LEPROSY
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- Title
- LEPROSY
- extracted text
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RF_DIS_8_A_SUDHA
Quest
8a.
A
f-
I
I .
!
I
LEPROSY CONTROL
A REPORT FOR KAP STUDY
Prepared for : UNICEF
/-
by : QUEST QUALITATIVE RESEARCH
BOMBAY
Quest
BACKGROUND
Anti leprosy work in India dates back to 1925, 12
but it iis only with the
dhiiouiicumcnt ul the Natiunal Leprosy Eradication Programmej (NLEP) in 1983
that the movement received the light locus and momentum.
Given the unabating magnitude and geographic dispersion of the incidence of
leprosy, the NLEP has been shaped by the following considerations:
(a)
Priority should be attached to those areas where incidence of leprosy
is high
(b)
Voluntary agencies already active in the field, of leprosy control
as
well as the public health system should be
extended all possible
support
(c)
Leprosy control
approach.
should form a part of a wider primary
health
care
As an answer
---- to the problem of drug resistance
that had become a serious
threat to <all leprosy control activities.
Multi-Drug Therapy (MDT) has
recently been introduced to bring down 1the infectivity expeditiously and to
thwart the emergence of drug resistance.
While UNICEF will continue to support the health education and
awareness
campaign at the national level, the MDT programme will concentrate
con
a
;rlC?' n,0Ving silnultaneously on all three fronts
...J
medical,
social and individual.
Out of the 98 hyper-endemic (over 10 cases per 1000 population)
districts
that qualify for MDT treatment, MDT has been introduced in 15
districts
.
Out
fnr-iccof I these,
. \.,ln three districts - vishakapatnar (Andhra Pradesh), Puri
and Chingelpet (Tamil Nadu),
i.ple«»tea with the
-- --- j of UNICEF.
UNICEF is aware that leprosy is as much <
’ “ problem as a medical one.
a social
Increasingly, the objectives of early detection,
t diagnosis and regular
treatment are being defeated by strong social
non-acceptance.
There is,
therefore, a need to develop ian
... effective communication strategy to help
break 1'
through the attitudinal barriers
li.-l — j that currently inhibit the control
and eradication of leprosy.
is against this background that UNICEF wished
w
to initiate research that
sensitive^enough to provide fresh insight
- :s into the social, cultural and
psychological aspects of
-- the
—- Problem and thereby assist in establishing the
objectives, approach
approach and
and methodology
methodology of
of the
the communication
communication programme
To
district stu^^
COmmlSSloned QUEST QUALITATIVE RESEARCH to conduct a
they commissioned
ten-
It
• **
...
Quest
i
ii.
RESEARCH OBJECTIVES
The major objectives of this study were to:
1
- investigate knowledge, attitudes and practices
with regard to leprosy
- generate data to aid the development of a relevant
il
communication strategy
I
- identify what needs to be communicated, how and
to whom.
it
11
1
/
i
ii...
Quest
iii
GEOGRAPHICAL COVERAGE
DISTRICTS
STATE
CHARACTERISTICS OF DISTRICTS
1.Vishakapatnam
Andhra Pradesh
2.Deoghar
Bihar
Hyper-endemic, MDT districts
in the most highly endemic
states
3.Ganjam
Orissa
4.Chandrapur
Maharashtra
5. Periyar
Tamil Nadu
6. Uttarkashi
Uttar Pradesh
7. Dangs
Gujarat
8. Tuensang
Nagaland
9. Alwar
Raj asthan
10.Kanpur
Uttar Pradesh
IMMHB ... t
Highly endemic districts with
mono-therapy
Low endemic districts with mono
therapy
Hyper endemic, entirely urban
district, monotherapy
. .
Quest
iv
SAMPLE
INTERVIEWS
Total no.of
No.of interviews
for urban district interviews
No. of interviews per
Rural District
Urban
Rural
7
8
- with family
(3)
(4)
- away from family
(4)
(4)
Medical Arm
5
4
doctors
(2)
(1)
- paramedics
(2)
(3)
- medical students
(1)
Families of patients
2.5
3
- patients with them
(1)
(2)
Patients
/
patients away from
them
SubTotal
135
15
150
81
9
90
50
c
55
9
1
10
32
3
35
(1.5) (1)
Voluntary Organisations
1
Opinion Leaders/
Influencers
1.5
2
school teachers.
(1)
(1)
4
(1)
- village elders
(0.5)
- journalists
•>
340
TOTAL NO. OF INTERVIEWS
I... .
.
Quest
i
V
SAMPLE CONTINUED
Group Discussions Amongst General Public
Rural
Total
Sex
Age
Education
Monthly
Urban
1.
Men
25-45 years
Graduate
Rs.1000-2000
1
(10)
2.
Women
25-45 years
Upto SSC
Rs.1000-2000
1
(10)
3.
Young
Adults 13-17 years
(Boys,
Girls)
Rs.1000-2000
1
(10)
4.
Men
30-50 years
Illiterate
Rs. 350-750
1
(9)
5.
Men
30-50 years
Upto SSC
Rs. 500-1000
1
(9)
6.
Women
30-50 years
Illiterate
Rs. 350-750
1
(9)
7.
Young
Adults 13-17 years
(Boys,
Girls)
Rs. 350-750
1
(9)
4
(66)
3
■
•
■
'
■
Quest
vi.
RESPONDENT CATEGORIES
A. General Public
* Men, women, adolescents
★ Rural, urban, tribal
* Literate, semi-literate, illiterate
B. Patient s
* With family, away from family
* Paucibacillary, Multibacillary
★ Mono- and Multi-drug therapy
* Male, female, adolescent
C. Patients' Families
* With patient, patient away
* Paucibacillary, Multibacillary patient
* Mono- and Multi-drug therapy
* Male, female, adolescent patient
D. Voluntary Organisations
* Indian
* Foreign
E. Leprosy Training Centres
★ Dehradun
★ Ganjam
★ Vishakhapatnam
•:r?.
'
Quest
Vll.
RESPONDENT CATEGORIES (CONTINUED)
F. Medical Arm
* Doctors (MOs at LCU, PHC; Homoeopaths; Allopaths; Vaids;
Private Practitioners; Specialists)
★ PMW
A
NMS, Health Educators
* LT
G. Influepeers/Opinion Leaders
* School Teachers
* Village elders
* Mahila Mandal members
* Journalists
* Religious Heads
1
Quest
viii .
METHODOLOGY £ FIELDWORK AND ANALYSIS
Selection of Villages
Within each district, two taluks were selected so that they:
i)
were not adjacent
ii)
did not represent an atypical community
iii)
had differing degrees of incidence/prevalence of leprosy
iv)
had differing leprosy control mechanisms such as LCU, SET, etc
Within each taluk,
selection
2-4 villages selected on similar criteria as for taluK
Selection of Respondents
Patients:
- differing degrees of disease and treatment progression
PB and MB
Mono and MDT
varying castes, communities, occupations, literacy and income levels
Patients 1 Families
included families with patients staying with them,
away from them
Doctors:
MOs at LCU
MOs at PHC
Private Practitioners
- Homoeopaths
- Vaids
- Specialists
as well as
patients
Quest
IX .
Paranu'dical Arm: spread among:
PMWs
MPWs
NMSs
LTs
Voluntary Organisations and LTC Staff:
Executive head
Doctor
- PMWs as applicable
Classification Data
For every respondent, data was classified on the following basis:
- Age, sex, educational level, caste, religion, household income, marital
status, occupation, family size and type, details of family members,
type of leprsoy, stage and treatment, places of treatment, etc.
It was used as a reference for check-back and analysis
Storing and Collection of Data
All depth interviews and groups were conducted by executives,
and specialist interviewers of QUEST
in
All depth-interviews
language -
and group discussions were conducted
All depth-interviews
verbatim in English
and group discussions were recorded and
consultants
the
local
transcr ibed
Enabling techniques such as personification, analogy, metaphor and role
play were employed, wherever applicable, in order to overcome rationalised
responses
Analysis and Int erprctat ion
The data in the transcripts were content-analysed by a team of qualitative
analysts into a number of relevant categories
Outputs of enabling techniques were decoded with the help of the concerned
research executive to interpret their significance in the particular social
context.
CJuesI
X.
LIST OF ABBREVIATIONS
GPM
General Public Men
GPW
CciRial Public Munich
GPB
General Public Teenage Boys
GPG
General Public Teenage Girls
PWF
Patient with Family
PAF
Patient away from Family
FWP
Family with Patient
FAP
Family away from Patient
OLJ
Opinion Leader Journalist
OLT
Opinion Leader Teacher
OLV
Opinion Leader Village Leader
VO
Voluntary Organisation
MO
Medical Officer
PMW
Para Medical Worker
NMS
Non Medical Supervisor
LT
Lab Technician
PB
Paucibacillary
MB
Multibacillary
UT
Under Treatment
C
Cured
DT
Discontinued Treatment
DI
Periyar
D2
Vishakapatnam
D3
Deogarh
D4
Chandrapur
SIB
. ........
...........
Quest
■
)
AN OVERVIEW OF THE DISTRICT-VISE ASSESSMENT OF KNOWLEDGE AND ATTITUDES
II
Quest
xi .
LIST OF ABBREVIATION (CONTINUED)
D5
Ganjam
D6
Dangs
D7
Alwar
D8
Kanpur
D9
Twensang
DIO
Uttarkashi
r
4
Quest
xii.
1.
KNOWLEDGE - DISTRICT PROFILE
In this section we have endeavoured to provide a picture of the varying
levels of knowledge about leprosy across the districts and have
When commenting on
commented on the factors that cause this variance,
'clusters ’,
various
the
districts,
we have looked at them as
Within
each
districts.
specifically, high, medium and low knowledge
the
varying
levels
of
knowledge
r’“group of districts, we have highlighted t'„the
different
respondent
categories.
among
High Knowledge Districts
knowledge were Kanpur,
The districts with fairly high levels of
The factors that brought about this
Viaskhapatnam and Ganjam.
commonality have been discussed below.
Common Features that Impinge on Overall Knowledge,
J
Urbanisation:
Kanpur
only urban
urnan centre
-xo group, while
Kanpur is
is the
the only
centre m
in this
Visakhapatnam
^ral component
nam
and Ganjam are districts with a rural
However, unlike the other districts, Visakhapatnam and Ganjam.do
Gangam do not
have a tribal
tribal populace
populace and
and the
villages
also
display
greater
signs of
the villages also display greater signs
urbanisation.
The effect of urbanisation on knowledge levels
ievels is no
where more clearly highlighted than in the case of Kanpur.
Kanpur. .^ere
---- -seems
to be a greater level of exposure to sources of information in the
urban situation and education -levels
- are ’higher.
• ’
. This leads to a much
and Ganjam, access to sources
better informed public. In
1.. Visakhapatnam
- ------- - -----as
of information and to media seems to be, higher, interesting j,
which has been discussed later in
a result of the MDT program, a factor i--- —
this section.
Further,Visakhapatnam district seems to display a gradually increasing
1.. Our
when compared to the other districts
level of industrialisation
---- ----faiTadmixture of farm labourers, industrial/
had a 1***^ -- ----,
respondent profile
i
’ •
workers and also many who were involved in municipal
work. This
quarry
to and the need for knowledge and resulted1 in the
has improved access to
traditional myths, foklore, etc., and an opening up
growing away from
1-- ---to the outside world.
urbanised and is mainly agrarian.
Therefore, it is
Ganjam is not so
However, the fact of the high level of
comparatively backward.
that is in
knowledge about leprosy can be attributed to the MDT program
full operation in Ganjam.
of
Drug regime: One of the major factors that has influenced levels
"
>
(gathering
knowledge has been the MDT program.
This program seems to
and
from respondent comments) come with a package of information
--The
medical
arm
is
kept
rigorously
education in addition to the drugs,
educated
and motivated to consciously impart this information to
patients whom they contact. Thus, both Visakhapatnam and Ganjam, where
Quest
xiii.
MDT is fully in progress, displayed higher levels of knowledge about
leprosy.
With regard to Kanpur, it is pertinent to note that the
knowledge levels are high not only because of the fact of urbanisation,
but also because MDT has been introduced here by the Damien Institute
and has been in progress for a couple of years.
The news of the visible results of MDT's efficacy and the stress on
education in this program have succeeded in creating a change in a
Monotherapy district like Kanpur.
Although Deogarh is also under the
MDT schedule, it does not, however, come under this high knowledge
category, a fact that we have discussed later.
Media: The presence of mass media and the levels of exposure to
has clearly had an impact on people's knowledge about leprosy.
them
Kanpur, by virtue of being a mini metro, has full exposure to mass
the
media and other media sources.
Consequently, a greater part o
populace is exposed regularly to the media than in other distric s.
Thus, whenever messages about leprosy have been beamed out, these have
found an audience in Kanpur.
‘ * r relating
Visakhapatnam and Ganjam displayed stepped up media activity
Pamphlets,
wall paintings/
part of the
the MDT
MDT program.
program.
1 .’
to leprosy, as aa part'of
It
the
main
sources
of
information
about
leprosy.
It was
posters form
actually
to
note
that
many
respondents
in
these
districts
interesting
disease,
verbalised that leprosy can be cured and that it is merely a
In doing so, some tended to mention having read
not a divine curse,
In the section on Media, we have discussed the
the media messages,
regarding
the
various sources and respondents' perceptions of
details
these sources.
Medical infrastructure:: One of the reasons for the high level of
knowledge in Kanpur, (Ganjam and Visakhapatnam could also be the large
Compared to the other districts, these
medical infrastructure *here,,
complex
and
far-reaching
system for leprosy treatment.
three have a (
low
The LCDs, SETs and ULCs are better represented here than in the
where
knowledge districts.
Kanpur has 22 PHCs and Ganjam has 29 PHCs
Visakhapatnam does not have
leprosy treatment is a regular feature.
and 4 ULCs and a record 49
-PHCs for leprosy but has, instead, 4l LUCs
SETs and a Temporary Hospitalisation Ward, which the others do not.
This stepped-up activity on the medical side has made some impact on
These medical
the overall awareness and knowledge of this disease.
well
manned
and
have
penetrated
deep
into
the
districts,
centres are --- ----- -- -- - *--intensive.
As a
thereby ensuring that the awareness is widespread and intensive,
- 3 another disease
result, the populace is beginning to view leprosy as
that can be treated and cured by the medical arm. The leprosy training
centre at Aska has also greatly contributed in bettering levels of
Its presence in Ganjam affords conknowledge among the medical arm.
to
information
and
enhances
interest.
stant recourse
'«•
I
Quest
xiv.
Further, the presence of voluntary organisations in these districts
(especially
in
Visakhapatnam and
Kanpur)
has
enhanced
the
infrastructure and their comparatively heightened levels of activity in
this area have contributed immensely to improving knowledge levels in
these districts.
By contrast, in Ganjam the voluntary organisation
plays no role in disseminating knowledge or training leprosy personnel.
The Daughters Charity merely distributes medication and provides mate
rial aid.
In comparative terms, the medical arm in Ganjam are not as
motivated as those in Visakhapatnam and do not bother to actively
impart knowledge about leprosy to the patients and their families.
Categorywise Knowledge Levels £ An Overview
While there have been certain common factors that have influenced the
levels of knowledge across the districts, it would be interesting to
assess the extent to which and the manner in which this has percolated
across the various respondent categories.
Medical Arm:
Obviously, the medical arm was the most highly informed
about leprosy and leprosy treatment.
They receive the information
directly and continuously from the Government (Health Ministry) or from
voluntary organisations, They are also highly involved in putting this
knowledge to practice and have learnt a lot more in this process,
However, even within the medical arm, there were variances in levels of
knowledge.
The MDT areas, for instance, revealed a more deeplyinformed medical arm when compared to the Monotherapy districts,
Visakhapatnam and Ganjam, therefore, had a team of doctors and
paramedical workers who were aware of the nuances of leprosy treatment
In the
and cure, and had regular access to new data in this field.
In
Monotherapy districts, in contrast, the medical arm were knowledgeable
but were not up-to-date on drug/treatment related information.
In Kanpur, which is a Monotherapy district, there was a difference
between the government team’s knowledge levels and those of the Damien
Institute (who administer MDT).
However, the presence of the MDT
regime and its effective results have prompted renewed interest among
However, it was interesting to note that it
the government team too.
was at the PMW level that this interest and desire for new information
The doctors tended to be more inflexible
was more strongly manifest,
about wanting to change, fearing this would reveal the lacuna in their
knowledge level and perhaps lead to loss of face or self image among
junior staff.
The PMWs, however,
however, were more enthusiastic and were
yearning to be exposed to more information about the new regime - to
them, this was the best way to render their function more effective, to
strengthen their hands, to basically 'get on with the job'. Across all
the 10 districts, we found that the medical students and practitioners
of homoeopathy and ayurveda were very poorly informed about leprosy.
!
Quest
XV .
__ Public:
Of all the respondent categories, the general public
General
was the least informed across all the districts, as they seem to have
Moreover, mass media has not
poor access to sources of information,
communicated messages relating 1to leprosy very effectively to this
segment.
However, WG noted that in the high knowledge districts, even the gene
more -----knowledgeable
than in the in other districts.
----- --ral public seemed
know
the
exact
scientific/medical
details, it was
they
may
not
While
note
that
at
least
they
sought
and
put
forward more
heartening to
scientific
and
health-related
explanations
and tended
pragmatic, more
----- ------- - .
to view the traditional beliefs and myths as unrealistic: and untrue.
facts
Most of them were still not fully conversant with thej medical
in
It
was
mostly
about leprosy but at least were open to new ideas,
to
increasingly
beginning
these districts that the lay public was
believe that leprosy is curable.
Opinion Leaders: This segment comprised teachers, journalists, village
elders and religious leaders. Among these, we found the journalists
most knowledgeable about leprosy as also about the new MDT regime and
The teachers and religious leaders
its advantages over Monotherapy.
displayed poor levels of knowledge and most often perpetrated ancient
misconceptions
about the disease and
the
prescribed
1
beliefs,
Some of the village heads were fairly well
interaction with patients,
informed wherever 1they had been harnessed by the PMWs to help with the
leprosy programme in their village.
Patients/Patients' Families: The patient's level of knowledge about
leprosy is directly proportionate to the inputs of the medical
In Visakhapatnam, the MDT
personnel he comes into contact with,
keeps
program, which is in full implementation, ensures that the PMW
patients and their families accurately informed - in fact, they see
this as part of their function, Thus, these patients saw their afflicresumption
tion in the right perspective and were hopeful of cure and i_
of normal life.
In Kanpur, the exposure of many patients to the information oriented
has led to a better grasp of
MDT program at the Damien Institute
Even
those
under
the
Government's
Monotherapy Program^came^into
facts. L —
contact with PMWs who, having heard of MDT at the Damien Institute,
Further, we cannot
were enthused to instil their patients with hope,
discount the fact that Kanpur is an urban centre and so, exposure to
media and sources of knowledge is greater.
This could affect the
patients/patient's family directly or be percolated to them via the
PMWs.
■’,iar
Quest
xvi.
However, in Ganjam, the scenario is quite different. We found that the
patients here displayed lower knowledge levels when compared to
Visakhapatnam and Kanpur.
The medical arm, however, is well informed
as they have been administering MDT for a while.
However, the factors
that seem to have impinged here are the attitudes and practices of the
medical arm.
The MDT program is being run by the government here, and
we discerned a difference in the attitudes of this medical arm when
compared to Kanpur and Visakhapatnam.
We shall discuss this in detail
in the Attitudes section. Suffice it to mention here that the patients
The
do not receive enough information from the medical functionaries,
voluntary organisation here - run by Mother Teresa - has not made any
impact in this direction either, as it is more involved with material
aid, rehabilitation and assisting the medicos, rather than any active
With regard to the patient’s family, it
dissemination of information.
is necessary to point out that in Kanpur and Visakhapatnam, the PMWs
took the trouble to keep them equally well-informed as the patients
themselves.
Medium Knowledge Districts
Those districts that we would classify as displaying medium levels
knowledge are Chandrapur, Periyar and Deogarh.
of
Common Features that Impinge on Overall Knowledge
___ :
The levels of urbanisation in this set of districts
Urbanisation
Within this
to
be
lower
than in the high knowledge districts.
tended
compared
to
Chandrapur
and
Deogarh
were
more
rural
when
'cluster’ ,
In
Deogarh
and
Chandrapur,
the
profile
of
the
populace
tended
Periyar.
to be mostly agrarian, with a few industrial workers in Chandrapur
(Deogarh was wholly agrarian) and so access to information sources was
limited to that extent.
The urbanisation levels in Uttarkashi and
Periyar were higher in comparison. Periyar registered the highest
levels of knowledge among these medium-level districts. While this can
be attributed to a number of other factors, we cannot overlook the fact
that this district, like Visakhapatnam, is increasingly becoming urba
nised and rural folk have begun seeking occupation as labourers in the
various dyeing mills or other small-scale industries that have sprung
The villagers find gainful employment here and
up in the rural areas,
their standard of life and earnings seem better than with agricultural
workers. We discerned an increase in the levels of education among the
younger generation in these households, more signs of modernity and
urban symbols like radios and other semidurables such as furniture and
other household appliances, etc.
Their new found awareness has led
them to constantly seek information on more topics.
>
Quest
xv ii.
Interestingly, during the interviews in this district,, we discerned a
and a
tendency among this populace to doubt traditional explanations
Also,
‘scientific’ lore.
need to replace these with more pragmatic,
helped
Erode
in
this
district
has
the presence of a large town like
speed the process of urbanisation.
Drug regime:
Interestingly, of the medium knowledge
xnowieuye
districts,
* i
Chandrapur
and Periyar, while they belong to the Monotherapy regime
L/'^and
have all
all just
administration of
of MDT.
MDT.
These drugs have gust
just begun
begun the
the administration
been introduced and their palpably remarkable success has been noticed
and,therefore,there is a heightened level of awareness of the treatment
but this has
and cure of leprosy.
Deogarh is wholly an MDT district hut
Respondents
in
these three
been in progress only for about a year.
districts were aware of the fact that this is a new drug re^
have witnessed its stepped-up activity when compared1 to Monotherapy.
Their interest has been aroused and, more importantly, there
nascent knowledge of more scientific facts about leprosy and the possibility of its cure.
Traditional knowledge still has a hold over this
populace, but there is a sense of ambivalence as to its veracity.
patients/patients' families were well-informed. The others i.e the lay
public, was either unaware or just beginning to hear about this drug
regime.
Even the medical arm in these districts, with the notable
exception of Periyar, were not highly knowledgeable about leprosy, We
have discussed this in detail in the section on categorywise differend--tiation in knowledge.
)
1,
__) adequately utilised in all
been
Media: By and large, the media has not
The
findings
indicate that, by and
...~ -these medium-knowledge districts. viz.
posters,
wall paintings that
large, it was the ‘static’ media, viz. posters,
_
_
1 .
Further, even
about leprosy,
were being used to disseminate knowledge
in
that
these
were
displayed
only
these media were being underutilised
As a result, only patients and sometimes,
at the LUCs, nowhere else,
exposed to these sources of information.
The
their families, were
effect of these cannot be assessed, however, as the patients we inter
viewed recalled these messages, sounded hopeful of a cure and were
emotionally reassured by the messages that advocated an attitude of
acceptance towards leprosy sufferers.
no
The lay public is largely unaffected by these messages5 and has
also
the
case
in
other source of information about leprosy.
This was a
therefore,
at
variance
Deogarh, which is an MDT district and this is,
with the other MDT districts like Visakhapatnam and Ganjam. The radio,
for
T.V., film are all media that do not seem to have been utilised
u
leprosy-related information.
1
------ aasr
Quest
xviii.
In Periyar, the film medium is used regularly by the Family Planning
Department and has created great levels of awareness and recall of the
FP message.
However, this has not been harnessed by the leprosy
personnel here. In Chandrapur, the Baba Amte Ashram is endeavouring to
spread the message verbally by delivering regular talks at local
schools, thereby clearing misconceptions among the younger generation.
Medical Infrastructure : These districts have a fairly well-represented
This infrastructure is
medical infrastructure in the area of leprosy,
not as intensive as in the high knowledge districts, in that it is not
well-represented in the entire district.
In Deogarh, there is a 20-bed government hospital mat
that is supposed to
be for leprosy patients.
However, we found that the reality is
different -- the
the functioning of this medical centre is not as imP^ss1^
who
as it sounds.
We heard stories of doctors and medical staff v..c
refused to touch patients or who took paying patients on priority.
There were voluntary organisations in addition to the government
leprosy arm in Doegarh and Periyar.
Deogarh has the Santhal Pahadiya
Seva Mandal and the Rajkumari Kusht Seva Ashram.
The former is ve^y
active in this area and is making a concerted effort to curb the
disease. However,
However, in terms of other related activities like dissemina
tion of information, they do not seem to have done too much.
Nor has
the government done anything in this direction.
Periyar
Periyar has
has the
the ASSISI,
ASSISI, a Christian missionary organisation that works
Other than hard
primarily amoncpthe tribals and also administers MDT.
,
nothing
is
specifically
done to
work at treatment and rehabilitation,
other
than
the
patients
and
their
disseminate knowledge to any one c
families.
%
Quest
xix.
Categorywise Knowledge Levels
Medical Arm
An Overview
The knowledge levels among this segment were the highest
nignest in
m Periyar.
This district has had the MDT regime introduced in the last year or so
by the government.
As a result, the entire medical arm has begun
undergoing training in this area, a drastic updating of knowledge on
leprosy and
and its
its cure.
cure.
This was clearly reflected in our interviews,
where most of the medical arm were able to talk knowledgeably about the
details of treatment and cure and of the MDT program as well. With the
beginning of this regime, the doctors as well as the paramedical staff
have begun to focus attention on the treatment of leprosy with greater
interest and are desirous of knowing all the details of this drug
regime, in order to attain success with their cases, Since only a few
had actually gained first-hand experience with MDT, overall knowledge
in this district was still not yet as high as in Visakhapatnam.
' 4 - has also begun MDT in a small way and this, again, has
Chandrapur
They were definiresulted in the medical arm being better informed,
old
beliefs
and
gearing
themselves
to be an MDT
tely moving away from (—---------district.
In Deogarh, however, knowledge levels were lower than in Periyar,
despite it being an MDT district. This could be attributed to the fact
that other than the voluntary organisation, the government medical arm
had nothing much to do with leprosy.
As a result, all the knowledge
and the activity in this field was confined to the Santhal Pahadiya
Seva Mandal and the government medical arm was not up-to-date on t is
disease.
General Public
)
By and-large, the level of knowledge pertaining to leprosy was
similar across these three districts.
fairly
The general public has not yet witnessed or heard about the impact of
the new drug regime and the resultant hope it has brought to patients.
Consequently, the old beliefs persist and the lay public are stlll J*0
aware that leprosy, like other diseases, is caused by a germ and has
nothing to do with one’s misdeeds or karma.
However, these districts
differed from the low knowledge ones in that the populace is beginning
to be ambivalent rather than rigid in their misconceptions about
leprosy.
They have begun to see some renewal of activity in this area
by the medical arm, have had stray exposure to media messages (a case
in point : the posters stuck on the marketplace and outside the LCU in
■ ‘ " system,
1
.
They
Periyar) and are beginning to review their ancient ■belief
attempt to put forward Reasons like poor- sanitation or contagion as
not accurate, are still
more likely causes of leprosy (which, though
1.
more 'scientific').
Quest
XX.
In Deogarh the knowledge levels plummet, as the people are not exposed
to any media, propaganda or activity in this field, despite the MDT
regime being in progress here,
We can include the category of opinion
leaders here, as they were equally misinformed about leprosy and
propogated the same myths.
Low Knowledge Districts
The districts that displayed poor levels of
Dangs, Tuensang, Alwar and Uttarkashi.
knowledge
overall
were
Common Features that Impinge on Overall Knowledge
Urbanisation : Interestingly, all these districts were marked by their
high tribal populace.
Levels of urbanisation were very low and all
were also fairly economically backward as a result.
It is hardly
surprising, therefore, that tribal customs, folklore, traditional
beliefs hold sway and exposure to modern thinking, to factual,
scientific information is low.
The traditional misconceptions about leprosy hold sway in these
districts and this is starkly reflected in their practices as well.
Drug regime:
All the four districts follow Monotherapy and have done
so for years.
The slow rate of treatment has disillusioned some
patients and led them to resort to traditional medicine, while others
are lackadaisical about their drug routine.
This has led to the perception among the populace that leprosy really has no cure.
Further,
Tuensang and Alwar are also low endemicity areas and thus the involveThis poor
ment with and the desire to know more about leprosy is low.
level of knowledge has, in turn, led to the most appalling practices
and customs being meted out to patients in these districts.
The Raphael Ryder Cheshire International Centre located at Dehradun
appears to have introduced the MDT drug regime.
The centre attracts
urban patients from Uttarkashi and other neighbouring districts,
However, this organisation, while it administers MDT,does not have any
interaction
with
the rest of the district (Uttarkashi)
where
Monotherapy is the main regime.
Media: The low level of urbanisation and the economic backwardness have
also led to poor exposure to media.
The audio or audio-visual media
are virtually unknown in these districts, while illiteracy renders the
printed medium redundant.
Moreover, even the medical arm here has not
utilised other information sources (talks, demonstration, etc.) to
propogate the right messages either. In Dangs, the government has made
a beginning in this direction - at the local fair, the Dangs Durbar,
they have begun displaying posters about this disease, talking about
it.
Interestingly, this had registered and was recalled by a few
respondents.
It has served to arouse curiosity at least among these
lew, even if it has not brought them away from their misconception and
superstition.
r
Quest
Medical infrastructure; In Dungs., there are uu iiCUo
or uTcs only a
number of SETs, while in Alwar there are some Family Health Centres and
the multipurpose here double up for leprosy.
The virtual absence of
medical activity in this field has resulted in poor levels of knowledge
even among the patients, who are normally best informed because of
their constant interaction with the medical arm.
Nor are there any
wi th their
voluntary organisations here that help step up interest with
supportive activity in this area.
In Tuensang, the medical infrastructure is such that the majority of
the patients are at the commune at Longleng and are treated with
Dapsone there - the concept of treatment at home is one that the
medical arm in Tuensang obviously does not subscribe to.
Categorywise Knowledge Levels
An Overview
Medical Arm
As in the other districts, the medical arm in the low-knowledge
districts was the best informed among all the respondent categories.
However, there was a difference between Alwar, Tuensang, Dangs and
Uttarkashi.
i
In Uttarkashi, the medical arm was best informed of these four districts and this, we feel, is because it is a hyperendemic area, As a
result, the doctors and PMWs here are treating more leprosy patients
regularly and their experience in this field is greater. However, since
they follow Monotherapy completely, they displayed poor awareness of
the details of treatment, They were not too sure about the best way to
handle drug resistance or contraindications, the kind of diet or
hygiene standards to be prescribed, etc. In this regard, we found that
in Dangs,the PMWs are poorly informed on all these aspects as they have
forgotten quite a bit of what they had learnt during their training
program years ago.
Thus, they tended to be unnecessarily strict and
advised patients against consumption of quite a range of foods,
believing them to be 'heating* and, therefore, likely to aggravate the
disease.
In Tuensang, Alwar and Dangs, the medical arm displayed abysmally low
knowledge levels - they saw themselves as mere dispensers of medicines
and were unmotivated to apply themselves beyond that in the treatment
Other than the doctors, the PMWs were unsure of the facts
and cure,
and this has been picked up by the patients who, consequently, lose
The doctors, too, knew all about Monotherapy but
faith in their PMWs.
had a limited supply f,f
not read
I <-<id of ik w advanc. s in this aie.i .Hid r.o,
I in ii 1I 1I i|i|>
lllll
di rprt1y
linn 'iiii
Hii.l 11 11 al III III
Hu -
mily
ill-I l h l
involved in leprosy work knew anything about it.
II. >ih< M . .p l I II • ,
in 1
IHu
li.
<• I .' .
V .1 I .1'. ,
li II. w
1 li f i > l med .
I
I
I.
/
1 I t I I *<
<1 II.I
I .
,
l.y
I ||l l‘H
The
ot her
.iimI
1.1 i
,
__
Quest
xxii.
General Public
If the medical arm is so inadequately informed, it is not surprising
that the lay public in Dangs, Tuensang and Uttarkashi is either igno
rant of any facts or hoplessly misinformed.
Local misconceptions,
superstitions and customs abound and the populace is really characte
rised by a low interest in this disease.
These people firmly believe
that leprosy is caused as a result of a divine curse for one's past
sins.
Interestingly, in Dangs, which is a hyperendemic area, some
people also tend to attribute this disease to more ’scientific’ causes,
such as the consumption of certain foods or drink (e.g.pork,alcohol) or
through air/water contamination.
The rural and the tribal
folk
believe strongly in karma or witchcraft practices as being the cause of
this dreaded disease.
The general public in these districts does not seem to recall any
messages relating to leprosy, is unaware that the government is
involved in this field and so continues to mystify and dread this
disease.
The so-called opinion leaders, viz. teachers, religious heads, village
heads,can be categorised with the lay public as far as their knowledge
of leprosy is concerned - they have the same misconceptions, reiterate
the same customs, with perhaps the exception of the Christian priests/
pastors in Tuensang, who, despite their poor knowledge, do not condone
the harsh customs.
Patients/Patients* Family
The patients and their families were a little more knowledgeable than
the lay public, to the extent that they understood the symptoms of
leprosy, its progress, the signs of cure, the extent of contagion, etc.
However, they were ambivalent about the cause and could not really
1
accept traditional beliefs as their own experience did not reiterate
They found, the medical arm - at least the PMWs whom they come
these,
in contact with - unable to provide satisfactory explanations and were,
therefore, curious to learn the truth. Their common complaint is that
the lay public refuses to accept any sensible explanation and due? to
Patients'
this lack of knowledge, ostracises and harrasses patients.
are
also
open
to
more
scientific
explanations
as
they are
families
the
patients
and
the
medical
arm,
but
in
the
absence
of any
close to
convincing explanations, tend to revert to folklore.
Quest
xxiii.
2.
ATTITUDES 1 DISTRICT PROFILE
When discussing attitudes across the districts, we have categorised
them as Hopeful (i.e. those with a more positive and open attitude to
leprosy). Ambivalent and Negative districts.
Hopeful Districts
They were
These districts were Kanpur, Visakhapatnam and Ganjam.
characterised by their overall attitude of hope and an attempt at
positive, forward thinking rather than easy acceptance of traditional
misconceptions.
This does not, however, mean that the populace in
these districts displays a greatly positive and the 'right* attitude
than
-rather, they are more open and willing to be positive rather t
wholly negative and closed.
Our findings reveal that the factors that have brought about this
attitude were those that affected knowledge levels too.
We have
discussed these factors and their influence on attitudes in the section
below.
Common Influencing Factors
_____ : It cannot be denied that a more urban populace is more
Urbanisation
open and positive in its attitudes than those in rural or semi-urban
areas.
Kanpur is a case in point : in terms of knowledge, it is not as high as
Visakhapatnam but in attitude terms, it excels, simply because of its
urbanisation. This is a mini metro and displays urban values which are
education, industrialisation and exposure to
a result of increased
Consequently, antagonism towards a sect is publicly frowmass media,
ned on and, overtly at least, one learns an attitude of acceptance of
The
differences, tolerance and learns to display humanitarianism.
'black and white* attitude of the rural areas is not prevalent here
and, at least for social acceptance,, one learns to mouth humanitariaThis
nism and a social spirit.
*...^~ has
-- resulted in a more pragmatic and
The
enlightened attitude to health and the treatment of diseases.
>
more
scientific basis of any disease and its successful treatment is
211^acceptable. Furthermore,
readily
1--------- traditional health care has given way
to a greater reliance on scientific medi-care. Thus, overall, people in
Kanpur were more hopeful about leprosy being cured and were desirous of
doing their
They believed medical
their bit not to ostracise patients.
science, by
its
activity
in
this
area,
has
created
the feeling that
by
everyone can
can do his bit to reduce the suffering of patients - material
help is the first (and easiest) to be offered, while a few were convin
However
ced they also needed to render moral and emotional support.
However,,
the
innate
fear
this does not encompass more than verbal gestures, as
the
medical
of contagion still lingers as people are unsure about
facts pertaining to this disease.
►
Quest
xxiv.
►
In Visakhapatnam, where knowledge levels are better, the overall atti
tudes are not as good as in Kanpur, as the rural component is greater,
Their low level of exposure to urban thinking has led to the same
traditional beliefs and misconceptions being handed down even today.
The more urban areas in Visakhapatnam or those with increasing urban
People here
facilities have led to a growing change in attitudes,
display the hope that leprosy will be cured and tend to reject the
concept of karma, of divine curses as traditional and impractical,
Further, the
definitely not beliefs they are willing to subscribe to.
urban need for presenting the right social 'face’ leads them to discard
ideas of ostracism and accept patients if facts prove this to be the
right thing to do.
►
►
►
►
►
Ganjam is not as hopeful as those two districts, but this is also
because the urbanisation levels are lower here, However, the attitudes
here are good despite this, as a result of the MDT regime in progress
here, an aspect we shall deal with in the following section.
Drug regime: Visakhapatnam and Ganjam are wholly MDT districts while in
Kanpur, the MDT regime has only been introduced by the Damien
Institute.
The interesting factor of the MDT regime that we noticed is, that the
personnel trained in this program have learnt to lay great stress on
and take pains to mould
imparting knowledge, counselling, advising
In the Monotherapy districts, in contrast, the
attitudes as well,
perceive
medical
personnel are not as knowledgeable and also,
themselves as dispensers of treatment and discount the importance of
emotional/attitudinal guidance.
We know that in the area of leprosy,
the social stigma and the negative attitudes have been more deleterious
to progress than anything else.
The MDT-trained personnel in
Visakhapatnam and Ganjam have recognised this and are succeeding in
filling patients with great hope, an attitude that rubs off slowly on
other people as well.
Secondly, the dramatic results of MDT - when
compared to Dapsone - have had an equally important role in raising
hope in these districts and improving attitudes to this disease. The
promise of a cure acts as an impetus to be cured with minimum fuss and,
even to the lay public, acts as proof that the leprosy patient can be
treated like other disease-sufferers, i
i.e.
. e. as someone with a temporary
problem but with the hope of regaining normalcy soon.
In Kanpur, MDT is not the mass-scale regime
but, nevertheless, the
effective results it has produced have begun to be talked about and the
patients are open to revamping their attitudes and beginning to replace
fear and despair with hope and determination.
Media: This is perhaps the most important factor in influencing
people's attitudes to leprosy, Mass media communication of factual and
In the few cases
positive messages cannot fail to create an impact,
the
LCUs in these
where it has been done, one has witnessed results
Hopeful districts have utilised posters/wall paintings to communicate
the message of hope and this has changed the attitudes of its target
TMar,.-'
T
Quest
XXV .
audience, vi z. patients and, sometimes, their families who accompany
However, by and large, this very influencing factor
them to the LCUs.
The change in attitudes
has not been harnessed in these districts.
can, thus, be attributed to a great extent to levels of urbanisation
and to the yeoman service rendered by the medical arm in these
districts.
Medical infrastructure: The medical infrastructure in Visakhapatnam and
Ganjam is well organised and intensive.
The MDT regime has reached
everywhere and the heightened activity this regime demands has been
communicated to the people. The patients have definitely picked up this
achievement-oriented, hopeful attitude and the lay public has not been
slow to recognise the efforts by the medical arm, as also the results.
In Kanpur, the government infrastructure‘ follows Monotherapy and is not
the Damien Institute has
as intensive in terms of personnel. However,
Il
team
of
PMWs
who
fan
out everywhere with
an active presence here, a
The
government
,
however, has a good
their drugs, counselling, etc.
clinics,
physiotherapy
infrastructure in terms of facilities such as
etc.
where
leprosy
patients
are
regular
visitors,
clinics, hospitals,
patients
to
feel
they
are
being
well
handled
by an
This has led
to
system
and
so,
are
hopeful
of
cure
and
willing
efficient, modern
undergo treatment.
aisu a major contributing
of voluntary organisations is also
The presence oi
in
these
districts.
In
Visakhapatnam
their presence is most
these districts.
factor
(GREVALTES,
UNICEF,
GMLF)
and
most
people
are aware of the
UNICEF,
powerful
This
has fired the
efforts they are expending for leprosy patients.
The
patients
who come
government medical arm to try and match them.
praise
for
into contact with the voluntary organisations are full of
determined
their zeal and efforts and display a far more positive and
and
attitude.
The impression of a <dedicated,
-------- hard-working, determined
.
enthusiastic medical arm was strongest
among voluntary organisations
such as the GREVALTE and GMLF, who run model institutions there.
‘ ‘ » effects
The Damien Institute in Kanpur is of the same calibre and its
are
on patients are palpable, In Ganjam, the Missionaries of Charity
for their selfless and enthusiastic efforts at
i
noticed by most people
helping patients.
Cateqorywise Attitudinal Levels
While Kanpur, Visakhapatnam and Ganjam are overall Hopeful districts,
we found that this attitude did not exist in equal measure across the
respondent categories.
Medical arm: The medical arm in these districts was most positively
predisposed to working with leprosy patients, They were of the opinion
Since their knowledge of
that leprosy is just another area of work,
was also high, they had
the facts about leprosy and its transmission
'A.,-**'- -vstsmasr.
' % -1W.SMXK?'
••Li
*
Quest
xxvi.
few qualms about handling these patients.
However,
However, the medical arm
in the rural areas confessed that though they were themselves of this
attitude, other members of their profession who were not involved in
leprosy, tended to perceive not just the patients but the doctors and
PMVs as 'out castes’ of sorts.
In Kanpur, the medical arm engaged in the area of leprosy
have a
fairly no-nonsense attitude and are, as is typical in an urban
situation,
desirous of achieving successfully cured cases.
The
introduction of MDT and its palpable results have created greater
interest among the government doctors and they are pushing for this
drug regime for their patients as well.
In Visakhapatnam and Ganjam,
the medical arm have the aid of the MDT regime and are highly motivated
to work in this area, now that modern technology has brought in hope.
General public: The attitudes of the general public are the poorest
when compared to the other respondent categories.
They
They have not been
affected very much by the new strides taken in the cure of leprosy and
continue to view it with horror
horror and
and dread.
dread.
They
They have
have heard or seen
some glimmer of this hope and so are not rigid but willing to know more
and willing to accept a change in attitudes.
However,
However, as discussed
earlier, no efforts have been made to educate them or mould their
attitudes.
Opinion 1eaders: While the attitude of the lay public can be excused as
arising due to lack of knowledge, the attitude of the opinion leaders
is difficult to justify. These are people who are supposed to be more
knowledgeable, pragmatic, in a position to ring in change among the
masses.
However, we found that they were of the same level as the
masses, in that they condoned traditional beliefs and customs as the
only ones they were aware of. There were many instances of journalists
or teachers who, despite their education, could only offer pity and
charity rather than an attitude of acceptance and support towards
patients.
£
t
I
ft
In Visakhapatnam we found a few of the village heads were more positive
attitudinally, as they had been harnessed by the PMWs in detecting and
counselling patients in their villages.
They had, therefore, been
counselled in turn by the PMW and so
were positively predisposed and
willing to ‘educate’ the villagers.
Patients/Patients ’ family: The effect of the MDT and the attitudes of
the medical arm have had the most directly positive result on patients
and some of their families.
The patients in these three districts were characterised by their
hopefulness and determination to be cured. The palpable effects of MDT
have led them to envisage total cure and a quick return to normalcy.
►
Ji
Quest
xxvii.
Further,the role of the PMWs in these areas also cannot be underplayed;
they constantly check on the patients, ensure they have their medi
cines, counsel them and their families, offer advice or help in rehabi
litation and offer emotional encouragement. This constant prodding and
attention have led these patients to slowly move away from despair, to
work towards regaining their self-confidence and the determination to
overcome their situation.
AMBIVALENT DISTRICTS
The districts we have termed Ambivalent are Periyar and Deogarh.
Periyar is a Monotherapy district, hyperendemic, with the MDT being
gradually introduced.
Deogarh is also hyperendemic but follows MDT
wholly.
Common Influencing Factors
Urbanisation: Periyar is mainly agrarian but has begun the process of
urbanisation gradually.
To that extent these people are attitudinally
just that much more open than in the fairly rural Deogarh district.
The levels of education and the general standard of living also seemed
better in Periyar and this has led to a revamping of old attitudes and
a desire to be more pragmatic and sensible. But it is still between two
worlds in its attitudes and this is reflected in attitudes to leprsoy
as well - a reluctance to give up the old and the stirrings of
curiosity in the new.
Deogarh is not among the Negative districts,
mainly because of the MDT program in progress there and due to the
efforts of the voluntary organisation there - we have discussed this in
detail later.
However, it is otherwise a strongly rural area, where
attitudes are still harder to change.
This process has begun with the
new drug regime.
J
Drug regime:
The MDT program is fully in implementation in Deogarh.
The effective results of this drug regime and the efforts expended by
the PMVs in this regime have raised the hopes of the patients who come
into direct contact with them.
There is the beginning of hope now
among patients.
This feeling is only prevalent among the few who are
involved in the MDT regime - as discussed earlier, only the Santhal
Pahadiya Sena Mandal does this work and it has a limited reach.
In Periyar, the MDT program has just been introduced in parts and
so
the results are not yet fully known. As a result,most patients and the
medical arm are ambivalent; they are no longer fully frustrated as
there is the hope of a new drug.
Nor are they as hopeful as in Kanpur
oi Visakhapatnam since the effects of MDT have not yet been witnessed
in Periyar.
Quest
I
xxviii.
There have been very few efforts made to harness media to he±p
the message of hope further. Thus, these districts rely only on
the few posters put up at LCUs for any mass communication and change in
attitudes.
This has begun with the patients as only they are exposed
to these posters. However, they do not see these messages supported in
other mass media
and thus their stirrings of hope are not really
encouraged further.
Media:
The other sections of society (general public) do not receive any media
messages pertaining to leprosy and have not changed old attitudes. The
medical arm has begun receiving information through pamphlets, training
programs on MDT and have begun the slow process of change in attitudes.
Categorywise Differentiation
Medical Arm:
In Periyar, the MDT has been introduced in small phases
Thus the
and the actual results have not yet been fully experienced.
medical arm here is still ambivalent in its attitude - they are willing
to leave behind the frustration of their Monotherapy experience but
unsure of being too hopeful till MDT is fully in progress.
In Deogarh, the government has nothing to do with leprosy and the
Santhal
Pahadiya Seva Mandal, works alone in
voluntary organisation, L
—
this field under the MDT regime.
Their task is, therefore, uphill, as
they lack the
on-going
infrastructure
of the government and it is
the
and
commendable
that their attitudes are still highly hopeful
enthusiastic.
The government doctors were uninvolved and yet curious
about the steps being taken by the voluntary organisation.
Genejral public: The lay public in Periyar and Deogarh displayed a
negative attitude, not even ambivalence.
Very few effort has been
made to bring about a change in their attitudes, Therefore, they still
and perceive leprosy
believe in traditional folklore and superstition
The
patients as being doomed for life and outcastes of society.
opinion leaders here were of the same attitude.
J
i
I
■
■
___
families: The patients were more hopeful. In Deogarh
Patients/Patients'
the effect of MDT and the counselling and moral support offered by the
voluntary organisation have resulted in a slow but certain growing of
more positive feelings among patients.
Most were hesitant and wary of
being too hopeful, but eager to give it a try.
In Periyar, the patients who had come under the MDT program echoed this
attitude, while the others were either ignorant of this new hope or
else had begun to hear of it and paused in their despair, ready to be
gently prodded back to a more positive attitude.
F
b
Quest
xxix.
NEGATIVE DISTRICTS
These were Chandrapur, Uttarkashi, Dangs, Tuensang and Alwar.
the high
This attitude was brought about by common factors such as
sources,
and
tribal
content
in
these
districts,
the
poor
media
rural
voluntary
the inadequate medical infrastructure (and absence of
that
organisations except the Amte Ashram at Chandrapur) and the fact
Dapsone is the main drug regime here.
We have discussed these factors
in the knowledge area,
and here we have only highlighted the
differences among the various respondent categories in these districts.
Categorywise Differentiation
: Except in Tuensang and Alwar, the medical arm m the other
Medical arm
attitude.
three districts displayed a remarkably hopeful and positive had been
since they
They seemed fairly involved with their cases
about some
bringing
years
and
were
desirous
of
treating theft., for
change.
uoany aud
In Tuensang
and Alwar, the medical arm is uninvolved and frustrated by
years
of
an
apparently slow-working drug, the constant^shortage of diug
years <
They seem to have
supplies and the transportation problems they face.
been
developed a lackadaisical attitude to their patients and this has
are
picked up by the latter. The most basic norms of leprosy treatment
medical
a
palpable
feeling
that
these
i...
not maintained and there is
workers have given up.
General public: On the whole, the attitudes of the lay public were at
They have no involvement with leprosy
their worst in these districts,
and patients have not heard of any new thinking or scientific/medical
advances in this area. Thus, the'taboos, ostracism and rigid attitudes
Thus, t‘.._ 1-1most palpable here, making these patients’ lot a terrible one. The
were
rural/tribal/backward1 classes segments are high in these districts and
and illiteracy are still major barriers to any health
their poverty <
or
’
revamping
of attitudes.
Nowhere was this more apparent
education
Tuensang,
where
a
separate
colony
for patients exists at
than in
We could find only six patients outside Longling and that
Longling.
at
the
early, patch stage and so unknown to society.
too,
Social ostracism
ostracism of patients and their families is high m these
districts, as the
the lay public is driven by unfounded fears, superstition
and rigid adherence to custom. The attitude of tolerance or a willing
ness to learn
learn is lacking.
Most often, in these districts, this
attitude of
of the generarpublic
general public has had a deleterious effect on the
patient and
nHprpH thp
the mpdical
medical arm from making headway wi
and even hindered
their cases.
i
Quest
XXX .
)
Patients/Patients * families: The unfortunate aspect of these Negative
districts is
that even the patients (who come into contact with the
medical arm and pick up the right information and attitudes) display a
not too hopeful attitude.
In fact, they were characterised by their
attitudes of despair, hopelessness and resignation to their unhappy
lot.
They have undergone long periods of treatment with Dapsone with
little apparent improvement and even the few who have begun MDT in
Uttarkashi and Chandrapur have not yet witnessed any change (the drugs
have been introduced very recently). Thus, even though the medical arm
in these districts (except Tuensang and Alwar) is hopeful, this
attitude has not percolated to the patients.
The other reason for
dejection
is
the
extremely
negative
attitude
of society here
their
cases OL severe social ostracism are rampant and this has served to
The latter,
dampen i ne hopes of patients and even their families.
ratiici. .nun jcxii3 supportive, came under the social pressure and rejecUnlike the
ted the patients, thus deepening zheir negative attitude.
other disci lets, xu thvie Negative districts, fewci uatients lived with
their families.
T
Quest
3.
MEDIA
‘
j
about
The media plays a considerable role in disseminating knowledge
leprosy. While a qualitative study can at best provide an insight into
people’s relationship with the various media, it cannot provide a
comprehensive or accurate assessment of the reach or effectiveness of
in this section
each mass communication medium. Hence the observations
—--people's
perceptions
and
the
must
be viewed as indicative of
>
a
definitive
understanding
of
researcher's observations rather than as
effectiveness
of
the
various
media.
’media habits and c----- -
It was observed across the districts that the audio-visual and other
to have a better reach in
media such as posters, pamphlets, etc. appear
urban areas than in rural areas.
village
- this
requires no norms of Iteracy on the part of the audience and n
investment or cost either. Further, we noticed that to most
the messages received with the participation/ sanction of their own
village heads/elders are viewed as gospel.
We have discussed
perceptions of respondents of the various media sources av^iiable.
Soing so, we have found it pertinent to comment specifically on rural
vs urban audiences.
Radio
the radio/transistor is almost
In both the rural and urban scenarios
of 'noises’
ubiquitous.
Most homes own one and it blares a variety
else
’
s home or in
through the day.
Or else, it is blaring in someone (- The radio
other public places for the: benefit of the neighbourhood.
of background to daily routine.
forms a sort c
Both rural and urban respondents mentioned that they heard] a variety of
health-education programs on the radio and these have, obviously, been
of some use, as respondents were able to recall many, However, it was
interesting to note that although the radio is currently not being
utilised for leprosy messages, many people who had registered some
stray messages (either through hearsay or through doctors), professed
to having heard these on the radio.
"I heard that one must treat
—i be cured these
leprosy patients with understanding and that leprosy- can
know
they
have all these
days ... I think I heard it on the radio, you
.
health programs, innoculation and family planning and all
,
=
...W to which
‘ ’ 'i
the radio is
radio
This quote sums up the extent
entrenched in people's perceptions as the
1— doctor
---- ’s/government’s welfare
'tool'; thus, any health related message must, to their minds, have
come from the radio.
Quest
xxxii.
The rurally backward areas as in districts like Dangs, Alwar, Tuensang
and even Deograh, to some extent, do not seem to have this easy access
to the radio. In fact, they have no access to most media forms and are
far removed from mass communication.
While the radio can be used for
leprosy messages, due to its wide audience, there is also the drawback
of the health message ‘clutter’ on this medium now.
Further, the need
of the hour is a bold impactive foray in moulding attitudes to leprosy
and the radio lacks the ability to make a strong impact.
Cinema
The cinema is more an urban medium than rural, simply because of the
logistics involved in regular screening (theatre, equipment costs).
The
However, rural audiences are exposed to the travelling cinema.
rural
to
has
been
screening
health
education
films
government
audiences, often with a bonus feature film as an incentive.
The impact
impact of this larger than life audio-visual medium is obviously
very powerful. Urban respondents, who have easy access to cinema, were
able to recount the various health education documentaries they have
The few
seen on the screen - most spoke of family planning films,
education
respondents
who had remembered seeing
health
rural
documentaries, also remembered the family planning film.
~
this medium is not being utilised for leprosy, but we feel
Currently,
this should be remedied, as it has a powerful impact on audiences.
Television
This is even more wholly an urban phenomenon and rarely, if ever,
reaches the rural audiences.
Respondents seem to recall many health
related messages from this medium as well and it is obviously the most
Like the radio, people are so
impactive in the urban situation,
addicted to, and conditioned by, TV that we also had some (urban)
us that they vaguely recalled seeing documentaries
respondents telling
1
on leprosy on TV - currently, no such documentaries are being screened
Respondents remembered the
on TV nor have they been for a while.
beamed
at
them by TV and some even
various social/'health messages
communication
on
leprosy
should
find a place in this
suggested that
They
believe
it
would
create
a
lasting
impression
if they were
medium,
to
regular
talk-shows
and
case
histories
on
leprosy
via this
exposed
audio
visual
medium.
powerful, in-home,
Posters/Wall paintings
This fairly ‘static’ medium is being extensively used by leprosyr worThe common
kers in both urban and rural situations. L-.
.
.practice currently
is to stick these on the walls of the LCUs or some clinics or hospitals
Thus, they are seen
run by the government/voluntary organisations.
- m
amitt..nr :
'‘.'.''i-v
Quest
xxxiii .
only by visitors to these places and these tend to be mostly the
leprosy patients and, sometimes, their family members who accompany
them. The posters have had some impact on patients specifically in
terms of creating the feeling that cure is at hand and that there is an
entire system that is geared to help them.
The drawback, however, is, that in the rural areas and among the urban
poor, illiteracy is rampant and,thus, the message in these posters/wall
2.
’
.
Mere visual depiction conveys nothing, as
paintings is lost
to them.
this is an area of some complexity and requires explanation.
Pamphlets
mostly those in the MDT
It is only the medical arm, and that too
program , who receive pamphlets with information on leprosy. This forms
partt of their training process and they have a constant supply of
printed information that explains the details and complexities of the
MDT program.
/ • • was; that the PMWs rarely gain access to
However, the common complaint
and
they
have to rely on the medical officers for most
this medium and 1
The
doctors/medical
officers, it is believed, rarely hand
information.
to
the
PMVs,
who are always eager for formal
£--- 1
out these pamphlets
training of any sort.
Pamphlets are not handed out to patients or the lay public: and are
In any case, most of the audience that
treated as medical literature,
medical
arm
reach
out
to
is
illiterate and pamphlets are, there
the
f ore, of no use to them.
“ ■ Ministry
The government medical arm receives these pamphlets from the
to
printed
material
of Health while voluntary organisations have access 1
on the subject from a variety of sources.
Folk Theatre/Plays
The folk theatre is used regularly in villages to convey religious or
In the urban areas, play's
plays with social messages are
social messages,
also common.
In
the rural set-up, this is a very effective medium for various
reasons.
Firstly,
thisthis
is is
an ancient
Firstly,
an <-- art form and villagers look
forward to education through these plays - the symbols used1 are interpreted with ease and are familiar and, therefore,
t------ - communicate messages
Secondly, the villager's illiteracy is no barrier to
successfully.
Thirdly, folk theatre is a big
receiving education via this medium.
event in villages and, since they are normally combined with a fair or
event, command a large and varied audience.
a festival or a religious
i
This form has
communication.
not at all been utilised so
far
for
leprosy-related
Quesl ;
SUMMARY OF MAIN FINDINGS
At the outset, it should be pointed out that this KAP was a qualitative
one.
Thus, while it was ideally suited for exploring the ranne of atti
tudes and examining the various patterns of behaviour, it was not geared to
making projections on factors such as knowledge levels and the extent of
prevalence of various behavioural patterns.
However, such a qualitative
KAP is much more insightful.
This is of particular relevance when one of
the major objectives of the research was to aid in the development of a
communication program.
In the course of a qualitative research study, the
researcher is exposed to the manner in which respondents express themselves
about the causes and treatment of the disease.
Consequently, the resear
cher is in a better position to recommend communication strategies that are
more in consonance with the beliefs and modes of expression used by the
respondents.
It also assists in identifying local terminology which makes
communication both more comprehensible and more credible.
In this section, we shall endeavour to answer the various
’ ich the research addressed itself.
questions
1.
the
I_s the level of knowledge about leprosy similar across
and the various respondent categories?
to
districts
Knowledge levels varied sharply across the ten districts,
Based on
their knowledge levels, we could classify them into three categories,
viz. High, Medium and Low Knowledge districts.
The High Knowledge districts were Kanpur, Visakhapatnam and Ganjam, the
Medium Knowledge districts were Chandrapur, Periyar and Deogarh, while
Uttarkashi, Alwar, Tuensang and Dangs comprised the Low Knowledge
districts.
The difference in knowledge in these districts was mainly the result of
factors such as urbanisation, exposure to media, the drug regime and
the medical infrastructure.
Thus, we found that the more urbanised
districts featured among the High and Medium categories, while dis
tricts with a high tribal/rural content tended to display a dip in
levels of knowledge about leprosy.
Misconceptions and lack of under
standing or information about this disease characterised the districts
with low levels of urbanisation.
Media presence and pressure does affect knowledge levels.
It was not
surprising to note, therefore, that the Medium and Low Knowledge dis
tricts had lower or negligible exposure to mass media communication.
The drug regime in a district, i.e. whether it is MDT or Monotherapy,
did have a strong role to play in influencing knowledge levels.
Thus,
High and Medium Knowledge districts were either totally or partially
under the MDT program, while Low Knowledge districts were the Monothe
rapy areas.
The MDT program seems to have a built in information
dissemination component and this has apparently paid off, in contrast
to the mere drug-dispensing culture of the Monotherapy program.
Quest
2.
all the efficacy of the drug regime nor the support systems of an
urban situation can, however, make much of an impact without an ef
<. f icient medical infrastructure. Thus, in the districts where the medical
arm is poorly represented or lacks the support of a voluntary organisa
tion, we found that the knowledge levels dipped - this, in some cases,
despite a fully ongoing MDT program.
not
In the 'District Profile* section of the Main Report, we have commented
on the differences in levels of knowledge across the districts.
Among the respondent categories too, the level of knowledge pertaining
The medical arm (MOs, PMWs, NHSs) was
to the disease varied sharply.
the best informed in all the districts except Tuensang and Alwar.
However, medical students, practitioners of ayruveda and homoeopathy
Medical students felt that
were grossly under informed about leprosy,
study
of
leprosy
did
not
merit
and
was
not
given adequate emphasis
the j
While
the
Vaids
recognised
the disease and were
in their curriculum.
able to prescribe a course of treatment, the practices followed by them
suggested that they reinforced some of the common misconceptions about
leprosy, e.g.
e.g. leprosy was a result of impurities in the blood and that
its cure required dietary control, etc. The Homoeopaths, on the othei
hand, clearly acknowledged that their science was not equipped to deal
with this disease.
As the medical arm is in frequent contact with the patients and their
families, these two categories of respondents tended to be better
informed than other 'publics' interviewed.
The traditional beliefs
j
and
transmission
of
the
disease
seem
to have given
concerning the cause <— ---------...
scientific
approach
communicated
by
the
medical arm.
way to the modern, Svachva*.
However, the interaction between the PMW and the patient/family concentrates more on the treatment and the cure than on the causes of the
disease.
This lack of knowledge about the causes of the disease
about the ultimate curability of the disease
results in some scepticism
j
and about the patients ability to live together with his family without
infecting them.
The findings suggest that there is very little difference ini the low
disease
between
levels of knowledge
of the various facets of thej d*
--opinion leaders (village headmen, teachers, ;journalists, etc.) and the
general public, These are also the categories where all the misconcep
tions about the causes and the transmission of the disease abound,
Consequently, they displayed a high level of dread and abhorrence of
In fact, they considered ostracism as a normal and natuthe disease,
■
■’
,
Among members of the
ral action to stop the spread; of the
disease,
it
was
clear
that
the
levels
ofliteracy
and urbanisageneral public,
—---- --- —
tion had an impact on the level of knowledge.
The more literate and
urbanised segment of the general public tended to be better informed,
as did
did literate
literate males
males and adolescent boys (who tended to attend school
longer than
girls)
The
than girls) about the various aspects of the disease.
higher level of knowledge among the literate and the urban public could
also be attributed to their wider exposure to media.
i'SMfi, "-flr
Quest
3.
2.
Hha.t are some, of the most common misconceptions about leprosy?
The cause/transmission
The cause and the transmission of the disease are shrouded in mystery.
Outside the members of the medical arm (MOs, PMWs, NIISs), there was a
fairly high level of ignorance about the causes and the transmission of
leprosy.
There were the traditional beliefs that suggested that
leprosy was hereditary or that it was a blood disease or that it was an
act of retribution of the Gods.
Then there were the quasi-scientific
mis-conceptions which related the disease to poor levels of hygiene and
to some bacteria and where the transmission was believed to be caused
by contact. Further, respondents were unaware of the fact that leprosy
could only be contracted from the infectious, multibacillary type of
leprosy patient.
In fact, the common misconception was that patients
with wounds, ulcers and deformities were the most infectious,
It was
not common knowledge that leprosy was an airborne disease; i t was
perceived as a disease which was transmitted through blood (genetic),
sputum, sexual contact and ingestion of contaminated food,
Thus, it
was believed that close physical or social contact with a leprosy
patient would result in the transmission of the disease,
As a conse
quence, segregation of the patient was perceived to be a necessary
precaution to restrict the spread of the disease.
There is also the
belief that men are more prone to contract leprosy than women.
This
misconception is borne out of the misconceptions about the cause of the
disease - that it is contracted through sexual transgressions and that
it is a blood disease. ' Since men are believed to be the greater
transgressors, it is believed that men are more prone to this disease.
The symptoms/progression of the disease
knowledge levels pertaining to the symptoms and the progression of the
disease were higher than the knowledge of the cause and transmission of
the disease.
Respondents were able to chart the progression of the
disease and specify distinctive symptoms that characterised
the
disease.
An anaesthetic patch was commonly associated with the onset
of leprosy but, in people's classification, it signified an early
'dry',
'raw' stage which was entirely curable and not contagious, The
major misconception pertaining to the progression of the disease
related to the association of deformities, ulcers and the leonine face
with the penultimate stage of the disease - "rotting -and wasting away".
These symptoms were not viewed (as they really area) as a results of
the patient's negligence but regarded as a symptom of the later stage
of the disease.
It is pertinent to note that patients often confused the side-effects
of the drugs with the symptoms of the disease.
For instance, dizzi
ness, feverish feeling, debility, etc. were perceived to be manifesta
tions of the disease rather than side-effects of the drugs.
Quesl ;
4.
Curability ajlA treatment
There ifl widespread awareness of the claim that leprosy is now curable,
In the MDT districts, this claim is felt to be credible because of the
Moreover, the
cures that have been effected through MDT treatment.
In
the
medical arm also reinforces this feeling of hope.
Monotherapy
areas, on the other hand,
nana, the message of curability lacks convictio
••
primarily because of the long duration
ofi the treatment and the ansence
People,
in fact, continue to assoof any tangible proof of the cure.
T
ciate the deformed patient with an active infection.
3.
Do attitudes to lepxosy. vary?.
Across districts
■'
•
— 3 the
As with knowledge levels; the attitudes that were manifest ^c^ss
had
Hopeful/
Ambivalent
and
Negative
districts also varied.
Thus, we 1
districts .
The Hopeful districts (Kanpur, Visakhapatnam and Ganjam) were marked by
an open attitude, a willingness to replace old beliefs with piagmati
The Ambivalent' districts (Periyar, Deogarh), as the very
and hope.
were still unsure, still holding on to their traditional
name suggests,
T,,cy vel° l".’"
beliefs but more as a habit than out of conviction.
desired
to
bring
more
pragmatism
to
bear
on
their atti
certain and
Negative
districts
were
most
prejudiced
towards
patients
The
tudes.
Further,
these
districts
were
charac
and the levels of hope were low.
an
attitudinal
'blinker'
to any
terised by their rigid, close attitude,
mention of this disease.
Across respondent categories
families, to some extent, were always comparatively negative.
>
The lay public/opinion leaders were the worst actually, as they were
poorly informed and harboured/perpetrated the misconceptions ost acrsm
etc
It is here that attitudes need to be revamped if the IlbEP is to
make headway, as their negative attitudes are imposed on patients and
)
patients' families.
,
•’ i the lay
than
The patients' families are attitudinally more positive Unfortunately,
U..
public, mainly due to the efforts of the medical arm.
? not allowed
they
are
most
often
pressurised
by
society
and
are
however,
Due
brought to bear by
1™ to_ the
--- pressure
.
to s trengthen this attitude.
patients
the general public, families sometimes have to ostracise the 1
to pathetic lengths to hide the fact of the affliction.
or go
□
>
■
ra
Quest i
5.
Those
The attitudes of the medical arm to leprosy were not uniform.
involved in the treatment of leprosy displayed a matter-of-fact atti
tude t<> I he disease.
Those in MDT disliicts, in particular, wore moi. <•
enthusiastic and tended to communicate this enthusiasm to patients and
patients’ families.
Among the senior officials, the attitudes varied
botweon
those
working for voluntary orpani aa
(vho
were
highly
motivated) and those working for the Government (who saw themselves in
a dead-end job). Homoeopaths, Vaids and medical students admitted that
they did not know much about the diseasee and had not come into contact
with leprosy patients.
They perceived the job of a specialist in
leprosy as one of low status and, in general, tended to display low
involvement in the disease.
Basic attitudes to leprosy
The basic attitudes, common to all categories of respondents, are ones
of fear of the disease, of social ostracism, of charity and, finally,
one of indifference.
As people are not aware of the manner in which leprosy is caused/
transmitted, the
the general public is fearful of contracting the disease
and tends to isolate and ostracise the leprosy patient.
There is a segment of society which feels that leprosy patients deserve
These people (who generally belong to the better educated
support.
segments of society) in most cases believe that they have done their
duty if they contribute to a charitable organisation working in the
field of leprosy.
The vast majority of the lay public displays an attitude of i n difference.
Most of them have not come into contact with leprosy
patients and, in any case, believe that it is for the Government to
Their ignorance of the causes of the disease and
tackle this disease.
their fears about it contribute to this feeling of indifference.
Overall, society’s attitudes is the most protective and supportive
By and large, they are not
towards children who contract leprosy.
isolated and an attempt is made to conceal the disease from the child
Society is also supportive of female
and from society at large.
patients because they are seen as economically unable to fend for
themselves.
Thus, they are only partially ostracised and are fed and
clothed by the family.
However, it is in case of the male patients
that ostracism comes*into full play.
It is believed that they are
capable of looking after themselves and it is considered a part of the
social obligation of the patient that he moves away from..his
. family.
Quest
6.
4.
■0
-5
'0
What
are Uie. factors that influence
of leprosy?
pa lion 15 * attitudes to the t f e aIr
The existence of the medical infrastructure in the community f or the
t realment of various diseases has itself been a considerable force in
"
. Moreover,
promoting a favourable attitude to the treatment of' leprosy.
who carry out regular sur^liys, keep in touch
the efforts of the PlIWs,
also contribute
provide them with hope and solace,
with patients,
positive
attitude
'on
the
part
of
patients.
significantly to a ]
Another factor that influences a patients’ attitude to treatment is the
Whore the
extent of support that the family provides to the patient,
obliged
‘,
the patient feels
to
family does not ostracise the patient,
not infect anyone else and hope to
follow the course of treatment,
However,
an air of fatalism peivades
regain his place in the family,
cases
where
the
patient
is
ostracised
by his family and his
those cases where 1
towards
treatment
is
frequently
not
positive.
attitude
*3
state of
of the
the disease
disease also
also influences
influences the attitude to its
Finally,
the state
At
the
early
patch
stage,
the
patient is keen to treat the
treatment.
that
he
does
not
fall
prey
to
its
later manifestations and
disease so
At
a
later
stage,
he
is
branded
as a leper and he is, to
deformities.
the
resigned
to
his
fate
and
not
so
enthusiastic about
some extent,
course of treatment.
5.
'"3
2
WhaJL 3X11 ilie factors that deter patients from seeking
with medical help?
or
continuing
abhorrence that leprosy engenders is so great
Ostracism: The fear and
he tends to blank it out.
that when a person knows he has leprosy,
results in his shying away from taking medication ini an at tempt
This
’
•
This practice is actually
to come to terms with his affliction.
not
social
ostracism
and
rejection that almost all
rooted in the fear of
of
seeking
medical help involves
Further,
the process
patients face.
reveal
one's affliction
having to go toi a 'public’ location and, thus,
society.
Most leprosy
leprosy treat-ment
treat-ment centres
centres are
are located in the skin
Most
to
clinics/departments and this further embarrasses
diseases and VD clinics/denartments
r
Even in MDT districts,
the patients go to a centralised
patients.
collection point and are checked by a visiting squad who are identified
Some
patients are fearful of being so) publicly
as leprosy workers.
J
associated with this disease and hesitate to collect medicines or visit
these centres.
Side effects: The
The drugs
drugs administered often have palpably uncomfortable
^Tde effects.
This
is particularly true with regard to HOT,
where
effects.
reddening of the skin,
weakness, nausea, giddiness, excess body hea ,
These cause too much discomfort or else scare off the
etc. are common.
refuses to continue with the drugs.
This
reluc
patient and he
sometimes occur despite being forewarned by the
t a n c e to thereapy can
At this stage,
it is
personnel
about
possible side effects..
medical
important for the patient to be motivated
i-------- and prodded constantly by the
this
reluctance.
medical personnel to overcome
Ques
7.
LdlUglh. 2.f treatment : The Dapsone drug regime for leprosy is a lengthy,
tedious one that stretches over months,
with slow or little a p p a r e n t
improvement in the physical condition.
This is one factor that very
often demotivates patients and causes them to discontinue treatment or
become irregular in following the regime.
In most cases, the rural patient has to travel out of
Time and. ef fort:
his village to collect the drugs, meet the PMW or NMS for checking,
The time, the physical effort (this is exacerbated in
monitoring etc.
the case of patients who are weakened by the drugs) and, of course, the
expense involved in this travel tends to lead patients to become irreOften,
in the MDT districts, the PMW or NMS notices this drop
gu1ar .
in order to remotivate him.
In
out and visits the patient at home,
the PMW takes the trouble to
some districts, Visakhapatnam notably,
continue visiting the patient and dispensing drugs.
Quest8.
R q c om in o n cl a t i. o n s.
1.
Ehat are
publics?
the.
Fnajor
messages that need to
be
commanicated
to
all
Whether the communication is aimed at the lay public or the patients or
even the rMW/NMS cadre, it seems to be critical that some messages are
beamed at all of them, as these are nebulous areas with most.
Firstly, it
i t is important to clear firmly and conclusively the miscon
ceptions and apprehensions regarding the cause/transmission of leprosy.
Except for the medical arm, the fact of mycobacterium lepare causing
the disease is unknown.
With regard to the transmission, however, the
misconception regarding heredity seems to prevail even among some of
the HlWs. There is a strongly held belief that leprosy is a 'blood'
disease.
This belief tends to reinforce the view that the disease is
hereditary.
It is necessary to communicate the fact that leprosy is a
skin or a nerve disease.
The 'location' of the disease in the correct
perceptive would assist in countering the notion that it can be spread
across generations in the same family. The communication task here is
to ffirmly
irmly disassociate leprosy from 'blood' diseases and thus remove
the fear of hereditary factors.
Rather, it should be understood
clearly to be a disease that affects the nerves and the skin.
Only
then will leprosy be viewed as just another disease and not a scourge
or blight.
Secondly, with regard to the cure of leprosy, so far the communication
has not been definite in its tone. It needs to convey that leprosy can
be cured and is a disease well within the purview of medical science.
So far, except for the medical functionaries, the others are still
ambivalent about whether leprosy can be fully cured.
Thirdly, with regard to the symptoms and progression of the disease, it
appears that most people - other than the medical arm - harbour the
overwhelming opinion that leprosy is almost invariably associated with
Currently, the medical arm uses terminology to desciibe
(1 i sf i (|in emriit .
I II'1 |' ll ' Il hl HI" 'll
I ||H
il i liieiiin (p g
|Iili'iliilil
ilihli in) uh
i i h Ikml'i
uliilii IInii il< I I III1 11
llhirli
fmm I ho dnfnrmities
stage.
II is important that the communication
s t age.
< »I• i I i I I :. «• - i
<ni
thin i nd
>iin
«■ I .i •; n I I i < • .i I i < m
.i nd
i <• i n I < • i < • • ••
ml i (pun
i|'*murn
this de linking, which would result in the early stage of tin? disease
being viewed with much less abhorrence and fear. Also, this de 1 inti mi
is likely to result in a more positive attitude to taking the treatment
and prevent ostracism of the patient.
Fourthly, there has been a belief - still held even by some members of
It is import he medical arm - that leprosy spreads through contact.
tan t that the communication combats this misconception by advocating
the 'right' practices, e.g. treatment of the patient at home, lack of
isolation, etc.
Quesl
9.
vzhich lead — tn
The communication should also stress that deformities
mon t of the abhorrence and ostracism - are not infectious but are ' the
In fact,
burnt out remnants/scars of a disease that once did exist.
could
draw
an
analogy
with
small
pox,
where
pox
marks
remain
long
one
fter
the
patient
has
been
cured.
a
At present, to the general public, oozing ulcers and pus; are sure signs
of leprosy.
It is vital to educate the general public and other sec
tions of
of ”society that these ulcers have inothing
----- to do with the disease
but
are. a result of negligence on 1part on the patient who, because o f
.
.....
anaesthesia, is unable to prevent injury to himself.
Overall, to sum up, the accent should be on steadily
developing an
s
hope-providing
scientific,
cohesive
alternative,
modern,
and
'mythology* to replace traditional mythology about leprosy.
Thus, the
focus of the communication should be on demystifying the disease and
positioning it squarely where it belongs among other infectious
diseases.
One of the ways of doing this would be by using analogies
with other major diseases that have, due to medical help, lost their
dreaded aspect today, such
such, as small pox, tuberculosis, cholera, etc.
Another way to
■_j 'demystify* the disease is through t:
t? e medical aim.
arm. The
PI1W is already doing a good job of informing the patients and their
families.
However,
However, it is important that the PMW understands both the
physiological and
The
and social implications of the disease better.
research findings
suggest
that
the
educational
material
used
by
volun
findings suggest
tary orgnisations is more effective in training and motivating leprosy
workers.
It is imperative that workers in the Government sector also
have access to similar information and training, so that in then
survey work as well as in the treatment of patients, they can communi
cate more effectively with patients, patients* families and the lay
public.
Finally, it is important that the infrastructure for leprosy
not be separate or be linked with sexually-transmitted diseases.
The
current infrastructure not only embarrasses the patients and makes them
less willing to take treatment but also 'locates* the disease wrongly.
Leprosy is an infectious disease like many others and it is important
that it is not seen as a blight.
)
)
)
)
)
>
)
)
)
)
)
>
>
>
>
>
>
k
- • •
? and trained
It may be argued that a separate medical .infrastructure
a
more
focussed
and
effective
dispersonnel for leprosy would ensure
funds
and
reflect
a
more
concerted
bursement of expensive medication,
effort on the part of the Government to control and eradicate the
However, at the same time, the segregation of leprosy treatdisease.
and
infrastructure
from the Public Health infrastucture has, to
ment
extent,
underscored
the fact that leprosy is the 'untouchable
some
issues.
and
must
be
handled
apart from other health issues.
Leprosy
disease
are
aware
of
their
patients receivingj medication at leprosy centres
so
dreaded
that
it
'outcast’ status land believe that their disease is
public health
health centre or hospital,
cannot bo treated at a common public
leprosy
workers believe that they are
the
medical
arm,
Similarly, in
Quest'
10.
the
outcasts within their profession and not accorded the same respect as public health workers, We believe that segregation of leprosy
treatment has, to some extent, reinforced current attitudes to the
disease and enhanced its 'dreaded’,, 'to be kept apart’ status vis-a-vis
other diseases.
2.
—ith. regard to. mass media communication,
segments that need to be addressed?
what are the various
target
The general public and the opinion leaders are two segments where
misconceptions abound.
Their lack of knowledge about leprosy and the
resultant ]negative attitudes cause the social stigma that is; attached
to leprosy patients.
_____________
1
-- It creates a negative
social climate
which
prevents the effective rehabilitation of leprosy patients and demotivates
patients from availing of the medication.
In the general public category, the males (both adult and adolescent)
appear to
1 be more exposed to the various media and could become important initiators of a change in attitudes towards; leprosy
They are
also likely to disseminate knowledge within the family and, hence, the
communication strategy must address its efforts to this segment of the
general public.
Opinion leaders,' such as village
elders teachers
'XAAuyk, tlUCLO,
LCdk-llCL
and journalists, can
play a major role in influencing attitudes withina the social community,
This influential segment must be harnessed via the communication
efforts.
Upto now, the
1’ program of imparting knowledge and changing attitudes has
concentrated on the PMWs
PHWSkk
The program
has not exploited the full
potential of the traditional schools of medicine (ayurveda, unani)
, which have significant 'reach' in rural areas.
i
3.
What is
regard?
the
inode of communication that would
be
suitable
in
this
The communication, in order to be most effective.
should be simple,
easy to understand and beam a limited (but critical) list of
messages.
The intention should to erode the most debilitating beliefs and not to
be a treatise of facts. rThe
” message should be couched in metaphors and
analogies that are commonly used and have been discussed in'the
— ------------- j report.
While selecting the media, the reach/popularity of the media should be
orne in mind.
Thus', the radio and popular cinema are immediate
choices.
Folk theatre, we believe, has not been adequately utilised
and is a medium that has considerable reach in the rural scenario. The
other advantage with folk theatre is that it uses familiar analogies
and symbols and is easily understood by the rural populace.
Posters,
wall paintings and other outdoor media forms should have a ubiquitous
presence, but much in the manner in which the family planning program
places Wlth Slmple' e¥e~catching symbols and high visibility at public
Quesl
11.
Another mode of communication that should be activated is the segment
of opinion loaders.
This is a very credible and effective medium for
propaganda and should not be ignored as it currently appears to be.
4.
H11A1 3X2. Ilia, current need gaps in the functioning of the NLEP?
The need gaps in I*
the NLEP seemed‘ to bo specifically in two major a r e a s ,
firstly, with regard to the personnel implementing it and,/ secondly. in
relation to the facilities offered by this program.
The personnel : We found that the doctors and the medical officers, i. e.
the upper echelons of the medical arm, did not seem to face as many
problems as the lower level, i.e. the PMW or the NMS.
The PHW is the mainstay of the program and the problems he faces seem
to be demotivating him. These could be categorised under the following
aspects:
NLEP implementation : In order to motivate him and also to strengthen
his hands and increase his efficiency, it is necessary to keep him well
informed.
The common complaint was that PMWs do not receive enough by
way of training and ongoing education in this area.'" The PMWs desire to
remain in contact with the latest developments in this field, as they
are keen to be more efficient and to gain greater credibility among
their patients.
Thus, they need to be trained prior to entering the
field.
At present, many of them are just thrown into the field and
have to learn 'on the job’. • In this regard, the more 'seasoned' PMWs
also desired exposure to refresher training courses that revamped their
knowledge and practices. To that end, they also need to be supplied
with pamphlets, leaflets etc. that apprise them of the latest develop
ments in the area of leprosy. This not only enhances their information
base but also'creates the feeling that they are part of a well-planned,
active system, not merely backwoods functionaries.
The PMWs also expressed the desire that the NLEP training be extended
to include basic health care. Often the PMW becomes the 'doctor sahib’
in the patient's family and is expected to offer counsel on other minor
ailments such as diarrhoea, fever, etc. Lack of knowledge and training
in these areas erodes the PMW's credibility among his patients.
Career cycle: The PMW is involved with the NLEP but does have his fair
share of long-term career prospects.
He aspires to move upwards, as
well as gain in terms of financial and job-related promotions.
Thus,
a career plan is important; the PMW must be moved 'upward' with time
and the posting in 'hardship’ areas should be reduced. To him, this is
a career and must provide the perquisites that go with one.
Personal:
At the personal level too, the PMWs often complained that
the Government is slow in repaying expenses incurred on the job, provi
ding the support of basic facilities like housing, help with schools
for their children, etc. It is this willingness to ease their day-today problems that inspires loyalty in an otherwise difficult job.
Queslv
12.
: Tn the survey and detection, as also in the treatment of
female patients, the problem faced is that the medical arm lacks women
workers.
This poses a problem in rural areas as the male P!IW is
rejected by female patients. To overcome this problem, it is necessary
to have more women among the field
force.Further, the local people
--- ---could also be induced to participate in the work, e.g. the older women
m the village could help in detection
---- and
—I survey, as also in counselling. To avoid
a 'watchdog’ attitude, however, it would
-- --- giving rise to
wv «
wwuld
be iimportant to ensure that the public is induced to be supportive and
participative .
Regarding facilities for treatment, I*
‘ to move leprosy clinics
the need‘ is
away from those where sexually transmitted disease are treated,, so as
to reduce embarrassment and motivate patients to visit the clinic.
This does not mean, however, that the clinic/ department be publicly
earmarked as being for leprosy, as it defeats the very purpose.
Even
within these leprosy treatment centres, it would be desirable if
patch' stage patients could be treated separately from the more advan
ced cases - thereby, mitigating the horror for early patients, creating
the hope of cure and also further reinforcing the idea that leprosy
need not always be an abhorrent affliction.
|
-flS- -
------ -
SOCIAL ASPECTS OF LEPROSY
findings from rural maharashtra
Sponsored by the Damien Foundation
RAVI DUGGAL
AMAR JESANI
MANISHA GUPTE
SUMMARY
MARCH 1988
4^ Foundation lor Research in Community Health
SUMMARY
OB’
FINDINGS
ICMR research
The present study began as an add on to an
focused on the NGO health sector in rural
which
project
to critically
The main objective of this project was
Maharashtra.
The
intervention from a comparative perspective,
evaluate NGO
establishing direct
opportunity that this major study offered in
rural population led to the
contact
with a representative rural population
'social aspects of leprosy',
Inclusion of a study to look into the
provide additional funds
The Damien Foundation willingly agreed to
to conduct the leprosy study.
* * * * * * *
unique feature in the sense that
Leprosy as a disease has a
afflicted person,
unlike most other diseases it stigmatises the
understanding the
This study aims at exploring and critically
correlates of this
and political
socio-cultural,
economic
been carried out in both
stigmatising disease. The study has
and focuses around
leprosy high endemic and low endemic areas
differentials, if any, due to endemicity.
i
political economy
The study places stigma in the context of
structure.
It rejects the behaviourist
and the entire social
of the
approach and examines the stigma against leprosy in terms
a
discrimination existing in an exploitative society
general
are
in which the basis of relations of production
society in which
and
discrimination,
domination,
alienation
domination,
differentiation,
ostracism.
often suggested that the
has been the inability to
that is
manner.
And the
the stigma.
with it has only
Stigma
explanation is
in rejected by the authors.
acquired and
reproduced In
t.he process
and is
is reproduced
in society
society as
as a part of the
stigma against leprosy
reproduction of inequality.
For instance
Inequality,
casteism and untouchabi11ty,
cannot be viewed independent of
racism and skin colour, class society and the working class,
behaviour by appealing
Health education that is aimed at modifying
stigma,
because like
to rationality has failed to eliminate
so
irrationality
inequality persists in a society of abundance
Therefore the fight
persists in the modern scientific age.
to change radically
against stigma of leprosy has to be a fight
I
i
the social reality itself.
* * * * * * *
r
S-l
The National Leprosy Control
Programme started in 1954 has
over the years failed to make
any significant dent in controlling
leprosy.
The Survay Education & Treatment (SET)
approach adopted
under National Leprosy Control
Programme (NLCP) to run a vertical
programme of national importance
has paid poor dividends, except
in small pocketsj of a few states often with
with active
active participation
of some NGOs.
The top-down approach of
the programme and a
disinterested bureaucracy is the
first stumbling block,
Policies
and programmes
are formulated ion the basis
of
ideas
that
little or no connection
have
with the context
economic aspects of the placement of the of socio-cultural and
disease in pcoplezs
lives.
The status accorded '
to the leprosy programme and as a
consequence to those who work in
it is very low.
This low statu*
is directly related
J to the stigma associated with the disease as
well as to its low priority in
the health system.
There is a
deep-seated stigma against the leprosy
Programme within the health
service <organization, and postings
to the leprosy programme
programme are
considered
J as a "punishment
-posting".
The weakest element
element of
NLCP's SET approach is
the education component.
* * * * * * *
The survey was carried
out in 22 villages spread over six
over
districts.
Four villages of two ais-cricts
districts (Wardha
(Wardha &
& Chandrapur)
have high endemicity of leprosy and 18 villages
leprosy and 18 villages from
four
districts
a nagiri,
pune, Aurangabad
Aurangabad and
and Dhule)
Dhule) have
low
endemicity.
The prevalence rate
the high
rate in
in the
hi^h endemic sample
was
14.68 leprosy patients
Per 1000 population and
and 1.6
1.6 per 1000 in the
low endemic sample.
The principal objective of
of the
the study was to
explore and
understand
stigma assoicated with
leprosy,
with
both from
the
perspective of the patient and the general population.
This
has
undertaken in a comparative
framework between the high and
low
endemic samples, as well as <
evaluating the effects of intervention
of a NGO in the high endemic
area.
All the registered
patients
from
these 22 villages and
persons from randomly
selected
households were interviewed
using quasi-structured
interview
schedules.
k
* * * * * * *
S-2
5/
LEPROSY AND SOCIETY
has
ing
ted
cal
ept
ion
d a
ies
ave
and
e s
a
ti
as
s a
1th
are
of
low
endemic
The high and
Charaoteriatlca of the Sample:
significantly on the basis of two
area populations differ
characteristics
- caste distribution and landholding
important
These two variables are prime determinants of
distribution.
In the low endemic area the middle
social and economic status.
(Marathas)
constitute
the
dominant group but in the high
castes
(balutedars) constitute a
(balutedars)
endemic area the occupational castes
This
distribution
has
resulted in a highly
large majority.
This distribution
Similarly in
the case of
significant
chi-square
value.
landholding the chi-square value is highly significant because in
the high endemic area the landless form a large proportion in
These
comparison to the middle peasantry in the low endemic area.
two differentials are very Important indicators in understanding
and explaining differentials if any, regarding leprosy stigma and
Educational
related aspects.
aspects.
Educational achievement is also an important
variable but between the two areas there is no significant
However, when
difference in the spread of this characteristic.
characteristic,
education is seen in the context of caste and landholding status
it presents significant differences showing a direct relationship
i . e . a better recognised social status (high caste) and a higher
economic status (large landholding) are important determinants for
access to higher levels of education.
six
>ur)
'our
low
was
th-
and
the
has
low
sion
jnts
uted
/lew
Knowledge of leprosy: As anticipated knowledge of leprosy is
significantly different between the low and high endemic areas.
Respondents from the high endemic area were better informed about
the disease.
They not only knew about the disease but cited its
symptoms and signs correctly more often.
High endemicity is
often,
largely responsible for this difference.
Because of the high
difference.
people get
get to
to see
see a
a lot
lot more
more leprosy
leprosy in the high
prevalence people
endemic area.
The distribution of other socio-economic factors
landholding
show
(caste,
landholding and
and education)
education)
show that with regard to
knowledgei about leprosy these factors don
don't
t matter in the high
endemic area but are very important in the low endemic area.
This
area.
is because high prevalence of the disease makes the knowledge
universal
- cutting across socio-economic
factors.
Whereas in
the low endemic area the ’’upper" castes, the richer peasants and
the more educated classes have better knowledge about leprosy
simply because their position in society makes
access
to
information, whether correct or incorrect, more possible.
S-3
'Stigma against leprosy: We began with the hypothesis that because
of high prevalence in the high endemic areas (as every other
stigma
against
household, may have a leprosy patient) the
leprosy
(at least physical expression) would be absent or
significantly lower as compared to the low endemic areas where we
also expected secrecy about the disease to be higher. This
Even when
when we
we
control the
hypothesis has been disproved.
Even
control
distribution
for socio economic
factors we find
that no
significant differences show.
show. This helps us in reaching the
conclusion that stigma against leprosy is almost universal: that
not only people living in high and low endemic areas share similar
attitudes and feelings with regard to leprosy but also stigma is
shared similarly by people from different economic, social and
educational backgrounds.
The main reasons given by respondents with regard to why they
uphold stigma against leprosy are fear of contracting leprosy and
the fear of being ostracised or socially boycotted for associating
with leprosy patients, The reasons given in both the high and low
endemic areas is similar.
* * * * * * *
PATIENT AND SOCIETY
■
Characteristics of patients: In the high endemic area the mean age
of the patient was significantly lower than the low endemic area.
This is because high prevalence affects a wider range
of
population and in a low prevalence area the disease manifests
Itself in a higher age group. Similarly a larger proportion of
women (though not statistically significant) have contracted
leprosy when compared with low endemic area patients.
However
males constitute as a significant majority of patient population
in both the areas. Eighty-two percent of the patients had "evermarried’' and out of those who were "never-married" 31% said that
they could not get married because they had leprosy. Further, on
the basis of caste and landholding the two patient populations are
significantly different. In the high endemic area the scheduled
caste and tribes and the small peasantry as a class have a
significantly higher proportion of patients, whereas in the low
endemic areas the "upper" castes and the landless class have a
higher proportion of patients.
S-4
I
F *’ ■’
■
-
uv?e
:her
Inst
or
3 we
Phis
the
no
the
that
liar
is
and
th -
ting
low
age
rea.
of
ests
n of
oted
'e ?
tion
•verthat
•, on
j are
luled
ive a
> low
re a
I’atlents Experience of the Disease:
Experiences of patients
of
the
disease,
I-ertaining to the onset
the symptoms and signs
experienced, treatment of the disease, advice about disease,
treatment, diet, cure, deformity etc, given by the health staff,
have been discussed in this section. The findings reveal that the
experiences of the patients in both the areas is not very
different. "Patch" is the most important onset symptom reported
In both areas and a similar proportion of patients in both areas
have reported it. However, surprisingly, the proportion of those
reporting deformity as an onset symptom is higher in the high
endemic area inspite of the fact (as seen earlier) that knowledge
is significantly better in the high endemic area.
The patients from both areas have shared similar experiences
v 1 s-a-vls advice given to them about the disease, its treatment
and cure, diet etc. More than 3/4ths of patients in both areas
have stated that no advice or information whatsoever was given to
them by the health staff who examined and treated them.
The only significant difference was with regard to regularity
treatment.
In the high endemic areas where an LOUS operated
of
the regularity of treatment was significantly better than the low
endemic areas. This is expected because of the special emphasis
However,
provided for leprosy control in the high endemic area.
inspite of the high profile leprosy activity in the high endemic
area only 51.4% of the patients were taking treatment regularly.
In the low endemic area 31.5% of patients were regular. The main
reason given for irregularity of treatment or "no treatment
currently'1 is irregular supply of drugs or an inconveniently
In the low endemic area 80% of the
located health centre.
irregular patients gave this reason and in the high endemic area
46% did so. This reflects on the poor performance of the NLCP,
even in the high endemic areas where special inputs are made
available. Infact, of the SET approach the survey and education
components are conspicuous by their absence.
Patient's Interface with society: We have seen earlier that stigma
against leprosy is almost universal. But when we asked patients
about their interactions in society in different situations they
said that things had not changed after they got leprosy.
This
leprosy,
would appear contradictory. But . maybe not, because xike
like the
harijans the
th^ leprosy
Anrosv patients take their defined position for
1enrosv
S-5
1
granted or accept it as normal, and therefore don't regard the
discrimination, if any, as unusual,
Also, the limitation of the
survey method to study a problem like leprosy when compared to
life-history analysis (which we haven't done) could be responsible
for this contradiction.
However,
interestingly,
the only change that the patients
have reported has been with regard to interaction with the health
staff,
Over one-third of the patients in both areas have reported
negative changes in interaction with the health staff.
The
changes were of two types i)
refusal to examine or see the
patients and ii) not giving proper information or advice about the
disease.
* ******
NGO INTERVENTION
The Gandhi Memorial Leprosy Foundation, Wardha, has been
taken up as a case study of a NGO which has done significant work
in controlling leprosy.
The GMLF has been running a LOU in that area since 1951,
besides a Leprosy Referral Hospital, Training and research centre
for leprosy started in later years.
In
what manner has
the GMLF's intervention
effecteu
significant changes in controlling leprosy and destigmatising
it?.
The findings reveal that the GMLF has successfully controlled
the prevalence of leprosy.
They have brought down the prevalence
from 25 per 1000 population in 1954 to 8 per 1000 presently.
In
our survey we recorded a prevalence rate of 6.36 patients per 1000
population in the GMLF sample.
In the government run ECU at Brahmapuri, with which we have
compared the GMLF performance, the prevalence rate was 22 per 1000
population.
Further, early detection in the GMLF area has been
S-6
1
he
he
to
le
ts
th
ed
he
he
he
en
rk
1,
re
facilitated by regular surveys. This is substantiated by the fact
that not even a single patient in the GMLF area reported the onset
symptom as deformity unlike the Brahmapuri LCU area where 16% of
the patients had reported deformity as an onset symptom.
With regard to regularity of treatment all the GMLF area
pa tjents reported regular treatment whereas only 41% in the
Brahmapuri LCU area did so.
with regard to knowledge,
stigma and related
However
aspects, aspects there were no differences between the GMLF and
Brahmapuri area, This is another unexpected result. Knowledge of
leprosy, stigma, related variables, attitude, of health worker
towards patient have a more or less similar pattern in both the
areas. This shows that the only significant difference that the
NGO has made is in making the delivery system more effective.
Therefore its contribution has been largely of a techno-managerial
nature.
This also raises questions regarding the much talked about
health education.
GMLFs intensive information and education
campaign to change the behavioural response of people towards
leprosy and its patients has not paid any significant dividends.
This provides evidence for the failure of the behavioural approach
to tackle the problem of leprosy stigma. It calls for a need to
look at more radical changes - changes that eliminates the
discriminating and differentiated social structure itself.
F
e<
ng
ad
i
□e
In
00
ve
00
sn
S-7
i
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SHOTION ONH
1.
:
X NTRODUCTI ON
A CRITIQUE OF STIGMA AND LEPROSY CONTROL
The Political Economy of Stigma
What is stigma?
Stigma in the Social Context
Social Aspects of Leprosy
Leprosy Control
A Note on the National Leprosy Eradication Programme
2.
OBJECTIVES, STUDY DESIGN AND
METHODOLOGY
Objectives of the Study
Study Design and Methodology
Sampling
Data Collection
Data Analysis
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1
A
CRITIQUE
OF
STIGMA AND
LEPROSY
CONTROL
Cultural traditions and social practices pertaining to health
and medicine have, in recent years, acquired a great significance.
This is consequent to an increasing Interest in the social
sciences about health related issues,
Infact the primary health
care approach and
'community health'
are results
of
this
interaction between the health and social sciences.
Historically,
every social system has evolved its healing
system providing for sick roles,
healers and an accompanying
ideology (see Parsons, 1951).
Invariably the process of healing
has been associated with values of the sacred and divine;
as a
consequence it has been operated and controlled by an elite class
(priestly class in India)
India)..
Even secularization into the modern
system of healing has not demystified the healing
heal in? system and
neither has it rid itself of its elitism.
Every healing system has had its limitations in that it has
been incapable of coping with every affliction,
But there have
always been explanations for grey areas.
Whatever was incurable
was assigned a metaphysical (or supernatural) cause and was left
to the practitioners of the supernatural (sorcerers,
exorcists,
faith healers etc.) to deal with and offer solutions,
Leprosy is
one such disease which, even today when its cure is well known, is
surrounded with awe and is considered generally as manifestation
of 'god's wrath'.
