TREATMENT, PHYSIOTHERAPY, RECONSTRUCTIVE SURGERY AND REHABILITATION IN LEPROSY

Item

Title
TREATMENT, PHYSIOTHERAPY, RECONSTRUCTIVE SURGERY AND REHABILITATION IN LEPROSY
extracted text
ISSN. 0586-117-9

JANUARY 1994

LEPROSY ERADICATION BY 2000 A.D

In this issue

swasth hind
Pausa-Magha
Saka 1915

January 1994
Vol. XXXVIII, No. 1

ELIMINATING LEPROSY

!

Page
Treatment, physiotherapy, reconstructive
surgery and rehabilitation in leprosy—an
overview
Dr N.S. Dharmshaktu

1

Leprosy—a few facts

8

Eliminating leprosy as a public health
problem—a unique opportunity in human
history

9

LEPROSY, a scourge as old as mankind, is
associated with social stigma. The estimated
prevalence of leprosy in the world was 12
million cases, of which four million was in India
(19,85). Indeed, leprosy can be eliminated as a
public health problem by the end of the century
provided that funds can be found to diagnose
and cure the patients over the next six years.
says the World Health Organization.

W.H.O.’s global
elimination

The Government of India had launched the
National Leprosy Eradication Programme in
1983 with the objective to eliminate leprosy as a
public health problem by the year 2000 A.D.

Mahatma Gandhi’s martyrdom day—30
January—is also observed as the Anti-Leprosy
Day in India to rededicate the governmental
efforts towards achieving the goal of leprosy
elimination by 2000 A.D.

strategy

leprosy

12

Problems due to misconceptions about
leprosy
Dr WH. Jopling

13

of leprosy in

14

Leprosy—past, present and future
Dr PA. Somaiya, Dr AC. Urmil and
Dr R.V. Awate

16

Role of non-governmental organisations in
leprosy eradication—a questionnaire study
S.S. Naik and Dr R. Ganapati

19

Strategy for elimination
India
Dr B.N. Mittal

Community
participation
Eradication Programme
S.K. Bhoi

for

in

Leprosy

22

Keeping this in view this issue of Swasth Hind
is devoted to:

The health of South-East Asia

26

ANTI-LEPROSY DAY—1994

Leprosy—a select bibliography
M. Sharada

28

SWASTH HIND WISHES ITS
READERS
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TREATMENT, PHYSIOTHERAPY,
RECONSTRUCTIVE SURGERY AND
REHABILITATION IN LEPROSY
—An overview
Dr N. S. Diiarmshaktu

The Government of India has accorded high priority to the National Leprosy Eradication
Programme. Multi-drug Therapy (MDT) services are being extended in a phased man­
ner in endemic areas taking district as a unit. Physiotherapy is an essential part of physi­
cal and surgical management of leprosy. The need for reconstructive surgery can be
reduced to a great extent by proper education of the community for early diagnosis and
proper treatment by stressing on treatment regularity and by education of patients as to
how to deal with anaesthetic hand and feet, says the author.
N 1981 about 12 million leprosy

Icases were estimated in the
world, out of which 4 million i.e.,

one thirds of the total world pro­
blem was estimated in India
alone. In 1991 the estimated case
load.in India has reduced to 2.5
million against which 1.4 million
leprosy cases are on record as on
March, 1993. 15 to 20% of leprosy
cases are in the age group of below
15 years, 6 to 12% of cases have
deformities, about 20% of cases are
infectious and the male, female
ratio is 2:1. The problem of lep­
rosy is aggravated by unjustified
social stigma and prejudices
attached to the disease and the
deformities occurring due to
negligence. The highest number
of leprosy cases is now in the State
of Bihar followed by Uttar Pradesh,
West Bengal, Madhya Pradesh,
Andhra and Orissa.
Government of India started
National Leprosy Control Pro­
gramme in 1955 with the objective
to control leprosy. Dapsone was

January 1994

the only treatment available till
recently and prolonged regular
treatment was required with Dap­
sone as a result of which many
patients could not lake the drug
regularly. This
resulted
into
appearance of many dapsone resis­
tant cases. Based on scientific
advancement in treatment of lep­
rosy and experiences with large
scale field research with Multi-drug
therapy (MDT), World Health
Organisation suggested MDT as a
main drug for treatment of Leprosy
in the year 1981. The Govern­
ment of India renamed National
Leprosy Control Programme as
National Leprosy Eradication Pro­
gramme (NLEP) in 1983 and gave
high priority by making it a 100%
Centrally Sponsored
Scheme.
The objective of NLEP is to
eliminate leprosy by the year
2000. It is estimated by WHO that
if the patient load is decreased to a
level of below 1 case for every 1000
population the disease transmis­
sion will be broken. The National
Leprosy Eradication Programme

has been included in 20 Point Pro­
gramme. The
infrastructure
available in districts with 5 or more
cases per 1000 includes District
Leprosy Unit, Leprosy Control
Unit in rural area (1 for each 4-5
lakh population), Urban Leprosy
Centre (1 for 50,000 population),
and a Temporary Hospitalisation
Ward. In low endemic areas also
such units and Survey, Education
Treatment (SET) Centres have been
created to cover endemic pockets
and support General Health
Care infrastructure.
At the National level an Apex
level institute, z.e., Central Leprosy
Teaching and Research Institute
has
been
established
at
Chengalpattu
in
Tamilnadu.
Three Regional Leprosy Research
& Training Institutes have also
been established namely at Aska
(District Ganjam) in Orissa,
Raipur in Madhya Pradesh and
Gouripur (Dist. Bankura) in
West Bengal. Thirteen Leprosy
Rehabilitation Promotion Units

have also been established in dif­
ferent regions of the country. A
total of 49 Leprosy Training Cen­
tres have been created under the
programme which include four
directly under DGHS, Ministry of
Health and Family Welfare, Govt.
of India; one under ICMR, 14
under Voluntary Organisations
and remaining under the various
State Governments.

The Government of India have
introduced multi-drug therapy
scheme in 135 endemic districts
upto the end of 1992 in a phased
manner since 1982 through full
time specially trained staff. MDT
was also started in remaining 66
endemic district on a modified pat­
tern from 1991, but now it has been
decided that all these 66 districts
will be covered on vertical pattern
from 1993 and 18 of these endemic
districts have already been covered
on vertical pattern in January
1993. 77 Districts having pre­
valence of leprosy between 2 to 4.9
per 1000 population will be covered
on modified pattern of MDT from
1994. The endemic pockets in all
the remaining low endemic dis­
tricts of the country (having pre­
valence less than 2) will also be
covered on Modified pattern of
MDT through 20 Zonal Offices.
Instructions have also, been given
to States (from 1993) to provide
MDT to the patients in all the low
endemic districts also through
general health care staff.
Objectives and Strategy

The Government of India has
accorded high priority to National
Leprosy Eradication Program­
me. The objective of the NLEP is
to arrest the disease activity in all
the known cases of leprosy by the
year 2000. The strategy of the pro­
gramme is

(i) to provide leprosy services
through separate infrastruc­
ture in the area where pro­
blem of leprosy is 5 or more
for every 1000 population.

EMBLEM FOR LEPROSY ERADICATION
PROGRAMME

NLEP emblem symbolises
beauty and purity in lotus;

(ii) to provide leprosy services
in areas with less case load
through existing general
health care infrastructure
and supportive leprosy
units(iii) Extend MDT services in a
phased manner taking dis­
trict as a unit.
Information
about
Multi-drug
Therapy
1. What is MDT
It is a combination of anti lep­
rosy drugs prescribed for treatment
of leprosy which results into com­
plete cure of the disease within
much shorter period than monotherapy.
2. Places where MDT is available
in India
(a) In 135 endemic districts hav­
ing case load of 5 or more per
1000 population; MDT is
available at every Leprosy
Control Unit and its field

Leprosy can be cured and
patient can be a useful mem­
ber of the society in the form
of a partially affected thumb, a
normal finger and the shape of
a house; the symbol of hope
and optimism in a rising sun.
The emblem captures the
script of hope and positive
action in eradication
of
leprosy.

clinics in rural areas and at
urban Leprosy Centres, tem­
porary hospitalisation wards
and other hospitals in
urban area.

(b)

In 66 endemic districts MDT
is available at all the health
centres such as hospital, com­
munity health centres, PHC,
Sub-centres. These 66 dis­
tricts are likely to be followed
on the pattern of 135 districts
mentioned above in near
future and in fact sanction
has been issued in January 93
to run MDT in 18 of these dis­
tricts on vertical pattern.

(c)

In all other districts MDT is
available for leprosy patients
in all hospitals, community
health centres and PHCs. In
certain areas where specific
leprosy units have been
created under the Govern­
ment sector or the voluntary
sector they also provide
MDT services.

SIGNS AND SYMPTOMS OF LEPROSY
One should suspect leprosy if any of the following signs are pre­
sent on the body:
(a) A discoloured patch on skin with partial or complete loss of
sensation to light touch and prick over the patch.
(b) Numbness in hand and feet (This is accompanied by thicke­
ning of peripheral nerves which can be confirmed by the
Health worker).

(c) Multiple, smooth ill defined red spots or patches on the face,
buttock, back or other parts with or without loss of
sensation.

Swasth Hind

3.

Do every patient having leprosy
need Multi Drug Therapy

All leprosy patients do not need
multi drug therapy. Many per­
sons having leprosy particularly
with least number of germs or no
germs in the body may have taken
Dapsone in past regularly. Such
patients may have already been
cured and will require no multi
drug therapy.

Patients with least germs or no
germ in the body arc curable with
Dapsone alone if taken regularly
for 3 to 5 years. If the treatment is
taken irregularly or stopped in bet­
ween such patients may sometime
develop resistance to Dapsone
showing no improvement in the
course of disease. Therefore,
Government of India has made a
provision of free multi drug therapy
for all previously untreated, incom­
pletely treated and Dapsonc resis­
tance patients (not responding to
Dapsone), even though the cost of
multi drug therapy is very high.
Hence if you are suffering from the
disease and you have taken Dap­
sone monotherapy earlier, consult
the doctor to confirm* whether or
not the person need a course of
Multi drug Therapy.
4.

The required duration of multi
drug therapy

The patients are broadly divided
into two categories—

(a) Those patients with multiple
germs in their body (MB
type): Such patients require
a minimum of 2 years multi
drug therapy regularly.

(b) Those patients with mini­
mum or no germs in their
body (PB type). Such pati­
ents require multi drug
therapy regularly for a mini­
mum period of 6 months.

January 1994

HOW CAN ONE HELP NATIONAL LEPROSY
ERADICATION PROGRAMME
Any common citizen including the patient and his family mem­
bers can be very useful to leprosy programme by helping in follow­
ing ways:
(a) Cooperate with the health workers in his programme
activities.

(b) Educate yourself about facts of leprosy and help in educating
your family and community.

(c) Accept leprosy patients in the family and in the community
like a patient of any other disease and help them to lead a
happy life.
(d) Help in dispelling the stigma and prejudices against leprosy
patients in the society.

(e) Leprosy should not come in the way of an individual for
marriage, employment and education of children in the
school.
(f) Teach people that deformity which has already developed in
a leprosy cured person is not a disease. It is just like post
scars on the face of a person who had suffered from small­
pox many years ago.
(g) One should know about activities of Government and volun­
tary organisations and motivate persons having early signs of
the disease for early treatment.

Most of the patients get cured
within the above duration if they
are treated with multi drug
therapy. Only a few patients who
do not get completely cure*'1 within
the above duration with MDT may
require extended period of treat­
ment as advised by the Doctor.
5. Omissions upto what period is
permissible for taking multi drug
therapy
(a) The patients with multiple
germs in the body (MB type)
must complete their 24 months
course of multi drug therapy
within 36 months.

(b) The patients with minimum or
no germs in their body (PB
type) must complete the
course of their 6 months multi
drug therapy within a period of
9 months.
One must however, try to avoid
omissions in taking multi drug
therapy as much as possible.

6. How important is skin smear test
for multi drug therapy

It is useful to cooperate with the
Doctor/Health worker when the
same is desired by them and it is
sometime very helpful for deciding
the classification and type of treat­
ment required. However, it is not
always necessary for the Doctors/
Health workers to have this test
done for starting treatment for
every type of patient.
7. Is WHO/GOJ recommended
multi drug therapy (MDT) as the
best combination available for
treatment of leprosy today?
Yes, it is the best combination
available today, as proved by its
success achieved in large number
of cases
in various coun­
tries. These drugs are given in
tablet and capsule form and not in
form of injection.

