• Volume 70 , Number 4
  • Page: 3–372
ABSTRACTS OF CONGRESS

Abstracts of Congress for Papers and Posters






Abstracts of Congress for Papers and Posters

 

 

ABSTRACTS OF ORAL PRESENTATIONS

 

 

 

CLINICAL ASPECTS

OCA 1

A LARGE SERIES OF DAPSONE HYPERSENSITIVITY SYNDROME PATIENTS IN NEPAL
Maria Jacob K., Murdo Macdonald and Ruth Butlin.
Anandaban Leprosy Hospital, PO Box 151, Kathmandu, NEPAL. E-mail: anandaban@mail.com.np.

Dapsone Hypersensitivity Syndrome (DHS) is an important although rare complication seen in the treatment of leprosy. It can be very distressing to the patient and in severe forms can even lead to death.
Aim: To review a large series of DHS patients, to be able to recognize and treat this effectively at its initial stages.
Methods: A retrospective study was carried out of a large series of 54 patients affected by leprosy; 47 MB and 7 PB, diagnosed with DHS in the past 11 years. Data of medical history was collected by a review of medical records charts.
Results: Thirty-seven of those affected by DHS in our series were male and 17 female. Time of presentation was usually within 3 months of starting MDT (5 at < 1 m, 30 at 1-3m. 1 at >3m). The patients presented with a variety of symptoms, the most common of which was dermatitis (74%). All were treated with prednisolone after immediate withdrawal of dapsone. A modified MDT regimen was continued. Eighty per cent of cases recovered fully within one month of starting treatment. A case report on one patient who had a protracted illness and extended stay in the hospital is also presented.
Conclusion: These observations will assist in the clinical management of DHS, and aid its early diagnosis.

 

OCA 2

ADVERSE EVENTS OF STANDARDISED REGIMENS OF CORTICOSTEROIDS FOR PROPHYLAXIS AND TREATMENT OF NERVE FUNCTION IMPAIRMENT IN LEPROSY: RESULTS FROM THE 'TRIPOD' TRIALS.
J.H. Richardus; S.G. Withington; A.M. Anderson; R.P. Croft; P.G. Nicholls; W.H. van Brakel; W.C.S. Smith
Department of Public Health. Erasmus University Rotterdam. P.O. Box 1738, 3000 DR Rotterdam. The Netherlands

Aim: Reactions in leprosy causing nerve function impairment (NFI) are increasingly treated with standardised regimens of corticosteroids, often under field conditions. Safety concerns led to an assessment of adverse events of corticosteroids in three trials studying prevention of NFI (the TRIPOD study).
Methods: A multicentre, randomised, double-blind placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Treatment was with prednisolone according to fixed schedules for 16 weeks, starting in one trial with 20 nig/day (prophylactic regimen: total dosage 1.96 g) and in the other two trials with 40 mg/day (therapeutic regimen: total dosage 2.52 g). Minor adverse events were defined as moon face, severe fungal infections, severe acne, and gastric pain requiring antacid. Major adverse events were defined as psychosis, peptic ulcer, glaucoma, cataract, diabetes and hypertension. Also the occurrence of infected plantar, palmar, and corneal ulceration was monitored, together with occurrence of TB.
Results: Considering all three trials together, minor adverse events were observed in 130/815 patients (16%). Of these, 51/414 (12%) were in the placebo group and 79/401 (20%) in the prednisolone group. The relative risk for minor adverse events in the prednisolone group was 1.6 (p=0.004). Complications with a significantly increased risk were acne, fungal infections and gastric pain. Major adverse events were observed in 15/815 patients (2%); 7/414 (2%) in the placebo group and 8/401 (2%) in the prednisolone group. No major adverse events had a significantly increased risk in the prednisolone arm of the trials. No cases of TB were observed in 300 patients which could be followed-up for 24 months.
Conclusion: Standardised regimens of corticosteroids for both prophylaxis and treatment of reactions and NFI in leprosy is are safe when patients are screened for contra-indications before treatment. The risk of minor adverse events was increased in the prednisolone group, but none required slopping of treatment. Major adverse events are rare, and no differences were found between the placebo and prednisolone arm of the trials.

 

OCA 3

ANTI-PGL I IN THE DIAGNOSIS OF PRIMARY NEURITIC LEPROSY
William R.Faber1; Samira Bührer-Sekula2; Linda Oskam2; Joanne Wildebeest1; Amir Zamarian1; Adalberto Santos3; Haroldo J. Matos4; Elisabeth P.Sampaio3; Euzenir N.Sarno3

1. Academic Medical Center.
2. KIT Biomedical Research, Amsterdam. The Netherlands.
3. Fiouruz, Av Brasil 4365. Manguinhos.
4. Bioinformatica Medica, State University of Rio de Janeiro, Rio de Janeiro, Brazil.

Primary neuritic leprosy (PN) is difficult to diagnose because skin lesions and bacilli in skin smears are lacking.
It was investigated if the addition of diagnostic tests might improve the decision for the diagnosis PN. In a retrospective study an anti-phenolic glycolipid I (anti-PGL I) Elisa was performed in patients with the clinical diagnosis PN. Anti-PGL I Elisa was positive in 10 out of 44 patients (23%) with the clinical diagnosis PN. Anti-PGL I Elisa was postive in 4 out of 25 patients in which the histopathological investigation of a nerve biopsy showed non-specific changes or normal histology (total no 36). And was positive in 2 out of 14 patients in which the PCR specific for M. leprae from a nerve biopsy was negative (total no 28).
As the presence of antibodies to M. leprae PGL I are supposed to reflect the bacterial load of the patient a positive anti-PGL I may increase the number of patients with the diagnosis PN; as it was detected in this study in one out of 2 patients with a negative PCR and a non-specific histopathology. When considering a field situation where in most cases histopathological investigations and PCR are not performed, detection of antibodies would confirm 23% of the cases.

 

OCA 4

BCG EFFECTIVENESS TRIAL AGAINST LEPROSY AMONG SCHOOL CHILDREN, IN NORTHERN BRAZIL
Sérgio Cunha1,2; Laura C Rodrigues2; Inês Dourado1; Susan M. Pereira1; Neal Alexander2; Maria Yury lchihara1,3; Emilia S. Pereira4; Maurício L. Barreto1

1. Instituto de Saúde Coletiva, UFBA/Bahia/Brazil.
2. London School of Hygiene and Tropical Medicine, UK.
3. Coordenação Regional da FNS na Bahia.
4. Fundação Alfredo da Malta. Manaus, Brazil.

Background: In 1994 the Brazilian Ministry of health recommended a dose of BCG vaccine to schoolchildren aimed to prevent tuberculosis. A trial started in 1996 to estimate the efficacy of such a vaccination in two sites. One of the sites (city of Manaus) is an endemic area of leprosy, and the trial in this site was expanded to estimate protection against leprosy.
Study design: Matched, clustered randomised controlled trial.
Study population: Children aged 7 to 14 years attending state schools.
Objectives.: 1. To estimate the efficacy against leprosy of one dose of BCG vaccine given to school children in a population with a high coverage of neonatal BCG; 2. to estimate the number of individuals that need to be vaccinated to prevent one case of leprosy in school children; 3. To estimate what proportion of all cases of leprosy would be prevented by vaccination in that population: 4. To compare these results with those obtained from vaccination restricted to household contacts.
Methods: The trial was implemented in 1998. 286 state schools in the city of Manaus, Brazil, were randomised into receiving BCG or not. Identifying information was collected for 156.331 school children, of whom 72.982 are in intervention schools. Trained nurses examined the right deltoid region to ascertain previous BCG vaccination status. Follow up relies on ascertainement of cases diagnosed at the health services and notified to the reference centre for leprosy. Blindness is guaranteed during linkage and validation of cases. Prophylactic STEROIDS TO prevent nerve function impairment.

 

OCA 5

BORDERLINE TUBERCULOID LEPROSY: AN IMMUNE RECONSTITUTION PHENOMENON IN AN HIV-INFECTED PERSON
Stephen D. Lawn1; Diana N. Lockwood1,2

1. Hospital for Tropical Diseases, Mortimer Market, Capper Street, London, WC1E 6AU UK.
2. Clinical Infection Unit, London School of Hygiene and Tropical Medicine. Keppel Street, London, WC1E 7HT, UK.

Culture-positive pulmonary tuberculosis (TB) and human immunodeficiency virus type 1 (HIV-1) coinfection were diagnosed in a 37-year-old Ugandan male. The plasma HIV-1 load was 120,000 RNA copies/ml and the blood CD4+ T lymphocyte count was 10 × 106/L at the lime of diagnosis, indicating marked immunosuppression. The patient responded well to multi-drug antituberculosis treatment and, during the continuation phase, highly active anti-retroviral treatment (HAART) was also commenced. Three months alter starting antiretroviral treatment the patient developed facial lesions that were clinically diagnosed as borderline tuberculoid (BT) leprosy in reaction anil this diagnosis was confirmed histologically. At that time the patient's CD4+ lymphocyte count had increased to 70 × 106/L and the plasma viral load was <50 HIV-1 RNA copies/ml. The temporal association between the commencement of HAART and the development of the skin lesions suggested that the leprosy was a manifestation of immune reconstitution. Such a phenomenon has not previously been reported. However, the occurrence of the BT form of leprosy (indicating marked cell-mediated immunity to Mycobacterium leprae) is counterintuitive in the context of marked CD4+ lymphocyteopenia. This presentation reviews the current understanding of the relationship between HIV-1 and leprosy.

 

OCA 6

CHRONIC NEUROPATHIC PAIN IN TREATED LEPROSY
Aki Hietaharju1; Richard Croft2; Rezaul Alan2; Paul Birch3; Aprue Mong4; Maija Haanpää1

1. Department of Neurology and Rehabilitation. Tampere University Hospital, Tampere, Finland.
2. Danish Bangladesh Leprosy Mission, Nilphamari, Bangladesh.
3. Cronehills Health Centre, West Bromwich, UK.
4. Chittagong Leprosy Control Project, the Leprosy Mission, Chittagong, Bangladesh.

Medical reports on neuropathic pain associated with treated leprosy are scarce. We describe the clinical findings of 16 patients with multibacillary leprosy who had chronic stimulus-independent pain despite finishing their treatment.
The study area was Nilphamari District, northwestern Bangladesh. The patients were recruited for this study with the help of local leprosy workers from four outpatient clinics. The workers were instructed to ask for the following symptoms: burning feet, formication, pricking, biting, or squeezing pain. Altogether, 38 patients were recruited, of whom 16 fulfilled the inclusion criteria and accepted the study protocol. The clinical neurological examination included assessment of tactile, pinprick, thermal, and joint position sensation and tendon reflexes, as well as dynamic and static allodynia. Furthermore, location of pain was recorded by using pain drawings. Thresholds for pinprick sensation were measured by using the weighted needle apparatus, and thresholds for tactile sensation by using Semmes-Weinstein monofilaments.
Pain in all 16 patients was either moderate or severe. It was mainly of burning, tingling or biting quality. Some patients complained electric shock-like pain. The duration of pain varied from two years to more than 20 years. In eight patients (50%) the occurrence of pain was continuous. The distribution of pain and sensory loss was equal in 1 1 patients (69%). whereas inconsistencies between distribution of pain and sensory abnormalities was found in five cases. Enlargement oi' tenderness of nerves was noticed in six patients.
Our results indicate that some leprosy patients suffer from neuropathic pain, but further epidemiological studies are necessary to determine the magnitude of the problem. Considering neuropathic pain as one of the medical problems in treated leprosy patients may open new therapeutic avenues in future "care after cure" programmes.

 

OCA 7

CLINICAL RESPONSE TO CYCLOSPORIN A TREATMENT IN SEVERE LEPROSY TYPE 1 REACTION (T1R) PATIENTS IN NEPAL AND ETHIOPIA

Sharon N.S. Marlowe; Jukka Knuutilla; Friedbert Herm; Elizabeth Bizuneh; Ruth Leekassa; Diana N.J. Lockwood
Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine. Keppel Street. London, WCIE 7HT. United Kingdom.
Green Pastures Hospital. Pokhara, Nepal.
ALERT, PO Box 165. Addis Ababa, Ethiopia

Background: Type 1 (reversal) reactions (T1R) are important tissue damaging phenomena responsible for a significant proportion of nerve damage in leprosy. Prednisolone is the principle treatment for reactions but 30 - 60 % patients will not improve. There is a clinical need for a new and better immunosuppressant. Cyclosporin A (CyA) is a potent immunosuppressant that is non-myelotoxic and has been used widely in other immune-mediated diseases for over 17 years. There have been 3 case-reports of the successful treatment of severe and recurrent T1R with CyA.
Aim: To assess the effectiveness of oral CyA in treating severe T1R.
Study: This is a closely monitored pilot study. Patients with severe T1R were recruited in Nepal and Ethiopia and given an Indian generic preparation of CyA at 5mg/kg/day. 40mg of prednisolone was given for the first 5 days until CyA blood concentration reached a steady slate. A clinical severity scale (CSS) was used to identify patients severe enough to enter the trial and the CSS was also used to monitor the response to CyA treatment. Patients were either in-or out-patients. CyA treatment was given for 3 months. Patients had regular assessments (during and after treatment) according to the CSS and were also examined and tested for CyA related side-effects.
Results: The effects of CyA on nerve function impairment, skin and systemic signs will be reported and any side-effects seen. The effficacy of CyA and prednisolone will be compared in each location (Nepal and Ethiopia) using retrospective T1R data on prednisolone use.

 

OCA 8

CYTOKINE EXPRESSION IN THE SKIN AND BLOOD OF SEVERE LEPROSY TYPE I REACTIONS TREATED WITH PREDNISOLONE AND AZATHIOPRINE
Sharon N.S. Marlowe; Niraj Shrestha; Rakesh Manandhar; Murdo Macdonald; Paul Roche; Saroj Khanolkar-Young; Diana N.J. Lockwood
Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WCIE 7HT, United Kingdom.
Anandaban Leprosy Hospital, PO Box 151, Kathmandu, Nepal.

Aim: To compare the cytokine production in skin lesions and blood of severe Type 1 Reaction (T1R) Nepali leprosy patients taking azathioprine and or prednisolone. To relate these findings to the clinical state of the patients and the dose of drug administered.
Study: 40 patients with severe T1R were recruited. 21 were treated with 3 months of azathioprine at 3mg/kg/day plus a 2 month reducing course of prednisolone starting at 40mg (AP). 19 patients were treated with a 3 month reducing prednisolone course starting at 40mg (P).
Results: Cytokine production (tumour necrosis factor. interleukin-10 and gamma-interferon) in whole blood assay was assessed by ELISA at day 0 and weeks 2. 8 and 16. 2 skin biopsies were taken from each patient to cover the whole time period (day 0, and weeks 4, 6, 8, 12 and 16). Immunohistochemical staining and semi-quantitative grading for tumour necrosis factor, interleukin-10 and interleukin-2 was carried out on the skin biopsies.
Comparisons will be made between the effects of AP and P treatments on patients' clinical status and cytokine production.

 

OCA 9

DIFERENCIAS - SIMILITUDES DOS MICOBACTERIOSIS LEPRA-ULCERA DE BURULI
Dr. Gomez Echevarría; José Ramón
Director Médico Lepra Sanatorio San Francisco de Borja.
Sanatorio San Francisco de Borja.
03791 FONTILLES (ALICANTE) ESPAÑA.
Teléfono: 96 558 33 50; Fax: 96 558 33 76; E-mail: ptorres@fontilles.org

Tras su experiencia de trabajo en Lepra y en Ulcera de Buruli en la región del lago Kassou, distritos de Sakassou y Bouq en Costa de Marfil, el autor intenta recoger las diferencias y similitudes entre ambas enfermedades de origen bacteriano.

 

OCA 10
ERITEMA NODOSO HANSÊNICO, PERFIL CLÍNICO E IMUNOPATOLÓGICO A PARTIR DE 90 PACIENTES ESTUDADOS EM GOIÂNIA.
Jackeline Gomes Guerra; Lia Cándida Miranda de Castro; Celina Maria Turchi Martelli; Mariane Martins de Araújo Stefani; Mauricio Barcelos Costa; Gerson Oliveira Penna
Introdução: O eritema nodoso hansênico (ENH) é um evento imunológico frequente responsável por hospitalização e incapacidade física em pacientes com hanseníase Borderline Lepromatosa e Lepro-matosa (BL e LL). No nosso meio há poucas informações disponíveis sobre essa patologia.
Objetivo: O presente estudo busca estudar características clínicas, epidemiológicas, histopatológicas. sorológicas e terapêuticas de pacientes com ENH atendidos em serviços de saúde de referência para hanseníase com o objetivo de caracterizar a demanda do ENH no atual contexto da eliminação da hanseníase.
Material e método: Estudo de série de casos de ENH recrutados no período de agosto de 2000 a janeiro de 2001 no Centro de Referência em Diagnóstico c Terapêutica (CRDT) e Hospital de Doenças Tropicais Anuar Auad (HDTAA) em Goiânia/GO. Foi preenchida ficha padronizada com dados epidemiológicos, clínicos e terapêuticos, posteriormente analisados. Foi coletada biópsia de pele para histopa-tologia e amostra de sangue para sorologia de anticorpos anti- PGLI. cujos resultados foram comparados com os de pacientes MB sem ENH.
Resultados: Foram incluídos 58 pacientes com ENH e 32 com hanseníase BL ou LL sem ENH. Os pacientes com ENH eram predominantemente do sexo masculino (58,6%), forma clínica LL (81%) e faixa etária média de 34,5 anos. Mais da metade dos pacientes com ENH apresentaram sorologia positiva para anticorpos IgM anti- PGLI, embora com títulos inferiores aos dos pacientes MB sem ENH. A histopatologia, a presença de infiltrado neutrofílico, paniculite, vasculhe e agressão neural foram estatisticamente significantes nos pacientes com ENH (p<0,00l). O primeiro episódio de ENH ocorreu durante o tratamento específico em 66% dos pacientes e foi tratado com corticosteróide em 77.6% dos casos.
Conclusão: Pacientes com ENH apresentaram sorologia positiva para anticorpos anti PGL-I e alterações histopatológicas estatisticamente significantes quando comparados com pacientes BL e LL sem ENH. Há a necessidade de ficha padronizada específica para coleta de dados do ENH para melhor avaliação dos seus aspectos clínicos, epidemiológicos e terapêuticos.

 

OCA 11
ESTUDIO SEROEPIDEMIOLÓGICO DE LEPRA. PROVÍNCIA CAMAGÜEY. AÑO 2000- 2001
Nieves Atrio Mouriño1; Dra. Maria Leticia Costa García2
1. Especialista de segundo grado en Dermatología. Jefa del grupo Provincial de Dermatología. Jefa del Programa de Lepra en la Provincia.
2. Especialista de primer grado en Medicina General Integral.
Centro Provincial de Higiene y Epidemiología General Gómez. No. 5 Camagüey Cuba.

La Lepra, representa un problema de salud universal; la lucha contra la enfermedad necesita la incorporación de todos los mecanismos demostrados para el control como son: el diagnóstico precoz, preclínico o muy temprano, mediante pesquisa a poblaciones consideradas de riesgo con un examen Dermatoneurológico, estudio Serológico y tratamiento oportuno con MDT En base a ello se realizó un estudio de intervención para conocer el comportamiento de la infestación por el Microbacterium leprae durante los años 2000-2001 en la provincia de Camagüey.
El universo poblacional estuvo constituido por todas aquellas poblaciones donde se notificó 1 caso de lepra durante estos años. Se realizaron 15 131 pruebas serológicas a la población de riesgo en aquellos municipios con una prevalencia de la enfermedad superior a 1 × 10 000, a los cuáles se le aplicó una encuesta. Las variables a analizar fueron: edad, sexo, raza, escolaridad, ocupación, lugar de procedencia, causas del pesquisaje, examen Dermatoneurológico, fecha y resultado de la Baciloscopia, Lepromina y tratamiento recibido, así como seguimiento serológico. Si la prueba serológica resultó por encima del nivel de corte (0.300), se le realizó Baciloscopia y Lepromina. Aquellos casos con respuesta inmunológica negativa recibieron tratamiento profiláctico y seguimiento serológico por un año. Este trabajo tuvo como principal objetivo conocer el comportamiento de la infestación por el Micobacterium leprae en la Provincia de Camagüey.
De las 15 131 resultaron por encima de nivel de corte 185, de estas fueron Lepromino negativas 29, enfermos de Lepra 4 y se trataron 29. En el seguimiento serológico se mantuvieron con igual cifra o inferior el 100%.

 

OCA 12

FACTS AND FALLACIES OF CORTICOSTEROID TOXICITY IN LEPROSY - AN EXPERIENCE WITH MORE THAN 1000 PATIENTS IN 10 YEARS
D.S.T. Sugumaran
Sacred Heart Leprosy Centre, Sakkotai, Kumbakonam, Tamilnadu, India-612 401.

Corticosteroids are used in various complications of leprosy like Leprosy Reactions (Type I and Type II), Neuritis and Quiet Nerve Paralysis (QNP). Most of these complications are due to immunological hypersensitivity response to M. leprae antigens. Corticosteroids act in a three pronged approach to control the symptoms of reacitons as well as prevent nerve damage. Even when there is evidence of nerve function loss corticosteroids can reverse the function loss and restore useful function in the majority of leprosy patients if the function loss is of less than 1 year duration. Some patients will need prolonged courses of corticosteroids because of their tendency to have prolonged and recurrent episodes of reactions or neuritis. Hence it is inevitable that some patients will develop one or more adverse effects of corticosteroids. Some of the side effects are mild and transient (moon face, acne etc.) while some are serious and life threatening (Secondary infections like tuberculosis, peptic ulcer perforation, diabetes etc.). Some side effects are neither mild nor life threatening but potentially disabling (osteoporosis, cataract, glaucoma).
While the side effects are alarming, the Doctor has to continue corticosteroids for the leprosy patients when indicated tackling the adverse effects as well as controlling the leprosy reactions and neuritis.
The present paper will furnish the incidence and implications of corticosteroid toxicity in the proper perspective without any prejudice so that clinicians will be able to understand and tackle the problem without fear thereby extending the maximum benefit to the patients. The problems and their solutions will be discussed with graphs and tables.

 

OCA 13

HISTOLOGIA DA ÁREA PERILESIONAL EM PACIENTES PORTADORES DE HANSENÍASE TUBERCULÓIDE E DlMORFA REACIONAL
Joel C. Lastória, D.V.A. Opromolla, Raul N. Fleury, Alexandra P. Bononi, Karina G. Pedroso, Carlos R. Padovani., Mariângela A.E. Marques
Depto de Dermatologia da E M. de Botucatu- UNESP

A hanseníase, de acordo com o sistema de classificação adotado pelo VI Congresso Internacional de Leprologia, 1953, apresenta duas formas polares, clínica e imunologicamente distintas: o tipo virchoviano e o tuberculóide. Apresenta ainda dois grupos instáveis, o indeterminado e o dimorfo. Em todas elas, exceto na indeterminada, a evolução crônica pode ser interrompida por surtos agudos, denominados de tuberculóide reacional (TR), dimorfo reacional (DR) e, quando na virchoviana, de eritema nodoso. Na tentativa de diferenciar os TR dos DR, os autores avaliaram a histologia da área lesional e perilesional em 17 pacientes com forma TR e DR durante o surto reacional e observaram que nos pacientes TR não houve alteração histológica da pele perilesional em l00% dos casos, enquanto que nos pacientes DR, 60% deles apresentaram infiltração nesse local, muito embora sem que houvesse diferença estatística, talvez pelo tamanho amostral. Com esses resultados, não podemos afirmar quanto à diferença entre estas formas pela histologia da região perilesional clínicas mas. no entanto, quando houver infiltrado perilesional. este paciente não deve pertencer ao grupo TR.

 

OCA 14
HISTOPATHOLOGICAL STUDY ON EXPERIMENTAL LEPROSY IN TUPAIAS (Tupaia belangeri yunalis)
Wang Heying; Liu Jihe; Yu Lingchong, et al.
Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for STD and Leprosy Control, Nanjing 210042.

In order to explore new experimental leprosy in tupaias. Ten tupaias were infected with 5.01042.67107 M. leprae by different routes, intravenous and subcutaneous (fore and hind foot pads. nose, ears) or intratesticular inoculation. These animals were scarified 373-786 days after infection, the average time were 546 days. Large patches of leprous granulomatous infiltration, containing a large number of acid last bacilli (AEB) were found at the inoculated sites by histopathological examination. The morphologic indices (MI) of most AFB were greater than 40%, and the bacterial indices (HI I ranged 5+-6+. The dermal nerves showed "onion skin-like" ± appearance and were severely destroted with large numbers of AFB and globi. It looks like borderline lepromatous leprosy in tissue sections. The bacilli in the foot pads of tupaia increased up to 5.97109/g of tissue. According to the histopathological observation and bacteriological determination, it is proved that experimental leprosy model in tupaia has been established.

 

OCA 15

IMMUNOHISTOCHEMISTRY, IN SITU HYBRIDIZATION AND IN SITU PCR IN THE HISTODIAGNOSIS OF EARLY LEPROSY
Mohan Natrajan; Kiran Katoch; V.M. Katoch

Histological confirmation of the clinical diagnosis of early lerosy using conventional histopathological techniques is possible only in a fraction of the cases. The present study was done to assess the role of immunoperoxidase techniques, in situhybridization and in situ PCR in the histodiagnosis of leprosy where conventional histopathology fails.
Forty four cases showing a non-specific pathology on routine histopathology and. which were negative for AFB were chosen for the study. Immunostaining for mycobacterial antigen using an indirect immunoperoxidase technique and the streptavidin-biotin system, revealed the presence of antigen in 10 of 44 cases (22.7%) cases. In situ hybridization using digoxigenin labelled oligonucleotides gave positive signals in a further 13 of 33 cases (39.3%). Finally, the use of in situ PCR in resulted in positive signals in 6/11 cases (54.5%) I which were negative by in situ hybridization.
The technical feasibility and limitations and the usefulness of these procedures will be presented.

 

OCA 16

INOCULATION OF M. leprae IN RIGHT FOOT PAD IN MICE AND ITS CONTRALATERAL EFFECT ON THE NEUROFILAMENTS OF SCIATIC NERVE
M.P. Save1; V.P. Shetty1; KT Shetty2; N.H.Antia1

1. The Foundation for Medical Research, 84-A R.G.Thadani Marg, Worli, Mumbai 400 018, India Tel: 91-22-4934989, Fax: 91-22-4932876 frchbom@bom2.vsnl.net.in.
2. National Institute of Mental Health and Neurosciences. Bangalore.

Mouse is a well established animal model for leprosy. The sciatic nerves of mice inoculated in both the hind foot pads with viable (VML) and heal killed M. leprae (HKML) showed the loss of immunoreactivity to phosphorylated epitopes of NF heavy chain (using SMI 31 antibody) in WB analysis of Triton X-100 insoluble cytoskeletal preparation. These observations were corroborated by the abnormal immunostaining pattern of affected nerves and ultrastructural changes such as compaction and arraying of filaments particularly in atrophied libers as well as at the S-L cleft region. It was also noted that HKML cause NF alterations earlier however transient, than the VML. The observations were suggestive of a role for cellular component(s) of M. leprae in triggering the onset of such degenerative changes.
The question then was: what is the effect of unilateral M. leprae inoculation on the contralateral side? Further experiments were carried out using a similar protocol. Adult Swiss White mice were inoculated into the right hind foot pad with 1 × 104 acid fast bacilli (both VML and HKML). Both left and right sciatic nerves were biopsied at regular intervals starting from one week till 12 month. Changes in the Rt and Lt sciatic nerves were compared.
Results showed a) qualitatively similar contralateral effect with both VML and HKML inoculation, b) The changes were of smaller magnitude as compared to ipsilateral side c) There was some difference in time kinetics. These results have far reaching implications on the mechanism of nerve damage in leprosy.

 

OCA 17

INTRAOCULAR LENS IMPLANTATION IN MULTIBACILLARY AND PAUCIBACILLARY LEPROSY PATIENTS.
Ebenezer Daniel; Sheena Koshy
Schiefellin Leprosy Research and Training Center, Karigiri, Vellore District, Tamilnadu, India - 632106.

Pre-operative, operative and post-operative ocular complications in 48 eyes of 39 leprosy patients who underwent standard extra-capsular cataract extraction and posterior chamber intra-ocular lens implantation, by the same surgeon, during 1997-1998, were studied retrospectively, 17 were male and 22 female. 13 (33%) were pauci-bacillary (PB) while 26 (67%) were mulli-bacillary (MB) patients. 3 patients were smear positive at surgery. Grade II deformity that included claw hands, absorbed fingers, saddle noses and foot drop were present in 64% of the patients. None had any previous intra-ocular inflammation although 1 patient had had Type I reaction and 5 patients, Type II reaction. Pre-operative complications like corneal opacities (3 eyes) and lagophthalmos (5 eyes) were not associated with lowered vision postoperatively. No significant operative complications were encountered except in one eye where there was a posterior capsular tear. 17 eyes (35%) developed uveitis of 3+ or more in the immediate post-operative period but abated with routine topical steroid eye drops. 6 months after surgery 7 out of 47 eyes (15%) had developed posterior capsular opacities (PCO). The amount of uveitis and PCO were similar to those reported in non-leprosy patients. There were no significant differences (p>0.05) in the visual acuity outcomes or ocular complications when MB patients were compared with PB patients. Post-operative complications were not significantly different in smear positive patients compared with smear negative patients. Visual outcomes in the 23 eyes followed up at 2 years after surgery were 6/18 or higher except in one eye which had sustained severe injury 1 year after surgery. IOL implantation in leprosy patients has definite advantages and given the right management, is reasonably safe.

 

OCA 18

LEPROSY TRANSMISSION AND MUCOSAL IMMUNITY IN HOUSEHOLD CONTACTS OF SUBJECTS WITH NASAL PRESENCE OF M. leprae Ravindra R Kamble; Dr. R.S. Jadhav; Miss A. Fernando; Miss V.S. Shinde; Mrs. S.P. Madhalie; Dr. V. K. Edward; Dr. J.R. Rao; Prof. W.C.S. Smith on behalf of MILEP-2 Study Group
Stanley Browne Research Laboratories, Richardson Leprosy Hospital, Miraj, Maharashtra-416410. Tel. No Off: 0233-21 1213 Fax: 0233-211708 E-mail: sblabtlm@vsnl.com

Multi Drug Therapy of leprosy has helped to bring down the prevalence rate, but the new case detection rate has not decreased in the endemic areas. A study was designed to look at the transmission and the development of mucosal immunity. In the present study, 3034 individuals from three villages in Miraj taluka in the State of Maharashtra, India were initially screened. Out of which a cohort of 154 subjects was identified as the household contacts of 42 individuals carrying M. leprae in their nose (PCR-C), and then followed up in a six monthly follow-up. Presence of M. leprae on the nasal mucosa in subjects studied was identified by Polymerase Chain Reaction (PCR) and mucosal immunity was detected by measuring the salivary anti-M.leprae IgA antibodies (sML-IgA) using ELISA. An average of 75% of the subjects (PCR-C) were positive for sML-IgA throughout the three follow-ups. sML-IgA positivity was higher in females than in males. Throughout the year, 65-80 % of the total subjects tested showed sML-IgA response. 3 subjects from PCR-C group were found to be PCR positive in the first follow-up. which became negative in the second follow-up. Subjects in all the age groups showed sML-IgA response. The response between BCG vaccinated and non-vaccinated individuals did not show any difference. In the follow-up studies it was observed that in the PCR-C group, two out three subjects were PCR positive in the summer season unlike the rest of the population, which showed peak of PCR positively in the monsoon. It is possible that close contact may play a role in transmission. Follow-up studies with shorter intervals can shed more light on the mechanism of.

 

OCA 19

LOW BONE MASS IN PATIENTS WITH PROLONGED REACTIONAL EPISODE
Ximena Illarramendi; José Augusto Costa Nery; Euzenir Nunes Sarno
Laboratório de Hanseníase, Departamento de Medicina Tropical, Instituto Oswaldo Cruz, FIOCRUZ, Av. Brasil 4365. Rio de Janeiro. R.J. CEP. 21045-900. Brasil.

Reactional episodes may recur after lowering the doses or ending the various treatments. Generalized osteoporosis has been reported during reactions and prolonged use of steroids could increase the risk for suffering it. In a previous study in treated leprosy patients, taking prednisone (PDN) resulted in 4 times higher risk of radiography diagnosed osteopenia. We evaluated 22 patients treated for multibacillary leprosy (10 females. 12 males) aged 23-49 years with prolonged reactional episodes. Bone mineral density (BMD) of the lumbar spine, the proximal femur and the distal radius was determined by dual X-ray absorptiometry using a LUNAR® densitometer. Erythema nodosum leprosum with neuritis was the most frequent form of reaction recorded (81%). The patients had been taken PDN among other drugs during an average of 39 ± 18 months. The mean daily dose received was 28.6 ± 13.1 mg/day. A positive significant correlation was found between the BMD measured at the different sites (femur/spine r=0.565 p=0.008; femur/radius r=0.678 p=0.001: spine/radius r=0.452 p=0.04). Osteoporosis was found in 5 patients (3 female, 2 male, 3 at age 20-29 years) in the spine and one also in the radius. Osteopenia was seen at 52 sites. No association was observed with sex or having a positive bacilloscopie index. For increasing cumulative dose of PDN lower z-scores were found in the femur (r=-0.45 p=0.04). The expected reduction of bone mass with age was not observed in this group of patients. The lowest mean values were observed in the lowest decade. In spite of the high daily doses of PDN received, few cases of osteoporosis were observed. Spinal osteoporosis could be a result of the prolonged use of steroids, but low bone mass at other sites could also be due to the reactional episode itself.

 

OCA 20

MARCADORES CLÍNICO-LABORATORIAIS AUXILIARES NO MONITORAMENTO DO ERITEMA NODOSO HANSÊNICO Martins, A.B; Simão. J.C.; Foss. N.T.; Souza. C.S.
Divisão de Dermatologia da Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo.

Grande parte das complicações da Hanseníase é decorrente das reações hansênicas. O eritema nodoso hansênico (ENII) demonstra efeitos de acentuada formação de imunocomplexos.
Objectivos: Avaliar a freqüência de alterações clínico-laboratoriais em amostra de doentes com ENH. Enumerar os exames laboratoriais relevantes para o monitoramento das reações hansênicas
Casuística e Métodos: Procedeu-se levantamento e análise retrospectiva de prontuários-médico dos doentes assistidos no Ambulatório de Hanseníase. HCFMRP. Verificou-se registro da investigação clínico-laboratorial em 24 prontuários de doentes em vigência de reação tipo ENH.
Resultados: No total de 24 doentes. 50% eram do sexo masculino. Dos doentes avaliados, 80.9% apresentaram elevação de proteína C-reativa. Em 8 doentes, o nível de mucoproteína foi normal e o α-ácido glicoproteína (α-AGP) elevado em todos. Na avaliação de enzimas hepáticas, 58,3% apresentaram algum tipo de alteração: γGT estava elevada em 47,6%, TGP em 25% e TGO em 20.8%. Verificou-se redução da albumina sérica em 30,76% e a de proteína total em 12.5% dos doentes. Foi observada leucocitose em 50% dos doentes e anemia em 62,5%, sendo que 4 apresentaram valores eram inferiores a 7.0 mg/dl. Em 54,2% havia febre; em 33,495 artiralgia; em 12,5% hepatomegalia; em 8,4% esplenome-galia: em 16.7% adenomegalia; em 25% sinais clínicos evidentes de neurite.
Conclusões: Nossos resultados confirmaram a relevância de avaliação mullissistêmica, indicando alta percentagem de doentes com elevação da proteína C-reativa sérica, sugerindo esta medida como parâmetro de monitoramento da reação hansênica. Salienta-se que as alterações de enzimas hepáticas, particularmente, as canaliculares e os distúrbios hematológicos que devem ser investigados nos episódios de ENH.

 

OCA 21

OCULAR COMPLICATIONS OF LONG-TERM ORAL CORTICOSTEROID THERAPY IN PATIENTS WITH LEPROSY REACTIONS
Monica Jeha Maakaroun M.D. Aldemar N.B; Vilela de Castro M.D.
Hospital São Geraldo/UFMG - Av. Alfredo Balena, 190 - Belo Horizonte/MG and, Sanatório Santa lzabel/FHEMIG - Betim/MG - BRASIL

The use of systemic or topical ophthalmic corticosteroids is an established risk factor in the development of ocular hypertension and/or posterior subcapsular cataract. Dermatologists often prescribe long-term oral corticosteroid therapy in the treatment of leprosy reactions and ocular side effects have not been reported yet. There were 31 patients (mean age 36,8 ± 13.0 years) with leprosy reactions studied. All patients were receiving oral corticosteroid therapy (prednisone) for a mean duration of 18.7 ± 10,1 months. The dose range was 5 to 60 mg (mean dose. 19,8 ± 11,8 mg) by the time of the ophthalmologic examination. Of the 62 eyes, 14 (22,6%) showed ocular hypertension and 12 (19,4%) had posterior subcapsular cataract formation. Regular eye examinations are recommended for all patients during the entire course of long-term oral corticosteroid therapy to minimize ocular side effects and to prevent iatrogenic visual loss.

 

OCA 22

PREVALENCE AND CHARACTERISTICS OF NEUROPATHIC PAIN IN 303 PATIENTS WITH LEPROSY
Patrick R.N.A.G. Stump; Rosemari Baccarelli; Lucia H.S.C.; Marciano; Jose R.P. Lauris; Somei Ura; Marcos Virmond; Manoel J. Teixeira
Instituto Lauro de Souza Lima, CP 3031, Bauru - SP, Brasil.CEP 17034-971.

Aim of investigation: This study aims to contribute to the knowledge of neuropathic pain prevalence in leprosy.
Methods: A total of 303 leprosy patients attending at Lauro de Souza Lima Institute and the Infections Disease Center were evaluated (58.7% lepromatous, 25.7% borderline, 13.9% tuberculoid and 1.7% indeterminate). All patients underwent neurological examination with special focus on the occurrence of pain, its localization, duration, installation, intensity (verbal scale) and quality (McGill Pain Questionnaire).
Results: Neuropathic pain was present in 174 (57.4%) patients. It occurred before (73.0%) or at the moment of evaluation (27.0%). Pain lasted more than six months in 138 (79.4%) and installed as bursts in 84 (48.3%) cases out of the 174 cases. It affected one or more peripheral nerve territories totalizing 291 territories, ulnar nerve in 101 (58.0%), tibial nerve in 48 (27.6%), polyneuropatic distribution as glove in 47 (27.0%) or sock 47 (27.0%.). Pain was present at the moment of evaluation in 47 (27.0%) patients. It was moderate or severe in 41 (87.2%), constant in 30 (63.8%) and remitted in only 9 (19.1%).
Conclusions: Neuropathic pain is an important, frequent and lasting occurrence in leprosy. It is also a disabling condition that can lead to poor quality of life by itself. The low frequency of remitted pain suggests the need to a better approach of antalgic therapy in leprosy. There is also a need to develop a national study to quantify the prevalence of neuropathic pain in Brazil and to discuss the need of a national politic to implement antalgic therapy in leprosy.

 

OCA 23

PROPHYLACTIC STEROIDS TO PREVENT NERVE FUNCTION IMPAIRMENT IN LEPROSY: A RANDOMISED CONTROLLED TRIAL (TRIPOD 1)
A.M. Anderson; W.H. van Brakel; S.G. Withington; R.P. Croft; P.G. Nicholls; J.H. Richardus; W.C.S. Smith
International Nepal Fellowship-RELEASE, PO BOX 28INF-RELEASE. PO BOX 28, Pokhara, Nepal aanderso@inf.org.np

Aim: It was investigated whether treatment with low dose prednisolone for the first four months of multidrug treatment (MDT) would reduce the incidence of leprosy reactions leading to nerve function impairment (NFI). in patients with multibacillary (MB) leprosy at diagnosis.
Methods: A multicentre randomised, double-blind, placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Eligible patients had a confirmed leprosy diagnosis, were between 15 and 50 years old, were starting MB MDT for the first time and did not require steroids for other reasons. Subjects were randomised to prednisolone 20 mg per day for 3 months, tapering during the 4th month, or placebo. Nerve function was monitored monthly. The main trial outcome was the percentage of patients needing full-dose steroid treatment for Type 1 reaction (RR), type 2 reaction (ENL), NFI or neuritis, assessed at 4, 6, 9 and 12 months from the start of the treatment.
Results: 636 patients were enrolled; 312 (49%) in the prednisolone arm and 324 (51%) in the placebo arm.There is a significam preventive effect of prednisolone at 4 and 6 months, bua Chis is noa sustained to the 12th month. At the end of the treatment phase, the relativerisk of a poor outcome given placebo compareci withprednisolone is 3.93 (95% CI 2.13-7.25). At 12 months there is still an increased relative risk, but the effect is not significant (RR 1.31, 95% CI 0.95-1.81)
Conclusion: Prophylactic treatment with steroids of MB patients starting on MDT with the given dose and duration prevents NFI at 4 and 6 months after the start of treatment, but the effect is not sustained at 12 months.

 

OCA 24

PROPHYLACTIC STEROIDS TO PREVENT NERVE FUNCTION IMPAIRMENT IN LEPROSY: THE EFFECT OF PRE-EXISTING NEUROPATHY OBSERVED IN THE TRIPOD 1 TRIAL
W.H. Van Brakel; A.M. Anderson; S.G. Withington; R.P. Croft; P.G. Nicholls; J.H. Richardus; W.C.S. Smith
TLM Research Resouce Centre, 5 Amrita Shergill Marg, New Delhi – 11003.

Aim: To assess whether prophylaxis with low dose prednosolone during the first 4 months of MB MDT will result in at least a 50% reduction in the number of patients experienceing Type 1 Reaction (T1R) leading to nerve function impairment (NFI) compared to those receiving placebo treatment. This report describes the effect of pre-existing neuropathy on the outcome.
Methods: A multicentre randomised, double-blind, placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Eligible patients had a confirmed leprosy diagnosis, were between 15 and 50 years old, were starting MB MDT for the first time and did not require steroids for other reasons. Subjects were randomised to Prednisolone-prednisolone 20 mg per day for 3 months, tapering during the 4th month, or placebo. Nerve function was monitored monthly. The main trial outcome was the percentage of patients needing full-dose steroid treatment for Type 1 reaction (RR), type 2 reaction (ENL), NFI or neuritis, assessed at 4, 6, 9 and 12 months from the start of the treatment.
Results: 636 patients were enrolled; 312 (49%) and 324 (51 %) in the prednisolone arms, respectively. Preexisting NFI older than 6 months was present in 153 subjects (24%). A striking difference was observed in the effect of the prophylaxis between these subjects and those without pre-existing NFI. In the former group, there was no significant difference between the treatment and placebo group at any point during follow-up, while in the latter, a strong protective effect was present at 4 months, relative risk 6.7 (2.7-16.7), gradually declining to 1.45 (0.97-2.18) at 12 months.
Conclusion: Prophylactic steroid treatment did not prevent reactions or NFI in those with pre-existing neuropathy. A strong protective efffective effect was observed in those without NFI during and directly after the prophylaxis, but this was not sustained during the 8 months of post-prophylaxis follow-up. The pathophysiological mechanism of reactions and neuropathy appears to be different in both groups.

 

OCA 25

STUDIES ON MECHANISM/S OF SILENT NERVE DAMAGE IN LEPROSY WITH SPECIAL EMPHASIS ON BIOCHEMICAL BASIS OF AXONAL ATROPHY
V.P. Shetty1; M.P. Savel; K.T. Shetty2; N.H.Antia1

1. The Foundation for Medical Research, 84-A R.G. Thadani Marg. Worli, Mumbai 400 018, India Tel: 91-22-4934989, Fax: 91-22-4932876; E-mail: frchbom@bom2.vsnl.net.in.
2. National Institute of Mental Health and Neurosciences. Bangalore.

Pathomechanism/s of silent nerve damage in leprosy is not known. A morphological feature commonly seen in leprous nerves was the presence of atrophic axons. Question that remained was why and how such atrophic changes occur. A further study therefore was carried out to understand the structural and biochemical basis of axonal atrophy in leprous nerves. Since axonal caliber is governed by the C-terminal phosphorylation of high molecular wt. Neurofilaments (NF-H and NF-M) it was hypothesized that there may be involvement of the same following infection with M. leprae. In order to test this hypothesis, the state of NFH phosphorylation was studied in leprous nerves using immunohistochemistry. SDS-PAGE, WB technique (using SMI-31 antibody) and correlated with morphological changes. Both human and experimental mouse sciatic nerve model are used for the study. The results indicate that there is disturbance in the phosphorylation mechanisms of neurofilaments in leprous nerves in contrast to controls. It is also noted that the bacterial antigens play a crucial role in triggering these changes It is suggested that the observed hypo-phosphorylation of NE proteins could be the factor behind the Silent Neuropathy that precedes clinically demonstrable manifest hypo-anesthesia and anesthesia.

 

OCA 26

THE DEFORMED FOOT: CORRECTIVE ARTHRODESIS IN LEPROSY IN NEPAL
Mark Macdonald; Malcolm Stoney; Richard Schwartz
Anandaban Leprosy Hospital, PO Box 151, Kathmandu, Nepal. E-mail: anandaban@mail.com.np

Nerve invasion by leprosy bacteria commonly results in neurologically impaired lower limbs. Denervation to external and internal structure can lead to stress fractures, collapse and recurrent ulceration. This commonly presents as a foot with change of normal anatomy and function. In a foot which has concurrent loss of normal protective sensation, the risk of further damage is high. The aim of corrective osteotomy and arthrodesis is to restore the foot to as close as possible to the normal anatomical foot, to fit conventional footwear and to decrease recurrent ulceration.
Aim: To review the results of corrective arthrodesis surgery performed over a twenty-year period at two major tertiary leprosy referral centres in Nepal
Methods: Data was collected by review of medical records of all patients who had undergone an arthrodesis of the foot or ankle at Anandaban Green Pastures Hospitals between 1980 and 2000. Types of procedure, methods of fixation, post operative complications and fusion rates were reviewed, as was the incidence of recurrent ulceration.
Results: 116 corrective arthrodesis were performed in 107 patients (73 male, 34 female) There was a infection rate and six patients required a further procedure. 16% failed to fuse but in some cases the fibrous ankylosis was adequate for stability. 63% avoided further admissions for recurrent ulceration after the procedure. The complication rate was high but in line with that of the literature.
Conclusion: These results indicate that corrective arthrodesis is helpful in reducing recurrent ulceration secondary to deformity, but that occasionally further procedures such as soft-tissue reconstruction must be considered. Corrective arthrodesis will also enable the patient to wear normal footwear in most cases. Arthrodesis in those with recurrent acute neuropathic symptoms can also prevent further bone and joint destruction.

 

OCA 27

THE INFIR COHORT STUDY: ANALYSIS OE RELIABILITY AND NORMAL DATA FROM THERMAL SENSORY TESTING
Peter Nicholls; Wim H. van Brakel; Loretta Das; Alex Mathew; Sujai K. Suneetha; Rupendra S. Jadhav; Pranava Maddali; Diana N.J. Lockwood; Einar Wilder-Smith; K.V. Desikan

Aim: The INFIR Cohort Study aims to find clinically relevant predictors of nerve function impairment (NF1) and reactions.
Design: A multi-centre cohort study of 300 multi-bacillary patients, followed for two years.
Methods: Staff in the field centres were trained, reliability testing of the key techniques was done and normal reference data were collected. The test methods include Thermal Sensory Assessment using the Medoc TSA II Neuro Sensory Analyzer, a computer-based system that logs warm and cold detection thresholds by nerve in a data base. After training, staff at each centre completed paired bi-lateral assessments of some 60 leprosy patients, assessing cold and warm thresholds on ulnar, median, radial cutaneous, posterior tibial and sural nerves. Having established adequate reliability, we proceeded with collection of data to assess normal detection thresholds for warm and cold sensation. We recruited consenting volunteers, without signs of neurological disorders or diabetes, from amongst individuals not affected by leprosy attending the hospital outpatient department. Data were collected on people in four age groups of 75 individuals each, 10-30. 31-40, 41-50 and 51-60 years, with equal sex distribution within each group. For both reliability and normal data analysis of thermal sensation we extracted data from the Medoc data base and completed the analyses using Excel and STATA. For the reliability study, analysis followed the method of Altman and Bland.
Results: We found good agreement between paired assessments for both warm and cold detection thresholds. From the analysis of normal data we present age group-specific thresholds within each sex group. Because of the skewed nature of the data we discuss the need to compute these from log-transformed data. Implications of our findings are discussed.
Conclusion: The investigations described show that thermal detection thresholds in hands and feet can be reliably tested and quantified in a leprosy-endemic population

 

OCA 28

THE INFIR COHORT STUDY: INVESTIGATING PREDICTION, DETECTION AND PATHOGENESIS OF NERVE DAMAGE AND REACTIONS IN LEPROSY
Wim H. van Brakel; Peter Nicholls; Loretta Das; Alex Mathew; Sujai K. Suneetha; Rupendra S. Jadhav; Pranava Maddali; Diana N.J. Lockwood; Einar Wilder-Smith; K.V. Desikan
TLM Research Resource Centre, 5 Amrita Shergill Marg, New Delhi - 11003 - wvhrakel@mail.com.