Is lack of knowledge or lack of technology the only reason
why leprosy enjoys a special (sic) status within our society? Is
the stigma and ostracism or isolation associated with leprosy a
simple result of this inability to tackle the disease adequately?
The answer is no.
The Political Economy of Stigma
What is stigma?
their
The origin of the term stigma is credited to the Greeks,
worldly view,
it referred to bodily signs designed
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to
expose something unusual and bad about the moral status of the
stigmatised - a blemished person,
ritually polluted,
to be
avoided, especially in public places
(Goffman,
p.ll).
1963,
Goffman further adds that later, in Christian times, two layers of
metaphor were added to the term :
the first referred to bodily
signs of holy grace that took the form of eruptive blossoms on
the skin,
the second, a medical allusion to this religious
allusion, referred to bodily signs of physical disorders.
Thus,
stigma while segregating the stigmatised individual,
invites
compassion for such individuals.
Medical historians have paid considerable attention to the
stigma attached to leprosy patients.
Much of the discussion I
centres around the time of Biblical antiquity and the early Middle
Ages to understand the roots of society's response to leprosy.
In
Biblical times ’’lepers" were segregated for it was believed that
all impurities werp contagious,
The "lepers" were considered both
unclean and impure.
In the early Middle Ages when leprosy became
endemic and no treatment proved effective, the Bible was resorted
to and segregation became mandatory (Sudhoff,
1917)
Similar
segregation is also reported from Japan where Buddhism became the j
dominant religion after its introduction into that country in the
7th century A.D. (Veith, 1947).
In India since ancient times, the
concepts of purity and pollution were central to the dominant
dominant
religious and cultural value system and practices.
I
Goffman classifies three gross categories of stigma:
(1)
(2)
(3)
abomination of the body-the various physical deformities,
blemishes of individual character perceived as weak will,
domineering or unnatural passions, treacherous
and rigid
beliefs, dishonesty etc., and
the tribal stigma of race,
nation and religion (Goffman, |
1963, p.14).
These notions of stigma are socially acquired and the
'normal'
are expected to
observe them,
The
process
or
socialisation, and consequently social control, is so encompassing
.that even the stigmatised (who have been marginalised by society
on some count) tend to hold the same beliefs about their identity
as the 'normals'.
This says Goffman, is a pivotal fact.
So
pivotal that it is the
'hook' on which the stigmatized hang all
inadequacies,
dissatisfactions,
procrastinations
and
all
unpleasant duties of social life,
depending on it not only as a
reasonable escape from competition but as a protection from social
responsibility
(Baker and Smith, 1939). The 'normal' accept these
'shortcomings'
of the stigmatized and encourage its perpetuation
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the
o be
.11).
rs of
odily
ms on
gious
Thus,
vites
the
ssion
iddle
.
In
that
both
ec
ie
orted
milar
e the
n the
, the
inant
will,
rigid
fman,
the
of
ssing
ciety
ntity
So
g all
all
as a
ocial
these
ation
A
because stigmatization apparently functions as a means of removing
Further,
if the
those minorities from avenues of competition,
'behave'
in the manner in which they are
stigmatized don't
Thus ,
expected to they arouse suspicion and are brought to book.
The
a t1gmati zatlon also becomes a means for social control.
Labeling is a very
vehicle of stigma are symbols or labels.
powerful social mechanism through which not only attitudes,
beliefs, norms and complex behavioral patterns are ingrained but
the entire
entire basis
basis of
of a class and exploitative society is
also the
Stigmatizing of leprosy is part of this
preserved and reproduced,
complex.
larger complex.
Tn one sense the disfigurement that may result
f rom the disease may be <directly responsible for the stigma but
when we look deeper, it appears as a malaise of the social
structure itself.
Stigma in Social Context
among
sociologists and
There
is
a
broad agreement
Stigma is a
anthropologists that stigma is a social phenomenon.
complex social
reanuy which
wnxvn is
social response
response to
to the
the concrete social reality
reproduced and
changed
in
the
course
of
historical
development.
and changed in
The social
social basis
basis of
of stigma is the unequal relationship between
individuals and
and or
or groups
groups of individuals whose social Identity is
defined from
from the
the stand point of economic and social status, race,
health
and
so on.
A social structure based on inequality
sex,
provides for an economic,
social and ideological mechanism to
In
reproduce unequal relationships in the daily life of people,
stigma
the course of development, the practical manifestation of
the
changes in accordance with the stage of
development,
continuous
realignment of socio-economic forces
within the
structure,
and in response to the need to cope with the crises,
In the process, new symbols of stigma are added, some of the old
ones are modified or discarded.
In the society as a whole,
various types of stigma co-exist, they influence and modify each
other, and all of them together help reinforce inequality in the
social Intercourse.
Historically,
societies have evolved on the basis of the
development of their productive forces.
Culture, folkways, norms
and attitudes have developed as a consequence of these productive
forces and the relations of production that dominate within that
society.
Primitive societies have given way to those whose value
This was a
systems are
are based on structural differentiation.
result of
a new and increasingly complex divison of labour,
of a
development of
greater
of private property and the consequent
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concentration of ownership of the means of production in fewer
The modern capitalist
hands (see Morgan 1877; and Engels, 1894).
method
exploitation which
society is based on a newer i..~—— of
— economic
-—
the political
is continuously reproduced with the help of
structure evolved from the need of such a society.
W
t*
M
«•
means of
modern
society
has evolved
modern
Though
summarily
not
exploitation and oppression, the older forms are
Rather, the relevant older forms are integrated with
discarded.
the newer ones in such a way that both the forms give a picture of
This also helps in providing an apparent
on integrated whole,
That is
continuity and Justification to the modern social order,
why in a society which has enough productive capacity to meet the
on the
needs of all people are deprived of those needs not only
basis of economic stratification but also in accordance with
The same is true in the field of
sex and racial status,
caste P
provide safe
health where the inability to control diseases,
are termed as ’’lack of political will",
nutrition etc.
water,
based on
which is nothing but a manifestation of a social system
inequality.
C!
h
r
b
n
t
A
1
d
deprivation and
Inequality in practice is expressed as
Discrimination is deeply ingrained in the daily
discrimination.
life in such a way that the perpetrator• and the sufferer develop a
behavioural pattern to suit the needs
i---- --of the discriminatory social
behaviour not
system , unscientific and irrational nature of such
of
all
types
standing.
Further,
in
daily life,
with
equal
arising from them are not given
discrimination and stigma
s
For example, in racial
importance at a given time and place,
But in sexual
relations the blacks are discriminated/stigmatlsed.
irrespective
of
and family relations,
women are discriminated
black women
race.
Similarly amongst women,
we find the
brings
a
This
discriminated against by the white women,
»
/
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complexity in the discriminatory relationship.
How does stigma against some diseases articulate within such j
a discriminatory system? As in the case of economic and/or social
so the
status,
the stigma against diseases is not uniform,
intensity of discrimination and stigma a gainst a diseased state
it's communicability,
depends not only upon the type of disease,
the overlap of the
ability
to treat etc,
but above all,
disease's manifestation with the cultural and social practices and
the religio-cultural
economic needs.
In the case of leprosy,
hence
the
universality
and high
overlap is the highest and
intensity of stigma.
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As
human
beings evolved from the primitive
stages,
they
brought with them various diseases and in the process acquired new
ones.
Even presently, the development of modern civilisation
is
introducing newer diseases and stigma attached to them.
Thus, in
the course of human development, the diseases ceased to be purely
biological phenomena, they acquired social and cultural dimensions
of
ly
th
of
nt
is
he
he
th
o
ife
on
ind
Uy
? a
lai
not
of
ual
ial
ual
men
a
>uch
3ial
the
sate
tty,
the
and
aral
high
as well.
do human beings
respond to diseases?
Rubin says,
By
How
necessity man has undoubtedly always been concerned with questions
health and survival,
and has sought within the framework of
of
knowledge
solutions to
problems
of illness"
(Rubin
1960,
his
p.785)
Therefore,
the diseases
which not only
threatened the
biological
safety of
the individuals
but also
the
social
and
economic life of the group, and for which no rational solution was
available
at
that
time,
human
reacted
by
isolating
human beings
beings
themselves,
by outcasting the
sufferers
and
so
on
(Foster
and
the sufferers
Anderson, 1978, p.34).
Infact
Infact there
there are
are instances
instances in history when
P-34).
such
measures
helped
in controlling epidemics
epidemics..
For example,
helped
isolating leprosy patients in
leprosaria brought about a
sharp
during the
decline in the incidence of leprosy in Western Europe
leprosaria ,
crowded
fourteenth century.
This was because in the
the undernourished and weak leprosy patients were easy targets for
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infections.
(Sigerist,
Of course this measure
secondary
infections.
(Sigerist, 1943).
1943).
ac tually eliminated leprosy patients rather than leprosy.
I
such human behaviour of eliminating
can
one explain
How
is seen
as
the
Sometimes this
the disease?
and not
patients
humans.
After all
Social
the
animal
instinct inherited by
school
in anthropology and
Darwinism"
or
the
"nothing but"
with
continuity of humans
sociobiology
instinctual
emphasises
from
that one
should refrain
their animal ancestors.
We feel
to
social
and
theories
applying
biological
explanations
phenomenon; for human evolution introduces the overwhelming social
with the animal world,
discontinuity to the biological <continuity
-------(Reed,
1978).
The
formation
of human
society
is
a
unique
phenomenon in the living world.
Thja human biological instinct has
got more or less reduced to the involuntary processes in the human
body.
The so
so-called biological behaviour is in essence the social
The
defense
reaction
of
of
individuals.
An
animal
behaviour
human
social
behaviour
the diseased is not the same as
discarding
of depriving and stigmatising some diseased people.
one
What is important to understand here is the distinction that
ought to make between a social necessity of isolating a
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diseased individual in order to reduce or control infection when,
no good cure is available, and stigmatising or depriving or
discriminating an individual for his or her diseased state, This
becomes glaring when the cure is available but the society's
structure does not allow it to reach to the diseased individual,
Thus
and when such isolation is not scientifically necessary.
such behaviour is only as much instinctual as is poverty or
untouchability or racism.
4!
explain
the
To sum up, there is not one reason to
Similarly
there
is
not
one
reason
relationships of domination,
to explain myths and stigma attached to sufferers and dominated
groups, for instance in India
inaia to the low caste groups, However
all such relationships, myths and stigmas condemn the target
individual or groups of individuals to exploitation, oppression or
Isolation for their taking birth in such oppressed groups or for
acquiring certain characteristics,
characteristics, including diseases in the
course of living.
The case of leprosy falls in this framework.
The isolating
and outcasting of the sufferers, misconceptions, myths and stigma
attached to it and so on were natural reactions of humanity for
its survival. But they also got ingrained in the societal life to
be continuously reinforced in the process of reproduction of
Inequality, exploitation and oppression of groups of people in the
society at its various stages.
As inequality persists in a
society of abundance, similarly irrationality persists in the
modern scientific age.
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In short, the fight against stigma towards leprosy cannot be
an isolated fight. It must be conceived as a part of the attempt
to change social reality as a whole.
Social Aspects of Leprosy
Leprosy as an illness exposes those afflicted to a long and
protracted experience with pain and sufferring and deformity, as
well as social ostracism. Death alone is not the frightening
element; the major threat is bodily deterioration and assault on
the body-ego (Gussow and Tracy, 1968). Therefore, "it appears
reasonable to postulate that it is this complex and its uniqueness
which is responsible for the unique social reactions to leprosy
(Skinsnes,
1964). Deformity and disfigurement then appears to be
the main associate of leprosy to stigma and invariably, deformity
is classified as a symptom of the disease (Rao,
1982). Society
8
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s
s
3
>r
e
n
d
r
t
r
r
e
S
a
r
o
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e
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e
e
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3
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7
7
resulting into
and Culture "have seen leprosy as incurable,
deformities, ulcers, changing the very identity of a person into
something which is aesthetically devastating and against the
sinners, worthy of
cultural image of the body....(afflicting)
afflicting)
divine punishment".(Mutatkar, 1981).
This then is the dominant view not only in society generally
but also among those who have enquired into the 'social aspects of
leprosy'.
However, stigma towards leprosy cannot be looked upon
is the
as
an
independent occurence
because
its basis
It is thus an
discriminating, exploitative social system Itself,
(of its
ideological issue.
The system defines the responses
adherents) towards the disease in the same manner as it determined
Thus,
social distance among various groups within its fold.
the
same
way
as
stigma
towards
stigma towards leprosy occurs in
the "untouchable" under classical Brahminism, of Stigma towards
blacks through racism in South Africa and the USA and most of the
"white”
world.
Moreover this socio-cultural inequality and
oppression is reproduced in economic and political relations
within society strengthening the adverse relationships between the
domineering and the dominated.
Consequently a leprosy patient,
like the harijan or black, is not only a social outcaste but also
suffers economically and politically, being forced into beggary
and other activities that are socially looked down upon.
For many years attempts have been made to explain social
s tigma of leprosy almost exclusively in terms of peoples adaptive
But behaviour is the effect and not the cause of the
behaviour.
All strategies that aimed at merely changing peoples'
stigma.
behaviour towards leprosy have met with partial success, and these
More importantly,
successes have not turned out to be permanent.
(say bringing its prevalence rate to
the control of the disease
one or less than one per thousand) has not ushered in societies
with
people banishing stigma towards
leprosy.
In Western
societies for instance,
leprosy is no longer a public health
problem, but the masses still harbour stigma towards the disease
and its sufferers.
The existence of leprosariums and the social,
economic and psychological problems faced by their inmates in
their societies is documented, although such studies concentrate
on the adaptive behaviour to stigmatised illness
(Gussow and
Tracy,
1968).
This also puts to rest the argument that
disfiguration of the body is the chief cause of the stigma towards
leprosy.
In fact, disfiguration is a contributing factor in
enhancing the stigma.
Hence, the need to eliminate it. But that
still does not touch the roots.
The social and psychological
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problems that leprosy patients face are substantially due to
more
but
societies defective view of the disease (Ibid),
system
:
importantly due to the defective (discriminating) social
itself.
The Leprosy Eradication Programme in India is based on the
strategy of Survey, Education and Treatment.
The surveys identify I
the sufferers who are then treated.
The role of education is 1
The
conceived as giving scientific
scienunc information about the disease to
the people and help the sufferer to adapt to the diseased state.
The underlying assumption is that once scientific information is
received,
the people will realise the irrationality of treating
leprosy patients as outcastes or untouchables.
Change in the
attitude of the people can be affected by health education. )
Health education aimed at informing people about the irrationality
of stigma and various superstitions and misconceptions about .
leprosy may reduce the intensity of stigma and earn lepro
patients some sympathy, but experience shows that it has not been
:: neither
able to
to eliminate
eliminate stigma
stigma
neither in
in societies with universal 1
education nor in societies where leprosy has ceased to be a ;
it is often stated by the people involved |
significant disease.
As
"people receive information,
but thatt
in leprosy control work,
Furthermore at it s worst,
the ;
doesn't mean they accept it".
information
in
absence
of
any
radical
change
in
social
|
scientific
introduces new symbols to identify stigmatised t
relationships,
To obvious deformities are added
added skin
skin patches, j
Individuals.
Thus,
while giving!
on.
thickened pinna of the ear and so on.
exposes
the
suffering .
information,
the programme
scientific
The purpose of scientific
stigma even
even earlier.
individual to stigma
informationl thus does not turn out to be a social fight against
This is not to,'
but a medical decision to detect leprosy,
stigma,
that early detection is not necessary or scientif’
argue
We only intend
Information should not be given to the masses.
cannot
be
fought
medically
alone.
point out that social malaise
social and economic compulsions force
At the same time,
with leprosy patients,
groups of people to associate and work
harm in associating;
although they may not believe that there is no
In brief,
such behavioural complexity has its;
brief,
with
them,
reality.,
in
the
socio-economic and
cultural
the
foundations
in order to bring about far-reaching changes in the
Therefore,
behaviour, i.e.elimination of stigma, corresponding changes in the
socio-economic and cultural life are required to be brought about
eliminating the "stigma" in the social relations itself.
In
by
absence of this, imparting of scientific Information learnt from
10
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en
al
a
ed
at
.he
al
;ed
jS ,
.ng
mg
fic
ast
fic
to
and technological advancement, will at the most reduce
I p 11! 1 f 1 ’'
r modify the behaviour to generate another complex behavioural
,ern.
out of
In order to go into the depth of the problem arising
in its
stigma towards leprosy, it is necessary to understand it
1 nnume rable connections, particularly in its relation to various
conditions.
It is necessary to relate various
ape 1o-economic
stigma towards leprosy to the social and economic
f rms of
occupied by the individuals manifesting such stigmatised
P-031 tion
The present study does make efforts in this direction
-’haviour.
the objective of acquiring a better understanding of the
w k th
social basis of leprosy and its stigma.
Leprosy Control
indicates that there are over 12
An estimate by WHO (1977)
the world, half of which reside in
million leprosy patients in
India
India accounts
accounts for about one-third of all
South-East Asia.
world,
an estimated 3.95 million cases in
leprosy cases in the world, an
cases of leprosy is expected to increase
The number of cases of leprosy
1981 .
detection improves; for example, between 1971 and
further as case
of cases detected in Maharashtra have almost
-----1981 the number
doubled.
leprosy began after independence in
India's fight against
of the National Leprosy Control
1954-55 with the launching
This was based on DDS, aa sulphone, discovered
Programme (NLCP).
In 1983, following
A3 a cheap
cheap and effective drug against leprosy.
Working Group appointed under the
»he recommendations of a
then
Member,
M.S. Swaminathan, the
chairpersonship of Dr.
was converted into the National
1‘lanning Commission,
the NLCP
Commission,
(NLEP).
The Eradication strategy
Leprosy Eradication Programme
developments
The advance in
was adopted in reponse to two developments
:’• The
motherapy with the advent of Rifampicin which reduced the
.luration of treatment, and the widespread reach of mass media.
rce
ts,
ing
its
ty.
the
the
>out
In
from
components - Survey,
The NLEP strategy is based on three
inclusion of education in
Education and Treatment (SET). The very
that health planners
r he strategy of leprosy control shows The role of education is
recognized its importance early enough,
information to people about the
conceived as giving scientific ithe diseased state.
Ihe
disease and to help the sufferer adapt to
receive information they
underlying assumption is that once people
leprosy patients as
will realize the irrationality of looking upon
11
outcastes or untouchables.
However, experience of people involved
in leprosy control indicates that reception of information is
is no
guarantee to its acceptance.
Thirty years of NLEP have not made any serious dents in the
problem of leprosy in India, except in a few isolated pockets in
some states through the active participation of a few NGOs,
(like
the GMLF which has been included as a case study in the present
study).
This is not to say that the NLEP has achieved no positive
results,
but to underline the fact that there is more leprosy
today than in 1955 and the problem of stigma is as serious,
Efforts are presently being made by health planners as well as
NGOs and researchers to reevaluate and reconsider the strategy for
the control of this as well as other diseases with special
emphasis on socio-cultural and economic factors.
Even the WHO in
1979 established a scientific working group on social and economic
research
which
sociologists,,
includes
sociologists
anthropologists,
psychologists,
among others.
These scientists probe peoples'
attitudes,
perception and behaviour in relation to disease and
disease
transmission;
economists assess,
from
national and
international perspectives,
not only the cost-effectiveness of
control
programmes but also the
economic rationale behind
decision-making in the household and how it is influenced by and
influences
disease
transmission (
UNDP/WB/WHO,
1985).
(UNDP/WB/WHO,
Prof.
Mutatkar has summarized this appropriately, "A greater realization
is coming to the medical scientists, that the human being can no
longer be treated only as an anatomical and physiological entity,
but that his individuality should be understood in terms of his
culture and belief system.
In fact, the individual perceptions of
the body image are moulded by the cultural determinants.
These
factors
have necessitated a
dialogue between the
medical
scientists and social scientists, even though the extent of
dialogue is limited in nature”
(Mutatkar, 1979).
This change in
perspective was also observed in the last International Congress
on Leprosy held in Delhi in 1984.
For the first time a whole day
was devoted to social and human aspects in the control of leprosy.
Whether this changed approach has an impact on the leprosy control
programme and in what direction, is yet to be seen.
Prof.
D.
Banerji commenting on the political economy of
leprosy control in a paper presented at the 1984 International
Leprosy Congress pointed out that this area of study
was
practically untouched by social scientists.
Political economy
concerns the analysis of forces which influences
decisions
concerning policies, plans and programs .... the low ■‘Status” of
12
...
thn leprosy program and its workers in the health services
services
themselves
• nd the stigma against leprosy in the health
ihnnerj i , 1984).
The top-down approach of the vertical leprosy program, and
I ts accompanying disinterested bureaucracy is the first stumbling
The bureaucratic design inhibits a
bio 'k in the leprosy program.
like any
prope r modelling and operation of the leprosy programs,
1982).
other activity of a health care delivery system (Foster,
ideas
that
Policies and programs are formulated on the basis of
socio-cultural
have little or no connection with the context of
in people's
and economic aspects of the placement of the disease
1 Ives.
a
The status accorded to the leprosy program and as
low.
This
low
status
consequence to those who work in it is very
Is directly related to the stigma associated with the disease as
As a result
well as to its low priority in the health system.
implementation of the leprosy program suffers grossly.
This neglect of implementation perhaps offers an explanation
of the paradoxical situation in leprosy programs in India : there
Is aa deep-seated stigma against the leprosy program within health
service organization and because of this health workers avoid
getting posted for leprosy work and those who are unable to avoid
doing so, have a low motivation - even antipathy for leprosy work
(Rao,
1982).
Our discussions with those working in the leprosy
program reveals that leprosy is considered a "punishment posting ‘
•nd leprosy workers, especially physicians, are not only most
disinterested in their work but also exhibit stigma towards the
d Lsease.
Though education constitutes a significant component of the
leprosy program the main focus continues to remain with caseand case-holding. This inspite of the realization that
finding
socio-cultural and economic factors need to be looked into to
bring about changes in community attitudes and practices.
this study, we have elicited responses from the people on
The
The responses
responses on
on knowledge of leprosy
certain forms of stigma.
Apart from relating
and leprosy patients has also been elicited,
towards leprosy
the knowledge of leprosy with their behaviour
and behaviour
patients, we have also related both, the knowledge
It should be noted
to their socio-economic position in society,
comprehensive
that this attempt is not to provide a very
In
i
i
13
understanding, but within the limitation of the study, to outline
one of the methods to study stigma - as a part of the socio
in the study
economic structure and to describe it as it exists
area.
A NOTE ON THE NATIONAL LEPROSY ERADICATION PROGRAMME
Plan (1955-56) the
In the last year of the First Five Year
(now renamed as the
National Leprosy Control Programme (NLCP)
in the
National leprosy Eradication Programme without any change
The
programme
is
overall strategy)
strategy) was
was launched in the country.
based on three principles :
(i)
(ii)
(iii)
the
especially those
of
Detection of all cases,
infectious types, at as early a stage as possible.
Provision of treatment facilities to all patients so
detected, and
Health Education
to create a favourable atmosphere
which will help both in case detection as well as case
holding programmes.
I
The stated objectives of the NLEP are
(a)
(b)
(c)
by
To reduce the load of infection in the community
to
positive
cases
converting the bacteriologically
bacteriological negativity inorder to interrupt the
transmission of infection in the community.
level when
To reduce the prevalence rate of leprosy to a
will no longer pose major health hazard i.e.
leprosy
less than one case per 1000 population.
Ultimately to rid the country of the disease.
To achieve the objectives,
established:
(1)
following
types of centres have
J
been
Education and Treatment (SET) Centres: They are
Survey,
generally established in rural areas with a prevalence
rate of less than 10 per 1000 population and covering
about 20,000 to 25,000 population. It is manned by a
Leprosy Technician and is supervised by the Medical
Officer of the PHC as well as the District, Non-medical
Supervisor.
I
14
11
b
3
(2)
/
e
e
e
s
(3)
Leprosy
Control
Unit (LCU)
•
They are generally
Control
10 or
established in
areas with prevalence rate of
in
in rural
They cover population of 2 to 4 lacs
above.
and
supervisors
A
medical
officer,
areas.
The main field
staff is provided with a vehicle,
other
covering 20 to 25
workers are
are leprosy
leprosy technicians, each
thousand population.
^nttArn
Urban Leprosy Centre (ULC): Workers on the SET patte
,
A
senior
covering 30 to 50 thousand urban population.
para- medical designated as Non-medical Assistant is
Government or
appointed there with attachment to a
Municipal Dispensary/Hospital.
ie
Wards, Reconstructive
addition, Temporary Hospitalisation
Centres and Leprosy Control Units,
Units, Voluntary SET
Surgery
Homes and Hospitals,
etc. are
Training Centres, Leprosy
Leprosy
areas. The achievement of the
the rural and urban
fl<5t up in
NLEP in Maharashtra State are given
components
of the
physical
In
>o
?e
56
below
NLEP INFRASTRUCTURE IN MAHARASHTRA STATE
□y
to
he
en
e.
■en
ire
ice
.ng
a
?al
?al
ACHIEVEMENT (NO.) TILL
MARCH 1984
PARTICULAR
42
;«prosy Control Unit (LCD)
211
’.Than Leprosy Centre (ULC)
970
>-urvey Education & Treatment Unit (bbl)
23
Temporary Hospitalisation Ward
11
Reconstructive Surgery Unit
25
District Leprosy Officer
192
•.on-Medical Supervisor
Statistical Assistant for SLO
7
L2
r 2-7 Training Centre
17
Leprosy
Upgradation of Old Unit
23
7
Upgradation of Urban Leprosy Centre
Upgradation of district Leprosy Office
5
Upgradation of Leprosy Training Centre
2250
Beds
neo of
of Voluntary
"-‘-t: . Leprosy
_
Maintenance
2
Rehabilitation
Promotion
Unit
1
Leprosy I--Assessment Unit.
Sample Survey-cum-Assessment
Unit.__________
+
TnHia Ministry of Health and Family
Government of India, Mini
y
igg4"
New
Source :
Welfare, "Health Statistics of India
la^
Delhi")
15
F
RHB’ECRHINCECS
W.Y. and Smith L.H. (1939) : 'Facial Disfigurement and
Personality',
Journal
of
the
American
Medical J
Association,
CXII, quoted in Goffman
E. , Stigma,
E.,
Penguin, 1984.
1.
Baker
2.
Banerji D.
(1984) :
'Towards a More Comprehensive Social
Science Approach to Health Programmes - the case of
Leprosy', Paper presented at the International Leprosy
Conference, New Delhi.
3.
Engel, F (1894) : The Origin of Family, Private Property and
the State, Lawrence and Wishart, 1972, London.
4.
Foster, G.M. (1982) : 'Applied Anthropology and International
Health - Retrospect and Prospect', Human Organization
41:3.
■
5.
Goffman E.
(1963) : Stigma - Notes on the Management of
Spoiled Identity, Penguin, 1984, Middlesex.
6.
Gussow Z. and Tracy G. (1968) : 'Status Ideology and Adaption
A study of Leprosy',
Stigmatised Illness
Human
Organization, 27:4.
7.
Morgan, L.H. (1877) : Ancient Society, K.P. Bagchi & Company, ;
New Delhi.
8.
Mutatkar
R.K.
(1979)
Saraswat, Pune.
9.
Mutatkar R.K. (1981) : Social and Economic Aspect of Leprosy,
WHO, Kuala Lumpur.
10.
Rao K.V. (1982) : Study of leprosy Control Programme
in a
Rural POlulation in Chingleput District, Ph.D. Thesis
JNU, New Delhi.
11.
Reed,
12.
Rubin V. (1960)
: 'Preface in Culture Society and health',
quoted in Foster and Anderson, Medical Anthropology,
John Wiley and sons, 1978, New York.
13.
Sigerist henry (1943), 'Civilisation and Disease'
New York.
14.
Skinsnes O.K. (1964)
: Leprosy Rationale, American Leprosy |
Mission N.Y., quoted in Gussow and Tracy op.cit.
Evelyn
(1978)
Press, New York.
Society
' Sexism
and
and
Leprosy,
Science',
Shubadha
Pathfinder
Ithaca
16
£
is
id
il
i,
16
11
17.
and
its
Hygienic
Ideas
'The
Sudhoff
Karl
(1917)
of
Medical
Manifestations in World History', Annals
History, Vol.I, PP- 111-117.
1 Jan.
IJNDP/WB/WHO( 1985) : TDR Seventh Programme Report
1983 to 31 Dec. 1984, WHO, Geneva.
Veith
' Bulletin of
Ilza (1947), 'Japanese Picture of Leprosy'
905-917.
Vol.
21,
pp.
CCZ
71
the History of Medicine,
3/
id
WHO (1977) : Expert Committee on Leprosy, Fifth
607, Geneva.
No.
al
2>f
on
an
ha
a
3i
er
Vi
sy
17
Report,
TRS
NLO's OBJECTIVES
NATIONAL LEPROSY
ORGANISATION, INDIA
1. Serve as a federation of leprosy institutions, leprosy workers and
sympathisers who believe in secularism (Sarva Dharma
Samabhava)
2. Bring closer such institutions
and workers and foster
brotherhood.
3. Provide a forum (through regional and all India conferences) to
leprosy institutions and workers to come together and discuss
problems and find solutions.
4. Take up matters and issues of common interest to all institutions
and workers.
5. Help them in improving their work by giving technical guidance
so that they render better service to patients of leprosy.
6. Bring out a quarterly Bulletin to give information about the
The National Leprosy Organisation, India (NLO) was
established in 1965 to remove the sense of isolation among
leprosy institutions and leprosy workers and to bring about
brotherhood among all those fighting and supporting the
>
cause of leprosy.
"The membership of the NLO is open to such leprosy
events, newer thoughts and developments in anti-leprosy field
7. Bring out material and aids helpful to f.eld leprosy workers in
undertaking health education of the community.
workers, persons interested in leprosy work and leprosy
institutions as believe in secularism and subscribe
in
writing to the objects of Organisation and the Policy
Statement made from time to time." Rule 2(a) of NLO's
Rules & Regulations.
EXECUTIVE COMMITTEE
\
of
The National Leprosy Organisation, India
The membership of NLO
is of two kinds: Annual
membership and Life membership. It is open both to
individuals as well as institutions. The fees are:
Annual
Life
1. for individuals
Rs. 10/-
Rs. 100/-
1. Dr. M.S. Nilakanta Rao, Bangalore, 560011
2. Dr. R.S. Sharma, Wardha, 442 103
3. Shri Jagdish Deen, Mairwa, 841 239
4. Shri Janardhana Reddy, Hyderabad, 500029
2. for institutions
Rs. 25/-
Rs. 500/-
5. Dr. M.S. Jayadevaiah, Bangalore, 560 003
6. Dr. M. Christian, Karigiri, 632 186
1 Dr Gurumohan Singh, Varanasi, 221 005
8. Shri Laxmi Singh, Akhlaspur, 821
1 101
9. Dr. D.S. Chatdhury, Calcutta, 700 019
10 Shri Indubhai Patel, Baroda, 390 002
11 .Shri John David, Chilakaluripet, 522 616
12.Sr. Lily Ignatius, Cochin, 682 006
13 Shri D.Kondala Rao, Visakhapatnam 530001
14.Shri S.P. Tare, Wardha, 442 103
15.Shri. D.S. Wele. Wardha, 442 103
The NLO Bulletin, a quarterly journal is supplied free to
all members. For institutional non-members, the annual
subscription of the Bulletin is Rs. 20/-.
Life
membership
is
accepted
in
easy
monthly
instalments.
/4- z
las
President
Vice President
Member
Secretary
Organising Secretary
j
33 Leprosy Relief & Rehabilitarion Centre Nmbhora-khurd
(Maha.)
34 St Joseph s Hospital Leprosy Control Unit, Prathipadu (AP)
35. The Society for the Eradication of Leprosy. Bombay (Maha )
36. Maharashtra Lokhit Seva Mandal
PATRON MEMBERS OF NLO
1. Dr. B. Mukhopadhyaya, Patna
2. Shri I.C. Patel, Baroda
3. Shri L.M. Patel, Bombay
- —.......... ”vui, oombay (Maha )
LIFE MEMBER INSTITUTIONS OF NLO
1. Maharogi Seva Samiti, Anandvan, Warora (Maha.)
2. Gandhi Smarak Nidhi, New Delhi
3. Vidarbha Maharogi Seva Samiti, Amravati (Maha.)
4. Kustha Seva Samiti, Dattapur (Maha.)
5. Santal Pahadiya Seva Mandal, Deoghar (Bihar)
6. Gandhi Memorial Leprosy Foundation, Wardha (Maha.)
7. Sacred Heart Leprosy Centre, Sakkottai (TN)
8. Assissi Seva Sadan, Allapalli (AP)
9. Rajendra Kushta Ashram Research & Training Centre,
Mairwa (Bihar)
10. Kushta Sevashram, Gorakhpur (UP)
11. Sreemanta Sankar Mission, Nowgong (Assam)
12. Acworth Leprosy Hospital, Bombay (Maha.)
13. Damien Social Welfare Centre, Dhanbad (Bihar)
14. Poona District Leprosy Committee, Poona (Maha.)
15. Trust for Leprosy Affected People, Bombay (Maha.)
16. Shram Mandir Trust, Baroda (Gujarat)
17. Bhagwan Mahavir Kushta Ashram, Doraha (Punjab)
18. Anand Gram Society, Poona (Maha.)
19. Gandhi Kushta Nivaran Pratisthan, Akhalaspur (Bihar)
20. Vimukti, Kakinada (AP)
21. Leprosy Health Centre, Nalgonda (AP)
22. M/s Suhrid Geigy Ltd., Bombay (Maha.)
23. Leprosy Relief Rural Centre; Settipatti (TN)
24. Katharina Kaspar Leprosy Control Scheme,
Bangalore
(Kama.)
25. Purva Khandesh Kushta Seva Mandal, Bhusaval (Maha.)
26. GRECALTES, Calcutta (WB)
27. Jhargram Leprosy Project, Jhargram (WB)
28. Central Leprosy Clinic and Home, Ponnur (AP)
29. Hansen Society, Howrah (WB)
30. Lok Seva Sangham, Bombay (Maha.)
31. GREVALTES, Visakhapatnam (AP)
32. BAM (INDIA), Calcutta (WB)
37. Leprosy Patients Welfare Society. Chingmeirang (Manipur)
38 Glady s Schumacher Memonal Leprosy Hosp.tal, Guntur (AP)
39. Grea erTenah Leprosy Treatment Education Scheme, Tenali
(AP)
40. Dr. Heythornthwaite Memorial Service, Kagal (Maha.)
41. Christian Hospital, Madarapakkam (AP)
42. Bharat Sevashram Sangh. Jamshedpur (Bihar).
43. Leprosy Hospital & Free Treatment Centre Solapur (Maha )
44. ALERT India, Bombay (Maha )
45. Hind Kushta Nivaran Sangh, Haryana
State
Chandigarh.
46. Marathwada Lokseva Mandal, Nerli, (Maha.)
47. Kushta Seva Samiti, New Delhi
48. Asha Gram Trust, Badwani (MP)
49. Damien Leprosy Centre, Vegavaram (AP)
50.
Hemerijckx
Rural Centre,
Rawattakuppam (TN)
~
'
------- .v. ..uuurxup^ai 11 J I in)
'tlX C*4
I____ _ I- *
•
Branch
50
ia/
- Mangalore
CO
IA,
, C ~ S Leprosy HosPital--------------pxuina) (Kama)
52. Word & Deed Hyderabad (AP)
53. Bombay Leprosy Project, Bombay (Maha.)
54. ELEP Leprosy Control Project, Dhrmapuri (TN)
55. AMG International, Vijayavada (AP)
56. Viswa Karuna Sangham, Warangal, (AP)
57. HKNS, Leprosy Project, Jammikunta (AP)
58. Gram Nav Nirman Samiti, Hyderabad (AP)
59. Shakti Brahmashram, Jalna (Maha.)
60. Ramdeobaba Satsang Mandal, Deshmukhwadi, WanifMaha.)
’-i4i‘ I * J I f. _l _ _ •
’*
61. KoHia
Kedia \/omrr\
Vanaspati
Ltd. Hyderabad (AP)
62. Kushtarog Nivaran Samiti, Wakdi (Maha.)
63. Udyog Dham, Badrikashram, Pune (Maha.)
64. Vanvasi Seva Kendra, Kusht Nivaran Samiti, Adhaura (Bihar)
65. Sree Srinivasa Leprosy Vimukti Organisation, Tirupati (AP)
66. Prema Samajam, Vijayanagaram (AP)
67. Holy Family Hansenorium, Fatimanagar, Tiruchirapally (TN)
68. Prema Samajam, Visakhapatnam (AP)
69. Vimala
• ••■•“•J Dermatological Centre, Bombay (Maha.)
70. Asha Sadan Leprosy Centre, Kalheri (UP)
71. Grameen Sarbatmak Kalyan Kendra, Calcutta (WB)
■
..............................................................
Institutional Members 1986-87
(Till August 1 986)
1. OXFAM India Trust, Nagpur, (Maha.)
2. Phoenix Seva Sangh, Subhashwadi, (Maha.)
3 Hubli Hospital for the Handicapped, Hubli (Kama.)
4. Swarm Vivekanand Kusht Seva Samiti, Bijapur (Kama.)
5. CULTES, Cochin, (Kerala)
6. Shri Gurudev Kushta Seva Mandir, Amla Vishweshwar,
(Maha.)
7. Kushta Kalyan Samiti, Charichaka, (WB)
8. DANIDA Leprosy Coordination Unit, New Delhi
9. Geeta Arogya Bhavan, Bhagwanpur (WB)
10. Swami Vivekanand Seva Trust, Jamshedpur (Bihar)
International financing agencies
participating in leprosy work in India
1. American Leprosy Missions, Inc. 566, Morris Avenue, New Jersey,
07901 (USA)
2. Leprosy Relief Work Emmaus Switzerland, Spitalgasse, 913011,
Berne (Switzerland)
leprosy
i. definition
■■Leprosy is a chronic, specific, infectious disease c- — ■
caused by a germ called
Dr P. Kapoor
II. SUGGESTIVE: SIGNS
tSheSPfX^Pr°Sy When an''person complains of or is seen with one c- or more of
and 5VmP,°mS a"d 'hen
>h^9hly' for a
(A) SKIN
1. Non-itching, non painful—
(i) HYPO-pigmented or
erythematous patch
or patches
(a) In the patches, following
are additional helpful suggestive signs of
leprosy—
3. International Co-ordinating Committee of the Leprosy Associations
(ILEP) 106, Rue Steven, Brussels, 4 (Belgium)
4. OXFAM, 274, Banbury Road, Oxford-OX2 7 DZ UK
5. Associazione Italiana ’ Amici de Roul Follereau” 44135 Bologna, Via
Borselli 4 (Italy)
6 German Leprosy Relief Association, Dominikanerpiatz 4 Wurzburg
(Germany)
(ii) Disseminated
diffuse
erythema.
(i) Numbness in the patch
(ii) Loss of hair
a «
L°SS °f SWe3t causin9 dr^-ness of patch.
/hi i
shiny. Itmay
inTddft'on^e
7. Leprosy Relief Organization, Munich e.v. Zenettistrasse 45 D 8000,
MUNCHEN 2, (West Germany)
(i) Small nodules on the earlobes, face and extremities.
(ii Thinning of eyebrows due to partial los of hair.
(in) Thick and elongated earlobes.
2. Sudden appearance of painful nodules on the face and
8 International Society for Rehabilitation of the Disabled, 219 East
44th Street, New York N Y. 1001 7 (USA)
extremities, with fever, nerve and joint pains Skin is
erythemaious smooth, oily and shiny.
3. Painful, swollen hand, particularly the base of the fingers.
9. Damien Foundation, Rue Steven, 16. B-1040 Brussels. Belgium.
10. The Leprosy Mission 7. Bloomsbury Square, London, W C.l. (U.K.)
11. Rehabilitation International. 432, Park Avenue South New York, N.Y.
10016 (USA)
(B) NOSE
bleTd^Xarth60'
C°mp,aint °f
block and
erwhen9 t
T"'
examinati°n, the skin will be found
erythematous, smooth, only and shiny.
Margin: III defined; Surface-smooth, occasionally dry; Sensory
changes-lmpairment of pain or touch sensation.
(C) NERVE CHANGES
7. Sensory changes
b Nerve Lesions Nerve thickening not necessarily present.
c Skm smears by sht and scrape method. Negative
d Lepromm reaction. Negative to doubtful.
of the nerve or ants-crawling
(a) Tingling sensation in the course
sensation.
(b) Numbness of the skin
(c) Painless blisters and ulcers in hands and feet.
(d) Pain m the nerves behind big joints like inner side of elbow, outer side
II. Tuberculoid Type
of knee and inner side of ankle joints.
a Skm Lesions Number—One to three; Size—Could be of any size;
Colour—Hypopigmented or varying shades of erythema; ElevationRaised or flat In the raised lesions the entire lesion may be raised or
only the edges may be raised; Margin-well defined. The edges in the
raised lesions are abrupt; Surface—Dry, rough, anhydretic.
Consistency in raised lesion-Firm; Sensory changes-Analgesia
and/or anaesthesia.
2. Motor changes:
(a) Weakness and/or wasting of the muscles of hands and feet.
(b) Paralysis of muscles of hands, feet and eyes causing claw.ng of
fingers, foot drop and lagophthalmos.
b. Nerve Lesions In cases with raised lesions, cutaneous nerves
leading to the skin lesion and regional nerve trunks are often
enlarged. In cases with flat lesions such nerve enlargement may not
be observed.
III. diagnostic cardinal signs
Presence of any ONE OR MORE of the following:
c Skin smear by slit and scrape method: negative
1. Complete or partial loss of sensation in an area.
2 Thick and/or tender nerves.
3. Presence of M. Leprae' in smears taken by standard slit and scrape
a. Lepromm: Positive (1+ to 34-)
method.
Hi. Borderline Type
If a definite diagnosis cannot be arrived at. refer the case to an appropr ate
observation for 3 to 6
authority for examination or keep the patient under observat.on
months by which time either the lesions will heal or very clear s.gns of
The borderline type of leprosy represents a clinical spectrum
reflecting the immunological gradation from the tuberculoid at one
end to the lepromatous at the other. Both flat and raised skin lesions
are found throughout the spectrum.
leprosy or some other disease will appear.
When under observation, the patient should be very carefully examined once
a. Skm lesions: Number—4 or more, sometimes satellite lesions may
be observed near the larger ones: Size-Could be of any size; ColourHypopigmented or varying shades of erythema; Elevation Flat or
raised. In the raised lesions the entire lesions may be raised or only
the edges may be raised. There could be thus various patterns e.g.
uniformly raised, dome shaped circinate, concentric or irregular.
Margin—In the flat lesions margins may be ill-defined, partially
defined or well defined. In the raised lesions edges are sloping.
Surface-smooth to different grades of dryness. Consistency of raised
lesions-Rubbery to soft. Sensory changes-Modalities of sensation
may be lost to varying degrees.
every month.
IV CLASSIFICATION
(As approved by Indian Association of Leprolog^sts in its XII Biennial'
Conference held at Agra from 9th to 112th
— September 1981)-
I. Indeterminate Type
The indeterminate type represents those cases where leprosy is in
the very early stages of evolution. The skin lesions cons.st of
macules The clinical characteristics of the lesions are g.ven below:
a Skm lesions One to three; Size: Small (5 cm or less in d.ameter):
colour Hypopigmented; Elevation: Flat and flush with rest of the skm;
b Nerve lesions: In cases with raised lesions, cutaneous nerves
leading to the skin lesions and regional nerve trunks are often
enlarged. In cases with flat lesions, such nerve enlargement may not
be observed.
•ZTViiW
Treatment of multibacillary leprosy with Dapsone
c Skm smears by sht and scrape methc a Moderately positive to
negative.
Adults:
Children (6-14 yrs.)
DDS 100 mg daily self administered.
DOS 50 mg daily
d Lepromm Moderately positive to negative.
Note : Borderline leprosy could be divided into macular and
(below 6 yrs.)
Duration:
DDS 25 mg daily
Till the patient becomes clinically
• infiltrated types -In the hands of experienced workers it would be
possible to subdivide it into Borderline on Tuberculoid side (BT) and
Borderline on Lepromatous side (BL) both in the raised and flat
inactive and bacteriologically negative,
assessment being done every year.
lesions.
Inrens e Pf Mu’tidrU0 Tre8tment ♦or Multibacillary leprosy
IV. Lepromatos Type
a. Skm lesions . The skin lesions in lepromatous vary according to the
Adults:
daily supervised treatment should be
Children (6-9 yrs.)
given during initial intensive
phase or 14 days with following drugs.
Rifampicin — 600 mg
Clofazimine — 100 mg
Dapsone — 100 mg
Rifampicin 300 mg daily
stage of the disease. In the early stages the lesions could be seen as
macules which are small, numerous, symmetrically distributed,
hypopigmented or coppery red, ill defined, smooth and shining with
no sensory loss. As the disease advances, the lesions get infiltrated
with a smooth shining surface and with colour varying from coppery
red to reddish brown, involving the skin of the entire body except for
certain areas like the axilla, groin and flexures where lesions are
relatively inapparent. In the more advanced stages, papules nodules
Clofazimine 50 mg daily
Dapsone 25 mg daily
Children (10-14 yrs.)
appear.
Rifampicin 450 mg daily
Clofazimine 50 mg daily
Dapsone 50 mg daily
b. Nerve lesions : Some of the nerve trunks are enlarged on both
sides and are soft in consistency. Loss of sensation is found in the
distal parts of the limbs.
c. Skin smears by slit and scrpe method: Positive.
Continuation Phase
Treatment is given at least for a period of 24 months, or until smear
d. Lepromin : Negative.
negativity, whichever is later.
Adults:
V. Pure Neuritic Type.
Rifampicin 600 mg once montly supervised.
Clofazimine 300 mg once monthly
24 doses should
be completed within
36 months.
In this type of leprosy, there are no skin lesions. Larger nerve trunks or
their branches are enlarged. There is sensory loss in the areas of distribution
of the nerves. A single nerve or multiple nerves may be involved. The
enlarged nerves are generally firm, but may also be soft. Skin smears are
negative. Lepromin reaction is generally positive, but sometimes may be
supervised and 50 mg daily self
administered.
Dapsone 100 mg daily
self-administered.
doubtful or negative.
Treatment of Paucibacillary leprosy with Dapsone
V. TREATMENT
Dapsone still continues to be the sheet anchor in the treatment of leprosy.
Dapsone is cheap, easily administered, safe, effective and thus eminently
suitable for domiciliary care. The risk of the emergence of dapsone resistant
strains of M. leprae can be reduced by (a) using the drug in full dosage and(b)
Adults.
Dapsone 100 mg daily
Children (0-5 yrs.)
self-administered.
Dapsone 25 mg daily
(6-14 yrs.)
Dapsone 50 mg daily
ensuring regular daily treatment without any interruption.
Lk~
’asr ■* unr
x.'-nr
Practical recommendations
Multidrug Treatment for Paucibacillary leprosy
Adults:
Children (0-5 yrs.)
(6-14 yrs.)
Duration
(Source: Leprosy: Guidelines on case detection, treatment follow-up &
reporting, published by DGHS. New Delhi 1985}
5
1 Be on the ,ook out for relapse, especially in patients with lepromatous
or borderline-lepromatous leprosy.
2. When suspicious, proceed to clinical confirmation ofthe presence of
sulphone-resistant bacilli.
3. Be on the look-out forpatients presenting themselves with any form
of leprosy that does not respond as rapidly as it should to standard
treatment regimens.
4. Bacteriological evidence of resistance frequently precedes the
clinical. Therefore regular and frequent examination of skin smears
should be performed on all patients whose multibacillary leprosy is
considered to be quiescent after adequate periods of treatment.
Rifampicin 600 mg once daily supervised.
Dapsone 100 mg daily
self-administered
Dapsone 25 mg daily
Rifampicin 300 mg monthly
Dapsone 50 mg daily
Rifampicin 450 mg monthly
The treatment should be continued till
six months doses have been
administered. If reatment is interrupted,
the regimen, should be recommenced
where it was left off to complete
the full course provided six monthly
doses are given within a period
of nine months.
(Drug Resistance m Leprosy by Dr. S.G. Browne Published by The Leprosy
Mission London Jan. 79)
VII. BACTERIOLOGY READING
i'k ■
VI DRUG RESISTANCE
i' .
When to suspect
A patient suffering from lepromatous or borderline leprosy who has been
taking sulphone for a variable period and with good clinical and
bacteriological result develops new lesion for no obvious reason. He is
usually still taking his drug.
The new skin lesions resemble the old ones, or may be in the nature of
rapidly developing papules of maculo-erythematous eruption reminiscent of
drug rash. These lesions are persisted, they are not tender to touch, they
increase in size end number and they are not accompanied by signs of acute
exacerbation.
t
It
R.
How to Prevent
In a leprosy treatment control programme where patients are seen
regularly by competent auxiliaries or doctors, dapsone may be given at full
dose from the beginning of treatment but nerve pain must be recognised and
t
*
treated at once.
I':./.
K
iSs
Ridley's method
One plus : 1 to 10 bacilli seen in 100 fields.
Two plus5 : 1 to 10 bacilli seen in 10 fields.
Three plus : 1 to 10 bacilli seen in one average field.
Four plus : More than 10 bacilli seen in one average field.
Five plus : More than 100 bacilli seen in one average field.
Six plus
: More than 1000 bacilli seen in one average field.
VIII. SIGNS OF ACTIVITY
Presence of any ONE of the following indicates that the disease is reactive.
SKIN
1. Increase or decrease in size and number or lesions 2. Increase and
decrease in anaesthesia 3. Erythematous and infiltrative lesions 4. Presence
of bacilli by standard method of examination.
NERVES
5. Tender .(Painful on tapping)(Neuropathic ulcers, deformities, residual lesions anaesthetic patches,
wrinkled skin, etc., do not indicate signs of activity.)
How to treat
In the case of multibacillary leprosy due to dapsone resistant bacilli, if
possible give rifampicin for-three weeks together with clofazimine 100 mg
every other day and continue indefinitely with this dose of clofazimine. If
rifampicin is not available, then give clofazimine alone.
IX. CRITERIA FOR DISCHARGE
When all signs of activity are absent for a continuous period of 1 Vi years in
non-lepromatous patients and for 3 years in lepromatous patients, review
being taken every three to six months, the patients are called d'SGdse
(ii) A few minutes after washing of the nose, an antiseptic ointment or
.. or cured During the intervening period, the patients are called
r.oct'. f cases of leprosy
cream should be applied particularly to the area where there is an
ulcer
Treatment should be stopped in non-lepromatous cases when disease is
cured In lepromatous and borderline cases treatment should not be stopped
even after declaring the case as cured, but their names should be removed
from the list of active cases.
(iii) Any crust in the nose should be gently removed and an ointment or
vaseline applied to the area.
(iv) Flies should not be allowed to sit on the nostrils.
4. CARE OF EYES
C Gu:de to Leprosy Control 'Dr P Kdpoor)
X. CARE AND PREVENTION OF
DEFORMITIES
If a patient develops anaesthesia a few simple precautions will prevent
secondary deformities and even primary deformities to a great extent.
(i) Exercise (closing and opening) of eyes in case eyes are becoming
weak.
(ii) Check yourself in a mirror, or someone to check your eye in case eye
ball is losing sensation.
(iii) Contact doctor immediately on getting pain or ulcer in eyes or sudden
decrease/difficulty/loss of vision.
CARE OF HANDS
(i) Examine both hands every morning in good day light for any injuries.
If there is any he should immediately get it dressed and/or consult a
doctor.
(ii) Not to touch any hot object. Women to preferably use tongs.
(iii) Be careful about holding sharp or rough gadgets or instruments etc.
(iv) Should use gloves or small towels formed into a pad, or the
implements they use should have soft rubber or thick cloth cover at
the part which is held in the hand.
(v) Regular exercises of hands and feet with any vegetable oil as advised
by the medical officer or physiotherapist or leprosy tachnician.
2. CARE OF FEET
(i) Use any type of foot-wear without nails.
MCR foot-wear is better.
(ii) Not to walk long distance at.a time.
(iii) Walk slowly, steps should be short.
(iv) Not to stand at one particular place for a long time.
(v) If any cracks or fissures in the sole, the feet should be kept in ordinary
water for half an hour every morning and after drying a thin layer of
any oil should be applied.
(vi) Examine feet every morning in good day light for any injuries. If any,
get it dressed and/or consult a doctor.
3. CARE OF NOSE
(i) The inside of the nose should be washed with ordinary water. Take
handful of water in the cupped palm of your hand, or in a small basin
and then dip your nose intothat. Repeat it 10-15 times at a sitting. Do
♦his 3-4 times a day.
XI HEALTH EDUCATION
Definition:— "Health education is the process and result of providing
experience to the people for influencing their knowledge, attitudes and
practices in order to promote and maintain health and prevent illnessthrough their own active efforts".
Principles of Health Education
1. It is not enough that a teacher teaches; more important is that the
student learns.
2. All people irrespective of class, sex, caste, age, creed literacy or
rural/urban background, are capable of learning. One cannot teach
unless he himself believes that the student is capable of learning.
3. Though all people are capable of learning, everyone will not learn his
lesson the same way.
Though all people are capable of learning, somewilltake longerthan
others to learn.
5. Learning is more effective when learner is motivated and feels the
need of learning.
6. Learner learns not merely because a teacher teaches but only if the
learning is reinforced with earlier experiences or subsequently
acquired varied experiences relating to the content-matter.
7. Learning only by one sense can be reinforced by learning by another
sense.
Method & Media
1. Individual approach:— through personal interviews for bringing
about
action. Useful in enlisting cooperation of departments.
I
municipal officers. MLAs. MPs. social workers etc.; useful in solving
6. Increase in the number of patients being treated in private;
social problems of leprosy patients; useful for rihabilitation 2. Group approach:— through group discussions, group meetings,
dispensaries;
7. Increase in percentage of attendance of patients at clinics;
8. Reduction in severity of problem and difficulties faced by leprosy
patients.
panel discussions, movie forum, dialogue forum, seminar,
symposium, workshops etc for creating awareness, or creating
motivation for enlisting active cooperation and for gaining social
approval.
3. Mass approach:— through films, drama exhibition, slides,
newspaper, radio, television, folders, pamphlets etc. for creating
mass awareness about the problem and reaching minimum message
XII RECORDS
A. FOR PATIENTS
to a larger number.
1. Running list of patients both for project area cases and outside
project area cases separately arranged chronologically with monthly,
Material
1. Guide line schedule 2. Slides & slide-projector 3. Film/film-strip with
projector 4. Photographs-coloured and black & white 5. Booklets, folders,
quarterly and annual abstracts.
2. Villagewise list of—
(a) Patients (b) Suspected Cases (c) Cured persons (d) Absentee
pamphlets 6. Models, panels for exhibition etc.
patients showing the efforts made to make them regular.
3. Treatment record of patients showing signs, symptoms, treatment
Groups to be covered
and progress of patients.
4. Clinic Register.
1. Homogenous
groups:—
Such
as
nurses,
teachers,
medical
students, doctors, municipal or ZP councillors etc.
2. Heterogenous groups:— such as housewives, mahila mandals
5. Bacteriological Work Register.
B. FOR SURVEY
social service clubs (Lions. Rotarians), people from neighbouring
houses, gossip groups, etc.
3. Readymade groups:— Such as schools, colleges factories etc.
surveys have been done and the probable dates for future surveys.
2. Villagewise familywise survey records.
3. Villagewise abstract of survey showing new patients detected, the
Evaluation
Short term evaluation helps to modify the approach and methodology.
Terminal evaluation helps, the extent of objectives achieved.
Evaluation can be done by applying following tools:
5. Baseline data
2.
4.
6.
7. Interviews
8.
1. The guide-line schedule
3. Observation of indices
1. Villagewise survey chart showing the month in which the previous
The questionnaire
Pre-stage and post-stage data
Survey & re-surveys
Experiences enlisted by workers.
prevalence rate etc.
4. Villagewise School Survey Register with abstract of surveys.
5. Villagewise Contact Survey Register.
C. HEALTH EDUCATION
1. Villagewise list of elected, political, social and other important
persons.
2. Health education diary with advance programme and summary.
D. ADMINISTRATIVE RECORDS
Indices lor evaluation
1. Increase in voluntary reporting of cases;
2. Prepareness to get lesions diagnosed voluntarily;
3. Preparedness to keep the patient in home;
4. Increasing cooperation in rehabilitation;
5. Increase in the number of private physicians treating leprosy;
1. Monthly progress records.
2. Quarterly progress records.
3. Annual progress records.
("Guide to Leprosy & leprosy Control" Dr. P Kapoor)
I
<
Notations used for charting
leprosy patients
Nodules
Hypopigmented flat patch with clear-cut margin.
Nodules with ulceration
Hypopigmented flat patch with clear-cut margin and
anaesthesia.
'ijoaookl
. a;ODR*ia
• urterntM
• rasa *q ■>
LirCDOQB vj
A
Hypopigmented, uniformly raised, patch with
anaesthesia and clear-cut margin. If the rising is
confined to the margin alone the dots should be
placed around the margin.
Hypopigmented uniformly raised patch with
anaesthesia, clear-cut margin and central healing.
Hypopigmented, uniformly raised patch with
anesthesia, clear-cut margin and central ulceration.
-J
imiin
A
s
Anesthesia
Flexion of fingers
Contracture of fingers
Loss of digits
(Vertical line to be longer than the horizontal line)
Hypopigmented. flat, ill-defined patch without
anaesthesia.
Ulcer
Hypopigmented. uniformly raised ill-defined patch
with anaesthesia.
Erythematous raised patch with anaesthesia.
Dense infiltration
Diffuse infiltration
Nerve thickening (represented by a thick line drawn at
rhe site where nerve is thickened)
Depressed nose
Gradation of thickening of nerves
Nerve not thickened
Nerve thickened but not Ilikely
' \ to cause deformities
Nerve thickened and likely, to
.J cr_z
cause deformities
Nerve thickening with deformities
N I
N II
N III
N IV
PREVALENCE OF LEPROSY
IN THE WORLD
CLASSIFICATION OF DEFORMITY
I. HANDS
Names of countries
Grade— 1-Anaesthesia to pain
2- Mobile claw hand Useful thumb.
3- lntrinsic paralysis involving fingers and thumb or fingers
only but with contractures (include wrist d-op)
4- Partial absorption of fingers but with useful length
Prevalence Rate
Per 1000
Canada, Panama, USA, Japan
Israel, Greece, Spain, USSR
0.0 to 0.5
Mexico, Jamaicas. Afghanistan, Ceylon,
Iran. Iraq, Maldivi Islands, Turkey
0 5 to 0.9
France, South Africa, South West
Africa, UAR Argentina, Cuba
China, Korea, Pakistan, Phillippines
Fiji, Tonga
1 0 to 4.9
Ethiopia, Kenya, Mauritania
Bhutan, Cambobia,
India, Nepal, Vietnam
5.0 to 9.9
Angola, Nigeria, Uganda, Surinam
10.0 to 19.0
Senegal, Burma
20.0 to 29.0
2- Colapse of nose.
.
3- Paralysis of eyelids, including lagopthalmos or paralysis of
Chad, Congo, Mali
30.0 to 39.0
the facial nerve.
4- Loss of vision in one eye or dimness of both eyes (cannot
see fingers.)
Gaban, Zambia, Spanish Equatorial
Region
40 0 to 49.9
Central African Republic,
French Guiana
above 50.0
remaining.
5- Gross absorption Stumps only left.
II. FEET
Grade— 1 -Anaesthesia
2- Trophic Ulceration (present and past)
3- Paralysis (foot-drop and claw toes)
4- Partial absorption of the foot (upto 1 /3rd of surface area of
the sole of the foot.)
5- Gross absorption (More than 1/3rd feet lost)
III. FACE
Type_ i - a p...
irk of stigma of leprosy not amounting to
uglir.cs; . ass of eye brows, deformity of ears).
IV. MISCELLANEOUS
Type— 1 -Gynaecomastia (in case of males)
2-lnvolvement of the larynx.
(WHO Technical Report Series No. 189)
I
NATIONAL
LEPROSY ERADICATION PROGRAMME
(Figures in thousands)
State/Union
Estimated
Leprosy
Territory
Cases of
(1981 Census)
Cases on
record by
31 31986
651
15
380
100
7
5
222
75
120
400
6
6
5
320
10
733
10
410
430
5
10
27
475
18
295
87
5
6
165
88
152
396
6
6
2
234
15
547
6
464
306
5
8
18
475
18
263
79
5
5
160
74
152
396
4
3
2
232
14
483
3
435
229
2
6
20
3947
3305
3060
leprosy
Andhra Pradesh
Assam
Bihar
Gujarat
Himachal Pradesh
Jammu & Kashmir
Karnataka
Kerala
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Nagaland
Orissa
Rajasthan
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
Goa Daman & Diu
Pondicherry
Rest of India
Source: DGHS. New Delhi
Leprosy
Cases under
treatment by
31.3 1985
engagements
_Di^>
/
I
Report of work done during December
1987
I. Total population
by end of previous month
INDIA
>.u of cases
No of
persons
examined
detected
total
H
II. Surveys
I
1
Sy
i
1. Upto the end of previous
month
2. During the month
3 Totai upto the end of month
...
III. Cases Detected
I
I
Upto the end of previous
1
month
2. During the month
3 Total upto the end of month
4 Cases died and left
I
1
■
II
;-v\re
IV. Cases registered
■
1
By end of previous month
I
2. During the month
3 Cases died and left
4 (al No registered and living
at the end of the month
(b) No. actually took treatment
during the month
V. Extra-zonal patients
Registered
1. During the month
2 No Previously registered
>
r
J
1
8
3 Total till end of month
4 No actually attended for
treatment
I
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PHYSICAL ACHIEVEMENTS OF FIVE YEAR PLANS
Target
Achieve
ments
40
4
31
4
Fhst Plan 1951-66
'
Lep. con Units
Stud/-cum-Treatment Centre
1.
2
3
4
20 m
Population covered
Cases recorded for treatment
Second Plan 1966-61
1
Lep Con Units
2.
SEI. Centres
Population covered
Cases recorded for treatment
Third Plan 1S61-66
3
4
1
2
Lep. Con Units
SET Centres
3
Lep Try Centres
Population Covered
Cases recorded for treatment
Annual Plans 1966-69
4
b
1
2
3
4
Lep Con Units
SET. Centres
Lep Trg Centres
population covei
recorded
5. Cases r~
-------- for treatment
0.17 Lakhs
100
4^1
103
44
12 51 m
0.95 Lakhs
50
786
10
46
564
10
40.69 m
4.59 Lakhs
26
659
4
l
1
379
1
1i C
p on
•/'w* •• •
2.10 Lakhs
Cumulative
Coverage
31
4
30 m
Plan
Allocation
Rs. 35
Lakhs
0.17 Lakhs
134
194
14.51 m
1.12 Lakhs
Rs. 529
Lakhs
180
758
20
55.20 m
5.68 Lakhs
181
1137
21
64.10 m
7.78 Lakhs
Rs 424 40
Lakhs
Rs. 62 7 7
Lakhs
E
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CO
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Centres
Cumulative
Coverage
Cumulative
Coverage
Plan
Allocation
Sixth Plan (till 31-3-1986)
Leprosy Control Units
Upgradation of LCUS
SET Centres
Urban Leprosy Centres
5 Upgradation of ULCs
6 Leprosy Training Centres
7, Reconstructive Surgery Units
8. Temporary Hospitalisation Wards
9 Disr Zonal Leprosy Officers
1
2
3
4
429
165
674C
772
52
43
10. Upgradation of DLO
73
266
209"
80
11. Upgradation of LTCs
21
12. Non Medical Supervisors
13. Cases on record
14. Cases discharged during (85-86)
15. Cases under tratment
16. Expenditure (1985-86)
Cash—
Kind—
Total—
17. Budget Allocation (1986-87)
CashKind—
12G5
33.05 Lakhs
4.36 Lakhs
30.60 Lakhs
1804.83 Lakhs
519.13 "
2323.96 •'
932.44 Lakhs
467.56 "
Totall400.00 "
t
f
NATIONAL
LEPROSY ERADICATION
PROGAMME
'.S
Leprosy training activities
(i) No of training centres 12
(it) Intake capacity per
annum
(a) Medteal
Performance of Voluntary Sector under NLEP
i
(b) Paramedical
Activity
Voluntary
sector
53 VOs
s
Government
sector
as on
July 86
(iii) No. trained so far
(a) Medical
Total
Leprosy cases on record 732669
(22.06)
2588883
(77.94)
33215 r2
Leprosy cases under
treatment
2431436
3060345
628909
(20.55)
Leprosy cases discharged
after cure
110357
(4.66)
Population covered (lakhs)489.26
(12.23)
Expenditure per leprosy
case (Rs)
184.80
Number of leprosy beds 18607
(57.68)
54.10
13649
(42.32)
32256
1500
20514
(7.31)
7000
(24.55)
28518
4000.00
2754.5
119
(49 58)
240
1765
(75.43)
2340
(24.57)
2537
(50.08)
5623
(20.12)
2529
(49.92)
22326
(79.88)
5065
121
(50.42)
575
27949
I
4
Grant in aid released, ty Central Govt, to V.Os
No.of V.Os
Amount
supported
(Rs. in lakhs)
(i) 1983-84
44
35.92
49
(ii) 1984-85
51.71
(iit) 1985-86
51
62.00
(iv) 1986-87
55.00
(Provisional)
Rehabilitation of leprosy
(ii) Vocational
(b) Paramedical
2366191
Annual budget Rs. in lakhsl 354.5
(49.17)
19014
(92.69)
21518
(75.45)
43
1
(79.45)
2255834
(95.34)
3510.74
(87.77)
1400.00
(50.83)
cases
(i) Medical
31
(72.09)
(27.91)
I
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JSsEsS 5
BACTERIOLOGY GF LEPROSY
V. Periaswami
MHH
Tilts
§§§§£& 3
ni III”
2 ST'
Rs. 5/-*
"The presentation of the subject is in simple language and lucid sty1®
— Dr. M.S Nilakanta Rao
I!
— Dr. Dharmendra
i
I
' The book gives background information and all usefull procedures
lab technician and the medical officer All
necessary for paramedical worker
lucidly described...
techniques.
essentials of smear technology
procedures and bps very useful "
— Dr. K.V. Desikan
W
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< QS'
o
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B 3-
XX X X X
v> v> m y> yi
3 3
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I
N) Q CO ir OI <B
O
£
3
C
3
I
>
3
£
Q
o
edition just published.
i
* Packing and postge extra
for both the above publications
2.
Piease Write to -
I
Secretary, National Leprosy Organisation
Hindinagar Wardha 442 103 Maharashtra
I
j
I
e°
i
I
I
■t
-
Very well received by field workers for its valuable information Second
I
3□
7i
v>
Dr. V. Ekambaram
Rs 6/-*
0
0
!
EPIDEMIOLOGY
FOR LEPROSY WORKERS
I
IB I
H&lis
fi
"It would certainly be o’ I'elp to new comers in the field of leprc-sy
particularly the paramed cai workers
—‘
3
5? w » « v v
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W NJ N> M W
88888g
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n□ 3~
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6’ □
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'i
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'SCKIEFFELIN LEPROSY1
(RESEARCH & TRAINING
CENTRE, KARIGIRI
WHO'S COlWRipij'iOn TO NLEP
I
WHO will collaborate with the Government of India in strengthening the
infrastructure of the National LepiuSy Fr^dir.ation Programme the major
S.L.R Sanatorium P.O.,
thrust will be on intensification of case finding activities, expansion of
treatment facilibes with mult i-drug regimens and improved case holding and
Dist. North Arcot
' The following teaching programmes are avilable for
' teaching the medical students and doctors about
leprosy.
surveillance activities, in 36 high endemic districts in the country
i
Duration Amount
in mtn.
1. Painless feet by Dr. E.P. Fritschi
,
16
Rs. 800/2. Mice against leprosy by Dr. Joel Alme‘d alO
Rs. 500/-
i
Assistance will be provided for strengthening research and. training
centres through the provision of equipment and the establishment of
facilities for monitor.ng drug resistance.
Video Tapes
I 3 Healing while walking by Dr. E.P. Fritschi45
■ 4. Keep blinking by Dr. N.S Suryawanshi 20
5. Trackingdown the mysterious agent
by Dr. C.J.C. Chacko
33
6 Temporalis Muscle transfe- by Dr E P. Fritschi28
20
7. The red eye by Dr. N. Suryawanshi
Slide-Audio Casette Programme
8. Leprosy : the great imitator by
42
Dr. S. Arunthathi
, 9.An introduction to leprosy control
20
|
by Dr. K. Jesudasan
10. Five faces of leprosy • Dr. S. Arunthathi55
IN 1987 88
!
Workshops. seminars and task oriented training courses based on well
designed modules will be organized to improve staff skills and promote
Rs.850/Rs.750/-
programme implementation. Fellowships will be provided for training of
technical staff in the epidemiology and control of leprosy.
Rs.845/-
Increased emphasis will be given to support the strengthening of health
education component of the programme in 2 or 3 States so that this can be a
model for other States to follow Community involvement will be promoted to
ensure the success of the new strategy.
Rs.680/Rs.700/-
Rs.950/Programme evaluation will receive priority support in order to assess the
effectiveness of the managerial process and the impact of the programme.
Rs.400/
Rs 950/-
Research projects will continue to receive assistance through the Special
Programme for Research and Training in Tropical Diseases.
The video tapes are available in VHS format
of the PAL system
For further details and orders please v/rite to
The Director,
Schteffeltn Leprosy Research & Training Centre
karigiri, Tamil Nadu, S. India, 632 106
1
!
I
BOOKS ON LEPROSY
--------- 1
1. Leprosy in Theory & Practice by Dr RG Cochrane Wright and Sons
Ltd Bristol
Window on Leprosy
Hand Book cf Leprosy by Dr W.H Jophng. Heineman Medical
Books Ltd London.
3 Hints on Diagnosis & Treatment of Leprosy by Dr R.V. Wardekar.
Gandhi Memorial Leprosy Foundation Hindmagar. Wardha
2
pp 395 Rs 75
EDITOR- Dr E R C/Mllerjee
Maharashtra 442 103 Rs 7-00
,|<-i ;dedlv
The overall conten! and app’icat '-n on ::ms valuable
r
.ill those
international This borA s' ould be on the working shelves c1
seriously interested in leprosy
LEPRO!’'*' REVIEW
197" 49 327
4
Leprosy: A text book by Dr Dharmendra Vol I. 1979 The Kothari
Book Depot, Acharya Dcr-.de Marc, Parel Bombay-400 012 Re
250 6 Window on Leprosy, Ed Dr. B R Chatterjee, Gandhi Memorial
5
pl
- has practical value for all categories of HD workers An
and comprehensive presentation of all aspects of HD
Leprosy Foundation. Wardha. 442 103 Rs 75-00
7. Epidemiology for Leprosy Workers by Dr V. Kkambaram, (2nd
I HF STAR
edition) National Lepropsy Organisation,
Maharashtra 442 103. Rs. 6 '-
19/B 38 6. 8
------ This commemorative volume is
class by itself
8
LEPROSV IN 'NDIA
1978. I*'
1- *168-
1
Society and Leprosy
9
Hindmagar,
Wardha
Bacteriology of Leprosy, by V. Periaswami, National Leprosy
Organisation, Hindmagar. Wardha, 442 103 Rs. 5/The Diagnosis & Management of Early Leprosy by Dr Stanley G
Browne, The Leprosy Mission, 7 Blooms bury Square London. W.C I.
10 Guide to Leprosy & Leprosy Control by Dr P Kapoor Poona Dist.
Leprosy Committee, 16-B1 Dr. Ambedkar Road Poona 411 001
11. Modern Concept by Dr Harry L. Arnold. Charles C Thomas.
Bannerstone House 301. 327 East Lawrence Avenue Springfield
Illinois, USA
12. Some Facts about Leprosy by Dr Dharmendra. Hind Kusht Nivaran
Sangh, I RedCrossRoad New Delhi 110001 (EnglishiRs 3/-(Hind;>
Rs. 3 75
13 Leprosy-Diagnosis & Management by Drs. Job. Selvapandian &
Pp 297 Rs. 30
RK MUTATKAR
Hr-af! ■ ' Dr;;.!- "
Leprosy: Guidelines on case detection, treatment, follow-up &
reporting; DGHS Nev. Delhi.
■ r
of
Kurian, HKNS. New Delhi Rs 19/14 Orientation for Doctors in Leprosy, HKNS New Delhi 110 001 Rs
n icgarding
Thebook fills a great need in the literature on health educatin'
pit workers
leprosy. It can be highly recommended for use of medical and so» 1
10/15 Leprosy Diagnostic. HKNS. New Delhi (paper back) Rs 10/-, (Hard
bound) Rs. 15/16. Text Book of Leprosy for Students and PMWs by Dr. RH
Thangaraj. Philadelphia Leprosy Hospital. Salur. Dist. Srikakulam
A P Rs 37/-
- A study in evaluation research. Health education protl'.
GMLF evaluated.
in leprosy.
dhai,k/'endra
For orders, please contact—
Gandhi Memorial Leprosy Foundation
Hindinagar, Wardha, 442 103, Maharashtra
17. Physical Therapy in Leprosy for Paramedicals by Ellen Davis Kelly.
Ph D . American Leprosy Mission 1262 Broad Street. Bloom Field
New Jersey 07003 USA
18. The book of outlines by Shri S. Hassan, Hind Kusht Nivaran Sangh
AP Branch. 3-4-760. Barkatpura. Hyderabad. 500 027
I
I
19 Handbook on Leprosy by Shr MK Balaknshna Menon. Ernakulam
District Leprosy Welfare Committee. Tnpunitura 682 301 Dist
Ernakulam. Kerala. Rs. 10
20 Essentials of Leprosy. Eo.ted by JMH Pearsun & AW
Al.
A valuable document by GMLF
Africa Leprosy & Rehabilitation Training Centre (ALERT; Aod-s
Ababa Ethiopia. 3rd Edition. 1 979.
,
A Guide to Health Education in Leprosy by P J Neville. ALERT jrd
21
MASTER PLAN
Edition. 1979
22 A Practical Guide to the Diagnosis & Treatment of Leprosy in toe
Basic Health unit, by AW Wheate & JMH Pearson. AlERT. 19/9.
23.
FOR ERADICATION OF LEPROSY
through
A Food-wear Mannual for Leprosy Control Programmes Part I. P.J.
MASS AWARENESS. HEALTH EDUCATION
AND COMMUNITY PARTICIPATION
a crystahzation of views
Neville. ALERT. 1977. 1st Edition.
Gandhi Looks at leprosy: Rs 5/- 1971 Gandh. Memorial Leprosy
24
Foundation. Hindinagar Wardha. 442 103 Maharashtra
Teaching Guide for PMWs in Leprosy Vol, I 6c II by Dr D.b
25
Choudhury. GRECALTES, 35'1 / A, Old Ballygunje. 1 st lane. Calcutta
expressed by experts from leprosy and allied fields.
Pages 75. size 21 cms x 21 cms
Rs. 50/- (Plus Rs. 8/- postage)
700 019
'I have no hesitation to say that this, no doubt, is a masterpiece-.
Dr. A M Kurup
Jt. Director, Ministry of Welfare
^rz73J0URNALS ,N LEPROSY
New Delhi
F<1
LF? 1 /
*
Indian Journal of Dermatology Venerology & Leprology. 7,
Shahayog-Opp. Dinbhai Tower, Lal Darwaja. Ahmedabad 380 001
'it has been brought out very well.. It addresses itself to the great necessity
of health education in leprosy without which Attack Phase- would be
ineffective.'
Rs. 20/C.—-2. International Journal of Leprosy, one Broadway. Eimwood Park,
3
N.J. 07407. USA.
Leprosy Review, Fairfax House* Couston Road. Colchester, CO! IPU.
England. 10 50 Poundo
/ r / ' "’z f :
4 Indian Journal of Leprosy/Hind Kusht Nivaran Sangh, I Red C oss
Road, New Delhi 110 001 Rs. 40/-.
Dr J M. Mehta
■
'-l
^3.
President
Poona District Leprosy Committee.
The document produced by GMLF is exemplary, for which Leprosy workers
should be grateful.'
5- Partner, Leprosy Mission, Health Education Centre. Naini, Allahabad
6
7. NLO Bulletin, National Leprosy Organisation, India Hindmagar,
Wardha, Maharashtra; 442 103, for members Free, For institutional
non-members Rs. 20/-.
8. Kusht Vinashak, HKNS, New Delhi, Rs. 5/-.
9. Joint Action, Post Box No. 7457 Bombay, 400 060, Rs 5 for 3 yrs.
10. Relief, Hansen Memorial Relief Organisation, Narasarao pet, 522
11
G.S. Dalmia
Secretary
Santal Paharia Seva Mandal
Deoghar (Bihar)
UP. 211 008
The Star, Box 325, Carville, La. 70721 USA, 1 Dollar.
601. Dist. Guntur, AP, Supplied free to members
Kusht Seva Gujrath Raktaphta Nivaran Seva Sangh, 2nd floor,
Kamaikunj, Gandhi Gate Road, Vadodara 390 017.
12. Snehadeepthi, The Ernakulam District Leprosy Welfare Committee.
General Hospital, Tripunithura, 682 301 (Kerala) Rs. 12/-.
Please wiiie lo
GANDHI MEMORIAL LEPROSY FOUNDATION
HINDINAGAR. WARDHA, 442 103, MAHARASHTRA, INDIA
1
HEALTH EDUCATION MATERIAL.
SANTAL PAHARiA SEVA MANUAL
DEOGHAR
SANTAL PAHARIA SEVA MANDAL is one of the very few
VOLUNTARY ORGANISATIONS in the COUNTRY, who serves for
the cause of human suffering since last 50 years.
ACTIVITIES
1 LEPROSY CONTROL PROGRAMME started in 1955:—
(!) Four SET Centres; (ii) Five Leprosy Control Units: (iii) Five
Leprosy Hospitals & (iv) Re-constructive Surgery Hospital-one.
Out-turn : Till July '86. Leprosy patients recorded 18.649 & cured
5.442, rehabiiited 2,362 leprosy patients through Re-constructive
Surgical Hospital, MADHUPUR, after surgical correction of
deformities etc.
Leprosy Eradication Programme through MULTI DRUG
REGIMEN PROJECT is continuing in 10 lac population since 30th
i Jan. 85.
1 2. Other Health Services:
one
two
four
one
(i) Maternity Hospital
i (ii) T.B. Cure Centre
! (iii) Ayurvedic Charitable Dispensary
(iv) Nature Cure Research Hospital
3. Educational
(i) Development of Santhali Language & Literature.
I (ii) High School : Three & Middle School : Four
' (iii) Harijan & Adivasi Hostel : four
• 4 .Other Activities
(i) Rehabilitation Training Centre for Handicapped Children: One
I
(ii) Krishi Vigyan Kendra: One
(iii) Paharia Kalyan Kendra, Chandna : One
(iv) Integrated Rural Development Work: One
(v) Khadi Gramcdyog Work.
Budget for the year 1986-87
Rs. 56,05, 800/-.
General Secretary : Shri Gauri Shankar Dalmia.
Available With
Gandhi Memorial Leprosy Foundation
P.O. Hindinagar, Wardha — 442 1 03 Maharashtra
PUBLICATIONS
1. Master Plan for Eradication of Leprosy
2. Window on Leprosy
3. Society and Leprosy
4 Gandhi Looks at Leprosy
5. Hints on Diagnosis and Treatment of Leprosy
6 Leprosy-Everyone s Concern
Hindi version
English version
Marathi version
Kannada version
7. Folders
(i) Leprosy-A misleading disease
(ii) Leprosy-Know the facts
(iii) This lies in Your Power
(iv) Ten points to remember
8. Pamph'et; Leprosy-Ouestions and
Answers (per 100)
Rs. 50 00
Rs. 75 00 V
Rs. 30 00
Rs 5 00 '-y
Rs 7.00 S
Rs 2 50
Rs 2.00
Rs 2 00
Rs 2 25
Rs. 10/- per 100
Rs. 30.00
Available m English. Hindi and Marathi
COLOURED SLIDES
A set of 48 coloured transparencies for
display in rural and school prografnmes and
group-talks in urban as well as rural areas. ’
(Per set)
Rs. 550.00
Exhibition on Leprosy
Wardha Nagari Sahakari Adhikosh (Bank) •
1
Maryadit Wardha
I
A set of 20 panels of 19" x 27" size beautifully screen-printed in
multicolours, each panel protected by a polythene cover, supplied in a sturdy
canvas bag Available in Hindi, Marathi and Bengali & English Can be
prepared in any language if order for 60 sets assured
HEAD OFFICE
Rs 700 00
per set
BHUTE BUILDING. MAGANWADI LAYOUT
WARDHA
I
Establishment
Phone : 2463
1969
Flash Cards
Branches:
A set of 10 flash cards printed in four colours on ivory card, laminated,
size 10" x 7". spiral bound. Protected in a plastic jacket. Useful for any health
education programme.
I
1 Mam Branch Wardha. 2 Kumarappa Marg. Wardha.
3. Hmganghat. 4 Pulgaon. 5. Arvi. 6. Smdi (Rly.)
Rs 30 00
per set
Position on 30.6.86
♦
i
Amount in Lakhs
13.21
1) Share Capital
i
11.20
308 98
84.59
218.45
2) Funds
3i Deposits
4) Investment
5'Loans
6) Working Capital
35348
4.04
A'
7' Profit
8) Auoit Class
Album
- ;
Contains 20 colour enlargements of 5" x 4"
Rs 45 00
Gandhi & Leprosy
!
Photographs of charcoal drawings of 21 events m Gandhiji's life showing
his association with leprosy work.
Size: . 15" x 12" — 1000.00 24" x 20" - 2000.00
(al We are paying 1% more interest on Deposits.
(b) We are having attractive Deposit Schemes.
(c) All deposits are secured under Deposit Insurance Scheme.
Fiims
'Put your Deposits in our Bank under Co-operative Sector'
ControHing Leprosy— A Colour documentary, 2000 ft. 20 minutes.
16mm prints available in English & Hindi.
Directors
Sarvashri. B D Patkey. Dr S G Bhalerao, R M. Deshmukh. K.A Borikar, P.B.
Dafaie, M B Batra, Dr. P R Khandeshwar, P.N Pande, G S. Chandekar, D G
Karmarkar, G.N. Khedulkar, S.P. Kawale, S G. Deshpande (Staff
hepreseniative)
Shri C G Vinze
(Chief Executive Officer)
Rs 4100 00
per set
*
Language versions can be made available if order for 30 prints assured
Rs. 4600
per print
Note: Packing and forawardmg charges for all the
above material will be extra.
I
LEPROSY
HOW THEY LOOK AT IT
HATE THE DISEASE
NOT THE PATIENT
Mahatma Gandhi
□ Leprosy work is not merely medical relief, it is transforming
frustration m hfe into the joy of ded-t ation. personal ambition into
seifless service
□ Why should there be a stigma about leprosy any more than about any
other disease?
□ Leper is a word of bad odour. India is perhaps a home of lepers next
only to Central Africa Yet they are as much a part of society as the
tallest among us. But the tall absorb our attention though they are
least in need of it. The lot of the lepers who are much in need of
W/f/? humble regards
JAIMINI PHOTOGRAPHERS
Ibrahimpura, Bhopal, 462 001
Telephone - 72333
attention is studied neglect. I am tempted to call it heartless which it
certainly is in terms of non-violence If we were all in earnest about
winning independence through quickest manner by truthful and
non-violent means there would not be a leper or beggar in India
uncared for.
Dr. R.V. Wardekar
□ Within limits of normality, every individual loves himself. In case
where he has a deformity or abnormality or developes later. Ins own
aesthetic sense revolts and he develops a sort of disgust towards
himself. Though with time, he becomes reconciled to his deformities,
it is only at the conscious level. His subconscious mind which
continues to bear the mark of injury brings about certain changes in
his whole personality making him suspicious of society
□ In changing our attitude towards leprosy patients we will not be
obliging anybody—we will be doing it only to make the environment
safe for us.
Indira Gandhi
We undertake specialised jobs like
Medical—Agricultural Industrial-Commercial &
with technical video filming j
Advertising photography
□ A major obstacle is the general public ignorance and superstition
regarding leprosy. People tend to evade ivestigation and hesitate to
admit to the disease al the early stages when a cure could be
complete and easier. This sense of shame is out dated and
dangerous.
(WHO Assembly, Geneva; May 1981)
Giani Zail Singh
j
JAIMINI means the highest
professional competence at your service.
D We must understand that a patient of leprosy is a MAN first and a
patient later .. We cannot afford to have over 35 lakhs of our citizens
out of the National mainstream, they are part of us and we have to
accept them back in our fold.
I
How to celebrate
Anti-Leprosy Week
rP.D. HIMATS1NGKA
Leprosy Day tn our country was being observed on 30th Januaty even
year HI 1968 From 1969. the Gandhi Centenafy year, live NLO. made
attempts for observance of a week instead of a day The Central Government
too issued instructions to States for observance of Leprosy Week, in 1974
WISHES
Leprosy workers and institutions can unde-take target oriented work tn
the Week Stress should be on intensive health education Following are
some of the activities suggested for Anti-Leprosy Week.
Intensification of health education by' holding two meetings per
worker per day
2
I
I
national
LEPROSY
ORGANISATION
I
I
■
J
S-
Complete Success
IN THEIR WORK
Arranging seminars'symposia on any aspect of leprosy, separately
for medical men, teachers and other groups.
3. Seminar/panel discussion for medteal men only.
5
Arranging exhibition on leprosy.
Persuading every irregular patient to take treatment regularly.
6. Attempt to register every unregistered patient, lepromatus patients
tn particular.
7. Examination of school-going children
8. Sale/distribution of literature on leprosy
9 Film show on leprosy.
10. Sale of leprosy seals through service organisations and students.
LEPROSY SEALS
Available with NLO & HKNS
at R. 26/- per 1000
postage Rs. 8/- extra
I
jDt«S gck G
APPR
LEPROSY IN RURAL INDIA
472
f.
Re-entry:
N
N?L L Total
i) Total PL in the ara
ii) No. of re-entries
Age, Sex classification of the total cases:
Sex
Age N N?L
Croup
Male
Female
L
Presence of
Ulcer
Presence of
deformity
Type
Upper Lower Face Absent Total Pre Absent Total
sent
Limb Limb
0-15
16-30
31-45
46 and above
0-15
16-30
31-45
46 and above
III. A) Detections:
N
N?L L Total
N
N?L L Total
a) P.L.
b) Dead
c) Untraceable
d) Double entry
e) Wrong diagnosis
B) Cured patients:
a) S.H.
b) LRD
c) Inactive under observation
1
CES
473
IV. Total active cases (Total cases
minus PLZ LRDZ SHZ Untraceablez
double entry, wrong diagnosis)
from the Project Area Only:
N
N?L L Total
N
N?L L Total
N
N?L L Total
V. Regularity of treatment:
i) Regular for 75% and above
of total weeks
ii) Regular for 50-74% of total
weeks
iii) Regular for 25-49% of
total weeks
iv) Regular for below 25% of
total weeks
VI. Bacteriological Examination:
1. Total No. of cases in the
project area:
2. Total No. of patients for
whom smear has not been taken:
3. Total No. of patients for whom
smear has been taken only once;
4. Total No. of patients for whom
smear has been taken twice;
5. Total No. of patients for whom
smear has been taken three times:
6. Total No. of patients for whom
smear has been taken four times:
7. Total No. of patients for whom
smear has been taken for more
than four times:
8. Total positive cases:
LEPROSY IN RURAL INDIA
474
Appendix *D’
VII. 1. Deformity among total patients from the project area:
N
N?L L Total
No. of patients with deformity
No. of patients without deformity
OLD MDT DISTRICTS PROPOSED FOR
INTEGRATION WITH GENERAL HEALTH CARE
Districts
Total
2. Deformity among patients from the outside project
area:
N N?L L Total
i) with deformity
ii) without deformity
Total
Signature
State
1. Srikakulam
2. Vijayanagram
3. Baroda
4. Belgaum
5. Dharwad
6. Amravati
7. Wardha
8. Ganjam
9. Ambedekar District
10. T.S. District
11. Purulia
Andhra Pradesh
Andhra Pradesh
Gujarat
Karnataka
Karnataka
Maharashtra
Maharashtra
Orissa
Tamil Nadu
Tamil Nadu
West Bengal
i
Appendix 'E*
LIST OF DISTRICTS COVERED UNDER MDT SCHEME
(REGULAR PATTERN)
State
Districts
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Anantapur
Guntur
Rangareddy
Mahaboobnagar
Nizamabad
Kham mam
Vishakhapatnam
Chittor
East Godavari
Krishna
Warangal
Na^gonda
Cuddapah
West Godavari
Karimnagar
Medak
Nellore
Kurnool
Prakasam
Adilabad
Hyderabad
Andhra Pradesh
22.
Karbi-anglong (PO Diphu)
Assam
23.
24.
25.
26.
Deogarh
Singhum
Bhagalpur
Rohtas
Bihar
27.
Dangs
Gujarat
477
APPJ
ICES
28.
29.
30.
31.
Panchmahal (Godhra) ’
Surat
Bharuch
Valsad
32.
33.
34.
35.
36.
37.
Bidar
Gulbarga
Raichur
Bijapur
Bellary
Mysore
Karnataka
38.
39.
40.
41.
42.
Alleppey
Trichur
Trivandrum
Quilen
Palghat
Kerala
43.
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
Durg
Rajnandgaon
Raigarh
Bilaspur
Bastar
Raipur
Bhind
Gwalior
Rewa
Ujjain
Sagar
Madhya Pradesh
54.
55.
56.
57.
58.
59.
Chandrapur
Nanded
Usmanabad
Yavatmal
Latur
Gadchiroli
Maharashtra
i
I
478
LEPROSY IN RURAL INDIA
60.
61.
62.
63.
64.
65.
66.
67.
68.
69.
70.
Bhandara
Nagpur
Thane
Solapur
Satara
Parbhani
Raigad
Akola
Buldana
Beed
Bombay
71.
Mon
72. Puri
73. Cuttack
74. Dhenkanal
75. Mayurbhanj
76. Balasore
77. Sambalpur
78. Bolangir
79. Koraput
80.
81.
82.
83.
84.
85.
86.
87.
88.
89.
90.
91.
92.
93.
Chingalpattu
Salem
P. M.R. Sivaganga
Kama raja r
Ramnathapuram
Dharampuri
Thanjavur
Periyar
Q. E.M. Dindigul
Madurai
South Arcot
Puddukottai
Tirchirapalli
Nellai Kata Bomman
APPENDICES
J
Nagaland
Orissa
Tamil Nadu
94.
95.
96.
97.
98.
479
V.O. Chidambamar
Coimbotore
Nilgiris
Kanyakumari
Madras
99. Varanasi
100. Barabanki
101. Dehra Dun
102. Faizabad
103. Sitapur
104. Kheri
105. Kanpur (Urban)
10$. Kanpur (Dehat)
107. Uttar Kashi
108. Pilibhit
109. Bahraich
110. Deoria
111. Hardoi
112. Raebareilly
113. Azamgarh
114. Ballia
115. Gazipur
116. Mirzapur
Uttar Pradesh
117. Bankura
118. Burd wan
119. Midnapore
120. Birbhum
West Bengal
e
I
121. Lakshadweep
Lakshadweep
12?. Pondicherry
123. Karaikal
124. Yanam
Pondicherry
125. Bishnupur
Manipur
Appendix 'F'
APPENDICES
DISTRICTS COVERED UNDER MODIFIED
MDT SCHEME
Districts
State
4
32. Shahdol
33. Surguja
i
Tirap
West Sian
East Siang
Towang
Arunachal Pradesh
34. Tamonglug
35. Chandel
Bihar
14.
15.
16.
17.
Dhanbad
Siwan
Patna
Aurangabad
Nawadah
Bhojpur
Purnia
Katihar
Muzaffarpur
Sitamarhi
Darbhanga
West Champaran
S. Parganas
36.
37.
38.
39.
18.
19.
20.
21.
22.
Kasargoda
Ernakulam
Cannannore
Malapuram
Kozhikode
Kerala
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
23. Bhopal
24. Indore
25. Khandwa
26. Satna
27. Datia
28. Tikamgarh
29. Chhatapur
30. Jabalpur
31. Balaghat
jk
A
Madhya Pradesh
481
Phulbani
Sundetgarh
Kalahandi
Keonjhar
Manipur
Orissa
40. Andaman
A & N Islands
41. East District
42.. South District
Sikkim
43.
44.
45.
46.
47.
48.
49.
50.
51
52.
53.
54.
55.
56.
Gorakhpur
Lucknow
Unnao
Rampur
Badaun
Shahjahanpur
Etawah
Fatehpur
Banda
Hamirpur
Jalaun
Basti
Gonda
Bareilly
Uttar Pradesh
57.
58.
59.
60.
61.
62.
63.
64.
65.
66.
Cooch Bihar
Howrah
Hooghly
Jalpaiguri
Maida
24 Parganas (S)
Nadia
24 Parganas (N)
W Dinajpur
Murshidabad
West Bengal
i
4&3
APPENDICES
Appendix ’G’
DIRECTORATE GENERAL OF HEALTH SERVICES
LEPROSY DIVISION
J
NATIONAL CONFERENCE OF VOLUNTARY
ORGANISATION INVOLVED IN NLEP - BOMBAY,
21-22 SEPT. 1991
MODERATELY ENDEMIC 77 DISTRICTS (PR - 2 - 5/'000)
SI. No. Districts
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
State
Gaya
Bihar
Hazari Bagh
Bihar
Giridih
Bihar
Ranchi
Bihar
Monghyr
Bihar
Begusarai
Bihar
East ChamparanBihar
Madhubani
Bihar
Sainstipur
Bihar
Nalanda
Bihar
Palamu
Bihar
Saharsa
Bihar
Saran
Bihar
Gopalganj
Bihar
Daman
Daman & Diu
Bangalore (U) Karnataka
Kolar
Karnataka
Mandya
Karnataka
D. Kannada
Karnataka
PathanammthitaKerala
Population
(in lakhs)
1981
Estmiated
PR/000
1981
31.38
21.95
17.13
30.59
33.14
14.56
24.27
23.24
21.16
16.38
19.16
29.52
20.74
13.61
0.48
34.92
19.05
14.18
23.36
10.76
4.8
4.5
4.4
3.1
*3.6
4.7
3.1
4.8
4.3
2.9
2.6
2.2
2.3
2.8
4.1
3.1
3.7
3.8
2.8
3.3
1
1
l
i
l;
Kerala
16.97
21. Kottayam
Kerala
9.71
22. Idukki
Kerala
0.55
23. Wynad
24. Hoshangabad Madhya Pradesh 10.03
Madhya Pradesh 7.82
25. Ratlam
Madhya Pradesh 10.57
26. Dhar
Madhya Pradesh 7.95
27. Jhabua
Madhya Pradesh 16.13
28. Barwani
Madhya Pradesh 10.01
29. Guna
Madhya Pradesh 7.21
30. Damoh
Madhya Pradesh 12.33
31. Chhindwara
Madhya Pradesh 10.37
32. Mandla
Madhya Pradesh 9.90
33. Sidhi
Madhya Pradesh 9.25
34. Betul
Madhya Pradesh 8.01
35. Rajgarh
Madhya Pradesh 7.95
36. Dewas
Madhya Pradesh 8.40
37. Shajpur
Madhya Pradesh 8.65
38. Shivpuri
Madhya Pradesh 13.03
39. Morena
Madhya Pradesh 8.09
40. Seoni
Madhya Pradesh 5.39
41. Panna
Madhya Pradesh 6.50
42. Narsingpur
11.85
Maharashtra
43. Jalna
30.04
Maharashtra
44. Jalgaon
28.08
Maharashtra
45. Kolhapur
20.59
Maharashtra
46. Sangli
14.54
Maharashtra
47. Ratnagiri
23.53
Maharashtra
48. Dhule
30.51
49. Ahmed Nagar Maharashtra
49.49
Maharashtra
50. Pune
18.23
Maharashtra
51. Aurangabad
20.02
‘
Uttar
Pradesh
52. Farrukabad
11.33
Utt^r Pradesh
53. Jhansi
18.07
Uttar Pradesh
54. Pratapgarh
20.38
Uttar
Pradesh
55. Sultanpur
3.3
3.1
3.0
3.6
4.6
3.8
3.2
4.0
3.2
4.3
4.3
3.8
4.2
2.7
2.7
2.3
2.3
2.7
2.0
2.1
2.9
2.1
3.4
4.1
3.4
4.0
2.2
2.6
2.8
2.2
2.8
2.8
3.2
3.3
3.6
484
LEPROSY IN RURAL INDIA
Appendix 'H'
56. Chamoli
Uttar Pradesh
3.64
57. Nanital
Uttar Pradesh
11.23
58. Moradabad
Uttar Pradesh
31.51
59. Jaunpur
’ Uttar Pradesh
25.27
60. Aligarh
Uttar Pradesh
25.65
61. Allahabad
Uttar Pradesh
37.81
62. Lalitpur
Uttar Pradesh
5.7
63. Tehri Garwal Uttar Pradesh
4.99
64. Pithoragarh
Uttar Pradesh
4.80
65. Calcutta
West Bengal
42.56
66. Darjeeling
West Bengal
11.49
67. Chamba
Himachal Pradesh 3.11
68. Shimla
Himachal Pradesh 5.10
69. Sirmur
Himachal Pradesh 3.06
70. Ajmer
Rajasthan
14.40
71. Bharatpur
Rajasthan
12.99
72. Ganga Nagar Rajasthan
20.29
73. Jaipur
Rajasthan
34.20
74. Jodhpur
Rajasthan
16.67
75. S. Madhopur
Rajasthan
15.35
76. Sirohi
Rajasthan
5.42
77. Udaipur
Rajasthan
3.56
3.2
3.2
4.2
4.1
2.1
2.7
2.6
2.9
2.7
4.0
4.0
2.7
2.0
2.6
2.5
2.6
2.5
2.0
2.0
2.7
2.2
2.4
NATIONAL COMMISSION FOR
ERADICATION OF LEPROSY
1. Chairman
2. Vice-Chairman
Members:
£
3.