Deformity—its Prevention and Care

About 7 to 12% leprosy patients
have deformity. Since 80% of
Indian population live in rural
areas, the study based on deformity
in rural areas may be helpful to
understand the extent of deformity
in leprosy. One such study con­
ducted in rural agricultural com­
munity by S. Kartikeyan (1991) in
the Latur district of Maharashtra
showed that 12% of leprosy patients
have deformity of Grade II
above. This report is based on
study of 1338 male/female patients.
The deformity was found highest
i.e., 24.4% in patients of age group
50 years and above. In the middle
age group 30 to 49 years 11.04%
patients had deformity and in the
younger age group between 15 to 19
years 4.61% patients had defor­
mity. The
deformity
mainly
affects hand, foot and eyes.

How can disability be prevented in
Leprosy'
Disability including loss of sen­
sation and paralysis in foot, hand
and other parts of the body can be
prevented in leprosy by:
(a) Reporting early for diag­
nosis.
(b) Starting proper treatment
early before the nerves are
damaged.
(c) Completing treatment regu­
larly for prescribed period.
(d) Prompt recognition of signs
of reaction, its primary
management and reporting
to the health centres early.
(e) Keeping
knowledge
of
danger signal of leprosy
reaction involving nerves
and eyes.

Learning exercises of Hand, Feet
and Eyes: All patients/cured per­
sons^ with weak or paralysis mus­
cles of hand, feet and unable to
blink (close eyes) normally should
learn some specified exercises. If
they have any difficulty to unders­
tand to do these exercises they
should consult the leprosy staff
during monthly collection of the
drug or whenever leprosy staff/

4

Drag Deliver)' point in a Village in an Endemic District under Multi-Drug Therapy

general health care staff visit the
village.
Role of Physiotherapy
Physiotherapy is an essential
part of physical and surgical
management of leprosy cases. It
helps in preserving the physical
functions of the affected muscles
and in preventing muscle atrophy.
It also helps in improvement of
nerve conduction in case of impair­
ment in nerve conduction. There­
fore, during the period of paralysis,
muscle activity should be main­
tained. If patient has already
developed muscles paralysis still
they should report to the proper
health centre early for physio­
therapy. Physiotherapy involves
assessment of nerve and muscles
function,
passive
movement,
massage, wax bath, ultra sound
diathermy, electrical stimulation
and splinting. Physiotherapy ser­
vices are available at most of lep­
rosy control units, THWs, Centres
where MCR chap pal are available,
with major Voluntary Organisa­
tions and at CLTRI, RLTRIs, CJIL
& many of its Leprosy Control
Units.
Role of Reconstructive surgery in
Correction of Leprosy Deformity
The need for reconstructive sur­
gery can be reduced to a great

extent by proper education of the
community for early diagnosis and
proper treatment by stressing on
treatment regularity and by educa­
tion of patient how to deal with
anaesthetic hand and feet. Ade­
quate time is given for a definite
trial of medical treatment and
physiotherapy before considering a
patient for surgery. The most
paralysed muscles regain function
if proper management of reaction
is done. For successful re­
constructive surgery pre and post
operative cooperation of patient is
essential. Thus surgery should
only be done if the patient is not
responding to medical treatment
and physiotherapy, the condition is
operable and if the patient is will­
ing to cooperate. Use of Clo­
fazimine in leprosy with its double
action on management of reaction
and treatment of disease has
reduced the need for surgery.
Aids and Appliances helpful to
Leprosy Patients/Cured Persons
with Disability and Deformity
(a) Footwear:
(i) MCR Chappal (for anaes­
thetic foot)
(ii) Below knee orthosis for
drop foot
(iii) Moulded shoe for ulcer
patient and deformed foot.

Swasth Hind

(b) Simple walking aid:
(i) Cane Ifof patient with
( ulcer and anaes(ii) Cruches i thetic fool
(c) Prosthesis (Artificial limb):
(i) Below knee prosthesis
(artificial leg such as Jaipur
foot, Madras foot, ALIMCO SACK foot for patient
with below knee amputa­
tion). This is a common
prosthesis
in
leprosy
patients with amputation.

(ii) Above knee prosthesis
(artificial limb)—It is not
generally required for lep­
rosy patients as above knee
amputation is extremely
rare in leprosy.
(iii) Cosmetic
thesis

finger

pros­

(d) Grip aids—It is used for assist­
ing in activities of daily living
such as eating, combing, hold­
ing utencils, etc.
(e) Splints:

(i) Cock-up splint (for wrist
drop)

(ii) Drop foot splint (for drop
foot patients)
(iii) Other functional splints
(for fingers and thumb).

(f) Eyes:

(i) Protective glass for dry eyes
and logophthalmos (In­
ability of blinking or clos­
ing of eyes).

Rehabilitation
Maximum benefit of disability
reduction in India has been due to
expansion of MDT Programme but
MDT alone is not sufficient for
actual control of human suffering
due to leprosy. 15 to 20% of people
who have or had disease have dis­
ability and are taken as risk group

January 1994

Leprosy Patient attending an Urban Leprosy Centre Covering about SO,000
Endemic Population

for developing injury, wounds,
ulcer and deformity. Early detec­
tion of such disability, proper
education of the patient, care of
ulcer and wounds, early manage­
ment of reaction, provision of
MCR chappal and other footwear
emphasising on self care and pro­
per rehabilitation are important to
provide relief. Though many
voluntary organisations are provid­
ing such need based care and
rehabilitation services to the lep­
rosy disabled and handicapped
persons but it is not sufficient in
view of magnitude of the pro­
blem. Some of the voluntary
organisations are providing ex­
cellent services for such human
sufferings.

Beside expansion of treatment
with MDT. other measures of
social, informative and administra­
tive character should also be given
importance. In areas where an
effective control has been set up no
new case of deformity should
occur.
The Ministry of Welfare
scheme
for
employment/self
employment of leprosy affected
cured persons gives an operable

definition of leprosy handicapped
as ‘Leprosy handicapped persons
are those who are cured/non infec­
tious and have physical and socio­
economical handicap’. The re­
habilitation benefits reaching to
leprosy handicapped is very less in
comparison
to
rehabilitation
benefits provided to other cate­
gories under various schemes/
provisions of Ministry of Welfare
and Labour which may be due to
following reasons :

(a) Unawareness of leprosy cur­
ed persons about schemes of
rehabilitation.
deformity
care and the places where it
is available.
(b) Unawareness of staff at
employment exchanges to
register leprosy cured per­
sons in the handicapped
category.

(c) Criteria of 40% or above dis­
ability to level the persons
orthopaedically handicapp­
ed.

(d) Disinclination of employers
to accept leprosy cured per­
sons fit for job in comparison
to other handicapped.

(e) Inadequate awareness of lep­
rosy staff, general health care
staff about location of cen­
tres for registeration for
employment
of
han­
dicapped, about the nearest
centre/voluntary organisa­
tion providing deformity care
and rehabilitation services.

ROLE OF DIET
Some people in remote rural areas still believe that diet has an
important role in causing leprosy and in its treatment. It would be

worthwhile to clarify the same. Some people still have the wrong
feeling that leprosy is caused by eating specific type of fish or dry fish

or smoked fish. Combination of hot and cold food (meat/fish/egg
with butter milk/curd) is avoided thinking that it will worsen the

The Government of India has
now universally adopted WHO
recommended MDT regiment and
14 days intensive therapy has not
been found to have any additional
advantage due to which intensive
therapy is now not recommen­
ded. Earlier even with 14 days
intensive MDT therapy its side
effects had been insignificant It
can therefore, be said that provid­
ing daily self treatment at home
and only once monthly supervised
pulse treatment at clinic is almost
risk free so far side effect is con­
cern. Economically also cost of
PB case treatment which con­
stitutes 80% of the cases has
reduced about three times with
modem MDT (cost of-MDT for PB
is Rs. 51 per patient and with mon­
otherapy Rs. 164) in comparison to
monotherapy. Whereas the cost
of MDT and monotherapy are
almost the same for MB cases, but
MDT has many definite advan­
tages including definite cure rate,
reduced duration of treatment
etc. In view of the above the verti­
cal staff in endemic district should
now concentrate more in giving
training of self care to each leprosy
patient and cured person with dis­
ability ranging from first aid, things

6

disease.

The diet has no scientific role to play in causation and treatment
of leprosy. No food is considered hot or cold. Thus, there should
not be any fear that any particular food may cause the disease. Nor­
mal diet should be consumed during the course of the disease and

there is no need to avoid any particular food unless suggested by the
Doctor for some other reason.

they should rightly have at home
for self care, early detection of reac­
tion and relapse, exercises of

encouragement,
increase
in
knowledge and skills about self
care

and

on

information

anaesthetic feet, hand and eyes,

avilability of services, the other

physiotherapy, awareness about
the places/centres where MCR

category of patients/curcd persons

chappal and other protective shoes
are available. The availability of
various schemcs/previsions, facili­
ties offered to the handicapped per­

with established recent disability/
deformity need care as well as
additional proper advice for
physiotherapy, exercise, surgery
etc. who may also require

a

sons by Ministry of Welfare/La-

definite link with some referral

bour and various other Govern­
ment Departments and NGOs

institutes in nearby area which
should be well known both to the

should be informed to the han­

patients

and

dicapped persons indicating the

workers.

Wherever such link is

nearest place where they can con­

lacking there is need to establish

sult in case of need.

them either under Government or
under Voluntary organisations.

to

the

health

While the category of cured per­

sons with disability (loss of sensa­

The third category of cured lep­

tion of hand/feet and involvement

rosy persons with major deformity

of eyes) can benefit from self

who are totally disabled with

Swasth Hind

having absorption of toes and

fingers of hand and feet, blindness,

How Deformity Increases Injury

etc., are by and large the old people
who have no one to look after or

those who are thrown from the

community

family.

and

The

under

existing

mercy

various

voluntary organisations

homes

should continue to take care as it

may be very difficult to provide

Normally while walking the weight of the body is spread up to
two thirds o'f the entire sole of foot at any time. If a patient has loss
of sensation as well as deformity of the foot (claw toes or dropped
foot), the weight of his body may be concentrated over a smaller
area. This will result in formation of spots of increased pressure
on his soles and wounds are likely to develop at those spots.

A.

proper care to such persons under
government institutions and at the

same time such person may not be
able to go back to his home and
take self care. The services offered
by voluntary organisations are

generally much more acceptable in
comparison to government insti­
tutions for the above category 2nd
and 3rd type of patients/cured per­

sons, due to dedication of the

staff. Existance of such debeli-

tated persons on the roads, near
religious places in the form of
beggars indirectly increases stigma

towards leprosy.

In Normal
Foot Print:
(Right Foot)

B. In Foot Print of
Dropped Foot:
(Right Foot)
C.

In Foot Print of
Claw Toes:
(Right Foot)
High pressure area

Normal people also sometimes get bums, cuts, abrasions on
their foot due to the negligence or by accident Because of the pain
they immediately take treatment and rest as far as possible. But
people with loss of sensation on foot when get such injuries they
continue to walk because they do not feel pain. If a misfit shoe is
used or if the shoe has pointing nail touching the sole it also causes
the injuries. Such injuries are prone to catch infection early.

Start by listening
Spreading the word about what people should do to be healthy is important. But this is not enough. We
have to understand that, in many situations, it is not only the individual who needs to change. There are
other things that influence the way people behave: the place in which they live, the people around them, the
work they do, whether they are able to earn enough money—all these things have a great influence, and we
must take them into consideration. Our first effort must be therefore to listen, to learn, and to
understand.
—Education for health : a manual on health educa­
tion in primary health care. Geneva, World Health
Organization, 1988, p. 1.
A

January 1994

7

LEPROSY—A FEW FACTS
Leprosy is a communicable disease caused by a
germ known as Mycobacterium leprae. The dis­
ease mainly affects skin, nerves and mucous
membrane.

The disabilities caused by leprosy are mainly
damaged limbs and eyes, and this affects not*
only the functioning of the parts but also causes
loss of sensation. Disfigurement and dis­
abilities due to the disease lead to serious psy­
chological, economic and social problems for
patients and their families.
The most important source of infection is by the
respiratory tract from an untreated case of
leprosy.

Not all persons infected with the leprosy germ
develop the disease. Resistance or immune
mechanisms in most people are able to.prevent
the occurrence of physical manifestations of the
disease.

Leprosy affects all ages and both sexes.
If the disease is not treated with the appropriate
combination of drugs, the disease worsens caus­
ing progressive and permanent damage to skin,
limbs and eyes.
Control of the disease, based until the early
1980s on treating patients with Dapsone, became
quite ineffective mainly because of the
emergence of drug resistance to the use of the
single drug.