Aim: To find clinically relevant predictors of nerve function impairment (NF1) and reactions, to determine which method(s) of nerve function assessment are most sensitive in detecting peripheral neuropathy, to study the pathogenesis of peripheral neuropathy and reactions and to create a bank of biopsy specimens and sera, backed up by detailed clinical documentation.
Design: A multi-centre cohort study of 300 multi-bacillary (MB) patients, followed for two years.
Methods: All newly registered MB patients requiring a full course of MDT are eligible. MB patients are defined as those who are smear positive and/or have 6 or more skin lesions and/or have two or more nerve trunks involved. A detailed history is taken, including an activities of daily living assessment, and physical and neurological examinations are done. Peripheral nerve function is evaluated at each visit using sensory and motor conduction testing, quantitative thermal sensory testing, electronic vibrometry, dynamometry, Senimes-Weinstein monofilaments (SWM) and voluntary muscle testing. The study outcome for sensory and motor impairment uses the latter two tests as the 'gold standard'. Oilier outcomes are Type 1 and 2 reactions and neuritis. A severity scale is used to grade the severity of the latter three outcomes. All subjects have a skin biopsy at registration, repeated at the time of an outcome event. At that time a radial cutaneous or sural nerve biopsy is also taken. The biopsies are being examined using a variety of immuno-histological techniques lo detect cell populations and cytokine production. Blood sampling for immunological testing is done at every 4-weekly clinic visit. Samples are frozen in liquid nitrogen and transported by train to the designated laboratories. A specimen bank has been set up at the Blue Peter Research Centre in Hyderabad.
Results: By February 2002. 230 subjects had been enrolled. Enrolment is expected to close in Spring 2002. Reliability studies of the neurophysiological tests have shown good results. Details of some of the methods will be presented.

 

OCA 29

THE LINK BETWEEN FACIAL PATCHES AND LAGOPHTHALMOS OCCURRENCE DURING TYPE I REACTION IN LEPROSY
Diltor V.A. Opromolla; Rosemari Baccarelli; Somei Ura; Marisa Goebel; Cassio Ghidella
Institute Lauro de Souza Lima, CP 3031, Bauru - SP, Brasil, CEP 17034-971.

Aim: This study aims to investigate the relationship between facial patches ami lagophthalmos occurrence during Type I reaction in leprosy.
Methods: The charts of paucibacillary leprosy patients attended at Lauro Souza Lima Institute (ILSL) in Bauru - SP, Brazil, were reviewed for facial patches due to Type I reaction and for recent zygomatic temporal branches damage of the facial nerve, facial patches were divided into "significant" patches (more than three centimeters in diameter, located on the zygomatic region and/or around the eye) and "other" patches (smaller than three centimeters in diameter and/or located elsewhere in the face). This study was divided in two categories: retrospective (patients attended at ILSL from 1983 to 1993) and a prospective part (patients attended at ILSL after 1993). To be part of this study the patient should not be using steroids during the reaction course.
Results: In the retrospective category, the majority of patients were already using steroids when they were studied. This also occurred in the prospective category, but in a smaller percentage. Overall. 7.5% of the patients studied were not using steroids and did not have lagophthalmos when they were examined throughout the course of the reaction.
Conclusions: The lagophthalmos is not a mandatory condition in the presence of facial patches due to Type I reaction therefore, there is no need to use the steroids as a prolilatic if there is no damage in the zygomatic temporal branches of the facial nerve.

 

OCA 30

USE OF AZATHIOPRINE IN THE TREATMENT OF LEPROSY TYPE I REACTIONS
Rachel Hawksworth; Sharon Marlowe; Ruth Butlin; Maria Jacob K; Murdo Macdonald; Peter Nicholls; Diana Lockwood
Anandaban Leprosy Hospital. PO Box 151. Kathmandu, NEPAL. E-mail: anandaban@mail.com.np

Type I reactions (T1R) are acute inflammatory episodes which occur in about 30% of non-polar leprosy patients. The standard treatment of these reactions is with corticosteroids (prednisolone). However, these often need to be given for long periods of time and so the risk of side effects is therefore considerable.
Aim: To reduce the overall steroid dose by the use of azathioprine as an adjunct treatment in severe T1R, and to document the safety profile of azathioprine in leprosy.
Methods: A total of 40 T1R patients were recruited between June 2000 and September 2001. The test group received azathioprine at a dose of 3mg/kg/ day with a reduced course of steroids, while the control group received the semi-standard WHO 12 week prednisolone course. Patients were assessed al intervals during and following the treatment course using a severity grading which included appraisal of skin, systemic anil nerve signs, and also VMT and ST assessments.
Results: During the six months of monitoring, 23 patients required extra prednisolone (13 in the azathioprine plus prednisolone group and 10 in the prednisolone only group). Results will be presented of a comparison between the clinical outcomes of skin, systemic and nerve indicators in the two treatment groups.
Conclusion: Azathioprine has been shown to be a safe drug for use in leprosy. Our evidence indicates that it may be a useful steroid-sparing agent in leprosy, but further studies in this regard are required.

 

OCA 31

ZONAS CUTÁNEAS INMUNES A LA LEPRA
Dr. José Terencio de las Aguas

Es evidente el dermotropismo del Mycobacterium leprae por la piel, y lo abundante y frecuente de estas lesiones, sin embargo hay zonas cutáneas que nunca o excepcionalmente son afectadas por la Lepra, como son las regiones inguinales, pubis, genitales masculinos y femeninos, axilas, cuero cabelludo, palmas y plantas.
Se expone nuestra experiencia personal durante 49 años en unos tres    mil enfermos y nunca hemos observado lesiones en axilas, genitales e ingles, pero sí aunque no son frecuentes en cuero cabelludo, palmas y plantas, y pubis, y casi todos en pacientes LL y BL siendo las lesiones clínicas maculas infiltradas y nódulos.
Más excepcionales son las Reacciones en las lesiones de estas zonas, habiendo observado algún caso de Eritema Nodoso en cuero cabelludo y genitales masculinos.
Curiosamente, no obstante, la preferencia del M. leprae por las zonas más frías y periféricas del cuerpo, poco suelen ser afectados el cuero cabelludo, genitales, palmas y plantas.

 

 

EPIDEMIOLOGY

 

OE 1

A PROSPECTIVE (SERO-)EPIDEMIOLOGICAL STUDY ON CONTACT TRANSMISSION AND CHEMOPROPHYLAXIS IN LEPROSY (COLEP)
J.H. Richardus1; H.F. Moet1; L. Oskam2; D. Pahan3; S.G. Withington3

1. Department of Public Health, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam. The Netherlands.
2. Department of Biomedical Research. Royal Tropical Institute, Amsterdam, The Netherlands.
3. Danish Bangladesh Leprosy Mission, Nilphamari, Bangladesh.

It has become increasingly apparent that treatment of leprosy patients alone will not lead to a decline in the incidence of leprosy. Previous studies indicated that chemoprophylaxis, especially of contacts of known leprosy patients, may make a major contribution in the prevention of leprosy. It was also shown that, by broadening the definition of "close contacts" from household contacts alone to a wider circle including neighbours and social contacts as well, sources of infection for new leprosy cases could be described more accurately.
The COLEP research project will investigate the efficacy and cost-effectiveness of a single dose of rifampicin to prevent leprosy in close contacts of newly detected leprosy patients. The study design is that of a single centre, randomised, double-blind placebo-controlled trial in which 20.000 contacts from 1.000 consecutive leprosy patients will receive one single dose of either rifampicin or placebo and will be I'ol-lowed-up for 4 years to study and compare the incidence of leprosy in the 2 study groups. In addition, the prevalence and incidence of leprosy in the general population by means of a referent group of 20,000 individuals will be studied. In the same framework, the application of serology on linger prick blood for the prediction of the development of leprosy and for the monitoring of the effectiveness of chemoprophylactic interventions will also be studied.

 

OE 2

A RETROSPECTIVE STUDY OF 3,062 MB CASES IN 12 YEARS FROM THE PROJECT AREAS OF ALERT INDIA
Joy Mancheril; A. Antony Samy; PR. Dewarkar; Dr. Sachin Salunkhe
ALERT-lndia. B-9 Mira Mansion, Sion (West), Mumbai - 400 022. India.

About 3062 MB cases in the project areas of ALERT-INDIA in Bombay and New Bombay between the years 1990 to 2001 (inclusive) have been studied here considering the following parameters: age, sex, duration of residence in Mumbai, province of origin in INDIA, mode of detection, bacteriology, deformity status, reactions, response to chemotherapy, and presence of other cases in the family. From the results and trends, recommendations for further control work are discussed.

 

OE 3

A STUDY OF RISK FACTORS OF LEPROSY TRANSMISSION IN AGRA DISTRICT
Anil Kumar; Anita Girdhar; B.K. Girdhar
Central Jalma Institute For Leprosy, Taj Ganj, Agra 282001

Background: Leprosy continues to be one of the major public health problems in some countries. Recent figures suggest that there are over 750,000 leprosy eases reported in the world and major portion of this comes from India. This is inspite the fact that MDT was introduced in India almost 2 decades ago. It is believed that apart from hidden cases there are other factors responsible for the continued transmission in the community. It is therefore important to study the factors that may help in transmission of leprosy.
Material and Methods: A total 92305 persons were examined during July 1999 - June 2001 from the 25 blocks in Agra district and about 300 sub units (localities) are surveyed in house to house examination. Rural population constitutes 32126 (35%). A team consisting of trained Paramedical workers and Medical doctors carried out the survey. The household details on housing and surroundings, personal detail like age/sex, work type and leprosy classification etc were recorded during the survey. Data has been analyzed using SPSS software and Logistic regression has been used to assess the risk.
Results: The prevalence of leprosy/10.000 in rural area was 47.9 (154/32126) which is significantly higher than 33.9 in Urban areas. Over 50% of the subunits were found to have atleast one active case of leprosy needing treatment. Univariate analysis suggested that leprosy prevalence was significantly high among persons living in rural areas, living in kuccha and dirty housing, houses without toilet facility and engaged in blue collar works mostly engaged in agriculture/leather and other manual jobs. Adult Males had preponderance of disease.
Conclusion: Important risk factors for leprosy are related to housing and work type. If these are taken care off along with the good coverage and regularity of treatment, leprosy eradication may be achieved faster in India.

 

OE4

AÇÕES DO CONTROLE DOS COMUNICANTES DE HANSENÍASE NO BRASIL (1889 A 2001).
Gazeta, C.E.; Mencaroni; D.A; Oliveira, M.H.P.; Pinto Neto. LM.; Villa, T.C.S.
Escola de Enfermagem de Ribeirão Preto/ Universidade de São Paulo. Av. Bandeirante, 3900. Campus Universitário - Ribeirão Preto - CEP 14040-902. São Paulo. Brasil.

Dentre os vários problemas de saúde pública que coexistem no Brasil, destaca-se a endemia hansênica, cuja prevalência c de 4.6 casos/ 10 mil habitantes. A distribuição da endemia é irregular e vários são os fatores que contribuem para a manutenção da mesma, entre eles, o baixo controle dos comunicantes, os quais apesar de apresentarem um risco maior de adquirir a doença, especialmente os contatos de doentes multibacilares, tem sido pouco valorizados pelos serviços e profissionais de saúde. Este estudo descritivo, realizado por meio de uma revisão da literatura buscou identificar as medidas de controle dos comunicantes de hanseníase no Brasil, de acordo com o estabelecimento de três periodizações a partir de 1889 à atualidade: o período do uso do óleo de Chaulmoogra até 1940, depois, do uso das sulfonas até 1990, e, por último, do uso da MDT. Nesses períodos os serviços e profissionais de saúde parecem ter privilegiado o espaço para o controle da doença e do doente, não valorizando o controle dos comunicantes e o cumprimento das legislações pertinentes a cada um desses períodos. Acreditamos que, com "doente tratado e comunicante controlado", os serviços de saúde podem contribuir para a eliminação da hanseníase como problema de saúde pública até o ano de 2005.

 

OE5

ANÁLISE DA TENDÊNCIA SECULAR DA HANSENÍASE NO BRASIL E MACRORREGIÕES NO PERÍODO 1985-2001
Gerson Fernando Mendes Pereira; Maria da Conceição Cavalcanti Magalhães
ATDS / SPS / DAB / MS

A hanseníase ainda é considerada um problema de saúde pública no Brasil. O país tem como compromisso internacional, a eliminação da doença como problema de saúde pública até o flinal do ano elo 2005 (taxa de prevalência de < 1 doente a cada 10.000 hab.). Nas últimas duas décadas as ações tio programa tem sido intensificadas, aumentando o diagnóstico tia doença (mais de 300%) em todo país, enquanto a prevalência foi reduzida em mais de 80%. O presente estudo tem como objetivo analisar os dados de detecção tias macrorregiões e Brasil entre os anos de 1985 a 2001, utilizando, análise de variância. Após o desenho tias curvas de tendências fazer a projeção tios casos para os anos subseqüentes e prever as taxas de detecção tia doença para o país até o ano de 2005 e contribuir para verificar a possibilidade tio alcance da mela de eliminação da doença até a data estabelecida.

 

OE6

ANALYSIS OF THE CASES OF LEPROSY NEWLY DETECTED IN ZHEJIANG PROVINCE FROM 1989 TO 1998
YAO Jianjun; ZHOU Ailin; SHEN Yunliang; I.UO Chi; XU Yaping
Zhejiang Provincial Institute of Dermatology, 313200. Deqing, Zhejiang, China
Objective: To discuss epidemiology character and control of leprosy in low epidemic.
Methods: A retrospective study was used for 271 cases of leprosy newly detected in Zhejiang province from 1989 to 1998.
Results: The mean of detection rate was 0.063/ 100,000. The main character of epidemiology: the age of attack increased; the ambiguity of source of infection manifold and the proportion of MB increased year after year. The most cases of leprosy newly detected have been infected outside the household. The disease duration shortened and the II level of disability rate decreased, assumed the connection of parallel.
Conclusion: Mostly control of leprosy: the health education should develop actively and the initiative outpatients increase, so that the forepart of patient detected cure in time.
[Key words] leprosy; the cases of leprosy newly detected; control

 

OE7

ANALYSIS ON CORRELATIVE FACTORS RELATED TO SUBCLINICAL INFECTION IN CONSANGUINEOUS CONTACTS OF LEPROSY
Shunpeng SONG; Yuejun SHI; Chengzhi LU et al.
Dalian Provincial Institute of Dermatology, 116021, Dalian, China.

Objective: To approach the status of subclinical infection in consanguineous contacts of leprosy and Analysis of correlative factors on subclinical infection.
Methods: Using ND-IgM-ELlSA method to examine the sub-clinical infections. Single and multi-factor non-conditional logistic regression analysis were used to analysis.
Results: The results of single factor X2 analysis revealed that: sex, age, the relationship with the patient, leprosy type of patienta, the length of contact were the risk factors related to the subclinical infection in consanguineous contacts of leprosy. But only sex, age, the relationship with the patient, leprosy type of patienta were significantly correlated with subclinical infection in multi-factors logistic equation analysis.
Conclusion: Sex, age, the relationship with the patient and leprosy type can significantly effect the subclinical infection of consanguineous contacts of leprosy.
[Key words] Leprosy subclinical infection, non-conditional, logistic, regression, analysis

 

OE8

ASSESSMENT ON THE EPIDEMIOLOGICAL TREADS IN LEPROSY-ENDEMIC VILLAGES
Weng Xiaoman1; Weng Yan1; Yuan Lianchao1; Li Huanying1; Yang Longde2; Long Hen2

1. Beijing Tropical Medicine Research Institute.
2. Wenshan Prefecture Institute of Dermatology, Qioube County Station of Dermatology.

How to assess the magnitude of leprosy problem, or to estimate whether the transmission of leprosy exists or not is a difficulty facing leprosy control at present. It was reported that three and 5 leprosy patients were detected newly in Tonghong and Nanqiou. Yunnan Province, during LEC in 1997. The epidemiological investigation was conducted in the two leprosy-endemic villages and the combination PGL-ELISA and PCR with nasal swabs is intended to estimate the intensity exposure to M. leprae. The investigative results showed:

  1.  Nine patients and 23 had been cured respectively since implementation of MDT in Nanqiou and Tonghong village. Two and 4 cases detected newly during of LEC were confirmed respectively by clinical, pathological and serological in Nanqiou and Tonghong village and most of them are under 25 years old.
  2. The prevalence and detective rate in Tonghong village are higher than those in Nanqiou village. But no significant difference can be found in the PGL-lgM positivities in general villagers between the two villages (18.7%, 76/406 & 20.86, 104/457; X2 =2.12. P= 0.145). However, in the <20 years age groups, PGL-IgM positivity in Tonghong village is much higher than in Nanqiou village (55.1%, 70/127 & 40.8%, 51/125 X2 =? 2 ?). Therefore, the positive correlation may exist between positivity of PGL-lgM in younger people and the number of leprosy patient in the population.
  3. In household contacts, PGL-IgM positivity and M. leprae nasal carriage with PCR are 30.4 % (17/56) and 23.1 % (9/39) respectively. Although PGL-IgM positivity in household contact was higher than one in general villagers (20.86 %, 180/863), no significant difference of PGL positivity can be found between household contacts and general villagers (X2=2.82,2=0.093).
  4. Whether Tonghong or Nanqiou village, the peaks of PGL-IgM positivity rate are in the <20 years age group and the positivities of PGL-IgM are decreased with increasing of age. in addition, PGL-lgM positivity in female is higher than in male.

The cases detected newly during LEC were distributed mainly in younger group and it parallels with the peak . PGL-IgM seropositivity can reflected the intensity of exposure to M. leprae in population of high endemic-leprosy village. It is necessary to monitor epidemiological trend in the two villages with serology based on PGL-1 or other more specific tests in order to demonstrate whether the transmission of leprosy is controlled in the two villages.
There is no significant difference in positive rates of PGL-IgM between household contacts 30.4% (17/56) and the general population 20.86% (180/863) (X2=2.82, P=0.093).

 

 

OE9

CAPTURE-RECAPTURE METHOD TO ASSESS THE PREVALENCE OF DISABLED LEPROSY PATIENTS
Jacques van den Broek1; Theo van Jaarsveld2; Ad de Rijk3; Kefas Samson4; Philip Patrobas4

1. Netherlands Leprosy Relief (NLR), c/o Van Ommerenslraat 16,5708 KB, The Netherlands.
2. Netherlands Leprosy Relief (NLR), c/o Grevinckstraat 26, 6525 CH Nijmegen, The Netherlands.
3. Netherlands Leprosy Relief (NLR), c/o Sophialaan 6, 1075 BR Amsterdam. The Netherlands.
4. Netherlands Leprosy Relief (NLR), Yelwa Club Room 3, PO. Box 759, Bukuru, Plateau State, Nigeria.

A two-sample capture-recapture method can easily be applied,

  • using data from hospital admissions, and
  • data from a sample survey Otl leprosy patients with impairments in the field.

Limitations: the completeness of reporting alter invitation in the field, as well as the probable biased sample of leprosy patients admitted to hospital.
Conclusion: relying on the initiative of patients to report to the clinics for prevention of disabilities and rehabilitation interventions to the clinics, causes the real size of the problem to be underestimated by a factor of 3 to 4.
Recommendation: the use of a special "care" register for disabled leprosy patients so that their needs for prevention of impairments and disabilities and lor rehabilitation are better addressed.

 

 

OE 10

CLOSE CONTACTS IN LEPROSY IN A HIGH AND LOW ENDEMIC AREA: COMPARISON BETWEEN BANGLADESH AND THAILAND
J.H. Richardus; A. Meima; R.P. Croft; T.C. Smith
Department of Public Health, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.

Background: As part of a larger study of the role of close contacts in leprosy transmission, it was investigated whether the proportion of newly detected cases with known close contacts with leprosy differs with different incidence rates of leprosy in a population.
Methods: Retrospective analysis of close contacts of all new leprosy patients diagnosed during a 10-year period in well-established leprosy control programmes in Thailand and Bangladesh. Contacts are defined as relatives and in-laws with contact to the new case, who were once themselves diagnosed with leprosy. Contacts were differentiated into three levels. In Bangladesh these levels were defined as 'kitchen contact'; 'house contact'; and 'non-house contact'. In Thailand comparable levels were defined as 'house contact'; 'compound contact'; and 'neighbour contact'.
Results: In Bangladesh 1.333 new patients, and in Thailand 129 were included. The average new case detection rate over 10 years was 50 per 100.000 general population per year in Bangladesh, and 1.3 per 100,000 in Thailand. In the high-endemic area approximately 25% of newly detected cases had a known close contact, whereas in the low-endemic area this was 75%. The distribution of patients with known contacts over the three contact levels was comparable in both areas. Around half of the contacts were found within the immediate family unit. In both areas children aged 0-14 years had the highest level of known contacts, primarily within the immediate family unit.
Conclusion: Different contact levels and their relative risks to contract leprosy need to be established more precisely. In high endemic situations the circle of contacts to survey may need to be wider than currently practised.

 

OE 11

COMPARAÇÃO DE MÉTODOS DE ESTIMATIVA DE PREVALÊNCIA DE HANSENÍASE EM DIFERENTES REGIÕES DO ESTADO DE MATO GROSSO
Eliane Ignotti; Alex Miranda Rodrigues
Escola de Saúde Pública Dr. Agrícola Paes de Barros - MT; Universidade do Estado de Mato Grosso; Secretaria Municipal de Saúde de Chapada dos Guimarães - MT. eignotti@uol.com.br; alexmr@vsp.com.br

O Objetivo deste estudo é comparar três métodos de estimativa de prevalência de hanseníase entre municípios das regiões do Baixo Araguaia e Baixada Cuiabana do estado de Mato Grosso no período de 1996 a 2001. Tendo em vista a intervenção da SES-MT no ano de 2001, para a eliminação da hanseníase. denominada: "Projeto prioritário Tolerância Zero: Mato Grosso sem hanseníase", fez-se necessário o cálculo da prevalência estimada para todos os municípios do estado. O planejamento das ações, assim como dos incentivos financeiros vinculados ao referido projeto dependem diretamente do aumento do coeficiente de detecção e altas por cura. A SES-MT agrupou os municípios em quatro estratos de prioridade, tendo por parâmetro a prevalência e 0 número de habitantes. Entretanto, estudos anteriores apontam para a necessidade de informações referentes ao grau de incapacidade dos doentes (FERREIRA et al. 2000) somada à coorte de casos novos registrados nos 5 anos anteriores à estimativa (GIL & LOMBARDI. 1997) para o cálculo da estimativa real por meio da prevalência oculta. Os autores discutem as deficiências de todos os métodos, tendo em vista a homogeneidade com que foram tratados os municípios na perspectiva do estado e as deficiências das informações quanto ao grau de incapacidade e coortes históricas, imprescindíveis na aplicação dos outros dois métodos.

 

OE 12

DOES THE CURRENT GLOBAL LEPROSY ELIMINATION STRATEGY REDUCE THE INCIDENCE OF LEPROSY?
A. Meima; W.C.S. Smith; J.H. Richardus; G.J. van Oortmarssen; J.D.F. Habbema
Department of Public Health, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

We investigate the impact of the current global strategy to eliminate leprosy as a public health problem on leprosy transmission, and the consequences of relaxing this strategy after 2005. Calculations are made using SIMLEP, a computer simulation programme for modelling the transmission and control of leprosy which can be used to predict epidemiological trends.
In many major endemic countries, the new case detection of leprosy did not decline in the 1990s. Using different epidemiological assumptions, we show that the underlying incidence may have been decreasing, but also that it may have remained static. Due to shortened detection delays, the incidence rate declines between 2000 and 2020 in all scenarios. The simulated annual rales of decline vary widely, depending on when and how fast leprosy transmission is assumed to occur. Relaxing control after 2005 leads to a fall in new case detection rates, and to a slowing down in the decline in the incidence rate of leprosy. Some simulations even show small temporarily increases in the incidence. The incidence rate decreases faster when policies of BCG vaccination of infants are adopted. The acceleration in the decline depends on the protective efficacy of BCG which may wane over time, and on the population coverage that can be achieved.
This study predicts that the current elimination strategy reduces leprosy transmission, but that the decline in incidence may be slow. Sustainabilily of early case detection and treatment after 2005 is critical for maintaining the decreases in incidence. Further research on transmission is essential for narrowing down the uncertainty regarding future leprosy trends and for long term planning of leprosy control.

 

OE 13

EPIDEMIOLOGICAL STUDY ON DISABILITIES IN 24128 NEWLY DETECTED LEPROSY PATIENTS IN CHINA
YAN Lianghin; ZHANG Guocheng; CHEN Xiang-sheng; et al
Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for STD and Leprosy Control, Nanjing 210042

To approach the status of leprosy disabilities in newly delected cases in recent 11 years in China and provide the scientific basis for formulating the preventive strategies. Based upon the records from the National Leprosy Recording and Reporting System in National Center for STD and Leprosy Control, 24 128 leprosy cases detected during 1989-1999 in China were analyzed in terms of leprosy disbility. The proportion of disabilies in newly detected leprosy cases in 1989 in whole country was 46.49% and decreased to 32.7% in 1999, and the proportions of cases with grade II disabilities were 25.55% (1989) and 22.06% (1999). There were 19 provinces where disability rate was more than 40%. Out of patients with disabilities, those with grades I and II disabilities and with deformities (loss of eyebrow, facial paralysis or saddle nose) accounted for 37.54%, 61.039 and 1.42%, respectively. There were 20 provinces where grade 11 disabilities accounted for more than 50% of all patients with disabilities. The disability rates in patients aged under 15 years, 15-65 years and over 65 years were 24.74%. 39.3% and 53.33%. The patients with a delay in detection of 2 years had a disability rate of 28.95%, and those with a delay of more than 2 years and 5 years had the rates of 48.06% and 60.95%, respectively. The disability rate was 53.76% in patients with leprosy reactions. The grade 11 disability rate in paucibacillary patients (28.53%) was significantly higher than that in multibacillary ones (22.03%). Disability rate of leprosy in newly detected cases is still high although it has decreased in the recent 11 years. The rale is associated with delay in detection, leprosy reaction anil leprosy type. It suggests that early detection of leprosy patients, regular treatment with multidrug therapy, and management of leprosy reactions will be the effective measures to prevent disabilities of leprosy.

 

OE 14

EPIDEMIOLOGY OF LEPROSY ON FIVE ISOLATED ISLANDS IN INDONESIA
M. Bakker1; M. Hatta2; A. Kwenang2; L. Oskam1

1. KIT Biomedical Research. Meibergdreef 39, 1105 AZ Amsterdam, The Netherlands.
2. Dept. Microbiology, Faculty of Medicine, Hasanuddin University, Makassar, Indonesia.

On 5 small islands in Indonesia a population-based survey was carried out to collect baseline data previous to an intervention study. Here we present the epidemiology of the present leprosy situation on these geographically isolated islands.
Of the 4,774 inhabitants living in the study area 4.140 (87%) were screened for leprosy. A total of 96 leprosy patients (85 new and 11 previously diagnosed patients) was found, representing a new case detection rate of 205/10,000. Of the new patients, 33 (39%) were classified as multihacillary, 16 (19%) as paucibacillary (PB) 2-5 lesions and 36 (42%) as PB single lesion.
Multiple logistic regression was used to determine which risk factors were independently associated with leprosy. Living on the island Kembanglemari was associated with leprosy (odds ratio (OR): 3.4) compared to Sapuka. Overall, no statistically significant difference in OR was observed between men and women. However, within age groups differences were seen: 20-29 year old men hail a higher risk of developing leprosy (OR: 2.7) compared to women in this age group. Within the group of new patients men had a higher risk to be classified as MB compared to women (OR: 2.5). Age and island were not related lo classification.
A spatial scan statistic was used to test for clusters of leprosy patients (both new and old) on each island. In this high leprosy endemic area leprosy patients were clustered: they were not equally distributed among the islands and within the islands among the houses.

 

OE 15

EVALUATION OF MLEC IN BIHAR STATE - INDIA
Dr. P. Krishnamurthy; Dr. G. Ramakrishna Raju; Dr. Bishwanath; Prasad, Dr. T. Prabhakar Rao; Dr. P. Vijayakumaran
Damien Foundation India Trust.

Modified Leprosy Elimination Campaign carried out in Bihar State with an intention to detect as many hidden cases as possible through publicity, active search and voluntary reporting in December 2001. Evaluation of MLEC was done in January 2002, to know the extent of coverage (Population), to assess the quality of case diagnosis in terms of accuracy and to assess the impact on awareness level in community. 38 blocks (average population of block is 1.50.000) in 22 districts were randomly selected and one team (One MO and I NMS) with vehicle for each block identified and briefed. Evaluators obtained lists of suspects and confirmed patients, identified village wise from the concerned PHC. They took the help of MO PHC and NMS/MPHW in preparing visit schedules and in identifying suspects and patients in villages. Totally 17.126 suspects were identilied, 8876 (51.8%) were screened by programme. Of the screened 3331(37.5%) were cases, 1106 (12.5%) old cases and 4439 (50%) not cases. 80% of cases confirmed by programme are screened by evaluators. The result was that 74.6% (1996) were real cases. 12.5% (334) were old cases and 12.9% were not cases. Of the 4439 suspects declared as not cases by programme. 3501 were examined by team. 103 (3%) were found to be new cases.
Sensitivity for diagnosis was 87.3%. Specificity was 90.4%. Only 8.2% of suspects not screened are new cases. During evaluation 821 additional new cases were detected. Awareness about disease among patients was good and awareness about programme among the community was also good.

 

OE 16
HANSENÍASE E EMIGRAÇÃO EM UMA ÁREA INDUSTRIAL
Ferrucio Fernando Dall'Áglio; Lúcia Mioko Ito; Rodrigo Sestito Proto; Juliano Cesar de Barros; Simone Santos
Departamento de Dermatologia da Faculdade de Medicina do ABC.
Av Príncipe de Gales. 821 - -09060-650-Santo André -SP- Brasil.

Introdução: Na região do Grande ABC. houve uma grande migração principalmente do Nordeste do país, com repercussões no número de doentes de hanseníase na região. Com isso, o número de casos novos incidentes ano a ano, permaneceu estável, apesar do serviço de Hansenologia local é de ótima qualidade, sendo feito somente por médicos especialistas e com todo o amparo do serviço público. Analisaremos o presente fato frente ao objetivo do Ministério da Saúde ter resolvido erradicar a hanseníase em 2003.
Casuística: Foram analisados as fichas de notificação compulsória e prontuários médicos de pacientes com hanseníase no período de 1991 a 1999, considerando como doentes emigrados os pacientes que residiam na região há menos de 07 anos e como da região, os autóctones e os emigrados há mais de 07 anos com residência estabelecida.
Resultados e discussão: Num total de 558 pacientes, 237 eram da região e 321 emigrados, mostrando a influência da emigração, sendo isso analisado em comparação com a emigração normal de não doentes. Foram analisadas ainda as causas de tal emigração

 

OE 17
INCIDENCE RATES OF ACUTE NERVE FUNCTION IMPAIRMENT (NFI) IN LEPROSY: A PROSPECTIVE COHORT ANALYSIS AFTER 60 MONTHS (THE BANDS STUDY)
J.H. Richardus; R.P. Croft; P.G. Nicholls; S.G. Withington; W.C.S. Smith

Background: NFI is the key outcome of the pathological processes of an infection with M. leprae, which can continue after completion of multidrug therapy (MDT) and lead to disability after leprosy patients are released from treatment.
Methods: Prospective cohort study of 2,664 new leprosy patients in Bangladesh, with an observation period of 60 months in multibacillary (MB) patients, and 36 months in paucibacillary (PB) patients. Incidence rates (IR) were calculated with the number of patients developing NFI for the first time as the numerator, and cumulative person-years at risk (PYAR) as the denominator.
Results: The IR of first event of NFI amongst MB patients was 16,7 per 100 PYAR, with 121/357 (34%) developing NFI during the observation period. Of the 121 with a first event of NFI, 77 (64%) had this within a year after registration, and the remaining 44 (36%) after 1 year. The IR of first event of NFI amongst PB patients was 0.9 per 100 PYAR, with 53/2153 (2.5%) developing NFI during the observation period. Of the 53 with a first event of NFI, 32 (60%) had this within the first 6 months and 16 (30%) between 7 and 12 months. The remaining 5 (10%) PB cases had their first event of NFI after 1 year.
Conclusion: NFI in MB patients is a common phenomenon, and occurs in over a third of the patients after completing the current 1-year course of MOT. In PB patients, NFI occurs in only a limited proportion of patients, but in 40% of the cases after completion of the 6-month course of MDT. Systems to monitor nerve function need to be designed to take into account this high frequency of development of new NFI after completion of MDT.

 

OE 18

IMPACT OF MLECs IN NLEP BIHAR - A STUDY
Dr. P. Krishnamurthy; Dr. G. Adisesha Reddy; Dr. Bishwanath Prasad; Dr. T. Prabhakar Rao; Dr. G. Ramakrishna Raju; Dr. P. Vijayakumaran
Damien Foundation India Trust

In addition to regular case detection activities by vertical NLEP in Bihar special MLECs were conducted in 1998, 2000 and 2001 for seven days, visiting all the houses in rural and urban areas of all the districts by search team. Of course in 1998 Bihar included Jharkhand also. Idea behind these campaigns was to detect all the active cases of leprosy from the hidden pool and involvement of General Health staff. In 1998 total cases detected were 2.05,559, in 2000 - 80,710 and in 2001 - 42,770. In comparison to total new cases detected in the year Ist, IInd, and IIIrd MLEC contributed 72.88%, 58.7% and 40.5% respectively with deformity rates among new cases 4.6%, 2.2% and 2.3%.
Only one week activity involving all the general health staff has yielded a good percentage of newly detected cases and in capacity building of Gil staff in leprosy work.
These figures show that consecutive MLECs have given a great additive impact on the NLEP in creating awareness, better understanding among the community and patients. Messages of leprosy disease, its cure by MDT, prevention of future or further worsening of deformities has reached the vast majority of the public and community. It is evident that there is decrease in PR, NCDR and deformity rates too.

 

OE 19

LEPROSY DISABILITY: A PUBLIC HEALTH PROBLEM FOR MANY YEARS TO COME
A. Meima; J.H. Richardus; G.J. van Oortmarssen; J.D.F. Habbema
Department of Public Health, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands.

It is disability that determines the burden of leprosy disease. Little is known about the prevalence of disability. The present study aims to estimate the present global prevalence of individuals with WHO grade 2 disability, and to give projections for this prevalence up to the year 2020.
We estimate the present global prevalence of grade 2 disability on the basis of assumptions on past incidence rates of disability, and on survival of individuals with disability using a lifetable approach. The estimates obtained will be compared with the only other available estimates which are supplied by WHO. These estimates of the prevalence of grade 2 disability range from in between 1 to 2 million (1994) to in between 2 to 3 million (2001). Projections up to 2020 will be obtained from the assessment for the current situation, scenarios for the future new case detection of leprosy as obtained with the leprosy simulation model SIMLEP and present percentages of new cases presenting with grade 2 disability. Starting from WHO's 2 million estimate for 1995 which is age-specific, we estimate the global prevalence of WHO grade 2 disability in 2020 to be at least 1.4 million. The uncertainty involved is considerable, and a range of scenarios will be presented. The main conclusion however remains unchanged: in terms of disability, leprosy will remain a public health problem for many years to come

 

OE 20

LEPROSY TRANSMISSION AND MUCOSAL IMMUNITY: M. leprae EXPOSURE AND HUMORAL MUCOSAL IMMUNE RESPONSE IN ENDEMIC POPULATION
Miss V.S. Shinde; Dr. R.S. Jadhav; Miss A. Fernando; Ravindra R. Ramble; Mrs. S.P. Madhale; Dr. J.R. Rao; Dr. V.K. Edward; Prof. W.C.S. Smith on behalf of M1LEP-2 Study Group*
Stanley Browne Research Laboratories, Richardson Leprosy Hospital, Miraj, Maharashtra-416410. Tel. No Off: 0233-211213 Fax: 0233-211708 E-mail: sblabtlm@vsnl.com

Introduction: Widespread use of MDT in closely monitored programmes has not prevented transmission of leprosy. Exposure to M. leprae may lead to primary nasal infection, which can be transient in most individuals. Mucosal immune response to M. leprae may develop during resolution of this initial infection. Frequent exposure could lead to high levels of mucosal immunity.
AIM: To study M. leprae exposure and the development of mucosal immunity in leprosy endemic population in which MDT has been used for more than 10 years.
Setting: Three villages from South Maharashtra comparable in size, socio-economic status and prevalence of leprosy, and in which MDT had been in place for at least 10 years.
Methodology: Polymerase Chain Reaction and Peptide Nucleic Acid - ELISA was used for the amplification and detection of M. leprae DNA present on the nasal mucosa. An ELISA based technique was used to study the mucosal immune response.
Results: 3035 subjects were screened in the study. Mucosal immune response against M. leprae was observed in approximately 679 of the subjects tested throughout the study with almost 127 subjects showing very high response (ML-IgA++). PCR positivity in this group of subjects was 1.78%. Development of high mucosal immunity and the PCR positivity changed in different follow-ups. 73-77% of the subjects with high immunity show indication of the mucosal immunity in the prior follow-up (6 months before). Similarly more than 60% of the MI-IgA++ subjects show M. leprae reactive antibodies in the subsequent follow-up.
Conclusion: Mucosal immunity against M. leprae appears to be widespread in the endemic population. As the M. leprae exposure seems to be a transient phenomenon, shorter duration follow-ups can shed more light on the correlation of the immunity and its role in protection.

 

OE21

LONG TERM FOLLOW-UP OF THE KARONGA PREVENTION TRIAL: 15 YEAR TRENDS IN PROTECTION AGAINST LEPROSY AND TUBERCULOSIS BY BCG, REPEAT BCG, OR BCG COMBINED WITH KILLED M. leprae IN NORTHERN MALAWI
Karonga Prevention Trial Group; Karonga Prevention Study; Chilumba; Malawi
Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK

BCG has been found to provide greater protection against leprosy than against tuberculosis in several populations, including in northern Malawi. A large randomized controlled trial of single BCG, repeat BCG, and BCG combined with killed M. leprae was undertaken in Karonga District starling in 1986. Data published in 1996 showed that a second BCG provided approximately 50% protection against leprosy over and above a single BCG, for 5 - 8 years after vaccination, thus indicating that two BCG vaccinations provided approximately 75 % protection compared to nil vaccine. No protection against pulmonary tuberculosis was observed. Data are now available reflecting incidence 12 - 15 years after vaccination. Analyses have not been completed in time for this abstract, but will be presented and discussed at the Congress.

 

OE22

MICRO-MONITORING-A KEY MANAGEMENT TOOL FOR PLANNING STRATEGIC INTERVENTIONS AND FACILITATING LEPROSY ELIMINATION GOAL
Dr T.P. Patro, Advisor; Dr. D. N. Nayak
DANLEP, Orissa, India

Introduction: Monitoring is an integral part of any project or program. Unless properly monitored, it can't be measured hence cannot managed. So the ultimate objectives are adversely affected and sometimes defeated. This holds good for leprosy elimination goal reset at 2005(WHO). Earlier monitoring was more focused at the macro level- Global and National level. Subsequently it was decentralized and focused at sub national/ stale level and district level. This was logical according to the then prevailing situation. But the situation is very different now. In Orissa PR has come down from 121.3/10000 in 1983 to 9.7/10000 at present with nearly 95% fall. But if we analyze the situation at sub district and sub health center level it is generally observed that caseload is not uniformly same all over. It varies from districts to districts and with in the districts.
Objective: To focus monitoring at sub district and sub health center level
Strategy: Analyze the leprosy elimination parameters such as PR, NCDR, DR, Cure rate, Coverage rate, Relapse rate, MB rate, Child rate and SSL rate. Analysis of the trends on the same process.
Purpose: To motivate the decision makers and program managers to take suitable decisions. To prioritize the focused areas and make interventions.

 

 

Conclusions: Based on the findings of the above table problem areas were identified. Special strategy for urban, tribal, rural and border areas are implemented. Interventions like SAPEL/LEC/GS are implemented. Replication is possible.

 

OE 23

PERIPHERAL NEUROPATHY IN HD; A PROBLEM FOR HOSPITAL OR EPIDEMIOLOGIC STUDY?
Judith Bell-Krotoski
National Hansen's Disease Programs, Rehabilitation Research, 1770 Physicians Park Dr., Baton Rouge, LA, USA, 70816

Peripheral neuropathy in Hansen's disease (HD) is often considered a problem for hospital treatment, not one for disease surveillance, or epidemiologic study. Dermatologic manifestations of the disease are readily treatable today. But the peripheral nerve complications that frequently accompany the disease are not as readily treatable. A patient may have nerve complications that lead to nerve impairment and disability either before being diagnosed, during the course of treatment, or even later. Many patients who are "effectively" treated with antileprosy medications today will not have disabling neuropathy or progression of neuropathy. If disease surveillance could easily detect those who do, then the overall success of pharmacologic treatment could potentially be improved. Focusing on patients who have evidence of continued peripheral nerve neuropathy as a group is more likely to identify those with persistent and resistant disease. Searching for factors that they have in common could improve treatment resolution and thereby increase the number of patients "cured". Were peripheral neuropathy simply arrested with chemotherapy against the M. leprae bacillus, resolution of the nerve complications and prevention of disability would be simple and straight-forward. But, it is known that some patients considered "effectively" treated for the infection per se, still develop disabling neuropathy. Hand and foot screen monitors have been developed and well tuned over many years, and can be used for surveillance as well as for case detection of those needing further treatment. This paper/report will review 25 years of peripheral nerve monitoring in HD, what we have learned, and implications for future directions and treatment.

 

OE 24

PERSPECTIVAS DE ELIMINAÇÃO DA HANSENÍASE ATÉ O ANO DE 2005
L.M. Bechelli; N.T. Foss
Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo

Em 1994 Bechelli analisou a resolução da Assembléia da Organização Mundial de Saúde (maio de 1991), que aprovou a eliminação global da hanseníase, como problema de saúde pública, até o ano 2000, definida como a redução da prevalência a 1 caso ou menos por 10 mil habitantes, concluindo que não parecia possível conseguir a eliminação global da hanseníase como problema de saúde pública, até o ano de 2000: a não ser que urna nova droga ou vacina fosse utilizada. Sansarricq e Daumerie (2001) preconizam a eliminação até 2005 destacando: "Todavia, em alguns países, a eliminação da prevalência em nível subnacional não seria conseguida". Bechelli, ligado ao problema da hanseníase desde 1934, reconhece a complexidade do problema e augura pleno sucesso ao plano. No entanto, parece que a eliminação dificilmente poderá ser atingida no prazo de 5 anos. Os esforços para combater a pobreza e outros fatores epidemiológicos de áreas endêmicas dificilmente terão o sucesso desejado nesse curto prazo. "A miséria deve favorecer a propagação da moléstia, como conseqüência do desasseio, promiscuidade nas habitações (aumentando a 'exposição') e depauperamento orgânico, favorecendo a baixa da resistência" (Bechelli e Rotberg 1956). A eliminação exige a erradicação da pobreza, responsável também pela presença de várias enfermidades (tuberculose, aids e outras). Na Índia (Maharashtra) Bansod Baliran (2001) julga que condições sócio-econômicas: sócio-culturais, habitats pessoais têm grande influência na propagação da moléstia. Não existe droga ideal, como a penicilina na sílilis. nem uma vacina como a antivariólica. Ademais, são desfavoráveis as condições sócio-econômicas nas áreas endêmicas, inclusive com o aumento de desemprego. Por isto não parece possível conseguir a eliminação global da hanseníase como problema de saúde pública até o ano de 2005.

 

OE 25

RISK FACTORS FOR NERVE FUNCTION IMPAIRMENT, FIVE YEAR FOLLOW-UP OF THE BANDS COHORT
P.G. Nicholls; R.P. Croft; J.H. Richardus; S.G. Wellington; W.C.S. Smith
University of Aberdeen; Department of Public Health, Polwarth Building, Foresterhill, Aberdeen AB25 2ZF, Scotland.

Nerve-function impairment (NFI) commonly occurs during or after chemotherapy in leprosy. Prom the completed follow-up of the Bangladesh Acute Nerve Damage Study (BANDS) we describe the development of NFI and present a simple clinical prediction rule identifying the risk of NFI during follow-up.
BANDS was a five year prospective cohort study of new leprosy cases in northern Bangladesh. Data from regular field assessments were recorded on computer. We used Cox's proportional hazards regression to identify predictive variables for first events of NFI during follow-up.
Amongst 2510 patients not requiring steroid treatment at registrration 175 developed new or further NFI during follow-up. Our analysis identified a simple predictive rule with three levels of risk for new NFI:
Low risk: PB leprosy with no history of nerve-function loss at registration
Medium risk: MB leprosy with no history or PB leprosy with a history of NFI.
High risk: MB leprosy with a history of Nil.
We will also describe our findings in relation to recurrent, chronic and late events and to risk factors for silent neuritis and for reversal reaction. We consider the implications for surveillance of new leprosy patients.

 

OE 26

STEPWISE REGRESSION ANALYSIS OF RISK FACTORS ON THE DEGREE OF DISABILITIES OF LEPROSY
Chengzhi Lu; Shujian Gao; Zhenguo Zhang; et al
Dalian Provincial Institute of Dermatology, Dalian 116021.

Objective: Analysis of factors impacting on the degree of disability of leprosy.
Methods: Based upon the individual records from 485 leprosy cases with disability in liaoning province. The arithmetic disability index(ADI) and weighted disability index(WDI) were used as the quantity index of the disability and eleven factors were analysed on SPSS 10.0.
Results: the results showed that the significant leprosy affecting disability were the same by these two indices, the factors are: the patients age, leprosy reaction, leprosy type, standard of living.
Conclusion: the pstient's age, leprosy reaction, leprosy type and standard of living can significantly effect the degree disability of leprosy. It is very effective to prevent the degree disability of leprosy through the early case-finding and immediate treatment, controlling the reaction, and increasing the standard of living.
[Key words] Leprosy, Disability, stepwise, regression, analysis

 

OE 27

TENDENCIA DE LA DETECCIÓN DE CASOS NUEVOS DE LEPRA EN PARAGUAY (1970-2001)
Oscar Leguizamón; Carlos Wiens; Wolfgang von Ballestrem; Arnaldo Alvarenga; Reinaldo Gil Suárez; Clovis Lombardi
Ministerio de Salud Pública y Bienestar Social - Departamento de Lepra and OPAS

En base a los datos que se procesan en el Archivo Central de casos nuevos de lepra delectados cada año en Paraguay, se hace un estudio de la tendencia temporal de la endemia en el país.
El estudio abarca el período 1970-2001 analizándose las formas clínicas de la enfermedad y los grupos de edad a través de las tasas brutas y específicas, así como las proporciones de las formas clínicas.
El período evaluado corresponde al marco de una política de control operacional uniforme para lodo el país, elaborado por el Departamento de Lepra del Ministerio de Salud Pública y Bienestar Social de Paraguay.
La tendencia global de las tasas de detección de casos nuevos muestra una declinación muy lenta que se hace más evidente desde 1992, manteniéndose casi estable, desde entonces hasta el año 2001.
Se nota además la mayor incidencia de casos en el grupo de "45 y más años de edad" a lo largo del período analizado, así como también la ascendente preponderancia de las formas multihacilares (MB) sobre las paucibacilares (PB) a partir del año 1983. La incidencia en menores de 14 años ha sido siempre baja, con preponderancia de las formas PB.
La poliquimioterapia (PQT) se inició en octubre de 1980. aunque la cobertura de la PQT recién alcanzó al 100 % de la prevalencia en 1996.

 

OE28

THE ANALYSIS OF SPATIAL PATTERNS OF SEROPOSITIVES OF LEPROSY WITH GEOGRAPHIC INFORMATION SYSTEMS (GIS)
M. Bakker1; M. Hatta2; A. Kwenang2; L. Oskam1

1. KIT Biomedical Research, Meibergdreef 39, 1105 AZ Amsterdam, The Netherlands.
2. Dept. Microbiology, Faculty of Medicine, llasanud-din University. Makassar, Indonesia.

Apart from individual and temporal factors, spatial factors may be important as well in infectious diseases. For leprosy this is the location of persons/patients in relation to each other: the role of proximity. Possible aims of analysing spatial patterns of seropositive persons and leprosy patients are to uncover mechanisms of disease transmission, to identify high risk groups, to identify locations of high prevalence (clusters) and to monitor intervention and control programs. For the analysis of spatial patterns of infectious diseases Geographic Information Systems (GIS) are more and more used. To describe spatial patterns with GIS, maps are needed.
During a cross sectional study on five small islands in Indonesia 3271 serum samples were collected (69% of the inhabitants) and analysed with ELISA to measure the presence of IgM antibodies to phenolic glycolipid I. 16 patients and 96 other individuals were seropositive, representing a seropositivity prevalence in the population of 3.4% (95% confidence interval: 2.8-4.0). Detailed maps of these islands, indicating the locations of all the houses were prepared.
Different methods will be presented which were used to describe the spatial pattern of seropositivity. A spatial scan statistic was used to test for clusters of seropositive persons on each island. Buffers were created around patients to measure the risk of close contact separate for MB and PB patients.