4.
5.
6.
7.
Prime Minister
Union Minister of Health
and Family Welfare
i
Union Minister of Finance
Union Minister of Planning
Union Minister of Education & Social Welfare
Five Chief Ministers of States in rotation
Eight Eminent leprologists, social workers and others
engaged in leprosy control and "Health for All" program
mes
8. Chairman of the proposed National Consortium of volun
tary organisations engaged in leprosy control work
I
487
APPENDICES
LEPROSY IN RURAL INDIA
486
*
Appendix 'I'
I
1946
NATIONAL LEPROSY ERADICATION BOARD
1947
1. Expenditure Secretary
2. Director General of Health Services
3. Director General, Indian Council of Medical Research
4. Secretary, Social Welfare Department
5. Secretary, Information & Broadcasting Ministry
6. Adviser (Health), Planning Commission
7. Member of Research & Development (whole-time)
8. Member for Implementation, Monitoring and Evaluation
1951
1951-52
(whole-time)
9. Member for Public Participation, Mass Media Mobilisa
tion and Health Education (whole-time).
1954- 55
1955- 61
1960
AN HISTORICAL REVIEW OF ANTI LEPROSY
WORK IN INDIA
1963
Early 19 th
Century
1873
1874
1875
1919
1925
1941
First Leprosy Asylum in
(a) Calcutta
(b) Varanasi
Hansen discovered Mycobacterium
leprae at Bergen, in Norway
The Leprosy Mission founded by a
dedicated Irishman, Mr. W.C. Bailey
Mission to Lepers at Chamba
(Punjab)
Mitsuda introduced the lepromin test
British Empire Leprosy Relief
Association
First official commitee for assessing
the leprosy problem in India
appointed by Central Board of Health
1964
1968
1969
1970
1971
1974
Cochrane first used dapsone in oily
suspension intramuscularly for the
treatment of leprosy in India
The above renamed as Hindu Kusht
Nivaran Sangh
Organised efforts of Leprosy control
in NGO sector by GMLF
The Gandhi Memorial Leprosy
Foundation started at Wardha,
in India
Dapsone introduced in Leprosy
Control
Leprosy Control Programme started
Leprosy Subsidiary Centres
Shepard first reported that Leprosy
bacillus may multiply to a limited
extent in the mouse footpad
Review by Director NLCP;
Reorganisation of programme into
LCD and SET
Pettit and Rees first reported on
secondary dapsone resistance in
Malaysia, proven by the mouse
footpad method.
Rimactane (firampicin) introduced
by CIBA Limited, Basle, Switzerland
Lamprene introduced by J.R. Geigy
Limited, Basle, Switzerland
NLCP - 100% Centrally sponsored
Assessment of NLCP by ICMR
Krichheimer and Storrs reported a
disseminated experimental
M. Leprae infection int he
ninebanded armadillo
Waters et al. first reported that
drug-sensitive M. Leprae is capable
o
488
LEPROSY IN RURAL INDIA
X
1980
1981
(May-June)
(Nov.)
1982
1981-83
1983
1986
1987
1989
1990
of persisting in spite of continuous
dapsone therapy
ULCs, THWs, RSU, DLO, Regional
Leprosy Training Centres
Rehabilitative Promotion Units,
SSAUs, Epidemiological Survey
Units
Call by Mrs. Gandhi for eradication
of
Leprosy from India by 2000 AD at
World Health Assembly and Jt.
Conference of Central Councils
of Health and Family Welfare
Mrs. Gandhi's call to Leprologists
and Social Workers
Wamdorff-van diepen reported the
first case of possible clofazimine resistant Leprosy
Revised Twenty-point programme of
Mrs. Indira Gandhi. Swaminathan
Committee
Relaunching of the programme
as NLEP
MDT Programme started
First Independent Joint Evaluation by
government of India and WHO
Second Independent Joint Evaluation
by government of India and WHO
Third Independent Joint Evaluation
by government of India and WHO
Critical Review by L)GH
BIBLIOGRAPHY
I
Aliz Mohammed, P. (1966): "Epochs in Our Fight Against Leprosy",
Maharashtra Medical Journal, Vol. 13, No. 2, pp. 127-129.
Almast, S.C. (1967): "Notes on History of Socio-Medical
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Anantharaman, M. and Nair, T.K. (1975): "Attitude of Urban
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p. 235.
Balakrishnan, S. and Christian M. (1980): "Assessment of Self
Administration of Dapsone in Urine by Out-Patients
Attending Field Clinics", Leprosy in India, Vol. 52, No. 2,
pp. 249-251.
Bechelli, L.M. et al. (1973): "Some Epidemiological Data on Leprosy
Collected in a Mass survey in Burma", Bulletin World
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Bhagoliwal, A. et al. (1979): "Some Observations on Default Among
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Browne, S.G. (1963): "The Variegated Pattern of Leprosy", Leprosy
in India, Vol. 35, No. 4, pp. 193-199.
Browne, S.G. (1974): "Self Healing Leprosy - Report on 2, 749
Patients", Leprosy Review, Vol. 45, No. 2, pp. 104-111.
Chakrabarti, D. (1966): "Health Education in Leprosy", Leprosy in
India, Vol. 38, No. 1, pp. 1-8.
Chandra Kumud, K., et al. (1979): "Treatment Defaulters in
Leprosy - A Retrospective Study of 42,000 Cases",
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Chandy, P.J., et al. (1963): "Leprosy in Uttar Pradesh - Some Points
of Epidemiological Interest", Leprosy in India, Vol. 35, No.
3, pp. 128-131.
Chang, Yao Teh. (1979): "Leprosy Control in shanghai".
International Journal of Leprosy, Vol. 47, No.l, pp. 56-59.
490
LEPROSY IN RURAL INDIA
Christian, M. (1969): "Leprosy in the Laccadive Islands", Leprosy
in India, Vol. 41, No. 4., pp.1-5.
Cochrane, R.G. and Davey, T.F. (1961): Leprosy in Theory and
Practice, 2nd Edition, John Wright and sons, Bristol?'
Das, V.P. (1965): "The Importance of Social Assistance and Social
Rehabilitation in Leprosy Control", Leprosy in India, Vol.
37, No.3, pp. 189-191.
Davey, T.F. (1972): "Psychological Rehabilitation in Leprosy in
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Davey, T.F. (1980): "New Dimensions in Our Understanding of the
Transmission of Leprosy and Their Impact on Priorities in
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Leprosy in India, Vol. 21, No. 4, pp. 180-192.
Dharmendra, (1962): "Social Welfare of Leprosy Patients",
Leprosy in India, Vol. 34, No. 4, pp. 306-309.
Dharmendra, et al. (1965); "Prophylactic Value of DDS Against
Leprosy - An Interim Report", Leprosy in India, Vol. 38,
No.4, pp. 1-20.
Dharmendra (1965): "Economic Conditions in Relation to
Prevalence of Leprosy" (Editorial), Leprosy in India, Vol.
37, No. 2.
Dharmendra, (1967): Notes on Leprosy, 2nd Edition, Manager of
Publications, New Delhi.
Dharmendra, et. al. (1967): "Prophylactic Value of DDS Against
Leprosy - A Further Report", Leprosy in India, Vol. 39, No.
3, pp.1-7.
Dharmendra, (1968):"Epidemiology and Control of Leprosy - (1)
The Main Epidemiological Features of the Disease",
Leprosy in India, Vol. 40, No. 1, pp. 13-21.
Dharmendra, (1975): "Sub-Clinical Infection in Leprosy and Not
Sub-Clinical Cases of Leprosy", Leprosy in India, Vol. 47,
No. 1, pp.1-3.
Dharmendra, (1980): "Indian Classification of Leprosy - Need for
a Review", Leprosy in India, Vol.52, No. 2, pp.192-201.
Dharmendra, (1980): "Contact with Intact Skin as a Common Mode
of Transmission of Leprosy", Leprosy in India, Vol. 52, No.
4, pp. 472-474.
BIBLIOGRAPHY
491
Dougall A.C. and Yawalkar. SJ. - Leprosy - Basic Information and
Management.
Economic and Political Weekly - A sameeksha Trust Publication,
Vol. XVI No. 48, November 28, 1981.
Ekambaram, V. (1967): "Leprosy Control Work in Madras State",
Proceedings of International Seminar on Leprosy, Agra
Govt, of India.
Ekambaram, V. (1974): "Absenteeism for Treatment, Their Causes
and Suggested Remedial Measures, Leprosy in India, Vol.
46, No.l, pp.46-48.
Ekambaram, V. (1976): "Ways and Means of Proper
Implementation of National Leprosy Control Programme",
Leprosy in India, Vol. 48, No. 4, (Supp.), pp. 790-798.
Ellard, G.A. et al. (1974): "The Application of Urine Tests to
Monitor the Regularity of Dapsone Self Adminstration",
Leprosy Review, Vol. 45, No. 3, pp. 224-234.
Ganapati, R. and Girija D. (1979) : "Prevalence Rate of Leprosy in
Some Urban Slums - Experience in Bombay", International
Journal of Leprosy, Vol. 47, No. 2, (Supp.) p.333.
Ghosh, B.N. et al. (1966): "A Note on the Results of Investigation on
Clinical Attendance Rate of Leprosy Cases in an Urban
Community", Leprosy in India, Vol. 38, No. 2, pp.1-4.
Golvan Gonzales, A. (1979) : "Leprosy in Primary Health Care",
International Journal of Leprosy, Vol. 47, No. 2, (Supp.),
p.320.
Goodwin, C.S. (1964): "Some Leprosy Problems and Anti-Leprosy
Work in Hong Kong", Leprosy in India, Vol. 36, No.3,
pp.212-215.
India, Government of (1972): Census of India 1971: Series 19, Tamil
Nadu Part X B: District Census Hand-Book - Village and
Townwise Primary Census Abstract, Chingleput, Vols. I
and II, Director of Census Operations, Tamil Nadu and
Pondicherry.
India, Government of, (1981): Census of India 1981: Series 20,
Tamil-Nadu-Provisional Population Total, Director of
Census Operations, Tamil Nadu and Pondicherry.
International Leprosy Congress (1979): "Workshop on
Epidemiology and Control Including Field Therapy",
International Journal of Leprosy, Vol.47, No.2, (Supp.),
pp.304-306.
Q
492
BIBLIOGRAPHY
LEPROSY IN RURAL INDIA
Jacob Thomas, et al. (1976): "Assessment of Leprosy Control Work
of the Santhal Pahadia Seva Mandal, Deoghar", Leprosy in
India, Vol. 48, No. 4, (Supp.), pp.801-807.
Jagadisan, T.N. (1969): "Role of Voluntary Agencies in Leprosy
Control and Relief", Leprosy in India, Vol. 41, No. 4,
pp.386-391.
Jungalwalla, N. (1965): "Leprosy Control - Present Status and
Suggestions for Furture Work - Integration of Leprosy
Control Programme in General Health Services", Leprosy
in India, Vol.37, (Supp.), pp. 407-410.
Kapoor, P. (1975) : Guide to Leprosy and Leprosy Control, 1st
Edition, Poona District Leprosy Committee, Poona-11.
Khoshoo, P.N. (1969) : "Leprosy Control Programme-Fresh Look
on the Leprosy Control Work in India, Leprosy in India,
Vol. 41, No. 4, pp.329-338.
Kotteeswarn, G., et al. (1980): "Skin Adnexa in Leprosy and Their
Role in the Dissemination of M. Lepral", Leprosy in Inida,
Vol. 52, No. 4, pp.475-481.
Kurian, P.V., et al. (1975): "School Survey as an Effective Method
for Leprosy Control in Rural Areas", Leprosy in India,
Vol.47, No.2, pp.75-78.
Lechat, M.F., et al. (1977): "An Epidemetric Model of Leprosy: A
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Vol. 45, N.I, pp. 1-8.
Lechat, M.F. et. al (1978) : "Application of an Economic Model to
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Low, S.J.M., and Pearson, J.M.H. (1974): "Do Leprosy Patients
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Naik, S.S (1978): "Irregularity of Dapsone Intake in Infectious
I
493
Leprosy Patients Attending an Urban Treatment Centre-Its
Magnitude and Causes", Leprosy in India, Vol. 50, No.l,
pp.45-53.
Natesan. S., Leprosy - Guidelines for Medical Students, Indian
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Newell Kenneth, W. (1966): "An Epidemiologist's View of
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Nigam, Pranesh, et al. (1977): "Leprosy - A Clinico Epidemiological
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Leprosy in India, Vol.32, No.2, pp. 126-129.
I
494
I
I
I
BIBLIOGRAPHY
LEPROSY IN RURAL INDIA
Shah, N.B. (1965): "Effect of Leprosy on Patients' Work Life",
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Wardekar, R.V. and Pandit, C.G. (1962): "Suggestions on
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Wardekar, R.V. (1969): "A Fresh Look at Health Education in
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Wheate, H.W. (1967): "Infectivity of Non-Lepromatous Leprosy",
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World Health Organisation (1952): "Expert Committee on Leprosy
- First Report", Technical Report Series, No. 71, Geneva.
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- Second Report", Technical Report Series, No. 189,
Geneva.
i
L.
495
World Health Organisation (1960): "International Work in Leprosy
- 1948-1959", WHO Chronicle, Vol. 14, No.l, pp.1-39.
World Health Organisation (1960) : "Scientific Meeting on
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World Health Organisation (1966): "Expert Committee on Leprosy
- Third Report", Technical Report Series, No. 319, Geneva.
’&v 7t-
SUMMARY
Chapter 13
SUMMARY
National Leprosy Control Programme is Ln the form of a
complex system. This system consists of a large number of
components which are in complex interaction with one
another. The epidemiological characteristics of the disease,
the social, cultural, economic and geographic background of
the population, the nature of technology adopted for
diagnosis and treatment of leprosy patients within the
population, the organisational structure and the various
logistical considerations are examples of some of the major
components which give shape to the complex interacting
system of the National Leprosy Control Programme. An
effort has been made to study the programme in its complex
multi-disciplinary dimensions. These interactions have been
studied simultaneously. This approach has been termed as
systems approach. This approach has provided insights iiito
the working of the National Leprosy Control Programme for
enabling development of an alternative programme which is
viable, nationally applicable, socially acceptable and
epidemiologically effective.
Leprosy Control Programme in the rural populations in
Chingleput district was studied in its multi-faceted
dimensions. This district has a high prevalence of leprosy.
Compared to other districts this district has much better
organisational, personnel and equipment inputs for dealing
with leprosy problem. The district also has the above average
inputs since a considerable time.
Data on epidemiological component, organisational and
management component, and components formed by the
patients and the community were required to be collected for
studying the functioning of the programme. These
44 7
components were studied in depth by adopting different
techniques like interviewing the key personnel at the different
levels in the programme, obtaining data from the all possible
secondary sources including perusal of official records,
documents and by participation in various meetings and
conferences. Additional epidemiological information from
the district as a whole was obtained directly by the
investigator from the various sub-centres through a
circulated proforma. . Some data regarding the
epidemiological characteristics were obtained directly by the
investigator from the patients and from the records
maintained by the workers. The information about the
organisation and functioning of the programme was obtained
by informal interview of the different categories of
functionaries and by a perusal of the records and registers
maintained by them as well as scrutiny of the reports and
diaries submitted by them to their higher authorities. The
information furnished by various categories of workers were
cross-checked with their supervisors and vice-versa.
For the more detailed data collection, Tambaram leprosy
control unit was purposely selected because it had better
performance figures than others. As it was not possible to
study all the twenty sub-centres of this unit, the sub-centres
at Kelambakkam and Tirupporur were purposely selected
because these sub-centres were away from urban areas. The
SET centre at Ponneri was selected because it happened to be
the only government run SET centre. The SET centre at
Madarpakkam run by Christian missionaries was selected
purposely because it covered rural populations. For each of
the two sub-centres of Tambaram control unit and the SET
centres, at Ponneri and Madarpakkam, the headquarters
village, two villages within 2 to 5 kms. from the headquarters
and two villages within 7 to 10 kms. from the headquarters
were included for the study of the patients. Thus in all,
patients in 20 villages were studied. One of the two villages in
either category belonged to the epidemiological survey areas.
I
448
LEI’ROSY IN RURAL INOLA
i
While the other two belonged to the non-epidemiological
survey areas. In all, 590 patients were studied in the 20
selected villages with the help of a schedule. The data
collected included the nature and duration of the disease,
patients' response to the organisation, and the social
interaction of the community. Clinical and laboratory data
were obtained through a check list.
The community perception of and the attitudes towards
the disease were studied in 6 villages by administering a
schedule to 20 percent systematic random sample of the
households in those villages. The headquarters villages of the
Kelambakkam sub-centre, and Ponneri and Madarpakkam
SET centres and one most distant village in each of the three
areas comprised the six villages for the community study.
The main findings of this study have been summarised in
the previous chapter where they have been used to formulate
an alternative perspective for dealing with leprosy as a
community health problem in India.
J
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Christian, M. et al. (1979): Assessment of the National Leprosy
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Wardekar, R.V. (1979): Report on Assessment of Vairag
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41.
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Govila, A.K. et al. (1980): "Study of Contacts Among
Leprosy Patients", Leprosy in India, Vol. 52, No. 3, pp. 411415.
43.
Selvapandian, A.J. et al. (1980): "School survey in a Rural
Leprosy Endemic Area", Leprosy in India, Vol. 52, No. 2, pp.
209-216.
44.
Mani, R.S. (1976): "Importance of Systematic School Survey
in Urban Leprosy Control", Leprosy in India, Vol. 48, No. 4
(Supp.), pp. 813-818.
45.
Ganapathy, R. et al. (1976): "Childhood Leprosy
Prevalence Rates and Clinical Aspects Through School
Surveys in Bombay", Leprosy in India, Vol. 48, No. 4,
(Supp.).
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;>4
"Duties of District Leprosy Officer", Circular K. Dis. No.
89309/L2/76, dated 14.4.76, Tamil Nadu, pp. 1-2.
Khoshoo,. P.N. (1965): "Review of Leprosy Control
Programme in India", Leprosy in bidia, Vol. 37, Ouly), pp410-425.
Dharmendra (1969): "Working Session - Leprosy Contro'
Programme", Leprosy in Indui, Vol. 41, No. 3, pp. 194
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4/77, dated 22.11.77, Tamil Nadu, pp. 1-2.
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Duties of Medical Officer, Leprosy Control Programme, Tamil
Nadu, pp. 1-8.
59.
Ekambaram, V. (1969): "A Fresh Look at Leprosy Control
Work", Leprosy in India, Vol. 41, No. 4, pp. 345-349.
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Tare S.P. (1974): "Impact of Leprosy Control Work on
Trend of Leprosy", Leprosy in India, Vol, 46, No. 2, pp.
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Programme, Tamil Nadu, pp. 1-3.
75.
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Nadu, pp. 1-3.
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University, New Delhi.
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India, Government of (1969): Operational Guide and
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I
_D>^ S-CL.S
AN OVER VIEW OF IMPACT OF TEN YEARS OF LEPROSY ERADICATION 435
t
I
Chapter 12
AN OVER VIEW OF THE IMPACT
OF TEN YEARS OF LEPROSY
ERADICATION WORK IN INDIA
Reduction of prevalence
As has already been commented upon, the prevalence has
been reduced by large scale removal of erstwhile leprosy
'cases'. No authentic data is available regarding the relapses
rate in the programme, to my knowledge the claim of the
success of MDT programme appears superficial and unwar
ranted at this stage. It is worth reiteration that most of the
existing cases have been on various stages of treatment with
Dapsone mono-therapy and most of them have been re
moved from the rolls. Moreover the impact of self healing
processes which have been estimated at 75% to 85% of the
total pauci-bacillary problem have not been given credit to.
Attributing the reduction of prevalence to a mere combina
tion of drugs does not appear to have a scientific base. Any
effectivity of the particular strategy can only be measured by
new case detections which is a positive ind« of a break in the
chain of transmission. It can be argued that same or better
results could have been achieved if the Dapsone monother
apy was followed up with same vigour in monitoring.
The next important question is about the drug regimen
itself. When a more easily amenable bacillus immersed in
hyperaemic conditions in the lung (M. tuberculosis) requires
a continuous daily dose of Rifampicin for six months, a
bacillus more chronic in nature difficult to culture and which
is supposed to be travelling along peri-neural lymphatics
(which areas are least vascular) cannot be expected to be
killed with an exposure of "potent bactericidal" drugs once a
i
month i.e. a total of 3600 mg. of Rifampicin in P. bacillary
cases over a six months period (in 6 once monthly pulses) and
14.400 mg. for M. bacillary cases (in 24 once monthly pulses)
is rediculous and catastrophic indeed - as we may soon land
up with rifampicin resistant M. Leprae.
Even this truncated methodology is not being constantly
pursued. For MB cases in higher endemic areas an initial
intensive phase of 14 days daily Rifampicin administration
has been advocated. This strategy has not been followed for
(a) P.B. cases (b) in modified MOT districts (66) where endemicity is estimated to be high but no adequate infrastruc
ture is available, (c) in low endemic districts (77). How can
anybody presume that Leprosy can be treated with different
strategies at different places, due to the whims and fancies of
the Leprologists. The decision on this truncated regimen and
inadequate exposure to the high 'potency' drugs seems to be
'economical' rather than technical or organisational. Where is
the scientific basis, tested in field conditions, which will
justify the efficacy of a particular regimen with special refer
ence to the dissolution of the lesions and the arrest of the
further progress of the disease?
The next important question is the reliability of the sur
veys themselves. Most of the field surveys tend to be inade
quate both in the matter of quantity and quality. Qualitatively
speaking the inadequacy of the para medical workers/leprosy inspections in examining the different parts of the body
is well known. In a tradition bound society there are limita
tions to the exposure of the body, especially among the
females, even if the workers tend to be sincere in their work.
Quantitatively more often than not the data is provided
without actually conducting the work consequent to the
target oriented time bound approaches.
Epidemiological issues
There are several epidemiological issues in leprosy eradi-
I
436
LEPROSY IN RURAL INDIA
AN OVER VIEW OF IMPACT OF TEN YEARS OF LEPROSY ERADICATION 437
cation work. Knowledge regarding the size, extent and distri
bution of the leprosy problems in the country is still inade
quate. Apart from the prevalence rates being unreliable there
is no authentic data regarding incidence rate. In chronic
diseases like leprosy the incidence is difficult to calculate
especially when the time of the origin of the patch cannot be
reliably estimated. In a milieu where the portals of entry and
exit of the bacilli are not known and in a scenario where the
multiplication of bacillus is slow, incubation period not very
well known, claims of success of the leprosy eradication
strategy certainly tends to be unscientific. The immunological
deficits in the host contributing to the occurrence of different
types of leprosy have still not been explained scientifically.
Moreover the phenomena of over-diagnosis of leprosy and
the processes of self-healing raise very vital questions regard
ing the epidemiology of the disease.
There are a number of technical areas apart from the
already mentioned bacteriological and immunological is
sues. The production of anti-leprotic drugs still is brimming
with problems of procurement and supply.
There is no reliable data on the quality control of drugs
periodically. The phenomenon of resistance in PB and MB
cases to the drugs exposed has also to be studied systemati
cally.
As regards research, the following paragraphs from the
NLEP document111 highlight the state of research in leprosy in
India. There is an urgent need for conducting research into
various epidemiological issues concerning leprosy and lep
rosy control leave alone eradication claims of pre-mature
success of the programme and attributing the same to the
MDT regimen will not take us anywhere.
'Tor over a hundred years Mycobacterium leprae has
defied the attempts by scientists in making conclusive break
throughs our knowledge base in many areas is inadequate
and major break-throughs are yet to be made.
i
The natural-history of myco-bacterium leprae infection
and the epidemiology of leprosy is still not clearly under
stood. Till recently there were no tests that could help monitor
sub-clinical infection and thus the spread of M. leprae infec
tion in the community. Recently available tests are opening
up new horizons our understanding of sub-clinical infection.
Emphasis is being put on tests that are simple to execute
and easy to standardise. The government of India has been
introducing these tests in selected research institutions in the
country for evaluation.
Leprosy is the only bacterial disease that causes periph
eral nerve damage. The exact mechanism of nerve damage
has not been properly worked out. Since deformity secondary
to neuropathy is a major problem in 20-25% of patients with
leprosy, efforts are being made to pursue studies which
provide insight to the patho-physiology of neuropathy in
leprosy.
Vaccine trials have been started in India and throughout
the world. The outcome of these carefully planned, epidemiologically well characterised field vaccine trials, over the next
five years, will enable us to decide on a strategy for eradica
tion of leprosy based on vaccination. There is cause for
optimism that an effective vaccine will be available soon.
The government of India recognises the lacunae in this
country in leprosy research. It is identifying institutions and
encouraging Indian scientists abroad to come forward to
meet the challenges of research in leprosy. The Central Lep
rosy Teaching and Research Institute, Chengalpattu (Tamil
Nadu), Central JALMA Institute for Leprosy, Agra and the
Regional Leprosy Training Institute (RLTI), Aska in Orissa
are the central government institutes for leprosy tfaining and
research, set-up at the beginning of the 6th plan. The 6th plan
proposals, included the establishment of six regional insti
tutes for research services and field studies. Two such insti
tutes have already been established at Raipur in Madhya
I
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i
LEPROSY IN RURAL INDIA
438
i
Pradesh and at Gauripur (West Bengal). There are proposals
with the Ministry of Health and Family Welfare for establish
ing institutes at Tetulmari (Bihar) and Magadi Road (Karnakata) where leprosy hospitals with field units are functionmg under the concerned state governments. Much of leprosy
research is virgin territory and the potential for research is
immense.
Administrative
As already stated there are a number of man-power,
training, supervisory, management and evaluation issues
apart from financing with require urgent attention to make
any appreciable dent in the leprosy problem.
Legal consideration in leprosy
The Lepers Act, 1898 has been repealed by the Govern
ment of India in respect of U.Ts. without legislatures. All
states excepting Bihar and Punjab have repealed the Act.
Legal Aspects of Leprosy
The various marriage acts need to be amended suitably in
the light of modern concepts of leprosy.
(a) Indian Christian Marriage Act of 1872, Sec. 13 (IV)
(b) Muslims Marriage Act of 1939 Sec. 2 (VI)
(c) Hindu Special Marriage Act of 1954, Sec. 27.
(d) Hindu Marriage Act of 1956, Sec. 10 and Sec. 13.
Under these acts, divorce is granted on the grounds of
leprosy.
According to Dr. V.V. Dongre, 112
"Surprisingly the Tarsi Marriage Act of 1936 does not
allow divorce on the grounds of leprosy.
|
AN OVER VIEW OF IMPACT OF TEN YEARS OF LEPROSY ERADICATION 439
— The Motor vehicle Act of 1939 second schedule, sec. (7) 5
needs rectification as only 25% of leprosy patients* have
sensory loss of the limbs. Hence the majority of the
leprosy patients, nearly 75% should be considered as fit to
get driving licences if they so want.
— Often we read in the Press that leprosy patients are not
allowed to contest in elections like the imbeciles and
idiots. This discrimination strengthens social stigma. The
election rules should be appropriately changed in the
light of modern concepts of leprosy.
The Life Insurance premium rates were higher for leprosy
patients. Recently the rules are modified but not quite
satisfactorily. There is still a scope for the modifications of
LIC rules for leprosy patients.
The existing rules about certification of leprosy' patients
for fitness to continue in jobs must be modified as per the
recommendations made by the expert groups from cen
tral Jalma Institute for leprosy. This issue is pending for a
long time.
All travel restrictions on leprosy patients by any mode of
public transport should be totally removed.
A person detained under the prevention of begging act of
1959, if found to be a leprosy patient is not discharged
after the completion of term of detention.
Under the various local accommodation acts, leprosy
patients are thrown out by owners from their places of
residence. Such acts are derogatory and must be suitably
rescinded.
It is also found that the children having leprosy or healthy
children of leprosy patients do not get easy admission to
the schools. They therefore, are likely to become outcasts
of the society. If they attend a school run by a Leprosy
Institution, they face a problem in training for a vacation
AN OVER VIEW OF IMPACT OF TEN YEARS OF LEPROSY ERADICATION 441
LEPROSY IN RURAL INDIA
440
Laboratory Services
The laboratory services have been uniformly poor. The
needed equipment is either absent or in short supply. There,
is no mechanism of checking the findings of laboratory tech
nicians - with the result quality of samear examination leaves
much to be desired. 34.2% of the laboratory technician posts
were vacant.
'
because of the address given on the School Leaving Certificate.
— If there are no separate acts for typhoid or for tuberculo
sis, why should there by a separate act for leprosy.
— Therefore it is urged that all the leprosy institutions
should make concerted efforts to do away with the out
dated legislation pertaining to leprosy patients/'
Temporary hospitalisation wards, rehabilitation
promotion units, reconstructive surgery units
There is a gross under utilisation of facilities at these units
with the result most of these are diverted to general surgical
purposes. There is also another administrative bottleneck in
that the temporary hospitalisation wards and urban leprosy
centres are not directly under the control of district leprosy
officers.
7
The vacancy position of physiotherapy technicians is
alarming. Only 50% of the posts are filled up. Even among
them only 88% are trained for leprosy work.
Independent WHO/GOI Evaluation of NLEP
So far three independent evaluations were conducted
jointly by and independent team consisting of WHO/govern
ment of India officials in the years 1986, 1989 and 1990.
The following is the summary of all the three evaluations:
Survey
The quality of survey is poor in the urban areas. The
school survey was uniformly poor in most of the states. The
evaluation also noted gross under-estimation of cases in
some States like Madhya Pradesh and Uttar Pradesh.
Staff matters
Sample Survey and Assessment Units (SSAU)
The evaluations noted uniformly poor quality in the
functioning of SSAU.
TABLE 138
VACANCY AND TRAINING STATUS BY CATEGORY OF STAFF113
TABLE 137
STAFF STATUS OF SSAU112
Location of
Unit
Pune
Hyderabad
Dharwar
Gandhi Nagar
Madras
S“>ff
sanctioned
r
8
18
18
16
Positions
vacant
Nil
1 (12.5%)
4 (26.6%)
5 (27.7%)
Nil
Posts
Persons
trained
8(100%)
2 (28.5%)
7 (63.6%)
7 (53.8%)
16(100%)
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I
i
Table 137 gives the staff status of SSAUs brought out by
evaluation team at Pune, Hyderabad, Dharwar, Gandhinagar
and Madras. The vacancy position excepting at Madras and
Pune is bad.
Zonal/District
Leprosy Officer
Medical Officer
Non-Medical
Supervisor
Paramedical
Worker
Lab Technician
Physiotherapist
Total
Sanctioned
Vacant
No. %
Trained
No.
%
238
35
(14.7%)
162
(79.8%)
1076
157
(14.6)
580
(63.3)
3654
628
(17.1)
2018
(64.5)
17683
1036
616
3345
355
308
(18-9)
(34.2)
(50.0)
12138
611
(84.6)
(88.4)
271
(87.9)
24303
4828
(19.9)
15780
(81.0)
AN OVER VIEW OF IMPACT OF TEN YEARS OF LEPROSY ERADICATION 443
LEPROSY IN RURAL INDIA
442
The vacancies in staff positions as indicated in table 138
seem to be the result of non-availability of trained man-power
and the ban imposed by certain states on staff recruitment.
The status of the District Leprosy Officers and the State
Leprosy Officers in some states still continues to be poor.
Training
TABLE 139
THE AVAILABILITY OF TRAINED MANPOWER IN
TWENTYFOUR MDT DISTRICT112
Num her Number
sanctioned vacant
Post
Medical Officer
Non-Medical
Supervisor
Health Educator
Lab. Technician
Physiotherapist
Paramedical
Workers
In
position
Number
trained
(86.6%)
115
16 (13.9%)
99
78
454
66
130
8
36 (7.9%)
4 (6.0%)
30 (23.0%)
2 (25.0%)
418
62
284 (68.0%)
(3.2%)
2
83 (83.0%)
6 (100.0%)
2011
100
6
252(12.5%)1759 1456
(82.7%)
The training status of key programme staff are indicated in
table 139. A peFusa! of tills 'table''reveals lack of training of important personnel.
TABLE 140
TRAINING STATUS OF MEDICAL OFFICERS AT DIFFER
ENT LEVELS OF NLEP112
Level
Trained
Not trained
10 (62.5%)
19 (48.7%)
9 (42.8%)
26 (34.2%)
4 (23.5%)
68 (40.2%)
State
District
ULC
LCD
SETs
(16)
(17)
6
20
12
50
13
Total
169
101
(39)
(21)
(76)
Table 140 gives the training status of medical officers at
different levels of NLEP. The training status of medical
officers who are to play a key role in case confirmation,
monitoring, removals from treatment and control etc. is
alarming indeed. Roughly one third of medical staff only are
trained at leprosy control unit and SET levels.
It is understood tliat in some states staff are recruited in
anticipation of training.
It is also disturbing to note that the training capacity of
Institutes are also not utilised adequately.
TABLE 141
UTILISATION OF TRAINING CAPACITY OF SEVENTEN112
TRAINING CENTRES
Name of the
course
Medical Officer
NMS
PMW
Annual training Staff trained
capacity
in the year
181
325
529
65
127
378
percent
utilisation
35.9%
39.0%
71.4%
Table 141 gives the details at seventeen training centres.
At most of the training institutes there is a general lack of
education materials. There is a poor disbursement of stipends
to traineees. There is no organised programme for re-orienta
tion of staff. The programme presumes that staff once trained
are fit enough permanently.
Topping the above inadequacies on the training front is
the transfer of trained programme staff to do non-leprosy
work.
49 Leprosy Training Centres (LTC) established during
successive five year plan periods are functioning throughout
the country. 14 of these are with voluntary orgtanisations.
The on going training programme and physical facilities
available at LTCs have been reviewed by two consullards
AN OVER VIEW OF IMPACT OF TEN YEARS OF LEPROSY ERADICATION 445
LEPROSY IN RURAL INDIA
444
$
during 1986-87. The major recommendations include:
(a) A training Cell should be created at Directorate General of
Health Services under Leprosy Division which will be instru
mental in specific requisite planning, implementation and
follow-up of staffing and thier training needs. The Cell will
also have an increasing role in matters of coordination and
follow-up action between central, states and non-governmen
tal agencies on various issues pertaining to manpower devel
opment.
(b) Orientation training of short duration for the general
health care staff should be considered necessary.
Supervision and Monitoring
The quality of supervision and monitoring are very poor.
The vehicles meant for leprosy work are diverted by others
for different purposes. The available vehicles are in a very bad
shape due to poor maintenance.
Treatment
In a massive treatment programme with MDT regimen,
there is a poor retrieval of treatment defaulters.
TABLE 142
MONITORING OF DRUG INTAKE
BY TABLET COUNT12
No. of patients
contacted in past
three months
No patient contacted
Less than 10
10-50
50-100
More than 100
Respondents
113
113
113
113
113
No. ofNMS
contacting
38
8
33
15
19
(33.6%)
(7.0%)
(29.2%)
(13.2%)
(16.8%)
The non-medical supervisors are expected to monitor the
regularity of intake of medicines by independent checks.
Table 142 gives the details of such checks made by Non
medical supervisors.
Consequent to poor quality of work, no importance is
being given in the programme towards identification of re
lapses and for watching out the development of drug resis
tance. The whole organisation is geared to reducing the
prevalence of the disease by large scale discharge of cases
who have completed the prescribed treatment.
Voluntary Organisations
Several voluntary organisations are being given "S.E.T.
grants". A number of organisations have eternal complaints
regarding non release or irregular and untimely release of
grants. Most of the organisations also complain of non
receipt of drugs of specified quantity and specified dosage of
the tablets.
[
I
SUMMARY
Chapter 13
SUMMARY
National Leprosy Control Programme is iii the form of a
complex system. This system consists of a large number of
components which are in complex interaction with one
another. The epidemiological characteristics of the disease,
the social, cultural, economic and geographic background of
the population, the nature of technology adopted for
diagnosis and treatment of leprosy patients within the
population, the organisational structure and the various
logistical considerations are examples of some of the major
components which give shape to the complex interacting
system of the National Leprosy Control Programme. An
effort has been made to study the programme in its complex
multi-disciplinary dimensions. These interactions have been
studied simultaneously. This approach has been termed as
systems approach. This approach has provided insights into
the working of the National Leprosy Control Programme for
enabling development of an alternative programme which is
viable, nationally applicable, socially acceptable and
epidemiologically effective.
Leprosy Control Programme in the rural populations in
Chingleput district was studied in its multi-faceted
dimensions. This district has a high prevalence of leprosy.
Compared to other districts this district has much better
organisational, personnel and equipment inputs for dealing
with leprosy problem. The district also has the above average
inputs since a considerable time.
Data on epidemiological component, organisational and
management component, and components formed by the
patients and the community were required to be collected for
studying the functioning of the programme. These
447
components were studied in depth by adopting different
techniques like interviewing the key personnel at the different
levels in the programme, obtaining data from the all possible
secondary sources including perusal of official records,
documents and by participation in various meetings and
conferences. Additional epidemiological information from
the district as a whole was obtained directly by the
investigator from the various sub-centres through a
circulated proforma. . Some data regarding the
epidemiological characteristics were obtamed directly by the
investigator from the patients and from the records
maintained by the workers. The information about the
organisation and functioning of the programme was obtained
by informal interview of the different categories of
functionaries and by a perusal of the records and registers
maintained by them as well as scrutiny of the reports and
diaries submitted by them to their higher authorities. The
information furnished by various categories of workers were
cross-checked with their supervisors and vice-versa.
For the more detailed data collection, Tambaram leprosy
control unit was purposely selected because it had better
performance figures than others. As it was not possible to
study all the twenty sub-centres of this unit, the sub-centres
at Kelambakkam and Tirupporur were purposely selected
because these sub-centres were away from urban areas. The
SET centre at Ponneri was selected because it happened to be
the only government run SET centre. The SET centre at
Madarpakkam run by Christian missionaries was selected
purposely because it covered rural populations. For each of
the two sub-centres of Tambaram control unit and the SET
centres, at Ponneri and Madarpakkam, the headquarters
village, two villages within 2 to 5 kms. from the headquarters
and two villages within 7 to 10 kms. from the headquarters
were included for the study of the patients. Thus in all,
patients in 20 villages were studied. One of the two villages in
either category belonged to the epidemiological survey areas.
448
LEPROSY IN RURAL INDIA
i
While the other two belonged to the non-epidemiological
survey areas. In all, 590 patients were studied in the 20
selected villages with the help of a schedule. The data
collected included the nature and duration of the disease,
patients' response to the organisation, and the social
interaction of the community. Clinical and laboratory data
were obtained through a check list.
The community perception of and the attitudes towards
the disease were studied in 6 villages by administering a
schedule to 20 percent systematic random sample of the
households in those villages. The headquarters villages of the
Kelambakkam sub-centre, and Ponneri and Madarpakkam
SET centres and one most distant village in each of the three
areas comprised the six villages for the community study.
The main findings of this study have been summarised in
the previous chapter where they have been used to formulate
an alternative perspective for dealing with leprosy as a
community health problem in India.
I
J
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,
•kswrMMwwf
*
I
LEPROSY
IN
RURAL INDIA
H
■
3
K.VENKATESWARA RAO
1
■51
■;:wl
wl
MANAK PUBLICATIONS PVT. LTD.
I
FOREWORD I
I
I
FIRST EDITION 1992
Copyright© Author, 1992
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The very ancient scourge of leprosy still remains a major public
health problem in India. This is despite the fact that the extensive
Leprosy Control Programme (LCP) was started way back in 1954.
Indeed, apart from a specific interest of Christian Missionaries in
this field, Mahatma Gandhi was also deeply concerned about the
problem while he was involved in constructive work in the country
as a part of the National Movement. While declining to open a
leprosy hospital set up by volunteers, he made the very perceptive
comment that he would be very glad to perform the closing cere
mony of the hospital after leprosy ceased to be a public health
problem. Much later, In 1981 the then Prime Minister Indira Gandhi
took a major initiative to mobilise the bureaucracy, leprosy experts
and her own Science Advisory Committee and the WHO to draw
up a programme for action to "eradicate" leprosy by 2000 AD.
While It is understandable that a political leader should have
coined such a catchy slogan, identification of some of the foremost
leprologists and scientists of the country and of WHO with this
slogan is most astonishing. Those even with most elementary
understanding of the epidemiology of leprosy in India could have
realised that such an expectation is utterly untenable. Unfortu
nately, such obviously unrealistic claims are also being made by
WHO and UNICEF in relation to some other communicable dis
eases. Tall claims were made by these organisations about the
impact of the Universal Child Immunization Programme in 1984,
but when the programme ended in 1990, they did not make any
epidemiological impacton the problem and, instead, made totally
untenable of "success" of UIP on the basis of data obtained from the
notoriously unreliablegovernmentsources. The WHO programme
for global eradication of poliomyelitis follows the same trend
(UNICEF 1992).
The prestigious Swaminathan Committee headed by the then
Chairman of the Prime Minister's Science Advisory Committee set
up in 1982 to draw up a programme for leprosy eradication in India
_________________________ VII_________________________
has hitherto been neglected. Dr. Rao had also recognised that, quite
apart from the well publicised ifsue of stigma against the disease,
t^iere are other important sociological and anthropological para
meters that are critical to the development of the programme. In the
course of data collection for his research Dr. Rao has collected first
hand information concerning the nature of interaction among the
key elements of the four categories mentioned above. Over and
above, using secondary data, he has also attempted to present a
pictureof the dynamics of the programme as a "system ' overa time
dimension. He has also updated his research by getting together
information concerning the developments that have taken place
since he conducted his field work. The observations he has made
on these developments fall in one with those that emerge from his
primary data and their interpretation and analysis.
_______________ _______ VI___________________
by 2000 AD also failed to provide leadership. First and foremost,
there was so little data base to make any semblance of scientific
analysis of the problem. Over and above was the pronounced bend
in favour of technocentric issues — immunomodulators to develop
a vaccine for leprosy eradication and multi-drug therapy. At the
same time it virtually ignored the epidemiological requirement for
making an impact on the problem, leaving aside the utopian goal of
eradication by 2000 AD. There were also huge gaps in the analysis
of the Administrative and social science issues. Only a pronounced
lack of understanding of the administrative issues can explain why
they asserted "Essentiality of verticality".
Not unexpectedly, thequality of decision making and their data
base has been uniform poor since the inception of NLCP. Dr. Rao his
repeatedly draw attention to the very substandard quality of the
data used in assessing the programme and in formulating the
changes. Unfortunately, the same group of leprologists have played
a leading role for long intervals in the dicision - making process.
This points to a much more serious "stigma" in leprosy work.
Leprosy workers have been so preoccupied with the undoubtedly
deep - seated stigma against it in the general population that they
have forgotten to note that they (i.e. leprosy workers) are stigma
tised among health workers and leprosy programmes occupy a
"low" position in the choice heirarchy of public health program
mes. That perhaps explains why the contributions from leprologists
in India have been so disappointing. If for nothing else, Dr. Rao
should be commended in bringing a whiff of fresh air in the
otherwise stagnant and stereotyped atmosphere in leprosy work in
India.
A distinctive feature of Dr. Rao's work is that he has conceptua
lised the programme as a complex, interacting system, requiring
interdisciplinary inputs. He has examined it as a managerial and a
technological process with epidemiological and sociological per
spectives. He has developed the methodology for this study on such
a broad based conceptual foundation. The research design includes
analysis of the managerial process, from the apical level right down
to the village level. Technological issues are studied in terms of
various diagnostic criteria, therapeutic approaches, deformity pre
vention and management ofdeformity, social support and rehabili
tation. Predictably, epidemiological analysis has been the sheet
anchor of his study. This has brought out many perspectives which
By applying system thinking in developing the concepts and
the methodology for his research, Dr. Rao has been able to draw
attention to a number of facets of the NLCP. He has gone on to use
a systems framework to make accurate forecasts concerning ad
vantages and disadvantages of implementing the report of the
Swaminathan Committee. The systems approach has also been
used by him to call into question some of the key assumption in the
strategy for "eradication" of leprosy. Dr. Rao's contention gets
strong support from the findings of the Danish' Assisted Leprosy
Project (DANLEP, 1988) in Rajanandgaon district of Madhya Pradesh.
They reported that by actively involving the communities, without
even carrying out house-to-house search, it is possible to dis
cover" a large number of additional cases (as much as 50-150
percent) which were apparently missed by the workers who car
ried out the surveys in NLEP.
I
t
An outstanding finding from Dr. Rao's research, which got
strong endorsement from DANLEP, was that there has been con
siderable flaws and distortions in social science studies of "stigma"
against leprosy in the population at large. Dr. Rao's study of the
village population, of the families of the victims, and the victims
themselves gives a different perspective to the "problem" of stigma.
This got strong support from the findings of the studies of DANLEP.
Through this research work. Dr. Rao has made a substantial contri
bution to the development of systems thinking at the Centre of
Social Medicine and Community Health of Jawaharlal Nehru
University for analysis and development of public health practice
in India.
PROF. D. BANERJI
IMM
PREFACE
FOREWORD II
with a physically and mentally deplorable life. It also has got a
deleterious influence on the family life as well as life within th
1 have great pleasure in writing the foreword to this ex e sive analysis of the Leprosy problem in India. People sh°uld
realise that Leprosy is curable and should be taken on han
at an early stage. Dr. Rao has provided an extensive data both
official and non-official sources. 1 am not aware of any other
book soextensive and complete on Leprosy. I commend this
book to everyone interested in the problem df Leprosy and its
control which is urgent. It is obvious Df. Rao has taken
enormous efforts to obtain data and to think about the
community.
The estimated case load in the country is 3.2 millions, out rf
which 20 to 25 per cent are having deformities. This case load
forms about one-fifth of the total leprosy problem.in the world.
Even though the government launched a National Leprosy Con
trol Programme in the year 1954-55, there has been no sociological
and epidemiological impact on the problem. The conceptualisa
tion of the programme was not based on any sound scientific
methodology applicable and epidemiologically effective solu
tion. The programme did not envisage an inter-disaplmary effort.
problem.
From the above it is obvious that Dr. R ao has taken very
pain to cover all the aspects of the problem of Leprosy in
India particularly in the rural areas. He has put in his Plication
all the materials possible on the subject. Although Dr. Rao
has not referred to Dr. Veeraraghavan's culture of Lepra
bacillus quicker and has been acknowledge from many Sci
entists in India and abroad . I commend this book to everyone
whether a Leprosy worker or an administrator or a policy
maker.
The Centre of Social Medicine and Community Health, Jawahar
lal Nehru University, under the able and dynamic leadership of
Professor Debabar Banerji, has been striving since its inceptionan
1972 to evolve and implement an inter-disdplinary approach tor
solving the various community health problems in India. Various
scholars of this Centre have accepted the suggestive motivation of
Professor Banerji and worked in various fields of community
health, when Professor Banerji initiated the discussion on the
community health problem posed by leprosy, J took up the
challenge to study the problem in its entirety. The systems
approach evolved for the study of community health problems by
!' Professor Banerji formed the main frame of the present study.
dr. k.s. sanjivi
t
The Voluntary Health Services, Medical Centre, Madras, under
the able leadership of Professor K.S. Sanjivi, gave additional
Ill
IV
support to me for accepting the challenge. The M.A. Chidamba
ram Charities generously came forward with financial assistance
for the study. The M.A. Chidambaram Institute of Community
Health, located in the Campus of the Voluntary Health Services,
Adyar, Madras, under the leadership of Brig. M.A. Ramaswamy
provided the encouragement needed all through the study.
to Dr. K.C. Das, Assistant Director General of Health Services
(Leprosy), Government of India, and Dr. S. Natesan, District
Leprosy Officer, Chingleput. Dr. Sharma and Dr. Natesan in
structed all the workers to extend to me their full co-operation.
Consequent to his perseverance and zeal for solving commu
nity health problems in spite of heavy odds. Professor Banerji,
amongst his multifarious commitments, gave his valuable time
and guidance to me in each and every phase of the study. His
interest in the study was so deep that he visited some of the field
areas along with me to get a first hand information about the
problem of leprosy at the grass-root level. I am greatly indebted
to him and to his commitment.
To Professor Sanjivi, I am deeply indebted for the encourage
ment he has been giving all along my career, which began at the'
Voluntary Health Services, founded by him.
The members of the faculty of Centre of Social Medicine and
Community Health, Jawaharlal Nehru University, Dr.(Mrs) Prabha
Ramalingaswami, Dr. Imrana Qadeer, Dr. Santosh Kumar Sahu
and Dr. Dipankar Gupta, have all encouraged me throughout my
study. I am extremely grateful to them. Dr. Santosh Kumar Sahu,
and E>r. Lakhan Singh stood by me in various stages of prepara
tion of this work, without which this work could not have seen the
light of the day.
Miss L. Lalitha, stenotypist, Voluntary Health Services and
other staff working at that Institute gave considerable secretarial
help.in the data processing, analysis and in preparation of the
draft. I am also extremely grateful to Mr. P.S. Rajagopal and Mr.
J.S. Baweja for the final typing work.
I owe a special debt of gratitude to Dr. C.S. Gangadhar
Sharma, the State Leprosy Officer, Tamil Nadu, for the uninhibi
ted support given to me du ring various stages of a data collection.
He has been most generous in responding to my numerous
requests for information and comments. My thanks are also due
I
A
To all the leprosy workers whom I contacted for the study, I
wish to express my sincere thqnks. To the various respondents in
the community and to the patients suffering from leprosy in the
different study villages, 1 am extremely grateful to the time they
spent in spite of their avocations and sufferings.
But for my mother, my wife and children, who tolerated my
long absence from home and for the uninhibited support they
have been giving me, including enabling me to catch the early
morning bus to the field areas, this research work could not have
taken shape at all. I am thankful to them.
To all those who have been to help to me in one way or the
other. I owe a word of thanks and crave their indulgence for not
acknowledging their help individually.
September 4,1992
K. VENKATESWARA RAO
I ,
REHABILITATION IN
LEPROSY WORK
Role and Experiences of NGOs
S. P. Tare
Voluntary agencies have played the pioneering role in leprosy as well as rehabilitation of
patients. Indeed, it is the voluntary agencies who are implementing, through trial and
error, the concept of community-based rehabilitation which seems to be the only sensible
way to fully solve the complex problem of rehabilitation.
r-pHERE is probably no other dis1 case which gives rise to so much
physical mutilation (with the ex
ception of yaws) as leprosy. This
characteristic along with a few
others, has wrapped leprosy into
myth and mystery, and has made it
a most abhorred disease. For cen
turies, a patient of leprosy is
recognised only when he has
obviously visible deformities, and it
is at that stage that he has been
shunned and hounded, over cen
turies, from job, home and society.
Being a chronic disease, and not a
killer, the person afflicted with lep
rosy has to carry the cross till he
dies, years later, either due to some
other reason or oldage.
Leprosy is as much a medical
problem as a social one. And of
the variety of problems which have
lo be faced, the most formidable
one is that of rehabilitation of lep
rosy patients. It arises that the
patient is de-habilitated from
society.
Il is thus no wonder that it came
lo the lot of voluntary agencies to
10
3^
111”
try to alleviate the social sufferings
of leprosy patients.
Rehabilitation made popular
borRehabilitation—a term
rowed from social welfare field—
was given a very restricted meaning
in leprosy field in the period soon
after Independence. What they
were actually doing was providing
vocational engagement to their
inmates within the confines of their
premises. It was the Gandhi
Memorial Leprosy Foundation,
which spear-headed the movement
to make an entirely difficult con
cept of rehabilitation popular. It
was stressed that rehabilitation is
essentially a decentralising process
through which patients are helped,
by training them in some skill or
craft, and to go back to their
original environment and win back
respectful place in their original
milieu. Any effort which falls
short of “sending the patient back”
is not rehabilitation in the real
sense of the term; it is an alternative
arrangement made out of failure to
rehabilitate a leprosy patient to his
former environment
There was almost total lack of
any follow-up of the patients so dis
charged, and consequently the
patients found themselves lost after
discharge. The only alternatives
available were either to become a
beggar or a landless labourer.
It was again the efforts of some
pioneering voluntary agencies to
explore other avenues of employ
ment for their patients. They tried
to help the patient to do whatever
job/work he was doing earlier, and
in some instances, through avenues
of self-employment. The patients
were helped in obtaining funds
through loans or advances to take
up poultry, or dairy or to take up
vending of things of daily require
ment. The capital necessary for
such activity was small and could
be had from numerous Govern
ment schemes for poverty-allevi
ation, employment generation etc.
Such efforts were very cost-effective
as compared to institutional-based
rehabilitation where the cost was
found to be too heavy.
The National Leprosy Eradica
tion Programme as it was originally
SWASTH HIND
^-3
U
iu
We now have the spectacle of 25 lakhs of the leprosy patients staying in their hoiimes and in their villages while taking medicines through
out-patient clinics.
conceptualised had an in-built pro
gramme for preventing dehabilitalion which in fact, should be the
major thrust to solve the problem
of rehabilitation in the long run.
SET programme brought about
c’-'v but definite changes in the
k
ietal attitude of intolerance and
we now have the spectacle of over
25 lakhs of the leprosy patients
staying in their homes and in their
villages while taking medicine
through out-patient clinics. Even
a deformed leprosy patient (whose
number has dwindled to less than
10%) is able to remain in society
and home.
Community-based Rehabilitation
The efforts as mentioned above
made by the voluntary agencies in
getting the patients gainfully en-
January 1993
gaged in society is very similar to
what is now being technically
termed as “Community-based re
habilitation (CBR)”. The patients
have the support of the entire
society in whatever they do to
assure their independence, and get
assimilated in the. society fully.
This is very satisfying to the patient
himself because his integration
with society is complete. It is very
cost-effective
as compared to
“institution-based rehabilitation”
(IBR) which is very expensive and
has very dubious results.
There is however no doubt that
the concept of CBR is not yet fully
understood ev
by the workers
engaged in reh. uilitation and there
is still relu lance to involve the
community fully by leaving all
initiative to them. It will take
some more time for the workers
and agencies to get correctly orien
ted to the concept of CBR and
accept for themselves the role more
of a facilitator rather than that of
the initiator or the service-pro
vider.
To sum up, the voluntary agen
cies have played the pioneering
role not only in the field of leprosy
but also in the field of rehabilita
tion of patient and have been the
only agency to take care of that
aspect The Governments have
only recently become aware of the
importance and urgency of re
habilitation and may make mon
etary provision to help the vol
untary agencies. It is also evident
that the voluntary agencies have
tried and experimented with dif
ferent models of rehabilitation and
11
*
in this process saved lakhs of lep
rosy patients not only from getting
dchabilitatcd but also in gaining a
place in their original society.
Finally, it is the voluntary agencies
who are implementing, through
trial and error, the concept of CBR
which, in the context of our present
knowledge, and means available to
us, seems to be the only sensible
way to fully solve the complex pro
blem of rehabilitation.
A
WO LONrFR
V •
ISSN
068b
_DiS g^.io
1179
I .y
■-
January 1990
anti-leprosy day number
In this issue
swasth hind
Pausa-Magha
Saka 1911
January 1990
Vol. XXXIV, No. 1
Towards Leprosy Eradication
Leprosy continues to be a major public health
as well as a social problem in the country. Social
prejudices, fears and superstitions still continue to
a large extent to obstruct early case-detection and
regular treatment activities.
In India, more than 430 million people live in 196
leprosy endemic districts with a prevalence rate that
vary between one and five cases for 1000 people. A
substantial population thus remains exposed to a
greater level of risk of leprosy infection.
To combat the disease, the Govt, of India launched
the National Leprosy Control Programme in 1955.
It was redesignated as the National Leprosy Eradica
tion Programme (NLEP) in 1982 with the ultimate
aim of arresting the disease activity in all the known
cases by the year 2000 A.D.
There are hopeful signs as the present decade has
witnessed a major expansion of the leprosy control
work in India both quantitatively and qualitatively
with the help of the new strategy: Multi-drug Treat
ment. Under this strategy, rapid cure is being brought
to patients by providing continuous treatment. Start
ing with two endemic leprosy districts in 1982 as
many as 112 of the 196 leprosy endemic districts have
been brought under the multidrug treatment (MDT).
Rest of the districts will be brought under MDT in a
phased manner by 1992. The Govt, of India is
doing all it can to control leprosy and ultimately era
dicate it.
However, the MDT can be a complete success only
with the participation of the people. The need there
fore is redoubling of efforts towards health education
among patients, their families and the community.
On Mahatma Gandhi’s martyrdom day—30 Janu
ary—which is also observed as the Anti-Leprosy Day
in India let us emulate the example set by him and
rededicate “ourselves to work for the cause of leprosy
relief and thereby bring succour to this section of
suffering humanity”. It is with this spirit Swasth
Hind devotes this issue to
Anti-Leprosy Day.
SWASTH HIND WISHES ITS READERS
A VERY HAPPY NEW YEAR
Editorial and Business Offices
Central Health Education Bureau
Kotla Marg, New Delhi-110 002
Edited by
Cover Design
M. L. Mehta
M. S. Dhillon
B, S. Nagi
Page
Multidrug therapy in leprosy
Dr S. K. Noordeen
1
Is anti-leprosy vaccine in sight?
Dr M. D. Gupte
3
Involvement of Female Health Workers in Leprosy
Eradication Programme
Dr D. K. Mahabalaraju
5
Role of rehabilitation in leprosy
Dr Saudan Singh
Dr Sanjiv Kumar Bhasin
7
Role of Central Leprosy Teaching and
Research Institute, Chengalpattu, in National
Leprosy Eradication Programme
Dr P. N. Neelan
9
Monitoring and evaluation under National
Leprosy Eradication Programme
Dr N. S. Dharmshaktu
11
Our new Minister of Health and Family
Welfare—Shri Nilamani Routray
13
Symposium on
How far the goal of leprosy eradication
by 2000 A. D. is achievable?
(a) If yes, what is the progress?
(b) If no, what are the impediments?
and how can they be overcome?
S. P. Tare
T. N. Jagadisan
R. K Mutatkar
14-19
International Gandhi Award on Leprosy—1990
21
Health Sector
—Priorities identified
Shri Nilamani Routray
22
News
Leprosy—a select bibliography
Smt. Krishna Basra
25
a* i
3rd |
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i
I
MULTIDRUG THERAPY IN LEPROSY
Dr S. K. Noordeen
It is well recognized that leprosy combines several problems which have serious
implications on the individual, the family and the community. The challenges posed
by the disease include its communicability, its potential for causing physical defor
mities, its chronicity, and its propensity to generate intense negative social reaction.
It is estimated that there are about 10 to 12 million cases of leprosy in the
world. However, the number of registered cases> has varied over the years: 2.8
million in 1966, 3.6 million in 1976 and 5.4 million in 1985. Since then, there has been
a distinct change in the trend with a significant reduction in the number of registered
cases to 3.9 million cases by 1988, a reduction of about 28%. This is attributed
to Multidrug Therapy (MDT) implementation and the resulting release from treatment of a significant number of patients.
T) y the early 1980s it was clear against M. leprae such as rifampi
D that dapsone was steadily los cin in the 1960s, the application of
ing its usefulness, due to drug re leprosy treatment through combina
sistance. and that there was a gene tions of drugs became a clear pos
ral lack of enthusiasm for leprosy sibility. It was realised that with
control in many countries because leprosy patients harbouring very
of the poor results being achieved. large bacillary populations similar
Although more potent anti-leprosy to those with tuberculosis, successful
drugs were available then, the in chemotherapy should be one which
formation and guidelines available is capable of preventing the selec
c >ow to apply them in a practical tion of drug-resistant mutants as
was insuflicient. It was under well as killing of all, or nearly all
these circumstances that WHO con drug-sensitive organisms. With the
stituted the Study Group on Chemo prevention of selection of drug-resis
therapy of Leprosy for Control Pro tant mutants and the killing of
nearly all drug-sensitive organisms
grammes in 1981.
it was expected that relapse after
The recommendations of the stopping chemotherapy could
be
Study Group- which are now re- virtually eliminated.
cognized as a milestone in the
history of leprosy, are not always Acceptance of the recommendations
fully understood, particularly its ra on MDT
The recommendations on the
tionale. With the problem of dap
sone resistance increasing in its MDT regimens made by WHO re
dimensions, and with the availabi ceived enthusiastic support from
lity of better bactericidal drugs most of the leprosy-endemic coun-
January 1990
tries, WHO Regional Committees,
international and national non
governmental organizations, donor
agencies, and professional bodies.
Some countries had introduced
modifications to the WHO recom
mended regimens, but these were
generally minor and within the es
sential requirements for MDT. In
several countries, MDT provided
the opportunity to increase the prio
rity for leprosy control and streng
then their political commitments.
Progress with implementation
MDT
of
The coverage of leprosy patients
with MDT has napidly increased
over the past few years to reach,
by October 1989, 45.3% of the total
registered cases in the world. The
increasing acceptability of MDT
among national health services and
leprosy patients themselves is due
to: (a) the fixed, and relatively short
duration of MDT treatment; (b) the
1
TABLE 1.—PROGRESS OF MDT COVERAGE
low-level of toxicity and treatment
related side-effects; (c) the very low
OctOct.
Oct.
Oct.
Oct.
1989
relapse rates following completion
1988
1987
1986
1985
of treatment (0.1% per year for PB
3,866
4,908
5,813
5,341
5,368
and 0.06% per year lor MB based
RegisteredI cases
(X’ 1000)
on information based on 85,125
PB cases a*nd 22,087 MB cases); (b) No. of cases on MDT 78,752 4,68,222 6,99,589 16,04,927 17,51,903
(d) the high level of acceptance of
clofazimine discolouration ((over (c) % of total cases on
45.32
32.70
14.54
8.77
1.47
98%; (c) significant reduction in MW
8,53,706
93,216 5,10,593 6,27,919
(d) of cases WHO comp- 9,425
frequency and severity of ENL
1
reactions. One more advantage of ^ed MDT
(cumulative total)
the WHO/MDT regimens is the
considerable increase in the propor
the priority for leprosy in some among old cured patients and a con
tion of self-reporting cases at an
countries as a result of other press tinued, albeit reduced, incidence of
early stage of the disease. Conse
ing health needs; (b) poor health new disease arising from infections
quently, this has led to a reduction
infrastructure to cope with MDT: caught several years earlier. Hence,
in the number and degree of defor
(c, inadequate resources particularly apart from investing heavily on
mities among new cases: an in
for drugs; (d) absence of a proper efforts to reduce leprosy preva
e
creased acceptance and compliance
plan of action to implement MDT; through MDT, there is a need to
of patients to the treatment: and
(c) inadequate training of health plan for the future so that leprosy
better community support to pati
workers; (f) lack of laboratory faci control becomes part and parcel of
ents.
lities for skin smear examina primary health care encompassing
Table 1 shows the global progress tions; (g) poor referral faci
of MDT implementation from 1985 lities to deal with complications; early detection, treatment, as well
to 1988. For the first time, and (h) insufficient patient education as disability prevention and manage
in spite of the considerable increase about what to expect from MDT ment. In addition, on-going re
in the number of newly detected jo that when the time comes for search in leprosy vaccines, if found
cases during MDT implementation, stopping treatment, the decision successful, offer great promise to
there are indications of a decline would be acceptable to the patients. interrupt transmission completely
in the total number of registered
and attain eradication.
patients in the world. This decline
supports the efficacy of the WHO Future prospects
There is no doubt that MDT
MDT regimens for leprosy control
has brought about a major change
With the increasing political com- in technology for leprosy control.
and opens the possibility of major
However,
the
world
mitment
in many countries to deal It has also resulted in a new outlook
reductions.
However, the world
with MDT
MDT for
for leprosy
leprosy with leprosy effectively, with the towards the
coverage with
disease, and raised
is very uneven with some countries increasing appreciation of the value hopes among patients, 1
h
having a high coverage and others of multidrug therapy as a very po workers, and programme managers
lagging behind.
tent technology, and with the in alike. Where the implementation
creasing
international cooperation, of MDT is vigorous and sustained,
Of the 109 leprosy endemic coun
both
from
the bilateral and multi the results are extremely gratifying.
tries only 47 countries (or 43%
have at least SO' ,, MDT coverage lateral sectors enabling additional Problems, both technical and opera
inputs, it is not unrealistic to expect tional, need to be constantly reviewof their patients.
a reduction of leprosy caise-load ed and solutions found. The oppor
Operational problems in implement by as much as 80% in the next five tunities to markedly reduce leprosy
ing MDT
to seven years, at least in countries in the next decade are immense. It
In spite of the tremendous pro with effective programmes. How remains to be seen whether or not
we make use of them, and whether
gress made with MDT, several pro ever. notwithstanding anticipated
or not leprosy will ultimately be
major
reductions
in
prevalence,
it
blems, particularly at the opera
eliminated as a public health pro
should
be
recognized
that
other
tional level are faced by leprosy
blem as part of the overall goal of
control programmes. These inclu problems will remain for quite some Health for All by the Year 2000. A
time
to
come
such
as
disabilities
de;—(a) the inability to increase
.
9
.
«
m
r-r-»
Swasth Hind
IS ANTI-LEPROSY VACCINE IN SIGHT?
DR M.D. Gupte
The need for vaccine against leprosy control cannot be over emphasised. Remarkable
progress has been made with respect to identifying various components of Mycobac
terium Leprae in their micro-structure. There are immense possibilities for develop
ing a genetically engineered vaccine as well. However, it is not possible to predict
when such a kind of second generation or third generation vaccine can be developed.
It is, therefore, essential to undertake comparative studies with the presently available
and promising anti-leprosy vaccines. Thus, answer to a question like, is anti-leprosy
vaccine in sight, should be given with guarded optimism, feels the author.
Difficulties in the treatment of test. There is a strong belief, and
F leprosy can be cured, then
even salted fish can swim”, goes leprosy, particularly lepromatous some good evidence, that persons
an old Chinese saying.
Decades leprosy also led to the belief, “a who are lepromin negative even
saying,
have passed since we knew that patient of leprosy remains always after exposure to Mycobacterium
effective treatment for leprosy is a leprosy patient”. A leprosy vac leprae, are susceptible to lepromaavailable. The prospects for curing cine usually can be considered as tous leprosy. Therefore, when in
leprosy are no longer bleak and it preventive vaccine or a prophylaxis 1939, Fernandez demonstrated that
is known that leprosy is like any against leprosy disease. A very BCG could convert the lepromin
other communicable disease. How unique possibility is being explored negative
individuals to leproinin
ever, the fear associated with leprosy with some of the anti-leprosy candi positive individuals, lot of enthu
and the stigma due to disabilities, date vaccines about their capa siasm was generated regarding the
deformities and disfigurement hap city to treat a patient of leprosy. possible use of BCG as a leprosy
pen to be very deep routed cultural Thus in addition to the immuno prophylactic agent. Several studies
characteristics. Therefore, the pro prophylactic uses, the anti-leprosy
were undertaken with BCG in diffe
position of leprosy prevention gets vaccine can be used as an immuno
rent parts of the world and the re
therapeutic
agent.
accepted enthusiastically and also
Patients of lepromatous leprosy sults obtained were quite variable
reales lot of expectations in all
me echelons of the society. Difficul are negative to a lepromin skin (Table-1).
ties in growing Mycobacterium le
TABLE 1
prae, the leprosy germ, in artificial
culture medium happens to be the RESULTS OF MAJOR FIELD TRIALS AGAINST LEPROSY WITH BCG
main obstacle in developing an anti
protec
BCG
leprosy vaccine. Efforts were, there
Control
tion
fore, directed to organisms similar Country
Incidence
Person
Incidence
(%)
Person
to the leprosy germ that can be us
years
% o per year
years
% 0 Per Year
ed for preparation of anti-leprosy
vaccine. We are now in a fortunate Burma
20.4
4.4
1,51,415
5.5
1,51,060
situation where it is possible to
46.0
3-4
29,300
6.3
27,100
consider a vaccine based on the New Guinea
leprosy germ derived from armadil Uganda
0.9
80-9
43,300
4.5
42,800
los as well as anti-leprosy vaccines
7.4
23.0
4,88,000
9.6
2,40,000
based on organisms similar to the India
leprosy germ.
“I
January 1990
3
Evidence available from the
African countries, for example,
Uganda, from Table- L indicate
that there is already a vaccine avail
able for leprosy. In fact, studies
based on BCG scars and historical
data as well as prevalence studies
in Malawi in Southern Africa indi
cated that BCG would be effective
at least to the tune of about 60 per
cent in preventing leprosy. However,
findings from other parts of the
world do not support this view. For
instance, in Burma, protective effi-
cacy of BCG was 20 per cent and
in India also it was similar.
that it was possible to achieve le
promin conversion by using this
combination in contacts as well as
in patients of lepromatous leprosy.
He convincingly demonstrated the
immunotherapeutic efficacy of this
combination in patients of leproma
tous leprosy. Studies of Dr. Convit
led to development of a candidate
leprosy vaccine, viz-, BCG in com
bination with armadillo derived kill
ed Mycobacterium leprae- This vac
cine is presently being tested in
Venezuela by Dr. Convit himself
and in -Southern Africa in Malawi
lopments in this field in India.
Drs. Bapat, Ranadive and Khanolkar, reported, way back in 1958. cul
tivation of a mycobacterium from
patients of
lepromatous leprosy.
This mycobacterium is called ICRC
bacillus (Indian Cancer Research
Centre bacillus). It was observed
that the ICRC bacillus was similar
to the leprosy organism. Drs. Deo
and Bapat continued research on
ICRC bacillus and were able to
develop an anti-leprosy vaccine.
They demonstrated the ability of
this vaccine in lepromin conversion
Parameters
The limited success of BCG in
preventing leprosy was not adequate
to justify the use of BCG for leprosy
prophylaxis. The search for newer
vaccines continued. Several para
meters were being identified to judge
the possible anti-leprosy efficacy of
a vaccine. Few of the parameters
are mentioned in Table-2.
as well as its immunotherapeutic
potentials. This vaccine is presently
being tested
for its prophylactic
value in Sholapur district in Maha
rashtra by Dr. Deo and his collea
gues.
There is one more cultivable bac
illus, somewhat similar to the
leprosy germ, called M.w. Dr. Talwarand his colleagues have develop
ed a vaccine based on the M.w. bac
illus. This vaccine also shows the
abilities for lepromin conversion as
well as immunotherapy in patients
of lepromatous leprosy. At present,
TABLE 2
immunotherapeutic trials with the
PARAMETERS TO JUDGE APPARENT ANTI-LEPROSY EFFICACY OF A/.h’. vaccine are being conducted
in Delhi by Dr. Talwar and his 'fl
A CANDIDATE VACCINE
leagues. It is expected that Dr. awar would be undertaking a prophy
(1) Lepromin conversion in animals
lactic vaccine trial in Kanpur district
(2) Lepromin conversion in initially lepromin negative healthy individuals in Uttar Pradesh.
and in patients of lepromatous leprosy.
A third candidate vaccine from
(3) Animal protection—Mouse foot pad studies
India is being developed in Central
Drug Research Institute. Lucknow.
(4) Immunotherapy in patients of leprosy
This vaccine is based on a mycobac
by Dr. P. E. M. Einc and his collea terium called Mycobacterium habaPioneering Research work
Di. Jocinto Convit from Vene gues for the prophylactic efficacy. na. Interestingly, this vaccine is ex
zuela has done pioneering research Both these trials are supported by pected to be effective against both
work in this direction. He used the IMMLEP Programme of the tuberculosis and leprosy. Develop
ments with respect to this vaccine
killed Mycobacterium leprae* de World Health Organization.
arc being watched with expectations.
rived from armadillo in combina
Developments
in
India
tion with BCG in some patients of
We should be proud of the deve Promising Results
leprosy and their contacts. He found
4
Availability of several cand’ e
vaccines is thus very promising. All
these candidates fulfil the require
ments of a candidate leprosy vaccine to varying extents. It is no t
possible, nor advisable, to use any
of these vaccines as prophylactic
vaccines at the present stage of
development. It is essential to prove
their prophylactic efficacy in well
planned and conducted studies. It
will be extremely useful and absolu
tely essential to compare these candi
date vaccines in similar situations.
(Contd. on page 8)
Swasth Him
INVOLVEMENT OF FEMALE HEALTH
WORKERS IN NATIONAL LEPROSY
ERADICATION PROGRAMME
Dr D. K. Mahabalaraju
Pregnant women and lactating mothers
Adult females are major victims of leprosy,
opined that female paramedical workers
are more susceptible to leprosy. So it is i
can achieve better coverage among females, particularly adult females. Hence,
inclusion of Female Health Workers in leprosy case detection activities is recommended for achieving better coverage among females.
ovcrall support by Government and cessful implementation of Leprosy
non-Government agencies at Na Eradication Programme.
tional and International levels are
Paramedical workers (Leprosy)
available. Using existing and new
play a very important role in case
knowledge, pooling the resources
detection activities. Early case de
and emphasizing health education,
tection needs complete examination
now it is possible to cure leprosy
of individuals with minimal cloth
at any stage. Thereby we can pre
ing. Our paramedical workers are
vent transmission of infection and
mostly males. Because of this,
protect healthy population. Preven
adult females usually refuse exami
tion of deformities and complete
nation by male workers. The follow
rehabilitation is also possible. These
developments suggest that Leprosy ing study supports the above state
The WHO from its very incep eradication is achievable in foresee ment and suggests that involvement
of female health workers is crucial
tion has given priority to Leprosy able future.
for the success of the National Lep
Control. In India National Leprosy
rosy Eradication Programme.
Eradication Programme (NLEP) Social stigma
was launched in 1983 with the hope
Social Stigma makes the patient
Epidemiological study
of eradicating Leprosy by 2000 A.D.
to conceal his disease. Female
An epidemiological study of Lep
Now, there are many recent ad patients refuse examination because
rosy
was undertaken by the Author
vances in the field of Leprosy. of social taboos against the exami
in one rural paramedical worker
More potent anti-leprosy drugs are nation of women by male health
sector, (Lokikere). This area is
available. Multi-drug regimen is worker. Hence, infectious patients
situated in Chitradurga district of
practiced to combat drug resistance. are undetected and hidden in all
Karnataka State. The study area
There is progress towards anti-lep sectors of societies. They are main
consist of 13 villages with a popu
rosy vaccine. Facilities for early taining the spread of infection, and
lation of 34,838
living in 5,317
diagnosis, treatment, rehabilitation, acts as a major barrier in the suc-
Leprosy is a major Public health
and grave socio-economic problem
in the developing countries: more
so in India. India accounts for four
million leprosy cases. The problem
is far more serious than is indi
cated by the number of cases alone.
The economic loss, physical-social
handicaps, psychological problems,
mental agony, and social stigma at
tached with the disease further com
pounds the problem.
January 1990
5
families. All the individuals resid
ing in the study area were contacted
by house-to-house visit and examin
ed for the evidence of leprosy.
Survey was started in the early parts
of the day (January 1987 to Decem
ber, 1988). So that the villagers
could be examined before they left
for the work.
Early case detection in leprosy
needs complete examination of
individuals with minimal cloth
ing. Our paramedical workers
are mostly males. Because of
this, adult females usually
refuse examination by male
workers.
Fem ales—m ajor v ictims
Observations of the study reveals
that out of 34,838 population resid
ing in the study area, only 31,367
(90.04%) population could be exa
mined for the evidence of leprosy.
Coverage was better among males
(91.25%). Examination of females
was less (99.77%). Only 77% of
females of 25-34 years of age group
could be examined for the evidence
of Leprosy. The less coverage of
adult females in this study was
mainly due to refusal of adult fe
males for examination. The studies
conducted by Ganapati in 1976.
Ramu et al in 1973 and Ecchelli ei
al during 1973 have shown that site
of prediliction of Leprosy lesions
was gluteal region and thighs.
Hence complete examination of body
is essential in case finding activities.
Females, particularly adult females,
refuse examination of these covered
6
parts by male workers. Females con
stitute nearly 50% of the population
and they are equally susceptible for
leprosy as males. Adult females
are major victims of leprosy. Preg
nant women and lactating mothers
are more susceptible to leprosy.
So it is opined that female para
medical workers can achieve better
coverage among females particularly
adult females. Hence, inclusion of
Female Health Workers in Leprosy
Case detection activities is recom
mended for achieving better cover
age among females.
KUSHT VINASHAK.
SEP-DEC. 1989.
WORLD AIDS DAY 1990 TO FOCUS ON WOMEN
Dr Hiroshi Nakajima, Director-General of the World Health Organi
zation (WHO) announced formally 22 January, 1990 that the theme
for World AIDS Day 1990 will li Women and AIDS, while addres
sing the Eighty-fifth session of the Executive Board during the debate
on the global strategy for the prevention and control of AIDS.
WHO announced that World AIDS Day 1990 will:
♦Heighten awareness about the risk of HIV infection and AIDS
especially in women;
* Expand and strengthen the worldwide effort to stop AIDS by
highlighting the impact of HIV/Al DS on women around the world
----- not only as a medical problem, but as HIV/AIDS affects women
as care providers, health-workers, educators, and mothers:
♦Strengthen AIDS prevention activities and programmes at all
levels of society, especially as they pertain to women:
*Promotc respect and care for all HIV-injected people and people
with AIDS; and
♦Contribute to lasting dialogue, sustained activity and long-term
commitment among all people in countries around the world.
World AIDS Day 1990 will also highlight the link between the
status of women within the family and society, and their vulnerability
to infection and its consequences. It will also draw attention to the
special concerns related to HIV/A1DS and pregnancy, childbirth and
raising children.
AIDS is a serious health problem which affects women, men and
children in countries around the world. Worldwide. WHO estimates
that at least six million people are now infected with HIV. and that
approximately two million — or one third - are women. It is ex
pected that by the end of 1992. a cumulative total of over 350,000
cases of AIDS will have occurred among women, or three times as
many as had occurred by the end of the 1980s. WHO projects that
by the year 2000, an estimated six million cases of AIDS will have
occurred among men, women and children, or 10 times the current
estimated number of cases. O
Swasth Hind
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&&
ROLE OF REHABILITATION IN LEPROSY
Dr Saudan Singh
Dr Sanjiv Kumar Bhasin
The leprosy patients and their family members are to
suffer from various traumatic experience due to disrup
tion of their social relationship.
Exclusion fiom
religious functions, social ceremonies, community gather
ings and denial from participation in educational insti
tutions and employment leaves these leprosy patients
as social oiit-casts. The voluntary organisations have
a significant role to play in the creation oj a social
environment by removing ignorance, superstition and
prejudice against the disease. Rehabilitation is oj
utmost importance both for the patient and the com
munity as rhe rehabilitated patients while being drawn
in the social mainstream will contribute towards the
national developmental efforts rather than being a bur
den on the society.
January 1990
TJ ehabiutation may be defined as “The diagnosis,
TV treatment and prevention of dehabilitation”. In the
context of leprosy, dehabilitation chiefly affects three
areas of life; the disease can cause a patient to lose his
family and place in society, his work and his means
of livelihood or his self-respect. It is, cited that on an
average 15-20 per cent of leprosy patients develop physi
cal disabilities, e.g., drop foot, claw toe, hammer toes,
planter ulcers, depressed nose, arthritis, multiple sinuses,
etc. Thus, rehabilitation of leprosy patients must ful
fil the triple objectives of their physical, economic and
social rehabilitation.
Rehabilitation is an integral part of leprosy control.
It must begin as soon as the disease is diagnosed. The
cheapest and surest rehabilitation is to prevent physical
7
deformities and social and vocational disruption by
early diagnosis and adequate treatment. The measures
that are taken in this direction are known as “preventive
rehabilitation”. The approach to rehabilitation should,
therefore, begin with dehabilitation. We should never
allow dehabilitation to take place and afterwards take
up the uphill task of rehabilitation.
Physical rehabilitation
The deformities caused directly by the disease and
secondarily due to factors operating on insensitive parts,
constitute the two most important elements in physical
rehabilitation of leprosy patients. Deformities affecting
the hands and feet seriously impair the working ability
of patients and require surgical correction in specialised
institutions. The existing facilities for physical rehabi
litation including Leprosy Rehabilitation Promotion
Units, Units for Reconstructive Surgery and Regional
Leprosy Training and Research Institutes (RLTRIs)
functioning under the NLEP are totally inadequate to
meet the need.
Economic Rehabilitation
Leprosy in India is largely a disease of the poor. The
financial hardship acquires almost tragic proportions if
the sole bread winner in the family contracts the disease.
The patient loses employment and new jobs are difficult
to come by. The disease often causes incapacitating
effects. Faced with poverty, antipathy from the family
members and scorn from the community, these patients
often fall victim to mental depression, they shun society
and neglect treatment.
Contd. from page No. 4
CJ1L Field Unit, Avadi, Madras,
situated in a leprosy endemic area
in Chinglcput district is planning
for such a comparative study. Pro
phylactic studies against leprosy
are expected to take long time—a
decade, if not more. Results of the
ongoing vaccine trials in India, as
well as in other countries, and the
proposed comparative vaccine trial
are thus expected in about 10 years
from now.
8
There are a large number of patients suffering from
leprosy, specially in rural areas, who continue with
their original work. However, their efficiency generally
becomes considerably low. Such persons do not need
actual rehabilitation but also require some financial
assistance to take up a subsidiary occupation in order
to supplement their income. Thus the three kinds of
activities required for vocational training are: —
— Selection of a suitable craft or vocation.
— Re-education and training in new vocations, and
— Placement of the trained persons.
Social Rehabilitation
The social dimensions of leprosy are often tragic and
frequently hinder the successful implementation of le
prosy control programmes. The leprosy patients and
their family members are subject to various traumatic
experiences due to disruption of their social relationship
Exclusion from religious functions, social ceremonies,
community gatherings and denial from participation
in educational institutions and employment Laves these
patients virtually as social out-casts. In the creation of
a social environment the voluntary organizations have
a significant part to play by removing ignorance, supers
tition and prejudice against the disease.
Thus rehabilitation which is tertiary level of preven
tion in National Leprosy Eradication Programme is of
utmost importance both for the patient and the com
munity as the rehabilitated patients while being drawn
in the social mainstream will contribute towards the
national developmental efforts rather than being a bur
den on the society.
Remarkable progress lias been
made with respect to identifying
various components of Mycobacte
rium leprae in their micro-structure.
There are immense possibilities for
developing a genetically engineered
vaccine as well. However, it is not
possible to predict when such a
kind of second generation or third
generation vaccine can be develop
ed. It is therefore essential to under
take comparative studies with the
presently available and promising
anti-leprosy vaccines.
The need for a vaccine against
leprosy cannot be overemphasized.
It is not possible to predict that
such a vaccine will definitely emerge
from the presently available candi
date vaccines. Thus, answer to a
quetion like, is anti-leprosy vaccine
in sight, should be given with
guarded optimism.
Swasth Hind
NATIONAL LEPROSY ERADICATION PROGRAMME
ROLE OF CENTRAL LEPROSY TEACHING
AND RESEARCH INSTITUTE,
CHENGALPATTU
Dr P.N. Neelan
The Central Leprosy Teaching and Research Institute, situated about 60 kms. south
of Madras City, was established in 1955 by the Government of India. It is function
ing as a peripheral office of the Directorate General of Health Services, Ministry
of Health and Family Welfare since April 1974 and has been providing strong
research and man-power training support to the National Leprosy Eradication
Programme (NLEP).
npuE original objective of the Ins1 titute was to develop it as a
National Centre for Training and
Research in Leprosy, (a) to under
take research into the basic problems
relating to the inception and spread
of leprosy, (b) to promote applied
research in the field which would be
of use in the control of leporsy, (c) to
‘rain leprosy workers of various cate
gories, (d) to function as a nodal cen
tre to provide technical guidance for
the promotion of anti-leprosy work
on sound lines, and (e) to participate
actively in the organization and deve
lopment of State leprosy institutions
when such are established, and make
available its services for the investi
gation of special problems in all parts
of the country.
division with Physiotherapy unit, a
Microcellular Rubber Manufacturing
unit and Orthotic and Footwear
unit; a Laboratory division with clini
cal pathology, biochemistry, patho
logy, microbiology and immunology
laboratories and a standard animal
house; and an Epidemiology division
with a field unit. Central Monitoring
and Evaluation unit. Statistics unit,
and Training section with a good
library facility. In addition, there is
an Administrative section headed by
an Administrative Officer with minis
terial staff to look after accounts,
stores and administrative matters.
monitoring and evaluation unit of
the Epidemiology Division.
Achievements in recent years
1. With the help of animal house
facility, the Institute has contributed
to a better understanding of the pro
blem of dapsone resistance in leprosy
through studies in the hospital as
well as in three different well-defined
control unit areas in Tamil Nadu.
An offshoot of this was to create
awareness and need for introducing
multidrug therapy (MDT) in the
NLEP in India.
2. Controlled clinical trials funded
by WHO THELEP, using Rifampi
Other facilities available are a cin, Clofazimine and Dapsone in
well-equipped library, a medical different combination regimens, have
illustration section, a microcellular shown that the problem of drug rerubber unit which produces sheets of sjstance js eliminated by using multi
required strength for use in the foot- ^rug therapy. Monthly administration
Organization
wear manufactured by the Institute of Rifampicin was found to be as
The Institute has a Clinical divi and other centres, ophthalmic facili- effective as daily administration,
sion with a 124 bed hospital and an ties for in-patients and out-patients These studies helped in evolving aptherapeutic regimens in
out-patients block; a Surgical care, and computer facility in the propriate
}
January 1990
9
the treatment and management of
multibacillary leprosy which were
incorporated in the MDT programme
of NLEP. Therapeuti: studies in the
field area of the Institute has shown
that six months MDT is adequate in
the treatment of pauci-bacillary
leprosy.
. t.
3. Co-ordinated work in the clini
cal, surgical, laboratory and field
divisions has resulted in a clearer
understanding of the clinical mani
festations of leprosy, complications
like reactions and neuritis, and also
the evolution and natural history of
the disease process and progress in
the affected individuals including bor
derline leprosy.
4. The Institute has devised a
simple laboratory test that could be
carried out in the field by peripheral
level workers to monitor dapsone
compliance among patients. It has
also taken up the responsibility of
procuring and distributing the Kits
and reagents for doing the test to
the various State units in India as a
part of NLEP activity.
■
‘
Animal House—mice cages
about epidemiology (distribution,
transmission etc.) of leprosy in these
parts of the country.
7. Laboratory division has stand
ardized the smear taking procedures
for the Programme and for monitor
ing cross-checking of smears.
8. With the help and guidance
5. One of the objectives of the
from
the WHO Consultant in
Programme is to reduce the incidence
Statistics,
officers in the Monitor
of disabilities in leprosy through
ing
Unit
have
brought out a Guide
early detection and efiective treat
line
for
Sample
Survey and Assess
ment. Basic studies in nerve involve
ment
Units
(SSAU)
in the States.
ment and consequent development
The
document
has
been
distributed
of disabilities, and management and to all States and Union Territories.
prevention of neuritis in leprosy are
areas of interest in the Surgical Divi The Unit is also training personnel of
sion of the Institute. Studies on the SSAU teams from the States.
structure and functions of the foot
9. The Monitoring and Evaluation
and its disorganisation in leprosy Unit has developed a Management
through use of barograph, EMG and Informationx System that has been
other equipments
have thrown light field tested and is being used for in. .
on the
f
understanding of the genesis depth monitoring of NLEP activities
of plantar ulceration. The surgeons of in Namakkal Control Unit of Salem
the Institute have tested and devised District.
District, The work is being contishort duration satisfactory treatment nued.
procedures for healing of plantar
ulcers using collagen sheets, zinc
________
___ _
10. One of the major
and continutapes and Debrisan. They have also ing activities in the Institute is the
devised original and modified techni- training of various categories of perques in surgical correction of defor- ?onnel working in NLEP in the states,
mities of hands and feet in the The Institute has also organized
leprosy patients.
workshops and meetings on behalf
of the DGHS to devise means to
6. The Institute has carried
c
out strengthen the existing leprosy trainlongitudinal follow-up off the3 popu- iing_ centres
and
also _
to
■
*in the
l states
____
: __
lation (through detailed surveys) in re-orient the training to meet the
the field area of the Institute over needs of the Programme. In addition,
a period of 20 years, and used seve- the Institute collaborates with JIPral intervention procedures like MDT MER, Pondicherry in training for
and chemoprophylaxis. This resul four months the candidates of the
ted in the collection of information postgraduate Diploma course in
10
.<■
Leprosy. A four week exposure to
surgery in leprosy is given to ortho
paedic and general surgeons. Fellows
sponsored by WHO come every year
for short training in leprosy control.
During the 7(h Plan period, the
Institute has further developed to
take up additional responsibilities
in support of a successful implemen
tation of the NLEP. We are confi
dent that the continued support from
the Ministry and the Directorate and
the future expectations based on the
assessment of our present perform
ance, will be fully reflected in our
activities in the coming years.
Some of the areas in which the
Institute is continuing its research
activities are (a) Developing a cul
ture medium for M- leprae. Effort in
this direction has already been star
ted; (b) developing simple serologi
cal test(s) that could be used in the
field as a screening test, (c) opera
tional research in cost effectiveness
of alternative approaches in MDT
implementation; (d) epidemiological
studies in incidence of deformity and
its impact on the programme, and
(e) operational research in cost effec
tiveness of alternative strategies in
disability prevention, limitation, and
rehabilitation.
The Monitoring and Evaluation
Unit is expected to take up in stages
the work of monitoring the Program
me in various districts in the country
and also in carrying out operational
research studies relevant to the effec
tive implementation of the Pro
gramme.
Swasth Hind
Monitoring And Evaluation Under National
Leprosy Eradication Programme
Dr N. S. Dharmshaktu
The National Leprosy Eradication
Commission has been constituted
consisting of the following for the
guidance and surveillance of the
National Leprosy Eradication activi
ties:
This commission is headed by
Union Minister of Health &. Family
Welfare as a Chairman. The mem
bers of the Commission are: Union
Minister of Finance, Planning Com
mission,
Chemicals AZ Fertilisers,
Education & Social Welfare and five
Chief Ministers of the states in rota
tion. Eight eminent leprologists and
social workers and others engaged
in leprosy work are also taken as
members. The Secretary, Health &
Family Welfare is ex-othcio Secre
tary of the Commission. The com
mission is a policy making body.
National Leprosy Eradication
Board: It has been set up under the
Chairmanship of Union Secretary,
Health & Family Welfare. The board
functions in the areas allotted under
rules of business to the Ministry of
Health and 1 amily Welfare. Ministry
of Social Welfare and Ministry of
Information and Broadcasting in so
far as the activities relating to eradi
cation of leprosy and rehabilitation
of leprosy patients are concerned.
The Board has the powers of Ministry/Deptt. of Government of India.
The Board serves as the executive
body responsible for implementation
of the plans and policies of the
National Leprosy Eradication Com
mission. The members of the board
are Secretaries of Welfare, Planning,
Rural Development, Information &
Broadcasting, Finance and the Secre
tary, Health who is the Chairman of
the Board. Other members of the
board are Director General of
Health Services, Director-General
of JCMR, Senior Deputy Director
General, ICMR (ECD), and Assis
tant Director General (Lep.) who is
the Member-Secretary.
January 1990
At the state level where leprosy
problem is high, similar policy and
implementation bodies have been
set up. Programme runs vertical in
endemic areas and in low endemic
areas where prevalence rate is less
than five per thousand population.
It is being run through general health
care staff. In the vertical set up of
the programme in-built system of
monitoring and evaluation consists
of regular reporting from:
SLO
Centre
PMW -> NMS -> MO -> DLO/ZLO
<-(State
(Leprosy
<<-(LCU/<ULC)
Dept.) Division)
In the low endemic area the inbuilt monitoring and evaluation con-
sists of regular reporting from:
MPW -> HA -> MO -> CMO -> DJD
«-(PHC)
<To strengthen the monitoring and
evaluation activities, the following
steps are being taken up in the
Seventh Plan:
(i) Creation of Sample SurveyCum-Assessment
units foi
more states.
(ii) Provision of a full time con
sultant for major state and
one for small two/three states/
UTs. Currently 9 such consul
tants arc functioning.
(iii) Provision of part-time lepro
logists to provide technical
supervision and guidance for
the high endemic MDT dis
tricts.
(iv) Annual independent evalua
tion of leprosy programme
was done in 1986, 1987 and
1989.
(v) Annual Conference of SLOs
and DLOs of MDT districts.
(vi) Annual Conference of Volun
tary Organisations.
(vii) Special study of some compon
ent of programme through
short-term consultants e.g.
Training and Manpower Deve
lopment have been studied.
State Dept.
Centre
(viii) Biennial Conference of Heads
of Leprosy Training Centres.
(ix) Establishment of Voluntary
Organisation Grant Committee.
(x) Monthly, Quartely and
nual review of the
gramme at all level.
Anpro-
(xi) Establishment of a “Consul
tants Coordination Cell’’ at the
national level.
Important components of Monitoring
and Evaluation:
I Central level
(a) Physical target achievement
(b) Objective target achievement:
case detection, treatment and
discharge.
(c) Expenditure report.
(d) Health education activities and
fund utilisation.
(e) Manpower development: staff
sanctioned in position and
trained.
(f) Leprosy Training Centres—
number of courses and seats
11
in the year, number of workers
trained in the year and number
of workers given orientation
training in the year.
(g) Drug position.
(h) Monthly progress of MDT dis
tricts.
ll State level
It is being done on the similar pat
tern as in the central level. Follow
ing aspects are also monitored
through SSAUs:
(a) Quality of data generated.
(b) Effectiveness of treatment in
cluding MDT at periodic inter
val.
(c) Estimate magnitude of leprosy
problem in the area where
infrastructure is not geared to
provide such information.
Ill District and Peripheral Unit level
ROLE OF VOLUNTARY ORGANISATIONS IN
LEPROSY ERADICATION
Voluntary Organisations have played a pioneering role all through
the history of the leprosy control activities in the country. Presently
over 275 voluntary organisations arc actively engaged in (he leprosy
relief services. Voluntary organisations are predominantly engaged
in the health education and
rehabilitation services under NLEP.
Many of them are also providing survey, education and treatment
services. Some of them arc imparting training to various categories
of staff in Leprosy. One of the voluntary organisations namely
Santhal Pahadia Sewa Mandal has also taken up MDT in a district.
In recognition of the great potential of voluntary institutions in
leprosy control, the Ministry of Health. Government of India, holds
annual meeting with them with a view to establish communication
and close rapport to exchange information to understand the nature
of their work and to support and recognise their contributions. The
last annual meeting was held in December 1988 at New Delhi where
127 voluntary organisations participated.
As per the information received from the voluntary organisations,
nearly 8 lakh leprosy cases are on their records. Voluntary Organi
sations operate under the guidelines of the National Leprosy Eradi
cation Programme are subject to the same type of monitoring and
evaluation system. Government of India have also been supporting
some of the voluntary organisations by providing grants-in-aid for
setting up of SET Centres, LRPUs, Training Centres as well as health
education activities. —KUSHT VINASHAK, SEPT-DEC. 1989
All the components of Central/
State level are monitored and evalua
ted in much more detail. Some of the
important activities monitored are
case-detection by various methods,
treatment, treatment regularity, de
faulters, bacteriological examination, visited. Previous two evaluations
cross checking of smears, cases dis have brought out that the reported
charged as cured, cases died and left data in terms of case-detection, treat
area, patients motivation, health-edu ment and cases cured were valid. It
cation activities conducted, relapse, was also found that over 90% of
vehicle position, availability of equip- patients live with their families, '('here
ment/material and training status, are problems in respect of comple
etc.
teness of infrastructure, filling up of
sanctioned posts, training of NLEP
The full-ime consultants visit staff and laboratory services in the
peripheral units and villages for states of Bihar, M.P., Assam and
monitoring and providing guidance. Karnataka. The 1987 evaluation was
also given to undertake an indepth
To ensure the accuracy of reported examination of MDT activities in
data and to improve the quality of districts which have completed inten
activities under the programme, inde sive phase of MDT. In all these five
pendent evaluation of programme districts visited, reported reduction
has been undertaken jointly by the in prevalence rate by more than
Government of India and WHO 75% has been validated.
thrice. Twenty-seven experts in leprosy/health programme including
nine members from outside the coun- Monitoring and evaluation of multi
tiy were members in each of the two drug treatment
evaluation
teams.
Nine teams
were constituted in April 1987.