The excellent opportunities available for
eliminating leprosy as a public health problem
must be seized now, so that future generations
can live in a “Leprosy-free” world.
The most important development in leprosy
control in recent years has been the use of a
combination of anti-leprosy drugs known as
multi-drug therapy (MDT), as recommended by
WHO. Since the introduction of MDT in the
early 1980s, the global burden of leprosy has
been reduced by more than 60%.
Over the past 10 years, more than 4 million lep­
rosy patients have been cured by MDT and
about 1 million patients are expected to be
cured every year.

8

The treatment with MDT is remarkably effec­
tive, of reasonable cost and acceptable to all
leprosy patients.

For the less serious forms of leprosy known as
paucibacillary leprosy (PB), the treatment con­
sists of administering a combination ot.Rtfampicin monthly and Dapsone daily for only six
months. For the more serious form known as
multibacillary leprosy (MB), the treatment con­
sists of administering a combination of Rifam­
picin and Clofazimine monthly and a
combination of Clofazimine and Dapsone daily
for two years.
Currently there are an estimated 3.1 million lep­
rosy patients in the world, of whom 2.3 million
are registered for treatment. These patients are
largely spread over 87 countries in Asia, Africa
and Latin America where about 6,00,000 new
cases are detected annually. Approximately
2400 million people live in areas considered
endemic for the disease.
WHO estimates that there are 2-3 million for­
mer leprosy patients needing care for dis­
abilities as a result of leprosy.

The introduction of MDT has led to
revolutionary changes in leprosy control with
some countries demonstrating an up-to-ten-fold
decrease in disease prevalence within five
years.
The optimism that developed as a result of
MDT led the WHO to aim at eliminating lep­
rosy as a public health problem .by the year
2000.

WHO plays a worldwide role in promoting
MDT, coordinating resources and monitoring
the leprosy situation closely, in addition to
building national capabilities to carry out lep­
rosy elimination programmes. WHO has also
been investing in research to develop still more
effective drug combinations for treatment.
In its efforts towards eliminating leprosy, WHO
works in close collaboration with international
non governmental organizations such as the
Member Associations of the International
Federation of Anti-Leprosy Associations
(ILEP), and agencies such as the Sasakawa
Health Foundation and the World Bank.
—W.H.O.

Swasth Hind

Feature

Eliminating Leprosy as a
Public Health Problem
—A unique opportunity in human history
The elimination of leprosy is technically feasible, financially acceptable and
viable. And the problems raised by it are of an operational nature. The international
community, W.H.O; and the various NGOs have clearly expressed their intention to
banish this scourge which has afflicted humanity for too long.
i have never come so close to
seeing leprosy defeated.
This ancient disease that still
afflicts millions of people physi­
cally and socially can now be van­
quished. In 1991, the Member
States of WHO declared their
intention to eliminate leprosy as a
public health problem in view of
the very encouraging results of 10
years of intensive use of an effective
course of treatment based on a
combination of medicaments,
known as multidrug therapy. That
same year, a Working Group on
Leprosy outlined the strategy for
elimination of the disease. In
1991 and 1992, the most affected
countries and WHO Regional
Offices discussed the practicalities
of this strategy and prepared
national and regional plans. In
July 1993, the Leprosy Working
Group and the main Non-govemmental Organizations (NGOs), met
to assess the progress that had been
made, adopt a global strategy and
bring the requisite resources into
play.

W

January 1994
2—14 DGHS/ND/93

But how can this be brought
about? Is it really possible to con­
quer a disease that has afflicted
humanity since time immemorial?
It is no simple matter, since leprosy
is an insidious, slowly-deve­
loping disease whose transmission
path is not well known and which
flourishes mainly in the ‘poverty
belt’ of the globe. It once affected
every continent and it has etched a
terrifying image in history and
human memory, of mutilation,
rejection and exclusion from
society. Leprosy has always and
everywhere been regarded as a spe­
cial disease. In our day, though
we know that leprosy is caused by a
bacterium—indeed, it was the first
bacterium identified in the history
of medicine—it still inspires fear,
even in countries where it no longer
exists. Mycobacterium leprae, the
bacillus responsible for leprosy, is a
strange and archaic germ. It pro­
liferates slowly, is transmitted by
mechanisms that are not fully
understood, and it cannot be
cultured in laboratories. It enters

the body discreetly, provoking no
violent symptom that would betray
its presence. It multiplies insi­
diously for years, infiltrating skin
and nerves before causing irrevers­
ible damage by destroying nerves,
leading to paralysis and mutila­
tion. This bacillus, which is very
well adapted to man, probably its
only reservoir, does not need to
infect many people in order to sur­
vive, and makes do with a small
proportion of the population; in
fact, some infected individuals har­
bour enormous quantities of
bacilli, up to 1000 billion, which is
quite sufficient to ensure transmis­
sion and therefore survival of
Mycobacterium leprae. How, then,
can this enemy, which is usually
hidden, be destroyed?

“Multi-drug” pressure
What seemed impossible 10
years ago became a reality with the
appearance and wide distribution
of a simple and relatively inexpen­
sive course of treatment; it is well
tolerated and accepted by patients

and it is highly effective. It
rapidly cures patients, interrupts
transmission of the disease and
therefore makes its elimination a
possibility. And yet, for this to be
achieved, the vast majority of exist­
ing patients must be diagnosed and
treated, and new cases appearing
must be given immediate treat­
ment Furthermore, since the dis­
ease has a relatively long in­
cubation period, this strategy must
be followed up for a number of
years; we have to keep up a
“multidrug pressure” on the reser­
voir of bacilli, if we are to have a
chance of destroying it

It is because of this opportunity
that leprosy must be given high
priority in a world that faces many
problems. All the work and
resources put in will bear fruit in
the short term. Over and above
the satisfaction of seeing leprosy
disappear, communities will no
longer need to look after people
who are handicapped, often for
life. The cost of the leprosy
elimination programme will quic­
kly be offset by the number of han­
dicaps forestalled, and by the
saving of many people from moral
and social harm.

The situation today and how multi­
drug therapy (MDT) is used in
endemic countries
Ten years after the development
of MDT regimens, the results seem
good. To take a few figures: 10
years ago, the estimated number of
cases was 12 million, less than a
third of whom received dapsone
treatment, which often continued
throughout life. Today more than
4 million patients have been cured
by MTD, the estimated number of
cases requiring treatment is 3.1
million, and more than a third of
them are undergoing multidrug
therapy. In other words, use of
MDT has reduced leprosy by 75%
in 10 years.. The treatment is so
effective, that even when applied by
health services with little in the way
of infrastructure and resources,
very few patients relapse or fail to
respond to treatment In addition,

10

it is practically certain that if it is
used properly, the treatment will
not create resistant strains of bac­
teria such as we find in other dis­
eases. Progress has indeed been
considerable, but the road is still
long and we must redouble our
efforts. Each year, more than
600 000 new cases are diagnosed.
Eighty-seven countries are regar­
ded as endemic, and 25 of them are
badly affected. In all those coun­
tries MTD has been employed; the
problem now is to provide and,
above all, maintain nearly 100%
treatment coverage. Sadly, it is
estimated that 2-3 million people
have been seriously handicapped
by leprosy, and the only way to pre­
vent this unacceptably high figure
from further rising is by providing
timely treatment for leprosy
patients.
WHO’s objective: less than 1 case
per 10,000 population
“Leprosy cannot be eliminated
unless we increase multidrug
therapy coverage to a level exceed­
ing 85%, and keep it there for 4-5
years”, says Dr Noordeen, Chief of
the Leprosy Unit at WHO;
“coverage at present stands at
around 50%, which is too low to
break transmission. We must*
redouble our efforts, especially
since the hardest part is ahead. It
will be increasingly difficult, and
expensive, to reach the patients
who have hot had treatment, since
we can assume that the most
accessible regions and most com­
pliant patients have been covered
first by health programmes”.
In numerical terms, the picture is
clear: health services throughout
the world will have to diagnose and
treat between 6 and 7 million cases
of leprosy by the year 2000. It is
estimated that the additional
resources required to do this will be
of the order of US $ 420 million, US
$ 140 million of which will be spent
on the drugs alone. The WHO
global strategy is based on five
elements: the formulation of
national, regional and global
action plans for elimination; the

mobilization of resources for inten­
sive application of MTD in priority
countries; epidemiological sur­
veillance and evaluation of results;
basic and operational research;
and strengthening of national
capacity for leprosy control.

The strategy is put into practice
by the Working Group on Lep­
rosy. It is convened each year by
the Director-General to analyse the
situation and decide on action to be
taken for the coming year. The
countries and regional offices that
have to deal with the highest
endemic levels have prepared
detailed plans. National, regional
and interregional meetings have
been organized to discuss the
measures to be taken. The
governments concerned, the bila­
teral and multilateral cooperation
agencies, the main NGOs and
WHO have been keeping in touch
to ensure that all the necessary
resources are available. At the
same time, action has been taken to
improve epidemiological monitor­
ing of the disease and to assess the
impact the programmes are
having. Regular evaluations have
been organized in the worst affec­
ted countries. A programme for
decentralized training of personnel
through a global network of
facilitators exists, and a special
group has been set up to promote
and initiate operational research in
zones or countries which are
encountering
special
pro­
blems. Naturally, basic research
wijl continue with the short-term
aim of developing alternative treat­
ment regimens that are even more
effective and easy to use. To this
end, WHO is coordinating trials in
many centres throughout the world
involving about 5000 patients and
over
200
researchers. Im­
munological research has been
conducted in order to devise
methods for protecting the popula­
tion at risk. National and inter­
national NGOs are taking special
care of handicapped patients and
increasing community awareness
towards the disease.

Swasth Hind

How to eliminate leprosy and at what
cost
Let us consider the situation
more closely. The South-East
Asian Region of WHO is the worst
affected. India, Indonesia and
Myanmar account for 70% of all the
cases in the world. Half of the suf­
ferers benefit from MTD, and the
control programmes already opera­
ting arc all aiming at increasing
MDT coverage. In that Region,
the .elimination process is deter­
mined by the large number of
patients to be treated. The govern­
ments of those countries have
made elimination of leprosy a
priority and have mobilized the
requisite resources. The World
Bank and various NGOs have
given the programmes forthright
approval and support. In spite of
considerable difficulties, the results
are encouraging.

In Africa, the second most affec­
ted area, the situation is more dif­
ficult for the moment. The AIDS
epidemic, the resurgence of the
major tropical diseases, weak­
nesses in health infrastructure,
social unrest and armed conflict
make leprosy elimination seem like
a luxury, an impracticable one at
that. Yet there is every reason to
be optimistic about the leprosy
situation. The disease was severely
curtailed by control campaigns
based on dapsone from the 1960s to
the 1980s, and it is on the retreat in
all countries. Fortunately, there is
no sign that the AIDS epidemic has
an impact on incidence of leprosy,
as is happening with tuber­
culosis. Furthermore, after a slow
start, most of the countries in the
continent are vigorously applying
MTD, with constant support from
the NGOs. In this way, the
African continent has progressed
from less than 10% coverage five
years ago to over 45% this year, in
addition, here more than else­

where, leprosy control is integrated
in the various health sys­
tems. Overall, it seems that lep­
rosy elimination is progressing in
most African countries. Never­
theless, in Nigeria and Zaire the
situation is not so good, and those
countries account for 25% of the
population, and a third of the cases
in Africa. Similarly, most of the
Sahelian countries have trouble in
giving patients access to treat­
ment. In order to resolve such
problems, which could com­
promise elimination, the countries
concerned are joining forces to tac­
kle these particular constraints.
The situation remains worrying
in Latin America. Brazil and
Colombia are particularly badly
affected, and they account for over
80% of cases in that con­
tinent. Brazil is reporting increas­
ing numbers of patients,- though it
is not yet clear whether this is
because transmission of the disease
is on the increase, because the sys­
tem for reporting and treating cases
has improved, or because of a com­
bination of the two. MTD is not
extensively used. However, in
1991, the Government adopted an
emergency plan to introduce inten­
sive MTD to the entire coun­
try. However, given the immen­
sity of the task, results will not be
visible for a number of years. The
situation in Brazil explains why the
MDT coverage in the American
continent is still low, about 30%.
Less is known about the situation
in the Eastern Mediterranean
Region. Reporting is difficult in
that region, where, in general terms,
leprosy has an especially negative
image. It is known that the dis­
ease is highly endemic in Egypt,
Iran, Pakistan and Sudan, and a
special effort is being made to
achieve a better evaluation of the
situation in those countries. Ac­
cording to available information, it
would seem that MTD is regularly

increasing and covers almost half
of the reported cases.

