W. R. Aykroyd, C.B.E., M.D., Sc.D.
Chairman. Oxfam Medical Panel
MEMORANDUM ON LEPROSY CONTROL
Medical attitudes towards leprosy control—like popular think
ing on anything to do with leprosy—fluctuate widely between
the extremes of easy optimism and despairing resignation.
Exact information on any aspect of leprosy may not only be
difficult to come by, but it may not be available or indeed
obtainable. Enough is known, however, of the size of the lep
rosy problem and the efficacy of treatment and control
measures, to provide the basis for a determined attack on a
disease that has so far resisted the combined efforts of official
bodies and voluntary agencies.
Size of the problem
For most countries, precise statistics of the number of leprosy
sufferers are not known, but in the world as a whole a total
of 15 million is probably an underestimate. There is always
more leprosy in a country than early guesses indicate, some
times much more. In the world the numbers are probably
increasing. There are several reasons for this: despite the fact
that a good drug has been available for over twenty years
and that during this time some millions have been cured of
leprosy, in very few countries have leprosy control schemes
been successfully organized. In precisely those countries that
have a big leprosy problem on their hands, medical facilities
in general are inadequate (especially for people living away
from the large towns), the population is increasing (that is,
there are more people to catch leprosy), the span of life is
lengthening (more people are being exposed to leprosy for
longer), and clothed leprosy patients in the growing towns
not only conceal the signs of leprosy more easily, but often
they arc not surrounded by good neighbours from their own
tribal group. In addition, in some countries the leprosy
campaign has shared with rural health services and preven
tive medicine in general the budgetary restrictions due to an
over-emphasis on curative medicine in large central hospitals.
Estimating the prevalence of leprosy
For the diagnosis of past or present leprosy infection, no
5
skin test (like the Heaf or Mantoux test for tuberculosis) is
known, nor is there a specific serological test (like those for
syphilis). Sample surveys of typical populations indicate
approximate prevalence rates. When treatment is provided,
and later is seen to be effective, and when facilities for re
constructive surgery and social rehabilitation are made avail
able, more people suffering from active leprosy and from the
results of past leprosy come forward for treatment.
Importance of leprosy
Leprosy is important not because it kills (like malaria, or
tuberculosis), or because it is highly contagious (like small
pox), or because it attacks whole populations (like schistoso
miasis), or because it is responsible for epidemics (like
cholera or measles) or for pandemics (like influenza).
Leprosy is important because it cripples. It vies with polio
myelitis as the world’s greatest crippier. If crippling includes
impairment of sensation, then about a quarter of those suf
fering from leprosy are crippled. Leprosy is thus the cause of
grave economic loss in many developing countries: instead of
producing, of contributing to the community, the crippled
victim of leprosy makes demands on his healthy fellows for
food, shelter and medical care. All this is quite apart from
the human tragedies that result from a disease that has
serious social consequences for the patient and his family.
Bases of control
In any given situation, there is one ideal combination of
methods that will make for effective leprosy control (Browne,
1968). Many ambitious and costly schemes founder because
they are partial or ill-balanced or fail to take cognizance of
some important factor or factors. These factors must be
taken into account in preparing any scheme for leprosy
control.
*
*
*
*
To make this Memorandum more helpful to non-medical
readers, some terms in common use by workers in leprosy
need explanation.
6
Indeterminate leprosy is the earliest manifestation. It is non-
contagious, frequently self-healing, and may develop into
one or other of the following types:
Tuberculoid leprosy is the commonest type in many countries.
For all practical purposes, it may be regarded as noncontagious. It is often self-healing, but it may be accom
panied by severe nerve damage.
Borderline (dimorphous) is an intermediate type, sometimes
almost tuberculoid, sometimes almost lepromatous, or
anything in between. It is contagious, often tends to
become worse (i.e. more like lepromatous leprosy),
shows no tendency to self-healing, has a varied and
unpredictable course, and is frequently accompanied by
early, widespread and progressive nerve damage.
Lepromatous leprosy begins insidiously and may smoulder for
years as symptomless patches in the skin. It is con
tagious, through the skin and nasal discharges. It shows
no tendency to self-healing, and nerve damage is late
and widespread, usually symmetrical. Borderline and
lepromatous leprosy are commoner among the lighter
Mongolian and Caucasian races than in the dark skinned.