 

OE 29

THE IMPACT OF LEPROSY ELIMINATION CAMPAIGNS ON LEPROSY INCIDENCE TRENDS
A. Meima; J.H. Richardus; G.J. van Oortmarssen; J.D.F. Habbema
Department of Public Health. Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

The effect that Leprosy Elimination Campaigns (LECs) may have on trends in the incidence of leprosy is evaluated using SIMLEP. SIMLEP is a computer simulation programme for modelling the transmission and control of leprosy which can be used to predict epidemiological trends.
In an earlier study, scenarios for future trends in the incidence of leprosy were explored using a baseline control programme with early case detection from 1998 onwards. Both this programme, and a less intensive programme with longer detection delays, are extended with LECs. It is assumed that each time a LEC is conducted, a fixed percentage of existing, undetected patients is delected and will start chemotherapy treatment. The simulations show that conducting only one LEC has a negligible impact on long term incidence trends for all scenarios considered. The additional impact of LECs which are repeated at regular intervals is much larger for less intensive control compared to baseline control which already detects patients early. The simulated additional impact of repeated LECs on trends in incidence increases with shorter intervals between LECs and when LECs detect more patients, and decreases with reverse assumptions. From the perspective of reducing leprosy transmission (and thus incidence), the main conclusion of the scenario analysis is that regularly repealed LECs which detect many patients can be an alternative for intensive leprosy control programmes.

 

OE 30

UNIVERSAL LIMITS, INTER-QUARTILE RANGES AND MEASUREMENT OF THE QUALITY OF LEPROSY CARE IN SUB-SAHARAN AFRICA
Dr. Osalion Ogbeiwi
Africa Monitoring and Evaluation Service, The Leprosy Mission International; PO Box 2847, Minna, Nigeria.

Much effort has been made to set standards that define universally acceptable quality of care. Such standards should be measurable in a way that makes the observed quality care in different programmes comparable contextually. The annual ILEP statistical reports for year 2000 for leprosy control and hospital data were reviewed to measure the quality of leprosy care in 23 programmes assisted by The Leprosy Mission International located in 13 sub-Saharan African countries. Limits given by ILEP (WHO for prevalence) qualified the standard levels where universal indicators are known. Where not known, the lower and upper values of Inter-Quartile Ranges (IQR) were used as 'the approximate normal limits' of quality care. IQR is the middle half of any set of values arranged in order of magnitude. By year 2000. the mean prevalence rate was still above 1/104, but 7 in 10 programmes were already in the elimination phase, mainly in Southern Africa and Nigeria.
The respective ILEP 'accepted limits' and 'thresholds' revealed low case detection rates, low child proportions, high disability assessment proportions and high grade-2 disability proportions in most programmes. While the mean MDT completion rates for both PB and MB were above the limit of 70%, case holding was still below the threshold of 85% in 2/5 programmes for PB and 2/3 programmes for MB.

The IQR limits placed three hospitals in Hast and West Africa at the top extremes for caseload and bed occupancy rate but at the low extremes for % ulcers and mean hospital slay. Hospitals mainly in Central and Southern Africa were at low extreme of caseload but the top extreme of % ulcer cases and mean hospital stay. These hospitals also were low in their rate of ulcer surgery. The level of hospital utilization was directly correlated with the number of surgeries performed: and the higher the % ulcer cases among admissions, the longer the mean hospital stay of the hospital. Like universal limits, IQR is thus an effective tool to determine levels of quality care on reliable indicators for programme monitoring purposes.

 

 

OK 31

VACCINAL SCAR BY BCG AND PREVALENCE OF CLINICAL FORMS IN LEPROSY PATIENTS AND THE RESPONSE TO LEPROMINE IN CONTACTS

Goulart, I.M.B.; Damian, M.G.C.; Ferreira, I.C.C.; Gonçalves, N.S.M.; Pires, B.C.O.; Silva, T.R; Machado, VS.; Berbel Júnior, A.S.
Centro de Referência Estadual em Hanseníase/Dermatologia Sanitária Faculdade de Medicina / Universidade Federal de Uberlândia. Av. Pará 1720. CEP 38400-902 - Uberlândia-MG, Brasil. Fax: +55-32182349: E-mail: inbgoular@ufu.br.

Brazil is signatory of WHO's aim to eliminate leprosy as a public healthy problem until 2005 (to inferior levels of I sick person in every 10 thousand inhabitants). One of the preconized steps is the application of 2 BCG doses in contacts of leprosy patients. In spite of the signs that the BCG can confer resistance to the disease, results in the literature have been controversial.
The objectives were: to establish the correlation between vaccinal scar by BCG. the prevalence of clinical forms of leprosy and the standard response to leprosy forms anil the standart response to lepromine in sick people and their domicile contacts.
A survey of promptuaries of the Hansenology Service - UFU and clinical visits to patients and contacts for verification of vaccinal scar by BCG and for Mitsuda tests. Were done, totalizing 36 patients and 104 contacts.
It was demonstrated that 80% of patients with 2 scars by BCG were Mitsuda positives, while 42.1% of patients without vaccinal scar responded positively to the lepromin test. In the paucibacillary patients, the average response raised from 8.2mm in the abscence of scar to 11 mm in those with 2 scars. The average of multibacillary patients varied from 1.9 mm with 0 scar to 4.5mm with 2 scars by BCG. Contacts of multibacillary patients, without vaccinal scar, showed an average of 7.3 mm of the Mitsuda test, while those with 2 scars showed an average of 10.2mm. The average response to the lepromin test of contacts of paucibacillary patients varied from 6.7mm with 0 scar of BCG to 8.5mm in those with 2 scars by BCG.
Results of this work come to subsidize the application of 2 doses of BCG as a control step to the Leprosy Program of the Healthy Ministry, since BCG seems to confer protection against the disease, mainly to the multibacilary forms.
Support: FAPEMIG

 

HEALTH EDUCATION

OHE 1

A COMPARATIVE STUDY BETWEEN MLEC AND ACTIVE SURVEY
Ashis Mukherjee; Sudhakar Bandyopadhyay
Greater Calcutta Leprosy Treatment German Leprosy Relief & Health Education Scheme Association, 35/1/A, Old Ballygunj 1st lane 23, Market Street, Calcutta - 700019 Calcutta - 700087

Physical examination of population through house-survey is a popular method in a vertical set up which has substantial contribution to detect early and new cases in an endemic country. It contributes directly to community awareness also. The weakness is that the population of a unit area needs more than 3 years to be examined. However, no vertical programme could continue forever and the ultimate is to integrate the vertical programme with the general health services. The mandatory condition of integration is to bring down the caseload to < 2/10.000, which will be manageable to a general health worker. With this aim, the Modified Leprosy Elimination Campaign (MLEC) has been designed to examine the total population of the state at a time. However, the result of last 3 MLECs shows that is has certain weakness and desired number of patients are not detected uniformly. In the same population, same year, it has been observed in the GRECALTES unit area in Calcutta that more than double number of cases have been detected through active survey and voluntary reporting. It is, therefore, suggested that in the endemic pockets, active survey should continue at least for next five years even alter functional integration.

 

OHE2

A CONSTRUÇÃO DO CONHECIMENTO E A REPRESENTAÇÃO SOCIAL DA HANSENÍASE
Colomhani, L.B.; Guedes, M.A.P.; Lessa, Z.L.; Sartorelli, M.E.; Vinhas, L.R.S.
Direção Regional De Saúde De São José Dos Campos - DIR.XXI. Av. Eng. Sebastião Gualberto n°545.

Introdução: A avaliação da situação epidemiológica da hanseníase nos municípios que integram a região, indica a necessidade de intervenções educativas e de organização de serviços para atingir a meta de eliminação proposta. Com o propósito de orientar a população sobre sinais, sintomas, tratamento e cura visando ao diagnóstico precoce foi realizada a Campanha de Combate à Hanseníase.
Objetivo: Avaliar os resultados das intervenções educativas identificando o universo de representações sociais sobre o conceito de hanseníase e as práticas correspondentes. O público alvo foi a população de Ilhabela. São José dos Campos e Santa Branca, com coeficientes de prevalência alto, médio e zerado.
Metodologia: Amostra de grupos de profissionais de saúde e população. Variáveis trabalhadas: sexo, idade, escolaridade, tempo de serviço e de freqüência na UBS. Análise quantitativa através de percentagem e os dados qualitativos analisados através da metodologia do "Discurso do Sujeito Coletivo", que tem como proposta reconstruir a partir de discursos individuais semelhantes, discursos sínteses, que expressem a representação social do estudo.
Resultados: Entrevistadas 746 pessoas na pré-campanha e 798, na pós-campanha. A análise qualitativa do conhecimento construído sobre hanseníase, demonstra que as pessoas possuem representações estigmatizantes e conhecimentos científicos atuais fragmentados.
Conclusão: A complexidade do discurso encontrado indica a necessidade de continuidade de intervenções educativas interpessoais e inovadoras que contribuam para o controle da hanseníase na região até 2005.

 

OHE3

A EDUCAÇÃO EM SAÚDE E AS AÇÕES DE CONTROLE DE HANSENÍASE: CONHECER O PASSADO. REFLETIR O PRESENTE E DECIDIR O FUTURO
Lessa, Zenaide Lazara; Sanches, Maria A.P.; Nogueira, Wagner; Berro, Elza; Metello, Heleida Nóbrega; Gonçalves, Otília J.S.
Secretaria de Estado da Saúde de São Paulo; Centro de Vigilância Epidemiológica-Núcleo de Educação em Saúde: End. Av. Dr. Arnaldo, 355 - 3o andar - sala 83. Cerqueira Cesar. CEP 01246-000 - São Paulo -SP. Fone: (II) 3066-8150/3085-5962.

Introdução: Historicamente a Educação em Saúde, a Saúde Pública e o Controle da Hanseníase, no Estado de São Paulo, caminham associados e direcionados por interesses econômicos, ideologias políticas e descobertas científicas na área de educação e da saúde, ocorridas no século XIX e XX. As ações educativas obedecem a diretrizes pertinentes a cada época enquanto subsídio para as ações de controle.
Objetivo: Identificar, associar, entender e refletir sobre a multideterminação dos fatores que contribuíram para o enfoque pedagógico adotado no controle da hanseníase no século XX e propostas atuais.
Metodologia: Composição histórica abrangendo os cem anos do sec. XX. Pesquisa documental e fotográfica com análise por eixos temáticos: campo da saúde e da educação: determinantes do processo saúde/doença; ação principal; enfoque metodológico; ator principal; cenário e papel do indivíduo. Divisão em quartos de século correlacionando situações factuais, políticas do controle da Hanseníase e respostas ao preconizado.
Resultado: As ações educativas propostas são direcionadas pelos determinantes do processo saúde/doença; pelo conceito dominante sobre o controle da Hanseníase e do processo ensino - aprendizagem e do esperado pela Instituição responsável pelo controle de agravo.
Conclusão: conhecer e entender o passado, observar e refletir sobre a prática, educativa atual, aceitar mudanças e desafios utilizando propostas pedagógicas inovadoras e alternativas é opção que contribuirá para a eliminação da Hanseníase como problema da Saúde Pública.

 

OHE 4

TEN-YEAR STUDY OF SELF REPORTED CASES IN AN URBAN LEPROSY PROJECT
P.V. Ranganadha Rao; V. Prabhakara Rao; B. Pratap Reddy; Sukumar Samson
Hyderabad Leprosy Project(HYLEP).
C/o LEPRA India. Krishnapuri Colony, West Marredpally. Secunderabad - 500 026. Andhra Pradesh, India.

Active case finding methods are usually adopted in leprosy programmes for identifying new cases of leprosy. Very minimal emphasis is laid on IEC as an intervention to support selfreporting of early cases.
In 1989, an urban leprosy project was started in Southern India covering a population of 1.5 million. Apart from routine case finding methods targeting general population and special groups like healthy household contacts and school children, IEC activities are conducted through specially designed Health Education programmes to improve awareness.
Clinical profile of the self-reported cases during the last two years was studied in relation to presenting symptoms and their onset. The distribution trends of the disease in relation to age and sex factors also were analysed. The perceptions of the patients about the symptoms and the factors, which influenced their treatment seeking behaviour, were studied by administering interview schedules. These findings are analysed and discussed.
7453 cases were registered in the past ten years. 1898 (25%) of the total registered cases have reported voluntarily. 10% of these patients had G-II disabilities. This indicates the need of understanding of the perceptions of the patients reporting voluntarily to improve IEC activities, which are relevant to the urban community.

 

OHE5

AN IMPACT OF FOCUS GROUP DISCUSSION ON LEPROSY TO CHANGE KNOWLEDGE, ATTITUDE AND PRACTICE IN COX'S BAZAR, BANGLADESH
Dr. Aprue Mong; Mr. David Baidya; Mrs. Jayontee Baroi; Mr. Ananta Chakma
Chittagong leprosy Control project (CLCP). House # 16, Road #4. Khulshi, Chittagong 4000, Bangladsesh.

Objective: The main objective was to assess the knowledge and changing attitude and practice towards leprosy patient through focus group discussion, to identify opportunities for intervention and their relative impact due to focus group discussion.
Study design: It is an intervention study of Focus Group Discussion through Pre and Post KAP questionnaire survey. Study subject were randomly selected from rural population and pre and post participants were matched.
Methods: Focus group discussion (FGD) conducted by trained Leprosy Control Assistant (LCA) and a group of Health Educator from National Leprosy Coordinating Committee. Data collection done by asking questionnaire individually to the participant before and after FGD and socio-demographic characteristics also collected during survey.
Result: A total of 607 participants in both pre and post survey, in which 374 (61.6%) male and 233 (38.4%) were female. Pre survey participants were 281 and age range from 10 to 80 years mean age 31.81 years and standard deviation 15.6. In Post survey group participants were 326, age ranged from 12 to 85 years, mean age 32.85 and standard deviation 15.53. There are improving of knowledge and practice average 30%, on leprosy disease due to Focus discussion method, which is highly significant, p value <0,001. But the attitude were not much changes as knowledge. In attitude survey risk difference found average 5% and p value = 0.25. which not significantly change. In practice survey found 28% improve health practice, p value <0,001.

 

OHE6

ANALYSIS OF NEWLY DETECTED LEPROSY CASES AFTER LEC
MU Hongjiang; LI Xian; Ke wei; WANG; Zhanghua; XIONG Ping
Guizhou Provincial Institute of Dermatology, 550002, Guiyang, China.

Objective: Discuss new case discover feature after enforcement EEC to offers reference that LEC and conventional case discover work in the future.
Method: make statistics analysis to the relevant information of leprosy case that implement LEC aro und in two leprosy height popular county.
Result: LEC can discover the overstock patients in large quantities, in the year, the patient counts (51 example) discovered recently and discover rate (2.77 / one-hundred thousands), exceed the LEC average of former 3 years (discover in average is 25, discover rate in average 1.39 / one-hundred thousands) to one time above, after LEC for 2 years, discover patient counts and discover rate have droped year by year, but the grade II disabilities and type ratio in new patient have not droped obviously, early stage (ill issue [2 years] discover rate is still around 50%, two city leprosy popular level still keeps in higher level.
Conclusion: It is very necessary that implement LEC in Leprosy height of popular area, but one LEC can not discover all of conceal patients. It is need implement LEC repeatedly to combine routine discover work and enlarge project to cover small towns. When the discover new patient counts and discover rate shows to drop stably, discover rate in early stage rises substantially, child proportion and grade II disabilities drop apparently to the condition of lower level, we can reach the purpose really to discover conceal patients and to reduce leprosy popular level and to promote to eliminate leprosy basically.

 

OHE7

BASES ESENCIALES PARA UN PROGRAMA SANITARIO APLICABLE AL PACIENTE CON ENFERMEDAD DE HANSEN

A, Torreja; L. Casañas; E. Fuste; M. Pérez
Servicio de Dermatología. Hospital de St.Pau, Barcelona, Conselleria de Sanitat. Generalitat de Catalunya.

Descripción: La educación sanitaria, es un intervención social, que tiene a modificar, de manera consciente y durable, los comportamientos en relación a la salud.
Objetivos: Facilitar modificaciones en los comportamientos o adquirir nuevos para prevenir la enfermedad, seguir los cuidados que ésta requiere y mantener o recuperar la salud. Para su diseño, se discuten varias dimensiones:
- Dimensión Biológica.
- Dimensión Psicoprofesional.
- Dimensión Cognitiva.
- Dimensión Psicoafectiva.
Ejecución o aplicación del programa: La recuperación y rehabilitación integral del paciente (Rehabilitación física, terapéutica, psicológica, social y laboral) dependerá del estado de la enfermedad, y de la educación del mismo y de la familia.
Evaluación: Valorar la consecución de los objectivos lijados en: El paciente, el docente y del programa.
Registros: Generar historiales e información estadística.
Realidad actual: Para la aplicación de este programa, existen diferentes niveles de dificultad, en función de las características socioeconómicas y culturales. Mundo occidental: desmantela sistemas públicos. El Tercer Mundo carece de medios. Existen recortes presupuestarios en todos los programas. Carga sobre el profesional que se ve obligado a priorizar aquellos aspectos que más puedan incidir y que estén a su alcance. Existen problemas en el seguimiento de las personas inmigradas, por carecer de domicilio y trabajo lijo, lo que dificulta su localización.

 

OHE8

BONECOS PARTICIPANDO ATIVAMENTE NA "LUTA" PELA ELIMINAÇÃO DA HANSENÍASE NO MUNICÍPIO DE S. PAULO
Ferraz, S.M.P.; Nascimento. A.C.F.; Oda. R.N.K.; Sao. M
Prefeitura do Município de São Paulo - Ambulatório de Especialidades Ceci e MORHAN - Movimento de reintegração das pessoas atingidas pela Hanseníase-núcleo Jabaquara.

Introdução: Apesar da Hanseníase ser ainda um problema de Saúde Pública no Brasil, o diagnóstico e tratamento continua tardio trazendo sérias incapacidades físicas e sociais. A população permanece com conhecimentos fragmentados a respeito dos sinais e sintomas e as campanhas de divulgação, pontuais e esporádicas não aprofundam os conhecimentos. Optou-se por um projeto pedagógico que funciona como atrativo onde há interação e socialização no conhecimento atual sobre Hanseníase: o teatro de bonecos.
Estratégias: Utilizar essa técnica pedagógica em todos os espaços de campanha e introduzir a discussão da temática em seminários e encontros de saúde. OBJETIVOS: Socializar o conhecimento científico atual sobre a problemática da Hanseníase, facilitando a tomada de decisão e ação para procura de diagnóstico precoce.
Metodologia: Problematizadora, dialógica, participativa, com interação interpessoal entre platéia e bonecos, facilitando a decodificação do conhecimento sobre Hanseníase e seu controle.
Resultados: Participação nas campanhas de: gripe e multivacinação de 1999. 2000 e 2001; de hipertensão, diabetes, de tuberculose. Abertura de encontros, sensibilização de profissionais e agentes de saúde do PSF de equipes municipais; em eventos: Semana de enfermagem, de prevenção de acidentes de trabalho e feiras de saúde. Após as apresentações houve um aumento da procura para esclarecimentos sobre manchas e solicitação de folhetos para trabalhos escolares. O trabalho despeitou interesse de Instituições e grupos profissionais, havendo expansão do projeto, para outras áreas programáticas além da Hanseníase. Os bonecos, com personalidade própria, são conhecidos e a apresentados hoje como "bonecos da Hanseníase".
Conclusão: A utilização de técnicas ludopedagógicas para a socialização do conhecimento científico sobre Hanseníase é válida e incentiva e buscar novos caminhos mediante resultados positivos, contribuindo para o diagnóstico precoce e eliminação da Hanseníase como problema de saúde pública.

 

OHE9

CHANGING ATTITUDES AND BEHAVIOUR TO SUPPORT LEPROSY INTEGRATION EFFORTS
Penny Grewal; Vera Andrade; Sunil Settinayake; Nimal D. Kasturiaratchi
Novartis Foundation (Switzerland), World Health Organization, Anti Leprosy Campaign (Sri Lanka), University of Peradeniya, (Sri Lanka).

Integrating leprosy into the general health services requires a lot of groundwork not just in terms of planning, training and logistics but above all in changing the attitudes and behaviour of various targel groups. Alter integration, patients are in touch with more people in the system ranging from the medical officer to the pharmacist. Any negative attitudes or behavior on the part of the health services toward leprosy patients can seriously undermine their confidence and self esteem and thus impact on their compliance with treatment. Moreover, health care providers need to accept that leprosy is part of their job description and always to "think leprosy" when examining patients with skin lesions.
Successful integration of the leprosy services also requires actively generating "demand" for diagnosis and treatment - for example, through media campaigns to emphasize the fact thai leprosy is just another curable disease, and to indicate that treatment is now available at all health facilities. This should also help create an environment in which patients do not hesitate to seek treatment. Person to person communication is crucial in breaking down any residual anxiety or prejudice about the disease.
The paper reviews the overall approach, experience to date as well as remaining challenges.

 

OHE 10

DOES KNOWLEDGE LEAD TO ACTION? HEALTH EDUCATION AMONG LEPROSY PATIENTS
Joanne Roberts; Jaganath Maharjan; Mark Macdonald
Anandaban Leprosy Hospital, PO Box 151, Kalhmandu, Nepal, E-mail: anandaban@mail.com.np.

Aims: a) To assess the extent of patient knowledge following health education about foot-care in leprosy; b) to assess the difficulties in implementation as perceived by the patient; and c) to assess health workers' responses to patient knowledge and problems.
Methods: Seventy two patients were interviewed from two matched groups, one in the community and one in a leprosy hospital outpatient clinic using a simple open ended questionnaire. A problem solving technique was taught to health staff and this was used in dealing with patients' difficulties in implementing health behavior.
Results: Overall knowledge of foot-care management was satisfactory. There was no significant difference in level of knowledge between the two groups or between genders. Knowledge relating to skincare, use of footwear, and protection from heat scored highly. Knowledge of the need to regularly self-inspect the feet scored poorly. In terms of implementation, almost one third (32%) expressed no difficulty, while 16% were too busy, and 16% had poor knowledge. In over two-thirds (68%) of the cases staff addressed the area of déficit in knowledge. In just over half (55%), difficulties in implementation were tackled
Conclusion: The results of this study helped identify deficits in knowledge and difficulties in implementation of self care measures. It will aid in designing more effective methods of health education

 

OHE 11

EFFECTS ANALYSIS FOR TRAINING ON THE NON-LEPROLOGISTS
Wn Xinsheng; Wang Rongmao; Ning Yong; Hu Lulang; Li Binyu; Wang Kai; Shil Ling; Hei Lu
Sichuan provincial Institute of Dermatology & Venereology, 12 Sidao Street, Chengdu, 610031, P.R.China.

In the activities of the healthy education on leprosy, sonic 900 non-leprologists have accepted professional training about the leprosy control among medical workers in 17 counties, LIANGSHAN prefecture, SICHUAN province. Contrast analysis has been made on the training effects. Before they had been trained, as far as their correlative knowledge of the leprosy, the total correctness rate is 50.5% and the lowest is only 22%. After that, the total correctness rate is up to 83.5% contrasted lo the number of pre-training, there is an obvious discrepancy (x2=27.34, p<0,005). Among all the scores to the test questions, the leprosy's infectivity, resulting to malformation and its curability showed the biggest difference. It proved that these three aspects are people's misconception to leprosy, and also are the main reasons of fearing leprosy. The analysis results attested this training is obviously effective and pertinent. What is noticeable is the attitude to the patients had no distinct difference between pre-training and after training. That is to say, for thousands of years, people showed inveterately bias and discrimination to leprosy patients which is difficult to relieve. So, more health education of leprosy should be put into practice.
Because the medical workers have authority of explaining disease; they will directly influence people's attitude and cognition to disease. So the non-leprologists are the first objects to accept the training.
[Key words] medical staff knowledge of leprosy control training analysis

 

OHE 12

ESTRATÉGIAS PARA ELIMINAÇÃO DA HANSENÍASE EM ALFENAS (MG)
Cláudio De Lélis Filgueiras De Souza; Avani Soares Almeida Magalhães; Elisa Oliveira Gonçalves Antunes; Wendel Antonio Fagundes; Mariza Bárbara Rissuto
Serviço De Hanseníase Da S.M.S. De Alfenas (Mg). Pça. Dr. Fausto Monteiro, 300 Centro Alfenas - Mg Cep 37130-000.

Os autores mostram que através de busca ativa de doentes com hanseníase por meio de campanhas, vem conseguindo diagnóstico em maior número com índices de incapacidades menores, foram analisados 888 pacientes atendidos em ambulatórios de atenção básica no período de outubro de 1998 a maio de 2001, convocados através de campanhas de conscientização sobre os sinais e sintomas da hanseníase, neste período, 154 pacientes tiveram seu diagnóstico confirmado, sendo 25 destes nestas campanhas.
Motivo da apresentação; mostrar a contribuição das campanhas realizadas no município de alfenas como fator importante para a eliminação da hanseníase, devido ao aumento de diagnósticos impulsionados pela educação em saúde proporcionada.

 

OHE 13

GRUPO DE ORIENTAÇÃO EM HANSENÍASE
Nidia Bambirra; Vanúzia Maria Lima
Ambulatório de Dermatologia do Hospital das Clínicas da UFMG. Alameda Alvaro Celso, 55 - Santa Efigênia - Belo Horizonte, Minas Gerais, Brasil. CEP: 30150-260 Fone: (31) 3248-9560 Fax: (31) 3226-3066 E-mail: adermato@hc.ufmg.br

A educação em saúde é reconhecida como um dos aspectos primordiais no controle da hanseníase, devendo se levar em consideração não apenas o volume de informações, mas a verificação de qual foi a percepção do paciente, familiar ou comunidade com relação ao conteúdo recebido. Dentro dessa perspectiva foi implantado em 12/04/00 pelo Serviço Social e pela Enfermagem o atendimento de grupo, dentro do Programa de atendimento aos portadores de hanseníase no Ambulatório de Dermatologia, HC/UFMG.
O objetivo do atendimento em grupo é proporcionar aos pacientes, familiares e comunidade um espaço no qual possam estar construindo novos conceitos da doença, favorecendo o entendimento e maior participação no processo de cura.
O público atingido, de abril de 2000 a abril de 2001 foi de 358 participantes, sendo 149 portadores de hanseníase, 67 com outras dermatoses, 22 em propedêutica, 70 acompanhantes e 38 alunos e profissionais em treinamento, em 32 reuniões.
O retorno verbal de muitos pacientes é que com o grupo puderam entender mais o processo de tratamento, principalmente com relação às reações, que muitas vezes eram consideradas como piora da doença e não como condição imunológica do organismo. Houve relatos de diminuição de ansiedade com o melhor entendimento da doença.
Avaliação da equipe é que houve melhora no nível de entendimento dos participantes sobre a doença e seu processo e diminuição do tempo de atendimento individual.

 

OHE 14

HEALTH EDUCATION IN RELATION TO PREVENTION OF DISABILITY (POD) PROGRAMME IN LEPROSY

German Leprosy Relief Association-India. 23 Market Street, Kolkata-700087, India.

Prevention of Disability is an important area of leprosy elimination programme which in a particular terminology of POD has been given priority since last six years. The introduction of MDT has drastically reduced the caseload including a considerable degree in reduction of impairment. Yet the existing deformity rate is not negligible. The social implication of deformity is multifarious; the degree of stigma and ostracisation largely depends on deformity and disability. Health education, individual patient counseling and demonstration of self-care procedures are the essence of a successful POD programme, which indicates prevention in all the steps, from pre primary stage to tertiary stage. In the early stage, impairment is prevented and in the next steps further deteriorations are checked. Accordingly, a retrospective study for 5 years was undertaken in the Balarampur control unit of Gandhi Memorial Leprosy foundation in Purulia district of west Bengal, lndia. The health education inputs were designed emphasizing early case detection without deformity, the preventive aspects of disability, patient counseling, self-care demonstration and transfer of technology was given due importance. The staff members were trained on the subject before field implementation of the programme. During the five years, substantial health education programmes were conducted. Total 3263 leprosy patients were detected, among them 226 had G1 and 25 had G2 deformities. POD activities were done for 5738 cases among them condition was improved for 537 cases, 75 cases were worsened and 5126 remained static without further deterioration

 

OHE 15

HEALTH PROPAGATION EDUCATION ABOUT LEPROSY AIMS TO PROMOTE PEOPLE'S KNOWLEDGE AND REVEAL NEW LEPROSY PATIENTS IN THAI NGUYEN PROVINCE
Duong Van Tuan; Nguyen Thi Lan
Director of Thai Nguyen Dermatology-Leprosy Control Centre.

Thai Nguyen province is midland - mountainous region in the north of Viet Nam with 3.541 km2 superficies. His population counts 1.2 million including 8 ethnic groups living common. The economic remains poor people's knowledge level is low. Thai Nguyen Dermatology Leprosy Control Center (DLCC) is responsible for dermato - venereal disease examination treatment and HIV/AIDS control; implementing program for leprosy elimination from health community; propagating, educating about leprosy; MDT treating new leprosy patients; supervising the contacts; carrying rehabiliting the invalid by leprosy.
Under the direction of Health Service of Viet Nam, directly steering by Dermatology Institute, and Netherlands Leprosy Relief support, Leprosy control program of Thai Nguyen province was being set up since 1998 by Thai Nguyen DLCC. From immemorial time leprosy was being fearful for people. It has been received as hereditary disease high contagious, impossible cured and must be isolated. Therefore Health education propagation about leprosy in communities become importance role, aims to aid people can be exactly under standing and striking out the inferiority complex of leprosy. Thai Nguyen DLCC has establishing successful propagation education program on leprosy.
Health education courses had initiated for health workers at grass-root level, cadres of sections associations at commune quarter level, heading-men of hamlets teachers in primary secondary schools, DLCC was learning, experimenting and verifying that education program will be successful. The participants will accepted quickly new knowledge if concrete teaching materials are being provided.
All participants have thought out, proposed idea, discussed, finally decided elaborate an image set comprising 4 leaves with 4 complete, laconical, intelligible contents.
The first leaf with dingy color scheme describes old conception on leprosy: disease is hereditary from parents through descendants, it is quickly easily contagious, therefore the people are being frightened and fled from lepers. The lepers had been expuled from village, thrown down into river, burned in flame, driven in camp of leprosy and must not reconcile to community.
The second leaf with brightly, blaging color scheme describes new conception: leprosy is not hereditary; it is caused by a type bacillus Mycobacterium leprae which visible under electromicroscope in bar form stained fuscin red color. Leprosy is cured completely if it is early revealed. Lepers are not isolated but need conciliate to community.
The third leaf describes leprous signs at early stage of disease; manifestations are skin areas with variation in color, in distinct border flat. The following images are distinctive border line areas, prominent on skin superficies. At last are the images of invalidity if it is not revealed early and treated in time.
The fourth leaf contents images described about ethnicgroups classes people in province manifeste their happiness for implementing program and eliminating completely from health community at 2000 year.
By complete, laconical, intelligible contents of 4 image leaves, DLCC doctors had aided tens thousands people in province understand exactly leprosy. Propaganda image about leprosy appear wherever commune health centres, schools, inhabitant areas, there by people in community may little by little change public opinion.
Beside propaganda image DLCC was applying new method: inserting into scholar schedule lime X poetic phrases implicated knowledge on leprosy:
Leprosy isn't hereditary
Weak contagious, will be quickly cured by effective medicine
There are on skin discolor area
Sharp pointed not to be in pain
Heat cool sensation disappear
It must be go to doctor
Disease'll be diagnosed and treated in time
From to now and for ever
Happiness comes to leper's life.
Poem is easily being retained with complete contents together teacher's knowledge school children were understanding exactly on leprosy: effacing false conception existed for long time. In his round school children become as propagandors aiding their parents and neighbours to understand and reveal leprosy themselves and each other.
In fact, a lot of people and school children after received knowledge by propag and images, meeting scholar schedule time have revealed themselves sick signs and gone to doctor. Disease has been diagnosed, treated early, the result successful no sequel.
Initiatives described over were applied in overall province in last years. Neighbouring provinces are leaning visiting and ask image pattern for applying in their area.
Beside over propaganda forms, DLCC is frequently infoming educating about leprosy by radio transmission, provincial television, intergrating leprosy content in meeting of other associations.
For 19 years Thai Nguyen DLCC was attaining successful results in propagation education activities on leprosy and had been estimated from Public Health Ministry and Central Dermatology Institute.
Since there was rare person understand about leprosy, by now almost people in province are fundamental knowledge about leprosy: before disease was only revealed by passive examination, up to now leprosy was revealed essentially by patients gone themselves to doctor in Health Centres for examination, because of their knowledge promoted.

New patients invalided decrease from 88.3% in period before 1983 year to 21.1 % in the last period.
Thai Nguyen ULCC considers Health education about leprosy as essential, frequent, continual activities for next year, for promoting people's knowledge.
There from lepers understand disease and goes lo doctor themselves for examination, revealation and treatment in lime, not to be invalid.
By endeavour, strive. Thai Nguyen province is attaning program result at of leprosy elimination from health community. Thai Nguyen is the 7TM province which has been ratified in 1988, awarded Labour Medal grade 3 by State President for antileprosy program fulfilment. In 2001, by leprosy elimination supervising conference, Thai Nguyen has been estimated by Central Dermatology Institute for program maintenance frequently.

 

OHE 16

IEC FOR ELIMINATION OF LEPROSY THROUGH THE TRILOGUE METHOD
C.S. Cheriyan; T. Jayaraj Devadas
India Co-ordinator, IDEA International. No. 4, Gajapathy Street, Shenoy Nagar, Chennai-600 030

Introduction: At this point of the global fight for the elimination of leprosy, dissemination of correct information is of immense value to the programs. Trilogue method (patientservice provider- people) has been found to be very effective both in urban and rural areas in imparting knowledge and skills on suspecting early signs of leprosy, informing about the availability of treatment and in motivating the patients to seek medical help. In fact it relies on the participation of the community through peer groups.
Objectives:
1. To identify and train peer groups among the people in the community.
2. To form health committees among the trained groups.
3. To sustain the educational activities of the peer groups in the community.
Modus Operandi: Peer groups are identified both in rural and urban areas and they are trained by adopting necessary methods and media especially the trilogue (patient - service provider - people) method. This is followed with the formation of health committees among the trained groups with clear responsibilities of influencing the rest of the community in suspecting early signs of leprosy and informing aboul the availability and reliability of treatment by motivating the patients.
Conclusion: The establishment of action groups within every community to function as a constant source of motivation and action is as important as focusing objectively on educational inputs.

 

OHE 17

INTERFERÊNCIA DAS CAMPANHAS EDUCATIVAS SOBRE HANSENÍASE NO COMPORTAMENTO DA COMUNIDADE FRENTE AOS PORTAORES DA DOENÇA
Mauricio Lisboa Nobre; Célia Rolim de Castro; Eliza Jones
LRA - The Leprosy Relief Association - Rua Vigário Bartolomeu, 635 sala 908, Natal/RN.

Em conjunto com as respectivas Secretarias Municipais de Saúde realizou-se uma campanha educativa sobre a hanseníase em 6 grandes municípios dos Estados do CE, RN e AL, voltada para uma população alvo total em torno de 250.000 pessoas e com atividades desenvolvidas durante um período de 3 meses. Para tanto foram treinados 1.045 agentes comunitários de saúde, 3.137 professores da rede pública de ensino e 1.561 lideranças comunitárias. As principais estratégias da campanha foram a realização de palestras, distribuição de panfletos e cartazes, e propaganda no rádio e televisão. Com o objetivo de verificar se a estratégia interfere no comportamento da população frente à doença, perguntou-se à comunidade se aceitaria convier na mesma casa e se aceitaria que o filho convivesse na escola com um portador de hanseníase. Foram entrevistadas 1399 pessoas antes e 1060 pessoas após a realização da campanha, Os questionários foram aplicados pelos agentes comunitários de saúde, aleatoriamente à população da sua área de atuação. Os resultados mostraram que o percentual de pessoas que aceitariam conviver no domicílio aumentou de 73 para 80% enquanto a aceitação para convivência na escola passou de 44 para 56%. Quando foi perguntado por que estas pessoas aceitariam a coabitação no lar, o percentual de respostas que revelavam conhecimentos corretos sobre a doença passou de 28 para 38% enquanto a falta de justificativa para esta pergunta caiu de 22 para 13%. Com relação à convivência do filho na escola, o percentual de justificativas que revelavam conhecimento sobre a doença aumentou de 47 para 57% enquanto a falta de justificativas caiu de 21 para 16%. Antes da campanha 53% das pessoas reconheceram as manchas dormentes como um sinal de hanseníase, o que aumentou para 67% após a campanha. Dentre as estratégias Utilizadas na campanha as mais referidas pela comunidade como fonte de informação foram a televisão (32%) e os agentes comunitários de saúde, citados em 50% dos questionários.

 

OHE 18
LEPROSY CASE DETECTION USING SCHOOL CHILDREN AN INNOVATIVE APPROACH
Geetha S Rao; Gift Norman; P Udayasuriyan; P Samuel; R. Santhosham
Schieffelin Leprosy Research and Training Center, Karigiri, India.

After the Government of Tamil Nadu State in India integrated the vertical leprosy program into the general health services, routine school surveys done by leprosy para-medical workers were discontinued. Nevertheless, early detection of leprosy among school children is important not only in the prevention of disability, but also because of its importance as a proxy indicator for the intensity of leprosy transmission in the community. This innovative program combined education of the higher elementary and high school students about leprosy and subsequently using them to identify suspects among their peers. The school principal chooses student leaders in classes VIII - XII who could be trained to do screening of children for dermatological problems. A trained leprosy worker conducts a leprosy education program for the student leaders and their teachers. The trained students then screen all children in the school for any dermatological condition and prepare a list of suspects. Within a fortnight, the leprosy worker revisits the school and screens all children on the suspect list for leprosy.
This paper explains the methodology and compares the new case detection rate (NCDR) using this method with that done when the vertical program was in operation. In 1992. the NCDR was 9.13 per 10.000 children. The NCDR using school children is 8.28 per 10,000. The paper concludes that using school children in case detection is as effective and efficient as doing a routine school survey. It has the additional benefit of dealing awareness among the children.

 

OHE 19

MAINSTREMING LEPROSY INTO THE CONCEPT OF CONVERGENCE - A STRATEGY FOR REACHING WOMEN IN LEPROSY ELIMINATION PROCESS
Nalini Kesbav Raj; Meera Lakshmi
Directorate of Public Health and Preventive Medicine, Chennai, India.

The Tamil Nadu Corporation for Development of Women Limited (a Govt. of TN-Organization) initialed the concept of Convergence with Directorate of Public Health. DAN IDA Health Care Project, Family Welfare, Reproductive Child Health. Aids Control Society and Directorate of Medical Services. The Vision of convergence is "Government of Tamil Nadu is committed to support health development as a means of socio economic development, through behavioral change communication processes and IEC efforts, through women Self Help Groups (100,000 groups functioning currently) thereby maximizing the benefits to the entire population." An IEC working group was formed under the concept of Convergence to work with SelfHelp Groups. Since Tamil Nadu is movingtowards Elimination of Leprosy, it recognized this opportunity to be the "best" to take IEC messages on Leprosy to these groups and to facilitate case finding through them to reach the women, particularly the poor women In Tamil Nadu, during the MLEC-111 conducted in November 2002. seven districts were identified as endemic and it was decided to have Active Search as a strategy while the rest of the States followed Passive Search. For every 5000 population 2 teams were formed for Active Search with a Health Inspector and a Village Health Nurse from the Primary Health Centres and each of these teams had one SHG woman in it. 11.8 million people were covered and 14,340 SHG members involved. They were trained in Leprosy and involved in case detection. The out come is encouraging. This paper aims to clarify the concept of Convergence, mainstreaming Leprosy into it, facilitating involvement of women SHG for Leprosy Elimination, the results of such involvement and the lessons learnt.

 

OHE 20

NECESSIDADES EDUCATIVAS VIVENCIADAS PELOS DOENTES DE HANSENÍASE EM UM SERVIÇO DE REFERÊNCIA EM PORTO ALEGRE
Letícia Maria Eidt
Ambulatório de Dermatologia Sanitária / Secretaria Estadual da Saúde e do Meio Ambiente do Estado do Rio Grande do Sul.

A Hanseníase caracteriza-se, principalmente, pelo acometimento de pele e nervos periféricos. Se não tratada precoce e adequadamente, pode evoluir para incapacidades físicas inestéticas e mutilantes, que muito contribuem para o preconceito existente a cerca desta moléstia. Além do tratamento com a poliquimioterapia, que interrompe a cadeia epidemiológica e previne a evolução da doença para deformidades físicas, a educação para a saúde do doente, de seus familiares, da comunidade em geral e das equipes dc saúde são aspectos fundamentais para o sucesso dos programas dc controle da Hanseníase. O presente trabalho relata a experiência da autora na assistência e educação para a saúde a pacientes com Hanseníase no Ambulatório de Dermatologia Sanitária, localizado na cidade de Porto Alegre, serviço de referência para atendimento a hansenianos no Estado do Rio Grande do Sul, Brasil. Aspectos como a necessidade de contínua atualização dos profissionais da saúde, a importância da divulgação dos sinais e sintomas da doença, a eliminação de falsos conceitos sobre a moléstia, o compartilhar de informações com o doente, estimulando-o ao autocuidado e o envolvimento da família e da comunidade no tratamento dos pacientes, entre outros, são apresentados.

 

OHE21

SPECIALIST REFERRAL TEAMS: A MODEL FOR LEPROSY ELIMINATION CAMPAIGNS
Mark Macdonald; Gopal Pokhrel
Anandaban Leprosy Hospital, PO Box 151, Kathmandu, Nepal. E-mail: annadahan@mail.com.np

Leprosy in Nepal is an important public health issue. With a prevalence rate of 3.8/10,000 (September 2001), WHO has targeted Nepal as highly endemic in the race to eliminate leprosy. A National Leprosy Elimination campaign (NLEC) was conducted in 1999, and this proved useful both in increasing public awareness and in finding new cases.
Aim: To assess the impact of specialist referral teams on difficult to diagnose cases in a Leprosy Elimination Campaign (LEC).
Methods: From 1st- 7th October 2001 a Leprosy Elimination Campaign was held in selected high prevalent districts in Nepal (PR> 5/10,000). Specialist referral teams, consisting of trained staff from Anandaban Leprosy Hospital, were involved in pre-campaign capacity building of health services staff, orientation of search teams and a public awareness programme. Case detection consisted of house-to-house photo survey, with referral to integrated basic health services for confirmation of diagnosis of suspects. Difficult to diagnose cases were sent to specialist referral teams at selected centres.
Results: A specially designed questionnaire was used to make an evaluation of the cases seen and treated, and to determine profiles of difficult to diagnose patients and the performance and usefulness of these teams. Data on 627 patients seen at referral centres during the campaign period was evaluated.
Conclusions: A review of the results and recommendations for the place of specialist teams in leprosy elimination campaigns will be presented.

 

OHE 22

SURFACING OF LEPROSY AFFLICTED PERSONS - A RATIONAL APPROACH
Mahmood. K. Dr.1; Murugesan. N.2

1. State Leprosy Officer, Tamil Nadu State, India.
2. State Project Co-ordinator, DANIDA/DANLEP, Tamil Nadu, India.

As part of intensive efforts for eliminating leprosy in the integrated setting, based on scientific analysis, areas needing greater attention were identified. These were considered as Focal Areas if it satisfied two or more of the criteria given below:
1. 5 or more new cases detected in clusters (Same house or neighbourhood) in that area for one year.
2. More than 3 new cases (MB or PB or both) detected for one year.
3. No new case was detected for 3 years
4. New cases detected with Grade II disability for one year irrespective of number of cases.
5. Smear positive cases, for one year irrespective of number.
Areas with a population of a unit of 1000 or multiples of 1000 were selected for intervention, which was called Focal Survey. Over all objectives of the interventions were: Strong input of IEC through interpersonal communication with a back up of mass media and encouraging the suspects to report voluntarily for examination.
Focal survey- what?
Community volunteers and peripheral field workers visited the houses in the selected focal areas. They passed on information to the people on signs and symptoms of leprosy, effectiveness of MDT, medicines on free of charge, treatment facilities, date and time of visit of search team to their houses and persuading the people with suspect lesions to be available at home for examination.
Equal opportunities were given to all the 1410 Primary Health Centre and Urban areas all over Tamil Nadu to select the Focal Areas as per criteria and conduct focal surveys.
As per local needs, based on criteria, all over Tamil Nadu focal areas were identified and Focal Surveys were carried out in Jan-April 2001.
The paper would highlight the outcome of the Focal Surveys:

  • Coverage of population and leprosy cases found and follow through action right from patient education, treatment and release of patients.
  • Effectiveness of the approach, conclusions, suggestions and recommendations

 

OHE 23

THE PROMOTION OF BEHAVIORS OF LEPROSY PATIENTS IN COMMUNITY HOSPITALS THROUGH GROUP PROCESS WITH SOCIAL SUPPORT
Pairoj Prompunjai; Nalinee Poolnaimuang; Wasana Sonthiphumas; Suchada Thanyasukpaisan
Office of Communicable Disease Control Region 5 Makorn Ratchasima, Nakornracharima Province, Thailand.

The objective of this quasi-experimental research is to identify group process with social support in order to promote behaviors of leprosy patient. The subjects was recruited from multibacillary leprosy patients in community hospitals There were 61 subjects who passed eligible criteria and then divided purposively into experimental group (31 subjects) and control group (30 subjects). Data was collected by interview before and after the intervention was implemented. The results were analyzed by Percentage, Mean, Standard Deviation, Student t Test, Paired Sample, T-test, Z-test, Pearson Product Moment Correlation and Chi-square Test.
The results show that there are increasing of the perception in term of susceptibility, severity, positively benefit among experimental group. In addition, the behavior of leprosy patients is improved significantly. The proportion of contact cases among experimental group is increased significantly. More over, perception of positive benefit and services satisfaction are correlation significantly with behavior of leprosy patients.
The researcher recommended that group process with social support should be implemented in community hospitals. The community hospital staff who are responsible for leprosy should be trained to give good quality of services.

 

OHE 24

TREATMENT DEFAULT AMONG PATIENTS DISCOVERED DURING LEPROSY ELIMINATION CAMPAIGN (LEC): EXPERIENCE OF KANO STATE NIGERIA
M.N. Mahmoud
TBL Control Program, Ministry of Health, Kano State, Nigeria.

Leprosy Elimination Campaign is an initiative adopted and recommended by the World Health Organization with the main objectives of creating community awareness on leprosy activities, capacity building (most especially among the lower cadre of health providers), and to enhance case finding and case holding. A Statewide LEC was conducted in Kano State, Nigeria, in the first half of the year 1999. The exercise was conducted with the set target of achieving the above objectives. The campaign was mainly sponsored by the World Health Organization, with support of the Netherlands Leprosy Relief and the Federal Ministry of Health. The campaign was to a large extent, a huge success taking into consideration its objectives. All villages in the State were visited, and over 1000 general health workers were trained on Leprosy. More than 68% of patients registered during the year were found during the campaign. However the State Tuberculosis and Leprosy Control Program observed a high default among the patients discovered during the exercise, and conducted a defaulter retrieval activity and also made an attempt to find outwhy these particular patients defaulted. Statistics on all the patients treated, defaulted, retrieved and lost are collated and analyzed.

 

 

PE 50

ESTUDIO SEROEPIDEMIOLOGICO DE UN FOCO DE LEPRA EN EL HOSPITAL "CELIA SANCHEZ MANDULEY", MUNICIPIO MANZANILLO, GRANMA
Dr. Leonel Alejo Gutierrez.; Dr. Eduardo Rodes Santiesteban
Centro Provincial de Higiene, Epidemiología y Microbiología de Granma, Parada # 6 e Martí y Marmol. Municipio: Bayamo Provincia: Granma.

Se realizó un estudio en el Hospital "Celia Sanchez Manduley" del Municipio Manzanillo donde fueron estudiadas 447 personas contatos extradomiciliarios compañeros de trabajo de 6 pacientes de Lepra multibacilar mediante estudio serológico con el antígeno PGL-I por el método Ultramicroanalitico (SUMA) y de acuerdo a los resultados e la serología, prueba de Lepromina y Baciloscopia. El 19.2% de los estudiados mostró niveles de anticuerpos superiores al nivel de corte establecido. Los resultados fueron analizadosd en relación al sexo, la edad, el tiempo de relación con los enfermos. Se naliza la conducta seguida al final de la Investigación, concluyendo que estos studios resultan de gran utilidad en el control de la Lepra.