Monitoring has to be carried out
who visited 15 states, 28 dis in the mobilisation and preparatory
tricts, 150 villages and interviewed phases initially and subsequently
300 patients, 600 community mem in the intensive and maintenance
bers and 60 para-medical woikers. phases. In the earlier two phases,
Several other categories of personnel monitoring of operational parameters
were also contacted in the districts is of greater importance where-
12
as in the later phases the clinical
and epidemiological parameters as
sume more importance.
1. Methods to be adopted-.
(i> Monitoring is done mainly by
holding monthly review meeting al
district level for all Medical Offi
cers of Leprosy Control Units and
at the unit level for all paramedical
workers. In these
meetings the
monthly reports will be scrutinised
and the achievements against target
reviewed.
(ii) Even more important than
monthly meetings are the field visits
by the District Leprosy Officer. Me
dical Officers, Non mcdical Super
visors and Para-medical workers.
During these visits the quality of
work also must be monitored. The
Para-medical workers will monitor
the regular intake of drug by the
‘Pill Count Method’. This will be
supplemented by the Medical Offi
cers.
(iii) Periodical
assessment
by
SSAU.
(Contd. on page 20.)
Swasth Hind
OUR NEW MINISTER OF HEALTH
AND FAMILY WELFARE
On installation of the National Front Government at the Centre and y
induction of New Cabinet on 5 December 1989, Shri Nilamani Routray has /
taken over as the Minister of Health and Family Welfare. Shri Routray g
(born in 1920 at Mukundapur in Balasore district of Orissa) comes from a
middle-class fapiily. The early part of his life was dedicated to freedom
movement and hectic political activity against the British Rule, He had to
face great obstacles even in completing his college education.
At the age of 12, while in school he was first arrested in 1932 for
shouting slogans along with elderly leaders picketing in front of an Opium
shop. As a student of Bhadrak High School, he participated in anti-Government meetings and was arrested to have the first taste of his jail life. Once
involved in the freedom movement he started organising the students and
the public, and carrying on the struggle.
• Z z- * •'
■
.
■
Slid Nilamani Routray
He joined Ravenshaw College, Cuttack, in 1937. As a student leader and the Secretary of All
Utkal Students Federation, he was in the forefront of of students’ activities in the freedom struggle.
In 1940, his final year of graduation, he was expelled from the College and the Patna University for
his involvement in political activities. Subsequently, he joined Calcutta University and completed his
graduation. After graduation, he joined Banaias Hindu University and registered himself both for
LL. B and Master in Political Science. In his final year, there was the call of 1942 movement. For
his active participation in Quit India Movement, he was externed from Banaras Division.
Thereupon he came back to his native place to mobilize public opinion against Second World
War. He was arrested and imprisoned for one year in Balasore jail. Once out of the jail, he was
shaken by the devastating cyclone that hit the entire northern Orissa in 1943. For several months
he was busy in relief operations in this area.
Then he went to Calcutta University with the hope of completing his Law. There he met
Dr Shyama Prasad Mukherjee who helped him in completing his LL. B in 1946. LDuring his stay in
Calcutta he was actively associated with the Calcutta based Utkal Samaj and worked extensively in
riot-torn Calcutta in 1946. He was also the Editor and Managing Director of ‘Prajatantra’, a leading
Oriya daily, in 1947-48.
In 1948, he was elected unopposed for the first time to the Orissa Legislative Assembly. In
1952 he joined the Council of Ministers as a Deputy Minister. From 1948 to 1951 he was the
President of the Orissa Branch of Indian National Trade Union Congress. In 1963, when he was
the Labour Minister of Orissa, he was nominated to lead the Indian delegation to International
Labour Organisation in Geneva.
In later years he continued as a Minister and in 1965 he was made the Deputy Chief minister
of Orissa.
He was elected as the President of Utkal Pradesh Congress Committee in 1967 and
continued in that position till 1970, He left Congress in 1970 and subsequently became President of
the Utkal Congress which was formed after break-up of the Congress Party in Orissa. From 1971 to
1973, he was again the Deputy Chief Minister of the State. In 1974, he became the President of
Bharatiya Lok Dal. In 1976, he was elected to Rajya Sabha. He resigned his Rajya Sabha seat in
1977 after he was elected to State Legislative Assembly on Janata Party Ticket and became the Chief
Minister. He continued as the Chief Minister of Orissa till 1980.
Shri Routray is one of the most respected surviving freedom fighters and political leaders in
Orissa. He is known for his amiable personality and political maturity. In 1986, he published his
autobiographical volume “Smrutj O Anubhuti” in Oriya.
January 1990
13
SYMPOSIUM
How Far the Goal of Leprosy
Eradication by 2000 A.D. is Achievable?
(a) If yes, what is the Progress?
(b) If not, what are the Impediments? and
How can they be overcome?
Can leprosy be erdicated by 2000 A.D.? Or controlled? Is it worthwhile to have an eradication programme
when the medical opinion worldwide is that disease can only be controlled and not fully eradicated? Will the
multidrug therapy prove effective? These are some of the questions that come to one's mind. SWASTH
HIND, in this Symposium, had invited tie opinion of three distinguished experts on leprosy who have done a
yeoman service in the field.
T.N. Jagadisan has this to say : “Even with an all-out effort on a war-footing to bring MDT to the
door of every patient, we may have to work at the programme for another ten years beyond 2000 A. D.
frrtting out new cases and observing the cured ones”.
“We need not worry too much about eiadicaticn of leprosy ij we succeed in creating such an atmos
phere (where leprosy patient is assured that he will not be discriminated against either by medical profession
or society) eradication will come later when we have better immunological tools”, says S.P. Tare.
The noted Anthropologist, R.K. Mutatkar, asks : Are our programmers willing to change the orien
tation of the programme from eradication of infection to control or prevention of deformities? If Yes. the
disease will be controlled by the year 2000”.
We reproduce here the views of these experts.
S. P. TARE
DIRECTOR, GANDHI MEMORIAL LEPROSY FOUNDATION, WARDHA
np he Government of India has pledged itself to
JL eradicate leprosy by 2000 A.D. This decision
was taken in 1983 by the Union Cabinet under ins
piration of Smt. Indira Gandhi, the then Prime Minis
ter. A Study Group was appointed by the Union
Cabinet to chalk out the strategy for eradication of
leprosy by 2000 A.D.
The background for this optimistic objective was
that we had a very promising technology in the form,
of multi-drug therapy (MDT) and it was believed
14
that if this is made available quickly to all patienU
in the country, it may be possible to eradicate lep
rosy. This was one of the important recommenda
tions of the above Study Group to achieve the ob
jective.
Majority of leprologists and leprosy workers, how
ever, had their apprehensions about the time-table,
though they agreed on the imperative to achieve the
objective of Zero-leprosy. A period of seven years
has passed and there is more sober realisation based
Swasth Hind
on the performance of MDT projects so far about
the problems in achieving the desired objective within
the time frame.
Progress so Far
There are 196 endemic districts in India to be
covered under MDT of which over 100 have been
covered, The first district in India to be covered
was Wardha in 1982. Since then, six districts have
completed over six years and 14 districts over five
years. The rest of the districts have functioned for
less than five years. The Government proposes to
cover all endemic districts by the end of the Seventh
Plan. Over 17.77 lakh patients have been brought
under treatment in 65 districts till March 1989. Of
these, 10.18 lakh patients were discharged from treat
ment and 7.59 lakhs are under treatment. The reduc
tion in prevalence is over 75% in nine districts, and
between 50% in 16 districts.
It will not be out of place to refer to the experience
of MDT in GMLF’s
(Gandhi Memorial Leprosy
foundation) Leprosy Control Unit at Sewagram. The
Unit had a prevalence of 23.30 in 1951-52 when con
trol work was started and monotherapy of DDS was
introduced. By 1977, the prevalence came down to
8.15, ’000. It was at this stage, that multidrug
therapy was introduced in the Unit. The new case
detection rate was 2.7/’000. Multidrug therapy was
extended to pauci-bacillary patients from 1984. The
prevalence in October 1989 is l.O/’OOO and new case
detection rate is 0.51/’000; the reduction being 88%
and 72% respectively.
The experience of over six years on large scale is
considered inadequate for having an effect on inter
ruption in transmission of leprosy. There is no evi
dence of reduction in incidence of leprosy in MDT
districts so far. But in all MDT districts there is a
universal experience that voluntary reporting has in
creased and new cases tend to come on their own
without fear or hesitation. I he intense activity of
workers moving from village to village in a jeep
and giving supervised treatment on the roadside, im
presses the patients. The pauci-bacillary patients
need treatment for six months; they- are regular lor
this small duration and are “removed from treat
ment”. As they form over 85% of the total patients,
there is a remarkable reduction in load of active
cases.
Another indirect result of the intense and hectic
movements of leprosy workers to cover their circuits
is that people in villages have become more consci
ous of the leprosy problems in their midst, and more
appreciative of the anti-leprosy campaign. This has
a definite impact on the social stigma against leprosy
with evidence of its gradual reversal.
What are the Impediments?
There are two types of impediments in the cam
paign to eradicate leprosy by MDT. Some are
related to scientific aspects of leprosy and some are
of an operational nature.
Jawto.ry 1990
Among the scientific aspects, there are a few pro
blems :
1. There is no evidence, in medical history that
any disease has been eradicated by medica
tion alone. Hence, it is doubtful whether in
absence of any immunological tools, leprosy
can be eradicated by multidrug therapy.
2. Due to the imminent danger of dapsone-resis
tance, there was no adequate time to try out
experiments to standardise the drug regimen
for multi-drugs. The regimen presently in force
is thus not decided on the basis of any scien
tific controlled trials.
3. We have lacunae in the knowledge about
transmission of leprosy and in the absence of
that knowledge, the entire strategy is based
on detecting every patient of leprosy and
treating him till he is cured. But firstly, detec
ting every case of leprosy is an impossible
proposition on national scale, and secondly, the
detection of a multibacillary patients is always
late in the sense that he may have done the
damage before being detected as a case.
4. There are very few drugs which are useful for
cure in 100% cases. That is true about multi
drug therapy as well. Secondly, the drugs may
kill very very large number of bacilli but not
all bacilli. The presumably very small per
centage of surviving bacilli may keep the
disease lingering and these lingering/surviving
germs may not respond to the available drugs.
The problems relating to operational aspects are
still more formidable:
1. Tie necessary preparation before introducing
MDT in a district is many times not done due
to the haste to increase geographical coverage.
2. There are number of lapses in monitoring with
the result that in places, drugs are not available in enough quantity, vehicles are . supplied
. -- late and there is no adequate provision for
oil; vehicles are not on road and repairs are
not made in time for shortage of funds/orders;
bacteriological work is the weakest link in the
MDT programme; disinterested medical officers
and workers hurriedly hand over the drugs to
road-side patients without verifying spot intake;
patients are not examined properly before
being put on MDT; etc. The list can be long
one.
3. There is an unnecessary haste to fulfil the tar
gets of case-detection and stoppage of treatment with the results that patients are removed
at the completion of the standard duration of
treatment without getting satisfied about both
clinical and bacteriological inactivity.
4. The case-detection activity (survey of total
population) has been relegated to a back place.
15
SYMPOSIUM
and only patients noticed casually and those
who voluntarily come forward are recorded as
new cases.
/Communicable disoK^ases are eradicated
by vaccination if vac
T.N. JAGADISAN
HONORARY SECRETARY cines are available for
the patricular disease.
KASTURBA KUSHTA
In tie case of small
pox. eradication on
NIVARAN NILA YAM
——
--------------- a global scale has
been
achieved
through
successful
vaccination.
In the case of leprosy, vaccines have been produced and
are reported to be effective. But, the administration
of vaccines on a wide scale can be attempted only on
further investigations on a global scale in differing
epidemiological and social conditions Hope of eradi
cation has therefore been fixed on early detection and
treatment of leprosy patients with effective drugs which
have a bacteriocidal effect. Today, there is a general
agreement among experts that multidrug therapy
(MDT) is the key to leprosy eradication.
5. The actual attendance of patients in MDT has
gone down to 50% or less in MDT districts
which are functioning for three years or more.
Moreover, the supervised part of drug-intake is
for one drug only but that drug is also hand
ed over to patient.
6. Another important function which is not receiv
ing the desired attention is about surveillance.
Once a patient is removed from the treatment
register, he is as good as forgotten and not
subsequently contacted.
The indirect effect of the great importance given to
MDT programme has been on the Leprosy Control
Programme in the districts where monotherapy is in
progress is completely forgotten, and out of mind of
the administrators. There is is no supervision and
guidance in these districts where lakhs of leprosy
patients are living. One can understand that due to
many constraints, MDT could not be introduced in
all endemic districts, but there can be no justifica
tion for neglecting them as grossly as it was occurred.
How to Improve?
MDT is a very valuable tool and can be helpful in
reducing the patient-load and taking us nearer to our
ultimate objective. What is actually happening how
ever is that in the enthusiasm for the new technology,
it is equated with total leprosy control programme
and all other aspects and activities are neglected, as
also work in those areas which are as yet uncovered
under this technology. Active case-detection pro-'
gramme, individual attention to patients and their
problems and the closer interaction between the patient
and the doctor, health education in a systematic
manner, surveillance of patients need to be paid more
attention.
It is also necessary that efforts are earnestly made
to involve general health workers in leprosy. The
varticlc leprosy programme cannot, and need not, be
continued so, it has to be horizontalised with general
health services in not too distant a future. Very
little efforts have been made in the last three decades
to involve them, train them, and motivate them.
As a part of the above horizontalisation, it is
necessary that
involvement of entire medical propre
fession (either in services or in practice) is achieved.
An experience of a leprosy patient being welcome in
a general hospital, PHC clinics and private dispen
saries/clinics will convince society that leprosy is a
disease like any other. Once this is achieved, there
will be no reason for an early patient of leprosy to
conceal his disease, and the quicker he comes for
ward to take treatment, the safer will it be for the
rest of the society.
The problem of a leprosy patient is not the ‘disease’
as such which gives him no physical discomfort in
16
‘Tj’ it possible to achieve through MDT leprosy erad;
cation by 2000 ADT\
Before answering this q.uestition, let us take a brief
backward glance at the previous history of leprosy
treatent.
Search for a drug: The search for a drug for leprosy
was a tortuous quest and a long story. First chaulmoogra or hydnnearpus (the best of the drugs of the pre
sulphone era), then methylene blue, then trypan blue
short-lived wonders—then diphtheria toxoid treatment
and back again to Chaulmoogra externally, internally
and eternally’, as the wag said.
_>
early stage, but the fear of societal attitude towards
him. Once he is assured that he will not be discri
minated either by medical profession or the society,
he will take treatment, get cured and will not hesitate
to tell others that he had leprosy. We need not
worry too much about eradication of leprosy if we
succeed in creating such an atmosphere: eradication
will come later when we have belter immunological
tools.
REFERENCES
i
1.
Report of Study Group to prepare a Strategy p/an for
Eradication of Leprosy, 1982.
2.
Dr. M.N. Casablanca: Monitoring and Evaluation of MDT
Programme; Paper read in XVI All India Leprosy Workers
Conference 1988.
3.
Annua! Report of GMLF;
4.
District-wise Progress of MDT as [on March 1989;
of India Publication.
5.
Proceedings of IAL Workshop on Monitoring and Evaluation
of Leprosy Programme; Junc^l988.
6.
Dr. M.V. Yellapurkar: Experience of the Current Systems
of Monitoring and Evaluation in Leprosy Eradication Pro
gramme—Paper read in the I AL Workshop 1988.
7.
Statistical Compedium on Leprosy; Centre for Social Science
Research in Leprosy 1989
1987-88 and 1988-89.
Govt.
Swasth Hind
SYMPOSIUM
Sulphone therapy: The outlook on leprosy treat
ment brightened with the coming of the revolutionary
sulphone therapy. For the first time cheerfulness and
positive hope entered the treatment of lepromalous
leprosy and its remoreseless multiplication ol leprosy
bacilli could be arrested. An entirely new situation
now arose for the leprosy patient. He could get treat
ment as near to his home as possible. He could look
forward to cure if only he took the right num
ber of the right tablets under medical Supervision
over the prescribed length of time. 1 he dread of iso
lation and separation from family and work was gone.
The leprosy patient could be a man like other men,
living in society and looking after his family. The
administrator was quick to seize the opportunity of
the new method of leprosy control. Widespread treat
ment with Dapsone through out-patient clinics became
the new strategy. 1 he Report of the WHO Expert
Committee on Leprosy (1953) declared: ‘Modern treat
ment which effectively reduced the infection in leprosy
patients, and therefore their infectiveness, is regarded
as the most potent generally applicable weapon now
available in the control of the disease”.
Undoubtedly, sulphone therapy has maintained its
place as effective for the vast majority of patients since
it can be reached out to a large number ol patients at a
low cost. Over the years, we have come to know the
merits and limitations of sulphone therapy. Treatment
with sulphones was prolonged and patients tended to
be irregular and they even dropped out. New cases
cropped up in sufficiently large numbers and relapses
occurred not infrequcnlly.
The great enthusiast of leprosy eradication through
extensive administration of sulphones, the late
Dr. James A. Doull wrote a sad confession towards
the end of his life. “The eradication of leprosy pro
mises to be a long and difficult task; sulphone therapy
is of great benefit to the patients, but its value as a
preventive is problematic”. Moreover, by about the
middle of the last decade, the leprosy bacilli had learnt
the trick of resisting the effects of Dapsone and the
phenomenon of drug resistance not unknown in other
diseases like tuberculosis, became a subject of world
wide concern. At this juncture, experts began to think
of combining more than one drug for the treatment
of leprosy.
January 1990
Dr Enno Freerksen, Director of the Institute for
Experimental Biology and Medicine at Borstel, West
Germany, conducted a well-conceived and well-execut
ed eradication programme in the Isle of Malta in close
co-operation with the German Leprosy Relief Association. This programme, which was continued for a
period of ten years, was highly successful. A follow
up investigation of the Malta Project by Dr. W. H.
Jopling and other experts of the WHO confirmed the
.success of the project in eradicating leprosy in the
island. They were specially impressed by the fact that
no side-effects had been encountered during the treat
ment. The WHO Expert Group had already come
forward with their recommendations in the Technical
Report Series No. 675, 1982, that three drugs. Rifa
mpicin, Clofazimine and Dapsone, be used in multi
drug therapy.
Potency of multidrug therapy
The potency of multidrug therapy has come to be
recognised. The patients, their relations and the
public have been impressed by the results. The regu
larity of attendance has improved. The great ad
vantage of MDT is that it is bacteriocidal and not
merely bacteriostatic. The period of treatment under
MDT is relatively short. It is, however, costly.
Happily. International Organisations like the members
of the 1LEP have come forward to collaborate with
Governments in MDT programmes and also to assist
voluntary organisations to carry out multidrug therapy
work. Wherever MDT programmes have been care
fully administered and monitored, the prevalence and
the incidence of the disease have come down and new
deformity is a rare occurrence. So, leprosy eradica
tion by 2000 AD through MDT is achievable and
the progress so far made is encouraging
The progress
The progress is noteworthy. However, large ende
mic areas in endemic countries have not still come
under MDT. There should be a rapid extension
of MDT work without sacrifice of quality. Pilot pro
jects like that of Malta have given a positive answer.
But even if the cost of the treatment is overcome by
increased Governmental allotments and the philan
thropy of International and National Organisations,
17
(Contd. from page 12.)
(v) Drawing of the time schedules
(iv) NLEP
consultants/Consulfor various phases of the pro
tant Leprologists
have been ap
ject including preparation of
pointed by the WHO at the request
calendar.
of the Government of India and
(vi) Promt release of advances by
are assigned one or more States/
GOl/its approved agencies.
Districts to be the eyes and ears
of the Government of India/State
(vii) Formation of District Leprosy
Government to monitor the pro
society and convening meet
gramme activities in the State in
ings periodically.
cluding the progress of MDT dis
tricts.
(viii) Preparation of health educa
tion action plan and its im
2. Paratn eters 11ndicators:
plementation and
The selection of parameters/indi
(ix) Validity of reported data to
cators for monitoring has to be cor
be ascertained by periodical
rectly done. Selection of a large
checks
by the
assessment
number of parameters may be good
team.
in a way out it will entail collec
tion of information in a detailed
manner involving more desk work 4. Clinical Monitoring -.
by field staff. Hence it is essential
The important indicators to be
to include only, the important, para
monitored
are: —
meters/indicators so that it will be
possible to monitor regularly. The
(i) Proportion of multibacillary
indicators in multidrug treatment
cases who have regular and
can be classified as (i) Operational,
adequate treatment.
(ii) Clinical and (iii) Epidemiolo
(ii) Proportion of paucibacillary
gical.
cases who have regular and
adequate treatment.
3. Operational Monitoring -.
(iii) Proportion of cases with com
This includes:
plications who are on adquate
(i) Sanctioning of posts, position
and regular treatment.
ing of personnel and ensuring
(iv) Proportion of cases released
that they are trained as per
from treatment (RFT).
time schedule prescribed.
(v) Clinical surveillance rale for
(ii) Supply of drugs, vehicles and
multibacillary cases.
other logistic facilities and
(vi) Clinical surveillance rate for
their utilisation.
paucibacillary cases.
(iii) Screening of all existing cases
(vii) Bacteriological surveillance rate
by medical officers in the
stipulated period before the
for multibacillary cases.
implementation phase starts (viii) Relapse rate.
and maintenance of prescrib
ed case cards.
The indicators (i) to (viii) are to
(iv) Updating of records at vari- ' be calculated from the data furnishous levels.
cd in the monthly report.
20
5. Ep idem iologimil moiuicniiig :
(i) Proportion of cases registered
as against estimated cases
(estimated by survey team).
(ii) Prevalence rate.
(iii) Incidence rate/new case detec
tion rate.
(iv) Proportion of multibacillary
cases to total new cases.
(v) Proportion of cases with de
formities to total new cases.
(vi) Proportion of cases among
children to total cases.
(vii) Proportion
contacts.
of
cases
among
(viii) Proportion of new cases volun
tarily reported.
It is essential to have the figures
for all these indicators before start
ing multidrug treatment so that its
progress can be assessed. A
WORLD HEALTH DAY—1990
THEME IS “OUR PLANET OUR
HEALTH TIUNK GLOBALLY
ACT LOCALLY”
This double slogan, with the echo of
the words of the late French ecologist
Rene Dubos, has been chosen by WHO
to epitomise World Health Day 1990.
The choice reflects the growing aware
ness of environmental problems, and
WHO's conviction that they will be a
major topic of worldwide concern during the next decade and indeed well
into the 21st century
In choosing the broad theme of en
vironment and health for World Health
Day this year, WHO intends to spot
light the measures that
individuals,
communities and countries can and must
take to check any further deterioration
in the overall health of the planet; be
cause it is on the health of the Earth
that depends the health of all its human
passengers. A
Swasth Hind
INTERNATIONAL GANDHI AWARD ON LEPROSY-1990
TT is, indeed fitting that medical scientists who have devoted their entire career to combat the
1 dreaded disease—leprosy—are honoured not only in recognition of their pioneering work but also
to kindle among the young medical scientists the spirit to enter this field. This is because leprosy is the
least attractive discipline among medical researchIt was towards this end that the wardha-based Gandhi Memorial Leprosy Foundation instituted
the International Gandhi Award for presentation once in two years to one Indian and one foreign leprologist in 1986. And if. within four years of its inception the Rs. I lakh award has already acquired a
prestige, it is reflected in Hie choice of the recipients.
The first set of recipients in 1986 included Dr (Mrs ) Turkan Sylen of Turkey and Dr Dharmendra of India and the second set in 1988 included Dr Ma Hai De of China and Dr T. N. Jagadisan ot
llKlj;1_all renowned for their valuable contribution to the understanding and treatment of the disease on
the one hand and rehabilitation of the cured patients on the other.
1 he third set—Dr Michael F. Lcchat of Belgium and Dr Ramacliandra Vishwanath Wardekar—
recipients for the 1990 award, belongs to this galaxy of leprologists.
Dr Lcchat
has established himself as a leading
a T 62, Dr Lcchat
T* epidemiologist who has contributed greatly to the cpidemiological understanding
of the leprosy problem.
A specialist in tropical
medicine and a doctorale
from the Johns 11 opkin;
School of Public Health
in Baltimore (U.S.), Dr
Lechat’s involvement with
leprosy work dales back
to 1953 when he took
over as Medical Dircctor of Lyonda Leprosy
Hospital in Mbandaka
(Belgian Congo).
The following years saw
him in a variety of assign
ments round the world as
Dr. Michel F. Lcchat
consultant
to
the
World
Health Organization, the
World Bank and the Swedish
international
Develop
ment Agency. This brought him to India also where he
worked as WHO consultant in 1986. His contribution to
the understanding of the disease led him to associate himself
actively with various national and international organisations
engaged in this field. He was President of the International
Leprosy Association for a decade from 1978, President of
the Medical Commission of International Federation of Anti
Leprosy Association (1974-78), the Associate Editor of Inter
national Journal of Epidemiology, Member of the WHO
panel of experts on leprosy, and Honorary Chairman of
International Leprosy Union.
January 1990
Dr Wardekar
—father of leprosy control work in India
Indian recipient, Dr Wardekar can rightly claim to
be the father of leprosy control work in India, which
accounts for one-third of
the estimated 12 million
leprosy cases ic
the
world. Way back in
1955, when the Nationa
Leprosy Control Pro
gramme was launched,
T
he
the Government of India
accepted I fie methodolo
gy for leprosy control
work evolved by Dr
Wardekar who was also §
ns t rument a I in the drafting of the first four five- 8
i
year plans for leprosy.
g
The goal was subsequ- §
ently changed from control (o eradication and
Dr. R. V. Wardekar
towards this and a scheme of covering endemic districts
with
Multi
Drug Treatment has been introduced. A
perceptible decline in the prevalence rate has been noticed
in the 112 endemic districts covered by the MDT programme.
But there is still a long way to go to reach the target by
the turn of the century.
There can, however, be no two opinions that the strong
foundation for this work was laid by the septuagenarian
{Contd. on page 24)
21
HEALTH SECTOR
-PRIORITIES IDENTIFIED
Nilamani Routray
In our efforts to achieve Health for AH by 2000 A.D., steps have been taken to
carry health education to the common man. The Government is close to achieve
the target for health delivery infrastructure in the rural areas. Voluntary Organi
sations and opinion leaders are being encouraged to spread the health and hygiene
awareness among the masses. With collective efforts of all, a cent r cent healthy
nation is not a distant dream, says Shri Nilamani Routray, Minist of Health and
Family Welfare.
T Tealth lor all by 2000 AD as
JLJL envisaged in the National Health
Policy is a worthy aim indeed. How
ever, it will continue to evade the
country unless we redefine priorities
and policies- There has to be a
shift in the accent and on priorities
considering the fact that health ser
vices are concentrated in urban
areas and rural India conlinucs (o
remain backward. Any action plan
on health for all has to incorporate
ways and means of not only in
creasing the number of Primary
Health Centres and Sub-Centres,
but has also to ensure that the ne
cessary manpower is deployed to
22
man them. Medical Profession con
tinues to be urban-oriented in our
country despite all our efforts in
the past to persuade qualified medi
cal and para-medical personnel to
Ian out in rural India, settle down
there and cater to the health needs
of the common people. In fact, our
efforts should be to take ‘Health’
Io the doorsteps of our villagers.
There is a need for establishing well
equipped medical centres of educa
tion and research in the rural areas.
India has made significant achievemenls in various health pro
grammes since Independence. The
investment on Health which was
Rs. 65.2 crores in the First Five
Year Plan has gone upto the level
of Rs. 3392 crores during the Se
venth Plan.
The significant pro
gress made in the control-cum-eradication of major communicable dis
eases has resulted in the decline
of death rate from 27.4 in 1941-50
lo 10 9 in 1988. I his has contri
buted appreciably to the rise of ex
pectation of life from 32 years in
1941-50 to -58 years in 1985-91.
The infant mortality rate consider
ed to be an index of health status
has shown a steep fall from 183 per
thousand live births in 1941-50 to
Swasth Hind
44 in 1988. The birth, rate has also
declined from 39-9 per cent in 1988.
TREMENDOUS SUCCESS
A number ol National Health
Programmes launched for the con
trol and eradication of major com
municable diseases have recorded
tremendous success. Smallpox has
been completely eradicated due to
intensive campaigns undertaken in
collaboration with the World Health
Organisation (W.H.O.) and the State
Governments. The country attained
Smallpox free-status in July 1975.
The cholera control programme
started in 1970 has brought down
the number of cholera cases and
deaths from 86,835 and 42,070 in
1951 to 5,813 and 154 in 1985.
Leprosy Eradication
For Leprosy, a National Leprosy
Eradication Programme was laun
ched in 1982 with the specific goal
of arresting disease activity by
2000 A D. The programme has ra
pidly expanded having a wide in
frastructure consisting of 708 Lep
rosy Control Units, and 7400 Sur
vey and Treatment Centres as on
March 31, 1988. For the first time
in 1987-88 the number of cases
cured were higher by 10 per cent
than the number of cases detected.
This trend continues. The Multi
drug Treatment introduced in 1982
has proved very successful in treat
ment of Leprosy cases.
Tuberculosis Control
Deaths due to Tuberculosis, a
major killer, have also declined
considerably with the launching of
National TB Control Programme.
Under the programme detection of
January 1990
new TB cases averaged at approxh
mately 16 lakhs in a year register
ing an increase of about 26 per
cent over 1985 figures. To reduce
the duration of treatment of TB
patients from 18-24 months to 6-8
months, short course chemothera
py drug regimen with very potent
anti-TB drugs was-introduced and
so far 176 districts have been co
vered during the last four years
(1984-88). This is being extended
to another 75 districts this year.
hand, research and training of doc
tors in the proper treatment of the
disease have been started and on
the other, health education to in
crease general awareness regarding
AIDS in schools, colleges and in the
public at large is a’so being undert?ken. Allied to this, a new scheme
for development and modernisation
of blood banking and transfusion
services has also been launched,
which aims at testing of blood from
donors, its safe storage and supply
to the needy patients.
Blindness Control
To fight the overgrowing problem
of drug abuse/addiction, a drug de
addiction
programme has been
launched which provides for sett
ing up of Drug De-addiction Centres
in major hospitals in big cities. Es
tablishment of 30 bedded Drug De
addiction Centres in seven hospitals
at Delhi, Chandigarh and Pondi
cherry has already been sanctioned..
Besides, efforts are being made to
set up OPD facilities in major pri
vate hospitals at Delhi, Vellore Lu
dhiana, Bombay, Madras and Cal
Under the National Programme
for Control of Blindness, each year
on average, a target of 12 lakh ca
taract operations are fixed for the
country as a whole. The achieve
ment rate which has been more
than 85.1 per cent since 1985 is
close to 99 per cent during the
current year. Important initiatives
taken have been on training of
Ophthalmic Assistants, greater in
volvement of voluntary organisa
tions and setting up of Opthalmic
Cells in 18 major States
FIGHTING AIDS AND DRUG
ABUSE
To meet the emerging threat of
AIDS, a new Programme for con
trol of AIDS with its three major
components, namely, surveillance,
education and information and
screening of blood donors was
launched in 1985. We now have 40
surveillance centres for screening
persons in the high risk groups.
In addition, 28 zonal blood testing
centres have been established in
Metropolitan cities for screening
blood donors. Blood donor screen
ing facility is being expanded to
cover all cities with a population
On the one
exceeding 0.5 lakhs.
cutta.Health Education
Above all, these years have seen
a shift in the emphasis from the ear
lier curative approach to the pre
ventive and promotive approach
providing for more and more Health
Education to the common people
with the aim of obtaining ‘Health
for All by the year 2000 A D.’ in
accordance with the objective of
•National Health Policy’. Several new
health programmes for the control
of diabetes, for dental health care
etc. have also been launched in the
current Plan.
POPULATION STABILIZA
TION PROGRAMMES
Family Planning Programmes
have formed the core of develop
ment planning in India. Allocation
23
for the same under the Plans in
creased.' from 6-5 million in the First
Five Year Plan to Rs. 32,560 mil
lion in the 7th Five Year Plan.
About 106.2 million births are es
timated to have been averted upto
March 1989 as a result of the work
done since inception. However, the
annual rate of population growth
continues to be still alarmingly high
(over two per cent). This is due
to a relatively slow lowering of birth
rate accompanied by a rapidly dec
lining death rate and hence this
forms the base of the present demo
graphic problems.
The total number of family plann
ing acceptors enrolled under the
programme has gone up from 16.44
million in 1984-85 to 24.11 million
in
1988-89—a record since the
inception of the programme. The
National Health Policy 1983 has
enunciated the long-term demo
graphic goal of the country to reach
a net reproduction rate of one by
the year 2000 A.D. at the lowest
feasible levels of birth rate at 21
per thousand and death rate at 9
per thousand.
UNIVERSAL IMMUNIZA
TION PROGRAMME
Provisions of services for safe
motherhood and for ensuring child
survival form the major planks of
the family welfare programmes. Pro
phylaxis against nutritional anaemia
for both the mother and the child
continues to be provided free by
giving them iron and folic acid
tablets and solutions. The children
between 1-5 years are also given
Vitamin ‘A’ doses twice-a-year to
prevent Vitamin ‘A’ deficiency.
With a view to protect children
against six common childhood dis
eases, an ‘Universal Immunization
Programme’ was started in the
year 1985. It is stipulated to immu
nize 100 percent pregnant women
against Tetanus and at least 85 per
cent of the infants against Diptheria, Pertussia, Tetanus, Tuberculosis,
Poliomyelitis and Measles by 1990.
Uptake of all the immunization ser
vices both to the expectant mothers
and infants has received a signifi
cant increase since 1985. The co
verage level under immunization
programme has steadily risen from
51 per cent to 75 per cent in case
of DPT vaccines, 40 to. 72 per cent
in case of DPV, 30 to 79 per cent
in case of BCG vaccine and from
40 to 63 per cent in case of TT
(PW) by 1986-89. Oral Rehydra
tion Therapy is also being promoted
to save children from deaths caused
by dehydration due to diarrhoea.
Ready-to-use Oral Rehydration Salt
(ORS) packets are being distributed
free through our health services out
lets.
CATERING TO RURAL
NEEDS
In our efforts to achieve Health
For All by 2000 A D., steps have
been taken to carry health educa
tion to the common man. The gov
ernment is close to achieve the tar
get for health delivery infrastructure
in the rural areas. Against a target
of establishing 1,30,000 sub-centres,
21,666 primary health centres and
2,708 community health centres
throughout the country by March,
1990, 1,21,776 sub-centres, 19,173
primary health centres and 1,665
community health centres were func
tioning upto 30 June, 1989.
Efforts are afoot to attain the
goal of ‘Health for all by 2000
A.D.’ by making it a people's
movement.
Voluntary Organisa
tions and opinion leaders are being
encouraged to spread the Health
and Hygiene awareness among the
masses. With collective efforts, of
all, a cent per cent healthy nation
is not a dislant dream. C'
(Contd. from page 21)
leprologist whose main contribution lay in changing the
conventional method
of leprosy work and bringing anti
leprosy work out of the four walls of colonies. He was
instrumental in bringing about governmental lead and parti
cipation in leprosy work.
Dr Wardckar was largely responsible for laying down the
patterns of leprosy control units, SET (screening, evaluation
and treatment) centres, training centres, urban leprosy centres
and referral hospitals. He won laurels for (his and these
24
included the Padmashri and lhe Dr P. N.
Award of the ICMR, both in 1973.
Raju Oration
Dr Wardckar has many publications to his credit cover
ing various facets of protection against the disease, its control
and ichabilil.ilion id leprosy palicnls.
He was President
of the Indian Association of Leprologists in 1965-67, Secretary
of the Leprosy Expert Group of the ICMR, Member of the
WHO expert advisory panel on leprosy and a Member of
the second leprosy expert committee.
Swasth Hind
1
NEWS
WHO LAUNCHES ‘INTER-HEALTH’
Cardiovascular diseases and cancer already figure
among the three leading causes of deaths, after the
teenage years, in both the developed and developing
world, WHO statistics show. Moreover, in absolute
numbers, there are more cancer cases and deaths in
developing countries than in industrialized countries.
—A Programme Against Diseases of
Lifestyles
The World Health Organization (WHO) has an
nounced the launch of “Inter-Health”, a programme
which sounds a warning against the threat to health
of noncommunicable diseases the diseases of lifetyles—and urges nations to act against them.
Lifestyles are no longer purely conditioned by cli
mate or by culture, he stated, but “are influenced by
newspapers, magazines, radio, films and television.
Lifestyle are imitated as fast as the written and elec
tronic media transmit ideas from country to country”.
According to WHO, noncomniunicable diseases are
the cause of 70 to 80 per cent of deaths in developed
countries and of 40 to 50 per cent in developing coun
tries.
A mosquito transmits malaria; a black 11 y, oncho
cerciasis or river blindness; a bug, Chagas’ disease;
a worm, dracunculiasis; a Ilea, plague; a bacterium,
cholera; and a virus, polio- These diseases are com
municable in the age-old manner through a single
vector: a parasite, bacterium or virus.
Such is not the case with noncomm unicable diseases.
They are “man-induced”, caused by choice of life
styles—notably by too much fatty foods, salt, and al
cohol; by tobacco; by a lack of exercise; and by pol
luted air.
One bad habit carries multiple risks to ill-health, as
for instance:
—Improper diet carries the risk of stroke, heart
disease, hypertension, colorectal, and stomach cancers,
diabetes, osteoporosis (a bone disease), malnutrition,
obesity and gastric ulcers.
—Tobacco holds the risk of heart ailments, lung
and mouth cancers as well as of respiratory diseases.
The aim of WHO’s Inter-Health programme is to
promote healthy living, as well as to advance the
cause of tobacco—free societies.
January 1990
The developing countries, therefore, bear a “double
burden of age-old, communicable diseases—such as
malaria, schistosomiasis, and other tropical diseases
—and of man-induced, noncommunicable diseases.”
•
—W H.O. Release
ADALAT FOR CGHS BENEFICIARIES
AND HOSPITAL PATIENTS
The Ministry of Health and Family Welfare has
set up a Shikayat Adalat to look into the grievances
of Central Government Health Scheme (CGHS) bene
ficiaries and the public receiving treatment at govern
ment hospitals. This Adalat will have a four-mem
ber bench chaired by a Deputy Director General of
Health Services. The Adalat will take up complaints
relating to CGHS and hospitals services and will be
held once in three months.
All complaints may be addressed to Director (EMR),
Directorate General of Health Services, Nirman Bhavan, New Delhi-] 10011. a
—Civil Services News, Oct. 1989
25
f
YOUR EYES
GLAUCOMA (KALA MOTIA)-A BLINDING DISEASE
*
*
*
Glaueoma (Kala or Neela motia) is a blinding disease.
In India one in seven eyes of glaucoma patients had lost vision before going to
the hospital.
One in 80 patients had lost sight in both eyes and was not
sight was due to glaucoma.
aware that loss of
*
Glaucoma and cataract occur in the same age group - above 35 years.
*
Blindness due to cataract can be corrected by simple operation but blindness due
to glaucoma cannot be cured.
4:
*
Dull pain iu the eyes, difficulty in seeing in dim light, seeing rainbow colour ring
around the bulb, frequent change in reading
in aa year)
reading glasses
glasses (often
(often in
year) are
are some
some
warning signals of glaucoma.
Whenever you go for eye examination, get your eye pressure checked to rule
out glaucoma.
National Society for the Prevention of Blindness - India,
Dr. R.P. Centre,
AIIMS, New Delhi -110 029.
Authors of the Month
Dr S. K. Noordeen
Chief Medical Officer
Leprosy Division of Communicable
Diseases
World Health Organization
Geneva, Switzerland
Dr M D. Gupte
Officer In-charge
CJIL Field Unit,
Indian Council
of Medical Research,
271, Nehru Bazar,
Avadi, Madras-600 054
Dr D. K. Mahabalaraju
Lecturer in Community Medicine
JIM Medical College
Davangere-577 004
Dr Saudan Singh
Asstt. Professor
26
and
Dr Sanjiv Kumar Bhasin
Senior Resident
1
Deptt. of Preventive and Social Medi
cine
Maulana Azad Medical College
New Delhi-110 002
Dr P. N. Ncelan
Director
Central Leprosy Teaching & Research
Institute
Ministry of Health and Family Welfare
Chengalpattu-603 001
S. P. Tare
Director
Gandhi Memorial Leprosy Foundation
Hindi Nagar, Wardha-442 103
T. N. Jagadisan
Honorary Secretary
Kasturba Kushta Nivaran Nilayam
Malayanthangal Post
(Via) Kandachipuram-605 701, SO
South Arcot District
R- K. Mutatkar
Deptt. of Anthropology
University of Poona
Punc-411 007
Dr N. S. Dharinslinktu
Dy. Assistant Director General
Leprosy Division
Smt. Krishna Basra
Dtc. General of Health Services
Librarian ‘Grade—I’.
National Medical Library
Nirman Bhawan
New Dclhi-110 011
Ring Road, Ansari Nagar,
New Dclhi-110 029
Swasth Hind
■IU
-J--------
No.D- (C) 359
Reg. No. R. N. 4504/57
SWASTH HIND
SPECIAL NUMBERS 1989
January
Anti-Leprosy Day
March-April
World Health Day
(Theme : Let’s Talk Health)
June
Eye Health Care—I
July
Eye Health Care—II
August
uNehru Centenary Special
September
Drug Addiction
December
World Day on AIDS
—j
Price Per Copy.
Combined issue
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Re. 1.00
You can also become a regular subscriber for Swasth Hind
Annual Subscription : Rs. 6/- (Postage Free)
Send your order alongwiih the cost by M.O.IPostal Order to :
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Kotla Marg, New Delhi-110 002
BOOK REVIEW
/
FULFILMENT THROUGH LEPROSY
‘FULFILMENT THROUGH LEPROSY' is a wellbrought out 436 pages hard-bound book (size 6" X10 ")
written by Mr. T. N. Jagadisan, a selfless and ardent
social worker moulded in Gandhian tradition, and
published by Kasturba Kushta Nivaran Nilayam,
Malavanthangal P. O., South Arcot District, TamilNadu-(6O5 701), India.
This is an autobiography. Mr. T. N. Jagadisan, who
was awarded Padmashri in 1957 and International
Gandhi Award for Leprosy in 1988 and who had been
described by the President of India, Mr. R. Venkataraman, as “the nearest approximation that I know of
to Gandhi’s concept of a constructive worker, cardinal
Newman’s definition of gentleman and Bhagavad Gita's
ideal of a sthitha-Pragna", is it’s author. He is a man
of letters par excellence and at the age of eighty he
has written in ‘fulfilment through Leprosy’ the story
of his life with utter candour and humility.
It is an autobiography where the cause is more than
the man. It is a record of the history of leprosy—from
ostracism to care, from care to cure to rehabilitation.
He has been a witness to the various phases of treat
ing the disease, from chaulmoogra oil to dapsone and
multidrugs, always insisting on avoiding euphoria, and
the supreme necessity of supporting treatment with
education and the raising of standards of living.
He was born on 2nd October 1909 in the village
Thachakkadu, near Chidambaram in Tamilnadu. His
father was a Revenue Inspector, who passed away in
1918 hit by the terrible epidemic of influenza. Thus,
Jagadisan lost his father at the age of nine. Though
he was still a boy, he had to bear the burdens of a
man. When he was a boy of 14, he was married to his
elder maternal uncle’s daughter Asanambal. What
Jagadisan has written about child-marriage in his
book is worth-noting: “Early marriage even with one
whom you liked, with the prospect of your liking
ripening into love, has its great disadvantages.
Alas! That in certain sections of our society, early
marriage is still the custom. Marriage before one rea
ches physical, mental and emotional growth, inflicts
a psychological trauma and deprives the couple of
the real joy of a wedding which is their due, and
cripples from the start the growth of their matrimonial
life.”
He developed non-infectious type of leprosy when
he was 10 years old. He had heard the people say
most fearful tilings about leprosy and panic seized
him. Those were the days (1926) when the general
practioners knew very little about leprosy. He had
gone to Karachi for treatment of his cracked and ul
cered heel. The doctors at Cuddalore explained him
facts about leprosy and assured him that he had a
non-serious and non-infectious form of leprosy. But
he has experienced wild fear and prejudice of people
towards leprosy and the social injustice to which the
innocent sufferers are subjected.
The person who made the most profound influence
on Jagadisan’s life was Right Honourable V. S.
Srinivasa Sastri, who was then Vice-Chancellor of the
Annamalai University. He gave Jagadisan deepest
understanding when he learnt that Jagadisan was suffer
ing from a slight touch of non-infective leprosy. With
the support of his master Srinivasa Sastri, Jagadisan
took to his heart the vow of educating the people on
simple facts about leprosy and make them view leprosy
as a disease and not dread it as a social disgrace. He
met eminent Leprologists, Dr Robert G. Cochrane,
Paul Brand and many others. He was convinced that
the greatest harm is done by the patient’s fear of os
tracism and his painful efforts at concealment till he
can no longer conceal.
Leprosy work brought Jagadisan through Thakkar
Bapa and Dr Sushila Nayar to Mahatma Gandhi. He
visited Sewagram Ashram in February 1945 along with
Dr Cochrane, his friend. He stayed thereafter with
Gandhiji ever since, spiritually, intellectually and in
the realm of constructive work. What Thakkar Bapa
was destined to do for Harijans and Girijans, Vaikunthbhai Mehta for Khadi, Sushila Nayar for Prohibition,
Soundaram Ramachandran for women’s uplift and
rural industries, Jagadisan was destined to do for
leprosy.
He is the Honorary Secretary of the Kasturba Kusht
Nivaran Nilayam, Malavanthangal, South Arcot Dis
trict, Tamil Nadu, from its inception in 1945 till now.
Because of his sustained efforts, it has been possible
to bring down the prevalence of leprosy in and around
Malavanthangal from 48 per 1000 at inception to 3 per
1000 in 1980s. He was actively associated in organizing
the All India Leprosy Workers Conference since its
inception till his retirement. He was the General Secre
tary of Akhil Bharat Kushta Samita.
Mr. Jagadisan’s autobiography “FULFILMENT
THROUGH LEPROSY” is a useful record of deve
lopment of strategies for leprosy control during the
last 50 years, from segregation to the recent and effec
tive multi-drug treatment through chaulmoogra oil and
dapsone, and from ostracism to rehabilitation through
care and cure. It is a neatly printed and calico bound
book that everybody interested in leprosy should pro
cure and study.
—DR P. V. PRAKASA RAO
ISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES), KOTLA MARG,
NEW DELHI-110 002 AND PRINTED BY THE MANAGER, GOVERNMENT OF INDIA PRESS, COIMBATORE-641 019.
ISSN, 0586=1179
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ANTI-LEPROSY DAY NUMBER
In this issue
swasth hind
Pausa-Magha
Saka 1914
January 1993
Vol. XXXVII, No. 1
LEPROSY ERADICATION
Mahatma Gandhi’s martyrdom day — 30 January — is also
observed as the Anti-Leprosy Day in India. For, India ranks
foremost among the countries saddled with the burden of leprosy
sufferers. It accounts for 2.5 million cases of the world load of
Leprosy patients. The Government of India had launched the
National Leprosy Eradication Programme in 1983 with the
objective to arrest the transmission of the disease by the year 2000
A.D It is a 100 per cent Centrally-Sponsored Programme.
Keeping this in view this issue of Swasth Hind is devoted
to the
Anti-Leprosy Day—1993
OBJECTIVES
Swasth Hind (Healthy India) is a monthly journal published by
the Central Health Education Bureau, Directorate General of
I lealth Services, Ministry of Health and Family Welfare, Govern
ment of India, New Delhi. Some of its important objectives and
aims arc to:
REPORT and interpret the policies, plans, programmes and
achievements of the Union Ministry of Health and Family
Welfare.
ACT as a medium of exchange of information on health
activities of the Central and State Health Organisations.
FOCUS attention on the major public health problems in India
and to report on the latest trends in public health.
KEEP in touch with health and welfare workers and agencies in
India and abroad.
REPORT on important seminars, conferences, discussions, etc.
on health topics.
SWASTH HIND WISHES ITS READERS
A VERY HAPPY NEW YEAR
Editorial and Business Offices
Central Health Education Bureau
(Directorate General of Health Services)
Kotla Marg, New Delhi-110 002
Edited by
Cover Design by
M. L. Mehta
M. S. Dhillon
Madan Mohan
Page
National Leprosy Eradication Programme
1
T.K. Das
and
3
National Leprosy Eradication Programme : Retros
pects and prospects
Dr B.N. Mittal
Dr N.S. Dhannshaktu
5
Socio-economic aspects of leprosy control
Prof. A.R.K. Pillai
7
Rehabilitation in leprosy work—Role and experiences
of NGOs
S.P. Tare
10
Research activities in leprosy
Dr Sushma Gupta
13
Leprosy vaccines---an update
Dr M.D. Gupte
15
A Project Model for attempting integration of leprosy
services with general health care services after the
prevalence of the disease is reduced in the endemic
districts on multidrug therapy for over five years
Dr N.S. Dharmshaktu
17
Beneficiary study of leprosy services among tribal and
non-£ribal population in the selected endemic districts
of Madhya Pradesh and Andhra Pradesh
Dr N.S. Dharmshaktu, Dr B. Kameshwara Rao,
Dr MA. Arif Dr S.L. Gupta,
Dr V.K. Afashi, Dr G.P. Mishra.
Dr G.R.K. Raju & Dr Srinivasa Rao
22
The state of the World’s Children 1992
24
Multidrug therapy
prospects
Dr S.K. Noordeen
in
leprosy—progress
Role of Health Education
Programme
Dr Manjit Singh
in Leprosy
Control
Leprosy—a select bibliography—1990-1992
K.C. Singh & H. Kaur
Book review
25
26
3rd
cover
Articles on health topics are invited for publication in this
Journal.
•State Health Directorates are requested to send in reports of
their activities for publication.
The contents of this Journal are freely reproducible.
acknowledgement is requested.
Due
The opinions expressed by the contributors are not necessarily
those of the Government of India.
SWASTH HIND reserves the right to edit the articles sent
for publications.
SUBSCRIPTION RATES
Single Copy
Annual
....
....
(Postage Free)
50 Paise
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-
V*
fl
ifl
NATIONAL LEPROSY
ERADICATION PROGRAMME
T. K. Das
tNDIA ranks foremost among the
Lcountries saddled with the bur
den of leprosy sufferers. As many
as 2.5 million cases of leprosy are
estimated to be found in India.
The disease is widely spread all
over the country. The prevalence
rate of leprosy exists above 5 per
1000 population in 201 districts out
of 468 districts of the coun
try. About 15% of the leprosy sufJANUARY 1993
ferers are children below 14 years
of age. The proportion of infec
tious cases varies from 15 to 20%
and equal number of patients suf
fer from deformities. At the time
of launching of the National Lep
rosy Eradication Programme in
1983 the disease was highly pre
valent in the States/UTs of
Tamilnadu,
Andhra
Pradesh,
Lakshdweep, Pondicherry, West
Bengal, Maharashtra, Karnataka,
Bihar, Nagaland, Sikkim, Anda
man & Nicobar. Now the pro
blem of leprosy has been reduced
in many of these States.
Programme objectives
The Government of India
launched the National Leprosy
Eradication Programme in 1983
with the objective to arrest the
transmission of the disease by 2000
A.D. It is a 100% Centrallysponsored programme.
1
Strategics
The adopted strategy under the
Programme involves: (a) Provi
sion of domiciliary multi-drug
treatment coverage in 135 districts,
having problem of 5 or more cases
per 1000 population, by specially
trained staff in leprosy, (b) In
troduction of modified MDT
scheme in the ramaining 66
endemic districts through existing
health care staff, (c) Introduction
of MDT services through existing
general health care services in the
low endemic districts, (d) Multi
drug therapy to Dapsone refractory
eases in other districts. Treatment
with combination of drugs includes
treatment with three drugs, viz.
Rifampicin, Clofazimine and Dap
sone. Education of the patients
and the community about the
curability of the disease and their
socio-economic rehabilitation are
other two key components of the
control strategy.
Centres—6097, Temporary Hos
pitalization Wards—291, District
Leprosy
Units—285,
Leprosy
Training Centres—49, Reconstruc
tive Surgery Units—75, Leprosy
Rehabilitation and Promotion
Units—13, Sample Survey-cumAssessment Units—39.
Infrastructure thus created has
been predominantly established by
the States in the endemic dis
tricts. In districts with endemicity
of less than 5 per 1000 population,
the general health care staff pro
vide the services. However, there
are still gaps in the 66 endemic dis
tricts due to financial con
straints. To extend the benefit of
MDT to over 0.7 million patients
living in these 66 districts, the
Government of India sanctioned a
modified MDT approach in these
districts from January, 1991. This
modified approach includes the
involvement of PHCs in the
delivery of services to leprosy
patients.
Infrastructure
Achievements
Over the years, a wast infrastruc
ture of leprosy workers has been
developed in the country, specially
trained for providing leprosy ser
vices. In the endemic rural areas
these services fan out from Leprosy
Control Units (one for 0.4 to 0.5
million population) while its urban
counterpart called the Urban Lep
rosy Centre caters to a population
of about 30 to 40 thousand. Tem
porary hospitalization ward having
20-bed capacity has been esta
blished, at least one in each
endemic district to render hos
pitalization services. Under the
programme 49 Leprosy training
Centres are engaged in providing
training to various categories of
health
workers
in
lep
rosy. Following
infrastructure
exists at the end of March,
1992: Leprosy Control Units—758,
Urban Leprosy Centres—900, Sur
vey Education and Treatment
Currently, about 70% of leprosy
patients are getting the benefit of
multi-drug therapy in the coun
try. Available information indi
cates that MDT is well accepted by
the patients, the tolerance is good
and side-effects are minimum.
There is marked reduction of over
90% in the prevalence rate in the 40
districts which have completed
MDT of 5 years or more. All the
201 endemic districts and 41 low
endemic districts have been
covered under multi-drug therapy.
Regular training in leprosy has
been provided to about 20,000
technical staff. As many as 6.39
million cases have been discharged
as cured by March 1992.
2
Target and achievements in 199192
During the year 1991-92 against
the target of 3,35,200 for new case
detection and treatment, a total of
5,03,390 new cases have been detec
ted out of which 5,00,242 cases have
been put under treatment.
The target for case discharge was
6,12,500 during 1991-92 against
which 8,16,538 cases have been
discharged.
The physical target allocated for
1992-93 consists of 2,89,600 cases
for detection and treatment and
5,73,900 for case discharge. The
budget estimate for 1991-92 was Rs.
2280 lakhs and for 1992-93 also
same amount has been allocated.
Sth Plan
During Sth Plan it is proposed to
provide MDT coverage to all the
districts with endemicity of 2 or
more per 1000 population and
MDT services will also be extended
through Primary health care in
other districts. During the seventh
plan a total of Rs. 85.82 crore has
been spent and a provision of
Rs. 150 crore has been kept during
the eighth plan. The financial
assistance proposed from World
Bank will be in addition to this
allocation.
World Bank assistance
To spread the MDT coverage to
uncovered areas and to further
intensify the efforts, the Govern
ment have sent a comprehensive
proposal to World Bank for finan
cial assistance of Rs. 300 crores.
In the proposed World Bank Pro
ject, it is envisaged to provide the
leprosy services with separate
workers in the 66 endemic districts
currently under the modified MDT
Programme, and additional ’ll dis
tricts would be taken up for
introducing the Modified MDT
Programme. The
monitoring
information would be strengthened
and a foundation laid to embark on
a rehabilitation programme.
A
SWASTH HIND
MULTIDRUG THERAPY IN
LEPROSY
—Progress and Prospects
DR S.K. Noordeen
Multi-drug therapy is extremely effective for individual treatment. Because MDT pro
gramme calls for well-organised case-detection and because the high patient acceptability
of the treatment tends to encourage self-reporting, MDT is usually associated with
increased early detection rates and a consequent fall in the frequency of new cases present
ing with deformity.
EPROSY is a major disabling
L/condition in the world with an
estimated load of 5.5 million
patients of whom about .VI million
arc registered in over 85 countries
of Asia, Africa and Latin America.
Over 82% of all registered cases in
the world are accounted for by only
five countries (India, Brazil,
Jigeria, Myanmar and Indonesia,
in descending order of magnitude)
and nearly three quarters of the
world’s known leprosy patients are
in South-East Asia. Yet despite its
relatively low prevalence and low
ranking as a cause of morbidity
and direct mortality, leprosy is for
many countries an intolerable relic
from the past, one that takes a dis
proportionately heavy toll on the
social, economic and psychological
wellbeing of whole families and
communities. It is in recognition
of its insidious repercussions on a
community’s overall health and of
the difficulty that many countries
with leprosy face in allocating
t
January 1993
resources to intensive leprosy con
trol activities, that the World
Health Organization now con
siders leprosy nt a prevalence rate
of at least one case per 10,000
population within a country or area
to constitute a public health
problem.
Dramatic change
Nevertheless over the past three
decades there has been a dramatic
change in the global picture of lep
rosy. In 1966, for example, when
reporting of leprosy cases had
become reasonably efficient in
many, if not most, countries, there
was a total of 2.8 million known
cases. Twenty years later, the total
had risen to 5.4 million. This
increase was probably due partly to
intensified detection of new cases,
particularly in South-East Asia. A
significant proportion of the
increase, particularly in the 1970s
and early 1980s, however, can be
attributed to failure of leprosy con-
trol programmes, many of them
unable to cope with rising rates of
resistance to dapsone. Between
1985 and the end of 1992 the num
ber of registered patients in the
world declined—for the first time—
from 5.3 million to 3.1 million, a
fall of over 41%. By 1992 MDT
was being administered to 1.3
million-patients and had released
2.9 million patients from treat
ment.
Implementation of MDT tends
to produce a bell-shaped curve of
leprosy statistics. Since organized
case detection is an integral part of
any well-run MDT programme and
since the short duration and low
toxicity of MDT tend to encourage
self-reporting, the institution of an
MDT programme is generally
followed by a rise in numbers of
registered cases. Indeed, much of
the increase in numbers of regis
tered cases worldwide in the 1980s
can be reasonably attributed to the
3
advent of multidrug therapy. After
a few years of MDT implementa
tion, discharge of patients complet
ing therapy produces a dramatic
decline in numbers of registered
cases. This trend is more clearly
seen in district or country leprosy
figures, and the unprecedented 41%
fall in global leprosy prevalence
between 1985 and 1992 to a large
extent is attributed to successful
MDT campaigns, particularly in
countries, like India, with large
numbers of patients.
On the positive side, multidrug
therapy is extremely effective for
individual treatment. Early lesions
in many instances resolve within a
few months of starting treatment
and infectivity is generally lost
within a few days of starting
paucibacillary
MDT. Most
patients can be discharged within
six to nine months and most mullibacillary patients within two to
three years of starting treat
ment. Relapse rates have been
extremely low, averaging, globally,
0.1% a year for paucibacillary lep
rosy and 0.06% for multibacillary
leprosy (vs. 1-2% a year for
dapsone monotherapy).
Patient acceptability
Because it is effective, finite, of
short duration and association with
fewer type 2 (erythema nodosum
leprosum) reactions than any other
treatment regimens, MDT, despite
the skin discoloration linked to its
clofazimine component, enjoys a
high degree of patient accep
tability: compliance rates average
between 80 and 90% in most areas,
vs. a maximum of 50% for dapsone
monotherapy. As a result, MDT
offers a rapid solution to a coun
try’s leprosy problem and thus a
rapid return on capital invested in
an MDT campaign. Backed by
strong national commitment and
the provision of adequate resour
ces, a well-run MDT programme
4
can reduce a national leprosy case
load by 70—80% within five years,
thereby releasing funds for other,
possibly longer-term, needs.
Because an MDT programme
calls for well-organized case-detec
tion and because the high patient
acceptability of the treatment tends
to encourage self-reporting, MDT
is usually associated with increased
early detection rates and a conse
quent fall in the frequency of new
cases presenting with deformity.
WHO’s contribution to its newly
proclaimed target of elimination of
the disease as a public health pro
blem by the year 2000 is mainly one
of coordinating and supporting the
many institutions, agencies and
organizations that have joined in
the effort to achieve this aim.
WHO receives invaluable support
from many participants in this
effort, including the Japan Ship
building Industry Foundation, the
International Leprosy Association,
the International Leprosy Union
and the International Federation of
Anti-Leprosy Associations.
Working group of leprosy experts
In recognition of the critical
stage that the world leprosy situa
tion has reached as a result of the
steady progress made over the past
five years in control activities,
WHO has set up a working group
of leprosy experts to oversee world
efforts to increase the momentum
created by recent progress. This
leprosy control working group
meets periodically to advise on
ways of stimulating countries to
intensify their leprosy control
efforts and of ensuring greater sup
port from and coordination of the
different agencies working in lep
rosy control. It also seeks ways of
improving control strategies and
sets priorities related to changing
epidemiological and socio-eco
nomic conditions. Part of the
working group’s mandate is also to
evaluate scientific progress and
assess the applicability of research
findings
to
leprosy
con
trol. Overall, the working group
provides the stimulus and direction
to the “race” towards leprosy
elimination by the year 2000.
Examples of WHO’s programme,
development functions include:
helping individual countries to
plan and implement leprosy con
trol activities, particularly through
general health service facilities;
helping countries to organize the
technical backup needed for effi
cient leprosy control activities,
including epidemiological evalua
tion and treatinent monitoring;
providing, at all levels of leprosy
control, updated technical guide
lines on diagnosis, treatment and
prevention of leprosy; setting lep
rosy control policy on all major
aspects of leprosy control, includ
ing diagnosis, treatment, follow-up,
and prevention and management
of disability; training of health per
sonnel at all levels and for all
aspects of leprosy control; in par
ticular, WHO
is organizing
national training courses in leprosy
control for managers.
Under its research promotion
activities, WHO supports field tests
of shorter, more effective and
operationally more readily im
plemented multidrug regiments
and new antileprosy drugs; sup
ports and coordinates health sys
tems research on (a) the most
cost-effective
leprosy
control
policies, especially those that pro
vide for the integration of leprosy
control with the general health ser
vices with programmes set up for
the control of other diseases; (b) the
organization of rehabilitation ser
vices and their integration within
existing rehabilitation program
mes; (c) improving case-detection
and management; (d) social and
economic factors, including educa
tional activities, related to com
munity involvement in leprosy
work; and organizes, supports and
coordinates the field-testing of lep
rosy vaccines for prevention.
A
SWASTE HIND
NATIONAL LEPROSY
ERADICATION PROGRAMME:
RETROSPECTS AND PROSPECTS
Dr B. N. Mittal
Dr N. S. Dharmshaktu
Target has been fixed that by the year 1995 all the districts of the country will be
brought under the coverage of multi-drug therapy which is likely to be achieved much
before. The additional 77 districts with prevalence rate between 2 to 4.9 cases per 1000
population are likely to be covered on MDT during the next year with World Bank
assistance. Endemic pockets in remaining low endemic districts are to be identified
and such endemic pockets will be supervised by 20 zonal officers for operation
of MDT.
eprosy has been known for
1—/many centuries and reference
to it is found in the ancient Hindu
Scriptures. Until a few decades
ago the disease was one of
neglect Leprosy control work
was started by the Government in
1941 for the first time though the
voluntary
organisations
and
nhilanthropists had started the
ame earlier. After independence
a committee was established in
1954 to suggest the leprosy control
measures. In 1955 the Govern
ment of India started the National
Leprosy Control Programme with
the objective to control leprosy
through domiciliary sulphone
treatment. It started as a centrallyaided scheme with its focus on
rural areas of high and moderate
cndemicity. In the low endemic
areas expectation was to provide
the services through the existing
infrastructure. The scheme was
converted into a centrally-spon
sored scheme in 1969-70 to give
t
January 1993
impetus to control work. The pro
gramme suffered because of
various reasons:
(a) Non-availability of potent
drugs for quick and complete
cure.
(b) The duration of treatment
with dapsone monotherapy
was long.
(c) Population was not fully
cooperative due to social
stigma attached to the
disease.
(d) Detection of all the estimated
cases was not possible due to
inadequate coverage, igno
rance and stigma.
As a result of such various
reasons many patients started
developing resistance to dapsone.
NLEP in Retrospect
WHO recommended multi-drug
therapy for treatment of leprosy
patients in 1981 based on its
experience
in
many
coun-
tries. Trial with multi-drug therapy
began in India in 1981 and in the
year 1983 the Government of India
re-designated the National Leprosy
Control
Programme
as
the
National Leprosy Eradication Pro
gramme. The
programme
is
operated as 100% centrally-spon
sored scheme and has since been
included in the 20-Point program
me. The objective of NLEP is to
arrest the disease activity in all the
known cases of leprosy by the year
2000. The World Health Organisa
tion has also set the goal of
elimination of leprosy by the year
2000 which is defined as achieve
ment of reduction in prevalence
below one case per 10,000 popula
tion by the year 2000 A.D. Lep
rosy being a least communicable
disease, its transmission in the
community is broken if the above
level of reduction is achieved in the
prevalence rate.
5
Multi-drug therapy services have
been meticulously planned in
endemic districts on vertical patlern. In such districts MDT has
been launched after creation of
complete infrastructure required
on vertical pattern, filling up of the
posts and training of the staff,
detection of most of the estimated
cases and commitment of the State
Government. Before launching
of MDT, a District MDT Society is
formed and the funds are directly
released to the Society. MDT Ser
vices are made available nearest to
lhe homes of the leprosy patients so
lhat no patient will have to travel
more than 2 kms for availing of
lhe same:
The vertical MDT Scheme has
been made operative in 135
cifdemic districts and in the
remaining 66 endemic districts
Modified MDT Scheme has been
sanctioned as complete vertical
staff could not be created in these
districts. Since the progress of
MDT is slow in 66 endemic disiricts on modified pattern and the
case-load is also high/hey are pro
posed to be converted into vertical
pattern with World Bank Assis
tance.
Available information with Lep
rosy Division indicates that till
March 1992, a total of 6.34 million
leprosy patients have been dis
charged, out of which about 50%
have been discharged as a result of
MDT. Out of 1.69 million patients
on record till March 1992,70% were
receiving
multi-drug
therapy.
There has been marked reduction
in prevalence rate by over 90% in
the districts which are on multi
drug therapy for over five years.
MDT has been accepted well and
its side-effect has been minimal.
The pattern has been developed
for extension of MDT to low
endemic districts. So far, 41 low
endemic districts have been
covered under multi-drug therapy
scheme.
NLEP in Prospects
The target has been fixed that by
the year 1995, all the districts of the
country will be brought under the
coverage of multi-drug therapy
which is likely to be achieved much
before. The additional 77 districts
with prevalence rate between 2 to
4.9 cases per 1000 population are
likely to be covered on MDT dur
ing the next year with World Bank
assistance. Endemic pockets in
remaining low endemic districts
are to be identified and such
endemic pockets will be supervised
by 20 zonal offices for operation of
MDT. The above 20 zones will
implement the MDT in the pockets
identified and the same is likely to
be started by 1993 with World Bank
assistance. Community
aware
ness activities will be strengthened
and training of general health care
staff will be carried out for all the
districts. The facility for ulcer
care and correction of deformity
including provision of footwear
wilj aho be expanded. Monitor
ing system is planned to be
strengthened. A comprehensive
proposal has been submitted to
World Bank for assistance of about
Rs. 300 crores for strengthening of
leprosy programme on the aspects
indicated above.
Attempts are being made to
further reduce the duration of treat
ment with still much more potent
drugs. Anti-leprosy vaccines are
also under field trial.
In the light of the above it can be
said that the target elimination of
leprosy by 2000 AD., can be
achieved.
A
WORLD AIDS DAY MARKED AT UN HEADQUARTERS
Secretary-General Boutros Boutros-Ghali
on 1 December told a meeting of the General
Assembly marking World AIDS Day that he
had created a single interagency advisory
group within the United Nations system, with
strengthened terms of reference. The Group,
which had held its first meeting last month,
would meet regularly and was committed to
create a ‘coordinated and effective response’
to the AIDS endemic Mr. Boutros-Ghali
said.
Noting that AIDS demanded a multi
sectoral, integrated approach from the United
Nations, he recalled his report to the
Economic and Social Council earlier thisyear in which he stressed that‘the need for the
6
United Nations to mount a comprehensive
and coordinated response’ was clear. There
were now 135 national AIDS programmes in
operation, which have been planned, set up
and assisted through the collaboration of
United Nations bodies and agencies, govern
ments and the private and voluntary sector,
the Secretary-General said.
The World Health Organization (WHO)
estimates that the HIV Virus has infected
about 11 to 13 million people worldwide.
More than two million people have
developed AIDS and most of them have
died.
—UN Newsletter
5 Dec. 1992.
SWASTH HIND
SOCIO-ECONOMIC ASPECTS
OF LEPROSY CONTROL
Prof. A.R.K. Pillai
People’s participation in leprosy eradication is of utmost importance and the existing pat
tern of collaborative work between Government and voluntary agencies may be further
strengthened so that net working possibilities can cover almost every corner of our vast
country. It is time that we open our eyes to ground realities and create long-term vision of
a progressive, healthy India, says the author.
y EPROSY is a major public health
L/ problem in our country and the
national goal is to eradicate leprosy
by 2000 A.D. There is political
will in the country to attain this
goal and the series of steps taken by
the Union Government and State
Governments bear ample tes
timony to this fact. We must bear
in mind the huge size of our coun
try and massive population. Ac
cording to the 1991 census figures,
our population was 843.9 million
with a density of 267 persons per
sq.km. The national literacy level
stood at 52.11% with female literacy
as low as 39.42%.
Background
It will be appropriate to look at
certain statistical data available to
us. The growth rate in population
is as high as 2.11% despite focus on
family planning measures over
several years. The population
below the poverty line was estimat
ed at 37% during 1984. In the
backdrop of these data, number of
leprosy patients in the world was
estimated at 12 million with India’s
total of about 4 million. However,
January 1993
the estimated number of leprosy
patients has come down in India to
2.8—3.00 million, thanks to the
vigorous efforts put in by the
Government and Voluntary Agen
cies.
Leprosy has two major dimen
sions—medical and social. There
has been substantial improvements
in the medical area concerning lep
rosy. Today leprosy is completely
curable with modem drugs.
Multi-Drug Therapy (MDT) offers
complete cure for leprosy at any
stage of the disease with treatment
span ranging from six months to
two years. The prevalence rate
has come down drastically where
MDT had been introduced and
deformity rates too have registered
a steep fall.
Social Dimensions
However, leprosy has social
stigma, attached to it over the
• generations. Reasons are many.
For centuries, there was no definite
cure for the disease. It is a dis
figuring ajjd crippling disease with
the patient landing up in defor
mities. It is a visible disease. All
these factors made the patients of
leprosy subject to the additional
burden of social boycott because of
stigma. They are rejected by the
society and patients suffer loneli
ness, poverty and allied areas of
social rejection. In view of this
anyone having symptoms tend to
hide the disease as long as they can,
rather than face rejection.
The number of leprosy afflicted
persons till about five years ago was
estimated to number about four
million. Of these about eight
lakhs constituted children below
the age of fourteen. The patients
and their families face social
ostracism and they are normally
prevented from participation in the
national stream of life. The pati
ents are thrown out of their jobs
and places of residences. Conse
quently they go about wandering as
beggars while most of them could
have pursued their vocations, con
tributed to gross national income
and earned their livelihood with
respect. The loss of production
and national income of four
million population is a colossal
waste occasioned by biased be7
haviour of an ignorant society.
Social stigma carried down from
generation to generation has re
mained tar too long and the society
in general has not updated in the
knowledge on leprosy and its
ramifications from a public health
angle. We as a people are far too
slow in correcting our attitudes and
approaches towards leprosy and its
sufferers.
While contributory
reasons are many, there has been
appreciable change in the scenario.
1'his welcome change has to be
taken further to help elimination of
leprosy from the Indian soil.
"A m
Main Factors
There are three main factors in
leprosy control and eradication,
viz. drastic reduction/elimination
of reservoirs of infection in the
community, clipping all possible
channels of transmission of the dis
ease and improving the immunity
levels of the population at risk.
While we proceed in the matter, we
have to bear in mind rapid
urbanisation and large mobility of
villagers into towns and cities caus
ing near collapse of civic facilities
in urban areas like lack of adequate
housing, transport and the like.
Poverty, illiteracy, superstitious
beliefs and a host of allied factors
play important contributory roles
in leprosy control effort.
We have 66 hyperendemic (pre
valence 10 plus) and 135 endemic
(between 5 and 10 prevalence rate)
districts in India and the pre
valence is not uniform in various
districts. MOT had been intro
duced in several districts with great
advantage and good results are
coming, up. The National Lep
rosy
Eradication
Programme
(NT F.P) aims at elimination of the
disease by bringing the prevalence
rate to 1 per 10,000 population by
the year 2000.
S
The leprosy patients and their families face social ostracism and they are normally prevented from
participation in the national stream of life.
Major Constraints
What are our major constraints
and how can we overcome them?
If the average citizen knows the
simple facts about leprosy and goes
to a medical centre for check-up on
seeing symptoms, the major battle
is won. For this two factors must
be established. First systematic
and continuous campaign to edu
cate the public on facts about lep
rosy. In a country like ours where
literacy is too low, audio-visual
communications may be taken
advantage of. Education through
TV, Cinema and Radio should be
given adequate emphasis. Secon
dly conditions must be brought
about in the community not to des-
pise leprosy patients. Treating
leprosy like any other disease and
lending societal support for the suf
ferers will help those with symp
toms to come forward and take
treatment Testimonial
cases
must be given wide publicity with
appropriate media targeting to get
the desired results. Leprosy treat
ment at Government and voluntary
agencies
is
completely
free
throughout India and this should
be made available through primary
health centres as is being done
progressively.
Women’s Status
Women’s status in Society is a
pivotal factor in a nation’s develop
ment. The declining sex ratio of
Swaste Hind
929 females to 1000 male popula
tion revealed by 1991 census is
noteworthy.
Inveslincnls in educating the
girls can yield the highest returns to
the society at large and the family
as well. Major initiatives to in
crease female education have
potential to transform society over
a period of time. Educated moth
ers and daughters are an asset to
any society. They choose to have
fewer children, whom they can care
well.
Though educating boys and girls
may be similar in its cost impact,
girls’ education is a safer long-term
nveslment towards generating rich
social benefits.
With higher female literacy
levels, greater autonomy for women
and higher avenues for self-reli
ance. better health and higher
quality of life will certainly result.
The States must lay adequate stress
on this area. Kerala is a standing
example before us to show how
female literacy and self-reliance
have brought out excellent re
sults.
Conclusion
Complete MDT coverage where
needed, with concurrent training of
primary health workers, con
tinuous education of the people
through mass media channels,
updating awareness levels in the
community and simultaneously
improving the living standards of
the people can bring about lasting
results in leprosy control and
eradication efforts. People’s par
ticipation is a must and the existing
pattern of collaborative work bet
ween Government and voluntary
agencies may be further streng
thened so that net working possibi
lities can cover almost every comer
of our vast country. We have
made rapid strides in elimination
and by increasing the tempo, won
derful results can follow !
It is time that we open our eyes to
ground realities and create long
term vision of a progressive, heal
thy India.
A
SCREENING FOR GASTRIC CANCER
A SIMPLE blood test may soon be all that is
ZV needed to detect patients at high risk of
stomach or colonic cancer.
This advance is in prospect as a result of
investigations carried out in North Staf
fordshire in the English Midlands to discover
why the area has the country’s highest
incidence of gastric cancer and lowest sur
vival rate among female colonic cancer
su fferers.
Three members of the Keele University’s
school of postgraduate medicine in Staf
fordshire, surgeon Prof James Elder,
biochemist Dr Richard Strange and epi
demiologist Dr Terri Knight, applied their
different disciplines to the subject and came
up with what have been described as “excit
ing discoveries”.
Dr Strange explained: "Our preliminary
findings in the laboratory show an exciting
link between a susceptibility to gastric and
colorectal cancers, and an inability to
January 1993
2— 15/DGHS/92
make an enzyme
S-transferase.
called
glutathione
"This enzyme appears to be necessary
for the proper detoxification of a number of
recognised carcinogens.
Some people
appear unable to make the enzyme, which
puts them at an increased risk of can
cer." Modern technology is now allowing
the study of an individual’s DNA using
molecular biological techniques by means of
a small blood test. The new approach would
allow simple screening of the relatives of
individuals with cancer, with monitoring car
ried out in hospital pathology labs.
Professor Elder said the eventual aim
would be for patients with a family history of
gastric or colonic carcinoma, to be able to go
to their GP and be given information on their
chances of contracting the disease.
A
— SPECTRUM
Sept.-Oct. 1992
9
RESEARCH ACTIVITIES
IN LEPROSY
Dr Susiima Gupta
Even though clinical trials for the available leprosy vaccines are under way, research is con
tinuing to develop yet another vaccine for leprosy......Studies are in progress to elucidate
mechanisms of deformities developing in leprosy patients, and steps for their prevention,
and effective surgical techniques for their correction.
ripHE Indian Council of Medical
1 Research carries out the major
parts of its Research activities in
leprosy through its permanent
institute, Central Jalma Institute
for Leprosy, Agra. The Council
also provides grant-in-aid for open
ended projects and fellowships in
various Medical Science Colleges.
The overall goals of the research
programme of the council have
been (i) to assess current methods
of diagnosis, treatment etc., and
improve upon them, (ii) to develop
newer methods and tools which
ill serve these purposes better, (iii)
.u improve our understanding of
the disease process and the com
plications that add to the morbidity
of the disease, (iv) to increase our
knowledge about the causative
organism so that we may develop
better methods to destroy it, (v) to
improve our understanding of the
disease dynamics in the com
munity and (vi) to carry out a com
parative trial of candidate vac
cine preparations.
The Central Jalma Institute for
Leprosy, Agra, mainly continues to
investigate leprosy and related pro
blems through various clinical.
January 1993
3— 15/DGHS/92
immunological, epidemiological,
microbiological and molecular
biological studies so as to help the
Government in successful im
plementation of the National Lep
rosy Eradication Programme.
Though clinical diagnosis of an
obvious case of leprosy is easy,
there are enormous problems in the
classification of early lesions.
Molecular biological methods e.g.,
probes, gene application techni
ques like Polymerase Chain Re
action (PCR), immuno-histology
and histology are used to classify
early lesions of leprosy.
Leprosy, known to be a disease of
nerves, macrophages and skin is
also a disease of altered lipid
metabolism. In a recently con
cluded study, it was observed that
there was a significant increase in
the circulating high density lipop
roteins and lipoproteins-a levels in
lepromatous leprosy as compared
to control and the tuberculoid lep
rosy patients. It appears that
these lipoproteins have a role in
immunological aspects of nerve
injury in leprosy.
Leprosy in the majority of the
cases can be diagnosed on the basis
of a proper examination of the case
alone. Therefore a set pattern
should be followed for examina
tion e.g. clinical and bacteriological
examination,
histamine
test,
biopsy and immunological test
However, the diagnosis of early lep
rosy has always been a chal
lenge. Newer in vitro tests such as
lymphocyte transformation test
(LTT) and leucocyte migration
inhibition test (LMIT) have been
developed and they are used to
detect the level of immuno
deficiency. The recent advance in
study of the epidemiology of lep
rosy is the development of
serological tests which gives hope
for a better surveillance. The
fluorescent
leprosy
antibody
absorption test is now widely used
for identification of subclinical
infection.
Till date there is no immuno
diagnostic test available for leprosy
diagnosis in the National Leprosy
Eradication Programme. A sero
logical assay standardised at CJIL,
using peroxidase labelled MLO4
(SACT-ELISA) was compared in
terms of their sensitivity and
specificity with two other currently
13
available serological tests deve
loped by other laboratories (PGLEI.ISA
and
PGL-AGGIU).
SACT-ELISA was found to be
more specific and sensitive than
the other two assays.
In lepromatous leprosy there is a
poor immunological response toM.
leprae. In a recently concluded
study to find out whether this is
related to interleukin-1 and/or 2
production, it was observed that
there was some immunological
defect with respect to production of
IL-1 in all forms of leprosy. Lep
romatous Lcprosy(LL)/ Border line
(BL) patients do not show defective
IL-2 production and after 6 months
of multidrug treatment (MDT), its
production rises significantly.
Various viability assays for rapid
determination of M.leprae are being
developed. These viability assays
could be applied to paucibacillary
leprosy which remain therapeuti
cally and prognoslically important
in this country. Three gene
amplification techniques alongwith highly sensitive ATP bioluminescent assay system are being
applied for viability assessment.
Cloning and sequencing of 16S
genes and flanking sequences of 12
species of mycobacteria had led to
identification of 9 variable regions
within rRNA gene & flanking
region of ribosomal genes of M.lep
rae and other mycobacteria. In
addition to 17 mer probe, some
more probes and primers have
been designed against these vari
able regions and synthesized. Ini
tial evaluation of the observation
results show that a few of these pro
bes could be useful at species/
genus
level. Methodological
studies for the clinical application
are in progress.
Gene amplification techniques like
PCR using primer based on 18Kd
and 36Kd antigen genes and an
reverse PCR is being standar
dised. Based on initial results
which suggest the need to further
optimise technique(s) for extrac
tion of nucleic acids from biopsies,
alter assay techniques, further
studies are being carried out An
enzymatic technique for isolating the
mycobacetrial nucleic acids from
biopsies has been developed and is
being evaluated.
Duration of anti-leprosy therapy
Anti-leprosy vaccine
In order to identify the best of the
available vaccines for Indian
situations, a randomised double
blind controlled five arm pro
phylactic vaccine trial against lep-ir
rosy involving two indigenously
developed vaccines e.g., ICRC,
M.w. and Killed M.leprae 4- BCG,
BCG and normal saline has been
launched in Chingleput district of
Tamil Nadu.. By July 1993, the
intake phase is expected to be com
pleted. This will be followed by
resurvey of vaccines.
Another clinical trial with ICRC
vaccine for Immunoprophylaxis
against leprosy is in progress. The
study is being conducted by Cane
Research Institute, Bombay, in
Osmanabad, Latur and Solapur
districts of Maharashtra. The
objective of the trial is to assess the
immunoprophylactic efficacy of
two vaccines containing (i) ICRC
bacillus (ii) BCG by measuring the
incidence of both multibacillary
and paucibacillary forms of Lep
rosy in ICRC vaccinated as com
pared to BCG groups. The intake
of about 34,000 households con
tacts has been completed and the
resurvey of vaccines has started.
New methods
Several new methods based on
analysis of lipids, isoenzymes,
immunological
relatedness of
enzymes have been developed.
Evaluation
of protein
elec
trophoregrams and zymodemes in
several mycobacteria including M.
leprae had shown that combination
of different zymodemes and pro
tein electrophoregrams can be used
for rapid identification & charac
terization of various pathogenic
mycobacteria. Further the de
tailed analysis of Restriction Frag
ment Length Polymorphism (RFLP)
of rRNA gene region has shown
that this technique & probes are
useful to characterise various
mycobacteria including M. tuber
culosis, M. avium and M. leprae at
species, subspecies and even
strain level.
14
The optimal duration of antilep
rosy therapy has been an issue of
debate. Studies are in progress to
determine the minimal length of
antileprosy therapy. The pre
liminary results indicate that in
lepromatous patients, it takes up to
12 months by DDS and clo
fazimine combined to kill rifam
picin resistant mutants suggesting
that minimum duration of treat
ment should not be less than one
year. With the aim to further
reduce the duration of treatment, a
regimen comprising of Dapson,
Rifampicin and Prothionamide is
also being tried.
India is playing a crucial role in
developing and testing immuno
therapeutic
and
immunopro
phylactic agents for leprosy.
Even though clinical trials for
the available leprosy vaccines are
under way, research is continuing
to develop yet another vaccine for
Leprosy. At
Foundation
f
Medical Research, Bombay,
study is being supported in which a
1.6 Kb M. Leprae DNA protein has
been identified as a potential
immunodominant protein. Insert
of this DNA fragment in E.Coli
holds promise of getting a recombi
nant M.leprae protein as a possible
vaccine against leprosy.
Studies are in progress to
elucidate machanisms of defor
mities developing in leprosy
patients, steps for prevention of
deformities and effective surgical
techniques for the correction
of deformities.
SWASTH HIND
)
LEPROSY VACCINES
An Update
Dr M. D. Gupte
It is not impossible to conceive emergence of effective anti-leprosy vaccines some
time in future. It \Vould be essential to understand the possible roles of these vac
cines in different situations. Alternative approaches and priorities for disease con
trol will have to be taken into account. Leprosy vaccine is a distinct research goal
and an area of high research priority.
TN 1990, the subject of anti-leprosy
1 vaccine was reviewed for the
readers of the Swasth Hind. Avail
able information on several can
didate vaccines was summarized
and the subject of second genera
tion vaccines was also reviewed.
Three years is a rather short period
for getting useful information on
potentials of anti-leprosy vaccines
in preventing leprosy. A pro
phylactic vaccine trial against
leprosy usually takes a decade
before reaching any valid con
clusions. However, preliminary
results from one field study in
Venezuela and progress of the
ongoing vaccine studies should be
of interest to the readers.
Venezuela vaccine trial
An immunoprophylactic trial
against leprosy using armadilloderived killed Mycobacterium leprae
and BCG vaccine was launched in
Venezuela
during
1983. The
Venezuela trial is the first of (he
three different vaccine trials in the
world where killed A/, leprae is
being used, the other two being in
Malawi and India. The first re
port of the results of the Venezuela
January 1993
trial, covering the period up to July
1991, has been published recently
in The Lancet (Convit et al 1992).
Zuniga, a colleague of Convit and
an eminent epidemiologist, obser
ved a sustained downward ten
dency of new case-detection rate
from 16 per 100,000 inhabitants in
1951 to 2.5 in 1981 in Venezuela. He
has drawn attention to the impor
tant demographic changes towards
increased
urbanization
and
changes in the epidemiological
profile of leprosy. According to
him, increase in the proportion of
multibacillary cases, increase in the
average age of new cases by ten
years and increased proportion of
leprosy in males indicated a rapid
natural decline of leprosy in
Venezuela. In Venezuela, the vac
cine trial is being conducted in the
three most highly endemic States,
viz., Apure, Tachira and Merida
(prevalence 6.9, 2.9 and 1.9 per
thousand population and inci
dence 10.9, 4.3 and 3.9 per 100,000
respectively) in the household and
extradomicillary contacts. As many
as 29,113 contacts were included for
the study. The vaccine trial in
Venezuela is a large-scale, ran-
domizcd, controlled, double-blind
trial employing BCG + killed A/.
leprae and BCG alone. The dose
of BCG was decided by the tuber
culin status of the individual, tuber
culin negatives receiving 0.2 mg
and tuberculin positives 0.04 mg.
The dose of M.leprae was 6 X 10“
bacilli. The contacts were initially
screened for leprosy and were given
the M. leprae Soluble Antigen
(MESA) and tuberculin tests. The
group of interest for the trial was
that of MLSA negatives.
The participants were carefully
examined for leprosy annually by
doctors
specialised
in
lep
rosy. Skin smears and biopsies
for histopathological examination
were routinely obtained. The
resurveys generated 150,026 person
years of observation and 59 con
firmed cases of leprosy. After
deleting 29 cases for reasons like
pre-vaccination history of leprosy,
occurrence of disease within one
year, etc., the remaining 30 cases
were considered for the final
analysis. Fifteen each of these
belonged to BCG and BCG+killed
Af leprae, irrespective of initial
MLSA status. Twenty of these 30
15
MB II |■l^■l
II
I
III I Illi
patients belonged to MLSA
negatives at intake, and in this
group of interest 11 belonged to the
BCG arm and 9 to the BCG +
killed M. leprae. The other inte
resting observations were, about 60
per cent protective efficacy of BCG
and strong persistent MLSA
positivity following BCG + killed
M leprae in the initial MLSA nega
tive group. Results from the
Venezuela trial remained incon
clusive regarding protective effi
cacy of the combination vaccine
over and above that of BCG
alone. Whether that is on account
of previous BCG vaccinations and
lepromin testing, high efficacy of
BCG in preventing leprosy, adop
tion of annual case-detection pro
cedures or epidemiological profile
is difficult to say.
BCG Story
BCG was considered as a poten
tial tool for leprosy control follow
ing the observations on lepromin
conversion. Encouraging results
with respect to its protective
efficacy are available from Uganda,
New
Guinea,
Malawi
and
Venezuela. A prophylactic effi
cacy to the tune of 50% to 80% was
observed in these places. Results
from Burma have shown an
efficacy of about only 20%. Similar
moderate level of protective effi
cacy was observed from the recen
tly analyzed data from the South
Indian BCG trial. BCG does not
appear to be a vaccine which could
be globally considered for preven
tion of leprosy, although it might be
effective in some regions.
ICRC Vaccine
ICRC bacilli were first isolated
in 1958 by Bapat, Ranadive and
Khanolkar. ICRC vaccine was
produced in 1979. Bapat and Deo
registered a patent for ICRC vac
cine (C-44 strain) in 1981. The ini
tial hospital based studies were
conducted at Acworth Leprosy
16
Hospital, Bombay, from 1979. A
prophylaxis study is in progress in
Maharashtra State since February
1987.
M.w vaccine
Taiwar’s group in Delhi was
looking for a mycobacterium hav
ing desirable cross-reactive anti
gens with M.leprae with respect to
the immune reactivity of TT
patients, and at the same time to
have antigens evoking responsive
ness in LL patients. M.w was
selected as a candidate for vaccine
production. Encouraging results
from
hospital-based
Phase-II
immunotherapeutic clinical trials
have been obtained in New Delhi.
A prophylaxis study in Kanpur is
in progress.
Comparative leprosy vaccine trial in
South India
On 30th January 1991, a com
parative leprosy vaccine trial
involving BCG plus armadillo
derived killed M.leprae, ICRC and
Mw was launched by the Indian
Council of Medical Research in
Chingleput district of Tamilnadu.
Information on the three candidate
vaccines had been discussed exten
sively in the Indian Council of
Medical Research, by the Indian
Association of Leprologists, as well
as at the last Pre-Congress
Workshop on leprosy vaccine trials,
in The Haugue in 1988. 4t was
uniformly agreed that all these vac
cines deserve to be tested for their
prophylactic efficacy. The recen
tly launched trial in South India is
providing an unique opportunity to
compare them together. It will
take 8 years to get the first results on
the prophylactic efficacy of these
vaccines.
Possible second
cines
generation
vac
A number of mycobacterial
antigens
have
been
iden-
tified. Natural or recombinant
forms of these proteins are now
available. Choosing
antigens
with possible prophylactic efficacy
could prove to be a very deceptive
exercise. Defining
“protective
antigens”, and “protective and
pathologic immunity” are some of
the questions that are being inves
tigated. Promising
approaches
for inserting different DNA
sequences in BCG have been
developed. However, the work on
second generation vaccines is still
very much in the exploratory
stage.
Relevance of a vaccine
The available parameters of
animal studies, sensitization to
M.leprae antigens following vac
cination and immunotherapy are
only indirect measures of probable
prophylactic efficacy of the can
didate vaccines. Vaccines trials
with different candidate vaccines
against leprosy are presently in
progress. Several
recombinant
and native antigens as well as
mycobacterial components are
being investigated for their role in
immuno-modualtion. It is not
impossible to conceive emergence
of effective anti-leprosy vaccines
some time in future. It woul
?
essential to understand the possioie
roles of these vaccines in different
situations. Alternative
approa
ches and priorities for disease con
trol will have to be taken into
account Efficacy of case-detec
tion and case-holding in controll
ing disease transmission, costs of
case-detection and case-holding
and the cost of preventing leprosy
cases will need consideration in an
overall context. Clearly leprosy
vaccine is a distinct research goal
and an area of high research
priority.
&
Swasth Hind
IM I II I
A Project Model for attempting Integration of
Leprosy Services with General Health Care
Services after the Prevalence of the Disease
is reduced in the Endemic Districts on
Multidrug Therapy for over Five Years
Dr N. S. Dharmsiiaktu
x <IJLTIDRIJG therapy has been
Vlintroduccd in India for the
..eatment of leprosy cases on a
large scale, in high endemic dis
tricts with prevalence of 5 or more
per 1000 population, through a
separate vertical infrastructure
parallel to the general health care
system (DGI1S 1989). After the
introduction of multidrug therapy
in a district the prevalence rate is
expected to be brought down to a
very low level by 5 years and, after
that leprosy care is planned to be
integrated with the general health
care system. Starting from 198283 multidrug therapy (MDT) has
now been sanctioned for all the 201
endemic districts of the country,
including the 66 districts for which
Modified MDT Scheme has been
auctioned. Recently, it has been
proposed to change the Modified
MDT Scheme into a regular verti
cal approach. The endemic disiricts where the prevalence has
been reduced to 1.5 or less per 1000
population, because of MDT inter
vention for 5 years or more, have
now been issued with Government
orders for integrating leprosy ser
vices with general health care with
effect from 1-4-1991 (DGHS
1991).
Integration of leprosy services
with general health care is being
practised in many countries (WHO
January 1993
SEARO 1988), but this has not
always been based on any definite
evidence showing that the inte
grated approach is better than ver
tical approach. Since one third of
world leprosy patients is estimated
to be present in India, it is time for
the Government and other interes
ted agencies and persons to plan
and study the feasibility of Integrat
ing leprosy services with general
health care services through wellconducted projects and gather ade
quate experience in the metho
dology of integration before in
troducing integration on a wider
scale. Integration done without
prior feasibility study may undo all
the success that has been achieved
under the National Leprosy
Eradication Programme. However,
we must also realize that we can ill
afford the financial burden of
maintaining the vertical structure
for an indefinite period.
Here I present a project model
for studying the effects of integra
tion of leprosy with general health
care based on utilisation of existing
health care infrastructure.
The Case for Integration
The case for integration is wellknown and is summarized below.
The general health care staff
have better access to the com
munity. For every 5,000 popula-
tion one male and one female
health worker are working full time
under the general health care sys
tem whereas, under the vertical lep
rosy services system one worker
covers 25,000 population.
The general health care system
has one female worker for every
5,000 population and also has the
support of trained dais and Anganwadi workers at village level
whereas, the number of female
workers employed is very small
under the vertical system of leprosy
services. Examination of female
subjects aged above 14 years is
therefore likely to be better if lep
rosy services are provided by the
general health care services in low
endemic areas.
During the surveillance period,
when the case-load in the com
munity is quite low, many patients
do not feel it necessary to visit the
leprosy clinic as they feel they have
been cured.
The number of
patient-health worker contact is
likely to be frequent with the
general health care system since
patients will be approaching the
general health care staff for their
other health problems and this will
lead to better coverage during sur
veillance.
Given adequate training about
early diagnosis, patient follow-up
17
II
IBII I
■
■■III ■■III
ror the treatment, referral and com
munity education about leprosy,
the general health care workers will
be able to give better coverage in
view of their easy access to the
population.
THE PROPOSED MODEL
The proposed model of integra
tion of leprosy services with general
health care services envisages:
(i) Development
of
training
curriculum in leprosy for general
health care staff; (ii) Job identifica
tion for each category of staff; (iii)
Short training of all general health
care staff including community
health workers; and (iv) Integra
tion of information system and
monitoring system with the general
health care system at various
levels.
The proposed model will test the
hypothesis that the type of
approach (TA), vertical or inte
grated, directly or indirectly deter
mines : the percentage of follow-up
of
cases
discharged
as
cured
(%FCD), the number of persons
examined for leprosy (# PF), the
number of females aged 15 years
and above examined for leprosy (#
F 15E), the number of new cases
detected (# NCD), the percentage
of patients pul on regular treatment
(%RT), the choice of patient for the
type of approach (COP) and the
choice of the general public for the
type of approach (CGPT). Sym
bolically the hypothesis may be
expressed as :
% FCD; * PE; # F15E; # NCD;
% RT; COP; CGPT- f(TA)
in which f is ‘function of.
Definitions of the terms used ;
(i) Choice of patients for the type
of approach (COP): In view of the
large number of patients in the
study districts it may be difficult to
contact each and every patient and
obtain her/his choice of the sys
tem. Therefore, all the patients
registered during the study period
IX
(3 years) including those cured dur
ing this period will be considered
for the study of their choice of the
system, (ii) Regular treatment
(RT) : Patients having a minimum
of 75% attendance for treatment
will be considered ‘regular’ and
treatment regularity will be esti
mated in terms of completed mon
ths. Any continuous break of two
months or more in treatment will
be considered as ‘irregular’, (iii)
Choice of general public for the
type
of approach
(CGPT):
Opinions of the village heads
(usually male) and heads village
Mahila Mandals (women’s groups)
regarding which approach is better
and should be adopted for treat
ment of leprosy patients will be
ascertained. The reply will be
graded as vertical/integrated/not
certain. The reason for the pre
ference will also be elicited and
studied. In urban areas, choices
of heads of wards (usually male)
and the Mahila Mandals (women’s
groups) will be ascertained and
recorded, (iv) Persons examined
(PE): This refers to the total num
ber of persons examined for lep
rosy, and Fl 5E’ refers to the total
number of females, aged 15 years
and above, examined for leprosy
during the study period.