These forms tend to be more severe in their systemic
effects, and to be more frequently accompanied by
damage to eyes and peripheral nerves. They are in the
main responsible for the continuation of the leprosy
endemic in any community.
The lepromatous/tuberculoid ratio is the expression of the
ratio between the numbers of patients with lepromatous
leprosy and those with tuberculoid leprosy. In some
countries and in order to convey a more accurate impres
sion of the seriousness of the leprosy situation, the term
lepromatous will include all patients suffering from the
contagious forms of leprosy, and the term tuberculoid
will include all the others.
7
“Open" disease is an administrative term denoting that form
of leprosy in which the patient sheds living organisms
from the nose and skin: in other words, he is contagious.
“Closed” indicates that, whatever the appearances, the
patient cannot be the source of contagion to others
because he is not shedding live organisms from his body.
The vast majority of leprosy organisms near the surface
of the body arc rendered incapable of living (and hence,
of multiplying) after a few months of treatment, though
it may be years before the last remnants of dead bacilli
disappear from the tissues.
The bacterial (or bacillary) index (B.I.) is an arithmetical
indication of the concentration of leprosy bacilli (alive
or dead) at the various sites (in skin and nose) examined.
The higher the index, the greater the concentration.
The morphological index (M.I.) is the percentage of the total
numbers of leprosy bacilli examined that may be re
garded as having been living when removed from the
body.
The slit-smear technique is the method of obtaining represen
tative amounts of material from the deep layers of the
skin or lining of the nose, and staining them so that the
leprosy bacilli present may be examined (M.I.) and
their concentration determined (B.I.).
Barrier nursing refers to the nursing of a patient suffering
from an infectious disease in such a way that the risk of
his passing on the disease to other patients in the same
ward is effectively reduced. Precautions arc taken that
all articles that may be contaminated by infective matter
(excreta, discharge from wounds, expired air, nurse’s
uniforms, etc.) arc so treated that they will not convey
the infection.
The word “leprosy” is frequently used in a loose way: it
means different things to different people. It includes any or
all of the following:
8
1.
A disease transmissible with difficulty, caused by a speci
fic micro-organism (Mycobacterium leprae) that is passed
on by patients suffering from lepromatous or borderline
leprosy (“open cases”) to susceptible contacts.
2.
A clinical condition exhibiting the widest divergence in
host-parasite relation—from a tissue reaction against
scanty dead organisms, to a bulky mass full of bacilli
that invades the skin and the mucosa of the upper
respiratory tract.
3.
A destroyer of peripheral nerves. Interruption of sensory
and motor pathways leads to loss of feeling, ulcerations,
contractures and painless deformities of hands, feet and
face.
4.
A state of tissue sensitivity, especially of certain structures
in the eyes (the iris and ciliary body), and of the main
nerve trunks of the limbs and face (hence, acute periphe
ral neuritis). This state is sometimes characterized by
prolonged and severe illness.
5.
A condition, half disease and half myth, surrounded by
numerous fears and superstitions, and accompanied by
psychological disturbance and social dislocation that re
sult not only from the disease itself, but also from com
munity pressures.
Aims and objectives of leprosy control
When we talk of “leprosy control”, we are really referring to
the prevention of the spread of a disease that is not very
“catching”. But there is more to it than this simple statement
indicates.
A clear definition of the objectives of leprosy control in
any given situation would at once reveal the inadequate
planning and sentimental basis of much that goes for leprosy
work. Granted, ideas may differ: one voluntary agency may
set much store on such salvaging operations as custodial care
for the hopelessly crippled or blind or outcast; another centre
9
L
may feel in duly bound to concentrate on reconstructive
surgery; and another on bringing leprosy treatment rapidly
within the reach of everyone needing it in a given area. In
some circumstances, a school for children with leprosy may
be a social necessity; elsewhere, it may be an expensive
anachronism whose construction is to be deprecated.
Some activities of some voluntary organizations may be
commendably philanthropic and altruistic, but have little
bearing on the control of leprosy or on the prevention of the
disease in the community. In general, voluntary agencies
are able to show more initiative and flexibility than govern
ments, but some may be tardy in adapting themselves to
modern views on leprosy control.
The cost/benefit or cost/effectivcncss of leprosy control
schemes must be estimated, notwithstanding differences of
objectives, methods and standards of care.