 

PE 51

ESTUDO DE INCIDÊNCIA E PREVALÊNCIA DE HANSENÍASE EM MENORES DE 15 ANOS NO MUNICIPIO DE PARACATU-MG DURANTE UM PERÍODO DE CINCO ANOS
Isaias Nery Ferreira; Rosicler Rocha Aiza Alvarez.
Fundação Nacional de Saúde/MS. Av. Olegario Maciel 660 - Centro. 38600-00 Paracatu - MG

Paracatu/MG é considerada pela Secretaria Estadual de Saúde como município prioritário para o controle da hanseníase devido aos altos coeficientes de incidência e prevalência desta nosología em sua população. Foi realizado um estudo de incidência e prevalência de hanseníase em menores de quinze anos diagnosticados e tratados neste município por um período de cinco anos. analisando diversas variáveis como forma clínica, idade, sexo, grau de incapacidade, escolaridade, cicatriz vacinal, contatos, entre outras. O objetivo deste estudo é obter um panorama epidemiológico desta doença visando subsidiar os serviços e secretarias de saúde municipal e estadual em suas ações, contribuindo para eliminar a hanseníase como doença de saúde pública

 

PE 52

ESTUDO RETROSPECTIVO DA OCORRÊNCIA FAMILIAR DA HANSENÍASE EM UNIDADE DE REFERÊNCIA NO MUNICÍPIO DE ITAPEVI - SP
Lima, S.S.; Kanagusuko.T; Techelsk, W.; Becker, O. M.; Gloria, I
Instituição: UBS IV - Rainha. Av. Nove de Julho, 39, Itapevi - São Paulo. Fone: (11) 426-3555 - ramal 45.

A hanseníase é uma moléstia que nos acompanha desde a antiguidade e ainda está longe de ser erradicada.
O Brasil é responsável por 85% dos casos das Américas, ocupando o 2lugar em número de doentes em todo o mundo.
Praticamente o único reservatório é o homem, dificultando pesquisas laboratoriais e fazendo com que o contato pessoal seja a principal forma de transmissão. Estudos epidemiológicos tornam-se então instrumentos importantes para compreensão da doença.
Este é um trabalho retrospectivo que se baseou no levantamento de dados de prontuários de doentes e seus respectivos familiares, acompanhados durante o período de 1996 a 2001 no UBS Rainha, unidade de referência para hanseníase, localizada no município de Itapevi - São Paulo. Enfatizamos os comunicantes familiares como integrantes do principal ambiente de propagação da moléstia. Avaliamos 78 casos com 642 comunicantes. A maioria destes últimos era assintomática. Porém. 9% apresentou hanseníase. Destes comunicantes doentes, 66% possuíam forma infectante (Borderline ou Virchoviana) perpetuando assim a transmissão domiciliar.
Variáveis como sexo, relação familiar dos comunicantes e forma do caso índice (multibacilar ou paucibacilar) foram analisados como fatores de risco para aquisição da doença.

 

PE 53

EVOLUÇÃO DA DETECÇÃO E PREVALÊNCIA DA HANSENÍASE REGISTRADAS DO CENTRO DE SAÚDE DONA LIBÂNIA- REFERÊNCIA EM DERMATOLOGIA SANITÁRIA - FORTALEZA -CEARÁ PERÍODO 1995 - 2001
Tavares, C. M.; Ferreira, M. L. L. T.; Alencar, T. M.; Araujo, M. A.; Santos. R.
Centro De Saúde Dona Libânia - Referência Em Dermatologia Sanitária - Fortaleza - Ceará

Ao realizar este trabalho, acerca de evolução da endemia hansênica utilizando indicadores de morbidade (incidência e prevalência) no município de Fortaleza, não podemos deixar de pensar na situação preocupante da referida endemia em algumas secretarias regionais de Saúde da capital cearense. Hanseníase, doença endêmica em todo território nacional, tem colocado o Brasil na incômoda posição de segundo país do mundo e primeiro das Américas em número de casos registrados. A meta preconizada pela OMS para o ano 2000 e postergada para 2005 é redução de 1 caso de hanseníase para cada 10.000 habitantes. O objetivo deste trabalho é estudar a situação epidemiológica e operacional da hanseníase no município de Fortaleza registrados no centro de referência Dona Libania no período 1995 - 2001.
A metodologia utilizada é de um estudo descritivo e analítico de uma série histórica, no período de 1995 - 2001. A casuística é constituída de todos os casos notificados no período. Os dados foram obtidos do S1NAN. Os resultados parciais encontrados foram que a média de casos por ano era de 700 casos e a distribuição por secretarias regionais de saúde -SER, observa-se um grande número de casos na regional VI (30% dos casos da capital), região do Conjunto Ceará e Grande Bom Jardim.
Concluímos que é imperativa a implantação de todas as ações de eliminação de hanseníase, previstas na Norma Operacional de Assistência a Saúde - NOAS para todas as unidades básicas de saúde do município de Fortaleza, e a unidade de referência apoiando esta descentralização, ficando a referência ocupando o seu verdadeiro papel de apoio para - Unidades Básicas de Saúde da Família - UBASF nos municípios de Fortaleza nos casos de difícil diagnóstico e controle.

 

PE 54

EVOLUCIÓN COMPARADA DE EL PRODUCTO INTERIOR BRUTO Y LA INCIDENCIA DE HANSENIASIS EN LA SEGUNDA MITAD DEL SIGLO XX, EN ESPAÑA
Almela Vich, Fernando; Vilata Corell, Juan José; Alfonso Sánchez, José Luis; Terencio de las Aguas, José; Salazar Cifre, Antonio
Organismo Público Valenciano de Investigación (OPVI) - Instituto de Medicina Tropical. C/ Salamanca Nº 68, pta 1ª, 46005-Valencia, España

Objetivo: Determinar si el Producto Interior Bruto y la lepra presentan una asociación en su evolución, haciendo especial hincapié en el análisis por Comunidades Autónomas.
Material y métodos: El material ha sido el conjunto de anuarios del Instituto Nacional de Estadística de España, el Registro de Enfermedades de Declaración Obligatoria y el Registro Estatal de Lepra del Instituto de Salud Carlos III. Para la recogida de datos y presentación de resultados se ha utilizado el programa informático Excel y para el análisis estadístico el PSPS.
Resultados: Los datos han sido recogidos por provincias, comunidades autónomas y globales para España. Mostraremos los resultados correspondientes a las tasas anuales nacionales presentadas a intervalos de 5 años. La lepra se expresa como incidencia acumulada cada 5 años dado el impreciso periodo de incubación y la baja incidencia. Se ha encontrado una correlación de Pearson de 0,82. El valor de p es < 0,01.
Discusión y Conclusiones: La correlación encontrada entre ambas variables es significativa a mas del 1 %, y es de es carácter inverso. Por tratarse de un estudio ecológico, no podemos considerar la asociación como causal; así mismo es necesario considerara la posibilidad de sesgos y factores de confusión.

 

PE 55

FATORES QUE INFLUENCIARAM A INADEQUAÇÃO DO DIAGNÓSTICO E DO ACOMPANHAMENTO DAS REAÇÕES EM PACIENTES COM HANSENÍASE EM RONDÔNIA, BRASIL
Carmelita R. Oliveira; Maria de Jesus F. Alencar; Sônia C. Santana; Gerson F. Nascimento; Sebastião A. Sena Neto; Alberto N. Ramos Jr.
Coordenação Estadual de Controle de Hanseníase e Tuberculose do Estado de Rondônia - Avenida Padre Ângelo Cerri s/n°. Porto Velho - Rondônia - CEP: 78903-400 - E-mail: hanse-ce-ro@ronet.com.br

Introdução: Os episódios reacionais em hanseníase mantêm-se como um grande desafio para os PCH. Apesar de se conhecerem os aspectos clínicos das reações e sua relação com lesão neural, ainda persistem questões a respeito de sua epidemiologia, o que dificulta a definição de estratégias para o controle efetivo.
Objetivo: Caracterizar os fatores que influenciaram a inadequação do diagnóstico e acompanhamento dos pacientes com hanseníase com reações e que tiveram alteração ou não do grau de incapacidade.
Métodos: Estudo descritivo, operacional, baseado nos casos novos diagnosticados em 1997 em Rondônia e com alta por cura. Estudaram-se 684 casos, dados demográficos e informações sobre a evolução da doença, considerando início da PQT e alta. Realizou-se pesquisa em prontuários para avaliação da conduta e caracterização de reações. Para a entrevista foram selecionados pacientes com reações apenas após a alta e os com progressão do grau de incapacidade durante tratamento, com avaliação clínica. Foi avaliada a estrutura do PCH nos municípios selecionados.
Resultados: Apesar dos avanços gerais obtidos pelo PCH no Estado, mantêm-se as dificuldades da abordagem dos estados reacionais. Foram identificadas falhas em vários aspectos operacionais da conduta das reações. A caracterização desta situação no Estado reflete a predominância de casos novos classificados operacionalmente como PB. Identificou-se a centralização do PCH e a necessidade de articulação com o PACS e PSF. As entrevistas refletem a inadequação dos serviços e mostram a necessidade de trabalho articulado para o efetivo controle das reações.
Conclusões: Faz-se necessária a redefinição de prioridades no Estado incorporando a abordagem das reações como medida estratégica para se alcançar a atenção integral dos pacientes.

PE 56

GENDER ISSUES AND LEPROSY FROM THE SLUM OF DHAKA
(The effectiveness of female LCA and volunteers in increasing urban slum population)
Christopher A. Baroi; David Khan; Prince Das
Dhaka leprosy Control Project, 9/4 Iqbal Road Mohammadpur Dhaka 1207 Bangladesh

Background: Dhaka leprosy Control Project was initialed by the Leprosy Mission to improve the quality of life of the people residing in the city of Dhaka. It is a joint venture by the government of Bvangladesh and the Leprosy Mission. The Lepropsy Mission is working in half of the Dhaka city. This project was initiated in 1996 where 80% of the leprosy control assistants were male. Later on it was felt that the workers mainly the male workers were going under difficulty to enter into the houses as during their visits mainly the témale portion of the population were in the house and the male were either working or roaming about. And we felt that female wlorkers/volunters should be recruited for smooth efficient and effective leprosy control activities.
Observation: The statistics of the years from 1996 to 2001 were observed and the following statistical reports were found regarding the achieved activities.

 

 

Result: A differtiation was before and after 1997. And athe results show clearly that percentage of diagnosis of new cases are quite high after 1997. This was due to the female 5-6 female volunteers, to make the balance of gender among the field workers. The increase in the per head of the new patients were some times 50-70% of the previous years. The disability rate came down from 12% to 5-6 % . The involvement of the female in credit proghram are 70% and which has resulted much improvement in their family economy.
Conclusion: Inclusion of female worker in the control services of leprosy bis critically important as it helps the group of workers easy access into the houses of the slum dwellers where female members of the family mainly in the houses. Involvement of the female workers has resulted in per head diagnosis of new patients, decreased the disability rate, ami increase in treatment compliance.

 

PE 57

GENDER, LEPROSY AND LEPROSY CONTROL: FOUR CASE STUDIES IN ACEH, INDONESIA; PLATEAU STATE, NIGERIA: PAR WEST AND EASTERN NEPAL; AND RIO DE JANEIRO STATE, BRAZIL
C.M. Varkevisser, O. Alubo, K. Burathoki; C. Idawani; P. Lever; P. Patrobas; T.A.M. Moreira; M. Yulizar;
Royal Tropical Institute, PO Box 95001. Amsterdam, The Netherlands

This study was carried out in the four countries to identify to what extent biological, sociocultural/economic and health service factors played a role in gender differences in case finding of leprosy patients. The quantitative part of the study consisted of analysis of a cohort of at least 500 patients registered in 1994 and followed up till declared cured in ultimately 1998. Qualitative interviews and FGDs with patients, RFTs. relatives, community leaders and leprosy staff followed in 1998-99. The M/F ratio was 1.5 and 1.7 in Indonesia and Nepal but roughly 1 in both Nigeria and Brazil. Despite these differences, males in all four countries were more seriously affected than females with MB leprosy, deformities and reactions. Biological (hormonal) factors appear to protect women. Only in the Ear Western Region of Nepal where services are rather inaccessible, both sexes were equally seriously affected. Where services had invested in decentralisation of treatment (Brazil, Indonesia) more women started reporting. Other service factors were sensitivity of stall in treating patients of opposite sex (80% F staff in Brazil; 75-80% M staff in the other countries), and adequate health education to community and patients', responding to their needs and stressing the strong points of MDT.
Mobility of men (financial and social) appeared in all four countries a positive factor in case finding, but women scored better in alertness to bodily signs. Yet, this not necessarily resulted in early case finding, because women opted sometimes for the 'wrong' healer: untrained private practitioner (Brazil), traditional healer (Nepal). In Aceh. where beliefs in traditional causes are strong, visits to dukun delayed men and women alike. In all four countries leprosy is a stigmatising disease at community and (less) family level, but predominantly in case of deformity and reactions. Involving well-coping, non-deformed ex-leprosy patients in community education proved a powerful instrument in combating the stereotypes of leprosy and promoting early case finding.

 

PE 58

GEOGRAPHICAL INFORMATION SYSTEMS AND LEPROSY CONTROL: USEFUL TOOL OR GIMMICK?
Jacques van den Broek; J.S.R.K. Sastry; Erica Hackenitz
Netherlands Leprosy Relief (NLR), The Netherlands, E-mail: jacvdbroek@planet.nl
Enviplan. Health-GIS Consultant, Hyderabad, India. E-mail: enviplan@vsnl.com
SBW INFRA. The Netherlands. E-mail: eha@shwinfra.nl

Concept and capabilities of Geographical Information Systems (GIS)
Significance in health care systems and (infectious) disease control, with special emphasis on leprosy control.
Review of the most important characteristics of some commonly used GIS software packages and GIS applications.
A GIS is a computer-based system for data input, data management, data manipulation and analysis, and display of all and any type of geo-referenced data.
Therefore, in leprosy control a GIS is a useful tool for planning and management (decision support); Epidemiology and surveillance; Education, persuasion and lobbying (advocacy): Complex analysis and research.

 

 

With the advent of Internet Mapping Servers (IMS) like ARCIMS, it is now possible to have the data at a central server and the GIS data can be accessed, queried and printed over the internet on the local computer.

 

PE 59

HANSENÍASE EM MUNICÍPIO DA GRANDE SÃO PAULO: CASOS AUTÓCTONES X CASOS IMPORTADOS
Anunciata F. S. Toniolo; lsabela M. Vincenzi; Raphael S. Campolim Almeida; Sidney Souza Lima; Teresa C. S. Ribas
Serviço De Dermatologia Do Hospital Darci Vargas - SP. Rua Dr. Seraphico De Assis Carvalho; 34: Morumbi; São Paulo

Objetivo: Demonstrar a prevalência e incidência de pacientes hansênicos num município da grande São Paulo- Itapevi - com população de 162.421 habitantes (IBGE 2000) com ênfase para os virchovianos, comparando os casos nativos (autóctones) o os "importados" e analisar sua influência sobre a população atual.
Método: Os autores examinaram 96 prontuários de pacientes matriculados no setor de hansenologia no município de Itapevi-SP num período de 6 anos, analisando fatores como: sexo, idade, naturalidade e procedência.
Resultados: Observou -se que 52 % dos casos são oriundos de outras localidades, em sua maioria de outros estados, sendo que 48% são casos autóctones. O índice de prevalência para os autóctones no ano de 2000, quando o número total de casos era de 41, foi de 1,6: 10.000 Hab e para os "importados" 1,3: 10.000 Hab.
Conclusões: Considerando-se, e tendo como média de 5 anos o período de incubação para a hanseníase, traduzindo esta média talvez um período mais curto para o pólo T e mais longo para 0 pólo L, estamos mostrando, no município de ltapevi- SP, como a influência de imigrantes hansênicos, sobretudo os virchovianos, interfere nos coeficientes de incidência e prevalência da patologia, aumentando aqui os números absolutos e relativos e diminuindo estes na sua origem. Este fato também indica a eficácia dos nossos indicadores de detecção.

 

PE 60

HANSENÍASE NA INFÂNCIA: ASPECTOS CLÍNICOS- EPIDEMIOLÓGICOS EM UMA ÁREA INDUSTRIAL
Lúcia Mioko Ito; Ferrucio Fernando Dall'Áglio; Rodrigo Sestito Proto; João C. S. Chiti
Departamento de Dermatologia da Faculdade de Medicina do ABC. Av Príncipe de Gales. 821- -09060-650-Santo André - SP- Brasil.

Introdução: O objetivo deste estudo é considerar deforma concisa os aspectos clínicos o epidemiológicos da hanseníase na infância na região do Grande ABC. As crianças parecem ser mais susceptíveis sendo que estas correm o risco pela presença de hanseníase pela família. Quase 60% dos adultos desenvolvem a moléstia na infância ou no início da idade adulta, portanto, relatos de longo período de incubação devem ser encarados com cautela, pois sinais físicos iniciais, podem ser discretos, além de que muitas lesões podem desaparecer espontaneamente.
Casuística: Foi realizado um estudo transversal retrospectivo, de casos de hanseníase na infância, abrangendo doentes de 0 a 14 anos, através da análise das notificações compulsórias e prontuários médicos arquivados no Centro de Vigilância Epidemiológica e Postos de Saúde credenciados nos municípios da região tio Grande ABC, no período de janeiro de 1990 a 1999.
Resultados e discussão: Nesse período, foram registrados um total de 571 casos novos de hanseníase, sendo que destes, 35 correspondiam a crianças de 0 a 14 anos. Notou-se que no período de 1990 a 1997, a hanseníase infantil permaneceu com uma incidência estável e após 1997, houve um aumento significativo do número de crianças acometidas, correspondendo à perda do poderio econômico da região, caracterizando assim a correspondência de hanseníase e pobreza.

 

PE 61

HANSENÍASE NA INFÂNCIA E ADOLESCÊNC1A
Lima S.S.; Balizardo D.; Caldeira F.P; Mendes M.S.; Valencio M.C.S.
Departamento de Dermatologia, Hospital Infantil Darcy Vargas, Rua Dr. Seraphico de Assis Carvalho 34, Morumbi, SP. Brasil.

Foram revisados 308 prontuários de comunicantes e doentes do dispensário de hansenologia de uma Unidade Básica de Saúde do município de Itapevi no período de 5 anos (1997 à 2001), constatando-se o diagnóstico de 94 casos de pacientes com Hanseníase distribuídos nas formas paucibacilares e multibacilares. Deste total, 16 eram crianças e adolescentes, constituindo elas 17% do total dos casos. Dos 214 comunicantes, 110 eram menores de 18 anos. Dos 16 menores hansênicos, 60% apresentavam pelo menos contato com um familiar portador da patologia, geralmente multibacilar. 32% destes menores receberam duas doses de BCG id e desenvolveram, mesmo assim, Hanseníase; porém sempre foram de formas paucibacilares. Conclusões: A) Hanseníase abaixo dos 18 anos é problema de saúde pública grave. Segundo nossa casuística, 17% do total de nossos pacientes estão neste grupo etário. B) Destes 16 pacientes com MH, os que receberam duas doses de BCG (5 pacientes), sempre foram paucibacilares. C) A prevalência e a incidência da patologia neste grupo etário obriga a ações mais enérgicas de controle, já que são comunicantes de comunidades "fechadas" (a família), permitindo-se. assim, maior contágio. Ressalta-se que 51% do total de comunicantes são menores de 18 anos.

 

PE 62

HANSENÍASE NA INFÂNCIA
Antonio René D. de Souza; Rose Porto O. Guilhon; Francisco José D. Branco; Maria Luci Landin T. Ferreira
Centro de Dermatologia Dona Libânia- SESA-CE. Av. Pedro I, 1033, Centro. Fortaleza - CE

De um total de 878 casos novos detectados pelo serviço no ano de 2001. 78 (8.8% ) pertenciam à faixa etária de menores de 18 anos. Destes casos, 3 (0.3% ) tinham 5 anos ou menos, 19(2.1 % ) tinham 10 anos ou menos; e 64 (7,2%) tinham 15 anos ou menos. Quanto ao sexo, 47 (57,3% ) eram masculinos: e 35 (42.7% ) eram femininos. No que se refere às formas clínicas, 2 (2.4% ) eram indeterminadas (I): 37 (45% ) eram tuberculóides (T); 34 (41%) eram dimorfas (D); 8 (9,8%) eram virchowianas (V); e 1 (1,2%) foi não especificado. De acordo com a classificação operacional, 89 (47.6%) eram paucibacilares e 43 (52,4%) eram multibacilares, sendo 22 (26.8% ) portadores de baciloscopia positiva, 58 (70.7% ) portadores de baciloscopia negativa e 2 (2.4%) com baciloscopia não especificada. Quanto ao grau de incapacidade física. 67 (81.7%) tinham grau zero: 8 (9.8% ) tinham grau I e 7 (8.5% ) tinham grau II ao início do tratamento.

 

PE 63

HANSENÍASE NO RIO GRANDE DO NORTE UMA ENDEMIA OCULTA?
Mauricio Lisboa Nobre; Luiz Antônio Bastos Camacho; Euzenir Nunes Sarno
Universidade Federal Fluminense - Av. Marquês do Paraná, SN. Niterói - RJ

Criou-se um banco de dados com informações sobre 2.799 casos de hanseníase, notificados no Rio Grande do Norte entre 1928 e 2000. As informações dos casos registrados foram conferidas pelas suas respectivas unidades de tratamento. Ao mesmo tempo, as medidas de controle da endemia no Estado foram estudadas através de livros históricos, documentos arquivados na Secretaria Estadual de Saúde e de entrevistas com os 6 coordenadores do Programa no período de 1977 e 2000. Neste trabalho apresenta-se a série histórica da detecção de casos novos nos últimos 20 anos e comparam-se estes resultados com a detecção registrada para o país no mesmo período. O trabalho demonstrou que os coeficientes anuais de detecção registrados no Estado mantêm íntima relação com o desenvolvimento de atividades mínimas de controle da endemia. Destacam-se quatro picos importantes registrados em 1984, 1988, 1992 e 1997; nestes anos o incremento observado para este coeficiente foi respectivamente de 57%, 65%, 31% e 52% em relação aos anos anteriores: enquanto para o país o incremento no coeficiente de detecção registrado nestes anos foi de -4%, 30%, 12% e 9%. Destaca-se que no Rio Grande do Norte, após os picos observados a detecção de casos novos não cai para os níveis dos anos anteriores às intervenções, mostrando que os serviços implantados e os profissionais treinados permanecem contribuindo para o aumento da detecção nos anos posteriores. Apesar do Estado apresentar coeficientes de detecção da hanseníase ainda considerados médios pelos parâmetros do Ministério da Saúde, este trabalho aponta para uma situação preocupante com relação ao controle da doença no Rio Grande do Norte, uma vez que o rápido e contínuo aumento na detecção de casos de hanseníase, nitidamente dependentes da implantação de atividades de controle, pode apontar para a existência de um importante reservatório de casos ainda sem diagnóstico (endemia oculta).

 

PE 64

HANSENÍASE: REAÇÃO REVERSA X FORMA CLÍNICA
Heitor de Sá Gonçalves; Ricardo Américo de A. Lima; Ana Célia de A. Mesquita; Ruth Helena O. Menezes; Francisco José Dias Branco
Centro de Dermatologia Dona Libânia - SESA - CE. Av. Pedro I, 1033, Centro. Fortaleza - CE

Em um total de 341 pacientes que deram entrada, como casos novos, no primeiro semestre de 2001, tivemos 77 (22,5 %) com reação reversa. Destes, 23 (29,9 %) apresentavam somente reação cutânea e 54 (70,1%) manifestavam somente reação neural. Com relação às formas clínicas predominantes tivemos: 5 pacientes (6,4 %) da forma tuberculóide (T); 50 (65 %) da forma dimorfa (D); 19 (24,6 %) da forma virchowiana (V) e 3 casos (4 %) sem forma clínica especificada. Vale ressaltar a maior predominância de formas neurais reacionais, principalmente nos casos dimorfos, como descrito a seguir: (T) - 40 % cutâneas e 60 % neurais; (D) - 24 % cutâneas e 76 % neurais; (V) - 57 % cutâneas e 43 % neurais.

 

PE 65

HANSENÍASE, INCAPACIDADES FÍSICAS APÓS PQT, NO PERÍODO DE 1994 A 1998 EM TERESINA - PIAUÍ
Ana Lúcia França da Costa

A hanseníase, doença crônica que acomete pele e nervos periféricos, é um dos mais antigos males da humanidade. As deformidades que causa são responsáveis por estigmas e tabus que ainda hoje persistem. A contribuição da poliquimioterapia (PQT) na diminuição da prevalência da doença no mundo é aceita por todos especialistas na área. Mas, qual a situação dos pacientes que receberam alta após tratamento com poliquimioterapia em relação às incapacidades físicas? Neste estudo procurou-se investigar a prevalência e a evolução dessas incapacidades cm pacientes com hanseníase, que receberam PQT, no período de 1994 a 1998, em Teresina, Piauí, Brasil. Por meio de amostragem probabilística sistemática, constituiu-se uma amostra de 617 desses pacientes. Nesta foi aplicada um inquérito de morbidade em duas etapas: teste de rastreamento e subsequentemente avaliação clínica de incapacidade. A amostra final foi de 319 pessoas, sendo 161 do sexo masculino e 158, do feminino. As idades variavam de 6 a 94 anos, com idade média de 43, 19 anos. De 135 pacientes avaliados segundo o grau de incapacidade (OMS/1988), 30,4% apresentaram incapacidade. Destes. 63,4% pacientes tinham grau 1 e 36,5%, grau 2, de 17 pacientes, que apresentavam grau 0 no momento do diagnóstico, 88,2% evoluíram: 70,5% para grau 1 e 29,5% para grau 2. De 15 pacientes que tinham grau 1 no diagnóstico, 73,3% mantiveram-se no grau 1 e 26,7% evoluíram para o grau 2. Finalmente, de 8 pacientes que apresentaram grau 2 ou 3 no diagnóstico, 25% regrediram para grau 1 e 75% mantiveram a graduação anterior. O tempo médio (em anos) de evolução desde o diagnóstico até a avaliação atual (1994 - 2001) foi de 4.32 anos, com período máximo de 9,79 e mínimo de 2,08 anos. A prevalência de incapacidades físicas em pacientes com hanseníase após tratamento com PQT, foi de 12,8%. Houve agravamento do grau de incapacidades em 28,8% dos pacientes examinados. Os idosos, os homens, e os pacientes multibacilares apresentarem maior risco para o desenvolvimento de incapacidades.

 

PE 66

ILEP-ORGANISATIONS SHOULD STRIVE FOR HIGH BCG COVERAGE IN THE COMMUNITIES UNDER THEIR CARE
Johan P. Velema
Evaluation & Monitoring Service, The Leprosy Mission International. PO Box 902, 7301 BD Apeldoorn, Netherlands.

A single BCG vaccination at birth or in the 1st year of life provides partial protection against leprosy. Nine case-control studies showed a vaccine efficacy of 20% to 81%, median 60%. It is reasonable to think that these studies underestimated the true effect since in some children the BCG scar does not persist. A prospective study and 3 randomised community trials showed efficacies of 36% to 80%, median 47%. Studies from India showed 20%, 42% and 60%. The duration of this protection is at least 10 to 15 years. Some studies suggest that BCG results in a shift from lepromatous to tuberculous forms of leprosy. BCG coverage is better than 80% in most countries in Asia but lower in Africa. Coverage in local communities may be much lower than the national average.
Systematic vaccination of all newborns will reduce the child ratio but will not noticeably reduce the NCDR. Repeated vaccination and vaccination at older ages would have more impact on NCDRs but is contraindicated in persons infected with HIV and may precipitate clinical disease in those infected with M. leprae . A special programme would be needed for vaccination at oldei ages, while BCG-vaccination at birth is a standard component of the MCH services in most countries.
ILEP organisations should monitor BCG coverage and advocate for provision of standard MCH services in all communities in which they arc involved thus reducing the risk of leprosy for children up to 10-15 years of age.

 

PE 67

IMPLEMENTAÇÃO DA POLIQUIMIOTERAPIA NAS RESERVAS INDÍGENAS DE DOURADOS E BRASILÂNDIA-MS
Antônio Carlos Modesto; Dra. Maria Angélica Gorga; Dra. Elza Garcia Dias; Dr. Pedro Lúcio Zanúncio; Dr. Joaquim Vilela; Dr. Adriano Cangussú Silva
Gerencia de Área de Saúde de Três Lagoas-MS. Av. Clodoaldo Garcia, 280, B° Santos Dumont, 79.630-180. Três Lagoas - MS. Fone: (67) 524-8012 ou FAX (67) 524-6000. E-mail: acm3l@terra.com.br
Trabalho realizado nas Aldeias Bororó e Jaguapirú, da Reserva Indígena de Dourados-MS e na Aldeia Ofaié-Xavante, no município de Brasilândia-MS.

O objetivo principal deste trabalho foi o de implementar a PQT nas Reservas Indígenas de Dourados e Brasilândia-MS. Muitos fatores contribuem para o limitado acesso das comunidades indígenas aos serviços de saúde: dificuldades causadas pela localização geográfica, problemas culturais, sociais e carência de profissionais de saúde treinados para suspeitar de casos novos de Hanseníase em seu meio. A estratégia foi a de treinar agentes de saúde indígenas, da FUNASA, professores indígenas, auxiliares de enfermagem dos programas locais, para atuarem na detecção precoce de casos novos e na administração da PQT nos casos confirmados mediante avaliação médica, realizada através de mutirões de atendimento médico. Foram treinados na Reserva Indígena de Dourados-MS: 10 Agentes Comunitários Indígenas de Saúde, 01 agente de saúde da FUNASA, 02 enfermeiras do PSF Indígena, 01 estagiária de enfermagem, 01 coordenador pedagógico da Escola Indígena Jaguapirú, 10 professores indígenas de 5 Escolas Indígenas locais. Ao todo foram 25 pessoas treinadas nesta Reserva. Na Reserva Indígena de Brasilândia foram treinados: 04 agentes de saúde da FUNASA, 03 servidores do Programa de Hanseníase local, 01 funcionária da Secretaria Municipal de Saúde local, 02 Agentes Comunitários de Saúde, 02 lideranças indígenas da Aldeia Ofaié-Xavante, ao todo 12 pessoas treinadas. Foram detectados 1 caso da forma clínica tuberculóide na Reserva Indígena de Dourados-MS (Incidência de l,4/10.000hab.)e 3 casos da forma clínica indeterminada na Reserva Indígena de Brasilândia-MS (Incidência de 576,9/ 10.000 hab.)

 

PE 68

IMPORTANCE OF CONTACT CHECKING FOR CASE FINDING OF LEPROSY IN A LOW ENDEMIC SITUATION
M.A. Hamid Salim1; Priojit Kumar Nandi1; Satyajit Naha1; Amir Ali1; Declercq Etienne2

1. Damien Foundation Bangladesh. House 33, Road 43, Gulshan II, Dhaka, Bangladesh.
2. Damien Foundation Belgium. Boulevard Leopold II. 263, 1081 Brussels, Belgium.

Introduction: Contact checking is the only active case finding method used by most of the Leprosy Control programmes. However, there is no definite guideline for how long contact survey should be continued. Damien Foundation Bangladesh follows the strategy to check the household contacts of smear positive cases once in a year for 5 years and for other cases only once. The question arose whether 5 years contact checking is necessary?
Material and methods: The results of the annual examination of household contacts of smear positive patients detected in 1995 in the greater Mymensingh district have been analyzed retrospectively. Out of 135 smear positive patients, the contacts of 129 cases could be examined for 5 successive years. Among these 129 cases. 86 had a Bacillary Index (BI) of 4+ or more.
Results: The data show that a total of 5,518 contact examinations were done in 5 years. The mean case detection rate among contacts was 87/10.000 population per year, with a maximum of 202 in 1st year and 134, 130, 21 and 54 respectively in the following years. The case detection rate was in average five times higher among the contacts of cases with a BI of 4+ or more, compared to those of smear positive cases with a BI of 3+ or less.
The case detection rate was 0.22/10.000 only in the general population in 1995.
Conclusions: The above data show the usefulness of the regular examination of contacts of smear positive leprosy patients. Although incidence seems to decrease over time, it remains high even 4 years after the diagnosis of the index case. Since it is not possible to extend the period of active contact examination indefinitely, it is extremely important to take benefit of these examinations to increase awareness on lhe early signs of leprosy among lhe contact population.

 

PE 69

INCIDÊNCIA E PREVALÊNCIA DE HANSEN (ASE NA CIDADE DE ARACAJU. NO ANO DE 1999
M. L. N., Pedrini3; M. C. P., Santana2,3; J. F. de, Santana1,2; M. S. de LIMA1,2

1. Fundação Hospital São Lucas: Aracaju-SE.
2. Universidade Federal de Sergipe.
3. Laboratório de Referência de Micobactérias: Instituto Parreiras Horta / Rua Campo do Brito, 551, Bairro São José. 49020-380. Aracaju-SE

Considerando a situação epidemiológica da hanseníase no mundo e considerando a inexistência de dados coletados e tratados em relação a casos novos e antigos de hanseníase no município de Aracaju-SE, este trabalho propôs conhecer o perfil de incidência e prevalência da referida patologia neste município, no ano de 1999. Para isso, adotamos os parâmetros: sexo, faixa etária e forma clínica predominante no diagnóstico. As fontes de informações foram os prontuários de pacientes cadastrados no Programa Estadual de Controle da Hanseníase e dados do Laboratório de Relerência de Micobactérias do Instituto Parreiras Hortas (Lacen-SE). O método utilizado foi o quantitativo, ao qual aplicamos o leste estatístico do quiquadrado (χ2) para responder às seguintes hipóteses formuladas: A ocorrência das formas clínicas da hanseníase não está associada ao sexo, As formas clínicas de hanseníase ocorrem independentemente do local onde as pessoas moram; Não há associação entre a idade e as formas clínicas de hanseníase. Escolhemos o teste quiquadrado (χ2) pela possibilidade de verificar a significância dos afastamentos entre as freqüências observadas nas amostras e as freqüências esperadas se as hipóteses nulas fossem verdadeiras, e porque nos interessava verificar a proporção de indivíduos com o atributo hanseníase em uma dada população. Concluímos que não existe associação quanto a incidência u prevalência da doença em relação às formas clínicas, sexo e faixa etária na amostra analisada

 

PE 70

INFLUENCE OF MULTIDRUG THERAPY ON SMEAR POSITIVE CASES IN TALUKA PANVEL
P.N.Gogate; U.H.Thakar; S.S.Naik; Pratibha Kathe
Kushtarog Niwaran Samiti, Shanlivan, Taluka Panvel. Acworth Leprosy Hospital for Research, Rehabilitation and Education in Leprosy. Wadala, Mambai -400031 INDIA.

Punvel Taluka has its unique features, such as surrounded by costal and hilly area where the residents are uneducated, in low socio-economic group of tribal and fishermen community and generally meales among them are out of homes six months in year to earn their liveligood. At the other hand there are several developed and developing big industrial packets in same Taluka, where residents around are highly educated, economically well setteled but under the influence of constant influx of semi and unskilled persons.
MDT was initiated in Panvel Taluka in 1990. The comparison of newly detected cases in pre and post MDT era in centres different regional and population set up was made. During last 5 years (1988-1992), total 1597 new cases (234 MB and 1363 PB) registered by conventional methods of SET. The analysis showed that there is a no change in child rate, deformity rate and smear positive cases rate in newly detected cases in pre and post MDT era but bacterial quantum based on B.I.of smear positive cases (n=166) reduced considerably after MDT and brought to the negligible state irrespective of regional and population variation. It is further noticed that the results are more impressive in area of educated and stable population.

 

PE 71

INTEGRATING DATA FROM HEALTH INFORMATION SYSTEM
Tadiana Maria Alves Moreira1; Elizabeth Moreira dos Santos2; Vera Andrade3

1. Secretary of Health. Rio de Janeiro State.
2. National School of Public Health
3. WHO

Epidemiological surveillance in leprosy is based in the evaluation and monitoring of the activities of the Brazilian program. It includes epidemiological and operational indicators constructed from data of the National System of Notilicable Diseases (SINAN) collected at the local level. Analysis of these indicators are used to the understanding of the epidemiological pattern of the endemic and also to subsidize managerial interventions in the Leprosy Control Program. The information related to the indicators by each state of the federation, which represents the foundations of the control, are analyzed from tabulations of aggregate data that are discussed in the text. In practical terms, there is not yet basic information such as the number of leprosy patients assisted by the SUS/MS, as well as the financial expenditure on these patients by the Federal Government, faking into consideration that the Notification Form is the only source of information existing today, it is observed some limitation regarding the type, quality and analysis of these data, making it difficult to know the concrete situation of the endemic in the country.
The aim of this study is to stress the importance of information related to medical services (SIA/SUS, SIAB, SIH/SUS and SIM) as a contribution to the epidemiological surveillance of leprosy. It is discussed also the need for updating data from health services to attain a systematic situational diagnosis, with periodical evaluation and patroni/ation in order to reorient decisions al the local level.

 

PE 72

INTEGRATION OF LEPROSY IN GENERAL HEALTH SYSTEM IN BIHAR
Dr. P. Krishnamurthy; Dr. Bishwanath Prasad; Dr. T. Prabhakar Rao. Dr. G. Ramakrishna Raju and Dr. P. Vijayakumaran
Damien Foundation India Trust

Prevalence rate of leprosy in Bihar was 29 and 15 in June 1998 and 2000 respectively. At present 29% of caseload of India is from Bihar. National Leprosy Eradication Programme in Bihar Stale was carried out by vertical staff only till 1998. After detection of 2,05,569 new cases in MLEC-I during 1998 and 1,11,609 new cases from on going activities, on conclusion of State level conference of Civil Surgeons and District Leprosy Officers for strengthening NLEP. Govt, of Bihar issued instructions for one day weekly leprosy clinic at all Health facilities on Tuesday and Drug distribution by General Health staff at DDP. (5000 Population) where vertical staff is not posted to ensure treatment compliance of all leprosy cases under treatment.
Keeping in view W.B assistance till March 2004 and good number of cases detected by on going regular performance and campaigns. Govt, of Bihar decided and issued orders in August 2001 to integrate leprosy work in General Health system (defining the work of each category of General Health and NLEP workers). Leprosy patients to be examined and treated at all health facilities on all working days in OPD and follow up treatment to continue through near by HSC on fixed day every week.
So far 22 districts are having Damien Foundation India Trust Support team. Out of these 22 districts 33.48% of Health facilities and 31.12% of HSCs have been integrated for leprosy work till December 2001 and complete integration of all health facilities and HSCs is expected by 2003.

 

PE 73

INTEGRATION OF LEPROSY SERVICES: EPIDEMIOLOGICAL IMPACT AFTER A YEAR OF ACTIVITY
Sunil Settinayake
Director. Anti-Leprosy Campaign, Central Leprosy Clinic. Room 21, O.P.D., General Hospital, Colombo 8, Sri Lanka

Leprosy integration into the general health services was completed in February 2001 and is already starling to bear fruit, but implementing the necessary changes has been a challenging task. Many new procedures had to be established, logistics improved, attitudes changed and health workers trained. A broad bridge between curative and preventive health services had to be built. Integration efforts were supported by an advertising campaign to inform people that leprosy, like any other illness, can be treated at all health facilities.
Contrary to the expectation that quality of service would drop following integration, more cases are now detected and an extensive network of government doctors is able to diagnose, treat and manage leprosy patients more efficiently. The new case load rate has increased from 0.89/10.000 inhabitants in 2000 (1700 new cases) to 1.2 /10.000 in 2001 (2398). The prevalence has increased from 1.158 in 2000 (0.6/10.000 inhabitants) to 1,583 (0.8 per 10.000 inhabitants). These figures have been corrected lor about 5 % of re-registration. Almost every district has registered an increase of case detection, though it was more significant in low endemic areas.
A few areas still need more attention, such as integrating MDT supplies within existing systems as well as improving the flow of information. The paper will focus primarily on the epidemiological impact of integration, experience with the Mow of information and future plans to further simplify the system.
Integration has definitely brought treatment closer to patients throughout the country, and is paving the way for the sustainable elimination of leprosy.

 

PE 74

LA LEPRA EN CIUDAD DE LA HABANA, CUBA AÑO 1997-2001
Dra. Olenia Hernández Gutiérrez; Dra. María Elena Alonso Gómez; Dra. Olenia Pesant Hernández
Centro Provincial de Higiene y Epidemiología. Ave. 31 # 7617 Entre 76 y 82 Marianao CP: 11400 Cuidad de La Habana. Cuba

Se analiza la situación de la endemia de la lepra en Ciudad de la Habana, capital del país. Donde la detección de casos nuevos en el último lustro 1977-2001, ha ido descendiendo, como promedio se detectaron 48 casos nuevos en los primeros 5 años y 27 en los últimos cinco. La ciudad tiene tina población de 2181395 hbtes. distribuidos en 15 municipios, siendo la Región Sur, (Arroyo Naranjo, 10 de Octubre y Boyeros) la de mayor detección y la liste (Cotorro) la más baja.
Finalizando 2001 con 34 enfermos y una tasa de prevalencia 0.2 × 104 habitantes, se reduce la tasa de 1993 en 4 puntos.
Las acciones del programa de control están descentralizadas e integradas en la Atención Primaria de Salud (APS), los enfermos y población en vigilancia son atendidos por medico y enfermera de la Familia, alcanzando a examinarse el 80.1% de la población total de riesgo.
En las estrategias actuales, Post eliminación hay sostenibilidad de las acciones, dirigidas fundamentalmente a la capacitación y desarrollo de recursos humanos (APS) y fortalecimiento del componente educativo del programa para lograr incrementar el diagnóstico precoz, y la interrupción de la transmisión como objetivo final.

 

PE 75

LEPRA EN GUINEA ECUATORIAL. SITUACIÓN EPIDEMIOLÓGICA 1999-2001
Dr. José Ramón Gómez Echevarría; Fátima Moll Cervera. Fisioterapeuta; J. M. Hernández; P. Simarro; J. M. Rodríguez; J.R. Franco; S. Elé
Sanatorio San Francisco de Borja.Fontilles. 03791 FONTILLES-VALL DE LAGUART (ALICANTE). Telf. 96 558 33 50. Fax. 96 558 33 76. E-mail: sanatorio@fontilles.org

Tras tres años de trabajo colaborando con el Ministerio de Sanidad y Bienestar Social de Guinea Ecuatorial, se consigue un Censo de casos nuevos, en tratamiento y enfermos discapacitados. Se realiza una valoración por Distritos, tanto en la zona continental como en la zona insular, reflejando las carcterísticas epidemiológica de los pacientes.
Se realiza una valoración comparativa con Censo de años anteriores.
Se recogen las principales características de los enfermos discapacilados. para lo cual se realiza una exploración neurológica simplificada.

 

PE 76

LEPROSY ELIMINATION PROGRAM: EPIDEMIOLOGICAL TREND IN EAST KALIMANTAN
Dr. Asik (nlrkaltim@hotmail.com and kingasik@hotmail.com )

Objective: to study the epidemiological trend of leprosy in East Kalimantan province from 1990 to 2000.
Material and Method: data were obtained from compilation of regular quarterly reports in line to lhe operational definition of WHO.
Result: a total of 1254 cases detected during 1990 to 2000, in which 152 cases of them were children, accounting for 12.12% of all cases. For disability grade-2 of the WHO grading system, there were 230 of cases detected (18.34). For the clinical classification, 891 were MB (71.05%) and 363 were PB (28.95%). About 56.70% of cases were found through active case finding. At the end of the year 2000, the prevalence rate was 0.86 per 10000 with case detection rate of 5.54 per 100000 populations. The peak of prevalence (3.61 per 10000 population) was occurred in 1992 then decreased annually till 0.73 per 10000 populations in 1998 and then slightly increased (1.04 per 10000 populations) in 1999. Meanwhile, the peak of detection was occurred in 1992 (9.93 per 10000 populations), then decreased till at the lowest level (2.32 per 100000 population) in 1995. In 1996, the detection tends lo increase and reach lhe second peak at 1999 (6.88 per 100000).
Conclusion: this study figured out that leprosy control in East Kalimantan province WHO target of elimination by year 2000 at provincial level, but at district level, there was uneven distribution. There were 5 of 12 district did not reach the target. The special effort should be addressed to reach elimination status at every district.

 

PE 77

LEPROSY ENDEMY CHARACTERIZATION IN UBERLÂNDIA-MINAS GERAIS, BRAZIL, 1996-2000
Goulart, I.M.B.; Barbosa, F.M.; Chaves, J.G.M.: Guedes, J.T.; Muni z D.L.O.; Netto, J.C.; Queiroz, L.B.; Silva, Y.A.
Centro de Referência Estadual em Hanseníase / Dermatologia Sanitária Faculdade de Medicina / Universidade Federal de Uberlândia. Av. Pará, 1720, CEP 38400-902. Uberlândia - MG. Brasil. Fax: +55-343218 2349: E-mail: imbgoulart@ufu.br

Aiming to eliminate leprosy as a public health problem in Brazil until 2005, the SUS (Unique Health System) in each city, with the purpose of decentralization of leprosy's control actions, has the necessity of knowing the aggravation through operational and epidemiological indicators and prevalence estimates undetected, in order to plan new strategies and evaluate their results, respecting local and regional realities. To characterize the leprosy endemy and estimate the occult prevalence in Uberlândia, a retrospective analytic study was realized with a survey of 613 leprosy patient's records during the period from January, 1996 to December, 2000, by SINAN (Complaint's System of Information and Notification).
The results showed an occult prevalence estimative of 146 cases until 2000, increasing the official prevalence from 4,47/10.000 inhabitants to a real prevalence rate of 7,39/10.000 inhabitants. The sanitary districts with higher occult prevalence estimative also demonstrated an increase of the detection coefficient in people under 15 years old and coincided with those areas where predominated the old disease focus. With an identification of prioritary areas, technical and operational factors were listed as factors which prevent the leprosy control. Therefore, it's craved to touch the SUS managers in the city, in the direction of proposing a health policy which prioritizes the quality of assistance and its hierarchy by a resolutive capacity consolidated in the health professional's competence and in the development of articulation and society mobilization mechanisms to eliminate leprosy until 2005.

 

PE78

LEPROSY IN CHILDREN - A RETROSPECTIVE STUDY OF CHILD CASES DETECTED IN NORTH EASTERN SUBURBS OF GREATER MUMBAI FROM 1995 - 2001
Sachin, R. Salunkhe; Samy, A. A.; Joy, M.; Dewarkar, P. R.; Vincent, A. K.
Alert-India; Association For Leprosy Education, Rehabilitation & Treatment - India.
B-9 Mira Mansion, Sion (West), Mumbai - 400 022. India.

Early detection of large number of child leprosy cases is one of the significant indicators of the continued presence of leprosy infection in a given geographical region. This study is based on the data of child leprosy cases detected over a five year period (1995 to 2001) at ALERT-INDIA's urban leprosy control projects in North Eastern suburbs of Mumbai.
The cases were studied from the epidemiological and clinical aspects as well. Case detection was initially done through School Surveys and Mass Surveys. As high as 36% were child leprosy cases. Follow-up examination of the family contacts of these children revealed that sizeable number of them were members of multiple leprosy case families.
Critical analysis of the data confirms the persistence of the chain of transmission as a primary factor leading to the appearance of new cases in the community.

 

PE79

LEPROSY SITUATION IN ENDEMIC STATES OF INDIA AT THE THRESHOLD OF ELIMINATION
Sathish Kumar, E; Subramanian, M.; Showkath Ali, M.K
Central Leprosy Teaching & Research Institute. Tirumani, Chengalpattu - 603 001, Tamil Nadu, India.

Although there is no reduction of NCDR in India, there is a significant reduction observed in two endemic states of Andhra Pradesh and Tamil Nadu. The ratio of PR and NCDR is declining and reveals at the elimination could be reached even when NCDR is at the higher level i.e. 4 to 5 per 10000 population with SSL proportion among new cases above 50%.
The significant number of cases detected in Bihar and Orissa during MLEC reveals that the lacunae in operational activities of new detection would result in a large number of undetected cases in the community. The voluntary reporting hovering about one-third only. This underscores the need for relying on active case detection for breaking the transmission, so has to achieve sustained elimination of leprosy.
The influence of socio-economic factor on continued occurrence of leprosy could not be ruled out. One of the reasons for the failure of models that projected the decline of leprosy by 2000 A.D. could be due to exclusion of economic status and health care seeking status as contributory factors.
The operation efficiency should be ensured by complementing NLEP with Health Management Information System (HMIS) at State/National level (Macro) and at selected district level (Micro) to gain in-depth knowledge of leprosy parameters especially on double entry / recycling of case.
In view of this situation, NLEP should adopt a more realistic approach for declaring the attainment of elimination level.