(v)
Follow-up of cases discharged as
cured (FCD): Treatment is ter
X
(TA) 1
minated in cured cases and they are
required to be followed-up once in
a year for 2 years and 5 years, in
paucibacillary and inuliibacillary
cases respectively, for detection of
instances of relapse. ‘%FCD’ refers
to the percentage of discharged
(cured) cases thus followed-up dur
ing the study period, (vi) in
tegrated General Health Care
System is one in which every
health worker deals with all
types of disease and health pro
blems in the area allotted to him/
her, including leprosy.
(vii)
‘Vertical leprosy services’ refers to
the system in which the worker pos
ted under the leprosy programme
deals with health problems of le
rosy patients only, in the popula
tion alloted to him/her. (viii)
Multidrug therapy refers to treat
ment of leprosy with a combintion
of dapsone, clofazimine and rifam
picin in the dosage schedule
recommended by the National
Leprosy Eradication Programme.
It follows from our hypothesis
that type of approach (TA) may be
looked upon as the independent
variable (XI) and the other
parameters (% FCD, #PE...) as
dependent
variables
(Yi.Ya...
Yz). The following path diagram
shows the relation between these
parametres.
Y
(FCD) 1
(PE)2....> (NCD)5... >(RT)6....>(COP)7
(F15E)3
(CGPT)4
It can be seen that
Yi, Ya, Ya. Y<
Ya = f(Ya); Ye
f(Xi);
f(Ys) and Yr
Chdice of patient (COP) in
favour of integrated services will be
positively inP.uenced by care for
other diseases and negatively
influenced by the levels of social
stigma, stigma by the worker and
self-stigma. It may also be influ-
f(Y.).
enced by educational status, occu
pation, rural/urban status etc.
Choice of general public in
favour of integrated services will be
negatively influenced by the social
and educational status of the
individual.
SWASTH HIND
Project Description
Two districts, ‘A’ and ‘B’, in
which the prevalence of leprosy has
been reduced to a very low level
(preferably, less than 2/1000 pop
ulation) as the result of five or more
years of multidrug therapy should
be selected, preferably from the
same state.
A team of 4 leprosy experts
should validate the alleged low pre
valence rate of leprosy in the two
districts.
The present vertical approach
will be continued in district ‘A’; but,
in district lB’ the integrated
approach will be adopted. The
incentive salaries of vertical staff
will be discontinued in district ‘A’
and no incentive salaries will be
paid to general health care staff of
district ‘B’. If these two districts
arc selected from the ones already
identified by the Government of
India as ready for integration and
for which orders have already been
issued for stopping payment of
incentives with effect from 1-4-91,
(here will be least administrative
problems, as incentives will not be
available for the control district
as well.
The vertical leprosy staff of dis
trict B' (integrated) will be utilized
for training general health care
staff of the district in leprosy. Af
ter that, they may be transferred to
ah adjoining district where vertical
approach is still being followed, or,
they may be sent for training in the
integrated system in an institution
nearby, depending upon the needs
of the State Government.
The period of training for the
general health care staff in leprosy
will be 5 days for medical officers
and all the staff of PHCs and sub
January 1993
centres and, it will be 2 days for the
village level workers like dais and
village health guides.
Male health assistants and male
multipurpose workers will be
involved in public awareness
activities,
population
surveys.
detection of new/suspected cases,
follow-up of cases on treatment
and cases under surveillance,
referral of cases, defaulter action,
etc. The female health assistants
and female multipurpose workers
will be involved in referring the
detected suspected cases, bringing
defaulter cases for treatment to the
PHC doctor, or, to the male
workers of the particular area for
recording and reporting. They
will also be involved in the public
awaicness activities about leprosy.
Immediately after training, the
general health care staff (of district
‘B’) will be introduced to the
patients and their records in that
area by the vertical (leprosy)
staff. This should take about five
working days for each male mul
tipurpose worker covering 5,000
population. This
introduction
will be done by the leprosy worker
of that area under the supervision
of the Non-Medical Supervisor or
the Medical Officer. Each vertical
worker looks after 25,000 pop
ulation. Therefore each vertical
worker will need 25 working days
for the complete handing over of
records and introduction of all the
cases to the five general health care
workers of that area. Incentive
salaries of the vertical worker will
be stopped from then on, if the
worker opts to remain in the same
district and become a general
health care worker for which he
will be sent for training in the
general health care system.
In both districts, the opinion of
male and female patients, general
public and the workers will be
ascertained at the start of the pro
ject-and at the end of the study
period (3 years). The same indi
viduals will be examined on both
occasions. A selfstructured ques
tionnaire will be used for com
parison. Therefore, standardiza
tion of the questionnaire will not be
required.
The level of basic knowledge of
general health care workers will
also be assessed initially and after
three years of integration. The
responses to the questionnaire will
be graded as correct/partly correct/
wrong.
The supervision mechanism in
district ‘B’ will be as under:
(i) The ‘integrated’ district will
continue to have a District Leprosy
Unit, which will be responsible for
providing supervision, technical
guidance, quality check of skin
smears and survey work. The staff
of the District Loprosy Unit will
also deliver talks on leprosy in the
monthly meetings at PHC level, on
rotation. The District Leprosy
Officer. (DLO) will work under the
overall guidance of and in close
coordination with the Chief Medi
cal
Officer/D is trict
Medical
Officer. The Medical Officers of
Leprosy Control Units in the dis
trict will be shifted to fill vacant
NLEP posts, or, given duties in the
primary health care set-up. The
non-medical supervisors, health
educators, . physiotherapy tech
nicians, laboratory technicians and
other categories of workers under
the .NLEP set-up will be redis
tributed against vacant NLEP
posts, or, will be reallocated
appropriate duties under the
19
general
health
care
set-up.
(ii) Multidrug therapy in the integ
rated pattern will be made avail
able at sub-centres, primary health
centres, community health centres,
dispensaries and hospitals. The
Medical Officer of the primary
health centre will be responsible
for NLEP activities (including
treatment delivery, case holding,
follow-up and reporting etc.,) in his
iirea as a part of his/her normal
duties.
The management information
system will be simplified in the dis
trict on integrated set-up and the
information collected will be res
tricted to population examined for
case detection, cases detected and
treated, treatment regularity, dis
charges and relapse.
Coverage of leprosy services will
be measured after 3 years of
implementation. Following data
from Jhesc two districts will be
compared : coverage of discharged
cases under surveillance, popula
tion surveyed, new cases detected,
treatment regularity of old and
newly detected cases, choice of
male/female patients and opinions
of general public and health
workers about their preference (of
integrated or vertical system).
Data source and data collec
tion : The district ‘A’ (vertical set
up) data will be collected from the
records with the DLO, leprosy con
trol units, urban leprosy centres
and
survey-education-treatment
centres in the district. In district
B (integrated), the source of data
will be the records at district,
primary health centre, sub-centre
level.
Assessment of efficiency of integ
rated
approach : As
indicated
below, for each parameter (FCD,
PE, F15E....) the values obtained for
districts ‘B’ and ‘A’ are worked out
and the efficiency of integrated
approach is assessed by the ratio
20
Value of parameter for ‘B’
Value of same parameter for ‘A’
which should be considerably greater than 1.0 to indicate a higher
efficiency of integrated approach. Thus the indicator index for each
parameter will be :
1. Surveillance : % FCD (B)
2. Survey
% FCD (A)
: # PE(B)
# PE males (B)
# PE females (B)
* PE(A)
* PE males (A)
# PE females (A)
: # NCD (B)
# NCD males (B)
# NCD females (B)
* NCD (A)
# NCD males (A)
* NCD females (A'
3. Survey of
: # F15E(B)
adult females * F15E(A)
4. New case
5. Treatment
: % RT (B) This may be separately calculated for old and
regularity
% RT (A) new (registered during study period) cases.
Finer details (like data on MB, PB cases) can be incorporated as
desired.
The preference of patients and
different categories of general
public (rural, urban; males,
females) is assessed by comparing
the proportion of subjects favour
ing
vertical
and
integrated
approaches initially and at the end
of the study period in each
district
Similarly the effect of integration
on the knowledge status of general
health workers is assessed by com
paring the initial and final scores of
these workers in each district
Time schedule: The time scale of
the various processes involved in
this study is as follows :
1.
2.
3.
4.
Appraisal of state 16 month
and
district
authority
Preparation
of 1 month
plan of study,
training curiculum
and preliminary
study
Training of staff
2 months
Handing over of 2 months
record and intro
duction of integ
rated approach to
patients in the
districts
$.
6.
Study period
36 months
4 months
7.
2 months
8.
2 months
9.
1 month
Additional financial and other
inputs: Any additional staff and
monetary input will be restricted to
only those items facilitating the
study. Financial support would
be required for the following
items :
Data collection
Data processing
Analysis
Report writing
(i) TA/DA for field visits of the
main investigator who will b
the key person for planning,
monitoring and evaluation of
the study.
(ii) Support for three statistical
assistants; one each will be
required for the two districts
and one to help the main
investigator.
(iii) Part-time secretarial support
to the main investigator.
(iv) TA/DA for statistical assis
tants for visits to leprosy
units/general health care
centres.
(v) Support for initial and final
appraisals by a team of four
experts to evaluate the pre
valence of the disease.
Swashi Hind
services with the general health
care system affects the coverage
and provision of leprosy services
after the prevalence has been
reduced to a very low level conse
quent to multidrug therapy for 5 or
more years. If such a study is also
carried out in other districts with
different levels of low prevalence of
leprosy it might also help in decid
ing the optimum timing and pre
valence level for successful integ
ration of leprosy services with
general health care services.
(vi) Financial support for short
training of general health care
staff in district ‘B’.
(vii) Provision of transport/fuel,
etc., for field visits. If it is
not possible to use a local
vehicle, a jeep may need to
be provided.
Concluding Remarks
Such a study as described above
may be expected to inform us how
this model of integration of leprosy
REFERENCES
DGHS 1989. National Leprosy Era
dication Programme. Guidelines for
Multidrug TYeatment in endemic
districts.
WHO-SEARO 1988. Situation analy
1
sis at Epidemiology & Control of
Leprosy in WHO South East
Region 1987.
DGHS 1991. Ministry of Health
3.
Guidelines for integration of leprosy
services with General Health Care in
the districts where the prevalence of
leprosy has been reduced to 13 or
less/1000 population due to effective
MDT intervention for five years or
more (No. A 11010/2/88-Lcp (coord)
dated 11-3-91).
Courtesy: Indian Journal of Leprosy
A
Vol. 64(3) 1992.
1.
CLOSING IN ON ASTHMA
Results of a new trial have provided further evidence
that asthma is the result of cells in the immune system
mistakingly becoming overactive. It has also given a
pointer to the type of drugs that could block these
cells.
Doctors at the UK National Heart and Lung
Institute, and London Chest Hospital, have found that
cyclosporin A, a drug used to suppress organ rejection
after transplant surgery, produced a marked improve
ment in chronic asthma sufferers. At the moment,
most asthmatics need high doses of steroids to control
their attacks, but these can produce serious side
effects.
Il has been suspected for sometime that “T
helper” cells of the immune system play a central role
(Con id. from page 28)
National
Leprosy
72. The
eradication Programme in
India. Mittal BN. World
Health Stat Q 1991; 44(1):
23-9.
73. National strategy for elimi
nation of leprosy in India.
Mittal BN. Indian J Lepr
1992 Oct—Dec;
64(4):
513—20.
74. Needs
and
prospects
for
epidemiological tools in lep
rosy Control. Feenstra P.
Lepr Rev 1992 Sep; 63
(Suppl I): 3s—10s.
January 1993
in asthma because their activation leads to the con
striction of the airways. Cyclosporin, which is
thought to work by preventing the process that
activates T helper cells, was used in a double-blind
trial and among the 26 people who completed it there
was a clear benefit from cyclosporin. The drug is
reported to have both improved the patients’ breathing
and reduced the number of episodes of severe asthma
y requiring extra steroid treatment.
Although, Dr Barry Kay, one of the leaders of the
research team, believes the answer to chronic asthma
is to block the T helper cells, he believes new drugs
with less potential side-effects may be needed instead
of cyclosporin.
—Medical News from Britain
75. The relevance of future lep
rosy vaccines to disease con
trol. Gupte MD. Lepr Rev
1992 Sep; 63 (Suppl I):
99s—105s.
76. Some indices pertaining to
the leprosy control pro
gramme in Tamil Nadu,
based on data from a ran
dom sample of fourteen
Government control units.
Nair NG, Radhakrishna S,
Ramakrishnan R, Sreenivas
V. Indian J Lepr 1991 Jul;
93 : 208—16.
77. Time lag between case regis
tration and commencement
of treatment in leprosy con
trol unit. Krishna Murthy
P, et al. Indian J Lepr 1992
Jan—Mar; 64(1): 8—13.
78. Towards the use of decision
sciences in leprosy con
trol. Habbema
JDF,
JozeFnoon E, VanoortmarssenGJ. Lepr Rev 1992 Sep;
63 (Suppl D: 485—523.
79. Training of health posts per
sonnel in urban leprosy
programme—a preliminary
report Revankar CR, et
al. Indian J Lepr 1991 Jan—
Mar; 63(1) : 97—100.
A
21
BRIEF REPORT
Beneficiary Study of Leprosy Services
among Tribal and Non-Tribal Population
in the selected Endemic Districts of
Madhya Pradesh and Andhra Pradesh
Dr N.S. Dharmsiiaktu, Dr B. Kameshwara Rao, Dr M.A. Arif, Dr S.L. Gupta, Dr V.K. Mashi,
Dr G.P. Mishra, Dr G.R.K. Raju and Dr Srinivasa Rao
qnllE Government of India
1 launched National Leprosy
I: radical ion Programme in the year
1983 with the objective to arrest the
disease activities in all the known
cases of leprosy by the year
2000. Under the
programme
MDT is being provided to the
patients in a phased manner taking
district as a unit. All 201 endemic
districts have been sanctioned
MDT project which include 135
districts on vertical pattern for
implementation and 66 districts for
modified pattern of implemen
tation. In the rural and tribal
areas of the districts there are often
many obstacles which may prevent
masses to make best use of services
available such as inadequate
motorable roads, inadequate com
munication, inadequate public
transport, scattered villages, inade
quate infrastructure, inadequacy of
staff and non-availability of ser
vices nearest to the houses of the
patients, illiteracy, pressure for
earning of daily livelihood, ignor
ance about the cause and curability
of the disease, stigma, etc.
In order to overcome the obsta
cles in the endemic rural and tribal
areas in providing MDT services
lollowing provisions have been
made under MDT scheme on verti
cal pattern:
(a) The funds for the project arc
directly released to the Dis-
22
trict MDT Society which
functions under the Chair
manship of District Col
lector.
(b) The services are provided to
all the segments of the popu
lation in the district by pro
per organisation of available
infrastructure. In all end
emic districts a District Lep
rosy Unit is established
under
District
Leprosy
Officer. Under the vertical
pattern of MDTimplementa
tion rural areas are covered
by the Leprosy Control Units
and its clinics. Each lep
rosy control unit covers a
population of 4 to 5 lakh with
its headquarters and 20
clinics in the field where one
para-medical worker is pos
ted for each clinic. While
the worker population ratio
is one for 25000 in rural areas
in general, the same is
reduced to 1 for 15000 in
tribal and difficult hilly
areas. Each of the urban
leprosy control unit provides
services for 30000 to 40000
population.
(c) In the vertical pattern of
MDT scheme the District
Leprosy Unit and Leprosy
Control Units are provided a
vehicle and fund for POL.
MDT allowance is given to
the Medical Officers and
Para-Medical
Workers
Funds are also provided for
short orientation trair
of
all categories of stan, for
making community aware
ness and for developing
records and patient cards.
From the leprosy control unit
and its clinics the services are
carried down to the patients
by dividing the area into cir
cuits and under each circuit
many drug delivery points
are identified in such a way
that no leprosy patient will
have to travel more than 2
KMs for collection of MDT
on fixed days.
(d) Each DLO Unit and leprosy
control unit mostly have a
. post of Health Educator.
The assistance of D’’ det
Media Unit, Block Exte. jn
Educator and other health
workers are also taken in
health education campaign
for creating community
awareness. A provision of
Rs. 24,000 per year per dis
trict is provided for com
munity awareness activities.
The present study was con
ducted in tribal and non-tribal
areas of Durg, Raipur and
Rajnandgaon districts of Madhya
Pradesh and in tribal areas of
Vishakhapatnam and Vizianagram
districts of Andhra Pradesh with
following objectives:
SWASTH HIND
(i) Conduct
demographic
analysis showing geo
graphical distribution of
tribal people in the dis
tricts studied.
(ii) Conduct analysis of ser
vice statistics in tribal and
non-tribal
people
to
determine the use of ser
vices and occurrence of
new cases for each
group.
(iii) To carry out follow up
interviews with male,
female patients to identify
their knowledge and
beliefs regarding leprosy
augmented by group dis
cussions With men and
women regarding the dis
ease and control pro
gramme in the selected
villages
of
selected
districts.
Methodology: District level in
formation was gathered by check
ing records available with the
District Leprosy Office on a pre
designed proformae. The villages
were selected randomly from tribal
and non-tribal blocks respec
tively. In the selected villages
group discussions were held based
on pre-dcsigned format with adult
males and adult females respec
tively. Wherever school was avail
able in the village the students of
9th and 10th standard were covered
under group discussion. The res
ponse against cause of the disease,
its curability, availability of treat
ment, programme activities and
choice of treatment were graded in
terms of % as correct, wrong and
uncertain categories. Patientsand
community members were inter
viewed by questionnaire method
and their response was graded
under correct, wrong and uncertain
categories. The village data veri
fication was also done in the selec
ted tribal and non-tribal villages
January 1993
separately and information was
gathered on a pre-designed pro
formae.
Summary of the Results: The per
centage of tribal population to the
total population of the district is
18.5% in Raipur, 12.6% in Durg,
25.3% in Rajnandgaon, 13.7% in
Vishakhapatnam and 8.5% in
Vizianagram. The % of rural pop
ulation is higher among tribals as
compared to non-tribal population
in all these districts.
tribal and non-tribal communities
with slightly higher side among
tribals. The majority of tribal and
non-tribal community members
stated that allopathy is the best
treatment available for leprosy (75
to 100%) and small percentage of
tribal community members in
Raipur district still feel Ayurveda
and Homoeopathy as better re
medy for leprosy.
Recommendations
1. Additional funds should be
The prevalence rate of leprosy
provided
to the District MDT
and annual new case detection rate
Society
for
carrying out intensive
are less among tribal community
community
awareness campaigns
compared to non-tribal community
about
leprosy
along with new case
in all the five districts under MDT
detection
drives.
A calendar of
project for a period of three to nine
the
cultural/religious
events celeb
years. The awareness of both
rated
by
the
local
people
be pre
tribal and non-tribal community is
pared
for
each
community
block
good in general about curability of
separately
particularly
for
the
tribal
the disease, availability of treat
areas
so
that
special
group
aware
ment at the nearest place, visit of
ness
and
case
detection
drive
can
leprosy workeis to villages and
be launched on those days with
their activities and people’s choice
vigour. Health education mess
of treatment. 90% of both tribal
ages about cause of leprosy, its
and non-tribal patients are satis
communicability and removal of
fied by improvement in their dis
stigma should be used with caution
ease condition as a result of MDT
in tribal areas which may otherwise
and 80 to 100% patients are taking
have negative effect
MDT regularly. 96 to 98% of
patients are found living with their
2. New case detection in the
families. While the level of lep
tribal areas should be done by
rosy awareness in general is less
group campaigns preferably on
among tribals in comparison to
Sundays by house visits. This will
non-tribals in the district of Raipur,
provide better coverage of the pop
the same did not differ much in
ulation for case detection and at the
Durg and Rajnandgaon districts
same time community awareness
among tribals and non-tribals.
would increase.
This may be due to intensive health
education campaign conducted in
3. Available local GovemDurg and Rajnandgaon
by
ment/Non-Government
staff and
DANIDA assistance in both tribal
and non-tribal areas. Community
the volunteers must be involved
members and patients had ade
for creating public awareness,
quate knowledge and awareness
referral of cases and retrieval of
about cause of the disease in both
defaulter patients. Identification
tribal and non-tribal areas. The
and
involvement
of
such
feeling that leprosy deformity is not
categories of persons should be
preventable and that the child bom
done by DLO and his staff as
to woman with leprosy will also
(Conid. on page 12)
have leprosy still exists both among
23
THE STATE OF THE
WORLD’S CHILDREN 1992
f I 'HE United Nations Children’s
JL Fund has made an impas
sioned plea for a renewed inter
national commitment to the task of
ending mass malnutrition, disease,
and illiteracy in the poor world.
Governments of developing counIries are indicated for spending, on
average, only about lz% of their
budgets on basic health and educa
tion services for the poor: rich
countries are criticized for allocat
ing only about 10% of international
aid to health, education, and family
planning.
Al a time when a new world
order is struggling to be born, says
the 1992 State of the World’s
Children report, the voice of the
poorest quarter of humanity must
be heard. One billion people still
lack adequate food, safe water,
primary health care, and basic
education. “For almost half a cen
tury, war and ideological division
have distracted attention and diver
ted resources from this task”, says
UNICEF. “Those threats are now
receding. And the time has come
for the world to recommit itself to
meeting basic human needs and
building a new world order which
will rellect mankind’s brightest
hopes rather than its darkest fear.”
Ending the worst of world
poverty is far from being a lost
repc
cause, says the report.
“We have
already travelled three quarters of
woi
the way towards a worla
in which
every man, woman, and child has
adequate food, safe water, basic
health care, and at least a primary
education. There is no financial
or technological barrier to prevent
the completion of that journey in
our times.”
Children
The ones who are being most
shamefully failed by the present
world order, says UNICEF’s Exe
cutive Director James Grant, are
the quarter of a million children
who are dying every week and the
millions more who survive into
half-life of malnutrition and
almost permanent ill health.
"This is not a threatened tragedy
or an impending crisis”, says
Grant. “Ilnappened today. And
it will happen again tomorrow. It
is a problem which should rank in
importance with any on the human
agenda. But in practice, it has
24
been given a low priority because it
is primarily a problem of the poor
and the powerless.”
There are some signs that this
may be changing. “The needs of
children are beginning to feature
on the political agenda in a way
that is unprecedented in UNICEF's
forty year history”, says Grant.
The most obvious sign of that
new priority was the convening of
the World Summit for Children in
September 1990. It was the largest
gathering of Presidents and Prime
Ministers in history, and it met
specifically to discuss the problems
of the world’s children. The out
come was an agreed programme
for, among other things, preventing
4 million child deaths a year, end
ing mass malnutrition, eradicating
polio, and ensuring clean water,
family planning services, and basic
education for all.
“The emergence of such an
agreement, at a time when the exist
ing world order is rapidly chang
ing”, says Grant “means that there
is today a better chance than ever
before of finding a place on the
world’s political agenda for the
rights of children and for meeting
the minimum needs of all fami
lies.”
Immunization
The setting of such ambitious
targets was prompted by the grow
ing realization that the world now
has both the low-cost means and
the outreach capacity to achieve
dramatic gains in children’s well
being. The most convincing de
monstration of that potential has
been the successful attempt to
reach 80% immunization coverage
by the end of 1990. When that
target was set in the late 1970s, vac
cines were reaching barely 10% of
the deyeloping world’s children.
Today, immunization is saving the
lives of over 3 million children a
year and protecting many millions
more against infection and mal
nutrition.
“Such programmes also help to
slow population growth”, says
UNICEF, “because parental con
fidence in the health and survival
of children is vital to family plan
ning efforts.”
Skewed spending
It is still too early to tell whether
the new commitments made at the
World Summit for Children are
real or rhetorical. The 159 nations
represented agreed to draw up,
within one year, national plans for
achieving the new goals by the year
2000. So far, over 60 nations nave
completed such plans and that
numoer is expected to rise to over
100 by early 1992. Some, like
Mexico, have already begun to
move; President Carlos Salinas de
Gortari has instituted a sixmonthly cabinet meeting to review
progrciM toward* the goals and
approved a 40% increase in the
budget of PRONASOL, the govern
ment programme which aims to
provide basic services to the
poorest fifth of Mexico’s people
and which has received $1.7 billion
in 1991 — over 8% of the govern
ment’s total social expenditure.
As agreed at the Summit, some
industrialized nations have also
been reviewing aid programmes to
see how they can promote progress
towards the new goals. The
public in the industrialized world
has long believed that the great
majority of the aid it gives to the
developing world is spent on direc
tly meeting the basic needs of the
poor”, says Grant, “whereas in fact
only a tiny percentage is used for
that purpose”. Only about 1% of
aid goes to the primary health care
systems which could prevent or
treat 80% of the disease and mal
nutrition in the developing world:
Only about 1% goes to family plan
ning services. And less than 1%
goes to primary education.
The same distortion can be seen
in spending patterns within the
developing world itself. UNICEF
estimates, for example, that three
quarters of all health budgets go to
urban hospitals, usually serving
only a small minority of the popu
lation. According to some esti
mates, 80% of the $12 billion
allocated each year to water-supply
systems is spent on putting pnvate
taps in the homes of the not-sopoor and only 20% is going to the
wells and stand-pipes which, with
today’s technology, could bring
clean water to the very poorest
communities at low cost. Spend
ing on education is similarly
skewed in favour of the few rather
than the many.
A
—UN Newsletter
Swasth Hind
/
■
■i
Role of Health Education in Leprosy
Control Programme
Dr Manjit Singh
•
♦
aims at
a healthy
community and a healthy nation.
Health Education is more impor
tant in Leprosy Control Pro
gramme because of. long incuoation period of the disease; social
stigma it carries: misconceptions,
wrong beliefs and long duration for
which a patient has.to take treat
ment, thereby leading to more
dropout rate.
Mycobacterium
Leprae is the causative organism.
75 Reconstructive Units
39 Sample
Survey
and
Assessment Units
Leprosy
Rehabilitation
and Promotion Units
Early detection of the case and
proper treatment prevents disabifity. Depigmented .patch on
skin with loss of sensation should
cause suspicion and the patient
should get him/herself investigated
further Tor leprosy.
A. In positive/confirmed cases,
It takes 3—5 years to manifest
as disease (incubation period).
Gandhiji had given most of his
time in the service of leprosy
patients to show that it does no
harm to those coming in contact
with the patients, thus encouraging
people to come forward in their ser
vice. People are ignorant and do
not have the scientific know
ledge about the cause of the dis
ease. They believe that they get
this disease becuase of their old
sins. There still exists a miscon
ception that those who come in
contact with them or their near and
dear ones only shall contract the
disease.
The Government of . India is
committed towards eradication of
the disease. It is providing ser
vices through following infrastruc
ture in the country:
* 758 Leprosy Control Units
• 900 Leprosy Centres
*6097 Survey and Treatment
Centres
* 291 Hospital Wards
♦ 285 Distt Leprosy Units
(i) W’h'<® .srh M.D.T.
NW T
t tEALTH Education
LjL healthy individuals
should be continued for the
period advised by the doctor.
He/she should not blow nose
or spit (secretions) to. avoid
formation of neclei which act
as a source of infection.
(ii) Patient should be made self
responsible for continuing
treatment through motivation
and health education.
(iii) Patient
should, continue
working along with continu
ing treatment. His co-workers and employers . need
intensive health, education to
cast away their apprehen
sions.
(iv) Patient should live and lead
normal life with treatment
(Drugs).
(v) There is no sensory loss if
drugs are continued for
specified period.
(vi) With proper care and treat
ment there is no need for
rehabilitation if treatment is
begun early.
B.
C.
Contacts of the case should be
kept under surveillance to
avoid any chance of having a
new case.
Relatives/friends/family mem
bers should be involved .in
Health Education Campaign
so that they do not carry
misconceptions/wrong beliefs
regarding the disease.
Leprosy organism produces
sensory loss, as a result of which
deformity, trauma, bums, etc. can
occur. Health education aims at
prevention of deformities by mak
ing patients aware of the conse
quences of sensory loss due to
disease and the precautions a
patient should observe so as to
avoid bums and injuries etc.
D.
Rehabilitation
If any one’s body part is lost
due to bum/injuty, constructive
surgery can help him to lead near
normal life.
Drop-foot, claw-toes, planter
ulcers, depressed nose, and multi
ple sinuses shall not be seen in lep
rosy patients if (1) detected early,
(2) proper and adequate treatment
is taken by patient
Health education about poss
ible risks due to disease should be
made known to the community at
large and patients in par
ticular. Let there be no lepers.
Help fight leprosy.
A
WORLD BREASTFEEDING WEEK-1-7 AUGUST
In an effort to re-establish and sustain global breast-feeding culture,
the World Alliance for Breastfeeding Action (WABA), with the sup
port of the World Health Organization (WHO) and the United
Nations Children’s Fund (UNICEF), had proclaimed 1-7 August
World Breastfeeding Week. This date marked the anniversary of
the Innocenti Declaration of July 1990, a landmark statement which
identified a set of goals for adoption in all countries to protect, pro
mote and support breastfeeding.
World Breastfeeding Week was intended to focus attention on a
variety of breastfeeding issues. The theme for 1992 complemented
the Baby-Friendly Hospital Initiative recently launched by
UNICEF and WHO to support and encourage breastfeeding.
Recognizing that breast milk provides the best possible start in life
for all children, WHO and UNICEF paid tribute to the many
January 1993
dedicated members of nongovernmental organizations that are pro
moting sound infant and young child feeding practices.
For many babies, breastfeeding can be a matter of life or
death. In the words of UNICEF Executive Director James P.
Grant, “ every day, 3000 to 4000 babies die from diarrhoeal dehydra
tion and acute respiratory infections because they are not
breastfed. Thousands more succumb to other illness and malnut
rition. And yet, the more science discovers about breastfeeding, the
more the benefits are confirmed.
“Only a global effort, involving both North and South, can remove
barriers to breastfeeding and permit mothers to offer the healthy
start in life their babies deserve”.
A
—UN Newsletter
25
i
■i
i
LEPROSY
—A Select Bibliography—1990-1992
K. C. Singh and H. Kaur
We publish below a select bibliography on Leprosy compiled by the National Medical Lib
rary (DGHS) as part of its activities aimed at providing Documentation Services to the
Health Science Community in the country. It covers selected contributions on Leprosy
during 1990-1992. Entries follow a classified arrangement using subject head
ings. Photocopies of these articles can be ordered from the National Medical Library
(DGHS), Ansari Nagar, Ring Road, New Delhi-110029.
DIAGNOSIS
1
A clinical and radiological
study of maxillary antrum in
lepromatous
leprosy.
Hauhnar CZ, et. al. Indian
J Lepr 1992 Oct-Dec;
64(4): 487-94.
2. Early detection of leprosy in
children. Dayal R. J Trop
Pcdiatr 1991 Dec; 37(6):
310-12.
3. Leprotic keratopathy in
India. Lamba PA, Rohtagi
J. Indian J Lepr 1990 AprJun; 62(2): 180—5.
4. Neurological examination
of patients suffering from
leprosy : Is it worthwhile ?
Jennekens FGI, JennekensSchinkel A. Lepr Rev 1992
Sep; 63(3): 269-76.
5. Recent advances in the
development of techniques
for diagnosis and epi
demiology
of leprosy.
Katoch VM. Indian J Lepr
1991
Jul-Dec; 63(3-4):
362—70.
6. Skin smear examination in
Paucibacillary
leprosy
patients. Bhatia VN. In
dian J Lepr 1991 Apr-Jun;
63(2): 209—12.
26
13. Leprosy in French Poly
nesia. The possible impact
of multidrug therapy on
epidemiological trends, Car
tel JL, et al. Lepr Rev 1992
Sep; 63(3): 223—30.
EPIDEMIOLOGY
7. Childhood
leprosy
in
northern India. Kaur I, et.
al.
Pediatr-Dermatol
1991 Mar; 8(1): 21-4.
8. Epidemiological
signifi
cance of indeterminant lep
rosy—A hospital based
study. Raveendranathan D,
Nair BK, Sarojini PA. In
dian J Lepr 1991 Jan-Mar;
63(1): 5—11.
^<14. Ixprosy in India : A statisti
cal compendium. Wardha
(Maharashtra), Centre for
Social Science Research on
Leprosy. 1989. 153P.
9. The epidemiology of dis
ability in leprosy including
risk
&
factors. Smith . z
WCS. Lepr Rev 1992 Sep;
63 (Suppl I) : 235—305.
10. Epidemiometric modelling
in leprosy based on Indian
data. Lechat MF. Lepr. Zz
Rev 1992; 63 (Suppl I):
315—393.
11. Estimated number of lep
rosy cases in the World.
Noordeen SK, Bravo LL,
Sundaresan TK. Indian J
Lepr 1992 Oct-Dec; 64(4) :
521—7.
12. Leprosy in French Polynesia
epidemiological trends bet
ween 1946 and 1987. Cartel
JL, et al. Lepr Rev 1992 Sep;
63(3): 211—22.
15. Screening of registered lep
rosy cases and its effects on
prevalence rate. Rao PS, x
Sirumban P.
Indian J
Lepr 1990 Apr-Jun; 62(2) :
180—5.
16. Seroepidemiological study
of leprosy in a highly
endemic population
of
South India based on
ELISA
using
synthetic
PGL-1. Krishnamurthy P,
et al. Int J Lepr other
Mycobact Dis 1991 Sep;
59(3) : 426—31.
ETIOLOGY
17. Analysis of HLA-DRe
associated polymorphisms
by oligonucleotide. Mehra
NK, et al. Hum Immunol
1991 Dec; 32(4) : 246—53.
SWASTE HIND
18. Characterization of circulat
ing lymphycytes by mon
oclonal antibodies in child
hood and adult leprosy.
Sehgal VN, Chaudhry A,
Sharma VK, Gupta CK.
Int J Dermatol 1991 Nov;
30(11): 780-4.
microbial
19. Conjunctival
flora in leprosy. Garg SP,
Kalva VK, Verma L. Indian
J Ophthalmol 1991 Apr-Jun;
39(2): 59-61.
20. Cytogenetic studies in lep
rosy patients before and
after
chemotherapy.
D Souza D, Das BC,
Thomas IM. Hum Genet
1991 Oct; 87(6) : 665—70.
21. Detection of M. leprae
specific antigens with dbtELISA in urine and nasal
samples
from
leprosy
patients. Singh
NB,
Choudhary A, Bhatnagar S.
Int J Lepr other Mycobact
Dis 1991 Sep; 59(3): 398404.
22. Histoid lesion in nerve of a
lepromatous
patient.
Gird ha r A, et al. Lepr Rev
1990 Sep; 61(3): 237-41.
23. Nasal myiasis in lep
i rosy. Husain S, et al. Lepr
Rev 1991 Dec; 62(4): 389—
94.
24. Ocular complication of lep
rosy. Chaya S. Br J Hosp
Med
1992 9-22 Jan;
47(1): 69.
25. Patterns of erythropoiesis
and anaemia
in lep
rosy. Sen R, et al. Lepr
Rev 1991 Jun; 62(2): 158—
70.
26. Prevalence of colour blind
ness among patients with
leprosy. Shwe T. Indian J
Lepr
1992
Oct-Dec;
64(4): 483—6.
27. Renal involvement in lep
rosy. Chopra N K, et al. J
Assoc Physicians India 1991
Feb; 39(2): 165-7.
28. The significance of facial
patches and type 1 reaction
for the development of facial
nerve damage in leprosy. A
retrospective study among
1226 paucibacillary leprosy
patients.
Hogeweg
M,
January 1993
Kiran KU, Suneetha Ku.
Lepr Rev 1991 Jun; 62(2):
150—4.
29. Transmission
of viable
Mycobacterium leprae by
Aedes aegypti from lep
romatous leprosy patients to
the skin of mice through
interrupted feeding. Banerjer R, et al. Lepr Rev 1991
Mar; 62(1): 21-6.
IMMUNOLOGY
30. Antigens of Mycobacterium
leprae in the cerebrospinal
fluid of leprosy patients:
detection by monoclonal
antibody based Sandwitch
immunoradiometric assay
and avidin/biotin immuno
blotting. Patil SA, et al.
Clin Exp Immunol 1991
Jun; 84(3): 515-21.
31. Association of HLA anti
gens with differential res
ponsiveness to Mycobac
terium W vaccine in multibacillary leprosy patients.
Rani R, et al. J Clin
Immunol 1992 Jan; 12(1):
50-5.
32. Association of mycobacterial-specific and Mycobac
terium
leprae
specific
antibody levels with clinical
activity in tuberculoid lep
rosy : a comparative study of
three serological enzyme
immunoassays. Chaturvedi
V, et al. Lepr Rev 1991 Jun;
62(2): 122-33.
33/ Cellular immune responses
to mycobacterial Heat shock
proteins in Nepali leprosy
patients
and
con
trols. Roche PW, Theuvent
WJ, Britton WJ. Int J Lepr
1992 Mar; 60(1): 36—43.
34. Detection of Mycobac
terium leprae cell wall
antigen in the urine of
untreated
and
treated
patients. Sharma VK, et
al. Lepr Rev 1992 Mar;
63(1): 28—35.
35. Enzyme immunoassay of
phagocytosis
stimulating
tetrapeptide ‘tuftsin’ in nor
mal and leprosy sera. Kaur
J, et al. Int J Lepr other
Mycobact Dis 1991 Dec;
59(4): 576-81.
36. Evaluation of four semi
synthetic
Mycobacterium
Leprae antigens with sera
from healthy populations in
endemic and nonendemic
areas. Douglas JT, et. al.
Lep Rev 1992 Sep; 63(3):
199-210.
37. A histopathological and
immunological profile of a
single lesion lepromatous
leprosy (LLS). Misra RS, et
al. Int J Lepr other Myco
bact Dis 1991 Dec; 59(4):
645—8.
38. Immunity in leprosy : II cell
mediated immunity. Sengupta V. CJIL Q Bull 1992
Jun; 11(2): 1-5.
39. Major proteins on Mycobac
terial strain ICRC and
Mycobacterium
leprae,
identified by antibodies in
sera from leprosy patients
and
other
con
tacts. Chiplunkar SV, et
al. J Clin Microbial 1992
Feb; 30(2): 336—41.
40. A rapid latex agglutination
test for detection of anti
bodies in tuberculosis and
Hansen’s disease. Ganju
L, et al. J Immunoassay
1991; 12(4): 579-95.
41. T-cell responses of leprosy
patients and healthy con
tacts toward separated pro
tein antigens of mycobac
terium leprae. Guile H, et
al. Int J Lepr 1992 Mar;
60(1) : 44-53.
MANAGEMENT & THERAPY
42. Comparison of two multi
drug. regimens in multibacillary leprosy. Jadhav
VH, Patki AH, Mehta JM.
Indian J Lepr 1992 Oct-Dec;
64(4) : 501—4.
43. Fixed duration MDT in
paucibacillary
leprosy.
Mathai R, George S, Jacob
M. Int J . Lepr other
Mycobact Dis 1991 Jun;
59(2) : 237—41.
44. Leprosy guidelines for medi
cal students. Natesan S.
Madras Indian Leprosy
foundation. 1991, 35P.
27
45. Modified multiple drug
phthalmos, using a semi
therapy in the National Lep
standardized steroid regi
rosy
Eradication
Pro
men. Kiran KU, HogwegM,
gramme, India. Me Dougall
Suneetha S. Lepr Rev 1991
AC. Lep Rev 1992 Sep;
Jun; 62(2): 150—4.
63(3): 288-90.
55. Utility of gelatin particle
46. Multidrug therapy in mul
agglutination test (MLPA)
tibacillary
leprosy: Ex
for rapid serodiagnosis of
perience in an urban leprosy
leprosy in hyperendemic
centre. Ramesh V, Misra v 7
area. Reddy BSN, BadRS, Saxena U. Int. J Lepr
rinath S, Snantaraman R,
1992 Mar; 60(1) : 13—7.
Harish BN, Sheriff Mo, Rao
47. Reactions in leprosy. A
RS, Garr BR. Indian J
study of 250 patients in a
Lepr 1992 Oct-Dec; 64(4):
469-73.
multidrug therapy project
Baroda District, Gujarat,
56. Variables influencing regu
India. Chopra NK, Aggarlarity of leprosy patients in
wal JS, Pandya PG. Int J
attending treatment clinics.
Dermatol 1990 Sep; 15(5):
Kannan N, Sivaram M. In
349- 51.
dian J Lepr 1992 Oct-Dec;
48. Paucibacillary
multidrug
64(4): 505-11.
therapy in leprosy IVi years
experience. Kans S, Sharma
VK, Basak P, Kaur I. In
PREVENTION & CONTROL
dian J Lepr 1992 Apr-Jun;
64(2): 153-61.
57. ALERT-India
1981—89:
nine years experience of lep
49. Reduction in caseload after
rosy control in the Slums of
multidrug therapy in an
Bombay. Samy AA, et al.
urban Leprosy Control Pro
Lepr Rev 1991 Sep; 62(3):
gramme — A retrospective
315-28.
study in Bombay. Revankar CR, et al. Lepr Rev 1991
58. A clinical and radiological
Mar; 62(1): 44—8.
study of maxillary aui urn in
50. Relapse rate in paucibacil
lepromatous
leprosy.
lary leprosy patients after
Haunhar CZ, Kaur S,
multidrug therapy in North
Sharma VK, Mann SBS. In
Arcot
District Ekamdian J Lepr 1992 Oct-Dec;
baram V, Rao MK Indian J
64(4): 487-94.
Lepr 1991 Jan-Mar; 63(1):
59. Community-Based rehabili
34-.42.
tation for the leprosy cured,
51. Results of surgical pro
Tare
SP. UDR 1991 Jul-Dec;
cedures for the correction of
5(2): 53—6.
foot-drop and of lagophthalmus
due
to
lep
, 60. A computerized informa
rosy. Weber MW, et al.
tion system for evaluation of
Lepr Rev 1992 Sep; 63(3):
NLEP through monthly
255-62.
progress reports. Murthy v
PK, et al. Indian J Lepr
52. Southern regional I AL con
1991 Jan-Mar; 63(1): 70ference
on
multidrug z
7.
therapy, Tirupathi; 21 & 22 z
Jan 1991. Indian J Lepr
61. Conference of voluntary lep
1991 Jan-Mar; 63(1): 138—
rosy institutions of Maha*
40.
rashtra, Panvel 13th to 15th zz
December, 1991. Indian J
53. Treatment Of leprous neuri
Lepr 1991 Jan-Mar; 63(1) :
tis by neurolysis combined
136-7.
with perineural corticos
teroid injection. Dandapat
62. Control of leprosy in India
MC, et al. Lepr Rev 1991
in the background of
Mar; 62(1): 27-34.
urbanization. Ganapath R.
54. Treatment of recent facial
Indian J* Lepr 1991 Jul-Dec;
nerve damage with lago63 (3-4): 334—41.
28
63. An educational approach to
leprosy control: an evalua
tion of knowledge, attitudes
and practice in two poor
localities in Bombay, India.
Crook N, et. al. lepr Rev
1991 Dec; 62(4): 395—401.
64. Effect of BCG on the risk of
leprosy in an endemic area :
a case control study. Muli- /
yil J, Nelson KE, Diamond
EL. Int J Lepr other Mycobact Dis 1991 Jun; 59(2):
229—36.
65. The factors influencing the
operational efficiency of lep- ’
rosy case detection program
me. Kumar A, et a/. Indian
J Lepr 1991 Apr—Jun;
63(2): 180-94.
66. Indicators for use in lepr<
/
control programme. Htoon i
MT. Lepr Rev 1992 Sep; 63
(Suppl): 735—765.
67. Induction of lepromin posi
tivity by a candidate Anti
leprosy Vaccine mycobac
terium W in lepromin nega
tive Healthy Contacts of
multibacillary
leprosy
patients. Kar HK, Sharma
AK, Misra RS, Zaheer SA,
Mukheijee A, Mukherjee R,
BeebaKR, Kaur H, Nair SK,
Talwar GP. Indian J Lepr
1992 Oct-Dec; 64(4): 495—
500.
68. Leprosy control and the
implcmcntation of multiple
drug therapy. To what
extent can the operational /
strategy be simplified ' '•
primary
health
ca*.,.
McDougall AC. Lepr Rev
1992 Sep; 63(3): 193—98.
69. Leprosy control in 7 districts
of South Sulawesi, Indo
nesia 1986—91. Day R,
Lever P, Asri M. Lepr Rev
1992 Sep; 63(3) ; 247— 54.
i
70. Leprosy
control
within
urban primary
___ ,___________
Health Care.
.t
Ganapati R. Indian J Lepr
1990 Apr-Jun;
C
62(2):
’
161—8.
71. Major issues involved in the
evaluation of leprosy control
programmes through MDT.
RaoCK. Lepr Rev 1992 Sep;
63 (Suppl I): 53s—60s.
(Contd. on page 21)
Swasth Hind
BOOK REVIEW
Maternal Mortality
A global factbook
Maternal Mortality: A Global Factbook—Compiled
by C. AbouZahr and E. Royston
1991, 608 pages (English only);
ISBN 92 4 159001 7
Sw. fr. 50-/US $45.00;
In developing countries: Sw. fr. 35.
Order No. 1930024
This book sets out the facts and figures needed to
understand why so many women continue to die as a
result of pregnancy and childbirth despite the fact that
' technical means to prevent such deaths have long
m available. Drawing upon a vast data base of
some 3,000 reports and studies, the fact-book shows, in
the form of country profiles, where women are dying,
what they are dying of and what other aspects of their
lives contribute to their deaths. Noting tnat maternal
death is most often the tragic end to a life-long chain of
events and disadvantages, the book tracks down the
underlying factors, often rooted in sex discrimination
present since infancy, as well as the more immediate
factors, such as lack of access to life-saving care, that
reveal the true complexity of the forces at work. In
formation such as that contained in this factbook pro
vides the key for effective action, making the best use of
limited resources despite the often difficult
circumstances.
The main body of the factbook, which runs to some
600 pages, consists of country profiles which, for the
first time ever, bring together and analyse the results of
all available surveys and studies on maternal mor
tality, women’s reproductive health and allied subjects.
as well as indicators of the coverage of maternity care.
family planning and other back-ground factors.
Profiles are given for each of 117 developing countries
in Africa, Latin America, Asia and Oceania. Data on
developed countries are also tabulated for com
parison. In compiling the profiles the, authors have
drawn upon the unique WHO women’s health data
base which, in addition to the more readily available
government reports and articles from scientific jour
nals, contains information from a large variety of dis
parate sources, including unpublished articles, doc
toral theses and consultant briefings.
To make it easier to compare countries, each profile
follows a common format, starting with a section con
taining demographic and socioeconomic indicators
that shed light on women’s lives in each country: their
chances of going to school, eating well, and receiving
health care, the age at which they are. likely to marry,
their chances of planning their families, and the num
ber of children they are likely to bear. These data
provide a backdrop for the detailed statistics on
coverage of care and maternal mortality which follow,
and which detail the numbers of deaths, the mortality
rates and ratios, the causes and circumstances sur
rounding each case, the groups of women most at risk
of dying, and the kinds of preventive and curative
actions that might have averted death.
The interpretation of this vast amount of information
is facilitated through the inclusion of four background
chapters. The first provides an overview of the
dimensions and causes of maternal mortality and
morbidity in the world today as well as of the extent of
the coverage of care. The different ways of measuring
maternal mortality are described in the second chap
ter, which discusses and strengths and weaknesses of
each method. The third explains how the results of
surveys should be interpreted and analyses the infor
mation that can, or cannot, be obtained from hospital
studies, community surveys or registration data. The
book also features a comprehensive listing of general
resource materials for readers who wish to expand
their knowledge on this complex issue.
A
Authors of the Month
T.K. Das
Joint Secretary
Ministry of Health & F.W.
Nirman Bhawan,
New Delhi-110 011
Prof. A.R.K. Pillai
President,
Indian Leprosy Foundation,
PB. 7477, 11 Hardeni Society
Bombay-400 060.
Dr M.D. Gupte
Officer Incharge/Deputy Director
CJIL Field Unit (ICMR),
Nehru Bazaar, Avadi,
Madras-600 054
Dr S.K. Noordecn
Chief,
Leprosy Unit,
World Health Organization
(WHO)
Geneva.
S.P. Tare
Director,
Gandhi Memorial Leprosy
Foundation,
Hindinagar, Wardha-442 103.
Dr Manjit Singh
Chief Medical Officer (Training)
Central Health Education Bureau
Kotla Road
New Delhi-110 002.
Dr B.N. Mittal
Deputy Director General
(Leprosy)
and
Dr N.S. Dharmshaktu
AsstL Director General (Leprosy)
Dte. General of Health Services,
Nirman Bhawan,
New Delhi-110 011
Dr Sushma Gupta
AsstL Director General,
Division of Epidemiology &
Communicable Diseases,
Indian Council of Medical
Research,
Ansari Nagar,
New Delhi-110 029.
K.C. Singh
and
H. Kaur
National Medical Library
Dte. General of Health Services
Ansari Nagar, Ring Road,
New Delhi-110 029.
ISSUED BY THE CENTRAL HEALTH EDUCATION BUREAU (DIRECTORATE GENERAL OF HEALTH SERVICES), KOTLA MARG,
NEW DELHI-110 002 AND PRINTED BY THE MANAGER, GOVERNMENT OF INDIA PRESS, COIMBATORE-641 019.
_D\S Stv
Lepr Re-']992) 63, 193-198
The All-Africa Leprosy and Rehabilitation Training Centre
(ALERT)
I
seeks a
Vh
K»
DIRECTOR OF TRAINING
Editorial
and a
DEPUTY DIRECTOR OF TRAINING
to plan, organize and manage our programme of leprosy and
related courses at the Centre in Addis Ababa and elsewhere
across Africa
ALERT is an international training centre, recognized by the WHO as
a Collaborating Centre for leprosy training, which operates a national
referral hospital and a large field control programme in the Shoa
Province for the purposes of training, demonstration and research in
optimal levels and strategies of patient care and treatment.
We are looking for two experienced professionals with complementary
skills to work together to help achieve ALERT's international training
goals. One of the positions should be filled by a well-qualified medical
specialist who has a comprehensive experience not only in clinical
leprosy but also preferably dermatology as well. The other position
would be filled by an educational specialist, with qualifications and
experience of such educational specializations as curriculum develop
ment, distance learning and educational management.
Considerable travel is involved in the job, and fluency in French and/or
other languages relevant to Africa an advantage.
Detailed CVs and the names and contact details of three referees
should be sent, within 2 months of the appearance of this advertise
ment, to:
The Executive Director, ALERT, P.O. Box 165, Addis Ababa,
Ethiopia. Telephone: +251 1 71 11 10. Telex: 21821 ALERT ET.
Fax: +251 17111 99.
Internationally competitive salaries and benefits are available for the
right candidates for these challenging and demanding positions. Free
furnished accommodation is available on ALERT's own attractive
campus, within easy reach of Addis Ababa’s many international
amenities.
LEPROSY CONI ROL AND THE IMPLEMENTATION
OF MULTIPLE DRUG THERAPY: TO WHAT
EXTENT CAN THE OPERATIONAL STRATEGY
BE SIMPLIFIED FOR PRIMARY HEALTH CARE?
-
£(
I on tk 6 pUfbl'Ca"On °r'he commendations of the World Health Organisation (WHO)
|
the use of regimens of multiple drug therapy (MDT) of relatively short duration for all
| cases of leprosy remarkable progress has been made, not only in the implementation of
g such regmens but also m the development of leprosy control programmes in many parts
he world. In the first few years, the implementation of MDT was slow reaching a
| coverage of only 8-8% m 1986, hut thereafter increasing rapidly to 55-7% in 1990 F ' m
total of 5-4 million registered cases in >985. the figure dropped <^ 7 in 1990 (a^educTon
I of about 31%). attributable mainly to the implementation of MDT and the release from
ndTn 3ndrcn,uallyrromsurvcil,ance)orvcry|i,r?enun’be"o'’palients Disability
I and chdd rates have come down, relapse rates are remarkably low, and the incidence of
& toxic (drug) reactions or nnmunological reactions based on either cell-mediated or
I ionmh mechan,sms: has bcen no Prea,cr (and possibly less) than with dapsone
| monotherapy-Given time, it is expected that some early reports of reduction in in • i
I rates following MDT will be confirmed. By 1987. speaking at a meeting in New Ddhi"on
Lenro^D0"
,hrO“gh Primary Hcalth Care <PHC), Dr SK Noordeen Chief
Chana
V’T" °rCo"lro1 of TroP'cal Diseases. WHO. drew attention to the major
___ by MDT. U1C
changes in
m technology brought C
about
the improved outlook, virtually
worldwide, towards the disease, and the immensropporUinhics
.. .
••
----; to reduce leprosy in the
next decade? In 1988,
widely circulated
--------a widely
circulated WHO
WHO nnhliruti™
publication ibore the title Multulru*
■ ■ therapy for leprosy, an end in siylud and this was f.
followed by a second in 1991, entitled
Towards elimination of leprosy,4 drawing attention
€------- --<iiiu u, uju possioiiiiy ot reducing i
less than I case per 10.000 of the population by the ye;
.. ..
- iar20()(). New estimates by WHO for
the number of cases >worldwtde
............
have recently been published, revising the previously
. quoted figure of 10 122 million cases to 5-5 million.5
’
'
>
:.[
;
■
The overall pace and extent of MDT implementation worldwide
Despite these encouraging results, concern has been expressed in recent years about the
| 0305-7518/92. 063193+ 06 SO 1 .00
T. Lepra
193
Leprosy control and the implementation of MDT
194
A C McDougall
195
‘ overall pace and extent of MDT coverage worldwide. A recent WHO report6 draws
whilst at the same time describing the basic, rather than optimal, requirements for
attention to considerable regional variations with regard to prevalence and MDT
0? using PHCJJHP T' ValUUhlC S'T i" thC dirCCti°n of si"’P,i^:ition. The principle
implementation between 1986 and 1990; the South-East Asia Region (SEARO) and the
Of using I II ,DHI
leprosy control seems to have been accepted by most agencies
Western Pacific Region (WPRO) have achieved satisfactory levels, but elsewhere this is
working m leprosy as the only operational technology likely to have a progressive
not the case. Progress in the development of control programmes and the implementation
These
T
"i;pacl-,bl,t
pri,ctlcc- i,s application continues to present problems
of MDT has been distinctly weak in Brasil, Nigeria, Myanmar and Indonesia. In Africa
These are basically similar to those which have been described for tuberculosis'3(AFRO Region), the overall rale at the end of 1990 was only 18 4% (compared for
planning, training, provision of supplies and supervision.
example with 66-2% for South-East Asia), with some notably low figures in Burkina
un^ee|v°tSSibili,y that ,htParCe and eX,enl °r M DT imPlementation are unsatisfactory and
Faso Cape Verde, Chad. Congo, Cote d’Ivoire, Guinea, Madagascar, Mali. Mozambi
unhkely to improve m the foreseeable future, unless new strategies are introduced has
que. Niger. Reunion, Rwanda. Sao Tome. Senegal, Swaziland, Togo and Uganda.
recently been reviewed m depth by Yuasa in the International Journal of Leprosy 14 He
Figures for the Americas arc also unsatisfactory. The reasons which lie behind this
outlines the mam problems which have so far been encountered and makes a plea for the
situation vary greatly from one
countryJ ..
to another,. or even in different regions
of thes^e
involvement o\ al! members of the health services, in all leprosy-endemic countries to
. ..................
(1)
lack
of
political
commitment
and
motivation,
(2)
constant,
$ | .b .h^MDT
Pat'entS
nCCd- WithOUt delay- He ^Phasizes that
country, but they include—----- r
,
><
.•time,
_ money
_____ __
A personnel to health nrnhlpms
even increasing pressure to allocate
and
problems other
other . W8
m
PrOgram mUS’ bC Simp'e’ S° that any 'eprosy-endemic country with
than leprosy (for example, AIDS/HIV infection, tuberculosis, malaria, immunization | I
K L
the currcnt state °r health services, can adopt if. His approach gives great
,0 ,^USe OrJHC and DHP PerSOnnel in detec[i"£- dia^mg and treftrng
population control), (3) poorly developed infrastructure and lack of trained personnel, (4) |S emnP
absence of a proper plan of action, (5) shortage of money, (6) lack of laboratory facilities, |
leprosy cases (but without any expectation that they will routinely participate in th!
prevention and management of disability or deformity-a somewhat unconventional
notably for slit-skin smears, (7) poor referral facilities for complications and (8) | I
inadequate resources, including regular supplies of dapsone, clofazimine and rifampicin j t □ed wdl'in tShUSphT'n mOre dntail be'OW)- The S,ra'egy deSCribed seems to ha«=
m
’PPln,eS’ Where " has ,o a large extent been carried out by
for MDT.
€
. . i S I h^t
We are now well into 1992 and the goal, whether in terms of‘control , elimination, W ■ I a 8 y 71'dW1VCS'WlthfaCl ltlesforsuPervisi°n and the referral of problem cases and
‘eradication’ or ‘MDT for all’ is almost universally directed at the year 2000. Despite the . J tncludmg the prov.s.on of MDT for both pat,ci- and multi-bacillary cases in biiMer
progress described above, it is clearly disconcerting that many leprosy endemic countries, | B anTf" PaCkSK Thr aCC°Unt °f a successful programme is by no means unique In 1982
especially in Africa, have barely started to implement MDT, or have achieved only single ■ *
entire number of this Journal was devoted to the subject of leprosy and PHC 15 with
I nZ? ° CXPer'enCeS rr°m TanZania' the Suda"’ Kc"ya- ,nd°-sia. Sri Lanka and
figure percentage results in their cases on treatment.
1
I
el
Sotme|reservat,ons were expressed, particularly about the timing of integration in
I J t
Z ,rcatnlcnt ofal1 kn<’wn eases- hut in general the views recorded were
| p sttiye and encouraging. In 1986. an important report from WHO1* described a
Integration with primary health care and the district health programme
consultauon on leprosy control and PHC. with contributions from the Gambia Malawi
Various proposals have been made through the years7 8-9 to overcome these problems, for j I Vietnam, Malaysia, Ethiopia. Brasil and Thailand. Some failures and a number of
the most part based on the wider use of PHC, including the District Health Programme | b problems were reported, but m general it was agreed by participants that the approach
(DHP), the latter being defined as ‘ ... a geographical area that is small enough for its j
had great advantages over the continued use of vertical, specialized systems.
health and related social and economic problems to be properly understood and for |
appropriate action to be taken in response, but large enough to permit the deployment of J
essential technical and managerial skills for planning and management of the health J I PHC and leprosy control in India
programme.
programme, ’ Writing
wnung in
m 1978,
17/0, before
mv.v.v, the development
------ of
- MDT as we now i know it,t
Buchmann reviewed the entire subject of PHC in relation to leprosy control in grea
Despite encouraging progress in the implementation of MDT in the National I
5eu^“c;ndud7ng;h7t'it''w^^^^
I
------------------------------------------------------' 7 “°n
in mdia. the Leprosy Division recently identified an area of
for the full development of leprosy control programmes, including treatment ^’^ry- ;. L difficulty tn extending MDT services to 66 of their endemic districts. The problem had
Since the publication of the Declaration of Alma Ata on
PHC in -1978,
---------------------all Who
. ■ t, j■ h''" accenluated bV ,he 'arge numbers of patients in need and the lack of trained
intents
and
publications
on
leprosy
(and
tuberculosis
-)
have
accepted
the
pnncip
■ personnel, coupled with the impossibility of training them in the foreseeable future A
documents and publications
tegrating leprosy control into the general health services wherever possible whtls a K dectsion of potentially great interest and importance, not only for India but for control
importance of maintaining a vertical, specialized elements . I
C,.S.eW,llyC' W!1S thcreforc lakcn hy tllc Leprosy Division late in 1990 when
| GMnesfor Modified MDT Scheme in Seleced Districts were drawn up and circulated
various levels of the programme, for supervision, referral facilities, drug supply and i |
financing. The International Federation of Anti-Leprosy Associations (I LEP), representing | I a/ThisTb nare4'dnS' aCC°mpanied bV
manuals for various grades of health
over 20 independent, voluntary organizations working in the field of leprosy, has also
’ I 7 PT d0CUnlenl 15 revlewcd
g™ter detail elsewhere in this Journal it
strongly affirmed its commitment to the use of the general health services based on PHC, | I describes the admimstrative and technical steps which must be taken in order to
■
■
I
I
K
It
196
AC McDougall
Leprosy control and the implementation of MDT
'implement MDT through the general health services, using PHC and DHP (as opposed to
|
using the specialized staff of the NLEP). The 14-day period of intensive therapy at the
outset, used hitherto by the NLEP, will be discontinued; the WHO regimen will be used
instead. Health education activities are to be intensified and the bacteriological
examination of skin smears will be limited to multi-bacillary cases, or suspected multibacillary cases. This initiative should clearly be monitored with great care; it represents, at
least in concept, a significant simplification of the existing operational strategy in India
(estimated to have 3 million cases), thus affording an opportunity for the collection of
date and an assessment of feasibility, presumably within a relatively short period of time.
Inherent in the modified approach is the continued use of NLEP staff wherever possible
and it bears repetition that this is in keeping with the advice which has been given by
WHO and other agencies advocating this approach, to the effect that integration with
PHC does not imply that all specialized elements should disappear from the scene; on the
contrary, a specialized element, wherever it is available, should be retained at various
levels.
J
chemotherapy with disability prevention and management have been, in general.
unsuccessful and partly because the proposed separation could, if properly planned and
executed, very considerably simplify the work of PHC/DHP personnel.
Conclusion
;
,
j-
I
|
Further simplification
In recent years, either from WHO or ILEP, several modifications which undoubtedly
simplify the approach needed at PHC level, have been made. They include the following
(1) for the treatment of multi-bacillary patients, 24 months' treatment (rather than
extending, wherever possible, until skin smears are negative, as in the original
recommendations of 1982) is acceptable, particularly if there are resource constraints, (2)
the supervision of monthly doses of rifampicin (pauci-bacillary cases) or rifampicin and
clofazimine (multi-bacillary cases) should ideally be carried out by a health worker, but if
this is difficult or impossible, responsibility may be delegated to other members of the
community (teacher, village leader, family member, etc.), (3) provided they are reliable,
skin smears are valuable and should be made available, but they are no longer regarded as
an absolute prerequisite for initiating MDT. since in most cases it is possible to diagnose
leprosy and distinguish between multi- and pauci-bacillary cases on clinical grounds. Two
further aspects of the subject call for more serious investigation in the context of
simplifying MDT at PHC level. The>.v/ concerns the use of systems which take note of
the number of skin, or skin and nerve lesions, or of the number of‘body areas’ affected, in
order to allocate patients to either pauci- or multi-bacillary groups for treatment. A
number of publications recording experience from different parts of the worldl8 l9’20,2i
suggest that this approach may be preferable in certain circumstances to reliance on skinsmear results. Th e second relates to the use of blister-calendar packs for MDT drugs22 and
to the need for an objective assessment of their value, particularly in programmes using
the PHC DHP approach. If found useful and potentially cost-effective, efforts should be
made to set up local production thus avoiding the main impediment to their wider use at
the present time, which centres on the additional cost of packs manfactured by drug
companies. Finally, the proposal by Yuasa, in the editorial referred to above,14 that
disability management should realistically be separated from the public health activities
of staff who are engaged in case detection and chemotherapy, giving responsibility to a
separate agency, or to non-government organizations, calls for serious consideration.
This is partly because current (and past) efforts to combine case detection and
197
£
-
L
The principle of using PHC/DHP in leprosy control appears to have been widely accepted
|.
cirrrrx
t
.t
•
’
by WHO and other agencies. Some progress has been made in its application, but in many
countries where control programmes and MDT are particularly weak no systematic
attempt has so far been made to develop its potential. The success of MDT under a wide
range of circumstances, including some which, at least at the outset, had sub-optimal
personnel and other resources, suggests that PHC/DHP should be considered more
widely. Some important simplifications for this purpose have already been made; others
could be developed quite quickly. Particularly for those who have identified the year 2000
fnr pliminatir>n
!-<<-> ckz-tr*
.« •
■
.
for elimination,
timefim*»
maymot/
be short,
unless new strategics are .used.« »Is this
perhaps the
moment to look more closely at what is needed and what is possible, and to use PHC/
DHP to close the gap. thus bringing the benefits of MDT to a much wider segment of
patients?
Department of Dermatology
The Slade Hospital
Heading ton
Oxford 0X3 7JH
England
A C McDougall*
'
References
_
|
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|
J
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I
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'
I WHO. Chemotherapy of leprosyfor control programmes. Report of a WHO Study Group. Technical Report
Series 675. World Health Organization. Geneva. 1982.
2 Noordccn SK. Global review of MDT implementation. Paper presented to WHO/SEARO Intcrcountry
Seminar on Implementation and Evaluation of Multidrug Therapy for Leprosy Control Programmes
Through Primary Health Care. SEA RO. New Delhi. 7 11 December 1987.
’ WHO. Multidrug therapy for leprosy: an end in sight. World Health Organization. Geneva, 1988.
WHO. Towards elimination of leprosy. World Health Organization, Geneva. 1991.
5 WHO. WHO Bulletin, volume 70. 1992. World Health Organization. Geneva. 1992.
6 WHO. World Health Statistics Quarterly. 44, No I. 1991.
7 WHO. A Guide to Leprosy Control, second edition. World Health Organization. Geneva. 1988.
g WHO. WHO Expert Committee on Leprosy. Sixth Report. Technical Report Scries 768. World Health
Organization. Geneva. 1988.
9 Feenstra P. Tedla T. A broader scope for leprosy control. Wld Hlth Forum. 1988; 9: 53 58.
10 Buchmann H. Leprosy Control Services as an Integral Part of Primary Health Care Programs in Dei eloping
Countries. German Leprosy Relief Association. Wurzburg, Germany. 1978.
II WHO-UNICEF Alma-Ata 1978. Primary Health Care. Report of the International Conference on Primary
Health Care. Alma-Ata. USSR. 6-12 September 1978. World Health Organization. Geneva. 1978.
WHO. Tuberculosis control as an integral part of primary health care. World Health Organization. Geneva.
1988.
International Federation of Anti-Leprosy Associations (ILEP). Basic requirements for implementation of
multidrug therapy. Medical Bulletin, issue number I. revised September 1990. (234 Blythe Road London
W14 OHJ, England).
1 Yuasa Y. MDT for all; target orientated leprosy control program in the 1990s. Int J Lepr, 1991; 59: 624 638.
Iaf ♦Correspondence: 87 Lower Radley. Near Abingdon. Oxfordshire OXI4 3BA. England.
198
A C McDougall
Lepr Rev
2) 63, 199-210
15
Leprosy Review. Leprosy and Primary Health care. Lepr Rev, 1982; 53: 161 242.
Ift
WHO. Report of a consultation on implementation ofleprosy control through primary health care. Geneva, 1618 June 1986. WHO/CDS/LEP/86.3.
17 McDougall AC. Modified multiple drug therapy fMMDT’) in the National Leprosy Eradication
Programme, India. Lepr Rev. 1992; 63: 288 90.
18 Becx-Bleumink M. Allocation of patients to paucibacillary and multibacillary regimens for the treatment of
leprosy—a comparison of methods based on skin smears as opposed to clinical methods—alternative clinical
methods to classification of patients. Int J Lepr. 1991; 59: 292 303.
Nash JE. Hudson BJ, PyakalyiaT. Leprosy score chart to assist classification. Lcttersto the Editor. Lepr Rev,
|989;60: 242 243.
20
National Leprosy Eradication Programme, India. 1989. Guidelines for Multidrug Treatment in Endemic
Districts. Leprosy Division. Directorate General for Health. Ministry of Health and Family Welfare. Nirman
Bhavan, New Delhi, 110011. India.
21
van Brakel WH. de SoldenhofTR. McDougall AC. The allocation of leprosy patients into paucibacillary and
multibacillary groups for multidrug therapy, taking into account the number of body areas affected by skin,
or skin and nerve lesions. Lepr Rev. 1992; 63: 231-46.
22
Gcorgiev GD. McDougall AC. Blister-Calendar packs potential for improvement in the supply and
utilization of multiple drug therapy in leprosy control programs. Int J Lepr. 1988; 56: 603 610.
Evaluation of four semi-synthetic
Mycobacterium leprae antigens with sera
from healthy populations in endemic and
non-endemic areas
J T DOUGLAS*. L M STEVEN*',, D.
D. S.
S. HIRSCHt
HIRSCHt,
T FUJIWARAt. K E NELSONS, M G MADARANGIi*
& R V CELLONA1I
University of Hawaii. Department of
Microbiology, 2538
2538 The
The
of Microbiology,
Mall, Snyder Hall III, Honolulu. Hawaii 96822; ^Hawaii Depart
ment of Health. Communicable Disease Division, P.O. Box 3378,
Honolulu, Hawaii 96801; XNara University, Institute for Natural
Science, Horai-cho 1230. Nara 631. Japan: ^Johns Hopkins Univer
sity. School of Hygiene and Public Health, Department of Epidemi
ology, Baltimore. M D 21205; Leonard Wood Memorial Centerfor
Leprosy Research. P.O. Box 727. Cebu City, Philippines
Accepted for publication 24 March 1992
Summary In order to determine the frequency of occurrence of antibodies to
scmisynthetic antigens of Mycobac terium leprae in clinically healthy nonpatient
populations and to establish a ‘baseline’ for comparison with antibody frequen
cies in both patients with a history of leprosy and their contacts. ELISAs were
conducted using representative sera from two areas: a leprosy endemic area. Cebu
City. Philippines and a noncndcmic area for leprosy Chicago. Illinois. USA.
These sera were tested, by an indirect IgM ELISA, for the presence of antibodies
reacting with four scmisynthetic antigens based on the phenolic glycolipid I
antigen of M. leprae: ND-O-BSA (natural disaccharidc with octyl linkage to
bovine scrum albumin). NT-O-BSA (natural trisaccharidc with octyl linkage to
BSA). ND-P-BSA (natural disaccharidc with phenolic ring linkage to BSA) and
NT-P-BSA (natural trisaccharidc with phenolic ring linkage to BSA). Using an
OD reading ^0 16 as positive, the antigen with the lowest background
serorcactivity was ND-O-BSA, which reacted with 5/398 (1-3%) sera from Cebu,
and 3 426 (0-7%) sera from Chicago. A total of 10 (2-5%) of 398 sera from the
endemic area reacted with at least one antigen and 5 (1-3%) sera reacted with all
four scmisynthetic antigens. Of the 426 sera from Chicago. 12 (2-8%) were
reactive with at least one antigen and 3 (0 7%) were reactive with all four
scmisynthetic antigens. Mean ELISA values for the 22 positive sera for each
antigen ranged from 017 to 0-3 OD units, while the mean values for all sera in
1
'Deceased 30 January 1990
’Deceased 8 January 1988
C.
•
0305-7518/92/063 1 99-4-12
( Lepra
199
210
Lepr Ret' (1992) 63, 199-210
Lcpr Rev
'92) 63,2!I 222
La evaluation de cuatro antigenos Mycobacterium leprae semi-sinteticos con
sueros de populaciones sanas en zonas endemicas y no endemicas
J T Douglas, L M Steven, D S Hirsch, T Fujiwara, K E Nelson,
M G Madarang y R V Cellona
Rcsumcn Para podcr determinar la frccucncia de ocurrcncia de los anlicuerposcn los antigenos scmi-sinlcticos
gf
de Mycobacterium lepraen populacionesclinicamente sanas que no son pacicntcs, y para cstablcccr una ‘lineade
base' para comparar las frccuencias de anticuerpos cn los pacicntcs con antcccdcntcs de lepra y sus contactos, se
realizaron ELISAs usando sueros representativos de dos zonas: una de lepra endemica, Cebu City, Islas
Pilipinas, y una zona no endemica. Chicago. Illinois. EE.UU. Sc probaron cstos sueros por medio de ELISA
IgM indirccta, para la prcscncia de anticuerpos que rcaccionan con cuatro antigenos semisinteticos basadosen
■
cl antigeno fenolico glicolipido I de Mycobacterium lepriv. ND-O-BSA (disacarido natural con enlace octilico
con albumina scrica bovina). NT-O-BSA (trisacarido natural con enlace octilico con albumina serica bovina),
I
ND-P-BSA (disacarido natural con enlace fenolico con albumina serica bovina), y NT-P-BSA (trisacarido
natural con enlace fenolico con albumina scrica bovina). Usando una lectura OD ^0,16 como positiva, el
1
antigenocon la scroactividad de fondomasbajo fuc ND-O-BSA quercaccionocon 5/398 (1,3%)de lossuerosde
■
Cebu, y 3/426 (0.7%) de los sueros de Chicago. Un total de 10 (2,5%) de los 398 sueros de la zona endemica
reacciono con al menos tin antigeno y 5 (1,3%) de los sueros reaccionaron con los cuatro antigenos semiI
sinteticos. De los 426 sueros de Chicago. 12 (2.8%) eran reactivos con al menos un antigeno y 3 (0,7%)
rcaccionaban con los cuatro antigenos semi-sinteticos. Los valores medios ELISA para los 22 sueros positives
de cada antigeno variaban entre 0.17 y 0.3 unidadcs OD, y los promedios para todos los sueros en cada zona
variaban entre 0.01 y 0,04 unidades OD para todos los antigenos. La rcactividad de 14 de los sueros positives
1
con algunos de los antigenos, pero no todos los antigenos semi-sinteticos, indica que el portador y los enlaces / |pueden ser asociados con esta rcactividad de fondo. Se justifica la investigacion de otros portadores y enlaces. 1
Concluimos que la rcactividad de fondo no espccifica con los antigenos semi-sinteticos que representa la
molecula PG-I de Mycobacterium lepra es 0,7 a 1,3%, valor basado en un valor de corte de >0,16 OD. Estes
i
datos nos permiten concluir que la rcactividad de individuos libres de lepra fue suficientemente bajo para
justificar el uso de estos antigenos cn un ambicntediagnostico, por ejemplocl control de contactos familialesyen ,
<•
populaciones muy endemicas. Cuando la incidcncia y frccucncia de la lepra son bajas, pruebas que usan estos |
antigenos no serian rcntablcs, al menos que sc les aplicara a individuos muy cxpuestos a riesgo. El control
w.
scrologico por medio de cstos antigenos podria ser util cn la dctcccion y difercnciacion de los relapses
bacteriologicos. las rcaccioncsde tipo I o 2. la dctcccion temprana de la lepra y para controlar el tratamientoen
zonas endemicas.
I"
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I
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r
Leprosy in French Polynesia.
Epidemiological trends between 1946 and 1987
J-L CARTEL,* J-P BOUTIN.* A SPIEGEL,*
Ph GLAZIOU,* R PLICHART, * R CARBINES! &
J-H GROSSETJ
*Institut Territorial de Recherches Medicales Louis Malarde BP 30
Papeete, Tahiti, Polynesie Francaise; 3Public Health Services, BP
611 Tahiti, Polynesie Francaise, XCHU Pi tie Salpetriere, 9/ Bd de
THdpi tai, 75634 Paris Cedex 13, France
Accepted for publication 24 April 1992
Summary The analysis of computerized data (OMSLEP system) on patients from
French Polynesia followed since 1940 has shown a decrease in the mean annual
detection rates for leprosy, all forms combined, from 24.73 per 100,000
inhabitants in 1946 to 8 1 per 100,000 in 1987 ( r= -0.49 .x4-45.83: p <0.05). In
fact, the decrease was significant ( r= - 118 v +83-54; p<() 05) during the first
half of the study period (1946-66). but not during the second half (1967 87).
Similarly, a significant decrease in all of the specific mean annual detection rates
(according to the form of leprosy and to the sex and age of patients), in the
proportion of multibacillary patients among the total of newly detected cases, and
in the proportion of all patients with disabilities al the onset of lepross was
observed only during the first half of the study period (1946 66). Nevertheless,
when comparing age-specific cumulative deteclion rales, calculated by lO-vcar
age groups over the period 1946-66. to those of the period 1967 -87. an ageing of
the leprosy population was noted. Finally, the decrease of mean annual detection
rates was greater in the smaller populations of remote islands than in the
population of Tahiti, the main island, where 70% of the total population were
living during the study period. This decline was shown to correspond to an
effective improvement of the leprosy situation which could be attributed, among
other factors (such as economic development and systematic BCG vaccination),
to the implementation of a control programme for leprosy in 1950. The
introduction in 1982 of multidrug therapy for all patients suffering active leprosy
has raised the hope of a subsequent decline of leprosy in French Polynesia in the
near future.
Introduction
fl
Up to now, leprosy control has been based on the adequate treatment of patients detected
as early as possible. The knowledge and understanding of the evolution of epidemi-
' 0305-7518/92/063211 + 12 SO 1.00
< Lepra
211
212
J-L Cartel ct al.
nrasy in Erei1( h Polynesia. Epidemiological trends 1946 87
ological indicators for leprosy are essential for evaluating and monitoring control
| ELS™'J',™"
strategy. Therefore, the collection and analysis of epidemiological data is a most
important part of leprosy control programmes. However, reliable epidemiological data
I
I
on leprosy are difficult to collect in most countries, especially for operational reasons. In
213
7"'™'"’
»
increased dramatically between I9d6 and leby V^ 'Pe ago
'eure ’> The population
were56.601 Inhabitant, |„
t, , , ’ '
“ lh' IT Sl« ’ "corda. there
French Polynesia, an area where the population is of a relatively small size and where
medical infrastructures arc considerable, a control programme for leprosy was imple
.IMS
mented by the end of the 1940s. In 1986-7, computerization of data on leprosy patients
registered from 1940 onwards was initiated according to the omslep1 system and reliable
information on leprosy for the past 40 years has now become available. This enabled us to
J
'—
Ration of French Po.ynesia
analyse the evolution of the main epidemiological indicators for leprosy in French
» were born on that
Polynesia for the period 1946-87.
i
g
Background
French
(KB usually inhabited), with a land
Trench Polynesia is made up of about 130 islands (88
surface of only 4000 km2, scattered over an oceanic area of 4 million km2. The 130 islands
arc divided into 5 archipelagoes (Society, Australcs, Tuamotus, Gambiers and Marque-
£/«o..wPeota
MARQUESAS
NukuHiva Q ^Ht^aOaCTo F rance)
W
K
I
K
J
|
|
I
1
", Jtny.u?“ntneS-,he 'eJ,rosy CO"trol programme stated with the construction of
,epr0Sariums’ ,he r,rst ,wo in Tahiti
i and in a remote valley of the Southern Marquesas
(1500 km north of Tahiti) in 1914;
a third one was opened in 1934 in Reao. one of the
easternmost islands of the Tuamotu
,eProsy to t...................
each new case of Icj
............. .........
prosy, a pat.cnt form rs died out indicating name. sex. date and place of
birth, dale and place of detection.
pathological examinations and' tlw na re nndT'^
''T'3'' microbiol^i-l and
J among
Institute is still in
g
the leprosy control programme and keeps the territorial
leprosy register.
Qaroline I.
Tahuat^j ,
r atuHiva.
'1 i
Flmt I.
George Is
JX* appointmant Is.
SOCIETY IS
4^,u;PakaFuka,
Motu 1
Fenua Ura BoraBor* • .H,uai /n® Fa^aravaMakerno • akshina
Moorea
Anaa . Nibiru IJu
U AMQTU(1?o Fran e)
Raiatei
•rfapeeU
%
• i. ‘ •4 wnu TaxakotZ)
l
(To France) TAJ [iri MiAeba Marutea'PukaRuha
/
Nengontngo
• Reao’
I
'Mitiaro
lereheretne t
Ahunui. • Tinaki_________________ I
tiu* 'Mauke
T
Duke af Gloucester Gr. ‘
Vanava M . JTureia
rM’^-fuIuroi\A£taJean. Group/
. Mana / Rxajum
la.*
T -i
Fan^atdufa'
Rimatara *
......................JVpr™............ XangarerJ
..............
•K*™™................................................... ” Oeno/.J*
Tl^B
The data analysed in this study enntes pnrtly Irtitn the territorial register and partly from
|: the medical files of patients followed iron/1946 to 1987 '
..............................................
I
UA1 kS
Kej/son Reef
Rapa.^
/
/
I
|
Msy for pathological (
examination. Clinical examination and biological tests also
permitted the assignment of
cases retrospectively into paucibacillary and multibacillary
|| categories.
■ ‘a
'll
Between 1951 and 1982 the basis of treat
j
/
/
Figure I. Archipelagoes of French Polynesia.
J
Pitcairn IJ
"Marobri /
.......
the search for acid-fast bacilli in nasal mucosa
r.
(To F r anc e J/<^q-
Materials and methods
*
patients.
zpmo
) was 19RC?_ Cr'bVr. .OCCds.'onally6 and •Hycarslor
periods of time from
1973Rifammrin
to 198^ Afer
.Hnuarv
over short
1973 to 1982. After January 1982,
|. are distributed free of clip—
a
. .. . °'.ChX?2.^,?.lh.10 Pat,e?tS- e"her at th= Institute, or in non^.specialized public health clinics (in this latter
Jcontrol unit).
...............
Se thc drugs arc Provided by the leprosy
i- 'Bi Ji
It
The annual prevalence rates for lenrosv were calculated accordjng (o (he
rates for leprosy were
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5.
Table I. Mean annual detection rates for leprosy according to (a) type, (b) sex and (c) age by 3-year periods between 1946 and 1987
(a) Type
Total
Pauabacillary
(b) Sex
Multibacdlary
Males
(c) Age
Females
15 Years
15 Years
3-year
periods
No.
Rates*
No.
Rates*
No.
Rates*
No.
Rates*
No.
Rates*
No.
Rates*
No.
Rates*
1946-48
1949-51
1952-54
1955-57
1958 60
1961-63
1964-66
1967 69
1970-72
1973-75
1976-78
1979-81
1982 84
1985 87
42
60
43
33
35
28
24
24
30
37
37
37
46
44
24-73
33-19
21-44
14-75
14-63
10-98
8-61
7- 75
8- 53
9- 67
8-94
8-11
9 19
8-06
17
27
1001
14-93
9-47
8-49
7-10
6-67
502
4-84
4- 26
5- 75
5-07
4- 82
5- 79
6- 04
25
33
24
14
18
11
10
9
15
15
16
15
17
II
14-72
25
31
25
23
21
16
15
15
16
21
16
28
28
26
28-04
32-08
24
20
1701
1202
10-32
9 18
8-58
10- 04
7-36
11- 73
10-74
915
17
29
18
10
14
12
9
9
14
16
21
9
18
18
21 07
33-06
1807
9-22
12 04
9-07
6-75
6- 15
8-48
8-85
10-07
4-13
7- 52
6-88
10
12
19
8
5
6
3
3
5
8
4
I
6
14
18-05
16-97
22-45
8-23
4- 80
5- 42
2- 49
222
3- 21
4- 83
2 30
0-55
314
6- 75
32
27-96
43 60
20-70
19-75
22-18
15-24
13-27
1200
12- 77
13- 34
13-72
1310
12-92
8-86
Total
520
19
19
17
17
14
15
15
22
21
22
29
33
287
* Per 100.000 inhabitants.
233
18-25
11-96
6- 25
7- 52
4 31
3- 59
2 90
4- 26
3-92
3 86
3-28
3-39
201
306
214
104
48
24
25
30
22
21
21
25
29
33
36
40
30
416
J
s-
I
I
I
I
I
S'
£
53
216
J-L Cartel ct al.
Potynesia. Epidemi,,lrends
•«.r
D
1946-66 : Y = -1.18 ; r = -0.89 ; p<0.05
9
C
t
1967-87 : Y = 0.01 ; r = 0.08 ; p>0.05
D
e
I K..
1946-87 : Y = -0.49 ; r = -0.80 ; p<0.05
c
t
’ 30 --
0
n
217
SSy
n
a 25
t
e
t
e
P
6 20 --
p’5"
r
9
1
0
0 15 --
! ,0--
0
0
0
I
n
h
a
b
t
a
n
t
s
r
0
0
All forms
6
5
Paucibacillary
Multibacillary
o
o
io --
‘i
0
’
2°-29
5 --
30-39
40-49
Tan-year age-groups
Figure 3. Agc-spccific detection rates
0----1947
-+- -4— H—
1950
1953
1956
--------1------- 1------- 1------- 1--------1-------- H------41-—
------ ------ 1
-4-
1959
1 962
1965
1 968
1 971
1974
11977
977
1 980
1980
1983
1983
1986
44 newly detected patients, 11 were multibacillary (2 01/100,000) and 33 were paucibacill
ary (6 04/100,000). The regression curve plotted on the basis of the 14 specific 3-year
detection rates showed a significant (/?<() 05) decline for both multibacillary and
paucibacillary detection rates. The decline was significant for multibacillary as well as for
paucibacillary detection rates between 1946 and 1966 (p<0 05), but not between 1967
and 1987 (p>0 05).
With respect to sex of the patients (Table 1), a significant decrease (p<0 0D of the
detection rate was observed between 1946 and 1987, from 28 04 to 9 15/100,000 in males
and from 21 07 to 6-88 in females. Again, the regression was significant in males (p< 0 01)
as well as in females (p<0 05) between 1946 and 1966, but not between 1967 and 1987
(p>005).
With respect to age (Table 1), of the 42 newly detected patients during the first 3-year
period of the study (1946-48), 10 were less than 15 years of age (mean annual detection
rate: 18 05/100,000) and 32 were 15 years of age or more (27-96/100,000). The regression
curves plotted on the basis of all 14 age-specific detection rates showed a significant
of leprosy between 1946 and 1966.
I
B
35?
K
D
1987.
rate) and 17 were paucibacillary patients (10/100,000) whereas, during the last one, of the
4
>w
|
• *.
Median years of 14 three-year periods
Figure 2. Evolution of mean annual detection rates for leprosy (all forms) by 3-ycar periods between 1946 and
50-59
c
t
J
n
>t
All forms
/
pi5-r
\ Paucibacillary
! ,0-0
0
5- •
Multibacillary
i
o
0-9
I1'
4-------------10-19
20’29t
'
30-39
H
Tan-year age-groups
figure 4. Age-specific detection rates
of leprosy between 1967 and 1987.
'
218
J-L Cartel et al.
Vosy in French Polynesia. Epidemio^ical trends 1946 H7
219
the regression curve plotted on the basis of the 14 i
3-ycar proportions ( r = - 109 8
x+ 114) indicates a significant decrease (p <0 05). As
»
was noted
previous'y reported, the decrease was significant between
1946 for other indicators
-...........j and 1966 but not
significant between 1967 and 1987.
decrease (/><()05) for both < 15 years of age and > 15 years of age detection rates; as
observed for previously reported epidemiological indicators, the regression was effective
(p<0 05) during the period 1946-66, but not during the period 1967-87 (p>0 05).
This led us to consider two study periods, 1946-66 and 1967-87, for analysing our
results concerning detection rates as well as other epidemiological indicators.
When considering age-specific, 21-year cumulative detection rates, calculated by 10year age groups, more pertinent data became available for analysis of results. Between
1946 and 1966, 265 new cases of leprosy (130 paucibacillary and 135 multibacillary) were
detected; as shown in Figure 3 the highest detection rates were observed in the 20-29 years
age groups for leprosy, all forms combined (30-5/100,000), as well as for multibacillary
cases (18 1/100,000); whereas, for paucibacillary patients, detection rates were not
significantly different in the 7 10-year age groups (p>0 05). During the period 1967-87
PROPORTtON OF PATtFNTS WtTH DtSABtL.TtPS OF GRADE >2 AT DETFCTtON
(Figure 4). 255 new cases (157 paucibacillary and 98 multibacillary) were detected, with
the highest detection rates being observed in the 50 59 years age groups for leprosy (all
r
_____ _____
:__ .1
I ■ n/x
\ as
__ ___
11 as
_ r
..........paucibacillary
..........: t_
• 11____ z(10-9/100,000)
i rx /1 /xrx
\ and
_ J for
forms
combined,
29-2/100,000),
well
for
multibacillary patients (18-3/100,000).
With respect to place of birth, during the period 1946 66, the highest mean annual
detection rates were observed in remote islands, especially in the Gambier islands, and in
the Northern and Southern Marquesas islands, where they were 198, 72 and 49 per
100,000, respectively (Table 2); during the same period, the detection rate was 9-2/100,000
in the Society archipelago (where 70% of the population were living). During the 1967-87
period, the mean annual detection rates decreased dramatically to 54 and 12/100,000 in
the Gambier and Northern Marquesas islands, respectively, while they remained stable in
the Southern Marquesas (49/100,000) as well as in the Society archipelago (7/100,000).
,,
i
I
$I
stgntficant decrease (p<0-05). Again, the decrease was significant (p<0.05) during",he
first period of the study (1946-66), but
---1 n°f during the second one (1967-87).
Olfiriicclnn
Discussion
'
1
|
A1 l™n'iOnC<? ab?Ve-,,le numbcr of newly-detected patients differed greatly from year to
year during the whole study-period. Such
number of cases and random
’ pll';nonl|cn°n maf he
either to the small
finding performed in the islands. TherefoSre0'to<’validate det” f 'nU'ty
,
'hC
S^=^s°:2f^^ators: th~'
’
PROPORTION OI MULTIBACILLARY PATIENTS AMONG NI-WI.Y-DETF.CTI-D CASES
The proportion of multibacillary patients among newly-detected patients was 59-5%
during the first 3-year period (1946-48) of the study and 25% during the last one (1985-7);
!
,
| along with the decreasT™the^tectmn ra's ^7, ^''?".°/
ra,eS
f
Table 2. Mean annual detection rates for leprosy according to place of birth in French
Polynesia by 21-year periods between 1946 and 1987
Place of
Place of birth
Society islands
Marquesas islands
Northern
Southern
Australes islands
Tuamotu islands
Gambier islands
Outside of FPf
1946 66 period
1967 K7 period
Mean*
Mean* No. Mean*
of cases
rate
population
Mean
Mean No. Mean
population of cases rate
58,388
5-4
9-2
97,405
7
fctectiX^ s”^^
in .he leprosy
influencing factors, such
J
7-2
? "i0"5'
■
2505.
1356
4206
6530
552
9708
18
08
09
2-2
11
042
72 2
49-6
22-1
34-3
198-4
4-4
4600
2824
7036
9655
870
18,239
06
14
07
14
05
0-7
12 4
49
9-5
14 3
54-7
3-6
• Annual mean population, number of cases and detection rates (per lOO.OOO
inhabitants).
t Patients born outside of French Polynesia, but detected in French Polynesia.
| Louis Mala’rde fnXte oTthe
f
I
le " l95°'
rn,ra"Za,i°n 31
no o important economm development occurred in french Polynesia but, because
220
J-L Cartel ct al.
ffiis only commenced after 1962,9 it is unlikely to be the only cause of the improvement in
the leprosy situation between 1946 and 1966. Moreover, this economic improvement
affected remote islands much less and much later than Tahiti; thus, it is not likely to be
responsible for the decrease of the detection rates for leprosy in the remote archipelagoes.
Though several reports have suggested that control programmes only resulted in
improvement of the leprosy situation in a few areas,10 some of our findings suggest that
improvement in the leprosy situation noted in French Polynesia could be attributed,
among other factors, to the efficacy of the control programme implemented in 1950. The
most
important
is mv
the |Z|
decline
in the
proportion
of newly-detected patients with
........ ... ..............
ux/wx.'v 111
vpvi UUII
V/1 IIV
w ij-uticucu
Willi
disabilities, which has been demonstrated in other countries" to be the main effect of a
control strategy. Another point is that the most important decrease in detection rates was
observed in remote islands. This suggests
including
not only
-. that
- control' programmes,
<
7 :
standardized treatment and the follow-up of patients, but also active case-finding among
household contacts, are easier to manage, and, thus, are more effective in small size
populations. That such a decrease was not observed in the South Marquesan population,
which is also of a small size, remains difficult to explain.
Regarding the second study period of 1967-87, the stability in detection rates might
r
what we have reported. However, the ageing of the leprosy population may have several
explanations, among them the introduction in French Polynesia by the mid-1960s of
systematic BCG vaccination for all new-born children. As reported by Bagshawe, BCG
should afford protection against leprosy, more particularly in vaccinated children under
15 years of age.13 Also, it is known that the efficacy of a leprosy control programme should
result in a more marked decrease in children.14 and that increase in the mean age of“
patients at the onset of leprosy reflects a decrease in the risk of infection in a community.
However, it should be kept in mind that increasing mean age of patients has been
considered as an indicator of long-term decreasing trends irrespective of any control
strategy.8 Why detection rates for leprosy remained stable during the period 1967-87 is
difficult to explain. It is assumed that, theoretically, effective treatment of all patients with
overt disease (known prevalence) together with the reduction to zero of the reservoir of
undetected cases (unknown prevalence) should interrupt transmission, and that after a
period of latency, no new cases should appear.15 In that assumption, a most important
point is that treatment should be effective: in French Polynesia, nearly half of the
multibacillary patients on dapsone monotherapy have relapsed and have become
additional sources of transmission.16 Therefore, it might be speculated that an additional
reservoir of infection, consisting of all relapsing multibacillary patients since 1946, has
contributed to the emergence of new cases of leprosy and to a slowing down of the
decrease in detection rates which was observed during the previous period. Whatever the
explanation and despite the stability in detection rates for leprosy during the period 196787, our results suggest that the leprosy situation also improved during the last 21 years of
the study. Finally, it should be noted that, ever since multidrug therapy was implemented
-87
221
■■
.T'
were observed in multibacillary patients "Ts CUmUla"Ve relapse rates of 3° 50%
suppressing or greatly reducing the occurrence r f
r^asonab,e to hoPe that, by
F-nch Po'ynesia will reduce the risk of transnri^siononheJ di seZe'Zd t ha t" " ^b'1 °T
fall in detectio:
-Jn rates should be observed in the near future
subsequent
'
References
3
I
j
suggest, as reported in a previous study,12 that no change
(
occurred in the leprosy 7 W
situation. It must be emphasized that, during that period, the highest detection rates were
|S'
observed in the oldest age groups (in terms of age at detection) whereas, during the first
j I;
period (1946-66), they were observed, at least for multibacillary leprosy, in the 20-9 year
age group. In fact, the difference between age at onset and age at detection was probably
longer during the first period than during the second, due to the delay in case finding.
Thus, the difference in age at onset between the two periods was most likely greater than
i„ French Polynesia. Epidemiological,rends 1946
1983. I.T.Stat. BP 395. Papeete Tahhi ""Xcmcn,s *enerat‘x
Lechat MF, Vandervcken M. W
.•_/.•
population en Polynesie Franeaise. 1946
' monitoring leprosy control. Sasakawa
* WHO. A guide
-Sh
J*"-leprosy control.1980. Geneva.
• WHo'f Paris*Jerne edition. Flamntarion Mcdecine
Noordee/sK. In
I wun c"™' Tokyo- 1983
, y eneva dy Gr™P
Z
Rcporl scrics- 198S; No 768. Geneva
Memorial Health
‘"nrr,,!. Technieal Report series. 1985: No 716.
1
1 f
CREDES/G
R°7 J T"'
'an,i <■" ’’••'misie
23 26 Ja"nXl989.
J , « Sansarricq
I L(" Smith WCS.ParkheSM Disahilitv ■ «e«ineT K‘' ' l98l; 52 ,SupP' 0: 15.
57: 251 9.
' assessment as a measure of progress in lepi
| J
•rosy control. Lepr Rev. 19R6:
I
rchipelsdePolynCTicFrancai^de
1
accination in Icprosj final
f'nn.:;■) 99
w
..........................................................................
Leprosy...................
Control Seoul (Koi
Frangaise. Rcsultats a 7 ans. Acta Jpr J 990®n,,,ePreuse
Nouvelle Caledonie el
.......
en Polynesie
"r
222
I.cpr R
l.epr Rev (1992) 63. 21 I 222
’992) 63, 223 230
Lepre en Polynesie Fran^aise. Tendances epidemiologiques entre 1946 et 1987
J-L Cartel, J-P Boutin, A Spiegel, Ph Glaziou, R Plichart,
R Carbines et J-H Grosset
Resume L'analyse des donnees informatiques (systeme OMSLEP) sur des patients de Polynesie franejaise
sun is depuis 1940 a revele une diminution des taux annucls moyens de detection de toutes les formes de lepre, de
24.73 pour 100000 habitants en I946jusqu'a 8,1 pour 100000en 1987 ( r = —0,49 .v4-45.43;p < 0,05). En realite,
la diminution etait significative ( r — — 1.18x4- 83,54; p < 0,05) pendant la premiere moitic de la pcriodc d’etude
(1946 66). mais no I’ctait pas pendant la sccondc (1967 87). De meme, on a observe sculcmcnt au cours dccctle
meme premiere moitie (1946 66) de la pcriode d’etudc unc diminution significative dans tons les taux de
detection annucls moyens spccifiqucs (scion la forme de lepre, Ic sexe cl I ago des patients), dans la proportion
des patients multibacillaires sur Ic total des nouveaux cas detectes, et dans la proportion de tous les patients
souflrant d’infirmites au debut de leur lepre. Pourtant. lorsque les taux de detection cumulatifs par age. calcules
par groupe d'age de 10 ans, au cours de la pcriode 1946 66. ont etc compares a ceux de la pcriodc 1967 87, on a
note un vicillisscmcnt de la population lepreuse. Enfin, la diminution des taux de detection annucls moyens etait
plus importantc dans les plus pelites populations des ilcs isolccs que dans la population de Tahiti, I'ilc principale,
ou 70”;. de la population totalc vivait pendant la pcriode de I’etudc. On a montre que cc dcclin corrcspondaita
unc amelioration rcclledc la situation quant a la lepre, que Eon pourrail attribucr, entre autres factcurs, (tclsque
Ic dcvcloppemcnt cconomiquc cl la vaccination BCG systematique), au programme de controlc de la lepre
execute en 1950. L’inlroduction cn 1982 d’unc therapeulique mullidroguc pour tons les patients atlcint de lepre
evolutive a fail naitre I’cspoir d’un nouveau dcclin de la lepre cn Polynesie francaise dans un avenir prochain.