Possible methods of control
The control of leprosy as a slightly contagious disease could
depend upon some or all of the following measures, enumera
ted in ascending order of practicability at the present time
and in the present state of knowledge.
1.
Segregation of all leprosy patients, or at least of all con
tagious leprosy patients, either forcibly or voluntarily.
This measure is quite impossible of application in any
developing country. It is too costly, leads to concealment
of leprosy (especially early and contagious and treatable
leprosy) and has never really worked where it has been
tried.
2.
Raising the general standard of living and hygiene, and
the abolition of domestic overcrowding. Historically, this
may explain the decline of leprosy in the north-west of
Europe and point the way to control elsewhere. This is
a long-term development. At present, in most countries
where leprosy is a serious problem, it is impossible.
3.
Prophylactic dapsone administration (in graduated doses
10
and entailing twice weekly oral dapsone for an unknown
but lengthy period). This has been shown by Dharmendra
et al. (1967) to provide an apparently similar degree of
protection against leprosy as B.C.G. to children exposed
to comparable challenge. (It is not known whether any
additional protection is afforded if dapsone is given as
well as B.C.G.). While theoretically commendable, this
method of prophylaxis—which requires strict supervision
of healthy individuals for several years while they are
taking a potentially toxic drug—is generally impracticable,
and may be undesirable.
4.
B.C.G. vaccination. This may enhance the potential re
sistance to leprosy challenge of children living in more or
less close contact with an open case of leprosy. In the
circumstances of the Uganda trial (i.e. scattered popula
tion, low leprosy prevalence, low lepromatous/tuberculoid
ratio), such protection is apparently afforded to about 80
per cent of children (Brown et al., 1968). In Papua and
New Guinea, the percentage is 50 (Russell et al., 1968).
In Burma (where the population is much denser, the lep
rosy prevalence higher, and the lepromatous/tuberculoid
ratio greater), B.C.G. apparently affords no protection
(Bechelli et al., 1970).
However, in view of the encouraging results from
Uganda, it is recommended that full co-operation be
accorded—from the standpoint of leprosy control—to
schemes of B.C.G. vaccination for tuberculosis. If B.C.G.
can prevent the development of lepromatous leprosy, this
will confer great benefits, and if it prevents tuberculoid
leprosy (and hence deformity) this, too, is no mean
achievement. If a statistician and a doctor versed in lep
rosy can be seconded to any such vaccination campaign,
valid conclusions regarding leprosy may be forthcoming.
Where such campaigns are initiated by voluntary agencies
in conjunction with governments or WHO, the fullest
collaboration between them is desirable.
c.
11
'
-
- 56C
5.
Reduction of the reservoir of infection. This is at present
the most certain measure that can be generally adopted.
The individual patients are rendered non-contagious, de
formity is prevented, and the cycle of transmission
broken. There is no known vector or intermediate host
of Myco. leprae. As far as we know, Myco. leprae is
found only in man. Therefore, an attack on the organism
in the only known source of infection, i.e. the patient
suffering from active leprosy, would appear at present to
hold out the greatest chances of ultimate success in
controlling the disease.
The cost of this measure depends on the prevalence of
leprosy, the population density, the facility of communi
cations, the lepromatous/tubcrculoid ratio among those
with leprosy, the presence and nature of existing medical
facilities (dispensaries, medical assistants, etc.).
Case-finding
The numbers of people (a) presenting themselves at a clinic
on their own initiative for diagnosis and treatment, suspecting
that they have leprosy; (b) begging in the streets and suffering
from various deformities attributable to leprosy; and (c)
seeking admission for asylum care—bear no necessary rela
tion to the size and importance of the leprosy endemic in
the locality.
The real prevalence of leprosy may be ascertained by:
(a)
regular and frequent (annual) whole-population surveys
conducted primarily for leprosy, or for other endemic
diseases (such as tuberculosis, trypanosomiasis,
trachoma, yaws, etc.). Where the prevalence of leprosy
is high, the population well marshalled and co-operative,
and the medical services adequate, this method has much
to commend it. But such surveys are expensive,
rarely practicable, and seldom desirable when under
taken for leprosy alone. Where the prevalence of lep
rosy exceeds 1 per cent in a rural or urban community,
12
everybody must be considered to be a potential contact,
although the majority of persons actually found to be
suffering from leprosy may deny all knowledge of pro
longed and intimate contact with anybody known to
be suffering from leprosy.