 

PE 80

NEMATÓIDES INTESTINAIS: AUMENTO DO RISCO PARA HANSENÍASE MULTIBACILAR?
Lucia Martins Diniz; Eliane Zandonade; Reynaldo Dietze; Fausto E. L. Pereira; Rodrigo Ribeiro-Rodrigues
Núcleo de Doenças Infecciosas, Centro Biomédico, Universidade Federal do Espírito Santo. Av. Marechal Campos, 1468, Maruípe, Vitória - E.S.

Introdução: Os nematóides intestinais induzem uma imunomodulação no hospedeiro caracterizada por predomínio da ativação de células Th2 e redução de algumas atividades das células Th1, o que pode interferir no curso de outras doenças, como na hanseníase, que para evolução benigna depende do estímulo da resposta Th1.
Objetivos: Estudo caso-controle para verificar a presença de nematóides intestinais em pacientes portadores de hanseníase atendidos em um centro de saúde.
Pacientes e métodos: Revisão de prontuários de 477 pacientes portadores de hanseníase com anotação de um resultado de exame parasitológico de fezes. Como controles: prontuários de 470 pacientes atendidos no mesmo posto, período e faixa etária, sem hanseníase, e com um resultado de exame parasitológico de fezes.
Resultados: A freqüência de nematóides intestinais foi maior nos pacientes com hanseníase do que nos controles, porém a diferença estatisticamente significante foi quando comparamos as formas multibacilares com as paucibacilares e os controles.
Conclusões: Os resultados sugerem uma associação significativa entre a presença de nematóides intestinais e as formas multibacilares da hanseníase, talvez possibilitando uma imunomodulação exercida pelos parasitas intestinais, favorecendo a progressão da hanseníase para as formas multibacilares.

 

PE 81

NON-CONDITIONAL LOGISTIC REGRESSION ANALYSIS OF RISK FACTORS ON DISABILITIES OF LEPROSY
Yuejun Shi; Shunpeng Song; Zhenguo Zhang; et al.
Dalian Provincial Institute of Dermatology, Dalian 116021, China

Objective Analysis of factors impacting on the disability of leprosy and provide the scientific basis for formulating the preventive strategies.
Methods Based upon the individual records of the living leprosy cases were collected by local leprosy workers of liaoning, using non-conditional logistic-regression analysis model to analysis effective factors on disability of leprosy.
Results the results of single factor non-conditional logistic regression analysis are: leprosy type, marriage, education, native place, standard of living, the reaction. The results of multiple factor nonconditional logistic regression analysis are: native place, standard of living, the reaction, leprosy type.
Conclusion the reaction, leprosy type, native place, standard of living, can signilicantly effect the disability of leprosy. It is very effective t o prevent the disability of leprosy through controlling the reaction, treating the patient in time, made their life rich and increasing the standard of living to made economical rehabilitation.
[Key words] Leprosy Disability non-conditional logistic regression analysis

 

PE 82

PERFIL DA HANSENÍASE EM ALFENAS (MG)
Avani Soares Almeida Magalhães; Cláudio de Lélis Filgueira de Souza; Wendel Antonio Fagundes; Elisa Oliveira Gonçalves Antunes; Mariza Bárbara Rissuto
Serviço de Hanseníase da S.M.S. de Afenas (MG). Pça. Dr. Fausto Monteiro, 300, Centro. Alfenas - MG. CEP 37130-000.

Os autores apresentam um estudo retrospectivo de 100 pacientes ingressos no Serviço de Hanseníase da S.M.S. de Alfenas (MG) no período de outubro de 1997 a maio de 2001. Tal estudo mostra a característica da hanseníase nesta região do estado de Minas Gerais, tais como incidência de homens 58% sobre 42% de mulheres e adultos 96% sobre 4% de crianças menores de 15 anos de idade. Nosso estudo mostra também outros dados epidemiológicos como a média baciloscópica, exames complementares, esquemas terapêuticos empregados e reações como eritema nodoso e neurite.
Motivo da Apresentação: Demonstração de que pequenos serviços públicos, com grandes esforços, estão fazendo para a eliminação da hanseníase em Minas Gerais.

 

PE 83

PERFIL DO DOENTE DE HANSENÍASE NO MUNICÍPIO DE JOÃO PESSOA - PB
Leila de Cássia Tavares da Fonseca; Clélia Simpson de Miranda

O presente trabalho descreve um estudo exploratório descritivo com abordagem quantitativa, realizado em João Pessoa, entre Abril e Maio de 2000, com o objetivo de traçar o perfil do doente de Hanseníase no município estudado. A amostra foi coletada a partir de 101 prontuários de caso notificados em pacientes no ano 1999, no Hospital Clementino Fraga. O estudo evidenciou que no município estudado os homens adoecem mais de Hanseníase do que as mulheres, com uma percentagem de 54% e 46% respectivamente, atingindo mais os casados com 547 e em seguida os solteiros com 41%; já os viúvos com 5%. Considerando o parâmetro grau de instrução, verificou-se que 507 dos pacientes da amostra estudada, possuíam o nível fundamental, bem como, com relação a faixa etária, os resultados revelam um índice altíssimo na população entre 25 e 60 anos com mais de 60% dos casos. Quanto aos bairros mais atingidos, a relação com a doença pesquisada é equitativa, a exceção dos bairros do Cristo Redentor, Mangabeira e Centro.

 

PE 84

PERFIL EPIDEMIOLÓGICO DA HANSENÍASE
Heitor de Sá Gonçalves; Ricardo Américo de A. Lima; Ana Célia de A. Mesquita; Francisco José D. Branco; Maria Luci Landin T. Ferreira
Centro de Dermatologia Dona Libânia - SESA - CE. Av. Pedro I. 1033, Centro. Fortaleza - CE.

Em um total de 878 casos novos detectados pelo serviço em 2001, 82 ( 8.8 %) tinham menos de 18 anos; 305 (34,7 %) tinham entre 18 e 38 anos; 377 (42,9 %) tinham entre 39 e 65 anos: e 114 (13.6%) tinham mais de 65 anos de idade. Quanto à forma clínica, 41 (4,6 %) eram indeterminadas (I); 234 (26,6 %) eram tuberculóides (T); 452 (51,4%) eram dimorfas (D); 148 (16,8 %) eram virchowianas (V); e 3 (0,3 %) não especificadas. Quanto ao grau de incapacidade, 452 (51,5 %) tinham grau zero; 151 (17.2%) tinham grau I; 47 (5,4%) tinham grau II; e 228 (26 %) tinham grau de incapacidade física não-avaliado. Quanto à baciloscopia, 345 (39.3 %) foram positivos; 500 (57%) foram negativos; e 33 (3.7 %) foram não especificados.

 

PE 85

PERFIL EPIDEMIOLÓGICO DA HANSENÍASE NO MUNICÍPIO DE TAUBATÉ - SP NO ANO DE 1999
Fátima de Oliveira Rabay; Lays Patryce Santos; Samuel Henrique Mandelbaum; Daniela Katayama; Erico Pampado Di Santis
Universidade de Taubaté. Av. Granadeiro Guimarães, 270, Taubaté - SP

O Brasil ocupa o segundo lugar do mundo em número absoluto de casos de Hanseníase. Em reunião promovida pela O.M.S., em 1999, o Brasil assumiu novo compromisso de reduzir os coeficientes de prevalência a níveis inferiores a um paciente em cada 10000 habitantes até o final de 2005.
Avaliou-se, retrospectivamente, a situação epidemiológica e operacional do controle da Hanseníase no Município de Taubaté - SP no ano de 1999.
Detectou-se coeficiente médio de prevalência (3.24 / 10000 habitantes) e alto coeficiente de detecção anual de casos novos para o ano de 1999 (1,27 /10000 habitantes). Cerca de 83,507 eram formas multi-bacilares e o esquema terapêutico predominante foi o da Poliquimioterapia em 80,037 dos pacientes. Dos que receberam alta por cura e foram avaliados quanto à incapacidade, 20.83% apresentaram graus II e III da mesma.
É proposto o atendimento pelas U.B.S., por estarem mais próximas da comunidade, oferecendo oportunidade de diagnóstico precoce e tratamento para todos os doentes. Encaminhamento a serviços de nível secundário e terciário seria feito para detecção diagnóstica mais apurada e na ocorrência de complicações.

 

PE 86

PRELIMINARY STUDY OF LEPROSY AMONG BRAZILIAN JAPANESE ORIGIN PEOPLE, IN SÃO PAULO, PARANA (BRASIL) AND LEPROSY RESEARCH CENTER (NIID) -JAPAN
Mitie Tada L.R.F. Brasil1; Lúcia E. Takaoka2; Norihisa Ishii3

1. Centro de Vigilância Epidemiológica - SES-SP -Brazil - dvhansen@saude.sp.gov.br
2. Sociedade Filantrópica Humanitas - PR - Brazil - sfhs@asahinet.com.br
3. Leprosy Research Center. NIID - Japan .

In the 90's decade, the emigration of Brazilian of Japanese origin people to Japan, in order fo work, has been in large number, netting 250.000 persons in the year 2000. It is a question of some concern, considering that Brazil is a leprosy high endemic country and Japan is considered a residual endemic country of leprosy. According to the Leprosy Research Center data, 56 new cases were diagnosed in Japan among Japanese people since 1993 up to 2000, including Okinawa Islands. In the same period of time, 75 new cases were detected among foreign persons and among them 33 were Brazilians. In Japan the notification is made without case identification, so it is impossible to find out if these cases are also in Brazilian Files. In order to measure the actual magnitude of the leprosy among the Brazilian people of Japanese origin in Brazil, a search was performed in São Paulo and Paraná States. These two states probably have the most of Japanese origin people living and may provide the most of emigrants to Japan, also. In the São Paulo State Surveillance System, three different files were searched, to cover the period since 1982 up to 2000 (19 years). Those informations are not easily accessible and it demanded a lot of manual work. After all, 578 notified cases were founded and 533 of them were new cases. An annual notified average of 28.05 new cases. The clinical classification was: 118 indeterminate, 147 tuberculoid. 68 bordeline. 140 lepromatous and 60 none classified. The information of Parana State was accessed using the SINAN -DOS data file, which has 202 cases recorded since 1954 up to 2000. The clinical classification was: 38 indeterminate, 65 tuberculoid, 26 bordeline, 71 lepromatous and 2 non classified. The coefficients were not calculated because the data about the number of Japanese descendents is not reliable. More details of this study will be presented during the Congress. The authors intend to continue with the search in order to know more about the transmission among these people in spite of the low number of cases (less than 1% of the total files researched). The problem exists and it seems to be worthy of more studies.
[Key words] - leprosy, surveillance system

 

PE 87

PREVALÊNCIA OCULTA DA HANSENÍASE NA DIRETORIA DE SAÚDE DE BELO HORIZONTE
Lana, F.C.F.; Melendez, J.G.V; Araújo, M.G.; Magalhães, E.G.
Escola de Enfermagem da UEMG, Av. Alfredo Balena, 190, Santa Efigênia. CEP 30130-100. Belo Horizonte - Minas Gerais - Brasil. xicolana@enf.ufmg.br

Esta investigação teve como objetivo analisar a prevalência da hanseníase na Diretoria Regional de Saúde de Belo Horizonte (DRS-BH), no período de 1995 a 1999. Trata-se de estudo epidemiológico, descritivo, que utilizou dados das fichas de notificação dos casos residentes na DRS-BH. As taxas de prevalência e detecção tem sofrido queda nos últimos anos, o que poderia significar uma tendência declinante da doença; entretanto, deve-se analisar se não se trata de problemas operacionais na detecção de casos novos, já que observamos que há uma prevalência oculta da hanseníase nos municipios da DRS-BH, sendo significativa em Belo Horizonte, Betim, Contagem e Santa Luzia: com estimativa, nos últimos 5 anos, de 247, 105, 82 e 58 casos, respectivamente. Os 492 casos que deixaram de ser diagnosticados são responsáveis por 82% da prevalência oculta da DRS-BH. O alto percentual de casos notificados com grau de incapacidade confirma que há prevalência oculta na região e que o diagnóstico está sendo tardio, podendo comprometer as metas de eliminação da hanseníase como problema de saúde pública, sendo necessário, intensificar as ações de controle, especialmente, exame de contatos.

 

PE 88

PROGRESS ON FIELD TREATMENT OF REACTION IN NORTHEASTERN STATES OF NIGERIA
Philip Patrobas
Office of the Representative, Netherlands Leprosy Relief, PO Box 759, Bukuru-Jos, Plateau State. Nigeria.

Efforts of the National Tuberculosis and Leprosy Control Programme in Nigeria (NTBLCP) and the Non-Governmental Organization (NGO) have resulted in a dramatic reduction in the registered prevalence 0.8 per 10.000 in 2001. Despite this achievement, leprosy remains a public health problem due to the back load of disabled ex-patients and stable Case Detection Rate (CDR) 0.7 per 10.000) over the last five years. Disability grate 2 among new patients is more than 10%.
Complications of leprosy (reactions and nerve damage) remain the most important causes of impairment and disability in Nigeria. It was the policy that all patients with reactions be referred to the referral hospital. Due to distance and other personal reasons, most patients when referred do not arrive at the hospital. It is well documented that about 15 - 30% of leprosy registered for MDT treatment develop reactions leading to nerve impairment or disability. No study has been carried out to ascertain the level of reactions in the field in 13 Northern states of Nigeria. It is also well documented that majority of patients who develop nerve function impairment after registration do so in the first year (about 809, reported in Indonesia and 67 - 91% in Bangladesh). As a result of the problems encounter by the patients and the field programme, the policy of treating reaction patients only in the hospitals was changed and field treatment of patients with steroid was started in 1998. This is aimed al making steroid treatment more accessible to patients.
The objective of this paper is, to access the actual magnitude of reactions in the field, to determine the actual number of patients who started steroid treatment and completed according to the standard guideline, to identify problems encounter with implementation of the field treatment with steroids, to make recommendations on ways of improving field treatment with steroids.
The method used in the study was the evaluation of reports received from the field, quarterly reports sent to the office by the programme officers, interviews with some leprosy control staff and Primary Health Care staff on their experiences.
In the period under study (1998 -2000). 13.148 new patients were treated with MDT out of which 581 patients were treated in the field with steroids. Of the total patients reported, 62% were males and 38% were females. Out of the 581 patients that were treated with steroids, treatment results were obtained for only for 499 patients showing 459 (91%) had their condition improved with steroids (reactions subsided or disability reversed) while 40 (9%) had their condition remain the same or had their condition deteriorated. Those who deteriorated were referred to the referral hospital for further management by the Medical Officer. Out of the results analysed, 201 (40% ) were females and 298 (60% ) were males. Treatment completion and improvement in condition was better with the females (95%) than the males (83.9%).

 

PE 89

PROGRESS TOWARDS SUB-NATIONAL LEPROSY ELIMINATION, BANGLADESH
Dr. Jalal Uddin Ahmed. Dr; Safir Uddin Ahmed; Dr. Vikarunnessa Begum; Dr. A.N. Maksuda; Dr. S.A. Hadi; Dr. A.H. Salim
National Leprosy Elimination Programme, Directorate General of Health Services. Leprosy Control Institute it Hospital Compound. Mohakhali, Dhaka 1212, Bangladesh.

Bangladesh has made considerable progress in achieving the goal towards elimination of leprosy at National level. At the end of December 1998, the registered prevalence of the country for the first time fall below 1/10.000 population and become 0.87 and further declined to 0.66 at the end of December 2001. Virtually Bangladesh have achieved the goal of elimination of leprosy al National level two years ahead of WHO target date. One of the major indicators of efficiency of case finding, the visible deformity/disability rate declined from 21.40% in 1993. 7% at the end of December 2001.
Eight NGOs are assisting the Government in MDT implementation in 29 districts (231 upazilas) of the country and has created an exemplary partnership record, where the resources from the Government and NGOs are pooled and optimally utilized. The NGO collaborative areas are endemic and contribute over 80% of the country caseload at any point of time. From 1985 to December 2001 a total of 130555 cases have completed MDT and declared cured. As of end of December 2001, 8540 cases are under treatment and the estimated prevalence of leprosy is about 12.000. The gap between the estimated and registered cases has reduced and is expected to reduce further each year.
Leprosy is not evenly distributed in Bangladesh in conformity with world pattern. The leprosy endemicity varies widely within the country. Eight (8) northern districts of Rajshahi division, two metros - Dhaka and Chittagong and 2 (two) district of Chittagong division - total 12 (twelve) areas contributing over 70% of the total cases and still having prevalence > 1/10,000 population. After achieving the elimination goal at National level the major attention of NLHP is to achieve elimination at sub-national level. More details including strategic plan 2002 - 2003 will be presented

 

PE 90

"REACHING THE UN-REACHED" IN RANDOMLY SELECTED URBAN AREAS OF ORISSA - A STRAETEGIC INTERVENTION BASED COMMUNITY PARTNERSHIP
Dr. D.N. Nayak; Dr T.P. Patro
DANLEP, Orissa, 24 VIP Area. Ekamrakanan Road, Nayapalli, Bhubaneswar, Orissa, India

Introduction: Orissa is situated along the east coast of India with a population of 36.7 million with 13% urban population. Leprosy elimination looks nearly achieved in Orissa. But if we analyze leprosy elimination parameters for the urban segments, it seems highly improbable to achieve this. This is because the PR in urban areas is roughly double ( 13.7/10000) the over all PR of the state (6.9/10000: This could be due to inadequate health infrastructure at grass root level to address the health issues in rapidly growing urban and periurban slums; lack of coordination between available service providers and systems. This needs timely interventions.

Objective:

  • To reach the un-reached population involving decision makers, health providers and community leaders and other allied players working in developmental sectors to facilitate leprosy elimination process.

  • Strategy:
  • Team (consensus) building of all players and partners to gain their commitment and enhance level of motivation.
  • Capacity building of all health providers.
  • Sensitization of key players.
  • Door to door search with community participation.
  • Strengthening the institutional capacity of health facilities lo promote voluntary reporting and integrated MIS.
  • Follow for six months.
    Activities and Process:
  • Identification and interaction with all the major stakeholders have been done in five urban areas.
  • Team building workshops have been conducted in three urban areas and other activities are in progress in remaining areas.
  • Conclusion:

  • Preliminary results show very good participation from decision makers, health providers and other players including community leaders.
  • This approach will definitely help us to reach the under privileged sections of the community.
  • Replication will he possible after impact assessment.
  • PE 91

    RECIDIVAS NO CENTRO DE REFERENCIA DE ESPECIALIDADES METROPOLITANO NO PERÍODO DE JAN/99 A FEV/02 - CURITIBA/PR
    Stahlke, Ewalda V. R. S.
    Secretaria Estadual da Saúde do Paraná. R Barão do Rio Branco 465 -1° andar. 80230 - 010. Curitiba - Pr, Brasil. Telefone: (41) 322 2299 R: 258 e 262 6374. Fax: (41) 322 2299 e 262 63 74

    A recidiva nos pacientes de hanseníase é motivo de preocupação entre as equipes de saúde, especialmente quando corresponde a 10% dos casos cadastrados no período. O objetivo deste levantamento é fazer o diagnóstico dos casos de recidiva a partir de janeiro de 1999 até fevereiro de 2002 através da revisão dos prontuários, tendo sido compiladas as informações sobre tempo decorrido entre a alta e o 2° cadastro, tratamento prévio, grau de incapacidade e situação dos comunicantes. Não houve diferença quanto a sexo, o tempo médio decorrido entre a alta e o novo cadastro foi de 5 anos, o grau de incapacidade avaliado como II e III correspondeu a 2l.87% no 1° tratamento e 18,75% no 2°, a média de comunicantes por paciente foi de 3,06, dos quais 69.38% foram examinados. Dos 11 casos que receberam PQB PB previamente, 9 foram classificados erroneamente 1 recebeu ROM e foi insuficiente e 1 foi indevido.
    Das 21 formas MB, 19 apresentaram IB em um sítio = ou > 2 e/ou atividade clínica e/ou EM ou EM persistentes, 2 não tinham justificativa para o tratamento A conclusão demonstra diagnóstico tardio, com GI alto no 1° cadastro e evolução para médio no 2° e que num universo de 309 casos novos cadastrados 32 foram por recidiva e dos quais somente 3 não se encaixariam nos critérios preconizados.

     

    PE 92

    REDIRECIONANDO ESTRATÉGIAS: META - A ELIMINAÇÃO DA HANSENÍASE NO MUNICÍPIO DE PIMENTA BUENO - RO
    Eliana Pasini; Roberto Cláudio Correia; Rosemary Aparecida Passador Sanches De Giuli
    Secretaria Municipal de Saúde de Pimenta Bueno - RO

    Introdução - O município de Pimenta Bueno está localizado ao longo da rodovia Br 364. estado de Rondônia sendo considerado hiperêndemico para hanseníase, segundo critérios da OMS, com prevalência de 38,18/10000 hab. e 44,42/1000 hab.de detecção no ano de 1996, quando houve então priorização pelo gestor local com ações específicas para a sua eliminação.
    Objetivo: Este trabalho tem como objetivo a reflexão da importância do envolvimento do gestor municipal para a Eliminação da Hanseníase,realizando ações simples.
    Materiais e Métodos: Estudo dos indicadores epidemiológicos dos anos de 1996 a 2000, relacionando-os as ações desencadeadas pela equipe municipal durante o mesmo período, as fontes são dados da Coordenação Estadual. Secretaria Municipal de Saúde Gerência Municipal do Programa.
    Discussão: Durante o período de 1996 a 2000, o município de Pimenta Bueno desencadeou ações estratégicas como treinamentos para guardas de endemias, profissionais de saúde de vários setores, líderes comunitários, agentes do PACS/PSF, agentes de saúde escolar, agentes de saúde rurais e outros, tendo como meta a eliminação da hanseníase.
    Resultados: Contribuir com a experiência, despertando gestores e gerentes municipais para implementação de ações viáveis em nível Municipal, redirecionando serviços e estratégias para atingir a eliminação da hanseníase.
    Conclusão: A determinação política do gestor municipal em eliminar a hanseníase é fator essencial, pois buscando estratégias baseadas na realidade local, reduzimos a prevalência para 12.63/10000 hab. a detecção para 11.69/1000 hab. no ano de 2000, ainda muito longe do almejado mas visualizando um caminho a ser trilhado, juntos, dirigentes e população.

     

    PE 93

    RESEARCH OF LEPROSY SPREADING AND CONTROL IN CHINESE WHITE-TROUSERS YAO NATIONALITY
    LONG Zuguang1; WANG Baojun2; LUO Jiuvi3; YAN Zhiwei1

    1. Nandan Skin and Venereal Disease Prevention and Cure Hospital. China
    2. Centre for Skin Disease Prevention and Cure in Libo County. Guizhou, China
    3. Hechi Sanitation and Ant epidemic Station. Guangxi, China

    The White-trousers Yao Nationality is one of the branches of the Yao nationality in South China. They mainly live in Lihu, Baxu of Nandan County and in Bagong of Hechi, Guangxi province and also in Yao Mountains of Libo County. Guizhou province. This nationality has its own original language, habits and customs. They never marry out and completely keep the features of its tribal history.
    Leprosy has been so popular in the White-trousers Yao nationality that it has made Nandan the third most popular county in leprosy in Guangxi province. In order to make a research on the spreading law of leprosy and the characteristics of its prophylaxes and cure in this nationality, we have had the research data of leprosy epidemiology in the White-trousers Yao nationality counted and analyzed. As a result, we found 364 cases of leprosy among the 290 thousand total While-trousers population, and the case rate of accumulation was l3.25%. That's 8 times higher than other nationalities in the same areas.
    The incidence of this disease in the most serious years (1952-1956) was 129.15 cases in 100 thousand people. The disease was distributed over a large area. There were lepers in 130 villages of the White-trousers Yao nationality (its total villages were 268) and the rate in other national villages was 48.51%. But the rate in other national villages was 9.56%. The incidence of the disease of families was very high, coming lo 5.77%. While other national villages was 0.59%. There were 61 families which had more than two lepers, which made up 22.34% of the total leper families, while other national families 11.25%. The female sex suffered from the disease more often than the male sex and the rate was ten to one (other nationality was three to zero point two). We have also found that the period of illness was long, on an average of 6.24 years, while the Zhuang nationality was 4.49 years. Therefore it had evident national spreading traits. Analizing through the grey-model relation finds that the related degree is the highest in the consanguineous marriages and it is believed that a closed marriage of the same clan probably leads to the increase of the leprosy susceptible gene. Besides the housing conditions of the White-trousers Yao nationality, their life, economy, culture and sanitation are poor. So it is very hard to reach the prevention and cure of leprosy and result in this disease spreading quickly, far and wide. Although we have taken active measures to prevent and treat it, the result is still not satisfied and even the spreading tendency of the disease is upward again and again. The clothing customs of white-trousers Yao nationality make their skin exposed outside too much and ibis makes it easier to be infected by the disease and it will also increase the rate of the female's suffering from the disease. According to the dynamic calculation through the grey model instrument, it will take about 40 years to reach the aim of wiping out leprosy in the White-trousers Yao nationality.
    [Key words] the White-trousers Yao Nationality. Leprosy Spreading and Control

     

    PE 94

    RESULTS AND LONG -TERM IMPACT OF LECHODEIDAH (YEMEN)
    Dr. Abdul Baset M. Al Dobai; Dr. Yasin Al-Qubati
    National Leprosy Control Program, P.O. Box. No. 55722 - TAIZ, Republic of Yemen, Tel: 967-4242306/7/9 and 967 792976 (Mobile) Fax: 967-4242308.

    Leprosy elimination Campaign (LEC) was implemented from 15th Nov'97 to 3rd May'98, in 22 districts of Hodeidah province in Yemen, which is an endemic governorate in Yemen which is known as a low endemic country, The Campaign was concentrated on the Health Education, Intensive Community Mobilization and training the local health personnel to detect hidden Leprosy cases. During the period of 11 weeks, 276 cases of leprosy were detected and placed on MDT. 192 (70%) of new cases delected and they confirmed as Leprosy cases classified as MB and the remaining 84 were PB, 69 cases (25%) suffered by visible deformities and 22 patients (8%) were children.
    Follow up made in December'99 the patients, who were placed on MDT revealed (93% and 92%) cure rates for both MB and PB cases respectively.

     

    PE 95

    REVERSAL REACTIONS - PARAMETERS CLINICAL AND EPIDEMIOLOGICAL ASSOCIATED TO ITS OCCURRENCE
    Nery J.A.C.; Chumpitaz, S.A.; Miranda. J.A.P.P.; Guerra, S.G.; Coutinho, Z.; Lyra, MR.; Vieira, L.M.M.; Galo, M.E.N.
    Leprosy Laboratory/IOC - FIOCRUZ; Dermatology Department of Gaffree e Guinle University Hospital. Rio de Janeiro. Brasil.

    Background: the study discusses the clinical and epidemiological parameters associated to the occurrence of reversal reactions in patients undergoing multibacillary therapy. Subject and Methods: the authors present forty-two patients with multibacillary disease treated with twenty-four doses of PQT-WHO at the Souza Araújo Outpatient Unit of FIOCRUZ from January of 1986 to January of 1991. They had clinical, dermatological, neurological and histopathological examination, bacillary index (BI) and lepromin skin testing. All of them had no prior treatment and where classified as primary cases.
    Results: there were thirty-two male patients (76%) and ten females (24%), a sex ratio was approximately 3:1. Seventy-four percent were between second and sixth decades. Twenty five patients (60%) were classified as borderline-borderline (BB), fourteen patients (33%) as borderline-lepromatous (BL) and three patients (7%) as lepramatous-lepramatous form (LL). Thirty-three percent had BI under 3+ while twenty-six percent had BI up to 3+. Clinically, in twenty-eight patients (67%) there were multiple lesions at the diagnostic time. In seventy-two percent of patients the reversal reactions started until the first six months of specific treatment. Forty-two percent of patients presented several episodes. Approximately fifty percent of newly diagnosed patients had no chronic disability. Commentaries: the reversal reaction is an important medical problem due to the risk of permanent damage, which impose a health and economic burden particularly in developing countries like Brazil. For this reason is of fundamental importance to dermatologists to know the clinical and epidemiological parameters, the immunopathogenic mechanisms and the correct medical management of these cases.

     

    PE 96

    SELF-ERADICATION OF LEPROSY?

    Andreas Kalk
    German Leprosy Relief Association. Mariannhillstr. 1c. 97074 Würzburg. Germany. Tel. +49-9317948123. E-mail: andreas.kalk@dahw.de

    The study investigates epidemiological prerequisites for the 'endemic fading-out' of a contagious disease and applies these findings to the particular features of leprosy. It identifies the 'basic reproductive rate' of an infection, the duration of latency and infectiousness, the life expectation and the size of the host population as factors determining the number of both latent and infectious infections in this population. It intends to demonstrate that once one single index case is given, leprosy can survive in an isolated population of approximately 30 persons only. It is concluded that the 'endemic fading-out' of a contagious disease does not depend on its prevalence, but either on the basic reproductive rate or on the host population size. If the reproductive rate is smaller than 1 (e.g. due to the decreasing susceptibility of the host population), or if a minimum popualtion size for continuous transmission is not given, the disease will eventually 'fade out'. As long as this rate is above the value of 1, leprosy can - due to its lasting infectiousness - survive in extremely small host populations.

     

    PE 97

    SENSITIVITY AND SPECIFICITY OF THE W.H.O OPERATIONAL CLASSIFICATION BASED ON NUMBER OF SKIN LESIONS
    Gift Norman; Geetha S Rao; J Richard; Raja Samuel
    Schieffelin Leprosy Research and Training Center, Karigiri, India

    The WHO Sludy Group on Chemotherapy of Leprosy Committee in 1993 concluded that approaches based on clinical classification may be required where reliable facilities for the bacteriological examination of skin smears are not available or reliable. The Committee recommended that leprosy patients be classified according to the number of skin lesions, into pauci-bacillary leprosy (2-5 skin lesions) and multi-bacillary (more than 5 skin lesions). However, the sensitivity and specificity of classification based solely on the number of skin lesions, using skin smear positive patients as a gold standard has not been reported.

    The Schieffelin Leprosy Research and Training Center has been carrying out leprosy control activities in Gudiyatham Taluk since 1962 as part of the NLEP. Using data from the control area, the sensitivity and specificity of operational classification based on number of patches was studied, using skin smear as the gold standard. The sensitivity of classifying five and above lesions as multi-bacillary leprosy is 97.0% while the specificity is 52.2%. The positive predictive value is 32.3% and the negative predictive value is 98.6%. The ROC curve shows that a cut-off of live lesions is the best option. The WHO criterion for operational classification of leprosy based on number of patches seems vindicated. The effect of including additional clinical signs such as size of the largest lesion or nerve trunk involvement on the sensitivity and specificity of the operational classification will be reported.

     

    PE 98

    SERO-PREVALENCE RATES OF ANTIBODIES TO PHENOLIC GLYCOLIPID-1 BY ELISA AMONG WILD NINE BANDED ARMADILLOS (Dasypus novemcinctus) IN ESPIRITO SANTO STATE - BRAZIL
    Patrícia Deps; Zoilo P. Camargo; Jane Yamashita-Tomimori
    Santa Casa of Misericórdia Hospital. Vitória-ES. Av. Nossa Senhora da Penha. 2190 CEP 29045-402. Vitória ES-Brazil.

    Introduction and purpose: The human being has, for a long lime, been considered the only reservoir of Micobacterium leprae. However, the armadillo infection, Dasypus novemcinctus species, was first reported in 1975 and natural transmission among armadillos in the southern parts of the United States has been described by Walsh and co-workers. Truman and co-workers found IgM antibodies to the PGL-1 antigens of M. leprae in 16% of the armadillos from Lousiana and Texas. In the Brazil, natural infection of M. leprae in armadillos wasn't reported.
    The enzyme-linked imunosorbenl assay (ELISA) test detect PCL-I antibodies is a useful tool confirm Ihe diagnosis of leprosy. We analysed Ihe natural infection with M. leprae in wild nine-banded armadillos, Dasyous novemcinctus, from hyperendemic leprosy area of Brazil, Espirito Santo State.
    Methods: We analysed forty-seven armadillos captured from wild by hunter. Those animals were anesthesiated and collected the blood by intracardiac punction. The ELISA was performed for IgM antibodies to PGL-I antigen of M. leprae. The pre-coated plates and the others reagents were given from Royal Tropical Institute in Amsterdam The cut-off value for posilivity was an OD of 0.200.
    Results: Were captured armadillos from country area of 6 cities of Espirito Santo State. The weight ranged between 350-5200g. The armadillo's sex, 24 were male and 23 ere female. In 47 animals, antibodies and PGL-I were detected in 5 (10,6%) animals by ELISA method.
    Conclusion: It is known now that about 10,6% of the armadillos front Espirito Santo State were M. leprae carrier. The discovery of M. leprae in the wild armadillo has not only raised many question about the transmission and host range of leprosy, but identified a possible public health risk.

     

    PE 99

    SERUM ZINC LEVEL AND ZINC INTAKE IN NON-REACTIONAL LEPROSY PATIENTS
    Yudhistirawati, I; Made Wisnu; Unandar Budimulya; Sjaiful Fahmi Daili; Emmy S. Sjamsoe; Sri Linuwih.
    Dep. Of Dermato-venereology Faculty of Medicine University of Indonesia. Jakarta - Indonesia

    A case control study was performed on 56 leprosy patients and 56 controls, aged 15-59 years, during January untill August 1999. The objectives were to describe variability of serum zinc level and dietary zinc intake in nonreactional leprosy patients compared with the controls, and to find out whether there-was a correlation between serum zinc level and dietary zinc intake by nonreactional leprosy patients.
    Serum zinc level was estimated by Atomic Absorption Spectrophotometry and dietary zinc intake was estimated by Food Frequency Questionnaire. The mean of zinc serum level in nonreactional leprosy patients was significantly lower than the controls and the mean of zinc serum level in multibacillary leprosy patients was also lower than paucibacillary which was statistically significant. Dietary zinc intake of nonreactional leprosy patients appeared lower than their controls (p = 0.008). There was no correlation between zinc serum level and dietary zinc intake on nonreactional leprosy patients.

     

    IMMUNOLOGY

     

    OI 1

    A NON-INVASIVE METHOD FOR DIAGNOSIS OF LEPROSY BASED ON DETECTION OF SPECIFIC ANTI-MYCOBACTERIAL ANTIBODIES IN SALIVA
    M. Yushin; M.N. Dyachina; A.A. Juscenko; V.A. Bochanovsky
    Leprosy Research Institute. Astrakhan, Russian Federation.

    The aim of the present work was to improve methods of diagnosis of leprosy through the development of immune test system for anti-M. leprae antibodies (Ab) in saliva. Samples of saliva and blood sera from 116 leprosy patients at different stages of their disease and 23 healthy donors (control group) were studied with using indirect enzyme labeled immune assay. As test-antigen for detection of anti-M. leprae Abs, preparations of M. lufu, a value of which for leprosy serodiagnosis was proved by us earlier, were used. Rabbit Abs against human peroxidase-labeled immunoglobulins (IgG, IgA. IgM) were used as conjugate. The investigations showed that Ab titers in saliva and blood sera were comparable both in patient and control groups. Correlation analysis indicated interrelations between Ab liters in saliva and serum samples. Dynamic investigations showed high tilers of Abs both in saliva and blood sera in patients with active leprosy. Inactive leprosy patients giving seronegative results for 1-2 and more years, showed no specific anti-mycobacterial Abs in their samples of saliva. In the periods of activation of the disease (relapses, exacerbations of leprosy neuritis) Ab levels against M. leprae in saliva were increasing in parallel with increasing anti-M. leprae Abs in blood sera. Thus, a test-system was developed, high diagnostic value and reliability of which was achieved owing to using a new antigen from M. lufu and conjugate of peroxidase-labeled rabbit Abs against human immunoglobulins of IgG. IgA, IgM classes. Detection of anti-M. leprae Abs in saliva opens possibilities for early diagnosis of leprosy infection in leprosy contacts and general population of leprosy endemic areas. Monitoring of Ab levels in saliva of leprosy patients under treatment allows estimating effectiveness of antileprosy therapy.

     

    OI2

    ANTIGENIC SPECIFICITY OF THE Mycobacterium leprae HOMOLOGUES OF ESAT-6 AND CFP-10
    John S. Spencer; Hee Jin Kim; Maria A.M. Marques; Patrick J. Brennan
    Department of Microbiology, Colorado State University, Ft. Collins, CO, USA.

    The recent completion of the sequencing of the genomes of M. tuberculosis and M. leprae provides the opportunity to identify leprosy-specific antigens. An analogous approach applied to M. bovis BCG allowed the identification of deleted genes and the development of antigens that can distinguish between M. tuberculosis infection and vaccination with BCG. Among those antigens which have shown promise are two low-molecular weight M. tuberculosis culture filtrate proteins, ESAT-6 (esat-6) and CFP10 (lhp), both encoded by genes in the RD1 region, a genetic segment that has been deleted from all strains of BCG. Because the M. leprae ESAT-6 (ML0049) and CFP-10 (ML0050) proteins have only 36% and 40% identity, respectively, to their homologues in M. tuberculosis (Rv3875 and Rv3874), we decided to analyze the immunologic cross-reactivity of these proteins in mice by characterizing the B and T cell epitopes recognized. We had previously reported this analysis of the ESAT-6 homologues, and found that the dominant B and T cell epitopes recognized in H-2d haplotype (BALB/c) strain mice for the M. tuberculosis and M. leprae proteins were in different regions. In addition, polyclonal antisera against the two forms of ESAT-6 did not cross-react at the level of the whole protein or with any of the heterologous peptides. We have since performed a similar immunological analysis of cross-reactivity with the CFP-10 homologues, and found that polyclonal antiserum raised against ML0050 did not cross-react with the M. tuberculosis homologue, and vice versa. We are currently in the process of analyzing antibody and T cell immune responses against members of the ESAT-6 family of proteins and other unique proteins discovered in the analysis of the M. leprae genome.

     

    OI3

    CELL MEDIATED IMMUNITY IN LEPROSY PATIENTS WITH ERYTHEMA NODOSUM LEPROSUM (ENL)
    Murdo Macdonald; Niraj Shrestha; Patrick Haslett; Rakesh Manandhar; Matthew Albert; Steven Lubinsky; Paul Roche; Gilla Kaplan
    Mycobacterial Research Laboratory, Anandaban Leprosy Hospital, PO Box 151, Kathmandu, Nepal. E-mail: anandaban@mail.com.np.

    The dramatic resolution of erythema nodosum leprosum (ENL) following therapy with thalidomide suggests that immunologic changes associated with this treatment may afford insights into the pathogenesis of ENL. It has been reported recently that thalidomide may promote Th-1 immunity. However, it is unknown if thalidomide acts in this way in patients with ENL.
    Aim: To study cell-mediated immune responses in Nepali leprosy patients with ENL undergoing thalidomide treatment, and to compare their response to those of lepromatous patients without ENL.
    Methods: Venous blood was obtained from appropriate (LL) patients: 20 with and 20 without ENL. Plasma levels of interferon gamma (IFN-γ), tumour necrosis factor alpha (TNF-α) and interleukin 12 (IL-12), and of soluble IL-2 receptor (sIL-2R) were measured using a standard immunoassay. Leprosy-specific and mitogen-induced IFN-γ producing cells in the peripheral blood were measured by ELISPOT and flow cytometry, respectively on days 0, 7 and 21 of a 21 day course of thalidomide.
    Results: Thalidomide-induced activation of Th-1 immunity was suggested by an increase in numbers of T cells induced ex-vivo to produce interferon IFN-γ as assessed by both ELISPOT and flow cytometric assays (p > 0.01). This activation was transient, however, observed on day 7 of thalidomide treatment. Although in is difficult to discern obvious trends in the plasma cytokine levels, there is some correlation between the patterns in TNF-α levels and those for IL-.12.
    Conclusions: Our results suggest transient T cell activation following thalidomide treatment, and may give some clues to the pathological processes underlying ENL as well as to new treatment strategies.

     

    OI 4
    CYTOKINE LEVELS IN TYPE 1 REACTIONS: RELATION TO NERVE DAMAGE AND THE RECURRENCE OF REACTION
    Murdo Macdonald; Niraj Shrestha; Rakesh Manand-har; Maria Jacob K; Paid Roche
    Mycobacterial Research Laboratory. Anandaban Leprosy Hospital, PO Box 151. Kathmandu, NEPAL. E-mail: anandaban@mail.com.np

    Aim: To elucidate the role of cytokines during and after steroid treatment of Type I Reaction (T1R), and their relation to recurrent reaction episodes
    Methods: We enrolled 192 borderline (BT, BB, BE) leprosy patients, 96 with T1R and 96 without, in this study. Blood was collected from Tl R patients at various timepoints before, during and after prednisone treatment, and used in a standard 24 hour whole blood assay.
    Results: Leprosy specific antigen-induced levels of IFN-γ, TNF-α and IL-10 were measured in a 24-hour whole blood assay in T1R patients. Cytokine levels were significantly increased when compared with appropriately matched borderline leprosy patients without T1R. Steroid treatment lowered levels of IFN-γ, but levels of TFN-α increased as the doses of steroids were lowered, IL-10 levels increased during steroid therapy. High TFN-α levels in untreated patients (higher than 75th percentile) was associated with a 5 times greater risk of reactivation of symptoms during treatment phase. High levels of TFN-α after treatment with 30mg of steroids was associated with a 3-5 times greater risk of nerve function impairment or failure to improve nerve function. The relationship between cytokine levels and subsequent reactions was investigated by follow up for up to three years after initial observations.
    Conclusion: This study seeks to link cytokine levels with recurrent T1R reactions and nerve function impairment and offers a means to identify patients failing to respond adequately to steroid therapy.

     

    OI5

    DENDRITIC CELL-MEDIATED PRODUCTION OF IL-12 AND IFN-γ BY Mycobacterium leprae-DERIVED CELL MEMBRANE
    Yumi Maeda; Masaichi Gidoh; Norihisa Ishii; Masahiko Makino
    Department of Microbiology. Leprosy Research Center, National Institute of Infectious Diseases. Tokyo. Japan.

    The development of reliable vaccination agents toward leprosy is currently desired. In order to identify molecules capable of inducing effective cellular immunity against Mycobacterium leprae, the antigenicity of M. leprae-derived cell membrane fraction was examined using human dendritic cells (DCs). Immature DCs internalized and processed the cell membrane components, and expressed Ags, which reacted to lipoarabinomannan mAb or to leprosy patient's sera. The expression of MHC class II. CD86 and CD83 Ags on surface DCs was up-regulated indicating that the DCs were potently stimulated by the membrane Ags. Moreover these stimulated DCs induced significantly higher proliferation of autologous CD4+ and CD8+ T cells and higher IFN-γ production by the T cells than those pulsed with equivalent doses of M. leprae-derived cytosol fraction or whole live M. leprae. The involvement of CD40 ligand signaling on membrane pulsed DCs enhanced the IFN-γ production. CD4+ and CD8+ T cells from tuberculoid leprosy patients produced marked and significantly higher IFN-γ than those from healthy donors, when they were stimulated by autologous cell membrane pulsed DCs. The CD8+ T cells stimulated for 10 days by DCs pulsed with the membrane and CD40L, produced intracellular perforin in the Ag dose or CD40L dependent manner, in 507 of lymphocytes donors. Furthermore, the M. leprae cell membrane was more efficient in the CD40L-associated IL-12 p70 production from DCs than the cytosol fraction, but was less efficient than cell membrane from M. smegmatis. Both hydrophobic and hydrophilic fractions of M. leprae cell membrane induced IL-12 p70. These results suggest that M. leprae cell membrane has pleural antigenic molecules that might be useful as the vaccinating agents against leprosy

     

    OI6

    EFFICACY OF SHORT TERM MULTIDRUG THERAPY ON THE CONTROL MULTIBACILLARY LEPROSY
    Foss, N.T; Ramalho. E.M.; Nunes. T.L.; Andrade, J.L.; Ferreira. M.A.N.; Souza CS
    Faculty of Medicine of Ribeirão Preto, São Paulo University.

    The purpose of this study is verify whether the short term multidrugtherapy (MDT) on leprosy treatment can be efficient on the immune response and the consequent control of the evolution of the disease. To evaluate this hypothesis 67 multibacillaries leprosy patients (MB) (lepromatous leprosy-LL and borderline leprosy-BL) were randomized to receive 12 or 24 doses of MDT and 9 healthy controls were evaluated. All the patients were classilied by Ridley-Jopling criteria and the bacilloscopic index (BI) serum antibody and PGL-I (APGL-I), inflammatory cytokines and the co-stimulatory and adhesion molecules serum levels were measured before and after MDT. The APGL-1, IFN-γ, IL10, IL6 and TNF alpha serum levels were determined by ELISA assay. The results showed that MDT 12 and 24 doses can reduce the APGL-1 levels in a similar range. The decrease of BI and APGL-1 levels is followed by the augment of IFN-γ serum levels associated with enhancement of LAF/CD4+ molecules. The quantification of the LAF/CD8+ molecules is higher in MB patients before the treatment and after 24 doses of MDT the values are similar to the normal controls. Since IFN-γ is a cytokine able to induce an enhanced cellular immunity this results can suggest that 12 doses of MDT might be efficient on the control of MB leprosy specially in those patients with moderate bacillary index (below 3,0)

     

    OI 7

    ENUMERATION OF IFN-γ-PRODUCING CD4+T CELLS AS A TOOL FOR SELECTING HIGH-LEVEL IFN-γ-lNDUCING Mycobacterium leprae ANTIGENS
    Márcia V. B. S. Martins2*; Monica C.B.S. Lima1,2,3*; John S. Spencer1; Maria A. M. Marques1; Heejin Kim1; Bruce C. Gregory1; Nadia C. Duppre1; José A. C. Nery1; Euzenir N. Sarno2; Patrick J. Brennan1; Maria C.V. Pessolani2; Geraldo M. B. Pereira2,3.

    1. Department of Microbiology. Colorado State University, CO, USA.
    2. Leprosy Laboratory, Oswaldo Cruz Institute. FIOCRUZ.
    3. Laboratory of Immunopathology. School of Medical Sciences, State University of Rio de Janeiro. Rio de Janeiro, Brazil.
    * These authors contributed equally to this work.

    The sequencing of the genomes of M. leprae and other mycobacteria has afforded new opportunities for the development of pathogen-specific diagnostic tests for mycobacterial infections, critical in the context of leprosy eradication. Recently, antigen-specific IFN-γ production was used with success for the diagnosis of latent tuberculosis. We evaluated the IFN-γ inducing capacities of various fractions derived from M. leprae itself (e.g. ammonium sulfate or ethanol precipitated cytosolic proteins; cytosolic proteins fractionated by anion exchange chromatography or isoelectric focusing) and various recombinant proteins dictated by analysis of the genome (e.g. ESAT-6, CFP-10, 10kDa, Ag85B, H1p, EfTu, MMP-I, MMP-II) and genetically fused versions of some of these recombinant proteins (e.g. CFP10-ESAT-6; ESAT-6-Ag85B). The initial screening was done with blood samples from two untreated newly diagnosed leprosy patients (TT and BT; from Leprosy Lab Outpatient Unit, Rio de Janeiro). The presence of lFN-γ-producing CD4+ T cells (IFN-T) was detected by intracellular cytokine assay, using flow cytometry, in response to several of these antigens and, when observed, was associated with high-level IFN-γ in the culture supernatants as determined by ELISA. In particular, some of the native M. leprae fractions, as well as MMP-l. had high frequencies of IFN-T and induced high IFN-γ supernatant levels, comparable for instance to that of S. aureus enterotoxin-B. (Research was supported by NIAID, NIH and FAPERJ).

     

    OI 8

    EXPRESSION OF CHEMOKINES AND THEIR RECEPTORS IN LEPROSY SKIN LESIONS
    Clement Alain Musonda; Alice Amanda Kirkaldy; Saroj Khanolkhar-Young; Sujai Suneetha; Diana N.J. Lockwood
    Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine. Keppel Street. London, WCIE 7HT. United Kingdom
    BPRC, Hyderabad. India

    Chemokines are small peptides that are potent activators and chemoattractants for leukocyte subpopulations and some nonhaemopoietic cells. Chemokines and their receptors have been associated with infectious diseases.
    Study: We have investigated the expression of chemokines and their receptors in leprosy skin lesions using immunohistochemislry. Skin biopsies from 25 leprosy patients across the leprosy spectrum, 11 patients undergoing Type I reversal reactions and 4 normal donors were immunostained by ABC peroxidase method using antibodies against CC and CXC chemokines and their receptors. We have also investigated mRNA production for MCP-1, RANTES and IL-8 chemokines using an in situ hybridisation technique.
    Results: Chemokine and receptor expression was detected in all leprosy skin biopsies. Expression of CC chemokines MCP-1 (p < 0.05), RANTES (p < 0.005) and CXC chemokine, IL-8 (p < 0.005) were significantly elevated in borderline tuberculoid leprosy in reversal reaction compared to borderline tuberculoid leprosy. However, the expression of CC (CCR2 and CCR5) and the CXC (CXCR2) chemokine receptors did not differ across the leprosy spectrum. Similarly, there was no significant difference in the expression of MCP-1 and IL-8 mRNA. Nevertheless, a small but significant elevation in RANTES mRNA (p < 0.05) was detectable in borderline lepromatous leprosy in reversal reaction compared to borderline lepromatous leprosy.
    Conclusion: Surprisingly, we did not find any difference in the expression of chemokine receptors across leprosy spectrum. In addition, RANTES expresion was slightly elevated in borderline tuberculoid leprosy in reaction. The presence of a neutrophil chemoattractant IL-8 in leprosy lesions, which do not contain neutrophils, here strongly suggests a role of IL-8 as a monocyte and lymphocyte recruiter in leprosy lesions.