In the 'Europe and Western
Pacific Regions, leprosy has been
reduced to such an extent that it no
longer constitutes a public health
problem at regional level. Yet the
situation is not so simple, and cer­
tain countries, or certain regions in
a given country, are still endemic
foci. In Central and Eastern
Europe, there are sporadic cases; it
is impossible at present to tell how
many such cases go unrepor­
ted. In the Western Pacific
Region, the fact that leprosy is no
longer a public health problem in
most countries is very encoura­
ging. Highly endemic countries,
such as China and Thailand, have
reduced the problem to a negligible
level with MTD. However, the
disease still causes considerable
problems in the Philippines, in
some islands or archipelagoes, and
in Viet Nam. The situation in
countries such as Cambodia and
Laos is unclear.
In spile of many obstacles, the
idea of eliminating leprosy has
made headway and has taken
definite shape in many countries,
in the space of only two years.
The most tangible results, over and
above the expression of political
will, have been considerable im­
provement of control programmes
in the most affected countries;
improvement of epidemiological
surveillance, arid a systematic
approach to solution of the pro­
blems. The problems raised by.
the elimination of leprosy—jvhich
is technically feasible, financially
acceptable and viable—are of an
operational nature. The inter­
national community, WHO and
the various NGOs have clearly
expressed their intention to banish
this scourge which has afflicted
humanity for too long.—WHO

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11

WHO’s GLOBAL STRATEGY
FOR LEPROSY ELIMINATION
eprosy, a

scourge as old as
mankind, can be eliminated as
a public health problem by the end
of the century, says the World
Health Organization (WHO), pro­
vided that funds can be found to
diagnose and cure some 6 million
patients over the next 6 years. “US
$ 420 million, including US $ 140
million for drugs, are required to
meet that target”, explained WHO’s
Dr Shaik K. Noordeen, Chief, Lep­
rosy Unit, at a meeting in Geneva
of the WHO Working Group on
Leprosy Control. “The required
technologies and strategies for lep­
rosy control exist and so now, it
appears, does the political will to
tackle the issue. We now have an
opportunity to solve a major public
health problem. It cannot be
missed.”

L

Leprosy is known for its poten­
tial to cause permanent and pro­
gressive physical disability. Visi­
ble evidence of the disease often
leads to intense social stigma and
discrimination against patients.

Since multidrug therapy (MDT),
a combination of three drugs for
severe cases and two drugs for
milder cases was introduced by the
WHO 10 years ago, leprosy has
been reduced by more than 60%.

Until the introduction of the
drug Dapsone in the 1950s, leprosy
control consisted mainly of isolat­
ing patients. The introduction of
Dapsone enabled patients to be
treated within the community and
when this was combined with case­
detection and health education, a
degree of success was possible.
But within 25 years, the disease
became resistant to the drug and so
treatment became increasingly
ineffective. This period of failure
and frustration changed dramati­
cally with the introduction of
greatly
improved
treatment
through the application of com­
binations of drugs, known as mul­
tidrug therapy (MDT), the standard
regimens of which were first recom­
mended by a WHO Study Group in
1981.

Leprosy, however, still occurs in
significant numbers in over 87
countries and territories of Asia,
Africa and Latin America. Es­
timates for 1993 indicate a global
total of 3.1 million cases, of which
approximately 23 million are
undergoing
treatment. Some
6,Q0,000 new cases are being detec­
ted annually. India alone accounts
for 64% of all registered cases.
Five countries—Brazil,
India,
Indonesia, Myanmar and Nigeria
together account for 81%.

The WHO recommendation on
MDT is recognized today as a
major technological improvement
in leprosy control and, in the
absence of an effective vaccine, it
remains the anchor for controlling
the disease. Experience in several
countries has demonstrated con­
vincingly that in well-organized
leprosy control programmes it is
possible to reduce the number of
registered patients up to tenfold
within a period of five years. As
MDT has proved to be highly effec­

12

tive and acceptable, there is every
hope that, through early diagnosis
and effective treatment, transmis­
sion of the disease can be stop­
ped. WHO defines elimination as
a “reduction of the prevalence of
leprosy to a level below one case
per 10,000 population”.

The progress is also significative
as regard the cost of the treat­
ment Although MDT involves
drugs which are relatively expen­
sive, the treatment periods are
much shorter compared with the
days when Dapsone was used, in
some cases, for a lifetime. The
average cost of MDT is now about
US S 15 per leprosy patient
WHO’s Working Group on Lep­
rosy Control was established in
1991 to advise on various issues:
increasing the participation of
leprosy-endemic countries in dis­
ease control efforts; increasing sup­
port and coordination between
various leprosy agencies; improv­
ing strategies for dealing with the
changing needs of disease control;
accelerating the elimination of the
disease as a public health problem;
and evaluating general scientific
developments in leprosy and their
future application to disease
control.

The Working Group normally
consists of 8—10 members from
endemic countries and major non­
governmental
organizations
(NGOs). In addition, major donor
agencies such as the Sasakawa
Foundation and NGOs such as the
(Contd. on Page 18)

Swasth Hind

Problems due to misconceptions
about leprosy
DR W. H. JOPLING
qpHERE are many misconceptions

1 held by patients, doctors and
the general public. Two common
ones are : (a) that the disease is
highly transmissible, i.e. that it is
easily transmitted from person to
person, and (b) that it is incurable
and therefore inevitably dis­
figuring. Let us consider each
in turn.

(a) The disease is not highly
transmissible as over 95% of adults
in the world are immune. On the
other hand it is highly infectious,
and this means that in Leprosy
there is a difference between infec­
tivity and pathogenicity. The ex­
planation is that lepromatous
sufferers, all of whom are highly
infectious if untreated, cause subclinical infection in contacts
(which can be proven by immuno­
logical tests), but less than 5% of
those with subclinical infection
develop signs of disease. Further­
more, lepromatous patients con­
stitute only about 20% of Leprosy
sufferers worldwide. They arc
infectious by virtue of the millions
of Leprosy bacilli which lodge in
the upper respiratory tract (nose,
mouth, throat, larynx and trachea);
many of these are expelled into the
surrounding air, especially by
sneezing or coughing. These
bacilli are within droplets, and one
speaks of droplet infection (as in
TB). The nonlcpromatous types
of Leprosy are not infec­
tious. During my work in London
I made a study of 20 married
couples for over 10 years, and
although one partner had the infec­
tious form of Leprosy and had
ample opportunity to infect the
healthy partner during the months
or years before diagnosis, in only
one case did a healthy partner
develop the disease. This pair

January 1994
3—14 DGHS/ND/93

were born and bred in Calcutta,
and the wife’s disease was dia­
gnosed soon after arrival in Eng­
land. One year later the husband
developed a borderline lesion on
one arm. This means that he was
infected in Calcutta as the incuba­
tion period is between 2 and 7 years
(usually 3-5 years), and my inves­
tigation gave a transmission rate of
1 in 20, or 5%, assuming that he was
infected by his wife.
(b) The misconception that the
disease is incurable can readily be
dismissed, for multidmg therapy
(MDT) carries a high cure rate.
Another interesting point about
MDT is that’it renders the patient
non-infcctious by the end of one
week’s treatment.
Some
Encounters with
Mis­
conceptions
1. In 1950, when the RedhillReigate district learned the purpose
of the alterations being made to
their Victorian isolation hospital, a
protect group was formed. It took
several public meetings .and the
strong support of the local Medical
Officer of Health, Dr. Tom Bin­
gham, who was held in high regard
by the community, to cany through
the project.
2. At the end of that year I
moved into the doctor’s house with
my family, and although two of my
children obtained places in a local
school, three years passed before
any local children were allowed by
their parents to visit the doctor’s
house.
3. Public misconceptions were
also demonstrated in two events
involving my patients. The first
involved a Maltese male who com­
pleted treatment at Jordan and
obtained a post in the office of an
insurance company in Reigate,
only to be summarily dismissed
when the manager heard about his

medical history. An even. more
outrageous event affected an
Anglo-Indian lady patients who
was told by her husband that their
two children had been expelled
from their London school when the
headmistress heard that their
mother was a patient at Jor­
dan. Happily, both these unjust
acts, prompted by misconceptions,
were resolved by diplomacy.

4. Misconceptions by patients
can be harmful in many ways, with
suicide as the ultimate disas­
ter. An Indian businessman was
admitted to Jordan from a distant
hospital late one afternoon. That
same night he committed suicide,
leaving a note stating that he could
not face the future.

5. Many doctors have not been
taught about Leprosy as under­
graduates and can be excused for
having misconceptions. On the
occasion at Jordan of an official
visit by the Redhill-Rcigatc branch
of the British Medical Association,
and the visitors had seated them­
selves in the concert hall, I gave, a
short talk on the disease in which I
explained that skin lesions were
mimicked by a number of skin dis­
eases, but being able to find a thic­
kened nerve was the diagnostic
clue. I invited members of the
audience to come up to the stage to
get a closer look at skin lesions and
to palpate nerves, but nobody res­
ponded to my invitation!

Hopes for the Future

Eradication of the disease must
be the objective, and success will
depend on victory in a battle on
four fronts—the first is earlier
diagnosis; the second is wider
implementation of MDT: the third
is the production of an effective
vaccine; and the fourth is the aboli­
tion of Third World poverty.
—Courtesy : Kusht Vinashak

Jan-Feb. 1993.

13

STRATEGY FOR ELIMINATION
OF LEPROSY IN INDIA
Dr B. N. Mittal
The objective of the National Leprosy Eradication Programme is to eliminate leprosy as a
public health problem by the year 2000. A multi-pronged strategy has been adopted for
controlling this disease through reduction in quantum of infection by continuous treatment
to break the transmission and thereby reduce prevalence/incidence of the disease.
a chronic disease
associated with social stigma.
The estimated prevalence of lep­
rosy in the world was 12 million
cases, of which 4 million was in
India (1985). Health for All is an
objective accepted by World Health
Assembly in 1979 following the his­
toric Alma Ata declaration in
1978. The World Health Organi­
sation in 1991 adopted a resolution
calling for elimination of leprosy as
a public health problem by the year
2000 AD (reducing prevalence to
less than one case per 10,000
population).
eprosy is

L

The Government of India laun­
ched the National Leprosy Eradi­
cation Programme in the year 1983
with the objective to eliminate lep­
rosy as a public health problem by
the year 2000 AD. A multi-prong­
ed strategy has been adopted for
controlling this disease through
reduction in quantum of infection
by continuous treatment to break
the transmission and thereby re­
duce prevalence/incidence of the
disease.
Strategy of NLEP as a whole

The main components of the

14

National strategy for elimination of
leprosy are—

(c) rapid survey to enumerate
undetected cases;

(a) early detection and regular
treatment of patients;

(d) screening of all cases to
delete cured, left, died cases
and regroup others as MB &
PB and preparation of indi­
vidual case cards.

(b) providing multi-drug the­
rapy (MDT) to all the pat­
ients at fixed points in or a
nearby village;
(c) education of the patients,
their families and com­
munity to remove disinfor­
mation, social stigma and
ensure early reporting and
accept regular, complete
treatment.
Strategy for endemic district with
complete vertical set-up
The districts with prevalence of
five and more cases per 1000 are
brought under regular MDT in a
phased manner with a separate
cadre of health workers specially
trained in leprosy to provide ser­
vices. MDT was started in 1982 in
two districts following the comple-*
tion of the preparatory phase
comprising:
(a) position of infrastructure in
the district;
(b) adequate training of staff in
MDT operations;

MDT was gradually extended by
1991 to 135’districts, where the dis­
ease prevalence-was 5+/1000 pop­
ulation. Presently, these districts
are at various stages of MDT
implementation and provide MDT
coverage to 55% of all recorded
cases.
Strategy for endemic districts with
inadequate infrastructure

Besides these 135 districts where
regular MDT is operated, the
remaining 66 endemic districts not
having adequate infrastruture, were
taken up for MDT with modified
approdbh.
The modified MDT approach
differed from the vertical pro­
gramme essentially in the following
respects:
(a) the district leprosy units
function under the overall
charge of the district medi­
cal officer;

Swasth Hind

(b) the leprosy services were
delivered through the Pri­
mary Health care staff sup­
plemented by leprosy wor­
kers to the extent available in
the district;
(c) the medical officer of the
PHC would be overall incharge of MDT operations in
the area;
(d) the treatment points were to
coincide with the PHC, the
subsidiary health centre, the
subcentre, the dispensaries
and the hospitals; and
(e) cash assistance was envis­
aged to leprosy patients for
collecting drug from the
treatment points with further
cash incentives to those com­
pleting treatment in time and
for reporting of new cases.
This is to compensate non­
availability of active case­
detection and active case
promotion for treatment
It was contemplated that this
approach would not only extend
the overall cover of MDT benefit
but would also gear the primary
health care services towards pro­
viding intensive leprosy care, thus
promoting the integration of the
two in the long run.