(b)
Surveys of people at special risk, such as household
and family contacts of known sufferers from leprosy.
Where possible, frequent (i.c. quarterly or six-monthly)
examination of such contacts is a sure method of dis
covering early cases of leprosy.
(c)
Selected groups of persons may be examined for leprosy
cither because of statutory requirements (recruits to the
armed forces or police, contracted workmen and their
families), or because they arc conveniently available
(school-children, prisoners).
(d)
Special attention should be given to patients attending
skin clinics or orthopaedic departments, and to those
with chronic ulceration.
(c)
In some countries, a very high proportion of beggars
in markets or on highways is suffering from active lep
rosy, or (more usually) from the results of past leprosy.
TREATMENT OF LEPROSY
The following principles arc generally applicable:
1.
No treatment for leprosy is to be given unless a positive
diagnosis has been made.
2.
When the diagnosis of active leprosy has been made,
treatment should be begun at once (except where contra
indicated on such grounds as acute reaction or neuritis).
3.
Some forms of leprosy are self-limiting and self-healing,
but it is difficult for most workers to recognize them.
In any case, treatment will expedite healing of early
(indeterminate) leprosy, and thus contribute to the
13
impact of the anti-leprosy campaign on the population;
it may also prevent the development of lepromatous
leprosy.
4.
A simple scheme of treatment suitable for application
by trained auxiliary workers to patients with any kind
of leprosy in rural or urban mass control schemes, should
be drawn up and promulgated. Only one drug, dap
sone, should be used in this scheme. Dapsonc is cheap,
has few side effects, is active in all forms of leprosy,
rarely induces drug-resistance, and can be given by
trained auxiliaries with the minimum of medical super
vision.
5.
All patients with active leprosy, except those in certain
well-defined categories, may be safely treated in domi
ciliary fashion with dapsone.
6.
Since the length of treatment to be advised, the contag
iousness of the patient, the prognosis, and the criteria for
discharge depend on the type of leprosy, and its duration
and severity, the classification should be determined and
the fullest possible records kept.
7.
In the case of tuberculoid and indeterminate leprosy,
treatment should be given for at least two years, or for
at least one year after all signs of clinical activity have
ceased. For all other kinds of leprosy (lepromatous and
borderline), treatment should be continued for at least
four years, or for at least two years after all clinical
and bacteriological signs of activity have ceased; co
operative patients in whom this kind of leprosy is
considered to be quiescent, are advised to take half the
therapeutic dose for the rest of their lives.
8.
After discharge, patients should be examined as follows:
every three months for a year; then every six months
for two years, and annually thereafter. Slit-smear
examinations arc more important than clinical examina14
tion when patients have had lepromatous or borderline
leprosy. Follow-up may be limited to patients in the
group most likely to relapse, i.e. those who have suffered
from borderline leprosy, and who took treatment for
an insufficient length of time.
9.
If resources are limited, it is far better to concentrate
on treating patients who are contagious than to attempt
to treat everybody. Dapsone being very slowly excreted,
impeccable regularity of treatment is not essential. If
75 per cent of contagious patients can be treated, and
if these patients can make 75 per cent of attendances
for treatment, then the threshold of infection will be so
reduced that the back of the endemic is broken.
10.
If the control is effective, the number of those develop
ing leprosy will show a progressive reduction after 3-5
years.
Note
1.
Patients no longer suffering from active leprosy, i.e.
those with residual deformities and ulcerations, do not
need treatment for leprosy; in fact, not only does dap
sone do them no good, but walking long distances to
get their tablets may further damage their insensitive
feet; this may bring the anti-leprosy campaign into
disrepute.
2.
Microscopic examination of slit-smear preparations
(from ear-lobes and the edge of an active lesion) is
advisable for all patients suspected of having lepromatous or borderline leprosy. Such examination should
be done (a) on diagnosis, and (b) annually thereafter.
An auxiliary can make the smears, fix them on the
spot, and either stain them (by Ziehl-Neelsen’s method)
at once, or send them to the laboratory for staining
and reading. The Bacterial and Morphological Indexes
should be determined.
15
3.
Lepromin testing is not necessary for diagnosis, but
helps in confirming the classification made on clinical
grounds.
4.