     

    OI 9

    HUMAN T CELL RECOGNITION OF FRACTIONATED ANTIGENS FROM Mycobacterium leprae: POTENTIAL AS DIAGNOSTIC REAGENTS.
    H. M. Dockrell1; R. Hussain2; J. S. Spencer3; G.F. Black4, F. Shahid2; S. Zafar5; S. TerLouw3; S. Chagu-luka3; L. Sichali4; A. Crampuv4; P.E.M. Fine1; P.J. Brennan3

    1. London School of Hygiene & Tropical Medicine, London WC1E 7HT, UK.
    2. Aga Khan University, PO Box 3500, Karachi 74800. Pakistan.
    3. Colorado State University, Fort Collins. CO 80523, USA.
    4. Karonga Prevention Study, PO Box 46, Chilumba. Malawi.
    5. Marie Adelaide Leprosy Centre, PO Box 8666, Karachi 74400, Pakistan.

    One approach to the development of species-specific mycobacterial antigens is to progressively fractionate the antigens in whole bacteria until functional specificity is achieved. Equivalent preparations of Mycobacterium leprae and Mycobacterium tuberculosis cell wall and cytosolic antigens were used to test lymphocyte proliferation and IFN production in 6 day assays in leprosy and tuberculosis patients in Pakistan. The M. leprae antigenic preparations were less potent for T cells from tuberculoid leprosy patients than the M. tuberculosis antigens, and also induced T cell responses in tuberculosis patients. Further fractionation of M. leprae cytosolic antigens (MLSA) produced components of potentially greater specificity. The presence of M. leprae-specific antigens within MLSA was confirmed in healthy, non-BCG-vaccinated young adults in Malawi, where IFN-γ production to MLSA in diluted whole blood assays was more strongly associated with skin test indurations to Rees MLSA than to M. tuberculosis PPD. Thus fractionation of the cell wall or cytosolic proteins of M. leprae may yield specific diagnostic reagents for leprosy.

     

    OI 10

    IFN-γ DETECTION AND ABSENCE OF IL4 IN SITU UNDER NON STIMULATED CONDITIONS IN PAUCIBACILLARY SINGLE SKIN LESION LEPROSY
    M. M. A. Stefani1; C.M.T. Martelli1; TP. Gillis2; J.L. Krahenbubl2; Brazilian Leprosy Study Group.

    1. Federal University of Goiás, Goiânia- Go. Brazil.
    2. National Hansen's Disease Programs, USA.

    Objectives: Define in early leprosy lesions the Cell Mediated Immunity by cytokine profiling: IFNγ, IL12, IL10, IL4, TNFα and M1PI and assess M. leprae DNA.
    Methods: 259 SSL-PB leprosy patients were enrolled (1997-98) for ROM therapy and were clinically monitored. Six cytokines- IFN-γ, IL10, IL12, IL4, TNFα and MIP1α had mRNA assessed by RT-PCR using Real Time PCR (ABI Prism 7700 Perkin Elmer) in skin biopsies from 39 patients with different clinical outcomes. M. leprae DNA-PCR was performed in skin biopsies using primers for the specific 18KDa protein gene.
    Results: Highest values of IFN-γ were among the TT group (median= 1.77) with well-formed granulomas, followed by BT (1.08) and I group (0.02). IL10 values were similar for TT (0.79) and BT (0.72) groups. MIPlγ detection was higher in TT lesions followed by BT and I groups. IL4 values were zero for all specimens tested. Statistically significant correlation was observed between IL12 and IFN-γ (r=0.4. p=0.02) and between IFN-γ and IL10 (r =0.67, p<0.05), possibly reflecting regulatory measures related to macrophage activation. Also IL10 and IL12 correlation was observed (r=0.6, p<0.01) suggesting in situ relationship between induction and control mechanisms in early leprosy lesions. 48.6% M. leprae DNA-PCR positivity was observed.
    Conclusions: Our results support the concept that SSL-PB leprosy patients are tuberculoid-like with reasonable strong CMI contributing to the good prognosis after early treatment with ROM. TDR/WHO grant 98100.

     

    OI 11

    IMMUNOPHENOTYPIC STUDY IN PAUCI-BACILLARY SINGLE SKIN LESION LEPROSY
    M.M.A. Stefani1; F.C. Figueiredo2; C.M.T. Martelli1; M.B. Costa1; Sousa A.L.O.M.1; Sacchetim S.C1; T.P. Gillis3

    1. Federal University of Goias/ Rua Delenda Rezende s/n. Setor Universitario. CEP 74605-050, Brazil.
    2. University of Brasilia/Brazil.
    3. National Hansen's Disease Programs/ USA.

    Objectives: Assess the microanatomy of single skin lesion paucibacillary leprosy (SSL-PB) characterizing the phenotypes of different cell populations present in the cellular infiltrates.
    Methods: 36 SSL-PB leprosy patients from Central Brazil, treated with ROM therapy were evaluated by immunostaining in skin biopsies collected before drug intake, lmmunophenotypic study was performed in deparaffinized skin biopsies using monoclonal antibodies and immunoperoxidase methods, after microwave antigen retrieval. The distribution, location and estimated proportion of seven cell populations were evaluated: T lymphocytes (CD3+), B lymphocytes (CD20+), T lymphocyte subpopulations (CD4+, CD8+) and NK cells, CD 68+ macrophages and mast cells. Samples were previously coded and all laboratory tests performed in independently, by different experts. Data were analyzed taking into account conventional histopathology and M. leprae DNA- PCR findings.
    Results: 50% of SSL-PB were classified as BT, 27.8% TT and 22.2% I. M. leprae DNA was detected in 14/36 (45%). Cell phenotypes immunohistochemistry markers were observed in all preparations regardless of the morphological classification. Presence of neural aggression observed in histopathology was associated with positivity for M. leprae DNA by PCR (p<0.05). Detection of different cell phenotypes in early leprosy lesions, many of them with confirmed M. leprae DNA detection, provides indepth evaluation of the in vivo immune/inflammatory response in early paucibacillary leprosy. TDR/WHO grant 98100

     

    OI 12

    IMPROVING SUBUNIT DNA VACCINES AGAINST MYCOBACTERIAL INFECTIONS.
    Britton W.J.1,*; Martin E.1,2; Kamath A.T.1

    1. Centenary Institute of Cancer Medicine and Cell Biology, Locked Bag No 6, Newtown, NSW, 2042.
    2. Cooperative Research Centre for Vaccine Technology, QIMR, P.O. Royal Brisbane Hospital, QLD, 4029, Australia.

    Immunisation with Mycobacterium bovis (BCG) confers significant protection against leprosy and has contributed to the control of the disease. We have demonstrated that immunisation with a DNA vaccine expressing the immunodominant 35 kDa antigen of M. leprae causes equivalent protection to BCG in the mouse footpad model of M. leprae infection (1). We have investigated two ways of improving the efficacy of this approach, using DNA expressing the M. avium homologue of the 35 kDa protein (DNA-35), which shows 95% aa identity to the M. leprae protein, and infection with virulent M. avium. First, we co-immunised mice with DNA-35 and a plasmid producing both chains of IL-12 as a self-cleaving protein. This resulted in increased frequency of antigen-specific IFN-γ secreting T cells, and a reduction in specific IgG antibody responses. Moreover, following IVI infection with M. avium, these mice showed significantly reduced bacterial loads compared to mice immunised with DNA-35 alone or BCG. This increased protection was associated with a significantly stronger IFN-γ response to both the 35 kDa protein and M. avium sonicate after challenge. Second, we examined whether targeting the 35 kDa protein to the B7 molecules on antigen presenting cells increased the vaccine efficacy. The 35 kDa gene was fused to the gene for CTLA-4-Ig within the DNA vaccine. Mice immunised with this construct showed an increase in both specific IFN-γ T cell and IgG responses. However, this was not associated with increased protection against M. avium infection. Therefore plasmid IL-12 is an effective adjuvant to increase the protective effect of DNA vaccines against M. avium. We are testing whether this increases protection against M. leprae infection. Future subunit vaccines against tuberculosis should also include dominant M. leprae antigens to ensure they provide cross-protection against leprosy.

    1- Martin E, et al (2001) DNA encoding a single mycobacterial antigen protects against leprosy infection. Vaccine 19;1391-6

     

    OI 13

    IN SITU EXPRESSION PATTERN OF IFN-γ, 1L-4 AND M. leprae ANTIGENS ACROSS SPECTRUM OF LEPROSY REFLECT DISEASE ACTIVITY RELATED TO REACTIONS
    C.E. Verhagen; A. Moens; Chi Han; I.C. van den Bos; R Fleury; W.R. Faber; B. Naafs; P.K. Das

    Recent studies on lesional skin derived T cell clones (TCC) from leprosy patients experiencing reversal reaction (RR) showed a polarised shift of M. leprae responsive TCC to Type-1 like phenotypes with predominant production of IFN-γ/TFN-α and low production of IL-4/IL-5/IL-13. With this background knowledge, we assessed the presence of IFN-γ and IL-4 (both protein and mRNA) in lesional skin biopsies of untreated leprosy patients during RR and erythema nodosum leprosum (ENL) reactions. The in situcytokines were identified on frozen biopsies by both immunohistoehemical staining and in situ hybridisation and RT-PCR methods. On the other hand in situ presence of m.leprae antigens was identified in both frozen and parafin embeded biopsies by specific monoclonal antibodies to phenolic glycolipid-1 (PGL-1) lipoarabinomanan (LAM) by immunohistoehemical single and double stainings. We found that both IFN-γ and IL-4 protein and mRNA were opresent in varying amounts in the lesions of untreated paucibacillary (PB) and multibacillary (MB) patients irrespective of their spectral status. No significant differences were seen regarding the in toto presence of these cytokines in individual lesions although their presence varied indifferent granulomas within one lesion. However in lesions with RR and ENL higher levels of IFN-γ and IL-4 were seen although in ENL IL-4 was relatively higher although not significant. These data of in situ expression of T cell cytokines appear to indicate the ongoing disease activity as is the case in patients with reactions. The in situ presence of PGL-1 and LAM with the macrophages in lesions of MB patients decreased dramatically with the treatment. However, in some patients, presence of these antigens persisted in lesions of MB as well as in PB patients, but with differing staining pattern. Such dynamics in the expression pattern of PGL-1 and LAM, in leprosy lesions appeared to he associated with reactions. Our studies suggest that the evaluation of m situ expression pattern of IFN-γ, IL-4 and M. leprae antigens can be regarded as important differential diagnostic critérium for recognising leprosy lesions and may have predictive value for recognising reactions during the evalution of the disease

     

    OI 14

    INTERLEUKIN-10 PROMOTER SINGLE NUCLEOTIDE POLYMORPHISMS: MARKERS FOR DISEASE SUSCEPTIBILITY AND DISEASE SEVERITY IN BRAZILIAN PATIENTS
    Moraes M.O.1; Santos A.R.1; Schonkeren J.J.M.2; Vanderborght PR.1; Coutinho D.1; Sales A.M.1; Ottenhoff T.H.M.3; Sampaio E.P.1; Huizinga T.W.J.2; Sarno E.N.1

    1. Leprosy Laboratory. Department of Tropical Medicine, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, RJ, Brazil.
    2. Department of Rheumatology.
    3. Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands.

    Single nucleotide polymorphisms at positions -3575, -2849, and -2763 on the promoter region of the inter-leukin-10 gene are arranged to form haplotypes that affect levels of IL-10 production. In this study we have determined IL-10 genotype and haplotype frequencies in leprosy patients compared to controls, and analyzed their occurrence with particular forms of leprosy (multi-vs. paucibacillary as severe and mild forms, respectively). No significant differences was observed in genotypes comparing patients to controls, but in -2849 SNPs genotypes were different in multi-bacillary (MB) when compared to paucibacillary (PB) patients (P=0.04). The observation of haplotypes suggested that -3575T/-2849A/-2763C is associated with the occurrence of the disease (P=0.038) irrespective of the further clinical outcome. Besides, AGC haplotype was diminished in patients group as compared to controls (P=0.001). The comparison among patient groups demonstrated that the rarely found IL-10 haplotype AAA was strongly associated to the development of the severe (P=0.003) form of leprosy and TGA haplotype was more frequent in paucibacillary group. The data suggest that distal IL-10 promoter haplotypes could be used as genetic markers that predict susceptibility as well as disease severity in leprosy.

     

    OI 15

    LATERAL FLOW ASSAY FOR CLASSIFICATION OF LEPROSY PATIENTS AND IDENTIFICATION OF HIGH-RISK CONTACTS
    S. Buhrer-Sekula; H.L. Smits; G.C. Gusscnhoven; J. van Leeuwen; P.R. Klatser; L. Oskam
    KIT Biomedical Research, Meibergdreef 39, 1105 AZ Amsterdam, The Netherlands.

    The interruption of leprosy transmission is one of the main challenges for leprosy control programs since no consistent evidence exists that it has been significantly reduced after introduction of MDT. Sources of infection are particularly patients with high loads of bacteria and infected persons in which the clinical signs have not yet become apparent. Detection of antibodies to PGL-I of M. leprae to identify those cases may be a tool for the interruption of transmission. An operational applicability of serology within the leprosy control services requires a simple test system.
    We have developed a lateral flow assay for the detection of antibodies to PGL-I which takes only 10 minutes to perform. We have compared its performance with that of ELISA. An agreement of 89.7% was observed between ELISA and the lateral flow assay when tested on 620 serum samples; the agreement beyond chance (Kappa value) was 0.76. No significant difference was found between the lateral flow assay and ELISA when seropositivity rates obtained in groups of leprosy patients, household contacts and controls were compared. Storage of the only reagents required, the lateral flow test and the running buffer, for up to a month at high temperatures, does not influence the results of the assay.
    The lateral flow assay is a fast and easy-to-perform method for the detection of IgM antibodies to PGL-I of M. leprae; it does not require any special equipment and the highly stable reagents make the test robust and suitable for use in tropical countries.

     

    OI 16

    LEPROSY TRANSMISSION AND MUCOSAL IMMUNE RESPONSE

    Dr. R. S. Jadhav; Miss A. Fernando; Miss V.S. Shinde; Ravindra R. Kamble; Mrs. S.P Madhale; Dr. V.K. Edward; Dr. J.R. Rao; Prof. W.C.S. Smith on behalf of MILEP-2 Study Group*
    Stanley Browne Research Laboratories, Richardson Leprosy Hospital, Miraj, Maharashtra-416410. Tel. No Off: 0233-211213 Fax: 0233-211708 E-mail: sblabtlm@vsnl.com

    Decrease in the prevalence rate of leprosy has not reflected in the incidence of new cases. Very little is known about the transmission of leprosy. Though household contacts of multi-bacillary cases are at high risk of developing disease, majority of the new cases have no history of household contact. A study was undertaken to look at the transmission and the development of mucosal immunity. Subjects (3035) from three villages were examined and followed twice at six monthly intervals. Polymerase Chain Reaction (PCR) was used to detect presence of M. leprae DNA on the nasal mucosa and mucosal immunity was tested by measuring the salivary M. leprae reactive IgA antibodies (sML-IgA) using ELISA. More than 60% of the subjects from all the three villages showed sML-IgA. This response was seen in all the age groups. The response between BCG vaccinated and non-vaccinated individuals did not show any difference. Overall PCR positivity (presence of M. leprae on nasal mucosal) was found to be 1.65% (42 out of 2552), 4.5% (56 out of 1252) and 1.9% (25 out of 1308) in the initial screening. 1st follow-up and 2nd follow-up respectively. Most of the positive subjects in the follow-up were negative in either the previous or subsequent follow-up suggesting transient nature of the PCR positivity. Presence of M. leprae reactive antibodies in the majority of population suggested a possible widespread exposure to M. leprae. This mucosal immune response could be of protective importance as most of the subjects showing presence of nasal M. leprae had these antibodies. Shorter intervals between the follow-ups may shed more light on role of mucosal immunity and late of M. leprae in the nasal passage.

     

    OI 17

    M. leprae INDUCES NF-B NUCLEAR TRANSLOCATION IN PBMC FROM LEPROSY PATIENTS
    Hernandez M.O.; Lopes U.G.*; Redner P.*; Sarno E.N.; Sampaio E.P.
    Leprosy Laboratory, Oswaldo Cruz Foundation -FIOCRUZ.
    *Molecular Parasitology Laboratory -Carlos Chagas Filho Institute UFRJ. Rio de Janeiro - Brazil.

    NF-B is a transcription factor involved in the regulation of many inflammatory genes, including TNF and IL-1. It has also been suggested to be involved in the regulation of apoptosis. M. leprae is known to induce TNF production by PBMC from leprosy patients in vitro. Recent data from our laboratory showed apoptosis to occur in a dose-dependent manner and that TNF seems to be a mediator of this process. In order to investigate whether NF-B is activated in response to M. leprae, nuclear proteins from stimulated PBMC were analyzed by EMSA. Initial results demonstrate that M. leprae, when added at 1 and l0g/ml, induces nuclear translocation of this transcription factor. To identify NF-B subunits activated by M. leprae, samples were assayed by super-shift. Subunits p65 and p50 were detected, while p52. c-rel and Rel-B were not. These results indicate that NF-B is activated in PBMC by M. leprae. Moreover, its role in the induction of TNF synthesis and apoptosis of TNF synthesis and apoptosis is under further investigation.

     

    OI 18

    M. leprae-SPECIFIC, HLA CLASS II-RESTRICTED KILLING OF HUMAN SCHWANN CELLS BY CD4+ TH1 CELLS: A NOVEL IMMUNOPATHOGEN1C MECHANISM OF NERVE DAMAGE IN LEPROSY.
    H.T. Spielings; T. de Boer; Brigitte Wieles; L.B. Adams; E. Marani; T.H.M. Ottenhoff
    Department of Imnuinohematology and Blood Transfusion and Department of Neurophysiology. Leiden University Medical Center, The Netherlands, National Hansen's Disease Programs Laboratory. Louisiana State University School of Veterinary Medicine. Baton Rouge. USA.

    Peripheral nerve damage is a major complication of reversal (or type-1) reactions in leprosy. The pathogenesis of nerve damage remains largely unresolved, but detailed in situanalyses suggest that type-1 T cells play an important role. Mycobacterium leprae is known to have a remarkable tropism for Schwann cells of the peripheral nerve. Reversal reactions in leprosy are often accompanied by severe and irreversible nerve destruction and are associated with increased cellular immune reactivity against M. leprae. Thus, a likely immunopathogenic mechanism of Schwann cell and nerve damage in leprosy is that infected Schwann cells process and present Ags of M. leprae to Ag-specilic. inflammatory type-1 T cells and that these T cells subsequently damage and lyse infected Schwann cells. Thus far it has been difficult to study this directly because of the inability to grow large numbers of human Schwann cells. We now have established long-term human Schwann cell cultures from sural nerves and show that human Schwann cells express MHC class I and II. ICAM-1, and CD80 surface molecules involved in Ag presentation. Human Schwann cells process and present M. leprae, as well as recombinant proteins and peptides to MHC class II-restricted CD4( + ) T cells, and are efficiently killed by these activated T cells. These findings elucidate a novel mechanism that is likely involved in the immunopathogenesis of nerve damage in leprosy.

     

    OI 19
    MATRIX METALLOPROTEINASE (MMP) mRNA EXPRESSION IN THE SKIN LESION OF LEPROSY PATIENTS

    Teles RMB; Samo E.N.; Geraldo N.T.; Moura D.F.; Vasconcelos B.S.; Shattock R.; Sampaio E.P.
    Leprosy laboratory, FIOCRUZ. Rio dc Janeiro- Brazil-Infectious Disease' Department - St. George' Hospital. London, England

    Introduction: MMPs are a zinc-dependent proteases family that collectively are able to degrade most extracellular matrix components. In general, MMPs are not constitutively expressed by the cell in vivo, but their expression can be modulated by cytokines such as TFN-á.
    Objective: To determine the pattern of expression of MMPs in reactions in leprosy patients who showed enhanced TFN-á production.
    Methods: Skin biopsies of 20 leprosy patients and 2 controls were collected and total RNA was extracted. RT-PCR to MMP-2, MMP-9 and TFN-á was performed, and the amplified products analyzed through electrophoresis in agarose gel.
    Results: The dermis of all (n= 15) reactional patients (RR and ENL) were positive to TFN-á and MMP-9 mRNA, and 84% (n= 12) to MMP-2 mRNA. In the dermis of the 5 unreactional patients, 60% (n= 3) were positive to MMP-2, MMP-9 and TFN-á mRNA. The 2 health controls are positive to TFN-á mRNA, but negative to MMP mRNA. In 50% of the patients MMP mRNA expression decreased during the treatment. In the epidermis of leprosy patients the TNFá mRNA was detected in all patients and MMP-2 and MMP-9 in 50% (n=3) and 16% (n= 1), respectively. TNFa and MMP mRNA was not observed in the epidermis of the unreactional patients. Preliminary experiments with Real Time PCR confirm the above data.
    Conclusion: The MMP mRNA expression was detected only together with TFN-á expression both in the dermis and epidermis. It is likely that these enzymes play a role in inflammatory reaction in leprosy.

     

    OI 20


    MHC AND IMMUNE REPONSE ACROSS THE LEPROSY SPECTRUM.
    Meenakshi Singh1; D.K. Mitra1; K. Katoch2; S. Ghei2; U. Sengupta2; N.K. Mehra1

    1. Department of Transplant Immunology & Immunogenetics, All India Institute of Medical Sciences.
    2. Central JALMA Institute of Leprosy. India.

    We earlier showed that HLA Class II genes modulate immune response following infection with M. leprae with preferential interaction among mycobacterial epitopes and particular Class II motif characterized by 'Arg' rich pocket 4 residues of the DRB1 molecule. It has been observed that cytokine polarized clinical states of leprosy correlate with the representation of phenolypable tine T cell subsets. We found that the functionally polarized subsets of CD4 memory T cells are identifiable on the basis of expression of CD11a, CD45RA and CD62L, viz those that primarily produce IL- 4 (MT2, CD45 RA- CD62 L + CD 11adim) or primarily y-Ifn (MT1, CD45 RA- CD62 L - CD 11abright). The frequency and representation of phenotypically definable memory T cell subsets (MT1 and MT2) was defined in all patients. We observed an overrepresentation of MT1 cells among BT subjects (Median, 3) compared to those with BL leprosy (Median, 15). Conversely MT, cells were over represented in BL patients (Median, 23) as opposed to BT subjects (Median, 3). Although median value of MT( representation among BL subjects was significantly lower than BT subjects, certain BL/LL patients had comparable higher frequency of MT1 cells as observed in BT cohorts. These results suggest a possible heterogeneity of immune response against M. leprae in these patients. Careful analysis of the data with regards to the bacillary load of BL patients revealed that MT1 cells were increased in only those BL/LL patients who had become bacillary negative following therapy. All BL/LL patients with a bacillary index of 2 or 4 showed lower frequency of MT cells. Our data indicates immune dynamics in leprosy and provides evidence that functional immune response as measured by cytokine producing memory T cells is dictated by the antigen load and presentation of relevant peptides of M. leprae by the host MHC.

     

    OI 21

    NEURAL PATHOLOGY DURING TREATMENT AND RFT
    D. Porichha1; A. Mukherjee2; Ramu3

    1. CGHS Medical Center, Parliament House Annexe, New Delhi, India. Pin. 110001. India.
    2. Institute of Pathology, Safdarjung Hospital Campus, New Delhi. India, Pin 110023.
    3. Sacred Heart Leprosy Center, Kubhakonam, Tamilnadu. India.

    Histological findings of 24 nerves, 15 developing pain and tenderness during treatment and 9 after RFT are presented in this study. Eight cases showed macrophage type and 15 had epithelioid cell type of granulomas. All cases were active except 3 macrophage granulomas where regressive changes were evident. One case had fibrosis with lymphocytic infiltration. No morphological difference could be observed between nerves biopsied during treatment and during RFT. Histology of epitheliod cell granulomas had interesting and diverse manifestations such as severe type I reaction, caseation necrosis with leque-faction and calcification. Three macrophage granulomas showed regressive changes, two were in ENL, while one case showed histoid changes. All the cases Studied showed similar granulomatous response irrespective of whether the pain and swelling appeared timing treatment or during surveillance. Nerves are thought to be immunologically more protected structures but once the taction is triggered the special nature of neural tissue seems to make the reactional episodes more explosive. Ascertaing relapse in nerves is more ambiguous due to smouldering nature of neural pathology.

     

    OI 22

    QUANTITATIVE ESTIMATION OF SALIVARY IgA ANTIBODIES IN LEPROSY BY ELISA USING INDIGENOUS POOLED SALIVA AS STANDARD

    Miss A.Fernando; Dr. R.S. Jadhav; Miss VS. Shinde; Ravindra R. Ramble; Mrs. S.P. Madhale; Dr. J.R. Rao; Dr. V.K. Edward; W.C.S. Smith on behalf of MILEP-2 Study Group*
    Stanley Browne Research Laboratories, Richardson Leprosy Hospital, Miraj, Maharashtra-416410. Tel. No Off: 0233-211213 Fax: 0233-211708 E-mail: sblabtlm@vsnl.com

    Background: M. leprae being the first organism to be discovered, yet a specific method for cultivation of M. leprae is still lacking. Leprosy is a unique disease; the disease is difficult to define due to the lack of gold standard for diagnosis. It is known that the primary lesions may be in the nasal mucosa. All mucosal sites are linked by lymphocyte re-circulation. The mucosal immune system is of importance in a putative protective response to infection.
    Aim: To investigate M. leprae reactive antibodies in saliva as a marker of anti-M. leprae immunity using indigenous pooled saliva as standard.
    Materials and Methods: Saliva samples were collected from subjects in leprosy endemic areas. ELISA studies were performed on all the saliva samples using whole a-irradiated M. leprae. Saliva showing high IgA concentration was pooled in appropriate quantities and a two-fold dilution of the pooled saliva was done to construct the standard curve. HRP conjugated antihuman IgA was added and the reaction was developed using o-phenylenediamine containing 0.05% hydrogen peroxide.
    Results: Standard curves prepared using pooled saliva samples were used to determine the concentration of IgA in terms of arbitrary units (AU) and used to compare the antibody levels in different individuals. For most of the saliva samples tested, 1:04 dilution of saliva appeared to be the right dilution. The optimum concentration of M. leprae cells used for coating was 1x107 cells/ml and the secondary antibody was diluted 1: 40,000.
    Conclusion: The pooled saliva used as a standard contributes to the uniformity in ELISA results. It was seen that this kind of quantitation was sufficiently a robust technique to give reproducible results.

     

    OI 23

    REAÇÃO DE MITSUDA EM PACIENTES PORTADORES DE HANSENÍASE NA FORMA TUBERCULÓIDE E DIMORFA DURANTE E APÓS O SURTO REACIONAL.
    Joel C. Lastória; Vladimir de A. Opromolla; Raul N. Fleury; Alexandra P. Bononi; Karina G. Pedroso; Carlos R. Padovani
    Depto de Dermatologia - F. M. de Botucatu- UNESP

    A hanseníase, de acordo com o sistema de classificação adotado pelo VI Congresso Internacional de Leprologia, 1953, apresenta duas formas polares, clínica e imunologicamente distintas: o tipo virchoviano e o tuberculóide. Apresenta ainda dois grupos instáveis, o indeterminado e o dimorfo. Em todas elas, exceto na indeterminada, a evolução crônica pode ser interrompida por surtos agudos, denominados de tuberculóide reacional (TR), dimorfo reacional (DR) e, quando na virchoviana, de eritema nodoso. A resistência à Hanseníase pode ser avaliada através da Reação de Mitsuda e, neste sentido, diferentes autores relatam que esta pode estar aumentada, diminuída ou inalterada em pacientes Tuberculóides e Dimorfos durante os surtos reacionais, sem contudo realizarem trabalhos específicos sobre o tema. Com esse objetivo, nesta apresentação, avaliou-se o comportamento clínico da reação de Mitsuda em 43 pacientes das formas Tuberculóide e Dimorfo, durante e após o surto reacional, e observou-se que há predominância da manutenção dos resultados da Reação de Mitsuda - tanto quando a avaliação foi feita separadamente, nos grupos TR e DR, quanto quando conjuntamente. Ademais, as alterações, quando ocorreram, foram predominantemente no sentido de aumento após o surto, ou seja, é possível que, na realidade, durante o surto reacional, alguns indivíduos possain apresentar uma diminuição de sua resistência específica ao M. leprae

     

    OI 24

    RT-PCR ANALYSIS OF PATHOGEN AND HOST EXPRESSION IN LEPROSY PATIENTS
    Shabaana, A.K.1; N.P. Shankernarayan2; D.C. Hoessli3; K. Dharmalingam1.

    1. School of Biotechnology, Madurai Kamaraj University, Madurai, India.
    2. VHS, Leprosy Project, Shakthi Nagar. India.
    3. University of Geneva Medical School. Geneva, Switzerland.

    Molecular analysis of nucleic acids in Paraffin-embedded infected tissues (PET) using RT-PCR is an effective approach to analyse gene expression of both host and pathogen genes. Punch biopsies obtained from leprosy patients across the leprosy spectrum (n=46) were fixed in formaldehyde and embedded in wax. RNA extraction conditions were optimized and first strand cDNA synthesis was carried using oligo dT primers. Semi-quantitative PGR was carried out using human cytokine specific primers as well as M. leprae specific primers.
    Analysis of the expression of regulatory cytokines, TGE- and IL-10 in relation to Thl/Th2 cytokines in different disease states confirm and extend the earlier observations that the LL condition is a mixed type of response having both Thl/Th2 cytokine production. Also, TGF- mRNA was found to be up- regulated at the LL end of the spectrum and could be responsible for the absence of any effect of TNF- and IFN-γ in borderline and lepromatous conditions. Finally the reactional conditions, reversal and ENL show similar cytokine profiles.
    Till date there is no documentation of the gene expression of M. leprae in infected host tissue. The same RNA extracted for cytokine analysis was also used for analysis of M. leprae specific genes 18kDa heat shock protein, 35kDa Major Membrane Protein I and two genes belonging to the Mce operon (Mammalian cell entry) namely mcelA and IprK. Amplification of these genes by RT-PCR from leprosy biopsies confirmed the expression of these genes in vivo. All amplified products have been cloned and sequenced to confirm the reliability of the system.

     

    OI 25
    SCREENING NEW LEPROSY ANTIGENS FOR POTENTIAL AS LEPROSY SKIN TESTS

    Murdo Macdonald; Niraj Shrestha; Parmeshwor Amatya; Rakesh Manandhar; Kees Franken; Tom Ottenhoff; Warwick Britton; Paul Roche
    Mycobacterial Research Laboratory. Anandaban Leprosy Hospital, PO Box 151. Kathmandu, NEPAL. E-mail: anandaban@mail.com.np

    There remains a requirement for leprosy-specific tests to detect leprosy exposure in communities with high levels of tuberculosis. We have previously demonstrated that levels of the cytokine interferon-gamma (IFN-γ produced in a simple overnight whole blood culture with leprosy antigens are increased in healthy contacts of leprosy patients.
    Aim: To investigate the efficacy of three M. leprae antigens (35kD antigen, 45kD antigen, and the M. leprae homologue of ESAT-6 (ESAT-6 ML)) as potential new skin test antigens.
    Methods: Whole blood was collected from almost 300 Nepali leprosy patients. TB patients, leprosy household contacts and unexposed subjects and used in overnight whole blood assays. Cells were stimulated with the above named antigens, and IFN-γ was measured in supernatants. The resultant cytokine levels in these stimulated short-term cultures were compared with longer (5-day) culture and with T-cell proliferation.
    Results: Very high IFN-γ response levels were observed in leprosy health workers compared with healthy control subjects. Both 24 hour and 5-day cultures gave similar results. In both cases cytokine levels observed were highest in response to M. leprae 35kD antigen, followed by ESAT-6 and 45kD.
    Conclusion: These data indicate the potential of these three relatively leprosy-specific antigens for use as leprosy skin tests in the future.

     

    OI 26
    SCREENING OF NEW Mycobacterium leprae ANTIGENS AS CANDIDATES FOR THE DEVELOPMENT OF TESTS FOR THE EARLY DIAGNOSIS OF LEPROSY

    Monica C.B.S. Lima 1, 2, 3*; Márcia V.B.S. Martins2*; John S. Spencer1; Maria A.M. Marques1; Heejin Kim1; Bruce C. Gregory1; Nadia C. Duppre1; José A. C. Nery1; Geraldo M.B. Pereira2,3; Euzenir N. Sarno2; Patrick J. Brennan1; Maria C.V. Pessolani2

    1. Department of Microbiology, Colorado State University, CO. USA.
    2. Leprosy Laboratory, Oswaldo Cruz Institute. Oswaldo Cruz Foundation2.
    3. Laboratory of Immunopathology, School of Medical Sciences, State University of Rio de Janeiro. RJ, Brazil.
    *These authors contributed equally to this work.

    The greatest needs from leprosy research are definitive diagnostic antigens to help understand transmission and allow early detection of disease. In order to further investigate the in vitro potential of new M. leprae antigens for in vivo skin tests or related in vitro tests, PBMC from leprosy patients, contacts of leprosy multibacillary patients, operational contacts, TB patients, and exposed or non-exposed healthy controls from leprosy endemic and non-endemic areas were stimulated with antigens from a collection of 26 M. leprae antigens, including crude and fractionated subcellular fractions of M. leprae and recombinant antigens. Cell-mediated responses were measured through IFN-γ secretion using ELISA, and some T-cell activation parameters (such as CLA and CD69 expression) were estimated by flow cytometry. Initial results obtained with these different groups of subjects indicate that sonic fractions/antigens are good inducers of IFN-γ production, and of CLA and CD69 expression, in leprosy patients, but not in TB patients. Responses were lower in lepromatous leprosy patients. These preliminary results suggested that some of our M. leprae antigens hold promise as specific diagnostic tools for leprosy. (Research supported by NIAID, NIH).

     

    OI 27

    STUDY OF EXPERIMENTAL LEPROSY IN INTERLEUKIN-12 DEFICIENT MICE
    Linda B. Adams; Nashone A. Soileau; Marilyn A. Dietrich; David M. Scollard; James L. Krahenbuhl
    National Hansen's Disease Programs Laboratory Research Branch at Louisiana State University. Baton Rouge, LA

    IL-12, a key regulatory cytokine of the immune system, induces the production of IFN-γ by T cells and NK cells and promotes the development of a Th1 type cell mediated immune response. To study its role in experimental leprosy, Mycobacterium leprae infection was evaluated in IL-12 knockout (KO) mice. Wild type control mice (C57B1/6) and IL-12 KO mice were infected in both hind foot pads with 6 × 103 viable M. leprae and bacterial growth, cell profiles, histology, and gene expression were monitored for over twelve months. In wild type mice, growth of the bacilli in the foot pads peaked on the order of 105 at six months post infection. In contrast, growth of M. leprae was enhanced in IL-12 KO mice, reaching 105 by three months post infection (P<0.01) and continuing to multiply to reach 106 by 12 months post infection (P<0.01). Histopathologically, control mice exhibited mild lymphocytic and histiocytic infiltrates at 12 months post infection. IL-12 KO mice also developed a mild inflammation with equal numbers of lymphocytes, macrophages and epithelioid cells. Lymph node cells from the draining popliteal lymph nodes were examined throughout infection for lymphocyte differentiation and activation surface markers. Cells bearing the CD44high CD45RBlow markers (activation/memory phenotype) constituted only 15.57 ± 3.93% of the CD4+ cells in the lymph nodes of wild type mice at three months post infection. This cell population increased to 29.14 ± 4.17% by six months and to 36.26 ± 10.49% by twelve months. A similar profile was observed in the lymphocytes of IL-12 KO mice. In summary, IL-12 KO mice exhibited a decreased ability to control M. leprae KO mice, yet did so without the massive granulomatous infiltration observed in those mice.

     

    OI 28

    T CELL RESPONSES TO PEPTIDES FROM M. leprae 10 KDA PROTEIN IN THAI LEPROSY PATIENTS, HEALTHY CONTACTS AND NON-CONTACTS
    B. Chua-lntra; S. Srisungngam; S. Wattanapokayakit; K. Mahotarn; J.Ivanyi
    Leprosy Division, Department of Communicable Disease Control. Ministry of Public Health, Non-thaburi, Thailand.

    Detection of M. leprae infected individuals using aT cell based assay is hampered by the lack of suitably specific test reagents. Thus the objective of this study was to identify M. leprae-specific immunogenic peptides from M. leprae 10 kDa protein. Although this protein has a homologue in M. tuberculosis, it was previously found to contain M. leprae-specific epitopes located within amino acid residues 24-39 as tested by murine T cell hybridoma and T cell clone. In this study, we analyzed the proliferative responses of peripheral blood mononuclear cells (PBMCs) to three synthetic peptides from 10 kDa protein of M. leprae among 73 paucibacillary (PB) and 124 multibacillary (MB) leprosy patients, 57 healthy household contacts and 20 non-contacts. These 18-mer peptides were located in 3 areas between residues 11-28. 22-39 and 55-72 containing 3-4 residues distinct between M. leprae and M. tuberculosis. Surprisingly, the result showed that frequencies of responders to all peptides were similar among the PB and MB patient groups. The most immunogenic peptide was p55-72, recognized by 34% and 48 % of PB and MB leprosy patients, respectively. M. leprae-specific P22-39 was recognized by 23-27% of patients but only 7% of healthy contacts which might be useful for discriminating between disease and sub-clinical infection. All peptides were recognized by non-contacts with significantly lower frequencies than the patient groups, suggesting that they were likely to be M. leprae-specific. Determination of the exact species-specificity would require further evaluation using T cell lines or clones. Combination of these peptides may increase the sensitivity of a prospective diagnostic test reagent above that, observed for the individual peptides.

     

    OI 29

    T CELL SUBSETS EXPRESSING NEURAL CELL ADHESION MOLECULE: ASSOCIATION WITH ANTIGEN INDEPENDENT, MHC UNRESTRICTED T CELL CYTOTOXICITY IN LEPROSY PATHOLOGY
    Eric Spierings; Tjitske de Boer; Tamara Dekker; Birhane Kaleab; Ben Naafs; William R. Faber; Pranab K. Das; Brigitte Wieles; Tom H.M. Ottenhoff
    Department of Immunohematology and  Blood Transfusion and Department of Dermatology, Leiden University Medical Center, The Netherlands, Department of Dermatology. Amsterdam Medical Center, The Netherlands

    We have investigated the role of Neural Cell Adhesion Molecule (NCAM or CD56) in the killing of Schwann cells and other NCAM positive targets by an NCAM expressing human T cell subset, isolated from leprosy patients. Involvement of NCAM expressing T cells in leprosy pathology was suggested by the observations that NCAM expressing T cells could be isolated from inflamed neural tissue. Furthermore, antigenic stimulation of these cells with Mycobacterium leprae increased both the number of NCAM+ T cells and their cytolytic activity against NCAM+ target cells. The cytolytic activity of NCAM+ T cells was antigen independent and could be attributed to the CD8+ T cell subpopulations. NCAM expression was not a stable but rather seemed an acquired characteristic, since it could be modulated in vitro on sorted, NCAM+ cell populations.
    In addition, a longitudinal analysis of leprosy patients undergoing active erythema nodosum leprosum (ENL or type 2 leprosy reactions) showed that M. leprae stimulation increased NCAM expression on CD8+ peripheral T lymphocytes only at the time of active ENL. In line with these observations, stimulation with M. leprae increased antigen independent lysis of NCAM positive target cells in close association with the period of active ENL. At the same time, CD8+ NCAM+ T cells could be visualized in ENL skin lesions.
    These results reveal a novel mechanism of antigen independent, T cell mediated tissue damage, which is likely to play a role in leprosy and possibly other peripheral neuropathies

     

    OI 30

    THE APPLICATION OF SEROLOGICAL TOOLS IN PATIENT MANAGEMENT AND LEPROSY CONTROL
    Samira Bührer-Sékula; Linda Oskam
    KIT Biomedical Research, Meibergdreef 39, 1105 AZ Amsterdam, The Netherlands

    The detection of human antibodies to the Mycobacterium leprae cell wall component phenolic glyco-lipid I (PGL-I) and its semi-synthetic derivatives can be performed using ELISA, agglutination tests, dipsticks or lateral flow tests. The results from these tests used to answer a number of important questions that are of direct relevance to patient management and leprosy control.
    Specifically, serological testing can be used to assist with the classification of leprosy patients into multi-bacillary (MB) and paucibacillary (PB) after clinical diagnosis, to detect patients who have an increased risk of relapsing after treatment and to identify contacts of leprosy patients that are in danger of developing leprosy in future.
    This presentation will give a critical overview of the various techniques in use. their relative advantages and limitations and the way in which these tools can be used to assist in patient management and leprosy control.

     

    OI 31

    THE ROLE OF MANNOSE BINDING LECTIN AND INFLAMMATORY RESPONSE IN LEPROSY
    N.T. Foss; M A.N. Ferreira; J.L. Andrade; E.M. Ranialho; T.L. Nunes
    Faculty of Medicine of Ribeirão Preto of São Paulo University.

    Mannose binding lectin (MBL) is a serum protein component of the innate immune system. MBL is able to enhance the phagocytosis of the pathogens by binding to the sugars on the microbial surface through an opsonin mechanism resulting in complement system activation. The deficiency of MBL is generally associated to susceptibility to infections. Leprosy is a chronic inflammatory and infective disease caused by the intracellular parasite Mycobacterium leprae which strongly bind to MBL. To evaluate the involvement of MBL on the evolution of the disease were selected 58 untreated leprosy patients, classified by Ridley & Jopling criteria (lepromatous leprosy-LL = 14, borderline lepromatous-BL = 8, borderline tuberculoid-BT = 11 and erythema nodosum leprosum-ENL = 25) and 10 healthy controls. Sera samples from the patients and controls were analyzed for determination of MBL, inflammatory cytokines (TNFα, IL6, IFN-γ), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and anti PGL1 antibody (APGL 1). It was observed that all ENL patients presented significantly higher levels of MBL (M = 2335.3 ng/ml) than LL (M = 301,3 ng/ml), BL (M = 428,2 ng/ml). BT (M = 486,1 ng/ml), or the normal control (M = 508,7 ng/ml). Additionally significantly elevated values of all the inflammatory parameters were found in ENL, when compared with the other forms of the disease and to controls. ALthough the bacilloscopic index (BI) of ENL and LL patients were similar (4.5 ±1.1 and 5.0 ± 1.5 respectively) the APGL1 levels (ENL 7.5; LL = 3.1), inflammatory cytokines (TNFα, IL6. IFN-γ, ESR and CRP levels were significantly higher in ENL than in LL, indicating that the reactional episode, type 2 reaction, could stimulate the liver cell to produce more MBL and induce the phagocitosis of the parasite, increasing the intracellular destruction. Thus, the data suggests that the protein MBL may act protecting the leprosy patients against the dissemination of the infection.

     

    OI 32

    THE ROLE OF TH1 AND TH2 CYTOKINES IN ACUTE LEPROSY NEURITIS
    S. Khanolkar-Young; A. Coulthart; S. Suneetha; D.N.J. Lockwood
    Department of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, Keppel Street, London, WCIE 7HT, United Kingdom.
    BPRC, Hyderabad, India

    Study: To assess cytokine production in nerves from patients with acute neuritis (defined as tenderness and/or loss of function within the last six months). The clinical samples skin and nerve biopsies from 57 patients with acute neuritis (BT = 30, BL = 18 and LL = 9) were collected.
    Imnumohistochemistry was done on skin and nerve sections to detect the cytokine proteins IFN-γ, IL-6, IL-10, IL-12, IL-13, TFN-α, TGF-β and iNOS.
    Results: Morphology: Granulomas were better defined and organised in nerve lesions. Cellular infiltration also more prominent in nerve. Th1 type cytokines (IFN-γ and IL-12) were present at high levels in skin and nerve. Nerves from LL patients had both low levels of IFN-γ and IL-12 and moderate levels of IL-6 and TGF-(3. Th2 type cytokines IL-6, IL-10 and IL-13 were present across the spectrum.
    Comments: Nerve damage may occur through two mechanisms, a Th1 dependent mechanism in BT and BL patients and a Th2 dependent mechanism in LL patients.

     

    OI 33

    TNF PROMOTER GENOTYPE INFLUENCE TNF PRODUCTION IN LPS- BUT NOT Mycobacterium leprae- STIMULATED WHOLE BLOOD CELLS IN VITRO.
    Moraes M.O.; Salgado J.; Abreu A.P.; Alves C.F.R.; Santos A.R.; Nery J.A.C.; Sampaio E.P.; Sarno E.N.
    Leprosy laboratory, Tropical Medicine Department, IOC-FIOCRUZ

    Single nucleotide polymorphisms (SNP) on TNF promoter are associated with the risk and progression of infectious and inflammatory diseases. Mutations at position -308 in TNFα (TNF2) promoter gene might affect levels of the cytokine production that are central in the outcome and the natural course of leprosy. The study was set out to investigate the contribution of TNF2 SNP in the cytokine mRNA expression and protein secretion in vitro. Paucibacillary leprosy patients were genotyped by PCR-RFLP for the presence of TNF2 allele (carriers = 13, non-carriers = 21). Whole blood cells from these patients were stimulated with LPS (1 ng/ml) and M. leprae ( 1 µg/ml). To mRNA expression analysis, semi-quantitative RT-PCR was performed after 3h stimulation. TNFα mRNA did not show any differences among the patients analyzed regardless the stimulus or the genotype of the patients. Nevertheless, LPS induced an increased in TNFα secretion in TNF2 carriers as compared to non-TNF2 carriers at 6h only (p<0,05). In M. leprae-stimulated cultures no significant differences were achieved. TNF2 allele influence the increased production of LPS-stimulated TNFα production was time dependent and restricted at the protein levels suggesting a post transcriptional regulatory role associated to the promoter polymorphism.

     

     

    MICROBIOLOGY & MOLECULAR BIOLOGY

     

    OM&BM 1

    ACCUMULATION OF NORFLOXACIN AND DAPSONE IN M. smegmatis
    K.Venkatesan; Nirmala Deo; A. Mathur*
    Central JALMA Institute for Leprosy, Agra -282 001 (India); *Deceased

    Quinolones are being increasingly used as second-line agents in the treatment of tuberculosis caused by multidrug-resistant strains. Dapsone is the main component of the MDT regimen for leprosy. At this juncture adequate knowledge of the transport of these chemotherapeutic agents will be of help in the development of new agents. A preliminary study has been conducted at this Institute on the accumulation of norfloxacin and dapsone using modified fluorescence methods. By employing exogenous norfloxacin concentration of 10 ug/ml, a steady state concentration (SSC) of 100 ng of norfloxacin/mg cells, by dry weight was obtained for M. smegmatis. Adequate care was taken to nullify the errors due to drug adsorption to the cell surface and to maximise the desorption using several standardised washings in the buffer. The addition of either dinitrophenol (2.0 mM) or CCCP (150 uM) 10 minutes before or or after addition of norfloxacin did not affect drug accumulation suggesting an absence of energy involvement in its transport process. In a parallel study on dapsone accumulation, the drug accumulated to a level of 78-106 ng/mg cells of M.smegmatis (by dry weight) during 15-60 minutes of incubation at an exogenous concentration of 10 ug/ml. Further studies using other agents like ofloxacin, rifampicin and clofazimine and several other mycobacteria are being planned. The experimental conditions for each mycobacterial strain and each antimicrobial agent are to be suitably standardised in order to get useful information. The method, once standardised, will be applied to drug resistant strains so as to evaluate the role of efflux pump in the emergence of drug resistance.

     

    OM&BM 2

    AN IN VITRO MODEL FOR STUDYING THE EFFECTS OF M. leprae ON SCHWANN CELL/NEURON INTERACTIONS
    Deanna Hagge1; David Seollard2; Greg McCormick2; Diana L Williams2

    1. Biological Sciences Dept. Louisiana State University, Baton Rouge, LA.
    2. Laboratory Research Branch. National Hansen's Disease Programs at LSU-SVM. Skip Bertman Dr. Baton Rouge. LA, USA.

