The factors influencing the operational efficiency of leprosy case detection programme.

Under our National Leprosy Eradication Programme, Leprosy cases are being detected by para-medical workers by conducting population surveys. In order to detect the leprosy cases early, for their timely anti-leprosy treatment, it is necessary that the leprosy surveys are implemented and supervised efficiently. However, present experience indicates that the existing survey efficiency needs to be improved, for which it is necessary to analyse the factors which may interfere with the optimal survey efficiency of para-medical workers. An attempt has been made through present piece of work to identify such factors in relation to (i) the para-medical workers and survey facilities, (ii) the implementation and supervision of leprosy survey and (iii) the community involved in survey. These factors are discussed in detail to assist the NLEP Administrators in devising a suitable action plan to improve leprosy case detection efficiency.

Screening of registered leprosy cases and its effects on prevalence rate.

Prevalence rates of leprosy in 6 endemic districts in Andhra Pradesh, India with a population of 168.71 lakhs (1981 census) were studied before and after screening of registered cases. The screening was carried out as part of multidrug treatment project implementation. After such screening a sharp fall in the registered prevalence rate, by 26.2% on the average, was observed in all the districts. About 34.8% of the total cases were declared as Released from control. The implication of these findings regarding registered cases fit for such release and the overall registered prevalence rates in the country must be kept in mind.

Observations on T-cell sub-populations in type II reactions.

15 cases each of Type II Reaction, LL and TT Leprosy and 50 endemic controls were studied for phenotypic markers T2, T4 and T8 by 2 step immunoperoxidase technique. There was statistically significant increase in T4 (helper) cells in Type II Reaction. There was also a decrease in T8 cells but this was not statistically significant.

Diagnostic value of cardinal signs/symptoms in paucibacillary leprosy.

With the help of sensitivity and specificity criteria, an attempt is made to quantify the gain in certainty in diagnosis with the use of various cardinal signs/symptoms (S/s) of leprosy in order to study their predictive value in correct diagnosis of paucibacillary leprosy (PB) by the Paramedical Workers. The study was based on the findings in 326 new cases of paucibacillary leprosy detected by 10 paramedical workers during a recent field survey. Observations in the present study confirm the scientific basis of presently used combinations of cardinal S/s for correct diagnosis of leprosy especially the combination of (skin) patch with loss/impairment of sensation. The detailed observations made in the study are discussed in this communication.

Evaluation of levamisole, an immunopotentiator, in the treatment of lepromatous leprosy.

Twenty subpolar lepromatous leprosy patients under multidrug therapy for a period of 1 to 3 years, who continued to be bacteriologically positive (BI 2 to 1 in Dharmendra's grade) were taken in the study. Ten cases (trial group) were given levamisole as an immuno-stimulator for 1 year along with chemotherapy. Another 10 cases (control group) continued to take chemotherapy alone. There was no conversion of Mitsuda reactivity in any of the cases from both the groups. There was no improvement of leucocyte migration inhibition in either group. In both trial and control groups, statistically significant clinical and bacteriological improvements and increase of E. rosette counts are found at the end of one year. However, only the bacteriological improvement in the trial showed statistical significance, when the improvements were compared with those of the control group. No adverse effect due to levamisole therapy was encountered.

Retrospective analysis of smear examinations from multiple sites in multi-bacillary leprosy.

A retrospective analysis was done on results of smears from six sites in untreated and treated multibacillary leprosy cases. The examination of three sites was found adequate to detect all multibacillary cases.

Limited duration acedapsone prophylaxis in leprosy.

A randomized controlled chemoprophylaxis trial was carried out in Madras city using 560 disease-free household child contacts of 264 multibacillary cases as study subjects. In the study, 13 cases were diagnosed among 280 contacts who received 3 injections of acedapsone at 10 weeks interval as against 30 cases among 280 contacts who had the same number of placebo injections, during the follow-up period of 225 weeks. The difference in the incidences in the two groups was statistically significant. (X2 6.45; P less than 0.02). The protection due to the limited duration of acedapsone prophylaxis was 56.7 percent. There were no cases of multi-bacillary leprosy in either group. The efficacy of prophylaxis was significant in male children over 9 years of age and female children in the age-group 1-8 years. The other prognostic factors like the infectivity status of the index cases in the household and the duration of exposure to them could have possibly influenced the effectiveness of prophylaxis in preventing progression from infection to clinical disease among the subjects studied. Their effects could not be assessed in this study.