Strategy for districts which have
completed seven or more years
of MDT

Ten out of 135 districts under
MDT have completed MDT inter­
vention for seven years. These
districts are being adopted for par­
tial integrated services approach.
For this purpose the following
models are being tried:
(a) at the field level the strength
of para-medical workers is
being reduced by 50% and
redistributing
the
area
among the remaining wor­
kers and services of medical
officers and non-medical
supervisors at controlling
unit level arc being diverted
to othej programmes and the
workers are being put under
primary health centres. At

January 1994

Expected outcome of the future strategy
(In ’000)

Year

No. of cases New Cases
in the begin­
ning of the
year

1993
1994
1995
1996
1997
1998
1999
2000

1167
990
760
530
310
150
100
40

+523
+370
+320
+280
+240
+220
+ 150
+120

the district level, district lep­
rosy unit is being retained.
Multi-purpose
workers
would help in identifying
suspected cases while health
assistants
and
medical
officers would help in con­
firming the diagnosis and
other programme activities.
(b) infrastructure created under
leprosy is being retained.
However, simple duties in
tuberculosis are being given
to them in addition to NLEP.
Both the above models are being
tried in some of the districts to iden­
tify the best alternate strategy for
future.

Strategy for future

With the introduction of MDT
there is a definite increase in the
number of cases released from treat­
ment. Against three million recor­
ded cases in 1985 there are only 1.16
million cases on record at the end of
March, 1993. The leprosy situa­
tion in the country has recently been
analysed with reference to its objec­
tives. On the basis of this analysis
following strategy has been worked
out to achieve the goal to eliminate
leprosy by 2000 AD:
(a) to bring 66 MMDT districts
under regular vertical MDT
for five years by providing
extra manpower by hiring
services for five years;

Discharge cases

No. ofcases
at end of
On MDT On Mono­ the year
therapy or
other reason

—500
—450
—450
—450
—380
—250
—200
—150

—200
—150
—100
—50
—20
—20
—10
—10

990
760
530
310
150
100
40
00

(b) introducing modified MDT
in 77 moderately endemic
districts with prevalenc * rate
between 2 and 5/1000;
(c) introducing MDT in the
endemic pockets of the re­
maining low endemic dis­
tricts establishing Zonal set­
up to cover pockets in con­
tiguous 5-6 districts;

(d) establishment of an informa­
tion, education & com­
munication cell at the
National Headquarter for
proper coordination, plan­
ning and guidance on acti­
vities related to community
awareness;
(e) organisation of short training
courses for health personnel
within the district through
expert teams;
(f) cleaning of registers in the dis. tricts with inadequate staff.
This will help in speedy im­
plementation of MDT in the
districts;

(g) providing ulcer care and dis­
ability management services;
(h) adequate provision of foot­
ware for the patients with loss
of sensation of foot and those
having foot ulcers;
(i) community based rehabilita­
tion of leprosy cured persons
would be attempted in few
selected districts to develop a
suitable model.

15

LEPROSY
—past, present and future
Dr p. a. Somaiya

Dr A. C. Urmil

and

Dr R.v. Awate

The success of the National Leprosy Eradication Programme entirely depends on
regular operational and epidemiological assessments. Such assessments need to be
carried out both at the State and National level and feedback be promptly provided to
the reporting units for implementing the remedial measures without delay.
eprosy is probably the oldest

L

disease afflicting the mankind
about which references are found
in our ancient scriptures/vedie
writings where it is mentioned as
“Kusht Rog”. Certain misconcep­
tions about the disease continued
to persist for centuries till recent
times and were mainly responsible
for the social stigma attached with
the disease. These misconcep­
tions included the belief that—(1)
the disease is highly infectious; one
can acquire the infection through
mere closeness or contact with a
patient, (2) the disease is hereditary
and can be passed on from one
generation to another and (3) the
disease is due to divine curse—a
punishment for the past sins.
With increasing knowledge about
the epidemiology of the disease
during the past century or so, these
misconceptions have been mostly
rooted out, barring in a few
orthodox communities in the
developing nations which still
remain backward socio-culturally.

The major advancements in the
field of leprosy include—(1) iden­
tification of its etiological agent, the
mycobacterium leprae or ? ^pra
bacillus by Hansen of Norway dur­

16

ing 1873 (The disease is therefore
also known as Hansen’s disease),
(2) Introduction of sulphone drugs
in 1943, e.g. Dapsone for its treat­
ment, (3) Discovery of suitable
“animal models” for culture of
Myco. leprae for research purposes,
e.g., foot pads of mice, armadillo,
nude mice, hamster, and hed­
gehog, (4) Introduction of Multi
Drug Therapy (MDT) during 1981
which has been found more effec­
tive, of shorter duration and with
less risk of development of drug
resistance among Myco. leprae. All
these advancements have been the
main contributory factors leading
to the current concept of leprosy
eradication by 2000 AD.

Global Scenario
Leprosy is world wide in its dis­
tribution although the major con­
centration of the cases is found in
countries of South East Asia, Africa
and Western Pacific (92.6% cases).
According to one estimate, there
were 10-12 million leprosy cases in
the world during 1986, out of which
the number of registered cases in
various WHO regions was around
5.3 million only. It is feared that
in general, the number of leprosy
cases are on increase probably due

to an increase in population and
life expectancy and voluntary
reporting due to better awareness
although a progressive decline in
incidence is noticeable in Northern
Europe, Japan, Hawaii, USA and
Venezuela due to socio-economic
development leading to reduction
in some “risk factors”.
Indian Scenario

Leprosy continues to be a major
public health and social problem
in India with an estimated 4
million (one third of total leprosy
cases in the world) cases. A total
of 196 districts, out of 445, in the
country, were found having a pre­
valence rate of 5 per 1000 popula­
tion or more. No district has been
found totally free from leprosy
cases. States
of
Tamilnadu,
Andhra Pradesh, Orissa, West
Bengal and Union Territories of
Pondicherry and Lakshadweep
contributed 60% cases. As per
official records, at the end of
October 1990, there were 2.5.million
registered cases, including 0.47
million new cases detected during
1989-90.

Out of estimated 4 million lep­
rosy cases, 20% are likely to be

SWASTH HIND

infectious, 15-20% cases with defor­
mities and 15% cases among
children afflicting nearly 1,60,000
children. About two to three lakh
new cases are detected every year
and about two lakh cases either get
discharged as cured or die.

Action Taken at National Level

The availability of dapsone mo­
notherapy prompted the Govern­
ment of India to launch the
National Leprosy Control Pro­
gramme (NLCP) in 1955 but since
it led subsequently to the emer­
gence of drug resistant strains of
Myco. leprae and their persistence,
the switch over was made to Multi
Drug Therapy (MDT) involving 3
drugs namely Rifampicin, Clofa­
zimine and dapsone instead of
Da^sone along. The efficacy of
MDT led the Government of India
to redesignate the programme as
the National Leprosy Eradication
Programme (NLEP) during 1983.
MDT has been introduced in a
phased manner under NLEP to
cover all endemic districts. The
necessity of introduction of MDT
in a phased manner became essen­
tial because of lack of adequate
infrastructure, trained manpower
for detection of at least 80% of
estimated cases besides establish­
ment of a District Leprosy Society
considered essential for achieving
the aim of eradication. MDT is
however also being given to those
patients under dapsone mono­
therapy for 5 years or more but
without any clinical/bacteriological improvement.

The infrastructure provided for
implementation of the programme
included—758 Leprosy Control
Units (1 for every 4.5 Lakh rural
population), 900 Urban Leprosy
Centres (1 for every 50,000 urban
population), 6097 Survey Educa­
tion and Treatment Centres (1 for
25,000 rural population under
PHC), 291 Temporary Hospital

January 1994

Wards, 285 District Leprosy Units,
75 Reconstructive Surgery Units, 49
Leprosy Training Centres, 39 Sam­
ple Survey with Assessment Units
and 13 Leprosy Rehabilitation Pro­
motion Units—by the end of
March 1992.

Various Intemational/national
voluntary organizations (VOs) are
providing support/assistance in
various forms. At present, about
285 VOs are actively engaged in
leprosy relief services. Information
received from 88 VOs during 1990
shows that they were poviding Sur­
vey, Education and Treatment
(SET) services to a population of
nearly 60 million spread in areas
with a prevalence rate of 1 to 32/
1000 population in different parts
of our country with 8.20 lakh cases
on their record and 7.61 million
under treatment Some important
VOs working in this field are1—
Swedish International Develop­
ment Agency (SIDA), UNICEF,
Leprosy
Mission,
DANIDA,
LEPRA, American Leprosy Mis­
sions, Hind Kusht Nivaran Sangh,
Gandhi Memorial Leprosy Foun­
dation, Amici Di Lebrosi (Italy),
Damien Foundation, Sasakawa
Memorial Health Foundation,
Danish Save the child Fund,
JALMA (taken over by ICMR in
1975) and German Leprosy Relief
Association, Vidarbha Maharogi
Seva Mandal etc.

Overall Impact of NLEP/Areas of
Concern

An independent evaluation of
the programme, jointly carried out
by the Government of India and
WHO first time in 1986 showed that
programme activities were very
satisfactory at aggregate level. The
third evaluation carried out during
1989 brought out one more en­
couraging finding that almost 99%
patients in rural areas are now
accepted in their families. As
against targets set during 1989-90

for case detection, bringing them
under treatment and discharge
after cure, the achievements were
123%, 120% and 104% respectively.
In Tamilnadu ahd Andhra Pradesh
the prevalence has already dropped
from nearly 12/1000 population to
2/1000 population. However, there
remain some areas of special con­
cern, too. For example the scope of
existing case detection technology
is not adequate to detect a large
number of subclinical cases, that is
why leprosy is described as an
“Iceberg** disease. Non-detection
of these cases is a major obstacle in
the eradication of this disease at
present
Prolonged incubation
period (usually 2 to 5 years, may be
up to 40 years or more), trouble free
signs, e.g. anaesthetic patches, lack
of physical discomfort during early
part of the disease, fear of social
ostracism are other reasons, for
delay in reporting on the part of the
patient Besides these, there are
still many gaps in our knowledge
on epidemiological aspects of lep­
rosy. The role of insect vectors in
its transmission still remains a mat­
ter of suspicion. We also do not
know whether there are. significant
extra-human reservoir of in­
fection.

Further
Action
National Level

Required

at

The success of NLEP entirely
depends upon two important
activities Le. operational assess­
ment and epidemiological assess­
ment which need to be carried out
regularly. Operational assessment
means (a) efficiency of case detec­
tion against estimated cases (b)
proportion of cases brought under
treatment (c) proportion of cases
under treatment who receive full
course of drugs and (d) clinical and
bacteriological surveillance of
cases after cure to detect relapses.
Epidemiological
assessment
means regular monitoring of pre­
valence and incidence rates. These

17

assessments should be carried out
both at the state and National level
and feedback promptly provided to
the reporting units for implement­
ing the remedial measures without
delay. Leprosy has already been
included in our 20 point pro­
gramme and therefore calls for a
concerted and consistent alround
effort to arouse public awareness
against the disease and to health
educate patients, their families and
communities concerned on its
various aspects with emphasis on
the need of its early cure. Re­
habilitation of cured patients needs
to be promoted through govemmental/voluntaiy efforts to make
them economically self-reliant and
socially acceptable. The ongoing

research in various fields connec­
ted with the disease, particularly in
developing an effective immuniz­
ing agent against it, needs to be
boosted up.
Besides, greater
involvement of mass media to
arouse public awareness, lessons
on the subject should be included

in school text books (Maharashtra
and Karnataka have already done

it) and more refresher/orientation
courses should be arranged for
various categories, e.g., doctors,
para-medicals, school teachers and
other community leaders etc.
Various VOs/social workers doing
commendable work in this field
should be honoured through
national awards and provided with
financial aid. At present, 100%
Central assistance in terms of
budget is being provided to States/
UTs which should continue.
Similary, although 2000 AD has
been earmarked as the target date
for leprosy eradication, in view of
its long incubation period cases
may continue to occur in small
number even beyond that date
hence the provision for prompt
detection and treatment must con­
tinue. Lastly, we should not lose
the hope regarding its eradication/
cure and remember what an emi­
nent worker in this field, had to say
about this disease—

“Greater effort has to be made in
making people aware that leprosy
is not a contagious disease and lep­
rosy patient should not be isolated.
Half a century ago, the fear of lep­
rosy was similar to fear of AIDS
that people have today but with the
advances in medical science, lep­
rosy is fully curable”.
— Dr. Data Edward
Lawrence (recipient
of Gandhi Memo­
rial
Leprosy
Award 1991)
References
1.