    Globally, millions of leprosy patients suffer from irreversible nerve damage, resulting in disabilities or blindness as a consequence of infection with Mycobacterium leprae, an obligate intracellular pathogen. The mechanisms of nerve damage have not been fully elucidated due to a lack of a well-developed in vitro model which maintains the viability of M. leprae and closely mimics disease conditions. Therefore, an in vitro model was developed using freshly harvested nude mouse-derived M. leprae, rat Schwann cells and Schwann cell/neuron co-cultures incubated at 33º C, a conductive temperature for M. leprae viability. At 33º C, Schwann cells and mitogen-expanded Schwann cells appeared to be morphologically similar, express similar levels of Schwann cell markers and function in a comparable manner when seeded onto cultured neurons as those cells maintained at 37ºC. M. leprae within Schwann cells retained 56 % of their original viability for at least 3 weeks post infection at 33ºC compared to only 3 % at 37º C. Infected cells exhibited morphological changes, gene expression alterations 33º C, but were capable of interacting with and myelinating neurons. Infected myelinated co-cultures maintained myelin sheath architecture and were morphological comparable to non-infected cultures at both temperatures. In conclusion, an improved model for studying the effects of M. leprae on Schwann cells has been described. Preliminary results using this model indicate that M. leprae, under the conditions specified, do not appear to have detrimental effects on Schwann cell functional capabilities in the peripheral nerve and suggest that the majority of the neuropathy observed in leprosy is most likely due to an aggressive immune response to infection within the nerve.

     

    OM&BM3

    CARBOHYDRATE METABOLISM IN LEPROSY PATIENTS
    V.P. Tsemba; V.Z. Naumov; N.G. Urlyapova
    Leprosy Research Institute, Astrakhan, Russian Federation.

    Leprosy infection is often accompanied by metabolic disturbances, and carbohydrate metabolism is no exception. To a large extent, parameters of carbohydrate metabolism depend on sex and age of the patients and reflect a metabolic state at the moment of taking samples. A state of carbohydrate metabolism was estimated in 150 leprosy cases, including 117 (78%) patients with multibacillary (MB) and 33 patients (22%) with paucibacillary (PB) forms of leprosy. Among the patients (of 45 to 93 years old) there were 75 males and 75 females. Carbohydrate metabolism was assessed by integral index of glycemia, i.e. glycolized hemoglobin (HbAlc) defined for the past 3 months by means of colorimeter method. Upper normal limit of HbAlc was 7,5%. In leprosy patients with normal carbohydrate metabolism level of HbAlc did not depend on either sex or age. Disturbances in carbohydrate metabolism were found out in 37 patients (25% of all studied), out of them there were 30 MB (81%) and 7 PB (19%) patients. Ratio of the patients with and without metabolic disturbances was approximately 1:3 in MB and 1:4 in PB leprosy. Diabetes II type was found out in 13 MB-patients (11%) and in 2 patients with PB leprosy (6%). Prevalence of diabetes in patients under observation was 10%. In one case diabetes preceded the development of PB-leprosy. and in other cases sugar disease occurs against the background of leprosy process. Latent disturbances of carbohydrate metabolism were detected in 15% of cases observed. Thus, the data obtained showed a higher prevalence of carbohydrate metabolic disturbances in leprosy patients (to 11%) as compared with that in general population, necessitating further investigations to elucidate their possible causes and mechanisms.

     

    OM&BM 4

    COMPARISON OF PCR MEDIATED AMPLIFICATION OF DNA AND THE CLASSICAL METHODS FOR THE DETECTION OF Mycobacterium leprae IN LEPROSY PATIENTS AND CONTACTS
    Torres P.1, Gomez J.R.1, Gimeno V.1, Camarena J.J.2; Nogueira J.M.2; Navarro J.C.2; Olmos A.2

    1. Sanatorio San Francisco de Borja, Fontilles (Spain).
    2. Servicio de Microbiología, Hospital Dr.Peset. Universidad de Valencia (Spain).

    Traditional staining and microscopic examination techniques for the detection of Mycobacterium leprae and Polymerase chain reaction (PCR), DNA amplification of a 531 -bp fragment of the Mycobacterium leprae specific pra gene were compared on different clinical specimens on 60 leprosy patients attending the Sanatorium of Fontilles and divided for the purpose of the study in. multibacillary patients (MB) with positive Bacteriological Index (BI), 30 MB patients with negative BI and, 10 paucibacillary (PB) together with 4 non-leprosy patients as controls.
    The results in the multibacillary BI positive group show a good correlation between practically all methods and specimens, most techniques detecting 100% of the cases.
    The results in the MB negative group reveal that a combination of test (humoral response to D-BSA, together with PCR biopsy and PCR post biopsy swab) are the most sensitive in some cases of this group for monitoring leprosy patients who have completed chemotherapy. In the paucibacillary group no level of positivity was detected by conventional or PCR methods.
    The prevalence of antibodies to Mycobacterium leprae antigens in serum was measured together with the presence of Mycobacterium leprae DNA in the nose and lepromin status in a group of 43 contacts of leprosy patients. Two individuals were found to form a potential high risk group.

     

    OM&BM 5

    DETECTION OF ANTILEPROTIC DRUG (S) INDUCED DNA DAMAGE IN HUMAN PERIPHERAL BLOOD LYMPHOCYTES BY THE ALKALINE SINGLE CELL GEL ELECTROPHORESIS
    P. Rajaguru1; K. Kalaiselvi1; M. Palanivel1; G. Ramu2

    1. Department of Environmental Science, PSG College of Arts & Science, Coimbatore 641 014, India.
    2. Leprologist, GKNM Hospital Quarters, Coimbatore, India.

    Multidrug treatment (MDT) is the WHO recommended method of treatment for leprosy. In MDT, dapsone and rifampicine are effective chemotherapy followed by other frontline drugs like clofazimine, and ofloxacin. These drugs are reported to induce cytogenetic damage in different test systems. Our previous studies indicated higher incidence of DNA strand breaks, chromosomal aberration, and micronucleus frequency in the peripheral blood lymphocytes of leprosy patients treated with MDT. Therefore, to clarify the possible role of components of MDT in inducing DNA damage in leprosy patients, in this study, the induction of DNA damage by antileprotic drugs (dapsone, rifampicin, clofazimine, minocycline and ofloxacin) and subsequent repair was investigated by the alkaline comet assay in human blood lymphocytes. Lymphocytes isolated from leprosy patients and healthy individuals were treated with increasing concentrations of antileprotic drug(s) for varying duration of exposure and subjected for the comet assay. Metabolic aclivation/inactivation of the drugs was studied by incorporating rodent liver microsomal activation system (S9-mix). DNA damage data in lymphocytes of leprosy patients were compared with that of health individuals.

     

    OM&BM 6

    DETECTION OF Mycobacterium leprae NASAL CARRIERS BY POLYMERASE CHAIN REACTION IN SINGLE LESION LEPROSY PATIENTS
    Silva, M.H.M.; Castro, F.; Visconde, A.M.; Sousa, A.L.O.M.; Rebello, P.F.B.; Gomes, M.K.; Nararashi, K.; Sacchetim, S.C.; Costa. M.B.; Stefani, M.M.A.; Marlelli, C.M.T.; Gillis, TP
    IPTSP/UFG, Rua Delenda Rezende s/n Setor Universitário, CEP 74605-050 Brazil: National Hansen's Disease Programs/USA

    Objective: Detect M. leprae DNA by PCR in nasal swabs among Brazilian single skin lesion paucibacillary leprosy patients (SSL-PB).
    Methods: 259 newly detected SSL-PB leprosy patients, negative baciloscopy, were recruited in 3 endemic regions. 155 nasal swabs and 134 skin biopsies were collected before ROM therapy, snap-frozen and stored (liquid nitrogen) for M. leprae DNA detection by PCR. After DNA extraction each specimen was amplified, undiluted and at 1:5, using pairs of primers for a 360 bp M. leprae specific fragment and products detected by slot blot hybridization using digoxygenin-labeled 212bp DNA probe. Specimens were coded and tested blinded to patient's characteristics at IPTSP/Brazil in collaboration with National Hansen's Disease Programs.
    Results: In nasal swabs, M. leprae DNA was detected in 9.7% (15/155) of SSL-PB. Higher positivity (14.1%) was found among specimens from patients living in the North region compared with samples from Southeast and Central Brazil, compatible with endemic levels. No association was found between patient's characteristics or presence of household leprosy contact with PCR positivity. There was no agreement between positivity of M. leprae DNA PCR in skin biopsies and nasal swabs (Kappa=0.07).
    Conclusion: Detection of M. leprae DNA in nasal swabs from SSL-PB patients may reflect exposure in endemic areas without agreement with bacilli detection in skin biopsy by PCR. TDR/WHO grant 981007

     

    OM&BM 7

    DISTINGUISHING VARIANTS OF M. leprae LABORATORY STRAINS.
    Richard Truman, Ph.D.; Thomas P. Gillis, Ph.D.
    Laboratory Research Branch, Division of National Hansen's Disease Programs, HRSA, Baron Rouge, La. 70894, USA

    Genotyping has practical application in outbreak investigations and variant classification of cultured strains. Though remarkably little variability has been noted among M. leprae, in recent times a few loci for allelic diversity have been identified. These include mainly small insertion sequences and tandem repeating elements. At least one of these, the TTC triplet occurring in the putative sugar transporter pseudo-gene, has been found to occur at variable copy numbers in different clinical isolates. To better understand the suitability of this and other VNTR markers in differentiating variant strains of M. leprae, we examined a battery of 12 M. leprae isolates derived from leprosy patients in different regions of the United States, Brazil, Mexico, and the Philippines, as well as from wild nine-banded armadillos and the Sooty Mangaby Monkey. The stability of the TTC VNTR was compared among the individual isolates as well as to those from bacilli obtained on subsequent passage in nude mice and armadillos. Copy numbers for the TTC repeat ranged from 10-15 among the isolates tested. No regional clustering was noted and all of the U.S. isolates showed a variable number of repeats. Strains derived from wild animals were not identical. Greatest variability in TTC was seen over long term passage with the Thai-53 strain, which has been maintained continuously in nude mice for many years. Thai-53 TTC copy number varied markedly over 8 passage intervals. However, the TTC VNTR genotype of most individual strains remained relatively constant for isolates passaged outside man for fewer than 12 generations. In addition, the TTC VNTR genotype of these strains tended to remain constant when passaged through an alternate animal host, the experimentally infected nine-banded armadillo. Even though the TTC VNTR occurs in a non-coding region of the M. leprae chromosome, its apparent stability among most short term passaged isolates suggests that it has utility for differentiating laboratory strains of M. leprae, and may be useful in assessing drift amongst isolates carried in long term culture.

     

    OM&BM 8

    EVALUATION OF TFN-α AND IE-10 SINGLE NUCLEOTIDE POLYMORPHISM (SNPS) AMONG HIV/M. leprae CO-INFECTED AND LEPROSY PATIENTS
    Galhardo, M.C.C.; Vanderborght, P.R.; Nery, J.A.C.; Silva-Filho, V.F.; Sarno, E.N.; Sampaio. E.P.; Santos, A.R.
    Oswaldo Cruz Foundation, Evandro Chagas Hospital, Leprosy Sector. Av. Brasil, 4365 Manguinhos Rio de Janeiro - Brasil CEP: 21045-900

    The effective immune response against pathogens depends on an interaction of different cells and molecules from which pro and anti-inflammatory cytokines like TFN-α and IL-10 have a fundamental role. Thus, up or down regulation of these genes can influence clinical manifestations and outcome of several diseases including aids and leprosy. Recently, several SNPs have been described in cytokine genes and associated with gene expression and a number of diseases. Although the mutant -308A TFN-α allele have been associated with protection in leprosy, no polimorphic TNF alleles was associated to outcome in HIV infection. The aim of this study was to evaluate the possible association of promoter SNPs on TFN-α (-238, -308) and IL-10 (-819, -1082) positions with the outcome in HIV/ M. leprae co-infected compared with leprosy patients. Twenty one co-infected patients classified as multi (10) and paucibacillary (12) MB/PB leprosy were evaluated besides a group of 300 leprosy patients (210 MB and 90 PB). The results indicated that for the TFN-α polymorphisms the frequency of -238A was higher in the co-infected group compared with leprosy patients (p=0,04) corroborating with previous studies in which this allele was associated with the more severe MB forms of leprosy. For the IL-10 polymorphisms only the -819T allele showed an increased frequency in co-infected patients (p = 0,01). Frequencies of-308 and -1082 did not show difference between groups. However, horizontal analysis of the co-infected group shows the higher frequency of -1082A (related to the down regulation of IL-10 gene) linked with a low frequency of -308A (related to the up regulation of TFN-α gene) suggesting a combination of genetic factors probably associated with susceptibility for the co-infection HIV/M. lepraeng laboratory strains of M. leprae, and may be useful in assessing drift amongst isolates carried in long term culture.

     

    OM&BM 9

    FURTHER STUDIES ON M. leprae - PERIPHERAL NERVE PROTEIN INTERACTION AND THE ROLE OF THE 25 kDa GLYCOPROTEIN MYELIN P0.
    Lavanya M Suneetha; Venkat Rami Reddy; Meher Vani; Deena Vardhini; David Scollard1; Jaun Archelos2; Sujai Sineedia

    LEPRA India - Blue Peter Research Centre, Cherlapally, Hyderabad - 501301.
    1. National Hansen's Disease Centre. Baton Rouge, USA.
    2. Department of Neurology. University of Graz, Austria.

    The invasion of Schwann cells and axons by M.leprae results in demyelination and axonal degeneration leading to motor, sensory and autonomic nerve damage and disfigurement which is the hallmark of leprosy. Other workers shown that tissue proteins such as fibronectin, β integrin, laminin-2 and αdystroglycan are involved in M. leprae - target tissue binding. Our earlier biochemical studies have revealed that a 25 kDa glycoprotein of the peripheral nerve has an affinity for M. leprae and is involved in binding. This glycoprotein is a major phosphorylated protein of the human peripheral nerve. Its molecular weight, carbohydrate content and phosphorylatable nature are similar to myelin P0.
    The present study is an immunological confirmation that this protein is the myelin P0. The 25 kDa phosphorylated protein was confirmed as myelin P by the following experiments - dot blot assays, immuno-precipitation, western blot and by immuno-hislo-chemistry using monoclonal antibodies to P0 and the HNK-I epitope.
    Since myelin P0 is a peripheral nerve specific protein, it could be one of the key target molecule for M. leprae binding/internalisation and may also explain the neural prediliction of M. leprae

     

    OM&BM 10

    GENE EXPRESSION IN Mycobacterium leprae
    Diana L. Williams1; Richard Truman2; Thomas Gillis1

    1. Molecular Biology Research.
    2. Microbiology Depts, Laboratory Research Branch, National Hansen's Disease Programs, at LSU-SVM, Skip Bertman Dr, Baton Rouge, LA, USA

    The genome of M. leprae has been completely sequenced and annotated. 1604 open reading frames and 1104 pseudogenes have been identified, however, the minimum gene set required for growth and survival (transcriptome) has not been defined. We have developed a protocol for M. leprae RNA purification and obtained RNA from two strains of M. leprae (T-53 and 4089). The expression of approximately 5% of the potential transcriptome was analyzed using RT-PCR. cDNA was produced using 1ug of RNA from each strain, random hexamers and reverse-transcription (RT). Gene transcripts were amplified from cDNA using PCR with primer sets flanking several potentially functional families. The cDNA from both strains was amplified and results demonstrated that genes encoding several enzymes including those involved with, folic acid synthesis, iron utilization, co-factor biosynthesis, gluconeogenesis, degradation of phosphorous compounds, degradation of DNA, detoxification, synthesis of mycolic acids, modification and maturation of ribosomes, synthesis of RNA, glycolysis, glyoxylate bypass, and genes containing secretion motifs or encoding stress proteins, and several genes with unknown functions were transcribed in both strains. These data have provided the first insight into the transcriptome of M. leprae. However, not all genes were expressed in both strains. Comparative analysis of gene expression theses strains will be discussed in greater detail. It is anticipated that this analysis along with cDNA array analysis will help to identify a larger set of functional genes in M. leprae which will potentially help us to understand the minimal requirements for growth and replication of this pathogen. This information may lead to the identification of new drug targets, skin test antigens and to identify factors that allow this pathogen to evade the immune system and destroy peripheral nerves.

     

    OM&BM 11

    GENETIC SUSCEPTIBILITY TO ERYTHEMA NODOSUM LEPROSUM (ENL) IN LEPROSY
    Murdo Macdonald; Niraj Shrestha; Ruby Sidiqui; Paul Roche; Gilla Kaplan
    Mycobacterial Research Laboratory. Anandaban Leprosy Hospital. PO Box 151. Kathmandu, NEPAL. Email: anadaban@mail.com.np

    Erythema nodosum leprosum (ENL) is a distressing complication, experienced by up to 40% of lepromatous leprosy patients, which is characterized by severe systemic symptoms, including fever, painful cutaneous lesions, and neuritis, which often result in permanent nerve damage. The determinants and mechanisms underlying the onset of reactional states, progressive nerve damage and the regulation of immunity in these patients are not well understood.
    Aim: To investigate the role of genetic factors in leprosy patients in their propensity for developing ENL.
    Methods: We have recruited over 950 Nepali individuals, including both leprosy patients and their first-degree relatives. DNA was obtained from blood samples taken from each of these participants, and the SSO technique used to estimate the prevalence of polymorphisms in a number of candidate genetic loci: specifically, HLA-DR, TNE-á and Vitamin D receptor genes.
    Results: Our results indicate that while the genetic loci under investigation may play a role in a patients' susceptibility to ENL, other factors may also have an effect. We will present data with regard to our analyses of the incidences of polymorphisms at these loci in each of the groups studied.
    Conclusions: We have applied a rapid technique to determine the prevalence of specific genetic polymorphisms among leprosy patients and their first-degree relatives. In addition, the establishment of a large databank of DNA from patients susceptible to KNL will be an important resource for future studies.

     

    OM&BM 12

    GENOMIC DIVERSITY IN RPOT GENE OE Mycobacterium leprae AND GEOGRAPHIC DISTRIBUTION IN LATIN AMERICA
    Masanori Matsuoka1; Yoshiko Kashiwabara1; Pedro Legua2; Carlos Wiens3; Mary Fafutis4

    1. Leprosy Research Center, National Institute of Infectious Diseases, Tokyo, Japan.
    2. University Peruana Cayetano Heradia, Lima, Peru
    3. Hospital Mennonita Asuncion. Paraguay.
    4. Universidad de Gaudalajara. Jalisco. Mexico

    In the study to establish the genotyping of Mycobacterium leprae, two genotypes of the rpoT gene were detected among isolates. Some of them showed the rpoT gene with 4 copies of 6 base tandem repeats and other isolates harbored 3 copies of 6 base tandem repeats in the gene. Most striking finding was the apparent dominant distribution of the 6bp 4 tandem repeat genotype of M. leprae in the main island of Japan and Korea. In contrast, almost all isolates from other regions in the world revealed 3-copy type. It is clear 6bp 4 tandem repeat genotype spread in Japan in concordance with the migration of the people from Korea to Japan. Biased distribution of each genotype in the world led us to imagine the spread of the leprosy concordant with the migration of Mongoloids to Latin American countries as revealed for other microorganisms. Geographic distribution of different rpoT genotypes of M. leprae isolated in Paraguay. Peru and Mexico was investigated in connection with human prehistoric migration. All M. leprae genotype of rpoT gene isolated in Paraguay and Peru showed three tandem repeats of 6bp. On the contrary, isolates from Mexico showed the 6bp 4 tandem repeat genotype. It seems that the M. leprae distributed in Mexico was carried by the movement of Mongoloid but the bacilli in two South American countries is originated in another source.

     

    OM&BM 13

    Mycobacterium leprae DNA DETECTION BY POLYMERASE CHAIN REACTION FOR EARLY LEPROSY
    Sousa. A.L.O.M.; Castro, F.; Silva, M.H.; Rebello, P.F.B.; Gomes, M.K.; Nararashi, K.; Sacchetim, S.C.; Visconde, A.M.; Costa, M.B.; Martelli, C.M.T.; Stefani, M.M.A.; Gillis.T.P.
    IPTSP/UFG, Rua Delenda Rezende s/n Setor Universitário. CEP 74605-050 Brazil; National Hansen's Disease Programs/USA

    Objective: To detect M. leprae DNA by PCR in skin biopsies among Brazilian single skin lesion paucibacillary leprosy patients (SSL-PB) prior to one dose ROM therapy.
    Methods: 259 newly detected SSL-PB leprosy patients, negative baciloscopy, were recruited in 3 endemic regions from 97/98 and followed-up for 3 years. Before drug intake, 4 mm punch skin biopsies were collected for conventional histopathology. In a subgroup of 134 patients, half of the skin biopsy was snap-frozen and stored (liquid nitrogen) for M. leprae DNA detection by PCR. After DNA extraction (phenol/chloroform/ isoamyl alcohol) each specimen was amplified, undiluted and at 1:5, using pairs of primers for a 360 bp M. leprae specific fragment. Products were detected by slot blot hybridization using digoxygenin-labeled 212bp DNA probe. Specimens were tested blinded to patient's characteristics at IPTSP/Brazil in partnership with National Hansen's Disease Programs.
    Results: 43.3% (95%CI 34.8-52.1) of M. leprae DNA positivity was detected among SSL-PB, representing an increase of 37.3% (50/134) bacilli detection when compared to the rare bacilli found in histopathology readings (12/134). There was an increased positivity trend with age (p<0.01). Patients with skin lesion on the face, Mitsuda negative (<5mm), anti PGLI negative were independently associated with positivity.
    Conclusion: M. leprae DNA by PCR was a valuable tool for diagnosis confirmation among early paucibacillary leprosy patients and to explore prediction factors of disease progression.
    TDK/WHO grant 98100

     

    OM&BM 14

    NASAL PRESENCE OF Mycobacterium leprae AND MUCOSAL IMMUNITY IN HOUSEHOLD CONTACTS OF LEPROSY PATIENTS
    Mrs. S. P. Madhalc; Dr. R.S. Jadhav; Miss A. Fernando; Miss V.S. Shinde; Ravindra R Ramble; Dr. V. K. Edward; Dr. J.R. Rao; Prof. W.C.S. Smith on behalf of MILEP-2 Study Group*
    Stanley Browne Research Laboratories. Richardson Leprosy Hospital, Miraj. Maharashtra-416410. Tel. No Off: 0233-211213 Fax: 0233-211708 E-mail: sblabtlm@vsnl.com

    Transmission of leprosy in the household contacts (HC), as reflected in new case detection rate does not appear to be affected significantly in the post-MDT era. Incidence rates have been reported 8-10 times higher in the HC than the general population. Major route of transmission of M. leprae is thought to be mainly through the respiratory system with nose as the site of initial infection. The aim of the study was to see the mucosal immunity and exposure to M. leprae in HCs of patients and non-contacts (NC) to understand transmission. The principal methods employed for this were the polymerase chain reaction (PGR) to detect small quantities of M. leprae DNA and measurement of mucosal immunity by ELISA. 201 subjects out of 3035 were identified as HCs. Saliva samples and nasal swab were collected from subjects to carry out this study. Overall analysis of all the samples shows that the percentage of PCR posi-tivity is almost same in HC (2.3%) and NC (2.5%). Similarly in both groups 68% of the subjects show mucosal immune response. Both the groups show similar pattern of exposure to M. leprae with PCR positivity peak seen in monsoon. Amongst the household contacts, females show higher PCR positivity (3%) than males (1.5%). The difference in the PCR positivity in noncontacts in males (2.2%) and females (2.8%) is relatively small. Exposure to M. leprae is likely to be followed by immunity in most individuals, which is consistent with wide spread transmission of M. leprae producing transient nasal carriage and the development of a mucosal immune response, which may be protective.

     

    OM&BM 15

    PATTERN & SIGNIFICANCE OF PARASITAZATION OF ENDOTHELIAL CELLS IN LEPROSY: MORPHOLOGICAL & INVITRO STUDIES.
    Sujai Suneetha; Lavanya Suneetha; David Scollard1

    LEPRA India - Blue Peter Research Centre, Cherla-pally. Hyderabad-501 301. India
    1. National Hansen's Disease Centre. Baton Rouge, USA.

    Previous studies have implicated the role of the endothelial cell in the dissemination of leprosy. In this paper we present a detailed morphological study of 17 skin biopsies (4 BT, 3 BL & 10 LL) in which acid fast bacilli were found in the endothelial cells and relate it to other morphological features in the biopsies.
    Among the 17 biopsies in whom bacilli were present in the endothelial cells: bacilli were also prevent in the nerves in 13 biopsies, in the macrophage in 16; smooth muscle in 10 and in the sub epidermal zone in 2 biopsies. Bacilli were present also in the walls of the blood vessels in 5 biopsies and in the lumen in 1 biopsy. Interestingly there was 1 biopsy in a BT patient in which bacilli were present only in the endothelial cells and absent elsewhere in the section.
    In vitro studies on M. leprae-endothelial cell interaction were carried out using immortalized endothelial cell lines. The short term cultured endothelial cells were isolated and phosphorylated with gamma P32 ATP. M. leprae binding studies were carried out on nitrocellulose blot. Preliminary experiments suggest that there is a phosphorylated glycoprotein receptor (55 kDa) on the endothelial cells that interacts and binds to M. leprae.
    These morphological and in vitro studies suggest that M. leprae has an affinity for endothelial cells which it parasitizes. The organism is then probably released into the blood stream resulting in its dissemination to distant sites of prediliction in the body

     

    OM&BM 16

    PERSISTERS IN LEPROSY AFTER MULTIDRUG TREATMENT IN MB PATIENTS
    U.D.Gupta; K. Katoch; H.B. Singh; M. Natrajan; VM. Katoch
    Central JALMA Institute for Leprosy (ICMR), Taj-ganj, Agra, India

    With the Multi-Drug Treatment (MDT) of leprosy, the results have been satisfactory all over the world. However, the presence of drug sensitive viable organisms is well recognized in MB leprosy. These persisting bacilli have special significance clue to their relapse potential. This study has been initiated to gain an overview of this problem and follow the trends in multibacillary cases treated with MDT. In this study, biopsies for Mouse Foot Pad (MFP) have been obtained from MB patients treated with (i) standard MDT +Minocycline + Ofloxacin for 12 months, (ii). Standard MB MDT after 12,24 and 36 months Bacilli harvested from the biopsies were inoculated in to mouse foot pad and estimation of bacillary ATP levels by bioluminescence assay as per established methods. Available results indicate that despite reduction in viability after MDT, viable persisters are detected even beyond one and 2 years of treatment. There has not been much change in the trends over the last 5-10 years. It would be important to carry out such surveillance in larger number of MB cases to know the trends and the resultant relapses.

     

    OM&BM 17

    PROTECTION OF MICK AGAINST Mycobacterium leprae INFECTION BY A DNA VACCINE ENCODING M. lepraE ANTIGEN 85A AND MUTANT MURINE IL-12
    M. Ngamying; R Sawanpanyalert; J. Nikasri; R. Butraporn; S-N. Cho; P.J. Brennan; L. Levy
    National Institute of Health. Department of Medical Science. Ministry of Public Health. Nonthabnri. Thailand.

    Female BALB/c were administered one of three DNA vaccines: M. leprae DNA: Ag85A; DNA: AgSSA + wild-type murine DNA: IL-12w; and DNA: Ag85A + mutant murine DNA: IL-I2m. Expression of Ag85A by the preparation of DNA: AgS5A had been confirmed by specific stimulation of I FN by murine spleen cells before it was employed in this experiment. Control mice were administered saline or the empty vector; live BCG served as a positive control. The mice were injected into the posterior tibial muscles with 200 g/dose/mouse of one of the preparations on four occasions four weeks apart, except for BCG, only two doses of which were injected. Four weeks after the last dose, the mice were challenged with 5000 M. leprae into a hind foot pad, and the organisms were harvested approximately live months later. The results of the harvests are summarized in the table. As shown by the control group, the results of the harvests demonstrate that the inoculum employed included only a small proportion of viable organisms. BCG appears to have conferred modest protection. Only the mixture of the DNAs encoding Ag85A and IL-I2m conferred protection, whereas the mixture of the DNAs encoding Ag85A and IL-12w appears to have enhanced the infection.

     

    OM&BM 18

    SCHWANN CELL GENE EXPRESSION PROFILE IS MODULATED BY Mycobacterium leprae
    Tempone, A.J.1; Silva, T.P.1; Rossle, S.2; Lopes, U.G.2; Brennan, P.J.3; Sarno, E.N.; Pessolani, M.C.V.1

    1. Instituto Oswaldo Cruz - Laboratorio de Hanseniase - Fiocruz.
    2. Instituto de Biofisica Carlos Chagas Filho - UFRJ.
    3. Dept. Microbiology Colorado State University Fort Collins. CO.

    The primary effects of Mycobacterium leprae invasion on the physiology and metabolism of Schwann cells, and to whar extent these effects might be related to the progressive, irreversible degenerative nerve damage observed in leprosy, are poorly understood. In this study, we have applied differential display PGR and DNA microarray techniques to identify genes selectively expressed or repressed in Schwann cells in response to M. leprae infection. Schwann cell lineage ST-8814 was cultured and incubated with M. leprae isolated from armadillo and from human biopsies between 1 and 24 hours. Complementary DNA synthesized from RNA isolated from these cultures was used lor differential display RT-PCR reactions and hybridizations against oligonucleotide chips. Currently bands identified in polyacrilamide gel electrophoresis as differentially expressed have been cloned and sequenced for subsequent northern blot and real time PCR confirmation. Images of microarray hybridizations have been acquired using the Gen Pix software. The cluster analysis has been performed using the Tree View software. Preliminary results indicate that M. leprae is able to alter the gene expression profile of in vitro cultured Schwann cell.
    NIH, WHO/TDR. sponsored this work.

     

    OM&BM 19

    SIMPLIFIED REVERSE TRANSCRIPTION POLYMERASE CHAIN REACTION FOR DETECTION OF Mycobacterium leprae IN SKIN SPECIMENS
    B. Phetsuksiri1; J. Rudeeaneksin1; P. Supapkul1; S. Wachapong1; K. Mahotarn1; P.J. Brennan2

    1. Sasakawa Research Building, Rajprachasamasai Institute, Leprosy Division, Department of Communicable Disease Control, Ministry of Public Health, Nonthaburi. Thailand.
    2. Colorado State University, Fort Collins. Colorado, USA.

    Diagnosis of leprosy based on detection of Mycobacterium leprae RNA remains a complicated process. To simplify the detection procedure, a one-step RNA extraction and reverse transcription polymerase chain reaction (RT-PCR) was established and evaluated for its potential in rapid detection of leprosy patients. The assay relies on the extraction of M. leprae RNA, and single-tube reactions of reverse transcription, followed by PCR amplification. Using M. leprae-specific primers targeting 171-bp fragment of the M. leprae 16s rRNA gene, the RT-PCR designed for convenience, and reproducibility resulted in detectable M. leprae in both slit skin smears and skin biopsies. The assay was specific for M. leprae in comparison with results obtained from Mycobacterium tuberculosis and Mycobacterium smegmatis. The use of digoxigenin-label DNA enhanced the positive signal of the amplified RT-PCR product. The method could detect less than 10 CPU of mycobacteria in analyzed samples indicating the sensitivity of the test. In the initial application, diagnostic results were obtained from 24 leprosy patients. Of these, 20 were multibacillary (MB) and 17/20 patients were positive for 16s rRNA of M. leprae in skin specimens. The assay particularly useful since slit skin smears negative in staining for acid fast bacilli were positive by RT-PCR. The method has also been evaluated for its potential to help monitor bacterial clearance in leprosy patients during chemotherapeutic treatment. We propose that this form of RT-PCR gives values in term of its simplicity and sensitivity to identify M. leprae in skin specimens especially when acid-fast bacilli are not discernable. The usefulness of RT-PCR in detection of viable leprosy bacilli needs to be extensively explored.

     

    OM&BM 20

    SINGLE NUCLEOTIDE POLYMORPHISMS (SNPS) OF TFN-α AND IL-10 GENES AND SUSCEPTIBILITY TO LEPROSY AMONG HOUSEHOLD CONTACTS.
    Santos. A. R.; Moraes, M. O.; Vanderborght, P. R.; Matos, H.J.; Silva-Filho, V. F.; Vasconcellos, S. E. G.; Maniero, V.C.; Sampaio, E.P.; Sarno, E.N.
    Oswaldo Cruz Foundation, Leprosy Sector. Av. Brasil, 4365 Manguinhos Rio de Janeiro - Brasil cep: 21045-900.

    The interindividual variations in the host response to a certain pathogen are one of the most important variables for the determination of susceptibility and severity of the disease, which is the result of environmental effects against the background of genetic factors. Thus, identification of such factors, which are somehow associated to a higher or lower susceptibility, is of fundamental importance for the prediction of development or establishment of the disease. The aim of this study was to evaluate the possible association of the SNPs at positions -238 and -308 of the TFN-α and -819, -1082 and -2849 of the IL-10 genes among household contacts of leprosy patients.
    Two hundred and sixty seven household contacts were enrolled in this study from which 67 became patients and 200 remained as healthy contacts. The results showed no statistic difference on the distribution of carriers and non-carriers of the -238a allele among sick and healthy contacts. For the -308 position, the number of carriers was significantly higher among sick in comparison to healthy contacts (p < 0,01). Moreover, when analyzed through the clinical spectrum of leprosy, all the -238A carriers developed multibacillary (MB) forms of the disease whereas 73,3% of the -308A carriers developed the paucibacillary (PB) forms. Regarding the IL-10 SNPs, the allelic frequency of the -819T was significantly higher in the healthy and -1082A in sick contacts (p <0,01 for both). Analysis according to the clinical forms revealed an increased frequency of the -819T carriers in the PB forms when compared to the MB (p < 0,01).
    The present data suggest that SNPs of cytokine genes could be used to screen contacts of leprosy patients as a prognostic marker of diseases susceptibility and severity.

     

    OM&BM 21

    SITE OF ENTRY: AN IMPORTANT FACTOR IN THE GROWTH AND DISSEMINATION OF M. leprae IN MICE.
    Gigi J Ebenezer; Sheela Daniel; Shantha Arumugam; Charles K. Job
    Schieffelin Leprosy Research and Training Center, Karigiri. Vellore District, Taniilnadu. India - 632106.

    Sixty eight thymectimized and irradiated mice were randomized and 36 inoculated intra-dermally in the flank and 36 in the footpad. In each of these two groups four different concentrations of M. leprae inoculation were used namely 107 in 0.1 ml, l06 in 0.1 ml, 105 in 0.1 ml and 104 in 0.1 ml. Mice were sacrificed at the 6th, 8th, 12th and 15th month and growth of M. leprae at the site of inoculation was estimated. Internal organs were subjected to histo-pathological examination.
    The 104 in 0.1 ml inoculum did not promote growth in mice injected in the Hank but growth was seen in all mice that were inoculated in the foot-pad. In all other groups there was growth of M. leprae but it was quantitatively more in the foot-pad inoculated animals than in the flank inoculated ones. Further, growth in the foot-pad inoculated mice was associated with disseminated of M. leprae to the internal organs while such dissemination was not seen in flank injected mice.
    We conclude that in mice, entry of M. leprae through a relatively cooler entry point (foot pad) allows better growth of M. leprae locally, needs smaller doses of inoculum to promote growth and allows dissemination of the organism to the internal organs. The site of entry of M. leprae and the dose may have a role in determining whether the person will be infected or not.

     

    OM&BM 22

    STUDIES ON NASAL TRANSMISSION BY M. leprae SPECIFIC GENE AMPLIFICATION
    H.B.Singh; V.M. Katoch; M. Natrajan; K. Katoch; Raj Kamal; V.D. Sharma; D.S. Chauhan; R. Das; K. Srivastava; P. Gupta
    Central JALMA Institute lor Leprosy (ICMR). Taj Ganj, Agra. India

    Nose has been considered as an important portal of exit and entry in leprosy. Due to continued high incidence rates in leprosy, there is a great need to understand the sources and spread of M. leprae. This study has been carried out to study the nasal positivity on in leprosy cases by using M. leprae specific PCR. Nasal scrapings were collected from leprosy cases across the spectrum. These were from untreated as well patients treated with standard MDT for varying duration. These scrapings were suspended in IE buffer, decontaminated and DNA was extracted by a physiochemical procedure already established at the laboratory. Gene amplification was carried out by using a system targeting 36 kD gene (Hartskeerl et al 1989). Amplicons were analysed by gel electrophoresis and southern blot hybridization. PGR positivity was been analysed in relation to type of disease and duration of treatment. Positive results were observed in a section of PB cases (classified according to current WHO criteria) and most of MB cases. This positivity persisted for varying periods after treatment. The relevance of these findings will be discussed keeping in view the potential application of this approach in studying the transmission of leprosy.

     

    OM&BM 23

    STUDIES ON STRAIN VARIATION BY M. leprae USING TTC REPEATS
    V. M. Katoch; Mallika Lavania; H.B. Singh; M. Natrajan; K. Katoch; Raj Kamal; V.D. Sharma; D.S. Chauhan; R. Das; K. Srivastava; P. Gupta
    Central JALMA Institute for Leprosy (ICMR). Taj Ganj, Agra. India

    There is a great need to develop molecular markers for eliciting the strain variation among M. leprae for understanding the dynamics of transmission of leprosy. This study has been carried out to study the strain variation in leprosy cases by using TTC repeats as markers. Biopsies were collected from leprosy cases across the spectrum. These biopsies were homogenized and DNA was extracted by a physiochemical procedure already established at the laboratory. TTC regions were amplified by using the primers and procedure described by Shin et. al. (2000). Amplicons were analysed by gel eletrophoresis. The polymorphism observed in the size of amplicons has been analysed in relation to geographical distribution, type of disease and possible sources. The relevance of these findings will be discussed in context of potential application in the molecular epidemiology of leprosy. Such techniques become very important due to persistent high incidence rates seen in our populations.

     

    OM&BM 24

    SUBCLINICAL TRANSMISSION OE M. leprae: OCCURENCE OE NASAL PGR POSITIVITY AND MUCOSAL IMMUNITY - ANALYSIS IN SCHOOLCHILDREN
    Miss A.Fernando; Dr. R.S. Jadhav. Miss V.S. Shinde; Ravindra R. Kamble; Mrs. S.P. Madhale; Dr. J.R. Rao; Dr. V.K. Edward; Prof. W.C.S. Smith on behalf of MILEP-2 Study Group*
    Stanley Browne Research Laboratories. Richardson Leprosy Hospital. Miraj, Maharashtra-416410. Tel. No Off: 0233-211213 Fax: 0233-211708 E-mail: sblabtlm@vsnl.com

    Background: The transmission of leprosy is less well understood. Infection from sub-clinical sources could play an important role than from active clinically apparent cases. Most of the individuals in high leprosy endemic areas have immunological evidence to M. leprae. Thus the first exposure, probably exposure in childhood is important and also, is the related mucosal immune response to characterize the immune status of the individual.
    Aim: To define the means by which M. leprae is transmitted and the development of immunity in school children in a population in which multidrug therapy had been used for more than 10 years.
    Materials and Methods: Three villages in South Maharashtra, where leprosy is endemic were selected. These villages were comparable in size, socio-economic status and prevalence of leprosy. The principal methods employed in this study were the PCR to detect small quantities of M. leprae DNA, and measurement of mucosal immunity by assay of salivary IgA.
    Results: 633 school children (267 of the total population) were analysed for the presence of M. leprae DNA and mucosal immunity. Analysis of the data show that the incidence of nasal PCR positivity (PCR+) in school children and rest of the population (ROP) is same (2.7%) whereas IgA positivity is 61% and 70% respectively. PCR+ percentages in school children and ROP in monsoons is 3% and 4% respectively as compared to 1.6% (school children) and 0.7% (ROP) in the summer months. In the group (5-9 years) the PCR+ percentage in household contacts is higher (7.7%) than 10-14 years group (1.3%). A significant difference in PCR+ percentage is observed in males (1.9%) and females (3.7%) in 5-9 years group.
    Conclusion: Results suggest though there is no obvious differences in between the groups, the exposure and mucosal immunity to M. leprae is affected by seasons and shows marked variation in males and females

     

    OM&BM 25

    THE Mycobacterium leprae HLP PROTEIN: A PUTATIVE ADHESIN THAT BINDS MULTIPLE EXTRACELLULAR MATRIX COMPONENTS.
    Lima. C.S.1,2,*; Marques, M.A.M.1,*; Sarno, E.N.2; Brennan, P.J.1; Pessolani, M.C.V.2

    1. Dept. of Microbiology. Colorado State University, Fort Collins. CO. U.S.A.
    2. Leprosy laboratory, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil;
    *These authors contributed equally to this work.

    Recent reports have identified a 21 kDa histone-like protein (H1p) as a laminin-binding protein of the Mycobacterium leprae cell wall (Shimoji et al, Proc. Natl. Acad. Sci 96: 9857-9862. 1999; Marques et al. Microbes & Infection 2: 1407-1417. 2000). The C-terminal domain of H1p (also known as ML-LBP21) contains Ala/Lys-rich repeated motifs, which are also found in the heparin-binding hemaglutinin (HBHA), a major adhesin of M. tuberculosis. These repeated sequences constitute the heparin-binding site of HBHA, suggesting that M. leprae H1p might also interact with glycosaminoglycans (GAG). In this study, we have further characterized the interaction of H1p with laminin-2 and other extracellular matrix components. To map the functional binding sites of H1p, truncated recombinant fragments corresponding to the N-terminal (rH1p-N) and the C-terminal (rH1p-C) domains of the protein were produced by a PCR cloning strategy. The capacity of recombinant H1p and truncated proteins to interact with extracellular matrix components was investigated using a solid phase-based assay. In these assays, soluble laminin-l and -2 were able to bind in a dose-dependent manner to rH1p and rH1p-C, but not to rH1p-N, rH1p and rH1p-C were also able to bind heparin and collagen I, III and IV, but not fibronectin. These observations suggest that the Ala/Lys-rich sequences present in the C-terminal half of M. leprae H1p constitute the binding sites to extracellular matrix proteins. The capacity of H1p to interact with other extracellular matrix components expands the potential role of H1p as adhesin in mycobacterial pathogenesis. Currently, in vitro adherence assays are under way to evaluate the role of H1p, collagen and GAG in the interaction of M. leprae with Schwann cells and epithelial cells.
    This work was upported by FAPERJ, WHO/TDR and NIAID, NIH.

     

    OM&BM 26

    THE USE OE POLYMERASE CHAIN REACTION (PCR) IN LEPROSY RESEARCH AND CONTROL
    Linda Oskam; Evi Beukelaar; Julia Teerling
    KIT Biomedical Research. Meibergdreef 39. 1105 AZ Amsterdam, The Netherlands

    The PCR is a sensitive and specific technique, that allows the detection of minute amounts of DNA in a matter of hours. Since the development of the first PCR assay for the detection of Mycobacterium leprae more than 10 years ago. the technique has been used on a whole range of samples, varying from biopsy material and nose swabs from patients and contacts to dust samples from the environment.
    The PCR has been used to investigate a variety of matters of clinical and epidemiological importance. We have now a better insight into the spread of leprosy in the society, because PCR made it possible to show that the presence of the bacterium on the nasal mucosa is widespread in the population. Also, PCR and another amplification technique, NASBA, have been used to monitor the presence of M. leprae DNA and RNA during and after treatment.
    This presentation will give a critical overview of the possibilities, applications and achievements of molecular amplification techniques and the way in which they have influenced and will influence leprosy research and control.

     

    OM&BM 27

    THREE-COLOR  1MMUNOFLUORESCENT STAINING TO IDENTIFY M. leprae WITHIN ENDOTHELIUM OF HUMAN PERIPHERAL NERVE.
    Shi, Ling; McCormick, G; Scollard, P.M.
    Laboratory Research Branch, National Hansen's Disease Programs at LSU. Baton Rouge, LA. 70803. USA.

    Studies in an animal model have suggested that M. leprae enter peripheral nerves by colonizing epineurial blood vessels and lymphatics, gaining access to the endoneurial compartment by passing through the vascular endothelium. To evaluate this possibility in human lesions, where excision and dissection of major nerve trunks is not possible, we have developed a method to assess endothelial involvement of cutaneous nerves in skin biopsies.
    Archived, paraffin-embedded skin biopsies from HD patients were selected based on lepromatous classification (LL or BL) and presence of at least one large cutaneous nerve. Schwann cells were identified using rabbit anti-S-100, biotin-goat anti-rabbit, and strepta-vidin-Alexa-Flour-350; bacilli were identified using guinea pig anti-M. leprae and FITC-goat anti-guinea pig; endothelium was identified using rhodamine-Ulex earopaeus -1 (UFA-1). Examined under appropriate filters, this allowed positive identification of nerve (blue), M. leprae (green), and endothelium (red). Images were captured by digital photography and superimposed using Adobe Photoshop software.
    Preliminary results from 5 biopsies indicate that the endothelium is infected in 29% of blood vessels associated with nerves, and 32% of blood vessels not associated with nerves. At this time, the sample is too small for differential analysis of infection of vessels at different levels of the dermis. The method appears to offer a sensitive means of positive identification of these and other structures that may be involved in vascular endothelial infection of nerves in HD.

     

    OM&BM 28

    UNIQUE METABOLIC PROPERTIES OF Mycobacterium leprae
    K. Prahhakaran; E.B. Harris; B. Randhawa
    OWL Hansen's Disease Center
    5111 Hickory Ridge Boulevard, Baton Rouge. LA 70817. U.S.A.

    The sequencing of the genomes of several microorganisms, including Mycobacterium leprae and Mycobacterium tuberculosis has been reported in recent years. M. tuberculosis contains a full complement of genes needed for survival and independent growth. On the other hand, M. leprae is deficient in genes coding for many biosynthetic enzymes, that makes the organism incapable of independent growth and survival, contradicting the claim that M. leprae is a competent bacterium. The finding explains the obligate intracellular parasitism of the organism and failure of attempts for over a century to culture the bacterium in chemically defined media. In addition, M. leprae was found to possess unique genes, not found in M. tuberculosis. These genes code for enzymes characteristic of the Hansen bacterium. We have discovered a unique enzyme activity, o-diphenoloxidase, in M. leprae. The enzyme is not present in M. tuberculosis or any other mycobacteria, including M. lepraemurium recovered from infected mouse tissues. It acts on phenolic substrates like 3.4-dihydroxyphenylalanine and related compounds, converting them to quinones. No rational explanation has been available for the unusual affinity of M. leprae for the Schwann cells of peripheral nerves, and for the hypopigmentation of skin lesions. Both Schwann cells, and melanocytes of the skin contain tyrosine hydroxylase that generates 3,4-dihydroxyphenylalanine (dopa), metabolized by the bacteria. Tyrosine hydroxylase occurs in the adrenal medulla that synthesizes dopa, epinephrine and norepinephrine from tyrosine. We found that adrenal medulla is a preferred site for early multiplication of M. leprae. In tuberculoid HD (Hansen's Disease) where the bacteria are restricted to specific areas of the skin, there is hypo-pigmentation of skin lesions. Melanocytes continually generate trace amounts of dopa, which is converted to melanin pigment. M. leprae diverts the substrate for its own metabolism, which prevents pigment formation. In melanocyte cultures, granules of melanin can be observed. When we added live M. leprae to such cultures, pigment production was suppressed. In lepromatous condition where the bacteria are distributed diffusely, only hypo-pigmented mottling results. The quinones generated by the bacteria can undergo reversible oxidation-reduction, helping in the utilization of other metabolites by the bacilli. Mycobacteria in general, can synthesize their own ATP. M. leprae, on the other hand, possesses a mechanism for the active transport of ATP from the surrounding milieu. β-Lactamase is a constitutive enzyme in mycobacteria, including M. tuberculosis. But M. leprae unexposed to β-lactam antibiotics showed no β-lactamase; bacteria recovered from experimentally infected armadillos treated with Bicillin (penicillin G benzathine), to control secondary infections, contained active β-lactamase. The enzyme activity persisted when these bacteria were used as inoula to infect other armadillos, which received no bicillin treatment subsequently. Once the enzyme is induced, it is not lost when the inducing agent is withdrawn: the phenomenon is referred to as derepression. A potent β-lactam-β-lactamase inhibitor combination. UNASYN, was bactericidal to M. leprae and M. tuberculosis, even resistant to other drugs. The compound could serve as an effective alternative drug for treating HD patients.