Tn field work, examination of skin specimens removed
by biopsy is not often feasible or indeed essential.
5.
Drug resistance. Fortunately, drug resistance is not the
problem in leprosy that it is in tuberculosis. Proved
resistance to dapsonc and to thiambutosinc has been
reported, but is not common. There is no reason to
advocate more expensive multi-drug regimes in leprosy
with a view to forestalling the appearance of resistant
strains of Myco. leprae, or in the hope of hastening
cure. When resistance does develop to dapsonc or to
thiambutosine (and possibly crossed resistance to the
sulphonamides), clofazimine is the drug of choice.
For purposes of leprosy control, as distinct from treating
everybody with leprosy, the following observations arc rele
vant:
1.
Patients suffering from active leprosy arc divisible into
two administrative groups:
(a) “Open”: patients in this group shed viable leprosy
bacilli from the upper respiratory mucosa, from
ulcerations of affected skin (as distinct from
neuropathic ulcers of the extremities), and (not so
commonly) from intact skin, hair follicles, sweat
glands and milk ducts. They suffer, usually, from
lepromatous or borderline leprosy; sometimes from
tuberculoid leprosy undergoing exacerbation.
After four to eight months of standard treatment,
such patients no longer harbour viable (i.c. morpho
logically normal) bacilli, although four to eight
years of treatment may be needed before all bacil
lary remnants are cleared.
(b) “Closed”: patients suffering from indeterminate or
16
tuberculoid leprosy may be regarded as noncontagious. There is a loophole here, since these
patients may on occasion apparently act as sources
of infection.
2.
Clinical criteria suffice in general for initial differentia
tion into “open” and “closed”, but bacteriological
examination (by the slit-smear technique) is necessary
for confirmation and for determining the non-viability
of bacilli.
3.
Nursing mothers suffering from lepromatous leprosy
rapidly cease, with treatment, to shed viable bacilli,
and suckling infants imbibe prophylactic amounts of
dapsone in the milk. Therefore, separation of nurslings
from their mothers is neither necessary nor desirable.
The social and psychological consequences of maternal
deprivation and high child mortality, are to be avoided
at almost any cost. For these and other reasons, the
creation of “Preventoria” (units for healthy children of
mothers with leprosy) is not recommended. Close con
tact must, however, be reduced to a minimum as long
as the mother is contagious.
IN-PATIENT FACILITIES IN DOMICILIARY
TREATMENT SCHEMES
The proportion of beds per 1,000 patients deemed necessary
varies with the lepromatous/tuberculoid ratio, area of scheme,
communications, money available, etc. In Africa, at any one
time, 5-10 beds per 1,000 patients should be adequate: in
India and the East, 10-20 beds per 1,000 patients may not be
enough, for leprosy is more serious in the East.
Local initiative and enthusiasm may demand more beds
and more facilities than are strictly necessary for control of
leprosy.
Most patients needing temporary accommodation as in17 COMMUNITY HEALTH CELL
326, V Main. I r’ ck
Koram-nr '
patients have conditions falling within the following cate
gories:
neuropathic ulceration of the extremities;
drug reactions;
acute reaction in lepromatous leprosy;
erythema nodosum leprosum;
acute neuritis;
acute foot-drop, or acute facial palsy;
acute iridocyclitis;
corneal ulceration following lagophthalmos;
preparation for reconstructive surgery;
those needing physiotherapy or education in
the use of anaesthetic extremities.
Occasionally, on social grounds, or in the case of child
ren, for schooling; the hopelessly crippled or blind; the
homeless and friendless; those learning a trade or skill;
patients learning to use prostheses.
The link between the domiciliary mass treatment scheme
and the central hospital should provide for the rapid diag
nosis of urgent complications and the rapid transfer of the
patient from periphery to centre.
ORGANIZATION OF LEPROSY
MEASURES
CONTROL
There is no need to reduplicate expensively existing medical
services to provide the facilities necessary for leprosy patients.
Skin clinics in hospitals, dermatology departments in teaching
units, general out-patient clinics, static and mobile dispen
sary units, general practitioners, should all be brought into
the leprosy campaign. Local susceptibilities regarding lep
rosy should be recognized and respected, but not slavishly
pandered to. For diverse reasons, the ideal of complete inte
gration of leprosy control measures into the public health
services cannot be achieved everywhere immediately, but it
must be kept in view as an objective to be attained as soon
as possible. The following measures should be adopted:
18
1.