(
s 1 vc
■
Leprosy in French Polynesia.
impact of multidrug therapy on
epidemiological trends
J-L CARTEL,* A SPIEGEL,! L NGUYEN NGOC,t
J-P MOULIA-PELAT,f P M V MARTIN! &
J-H GROSSETJ
*Jnstitut Territorial de Reeherehes Medicales Louis Malarde BP 30
Papeete, Tahiti, Polynesie Fran^aise; Mnstitut Louis Malarde:
XCI1U Pitie Salpetriere. 91 Bd de THopital, 75634 Paris Cede.x 13,
France
£
Accepted for publication 28 February 1992
La lepra en la Polinesia Francesa. Las tendencias epideiniologicas entre
1946 y 1987
Summary In 1982. following the recommendations of a WHO study group,
multidrug therapy (MI)I) was introduced into French Polynesia to treat all
patients suffering from active leprosy, and only on request those still on
dapsonc monotherapy. After 5 years, a clear-cut decrease of prevalence and mean
annual detection rates for leprosy (except for detection rates among children aged
less than 15 years, many of such cases being detected early by increased household
contact training) has been observed. There was also a decrease in the proportion
of newly detected cases with disabilities. During the 21-year period preceding the
introduction of MDT into the control programme, mean annual detection rales
for leprosy had remained stable, and this led to the consideration that such a
decrease was due neither to the natural decline of the disease nor to the economic
improvement of the country . Our results, together with the fact that, to date, the
relapse rate was nil in the Polynesian patients pul on MDT. strongly suggest that
the implementation of MDT has resulted in a decrease of detection rates for
leprosy which may be a consequence of a decrease in the transmission of the
disease.
J-L Cartel. J-P Boutin, A Spiegel, Ph Glaziou, R Plichart. R Carbines
y J-H Grosset
Resumen El analisis de dates informatizados (sistema OMSLEP) sobre pacicntcs de la Polinesia Francesa
desde 1940 ha indicado una reduction del promedio anual de detection de la lepra, cn una combinacion de todas
sus formas, de 24.73 por lOOOOOhabitantcs cn 1946 a 8,1 por 100000 cn 1987 ( r - — 0,49 x 4-45,83); p<0.05).
En cfccto, la reduction durante la primcra mitad del periodo del cstudio (1946 66) fue significativa (y= -1,18
a 4-83.54; /><0.05), pcro no durante la segunda mitad (1967 87). Igualmcnlc, sc observd una reduction
significativa de lodos los promedios anualescspccificos de frccuencia de detection (segun la forma de la lepra yel
sexoy edad de los pacicntcs), cn la proportion de paeienles mtillibatilaresen cl total de casos rccien dclcctados.y
en la proportion de lodos los pacicntcs con incapacidades al initio de la lepra, durante cl la primcra mitad del
periodo de cstudio (1946 66). No obstante, tuando se com para la Irctuentia de detection cumulativa para
edades cspecilicas. cnlculada cn grupos de 10 anos durante el pciiodo 1946 66. con la frccuencia para 1967-87,
sc nolo un aumento de la population lepiosa. I'inalmcntc, la reduction del promedio anual de frccucnciasde
detection fue mas grande cn las populacioncs mas pequenas de las islas rcmotos que cn la population de Tahiti,
la isla principal, donde vivia 70% de la populacion total durante cl periodo del cstudio. Sc mostro que la
disminucion corrcspondia a una mejora efcctiva de la situacion leprosa que se podia atribuir a, entre otros
factorcs (como el dcsarrollo cconomico y la vacunacion anlitubcrculosa sistcmatica), debida a la implementacion de un programa de control de la lepra en 1950. La introduccion cn 1982 de una tcrapia multi-droga para
lodos los pacicntcs que sufrian de lepra activa ha creado la esperanza de una reduccion posterior de la lepra en la
Polinesia Francesa cn un future proximo.
Introduction
i
From the early 1950s. dapsone monotherapy was the basis of the treatment for leprosy in
French Polynesia, prescribed to paucibacillary patients for an average of 10 years and for
lifetomultibacillary patients. In November 1982, following the recommendation of the
WHO study group,' multidrug therapy (MDT) was introduced to treat all patients
suffering from active leprosy. These included newly-detected patients as well as those
detected before 1982 and suffering a relapse: patients detected before 1982 and still on
dapsone monotherapy without signs of active leprosy were put on MDT only on request.
The aim of this study is to discuss if changes in the epidemiological trends of leprosy have
0305-7518/92 0 6 3 2 2 3 4 08 $01 ()()
< Lepra
223
r224
J-L Cartel et al.
<>s \ in I rcru h Polynesia. MDT and epidemiological trends
been observed after MDT was introduced and to determine it this could be attributed to
the introduction of MDT into the control programme. Because the results of a previous
study have indicated that detection rates for leprosy remained stable between 1967 and
1983,2 the epidemiological indicators were analysed over the period 1967-83 (pre MDT)
and 1983-90 (post MDT).
Patients and methods
As shown in Table I, the population increased dramatically in French Polynesia between
1967 and 1990; according to I.T.Stat.3 records, there were 98.378 inhabitants in 1967 and
197.061 in 1990. For each year of the study period, the population was calculated from the
results of 5 censuses (1967,1971, 1977, 1983 and 1988) assuming a linear increase between
2 censuses. During the entire period 1967-90 about 75% of the total population were
living in Tahiti although only 50% were born on that island.
The data analysed in the study came partly from the territorial register and partly from
the medical files of patients followed from 1967 to 1990. The diagnosis of leprosy was
Table I. Annual population and prevalence rates* for leprosy in
French Polynesia between 1967 and 1990
Year
Population
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
98,378
103.199
108,020
112.842
117.663
120,949
124,236
127,522
130,808
134.095
137,381
142.276
147,172
152,067
156,962
161,858
166.753
169,778
174.141
178,619
183.232
187,841
192.451
197.061
No. of patients on treatment
Prevalence-----------------Rates*
Total DDS MDT Olhert
3 21
3 09
2 94
2-57
2-47
236
2 28
2 26
221
213
21
I 98
I 95
!-76
I 66
I 45
1 25
11
0-96
0-59
0 48
025
018
014
315
319
318
290
291
286
283
288
289
286
288
281
287
267
260
234
209
186
141
105
88
46
35
28
315
319
318
287
285
272
271
276
277
283
282
269
266
251
234
181
141
98
55
51
35
19
19
17
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
I
14
60
67
44
43
21
14
II
’
0
0
0
3
6
14
12
12
12
3
6
12
21
16
16
52
54
28
19
10
10
6
2
0
* Per 1.000 inhabitants.
t Rifampicin added to dapsonc monotherapy (patients diag
nosed before 1983).
225
based on the clinical examination of the patients (including examination of the skin and
the large nerve trunks) supplemented by biological
tests: the lepromin intradermal
reaction, the search for acid-fast bacilli in the nasal mucosa
and the skin (earlobes and
skin lesions) and biopsy for pathological examination. Clinical examinations and
biological tests permitted the diagnosis of leprosy and. retrospectively, the assignment
into paucibacillary and multibacillary categories.
gnment
NinT.JL5r:1PSO'le nlOno,heraPy has
the basis of treatment for leprosy from
1970 to 1984 nfampicm (RMP) was prescribed occasionally and over short periods to
patients on dapsone monotherapy. After November 1982. the multidrug therapy for
paucibacillary patients has consisted of the daily administration for 6 months of 100 me of
dapsone (DOS) and 10 mg per kg of RMP. For multibacillary patients MDT has
consisted of the daily adnumstration for 24 months of DOS and R M P in the same doses as
’ l/month
I3"? s'
a
SUpP'emCnt of 100
^clofazimine (CLO) durine the first
I2monthsand of5 mg per kg ethionamide (PTH) for the first 2 months. All thedrugs are
distributed free of charge every month to the patients, either in the Leprosy Control Unit
or in
in nnn-cnerri
7,.,! Public
I I...Health
.1.1. z i- Clinics.
•
VUIIIK)! unit
or
non-specializcd
Annual
bvthe
WHOprevalence
r rates
” for leprosy
PrOS> T"0 calcula,cd a^ing to the definition given
( by the WI IO Expert C om.mttee m 1988.'. i.e. taking into account only leprosy patients on
, treatment. Because of the annual variations in the number of newlv-detectcd leprosy
patients, the billow mg epidemiological indicators were calculated on 3-year periods'mean annual dctechon rates, proportion of multibacillary patients among the total
number of cases and the proportion of patients with disabilities5 of grade >2
OM8 FP13
"’C1 nlC?iC:’1 r',CS °r ,hC piltien,s 'vcrc aa<’'Lvmouslv enfered on the
test and th-T
bv c'omPuter. I or statistical analysis. Pearson's f
test and the Spearman test were used/ Regression curves were established using a
; computer statistical package (Chart 3 Microsoft).
Results
PATIENTS ON Ml) I
theranv 86 s
1 i"
T" " ' >W' Ul ,cPr^'were given multidrug
PyT Sr|"LrC|nc"1'"llc,cc,ed «>ses and 55 were patients diagnosed before November
19 - and st.ll on <h,psone nmnotherapy (including 2 mullibacillary patients who relapsed
while on dapsone monotherapy).
PREVALENCE RATE
j The number of patients
on treatment decreased steadily from 315 in 1967 (prevalence rate
3-20/1,000) to 209 in I"
1983 (prevalence rate 1-25 1.000)-that is a 61% reduction oser 17
years (Table 1). 7 he regression curve plottedi on the basis of the 17 annual prevalence rates
: indicates a significant decrease (y
(y= *0 ,
= -0 10 z + 208-43; r=-0 97; p<000l). Alter the
introduction of MDI into the control pronranimc.
-. the number of patients on treatment
| decreased from 209 in 1983 to 28 in 1.....
1990 (prevalence rate 0 14 1.000)—that is a reduction
of more than 89".. over 7 years. The regression curve plotted
on the basis of the 7 annual
I prevalence rates indicates a significance decrease (v
0
17
346-12; r
0 97;
I p<0001).
226
J-L Cartel ct al.
in I reach Polynesia. M DI imu
and cpiaemioio^ical
epidemiological trends
trends
‘DETECTION RATES
?KSc“^
Between 1967 and 1990, 276 leprosy patients were delected in French Polynesia or whom
107 (38-8%) were multibacillary and 169 paucihacillary; 44 (16%) were less than 15 years
old and 232 were 15 years old or more (Table 2 and 3).
As shown in Table 2, the mean annual detection rate for all forms of leprosy was 7-75/
100,000 during the 1st 3-year period of the study (1967-1969) and remained roughly
stable up to the 7th 3-year period (1985 1987); no significant difference^ = 0-10,p>0 05)
could be demonstrated between the 7 detection rates. During the 8th 3-year period of the
study (1988 1990), the mean annual detection rate fell to 3-46/100,000 and was
significantly lower (p < 0-01) than those of the previous period.
According to the type of leprosy, the mean annual detection rate for multibacillary
leprosy remained roughly stable between the 1st and 6th 3-year period of the study, and
Paucihacillary
Multibacillary
3-year periods
No.
Rates*
No.
Rates*
No.
Rates*
1967 69
1970 72
1973-75
1976 78
1979 81
1982-84
1985 87
1988-90
24
30
37
37
37
46
44
21
7- 75
8 53
9-67
8- 94
811
9 19
8-06
3 63
15
15
22
21
22
29
33
12
4-84
4- 26
5- 75
5 07
4 82
5-79
604
1-9
9
15
15
16
15
17
11
9
290
4-26
3 92
3 86
3 28
3 39
201
1 39
Total
276
169
90
conver?',hc H9—^"2
detection rate over ,he previous 7 Lear Z"h?:'
'f
‘han the mean
i -2S3S3Jzsx?r,*7
decreased to 8-86 100 000 in 1985 87 t
1\
1 lestlK (r~° 49<P>0 05) then
these las, 2 nrean annual d Ldon r , e
T
L n0,'00"
9° <Tablc 3)- B"'h
- (p<0 05 and /xO OOl) ,han he ,n L 8 86
4 X0/,0,,-0()0)
signilicantly lower
f Previous 6 3-fear periods cLverselv n"" dC(!CCt,Onirate 3 03/It,0.000) over ,he
Table 2. Mean annual detection rates For leprosy according to type by 3-ycar
periods between 1967 and 1990
Total
I (p>005) between the 8 „le ln annual I , "
‘''"erence could be evidenced
‘ years.
de,CCtlon r:lles '<’r leprosy patients less than 15
'
‘li
PROPORTION of MULUBACn.LARY PATENTS AMONG NEWLY DETECTED CASES
I PROPORT,ON or PAT,ENTS W.TH D,SAB,L,T,ES OF GRADE >2 AT DETECT,ON
™ ±1:.ud"‘ dVd967 ■8,)-,he propor,ion °rpa,ients
1
107
l 29-2% ,o ?2.6% (TahVs)
* Per 100,000 inhabitants.
Table 3. Mean annual detection rates for leprosy according to age by 3-year
periods between 1967 and 1990
Total
15 Years old
No.
Rates*
No.
Rates*
No.
Rates*
1967 69
1970 72
1973-75
1976 78
1979 81
1982 84
1985 87
1988-90
24
30
37
37
37
46
44
21
7-75
8 53
9-67
8 94
811
9 19
8 06
3 63
3
5
8
4
I
6
14
3
2-22
3 21
4 83
2-30
0-55
3 14
6-75
1-45
21
25
29
33
36
40
30
18
12 00
12 77
13 34
13-72
13 10
12 92
8 86
4 80
Total
276
44
* Per 100,000 inhabitants.
fl
. .'I J
...............
> 15 Years old
3-ycar periods
232
227
Total
Pauci bacillary
Multibacillary
No.
No.
3-ycar periods
No.
1967 69
1970 72
1973-75
1976 78
1979 81
1982 84
1985 87
1988 90
24
30
37
37
37
46
44
21
100
100
100
100
100
100
100
100
15
15
22
21
22
29
33
12
62 5
50
59 5
56-7
59-5
63
75
55
9
15
15
16
15
17
II
9
37-5
50
40 5
43 3
40 5
37
25
45
Total
276
1(K)
169
61 2
107
38 8
228
J-L Cartel cl al.
'rosy in French Polynesia. MPl and epidemiological trends
Table 5. Proportion of patients with disabilities at detection by
3-year periods between 1967 and 1990
Newly detected cases
with disabilities
Total newly
detected
No
1967 69
1970 72
1973 75
1976 78
1979 81
1982 84
1985 87
1988 90
24
30
37
37
37
46
44
21
7
10
11
12
12
7
3
3
29 27
33-33
29-72
32 43
32 43
15 21
6 81
14 3
Total
276
65
23 6
3-year periods
Discussion
The main finding of this study is that, in French Polynesia, a clear-cut decrease of leprosy
prevalence and mean annual detection rates has been observed in the 3-year period 198890. There was also a decrease in the proportion of newly-detected cases with disabilities.
However no significant decrease occurred in the detection rate among children less than
15 years old. The crucial question is to determine if such findings are related to the
implementation of MDT from 1982.
A gradual decline in the prevalence rate was observed between 1967 and 1983, before
the implementation of M DT into the control programme, but this decline was much more
marked in the years after this, obviously because of the increasing number of patients who
were released from the active file on completion of treatment. More important, from the
epidemiological point of view, is the reduction in the detection rates. Following the
introduction of MDT into any control programme, a decline in ncw-case detection is only
expected after 5 years;7 this was effectively observed in the current study. The fact that
such a decline was observed in all specific detection rates except in that for leprosy in
children less than 15 years old is not surprising. Active case-finding, which is only
performed in household contacts in French Polynesia, has been more intensive in the
years following the introduction of MDT, which has resulted in an increase in the number
of new cases among children. As a matter of fact, this number was 14 (of which 11 were
detected among household contacts) over the period 1985 87, approximately twice as
high during this period as during the 6 preceding 3-year periods. Similarly, intensive active
case-finding should permit the detection of new cases at an earlier stage of the disease,
thus resulting in a decrease of the proportion of patients with disabilities at detection; this
was also noted in the present study.
When assessing the decrease in detection rates for leprosy, it might be questioned if it
reflects an improvement of the leprosy situation due to the implementation of MDT or
whether it is caused by other possible influencing factors, such as a change in the control
programme efforts, the economic improvement of the country and the natural decline of
229
the disease. Since detection rates remained stable during the period 1967 87. that isover
I years, one is led to assume that the subsequent decrease observed after 1987 is more
likely to be due to other causes than natural evolution. Moreover, even in the case of
natural decline, it is known that the decrease in detection rates, which has effectivelv been
observed m some countries before MDT was introduced, has been very gradual J With
respect to the organization of the Leprosy Control Unit, no change occurred during the
past 24 years except for the implementation of MDT. which has resulted in intensifving
active case-hndmg and in improving the management and follow-up of patients, newlvetected as well as 'old' ones still on dapsone monotherapy and who were put on
multtdrug therapy on request. The only other factor which could have possibly influenced
he evo'utmn of the disease might be the economic improvement which started in the early
1960s in f rench Polynesia.1 Nevertheless, if such a factor has to be taken into account
again, one would expect a faster improvement in the leprosy situation: in the present study
the improvement began to be noted only after 25 years. Also, the rapid decrease in
detection rates observed between 1988 and 1990 does not fit well with the possible long
term effect of economic improvement; such a result is much more consistent with the
Snr? rnS n 'h,COrc,it:'1 ™'™la'ions on what is expected from the implementation of
MDT Finally. the small number of cases detected over the whole study-period might be
considered to represent a possible limitation in the intepretation of our findings. In fact,
precisely because detection rates for leprosy were already low before MDT was
implemented, it may be assumed that any significant decrease should be more difficult to
prove and. if proved, that decrease should be considered even more significant
From the results reported here it may be suggested that, together with the
improvement of the economic situation of the country, the implementation of MDT has
resulted in F rench Polynesia in a decrease of detection rates for leprosy, which mav be a
consequence of a decrease in transmission of the disease. I his finding, and the fact that, to
date, the relapse rate was nil in the Polynesian patients put on MDT.10 strengthens the
hope that total control of leprosy might be obtained through MDT in the next decade(s).
References
No"°75SX“"’Ur
................
...... ..
W HO | ccliiiic:d Report scries. ,9X2;
LCPrO”'in PrCnCh P‘,l>nC,ia
! eXmos^I uen'i;tt„Aiw6Uand TO*
Six^ rc',"r' Tcchnical Report series. I9XX; No 76X. Genera
UMSLhl . S.fThnu denreg's/rement et de notifuaiion des nudadcs de la lepre Unite dTnidemiolo™
‘ Schwart'r DF q il'T’ F LOU'a"1.
C" collaboration asee I O.M.S 3rd Ed Genise. 19X7
? ScienS Paris DXL
""
' ^.ne edition. Flammarion Medecine
’
' Sasa" o' Viia>^um:lran P- Pannikar VK. Christian M. Impact of MDT on leprosy
selective indicators. Lxpr Rev. 1988: 59: 215 23.
’ as measured by '
J Skmsnes OK. Epidemiology and decline of leprosy in Asia. Im J Denn. 1983- 22- 348 67
SIX
io
CKEDLS Unit n Gcograplnque Internationale. Paris. 23 26 Janvier 1989
cn N,,uvd,c c
«- p<>'>"^
International Journal of Leprosy
Seroepidemiological Study of
iprosy in
•J
a Highly Endemic Population of South India Based on
an ELISA Using Synthetic PGL-I1
Padebettu Krishnamurthy, Potluri S. Rao, Bapura N. Reddy,
Murugan Subramanian, Subramanian Dhandayudapani,
Vivekanad Bhatia, Phillapakkam N. Neelan,
and Arabinda Dutta2
i
Leprosy is an enigmatic disease. Persis
tent efforts to unravel the various facets of
the disease have met with limited success.
The phase of infection still remains unrec
ognized. A reasonably valid marker, sero
logical or otherwise, of past or current in
fection with Mycobacterium leprae would
certainly help in understanding the natural
history of the disease and would answer
many epidemiological questions, such as the
probable major course of transmission, the
incubation period, the risk factors for in
fection and disease, etc., answers that re
main elusive to this day (9). The recognition
of infection, which is one of the principal
goals of leprosy research (l7). will also pro
vide us with credible support for the control
of the disease.
Several serological tests have been de
veloped over the past 80 years to detect
leprosy infection (l5). The results, however,
are not gratifying. Interest in the past few
years in serodiagnosis has been heightened
by the development of serological tests based
on supposedly M. /eprar-specific antigenic
determinants (4 7-l3-I8> iq). The onzymelinked immunosorbent assay (ELISA) based
Received for publication on 2 January 1991: ac
cepted for publication in revised form on 16 May 1991.
; P. Krishnamurthy. M.D. (PSMK Assistant Director
(Epid.k P. S. Rao, D.P.H.. D.T.M.&H.. Deputy Di
rector (Epid.); B. N. Reddy. M.D. (PSM). Assistant
Director (Epid.k M. Subramanian, M.Sc. (Stat.), Sta
tistical Assistant: S. Dhandayudapani. M.Sc.. Ph.D..
Senior Research Officer. V. N. Bhatia. M.D. (Micro.).
Former Director (Micro.); P. N. Neelan. D.P.H..
M.P.H.. Former Director: A. Dutta. D.P.H.. D.E.C.D..
Director. Central Leprosy Teaching & Research Insti
tute. Chengaipattu 603001. India.
Repnnt requests to Dr. Krishnamurthy.
Present address for Dr. Bhatia: Serologist and Chem
ical Examiner. Calcutta, India.
426
on phenolic glycolipid-I (PGL-I)(>2) is now
widely used in seroepidemiological studies
The availability of the synthetic disaccha
ride portion of PGL-I as an antigen in
ELISA, its relative specificity to leprosy, and
the fact that it is the only assay thus far
standardized among laboratories, may be
the reasons for its widespread acceptance.
The majority of the serological studies that
have been carried out so far have been con
fined to small, selected, nonrandom popu
lations of cases and controls. These studies
have reported widely varying results, e.g.,
from 6% to 92% (,-3-516) seropositivity
among contacts of leprosy cases. There have
been only a few large-scale seroepidemiol
ogical investigations using an ELISA based
on PGL-I reported to date (6-l0).
This paper presents the results of a sero
epidemiological study conducted in a highly
endemic area of leprosy in South India using
a synthetic ND-O-BSA ELISA.
MATERIALS AND METHODS
The 54 villages in the field area of the
Central Leprosy Teaching and Research Institute (CLTRI) located about 10 kins from
Madras, with a total population of about
100,000. were divided into 135 population
clusters varying in size from 400 to 100. •
Each cluster, which was formed keeping m
mind the natural or administrative boun
ary’, was weighted. Cluster weighting
done using the criteria of relative risk
rived from available data of the study a
to obtain the incremental gain(s) in P
spective case detection. Each househo
a cluster was given a risk factor depend^
on the presence or absence of a leprosy
(paucibacillary or multibacillary) in
household. If there was one or more P
fI?59,3
Krishnamurthy, et al.: PGL-I Seroepidemiology
427
^-Mcillary' (PB) cases in ° ‘household, a risk blood) was punched out from each dried
2 was given and
, was multiplied blood spot and treated with 140 gl of PBST
number of household members mi- separately in plastic vials for 2 hr. The
tfjg case to arrive at the weightage score eluates were considered equivalent to a 1:40
flU5
■ e household. For instance, a PB case dilution of the sera.
foTthe
household of five constitutes a weightSynthetic glycoconjugate antigen (ND-Ol^eofS = R x (5 - 1)J. A single multi- BSA), supplied by IMMLEP. World Health
'lacillary (MB) case in a household would Organization (WHO), was coated on one
eet a score of 5, and multiple MB cases, a half of flat-bottom, microtiter plates (DyfJcoreofS.
natech, Germany). The other half was coat
|| js hypothesized that a case in a house ed with BSA alone in order to measure the
hold would contribute to a neighborhood nonspecific binding of the eluates. The coat
effect in terms of transmission of infection, ed plates were incubated overnight at 37°C
especially since the households and houses and then washed with PBST. The eluates of
in a rural setting are closely crowded. Risk the blood specimens were then applied in
tfactor scoring ranging from 1.5 to 2.5 was duplicate antigen and control wells. After
i. therefore resorted to for neighboring houses incubation and washing, peroxidase-conland households, and for one house all jugated. antihuman IgM (Dakko. Denmark)
^around the house in which the case was Io was added, and the plates were incubated
heated, keeping in mind the proximity of the and washed again. Following washing, chro
^inhabited structures. A house was defined mogenic substrate O-phenylene diamine and
?8S a structure, tent, shelter, etc., used for hydrogen peroxide in citrate buffer. pH 5.0.
Presidential or nonresidential purposes, or were added to develop color. The color was
-both. A household was defined as a group then read as absorbance at 490 nm using a
fof persons, who may or may not be related Dynatech ELISA reader.
Sto one another by blood, living together and
The serological data were linked to in
taking food from a common kitchen.
formation in the household schedules and
j All of the 135 clusters were weighted and analyzed by computer at CLTRI. The stan
a random sample of 20 clusters was selected dardized seropositivity ratio for contacts and
after stratification for size and weightage. noncontacts was calculated using the indi
jThe population sampled was 14.633. with rect standardization method.
a ratio of cases to household contacts, neighA contact was defined as a person who
^borhood contacts, and noncontacts of 1:5: had stayed for more than 6 months with
<10:30, respectively.
and was found in the same household as the
y Examination of the population for lep- case at the time of blood collection.
Jrosy was done by research officers, and con
RESULTS
firmation of the diagnosis of leprosy was
f based on clinical examination alone.
Sera from 4243 individuals (including 132
J Finger-prick blood samples were collect- leprosy cases) from seven clusters have been
• M from individuals in the study area on analyzed. The demographic particulars of
; Whatman no. 2 chromatography paper. this population are given in Table 1. Out of
Our spots (each at least 15 mm in diameter) the 132 cases examined, there were 10 MB
:*ere collected from each person: two spots cases and 122 PB cases. The disease prev
|
on a single 2.0 x 7.5-cm sheet of paper alence rate among females was 24.15 per
j2°wbich the identification particulars were 1000 and it was 38.19 per 1000 among
7 jmtten. The papers were air dried, placed males: 36% of the PB cases and 63.6% of
Z1P'Seal plastic bags, brought immediate- the MB cases were females. Seropositivity
:/yfothe laboratory’ at CLTRI and stored at (defined as OD > 0.200) was 12.7% in PB
until tested.
and 28.6% in MB cases (Fig. 1). All of the
I m 1 l^e r’me
testin8’ lhe blood speci- MB cases were under treatment for vary ing
I fjneihSWere Ia^en from the freezerand eluted penods (3 months to more than 1 year).
I Bine ioSp^aie'b»ufrereci saline (PBS) containFigure 2 shows that nearly 80%-90% of
I - OOso/0 k°vme serum albumin (BSA) and the population in the different age groups
f<t^d%Tween-20 (PBST). A 7-mm-diame- had low antibody levels. Seropositivity in
ISC (Contaming approximately 7 gl of the general (noncase = contact 4- noncon-
International Journal of Leprosy
428
199! 1
Krishnamurthy, et al.: PGL-I Seroepidemiology
3
i
•
CD
cCZ
^5
I
. .C
r
t
o ^1■ i.T-
r
. .c
“•“r
i
r
i n il
I
I
b
r
r. i L
Ia
-
I
I
Fig. 1.
. I
I
I
I
—I
I
I
I
x
I
I
I a nb
bi
I’/.’1--------
Antibody level against PGL-I (Absorbance 490) among paucibacillary and multibacillary leprosy
cases.
tact) population was 10.5%. Although the
peak of seropositivity is seen at 10 years, it
is sustained until the age of 30 years and
then shows a gradual decline (Fig. 3). Among
contacts the seropositivity was 14.5%: in
10
ts
I
10
6
i
r 0 Q02004= °7C 099120’ 49 17*199 220.249 27O.299 3 04324+
1
lCVEL ABS TO POJ
5
(XA490)
+ Fig 2. Distribution of IgM against PGL-I in the
«neral population.
; I!
i
b
I n ab
I t’.-rr
I
C
I .
I U.JbI
b
I . .C
J n./’i—
i —-b
I-
'.2
Fig. 3.
i
10
15
20
25
35
30
40
AGE N YEARS
45
55
SO
55)
Seropositivity among the general population.
I 11one in order to even out the differences in was found to represent three standard de
I n
I
n jr
c:
1*18 j
l
l
I
I
I
I
! —'b
I
b
'Ji V
Cb
b
I U./H
i
r
I . .c
I
r
n
1
I
1
I n nf
I ‘-’.or
!
L
I . .b
L
rC
-.6
I -’-j.
P8
b
n nf
•8
I
• » ____
I el • «
I
II
I n cc
•"b
h
c Ql.
429
noncontacts it was 13%. It was higher among
female contacts than male contacts (Table
2). The marginally higher rates are borne
out by the standardized rates for the two
groups of both sexes. (Standardization was
ic age structure between the contact group
id the noncontact group.) This difference,
iwever, was not significant.
16 BCG scar status as a variable was not
Studied because the BCG scar rate in this
^population was less than 10%.
DISCUSSION
J This study is part of a longitudinal im^jnimoepidemiological study being carried
fout in a highly endemic district (prevalence
10 per 1000) of South India. One of
7the objectives of the study was to see if
|BLISA using PGL-I could be used as a speT-dfic marker oi leprosy infection in endemic
populations. The determinate criterion for
Tippreciating the difference between infected
noninfected populations should be
jtasedon disease endemicity. In an endemic
|irea the criterion value is set at a decidedly
..high level to achieve reasonably unequivocal specificity. Positivity criterion of OD
^.0-200 was adapted-in the study because
e area is highly endemic, and the value
viations above the mean (4- 3 S.D.) of a
sample of sera from healthy persons in this
area. The finger-prick spots on Whatman
paper withstood the rigors of the field con
ditions. and the results obtained were com
parable with those of venipuncture sera (8).
Even though a higher positivity is seen in
MB cases, which could be explained on the
basis of a higher antigen load seen in these
cases, overall it appears surprising that in
both MB and PB cases the seropositivity is
low. The ven- low seropositivity (11%)
among cases could be due to the fact that a
majonty of the cases were PB and most of
the cases were under treatment. The prev
alence of seropositivity of 14.5% among
contacts compares well with the 14.4% ob
tained in an earlier study (4) carried out
among contacts in the same area using the
FLA-ABS test. The manifest default of dis
tinction between contacts and noncontacts
by this test appears disappointing. This pos
sibly could be due to the fact that in an
endemic area the intensity of exposure to
Table 1. Distribution of study population by contact status case. sex and ageAge group
(vr)
I
0-4
5-9
10-14
15-24
25-34
35-44
45 +
Total
Contact population
Male
30
43
34
54
35
18
26
240
(215?
Female
18
32
22
54
32
22
29
209
(187)
Noncontact population
Male
228
302
251
438
377
234
339
2169
(1843)
* Figures in parentheses = number of individuals examined.
Female
239
284
260
468
312
263
325
2151
(1866)
Table 2. Seropositivity rate among cases, contacts and noncontacts by age.
Leprosy
Male
Female
o-
0
1
8
11
5
8
24
57
2
15
22
15
13
25
92
0-4
•Cases
^Contacts
^gNoncontacts
0
12.5
5.14
5-9
0
6.98
15.19
10-14
15-24
25-34
35-U
45 +
Total
SSPR*
20
10.64
16.74
Males
10
13.04
13.44
20
12.90
12.11
8.3
11.76
10.7S
18.18
8.70
8.97
15.1
11.68
12.26
1.21
0.953
0.995
7.14
13.04
9.48
13.04
18.18
13.93
0.905
1.229
0.977
Females
20
12.5
10
0
0
25
^K^utacts
26.66
21.05
8.16
23.81
7.69
28.13
j^Bu^^ntacts
14.04
17.27
17.25
7.14
13.79
14.11
l5n^arcllzed seropositivity ratio using the indirect standardization method.
;ACases
i
a
430
. .
iI
International Journal of Leprosy
leprae is likely to be high and, at the
same time, the risk of exposure may be uni
form in the population.
The reason for a marginally higher sero
positivity among females is not clear. High
er seroprevalence rates among females were
reported in other studies as well (6-10). Case
rates among the female population in this
region are not higher than in males. An at
tempt has been made to explain this phe
nomenon on the basis of relative IgM globulinemia reported among females (‘1 •15) and/
or to a higher probability of seroconversion
among males (10).
The reason for the higher positivity rates
among adolescents and young adults, when
compared to other age groups, is not clear.
Seropositivity may be a transient phenom
enon and is perhaps reversible. What is re
ally interesting is that it parallels the case
prevalence pattern observed in the area.
It now appears that the excitement gen
erated a few years back by the introduction
of various serological tests, especially ELISA
using PGL-I, is waning because of the dis
appointing results that have been obtained
in several studies. PGL-I based on an ELISA
does not appear to be effective as a seroepidcmiological tool for diagnosing prcclinical
infection or of prognostic value for clinical
disease, at least in high-endemic popula
tions.
SUMMARY
As part of a continuing longitudinal immunoepidcmiological study, blood samples
were collected by finger prick from 4243
individuals living in a highly endemic area
for leprosy in South India. The samples were
tested for IgM antibodies against phenolic
glycolipid-I using an ELISA. Seropositivity
defined as optical density > 0.2000 was
marginally higher in the age group 10-30
years and in females. There was no evidence
for a higher level in contacts than in non
contacts. The future prospect for the large
scale use of this ELISA in high-endemic
populations in special epidemiological in
vestigations or routine control programs as
a serological tool to detect leprosy infection
appears questionable.
RESUMEN
Como parte de un estudio inmunoepidcmioiogico.
se colectaron muestras de sangre por puncion digital
^3
Krishnamurthy, et al.: PGL-I Seroepidemiology
(S’j
l^soflepr05/- Indian J. J'•or. 62 (1990) 296de 4243 indr
is habitantes de un area al ' ‘ ”3
endemica del.
^e la India. Las muestras se ian>e’*e
- S J- Draper, P., Pa.ne, S. N. and Rees.
para la busqueda de anticuerpos IgM in
1
^ett.
Serological activity of a characteristic
glicolipido fenolico-I usando un ELISA. La
1
jlJ- *■
)Uc glycolipid from Mycobacterium leprae in
tividad. definida como una densidad opticT031**’
“ ‘-noEt sssr
mayor a 0.2000. fue marginalmente mayor en
ffrom patients with leprosy and tuberculosis.
Exp. Immunol. 52 (1983) 271-279.
de edad entre 10 y 30 anos y en mujeres. No
j
evidencias de que los niveles de anticuerpos fiX? 1 I® tocHANAN. T.. Dissanayake. S., Young. D. B..
mayores en los contactos que en los no contacuxS^ I [R- A-’ Acedo' J- R" Harn1SCH’ J- plo tanto. la utilidad de este tipo de ELISA com u 1 HK^unolkar. s. R. and Estrada-Parra, S. Evaltion of the significance of antibodies to phenolic
rramienta para detectar la infeccion leprosa en 1
1
^coiipid of Mycobacterium leprae in leprosy patudios a gran escala en poblaciones altamente
3
[ W tents and their contacts. (Abstract) Int. J. Lepr.
micas, parece ser muy cuestionable.
id
'.WO 51 (1983) 658-659.
Cartel. J.-L.. Chanteau. S.. Boutin, J.-P..
/W Puckart- R- Richez. P.. Roux. J.-F. and GrosRESUME
set J.-H. Assessment of anti-phenolic glycolipidj IgM levels using an ELISA for detection of M.
Dans le cadre d’une etude immunoepidemiologjq® j
leprae infection in populations of the South Pacific
longitudinale. des echantillons sanguins ont ete
’J
Islands. Int. J. Lepr. 58 (1990) 512-517.
leves par piqure au doigt chez 4243 personnes viva ' ]
S.-N.. Yanagihara. D. L., Hunter, S. W..
dans une region a forte endemicite de lepre dans le Sod 1
de ITnde. Les echantillons ont ete testes par un ElJSA I ^KGelber. R- H. and Brennan. P. J. Serological
L®. specificity of phenolic glycolipid I from Mycobacpour rechercher la presence d'anticorps IgM vis-J-vg
$$$terium leprae and use in serodiagnosis of leprosy.
du glycolipide phenolique-I. La seropositivitc defiw
rInfect. Immun. 41 (1983) 1077-1083.
comme une densite optique > 0.2000, etait legeremeo
Dhandayuthapani. S.. Anandan, D.. Vasanthi.
supcrieure pour le groupe d’age 10-30 ans et pour la
B-andBEATix. V. N. Use of eluates of filter paper
femmes. Il n’y avail pas d’evidence de taux pluselevii
,blood spots in ELISA for the serodiagnosis of leppour les contacts que pour les non-contacts. La per
i^Pprosy. Indian J. Med. Res. 89 (1989) 150- I 57.
spective d’une utilisation a grande echellede cet ELISA
Fine. P. E. M. Leprosy—the epidemiology of a
comme un outil scrologique pour detecter I’infectke
fellow bacterium. Epidemiol. Rev. 4 (1982) 161lepreuse dans les populations a haute endemicite pow
des rcchcrches cpidcmiologiques particulieres ou pour
H88.
des programmes de routine de lutte centre la lipre.
i. Fine, P. E. M.. Ponnighaus. J. M.. Burgess, P..
Clarkson. J. A. and Draper. C. C. Scrocpidcapparait discutable.
miologica: studies of leprosy in northern Malawi
based on an ELISA using synthetic glycoconjugate
^gmtigen. Int. J. Lepr. 56 (1988) 243-254.
Acknowledgment. This investigation received frnancial support from the UNDP/World Bank/WHO
Special Programme for Research and Training in Tnx>
ical Diseases (TDR). The authors are thankful to Mr
Muthukumar Muthuknshnan and Mr. Balakrishn*
Chengalvarayan. senior computers at Central Lepm5.
Teaching and Research Institute. Chengalpattu, I
for their assistance in data entry and the computenz*
lion process.
REFERENCES
1. Abe. M.. Minagawa. F.. Yoshino, Y.,
Saikawa. K. and Saito. T. Fluoresce*
antibody absorption (FLA-ABS) test or
subclinical infection with Mycobacten
Int. J. Lepr. 48 (1980) 109-119.
2. Bharadwaj. V. P.. Ramu. G. and
A preliminary repon on subclini
leprosy. Lepr. India 54 (1982) 220'2<naK
3. Bhatia. V. N.. DhandayuthapaM. 5.,^
D., Rajendran. M.. Vasanth, B-. A
.
and Vinod Kumar. C. H. D.
tion with.\fycobacterium leprae in o
431
11. Grundbacher. E. J. Human X chromosome car
ries quantitative genes for immunoglobulin M.
Science 176 (1972) 311-312.
12. Hunter. S. W. and Brennan. P. J. A novel phe
nolic glycolipid from Mycobacterium leprae pos
sibly involved in immunogenicity and pathoge
nicity. J. Bacteriol. 147 (1987) 728-735.
13. Kuatser. P. R., de Wit, M. Y. L. and Kolk. A.
H. An ELISA-inhibition test using monoclonal
antibody for the serology of leprosy. Clin. Exp.
Immunol. 62 (1985) 468-473.
14. Maddison. S. E.. Stewart. C. C., Farshy. C. E.
and Reimer. C. The relationship of race. sex. and
age to concentrations of serum immunoglobulins
expressed in international units in healthy adults
in the U.S.A. Bull. WHO 52 (1975) 179-185.
15. Melsom. R. Serodiagnosis of leprosy: the past,
the present, and some prospects for the future. Int.
J. Lepr. 51 (1983) 235-252.
16. Menzel. S.. Harboe. M., Bergsvik, H. and Bren
nan, P. J. Antibodies to a synthetic analog of
phenolic glycolipid-I of Mycobacterium leprae in
healthy household contacts of patients with lep
rosy. Int. J. Lepr. 55 (1987) 617-625.
17. Serological Test for Leprosy. (Editorial) Lan
cet 1 (1986) 533-535.
18. Sinha. S.. Sengupta, U.. Ramu. G. and Ivanyi.
J. A serological test for leprosy based on com
petitive inhibition of monoclonal antibody bind
ing to the MY2a determinant of Mycobacterium
leprae. Trans. R. Soc. Med. Hyg. 77 (1983) 869871.
19. Young. D. B. and Buchanan. T. M. A serological
test for leprosy with a glycolipid specific for My
cobacterium leprae. Science 221 (1983) 1057-1059.
krutzr rtutiUfiui jumnai Uj
fects of the AIDS epidemic on the tuberculosis
problem and tuberculosis programmes. Bull. Int.
Union Tuberc. Lung Dis. 63 (1988) 21-24.
18. Ter el, J. L., Liano, F., del Hoyo, M.. Rocamora. A., Mompaso. E. G., Quereda. C. and Ortuno,
J. Successful kidney transplantation in leprosy and
transiton .-ecurrence of the disease. Int. J. Lepr.
53 (1985) 410-411.
19. Turk. J. L. and Rees, R. J. W. AIDS and leprosy.
Lepr. Rev. 59 (1988) 193-194.
Added in proof: Since submission of this
paper two other recent investigations on HIV
and leprosy have been brought to our at-
tention Neither found any evidence f
associ
n between the two conditio^11 j
I
Ka • I b
Effect ^f BCG on the Risk of Leprosy in an
Endemic Area: A Case Control Study1
Leonard, G., Sangare. A., Verdier
sou-Guesseau, E„ Petit. G., Milan, j.
.
S., Rey. J.-L., Dumas. J.-L., Hugon, j’., >^*’1
oro. I. and Denis. F. Prevalence of HlV inL^*’ |
Jayaprakash Muiiyil, Kenrad E. Nelson, and
among patients with leprosy in African
Earl L. Diamond2
and Yemen. J. Acq. Immun. Defic. Syndr
1109-1113.
’
.
Tekle-Haimanot, R.. Frommel, D., Tade^e t '
£
Abebe. M.. Verdier. M. and Denis, F. a
A 2 lyxhere has been considerable uncertainty troduced, primarily as an antituberculosis
of human T-lymphotrophic virus type 1 and^ • i
girding the effect of BCG vaccination on vaccine, in a high incidence area for leprosy
man immunodeficiency viruses in Ethiopian
;
Ksk of developing leprosy. Even though in the state of Tamil Nadu. India. Our study
rosy patients. AIDS (in press).
I
IfI
It
B-
-4
#
Lrt is experimental evidence to suggest a
Elective effect (,0-21-23), major field trials
Ee failed to produce consistent results,
rfc study from Uganda (25) showed 80%
Action, while studies from Papua New
Enea (18-20) and Burma (*) showed 46%
E20% protection, respectively. A study
Jfrn India showed 23% protection (Triyhy S. P. Chingleput trial of the proteceffect of BCG against leprosy. Paper
resented at the Sixth IMMLEP SWG
Herting, Geneva. June. 1982). More rejfwtly, a case-control study from Malawi
lowed 50% protection (l2). The variation
■ the protective efficacy of BCG in these
todies has been postulated to be related, in
to variations in the intensity of exjosure, prevalence of other mycobacteria
providing some protection, differing strains
iMycobacterium leprae, and genetic susJtptibility of the populations in these stud-
1ip.
f At present, several field trials are being
fanned or are in progress in different parts
Ifthe world to measure the protective effect
various mycobacterial vaccines against
(12)- A fresh look at the effect of BCG
.•ay help in planning these studies and in
?^retmS the results. Using a case-control
we have evaluated the efficacy of
tn leprosy prevention since it was in-
r
fi
i
f°r Publication on 4 September 1990:
for
tor publication
Publication in revised form on 7 January
■^3
■W
i
i
volume jy, inuihuvi
Printed in the U.S.A.
journal of Leprosy
^Co^’ M-D-- Dr.P.H.lEpid.), Associate ProtestCoSTUn,ly Hcalth Department. Christian MedKM.D epVellore
902. South India. K. E. NelPj-’p Otessor 111 Epidemiology. E. L. Diamond.
** ^ubl° eu°r 01 EPl<lem,ology. School of Hygiene
^8sioreCJr ea*lh- The Johns Hopkins Univcrsitv.
^eprindryland 21205. U.S.A.
g requests to Prof. Nelson.
raises interesting methodologic questions
concerning the efficacy of BCG and suggests
that the vaccine may have differential effi
cacy in different types of leprosy.
METHODS
Study area. The state of Tamil Nadu in
India is known to be highly endemic for
leprosy. The prevalence of leprosy in the
Indian stales of Tamil Nadu and Andhra
Pradesh has been reponed to be about 20
per 1000 (5). BCG vaccination against tu
berculosis has been done in Tamil Nadu
since 1960. Therefore, this area offers an
ideal setting for measuring the protective
effect of BCG vaccination against leprosy
using a case-control design (24).
The study was carried out in the leprosy
control project area of the Department of
Community Health. Christian Medical Col
lege. Vellore. The project has responsibility
for a rural population of about 200.000 per
sons. The annual case detection rate is about
2.5/1000. Leprosy surveillance and diag
nosis is done in accordance with the guide
lines established by the National Leprosy
Eradication Programme of India. Case de
tection occurs through various surveys and
voluntary reporting. By 1983 the entire
population had been covered by a general
survey at least once. The information per
taining to the members of each household
was recorded sequentially on separate pages
in the general survey register during the
house-to-house survey. These registers, with
200 pages each, played a key role in the
design and conduct of our study.
Initially, BCG vaccination (1331 Copen
hagen strain) was offered to all Mantoux
negative individuals younger than 20 years
of age as pan of the National Tuberculosis
t
1
(
V
I
Control Programme. Pretesting with Man type of house, ii) occupation, iii) iac
toux was subsequently discontinued. Dur ership, iv' ‘ imber of years spent in‘"down.
J School
ing the early 1970s school children formed and y) le'
yf education of the hl.ghes
t£
the main target population of the BCG team. ucated individual in the family.
By 1980 the vaccine was being offered
Exposure to BCG was ascertained
the
mainly to newborns at the hospitals and to nonmedical supervisor by
lookir f"0»y;' .7
oy looking
the infants at the under-five clinics. The rate typical scar over
(
the deltoid region. Th •
vas recorded as positive n615'
of vaccination in the control population was formation was
ivocal. Individuals with eq?*
42%; rates varied from 26% for those 5-9 tive, or equivocal.
years of age to 56% in those 20-24 years ocal BCG scars were excluded from 2
old.
analysis. Every effort was made to maskth>
Study population. All newly detected BCG reader regarding the clinical status^
cases of leprosy, aged 5-24 years, from the subjects by presenting them as a mix^
among the resident population of the proj group and exposing only their deltoid region,
ect area during July 1986 to June 1988 were to the reader. Controls were examinS to
included in the study. .All individuals whose rule out any clinical evidence of leprosy
names appeared in the general survey reg Similarly, all other members of the housl
ister by 1983 were considered residents of hold were also examined. Information on
the area. The cases were subjected to a skin the presence of an extra-household family
smear examination and classified by trained member with leprosy and the socioecophysicians using the Ridley and Jopling nomic characteristics of the household were
classification into tuberculoid (TT). border- obtained by interviewing the subjects and
line tuberculoid (BT). borderline (BB). bor- the adult members of the family.
derline lepromatous (BL), and lepromatous
The data were analyzed on an IBM com
(LL) leprosy (l7). Macular lesions with puter (Model 4381) using the Statistical
equivocal loss of sensation were classified Analysis System (SAS) package. Unas indeterminate leprosy. Histopathological matched logistic regression was carried out
examination was earned out only in doubt with the Logiest program prepared by Frank
ful cases. Cases were identified by general E. Harrcl. Jr. Matched set logistic regression
survey (86 cases), school survey (141). con (-) was done with the McStrat program
tact exam (22), voluntary referral (76). and prepared by James N. Naessins, et al. (SAS
other means (72).
Inc.. 1986). These procedures indirectly
Controls were chosen from among the measure the odds ratio (OR), which is the
resident population and they were matched ratio of the odds for the disease among the
with a case for age (± I year), sex. and lo exposed to that among the unexposed. Ina
cality. Matching for locality was achieved relatively rare disease, such as leprosy, the
by selecting the controls from the same gen odds ratio gives a good estimate of the rel
eral survey register to which the cases be ative nsk (1 -odds ratio) % gives the protec
longed. A table of random numbers up to tive effect of the vaccine.
200 was used to identify the page number
RESULTS
in the register from which the search for
During the study period. 421 eligible cases
each control was to start. Two controls were
chosen for each case younger than 1 5 and were detected; 405 cases and 694 controls
were followed up. BCG was recorded a5
one control for each older case.
Cases and controls were visited at their equivocal for eight cases and 25 controls_ ___ consisting
_.o
___ of
________
homes by _a team
the investiand these have been excluded from the io'
gator. a 1nonmedical supervisor, and the lep- lowing analysis. Thus, there were 397 cas^
rosy paramedical worker. The following in and 669 controls available for unmaten
formation was obtained regarding the cases analysis and 380 cases and 625 contro
and controls: a) presence of BCG scar: b) available for matched set analysis.
The distribution of cases according10
presence of a known case of leprosy in the
household: c) presence of previously un and sex is shown in Table 1. The ^strl
known case in the household: d) presence tion of cases according to the type oflep
of a case among the extra household rela and nerve involvement is shown in * «
tives; e) socioeconomic characteristics: i) 2. Three of the six BL cases were stu
Distribution of cases according
ItabLE 1;
md
sex.
_____
^gge er.. • foups
W
w1^14
F115-19
W 20-24
Total
Table 3. Comparison of cases and con
trols by age, education, and family size.
Totals
Males
Females
(°/o)
(%)
(%)
49
(20.0)
105
(42.9)
60
(24.5)
31
(12.7)
47
(30.9)
58
(38.2)
31
(20.4)
16
(10.5)
245
(100.0)
152
(100.0)
96
(24.2)
163
(41.1)
91
(22.9)
47
(H.8)
397
(100.0)
% slit-skin smear and were bacteriologi■^ally positive.
^Several socioeconomic and demographic
Lracteristics in the control population were
iimificantlv associated with the presence of
Arnone these
BCG crar
scar. Among
these were
were age
age and
and sex:
sex:
57.2% of males and 33.5% of females had
Ibcg scars. The number of years of edu
cation of the individual and the duration of
■Sucation of the highest educated member
Jof the household were both associated with
|BCG vaccination. Also, the type of housing
Bind land ownership were surrogates for the
Jjocioeconomic level of the family; both corSrelated with BCG vaccine status. Housing
4fype was classilied as “pucca” if it was ot
Jgbrick construction with a tiled or cement
5jroof hut (or “katcha”) if it had mud walls
^ind had a thatched roof, or “semipucca” if
j||ftwas between the above two in construc-
Ipcn.
Analysis of the distribution of these char.Jlcteristics among the cases and controls
l^lhowed they were well matched by age. ed
ification, years of schooling of the most edy ucated in the familv, and familv size (Table
o
Age
No. years in
school
No. years in
school of
highest
educated in
household
Size of family
Cases
Controls
(mean ± S.D.)
(mean ± S.D.)
13.13 ± 4.88
12.30 ± 4.43
5.34 ± 3.11
5.32 ± 3.06
8.18 ± 2.84
6.74 = 1.85
8.34 ± 2.94
6.93 ± 1.81
3). /Also, cases and controls were well
matched by occupation (Table 4) and by
housing type (Table 5).
The unmatched analysis showed that BCG
was
not significantly
associated with the risk
-----------o----------- .----of leprosy (Table 6). The presence ofa known
case in the family appeared to increase the
risk of the disease considerably (odds ratio
= 4,75. x2 = 89.7, p < 0.001).
Exposure to noninfectious (I, TT, BT) and
infectious (BB, BL. LL) leprosy cases within
the family increased the nsk for the disease
2.7 times and 11.7 times, respectively, when
compared to those having no familial cases
in the household (Table 7). Similarly, there
was a significant association between having
an extra familial case in the household and
the nsk of leprosy (OR = 1.7). Age and sex
did not appear to significantly modify the
effect of BCG on the nsk for leprosy (Table
8)When the effect of BCG on the risk of
developing the different types of leprosy was
studied, an interesting pattern emerged.
Table 4. Distribution of cases and con
trols by type of work of head of household.
./J:
^.4. Table 2. Frequency of nerve involvement
leprosy type.
I
Total
| BT
25
303
61
B fit
S^Total
1
No.
%__
0
11
24
1
4
0
3.6
39.3
50.0
66.7
Laborer
Small fanner
Self-employed
Medium farmer
Artisans
Clerk/Teacher
High income
None
Not known
10.1
Total
Nerve involvement
r leprosy
I type
6
397
Cases
Occupation
40
Controls
No.
%
No.
%
179
50
65
26
267
80
89
59
28
105
17
5
39.9
12.0
13.3
8.8
49
9
1
2
45.1
12.6
16.4
6.5
4.0
12.3
2.3
0.3
0.5
19
15.7
2.5
0.7
2.8
397
100.0
669
100.0
16
Table 5. Distribution of cases and con
trols- by type of housing.
Housing
type
Pucca*
Semipucca'
Hur
Total
Cases
No.
100
103
180
383
Controls
%~~
26%
27%
47%
100%
%
No.
182
182
286
650
r
28%
28%
44%
100%
BCG appeared to increase the risk of de
veloping indeterminate leprosy (OR = 2.7),
but when one went down the spectrum from
tuberculoid to borderline diseases, there was
a gradual increase in the degree of protec
tion associated with BCG (Table 9). BCG
was found to offer 61% protection against
Borderline forms of leprosy after adjusting
for significant confounders in a matched set
analysis using multiple logistic regression
(Table 10). Variables adjusted for this anal
ysis included the following: a) having a
known case in the family, b) having an in
fectious or noninfectious case in the house
hold. c) having an extra-household relative
with leprosy, d) being a laborer.
DISCUSSION
Malching the cases and controls for the
general locality of the household appears to
ha\ e created a good balance between cases
and controls with respect to many of the
socioeconomic factors which could have had
a bearing on the chance for receiving BCG.
on the one hand, or the risk of disease de
tection on the other. The magnitude of the
association between infectious and nonin-
k
Table 6. Effect ofselected risk factors on
risk of leprosy: unmatched analysis (uni
variate).
Odds
ratio
BCG
Infectious case
in family
Noninfectious
case in family
Extra house
hold family
case
Landless
laborer
-
95%
Confidence
interval
0-172 I
3.97-34.71
2.73
1-90-3.92
1.74
1-09-2.80
Odds ratio ±
S.E.M.
p
BCG
Known case in family
Own land
In school >5 years
Living in a hut
Having anyone in house
with >8 years in
school
0.82 r 0.13
4.75 ± 0.17
0.99 ± 0.13
0.98 ±0.13
1.02 ± 0.13
0.12
< 0.001
0.925
0.875
0.844
0.928
Males
0.84
0.65
0.54-1.30
0.35-1.22
0.434
0.77
0.54-1.10
0.155
102(192)
39 (46)
Females
0.63
0.71
0.34-1.16
0.30-1.70
0.136
0.422
All females______ 141 (238)
0.65
0.40-1.00
0.422
AU males
151 (288)
88 (99)
239 (387)
<04)0
0.021 I
I 5-14
I 15-24
Odds ratio
0.179
• Figures in parentheses are number of controls.
1.26
0.94-1.68
Q.JZ? 3
*, .All . of
. the ,above risk factors
— were simuli
entered into the model so
<_ that
:1__ the
• independenT
1Kgsfarillary to multibacillary leprosy. There
tnbution of each factor to the
61% protection against borderline types.
outcome of a kjra, j
infection could be assessed.
Rffilthough the finding appears to be para-
5-fioxical at first glance, this may offer a new
fectious intra-familial cases and risk of (fa. 1 M&ifight into the manner in which BCG afthe natural history of the disease. M.
ease is similar to that reported by the other
infections elicit a highly variable reworkers (s-9-16).
K|iponse in the host, ranging from subclinical
BCG was found to increase the risk of '■
JOifection to polar lepromatous leprosy. A
indeterminate leprosy while offering pn>
tection against the borderline forms. The 1 KjpMjority of the indeterminate and some of
tuberculoid cases may heal spontanepoint estimates of the odds ratio suggest is- ;
KSjwsly, and may not contribute substantially
creasing protection as one goes down the 1
Public health importance of the disspectrum from the indeterminate to pao- ]
I ;3-ttse (4’13-14). Following vaccination with
I JBCG, the host immune response may be
Ijlhifted to the ieft (The Figure), resulting in
Frecuency of reoonse
I Jlgreaterpropomon of individuals respond- ---t0 infeetion with subclinical disease and
FJBdetcrminate leprosy and a smaller prof?®>rtlon manifesting borderline forms of the
I ^disease. This
’ wouldy explain
__ _ the
__ variability
_ ___
BCG
[^the protection ofiered by BCG withi reL''
t0 the different types of leprosy.
Klak
' k 6 resu^s the BCG trial in New Guin: it-itthad some similarities to our findings (20).
tbcut
3CG
W e^’ t^le Prolective efficacy against in-
determinate, tuberculoid, and borderline
tuberculoid forms in the New Guinea trial
were 20%, 27% and 69%. respectively.
However, the protective efficacy against
what probably was BB/BL and LL disease
was 39% and 40%, respectively. The Uganda
trial found 80% protection: all cases but one
in this study were tuberculoid.
The findings of this study also offer a pos
sible new explanation for the variation in
the protective effect of BCG reported by the
major field trials. The study from Uganda,
which reported the greatest protective effi
cacy of BCG, was designed in such a wav
_____
that the________________
duration between_examinations
was
about 3 years (-5). This implies that the investigators would have missed many of the
self-healing forms, and were dealing with a
higher proportion of persistent cases. In the
Burmese study, on the other hand, the subjects were examined annually and a greater
proportion of earlier and transient forms
would have been detected (‘). If BCG causes
a shift in the immune response, it is con
ceivable that the vaccinated population mav
manifest a higher risk for these transient
\ \
^ble 9. Effect of BCG according to type of leprosy; matched set analysis using logistic
“ ssion (univariate).
\
\
^Prosy type
o1—1— —i----------a_______ i_______ 12:
sub ci.
Ind
TT
ST
SB
BL
Immunological spectrum
1.00 - 0.13
P
No. sets*
< Oj)Q |
Protection
Risk factor
95% Confidence
interval
^ge group
(yr.)
5-14
I 15-24
0.80
11.74
233
LE 8. Effect of BCG on leprosy by age and sex; matched set analysis using logistic
lion.
Table 7 Association between sei
factors
------- - Ma
eprosy; matched set
ing multiple logistic regression
Risk factor*
* Brick construction with
tiledor cement roof.
------Between pucca and hut.
c Mud walls and thatched roof.
I
iviuuyu, ci di., zjcir reject on Leprosy kisk
journal oj Leprosy
I
The Figure. Hypothesized effect of BCG
immunological spectrum of leprosy.
U-
No. sets*
Ind.
23 (41)
IT
291 (489)
BT
59 (85)
■ BB/BL
7(10)
^?^BB/BL
66 (95)
Ptures in
Parentheses are number of controls.
Odds ratio
95% Confidence
interval
2.76
0.78
0.32
0.25
0.85-8.97
0.56-1.09
0.14-0.73
0.03-2.22
0.31
0.14-0.67
P
0.092
0.150
0.006
0.250
0.003
r
the effect of moving the odds
have
to unity (*3), thus providing a
^5 closer
of risk ft determinate lep■restin1316
75% Confidence
?ction
agaii.-- oorderline forms.
Leprosy type
Odds ratio
No. setsb
protec
interval
P
BEnv"had there been self-selection bias
Ind.
23 (41)
2.74
0.84-8.95
^S^’nect to vaccination, the association
TT
291 (489)
0.85
0.59-1.22
0373
been unidirectional for the enBT/BB/BL
66 (95)
0.39
0.17-0.83
o*O3$ M
a Adjusted for a) belonging to a family with known case: b) having an infectious or noninfectious case'^' - ^SSSon, our study found that BCG
conciubivu,
household; c) having an extra-household relative with leprosy; d) being a laborer.
10
W** s about 60% protection against borderb Figures in parentheses are number of controls.
‘.,^3 of
leprosy probably_______
by bringing
forms
<___
^irt'ashift in the immune response to a
level of cell-mediated immunity. This
forms of leprosy (4-,l-13- H4). This hypothesis the degree of protection offered by the vac.'1
^appeared to cause an increase in the
is also consistent with the: reports on “BCG- cine
needs to
be studied
Cnnim* 1
----------------------------— further. Convift
induced Leprosy” (26).
experiments with the immunotherapy
'
i for milder forms of the disease. From
public health point of view, BCG should
From a public health point of view, lep cases appear to suggest that immunization
rosy cannbt be considered to be simply a with some M. leprae-dtnNQd vaccines may - ^recommended for the prevention of lepdichotomous phenomenon. A vaccine that be useful even after exposure to At. lepr^ J
until a better vaccine is available. In
|ELning field trials to measure the protecprotects against the more serious forms of (6-7).
|£^cts of other mycobacterial vaccines
leprosy might be recommended even if it
A case-control study of the type we per.
’
increased the risk for milder transient forms formed is more easily done in <developing
leprosy, efforts need to be made to
■;
Sflionstrate type-specific protection against
of the disease. This study also highlights an countries with limited resources than isa
important issue related to designing field placebo-controlled vaccine trial. Of course, J SEvarious types of leprosy in addition to
trials of vaccines against leprosy. The em there are several sources of bias that need
-U^erall protection.
phasis should be on type-specific protec- to be considered in interpreting case-control j
SUMMARY
tion, rather than on overall protection. Since studies of this type. Most importantly, the •
classification of early lesions may be diffi controls should be selected from a popula
OThe effect of BCG on the risk of leprosy
cult and since one is ethically obliged to tion having a similar risk of exposure to
Wm measured using a case-control design in
treat all detected cases promptly, too fre leprae, of diagnosis of leprosy, and acces
area endemic for the disease. In this study,
newly diagnosed cases and 669 controls
quent a follow up of subjects may provide to vaccination. In order to obtain unbiased
misleading information on the true impact estimates, it is important that the proba- : Matched for age, sex and locality were seof the vaccine (14). Another issue in vaccine bility of selection on the basis of outcome ; MCted from a defined population. Infortrials relates to the duration of follow up is independent of the probability of selec
Mtttion on exposure to BCG. contact with
Ottother case of leprosy, and relevant sociorequired to reliably estimate vaccine effi tion by vaccination status.
We attempted to minimize bias by se
^tonomic variables were obtained from the
cacy. Since multibacillary leprosy may have
;gBbjects. Having infectious (multibacillary)
generally longer incubation penods than in lecting controls from the same population
/yind noninfectious (paucibacillary) contacts
determinate or paucibacillary types ("), a as the cases. When we examined the con
study that is not continued for a sufficient trols and cases stratified by various socio- ; TPthe household increased the risk of dis7 K 11.7 times (p < 0.001) and 2.7 times
length of time may underestimate vaccine economic variables, namely, occupation,
education, education of household head.
.< 0.001), respectively. Overall, the pro
efficacy.
ton offered by BCG was not significant
Since there were no cases of lepromatous type of house, and land ownership,
leprosy in this senes among patients aged groups were similar in distribution. As
- ids ratio = 0.8: p — 0.17). However. BCG
5-24 years, we cannot draw any conclu expected, many of these socioeconomK
t0 increase the risk for indeter^■^P^te leprosy (adjusted odds ratio = 2.7:
sions on the effect of BCG with respect to variables were correlated with BCG vaCC1
^09) while protecting against borderthis type of disease. The age at vaccination nation status. Controls and cases
disease (adjusted odds ratio = 0.39: p
of the subjects in our study was not known. matched by age. sex. and geographic
gj. )• is possible that BCG causes a
It is extremely unlikely that any of our cases residence. The matched analysis
wcic vaccinated
vauciiiaicu unci
me miovi
GmimateJ bias
Liao related
luaicu to
id SCVCral
1
the overall cell-mediated immune
were
after the
onset m
of leprosy. eliminated
since by 1980 BCG was used exclusively graphic and socioeconomic characters
g°nse, thus increasing the risk for milder
among newborns and in the under-five clin- Residual
Residual bias,
bias, such
such as
as the
the presence
presence ol
ol3^^ 1 || gtransient forms of leprosy while proics. Unfortunately, since they were not in
in the
the household,
household, was
was adjusted
adjusted for
for 33
j g
against more serious forms. These
available we could not verify the time of tivariate analysis (Table 10).
--I h gj^may have important implications
jfa. 5 design and interpretation of vaccine
BCG vaccination with medical records. The
Random misclassification could ha _
gj- Namely, trials should be designed to
’j
effect of the temporal relationship between currcd in exposure ascenainment
n^nmmpnt an
e the protective efficacy of vaccines
vaccination and exposure to .\f. leprae to lection of cases and controls. This, no
Table 10. Effect ofBCG by type ofleprosy*; matched set analysis using multiple I
regression.
■!
i
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- :—■—
i
/
''
against the more serious forms of leprosy,
which have the greatest public health sig
nificance.
RESUMEN
Usando un programa disenado para el control de
casos en un area endemica de lepra, se midio el efecto
del BCG sobre el riesgo de desarrollar la enfermedad.
Para el estudio, se seleccionaron 397 casos recien diagnosticados y 669 individuos control similares en cuanto a edad, sexo y localidad. De los participantes se
obtuvo informacion sobre exposicion al BCG. contacto
con otros casos de lepra, y aspectos socioecondmicos
relevantes. Los resultados senalaron que el tener contactos infecciosos (multibacilares) y no infecctosos
(paucibacilares) dentro de los convivientes. aumento
el riesgo de la enfermedad 11.7 veces (p = 0.001) y 2.7
veces (p = 0.001). respectivamente. Aunque en lo gene
ral, la proteccion conferida por el BCG no fue significativa (relacion entre grupos = 0.8; p = 0.17). el BCG
parecio incrementar el riesgo para lepra indeterminada
(relacion = 2.7; p = 0.09) al mismo tiempo que parecio
proteger contra formas intermedias de la enfermedad
(relacion = 0.39; p = 0.03). Es posible que el BCG
cause un cambio en la respuesta inmune celular gene
ral. aumentando el riesgo para las formas leves y transitorias de la lepra y protegiendo contra las formas mas
severas. Estos hallazgos pueden tener imponantes impiicaciones en el diseno y en la intcrpretacion de los
resultados de los programas de vacunacion; esto es, los
cnsayos de campo deben disenarsc para medir la eficacia protectora de las vacunas contra las formas se
veras de la lepra, las de mayor importancia en salud
pubhea.
<
RESUME
L'influcncc du BCG sur Ic risque de Idpre a etc mcsure par une etude de type cas-lcmoin dans une region
endemique pour la maladie. Dans cotte etude. 397 cas
nouvcllemcnt diagnostiques ct 669 temoms appanes
pour Tage. le sexe et la locaiite ont cte selectionncs d
partir d’une population definie. Des informations sur
I'exposition au BCG. un contact avec un autre cas de
Idpre. et des variables socio-economiques pertinentes
ont etc rccoltees chez ces personnes. Lc contact domiciliaire avec un malade infectieux (multibacillaire)
ou non-infectieux (paucibacillaire) augmentait le nsque
de maladie respectivement de 11.7 fois (p < 0.001) ct
2.7 fois (p < 0.001). Dans I’ensemble. la protection
offerte par le BCG n'ctait pas significative (odds ratio
= 0.8; p = 0.17). Cependant. le BCG semblait accroitrc
le risque pour la lepre indeterminee (odds ratio ajuste
= 2.7; p = 0.09). mais protcgeait contrc la forme bor
derline de la maladie (odds ratio ajuste = 0.39; p =
0.03). Il est possible que le BCG provoque une mod
ification dans la reponse immunitairc de type cellulaire. augmentant done le risque pour une forme plus
benigne ct transitoire de lepre. mais protegeant contre
les formes plus severes. Ces observations peuvent avoir
• 4
%
236
des implications importantes pour la conception et 1’interpretation de’essais de vaccination. Plus precisement, des essais devraient etre census pour mesurer
1’efficacite protectrice des vaccins centre les formes plus
sevdres de la lepre. qui ont la plus grande signification
du point de vue de la sante publique.
Acknowledgment. We are grateful to the Damien
Foundation Belgium and to the Ford Foundation.
U.S.A., for supporting this study and to Professor
Abraham Joseph. Head of the Department of Com
munity Health. Christian Medical College, lor his en
couragement.
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i
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‘
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, ®
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;
■<
•
°fthe
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W
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or
24. Smith. P. G. Evaluating interventions
|
multidrug (WHO; MDT) treatment for pautropical diseases. Int. J. Epidemiol. 16(1987)
■i wonanesthetic patch was classified as indei ^terminate leprosy. A well-defined, hypopig- cibacillary leprosy (8) consisting of rifampin
166‘
\< as* 1
600 mg administered once a month under
25. Stanley. S. J.. Howland. C.. Stone. M.
|
anesthetic patch or a well-defined
Sutherland. I. BCG vaccination against 1^ I
supervision for 6 months along with dap
anesthetic plaque was clasin Uganda: final results. J. Hyg. (Camb.)87( ■
g
tuberculoid leprosy. An ill-defined sone (DDS) 100 mg daily for the same pe
233-248.
| SKpcsthetic or anesthetic patch or a plaque
riod. Children were given appropriately
26. Wade. H. W. BCG induced activations1
smaller doses. Regimen II consisted oi dap
Lepr. 28 (1960) 179-181.
sone monotherapy with daily doses ot 50
g^^
v
ed
for
publication
on
29
J
unc
1990;
accepted
27. Watson. J. D. Prospects for new generan
mg for 5 years. Patients on Regimen I were
’
cation
in
revised
form
on
4
January
1991.
cines for leprosy: progress, barriers.
seen once a month for the initial 6 months
g^Mathai,
M.B.B.S..
D.D..
F.R.C.P.(G):S.
George.
strategics. Int. J. Lepr. 57 (1989 ) 834-84^
M D ’ M >; A M-S ‘- M- Jacob- M-B.B.S.. and then at intenals of 6 months up to 2‘/a
fej/y-S•’ Professor and Head. Department ot Dcr- years from the time of initiation of treat
Medical College & Hospital. Velment. Patients on Regimen II were seen at
K*?004. South India.
intervals of 6 months.
reciuests to Dr. George.
,
)■
.gjll
237
’Bck
, 394
.S Husain ct al.
I.cpr R,. ,1991) 62, 395 40!
match and healed better. The results were satisfying to the patients, improving their
appearance. Bone grafting was not done because the disease was active and there was risk
of graft absorption.
To prevent nasal myiasis patients need to be educated about routine nasal care and
hygiene. Instillation of oily nasal drops (liquid paraffin with eucalyptus oil) prevents crust
formation and nasal obstruction. Partial closure of nostrils using local mucosal flaps
(Young’s procedure)8 has been tried by us successfully in
in aa few
few cases to
to prevent
prevent
recurrence.
An educational approach to leprosy control:
an evaluation of knowledge, attitudes
and practice in two poor localities
in Bombay, India
Acknowledgments
The authors are indebted to Dr H Srinivasan, Director lor his criticisms and help in
preparing the manuscript. The secretarial assistance of Mr Shelandra Kulshrestha and
the photographic work of Mr Hariom Agrawal and Neeraj Dubey is gratefully
acknowledged.
References
Sahay LK. A study of maggots and their otorhinolaryngcal manifestations, hut J Otolaryngol. 1959; 11: 146
8.
? Sreevatsa. Malaviya GN. Husain S. Girdhar A. Bhatt HR. Girdhar BK. Preliminary observations on myiasis
in leprosy patients, txpr Rev. 1990; 61: 375 8.
Barton RPE. I he management of leprous rhinitis. I.epr Rev. 1973; 44: 1X6 9|.
4 Davey II. Barton RPE. Leprous lesions of nose. In: Leprosy. Vol I. Dharmendra (cd ). Bombay Kothari
Medical Publishing I louse. 1978; pp. 168 73.
Rao GR. Myiasis in lepers, hul MetKlaz. 1929; 60: 3X0 quoted by Bose, l)N I.cpr India. I960; 32: 181 2.
Bose DN. Maggots in the nose of a lepromatous case of leprosy. I.cpr India. I960; 32: IXI 2.
Weir N. Myiasis. In: Scott-Brown's Diseases of Ear. Nose and Throat. Vol 3. Ballantyne and Grooves (cds)
London: Butterworths. 1979; pp. 204 6.
Y oung A. Closure of nostrils in atrophic rhinitis. J Laryngo Oiol. 1967; 81:514 24.
I.cpr Rcr (1991) 62, 389 94
Myiase de la muqueuse nasale chcz les lepreux
S Husain. G N Malaviya, A Girdhar, Sreevatsa et B K Girdhar
Resume Les larves de certaines mouches peuvent ctrc la cause d'une infcstalion des muqueuscs nasales chez les
lepreux qui resultent en des doulcurs graves ct intenscs et pent causer d importantes lesions tissulaires. Les
factcurs de predisposition, le tableau clinique et Ic traitement sont dccrits.
Miasis nasal en la lepra
S Husain. G N Malaviya. A Girdhar, Sreevatsa y B K Girdhar
Resumen La inlestacion de la nariz con larvas de cicrtas inoscas puede scr observada cn pacicnlcs con lepra.
Esto rcsulla cn gran dolor y agonia y puede causar tin extenso dano al lejido. Se dcscriben los lactorcs de
prcdisposicion. la prescntacion clinica y el tratamiento.
|
N CROOK.* R RAMASUBBAN.t A SAMY}
& B SINGHt
* School of Oriental and African Studies, University of London,
1 hornhauyh Street, Russell Square. London WCl H OXG, England:
^Centre for Social and Technological Change. 10 Zeha Corner.
Sheri v Rajan Road. Randra. Romhay 400 050. India; and + Alert India. 6 R Mukhyadhyapak Rhavan. Sion ( H est). Romhav 400 022
India
Accepted for publication 1 February 1991
Summary Based on the hypothesis that a systematic, carefully planned educa
tional approach to leprosy would yield results in terms of knowledge, attitudes
and case presentation superior to those of the established and traditional mass
suncy method. Al I R I-India launched a propiamme in S ward of Bombay in
I cbmaiy 19X5. locompaic I he two. An inlcnshc pi ogi amine of health education
using named teams, wascarried out in one /one of this ward oxer a period of 12
months. Eight months later, mass survey work (as used routinely in prex ious years
ami on a country-wide basis) was carried out in an adjacent zone. In 19X7. the
( entic (or Social and I ethnological ( hange in Bombay, in association with the
School of Oriental and African Studies. Unixersity of London, was requested to
exaluate the effect of the aboxe educational approach in terms of knowledge
attitudes and practice in both the trial and control zones. Other aspects of this
cxpenmenlal approach, including its cost and cffectixeness in identifying cases of
leprosy, will be published separately The design of the K AP‘ evaluation and the
social and cnxironmental controls introduced in the statistical analxsis arc
described. I he results pointed to a considerable degree of ignorance about’leprosy
as a disease (and its treatment) in both the study and the control zones'
Know ledge about early symptoms was particularly weak and on all aspects scores
for women were invariably lower than men. General education enhanced the
absorption ol specific knowledge, and the education of children compensated
adequately for lack ol parental education in this respect. Overall the ex ablation
indicated that the intensive educational approach was superior to the survey
approach in terms of improving knowledge, attitudes and practice.
0305-75IX 9| 062395 4 06 SOI 00
< 1 epra
395
396
N Crook ct al.
Introduction
ALERT-lndia is a voluntary organization committed to the control of leprosy in the
eastern suburbs of Bombay, by identifying and treating early cases of leprosy, and by
enlightening the public on various aspects of the disease.1 The prevalence rate for leprosy
in Bombay is believed to be between 10 and 15 cases per 1000 population.2 4 and the city is
listed as a hyperendemic district by the National Leprosy Eradication Programme.5 The
neighbourhoods covered by ALERT consist mainly of slum settlements, with an
aggregate population of some 400,000. For case detection the main tool has been the
door-to-door survey, during which some educational material is disseminated, mainly in
the form of leaflets. The educational component is backed up by slide or film shows at
local schools, factories, and community meeting places.
A major drawback of the mass survey method is that it is time consuming. Further, as
the approach is one of seeking out the patient, and following him or her up to ensure
completion of the required treatment, patient conviction and motivation are sometimes
lacking. Finally, as an educational tool, the method has disadvantages. Whatever
education is imparted mainly reaches the patients as a result of treatment and follow-up.
Non-paticnts receive only perfunctory information at the time of the initial door-to-door
examination, and the community-level programmes are spread too thinly over the
population, whose attendance at these events is sometimes meagre.
Methodology
In . 1985 ALERT launched an experimental approach designed to eliminate these
drawbacks. Over a 12-month period a well-defined slum community (referred to as L
zone) was visited by a health education team, which held a film or slide show at the end of
every road or lane. Leaflets were distributed door-to-door. Posters and stickers were
widely displayed and talks and exhibitions held at the community level. In short, the
approach was one of intensive education, rather than mass survey and more peripheral
education.
1 his paper reports the results of a subsequent evaluation of knowledge, attitudes and
practice carried out in 1987 in L zone by the Centre for Social and Technological Change.6
A questionnaire was presented to 200 residents; they were selected so that there should be
100 patients and 100 nonpatients. Similarly, in another community (referred to as M
zone), where a mass survey had been conducted in 1985 8 months after the experiment in
L zone, a further sample of 200. similarly selected, was used as a control. The
questionnaire was designed to test the public's basic knowledge about, attitudes towards,
and behavioural practice of relevance to the disease. Items for the test of knowledge
consisted of a range of symptoms, the bacteriological origin of the disease, the
transmission mechanism, and the curability and methods involved. Knowledge of
symptoms was graded from basic knowledge (the existence of a skin patch), through an
intermediate level (for example, absence of sensation on the patch) to a higher level (for
example absence of hair or sweating on the patch). Use of a questionnaire to elicit
responses on questions such as these may not be fully reliable in a semi-literate
population. However, in Bombay the illiterate arc more familiar with the ways of the
modern world than they would be in a remote rural village, and in our experience are
■ Io educational approach to leprosy control
397
unusually articulate. Furthermore, the investigators were paramedics working for
ALERT, who would have some familiarity with testing opinions and knowledge in this
population.
Results
In both zones the amount of knowledge absorbed was distressingly low: only 30% of
respondents could recall the symptom classified as basic, roughly the same proportion
recalled symptoms at the intermediate level, and 17% at the higher level. However, the
difference between the experimental and control zones was brought out fairly clearly, with
the experimental zone yielding a higher proportion of respondents with pertinent
knowledge at all levels (a statistically significant difference at the two higher levels, as
illustrated for the medium level in Table I).
As the sample design was not stratified by social factors it would seem desirable to
control for these statistically. Doing so reveals that, for example, in households where
fewer than half of the adult members have achieved the middle school level ofcducation
basic knowledge of symptoms is still further enhanced by the intensive education
programme (though the effect in the belter-educated households is unclear); medium level
knowledge is also better in the experimental zone after general education controls are
made. Similar findings arc made regarding the knowledge that leprosy is caused bv a
‘germ': the differences between the zones are large, and statistically significant in the case
of the less educated households (Table 2). This pattern of the superiority of the
experimental zone over the control tends to repeat itself for most items of knowledge and
is robust against the effect of general education differentials.
Respondents were canvassed on their attitude to different aspects of the disease: here
responses from the patients proved most conclusive, with their willingness to accept the
diagnosis and their confidence in the cure both being significantly enhanced by the
intensive educational programme in comparison with the survey method (Table 3). I his is
a clear indicator of the better motivation achieved when patients have been identified by
themselves (or their peers) rather than by visiting paramedics. Again the observation
remains valid when controls for general educational attainment are introduced. However,
some care in interpretation is needed here, in that a small proportion of patients will have
table 1. Medium lc\cl pciccption of sunpl oms bs zone
Zone
M
I.
Total
46
(23 0)
77
(3X-5)
123
(30 7)
Rest
154
(77 0)
123
(61-5)
277
(69 3)
total
200
(100 0)
200
(1000)
400
(100 (!)
Know ledge
DifTcrcncc between zones is significant at 5level
1
398
N Crook ct al.
zln educational approach to leprosy control
Table 2. Knowledge of germ according to educational composition
of household
Zone
M
L
Less than 50% of educated adults in household
Knowledge of germ
14
15
(H-2)
(22-7)
No knowledge
Total
III
(88 8)
51
(77-3)
29
(15-2)
162
(84-8)
125
(100)
66
(100)
191
(100)
More than 50% of educated adults in household
Knowledge of germ
18
47
(250)
(364)
No knowledge
Total
Total
(against only I I'1;, in the control zone). It is possible that those motivating, though no
greater in number, were more active and successful in I. zone.
In some cases the superiority of the intensive education method was enhanced or
diminished by other characteristics of the individuals surveyed (besides zonal residence).
For example, overall educational attainment by adult members of the household nearly
always strengthened the effect of the experimental method in imparting knowledge and in
improving attitudes (sec. for example. Table 2). More strikingly, relevant knowledge was
increased by the presence of school-attendant children in the household, often
compensating for the effect of lack of parental education, flic sex of the respondent was
another important differentiating characteristic. Women were in possession of less of the
relevant knowledge than were men. even in the experimental zone.
Discussion
54
(75 0)
82
(63 6)
65
(32-3)
136
(67-7)
72
(100)
129
(100)
201
(100)
Difference between zones is significant at 5% level in the lesser
educated group. Difference between educational levels is also
significant at 5% level.
already suffered some deformity, so that the concept of cure will have had some ambiguity
for them since chemotherapy cannot repair the damage already done.
As far as practice is concerned, our questions were confined to eliciting information on
how far people looked for symptoms in each other and motivated clinic attendance in
suspected patients. Here the superiority of the experimental zone failed to emerge.
However. 30% of patients in that zone claimed to have been motivated in that way
Table 3. Confidence of patients in cure
Zone
M
I.
Total
Confident of cure
71
(72-4)
84
(88-4)
155
(803)
Not confident
27
(27 6)
II
(11-6)
38
(19 7)
Total
98
(100 0)
95
(100 0)
191
(100 0)
Difference between zones is significant al 5% level.
399
It should be stressed that this evaluation was not intended to test the superiority of case
detection in the experimental zone. Its purpose was purely to see whether the same levels
of public awareness would be achieved by the cost-saving experiment of an intensive
community-level educational approach in place of the laborious door-to-door survey
technique. In fact both patients and non-patients who were subjected to the educational
experiment showed superior awareness of important facts relevant to the prevention, cure
and social understanding of the nature of the disease. This should constitute a step on the
road towards the ultimate removal of stigma. Furthermore, since a higher proportion of
those in the experimental zone claimed they were convinced that treatment would be
effective, there is some reason to expect that non-compliance would be reduced. Some of
the recent literature has linked compliance to the quality of information that is provided
to the patient.' The outcome of our study has prompted ALERT-India to enhance the
educational component in its existing survey programme.
The question may be raised, however, as to whether appropriate personnel would be
readily available to replace the survey technique comprehensively with an intensive
educational programme. I he ALFR I experiment drew on the existing skills of its health
educators, and simply used more intensively the educational materials they already
possessed. Our view (which in essence is shared by others/ is that at least the more
experienced members of the existing paramedical corps could be adopted as health
educators in the programme; they would need to be equipped with additional educational
materials which would add to the resource cost, but only as a one-off expenditure. I his
would create a two-tier structure of paramedics, which would have the added advantage
of offering promotional prospects as an incentive for the greater involvement of new
recruits in the wider aims of the organization: by developing their understanding of and
ability to interact with the community, rather than simply acquiring skills in case
detection and delivery of curative services, they would be securing a career for themselves
as a valuable cadre of health educators. Al the same time, this awareness would ensure
some much needed variety in the acti\ities and career structure of paramedics, for whom
the repealed combing of vast urban slums for new ;ami‘ recalcitrant patients is a tedious
chore, as detrimental to the moth alien of paramedics* as to the compliance of their
patients.13
Finally our study brings out the importance of seeking to in\of.• e specifically both
400
N Crook et al.
I.epr Rci (1991) 62, 395 401
women and children in any health education programme. The less informed responses of
women in both our zones underlines how any programme of information that relies upon
the spontaneous attendance of women is likely in most cultures cllectively to discriminate
against women: special programmes for women's groups and appropriate timings for
women to attend would seem to be the solution. At the same time, the fact that better
informed respondents came from households where school-attending children were
present suggests the value of carrying out leprosy education work in schools, especially in
urban settings where attendance is high.
401
I.e controle de la lepre grace a reducation: une
evaluation des connaissances, des
attitudes et des habitudes dans deux localites pa
tn res de Bombay en Inde
N. Crook. R Ramasi bban. A Samy pi B Singh
Resume Fslnnant qu un programme etlucalil bicn convu
Mirki lepre d.Hinciml des mcillcurcsinlormatit.nscn
maticrc de connaissances. d attitudes ct tL
de d,
dcpisliige des cas de lepre que celles obiemres par les enquues
traditionnclles ;i grande cchelle. Al I R I India
des equipcs entrainces fui organise dans
Acknowledgments
The authors are indebted to Dr A Colin McDougall for much helpful advice on the
presentation of this material: the views expressed here, however, remain the authors'
alone. I he School of Oriental and African Studies is grateful to the Gatsby Charitable
Foundation for its support; and ALERT-lndia is similarly grateful to the Damien
Foundation.
.......
prufondedcl:, lepre el de s..„ I, aiu.nenl dances
h,i
I obk-! de Iclude Hhn l'”
speedimies e. Pedueau.,.:^™
" l""" lg"'.'l''"KC
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^a^dee^
References
1 Samy AA. Mancheril J. Manek K.P. McDougall AC. ALERT-lndia 1981
1989: 9 years experience of leprosy
control in the slums of Bombay (in preparation).
Dharmendra (cd.), l.eproyy. Volume II. Bombay: Samant. 1985
' 7/K y'ZeprR|985'V57-k383* 8 D°ngrC VV Prevalcncc ol lcProsy in slums in Bombay including a leprosy colony.
Revankar CR Dudbalkar B. Raja GD. Ganapati R. Leprosy survey in urban slums: possibilities for
< epidemiological investigations. l,epr Rev. 1982; 53: 99 |(M.
Leprosy: status report 1985 86. National Leprosy Eradication Programme in India. 1986. Leprosy Division
Directorate General of Health Services. Ministry of Health and Family Welfare. Delhi.
Ramasubban R. Crook N. Singh B. Educational approach to leprosy control: an evaluation of knowledge,
attitudes and practice in two poor localities in Bombay. Centre for Social and lechnological Change
Bombay. 1990.
6
7 AW
8J|'|1S * P MUl1 °S C l,l,llrt and 'con’pli:,nce' :"non8 leprosy patients in Pakistan. SoeSci
Van Parijs LG. Re-defining health education in leprosy: a personal view, l.epr Rev 1990; 61: 145 50.
Ramasubban R. Singh B. Crook N. Paramedics as Promethcans? A study of leprosy control in Bombay
Technical paper. Centre for Social and Technological Change. Bombay. 1990.
^Lenaf\,(,,,e cducaciona,idd
<Ie la lepra; una evaluacion del conocimiento
actitudes y practica en dos localidades pobres de Bombay, India
N Crook. R Ramasi bban. A Samy v B Singh
r> s
314
I Jtiyaptil et al.
I .< pr P, i I
La coloration an diacetate de fluoresceine et bromure d’ethidium pour determiner la
viabilite de Mycobacterium smegmatis et d'Escherischia coli
• xo
) 62. ’I S 12K
SPECIAL ARTICLE
V Jayapal, K. M Sharmila, G Sf.lvibai. S P Thyagarajan.
ALERT-India 1981—89: nine years’ experience
of leprosy control in the slums of Bombay
S SlIANMl’GASUNDARAM FT S SlJBRAMANIAN
Sommaire La capacitc de la methode de coloration au diacetate de lluoresceinc et bromure d’ethidium pour
estimer le pourccntagc de cellules baclcriennes viables en suspension a etc comparee avec la methode de comple
des colonics sur plaque. Des suspensions de cellules de Mycoluicteriuni snieynmiis et d’Escheii\chi<i coli out etc
incubccs a 60 C. Aux dificrcnts intervallcs de temps des echantillons out etc pris ct le pourccntagc de cellules
viables estimc sur chaque cchantillon par la methode de coloration lluorcscenle. I.c rcsultat ohtenu a ele
compare a la comple des colonies sur plaque. La methode de coloration lluoresccntc a montre une correlation
positive avec la methode de comple sur plaque. Neanmoins. la valeur obtenuc pour la rccomple des colonies
viables sur plaque a etc moins clevec que chcz la methode de coloration apres incubation a 60 C. ce qui indique
un dccalage entre la mortc des baclerics ct la deterioration des enzymes. D’ou la methode de coloration
lluoresccntc pent ctrc utiliscc pour cstimcr les tendances dans Ic deperissement des baclerics plutot que pour le
calcul exacte du nombre de bacilles viables.
A A SAMY. J MANCHHRIL. K P MANEK &
a c McDougall*
Alcri-Imlia: Assoc iation for Leprosy Echu ation. Rehabilitation and
Treatment India. 6-R Mukhyadhyapak Rhavan. 3rd I'loor. Sion
< H est). Romhay 4()t) 022, India: and * Department of Dermatology.
I he Slade Hospital. Headingion. Oxford, 0X3 7JH, England
Coloration a base de diacetato de fluorcsccinc y bromuro de etidio para detenninar
la viabilidad de Mycobacterium smegmatis y de Escherichia coli
Accepted for publication 19 April 1991
V Jayapal. K M Sharmila. G Selvibai. S P Thyagarajan.
S Shanmugasundaram y S Subramanian
Summary Bombay has a population of about 8 million people, one-half of
whom lixe in slums. In 1981. \I.rRT-!ndia started its first leprosy control project
in N. S and I \\ aids ol Greater Bombay Municipal ( orporation covering an area
of 122 sq km in the north-eastern suburbs of Vidhy axihar. Ghatkopar. Vikhroli.
Kanjurmarg. Bhandup and Mulund. with a total population of I.IOO.OOO
according to the 1981 census. In the 9 years of operation, over 12.000 patients
haxc been registered and treated and of these 7425 have been released from
treatment, having satisfactorily completed courses of chemotherapy. However,
over 1000cases are still identified every year by house-to-house or school surveys,
or by self-rcporling, including a considciablc percentage in children I he origin,
development, stall structure, operational procedure, administration and reced
ing system ol Al PR F-lndia arc described in detail, with emphasis on what has
been accompolishcd with purely outpatient facilities, using paramedical workers,
all of whom have received inservice training from Government recognized
training centres for their specific tasks. The account includes a brief description of
an expansion of the organization's work into townships in New Bombay, where
preliminary surveys in 1988 confirmed the presence of leprosy cases and the need
for treatment facilities. 1 he discussion addresses: I. the belter use of the large
volume of statistical information which has been collected by AI.FRT-India
during the past 9 years, with emphasis on its value in assessing the impact on the
control programme and modifying future policy: 2. the need to radically examine
the present policy of survey, i ersus an ‘education campaign approach’ with regard
to increasing early case-detection and self-rcpoiling: 3. (he establishment of a
central coordinating body lor leprosy control in Bermbay to exchange informa
tion. coordinate efforts and formulate a future plan ol action, the, latter in
association with the National l eprosy Eradication Programme: and 4. the
development ol a health education resource centre in association with the
Bombay Municipal ( orporation.
Rexumcn Sc compare cl nictodo de coloracion a base de diacetato de lliiorvsccina y bromuro de etidio para
calcular el porcentajc de celulas bacterianas viables en suspension con el metodo de cticnla de colonias sobre
placas. Se incubaron a 60 C suspensioncs de celulas bacterianas de Mycohtu tcriimi snicyntiiiis \ de Escherichia
coli. Se toniaron muestras a intcrvalos de ticnipo distintos. se calculb el porcentajc de celulas xiables en cada
muestra per cl nictodo de eolorantes fluorcsccnlcs y sccomparbcl rcsultado al oblenido per cl metodo dccucnta
de colonias sobre placas. Se hallo una corrclacibn positiva entre los rcsullados obtenidos por ambos metados.
No obstante, la cuenta de celulas viables por el metodo de cucnta tie colonias sobre places rcsultb inlcrior a la
cuenta obtenida por medio del metodo de eolorantes (llevandosc la incubacion a cabo a 60 ( 1 F’slo stigicrc que
exist e mi periodo de rctraso tras la muei le de las bacterias hast a miciarscel deteiioro tie lasen/imas Pot Io lanto,
cl metodo de coloracion lluoresccntc pticde ulilizarse mas bien para evaluar las tendencias del decaimicnto de las
bacterias que para calcular cl numero cxacto de bacilos viables.
0305-"5IS
I)G21|X.. |j su] <)<i
< I epra
315
316
' !\1 -hulni /9.S7 ,S9 l.rpinw imilinl m Hnmbux ^lunis
J .1 Slimy cl al
Introduction
ALERT-India was founded in October 1978. The letters stand for ‘Association for
Leprosy Education. Rehabilitation and T reatment’ and this organization in India should
not be confused with the All-Africa Leprosy and Rehabilitation Training Centre, also
called ALERT*, in Addis Ababa. Ethiopia. ALERT-India is registered under Acts of I860
and 1950; it is a registered charity with audited accounts and donations arc exempt from
tax. The main financial support up to 1984 was from OXI-AM (UK); from 1985 onwards
it came from the Damien Foundation (Belgium) and other 1LEP agencies such as the
Associazione Italiana Amici de Raoul Follercau (Italy). Institute Fame Pcreo (Canada)
and the Association I’rancaise Raoul Follercau (France). T he Damien Foundation is the
ILEP Coordinator in India for finance and technical supervision. Ils main objective is the
eradication of leprosy, but the full list of subsidiary objectives as formulated and adopted
by the Founder Members in October 1978 is as follows:
1 T o detect early and infectious cases of*leprosy in the community and reach the goal of
total case detection through intensive surveys.
2 To treat every person diagnosed as suffering from active leprosy with adequate case
holding.
3 To create leprosy consciousness among the sections of the community through
intensive health education programmes.
4 To work ardently towards total prevention of dchabililation and promote sociopsychological and economic rehabilitation of leprosy patients in the milieu of the
community.
5 To undertake and promote study and research in leprosy and related sciences.
317
2 Health education Centre:
3 Undertake and promote study and research.
Phase Three
1 Implementing the economic, occupational, rehabilitation programmes:
2 Promotion of an I ’rban I raining ( cntic (wocfullj lacking) and the establishment ol a
social research wing to promote the cause of eradication. Depending upon the progress
made, funds available and the situation then prevailing, it will quite likely be possible to
dovetail the phases into each other and thereby implement the programme more
expeditiously and effectively.
Board of management
ALERT-India has a Board of Management of 9 members, most of whom have been on
the Board since at least 1983; some were in fact founders of the Association. Some arc
medically qualified and experienced in leprosy, others have backgrounds in community or
social work, education, nursing or administration. The Board is the legal body
responsible for the Association and the overall policy decisions directives and sanctions.
The Chief Executive is an Ex-officio member of the Board of Management. Project
planning, implementation and day-to-day administration are delegated to the Chief
Executive, w ho carries out tasks through his team of officers and field staff. 1 le also acts as
Project Holder for the sponsoring agencies on behalf of the Association and as the
‘Reporting Trustee* to the Governments and their departments.
To reach these objectives, three phases were envisaged.
Buildings, offices, clinics
Phase One
1 The establishment of a control programme and personnel to implement it: and
2 Bringing the maximum area under the Urban Leprosy Control Programme of the
Association.
I hesc would entail undertaking the following activities:
(a) conducting on-going surveys (house-to-house) in the project areas;
(b) progressively establishing treatment centres in surveyed areas;
(c) carry out a widespread programme of education particularly towards removal of
existing deep-rooted prejudice and bias against the disease and its victims;
(d) setting up the office and records system (data collection, tabulation, analysis and
control);
(e) establishment of a laboratory and a physiotherapy centre;
(f) publicising ALERT’s aims, objectives and involvement, gaining community goodwill
and cooperation at large, and the mobilization of local resources.
Phase Two
I Establishment of a mini-hospital for special cases together with a full-fledged
physiotherapy (physical rehabilitation centre); and
The main administrative office is convenient to the centre of Bombay and is used by the
Chief Executive and office staff, lor field work and administration, two large rooms were
acquired in 1985 in an industrial block in the heart of the control area. Vikhroli. This
‘Project Office* includes a laboratory for slit-skin smears, storeroom, office accommo
dation. a leaching or meeting area and space for the reception and treatment of patients at
a weekly clinic.
The project area
The area allocated is that of the three wards N. S and T as shown in figure I. I hesc wards
include the areas know n as Vidyax ihar. Ghatkopar. Kanjurmarg. Bhandup and M ulund.