Kurup, A.M. (1992). All About Leprosy;

Social Welfare, Dec 91- Jan 92, Central

Social Welfare Board, Samaj Kalyan
Bhavan, New Delhi-16, pp. 20-23.
2.

J. E. Park, K_ Park (1991). Leprosy, Park’s
Text

Book

Medicine,

of Preventive
13th

&

Soda!

edn, publisher M/s.

Banarsidas Bhanot, Jabalpur, pp. 215-

225.
3.

CHEB (1991). Swasth Hind, Vol. XXXV,

No. 1, Jan 91 (Issue mainly devoted to
Leprosy).
A

W.H.O’s GLOBAL STRATEGY—(Contd. from Page 12)

International Federation of Anti­
Leprosy Associations, the Inter­
national Leprosy Association and
the International Leprosy Union
are represented.
The purpose of the present meet­
ing is to review the leprosy situation
and the achievements made
towards elimination of the disease
through the global strategy and

18

take action to implement the
strategy efficiently.

“Eliminating leprosy as a public
health problem before the year
2000 is no longer a dream”, says Dr
Noordeen. “We have the know­
how, the determination and the
necessary network to achieve
this. The strategy developed for
this purpose calls for increased
focus on the highly endemic areas

of the world for case detection and
MDT coverage. It also implies
better coordination with the
various agencies involved in lep­
rosy work and improved participa­
tion of the community. The in­
creased resources needed will be
used to buy drugs, but also for
training, health education and
organization of services for deliver­
ing MDT to people affected by
leprosy.”—W.H.O.

Swasth Hind

ROLE OF NON-GOVERNMENTAL
ORGANISATIONS IN LEPROSY ERADICATION
—A Questionnaire Study
S. S.NAIK and Dr r. Ganapati
A questionnaire study on the Role of Non-governmental Organisations in leprosy eradica­
tion was conducted by the authors. Out of the 62 organisations who responded, 53 were
from South India and only 10 from North India. South India being endemic for leprosy, the
international agencies have concentrated their efforts in this part of the country. The num­
ber of active patients on the list of NGOs is 76,582 and have a facility of 3,876
hospital beds.
EPROSY work

in India has a
rich tradition of involving
non-governmental organisations
(NGOs), dating back to a period
when the government did not have
any specific strategy at the mass
level for leprosy eradication.
Mr Wellesly Cosby Baily, a Scottish
school teacher, after seeing the
pathetic conditions of leprosy
patients in Ambala (now in
Haryana State) is reported to have
collected donations from his
friends
and
established
an
organisation in 1874 (after the
Norwegian scientist Armauer Han­
sen discovered M. leprae), now
known as “The Leprosy Mission”.
This institution during the past 10
years has contributed significant
services to leprosy patients and at
present runs 188 leprosy centres
and is in collaboration with 34
countries in the world.

L

Later,
another

on 31 January 1924
organisation
called

January 1994

“British Leprosy Relief Associa­
tion” (BELRA) was established in
London with a view to study the
leprosy problem on a scientific
basis and institute anti-leprosy
work. They approached kings in
different states of India arid are
reported to have collected Rs. 21
lakhs for leprosy work in the coun­
try.
The main centre of this
organisation was situated at the
“School of Tropical Medicine” in
Calcutta. BELRA is credited with
the first survey of leprosy in India,
prompted by an attempt to judge
the quantum of leprosy work
needed and to lay down the foun­
dation of leprosy work in the coun­
try.
After independence, the
organisation was renamed as
“Hind Kusht Nivaran Sangh”
(HKNS) in 1947.
In 1951, Gandhi Memorial Lep­
rosy Foundation (GMLF) funded
by Gandhi Memorial Trust was

established in Sevagram. GMLF
initiated Survey, Education and
Treatment (SET) in leprosy. This
pattern was taken up by the govern­
ment for “National Leprosy Con­
trol Programme” in 1955. Several
NGOs, national and international
are at present supporting this pro­
gramme now rechristened as the
“National Leprosy Eradication
Programme” (NLEP). The NGOs
in general share about 10% of lep­
rosy work in the country. Strong
components in most of their ser­
vices are hospitalisation and re­
habilitation.

Questionnaire Study

Taking
advantage
of
the
National Conference of Voluntary
Organisations engaged in NLEP
which was held in Bombay in Sep­
tember 1991, a questionnaire was
sent to various organisations, with
the permission of health depart­
ment of the Government of India

19

with the object of obtaining the
following updated information
about their activities : (1) the year
of establishment, (2) number of
staff, (3) source of finance, (4)
major activities, (5) significant
achievements and (6) difficulties if
any in running the programme.
One special question was aimed at
knowing attempts if any at integra­
tion of their leprosy work with
general health services.
Eighty-two organisations % res­
ponded to the questionnaire, of
which 6 were from major funding
agencies. Sixty-two organisations
were working in field areas as a part
of NLEP and 14 were involved in
research, training or rehabilitation
in leprosy and these were not
engaged in routine field work.
Some of the institutions did not fill
up all the columns of the question­
naire. In these cases an attempt
was made to analyse whatever
information was available to reach
some gross conclusions.

Out of 62 respondent or­
ganisations, 53 are from South
India and 10 are working in North.
The establishment year of these
organisations are as follows: 5
before 1950, 9 in 1951-60, 12 in
1961-70, 21 in 1971-80, 15 in 198190. The majority of the voluntary
organisations,/, e., 84% are in South
India and are supported financially
by well-known international agen­
cies, and as such they do not have
any difficulty to run the pro­
gramme.
South India being
endemic for leprosy it is understan­
dable that international agencies
naturally concentrated their efforts

20

in this part of the country with the
consent of the Government of
India. Many organisations i. e., 21
(33%) sprang up in 1970-80 and
some more, i. e., 15 (24%) in 1980-90
due to initiation by international
agencies and these now seem to run
a programme to the standard
level.
It is clear that northern part of
the country is deprived of the con­
tribution by voluntary agencies.
Ten organisations working in
North India receive financial sup­
port from government and due to
irregular and inadequate grant-inaid their activities are considerably
restricted and hampered in their
opinion.

The information obtained from
the institutions regarding their staff
(total 2881) is as follows:—359
medical persons (12%), 1170
paramedical persons (41%) and
1352 others (47%). The ratio of
medical personnel to others is 1 :7
which appears quite adequate.

The financial support, received
by these organisations through
voluntary contribution is Rs. 731.4
lakhs, Rs. 70.6 lakhs (9%) from
national, Rs. 660.8 lakhs (91%) from
international agencies.
The
Government supplies the major
bulk of leprosy drugs alongwith
grant-in-aid of Rs. 114.3 lakhs.
Activities
Most of the organisations
followed NLEP pattern of work
and restricted their activities to sur­
vey, education and treatment A

few carry out services like tuber­
culosis work, child welfare, re­
search and training.
Leprosy
services are offered by way of field
work on NLEP pattern (38 rural, 24
urban). Number of active patients
on list are 76,582 and facilities of
3,876 hospital beds are existing.
MDT Programme
Most of the organisations initi­
ated MDT programmes 6 years
before and the major achievements
of their programme mentioned by
them are (1) reduction in pre­
valence rate in their operational
area and (2) reduction in deformity
rate in newly detected cases. The
load of leprosy cases is reduced and
thus the quantum of work against
existing staff is very low. To keep
the staff engaged, a few institutions
already have initiated community
based rehabilitation, prevention of
dehabilitation of leprosy patients
by deformity care programme etc.
Two organisations extended their
NLEP work in nearby taluks.
Sample surveys carried out in
some areas under multidrug
therapy revealed that though the
prevalence rate of leprosy has been
reduced to less than 2 per 1000, new
smear positive cases still get detec­
ted. So the programme can now
concentrate more on the detection
of new smear positive cases, ret­
rieval of drop out smear positive
cases and clinical examination of
old arrested smear positive cases
under dapsone monotherapy for
evidence of relapses.

Swasth Hind

Integration with General Health
Services
Leprosy eradication programme
in another decade will be adopting
the policy of integration with
general health services, though very
few i. e., 16 (25%) institutions have
thought of integration or make
attempts in this direction. The true
sense of integration of involving
other service programmes in lep­
rosy which does not consist in mak­
ing just sporadic or patchy attempts
is not fully understood by these
organisations.
However, a few
institutions have already succeeded
in getting co-operation from non­
leprosy agencies for training, medi­
cal treatment including surgery, job
placement etc. to help leprosy

patients and such organisations
may offer guidelines for future
work.
1. It seems that in northern part of
the country, there is a need to
enhance anti-leprosy activities
through active participation of
voluntary organisations during
the next decade.

2. Strategy for integration of lep­
rosy services into general health
service programmes, has to be
defined properly for future
guidance of voluntary or­
ganisations in leprosy.
3. In. view of the decrease of
general work-load in the NLEP,
SET type of work by NGOs

assumes
less
importance.
Emphasis has to be given more
on field based disability preven­
tion and correction of deformity
of leprosy patients.
4. NGOs may assist NLEP in
ensuring regularity of drug
intake of smear positive cases
along with a drive for proper
clinical examination of old
arrested smear positive cases
who were under monotherapy
with dapsone.
5. Such of those NGOs capable of
undertaking
field-oriented
research and training, may need
more encouragement till the
goal of eradication of leprosy is
reached.

Dr UTON M. RAFEI NOMINATED W.H.O. REGIONAL DIRECTOR
FOR SOUTH-EAST ASIA
Dr Uton Muchtar Rafei (Indonesia), was nominated as the Regional Director of the WHO South-East Asia
Region by the Regional Committee on 21 Sept 1993 in New Delhi. Dr Uton will succeed Dr U Ko Ko,
Regional Director since 1981, on 1 March 1994 after the nomination is confirmed by the WHO Executive
Board in January 1994.
Dr Uton, who has been Director, Health System Infrastructure since 1988 in WHO’s Regional Office for
South-East Asia, joined WHO in 1981 as Regional Adviser in Primary Health Care. In December 1984 he was
appointed Director, Health Protection and Promotion. Dr Uton obtained his M. D. in 1963 from the pres­
tigious Airlangga University, Indonesia and commenced his career in public health holding positions of
increasing responsibility over the years.
An M. P. H. from Tulane University, U. S. A., Dr Uton obtained a Diploma in Project Planning and Systems
Analysis for Developing Countries from Bradford University, U. K.

A recipient of several awards for his outstanding performance in various academic and professional pursuits,
Dr Uton is a member of several professional and social welfare associations and has published extensively in
leading technical journals.
A

January 1994

21

COMMUNITY PARTICIPATION IN
LEPROSY ERADICATION PROGRAMME
S.K. BHOI
Community participation assumes a very specific meaning in the control of leprosy. In­
volvement of people will certainly differ from group to group in dealing with the pro­
blem. The author in this article discusses the role of some specific groups in leprosy
eradication like doctors, teachers, leaders, government officers, nurses, etc.
is a major public
health problem in the coun­
try. It is a multifaceted problem
and it needs multi-pronged attack.
If this problem has to be solved, co­
operation of everyone in the society
is needed and it can no more be left
with a selected band of leprosy
workers. Indifference
towards
this disease by the people in
general and the intelligentia in par­
ticular has damaged the pro­
gramme to a considerable extent
It is high time to give proper atten­
tion to this drawback.

L

eprosy

Community participation assu­
mes a very specific meaning in the
control of leprosy. Based largely
on health education and mass
awareness, its goal must be, as Prof.
George M. Foster of the Depart­
ment of Anthropology, University
of California, put it “to win the
sympathy and tolerance for
patients, and to lead a correct
understanding of the nature of lep­
rosy itself, particularly that it is a
relatively limited threat to the vast
majority of community members.”
The real objective of community
participation is to make the com­
munity conscious about a specific
problem so that the community
will find out its own ways to solve
it By ‘Community Participation

22

in Leprosy Eradication Pro­
gramme’, we generally mean a few
things, viz—
(a) accepting leprosy as a disease
like any other common dis­
ease and nothing else,
(b) accepting the person cured of
leprosy in the family and the
society as a normal person,
(c) removing the wrong notions
of the people about leprosy by
giving correct information as
regard to its cause, spread,
curability, infectivity, defor­
mity, etc,
(d) persuading
the
known
patients of leprosy for taking
regular treatment as advised
by the doctors,
(e) giving guidance to the suspi­
cious cases of leprosy to the
proper places for diagnosis
and treatment,
(f) solving the problems, if any,
of the patients or any mem­
bers) of the patients families
or relatives and,
(g) helping the leprosy workers in
early case detection, treat­
ment and other activities.