Leprosy to be taught to medical students, postgraduate
doctors, nurses, physiotherapists, and medical auxi
liaries—as part of their course of lectures and clinical
demonstrations.
2.
Existing diagnostic and treatment facilities to be
utilized for leprosy patients wherever possible. Leprosy
patients may be safely treated in general wards, pro
vided that, if they are still contagious, the principles of
“barrier nursing” be observed.
3. Leprosy should be treated at rural and urban static or
mobile all-purpose treatment centres wherever possible.
4. As a temporary or transient measure, or sometimes
(where local circumstances warrant) on a more per
manent basis, mobile treatment runs may be organized
on a regular itinerary: a mobile team follows a prede
termined route (weather and roads permitting), halting
at set points to provide treatment, to examine new and
old patients, to offer advice and give instruction. Treat
ment for other chronic diseases (such as tuberculosis,
trachoma, trypanosomiasis) can with advantage be com
bined with leprosy treatment. As much depends on the
keenness and integrity of the medical auxiliaries, as
on the reliability and road-worthiness of the transport.
Bicycles may be used to supplement motor vehicles.
5. Where conditions permit only rare visits by a super
vising doctor, supplies of dapsone may be entrusted to
an auxiliary, or even a dependable village headman, to
distribute to patients on demand. Where all medical
treatment is free, and the people know it, this apparently
unsatisfactory method is less open to abuse than would
be thought likely. Visiting leprosy patients in their
homes and giving them three months’ supply of dapsone
may be less expensive than trying to trace defaulters.
6. In all legislation, notification, and administrative mea
sures, leprosy should be treated as a public health
19
problem amenable to principles of general application.
The sooner that leprosy is no longer regarded as
"unique” or special, the better for all concerned.
7.
The training of medical auxiliaries in the recognition
and treatment of leprosy, in the organization and
execution of control schemes, in simple physiotherapy
and the making of protective footwear—is of para
mount importance.
Segregation villages have occasionally served a useful pur
pose, where good farming land was available, where the
scheme was recognized as a temporary expedient, and where
patients were free to leave when desirable. Such villages
may, however, help to perpetuate the myth of the “unique
ness” of leprosy, its hereditary taint and incurability. They
become the permanent dwelling-places of the cured, the
ostracized, the ne’er-do-wells, and their children may be tied
to the land. For similar reasons, villages that tend to arise in
the vicinity of leprosaria arc to be discouraged.
Occupational therapy, or more properly vocational therapy,
has its place in leprosy, provided that the skills taught arc
practical, saleable, locally viable, do not require permanent
help in the form of raw material or sales organization, and
afford the ex-patient the chance of becoming self-supporting
and an economically independent citizen. Expensive imported
apparatus is anathema. For the majority of leprosy patients.
vocational therapy will teach skills that will make him (or her)
a better farmer than before, able to fend for himself (or
herself), and able to compete successfully with healthy fellow
villagers. Teaching women to protect their hands when
cooking and their feet when walking, is a rewarding occupa
tion. The making of moulded handles for kitchen utensils,
farming implements and tools, non-conducting handles for
crockery and cutlery—may not only provide work, but
should also prevent deformity by protecting insensitive hands.
20
THE ROLE OF RECONSTRUCTIVE SURGERY IN
LEPROSY CONTROL
The over-emphasis on reconstructive surgery that may of
late years have been detectable in some centres is giving
place to a more sober appreciation of its proper place in
leprosy control. In good hands, and for the right patients,
surgery can restore a hopeless cripple to a dignified indepen
dence. Simple surgery for plantar ulceration, foot-drop, flail
feet and lagophthalmos, and simple physiotherapy (medi
ated in general by auxiliaries trained by qualified staff) will
do more good for some people than highly sophisticated
operative procedures performed by general surgeons who
cannot gain the necessary skill that comes only with con
stant practice. Successful surgery has excellent propaganda
value in a leprosy campaign, but limited resources cannot
be spent on operations and prolonged in-patient treatment
and physiotherapy for the favoured few (especially when
anatomical reconstruction is not accompanied by sensory
restoration) if this means that no money is left for the pre
vention of deformity in the many suffering from active
leprosy. Surgery for leprosy patients may with advantage be
included in the work of a general orthopaedic department
and not organized in a separate unit.