Medical care delivery through leprosy clinics--consumer's perception, experiences and suggestions.

Randomly selected 500 adult leprosy patients, registered for treatment with six Sectors of a Leprosy Control Unit in Chingleput District of Tamil Nadu (India) were interviewed to study their perception, and experiences with medical care being delivered to them through leprosy clinic(s), and their suggestions to improve the system. About 14% patients did not perceive their disease as leprosy. And 8% of the total patients were taking treatment outside their sector leprosy clinics. The services like physiotherapy, rehabilitation, health education etc. were known to only 3-8% patients, perhaps on account of their non-availability and or non-practice. On an average, a patient had to cover a distance of 2.1 +/- 2.5 KMs (one side) in 24 +/- 49 minutes to reach clinic spot, mostly by walk (83.2%), and spent 58.9 +/- 32.2 minutes at clinic, of which two third in waiting for service(s). Each patient had consulted 1.23 +/- 0.55 medical agencies for treatment of leprosy. The average man-day and wage losses to a patient, due to monthly clinic attendance, were estimated to be 0.48 +/- 0.49 days and Rs. 2.28 +/- 3.06, respectively. Only 10.6% of the 500 patients got admitted 1.55 +/- 0.89 times in leprosy hospital for a duration of 63 +/- 69.30 days and lost wages of Rs. 126.4 +/- 85.64 per month of stay in hospital. Availability and efficient delivery of comprehensive medical care through well organized and regularly conducted leprosy clinic, by considerate and sympathetic staff was much emphasised by patients. Various factors influencing medical care delivery and its utilization by patients, are discussed in this communication.

Hepatitis and multi-drug therapy in leprosy with special reference to prothionamide.

Hepatotoxicity in two drug regimens was studied at Central Leprosy Teaching and Research Institute, Chengalpattu (Tamil Nadu) during 1983-84. In 'P' regimen-prothionamide 350 mg daily, dapsone 100 mg daily and rifampicin 600 mg at monthly intervals were given. In' C' regimen-dapsone 100 mg daily, rifampicin 600 mg once a month and clofazimine 300 mg once a month and 100 mg alternate day were given. Trial was started with fifty multibacillary adult leprosy patients in each group. Enzymatic hepatic dysfunction was noted in 52-58 per cent of the cases even before the therapy was started. In 'P' regimen, four cases of clinical jaundice and six cases of high bilirubinaemia was noticed during the trial as against two cases each of clinical jaundice and high bilirubinaemia in 'C regimen. Of the two cases of clinical jaundice in 'C' regimen, one turned out to be a case of HBV infection. The study which is in progress, indicated higher hepatotoxicity in 'P' regimen which is probably explained by the simultaneous use of two hepatotoxic drugs. Viral hepatitis is endemic in this area and might have aggravated the hepatotoxicity observed.

Diagnostic efficiency of paramedical workers involved in leprosy case detection programme.

The diagnostic efficiency and accuracy in classification of leprosy and its activity status, by four senior trained Paramedical Workers (PMWs) involved in leprosy case detection programme, was assessed on 1394 cases detected by them and concurrently confirmed by an experienced medical officer. The inter-observer variation between two experienced PMWs in diagnosis and classification of leprosy on 216 patients, was also studied. Of the 1394 cases detected by PMWs, 257 (18.44%) were wrongly diagnosed as leprosy, mostly as non-lepromatous (N) type. Though all lepromatous (L) and 98% of N-type cases were correctly classified by PMWs, 25.64% of borderline (N ? L) cases were either under-diagnosed as N-type (17.95%) or over-diagnosed as L-type (7.69%). The activity status of 19% cases was wrongly assessed by PMWs, including 8% active lesions assessed as inactive. The discrepancy between two PMWs in diagnosis, classification and assessment of activity status of leprosy was found in 1.39%, 7.41% & 25.67% cases, respectively. The implications of these observations, and the suggestions to improve the technical skills of workers for an efficient and effective implementation of leprosy control programme, are discussed in this communication.