It is not that each and everyone
in the community will co-operate
or participate in the same way and

to the same level. The people,
according to their own profession,
may think of participating in dif­
ferent aspects of leprosy eradica­
tion work. Such involvement of
the people will certainly differ from
group to group in dealing with the
problem. A few suggestions for
some specific groups are given
here.

1. Doctor: A general medical
practitioner may play a very vital
role in NLEP. Common people
are usually not aware of the early
signs of leprosy. They may not
even have any suspicion for it.
But a practising doctor can detect
early signs of leprosy and treat the
patients. He may, however, co­
operate in the following ways:
(a) suspect and detect early lep­
rosy cases, if any, from
among the general patients
while examining them in
his dispensary,

(b) treat at least the early leprosy
patients,
(c) eradicate fear and remove
misunderstandings
about
leprosy from the minds of
the people through casual
talks,
SWASTH HIND

(d) giving guidance to the per­
sons coming to him with
queries,
(e) keep literature on leprosy
(journals, pamphlets etc.) in
the waiting room along with
other journals.
By following these steps a doctor
can help in two ways (i) he can
bring hundreds of cases under
treatment and (ii) his co-operation
would be of great help to all those
leprosy patients detected at an early
stage who are hesitant in attending
leprosy clinics for fear of there
being recognised by the people
as such.

(2) Teacher: Teachers are moul­
ders of young minds who in their
tender form can be made to accept
new knowledge without inhibi­
tions. Therefore if the teachers
are acquainted with the basic scien­
tific facts about leprosy, they may
transmit the same to their students
and thus they can bring about a
healthy change in the attitude of
the young generation towards lep­
rosy and its sufferers. A few
points are given here suggest how a
teacher can participate in NLEP.
(a) teach or discuss the basic
facts about leprosy to the stu­
dents and fellow teachers,

(b) prevent
discrimination
against a student or a member
of the staffjust because he has
leprosy,
(c) help the leprosy workers in
the school-survey,

(d) publish small articles on lep­
rosy in the school magazine.
(3) Leader: A
leader
(not
necessarily a political leader) may

participate in NLEP in the follow­
ing ways:
(a) give active help and co­
operation in house to house
survey for early case-detec­
tion, establishing treatment
centres, organising health
education activities and other
programmes in his area.
(b) persuade the patients known
to him to take regular treat­
ment,
(c) prevent social harassment to
the leprosy patients,
(d) help the patients and mem­
bers) of the patients’ families
or relatives in solving the pro­
blems, if any,
(e) prevent dehabilitation of the
leprosy patients and help in
rehabilitation.
(4) Heads of Institutions: Their
participation in the NLEP may be
of the following nature:
(a) retain a leprosy patient in his
job and give additional help
or facilities to him, if
necessary,
(b) help in job placement or
rehabilitation,
(c) provide resources and help in
organising programmes.
(5) Government Officer: He may
(a) mould public opinion,
(b) help in establishing different
centres as and when neces­
sary, and (c) help in organis­
ing programmes and in
rehabilitation.
(6) Nurses:
(a) they can accept leprosy like
any .other disease and extend
the same nursing and medical

care to leprosy patients as she
does for others,
(b) encourage the leprosy pati­
ents to take regular and ade­
quate treatment,
(c) boost the morale of the
patients known to her,
(d) remove the misunderstan­
dings of the people about lep­
rosy during her normal visits
to the community,
(e) help in examining the female
population as and when
possible.
(7) What all of us can do :
(a) impart basic facts about lep­
rosy to our family members,
relatives and neighbours,
(b) make people conscious about
early signs of leprosy so much
so that people seek medical
opinion on slightest sus­
picion,
•(c) provide information to the
people about the available
facilities of diagnosis and
treatment of leprosy, give
necessary co-operation to the
leprosy workers during their
house-to-house visits for case­
detection and in other work
pertaining to eradication of
leprosy.
(d) accept the persons cured of
leprosy in the society as nor­
mal persons.
One can participate in many
other ways. Let us join our hands
and move on in the right direction
with open mind to eradicate
lepiosy.
“Coming together is a beginning,
Joining together is progress,
Working together is success.”

DIET LINK WITH MENTAL HEALTH
Women who eat more fruit and vegetables enjoy better mental health, research at the University
College of Swansea in Wales has revealed. Reporting his findings to the British Psychological Society, Dr.
David Benton, Reader in Psychology at the university, says a random postal survey showed that women who
ate large amounts of fruit and vegetables were less likely to be anxious or depressed. The doctor says this
may indicate that an increased intake of vitamins and minerals is linked with better mental health. Alter­
natively, it could be a case of women with higher self-esteem being more likely to eat fruit and vegetables in an
attempt to slim.

But whatever the reason, Dr. Benton could find no evidence that there is a similar link between diet
and mental health in men. —Medical News from Britain

January 1994

23

WOMEN IN INDIA’S DEVELOPMENT
—An Exhibition
N exhibition was organised at
.Teen Murti Bhavan by the
Ministry of Human Resource
Development on the theme ‘Role of
Women in Development of India’
from 14th to 28 th Novem­
ber, 1993.

A

The Central Health Education
Bureau, as one of its functions,
organised a stall on the theme
stressing mainly on the health
aspect on 14th November, the
inauguration day of Exhibition.

Sbri Pawan Singh Ghatowar, Dy. Minister of Health and Family Welfare viewing the stall on
Women’s Contribution towards Health put up by CHEB during the exhibition on Women in
India’s development at Teen Murti House, New Delhi.

Smt Sonia Gandhi along with
other colleagues visited the
exhibition and evinced keen
interest She admired the work
done by CHEB in highlighting the
role of women in development of
India, more so in the field of
health.

The other dignitaries who
visited the Exhibition were Shri
Pa wan Singh Ghatowar, Dy.
Minister of Health and Family
Welfare and many experts in the
field of health. Students from all
over Delhi had an exposure to
health education messages during
this period. The star attraction
was a working model on human
anatomy. The parts of the body
were demonstrated by the faculty
of CHEB.

CHEB was awarded an apprecia­
tion shield for participating in
this exhibition.
Smt. Sonia Gandhi evinced keen interest in the stall on Women’s Contribution towards Health
put up by CHEB during the exhibition on Women in India’s development at Teen Murti House,
New Delhi.

24

—Dr Manjcct Singh
CMOCD

Swasth Hind

Shri IJ. Chaudhary, Additional Secretary (Health)—second from right—inaugurating the First Certificate Course in Health Education for
ISM and Homoeopathy on 1 November, 1993 at CHEB, New Delhi. Seated from left to right are : Dr Suresh Prakash, Director, Health
Services, Delhi Administration; Dr Narendra Behari, O.S.D. (DGHS); Dr V.S. Singhal, Director, CHER; and Shri Alok Pcrti,
Director, ISM.

Certificate Course m Health Education for
ISM and Homoeopathy Doctors
A five-day Certificate Course in Health Education for Doctors of Indian
Systems of Medicine and Homoeopathy Was held from 1st to 5th November,
1993 at the Central Health Education Bureau, New Delhi. The course was
inaugurated by Additional Secretary (H), Shri I.J. Chaudhary. This was the
first time that doctors of different systems of medicine sat together and
exchanged their experiences; more so in the field of Health Education. 27
participants from various agencies like Municipal Corporation of Delhi, Delhi
Administration, Tibia College and six Post Graduate students of Preventive
and Social Medicine of Delhi University attended this course. There was
100% participation. During the Valedictory Session all the participants
admired the efforts taken by CHEB for bringing together doctors of different
systems of medicine on one platform and sensitizing them for the need to
impart health education as one of their duties.
—CHEB

January 1994

25

THE HEALTH OF SOUTH-EAST ASIA
—WHO Regional Director’s Report
efforts by the
health and health-related sec­
tors have resulted in an improve­
ment in the health status of the
population in WHO’s South-East
Asia Region. This is exemplified,
among other factors, by the lower
infant mortality rates and im­
proved immunization coverage of
children. There are, however,
some problems which continue to
cause concern. This is stated in
the biennial report on the work of
WHO in the South-East Asia
Region covering the period 1 July
1991—30 June 1993.
The report, presented by the
Regional Director, Dr U Ko Ko, to
the 46th session of the WHO
Regional Committee for SouthEast Asia, held from 21—27 Sep­
tember, 1993 in New Delhi, stated
that rapid population growth and
unplanned urbanization were
affecting the health of people,
especially in the slums and squatter
settlements. In this context the
report stated that greatly increased
efforts would be needed to realize
the water supply and sanitation
coverage targets set for the year
2000, particularly with regard to
sanitation.
Recognizing the advantages of a
holistic approach to child survival
and development, WHO, together
with other United Nations agencies
and nongovernmental organi­
zations, was developing integrated
systems of MCH/family planning
service delivery as a part of primary
health care through the safe
motherhood initiative, among
others. Considering the recent
changes in socio-politico-economic structure as well as in the
epidemiological patterns of dis­
ease, particularly in developing
countries, WHO was reviewing and
updating the health research
strategy in the Region.
The report stated that while high
immunization coverage had been
achieved and sustained in most

C

26

oncerted

countries in the Region, it was less
than the national coverage at some
sub-national levels. Surveillance
remained the weakest component
in most national immunization
progiammes. Since
difficulties
were anticipated in the supply of
vaccines in several countries, WHO
was exploring diversified sources to
fill the gap. Diarrhoeal diseases
continued to pose a serious threat
to children in the Region and con­
trol activities constituted a priority
programme. According to present
estimates, four countries in the
Region—Bangladesh, India, Indo­
nesia and Nepal—accounted for
about 40 per cent of the global mor
tality caused by pneumonia in
young children. In this context,
particular emphasis was being
placed on the appropriate training
of health workers in control of
acute
respiratory
infections
(ARI).
Tuberculosis, according to the
report, continues to be a serious
health problem in the Region. In
1991, nearly 2 million cases were
reported, which was almost 50 per
cent of all the cases reported
globally. The disease takes a toll
of nearly one million annually in
the Region. With the emergence
of HIV and AIDS, there is a
renewed interest in the control of
tuberculosis. The main thrust of
WHO activities was to support the
Member Countries in achieving a
cure rate of 85 per cent of detected
smear-positive cases and to detect
75 per cent of such positive cases by
the year 2000.

Referring to the situation of HIV
infection and AIDS, and the fact
that its extensive spread did not
begin till the mid-1980s, the report
stated that the impact is already
severe. More than 1.5 million
people are estimated to have been
infected with HIV and nearly
20,000 have developed AIDS in the
Region. In response to the threat,

governments in the Region had
developed national AIDS control
programmes with WHO sup­
port. While political commitment
was growing, multisectoral respon­
ses, including the active involve­
ment of NGOs and the private
sector were being mobilized.
The report referred to the signifi­
cant progress achieved in the
development of new vaccines and
in the transfer of technology for the
production of vaccines and sera.
These include the production of
vaccines against dengue haemor­
rhagic fever, plasma-derived hepa­
titis B vaccine, snake venom
anti-sera, and vaccines against
Japanese encephalitis and DPT.
Countries in the Region are
endemdic for many vector-bome
diseases such as malaria, dengue
and dengue haemorrhagic fever,
filariasis, Japanese encephalitis
and
leishamiasis
(kala-azar).
Concentrated efforts were being
mounted in the areas of oper­
ational research, appropriate tech­
nology development and its appli­
cation and training as well as
public health education to prevent
and .control these diseases. New
malaria control strategies were
being developed to tackle the situa­
tion which had been static for some
years.

The report added that with the
introduction of multidrug therapy
(MDT), and an intensification of
control activities, there has been a
dramatic decline in cases of leprosy
in the endemic countries of the
Region.

The report stated that health
development had received a new
impetus and it was being in­
creasingly recognized that health is
an essential component of human
development. A healthy, happy
and prosperous South-East Asia
Region was the goal that was to be
achieved. The Regional Director
was confident that with continued
collaboration and renewed vigour,
the cherished goal would be
achieved.

Swasth Hind

19 MILLION DOLLAR WFP AID TO ICDS
HE United Nations World Food
Programme (WFP) will provide
an additional 19 million dollars
worth of food aid for the Integrated
Child
Development
Services
scheme in India.

T

The Committee on Food Aid
Policies and Programmes, WFP’s
governing body, approved the
budget increase for the fifth phase
of the ICDS programme at a meet­
ing which ended in Rome on 29
October 1993.