The provision of simple protective footwear, however,
perhaps with moulded microcellular rubber, or plastazotc
insoles introduced into rigid soles, may prevent disability and
neuropathic ulceration of the feet. Such expenditure is a
very sound investment, provided that the shoes arc cheap,
hard-wearing, repairable, and not stigmatizing. Simple prosthcscs are required for legs, and various plastics arc now
being utilized. The more complicated and expensive artificial
forearms and hands are beyond the needs and resources of
most people in the developing countries.
THE ROLE OF EDUCATION
In view of the widespread superstitions and false notions
about leprosy, education of the public is an essential part
21
of the attack on the disease. Educational material adapted
to the country is aimed at different classes of society:
1.
2.
3.
4.
5.
The patient;
The patient’s relatives and friends;
Schoolchildren;
Students in teacher training colleges; medical students;
Special groups: women’s and church groups; trade
unions; youth clubs; travellers by public transport, etc.
All the resources of modern mass communication media
should be utilized as opportunity affords:
1. Pamphlets, brochures, cartoons, posters;
2. Radio and television;
3. Film-strips; full-length films; loudspeakers;
4. Essay competitions; projects; model-making;
5. Lectures, talks;
6. Exhibitions—static and mobile;
7. Semi-popular booklets, such as Insensitive Feet and
Watch those eyes; *
8. Disseminating the results of leprosy research through
professional journals, so that the time-lag between the
acquisition of new knowledge and its field application
may be shortened;
9. Training courses and refresher courses for medical
auxiliaries;
10. Scholarships, fellowships, bursaries for doctors and
others engaged in leprosy campaigns.
THE ROLE OF RESEARCH
Highly technical research in the field of leprosy may seem
far removed from the pressing day-to-day problems of
•Published by The Leprosy Mission, 50 Portland Place, London
WIN 3DG.
22
applying the knowledge we already have, to the needs we
face. Yet research must hold the key to better and less
costly methods of control, to better and more efficacious
drugs, to unequivocally effective preventive measures. Serious
research in all aspects of leprosy-—in laboratory, in operat
ing theatre, in village control schemes—provides an oppor
tunity for the advantageous investment of funds. Every
recent advance in knowledge of leprosy has come about
because somebody with an enquiring mind asked certain
questions and tried to answer them.
The publication in scientific journals of the results of
research is the best way of recording the progress made and
sharing it with the world. Only thus can the new knowledge
be brought to bear on leprosy in the individual and the
mass. The financing of such publications is thus a most
proper way to use funds subscribed for “leprosy”, and every
body engaged in the leprosy service should be encouraged to
read these journals, and to keep up-to-date. The best-known
of these are:
International Journal of Leprosy
1200-18th Street, N.W., Washington, D.C. 20036.
16 Bridgcfield Road, Sutton, Surrey.
Leprosy Review
57a Wimpole Street, London W1M 7DF.
Leprosy in India
Hind Kusht Nivaran Sangh, Red Cross Road, New Delhi-1.
Fontilles Revista de Leprologia (Spanish)
Sanatorio de Fontilles, Prov. de Alicante, Spain.
Acta Leprologica (mainly French)
3 place Claparede, Geneva.
VOLUNTARY AGENCIES, COSTS AND
CO-OPERATION
The voluntary agencies, particularly Christian Missions, were
first in the field of leprosy work (care for leprosy sufferers,
introduction of new treatments, reconstructive surgery, and
rehabilitation), and raise large sums of money for leprosy.
23
In some countries, they arc still responsible for a consider
able share in the anti-leprosy campaign, and in the world
as a whole make a significant contribution to treatment and
research. Having invested more in installations, some of
them have tended in the past to be institution-orientated,
and their compassion may not always be untinged by senti
mentalism. They are now working together more closely
with each other (mainly through ELEP, the European Feder
ation of Anti-Leprosy Associations) and with governments.
They bring to the care of leprosy sufferers Christian ideals,
accumulated experience and local knowledge, as well as
flexibility and initiative. Grants channelled through missions
are usually spent to good purpose.
Governments have the final responsibility for the organiza
tion of leprosy control programmes, and voluntary bodies—
as welcome and appreciated guests—should act in con
formity with official plans and policies, implementing and
supplementing them wherever possible.
