Reactions and their management.

The uneventful response to chemotherapy in leprosy is marked by clinically disturbing episodes encountered in 20-30% of patients and these phenomena are called "reactions". Generally they are classified as reversal reaction (type-1) and erythema nodosum leprosum (type-2). The cutaneous menifestations are: (1) Type-2 reactions in LL, BL types constituting erythema nodosum leprosum, erythema multiforme, erythema necroticans, subcutaneous nodules, lepromatous exacerbation. (2) Type-1 reactions in borderline and tuberculoid leprosy. The other manifestations include: Acute neuritis, lymphadenitis, arthritis, oedema of the hands and feet, ocular lesions, etc. Sequelae of reactions are: Paralytic deformities, non-paralytic deformities, extensive scarring and renal damage. A simple guideline to identify the risk-prone cases has been narrated. Prednisolone in standard dosage schedule as recommended by WHO is now being widely used in control programmes.

Disability prevention and management in leprosy: a field experience.

Bombay Leprosy Project has conducted operational research into cost effective ways of using therapeutic management for prevention of disabilities (POD). The goal of achieving this are broadly divided as 1) prevention of impairments and disabilities [POID] and 2) prevention of worsening of disabilities [POWD]. About 33-56% of newly registered leprosy patients already have clinically detectable nerve function impairment [NFI], often no longer amenable to MDT. An analysis of 892 leprosy cases treated with WHO-MDT stresses the need to focus attention on leprosy patients having > 5 skin lesions and multiple nerve thickening. Assessment of 454 disabled leprosy patients after 4 years indicated that the compliance for the services offered was good and it helped to improve the disability status in more than 50% of patients. In terms of effectiveness of the services, it was found to be effective in preventing worsening of deformities in hands and healing of trophic ulcers in feet. The methodology adopted has also helped us to develop an operational research model about the necessity to systematize the assistance and support to be given if the services can be routed through a public health facility. Because of the large numbers of leprosy patients with disability living in this region and the limited resources available, the services have to be targeted towards those who are most in need. The major advantage of such community based program is an attempt to eliminate the social stigma in the patients' families and the education of the community.

Survey of leprosy in unapproachable and uncovered areas.

Leprosy surveys in tribal population, fishermen and labourers engaged in construction work revealed prevalence rates of 32/10,000, 109/10,000 and 20/10,000 respectively, suggesting that systematic surveys have to be carried out in such population groups, to reach the goal of a "World without leprosy".

Hidden sources of infection in unapproachable areas.

The population living in the hilly terrains of Panvel taluka, District Raigad of Maharashtra State was examined in a special campaign carried out during a time when the majority of the population will be stationed at the hills. Examination of 10499 persons revealed 108 leprosy cases (PR 10.3/1000) of which 72 were paucibacillary (PB) and 29 were multibacillary (MB) cases. Among the PB cases, only two had single lesion type and among the 29 MB cases, 14 were smear-positive, having BI more than 4. These untreated advanced leprosy cases, in view of their frequent migrations in order to earn their livelihood, may be responsible for transmitting the infection in the plains areas where multidrug therapy is practiced since 1990. In order to achieve early leprosy elimination, it is necessary to cover populations in difficult areas like the one mentioned by special action programmes.

An evaluation of the contribution of the Swedish International Development Authority (SIDA) to leprosy control in India based on the implementation of multiple drug therapy (MDT) 1981-1993.

The Swedish International Development Authority (SIDA) first supported the National Leprosy Control Programme in India in 1978. In 1981/82 priority was given to the implementation of multiple drug therapy (MDT), starting in two high-endemic districts, and gradually extending to a total of 19 districts in the years by 1993. SIDA then decided to undertake a detailed evaluation of its 12-year contribution and this was carried out by an international team between November 1993 and April 1994. In terms of epidemiological and public health impact, the main results were impressive and clear-cut; 837,519 cases (old and newly arising) were successfully treated, with few complications and a low rate of relapse. The voluntary reporting rate had improved significantly. Data relating to new case detection, child and disability rates were, however, less clear and difficult to interpret. Deficiencies were also identified in the areas of health education, community participation, gender issues, disability prevention and management, rehabilitation, operational research and assessment of cost-effectiveness. These problems should not, however, detract from the contribution of SIDA, from 1981 onwards, in establishing the implementation of MDT in two 'pilot' districts at an early and important stage in the history of the MDT programme in India. SIDA also made significant contributions in other areas, namely pre-MDT 'screening' of registers in 45 endemic districts in 1990-1993, appointment of consultant leprologists at district level, group education activities, annual meetings of voluntary agencies and the development of a monitoring and information system, with computer facilities, at national level. This paper describes the design and methodology, main findings and conclusions of the evaluation, based on the final report and the appendices submitted to SIDA in Stockholm in April 1994.