The estimated population of the three w ards is 1.500.000. I or administrative purposes the
whole target area has been divided into 18 zones, each of which has one paramedical
worker in charge, w ho carries out a full range of control activities, including surveys, case
detection. follow-up and health education, he also assists the medical officer during
weekk visits to each zone. A field supervisor is responsible lor the performance of 4 to 5
paramedical workers, and he in turn is supervised by the Project Officer, who is also
318
1
/I Samy ct al
l.R 7-huliti /9.S7 .S9
Lc/)if>\y comrol in Bombay slums
319
responsible for the planning and execution of the control programme as a whole. The
medical officers arc ultimately accountable for the proper implementation of all technical
and professional aspects of the programme and arc directly responsible for the diagnosis
and treatment of all patients. E\er\ 3 months there is a general meeting of the entire staff,
including health cducalc’rs and the social worker to discuss problems and to review
progress. Once yearly a general self-evaluation is carried out by field workers and officers,
using a questionnaire, and the outcome discussed at a meeting, chaired by the Chief
Executive.
Staffing
This includes. 1. the € hief Executive (with qualification in social welfare administration);
2. two full-time medical officers (one of them functioning as the Project Officer); 3. four
field supervisors (trained paramedical workers); 4. twenty paramedical workers, all of
whom have had inservice training with ALERT-India and in Government recognized
training centres; 5. one smear technician; 6. one physiotherapist; and 7. one social worker
(female: with a degree in social work), one driver and one typist. One paramedical worker
is responsible on average, for about 5().()()() people, with four field supervisors for 20
paramedical workers. I iftccn out of the 20 paramedical workers arc already trained as
health educators and the rest will complete their training in health education in 1991.
MAnxttuno
Control policy and field activities
These follow essentially conventional lines, as laid down (and used widely in India) b\ the
National Leprosx Control (now Eradication) Programme in 1954.' I his is based to a large
ARABIAN SEA
G
extent on the principle of sur\ey education and treatment’. Surveys have been carried out
in this project in: I. the general population; 2. contacts of known casesand 3. schools. In
addition, a considerable number of cases are referred from private practitioners and
others arc apparently entirely self-reporting.
Ihrough the 9 years of operation, the
approximate percentages of cases found in the above categories arc: 1.37”-;,; 2. 16",;, and 3.
12%. I rom the IX zones referred Io above in the three wards of this project, one is still to
be sur\e\cd. but in the others surveys have been completed on a door-to-door basis,
identifying slum colonics, one room tenements and lower middle-class housing societies in
CHURCHGA1C
each zone of the project area. 1 hesc teams examine X0";> of the population in every cluster.
Anyone familiar with conditions in the slums of Bombay will readily agree that this is
neither complete nor satisfactory as a basis for ‘survey’ and it is likely that the teams fail to
contact some members of the community, including those who leave the house early to go
to work, even if visits are repeated. It has also to be appreciated (sec Discussion) that the
population is to some extent ‘shifting due to employment
opportunities
iin the City or in
.
.
. ,
villages which defy monitoring. All survey activity has been accompanied, from the early
Figure 1. Map of Greater Bombay; total population 8 million. The letters A U.K N. P. S and T refer to ‘wards’
of Greater Bombay, of which N, S and T (shaded ara) arc the control areas for Al.ER I -India. The area of the
‘New Bombay Townships', in which programmes will be set up by ALER I-India in 1990, arc to the right of
Thane Creek, i.c. inland, towards the East.
years of the work of ALERT-India. by
intensive health education, using verbal
communication, leaflets and pictures of early leprosy , and the attempts w hich have been
made to assess its value will be discussed below.
320
A A Samy ct al
' LERI-buhn /9<V/ 89: /.cpro.w t antral in Bomha\ slums
use in the future, especially if advantages in compliance arc demonstrated by trials, has
not however, been ruled out. Based on personal interviews with patients, pill counts,
occasional checks of the urine for dapsonc and assessment of the clinical and
bacteriological results, our impression is that compliance to prescribed medication is
satisfactory.
Treatment
Nineteen clinics arc scattered throughout the project area and they arc held weekly, each
patient receiving medication for 4 weeks at a time, on the occasion of attendance for
supervised drugs. The regimens followed arc those advised by the World Health
Organization (WHO) in 19823 (not those of the National Leprosy Eradication
Programme) and the criteria for the grouping of patients for pauci or multibacillary
regimens are also those of WHO, with the following modifications: 1, All patients with
less than 4 lesions are treated as pauci-bacillary; 2. all patients with 10 or more lesions are
treated as multi-bacillary, regardless of bacteriological findings (i.c. even if negative); 3,
all cases with between 4 and 9 lesions, and less than 3 nerves involved, arc treated as
paucibacillary; and 4, all cases with more than 4 lesions and more than 3 nerves involved
are treated as multibacillary. Pure neuritic cases with only 1 or 2 nerves involved are
treated as paucibacillary and those with multiple nerves involved as multibacillary, but
only after thorough examination and assessment by a medical ollicer. The periods of
treatment are also essentially those advised by WHO, with the following modifications:
Planning, monitoring and evaluation
From the earliest stages of work, attention has constantly been given to the yearly
development of a plan of work', identifying priority areas for attention, writing specific
objectives and drawing up a monthly timetable of work for all members of the team
Monthly progress and work reports have been in use throughout, including specific
suggestions for the improvement of work performance. Quarterly reviews and reports arc
made by the Project Officer, including an analysis of achievements (or failures) in priority
areas. Half \early and \early evaluations arc made by the Chief Executive, including an
analysis of the overall achievements of the Association, based on the set objectives. Of
particular importance arc the operational assessments which have been carried out every
3 years by an external team (usually 3 or 4 experts in the field of leprosy control), to assess
the quality of work, achievements and overall plan of action, whilst at the same time
making proposals for changes, corrections and improvements for the future.
1 All paucibacillary cases are allowed a maximum of 9 months to complete the course of
6 supervised doses.
2 If a medical officer confirms that there is clinical activity on completion of the 6
months course, treatment may be continued for a further 6 months.
3 Triple drug therapy for multibacillary cases should be completed within 36 months, or
continued until smears are negative and or clinical inactivity, w hichever is the longer.
4 In certain cases, however, at the discretion of the medical officer, treatment for
multibacillary cases has been slopped after 40 supervised doses, regardless of bacteriolo
gical positivity.
It is important to note that multiple drug therapy is given only to patients who are able to
give an address or contact point; who understand what is needed by way of monthly
attendances and daily, unsupervised treatment; and w ho agree to keep in touch with the
programme for the necessary period of time. Unless these criteria are met ALERT-India,
in common with other agencies doing leprosy work in Bombay, has not used multiple
drug therapy. These patients are either given a supply of dapsone 100 mg to take daily,
with a prescription or a letter introducing them to the health services in another part of
India, if they intend to leave Bombay. This policy, developed because of the danger of
issuing expensive and potentially toxic drugs to patients who might never appear again, is
judged now to be increasingly unacceptable, and alternative strategies to ensure that all
patients presenting with active leprosy, especially if multibacillary. receive multiple drug
therapy, are under discussion (see Research).
Drug supplies and distribution
Referral of reactions, complications. cases requiring hospitalization
It is of interest that the need to refer patients for any of these reasons has been remarkably
low. It has in fact been necessary to refer patients for severe reactions or other serious
complications on less than 100 occasions, during the 9 years of the programme. We have
been fortunate to have excellent contact with the staff and facilities of the Vimala
Dermatological Centre, to whose physicians we are extremely grateful. Patients stay in
hospital for a minimum of time needed and then return to our care. The entire element of
‘removal- to an isolated leprosarium has thus been avoided by an almost totally
outpatient approach and this may have contributed to the high level of interest and
cooperation b\ patients and the community.
Laboratory services for slit-skin smears
Facilities for taking smears arc available in iall 19 clinics of the project area. Sites U1U
are
.■ selected cither by a medical officer or by the next most highly experienced parmnedical
worker available. Smears arc taken and fixed by a laboratory technician or a paramedical
worker trained in this procedure. Until the end of 1985. patients with less than 4 lesions
were not routinely smeared, unless requested for some special reason. The present policy
bthat all cases are smeared prior to starling treatment, the only exception being children
'■'ji
*7 a smgle lesion on the face. Appropriate instructions have been issued to Medical
Officers concerning the possibility that multibacillary patients, who are partially /and
perhaps inadequately i treated, or relapMng. may present with less than 4 lesions. Once
■
Dapsone, clofazimine and rifampicin are supplied loose in stock bottles or plastic
containers and made,up into 1-month supplies (in the case of dapsonc and clofazimine)
for dispensing to patients. Blister packs, already w idely used in some other parts of India,
have not been used in this project, nor to our knowledge, in other parts of Bombay. Their
321
322
A A Samy et al
t
fixed, labelled and dated, smears are sent to the ‘Project Office' in Vikhroli. where one
laboratory has been maintained through the years for the staining, examination and
reporting of all smears, in accordance with advice given in a recent publication on the
subject,' to the elfect that selection and taking may be peripheral, but the staining and •
interpretation should be centralized and constantly under supervision. The bacteriologi- ■'
cal index (BI) only is recorded, not the morphological index (MI) or any other index. One
technician has been trained at the SchielTelin Leprosy Research and Training Centre in i
Vellore. South India. It has been possible only during the last 2 years to organize
reliability or comparability checks with other centres in India, but medical officers check
approximately 5% of smears on a random basis. Particularly in view of the recent ;
recommendations by WHO4 that the finding of a positive BI at any site means that the a
patient should receive the multibacillary regimen (3 drugs for a minimum of 2 years), all
slides with a BI of 1 will be double checked by a medical officer from now on.
^T-hulia /W/ A’9 Leprosy nmtrfil in Bombay slums
323
I able I. ALLR I-India 1981 89: population covered, new cases detected and prcvalancc
rate per thousand
I
2
3
4
5
Door to door survev among
slums, chaw Is and housing
colonics
School survc) among
municipal, private,
primarv and secondary
school
Contact examination of known cases
Health contact examinations
Voluntary rcfcrals and others
Total
Population
cos cred
New cases
detected
461.628
4150
37
89
249.122
48.060
I 348
1189
586
3946
12
II
5
35
54
24-7
I 1.219
100
PR !(X)(I
Records, registers and reports
In recent years, following recommendations made by independent consultants, the
years. The case detection rales per thousand in recent years have been as follows: 1.
number of registers and reports has been considerably reduced, but it is still necessary to
1984—416:2.1985 4 66:3.1986 9 79; 4. 1987 6-4; 5. 1988 4 2: and 6. 1989 5 7.
supply them for three different agencies: I. ALERT-lndia itself; 2, the Government of
The overall prevalence of new cases among school children was 5-4 per 1000.
Maharashtra; and 3, the International Federation of Anti-Leprosy Associations (ILEP)
in London. (The OMSLEP recording system has not been used.) The forms in use for
ALERT-lndia for clinical details, smear reports, survey findings, contact examinations,
Rehabilitation
etc., are entirely conventional and relatively easy to complete, but the monthly progress
report for the Government is a lengthy and somewhat complicated document of 24 pages, '
which is time consuming for the health stall'concerned, but nevertheless obligatory for ■ This term appears in the title of ALERT and in the ‘Plan of Action' of 1978, but in the
sense of mental and physical rehabilitation of disabled patients to enable them to find
administrative purposes. The ILEP Questionnaire or Form BG called for over 150
gainful occupation, it has not been possible to develop this activity with much elfect.
separate items of information, and although these arc for the most part readily available
Although this has been largely due to lack of trained stall, premises and equipment, it
from other sources and the form is required only once a year, it is clear that health staff are
generally being asked to allocate an unreasonable amount of working time to the 1 became clear after only a few years of experiences that it is extremely difficult, probably
unrealistic, to rehabilitate patients in a community where there is already unemployment
completion of these and other forms. Our belief is that the most important items which
amongst healthy people, or to train them for useful work in remote villages, if they intend
require recording are: I. the total number of patients registered; 2. the number on multiple
to return home. In the more general sense, we continue to teach disability prevention and
drug therapy; 3. the number who have satisfactorily completed it and been released from
treatment; and 4, the proportion of new and currently registered cases with significant i self-care
..... by .patients, but incline increasingly
- - to the view that the treatment of seriously
«•••/
disability.
disabled patients and their rehabilitation should be undertaken by agencies which have
the staff, expertise and premises, and who arc prepared to integrate leprosy patients with
those disabled from other causes.
Healthy contact survey examination
Public reactions to house-to-house and other forms of survey
As far as possible all contacts of index cases are examined once yearly, except contacts of
multibacillary cases, who are examined every 6 months. The total number of contacts *
examined between 1981 and the end of 1989 was 48.060 from which 1189 cases (2-4%) J We had anticipated opposition and refusal to allow health stall to enter houses and
examine occupants, but this occurred on only a very small number of occasions. A second
have been diagnosed as having leprosy and treated.
■
'•
visit, once confidence has been established, usually meets with complete success. We
attribute such good relations to: I. the careful orientation of stalf before they embark on
School surveys
i this kind of work, to ensure that they proceed diplomatically and with respect for the
1
_ |i privacy and convenience of others; and 2. the fact that the slum populations of Bombay
To date 249,122 school children have been examined, all between the ages of 5 and 15
are now more than used to visitors, students and health or social workers of various kinds:
i
Table 2. ALERT-India 1981-89: yearly case detection, child and disability rates, smear positive cases
r_>
1
2
3
4
5
6
7
8
9
Total cases detected in each year (Annual)
(new & old cases)
New cases among the above
Percentage of new cases
Child cases among the new cases
Percentage of child cases
(new cases)
Deformed (Grade 2 & 3)
cases among new cases
Percentage of deformed cases
(new cases)
Smear positive cases among new cases
Percentage of smear positive cases
.(new cases)
1981
1982
1983
1984
1985
1986
1987
847
847
100
213
1416
1313
92
402
1615
1517
94
627
1019
964
94-6
266
1921
1875
97-6
349
2038
1831
89-8
586
1018
896
88
285
1988
1989
Total
1094
988
90 3
440
1088
988
90-8
326
12.056
11,219
93
3494
25
30-6
41-3
27-5
18 6
32
31-8
44-5
33
31
45
47
76
42
76
85
35
40
47
493
5-3
28
3-5
76
5
97
4-3
54
4
132
4-6
165
3-9
94
4
78
4-7
74
4-4
798
3-3
5-7
6-3
5-6
7
9
10
7-8
7-4
7
fa
Table 3. ALERT-India 1981-89: total of registered cases, chemotherapy, cases released from treatment or lost to control
2
Total cases registered
(new & old) (Annual)
Total cases put on MDT
3
Total cases put on dapsone monotherapy
4
Total cases on MDT released
from treatment (RFT)
Total cases released from control (RFC)
including some on dapsone monotherapy
Total cases lost to control
(deletions)
1
/<!
0/
%
5
6
1981
1982
1983
1984
1985
1986
1987
1988
1989
Total*
847
I
0-12
846
99-8
1416
55
3-8
1361
96-2
1615
149
9-2
1466
90-8
1019
132
13
887
87
1921
1126
58-6
795
41-4
2038
1434
70
604
30
1018
1052
103
1094
1022
93
72
7
1088
1019
94
69
6
12.056
5990
49-6
6066
504
2
53
58
180
1270
1006
727
882
4178
1
13
44
139
394
1611
723
322
3247
164
198
172
423
573
620
313
355
2826t
8
in this column have to be interpreted in the light of the fact that 15% of all cases are still on MDT or monotherapy at the time of
* The figures
writing this report.
social workers in ALERT-India and other agencies working in leprosy control in Bombay, indicaies that
t Anecdotally, information
from
—
’--------- • for
'■-t treatment.
have transferred to other parts of the City
and■ re-registered
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326
A A Samy et al
control in Bombay, the Ministry of Health of Maharashtra and probably also the fj
national Leprosy Eradication Programme of India. Meanwhile, we have outlined a pilot y
research programme to: 1. identify the patients concerned in greater detail; 2. define the
sociological and other reasons which impede safe implementation of multiple drug
therapy; and 3, propose solutions.
The second subject concerns the remarkably large number of private practitioners in
the N. S and T wards of this project and the likelihood that many more will settle in the
New Townships in the coming years. The potential of private practitioners in Bombay in
cae-detection and referral for treatment has already been shown to be considerable and it 1
is now our intention to compile a comprehensive list of all practitioners in the area and to |
invite their cooperation, whilst at the same time carefully respecting their right to receive i
and treat patients as they see fit. and any element of professional confidence which may be 1
involved. This enquiry will include information on the controversial question: ‘Does the
acceptance and treatment of leprosy patients in private practice enhance, or damage, the
reputation of the doctor and the numbers of patients who come for consultation?’
Discussion and future plans
The registration of over 12.056 cases in a period of 9 years, followed by the release from
control of over 7425. after completion of satisfactory courses of treatment, would appear
to be a significant contribution towards the control of leprosy in the urban slums of this
project. The disease has obviously been arrested in a large number of individuals; nerve
damage has been prevented; relapse rates are low and there is at least a possibility that we
have reduced the pool of infectious/contagious cases. There remain, however, a number
of disconcerting aspects to this work, including the fact that we continue to register about
1000 new cases each year, but have little knowledge of their source of infection, whether
within the project area or from some other part of Bombay (or India). We are also
uncertain about the cost-effectiveness of our approach to case-detection and treatment.
Survey can be laborious^ time-consuming and expensive and it is notorious for the
‘discovery’ of cases who are unlikely to accept the diagnosis of leprosy and attend well for
treatment. Broadly based educational campaigns, using all kinds of media, have been
found by Ganapati8 and others to have advantages over routine survey and it is to be
hoped that the study already referred to in Maharashtra Nagar will contribute further
information in this area.
Under Treatment it has already been pointed out that a considerable number of
patients with active leprosy do not, for a variety of reasons, receive multiple drug therapy
and this is a matter of considerable concern which points to the need for some kind of
central or coordinating body amongst the agencies working in leprosy control in Bombay.
It should not be impossible to analyse and overcome the operational and other obstacles
which give rise to this situation, whilst at the same time reviewing working methods,
report forms, records and other matters of mutual interest to the 10 agencies concerned.
As already indicated, ALERT-India is now entering a new phase of work in the
Townships of New Bombay and this may point to the urgency of making sure that
baseline data are properly assembled and that data from the main project areas is
analysed to greater advantage. We aim to educate the public and prevent disability
through early case detection and chemotherapy. To do this effectively, we have to
:7?7-India 198/ 89: Leprosy control in Bombay slums
327
constantly keep in mind the need to studs not only the disease and the drugs available for
treatment, but also the complex and challenging pattern of society in the slums where we
work.
Acknowledgments
We are grateful to Dr Claire Vellul. Ms Simone Liegeois. Dr M S Nilakanta Rao. Dr D
Lobo and Mr M S Meliendale for permission to use information recorded b\ them in their
Second and Third Operational Assessments of ALF.RT-India. Bombay. 1987 and 1990.
References
1 National Lcprosx Eradication Programme. Leprosy Division. Directorate General of Health Services.
Nirman Bhaxan. New Delhi. India; \<iii<>nal Leprosy F.ratHf ation Programme in India. 19X7 Guidelines for
Multidrug Treatment in Endemic Districts
2 WHO Studs Group. ( hemoiherapx of leprosy for control programmes. Technical Report Series No. 675
WHO; Genes a. 19X2.
5 Gcorgicv GD. McDougall AC. A re appraisal ol clinical and bacteriological criteria in the implementation of
multiple drug therapy for leprosy control programmes and proposals for their better use. Special article, t.epr
Rev. 1990; 61: 64 7?.
4 WHO Expert Committee on Leprosy. Sixth Report. Technical Report Series No. 768. WHO: Genesa. 1988.
5 Vadher A Patient treatment compliance in leprosy: a social psychological perspective. Ehesis for degree of
Doctor of Philosophy. Department of Experimental Psychology. University of Oxford. In preparation. 1991
6 Crook N. Ramasubban R. Sams AA. Singh B. An cdin ational approach to leprosy control: an ct alaation of
knowledge, altitudes and prat lice in two poor Im alilics in Bombay. India. 1991. 1991; Submitted for publh ation
J Samy AA. Mancheril J. Ammu L Leprosy in the I ashi and 7urbhe townships ol New Bombay, a preliminary
report based on house-to-house and school surveys. Submitted for publication.
’ Ganapati R. ResankarC R. Bandkar KR: Dongrc VV. Lcpross detection through non-sursey techniques. Ini
J Lepr, 1984; 56: 622 5.
ALER !-India 1981-89: I ne experience de 9 ans du controle de la lepre dans les
taudis de Bombay
AA Samy. J Mam hi rii . K P Manek et A C M( Doucjai.e
Rcninic Homh.n ;i line popuhitinn d'ciB iimi X millions <1 h.ibilmitsdont lu moilii- \it duns des taudis E.n 19X I.
ALER I India ii'innunvi son picmivi piojcl de lonliole de la lepic dans les qnailicis N. S et I de la
municipalitc du grand Bombas d une suilavc de 122 kin cane dans les faubourgs nord-est de Viilhsasih.ir.
Ghatkopar. Vikhroli. Kanjurrnarp. Bhandup ct Mulund dont la population totale s'clcvc a 1.100.(XM) habitants
dapres Ic reccnsemcnt cHcctue cn 19X1. Au tours des neul’annccs d activitcs. plus de 12.<M>0 patients ont etc
enregistres ct soignes dont 7425 chcz qui le traitement a etc arrete as ant (ermine avcc succcs un traitemenl
complct de chimiothcrapie. Toutclois. plus de 1000 cas sont encore identifies chaque annee par des enquetes a
domicile ou dans les ecolcs ou par notification solontairc ct comprcnncnt un grand nombre d enfants La
creation. Ic dcscloppcmcnt. le personnel. Ics methodes de trasail. l administration ct la methode d'enregistrement utilisee par ALERT-India sont decrits cn detail. I. accent cst mis stir Ics resultats obtenus uniquement cn
consultations hospitalicres cxterncs a\cc 1’aidc des paramcdicaux qui ont tons rccu unc formation spcciftquc cn
cours d cmploi dans des centres de formation rcconnus par le gouvernement. I.e rapport inclul unc brese
description de l essor des acthitcs de Eorganisalion dans Ics banlicues de New Bombay ou les enquetes
prcliminaircs cirectuces cn 19X8 confirmaient rc.xistcncc de lepreux cl la necessite de dispensaircs. Les questions
abordees sont les suixantes: I. I cmploi plus judicieux des donnccs statistiques recucillics par ALERT-India au
cours des 9 derniercs annecs soulignant leur importance stir l exaluation de Eimpact du programme de controle
etsur 1'exolution des politiques futures; 2. la neccss’tc de comparer cn detail Ic programme actuel d enquetes au
syslcmc de campagnes cducatixes alin de promouvoir Ic depistage des cas prccoces et les notifications
r>f^ sa.i"!
INDIAN JC
Al. OF DISABILITY AND REHABILITATION
JULY-DECEMBER. 1991
Community-Based Rehabilitation for the Leprosy Cured
S.P. Tare
Director. Gandhi Memorial Lcpn»sy Foundation. Ilmdinagar, Wardha 442 103 (Maharashtra) India.
■q eing primarily a medical problem with very serious social overtone, persons suffering
15 from leprosy have to face numerous problems. But the rehabilitation of the leprosy
cured is a very major problem and at the same time, a very complex one. It calls for efforts
not only of the leprosy workers, but requires multi-pronged efforts involving people from
influential groups in society, social leaders as well as the entire community in general.
Rehabilitation of a leprosy patient cannot be achieved unless the community in general is
willing to accept persons having leprosy or cured of leprosy in their fold.
The problem of rehabilitation arises primarily because of the deformities which are
associated with leprosy so much so that people generally equate leprosy work with that of
rehabilitation of leprosy patients. The presence of physical deformities results in: (a)
making out the person with deformity as a patient of leprosy. (2) incapacitating him from
doing normal work, and (3) creating a strong societal reaction in the community leading
first to loss of job by the patients and subsequently losing family support and finally dis
placement from society.
The Indian Model
The model that was followed in India about three decades ago before a nation-wide
leprosy control programme was launched was providing life-long shelter to rehabilitated
patients in an institutional set-up. These institutions not only provided shelter and food for
life but also kept the patients vocationally engaged in one or the other departments. The
patients thus lived in a separate world of their own. permanently cut-off from their family
and society.
After the launching of the national programme to control leprosy the concept of reha
bilitation also underwent a change and it was realised that the life-long institutional shelter
provided to patients of leprosy was no rehabilitation in the real sense of the term. It was also
recognised that the existing institutions could play a role in short-term training of leprosy
patients in some skill, vocation or craft so that the patient could be sent back to society, after
training. Many institutions gradually accepted this modified concept and started discharg
ing leprosy patients after training them in some trade/skill. Unfortunately, there was no
mechanism of follow-up of the discharged patients with the result that very little inlormaI.IDR. Jul)-December 1991
54
S.P. Tare
Comnuinily-Bascd Rchuhiliiation for :hc Leprosy Cured
lion was available with the institutions as to how the trained pat
were faring after their
1 discharge. Two studies conducted in respect of patients discharged from two supposedlyideal rehabilitation centres brought out a sad revealation that majority of trained-anddischarged patients were not continuing the trade-craft in which the training was provided
and had become either beggars or agricultural labourers. A further probe in the reasons for
this failure brought out the following:
I.
I hese patients were trained in something other than what they were doing earlier.
2. They were trained in something other than what they would have liked to do; the
institutions chose the skill/job in which to train them without taking into account their
performance or liking.
3. There was no follow-up of patients discharged from the institutions.
4. There was hardly any support extended to the discharged patients to gainfully establish
themselves in the field of their training; either by providing them with necessary tools,
or by helping them in obtaining raw material or in marketing of the things they
produced.
In view of the limitations noticed in institution-based training programmes and
consequent loss of considerable time; energy and money spent on the training, an effort was
made to explore avenues of placement of leprosy patients in already existing/available jobs.
A study of 23 public sector industries was conducted by the Gandhi Memorial Leprosy
Foundation (GMLF) and thousands of job specifications were studied to identify thosewhere patients with varying degrees of infectivity and deformity could safely be placed.
This study brought out a list of thousands of jobs where even an active patient of leprosy
could be employed without any risk of spread of infection to other co-workers, without any
likelihood of further damage to his limbs and without need for any special training
acquiring skills. The findings of this study brought out the great potential of likelihood of
vocational placement of a large number of even illiterate and unskilled patients for various
jobs.
In GMLF, greater emphasis was given to “prevention of dehabilitation” rather than to
“rehabilitation of dehabilitated patients” because it was felt that the final solution of the
problem of rehabilitation will come out only if the process of dehabiIitation of patients from
society could be totally halted. There is no doubt that those who are already dehabilitated
have to be taken care of. but that alone will not solve the problem as long as problem
continues to be aggravated in numbers by addition of newly dehabilitated patients year after
year.
55
Every case of leprosy is trea. freely in a clinic locally close to his village. The therapy
earlier was monotherapy with DOS and for a decade now- multi-drug therapy. It may be
noted that these field centres were located in rural areas and hence the experience is based
on work with rural population.
Simultaneously, with detection of every new patient and his treatment, special efforts
weir made to lake interest in the social life ol every patient and Io help him to slay with
family and stand on his own. Some ol lhe el foils, lor example, are as follows:
I. Help the patient to continue w hatever woik he is doing and intervene in instances where
he is on brink of dehabilitation (e.g. helping teachers with deformity to carry on as
teacher by convincing/persuading his employers; co-teachers and guardians of pupils
of the school in which he is teaching. Similarly, ah employee in a Bank by convincing/
persuading his officers, co-workers. Trade Union of the Banking Staff and clients of the
Bank.
2. Help a patient to regain the job which he was doing earlier but ha', lost it (e g. helping
a school-teacher who was dismissed on the ground of leprosy to be re-instated in his post
with all back-benefits paid to him)
3. Wherever it is necessary to provide a new job to a patient, to help him in one of the
avenues of self-employment in his village (e.g. as a vegetable-vendor, or taking up
smithy or dairy or poultry or tailoring or spinning, etc.). This prevents, on the one hand,
any likelihood of getting displaced and on the other hand, enables him to continue with
the family as an earning member and with acceptance from society.
4. Help a patient to obtain benefits of numerous schemes of the Government as a part of
their employment, poverty-eradication or welfare programmes and old-age/disability
schemes (e g. to obtain land, to obtain loan for building a house, to receive pension for
old and crippled patients, to receive loans extended to start self-employment project,
etc.).
The above efforts have been conducted for nearly four decades now in the field of
GMLF. and the results achieved can briefly be summarised as follows:
I. There is no deformed patient among the newly-detected cases for last four years.
2. There is no active patient having an ulcer (the credit entirely goes to the patients who
have understood the importance of taking self-care of their affected limbs, and devel
oping it into a daily habit of check-up.
The methodology followed for preventing dehabilitation was two-fold:
Early detection of every patient of leprosy.
Immediate and full treatment of every patient of leprosy in as early a stage of the
disease as possible.
In every field centre of GMLF. a population of 2 to 3 hundred thousand is covered and
entire population is physically examined, once a year to delect any new case of leprosy.
a)
b)
IJDR, July-December 1991
3. There is no instance, in over twenty years, of any single leprosy patient being compelled
to leave family or home.
4. There is no instance, in over a decade, of any employed leprosy patient being removed
from job on account of leprosy.
IJDR, July-December 1991
56
S.P. Tare
INDIAN JOl'P
5. There is no instance, in over a decade, of a patient-w
»eing divorced (through
*.GMLF’s doctor appearing in the court as an expert witness in defence of the patient
wife and testimony being accepted by the Court to reject the petition for divorce) or
being rejected by the husband (through direct persuation of the husband and/or taking
help of local support to convince the husband to accept the patient-wife back).
I. Of DISABII.i l Y ANJ) REHABII H A I ION
JULY-DECEMBER, 1991
TRENDS AND OPINIONS
6. There are numerous instances of young patients being helped to get married to a healthy
spouse; even young girl-patients with visible deformity could gel married to a healthy
groom with his and his family’s full knowledge.
Planning for the Disabled Child
What is explained above is what is being presently termed as “Community-based re
habilitation”. The GMLF had based the entire strategy in respect of its approach to deal
with rehabilitation in helping the patient to remain in his natural environment, and getting
gainful employment in his own surroundings with full support of the community in which
he lives. This strategy entirely does away with the costly model of institution-based
rehabilitation which need workshops, machinery, craft-teachers and whole range of
production and marketing mechanisms, and fails if there is no follow-up support for
considerable length of time to see that the patient is not only carrying on gainfully in what
he was trained for, but also that he is accepted by the community to which he has gone back.
To summarise, it can be stated that:I. It is very important to carry on case-detection at as early a stage as possible and
introduce therapeutic intervention as quickly as possible so that no patient develops
physical deformity and is exposed to the threat of vocational and social displacement.
2
I
Active efforts should be made to take interest in social problems faced by every patient
and effective intervention be made in case of those identified as being on the brink of
dehabilitation, so that the patient is not dehabilitated. In other words, prevention of
dehabilitation is the final and ultimate strategy to get rid of the problem of rehabilita
tion.
3. As far as vocational rehabilitation is concerned, the strategy of “Community-based
rehabilitation” is far more effective compared to the model of institution-based
rehabilitation programmes. This implies in helping the patient to continue to do what
he has been earlier doing, but do it in a better way and/or to help him through some
avenues of self-employment. This strategy is preferable because I) it is very cost
effective, 2) it is very satisfying to the patient concerned because this enables him to
stay in his own environment and do what he likes to do, 3) moreover, it ensures his
integration in his own community in a very smooth way. 4) finally, it has an educational
value for the rest of the society to see that leprosy is curable and not such a fearful
disease, and that a person having leprosy is as much a part of the society as any other
person.
D.J.K. Cornelius
Navajyothi Trust. Madras
ABSTRACT
ChUdhond is the most dynamic period of development, consequently "un
treated childhood disabilities will result in profoundly handicapping conditions.
Specially developed schooling programmes are essentialfor "e.xceptional” children.
Most disabling conditions can be managed with the exception of Mental Retardation,
which will respond largely to special educational and training exposures, h is
necessary to determine the aetiology of the condition to plan appropriate interven
tion systems. Services initiated early are most benificial. While services are targelted
to the disabled child, appropriate services need to be plannedfor the care giver. Edu
cational facilities need to be upgraded and the aspect of intergrated education
carefully evaluated. The challenges of service delivery in developing countries with
a large proportion of its population in the villages are stupendous and have to he most
carefully planned, to make them relevant. Perhaps the greatest input to successful
habilitation and rehabilitation will be the introdm tion of environmental restructure
to meet the specific needs of the disabled child. A recommendation for a CBR
programme has been made.
Planning for the Disabled Child
Childhood is a period extending, classically over twelve years (from the age of two
years, or as generally understood, upto eighteen years, when the period of adolescence
concludes). When services are understood as a system organised to provide for needs; the
enormity of the challenge of meeting them, over the continuosly changing requirements
throughout this relatively long developmental process in childhood, is not difficult to
concieve.
Recalling the need for a clear understanding of the concepts; for this purpose, the
following definitions have been adopted:- That
UDR. Jah-Drcrmbt-r ITH
i
. Vol 62 No. 2
INDIAN JOURNAL OF LEPROSY
tAO&SIRUMBAN—SCREENING C
Apr-Jun 1990
•GISH-RED CASES & ITS EFECTS ON PREVALENCE
MATERIAL AND METHOD
SCREENING OF REGISTERED LEPROSY CASES AND ITS EFFECTS i
ON PREVALENCE RATE
8
.ID-
P. SlVARAMAKRISHNA RAO1 AND P. SlRUMBAN2
)<:
Prevalence rates of leprosy in 6 endemic districts in Andhra Pradesh, India
with a population of 168.71 lakhs (1981 census') H ere studied before and after
screening of registered cases. The screening was carried out as part of multi
drug treatment project implementation. After such screening a sharp fall in the
registered prevalence rate, by 26.2% on the average, was observed in all the dis
tricts. About 34.8 % of the total cases were declared as Released from control.
The implication of these findings regarding registered cases fit for such release
and the overall registered prevalence rates in the country must be kept in mind.
.Si
Data on screening of registered cases and detection of new cases by
rapid survey were collected from 6 endemic districts in Andhra Pradesh
where multidrug treatment projects were under implementation, through
■ the courtesy °f tbe NLEP Consultant and concerned District Leprosy Offi
cers. Rapid survey and screening of cases was completed in one year on
aa average in these districts (except in Visakhapatnam District where it
r took two years) between 1985-87. Prevalence rates of registered cases bei fore commencement of screening and after completion of screening were
I calculated, based on the estimated population for each of the districts and
£ the percentage fall in prevalence rates were worked out.
i
From 4 of tiic 6 districts information was collected on case detections, discharges annually and the number of cases in the registers at the
•3
The prevalence pool of leprosy in a population in general is in a cons- J I beginning and at the end of the year, for 4 years prior to the screening year.
tant flux resulting from inflow of cases (new cases, relapses and immigra- .j | Point prevalence rates at the beginning and end of the year, percentage fall
I or rise in prevalence rates, new case detection ra»es and proportions of
tion) and outflow of cases (cure or inactivation, emigration and death).
I cases made R.F.C. were calculated year-wise.
Where leprosy treatment facilities exist, inactivation or cure due to 1
specific treatment is an important mode of elimination of cases from |
the prevalence pool (Noordeen 1985).
However, information onregis-J
RESULTS AND DISCUSSION
tered leprosy cases is often not updated and inactive cases often remain in |
As may be seen from Table I, the coverage of screening of legistered
the registers, either because patients have been lost to follow-up or be-^
cause of the inability to assess the patients’ clinical and bacteriological | L leprosy cases ranged from 70.4% in Visakhapatnam to 97.4in Chitoor
condition (W.H.O., 1988). To what extent inactive cases remain in the 1 | District with an average of 88.1% for the 6 districts. The registered fall
' in prevalence rates varied from 9.75% in Krishna District to 43.65% in
registers is not known.
Visakhapatnam District, the over all average being 26.2% for the 6 districts,
in the year when the rapid survey and screening of registered cases was unMultidrug teatment (MDT) projects divided into 4 phases (Mobilisa
tion, Planning and Preparatory, Intensive and Maintenance) are being i dertaken. As compared to this, the fall or rise in prevalence rates in each
implemented in several endemic districts in India since 1983. Rapid survey j
year for 4 years prior to screening in 4 of the districts ranged from a fall of
6.16%in West Godavari District during 1985 to a rise of 9.30% in Cuddapah
of the community (to detect hidden cases) and screening of registered cases
District during 1982 (Table 11). As such, the percentage fall in prevalence
medically (to declare cured cases as released from control (R.F.C.) and to .
rates in the year when rapid survey and screening was conducted, was
identify cases for multidrug regimens) are the two important activities un- j
considerably high. The new case detection rate (per ICCO population)
dertaken during the planning and preparatory phase (NLEP, 1987). =
; in the rapid survey year ranged from 1.33 in West Godavari District to 4.09
\ inCudappah District, the average being 1.92 for the 6 districts. The annual
1. Dr. P. Sivaramakrishna Rao, MBBS, DTM & H, DPH., Deputy Director
j
new case detection rate in 4 of the districts for the 4 years immediately prior
(Epidemiology) and Head of Division of Epidemiology and Statistics,
to screening and rapid survey ranged from 1.12 in West Godavari District
during 1984 to 2.29 in Cuddapah District during 1982 (Table II). The
2. Mr. P. Sirumban, M.Sc., Senior Statistical Assistant,
sharp fall in prevalence rate during screening year occurred despite an
Central Leprosy Teaching and Research Institute, Tirumani Chengalpattu,
_
i
appreciable increase in new case detection rate during that year.
Tamilnadu 603 001.
Jr
INTRODUCTION
'
\
r
■
■>:
k
180
181
I
I
Table I.
oo
K)
Data on Popul
j. Leprosy Case Detections. Screening Cases Etc., in 6 Dis
<s of Andhra Pradesh.
<
- o.
bJ
Districts
z
Particulars
Vishaka- E. Goda- W. Goda- Krishna
CUDDA-
PATNAM
VARI
VARI
PAH
Chitoor
Total
1.
Population (1981 census—in lakhs)
25.76
37.01
28.74
30.5
19.33
27.37
168.71
2.
Cases detected during rapid survey and screening
4651
8826
4283
4915
8923
5040
36638
Z
3. Total cases for screening
22105
38386
16722
25048
31728
33010
166999
>
z
g
4.
70.4?/
96.7?/
95.7?/
73.8?/
94.7?/
97.4?/
Cases screened
0
81.1%
5.
Cases deleted during screening
12065
16543
6627
6585
12867
14472
69159
6.
Cases deleted as RFC
6639
10028
4192
4122
8293
11290
45364
5.98
7.18
3.92
5.95
10.62
9.3
6.95
55
z>
o
“fl
w
7. *Prevalence rates (per 1000) before screening
0
00
8.
Prevalence ratesfper 1000) after screening
3.37
5.22
3.13
5.37
8.64
6.07
5.13
9.
Fall in prevalence rates
43.65%
28.34%
20.15%
9.75%
18.64%
34.73%
26.19%
10.
R.F.C. case proportion to total Regd. cases
38.04
33.92
40.13
20.47
36.37
40.36
34.80
11.
New case detection rate (per 1000)
1.56
2.11
1.33
1.43
4.09
1.65
1.92
cT
tl
Cases detected during rapid survey and screening were excluded for calculating Item 10.
* (Item 3 — Item 2)
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Districts
W. Godavari
E. Godavari
Particulars
1. No. of cases
at the beginn
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2. New cases
detected
1982
1985
1984
1983
1982
1985
1984
1983
1982
1983
zo
Cuddapah
Krishna
tj
1985
1984
1984
1983
1982
1985
23720 25255 26608
24295 22648 24288 25779 25443 21522
41944 43446 42997 41692 22834 23845 24440
5310
5749
3808
3. Cases deleted
3722
5362
5338
5300
2711
6643 7619
3720
3421
3374
4442
3561
2779
4400
2759
4252
4206
4116
4554
3303
3418
4177
2762
4541
3782
2346
1778
2065
3110
181
318
276
516
3.97
1.31
1.09
1.94
z
73
z
?
4. Cases deleted
as released
from control
627
3726
941
1444
1811
2345
1252
1471
2171
474
3942
1483
5. R.F.C. case
proportion to
total Regd.
cases
8.91
4.12
3.99
7.45
9.65
5.52
6.06
5.83
1.44
9.17
8.42
1.13
6. Percenuge
fall/rise in pre
valence rates
—1.36 —3.67 +6.31 -r5.21
2.12
0.00 4-9.30 +5.49 +4.44 +1.64
-1-2.64 —1.85 —3.79 —6.16 +3.59 +1.62
1.33
1.30
1.25
7. N.C.D.R.
1.36
1.37
1.40
1.35
1.26
1.40
1.20
1.12
1.13
2.00
1.65
1.63
2.29
i
<5
excluded for calculation of Item 5.
O
year were----------Note : Cases detected during theN.C.D.R..
: Annual new cases detection rate per 1OOO population.
— : fall.
-+- : ri«o.
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^ol. 62 No. 2
Illustrations including charts and photographs should I^Pstnctcd to the neces-|
sary minimum. They should be capable of reduction. Line drawings may be sent
black and white glossy prints or as drawings, neatly executed in Indian ink on stiff |
white paper or Bristol board. Only black and white glossy prints of photographs of j
good quality are acceptable. Authors will have to bear the costs of colour reproduo|
tions.
’Altf
Apr-Jun 1990
editorials are written by the Members of the Editorial Board or by guest
writers. The editorials express the personal views of the writers).
iuPROSY CONTROL WITHIN URBAN PRIMARY HEALTH CARE
Leprosy is the same whether it is encountered in the rural or urban
hrea. But the approach towards control of the disease in these two diffe|rcnt situations warrants some differentiation. An urban area is a highly
Artificial situation where a large number of human beings have learnt to
Bve together in close proximity to meet their needs. Urbanization brings
gfogether, among others, patients suffering from leprosy and it is noticed
wftat the health services needed to combat leprosy are inadequate unlike
|me of the other facilities. Studies in the field of leprosy and field research
|for its control have in the past been confined to those carried out under
Enral set-ups. It is only since the early 1970s that urban ecology and living
|patterns in relation to the spread of leprosy have received serious attention
If
i
L.
I
I
I
.!r
‘f
I Asia arranged
the Sasakawa
Sasakawa Mcmorir
Memorial Health
•Rff
arrangeq in
,n Singapore
^’ngapore in
in 1983
iy«J by
by the
H Foundation together with the Ministry of Health of Singapore
c x - - and the
| Singapore Leprosy Relief Association in collaboration with the WHO.
|The Report of the WHO Expert Committee on Leprosy (1988) has made
| & more detailed reference to the problem of urban leprosy and it is grati| lying to note that the recent WHO Guide to Leprosy Control (1988) has
|devoted a chapter to this important subject. A review of the subject in
'1 Krelation to the Indian context was made by Dharmendra and Ganapati
V ■
f..........
1
R. Ganapati, Director, Bombay Leprosy Project, Vidnyan Bhavan, 11 V.N.
1 FCL,. * Dr.
Purav Marg, Sion-Chunabatti, Bombay - 400 022.
160
f
i
More recently, “Leprosy control in uiban community’’ was the spe-
I
iBi icial topic for the Fifth International Workshop on Leprosy Control in
’l1'
c
v'
■I
■
The earliest references one gets from the literature on the subject of
[ urban leprosy are the recommendation^ of the WHO Fifth Expert Committee on Leprosy (1976) as well as the panel on leprosy control at the Tenth
| International Leprosy Congress. Bergen. (1973) which stated that research
| Studies should be undertaken regarding the methodology to be applied in
|urban leprosy control. Since then considerable amount of leprosy contirolwork has been carried out in many major cities located in endemic aieas,
| but reports of systematic field studies have been scarce in the scientific
41 I literature with a few exceptions such as those from the city of Bombay.
S
r-!‘
R. Ganapati*
for publication in the Correspondence section. The Editor reserves the nght
publishing material in this section.
',<.^9
25 reprints of papers (except those published in the Correspondence sectio^
- _ __
\ or■ the author with whom the EditOTi
will be supplied free of cost to the first
author
Requests
for additional reprints, to be paid for by
corresponds regarding the paper.
the
time
of
submission
of the script.
the authors, should be sent at L..
Ml
J
■i
Short communications and comments (not more than 300 words) may be s«3
A
JOURNAL OF LEPROSY
EDITORIAL
Illustrations should be serially numbered as figures, using Arabic numerals.|
They should not be pasted in the middle of the text, but their place in the text should|
be indicated. The names of author(s), short title of the paper, figure number, and they
top of the figure should be indicated lightly in pencil, (not ball pen) on the back of|
each figure.
Legends to figures should not be written on the back of the figures but typodj
in a separate sheet, as part of the script.
The editor has the right to exclude Tables and Figures not considered necessary^
‘v.
INDL
161
I
Vol. 62 No. 2
0
Apr-Jun 1990
INDLAN JOURNAL OF LEPROSY
>n 1983 and since then more and more information is becoming available
on the extent of the problem in cities like Delhi. Bombay. Calcutta, Madras,
Bangalore, etc From Africa and South America, reports on urban leprosy are available for Dakar (Senegal), Bamako (Mali), Freetown (Siem
Leone), Georgetown (Guyana) and Sao Paulo and Rio de Janeiro (Brazil).
Transmission factors of special significance to urban environments
ed with
he d uaSe' However> tllis may not be true for the risk associatpttkuLlvU± aryt Pr°Sy- The ’ar8e nUmber of multibacillarv cases,
not exP°sed to adequate chemotherapy, together with
r”r
J “ sr
*-
respect 7
' pro8ra,nmes seem to be better
off in this
e Peet mformadonon urban reservoirs of infection, by and large are
unc ear Still, some conclusions are available through limited studies
made
,l,„ „!pecl
&
Will n
•i
n[ect,ons 'n urban locations m various parts of the world
the probit
inf°rmati0n to enab,e better e>obal understanding of
■\
I
to farTff nl'a"8 7 hyPerendemic s,ums maV
to ‘he spread of disease
period and h
m'gration- 1,1 view of
prolonged incubation
fection " , H
y " CP''05J/ 11 is not eas* t0 identify the sources of in
the Oh
"posl'r" ractors ’n such instances. It is worthwhile to recall
bneter rV I0".
(’978) Wh° Stafed “Considering the clinical and
leprosy n8th
7
r kn°Wn Un,reated Patient with early lepromatous
sinn and
d SC 108
personaI habits, social behaviour, insect transmsin the 1 f
7 tranSPOrt’beC°meS pOSSible t0 envisag= a" o^inary day
neo l
C ° ^hlS Patlent In wh,ch he becomes the source from which 100
P pie are infected with M. leprae up to a distance of 50 miles from his
nome. In one month this total hecnmM
innn and
™d if
.t only i1 o/
- .... devei
ij
becomes 3000
% of them
162
lop clinical leprosy. 30 cases of leprosy w ould result, of whom possibly three
could be potentmlly lepromatous in type". This may be an overstatement
of the case but it clearly brings out the nature of the problem. If such state
ments and experiences are really significant, there is a great need to study
rural-urban migration patterns in different cities and for urban leprosy
programmes to have better coordination with their rural counterparts.
The importance of bringing down the bacillary load resting in adult
infectious cases living m urban communities as against the unjustified emphaS'S on repeated school surveys has also been brought out by well-planned
e investigations (Ganapati et a!., 1977, Ganapati and Revankar, 1978).
The exact place of repeated school surveys resorted to as an easy recourse
to case detection in hyperendemic urban foci needs to be reviewed.
0
their r i y ‘
EDITORIAL—LEPROSY CuNIROL WIIHIN PRIMARY HEALTH CARE
r
::
Case detection
Cost-effective methods of case detection, not based on whole po
pulation surveys, and specifically suitable for metropolitan areas have to
be considered for mban programmes in the light of uiban primaiy health
care. There is enough evidence in the literature on the effectiveness of
using health education and surveys of captive adult populations such as
those in general hospitals and industries as techniques for case detection
Massive campaigns organized in collaboration with public services like
city railway or bus service systems in populous cities like Bombay and
Madras have registered a spurt in the voluntary registration of new cases
Novel methods of attracting suspicious cases for examination in crowded
cities by using mobile exhibitions, have been tried (Ganapati ct al 1987)
Techniques using medical students for unearthing new cases in the commumty have also been reported by Bombay Leprosy Project (1988).
A. method referred to as “passive surveillance" consisting of encourag
ing referrals of suspected cases by medical personnel working in out-patient
departments of general hospitals is in vogue in some parts of India Com
munity health volunteers consisting of women from slum areas who receive
small incentives have also been employed with advantage for case-detec
tion in some situations. This procedure is believed to be more cost-effec
tive than using salaried paramedical workers.
While the urban context is particularly suitable for adopting several
such innovative techniques, it is very important to analyse how many of
these techniques are actually employed in various cities for case detection
It would also be interesting to know from the concerned people about the
problems met with in employing them in special urban locations.
163
1
■ V(ir. 62 No. 2
INDIAN JOURNAL OF I EPROSY
Apr-Jun 1990
Case holding and treatment delivery
Diflicultics encountered in case holding are mainly related to the pro
longed nature of treatment and patient mobility leading to a high propor
tion not completing the prescribed course of treatment. Lack of coordi
nation among the different agencies leading to multiple registrations and
the desiie of patients, at least in some cities, to remain unknown are also
real problems.
There has been no occasion to discuss case holding with Multi Drug
herapy (MDT) in an urban environment based on the experience so far
gained. Since the advent of MDT, some of the problems met with during
dapsone monotherapy era and in the early stages of introduction of MDT,
have been overcome. As we arc gaining more knowledge about the scien
tific basis and piacticc of short-term fixed-duration chemotherapy, the na
ture of case holding problems have changed and methods to overcome
them are also likely to change. Therefore, those practising management
of leprosy in in ban locations should be quick to keep abreast of these chan
ges. In fact, it is the expeiicnce of some that if treatment facilities aic offer
ed in an integrated manner in a general medical set-up instead of in a spe
cial centre for leprosy and if that is coupled with suitable motivational
techniques at the time of initiation of MDT, case holding became easier.
It is difTeicnt dming surveillance phase without chemotherapy when a pro
portion of patients have persisting clinical symptoms as well as sequelae
and when patient motivation is not strong. This calls for a degree of co
ordination among leprosy control projects, whether rural or urban, and also
among private piactitioncrs who are involved in the treatment of leprosy
in cities. It is in this context that running leprosy programmes in a verti
cal and isolated manner is harmful to leprosy control. Those responsible
for leprosy control, particularly in urban areas, have a special responsibility
to incorporate leprosy treatment into the structures offering general health
services. Difficulties in achieving such integration in various cities need
to be discussed at length.
The actual motivational techniques to ensure completion of treat
ment of supervised MDf administration are by now quite well-known.
Logistic difFiculties to trace residences of multibacillary patients living in
slums pose a problem. It has been suggested that a spot map indicating
the location of each patient be attached to case records as soon as a patient
is registered so that by using these maps anyone can locate the patient’s
home.
164
EDITORIAL—LEPROSY CO?
3L WITHIN PRIMARY HEALTH CARE
Tkc concept of “care after cure", gaining currency with the increas
ing number of patrents completing MDT, could also be practised in an
m egrated manner, though admittedly it is relatively more difficult. While
it may be difficult to offier ulcer dressing facilities in the surgical depart
ment of a general hosprtal or physiotherapy to a disabled leprosy patient
in a hospital out-patients section, attempts could be made in these direchons to adopt innovative methods most suitable to overcome local problems
Whenever such an approach is followed, case-holding of even deformed
subjects appears to be possible in an integrated way.
If urban programmes are lucky to function in the vicinity of hospitals
wth trained surgeons, they should attempt to get the reconstructive sur'gery foi leprosy patients done in such centres, instead of referring patients
far off rural leprosy hospitals. I bis, however, may be possible only in
some cities at present.
J
While treatment delivery of patients living in slums may be effected
■ rn small drspensarres offering primary health care services as part of muni
cipal health servrees. it is more challenging to offer such help to inmates of
self-set led leprosy colonies commonly found in some metropolitan areas
Some degree of successful ease holding is possible even in such situations
JT io 41USew°l n’otivat"' volunteers like university students (Ganapati
al., 1984). Whether such field experiences are replicable under diffe
rent situations is not very clear. Unless more urban programmes offer
scientifically'
integrated1 sc'' ices, urban leprosy work will be con. . planned
.
ftned o just sympathy and charity from .some motivated social workers
philanthropists or service clubs. The very existence of self-settled leprosy
colonies located in proximity to some cities, and exclusive leprosy services
propagated by well-meaning citizens, are serious deterrents for educating
he patients and the public on the positive aspects of integrated leprosy
work.
J
!
Health education
The advantages of health education <at‘ the
' community level as well
as through mass campaigns in augmenting both case dctccJion 'and
...................... J case
holding have been referred to earlier. It must be reiterated that the
very
magnrtude, complexity and stratification of urban society offers enormous
scope for the applrcation of a variety of health education tools, to lead to
‘°T.rceP'anCC. 0f,'Cpr?^ pa'ien,s in tl,c not 'oo distant future. The
enlightenment of urban folk on health aspects may also have an ovciflow
effect on rural populations, This function of an urban leprosy programme
cannot be overstressed.
165
I
Vc-L 62 No. 2
INDIAN JOURNAL OF LEPROSY
EDITORIAL—LEPROSY CC
Apr-Jun 1990
The phenomenon of non-acceptance of leprosy patients in general I |
medical facilities has been commented upon in almost every forum discuss* ’
ing leprosy. As medical institutions and universities are often found in I
clusters in metropolitan areas, leprosy programmes functioning in such i
situations have the added responsibility of establishing rapport with this 1
sector which consists of nurses, medical students, postgraduates and teachers.
With necessary resources made available, it should be possible to provide |
.OL WITHIN PRIMARY HEALTH CARE
various units should co-ordinate their activities periodically in order to avoid
duplication of work. Occasionally an altitude of cSo on the part of some
programme managers is noticeable which will need to be subdued in the
larger interest of patient services. C
Coordination meetings should help
to resolve any conflicting issues among units.
guidance to medical students, arrange for competitive examinations, pro- j
vide relevant literature and encourage students to participate in leprosy |
surveys, etc. Competent personnel should paiticipate in (he teaching of I
RFFFRENCF-S
leprosy in medical schools and should interact with other teaching staff ;
of medical institutions. In such instances, audio-visual aids are likely to a
hv
Lcpros* Pr°jCCt (’9R8)- Stla/ies on r^y
to 1986. Published
by the Bombay Leprosy Project, Bombay 400 022, p 401.
be of great use. Fortunately, in the field of leprosy such material is available, and leprosy programmes in the neighbourhood of such institutions 1
2. Davey, T.E. (1978).
A day in the life of Yecranna—a cautionary talc”.
could use this to their advantage.
. Lepr. Rev., 49 : 269-274.
Training
L
■'r
I Lhp 3'r Dharmendra AND Oanapah, R. (1985). Ch. 13., Urban leprosv - Impor.. lance of, In Leprosy, Vol. 2 cd. Dharmendra, Samant and Company, Bombay, pp. 1413-
I
The recent report of the Expert Committee on the involvement of I
primary health care in leprosy in India has laid great stress on the need for | ! inthe4UrbjnlhrIn,Crna'iO'1.aLWOr'<S',OP 0,1 l cprosv Conlro1 in Asia. “Leprosy Control
y-r pn8aPOre' 24’27 °CI- ,983Sasakawa Memopreparatory “job oriented brief training of all categories of primary health | ! tialXalth F
L Ual Health Foundation, Tokyo, 1984, p. 189.
centre staff” before assigning them the tasks pertaining to leprosy. While
5. Ganapah, R. (1983). Urban Leprosy Control. Trap. Doctor, 13 : 76-78.
this Committee had essentially a rural scenario in view, the situation regard- j
ing training of personnel engaged in urban primary health care, such as
I wheels’
R,.’
V-V--(-’CD.H.,JAmIAv, V.(!987). Inhibition
those manning city dispensaries and hospitals, is the same. Lcprcsy prog- | ..l wheels
on
wheels —a technique for detection of Hansen’s disease. Tke Star, 47 (2) : 14.
rammes functioning in such locations should equip themselves suitably
.•L ?ANAP,\r!’ R” G,RnA’ D G979). Leprosy from the Urban Angle, Bombay
to offer such training. Training does not necessarily imply elaborate class- j
I.si, Hospital
Journal -21 .*: 13-16.
•
............
rooms or fancy equipment or even highly qualified staff’. Simple field tech- i
niques such as case detection through surveys, skin smear examination, i r valkar N.A., Deshpande, S.S. (19^).
supervised administration of MDT, health education, and elementary j
disability care can be demonstrated by experienced leprosy paramedical | . rapy in leprosy eolomes through volunteers-A baclriological Assessment. Indian J.
workers. As medical colleges are gradually showing an inclination to get J Lepr., 3o : oo-yu.
involved in community health strategies to overcome health problems, a 4
9. Ganapatj, R., Pandya, S.S., Naik, S.S., Dongrf, V.V., Dfsouza, N.G (1977)
medical student of today, at least in some situations, is not averse to learn- 3 Assessment of School Surveys as a method of case detection in an Urban Area Endemic
for Leprosy. Ind. J. A fed. Res., 66 : 732-736.
ing about leprosy from health auxilliaries.
Co-ordination
In many large cities multiple voluntary agencies, international as well
as national, are operating field programmes adopting well-defined areas
for their leprosy control work. Local government or city corporation
units may also be functioning in the same areas. It is essential that the 166
>.?aANAPAI'L ?■’ Rfvankar’ C R • <I97«). Associated cases in the families of
school children with Leprosy, l.cpr. Rev. 49 : 43-46.
11. GANArAit, R.. Rrvavkap. C.R.. Do-x.ai V.V. (I9R5). Prevalance of Leprosy
in slums in Bombay including a leprosy colony. Indian J. Lepr., 57 : 383-388.
12. Ganapati, R_. Revankar. C.R., Naik S.S. (1986). PC ’ '
Risk of exposure to leprosy in hyperendemic slums of Bombay. Lepr. Rev., 57 : 275.
167
I 1
' Vol.”62 No. 2
INDIAN JOURNAL OF LEPROSY
Apr-Jun 1990
Revankar, C.R., Dudhalkar, B., Girua, D.R., Ganapati, R. (1982). Lep
13.
rosy surveys in urban slums—Possibilities for epidemiological investigations. Lepr.,
Rev. 53 : 99-104.
14. Tenth International Leprosy Congress, Bergen, 13-18 August 1973, Committee
7, Leprosy Control, Transactions. Int. J. Lepr., 41 : 465-468.
15.
WHO (1977).
Fifth Expert Committee on Leprosy. Technical Report series
Vol. 62 No. 2
INDIAN JOURNAL OF LEPROSY
Apr-Jun 1990
CULTIVATION IN VITRO OF ACID-FAST NOCARDIOFORM CHEMOAUIOTROPHIC BACTERIA FROM MOUSE FOOT-PADS
INFECTED AMT II HUMAN ST RAINS OF LEPROSY BACILLUS
I
A.N. Chakrabaru
S. G. Dasudar2, S. Das3 and A.K. Chandra4
No. 607, World Health Organization, Geneva.
16. WHO (1988). Sixth Expert Committee on Leprosy. Technical Report Series
No. 768, World Health Organization, Geneva.
17.
WHO (1988).
Urban Leprosy Control, Ch. 10 in .4 Guide to Leprosy Control,
World Health Organization, Geneva, pp 70-71.
Four acid-fast nocardioform bacteria could be isolated and cultivated as pure
cultures m vitro from mouse foot-pads (MFR), uhich were infected with serially
passaged strauv; of human leprosy bacillus; the liquid mineral medium, such as
Ptr%\
V^in gelatin minimal (PGM), gelatin minimal
I
), and j. 1 agar ((jMA) slants containing only simple sources of C and N
were used, just like the human and the armadillo isolates of these organisms re
ported earlier. Morphologically, metaholically and enzymologically, these
were closely related to the previous ones and were also cliemoautotrophic in nature,
biologically there appears to be a hererogenicity in these isolates, i.e.. some of
them showing higher affinity to nocatdio forms while others showing significant
binding to several mycobacteria. Normal (uninfected) mouse foot-pad harvests
neie not found to harbour such organisms.
■
•f
INTRODUCTION
We had reported previously on the in vitro cultivation of a cluster
of cliemoautotrophic. nocardioform bacteria from human multibacillary
cases o leprosy which could not be grown on any conventional media and
al: sue i organisms could not be recovered from non-leprosy cases (Chababarty et al.. 1986 a. 1986 b; 1987). Dastidar et al. (1987)'reported furUier on the Isolat1on in pure culture of a similar bacterium from the spleen
ssue of an armadillo, experimentally infected with M. leprae (Kirchheimer
i. Dr. A.N. Chakrabarfy, M.D., D.C.P.,
D. Bact. Professor, Deptt. of Medical
and Pamsiroloey, Catc’utta University College of Me.lieine,
244 B, Acharya J.C. Bose Road. Calcutta 700 020.
<1
2
1 Mr St DrS' M r’ ’ID C P - Research Associate (ICMR), Deptt. of Medical
Man a ?Py
C'-'R-utta University College of Medicine
244 B, Acharya J.C. Bose Road, Calcutta 700 020.
4’ Mr't-A'I<\vh!!?<?r?’ M SC'’ Ph'D- Rcsearch Associate (ICMR), Deptt. of
Medrca! Mrcrobro ogy and Parasitology, Calcutta University College of
Medicine, 24 4 B, Acharya J.C. Bose Road, Calcutta 700 020.
168
169
52s
J D F Habbema et al.
1
■
r>)5 8a .'X'2Lepr Rev (IS
63, Supplement. 53s 60s
Conclusions
The success of decision models as an aid in leprosy control cannot be guaranteed
beforehand. But applied modelling could be important when addressing questions in
prediction, planning, monitoring and evaluation. There are excellent control programmes
with longitudinal data which could form the backbone for constructing validated W
simulation models. Those in charge of leprosy control programmes should seriously .J
consider a collaboration with scientists and decision makers for jointly developing
practical decision aids.9-1011
H 6 W
Major issues involved in the evaluation of
leprosy control programmes through MDT
C K RAO
fl
References
I
A /J
i1 G.lbody JS. Impact of mullidrug therapy on the treatment and control of leprosy, hu J Lepr. 1991; 59:458- 1•
Introduction
PJ Van rk’ Koning HJ de- ,neve|d BM van. Oortmarssen GJ van. Habbema JDF et al The cost- 1
effectiveness of breast cancer screening, bit J Cancer. 1989; 43; |()55 6()
1
Oortmarssen GJ van. Habbema JDI . Maas PJ van der. Koning HJ de.’ Collette HJA et al A model for J
breast cancer screening. Cancer, 1990; 66: 1601 12.
.<
a mooei tor H
Remme JHF et al. Epidemiological modelling for tropical disease control. Lepr Rev 1992; 63, Supplement, |
In the past 4 5 years countries where leprosy is endemic have increasingly adopted
multidrug therapy (MDT) in the treatment of leprosy. The broad aim of MDT is to
interrupt the transmission of infection through early case detection and regular and
complete treatment, and also to prevent disabilities and deformities. Reports on
5 Plaisier AP. Oortmarssen GJ van. Remme JHF. Alley ES, Habbema JDF. The risk and dvnamics of 1 I effectiveness, safety and patient acceptability from countries implementing MDT have
6 H^benVr
cessation of vector control. Bull. WHO, |99l; 69: 169-78.
f -J
continued to be positive, and also show that MDT has increased community confidence in
Habbema JDF, Plaisier AP. Oortmarssen GJ van. Remme J. Alley ES. Prospective evaluation of
the curability of the disease, which promotes voluntary self-reporting of patients.
onchocerciasis control strategics. Acta Leidensia, 1990; 59: 387 98
ias
!
Planning and evaluation arc managerial tools that contribute to the success of leprosy
Plaisier AP. Oortmarssen GJ van. I labbema JDF. Remme J. Alley ES. ONCIIOS1M a simulation model for
43C ‘r6anSm,SS,On and con,ro1 °f onchocerciasis. Computer Methods and Programs in Biomedicine, 1990; 31: d control programmes. Evaluation helps further prospective planning to be effective by
R IPZ/O,1 197;^36 |,V73VdlUt CM’
CB’ BoUckncrt A Un moddc epi^niiometriquc de la lepre. Bull . ] identifying achievements or shortcomings and highlighting the points that could improve
I programme performance.
9
Lechat M F. Misson CB. Bouckaert A. Vellut C. An epidcmiomctric model of leprosy: a computer simulation 1
>
The implementation of M DT for leprosy cases demands a highly sensitive monitoring
of various control methods with increasing coverage, bit J Lepr. 1977; 45: | 8
1
and
evaluation system to ensure the programme's smooth and coordinated progress. The
in
Lechat MF Misson CB Vanderveken M. Vellut CM. Dcclercq EE. A computer simulation of the effect of
nui tidrug therapy on the incidence of leprosy. Ann Soe belga Med Hop. 1987; 67: 59 65
j
use of expensive and effective drugs under supervision for relatively long periods makes
11
1^™^OLC"U' ( M SdCe'i,,n ,,r M” ' S'ra‘*S 'hr™gh
| treatment monitoring a crucial component of the programme. The correct time of
programme inputs, including drugs and educational material, is ensured through
j
I programme monitoring. Monitoring also helps in rcshuflling priorities, dropping
Figure 1. Model development (1) and application (2).
unproductive efforts and in indicating neglected areas.
In this paper evaluation has been taken to include both monitoring (day-to-day
follow-up of activities) and evaluation. Monitoring is also referred to by some
programme designers as internal evaluation and is often in-built in leprosy control
programmes Unlike monitoring, external evaluation is periodic and independent of the
programme pe'sor.rc-l.
e-.
d
reported
My experience in planning and participating in the independent evaluation of leprosy
programmes in India and Myanmar in recent years is the basis for delineating important
issues involved in the evaluation exercise.
Issues
OBJECTIVES ()l EVALUATION
The objectives of the programme may vary from country to country, depending upon the
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aims,1 strategies, infrastructure, and duration of the MDT operations, and may include
some or all of the following:
—Assessment of case detection progress, case treatment, drug delivery and reasons for
patient default.
Validation of reported data through examination of records and field visits.
—Assessment of the ongoing information system in terms of its promptness and
completeness.
—Ascertainment of the technical competence and devotion of the staff involved.
—Determination of the impact of health education, if any, in dispelling ignorance/
prejudices in the community, in promoting regularity of treatment and in retrieving the
defaulters.
—Examination of the impact of the measures on the disease.
KEY COMPONENTS IN MDT DELIVERY
Major issues ini oli ed in evaluation of LCP with MDT
55s
the community, this may receive very little attention from most of them, especially in
integrated programmes. Voluntary self-reporting of cases, a high compliance rate and a
high rate of treatment completion reflect how effective the education component is in the
community, considering patient awareness, patient participation and community
acceptance.
Leprosy profile
General information on leprosy prevalence and other epidemiological indices in the area
before and during MDT should be available.
Infrastructure
Enumerating general health services personnel and/or special leprosy workers involved/
available for a leprosy programme and designating their job training status.
Treatment delivery
MDT is delivered once a month by the health personnel at predetermined points near the
patient’s home or in health centres/dispensaries/out-patient departments of hospitals,
either to all eligible patients or only to selected patients, as decided in a country’s
programme.
Voluntary organizations
These have to be active participants in monitoring and evaluation from the programme
planning stage when working for leprosy control in a country
Monitoring methodology
Case detection
This is achieved through the promotion of voluntary self-reporting of patients, through
active surveys, or by both methods, envisaged under the programme chosen.
Patient card maintenance
This should indicate the clinical/bacteriological status before, during and after MDT.
The existing information recording and reporting procedures followed to monitor a
leprosy control programme may vary from country to country. Most programmes that
originated as strong vertical programmes continue to have a comprehensive reporting
system compatible with adopted from OMSLEP. Appropriately most integrated pro
grammes have a simple and practical reporting system that include the core activities of
case detection and case treatment as a part of health care reporting. The aim of leprosy
information systems is to give timely though roughly correct figures rather than unduly
precise but delayed data.
Case treatment
It should be specified which MDT regimes are followed for multibacillary (MB) and
paucibacillary (PB) cases, and the regularity of MDT and monitoring drug intake by
patients under the programme.
Sources of information
Record maintenance
Training of monitoring personnel
Data recording and reporting systems should be maintained at different levels and there
should be officers responsible for this, and feedback should be given to the senior officers
clarifying the strong and weak points in the reports.
All health workers responsible for monitoring data collection and for supervision should
obtain their skills during job training for leprosy control.
These should be leprosy patient cards and registers, leprosy survey data, surveillance
information and supervisors' reports.
Selection of indicators for monitoring leprosy programmes
Health education
This occupies a high priority in the success of MDT- though it is the responsibility of
every health worker involved in the programme to educate the patients, their families and
These may vary from country to country based upon the programme aims, strategies and
the infrastructure implementing it. The broad goals of MDT in leprosy control
nrnprammes should be Io nrovidr in full thr roiir^p nf MDT tn knrncv rococ thArAfnrA
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certain minimum indicators must be monitored. The following five indicators suggested
to be ‘required’ at the WHO Consultation on Technical and Operational aspects of
leprosy in Male, Maldives, in .lune 1990, arc considered appropriate as minimum
indicators: (i) prevalence; (ii) case detection; (iii) the proportion of patients with disability
grade II among newly detected cases; (iv) MDT coverage, i.e. the proportion on MDT
against all registered cases'for chemotherapy; and (v) MDT completion, i.e. the
proportion who have completed MDT among those put on MDT. Advanced pro
grammes could develop additional indicators that were suggested in the report of the
WHO Study Group on the Epidemiology of Leprosy in Relation to Control (TRS716).
Operational criteria for definition of an active case for computing prevalence suggested by
the Sixth Expert ( ommittee on Leprosy (T RS76X) would be appropriate to ensure
uniformity, to define the targets for MDT and to determine the disease trends following
MDT' programmes.
.fajor issues involved in evaluation of L( P with Ml)T
57s
mentioned earlier, an evaluation undertaken by an expert who is independent of the
programme planning and implementation, ensures lesser individual bias and a greater
reliability of data.
Objectives
The objectives of evaluation listed above arc perhaps relevant for external evaluation as
well as with varying priorities. Broad objectives of evaluation arc two-fold: one is
determination of operational efficiency, i.e. to examine if what was planned or expected
was in fact carried out. and the other is the determination of the impact of the control
measures on the selected indices, i.e. whether what was expected in terms of selected
indices did actually happen.
Collateral benefits
Supervision
Ibis is central to monitoring. Supervision ranges from validation of disease diagnosis,
classification, activity, treatment delivery, treatment intake, detection and the manage
ment of reactions, skin-smear results and also logistics—delivery of drugs and transport.
Part-time or full-time supervisors at different levels arc identified and trained in the
supervisory skills and techniques of leprosy control programmes.
An element of healthy competition among the staff, especially middle-level managers,
raises the morale of the peripheral staff, motivating health administrators, health planners
and politicians for their increased support. Through their active participation it educates
the administrative medical officers at state division level on the strengths and weaknesses
of the programme in their area vis-a-vis at the national level.
Sources of data
Feedback on reports
Regular feedback from supervisors on their observations concerning both strong and
weak points of the programme and comments on reports to lower reporting echelons,
though not involved in decision-making, improves the programme performance.
siRi Nt;riiENiNt; monitorinc; system
An in-built monitoring system is often subjected to decay, and becomes less effective with
time. However, the decay could be minimized and delayed by the periodic training of
workers in skills to review critically the data and initiate corrective actions, maintenance
of patient cards, encourage effective supervision, a periodic programme review of
different levels by the highest administrative authority, listing priority indicators for
monitoring, issuing a periodic news letter, maintenance and storage of records, etc.
The Indian programme appears to be unique in having a system of internal evaluation
of leprosy programmes by creating regular assessment teams supported by the central
programme at the state level and hiring full-timc/part-time consultants supported by the
WHO at national level. T hough a formal review of their contributions has not been done,
it is considered that (hey help to improve the quality of reported data, as well as tackling
the operational/administrative problems in time. T he programme is considering ways and
means of keeping internal evaluators on a continuous basis.
I XTERNAL. EVALUATION
The existence of a leprosy information system is basic to evaluation and monitoring. As
Records and reports maintained at all (peripheral to national) levels on the programme
activities to delineate the leprosy profile.
Annual reports of the programme for the last 2 3 years.
Monthly quarterly reports, if any, for the current year and previous year.
Leprosy patient datacards maintained at villages/health centres.
Data obtained from discussions with programme managers national, provincial,
divisional, township regency district levels.
Intersiews with health workers, supervisors, leprosy patients and community
members.
Questionnaires for data collcclion
Appropriate questionnaires are constructed anil pretested by the country programme
manager taking account of the terms of reference for independent evaluation and the time
available for evaluation. The questionnaires arc used for interviewing programme
managers, medical officers, supervisors and health workers involved in leprosy control at
different levels to determine their competence and contribution. Questionnaires arc also
used for interrogation of leprosy patients and community members to determine the level
of their awareness, participation in the programme activities, perception on social aspects
of leprosy, etc. Questionnaires arc also dc\eloped to collect appropriate data on leprosy
control programmes at different levels. About 14 or 15 questionnaires were used in the
three Indian programme evaluations and 7 in the Myanmar programme evaluation.
Questionnaires to ascertain the leprosy profile from the states in India and divisions in
Myanmar were sent to all concerned with the central programme 2 weeks before the
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proposed field visits with a request to place the data at the disposal of the evaluators,
should they visit that particular state/division. This ensured a timely submission of data
and self-review of the data in the states/divisions irrespective of the actual visit of
evaluators.
Sample selection
Effective evaluation, unlike monitoring, can only be carried out in a small sample because
of time and funding constraints. Samples for field visits were selected by a WHO
consultant independent of the programme managers both in India and Myanmar.
Random samples of states and then districts were selected in India to ensure wide
coverage of the country after stratification by levels of leprosy cndemicity, varying
organizational infrastructure and duration of MDT activities in force. A total of 10
multibacillary (MB) and 10 paucibacillary (PR) patients and 20 community members in 2
villages selected by the evaluators were interrogated in each of the districts assigned for
evaluation in India.
In Myanmar 5 MB and 5 PR patients were chosen to be interviewed in 2 villages in
each township selected for evaluation. Voluntary organizations involved in leprosy
control efforts in the districts selected for evaluation were also included for evaluation of
the Indian programme. No voluntary organization was involved in leprosy control work
in the townships selected for evaluation in Myanmar.
Selection of evaluators
In India teams of 3 experts each have helped to improve competent evaluation of
programme management (by a health administrator), impact assessment (by an
epidemiologist), and validation of reported data (by a leprologist) besides giving other
administrative and operational advantages of a team approach. In India 9-12 teams were
formed for the three evaluations of the programme in 1986, 1987 and 1989. As mentioned
above, each team had the services of a leprologist/leprosy control expert provided by the
WHO from outside India. National evaluators were drawn from directors of health
services of states or the equivalent, professors of community health or the equivalent and
similar experts working with voluntary organizations whose involvement motivated them
to support the programme.
In Myanmar, regional leprosy officers from outside their divisions were involved as
evaluators along with a WHO consultant, the latter having selected the divisions and
townships on a random sampling basis, and 2 teams of 3 experts were formed.
Should in-depth evaluation of some areas or some component of the programme be
considered necessary, suitable experts as evaluators have to be recruited.
It is necessary to ensure that the evaluators are adequately briefed at the start of the
evaluation so that they are able to fill the questionnaires and collect the requisite data
correctly and uniformly. Briefing was given for 2 days both in the Indian and the
Myanmar evaluations.
Duration of evaluation
It is convenient to complete the evaluation—travel, briefing and report—in 10-15 days.
Major i.wucs imolt cd in evaluation of IX P with MDT
59s
With appropriate planning and preparation this period was found to be satisfactory.
Disruption of routine programme activities arc marginal in brief evaluations. When a
smaller number of evaluators teams arc available, evaluation has to be prolonged over a
relatively longer period. The Indian and Myanmar programme evaluations were all
completed within 15 days. I unds for these evaluations were available from their
respective WHO country budgets.
Collection of data
Appropriate data are collected by the evaluators from the reports using the assigned terms
of reference. Information on the infrastructure availability against the sanctioned
strength, training status of personnel, leprosy prevalence, case detection, case treatment.
MDTcoverage. MDTcompletion, health educational activities and their impact, quality
of laboratory services, quality of supervision, supply of drugs, mobility, etc. arc collected
by the evaluators on a sample basis. Evaluators also validate a small sample of reported
data on diagnosis, classification, treatment schedules, regularity of drug delivery and drug
intake, disease activity, skin-smear results, etc. and record the data on the appropriate
questionnaires.
Analysis and interpretation of data
Evaluators arc expected to present orally their findings to the senior health officer of the
state/division at the end of the visit. Hence data collected will have to be analysed before
leaving the assigned states/divisions. It is a good strategy first to highlight the strengths of
the programme, if any. before indicating the areas that need strengthening by the state
division health administration. On return to the central programme headquarters to
report and deliver the duly completed questionnaires the points of view of the state
division, if any. have to be considered to see if it is necessary to relay them to national
level. During oral presentation and debriefing the strengths found arc to be projected
while also suggesting areas that require urgent corrective action at all levels of the
programme, including the central level.
Report and recommendations
Each esaluator team has to give a narrative report with the completed questionnaires
using the terms of reference assigned for evaluation. Brief, lucid and timely reports
including positive features of the programme are helpful to improve strengthen the
programme performance. The evaluation reports have provided valuable support to the
Indian programme—strengthening laboratory services; making possible the rapid
extension of MD T to a large number of districts; the timely release of funds for health
educational activities; giving priority to the filling of vacant posts: the training of
personnel; and increasing the budget.
Actions taken on the report
The major aim of leprosy programme evaluation is to improve its performance.
Evaluation guides in decision making. This purpose will not be achieved if the report is
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unduly delayed or timely corrective actions arc not initialed. Hence it is necessary to
review the actions taken on the recommendations of earlier evaluation, if undertaken.
Conclusion
Defining a case of leprosy
It may be slated that leprosy evaluation procedures followed in one country could be
adopted in another country with only minor modifications, where warranted, to suit the
local conditions.
V K PANNIKAR
Introduction
In leprosy, as in many other diseases, there are situations where the definition of a 'case' is
uncertain. Some diseases can be diagnosed with certainty at autopsy only, such as
Alzheimer's disease, and hyaline membrane disease, lor some other conditions, such as
cervical dysplasia and the adult onset ol diabetes, there is a continuum from normal to
abnormal with no clear demarcation line between them.
A Dictionary of Epidemiology' defines a case as 'a person in the population or study
group identified as having a particular disease, health disorder, or condition under
investigation'.
There have been attempts to provide an operational definition by assigning levels of
certainty to the diagnosis of a number of different diseases. The Expanded Programme for
Immunization (EPI) has produced guidelines to grade various EPI diseases as ‘suspect’,
‘probable’ or 'certain'.2 To formulate a definition of a ‘case’ that would cover all aspects of
a disease would be difficult, since it would be voluminous and academic, and probably of
very little practical value. The usefulness of a definition that is meant to serve as a basis for
action an operational definition may be determined by its practical applicability, not
by the degree of its completeness. An operational definition must be judged in the light of
its staled purpose, and what is relevant is whether it contributes to meeting the agreed
purpose, which is control of leprosy in the community. It is widely recognized that the
diagnosis of leprosy is often difficult. It has even been said that the absence of a clearlystated 'case' definition calls into question much of the leprosy literature in so far as it
renders results incomparable and unreproducible. Newell' remarked that 'there is no
definite, finite or absolute test, sign or finding which can be said to divide a person with
leprosy infection or leprosy illness from the rest of the population'.
The disease
Leprosy is often defined as ‘a chronic disease of man resulting from infection with
Mycobacterium leprae and affecting primarily nerves, skin and mucosa of the upper
respiratory tract'. In the absence of any reliable tools for detecting the subclinical stages of
the infection process, the emphasis for diagnosis of the disease is on clinical manifes
tations. The most remarkable thing about leprosy is the enormously wide variation in the
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, oh the controi measures (number of patients cured with MDT). The information
generated by the system has to be carefully analysed for decision-making, and feedback
information should be given to the users.
The quality of the surveillance system should be regularly assessed to ensure that it is
based on a good understanding of the epidemiology of leprosy. Hie surveillance system
should facilitate rapid action which in turn leads to a reduction in the prevalence and
incidence of the disease.
Information collected routinely at the periphery is usually considered to be of poor
quality and inadequate. However, this is often a misconception. Most leprosy control
managers are aware of the fact that health workers in the field are faithfully collecting,
recording and reporting the data. Unfortunately, this vast amount of painstakingly
collected data is neither compiled nor analysed at the intermediate or central level.
Moreover, whenever information is required, there is an attempt to conduct fresh surveys
or demand the completion of new sets of forms. This has often resulted in an increase in
the workload without any potential benefit to the programme. If we study carefully the
available data, we can see that it is more than adequate and of a reasonably good quality.
If the data are compiled properly and analysed they provide a very powerful tool for
decision-making. Cohort analysis will be able to do this efficiently for the various needs of
leprosy control, without overburdening the routine activities.
Indicators for use in leprosy control programmes
MYO THET HTOON
The leprosy control measures currently being undertaken in almost all the control
programmes in the world are based on the two main strategies of case-finding and
treatment. These two measures have been the cornerstone of leprosy control activities
since the era of chemotherapy with dapsone. Unless a major breakthrough occurs in the
development of a vaccine, these two measures will be the main strategy used in the
elimination of leprosy as a public health problem by the year 2000.
Most of the leprosy control programmes operating in endemic countries arc to be
monitored and evaluated using these two activities. Depending on the type of the health
care delivery system and availability of resources, each country or even each region in a
country have developed their own unique case-finding and treatment activities. Indicators
to be used for either monitoring or evaluation arc going to differ from programme to
programme, depending upon the type of control programme (specialized vertical or
integrated), nature of activities undertaken and the availability of resources.
Generally it is felt that as leprosy control measures are integrated into the primary
health care services (w Inch means that less specialized persons arc to be used) the amount
of data routinely to be collected needs to be reduced as well as simplified. Certain
information that was routinely available during the years when leprosy control was a
specialized service activity will no longer be routinely available. A trade-off between
information that is thought to be essential and that which is not essential must be made.
The operational and epidemiologic indicators to be used for the monitoring or evaluation
of a leprosy control programme will also differ between that of a central or intermediate
level programme manager and a peripheral programme manager. Some of the indicators
intended for use by the peripheral programme managers may not be of use for the central
planners.
Since the programme managers at the peripheral levels arc the ones who arc mainly
involved in the day to day implementation of the case-finding and treatment activities it is
important that a set of minimum indicators be identified which could be routinely
collected and used by the personnel at the peripheral level. Indicators are to be divided
into two categories. One set of indicators arc intended for the peripheral programme
managers and the second set for the central or intermediate level programme managers.
Each set of indicators is then to be subdivided into operational and epidemiologic
indicators.
The formula for the calculation of each indicator is as shown in the OMSLEP,
0305-7518 92 063073s+ 04 SO 1.00
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Myo Thet Htoon
Recording and Reporting Systems for Leprosy Patients, edition 3.' The list of indicators
recommended for use in integrated leprosy control programmes is as follows.
REGISTERED PREVALENCE
The registered prevalence is a very useful indicator and has been used by almost all control
programmes. It is also easy to calculate since almost all control programmes have the total
number of registered cases. Usually the registered prevalence is calculated as a point
prevalence. Since the treatment duration for paucibacillary (PH) patients is now much
shorter under the MDT regimen, in programmes where MDT treatment activity is
efficient the registered number of cases may be comprised of only multibacillary (MB)
cases. If the true magnitude of the problem of leprosy in an area is to be estimated, the
period prevalence may be more appropriate.
With the introduction of M DT in most control programmes the registered prevalence
has drastically declined in a very short period and it may no longer reflect the true
situation in areas where the detection rates do not approximate the incidence rate.
PROPORTION OF REGISTERED CASES AMONG ESTIMATED CASES
This is a very useful indicator for central or intermediate level programme managers,
especially if one aims at cutting the transmission through MDT. As pointed out in the
OMSLEP, the problem is finding the denominator for this indicator which is the total
number of estimated leprosy cases. If future leprosy control programmes are to have a
specific time frame target, this indicator will highlight the success of the control measures
in an area. It is possible that an area may report a very low registered prevalence but the
present registered caseload could be only a small fraction of the total estimated cases as a
result of poor case-finding activities.
TOTAL NUMBER OF SCHOOLCHILDREN SCREENED FOR LEPROSY. SCHOOL
DETECTION RATE, TOTAL CONTACTS EXAMINED, CONTACT DETECTION RATE,
TOTAL POPULATION MASS SURVEYED, MASS SURVEY DETECTION RATE AND
Indicators for use in LCP's
75s
registered cases on MDT will become obsolete as the MDT coverage expands in an area
and reaches 100%. This indicator is useful during the transition period from dapsone
monotherapy to MDT in assessing the operational coverage of MDT, especially in
programmes introducing MDT on a phasc-by-phase basis.
I he numerator for this indicator is the total number of cases obtaining treatment
during a given period. The denominator is the total number of cases registered for
treatment in that specific area during the same period. This is a kind of period prevalence,
where the total number of prevalence cases at the start of the period of reporting is added
to the total number of cases that are newly treated during the same reporting period.
PROPORTION OF OASIS ON REGULAR MDT
This indicator could be calculated for all cases on MDT or separately for PB and MB
cases. Regularity of treatment is to be taken as those who receive at least two-thirds of the
recommended number of MDT doses during the year as defined in OMSLEP. Though
this information is important for assessing whether patients are receiving sufficient
treatment, this information could not be collected routinely through monthly reports and
should only be calculated on a yearly basis.
NEW CASE MB PROPORTION AND NEW CASE UNDER 14 YEARS PROPORTION
These two indicators arc useful in assessing the transmission of the disease when incidence
could not be calculated easily. As stated in OMSLEP, when the MB proportion stabilizes
the detection rate approaches the incidence rates.
These two indicators could be influenced by the mode of case-finding activities
conducted in a specific area. A programme which stresses school surveys will have a high
proportion of new cases under 14 years of age. Programmes with only passive case-finding
activity may be picking up relatively more M Bs than PBs and so in such areas the new case
MB proportion will be high.
Assuming that no drastic change in the mode of case-finding has occurred in the past,
these two indicators arc useful in assessing the transmission of the disease.
ACTIVE CASE-FINDING PROPORTION
Hie indicators concerned with the operational aspect of the active case-finding activity
are the total numbers of schoolchildren screened for leprosy, the school detection rate,
total contacts examined, the contact detection rate, the total population mass surveyed,
the mass survey detection rate and the active case-finding proportion. In programmes
where the registered cases are almost equal to the number of estimated cases or if the
incidence of leprosy is too low the active case-finding measures may be very inefficient and
costly. In such programmes these indicators need not be used on a routine basis. In
programmes where the proportion of registered cases is still low compared to the
estimated number of cases, these indicators arc helpful in monitoring the operational
aspect of the case-finding activities with the aim to increase them.
PROPORTION OF REGISTERED CASES ON MDT
This indicator is useful in monitoring the MDT coverage of an area. The proportion of
PROPORTION OF GP \DF II DIS
11 I!’i
This indicator reflects the effectiveness of the case-Wding acti .itv It is a good opera'ional
indicator, especially when u^ed together with othV case-finding indicators. Since the
numerator of this indicator includes only '.i .ihlc divibility (grade II) this indicator will
approach zero as cases arc being detected at an early stage as a result of a good case
finding programme.
TOTAL CASES COMPLETING MDT OCRING THE YEAR
The total number of cases completing MDT during the year is to be used as a crude
indicator to measure the efficiency of the MDT activity. This figure is easy to obtain and
though it reflects MDT activities carried out in the past it nevertheless gives a rough
estimate of the outcome of the MDT activity in an area. Assuming that the regularity of
76s
Myo Thet Htoon
Lt’pr Rev (1992)
Supplement. 77s-83s
Tablc 1. Indicators for use in control programmes
Peripheral
programme
managers
Indicators
1 Registered leprosy prevalence
2 Proportion of registered cases among estimated <eases
3 Total schoolchildren screened for leprosy
4 School detection rate
5 Total contacts screened
6 Contact detection rate
7 Total population mass surveyed
8 Mass survey detection rate
9 Active case-finding proportion among new cases
10 Proportion of registered cases on MDT
11 Proportion of cases on regular MDT during the calendar year
12 New case MB (proportion)
13 New case under 14 years (proportion)
14 Proportion of grade II disability among new cases
15 Total cases completing MDT during the year
16 Relapse rate (MDT)
Op:
+
Epi:
Central/
intermediate
programme
managers
Op:
Epi:
E DECLERCQ
++
+
4 I
4- 4-
+
+
+
+
+
+
+
4-
4■l
+
+
treatment has not changed during the period under study, it could be assumed that this
indicator reflects the MDT activity carried out in the past.
RELAPSE RATE
The relapse rate to be estimated is based on the clinical relapses detected. As pointed out
in the OMSLEP, the problem with this indicator lies in the validity of the denominator.
The total accumulated discharged cases are difficult to review during a given year,
especially in programmes where the on going MDT caseload is still high. The majority of
the relapses will be self-reported and tbc denominator will be made of all discharged cases.
This makes the interpretation of the relapse rate a little difficult since a cohort analysis of
the discharged cases will be impossible to calculate from routine data collection forms,
especially in an integrated leprosy control programme. The programme managers will
have to use this as a rough measure to assess the efiectiveness of the MDT in an area.
Reference
1 OMSLEP. Recording and Reporting Systems for Leprosy Patients, edition 3.
OMSLEP as an evaluation tool
If leprosy is to be controlled, those in charge of the programmes at the local, regional or
global levels should be able:
—to check whether the control measures, that is the strategies and targets that have been
planned, are effectively and efficiently implemented. This is the operational evaluation;
and
—to evaluate whether the programme has reached its medium- or long-term objectives,
that is the reduction of the problem in terms of the numbers of patients in need of the
health services. 1 hat is the epidemiological evaluation.
The evaluation process should be based on the use of objective indicators. These
indicators need also to be simple to allow health workers at all levels, even the most
peripheral, to collect the data necessary to calculate them.
The need to use standardized indicators is evident at the national level. It is also
advantageous at the regional or global level. For instance it would allow the
epidemiological trend to be analysed in relation to the control strategies used locally.
From the start this has been the objective of the OMSLEP system in the recording and
reporting of leprosy patients: to propose not only a set of standard indicators for the
operational and epidemiological evaluation, but also a system for collecting the data
necessary to calculate them.
When it was decided to create the system in 1976. the first step was to make a review of
the information systems used in 78 leprosy control projects from 45 countries. This
enabled a list to be drawn up of indicators whose value had been thoroughly reviewed by a
group of experts. Then the data that needed to be collected were listed, and an individual
patient form and two annual statistical forms designed. A booklet was published,
explaining how to fill in the form, how to calculate the indicators, and how to interpret
them.
From the start, the OMSLEP system was also designed to facilitate the transfer of
data onto microcomputers.
In the years following its conception, a second edition of the booklet was published,
with some minor modifications. In 1987 the third edition was published in order to adapt
the system to evaluate M DT programmes, based on the list of 25 indicators recommended
by a WHO Study Group in 1985. T he design of the system remained basically unchanged,
with an individual patient form, and two annual statistical forms:
—the individual patient form is a summary of the patient’s clinical chart, which only takes
into account the data necessary to calculate the indicators (Appendix 1):
—the detection form, which is a summary of the status at detection of all the patients
0305-7518 92 063077s + 07 SOLDO
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S3, Supplement, 3 ls-39s
disability still need to be developed and the approach adopted by the new International i||l
Classification of Impairments, Disability and Handicaps needs to be given consideration
by those in the leprosy field. Measures of disability are important for evaluation of;2
programmes, evaluation of treatments, to identify needs for patient education and for f'
rehabilitation. Approaches to disability prevention need to be evaluated in terms of cost- II
Epidemiometric modelling in leprosy based on
Indian data
effectiveness which take into account the natural progression of disability and must be S
based on controlled trials. Disability is the measure of progress in leprosy control which is ||
relevant to the general public.
fl
M F LECHAT
References
l
1 Brand PW. Deformity in leprosy. In: Leprosy in theory and practice, Cochrane RG, Davey TF (eds), Bristol:
John Wright and Sons, 1964, 2nd Edition, pp. 447 96.
VfM Introduction
Smith WC S, Antin US, Patolc AR. Disability in leprosy: a relevant measurement of progress in leprosy Lepr Vg
Rev, 1980; 51: 155 66.
3 Srinivasan H, Dharmendra SH. Deformities in leprosy. In: Leprosy Vol I. Dharmendra SH (ed), Kothari S Today, I suppose, any moderately bright child who has had a minimal exposure to
Medical Publishing House, Chapter 27, pp. 197.
computers could programme an epidemiometric model on a rainy Sunday afternoon
World Health Organization. International Classification of impairments, disabilities and handicaps. Geneva:
using existing softwares and a technologically basic machine, but the situation was quite
WHO. 1980.
5 WHO Expert Committee on Leprosy. World Health Organisation. Technical Report Scries No 189, 1960. ft different in the early 1970s when the leprosy epidemiometric model was first designed.
6 Bechelli LM. Martinez Dominguez V. Disability index for leprosy patients. Bull WHO, 1971; 44: 709-13. 'S
The problem addressed was clearly circumscribed. After 20 years of large scale, mass
7 WHO Expert Committee on Leprosy. World Health Organisation. Technical Report Series No 768, 1988. |
8 Ponninghaus IM, Boerrigter G. Fine PEM, Ponninghaus JM, Russell J. Disabilities in leprosy patienU W control campaigns based on dapsone monotherapy, leprosy had not been eradicated, and
ascertained in a total population survey in Karonga District. Northern Malawi. Lepr Rev, '990; 61: 366-74.
even worse, it was not known whether the disease was or was not on the decrease.
9
Noordeen SK, Srinivasan H. Epidemiology of disability in leprosy, bit J Lepr, 1966; 34: 159-69.
International funding agencies such as UNICEF, nongovernmental organizations, as
10
Kushwah SS, Govila AK, Kushwah J. An epidemiological study of disabilities among leprosy patients
well as governments, all were getting tired of emphatic promises and overdue delays.
attending leprosy clinic in Gwalior. Ini J Lepr, 1981; 53: 240 7.
Noordeen SK, Srinivasan H. Epidemiology of disability in leprosy, bit J Lepr, 1966; 34: 170-4.
J There were talks of a vaccine which could revolutionize the control strategy.
12 ParkheSM, Smith WCS, Samson PD, Solomon M. Sudden paralysis associated with MulliDrugTherapy—a
The concerns at that time were: (1) was it reasonable to expect a decline of the leprosy
cautionary talc. Abstracts of the 13th International Leprosy Congress. 1988. p. 380.
Smith WCS, Parkhe SM. Solomon M, Samson PD. Leprosy disability in a control programme—trends over
‘ problem in the next 20 years, using current control methods? How much of a decline?
10 years. Abstracts of the L3th International Leprosy Congress. 1988, p 603.
How long would this take? (2) Could some improvements in the implementation of
14 Smith WCS, Parkhe SM. Disability assessment as a measure of progress in leprosy control. Lepr Rev, 1986; i
control, such as earlier detection or better compliance, speed up the decline? (3) Could
57 • z. 51 ~ 9.
15 Watson JM. Disability control in a leprosy control programme. Lepr Rev, 1989; 60: 169-77.
i some radical changes in the strategy, such as old-fashioned isolation or futuristic
vaccination, modify the prediction? In what direction, and by how much?
The model aimed at predicting the trends in incidence over 20 years by using the
control methods of that day. It also attempted to simulate the trends which resulted from
changes in the control parameters. The indicator used was incidence, i.e. the number of
new cases per year in the population.
Structure
J Asa first step, the development of the model required the definition of a structure and the
■ identification of the various population subgroups (stages) as well as the permitted
transitions and their directions (Figure 1). The stages were:
healthy susceptible;
latent;
multibacillary patients,. nontreated,
treated for less than 1 year, treated for 1 year or more,
____________
. dropped from treatment, discharged;
paucibacillary patients, with the
...j same categorization as the multibacillary patients.
0305-7518,92 063031 s + 09 $01.00
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•/</( niionirli h nimh Him; in /*/>/
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33s
For the sake of keeping it simple, the structure of the model is based on a number of
epidemiological assumptions, such as no discharge without treatment, no reversal
reaction, no extra-human reservoir, a constant age distribution of the population, and no
migration out of or into the area.
The model is macroscopic and deterministic. It is macroscopic since it intends to
describe the evolution of incidence and prevalence of the disease in the entire population,
or in subpopulations, rather than in foci or at the individual level. It is deterministic
because it only considers the prevalences and incidences as averages, and does not take
their variability into account.
posteriori, were minimal. Data \alidation lor various types of internal inconsistencies
caused the rejection of less than
There were 2S parameters calculated from the observed data or estimated bv a
statistical approach. Those parameters calculated from observations were the annual
population in each stage, the transition rales, the birth and death rates, and the respective
proportion of multi- and paucibacillarv patients.
To represent the transition from one stage to the next. 2 types of equation were used.
