The contribution of "cure by dapsone monotherapy' to the reduction of prevalence of leprosy in the State of Orissa, India, 1983-1993.

The implementation of multiple drug therapy (MDT) in the State of Orissa, India, started in early 1983 and was extended in a phased manner to nine out of the then total of 13 districts by 1993. As part of a programme to bring the remaining four districts under MDT, an intensive screening of the registers was carried out in early 1993. From a total of 28,855 cases registered in these districts, 26,113 (90.5%) were examined and 18,008 (69.9%) deleted. The deleted included patients who had died, emigrated, double (or occasionally treble) entries for the same patient and those in whom careful re-assessment suggested that the original diagnosis of leprosy had been wrong. In addition, however, 8,260 (45.8%) of the 18,008 cases deleted were considered to have been cured by dapsone monotherapy. This figure, from districts with a relatively poor development of services for leprosy control, prompted a retrospective examination of data from the other (more privileged) nine districts. This revealed that from a total of 264,000 patients screened, prior to the implementation of MDT from 1983 onwards, 75,590 (28.6%) were removed from the registers, and that of these, 63,562 (84.0%) were considered to have been cured by dapsone monotherapy. Thus from a total of 93,598 patients removed from registeres in this State since 1983, 71,822 (76.7%) have been assessed as cured by dapsone monotherapy. The significance of this finding and its apparently considerable contribution to the overall reduction in the prevalence of leprosy in Orissa, 1983-1993, is discussed.

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.

Histopathological examination of skin biopsies from an epidemiological study of leprosy in northern Malawi

"This report describes the histopathological findings in 686 biopsies obtained from 664 individuals during the course of a total population survey for leprosy in Northern Malawi. The criteria for the selection of cases for biopsy; the biopsy technique using a 4-mm punch; fixation method; transport of biopsies from Africa to the United Kingdom; and the method of coding histopathological results are described. Fifty-two percent (354) of the biopsies showed definite evidence of leprosy on histopathological examination. Using the Ridley-Jopling system; these biopsies were classified as follows: TT = 60 (17 percent ); TT/BT = 68 (19 percent ); BT = 194 (55 percent ); BT/BB = 4 (1 percent ); BB = 4 (1 percent ); BB/BL = 4 (1 percent ); BL = 7 (2 percent ); BL/LL = 3 (1 percent ); LL = 6 (2 percent ). In addition; four (1 percent ) biopsies were classified as ""indeterminate"" on histology; meaning that although there was evidence of leprosy it was not possible to provide a precise classification. A further 117 biopsies (17 percent of the total) had abnormal changes; often including epithelioid cell granulomas; possibly caused by leprosy but lacking specific criteria for that diagnosis. Finally; 203 (30 percent ) of the biopsies had nonspecific (often minimal) changes; and 11 (2 percent ) of the total showed evidence of some dermatological condition other than leprosy. Histopathological examination of biopsies in this study confirmed the clinical classification in 98 percent of the cases in which the histopathologist found evidence of leprosy; and supplied further evidence for the very high proportion of paucibacillary cases in this part of the world."

Comparability among histopathologists in the diagnosis and classification of lesions suspected of leprosy in Malawi

Identical slides from 200 biopsies obtained from individuals suspected of having leprosy during the course of an epidemiological survey in Northern Malawi were examined sequentially and independently by three histopathologists; using a standard protocol to report their findings. Their results are compared among themselves and with a standardized clinical assessment of each subject. There was more agreement among the histopathologists as to classification of leprosy cases than there was on the diagnosis of leprosy. The proportion of biopsies considered to show definite evidence of leprosy varied from 39 percent to 58 percent among the histopathologists. An appreciable additional proportion of biopsies (11.5 percent to 38.5 percent for the three histopathologists) was considered to show evidence suggestive but not pathognomonic of leprosy. Although there was; in general; good agreement on classification; the proportion of biopsies considered to show evidence of indeterminate leprosy varied from 1.5 percent to 21.5 percent among the three histopathologists. This suggests that some of the reported differences in the prevalence and proportion of indeterminate leprosy in different populations is due to terminology alone. A follow-up meeting of the study participants revealed that many of the differences in diagnosis certainty were due to difficulties in interpreting evidence of nerve involvement. It is recommended that greater attention be paid to the difficulties of diagnosing leprosy on histopathological as well as clinical grounds. A revised standard protocol for reporting histopathological evidence of leprosy is presented