The World Health Organization, in conjunction with
UNICEF, will provide drugs, transport and expert advice
at the request of governments.
Costs. Dapsone, in general use for leprosy treatment, is
ridiculously cheap, costing about five new pence for a year’s
treatment. Second-line drugs (thiambutosinc, sulphormethoxine, clofazimine) are more expensive, and the drugs
used in the treatment of acute exacerbation (proprietary
antimonials. chloraquinc. corticosteroids, clofazimine) arc
costly.
Ambulatory treatment is the method of choice for the
vast majority of patients; dapsone being cheap, the costs of
getting the drug to the patient account for a large proportion
of the cost per head per year—mainly transport and salaries
of medical auxiliaries.
Hospital treatment costs from 30 to 50 times that of
domiciliary treatment, and should be reserved only for those
categories mentioned above (p.18).
24
The provision of facilities for reconstructive surgery to deal
with the back-log of crippled patients suffering from defor
mities that should have been prevented, is a necessary
luxury. Some developing countries cannot afford to devote
even 10 per cent of the leprosy budget to this end, and rely
on voluntary organizations to tackle this expensive individual
therapy. With nursing care, physiotherapy (one-sixth to onetwentieth of a physiotherapist’s time per patient), multiple
operations, proslheses, post-operative training and follow-up,
major reconstructive surgery is costly, but where it can be
undertaken, its value and impact both direct and indirect are
considerable.
It is, however, a misuse of resources to overtreat a few
privileged patients and at the same time allow thousands to
become crippled for want of treatment, and fail to break the
cycle of transmission of leprosy from the patient with “open"
disease to the susceptible contacts.
THE OUTLOOK FOR THE FUTURE
The task of tackling leprosy is more costly, more difficult
and more protracted than we were led to expect twenty
years or so ago. In some quarters, there is disillusionment,
even despair. Serious forms of leprosy arc not easily arrested.
and the disease seems often to smoulder for years in the
individual sufferer and in the community, ff the present
mood of sober realism leads to a reappraisal of the situation
and a redeployment of men and means in a concerted co
operative attack on the disease—this will be all to the good.
If existing knowledge about leprosy were
conscientiously and persistently applied.
the disease could be controlled in our
generation and eradicated in the next.
25
COMMUNITY HEALTH CELL
326, V Main, I Block
Koramongala
Bangalore-560034
India
REFERENCES
Macgraith, B. G. and Gilles, H. M. (1971) Clinical tropical
diseases. Chapter: Leprosy. Blackwell Scientific Publications,
Oxford. 3rd Edition.
Bechclli, L. M., Garbajosa, G., Uemura, K., Engler, V., Dominquez,
V. Martinez, Paredes, L., Sundaresan, T., Koch, G. and Matejka,
M. (1970). Bull. Med. 42, 235. B.C.G. vaccination of children
against leprosy. Preliminary findings of the WHO-controlled trial
in Burma.
Brand, Margaret (1969) Watch those Eyes. The Leprosy Mission.
Brand, P. W. (1966) Insensitive Feet. The Leprosy Mission.
Brown. J. A. K., Stone, M. M. and Sutherland, I. (1968) British
Medical Journal, 1, 24. B.C.G. vaccination of children against
leprosy in Uganda: Results at end of second follow-up.
Browne, S. G. (1967) Transactions of the Royal Society of Tropical
Medicine and Hygiene, 61, 265. The drug treatment of leprosy.
Browne, S. G. (1968) Leprosy: New Hope and Continuing Challenge.
The Leprosy Mission.
Browne, S. G. (1968) International Journal of Leprosy, 36, 541.
Priorities and Co-operation: Blueprints and Guidelines.
Browne, S. G. (1970) Leprosy. Documenta Geigy. Acta Clinica No. 11.
Dharmcndra, Noordccn, S. K. and Ramanujan, K. (1967) Leprosy in
India, 39, 100. The prophylactic value of D.D.S. against leprosy:
a further report.
Russell, D. A., Scott, G. C. and Wigley, S. C. (1968) International
Journal of Leprosy, 36, 618. B.C.G. and prophylaxis—the Karimui
trial.
World Health Organization (1968) Technical Report Series No. 319.
World Health Organization Expert Committee on Leprosy. Third
Report; Fourth Report.
27
- Media
297.pdf
Position: 1211 (7 views)