Equations of the first type were based on a negative exponential probability function
of staying in the initial stage 1 hey were in the form of a negative exponential. I hev were
used to calculate the transitions from undetected cases to detected, treated to drop-out.
drop-out to retreated. I he second type included conditional probabilities of transition
from 1 stage to another but no special f unction of duration in the initial stage was used.
A negative exponential function was also used to model the delay at detection. It was
set up in such a wax that 75 ■ of the new patients could be delected after I year from the
onset of the disease Io the best of the knowledge of the field staff this estimation was
reasonable.
Two major parameters could not have been directly derived from actual observations
and had to be estimated by a least-square method. They were (I) the latency period
between infection and onset of disease lor both multibacillary and paucibacillarv patients,
and (2) the specific infective power of these 2 patient types. 1 he latency period was
estimated to be shorter for multibacillary than for paucibacillarv patients (respectively 2 4
and 4 0 years). I hose v allies arc in clear contradiction to the periods calculated from a few
actual observations in Louisiana and among US War Veterans. Estimation of the
infective capacity by considering the type of leprosy yielded more consistent estimates.
The risk of a person developing leprosy through contact with a multibacillary case is
higher than through contact with a paucibacillarv one. This agrees with the epidemi
ological studies of Doull.' However, due to the high proportion of paucibacillarv patients
among the diseased population, those patients constitute a nonncgligiblc source of
infection.
Kstiniation of parameters
Simulations
T he equation of the model was based on actual data. We were quite fortunate to have
access to the files that had been assembled for nearly 16 years (1955 70) at the Leprosy
Centre. Polambakkam, South India. T hey were allocated first by Dr F Hemerijckx, then
by Dr C Vcllut and their respective staffs, on 35,262 patients, representing 320,000 personyears of observation. These data had distinct characteristics.
A number of simulations were carried out. cither at the initial stage of the model, or later
by changing some of the basic epidemiological assumptions.
Incidence depending on multibacillary or paucibacillarv types of leprosy was
predicted over a period of 20 years with ongoing control methods. I he results indicated
that with dapsonc monotherapy a reduction of 50",. incidence could be expected after 12
years (Figure 2). We believe this conclusion was important as it showed that control of
leprosy requires perseverance, firm financial commitments, and unyielding efforts.
Eradication cannot be achieved overnight.
Earlier detection, resulting in airincreasc to 90":. from 75",, of the annual input of new
patients detected w ithin 1 year of onset (assuming a negative exponential detection rate
over time) does not significantly change the incidence in the long run (Figure 3).
Intensifying case detection, a costly anil fastidious method, had been repeatedly
advocated as one of the more ellicient ways to improve control. Long-term incidence is
slightly more sensitive to the rate of compliance to treatment. After decreasing by 50% the
POPI'I.AIIQN
IMMUNE j
SIISCIPlIBIfS
PAUCIBACIIJ.ARY
LATENT
MUI TIBACll.I.ARY
LATENT
AR Yr*------- I PAIICIHACU I ARY
PAI’CIBACII 1 ARY
-•d
iNiicnvi
DROP our
MIH IIHAI II I ARY
INI I Cl IVI
PAUriBACH I ARY
NON INHCIIVF
II
MIILTIB LATENT
RESISTANT
MOI.IIIWII | ARY
DROP 0111
MULTIBACILLARY
RESISTANT
MULIIBACII I ARY
NON IN1ICIIVI.
Figure 1. Model structure. Rcproduclcd by kind permission of the Ihillrfiii dr I'Organisation mondiale de la
Sanfe.2
1 They were population based, i.e. the whole population of 500 villages in a
circumscribed area was regularly surveyed during the period.
2 No individuals from outside the area were included.
3 Detection was carried out in a standard way by personnel trained in the same manner
over the whole period.
4 Treatment remained unchanged, based on dapsone monotherapy at a weekly dose.
It is possible that some occasional divergences from this ideal pattern occurred during the
period. T he consensus was that such divergences, which could not be controlled a
34s
M I ' Let hal
..pitlemiamrtric modelling in leprosy based on Indian data
■■
INCIDENCE
PER
35s
Pic IDE’.'I-E
PER
10.000
lO.npo
2.5
2,5.
\\
■
'A
2.0 -
If
i
1.5.
‘
i
I
Ii
1,0.
II
’i
2,0 .
1.5 .
1.0 .
i
'''■
2
\
0,5.
1
0,5 .
\
I
1
5
>-'$1
15
20
1
YEARS
Figure 2. The incidence of 20 years:
1 he initial simulations suggested that vaccination was by far the most promising
method (Figure 2). This conclusion is one of the major drawbacks of the exercise It could
have encouraged investing resources in a long-term research programme on the basis of a
much too simplified model. Subsequent simulations draw a distinction between a
prophylactic and a therapeutic vaccine and show that the effect of a vaccine preventing
infection is delayed for several years. In the long run it is quite effective though slow for
decreasing incidence (Figures 4 and 5). On the other hand, a ’vaccine active in preventing
the appearance of leprosy in those individuals already infected has an immediate effect. It
must be repeated at periodic intervals to catch those recently infected, which reduces its
long-term effectiveness. In addition, the respective efficacy of using either one of these
types of vaccines depends on the prevalence of infection in the population.
10
15
20
YEARS
Figure 3. The incidence of 20 years:
J
(1) present control methods;
(2) reduction to 50% drop out; and
(3) vaccination of 100% of the population with immunoprophylactic vaccine.
annual proportion of patients who abandon treatment, incidence is reduced by 50% after
20 years (Figure 2). A cost-benefit analysis has shown that the latter method is much more
advantageous than increased efforts to achieve earlier detection.
The effects of isolation were also simulated. This confirmed die largely held belief that
the isolation method is futile in reducing long-term incidence (Figum 3j
---------- -
5
(1) present control methods;
(4) 90% detection within one year of onset; and
(5) isolation of multibacillary cases at detection.
,
Simulation of various treatment regimens
for all
regimens—
—dapsone
dapsone monotherapy
monotherapy for
all patients
patients.
multiple drug therapy (MDT) for all patients, MDT for multibacillary cases and dapsone
therapy for the paucibacillary ones showed that because of the ratio of multi- to
■
"hiCh PrCVai’S SO,”,1 ,ndia <about
of multibacillary cases).
1 MDT treatment for all patients, including paucibacillary. is imperative (Figure 6).
j
MDT •"
to •*-the multibacillary
patients is; of little or no avail (for the
v Restricting K4rvr
•* *
■
••
• •in spite of--their
- -low infectivity, constitute a significant source of
]paucibacillary
patients,
11
J infection because of their large numbers). This introduces the paradox that if MDT is
;J restricted to only one t
type of leprosy, in this model it is most effective when only applied to
. 1 paucibacillary patients,
I /
’ *
An obvious conclusion is that it would be incorrect to restrict treatment to the
‘ I paucibacillary patients5 cven when resources are scarce. This demonstrates the paradox of
: individual risk vs population risk.
]
Simulation of various relapse rates (10
("“ 100%)
------ in
* multibacillary cases with various
treatment regimens indicate that relapse with MDT is not
.._l a major problem (Figure 7).
1 The declining trend of incidence slows down (with a 20% relapse rate) or is slightly
36s
M F Lechat
izpidcniionictric nuidcllinjr in leprosy bau d on Indian data
37s
INC. (0/00)
3
Incidence
per 10000
2.513
2 -
Vaccination
11
• DOS MOHOn CRAPY’
o MDT MD . DDSPB
■ MDT FOR MB ♦ PB
1.5
9
1 -
7
!
5
0.5 -
No vaccination
10 7.
3
0 40
507.
1
-10
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
-5
0
5
10
19
20
YEARS
907.
Figure 6. C omputcr simulation of incidence of leprosy with three different therapeutic regimens. Reproduced by
kind permission of the International Joinna! of l.eprii\\ 4
15 years
Figure 4. Prediction of incidence for both types of leprosy with an immunoprophylactic vaccine covering 10—
50—90% of the population. Reproduced by kind permission of the International Journal of Leprosy)
INC. (0/00)
3
• DAPSONE MONOIHERAPY
O MDT WITHOUT RELAPSES
■ MDT WITH 10% RELAPSE RATE MB
□ MDT WITH 20% RELAPSE RATE MB
A. MDT WITH 50 % RELAPSE RATE MB
ZS.MDT WITH 100 % RELAPSE RATE MB
2.5 ■■
Incidence
per 10000
2
1.5
■
13 Vaccination
1
11 -
0,5
975-
3
'’J
No vaccination
040
-t-
1
7
8
18
19
20
YEARS
===feZ^/10 7.
==-507.
'907.
■
ti
«I
Figure 7. Computer simul ition of incidence with dapsonc and MDT with different relapse rates
reversed for a period (with a 50 I()()“;> relapse rate) only after 8 years. These results are
important in view of a jpopular claim that multibacillary patients under MDT should
-10
-5
0
5
10
15 years
continue
treatment after 22 ?years even when they become bacillary negative. Some say they
‘ ■ RO
l iRure 5. Prediction of incidence lor both types of leprosy with an immunotherapeutic vaccine covering IO™
should even be treated lor life. As lor control, relapses arc not significant as long as they
50—90% of the population. Reproduced by kind permission of the International Journal of Leprosy)
are detected early : in other terms, all treatment requires a close surveillance system.
4
Simulation of resistance required the introduction of new compartments in the model
1 and an extension of 50 years (which probably has little justification due to the long-term
1
■4
4
38s
M F Lechat
Jcmiomctric modelling in leprosy hosed on Indian data
Incidence
per 10.000
30
25
20
2 7o
r.
.
■
15
10
I 7.
5
No resistance
5
10
15
20
25
30
35
40
45
50 years
Figure 8. Prediction of incidence for both types of leprosy with I 2 3% secondary drug resistance.
Reproduced by kind permission of the International Journal of Leprosy.3
unpredictability) (Figure 8). In the observed conditions, secondary resistance constitutes
a major problem. With a 3% annual incidence of secondary resistance, the declining
trends in incidence slow down after 6 or 7 years and then begin rising at increasing speed
after 15 years. These results are more forboding because no provision was made in the
very simplified model for the contribution of subsequent cases with primary resistance to
incidence in subsequent years.
Cost-benefit analysis can also be simulated by introducing various cost-parameters.
Such econometric analysis should be subject to caution, for it is often difficult to calculate
the various components of different control strategies. This approach is interesting to
compare annual cost with long-term cumulative cost. Highly effective strategics are costly
at the beginning, but may prove to achieve good long-term saving.
Conclusion
Overall, we must consider the possible uses and drawbacks of the model. It was developed
in a specific area. South India, which presents its own special epidemiological contexts.
Therefore it has clear limitations.
The resulting figures should be viewed with caution. The results arc highly sensitive to
a number of parameters, either directly observed or derived through statistical estimation.
The model is based on a number of assumptions, not all verifiable and possibly too
simplified. The quantitative results should not be generalized for use in other areas which
might have different conditions of prevalence, incidence, multi/paucibacillary ratios,
39s
birth and death rates. It is not certain that epidemiological data with an equal value to
those collected in South India could be found in many places.
The model serves its own purpose and might not be best used when repeating the
exercise exactly in different places. It acts as a type of grammar or structure. The model
helps to clarify epidemiological concepts as exemplified by the existing differences
between immunoprophylactic and immunotherapeutic vaccines or the epidemiological
similarity of noncompliance and treatment-sensitive relapse albeit on different time
scales. The model's most important purpose is to list the problems it tackles in the order of
importance and make various comparisons. It could consider whether every patient
should receive MDT. or only multibacillary patients: it could compare the relative
insensitivity of incidence to early detection (despite the complete and early detection in the
study area); or it could stress the importance of resistance in the long term as compared to
nondrug resistant relapses.
Due to the present success of MDT-bascd control, this modelling approach in leprosy
is no longer a part of basic research. The future belongs to microscale modelling for
disappearing diseases. What can be expected in terms of limited foci, clusters, and erratic
time fluctuations? This could be called, to use a fashionable new avenue of research,
fractal epidemiology.
References
i
1 Doull J A ct al. The Incidence of Leprosy in Cordova and Talisay. Cebu. PI. hit J Ix-pr. 1942; 10: 107 31.
2 Lechat MF ct al. Un modcle cpidcmiomctriqucde la lepre Bull Organisation mondialcSame. 1974; 51:361 73.
Lechat MF et al. Simulation of vaccination and resistance in leprosy using an cpidcmiometric model bit J
Lepr, 1985; 53: 461 7.
4 Lechat MF et al Selection of MDT strategics through cpidcmiometric modeling, hit J Ixpr, 1990; 58; 296
301.
A
v
library
7
'T-S
Chapter 1
INTRODUCTION
We™VZXle«f' est^d
by c—
follows- Africa 3 868,000, America 358,000, Asia 6,475,0 ,
Emope 5^000 and Oceania 33,000. About 2,097 million people
werePesttaated to be living in areas with prevalence rates of
^KUXX^m a number of larger countries
indicate that the total cases throughout the world may well
exceed 12 million.3
Pr<,Up”c.‘; ““major puhUe health problem 1„ India, U*
estimated Ibal (here are 3.2 mUbon leprosy-eases mto
I
I
c; SX^pe,^^"
endemic areas of leprosy.'
ipnrosv cases
cases in
about 2b per cent 01
p
leprosy
in India,
per cent suffer from
infectious nature and about 25 to 30are
socio-economically
deformities. About 4,00,000 patients
have become floating
dislocated and about 200,000 patients
cases are children
beggars. About 25 per cent of the leprosy
I
L-
I
INTRODUCTION
4
LEPROSY IN RURAL INDIA
up to 14 years of age.4 2.4 million out of 3.2 million estimated
cases were detected and 2.2 million cases were brought under
treatment.
The state-wise distribution of cases according to the latest
(1978)5 estimates is indicated in Table 1. This shows that the
Union Territories of Lakshadweep and Pondicherry are hav
ing the highest degree of leprosy. They have a prevalence rate
of 31.3 and 40.3 per 1,000 respectively.
Among the states, Tamil Nadu has the highest prevalence
rate of 19.0 per 1,000, followed by Andhra Pradesh and Orissa
with a prevalence rate of 14.5 and 10.8 per 1,000 respectively.
Bihar, Karnataka, Maharashtra, Manipur, Meghalaya,
Nagaland, Sikkim, Tripura, West Bengal, Andaman and Ni
cobar islands, Goa, Daman and Diu have a prevalence be
tween 5 and 9.9 per 1,000.
Gujarat, Himachal Pradesh, Jammu and Kashmir, Kerala,
Uttar Pradesh, Arunachal Pradesh, Dadra and Nagar Haveli
and Mizoram have a prevalence rate ranging between 1 and
4.9 per 1,000.
Assam, Rajasthan, Delhi, Haryana, Madhya Pradesh, and
Punjab have a prevalence rate of less than 1 per 1,000.
The state-wise prevalence is indicated in Map 1.
Problem in the State of Tamil Nadu
There are about 8,50,000 living cases of leprosy in Tamil'
Nadu out of which about 99,513 cases have been released
from control. After taking away 85,864 cases having inactive
disease, there are 665,000 cases in Tamil Nadu of which
557,000 are under treatment.6 The district-wise prevalence of
the disease in Tamil Nadu is indicated in Table 9. Of the
665,000 active cases, 17.9 per cent have got deformity. There
are 7,500 beggars suffering from leprosy.
E
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Problem in the Chingleput District
There are 80,528 known cases of leprosy in Chingleput
5
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219.5
135.5
257.7
2.1
412.0
15.6
15. Orissa
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Punjab
Rajasthan
Sikkim
Tamil Nadu
Tripura
Uttar Pradesh
West Bengal
A & N Islands
Arunachal Pradesh
Chandigarh
883.4
10.8
0.2
0.1
0.0
7.8
0.1
1.6
0.4
7.7
19.0
6.4
1.9
8.6
8.7
2.1
4.7
3.8
0.0
0.0
2.6
0.7
40.7
8.6
0.3
3.3
4.7
0.0
0.0
0.1
0.0
0.0
0.2
1.4
0.3
5.8
31.3
3.0
5481.6
32.5
5.9
443.1
1.2
26. D&NHaveli
27. Delhi
28. Goa Daman & Diu
29. Lakshadweep
30. Mizoram
31. Pondicherry
India
2.4
0.0
I
40.3
5
30
C
Source: National Leprosy Control Programme - Annual Report 1978 Lep. section-DGHS (Mins. ofH&F.W.)
Govt, of India, Nirman Bhavan - pp. 1-44.
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INTRODUCTION
8
9
LEPROSY IN RURAL INDIA
was found to be high in Assam, Bihar, Madhya Pradesh,
Madras (Tamil Nadu), Orissa, West Bengal, TravancoreCochin, Hyderabad and pockets of Uttar Pradesh. The endemicity was moderate and low in other areas of the country.
At that time in the whole country there were 152 leprosy
homes and hospitals with about 19,600 beds and ab )ut 1,203
out-door clinics. About 100,000 to 200,000 cases (about 10 per
cent of estimated cases) were taking treatment.11 On this
basis, on the recommendations of the committee, the Govern
ment of India launched what is now called the National
Leprosy Control Programme (NLCP) in 1954-55. According
to NLCP, cases were detected through house to house survey
of population by physical examination. The treatment of the
cases was in the form of oral administration of Dapsone.11
These services were provided through a network of leprosy
subsidiary centres. Each subsidiary centre covered a popula
tion of 60,000 to 80,000. Each subsidiary centre had two
medical officers and four pafa-medical workers in addition to
ancillary staff.12 For the country as a whole, four Leprosy
Treatment Study Centres were established to provide train
ing for the staff of the NLCP and supervision to subsidiary
centres. This strategy was continued during the Second Five
Year Plan.
district, of which 56,180 cases are active. Among these, 47,273
are under treatment. Of these 14.4 per cent have got visible
deformities.7 The magnitude of the problem in Chingleput
district is indicated in Table 15.
Anti-Leprosy Work in India
In India, most ancient references to this disease are found
in the medical works of Charaka, Sushruta and Vagbhatta.*
In the late Eighteenth and early Nineteenth century some
beds were provided in contagious disease hospitals for cases
of leprosy. Poor homes were established throughout the
country. The establishment of the Indian Council of the
British Empire Leprosy Relief Association in 1925 provided a
fresh impetus to organised anti-leprosy work in India. As a
result of the working of this Association, the knowledge
regarding problem of leprosy in the country increased. By
1937, 32 institutions of mission to lepers were established
having 8,000 inmates.
The attainment of independence in 1947 resulted in a fresh
upsurge in national interests in the disease. This upsurge for
tunately coincided with the introduction of new and potent
drugs against the disease. The first official committee for
assessing the leprosy problem was appointed in 1941 by the
Central Board of Health.9 The report submitted by them put
the leprosy cases in India at 100,000.
I
LEPROSY CONTROL WORK DURING PLAN PERIODS
I
First and Second Five Year Plan Periods
During the First Five Year Plan a committee for the control
of leprosy was formed by the Health Ministry of Government
of India at the recommendation of the Central Council of
Health.10 That committee, based on limited sample surveys,
estimated the total cases at 1,500,000. Prevalence of disease
4
A
Third Five Year Plan Period
In 1963, a review by the Director, National Leprosy Con
trol Programme revealed that 300 million out of 439 million
(1961 census) population of the country were exposed to risk
of infection with leprosy and that there were 2.5 million
leprosy cases. The states in the country were grouped de
pending upon the estimated endemicity into high, moderate
and low endemic zones. During this plan period, for popula
tion with endemicity of 10 or more per thousand, the leprosy
subsidiary centres were reorganised and redesignated rs
10
LEPROSY IN RURAL INDIA
INTRODUCTION
Leprosy Control Units and their coverage was increased to
1,50,000. Each unit was manned by one doctor and 11 para
medical workers and other ancillary staff. For a population
with an endemicity between 5 and 10 per thousand, the
concept of Survey Education and Treatment Centres (SET
Centres) was introduced, to integrate leprosy work with
various institutions providing general health services, like a
Primary Health Centre or a dispensary or a hospital. An SET
centre provides leprosy services to 20,000 to 25,000 popula
tion through a trained para-medical worker. For every 5 para
medical workers, one non-medical supervisor was appointed
for supervision and guidance. One hundred and eighty one
Leprosy Control Units, 774 SET Units, and 10 training centres
were established during the Third Plan. There were 28,100
indoor beds for leprosy. There were 29 voluntary organisa
tions doing leprosy control work.12
Fourth Five Year Plan Period
In the Fourth Plan Period the magnitude of the problem
was reassessed. The population living in endemic districts
was 372 million as per 1971 census. The estimated case load
was 3.2 million.13
During this Plan, the National Leprosy Control Pro
gramme was categorised as a centrally sponsored scheme
with 100 per cent grant-in-aid to the states for the expansion
and implementation of the programme.
Tlie population coverage by each control unit was in
creased to 300,000,with one medical officer, one non medical
supervisorz15 para-medical workers and other ancillary staff.
The endemic population coverage up to the end of the
Fourth Plan period was 131 million out of the estimated 372
million. The total number of control units by the end of Fourth
Plan was 251 and the number of SET centres was 1,500. There
were 13 training centres. There were 30 voluntary organisa-
11
tions doing leprosy work. The total indoor beds for leprosy
were 28,300.14
Fifth Five Year Plan Period
Several new components were added to the scheme in
addition to the control units, SET centres and Training
centres. These were urban leprosy centres, temporary hospi
talisation wards, reconstructive surgery units, district lep
rosy units and regional leprosy training-cum-referal institu
tions. At the end of Fifth Plan, the programme achieved a
coverage of 320 million out of the estimated 370 million
endemic population. 2.4 million out of 3.2 million estimated
cases were detected. 2.2 million cases were brought under
treatment. During this Plan about 0.6 million cases were dis
charged from the list as disease arrested and cured.11
382 control units, 6,595 SET centres, 430 urban leprosy
centres, 71 reconstructive surgery units, 190 temporary hos
pitalisation wards, 106 district leprosy units and 41 training
centres were functioning in the country by the end of Fifth
Five Year Plan.11
During 1979-80 and 1980-81 some SET centres and leprosy
control units with their workers merged into the Multi
purpose Scheme. As a result, there was a setback to the
programme and the tempo generated during the first three
years of the Fifth Plan was lost.11
The number of institutions engaged in leprosy control
work up to the end of Fifth Five Year Plan are indicated in
1
t
t-
Table nrCAT
Sixth Five Year Plan Period
The following targets have been laid down to be achieved
by the end of Sixth Five Year Plan i.e., March 1985.4
I
13
LEPROSY IN RURAL INDIA
12
TABLE 1A
Number of Leprosy Units and Institutions of any kind
Established or Functioning upto the end of V Plan
Leprosy Homes and Hospitals
Leprosy Control Units
SET Centre
Urban Leprosy Centres
Reconstructive Surgery Units
District Leprosy Units
Leprosy Training Centres
Temporary Hospitalisation Wards
Regional Leprosy Institutes
Central Institutes for Research
and Training
Voluntary Leprosy Organisations
International Agencies Engaged in
Leprosy Work
_____ _______
300
382
6595
430
71
106
42
190
(20 beds each)
2
2
35
8
Source: Report of the Working Group on the Eradication of Lep
rosy - Ministry of Health and Family Welfare - Govern
ment of India, New Delhi (1982).
(a) reduction of active prevalence rate by 50 per cent;
(b) reduction of infectious case-rate by 50 per cent (pres
ent rate 20 to 25 per cent);
(c) reduction of deformity rate of active cases by 50 per
cent (present rate 20 to 25 per cent);
(d) correction of 50 per cent of correctible deformities;
(e) preparation for rehabilitation of 50 per cent of the
socio-economically dislocated patients.
The following lines of action were prescribed to achieve
the above objectives:
(1) early detection of cases;
(2) all detected patients to be brought under treatment;
INTRODUCTION
(3) multi-drug therapy for all infectious cases, following
pilot study in 15 hyper-endemic districts;
of regional training centres;
(4) establishment
estabbshment of 15 rehabilitation promotion units o
(5) act as epidemiological centres for rehabilitation to
meet the minimum rehabilitation needs of the patients;
a vaccine
special emphasis on research to produce
against leprosy;
&
1-------- cum assessment units
(7) establishment
of' sample
survey
to define the magnitude of leprosy problem in uncov
ered areas and for assessment of the work of leprosy
(6)
creation ofEpidemiological surveillance units for con
(8)
solidation and intensification of work in hyper-en-
demic districts;
.
leprosy
beds
both
in
governmental
(9) creation of more
and voluntary sectors;
(10) emphasis on health education through Pan'P1J^'
posters, booklets, slides and short films and pubhaty
gradualkitegration pf leprosy work in general health
services starting with low-endemic areas;
the Union Government to take responsibility for run
(12) ning regional leprosy training cum referal institutes,
pilot projects for intensification of leprosy control
work, epidemiological surveillance teams, leprosy re
habilitation promotion units and sample survey cum
assessment units.
(ID
The physical targets laid down for the Sixth Five Year Plan
are indicated in Table 1(B).
,
,
Funding: In the first three Five Year Plan periodsJhe
ea. iU
14
LEPROSY IN RURAL INDIA
the programme is entirely centrally sponsored.
More Recent Developments
The Prime Minister while opening a three day joint confer
ence of Central Council of Health and Family Welfare on 15th
June, 1981, gave a call for eradication of leprosy by 2000 A.D.
She had also made a reference to the programme of eradica
tion of leprosy from India by the end of the century in her
address to the World Health Assembly in May, 1981.14 Fol
lowing this directive, the Ministry of Health and Family
Welfare, Government of India, constituted a working group
for formulating an appropriate strategy for undertaking an
eradication programme for leprosy control in the next twenty
years with Dr. M.S. Swaminathan, Member, Planning Com
mission as Chairman. The committee has been requested to
make a time-bound programme.13
TABLE IB
Physical Targets for the Sixth Five Year Plan
Leprosy Control Units
15
SET Centres
200
Urban Leprosy Centres
50
Reconstructive Surgery Units
10
Leprosy Training Centres
3
Leprosy Wards
50
District Leprosy Units
50
Regional Leprosy Institutes
6
12
Leprosy Survey Units
Leprosy Epidemiological
Surveillance Teams
15
Leprosy Rehabilitation Promotion Units
15
District-wise Leprosy Pilot Projects
8
for Intensification of Leprosy Control Programme
Source: Report of the Working Group on the Eradication of Lep
rosy - Ministry of Health and Family Welfare - Govern
ment of India, New Delhi (1982).
INTRODUCTION
i
15
Again a sense of urgency for leprosy control was indi
cated by the Prime Minister when she received a group of
eminent leprologists, social workers, administrators in the
voluntary sector on 20th November, 1981. Leprosy has also
been included as a part of the new 20-point programme an
nounced by the Prime Minister on 14th January, 1982.15
Leprosy Control Work in Tamil Nadu
Prior to independence, leprosy control work in Tamil
Nadu was mainly in the hands of voluntary organisations in
places like Tirumani, Pollambakkam, Thirukoilur etc. Soon
after independence the State Government created a state
leprosy survey unit with one health officer, one health inspec
tor and one health visitor (both of them trained in leprosy).
The headquarters of this emit was at Vellore. One district unit
was created at Thirukoilur. These units coUected some par
ticulars regarding the prevalence of the disease.16
During the First Five Year Plan one Leprosy Treatment
and Study Unit was started as a pilot scheme for field study
of leprosy control through chemotherapy, at Thirukoilur in
South Arcot district which is one of the endemic districts in
Tamil Nadu.17
During later phase of First Plan and Second Plan units
subsidiary to the pilot project at Thirukoilur were started in
some places and they were designated as Leprosy Subsidiary
Centres. Thirteen such centres were started up to the end of
Second Five Year Plan. A training centre was established at
the Treatment and Study Centre in Thirukoilur. It gave train
ing to 80 para medical workers (now called Leprosy Inspec
tors in Tamil Nadu) and the duration of training was 9
months.
In the Third Plan eight control units were established each
with 11 para medical workers (Leprosy Inspectors). Six of the
subsidiary centres were upgraded as control units to cover
16
LEPROSY IN RURAL INDIA
17
INTRODUCTION
“O
wider area and larger population and each had 11 para
medical workers (Leprosy Inspectors). Each upgraded sub
sidiary centre covered a population of 1,50,000. Seventy eight
SET centres were established.
In the Fourth Plan, the number of para medical workers
was increased to 15 and the population coverage was in
creased to 3,00,000. Each para medical worker was in charge
of a sub-centre and covered a population of 20,000 to 25,000.
Forty four SET centres and 10 control units were added. In
addition, 7 subsidiary centres established during Second Plan
were upgraded as control units.
During the Fifth Plan, there were 20 para medical workers
for a control unit and it covered a population of 4,00,000. Each
para medical worker (Leprosy Inspector) was in-charge of a
sub-centre. Each sub-centre served a population of 20,000 to
25,000. Twenty seven control units were added during this
period. The area of each sub-centre of the control unit, which
is under the charge of a Leprosy Inspector, has been divided
into epidemiological survey areas and non-epidemiological
survey areas. A group of villages yielding approximately
5,000 population has been demarcated as Epidemiological
Survey areas, and the rest of the villages have been desig
nated as non-epidemiological survey areas. In the epidemiol
ogical survey areas, a total population survey is done every
year. In the non-epidemiological survey areas, a general
population survey is conducted once in 3 or 4 years.
Urban leprosy centres were established with one Leprosy
Inspector to cover an area of 80,000 population. In order to
supervise the larger number of units created and also to
intensify the health education programme posts of district
leprosy officer and health educator were created, thirteen
district leprosy officers wee sanctioned.
The growth of National Leprosy Control Programme in
Tamil Nadu is shown in Table 2. Present position of number
of centres for leprosy control work in Tamil Nadu is indicated
in Table 34.
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18
INTRODUCTION
LEPROSY IN RURAL INDIA
In the North Arcot district. Karat et al (1967)24 in a survey
of 197,756 persons in Gudiyattam taluk observed a gross
prevalence rate of 29 per 1,000. Ekambaram et al (1969)25
described a fall in prevalence from 5.9 per cent to 4.5 per cent
in a decade within a population of 6,000 in Thirukoilur taluk
of South Arcot district. Wardekar R.V. (1969)26 observed a
reduction of 61.9 per cent in the 'incidence' of the disease.
Noordeen (1972)27 in a long term population study of 8,000
population in Chingleput district (population not precisely
defined) worked out a mean prevalence rate of 60.3 per 1,000.
REVIEW OF LITERATURE
One of the significant features of the relevant literature is
that there are virtually no studies available which give rea
sonably reliable dat on epidemiological, sociological, clinical
and organisational aspects which can be used to formulate a
nationally applicable, socially acceptable and epidemiologically effective leprosy programme for the country. This re
view has therefore to be confined only to studies which can at
best be called adhoc studies because of their many methodological limitations.
Age Distribution
In Mohammed All's study22 of 1963, 68 per cent of all
the patients were above 25 years. Eighteen per cent were
below 15 years and 14 per cent were in 16 to 25 year age group.
Christian et al (1963)28 in a study at Zaheerabad found 14.2
per cent being below 14 years, 4.6 per cent in 15 to 19 years,
7.1 per cent in 20 to 24 years, 10 per cent in 25 to 29 years, 21.8
per cent in 30 to 39 years, 20 per cent in 40 to 49 years and 22.3
per cent in 50 years and above.
Dutta Chowdhury (1965)29 working in Bankura observed
23.0 per cent of cases occurring below 15 years and 77 per cent
cases occurring above 15 years.
The percentage of children among leprosy patients was
13.5 per cent in Kapoor's study (1963)21 and 17 per cent in
Mohammed All's22 study.
EPIDEMIOLOGICAL STUDIES
Prevalence
Dharmendra (1945)18 observed a variation in prevalence rate of 1.7 to 66 per 1000 in the different parts of India.
He also (1963)19 observed regional variations in both epidemi
ological and clinical manifestations. He described variations
in type distributions, the prevalence rates, sex ratio and in age
distribution m the different regions and in the same region for
different races.
Mohammed Ali (1963)20 gave a prevalence rate of 30.9 per
1,000 in Madras State based only on findings of leprosy
control centres. In the same year Kapoor (1963)21 worked out
a prevalence rate of 8 per 1,000 for some areas in Maharash
tra.
Specially for Chingleput district, Mohammed Ali (1963)22
reported on a study of 213,721 population in 381 villages, a
prevalence rate of 21 per 1,000.
Sharma (1969)23 compared figures in 1937 and 1956 in a
10,000 population of Bengal and found almost no difference
in the child prevalence, male and female prevalence between
those two surveys.
19
)
Age at Onset
Sehgal et al (1977)30 reporting on a study of 1,053
patients in Goa found the onset of disease to be between the
ages 20 and 39 years. Age at onset was lowest in nonlepromatous type and highest in neuritic type and in between
in the lepromatous and border-line (N?L) types. His findings
do not tally with the data on prevalence of leprosy among
children in general and school children in particular given
later in this chapter.
21
INTRODUCTION
20
LEPROSY IN RURAL INDIA
Type Distribution
Kapoor (1963)21 worked out a lepromatous rate of 25
per cent. He observed lepromatous rate to be inversely pro
portional to the prevalence rate.
Mohammed All (1963)22 calculated a lepromatous rate of
14.3 per cent, non-lepromatous rate of 84.5 per cent and nonlepromatous positive rate of 1.2 per cent in the Chingleput
district.
Karat et al (1967?* in their study at Gudiyattam observed
50 per cent having tuberculoid, 20 per cent having leproma
tous type, 20 per cent having indeterminate type and 10 per
cent having border-line type.
Sex Ratio
Mohammed Ali (1963)22 worked out the male and female sex
ratio as 3:2; the rate given by Karat et al (1967)24 was 3.2:2.4.
Noordeen (1972)27 gave a sex ratio of 2:1.
Deformity
Mohammed Ali (1963)22 observed that 40 per cent of
lepromatous type and 14 per cent of non-lepromatous type
had deformities.
Dutta Chowdhury (1965)29 observed a deformity rate of
43.5 per cent in lepromatous and 19.7 per cent in non-lepro
matous cases.
Noordeen et $1 (1966)31 in a total population of 200,000 in
300 villages analysed male patients above 15 years of age.
Physical disability was found in 15.7 per cent, social disability
was found in 1.9 per cent, combmed physical and social
disability was found in 17.8 per cent. Harijans showed a low
disability rate. The disability rate increased with the duration
of the disease. 13.5 per cent of patients changed or lost their
occupation because of the disease. Disability was least in
skilled light occupations and in agricultural work. Disability
and worsening of economic status went together.
gSSESES
w«e more common in skilled heavy workers and weavCT^
' Noordeen et al (1969)« in a study at Snperumbudur taluk
of Chingleput district observed a deformity rate of 1 . p
rlnt The deformity rate increased as the age increased. The
^nXattonTf leprosy for the deformed was 8.1 years and
for the non-deformed 5.4 years. Males had a deformity rate o
S per cent and females' had a rate of 11.0 per cent. Hand
than foot deformities. Dedeformities were more common I
were common than those ■
formities involving multiple limbs
solving one Umb alone^
Hyderabad
Sties from rural areas. 66.4 per cent of
had deformities. 29.1 per cent of hands, 30.7 per cent
and 5.2 per cent of faces had deformities.
R'Ve’u'ul
in . W
folto» up
up
10 year
year follow
iepromatous
a mUy of reiapses
first six years of bacteriological negativity.
Studies on contacts
found the prevalence among contacts
Kapoor (1963)21 fo
to be 28.0 per cent.
the infection rate among
Mohammed Ah (1963)22 gave
contacts as 17.0 per cent.
22
LEPROSY IN RURAL INDIA
Noordeen (1964)36 in a study of 579 multiple case families
found 15.8 per cent of families having leprosy had more than
one case. He also found the family size to be large in multiple
case families. The average number of cases remained at 2.2 in
all multiple case families irrespective of the size of the family.
Mohammed Ali (1965)37 in a study of conjugal leprosy
among 4,384 leprosy patients found 5.5 per cent spouses
living with an affected partner had the disease. They esti
mated that this figure might actually be very low as some of
the spouses could have contracted the disease prior to their
marriage. Ninety of the 106 spouses developed the disease
even though their spouses were not discharging bacilli.
Christian et al (1966)38 in a study of 793 families observed
the occurrence of the disease in grand and great grand chil
dren. They found that all persons exposed to the disease do
not get infected due to variations in susceptibility. The de
crease in the lepromatous rate in the third generation is
attributed to the development of resistance in the affected
families which is possibly inherited from their parents by this
third generation.
Prasad et al (1966)39 in a study of 579 families consisting of
3,382 individuals found 38.4 per cent of the exposed popula
tion had contracted the disease. They suggested genetic stud
ies to find out the susceptibility among individuals.
Figueredo et al (1967)40 studied 1264 family members from
the records of the Acworth leprosy hospital in Bombay and
found that 27.8 per cent of the contacts had developed the
disease. He found no difference in the risk of infection for
both sexes. Risk decreased with increasing duration of con
tact and with rising treatment status of infector. They ex
plained the differences as probably being due to an immune
mechanism.
Noordeen (1972)27 in a study of 8,000 population in Chingleput district, estimated that cases among contacts form 12
per cent to 15 per cent of total leprosy problem.
INTRODUCTION
23
Rao et al (1975)4t reporting on a study of 23,285 contacts
from 5,088 families, worked out a secondary attack rate of 6.8
per 1000 person years as compared to an annual incidence
rate of 0.8 per 1000 in the total population. The secondary
attack rate doubled when there were multiple index cases in
the family.
Govila (1980)42 in a study of 96 families at Gwalior ob
served more than one secondary case in 13.6 per cent of the
families.
School survey
Selvapandian et al (1980)43 in a study of 10,163 chil
dren in 53 schools of Kaniyambadi panchayat area in North
Arcot district reported a prevalence of 13.5 per 1000 among
school children. The prevalence figure rose to 38.6 per 1000 in
the age-group of 13 years. Study of distribution of patches did
not reveal any difference from covered and uncovered parts.
Mani (1976)44 reported findings at Madras in two consecutive
school surveys at 2 year interval. The average prevalence
among school children was found to be 11.3 per 1000. Thirty
per cent of the cases detected were among already examined
children. School surveys contributed 29.9 per cent of the total
cases in their project area. Ganapathy et al (1976)45 sum
marised their experiences in greater Bombay school survey.
The prevalence rate among school children varied from 3 to
10.8 per 1000. Even school children coming from richer fami
lies had a prevalence of 6 per 1000. 24.7 per cent of the children
had progressive form of disease. However, Koticha (1979)46
reporting on a study of 415,497 children in Bombay schools
found a prevalence rate of 4.8 per 1000. He found the disease
to be more common among male students in the age group of
10 to 19 years. Sixty-one per cent of cases were single lesion
cases mostly in the covered parts of the body. Sehgal et al
(1977)47 in their study of 8 schools at Panaji in Goa reported a
prevalence of 5.3 per 1000. Majority had a single lesion at the
exposed parts of the body.
24
i
LEPROSY IN RURAL INDIA
25
INTRODUCTION
Self healing leprosy
Ekambaram et al (1977)48 in a study at the ELEP lep
rosy control project at Dharampuri studied 432 untreated
children after 6 year period. 72.9 per cent of the cases became
self healed and 20.8 per cent have remained stationary. Only
6.3 per cent have become worse. Ramanujam (1979)49 in a
study of 690 untreated children at Saidapet, found 88.7 per
cent of tuberculoid major cases showing spontaneous heal
ing.
These findings are of considerable importance in dealing
with the problem of leprosy in India.
Social Aspects
Social aspects of leprosy have not been studied very
systematically. Different scholars like Selvapandian A.J. et al
(1972)50, Damle (1972)51, Dwivedi (1974)M, Ramu et al (1975)53,
Christine M.E. et al (1978)54, have studied only a few social
aspects. The studies have been carried out in different parts of
the country and so they are not comparable. Finally the
designs of the studies in terms of the study population,
research tools and the process of data collection also showed
not only wide variations but also considerable limitations in
each of the studies.
Assessment of the Leprosy Control Programme
It has to be recognised that the National Leprosy
Control Programme is in the form of a complex system. This
system consists of a large number of components which are in
complex interaction with one another. The epidemiological
characteristics of the disease, tlie social, cultural, economic
and geographical background of the population, the nature of
technology adopted- for diagnosis and treatment of leprosy
patients within the population, the organisational structure
and various logistical considerations are examples of some of
the major components which give shape to the complex
i
I
!
/
<
interacting system of the National Leprosy Control Pro
gramme. The Leprosy Programme has thus to be assessed
while considering all its major components in all their com
plex interactions. A review of the literature reveals that
virtually no efforts has thus far been made to study the
programme in its complex multi-disciplinary dimensions.
Indeed in 1969 the Director General of Health Services,
Government of India requested the Director General of In
dian Council of Medical Research to undertake the assess
ment of the National Leprosy Control Programme in opera
tion in the country. A committee was appointed to advise the
council to define the methodology of assessment for leprosy
control centres. The deliberations of the committee were
published as a report on "Methodology and measurements
for assessment of leprosy control work in India" by the Indian
Council of Medical Research.55
The scientific working group constituted by the Indian
Council of Medical Research have recommended three types
of assessments viz. (a) operational assessment, (b) assess
ment of effect on patients and (c) assessment to determine the
trend of leprosy in the area (Wardekar 1979)5*.
In 1974 the Indian Council of Medical Research appointed
Dr. R.V. Wardekar and Dr. M. Christian as Project Officers for
assessment of the National Leprosy Control Programme, at
Vairag leprosy control unit (Sholapur district, Maharashtra
State) and at government leprosy treatment and study centre,
Thirukoilur (South Arcot district, Tamil Nadu) respectively.
Each of the officers-in-charge had a medical officer, para
medical workers and some ancillary staff to assist them. The
methodology pursued at both places was to peruse records
maintained at the respective unit headquarters and collect
statistical information. It is important to note that no field
work was conducted. Obviously these data are not uniform in
terms of statistical reliability and validity. Information re
garding various aspects was collected at both the centres from
i
I
26
LEPROSY IN RURAL INDIA
1955 to 1974, by dividing them into 4 or 5 cohorts. In the
Vairag centre between 1955 and 1964 data was collected from
22 villages. From 1965 and 1973 it covered data from 42
villages, and for the year 1974 data of only 17 villages were
includedIn the Thirukoilur study55 an attempt has been made to
study the locational facilities at the headquarters. Though
passing references were made to the records maintained by
the leprosy inspectors (then called para medical workers) no
efforts was made to talk to individual workers and assess
their performance.
Though the assessment at Thirukoilur was expected to
cover operational and epidemiological aspects, excepting a
mention of the inadequacy of facilities at the organisational
level, the whole study was devoted to evaluating the time
differences in various epidemiological parameters based on
the information culled out from the records of the centres. No
attempt was made to interview the patients or the community
to assess the impact of the programme.
The Summary of the Findings of the Thirukoilur Study are:
Active case finding by general survey and healthy
contact survey was 67.0 per cent in 1965-74 as compared to
75.0 per cent in 1958-64. In the earlier years 80.0 per cent of the
villages had 90.0 per cent population coverage by surveys,
whereas in 1970-73 only 26.0 per cent of the villages had 90.0
per cent population coverage. Eighty nine per cent of all adult
contacts were covered in 1957 as compared to 33.0 per cent
coverage in 1974. Coverage of child contacts up to 1957 was
88.0 per cent as against 38.0 per cent in 1974. The healthy
contact coverage was poor in distant villages when compared
to proximal villages.
Almost every component of the organisation was in a bad
shape. This included correction of deformities, facilities for
dispensing of drugs and for dressing of ulcers, laboratory and
INTRODUCTION
27
physiotherapy services, transportation, health education and
case holding activities.
The following epidemiological information was obtained
in the study: The prevalence in 1955-57 was 62.7. In 1967-73 it
was 43.1. Prevalence of lepromatous type was 11.7 in 1955-57
as compared to 5.1 in 1967-73. Non-lepromatous type preva
lence was 48.7 in 1955-57 as against 35.6 in 1967-73. Borderline
type prevalence varied between 2.3 and 2.1. Male-female ratio
was 1.6:1 in 1955-57 and 1.3:1 in 1970-74. Child rate was 28.0
per cent in 1955-57. Tlus increased to 47.0 per cent in 1970-74.
Lepromatous rate was 18.0 per cent in 1955-57. This de
creased to 2.0 per cent in 1970-74. Lepromatous rate in survey
cases was low as compared to lepromatous rate among volun
tary cases. Speed of commencement of treatment was slow in
females, older patients, non-lepromatous cases and in cases
coming from distant villages. Seventy-one per cent of the
patients collected 50.0 per cent of drugs in 1958-60 whereas
in 1970-71 only 36.0 per cent of patients collected 50.0 per cent
of the drugs. The regularity was dropping with each year
after registration. The irregularity of drug collection was high
in non-lepromatous cases, young people, females, survey
cases, and in patients coming from distant villages. Nineteen
per cent of lepromatous cases, 20 to 60.0 per cent of borderline
cases and 3 to 5.0 per cent of non-lepromatous cases were
bacteriologically positive. Bacteriological assessment was not
undertaken periodically after the start of treatment, even for
lepromatous cases. Initial deformities were higher for lepro
matous cases, voluntary cases, males and in those aged above
45 years. Initial deformities were more in hands followed by
face, feet and least in the eyes.
The following findings were reported from the Vairag
study:56
Epidemiological Information :
Only 59.2 per cent of the total cases in 1974 were being
detected by active search. Only 32.2 per cent of lepromatous
28
LEPROSY IN RURAL INDIA
cases were detected by active search. Contacts and healthy
contacts have contributed to 24.0 per cent of the total case
load. Prevalence rate per 1,000 examined healthy contacts
was 4.3. 7.8 per cent of the cases were detected through school
surveys. Prevalence of leprosy among school children was 1.9
iii 1974. There was a significant decline in the prevalence rate.
Age Distribution
1.3 per cent were in 0-4 year age group, 13.3 per cent
were in 5-9 years, 24.7 per cent were in 10-14 year age group,
17.3 per cent were in 15-24 years, 30.7 per cent were in 25-44
year age group and 12.7 per cent were in 45 years and above
age. Male-female ratio was 1.9:1. Lepromatous rate was 11.2
per cent in 1970-74 as compared to 21.3 per cent in 1960-64.
Non-lepromatous rate was 82.0 per cent in 1970-74 as com
pared to 78.5 per cent in 1960-64. Borderline rate was 6.8 per
cent in 1970-74 as compared to 0.2 per cent in 1960-64.
Type and Age
4.5 per cent of lepromatous cases, 91.8 per cent of nonlepromatous and 3.7 per cent of borderline cases were in 10 to
14 year age group. 9.6 per cent of lepromatous cases, 86.2 per
cent of non-lepromatous and 4.2 per cent of borderline cases
were in 15 to 24 year age group. 22.1 per cent of lepromatous
type, 65.3 per cent of non-lepromatous type and 12.6 per cent
of borderline type cases were in 25 to 44 year age group. 8.7
per cent of lepromatous cases, 82.6 per cent of non-leproma
tous cases and 8.7 per cent of borderline cases were in 45 years
and above age group. 11.2 per cent were lepromatous cases,
82.0 per cent were non-lepromatous cases and 6.8 per cent
were borderline cases in all the age groups put together.
Deformity rate has shown a decline from 33.0 per cent to 11.4
per cent. Highest deformity rate was in 25-44 year age group.
Defonnity rate in lepromatous type varied from 36.1 per cent
to 51.2 per cent. 30.6 per cent had defonnity of both hands. 9.7
per cent had deformity in both legs. 3.2 per cent had deformi-
INTRODUCTION
29
ties in face.
Record maintenance was very poor in the centres studied.
Very few bacteriological examinations were done even for
lepromatous cases. There was a lot of delay in declaring
disease arrested patients. Healthy contact examination was
poor and varied between 55.0 to 89.0 per cent.
In addition to assessment of National Leprosy Control
Programme by Indian Council of Medical Research, some
eminent leprologists have also made some impressionistic
remarks on the Leprosy Control Programme. While these
assessments can provide some valuable insights into the
working of the programme, they cannot be considered as
scientific studies of the programme.
Khoshoo (1965)57 in his review of the Leprosy Control Pro
gramme in India indicated that the states have not utilised the
plan allocations. He has indicated some lacunae like im
proper location of control units, non-provision of full comple
ment of trained staff, inadequate health education, non
utilisation of funds for welfare benefits and the state leprosy
officers were not given the same supervisory responsibilities
as others for leprosy control units.
According to Dharmendra (1969)58 the Leprosy Control
Programme has no doubt expanded but the attendance of the
patients has usually been so low that with this low attendance
the spread of leprosy cannot be expected to be controlled.
Ekambaram (1969)59 identified some defects in the im
plementation of the programme while taking a fresh look at
leprosy control work. He advocated more facilities for a
control unit so that the medical officer of a control unit is not
a distributor of DDS tablets, but a real doctor. He identified
prolonged treatment and deplorably low living standard of
patients, resulting in a mental apathy and indifference to
getting treated consequent to his struggle for existence as the
main reasons of absenteeism.
Tare (1974)60 opines that all that was planned in the SET
methodology has not been implemented. According to him
.
30
LEPROSY IN RURAL INDIA
surveys of 80.0 per cent of the population, that too once in 7
or 8 years, have no value. Education component of SET has
been attended in default than in implementation.
In another study. Tare (1975)61 has also observed that the
patients feel tired due to monotony of long term treatment.
He identified some challenges in the course of leprosy control
work like lack of interest in workers, falsification of diaries,
improper training by untrained staff, excessive load of work
on the workers, lack of security in service and social security
in old age for workers in voluntary organisations, increasing
governmental controls and dictation on the private leprosy
institutions through the conditioning of grant-in-aid.
Kapoor (1976)62 in his critical assessment of National
Leprosy Control Programme has stated that many of the
States were not doing the work according to the operational
guide prescribed due to lack of proper liaison between centre
and states. He also observes that there is inadequate provi
sion for temporary hospitalisation, non-removal of self healed
and patients with resolved lesions from the lists, inability of
the medical officers to look after SET centres and to supervise
and guide the work cf staff. Medical officers were not trained
for the work; undergraduate training is very inadequate. The
training facilities for non-medical supervisors were not
proper and were inadequate.
Das (1976)63 has indicated that the programme did not
gain the required momentum because of the slow rate of im
plementation and insufficient recruitment of the staff, and
purchase of material and equipment.
Noordeen (1977)64 assessed the present level of efficiency
in applying mass treatment at 30.0 per cent. In his opinion the
reasons for this low level of efficiency is among other things
the operational component and the methodology of the pro
gramme which have not changed since the inception of the
programme. In his opinion they were not based on any well
w tested operational studies not only to review various compo
nents of the programme but also for development of newer
INTRODUCTION
31
operational components.
Studies in Absentees/Defaulters
Hemerijckx (1959)65 reported that among 13,394 patients
registered at Pollambakkam, 12.7 per cent were irregular and
42.2 per cent were absentees. Associated with this redeeming
feature was the higher attendance rate among lepromatous
patients.
Karat el al (V)b7)2i in a study at the Brahmapuram centre
in North Arcot district, reported that 60.0 per cent of the
registered cases were defaulters.
Kapoor (1969)66 reviewing leprosy control work in Ma
harashtra identified reluctance of the patient to walk miles to
just get a few tablets, lack of proper attention to patient, lack
of accommodation, physiotherapy and ulcer dressing, lack of
attention to concomitant ailAients and bad personal behavi
our of para medical workers as the causes of absenteeism by
patients. He stressed that lack of devotion on the part of
everyone as being a major hurdle to the success of the pro
gramme.
Neelan (1972)67 in his study of 454 registered cases at Chingleput and Sriperumbudur taluks reported a 40.0 per cent
defaulter rate. The relapse rate among those cases was high.
Noordeen (1972)27 in his study of 8,000 population in Chingleput district found a defaulter rate of 90.0 per cent in nonlepromatous cases.
PREMISES OF THE PRESENT STUDY
From a perusal of the above studies it is evident that no com
prehensive assessment of the problem has been made so far.
Only piecemeal attempts were made to identify the different
problems, by different workers at different times. The leprosy
problem was not viewed as. a system consisting of a number
of sub-systems. There was no holistic approach for assessing
the different components of the programme.
INTRODUCTION
32
33
LEPROSY IN RURAL INDIA
The structure and functioning of the organisation for
leprosy control in a population is woven around the epidemi
ological issues of the disease. These again depend on the
attitude of the patients and the community to the programme.
Thus all the four components namely (1) the structure and the
functioning of the organisation, (2) epidemiological issues
related to the problem of leprosy, (3) the attitude of patients
and (4) the community at large, are in complex interaction
with one another and they must be studied together: they must
be studied as a whole.
Such a holistic approach is necessary not only to study all
the major facets of programme, but also to study simultane
ously the interaction amongst them. On the basis of identifica
tion and study of the major components and interactions
amongst them, it will be possible to develop insights into the
working of the National Leprosy Control Programme which
will provide the basis for bringing about changes within it to
make it more effective.
For the purpose of this research Chingleput district of the
State of Tamil Nadu was selected. Chingleput district has a
high prevalence of leprosy and the district has been having
inputs in terms of organisation, personnel and equipment to
deal with this problem for a considerable time. Because of
these considerations, the leprosy programme in Chingleput
district provided a very good setting for studying all the four
components of the system of leprosy control programme in a
population, (organisation and management component, epi
demiological component, the component formed by the pa
tients and the community component).
Objectives of the Study
In developing an approach to study the Leprosy
Control Programme in the district of Chingleput, the first
objective will be to obtain data concerning the four compo
nents mentioned above, including how the functioning of the
programme at the state level influences the functioning of the
programme at the district level.
The second objective will be to bring together the data con
cerning the four components in order to describe the func
tioning of the programme as a whole within the district.
The third objective will be to use the data from the study
to offer suggestions for improving the functioning of the
programme at various levels.
Dl
Scv '
Chapter 10
LEPROSY ERADICATION
EFFORTS THROUGH MULTI
DRUG TREATMENT
4
In view of the limitations of Dapsone monotherapy viz. (1) the
prolonged treatment adversely affecting case-holding and (2)
evidence of development of resistance, the multi-drug treat
ment was introduced in higher endemic districts with preva
lence rates of 5 or more for 1000 population as a national
policy since 1982. The priority in the treatment is being given
to multi-bacillary patients.
The programme, redesignated as National Leprosy Eradi
cation Programme in 1982-83, is a 100% centrally centrally
sponsored scheme.
Programme objectives and strategies in regular
MDT districts
The ultimate aim of the eradication programme is to
achieve the zero transmission of leprosy by the year 2000 A.D.
To achieve this, the programme aims to bring all endemic
areas in the country under MDT by the end of 1992. The
adopted strategy involves provision of domiciliary multi
drug treatment (MDT) coverage in the high endemic districts
in a phased manner by staff specially trained in leprosy.102
New classification of leprosy
Currently the Leprologists have agreed to classify leprosy
as multi bacillary (MB) and Pauci Bacillary (PB).103
The types included in the old classification coming under
the new Multi Bacillary (MB) classifications are as follows:
LEPROSY IN RURAL INDIA
416
a) Lepromatous
d) Border line Tuberculoid
(more than 5 lesion)
b) Border line lepromatous
c) Poly-neuritic (more thane) Border line borderline
one nerve involvement)
leprosy fradication efforts through multi drug regimen
(b) Daily Domiciliary Doses for 24 months
15 yrs +
10-14 yrs
6-9 yrs
50 mg
(twice
weekly)
25 mg
The types included in the old classifications presently
coming under the Pauci Bacillary (PB) group are as follows:
Clofazimine
50 mg
(daily)
50 mg
(alternate days)
a) Indeterminate
b) Tuberculoid
c) Poly neuritic (one nerve)
d) Border line Tuberculoid (1-4)
Dap sone
100 mg
50 mg
II. Paud Badllary cases
(a) once
Drug Regimen
I.
Multi Bacillary cases
(1) Two weeks intensive treatment at the clinic with daily
doses of:
15 yrs
10-14 yrs
6-9 yrs
Rifampicin
Clofazimine
Dapsone
600 mg
100 mg
100 mg
450 mg
50 mg
50 mg.
300 mg
50 mg
25 mg
(2) Continuation phase of multibacillary treatment regimen
(a) Once monthly Doses for 24 month at the clinic
Rifampicin
Clofazimine
Dapsone
417
15 yrs +
10-14 yrs
6-9 yrs
600 mg
300 mg
100 mg
450 mg
150 mg
50 mg
300 mg
100 mg
25 mg
Rifampicin
Dapsone
monthly Doses for 6 months at the clinic
^5 yrs + 10-14 yrs
6-9 yrs
1-5 yrs
450 mg
50 mg
300 mg
25 mg
150 mg
10 mg
15 yrs + 10-14 yrs
6-9 yrs
1-5 yrs
100 mg
25 mg
10 mg
600 mg
100 mg
(b) Daily/Domiciliary Doses
Dapsone
50 mg
selection of distric under the MDT pro
The criteria for
gramme are as follows:10*
i) Complete infrastructure in position in the dist^
u) Adequate training of leprosy staff in MDT operations,
iii) Rapid survey to detect the undetected cases; and
iv) Screening of all recorded cases and preparation of
individual case cards.
MDT' S^bsS^detiST^eliSTnTot ope^
LEPROSY ERADICATION EFFORTS THROUGH MULTI DRUG REGIMEN
418
LEPROSY IN RURAL INDIA
I
t
were developed, printed and distributed. In all 136 endemic
districts with disease prevalence of five or more per thousand
population were brought under MDT coverage. Presently
these districts are under various stages for MDT implementa
tion. Out of these 11 districts have been proposed for integra
tion of leprosy activities with General Health Services. The
names of these districts as well as the remaining 125 districts
are given at Appendix 'D + Ez.
At the end of March 1991 nearly 75% of the recorded
leprosy cases i.e., 1.5 to 1.6 million cases are getting MDT
inthe above 136 districts.102 Over a million leprosy cases have
been disharged since 1985 as disease cured due to effective
MDT implementation in the above districts.
I
Modified MDT Programme105
In 66 endemic districts where 25% of the total leprosy
problem stdl exists (mainly in the states of Madhya Pradesh.
Uttar Pradesh, Bihar, Orissa, Kerala and West Bengal) a
modified MDT has been planned. Most of these districts have
inadequate infrastructure to implement Multi Drug Treat
ment as per Government of India guidelines issued for en
demic districts. The names of 66 districts are indicated in
Appendix Tz.
3.
4.
5.
6.
J
I
7.
8.
419
However, the NLEP staff will be paid from programme
funds.
The funds for operation, as envisaged in the modified
MDT scheme would be provided to the District Lep
rosy Society by the Central Government. The District/
Zonal Leprosy Officer of the District will act as mem
ber secretary of the society.
Chief medical officer of the district or equivalent will
be the vice-chairman of the District Leprosy Society.
Funds for this project would be operated by MemberSecretary of the Society under control of the District
Leprosy Society.
To encourage Primary Health Care functionaries, a
scheme of awards based on their performance willbe
introduced. The details of the scheme would be
worked out separately.
To improve new case detection, an incentive @ Rs.
3/- per new case detected/reported will be intro
duced.
Similarly to imporve case holding, patients will be
paid Rs. 10/- for each supervised pulse administered
limiting 24 pulses in MB and 6 pulses in PB. In addi
tion, patients taking the full course in prescribed pe
riod will get Rs. 100/- in cash or kind as may be
decided by the District Leprosy Officer.
Salient Features of Modified MDT Strategy
IL Technical
I. Administrative
1.
2.
Each endemic district would have a registered District
Leprosy Society under the Chairmanship of District
Collector. The Society would have overall responsibili y for the operation of modified MDT activities, in
cluding funds and health education activities etc. as
envisaged in the guidelines.
nnd TA/DA of the general health care staff
and/of NLEP staff wherever available in the district
under the project will continue to be bom on source.
1.
i
2.
3.
14 days intensive therapy for MB cases will be discon
tinued.
Fixed duration chemotherapy will be introduced for
allMB and PB cases. However, PB with multiple le
sions will be examined at the time of sixth pulse.
Instead of rapid survey prescribed in the government
of India existing guidelines. Health Education activi
ties will be intensified to encourage voluntary report
ing. It is expected that adequate case detection can be
LEPROSY IN RURAL INDIA
420
4.
ensured by intensive Health Education supported by
case detection through screening and patient satisfac
tion due to effective treatment.
Bacteriological examination of skin smears will be
continued to MB cases and suspected MB cases.
However, MDT will be started on basis of clinical
examination.
III. Main objectives
The main objectives of the modified MDT programme are:
1. To render all infectious cases as non-infectious in a
short period, so as to interrupt the chain of transmis
sion of the disease in the community.
2. To give adequate and regular treatment to allthe exist
ing and new cases and cure them in a short period.
3. To prevent the emergence of drug-resistant strains of
M. leprae.
4. To ensure early detection and treatment of cases to
prevent deformities.
5. To carry-out systematic health education activities,
with a view to disseminate important facts about
leprosy and to remove social stigma.
6. To prevent the spread of leprosy.
7. To finally eradicate leprosy.
IV. Prerequisites for starting modified MDt in a District
To ensure satisfactory introduction of modified MDt the
district shall satisfy the following criteria.
1. Prevalence rate per 1000 population should be five or
more.
2. The district should have a full time functioning DLO
supported by minimum ancillary staff.
3. The districts have adequate coverage by Primary
Health Care set-up.
LEPROSY ERADICATION EFFORTS THROUGH MULTI DRUG REGIMEN
421
4. One trained non-medical supervisor shall be available
at block level and he will be attached to the community
health centre. However, it shall be ensured that one
non-medical supervisor's available for about 1,00,000
population.
This approach differs from the original MDT pattern in
the following manner:
i)
ii)
iii)
iv)
v)
vi)
vii)
District Leprosy Unit would function in the district
under overall charge of the district medical officer.
Leprosy services would be delivered though primary
health care set-up. Leprosy workers would be pro
vided to the extent they are available in the district.
Medical Officer of the Primary Health Centre would
be overall incharge of MDT operations in the area.
No cash incentives would be given to the health work
ers.
Cash assistance would be given to the leprosy cases to
collect their drugs from the treatment points.
Cash awards would be given to theh leprosy patients
who complete the MDt treatment schedule in time.
Treatment points would co-incide with Primary
Health Centre, Subsidiary Health Centre, Community
Health Centre and Hospitals.
Mobile central training teams are being sent to the dis
tricts to train medical officers and other health workers in
these districts. Some of the districts have since started actual
MDT operations. Rest are likely to follow shortly.
Future approach to cover the remaining cases
approximating to 8% of total case'402
Presently 90-92% of the cases residing in the endemic
districts have been extended the benefit of MDT. The remain
ing 8% of the cases are from the 254 low endemic districts.
These cases are not uniformly distributed in the districts.
There are pockets here and there within the districts where
I
LEI’ROSY IN RURAL INDIA
422
LEPROSY ERADICATION EFFORTS THROUGH MULTI DRUG REGIMEN
cases are actually residing. Majority of these cases roughly
totalling 180,000 - 200,000 are residing in the 77 districts of the
country.
To achieve an effective break in the disease transmission,
it was found necessary that these cases are also brought under
MDT within the near future. Modified MDT approach would
be followed in these districts. There is a proposal to seek
world bank assistance for implementation of MDT in these 77
districts. The names of the 77 districts are given at Appendix
'G'.
THE ORGANOGRAM OF LEPROSY ERADICATION
PROGRAMME IN TAMIL NADU
Commissioner & Secretary (Health)
r
DME
T
I
DMS +
DPH
SHTO
DANIDA
RH + FW
The Organisational Structure of the NLEP in India
Addl. Dir. (L)
National leprosy Eradication Commission
District Level
N.L.E Board (Appendix 'I')
Jtd. Dir of
MS + RH + FW
Leprosy Division, Directorate General of Health Services
--------------- Ministry of Health and Family Welfare
l
DLO
Central Ac Regional
Leprosy Training &
Research Institutes
r
Directorates of Health Services of State/UTs
LCU
ULC
SAI
LT 1
NMS 1
LI 1
HE 1
THW
Voluntary Organisations
Leprosy Bureau in States <&c UTs
V
Leprosy Training Centres
Reconstructive Sur. Units
>f
'
DistrictZ21on.il Leprosy Office
J
47“
4
Leprosy Control Unit Temporary
Hospitalization
Ward
Survey, Eradication Urban Leprosy
and Treatment
Centre
Centre
423
I
t
1
DRUGS
1
DIM
s
* 4
LEPROSY
HQ Miss a turn to comfort your neighbour who has just dis
covered that he has leprosy. Tell him that Nature knows no
despair. It heals itself. So will his body if he has the will to take
the treatment. The future is nothing more than the will to live.
00 Talking to your clients at the beauty saloon, has helped
many to know the facts of the disease and to overcome their
fears and prejudices. Most people, unfortunately, think that lep
rosy is incurable, and that it disfigures and deforms a person.
Excellent! Advance 3 steps.
ns
Don't let the patch on your arm frighten you. Miss a turn
while you check to see if there is hair on the patch. Do you feel
any sensation there? Does the skin sweat in that area? Only if
you have no sensation, no hair, no sweat on the patch need you
check with a doctor.
HH You have saved a mechanic his job by explaining to his
employerthat there are two kinds of leprosy: the infectious and
the non-infectious; and that only 15% of the leprosy cases in
India are infectious. The mechanic has the non-infectious type
of leprosy. Go ahead 3 steps.
00 Your tailor does seem to have the infectious type of lep
rosy. He has innumerable patches all over his body. These are
oily and shiny and do not seem to have any clear cut edges.
He can be made non-infectious within a month if he is started
on the multi-drug therapy. Miss 2 turns. Get him started on the
treatment. Ask people to continue to give him their orders.
00 You did well to explain to Asha that leprosy is caused by
a germ and that it is not a punishment from God. She has been
crying bitterly thinking God has punished her for some
misdeed.Have another turn.
Miss a turn. Repeat three times: Leprosy is not a dreadful
disease. It is not incurable. It is not hereditary. It is not a
punishment from God. It is caused by a germ. It does not
require separation from others. It does not always lead to de
formities and disabilities.
00 Advance 3 steps. Visit Mrs. Gupta. She is annoyed that
her son has become a smuggler and has threatened him that
God will punish him with leprosy.Tell her that you understand
how she feels. Smuggling is bad, but her threats will promote
incorrect ideas about leprosy.
BE3 Miss a turn. Repeat 3 times: Because leprosy affects the
motor nerves, they do not send messages from the brain to the
muscles. Unused muscles become wasted and weak and this
leads to disabilities.
00 You broke off your engagement to Keya when you discov
ered one of her relatives has leprosy. Did you not know that
leprosy is not hereditary? Move backtthree steps.
□0 Sharad insisted that one could get leprosy when bitten by
a two headed snake. You had no courage to contradict him and
give him the facts about leprosy. Move back 4 steps.
00 You still doubt the curability of leprosy! Why did you refuse
to employ that woman because her fingers are misshapen ?
She has been cured long ago. Move back 4 steps.
00 You did not employ that woman because you were scared
of the reactions of your friends and neighbours. When are we
going to give the cured acceptance ? A chance to live ? Miss
two turns to organize a talk on leprosy at your residence. Invite
as many as you can to this talk.
00 Advance 5 steps. You did well to write to the Editor of the
Times of India protesting the use of the word 'leper' and indicat
ing that we do not talk of 'chicken-poxers', 'aidsers', 'cancerites'
or poliottes'. Why do we not refer to those who suffer from
leprosy as leprosy patients ?
00 With the letter Dr. Kumar gave you certifying that Kumar
has leprosy, you booked him a round trip ticket to Wardha for
treatment, obtaining a 75% discount. This discount is available
to all leprosy patients Advance 4 steps.
00 Your efforts to convince your uncle that leprosy is both
curable and not always infectious has saved your aunt from
being turned out of the house. Take 2 more turns. 85% of the
leprosy cases in India are non-infectious.
00 You have again said, 'leper'. Move back 6 steps. Remem
ber to say 'leprosy patient'.
00 Leprosy patients hide their illness from everyone, includ
ing doctors. They are terrified of being rejected by society - by
US , you and me ! Miss a turn and spend some time trying to
imagine how they suffer in their isolation.
00 The leprosy patients who came to your talk today were
struck by this comment. "Tears can never blot out the sun, but
they can kill our appetite for food, work and life." You certainly
did well to motivate them to continue with the treatment. Ex
cellent ! Have another turn.
HH Do you know that a judgement was reversed in the High
Court in Madras on the evidence provided by a leprosy patient ?
Once upon a time, leprosy patients could not be presented as
witnesses. Now they can. Move ahead 2 steps. Spread this
information as you move ahead.
Q0 If you come from any of these states, you may move
forward 3 steps as the Indian Lepers Act of 1898 has been
withdrawn by their State Governments: Maharashtra, Andhra
Pradesh, Karnataka, Madya Pradesh and the Union territories
of Delhi and Chandigarh.
00 Are you hoping to get a divorce on the grounds that you
wife has leprosy ? Rememberthat you live in Maharashtra where
the courts have rejected such petitions. Miss a turn. Get over
your hang - ups.
00 You did very well to make clear to your friends that lep
rosy affects the nerves. The person loses sensation when the
sensory nerves are affected. We lose the capacity to move our
fingers when the motor nerves are affected. Have another turn.
0H Move 4 steps ahead. Give Minoo a treat. He has followed
your instructions very carefully, daily checking his hands and
feet for any cuts or scratches. This is very necessary as the
cuts can get infected and lead to gangrene.
E10Q Weren't they surprised when you told them leprosy was
curable unlike diabetes which isn't ? That was a good compari
son to shake people up. Move ahead 2 steps.
00 Explain why it is so necessary to check daily for cuts or
scratches. Does the person not know when she cuts himself/
herself ? If you cannot, move back 5 steps. (Answer in no:84)
E1E3E! Cheers I The National Institute of Immunology has de
veloped a leprosy vaccine which has been approved by the Drug
Controller of India. It will be available at an affordable cost soon.
Take one step forward.
00 Even though you are a temporary worker in your company,
as a leprosy patient you can take special extraordinary leave of
18 months on producing a medical certificate. Stop hesitating.
Go apply for leave. Have another turn.
E1E1E] This is an excellent idea creating a network of penpals
between leprosy patients and children from your neighbour
hood. Have 2 more turns. Continue to collect addresses of chil
dren who want a penpal.
As a student representative, you did well to urge your
principal to join with other principals to demand that the Text
book committee include a chapter on leprosy in the Science
Textbook for Std.X. Move forward 2 steps.
QE!0 Do you know of this contribution Gandhiji made to the
nation. Pacchure Shasthri , suffering from leprosy, came to
Seva Gram for assistance. Move ahead two steps telling peo
ple along the way about Gandhiji's personal care of Pacchure
Shasthri, his attitude to the disease, to those suffering from it,
and to those fearing it.
HH0 You have been collecting money and old clothes for
distribution to leprosy patients at Divali. This is good, but don't
you realize that they want to be treated as 'people'.They want
our acceptance more than our charity. Miss 2 turns to think
about ways in which you can organize something different to
stress this acceptance.
E30S Excellent! You have done well to go on a door to door
campaign in your village explaining away fears about leprosy so
that a widow in the village can continue to use the village well.
Move 4 steps ahead.
Q@S List 3 important symptoms of leprosy. If you can, move
forward 4 steps, if you cannot, move back 7 steps. (The symp
toms are in no: 22)
EJE10 Advance 4 steps. You did well to explain to people that
leprosy does not always disfigure and deform a person, espe
cially if treatment is started before the motor nerves are affected.
5.
Disease Control
6.
Leprosy Patients Care
Utilizatio nPattern of Tibetan Hospitals
In our General Secretary, Mrs. Namgyal
L. lakllia’s recent visit to three Tibetan
Settlements in Arunachal Pradesh (Tezu, Miao
and Tenzingang) she met three leprosy
patientsand visited their homes.
All are
under treatment from local Indian authorities
but Mrs. Taklha was concerned to discover
that some ol their family members have
contracted the disease too.
Mrs. Taklha and 1 visited the Palampur
Leprosy Hospital and Home on June 17th
1991.
Of the 30 patients resident there, 10
are Tibetan.
Under the supervision of Dr.
Issac R. Nath (Superintendent) and his assis
tant Mr. Das, the home is well run and
patients are treated as part of the family and
seem very happy. We therefore plan to admit
all Tibetan leprosy patients from the Northern
EVALUATION
In 1990, as pari of the fulfilment of his
final examination in the post-graduate diploma
in Health Care Administration, Mr. Dawa
undeitook the study into the Utilization
pattern of Tibetan Hospitals in the state of
Karnataka. The following is a summary based
on the paper.
I here is no doubt that a hospital could
play an important role in the provision of
health care to a community. But one should
not over look the facts that hospitals are
complicated organizations, expensive to build
and maintain, requires professional manage
ment of its staffs and facilities and are not
always responsive to the health needs of the
public. It is therefore imperative that regular
sutveys and audits are undertaken to maintain
quality, and to initiate changes.
Three hospitals in three separate Tibetan
Settlements in the state of Karnataka in India
were studied. The backgrounds and findings
of each are as follow s.
Zone to Palampur. where we will also be able
to give them better attention from our side,
we are asking Community Health Workers
(CHWs) to report all Leprosy patients in
their settlements so we can establish a leprosy
register and monitor their treatment and
progress more efficiently.
Tsamcho Dolma (Mrs)
Project Officer
Disabled & Handicapped Unit
The Doeguling Tibetan Hospital in Mundgod was built in 1969 and serves a population
of 10,000. It employs 34 stall's including. I
medical officer, 2 staff nurses, 5 nursing aids
and 8 CHW. It has 40 beds for general and
12 beds for T. B. patients. It provides an
out patient service and has X-ray and other
laboratory facilities and has launched a PHC
programme and TB Control Project. It has
also set up a peripheral dispensary to serve
those li\mg farther away. 25% of the hospital
budget is financed by local Health eareeontri
bution and the rest through donations
IMITv lj r a i ru
32b. V Main, J Block
Koranir rgnja
Bangalore-560034
India
«
jj
In the questionnaire administered to 5
selected members of the 19 strong Management
Committee, 4 felt that the hospital facilities
were 75% utilised and one 25% utilised. When
asked which facilities were under-utilized, one
identified in-patient service but 4 identified out
patient services only.
Table No.
Year
1987
1988
1989
1990
Ave. out-patient
attn.
per working day
34
42
35
30
% inpatient
bed occupancy
1
no. of
Laboratory
investigations
per working day
6.5
6.0
3.8
4.6
26
20
19
19
The second hospital studied serves the
Dhondenling Tibetan Settlement in Kollcgal.
Mysore district, with a population of 4500. It
was established in 1976 and most of its budget
is now self generated. It has 35 beds, provides
outpatient, TB Control, Maternal and child
Ave. no. of
X-ray taken per
Working day
per technician
1.4
1.4
2.0
5.0
health and community opthalmic services. It
has X-ray and laboratory facilities and has
started training CH W in May, 1990. It employs
a total of 12 staffs, including a medical officer,
2 stall'nurses, 1 health coordinator cum X-ray
technician and a lab technician.
Table No. 2 *
Year
1987
1988
1989
1990
Ave. O. P. attn
per working day
26.8
26.1
% bed
occupancy
7.2
10.2
8.9
9.4
*When 5 members of the management
committee were asked about utilisation rate
only one replied to the figure of 25%, the
others chose 50% or 75%.
The last hospital studied is the Rabgayling
12
no. of lab.
investigations*
per working day
1.5
3.2
1.3
1.0
no. of X-ray taken
per working
day
0.6
Tibetan Settlement in Hunsur. It was built in
1971 and serves a population of 3650. The
hospital has facility for 35 inpatients but due
to the lack of a full time attending physician,
this is not being utilized. A local doctor
visits thrice a week. Once a month the medical
)
li
officer from Dhondenling Hospital visits to
supervise the T. B. Control Project. 9 stall's
are employed, including 2 CHW and 1 nurse
aid.
Table No.
1987
12.0
20.4
20.0
19.6
1988
1989
1990
F'I
When the respective camp or village leader,
nearly all of whom have resided in their Settle
ments since establishment, were asked about
where the settlers go to consult when they are
sick, the following figures were returned.
One should note that the responses were based
on the leaders' impressions, not quantitative
analysis.
3
Ave. OI’D attn
per working day
Year
utilized, and most expressed that this was
especially so for in-patient and laboratory
services.
-----------
All 5 elected members of the imanaging
committee felt that facilities were only 25’4
Although the study was
hampered
by a lack of important datas, a number of
observations may be made.
WHERE DO PEOPLE IN THIS LOCALITV GO TO
V»rHEW TOEY
ARE SICK AND REOIilRE
TALt;:attoh ?
'k
38%
k
3 2%
3 2%
h
\ 21%
24%
r
1
I
19%
•rafc
I
6%
ia Ml
HOSPITAL A
SETTLEMENT TRAD I HOSPITAL TIONAL
MEDICAL
CLINIC
hospital b
DISTT
HOSPI.
TAL
PRIVATE
PRACTI
TIONERS
hospital
VOLUNTARY
hospital
13
I.
In all the three hospitals, there is possibly
evidence of substantial under-utilization
of a large proportion of the facilities
available.
T
In Rabgayling, the difficulty with stall
recruitment may have contributed towards
an estimated 92% of the settlers seeking
help from outside the Settlement hospital.
3.
There is a lack of important datas, such
as the cost to maintain one hospital bed,
to be able to assess elHciency.
4.
Areas of under-utilization of existing
facilities may be under-estimated by
members of the hospitals.
In conclusion, although the 3 hospitals
studied on the whole provide a wide range of
useful services to their people, some of these
services seems to be substantially under
utilised. The paper suggests the following areas
of study and research :
a.
The study of break-even analysis of
X-ray plants
b. The role of a hospital managing
committee.
c. The organization climate of a hospital.
d. The educational status and age group
of people who avail themselves of the
hospitals.
c. Common ailments among the people.
ATTENTION :
Since 1987, “Tibetan Health” has been published twice a year to inform
all our friends, donors and health workers at home and worldwide about the
activities of the Department of Health.
Now we feel, it is time lor us to evaluate Tibetan Health to see whether
it is serving your needs. Your frank Comments will be much appreciated.
Please send us your suggestions before September 1991.
a
14
a
I
I
pot
P£
MFC Mt'H
zJhALPA
it
to keep the fact in mind that Leprosy disappeared
i
from Europe by the 16th Century at a time when- we knew nothing of microbes,
■Je
have
Natural history of leprosy in the individual
infections and chemtherapy.
dictates self-healing or self-limiting disease. This is reflected at the
community level in a slow but steady correction of the endemicity with a
decline in the rates of lepromatous types of leprosy, even as there is a rise
in non-leproraatous disease. This is the result of a slow correction of the
susceptibility trait (susceptibility to develop lepromatous types of the
disease) at the genetic level. When we see less lepromatous leprosy, it means
there are fewer people in the community to manifest lepromatous leprosy, an
improvement in the genetic stock of- the population.
Unless this equilibrium is attained^ and this is a natural process - no
amount of Chemotherapy can bring this about in leprosy as is clearly evidenced
by the undiminished nevz case detection rates USCIR) even in areas brought
under MDT coverage for 15 years - leprosy will continue to be with us for some
more time. The unseemly haste with which the WHO and the Ministry of Health is
going about eliminating leprosy is doing lot of disruption to the programme.
Workers under the Voluntary Organisations face a dim prospect of abolition of
the Grants-in-Aid after 2001 AD. Definition of a case of leprosy is being
compromised to show less number of cases.
yVhatever little could be achieved by the NLEP is also negated by
half-baked treatment regimens with bizarre and impractical combination of
drugs. There is a great deal that could be done even within the constraints
dictated by the natural history of
leprosy if the drug regimens were
rationalised, and an effective immunotherapy brought in. This vital dimension
of Immunity has been a casualty in the din of the "drugs that kill the bugs".
Unless this vital dimension of immunity is appreciated as the centre-piece of
leprosy, drug treatment alone to eliminate leprosy will be an unrealistic and
costly exercise. One must never lose sight of the fact that persisting bacilli
alive or dead, will continue to precipate reaction, and reactions are the
bases of leprosy pathology and symptomatology: the pathology of leprosy is
rightly called immunopathology.
Lastly, we are still ignorant about raany facets of leprosy knowledge in
which could help.
\
Dear Friend,
I am sending a copy of Sathya's review of the leprosy control program. Hope you have got
the previous mail regarding tuberculosis etc.
V
Yogesh
LEPROSY (review of some documents, for discussion at the ID cell meet in July 1988)
History of leprosy control programe:
C. Sathyamala
1871-72 :
1890-91 :
1925 :
191.1 :
1954 :
1955 :
1969-70 :
1976:
1981 :
1981 :
Leprosy survey as part of the British Imperial Census
British Leprosy Commission
Indian Council of the British Empire Leprosy relief association later renamed as
Hind Kusht Nivaran Sangh in 1947
Committee appointed by government of India to review the extent of the
problem and made specific'recommendations
(Till 1950 prevalence rate obtained as part of dicennial population census)
Concrete plans for the control of leprosy including legislation
In the last year of the first five year plan the National Leprosy Control
Programme was launched as a centrally aided scheme, main objective to
control through domiciliary dapsone therapy
100% centrally sponsored programme. Programme was input oriented .
Programme made performance oriented. Each state was given a target of new
cases to be detected and brought under treatment and number of patients to be
discharged as disease arrested or cured. Performance was to be measured by
the percentage of endemic population served and percentage of
estimatedcases detected. Each LCU/SET was expected to undertake total
population examination once in 5 years only. The NLCP was launched in rural
areas because 80% of the population lived in the villages and ' leprosy being a
disease of rural incidence and urban prevalence' control in rural areas would
decrease migration of cases . This was found not to be completely correct
because of indigenous urban foci and so was extended to urban areas as well.
The programmes assumption was that by detecting all the cases and bringing at
least 90% of them under continuous treatment with sulphones it would be
possible to bring down load of infection by about 80%.
Indira Gandhi makes an appeal in the World Health Assembly for all developed
countries to help in leprosy eradication. Working group set up under the
chairperson ship of 8 Swaminathan, the then member, Planning Commission to
evolve strategy to tackle leprosy. The changes in the programme were NLCP
was to be changed into time bound programme with the specific goal of arrest of
disease activity in | all leprosy cases by 2000 and sulphone was to be
supplemented by on(e or more bactericidal drugs.
WHO recommends Multi Drug Therapy (MDT) because of problem of resistant
bacilli to Dapsone for treatment of all Multi Bacillary(MB) and Paucibacillary
(PB) patients . GOI launches MDT with the assistance of SIDA and UNICEF.
1983 :
1991 •:
1993-94 :
1997 :
Leprosy 'eradication’ programme with the aim of achieving arrest of disease
activity in all the known leprosy cases in the country by 2000AD
Aim changed to achieve elimination of leprosy by reducing case load to 1 or
less/10,000 population, following the World Health Assembly resolution
Agreement signed with the World Bank for a total assistance of Rs 3Q2 crores
for a period of 6 years. After this agreement the whole country has been
brought under MDT through 490 DLSs (?)
Mid term appraisal by World Bank in April . Following recommendations of
WHO the duration of MDT reduced to 12 months for MB patients from Nov
1997. Single dose ROM treatment for single lesion introduced from Jan 1998.
Modified Leprosy Elimination Programmed)
LEPROSY SITUATION IN INDIA:
Till 1950, prevalence rate was obtained as part of the dicennial population census
In 1931, there were 160,000 cases registered ( prevalence rate of 0.49/1000 population)
This was an under estimate because:
*
it included cases with the advanced form of the disease only
*
all cases were not reported because of stigma
*
many cases not recognized
*
errors in coverage of population
In 1951 - prevalence rate (PR) 3.81; in 1961 PR 5.83; in 1971 PR 5.84; in 1981 PR 5.72.
Endemicity differs from state to state:
14.1
In 1951
West Bengal
8.4
Tamil Nadu
7.8
Himachal Pradesh
7.8
Orissa
In 1966, population covered was 54.724 million i.e., 14.7% of endemic population. During the
IV Five Year Plan, another 16.§% population was added and in 1974-1977 another 35.99 At
the end of 1985, total population covered was 439.9 million representing 64.2% of the endemic
population. This coverage also differed from state to state with Bihar and West Bengal less
than 50% and Tamil Nadu and Andhra Pradesh more than 70%.
In 1981 review the PR in different states were
I
K
HIGH ENDEMICiTY
Pondicherry
Lakshadeep
Orissa
Tamil Nadu
Andhra Pradesh
MOD.ENDEMICITY
West Bengal
Sikkim
Nagaland
Maharashtra
31.67
25.00
12.14
15.14
11.58
7.88
7.81
6.49
6.37
Population at risk is also uneven from steite to state. Most of the load is in the eastern belt. ’
According to the 1981 census, about 400 million (58%) of the population was estimated to be
at risk due to leprosy in areas with prevalence rates of > 5/1000.
The Status Report of 1985-86 states that ‘the disease is on the decline'. On the bais of work
done over a period of 12 years, the PR decreased in an observed area from 2.16% to 1.1%
and total infectiousnes^s (?)declined from 149 to 36 with an average reduction of 9% per year
though the incidence rate did not come down appreciably (How did they measure
infectiousness and incidence??)
In 1991 the countrywide PR was 3.26/1000
An explanation given for the high prevalence rate of the earlier period was
*
they represented the cumulated number of cases,
*
the surveys were ususally carried out in endemic areas with high PR and this was
extrapolated to the
whole country. The trend of increase in the 'estimated' cases got
arrested after 1983 when the MDT programme was introduced. Because of intensive case
finding and establishment of reliable information, and because it discharged from existing
registers patients who were no longer in need of treatment
*
'new case' detected increased phenomenally during the first three years before
levelling off and even started a slow decline. The upsurge comprised of:
- new cases representing recent transmission (1-3 years)
- cases resulting from infection acquired a long time ago (10-30 years)
- the backlog of cases that had failed to report during the earlier years.
(??????????)
'The pattern of new case detection rates during the first three years of MDT strongly suggested
that most of the backlog of the earlier undetected cases would now be on record (a trusim?)
Cases registered for MDT approximated to the true load of leprosy cases needing treatment'.
Estimated case load for June 1990 was 27,64,000 cases giving a PR of 3.26/1000 population
(registered cases were 23,70,687. Tamil nadu, AP,Orissa, Bihar, MP, UP, Maharashtra and
WB accounted for approximately 90% of total registered case loadand an equal percentage of
population at risk in the country. By 1991, MDT had reached all 201 districts which had an
endemicity of 5/1000 or more. In March 1991, the infrastructure facilities extended upto 568.5
million representing 67.4% of endemic population. The introduction of MDT entailed large
scale elimination of cases at initial screening and was supplemented by actual decrease in the
number of cases in areas where MDT had been in operation for more than 3 years.
In March 1991, cases on record 20,43,136, brought under treatment 18,77,199 (91.9%) and
discharged/
cured/died 5.41 million cases.
(an interesting graph from page 30)
The incidence rate(?) in children varied from 1.61 to 54.5% of all new cases with an average of
23.9%,
|
deformity accounted for 5.0% of the new cases. The unusually high childhood rate was seen
to be due to
detection of the disease in children in large numbers at the surveys that focused primarily on
schools (?
interesting but could also represent incidence of disease?)
Examination of skin smears for bacilli was essential prerequisite of MDT programme. Such
examination was carried out to supplement (? not mandatory?) disease classification before
starting treatment and later as a follow up measure. The document however states that
'currently bacteriological services constituted a weak link. On an average, 60.0 percent of the
patients were subjected to bacteriological examination and
bacteriological cover was available to 72.5% MB and 47.6% of PB cases.
(ID cell members can find out what % of MB cases are being bacteriologically examined).
The epidemiological indices used are:
* Prevalence rate per 1000
* annual case detection rate per 1000
* proportion of MB cases among the new case per 100 (%)
* childhood leprosy rate among new cases per 100 (%)
* Deformity rate in new cases per 100(%)
* relapse rate per 1000 (cases??)
* voluntary reporting rate per 100
(Tables 24 and 25 show targeted acheivements under NLEP till 2001 Seems more of wishful
thinking!)
Tentative plan for the elimination of leprosy by 2000 AD : By providing rapid universal MDT
coverage in
endemic areas. Concern raised about
*will the general health services be able to maintain leprosy control in the face of competing
priorities of Family Planning and other diseases?
* do the general health staff possess the necessary competence , knowledge and skills and
above all the
commitment for leprosy control?
India 1996 (from WER, 2 May 1997)
New cases 44,2114
New cases classified as MB 82,251 (18.6%)
Skin smear positive 39,790 (9%)
New cases with bacterial index more than 3+
institutions or projects)
8842 (extrapolation from reports of specilized
WER 6 June 1997 (Progress towards leprosy elimination)
One of the major difficulties is to assess the proportion of the population covered by the
programme.Special Leprosy Elimination Monitoring programmes have been set up.
Performance of national elimination prog is assessed by
* re duct ion in performance
*MDT coverage
‘number of patients cured
Increasing attention is being paid to
‘geographical coverage
‘quality of MDT services |
‘timely detection of cases(
*prevention of impairment of disabilities
Prevalence in the world continued to show a declining trend. Number of countries showing PR
of >1/10,000 has been reduced from 122 in 1985 to 55 in 1997. But in some major endemic
countries (including India), there is a slowing down of a further reduction in prevalence.
Although it is too early to judge whethel or not this situation is sustainable, one can be
reasonable confident that leprosy as a public health problem has been eliminated from most of
these countires (Not at all sure how WHO can say this with such confidence)
* Distribution of estimated and registered prevalence by WHO region shows only a MODESI
reduction in the number of registered cases between 1996 and 1997.
‘The global PR is still 1.6/10,000
* In the 16 major endemic countries which represent 91% of the global leprosy problem, the
prevalence rate is 4.3/10,000
* It is possible that some of the countries might need to continue and intensify activities beyond
2000 to reach their targets
800,000 (5.7/10,000)
South East Asia (1996-97) Estimated number of cases
651,562 (4.72/10,000)
No.of registered cases (1996)
637,413 (4.5/10,000)
(1997)
-2
% change
The global detection in 1996 was approximately 566,000 (9.8/100,000). 95% of this was from
the 16 major endemic countries and 73% of the newly detected cases were living in India
alone. The detection rate for SE Asia was 32.36/100,000. Among the newly detected cases
16% were children below 15 years; 31% were MB; and 5.5% showed severe disabilities.
The WHO asserts that the increase in detection in endemic countries is due to increase in
case finding activity and increase in geographical coverageand states (without any hard core
evidence) '....it should be recognized that there is no direct relationship between detection
trends and intensity of transmission of the disease and therefore detection trends should be
interpreted with great caution(!)
WHO supplies MDT, the last two years, free of cost through a contribution from the Nippon
Foundation for >1.7 million patients living in 35 endemic countries
Top endemic countries have the following characteristics
* Prevalence rate of >1/10,000
* number of prevalent leprosy cases > 5000
* number of newly detected cases > 2000
* Ranking countries based on number of ESTIMATED cases
High prevalence in Brazil (6.56); Nepal (5.83); Myanmar (4.08); Mozambique (6.1);
Madagascar (4.3); and Guinea (5.0).
Indian situation in 1997 : PR is 5.86/10,000; Detection rate 44/100,000;cases on MDT 97%.
Operational challenges: to reach geographical areas and populations which have not yet
registered for MDT; to reduce delay in detecting and diagnosing the disease; and to continue
providing patients with good quality services including the supply of drugs free of cost.
WER No.24, 13 June 1997 (Global case-detection trend in leprosy)
The report states that ’although it was logical to consider monitoring of incidence as a more
appropriate and theoretically more relevant measure for evaluating progress towards leprosy
elimination, it was clear that this was not technically possible' because ’...unfortunately
dependable tools for measuring infection and for monitoring incidence trends in leprosy are still
not available. Assessing incidence requires special prospective studies which involve large
amount of resources and would have to be repeated using consistent procedures and several
years if trends are to be assessed.'
(Actually there is nothing 'logical' , it is merely epidemiologically sound!. This is an important
point for discussing at the ID cell meet)
The detection of leprosy globally has* remained unchanged over the last 10 years in.
quantitative and to some extent qualitative terms. Acording to the WHO, what is not clear is
the extent to which these changes can be attributed to the level of transmission, improved
case finding, expansion of health services, changes in case definitions, increased population
at risk or a combination of these factors. From 1985-96, MDT coverage increased to 97% of all
registered cass which is = to 75% of estimated cases. The average duration of treatment
decreased to between 2 to 4 years. Thus introduction of MDT was successful in clearing
backlog of cases and the new situation is that 'for the first time prevalence and detection are
converging'.
FACT is globally, and at a national level in many countries, detection has been increasing
'significantly' over the last 10 years to reach a plateau of about half a million NEW cases per
year.
The WHO asks itself 'how can this increase and persistence be explained?'
* Is the incidence of leprosy really (!) increasing in many countries?
* Is it the result of the impact of elimination strategy leading to improved coverage?
* Is it just the effect of an improved information system, or changes in case-finding methods?
* Is it an after-effect of the 'clearing of registers' forcing some programmes to bring back some
patients
from the cleared prevalence pool to the new detection pool? ( what does this
mean????)
* Was the leprosy problem so much under estimated that the backlog is much higher than
expected?
’In all probability, several of the factors mentioned above have contributed to the current
situation. However, it is difficult to estimate the proportionate contribution attributable to any
one of the above factors to the stagnation of case-detectin trends'.
Fact is between 1985-96, while a steep reduction in prevalence was observed (78%) in this
group of endemic countries, the trend in new cases detected has remained stable. Because
the weight of India in relation to global figures is so important that statistics have been
provided with and without India.
* The prevalence trend is steeply decreasing (70% while the detection trend is significantly
increasing
especially after 1991
* While the child specific detection rate was 8.0/100,000 population in 1985 and 8.9 in 1996,
the peak of 15 was reached during 1991.
* the proprtion of patients disabled at the time of diagnosis decreased from 9.7% to 5.4% but
excluding India, it has increased from 6.8 to 10.3%
* While the detction rate/100,000 of MB leprosy was 5.9 in 1985 and 7.1 in 1996 with a peak
of 10.2 in 1992, excluding India it has increased from 1.9 to 4.7
(I will now quote from the WHO document verbatim)
'At first glance, one might think that incidence of leprosy is reihaining the same or is even
increasing in some part of the world, despite the considerable reservoir. This is in
contradiction with information collected through some special itudies which show that the
incidence of leprosy is decreasing by about 10% a year. However, an increasing detection
trend with a decreasing incidence trend is compatible when a significant number of backlog
cases exist in the community. In one way, increasing detection trends providde reassurance
since they clearly demonstrate the effectiveness of the global elimination strategy in
identifying the backlog cases for treatment with MDT. This is likely to be the scenario in •
countries which still have a high endemicity for leprosy and where the programmes are
continually expanding their activities to previously uncovered areas, leading to improvement in
their case-finding activities. However, considering that leprosy distribution is very uneven
among countries and that different countries in the world started with different different levels
of prevalence and incidence, and considering the variations in the intensity of operations
among countries, it is useful to analyze the situation according to different country groupings
and regions in the world'.
Even after doing all that, WHO is not in any position to come to a conclusion about
transmission and incidence.
In India, although detection trend is declinig the current rate is still very high and the decline
not as fast as one could expect. This according to the Who, is because the last 40 years
efforts were mainly concentrated in AP;MS and TN and here the PR and DR have decreased.
The profile of cases newly detected in these states show a high proportion of single lesions,
low incidence of MB, low disability rate which indicates that the disease is being recognized
very early. On the other hand states like Bihar, MP and UP which are not considered highly
endemic are getting priority and here there is a backlog of cases, and that the combination of
these factors could explain the overall high rates and slw progress in India which is a matter of
concern, and that it would be unrealistic to expect major changes in the epidemiological trend
of the disease in the near future (straight from the WHO’s mouth!!!)
I will be presenting the relevant tables at the meet.
The controversial issues that become apparent reading these papers are
1. Use of PREVALENCE instead of INCIDENCE as a measure of global elimination
2. There seems to be evidence from the WHO's own data that the elimination strategy is in
fact producing
information contradictory to the claim that the disease is on the wane. WHO refuses to accept
that there could be an increase in transmission rate or incidence. We need to look at the data
more carefully
.
3. A concern about the possibility of increasing disability rate has been raised. This is
particulary important when and if the LEP gets integrated with general health services where
the health personnel may not be trained in leprosy
4. Issue of MDT and ROM that Dr BR Chatterjee raises in the two articles on leprosy in the
mfcb. The GOI has reduced the duration of treatment for MDT fro 24 doses (2 years) to 12 (1
year). This is based on scanty data (I think). We need to look at their 'double blind' clinical
trials.
5. What is the consequence of declaring a country leprosy eliminated if the trends are not so
clear. Is there a possibility of doing computer simulation exercises to look at trends 5, 10 years
frormnow?
6. Tjiere seems to be a disparity between recommendations and field level activity, t-or
instance, the case
definition for a MB case (What percentage are detected through bacteriological examinations.
India alone accounts for 73% of the newly detected cases in the world so whatever strategy is
being
implemented affects our country the most.
- Media
RF_DIS_8_A_SUDHA.pdf
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