Under the increased budget
allocation, the WFP, the Food aid
organisation of the United Nations,
will provide an additional commit­
ment of 35,716 tons of soya fortified
bulgar wheat (SFBW), 5,687 tons of
com-soya blend (CSB) and 5,032
tons of vegetable oil as supplemen­
tary nutrition for pre-school

children, expectant and nursing
mothers under an
ongoing
project

per cent are children between three
and six years of age who are eligible.
for pre-school education.

WFP’s support to health and
nutrition schemes in India has
focused on the Integrated Child
Development Scheme (ICDS) and
similar programmes set up under a
project since March 1976.

In April 1993, a WFP mission
which reviewed the ongoing phase
of the project concluded that con­
tinued food assistance to the ICDS
was merited. To attempt certain
innovations in the project, the
WFP recommended a 12-month
bridging phase until March 1995.
The enhanced WFP commitment
will provide adequate resources to
allow project activities to be main­
tained at the existing level of
utilisation over the extension
period.

The WFP assisted project sup­
ports the ICDS in five States,
Assam, Kerala, Madhya Pradesh,
Rajasthan and Uttar Pradesh. An
average daily total of 2.12 million
beneficiaries are provided with
supplementary nutrition through
this project.
Of those receiving supplemen­
tary meals, about 15 per cent are
expectant and nursing mothers, 40
per cent are children under three
years of age and the remaining 45

Commodities supplied under the
ICDS have been mostly in the form
of supplementary food. The WFP
assistance has amounted to a total
of 233.9 million dollars over
17 years and five expansion
phases.
—-U.N. Newsletter
13 Nov. 1993

DIABETES CASES RISING RAPIDLY TOWARDS 100 MILLION
World Diabetes Day 1993 Aimed To Increase Global Awareness
HE World Health Organization
is warning that the number of
people with diabetes is rapidly
increasing, and could exceed 100
million worldwide by the end of the
century,
compared
with
an
estimated 60 million three years
ago. A WHO study group on the
prevention of diabetes is predicting
that the major part of the increase
will occur in developing coun­
tries.

T

For the third successive year, in
an effort to increase awareness of
diabetes among governments and
the
general
public,
WHO
co-sponsored World Diabetes Day
on 14 November 1993, along
with the International Diabetes
Federation.

Dr Hilary King, the WHO medi­
cal officer responsible for diabetes
said today: “There is no doubt that
this disease is now a global health
problem, with populations of
developing countries, minority
groups and disadvantaged com­
munities facing the greatest risk”.

“The rapid rise in the frequency
of the disease in these populations
seems to be closely associated with
lifestyle changes that accompany
industrialization, urbanization and
socioeconomic changes in the
developing, world. Globally, the
only question that remains is how
huge the problem really is. We
expect to have the answer soon, and
it may well confirm the view of
many experts that there are now as
many as 100 million sufferers”.

The study group, in a report to be
published next year, says: “There
is every reason to suppose that
diabetes will remain a threat to the
public health in the year 2000 and
beyond. Demographic and epi­
demiological evidence suggests
that, in the absence of effective
intervention, diabetes will continue
to
increase
in
frequency
worldwide. Thus, prevention of
diabetes and its consequences is
not only a major challenge for the
future, but essential if health for all
is to be an attainable target”.
Diabetes prevention is largely
based on encouraging positive
lifestyle changes—for example,
reducing obesity, increasing physi­
cal activity, and switching to a
high-fibre, low-fat diet.
—W.H.O.

January 1994

*

LIBRARY
(

II

and

—11

DOCUMENTATION
V

UNIT

ga i.6

7/

LEPROSY
—A Select Bibliography—1992-1993
M. Sharada
We publish below a select bibliography on “LEPROSY” with reference to Indian Context,
compiled by the National Medical Library (D.G.H.S.) as a part of its activities aimed at
providing Documentation Services to the Health Science Community in the country. It
covers selected contributions on “LEPROSY” during 1992-93. Entries follow a
classified
arrangement
using
main
Subject
headings
and
Sub­
headings. Photocopies of these articles can be ordered from National Medical Library
(D.G.H.S.) Ansari Nagar, Ring Road, New Delhi-110 029.

EPIDEMIOLOGY
1. Study of Leprosy among slum
dwellers in Pune part I. pre­
valence. Krishnan B K et al.
Indian J Public Health 1992
Jul-Sep; 36(3): 78-86.

2. Study of Leprosy among slum
dwellers in Pune part II. Dis­
abilities. Krishnan B K et al.
Indian J Public Health 1992
Jul-Sep; 36(3): 87-92.
3. Workshop on “MDT expe­
riences and incidence trends”
at Chilakalapalli (AP) on 1415, June 1992. Indian J Lepr
1993 Jan-Mar; 65(1) : 132-9.

ETIOLOGY & IMMUNOLOGY
4. Analysis
of
circulating
immune complexes from
Leprosy
patients
for
Mycobacterium
leprae
antigens. Sinha S et al. Int J
Lepr Other Mycobact Dis
1992 Sep; 60(3) : 396-403.
5. Association of HLA antigens
with differential responsive­
ness to Mycobacterium W
vaccine in Multibaccillary
leprosy patients. Rani R et al.
J Clin Microbiol 1992 Jan;
12(1) : 50-5.
6. Major proteins of Mycobac­
terial strain ICRC and
Mycobacterium
leprae,
identified by antibodies in

28

sera from leprosy patients
and their contacts. Chiplunkar S V et al. J Clin Microbiol
1992 Feb; 30(2) : 336-41.

7. Ocular complications of Lep­
rosy. Chaya S Br J Hosp Med
1992 Jan 9-22; 47(1) : 69.
8. Pattern of leprosy deformities
among agricultural labourers
in an endemic district: a pilot
study. Kartikeyan S et al.
Indian J Lepr 1992 Jul-Sep;
64(3): 375-9.

9. Specificity of IgG subclass
antibodies in different clini­
cal manifestations of lep­
rosy. Dhandayuthapani S et
al. Clin Exp Immunol 1992
May; 88(2): 253-7.
10. Suppressive effect of circulat­
ing immune complexes from
leprosy patients on the
Lymphocyte
proliferation
induced by M Leprae anti­
gens in healthy respon­
ders. Tyagi P et al. Int J Lepr
Other Mycobact Dis 1992
Dec; 60(4) : 562-9.
11. Tongue involvement in lepromatous leprosy. Sharma V
K et aL Int J Dermatol 1993
Jan; 32(1): 27-9.
12. Tuberculosis and leprosy—
not uncommon association.
Mittal A et al. J Assoc
Physicians India 1992 Feb;
40(2): 83.

GENERAL ASPECTS

13. A Study of cause and treat­
ment practices of leprosy
among rural communities in
Agra subdivision. Agnihotri
S P .et al. Indian J Hosp
Pharm
1993
Jan-Feb;
30(1): 29-31.

14. Child to parent education : a
pilot study. Bhore P D et al.
Indian J Lepr 1992 Jan-Mar;
64(1): 51-7.
15. Evaluation
of
disability
knowledge and skills among
leprosy workers. Rao S P et al.
Indian J Lepr 1992 Jan-Mar;
64(1): 99-104.
16. Leprosy in children. Sehgal
V. N. Indian J Clin Practice
1993 Nov; 4(6) : 56-8.
17. Leprosy in children : a pros­
pective study. Sehgal V N et
aL Int J Dermatol 1993 Mar;
32(3): 194-7.
18. Leprosy of the larynx. Soni N
K. J Laryngol Otol 1992 Jun;
106(6): 518-20.
19. Study of the characteristics
and causes of relapse
amongst leprosy cases in an
urban area (Calcutta). Saha
S P et al. Indian J Lepr 1992
Apr-Jun; 64(2): 169-78.
20. Leprosy: A reference guide
for medical practitioners, pro­
grammers, managers and
SWASTH HIND

leprosy workers. Misra R S
New Delhi: Concept Pub­
lishing Cdmpany, 1993.

21. Studies on leprosy 1977-1992
supplement—4. Veeraraghavan N Madras: VHS, 1993.
MANAGEMENT AND THERAPY
22. A Project model for attempt­
ing integration of leprosy ser­
vices with general health care
services after the prevalence
of the disease is reduced in
the endemic districts on
multidrug therapy for over
five years. Dharmshakter N
S. Indian J Lepr 1992 Jul-Sep;
64(3): 349-57.
23. Combined multidrug and
Mycobacterium W vaccine
therapy in patients with multibacillary leprosy. Zaheer S
A et al. J Infect Dis 1993 Feb;
167(2): 401-10.

24. Does isoniazid increase the
hepatotoxicity of the com­
bination
prothionamidedapsone ? isoprodian study
group. Int J Lepr Other
Mycobact Dis 1992 Dec;
60(4): 536-41.
25. Early diagnosis of leprosy
under field conditions. Gupte
M D. Indian J Lepr 1993 JanMar; 65(1) : 3-12.

26. Filter paper blood spot test for
detection of anti-ND-BSA
antibodies in school children.
Sahasrabudhe R et al. Indian
J Med Res 1992 May; 95 : 10511.
27. Histopathological monitoring
of an immunotherapeutic
trial with Mycobacterium W.
Mukherjee A et al. Int J Lepr
Other Mycobact Dis 1992
Mar; 60(1) : 28-35.
28. Intravascular hemolysis and
acute renal failure following
intermittent
rifampin
therapy. Gupta A et al. Int J
Lepr Other Mycobact Dis
1992 Jun; 60(2) : ,185-8.
29. Maxillary antrum involve-’
ment in multibaciliary lep­
rosy : a radiologic, sinuscopic, and histologic assess­
ment Hauhnar C Z et al. Int J
Lepr Other Mycobact Dis
1992 Sep; 60(3) : 390-5.
30. Multidrug therapy in multibacillary leprosy : experi­
ence in an urban leprosy
center. Ramesh V et al. Int J
Lepr Other Mycobact Dis
1992 Mar; 60(1) : 13-7.

PREVENTION AND CONTROL
33. Anti-Leprosy
vaccines :
current status and future pro­
spects. Kartikeyam S et al. J
Postgrad Med 1991 Oct; 37
(4): 198-204.

31. Time lag between case regis­
tration and commencement
of treatment in a leprosy con­
trol unit Murthy P K et al.
Indian J Lepr 1992 Jan-Mar;
64(1) : 8-13.

38. Some problems and sugges­
tions for leprosy control
within urban primary health
care in Bombay. Pandit D D
Bombay Hosp J 1992 Jul;
34(3) : 99-102.

32. Treatment of paucibacillary
leprosy. Saxena U et al. Int J
Dermatol 1993 Feb; 32(2):
135-7.

39. Prevention of disabilities in
patients
with
leprosy.
Srinivasan
H
Geneva:
WHO, 1993.

34. Health and human resource
mobilization an assessment
of staffing pattern in NLEP'at
operational level. Reddy J
V. Indian J Lepr 1993 JanMar; 65(1) : 81-93.

35. Leprosy Control yesterday,
today and tomorrow. Ekambaram V. Indian J Lepr 1992
Apr-Jun; 64(2): 232-9.
36. Nutritional status of children
of Urban leprosy patients
staying at preventoria based
on biochemical parameters.
Chattopadhya D et al. Eur J
Clin Nutri 1992 Dec; 46(12):
885-95.

37. Sensitization potential and
reactogenicity of BCG with
and without various doses of
killed Mycobacterium lep­
rae. Gupta M D et al. Int J
Lepr Other Mycobact Dis
1992 Sep; 60(3) : 340-52.

AUTHORS OF THE MONTH
Dr N. S. Dharmshaktu

Asstt. Director General (Leprosy)
Dte. General of Health Services
Ninnan Bhawan
New Delhi-110011.
Dr B. N. Mittal

Dy. Director General (Leprosy)
Dte. General of Health Services
Ninnan Bhawan
New Delhi-110 011.
Dr P. A. Somaiya

Professor

Dr A. C. Urmil

Dr R. Ganapati

Professor

Director
Bombay Leprosy Project
Vignyan Bhawan
11 V. N. Purav Marg
Sion-chu nabhatti
Bombay-400 022

and
Dr R. V. Awate

Lecturer
Deptt. of Preventive and
Social Medicine,
Krishna Institute of Medical Sciences
P.O. Karad-415 110 (Distt.-Satara)
Maharashtra
Shri S. S. Naik

Hony. Secretary
Acworth Leprosy Hospital for Research,
Rehabilitation and Education in Leprosy
Wadala
Bombay-400 031

Shri S. K. Bhoi

Health Education Officer
Central Health Education Bureau
Kotla Road
New Delhi-110002
M. Sharada

National Medical Library
(D.G.H.S.)

Ring Road. Ansari Nagar
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.

SOSTH HIND^

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No. I) <C)3<9
Regd: No. R.N. 4504/57

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