     

    OM&BM 29

    USE OF PCR IN THE RAPID DIAGNOSIS OF RI-FAMPICIN RESISTANCE IN LEPROSY
    Murdo Maedonald; Niraj Shrestha; Andrea Thomas; Paul Roche; Nadine Honore; Stewart Cole.
    Mycobacterial Research Laboratory. Anandaban Leprosy Hospital, PO Box 151. Kathmandu, NEPAL. E-mail: anandaban@mail.com.np

    As rifampicin is the major bactericidal drug used in MDT therapy of leprosy, it is essential that resistance trends be monitored. The established method of assessing drug resistance, using culture in the mouse footpad, has recently been augmented by the development of a rapid PCR detection method.
    Aim: To test for defined mutations in the M. leprae RNA polymerase a chain gene (rpoB), and to correlate these with drug resistance in the mouse footpad system.
    Methods: A novel PCR based technique was used to examine bacteria obtained from skin biopsies from MDT defaulters or non-responders, and from samples which had previously been passaged in the mouse footpad. M. leprae DNA was extracted from these and a set of oligonucleotide probes immobilized on a nylon membrane used to probe for mutations associated with rifampicin resistance. The test combined positive and negative controls and used chemiluminesence for detection.
    Results: A number of samples were found to have the rifampicin resistant genotype in the PCR assay. We will present data on all of these M. leprae strains genotyped for rifampicin resistance and tested at full (10mg/kg) and half (5mg/kg) doses in mouse footpad cultures.
    Conclusions: While the rapidity of PCR based methods is a major advantage over MFP, the validation of genotype methods of detecting drug resistance in leprosy is critical for their wider use in monitoring this important problem

     

    OM&BM 30

    VIABILITY OF M. leprae IN LEPROMATOUS PATIENTS AFTER COMPLETION OF 12 MONTHS OF MULTI-DRUG THERAPY.
    Gigi J Ebenezer; Thomson Sugumaran; Sheela Daniel; Geetha S. Rao; S. Arunthathi; P.S.S. Sunder Rao; Charles K. Job
    Schieffelin Leprosy Research and Training Center, Karigiri. Vellore District, Tamil Nadu, lndia-632106

    The Seventh WHO expert committee had recommended shortening the duration of multi-drug therapy (MDT) to 12 months from 24 months for multi-bacillary (MB) patients. We carried out a study to determine whether viable bacilli can persist in the body of treated MB patients after 12 months of MDT. 34 untreated lepromatous patients who had an initial average bacterial index (BI) of 3+ or more were enrolled in the study. At the end of 12 months of MDT, skin biopsies were obtained from a site, which displayed the maximum number of bacilli on skin smear examination. An M.leprae concentrate was prepared from each of the biopsies and inoculated into the footpads of five thymectomized and irradiated (T900r) mice. The preparation of innoculum, method of inoculation, harvesting and counting of M.leprae from the footpad tissue was done using the method described by Rees. Harvesting was done at 6th, 9th and 12th month. Skin histopathological examination was also done on 32 patients on completion of 12 doses of MDT. In nine (26%) out the 34 biopsies M.leprae continue to exist in the footpads of T900r mice. These nine patients had an initial average BI of 4+ or more at the time of starting MDT. Histopathologically, resolving granulomatous lesions were found only in eleven (34%) of the 32 skin biopsies at 12 months. Skin smears at the completion of 12 months of MDT showed a fall of one log BI or more in only 18 (56%) patients. This study demonstrates that at the completion of 12 doses of MDT a considerable proportion of MB patients with initially high average BI, harbor bacilli. It is possible that these are dead bacilli, not yet absorbed by the tissue. Long-term follow up of these patients will reveal whether these bacilli are alive or not. It may be necessary to maintain these mice for longer periods to study the behavior of persisting bacilli.

     

     

    OPERATIONAL ASPECTS OF ELIMINATION

     

    OOAl

    ACTIVITIES OF THE TASK FORCE IN THE ACCELERATION OF THE ELIMINATION OF LEPROSY IN BRAZIL
    Vera Andrade1; Tadiana Maria Alves Moreira2; Gerson Fernando Mendes Pereira3; Marcos Virmond;4 Artur Custodio de Souza5

    1. WHO.
    2. Secretary of Health of Rio de Janeiro State.
    3. Ministry of Health.
    4. Institute Lauro de Souza Lima Gil Soares - PAHO.
    5. Movement for the reintegration of leprosy affected persons (MORHAN).

    The strategy to encourage municipal health secretaries to be committed to the elimination of leprosy, by increasing coverage of MDT services, is a conjoint initiative of the National Council of Municipal Health Secretaries (CONASEMS) and WHO with support from the Technical Area of Sanitary Dermatology of the Ministry of Health, MORAHN and PAHO. To establish such strategy CONASEMS has created in 1998 the Task Force for Accelerating the Elimination of Leprosy (GT/HANSEN/ CONASEMS), which aim is to identify practical solutions at the local level within the available structure and resources of the basic heath system. At the methodological level it is stressed the need to strengthen the participation of various social and institutional partners, involving mainly the municipal managers and the community. At the political level, after including the issue of elimination in the agenda of local managers, it was created adequate condition to increase the coverage for diagnosis and treatment of leprosy with the additional outcome of a political profit to the local manger due to the success of eliminating leprosy from his municipality. In august 2001 the project has covered 52% of the municipalities through the country (2898 municipalities in 14 states), out of them 38% are priority municipalities for the MoH, mainly in the north and northeast region. In Tocantins. Piaui and Rio de Janeiro the process of decentralization is in its stage of consolidation. To support the deconcentration of diagnose and treatment the following material has been distributed: 25.000 booklets, 25.000 posters on signs and symptoms, 2 million leaflets on signs and symptoms in simple language to the community, leaders of the Children's Pastoral from 3379 municipalities and their families and educational videos for 5600 dioceses. It was sent to all municipal managers (5559), trough CONASEMS, technical information, a video with two vignettes and the film produced by the Global Alliance (WHO). Nowadays, it is difficult to identify in Brazil a municipal health secretary that is not aware of the strategy for elimination of leprosy. No doubt, this Strategy, by its content and quality, represents an innovative and effective contribution towards elimination of leprosy and. in addition, citizenship.
    Financial support was provided by the Brazilian Ministry of Health. CONASEMS, WHO and Novarlas Foundation for Sustainable Development.

     

    OOA 2

    ANALYSIS ON THE DETECTION OF NEW LEPROSY CASES BEFORE. DURING AND AFTER THE YEAR OF LEPROSY ELIMINATION CAMPAIGNS
    Shen Jianping; Li Wenzhong; Yu Meiwen; Yang Jun; Zhou Longchao; Wang Rongmao; Hu Lufang; Mou Hongjiang; Ye Fuchang; He Xinguo; Pan Liangde

    In order to analyze the impact on the situation of ease finding after Leprosy Elimination Campaigns, the data of newly detected leprosy cases in the leprosy high endemic area have been collected before, during and after the year of carrying out Leprosy Elimination Campaigns. The result showed that the number of new leprosy cases detected during the year of leprosy elimination campaigns was significantly high. The number of newly detected cases after the year of Leprosy Elimination Campaigns was similar to that of detected before the year of carrying out Leprosy Elimination Campaigns in counties with persisting case finding activities. But the number of newly detected cases after the year of Leprosy Elimination Campaigns significantly decreased in counties without active ease finding activities. The average distance from the house of leprosy cases detected during Leprosy Elimination Campaigns to the leprosy control unit at the count town is 62.8 kilometer which is farther more than that of other leprosy cases detected before and after the year of Leprosy Elimination Campaigns. The average disease delay-time of leprosy cases detected after the year of LEC shortened. The results also showed that carrying out Leprosy Elimination Campaigns will have no the significant impact on the trend of cases finding within a short time in local areas. But it may improve some indicators of leprosy patients and so promote the leprosy control in local areas.

     

    OOA 3

    AS AÇÕES DO PROGRAMA DE ELIMINAÇÃO DA HANSENÍASE NO MUNICÍPIO DE FERNANDÓPOLIS - ESTADO DE SÃO PAULO/ BR.
    Gaggini, M.C.R.; Gomes, A.A.L; Mencaroni; D.A.; Pansani. A.A.; Pinto Neto. J.M.
    Escola de Enfermagem de Ribeirão Prelo/ USP. Av. Bandeirante. 3900. Campus Universitário - Ribeirão Preto - CEP 14040-902. São Paulo/ Brasil. CADIP Av. Brasília, 756 - Vila Regina. Fernandópolis -CEP: 15600-000-São Paulo/Brasil.

    O município de Fernandópolis situado a noroeste do estado de São Paulo, a 553 Km da capital do estado, constitui-se em um pólo regional com 60.521 habitantes. Configura-se como referência na área da saúde para uma micro-região de treze municípios. Adotou dentro do processo de municipalização da saúde a Gestão Plena de Atenção Básica Ampliada. Como problema de Saúde Pública destaca-se a endemia hansênica, objeto de vários estudos. O objetivo desse estudo é descrever como ele está se organizando para cumprir as metas de eliminação dessa endemia que até 2001 estavam sob responsabilidade do estado. Mantém altos coeficientes de prevalência a mais de trinta anos. sendo considerado atualmente hiperendêmico com 10.25 casos/ 10 mil habitantes. Apesar de possuir onze unidades básicas de saúde concentra as ações de tratamento e seguimento dos doentes e contatos em uma unidade de saúde específica para o atendimento de doenças infecto-contagiosas e parasitárias, ficando sob responsabilidade das demais portas de entradas do SUS a suspeição diagnostica. Assim, acreditamos que a centralização de algumas ações poderá melhorar alguns indicadores operacionais. No entanto, os grandes desafios permanecem: o diagnóstico precoce; a descentralização c ou desconcentração das ações para todas as Unidades de saúde e atingir a meta da eliminação até 2005

     

    OOA 4

    BRIDGING EFFECTS OF INTEGRATION: COULD INTEGRATION OF LEPROSY HAVE UNINTENDED IMPACTS?
    Nimal D. Kasturiaralchi
    Consultant Novartis Foundation and Director. Medical Education Unit. Faculty of Medicine, University of Peradeniya, Peradeniya 20400, Sri Lanka

    In many former colonial countries there still exists a sharp demarcation between preventive and curative sectors of healthcare. The bureaucracies in most health services are divided along these lines with little or no interaction between them. One of the reasons for the continuation of this division seems to be that the two sides have evolved to be relatively independent of each other in carrying out their routine duties. However, with the introduction of new health policies such as the integration of leprosy services, new perspectives are unfolding which provide practical guidance to bring the curative and preventive sectors closer.
    This paper discusses the influence of integration on the general health system of Sri Lanka based on empirical evidence. It could serve as an eye opener for individuals trying to bring together existing health services to facilitate the provision of better and more cost effective healthcare.

     

    OOA 5

    CHARACTERISTICS AND TREATMENT OUTCOME IN LEPROSY PATIENTS DIAGNOSED DURING ACTIVE AND PASSIVE CASE-FINDING ACTIVITIES
    C. Phaff; J. van den Brock; Y. Stuip
    Netherlands Leprosy Relief (NLR), P.O.Box 95005. 1090 HA Amsterdam, The Netherlands

    Objective: To assess whether the case-finding method is a determinant for diagnostic characteristics and treatment outcome of newly diagnosed leprosy patients in northern Mozambique.
    Methodology: A retrospective cohort study about the differences between entrance characteristics and treatment outcome in self-reporting patients and active case-finding during a Leprosy Elimination Campaign in 1999 in northern Mozambique.
    Results: As a consequence of LEC activities three times more patients were found compared to a comparable period one years earlier. More young (<15 years) PB cases were diagnosed during LEC activities with -surprisingly - equal percentage of disability grades. No gender imbalance was found in diagnosed LEC patients contrary to self-reporting patient groups.
    Comparing active case finding in 1999 with the passive group of 1998 and 1999 showed a slight but statiscally significant better treatment result for the passive group. The classification of leprosy (in favour of PB) and age (in favour of older age groups) were also determinants for favourable treatment outcomes.
    Finally, the type of health worker proved a major determinant of a favourable treatment outcome. Limited trained volunteers had a significant better result of treatment compared to trained nurses.
    Conclusions: LEC proved to be a useful addition to the national Leprosy and Tuberculosis program in Northern Mozambique. As a result, many new cases were diagnosed and put on treatment, and their treatment results were comparable to those of self-reporting patients.
    The type of health worker appeared to be a major determinant of a favourable treatment outcome. Limited trained volunteers have a significant better result of treatment compared to trained nurses, regardless of detection method.

     

    OOA 6

    COMMUNITY INVOLVEMENT FOR LEPROSY ELIMINATION
    P.R. Manglani; B.L. Sharma; S. Postma

    Delay in achieving elimination in an area enables the programme managers to analysis the factors responsible. The reasons elicited were enlisted. They are lack of Community involvement and support, stigma attached to the disease and passive role of service recipients.
    The process of community involvement was given higher priority through service based action programs like; Care & concern Camps, Skin Disease Diagnosis Treatment & Education Camps. Dastak i.e. knocking the doors to knockout leprosy, introduction of festivity in Leprosy Elimination etc. This has lead to creation of concern, demystification and destigmatisation of disease and openness for early diagnosis and treatment. This has also helped for Zeroing distances between the patients, people around and providers.

     

    OOA 7

    CO-OPERATION BETWEEN NATIONAL AND INTERNATIONAL N.G.O.'S IN THE FIGHT OF LEPROSY -YEMEN EXPERIENCE
    Dr. Abdul Rahim Al-Samie
    NLEP. Office of the National Leprosy Control Program. P.O.Box.No.55722 -TAIZ. Republic of Yemen. Tel: 967-4-242306/7/9 and 967-792976 (Mobile) Fax: 967-4-242308.

    Leprosy in Yemen is considered as a public problem more than a health problem. Before 1964, leprosy patients were subjected to an obligatory isolation in unsanitary houses outside the main cities.
    Between 1973 and 1982. some leprosy patients were given medical care by dapsone monotherapy. Though MDT was officially adopted in Yemen in 1983. there were no real leprosy control activities due to lack of support till an agreement between Ministry of Public Health (MOPH) - Republic of Yemen and German Leprosy Relief Association (GLRA) - Wurzburg - Germany was signed in 1989.
    In 1992, a local non-government organization called Yemen Leprosy Elimination Society (YELEP) was formulated. This Society together with GLRA further strengthened our lighting against leprosy in Yemen. With the support of GLRA. YELEP and other national and international non-government organizations the prevalence of leprosy was brought down from 0.70 per 10,000 populations in 1992 to 0.32 per 10.000 population in 1999

     

    OOA8

    DEVELOP PARTNERSHIP, STRENGTHEN INTEGRATION, TRANSFER SKILLS AND OWNER-SHIP TO HASTEN ELIMINATION
    Mahmood K., Dr.
    State Leprosy Officer. Tamil Nadu. India

    The presentation evolves around Tamilnadu's success story. The PR was 118 / 10000 in 1983 when MDT was introduced, which was drastically reduced to just 31 / 10000 in 1991 when total coverage was reached. In October 2001 the PR was 3.7, indicating elimination a definite possibility.
    Since maintaining a vertical structure with declining PR was not cost effective the programme was integrated with the Primary Health Care system in 1997.
    Massive capacity building measures were undertaken to ensure that the PHC system provides better MDT services. This means, to suspect and refer cases for confirmation, treat, manage complications and refer, maintain simple information and reporting system and counseling to patient, family and community.
    Integration has not reduced detection of new cases by routine methods. Instead, voluntary reporting has increased due to easy accessibility. The availability of the Female Health Worker has helped women in terms of coverage and accessibility to services.
    In essence, integration ensures full participation of the PHC services in Leprosy Elimination. The deficiencies are addressed by regular capacity building measures to upgrade skills and equip the PHC system to accept responsibility and ownership of the programme to hasten Elimination.
    The presentation records with appreciation the sacrifices made by all those involved in the Programme beginning with the Missionaries, various Partners and the Community. It is their contribution that has helped in greatly reducing the disease burden and the stigma attached with it.
    We shall move forward in building a World without Leprosy with all our Partners

     

    OOA9

    EARLY LEPROSY CASE DETECTION BY VOLUNTEERS IN DIFFICULT AREAS IN THANE DISTRICT, INDIA
    Prakash R. Dewarkar; M. Joy; B. Geeta; S. Vinaya; C. Kamlesh; A.A. Samy
    ALERT-India; Association for Leprosy Education, Rehabilitation & Treatment - India. B-9 Mira Mansion, Sion (West), Mumbai - 400 022. India.

    House to house leprosy case detection is very expensive and time consuming if we depend only on regular trained Para Medical staff. Given the fact that sufficient number of trained paramedical personnel not available one may have to seek alternate human resources for the primary task of leprosy case detection. ALERT was required to survey for identifying new cases in far Hung remote villages of Thane District that had become part of the Navi Mumbai Municipal Corporation limits in the recent years and is also part of ALERT's leprosy control project area. There was an urgent need to ascertain the leprosy situation in 40 villages newly added.
    As qualified persons were not available, particularly because numbers were not adequate to complete the survey within a short period of 5 to 6 months ALERT decided to engage volunteers and give them intensive training to identify cases of suspected leprosy.
    These volunteers made house-to house visits and examined 1.29,383 persons in 40 villages. Volunteers suspected 332 'leprosy cases'. Of these, the doctors and trained paramedical workers confirmed as high as 54 per cent as leprosy cases. A further 10% were kept under observation. This study indicates that a significant number of new cases 14/10,000 has been detected with less expenditure and in a short duration by utilizing the services of adequately trained volunteers in difficult areas too.

     

    OOA10

    FIRST STEP TOWARDS INTEGRATION: DEVELOPING A BLUEPRINT
    Nimai D. Kasturiaratchi; Sunil Settinayake; Penny Grewal
    University of Peradeniya (Sri Lanka), Anti-Leprosy Campaign (Sri Lanka), Novartis Foundation for Sustainable Development (Switzerland)

    Planning and implementing the structural changes to integrate leprosy in the general health services is a challenging task as established procedures, responsibilities and relationships, both institutional and personal have to be altered. A blueprint which clearly articulates the vision of how the integrated system should function is critical to guide the implementation process. In Sri Lanka the blueprint was drawn up in a highly participative manner involving intensive discussions with various categories of health care staff both at peripheral and central levels over a three month period.
    The blue print clearly outlines the new procedures, roles and responsibilities as well as monitoring mechanisms based on a careful understanding of the tunctioning of the general health services, likely problem areas and pragmatic ways to deal with them. Various technical details had to be worked out including, a distribution system for MDT, simplifying records and the reporting system, monitoring procedures at the local level, and role definitions for the most important partners involved. This process culminated in a goal oriented project planning workshop at which the detailed plan for the integration process was developed, which was then presented to the National Steering Committee and WHO for approval.
    This paper describes the process adopted, the components of the blueprint, proposals For action and how it was used as a springboard for action. The blueprint also serves as a source of institutional memory and a shared reference document for the different players to be involved in the process

     

    OOA 11

    FOCAL SURVEY FOR INTENSIFIED CASE DETECTION - A COMPARATIVE STUDY CONDUCTED AT ENDEMIC AND NON ENDEMIC STATES IN INDIA
    Thomas Abraham; T. Jayaraj Devadas; M.V. Ramana; Shibu George
    German Leprosy Relief Association-India
    No.4, Gajapathy Street, Shenoy Nagar, Chennai-600 030

    This is an intensive case detection activity implemented in selected pockets of certain endemic and non-endemic states in India, where the ease detection is low due to various reasons. The survey team consist of 20 Paramedical workers (PMW's), 2 Non Medical Supervisors (NMS) and a Medical Doctor. 10 PMW's, 1 NMS and the Doctor are from out side the state. The duration of survey is one week, covering a population of 7000 - 10000. In most of the places the focal survey team could detect 2-3 fold more new cases than the normal case finding activity. It was also observed that, whether it is an endemic or non-endemic state the case detection was almost same. The results of this survey helped the management to decide the future strategy of leprosy work in the area. It was also reported that after the focal survey there was an increase in new case detection in the respective places

     

    OOA 12
    IMPLEMENTATION OF MODIFIED LECS WITH INTEGRATED APPROACH IN THE STATE OF ORISSA- INDIA HELPED IN REDUCTION OF NCDR

    P.K.B. Patnaik
    Assistance State Leprosy Officer, OrissaDirectorale of Health Services, Government of Orissa, Bhubaneswar, Orissalndia751001

    Orissa is one of the constituent states situated along the east coast of India with a population of 36.7 million. Leprosy was highly endemic in the State with PR 121/ 10000 in 1983. In 1998 though PR had come down to 9.6/10000 but NCDR with 21.7/10000 was posing main hindrance in leprosy elimination within targeted period. Successive 3 rounds of Modified LECS in the State with regular intervals have helped in bringing down NCDR to 7.8 and now goal of elimination looks real possibility in next 3 years. MLECs are well planned, short time, intensive, integrated community approach for detection of all undetected cases of leprosy in a community where disease is highly prevalent and dealt by vertical infrastructure. MLEC-I was implemented in Orissa in 1998 resulted in detection of 62844 cases in 28961085 populations with NCDR 21.7. MLEC-II was implemented in 2000, resulted in detection of 27197 cases in 27715988 popl. With NCDR 9.8. MLEC-III was implemented in 2001 with detection of 12326 cases in 15802564 popl. with NCDR 7.8/ 10000. Fall in detection rate in 3 and 1/2 years was 64%. This fall would have not been achieved even in another 10 years of MDT implementation with routine manner through vertical infrastructure. 3 rounds of MLEC in Orissa not only helped in detection of large number of undetected cases within shortest possible time but also helped integration of leprosy control activity with General Health care System and at village level with integrated child and women development scheme, in reduction of average duration of case presentation from more than 2 years to only 6 months, improvement in drug compliance from 78% to 99.6% and voluntary reporting of cases from 50% to 79.6% and have created new hope for elimination of leprosy in a highly endemic State of Orissa.

     

    OOA 13

    INTEGRATING LEPROSY CONTROL INTO GENERAL HEALTH SERVICE IN A WAR SITUATION: THE LEVEL AFTER FIVE YEARS IN EASTERN CONGO
    Denis Byamungu; Osahon Ogbeiwi
    Provincial Leprosy Control Programme. Bukavu, South Kivu Province DR Congo

    Although plagued by insecurity and inaccessibility due to two consecutive wars, South Kivu Provincial Leprosy Control Programme, DR Congo since 1995 started a process to integrate leprosy into general health facilities. General health workers (GHW) were trained, and a network of district TB/Leprosy supervisors provided, as regularly as possible, drugs, logistics and supervision to general facilities having patients. A questionnaire survey of 9 of the 14 districts in the province assessed the level of integration after 5 years. Structural integration was assessed by the proportion of health facilities with MDT and functional integration, by the proportion of health facilities where general health workers (GHW) are involved in leprosy activities. 37.5% of facilities had MDT and 73% had a trained nurse. GHW were involved in screening in 59% of facilities but diagnosed in only 36%. For drug dispensing and POD, they were involved in 78% and 26% respectively. Their degree of involvement put health facilities into four grades of functional integration: 1. Fully functional, fully integrated: tasks performed entirely by GHW. 2. Semi-functional: jointly performed with supervisors, 3. Semi-integrated (structured but not functional): leprosy supervisors did these activities alone, and 4. Non-integrated: nobody performed these activities. 80% of facilities had some degree of integration. 70% of the facilities were fully integrated in dispensing MDT and keeping records; 31% were semi-functional and 49% semi-integrated in diagnosis of leprosy.
    The leprosy prevalence at the districts directly correlated with the levels of structural integration, dispensing MDT and case finding. The presence of a trained nurse significantly related to performance of case finding and records keeping, but it was irrelevant to suspecting leprosy, dispensing MDT or doing POD. Structural integration is thus low in South Kivu and the gap between % of facilities with MDT and % with a trained nurse suggests a delay in actually integrating leprosy after training. This could be a direct result of movements of trained nurses because of the war. Functional integration is higher in MDT activities and low in case finding and POD, where obviously more skills are required.

     

    OOA 14

    INTEGRATION OF LEPROSY SERVICES AND THE CONCERNS ABOUT QUALITY OF CARE. THE EXPERIENCE OF JIGAWA STATE OF NIGERIA.
    Dr. Kefas Samosn
    Netherlands Leprosy Relief, Office of the representative in Nigeria. Rm 3, Yelwa Club. Bukuru Nigeria.

    Since the inception of the Nigerian National Tuberculosis and Leprosy Control Programme (NTBLCP), integration into the Primary Health Care system (PHC) has been a major objective. Jigawa State, located in northern Nigeria, is currently one of the most leprosy endemic states in the country and in the fore front of the integration initiative. During a Leprosy Elimination Campaign (LEC) organised by Jigawa in 1999, 304 PHC workers from various health units, and 368 volunteers were trained in basic leprosy, all of whom participated in case finding and initiating MDT treatment. Consequently there was rapid expansion of MDT services from 75 clinics prior to the LEC to 264 in 2000. Since then, leprosy patients are managed by the PHC workers, while specialised staff provides technical advice.
    In order to assess the impact of die integration on the quality of leprosy services in Jigawa State, treatment records of 159 selected leprosy patients in Jigawa State were studied. 76 of these patients were detected and treated by the vertical staff between 1997 to 1998 (pre-integration), while 83 were detected and managed within the period 1999 onwards (post-integration).
    The study found that quality of care for leprosy patients including assessment at diagnosis, monthly follow up, disability prevention and management ami treatment results were not significantly affected by the integration of the MDT services. It is therefore concluded leprosy care is not necessarily jeopardised by integrating into the GHS, instead could improve the accessibility of MDT services.
    Details of findings to be discussed.

     

    OOA 15

    INTEGRATION OF LEPROSY WORK - AN EXPERIMENTATION
    Sudhakar Bandyopadhyay
    German Leprosy Relief Association-India. 23 Market Street. Kolkata-700087. India

    It was expected that the leprosy services would be integrated with the general health services in the area with reduced prevalence rate. The introduction of MDT has resulted in a sharp decline in prevalence rate by over 907c with a drastic reduction of visible deformities among new cases. Districts where MDT has been implemented for 15 years have the NCDR of 20/10,.000 on an average. In a 5000-population area, the estimated active caseload will be 10 and this load is expected to be managed by a general health worker. Accordingly a 10-years retrospective study was conducted in an experimental zone of the Balarampur control unit of Gandhi Memorial Leprosy foundation in Purulia district of west Bengal. Total 41 General Health workers were involved in the programme from 1988 to 1997. It was observed that the contribution of the general health workers was substantial in relation to case-detection, patient persuasion, and inclusion of leprosy in health-talks and handling adverse situations. Total 440 persons were referred, 373 diagnosed as leprosy cases, 1029 patients were persuaded for regular drug intake and leprosy was discussed in 1204 health talks. Six social problems were handled. It was observed to be cost effective with better utilization of logistics and human resources. The integration processes should be supported with adequate training and supervision and monitoring system at least for next five years till the GHWs develop their own expertise. They should also gradually be exposed to and entrusted with the processes of rehabilitation and POD activities, which is utmost necessity in leprosy field

     

    OOA 16

    IS LEPROSY ERADICATION PROGRAM FEASIBLE IN VIETNAM?
    Hong Hai Phan
    Hospital of Dermato-Venereology, Hồ Ch� inh City. Vietnam

    Since leprosy is no longer a serious national health problem in Vietnam, the decreasing workload in terms of leprosy disease prevalence has pushed the stakeholders to find the ways to sustain leprosy works. The target set for eradicating leprosy is to cut the transmission of leprosy, and the provincial managers have to focus on areas where leprosy is endemic, or leprosy pools.
    LEC is continued where leprosy prevalence is still high or previously known to have had many leprosy cases. Recruitment of ex-leprosy patients as volunteers among community members can be a good idea: Health education materials should be distributed to the community to create people's awareness on leprosy, break down the silence and stigma surrounding leprosy and promote early reporting of leprosy patients. The use of community volunteers and ex-leprosy patients as health educators is considered. Education for school children is seen as the most effective approach to broadcast messages on leprosy to the people. A kind of quizgame called democratic picking flowers has been initiated and proved that it is very promising.
    Besides the traditional training, the problem-based teaching and learning as well as field training are adopted. A new module of training called active education has been realized, setting a new style of training in Vietnam.
    According to the WHO proposal, Vietnam begins to implement for a post-elimination surveillance system. A part of leprosy program is shifted to rehabilitation aspect, which is the rising concern of the people and local government for leprosy-affected-people. These efforts for improving the (ex-) leprosy patients lives should be mobilized nation-wide, to respond to the noble mission: working together for a world without leprosy.

     

    OOA 17

    LEPROSY ELIMINATION MONITORING (LEM) 2001, BANGLADESH
    Jalal Uddin Ahmed; Safir Uddin Ahmed; S.K.S. Hossain; Sivaprakasam; L.R. Talukder
    National Leprosy Elimination Programme. Directorate General of Health Services
    Leprosy Control Institute & Hospital Compound. Mohakhali, Dhaka-1212. Bangladesh.

    Leprosy Elimination Monitoring Exercise was carried out in Bangladesh between 21 January 15 February 2001. To validate data on prevalence, detection, integration and quality of MDT Services. The sample covered 1202 cases, records collected from 60 MDT centers (10%) of 20 randomly selected districts. Data collection was done by qualified Medical officers, especially trained for this activity using WHO recommended schedules.
    Exercise was guided supervised and lead by WHO nominated Monitor along with one independent national Monitor nominated by the national Govt.
    The actual data collection in the field was carried out between 30 January - 08 February 2001. The data consolidation and report preparation was done between 09-14 February 2001.
    Over 5 years reduction in prevalence is observed. However this fall is not associated with expected change in clinical profile of new cases. As majority of the cases were detected by voluntary Reporting (40%) with long duration of delay (average 20 months) and grade 2 disability (10%). This pattern confirms further the need for intensive BCC in population and reorientation of staff on identification/detection of early Leprosy.
    The summary of the main findings and observations of LEM will be presented

     

    OOA 18

    NEPALESE LESSONS ON COMMUNITY AWARENESS AND CAPACITY BUILDING OF HEALTH SERVICE DELIVERY SYSTEM TOWARDS LEPROSY ELIMINATION
    Shushil Battarai M.A., M.P.H.; Suraj Chalise M.A., D.H.P. Ed; Mitha Ram Thapa B.A., NMSS
    Leprosy Control Division. DHS/MOH (HMG/N). Kathmandu, Nepal

    Nepal, a tropical country in South Asia has a history of high prevalence of Leprosy since last 150 years. Nepal has adopted the WHO resolution to eliminate leprosy by 2005 from the world and by the end of 2003 from the country.
    Leprosy elimination activities were escalated from 1996 onwards with intensive Leprosy Elimination Campaign (LEC) during 1999 and 2001. Nepal is actively engaged in Information Education and Communication methods and mediums. The country is building up the capacity of health service delivery system / basic level health care workers to provide diagnostic and treatment services up to the Village Development Committee level, which is lowest. It is found that strong political commitment followed by an efficient programme support on intensive IEC component helps achieve this time bound vision.
    This paper discusses the objectives, strategies, activities and major outcomes of elimination efforts. Paper includes secondary information (data) gathered from LCD/ DHS/MOH and presented with the help of simple statistical tools.
    The study revealed the fact that prevalence rate has gone up significantly alter planned LEC; such sustained campaign has been contributing to reach the un-reached population (hidden/undetected/cases of consequence) in the areas where the prevalence rate is more than 3/10, 000. The current trend shows that the MB proportion, child proportion and GII disability is declining considerably providing hopes of elimination within the stipulated time

     

    OOA 19

    PROBLEMS ASSOCIATED WITH INTEGRATION OF LEPROSY IN BIHAR STATE IN INDIA AND POSSIBLE SOLUTIONS
    Raman. D.K.; Menezes, L
    State Leprosy Officer, Patna, Bihar C/O. Damien Foundation India Trust, 27, Venugopal Avenue. Spurtank Road, Chennai 600 031 India. E-mail: damienin@vsnl.com

    Bihar is the second largest populated state in the country comprising 11% of the population of India. It is highly endemic for leprosy. It has the highest number of cases of leprosy in India and it accounts for 28% of caseload of the country. Since introduction of MDT in 19% more than 800,000 cases have been treated and at present (Jan 2002) total of 105000 cases are registered for treatment with MDT. The phase II of NLEP has identified integration with General Health Care Services as one of the key strategies for easy accessibility of leprosy services for early detection and treatment. Integration in Bihar has been undertaken from July 2001. These are however a few problems being faced in applying integration in practice and therefore the emphasis is presently being given on functional integration down to Health Sub Center level. Integration of following aspects is being implemented viz. Provision of diagnosis facilities on all days at PHC. Addl. PHC and Government hospitals and drug delivery to patients. Some of the factors which contribute to the problem are deficiency of GH staff.(44%) and NLEP staff (56%) with a wastage of 3% every year, poverty, low literacy and low awareness level among the medial fraternity and community. The Government has taken various measures to tackle these problems. The details will be discussed.

     

    OOA 20

    PROJETO PRIORITÁRIO "TOLERÂNCIA ZERO: MATO GROSSO SEM HANSENÍASE"
    Secretaria de Estado de Saúde de Mato Grosso

    Mato Grosso é campeão brasileiro de prevalência em hanseníase com 20 casos por 10 mil habitantes. Por esta razão o Governo em parceria com a SES-MT, lançou o projeto "Tolerância Zero" que tem por objetivo a eliminação da doença como problema de saúde pública até o ano 2005. Atualmente são 2.913 casos notificados e 3.900 casos estimados. Como incentivo a detecção precoce a SES-MT proporciona um "bônus" para equipes e saúde da família e agentes comunitários. Para cada caso detectado, o agente irá receber RS 20 (vinte reais) e os integrantes da unidade de saúde RS 100 (cem reais) por paciente com alta por cura. Na primeira etapa que compreende 2001 a 2002, o projeto foi implantado em todos municípios do Estado, que foram divididos por ordem de prioridade em 4 categorias, tendo por parâmetro a prevalência e o número de habitantes. Cada município deve elaborar um plano de intervenção para implementar atividades em sua área de abrangência, considerando o perfil epidemiológico e operacional da região, identificando as áreas de maior risco da endemia para definição de ações a serem desencadeadas, compor equipe técnica com profissionais qualificados, desenvolver parcerias com demais entidades, ONGs e órgãos, além de criar agenda de treinamentos e acompanhamento da equipe. Os municípios que atingirem as metas estabelecidas receberão um incentivo de acordo com os níveis de prioridade que vão de R$ 30 mil a R$ 2 mil reais, visando a detecção de 95% dos casos estimados nos municípios e redução da prevalência de 30% ao ano. Este recurso deverá ser investido, pelos municípios, na implementação das atividades de promoção, prevenção c atenção básica de saúde.

     

    OOA21

    REACHING NLEP SERVICES TO THE DISTANT POOR TRIBAL POPULATION IN CHHATT1S-GARH
    B.P. Mukherjee; B. Sharma.
    DANLEP Chhattisgarh, Civil Lines. Raipur (Chhattisgarh). 491001 INDIA Ph. No. -+91-0771-423058 Fax-+91-0771-423057

    DANIDA assistance in the programme of NLEP helped in the satisfactory coverage of under-privileged poor people living in the distant inaccessible tribal areas. The indicators also reflect that prevalence of leprosy have been reduced considerably in these areas since DANLEP extended services to cover wider areas in all the districts including tribal districts. As women population who in general gets neglected and deprived of many health facilities, in NLEP particularly coverage of women in the programme has been seen to be satisfactory. The trend of reduction is an indication of probability of elimination of leprosy by 2003.

     

    OOA 22

    REGIONALIZAÇÃO DAS AÇÕES DE ELIMINAÇÃO DE HANSENÍASE INTEGRADAS NA ATENÇÃO BÃSICA - BAHIA. PERNAMBUCO E PIAUÍ
    2001 -2002

    Lúcia Possídio1; Geania Rocha2; Tâmara Stélvia3; Vera Andrade4

    1. 8a DIRES - Petrolina Pe.
    "PIRES - Juazeiro Ba.
    3. Secretaria de Saúde Pi.
    4. GT/HANSEN/CONASEMS

    Através da articulação com GT/HANSEN/ CONASEMS e principalmente a partir da vontade e adesão dos gestores estaduais e municipais da Bahia, Pernambuco e Piauí foi elaborado um plano na perspectiva da estratégia de aceleração proposta pelo referido grupo técnico, que prevê o aumento da oferta do diagnóstico e tratamento da hanseníase com a descentralização e desconcentração das ações, integrando-as nas atividades da atenção básica, passando pela implementação de uma rotina de atualização sustentável dos profissionais de saúde da rede, pela ampla divulgação sobre a universalização da cura da doença e pelo estabelecimento de parcerias com instituições e áreas afins, sociedade organizada e comunidade. A 8ª Regional de Saúde /Pe. expandiu o PCEH para 100% dos seus municípios, a cobertura anterior ao plano era 43%. Em relação aos serviços a cobertura passou de 11,4% para 82,3%.No Piauí as ações de eliminação foram descentralizadas para mais 50 municípios e o número de unidades em 53 municípios aumentou de 50 para 136. Na 15ª Regional de Saúde/ Ba, o PCEH estava implantado em 100% dos municípios. A cobertura dos serviços no período anterior ao plano, era de 15,7% que passou para 64,5%.O trabalho que vem sendo desenvolvido busca atingir o objetivo proposto de facilitar o acesso da população ao diagnostico e ao tratamento integrando as ações de eliminação nos serviços da atenção básica, detectando precocemente os casos reduzindo a morbidade e o aparecimento de casos com incapacidade física. Nessa perspectiva pode-se afirmar que o controle e eliminação da hanseníase como problema de saúde pública pode ser efetivado

     

    OOA 23

    RESISTANCE TO CHANGE; HIGH POINTS IN THE SRI LANKAN INTEGRATION PROCESS
    Sunil Settinayake; Nimal D. Kasturiaratchi; Penny Grewal
    Anti-Leprosy Campaign (Sri Lanka), University of Pcradeniya (Sri Lanka), Novartis Foundation (Switzerland)

    The sheer scale of the process of converting a vertically structured leprosy service into a horizontally structured system, during decentralization inevitably involved a number of formidable challenges. The Anti-Leprosy Campaign had for decades been accustomed to working directly only with the 24 leprosy workers - with the general health services playing only a supportive role. Now it had to collaborate on a broader basis with provincial health directors, epidemiologists, dermatologists, pharmacists, and directors of numerous local hospitals, motivating them to provide the necessary services without the necessary "authority" to ensure that the services are provided. It became clear that considerable skills in the areas of team building and teamwork, conducting negotiations, and monitoring were needed.
    Integrating leprosy services into the local health-care system has also involved a sometimes delicate exercise in sharing responsibility and adjusting to new roles. Natural resistance to these changes was observed both within and outside of the ALC.
    This paper shows how the different levels of players perceived integration and how they reacted. The paper also proposes what should be done to sensitize stakeholders and what they ought to consider before launching integration.

     

    OOA 24

    ROLE OF COMBINED MONITORING AND UPDATING REGISTERS IN ELIMINATING LEPROSY IN AFRICA, GUINEA AND CAMEROON EXPERIENCES
    Bide Landry; Tiendrebeogo Alexandre
    WHO/AFRO, DDC/LEP, PO BOX 773 BE, Harare Zimbabwe

    Leprosy Elimination Monitoring (LEM) is a process to collect data and build three groups of 22 indicators enabling to identify leprosy programme weaknesses and to propose measures for improving activities towards the elimination of leprosy. Updating Leprosy Registers (ULR) is an exercise to review leprosy information forms and examine leprosy patients under Multiple Drug Therapy (MDT) in view of obtaining the real prevalence according to the definition of a case of leprosy. These two activities can be combined and implemented by external monitors, leprosy programme national managers and district health teams. Combined LEM and ULR exercise is a strong tool for the reduction of leprosy prevalence and improvement of leprosy programme activities. The Regional Office of WHO for Africa initiated 2 combined LEM/ULR in Guinea and Cameroon, respectively in November-December 2000 and August 2001. These combined exercises permitted to reduce the prevalence of leprosy of 50% in Guinea and 38% in Cameroon. Recycling old cases of leprosy, late or false diagnosis, over-treatment of MB patients, mismanagement of MDT blister packs were main problems identified with LEM indicators. Recommendations were proposed to solve those problems. They consisted mainly the integration of MDT services into general health services and routine ULR during supervisory visits to peripheral health facilities.
    [Key words] Updating, Monitoring, and Elimination

     

    OOA 25

    SURVEY OF LEPROSY IN UNAPPROACHABLE AND UNCOVERED AREA
    Shri U.H. Thakar; R. Ganapati; S.S. Naik; Pralibha Kathe
    Hind Kushta Nivaran Sangh Hind Kushla Nivaran Sangh C/o Acworth Leprosy Hospital for Research. Rehabilitation and Education in Leprosy, Wadala. Society for Research. Rehabilitation Mumbai - 400 031 INDIA.

    There is no doubt that due to the implementation of multidrug therapy the prevalence rate (PR) of leprosy has declined drastically. New case detection rate, however, has reduced only marginally or has remained static in certain areas, this may be due to the foci of infections in the society lurking in junap-proachable areas or due to mobility of the community members and spreading the disease.

    a) The examination 3030 labourers of five different construction work places revealed six leprosy cases giving a PR of 20/10000.
    b) The group of male fishermen (304 persons at Panvel) who remained 8 months on sea were examined in rainy season evealed four new cases (PR 131/1000) of which one was smear positive MB ease.
    c) The examination of 3457 tribal population on hilly area of Pen yielded 11 leprosy cases (PR 32/10000) of which live were MB. Such pilot studies suggest that special surveys of selected population groups may have to be undertaken systematically, if the leprosy elimination target by the year 2005 AD is to be reached.

     

    OOA 26

    TECHNICAL SUPPORT TEAM (TST) FOR THE PROMOTION OF LEPROSY AND TUBERCULOSIS WORK IN THE DISTRICT - A CONCEPT PAPER
    Thomas Abraham; T. Jayaraj Devadas
    German Leprosy Relief Association-India. No.4. Gajapathy Street. Shcnoy Nagar, Chennai-600 030

    The National Leprosy Elimination Programme (NLEP) and the National Tuberculosis Control Programme (NTP) are the two effective programmes taking care of the leprosy and tuberculosis problems in India respectively. The involvement of Non Governmental Organisations (NGO) in the National Leprosy and Tuberculosis programmes are well recognized. German Leprosy Relief Association (GLRA) and Swiss Emmaus Leprosy Relief work (ALES) are two international organisations engaged in leprosy and tuberculosis work in India. These two organisations already launched Technical Support Teams (TST) in 5 districts of Andhra Pradesh for providing support to the ongoing National Leprosy Elimination Programme (NLEP). This district based Technical Support Team consist of a well-experienced Medical Officer, trained both in leprosy and tuberculosis, a trained supervisor and a driver. The same team will be used for the support of the Revised National Tuberculosis Control Programme (RNTCP). by augmenting the system.
    The concept of TST for leprosy and tuberculosis conveys the following:
    Intensified leprosy elimination process and effective integration with General Health System.
    Improved cure rate of sputum positive tuberculosis to more than 85%.
    Through a well drawn out work plan with the government this concept will prove to be an effective strategy.

     

    OOA 27

    URBAN LEPROSY CONTROL IN ENDEMIC COUNTRIES - AN UNDER - RECOGNIZED PROBLEM
    R. Ganapati; V.V. Pai; H.O. Bulchand
    Bombay Leprosy Project. Sion-Chunabhatti. Mumbai-400 022. India

    Since the recommendations of the International Leprosy Congress held in Bergen. Norway in 1973 focused world attention on the need for research in urban leprosy, several national and international meetings have stressed the exclusive importance of this aspect of leprosy management. It is however debatable whether the reduction in mean prevalence rate (PR) through MDT is due to an exclusive strategy adopted consciously in urban areas by the planners of leprosy control.
    Perhaps we are driven to the necessity of bestowing attention on this subject as the incidence rate of leprosy is not coming clown clue to urban pockets, especially those in the slums, with hidden leprosy. Due to rapid industrialization and migration of population into the slums, especially of metropolitian cities of the endemic world, special challenges are posed to reach the target set for elimination of leprosy. The population in major cities in the Indian sub-continent is expected to increase by nearly 40% by 2015.
    The slum population (about 6 million) in Bombay it-self reaches the dimension of the entire population of some countries in the developed world.
    Though the lesser cities also face the problem in varying degrees, the exact magnitude is not known. The anomaly of using P.R to judge the effectiveness of leprosy elimination is classically exemplified by the unrealistic statistics relating to the megalopolis of Bombay, where the P.R is reported to be just 2 per 10.000 in the face of about 5000 new cases (10% skin smear +ve) being detected every year.

    It is strongly urged that the recommendations already made by a series of Seminars. Workshops, Congresses etc., especially in the Indian subcontinent be implemented meticulously

     

     

    POD & REHABILITATION

     

    OPOD 1

    A GRASS ROOT PERSPECTIVE ON REHABILITATION EFFORTS
    Ulla-Brilt Engelbrektsson; Ishwor Khawas
    Department of Social Anthropology, University of Goteborg, Box 700, SE 405 30 Goteborg, Sweden

    In 1975, the International Nepal Fellowship (INF), a Christian medical mission, was assigned the responsibility for the National Leprosy Control Programme in the western part of the Kingdom of Nepal. In the same year, INF founded the Socio Economic Services Programme (SES). The aims were to assess the needs of patients and where called for, to undo adverse social and economic consequences of leprosy. In 1997, SES became the Partnership for Rehabilitation Programme (PFR).
    The decision to carry out an impact evaluation was taken in 1998. The objective was to investigate the outcome of the socio-economic rehabiliation interventions with emphasis upon how the clients and their communities viewed the assistance given. Starting in mid-1999, for a year and an half, two thirds of the clients from the cohort of new clients of 1995 were followed up in the field.
    The study was essentially a retrospective observational, before and after, evaluation which sought to determine if the interventions were relevant and appropriate for the client needs, if they were properly carried out, and their short and long term effects on the target population.
    In all instances clear cases of need were demonstrated, in the great majority of cases the interventions were implemented in a way acceptable to the clients and their communities, and in almost every instance, the immediate results were positive. However, for most of the clients the input of SES/PFR only changed their life for the better for a time, but did not drastically change their situation long term. Perceived reasons as to why will be presented.
    The project based within the Statistics and Research Department of RELEASE, ran over a year and an half.

     

    OPOD 2

    A HARD LOOK AT THE PROBLEM OF REHABILITATION IN LEPROSY
    H. Srinivasan FRCS.; FRCSEd
    25, First Seaward Road, Chennai - 600 041. India

    At present, rehabilitation activities are carried out by different organisations as ad hoc provision of some help to some of those who demand it. Such programmes do not inform us about the non-users of the services and the reasons for their not using them. By and large, the approach to rehabilitation, especially in the context of leprosy, has been governed more by emotion than reason and this has led to some distortions in our perceptions, attitudes and activities. First, any help provided to leprosy-affected persons (even providing MDT!) is equated with rehabilitation. Second, rehabilitation is still considered as charity towards the affected. Third, all persons with leprosy-related deformities are considered as needing rehabilitation. Fourth, correction of deformities is considered essential for rehabilitation. Fifth, vocational rehabilitation is considered as the solution to the problem of dehabilitation. Sixth, interventions for rehabilitation are considered as one-time activities.

    OPOD 3

    A HOLISTIC APPROACH TO PREVENTION OF DISABILITY IN LEPROSY
    Mannam Ebenezer; Premeaj Isaac

    PAMIC (Prevention and Management of Impairments and Consequences) is a multidisciplinary, multiprofessional approach to disability prevention in leprosy. WHO International Classification of Impairments, Activities and Participation (1998) for diseases classifies human functioning at the level of body, the whole person and the person within the complete social and physical environment. In the context of leprosy physical impairments lead to social, economical and psychological problems. Often physical impairments are relegated to a secondary role to psycho socio economic issues. This programme addresses disability prevention in leprosy holistically.
    A questionnaire modeled along the lines of WHO's ICIDH-2 for diseases has been used to identify patient's issues under the headings of impairment, activity limitation and participatory restriction. The questionnaire is semi structured with a degree of open endedness to enable patients to describe the problems in their own words.
    About 200 patients have been through this programme. After identifying the issues in a multidisciplinary approach patients are involved in drawing up of interventions and their implementation. The patients are followed up to assess the impact of this programme in preventing and managing disability. The effectiveness of this questionnaire in identifying disability issues and in arriving at interventions with the patient's input is discussed.

     

    OPOD 4

    A METHODOLOGY FOR THE EVALUATION OF REHABILITATION PROJECTS
    Johan P. Velema1; Huih Cornielje2

    1. Evaluation & Monitoring Service, The Leprosy Mission international, PO Box 902, 7301 BD Apeldoorn, Netherlands.
    2. ogeschool Leiden. Department of Public Health. Leiden, The Netherlands

    A comprehensive evaluation should consider both the rehabilitation project and the project environment. Assessment of the environment includes questions about the causes and types of disability, the number and status of persons with disabilities (PWDs), and the resources available to them. Status of PWDs refers for example to access to education and employment and local attitudes and practices towards disabled persons. This should establish the needs to be met and the relevance of the project. Evaluators should always begin by asking what the project set out to achieve and what approaches were used. Project performance should be assessed in these terms. Only then can they give their opinion about the project and suggest changes for the future.
    It is important to ask what services are offered, who is eligible for these services (comparing written criteria to profiles of actual clients) and how many utilize them. Whether physical or psychological or socio-economic rehabilitation is the aim, it must be possible to demonstrate improvement of clients on relevant outcome measures. Where appropriate, the role of relatives or other community members may be assessed both in the client's rehabilitation process and in the running of the project.
    The degree of control of clients over their own rehabilitation process will be evident from efforts by the provider to explain the choices involved and from the negotiation that goes on between provider and client, possibly with involvement from relatives or community members. Participation of clients in decision making for the project will lead to a sharing of vision and a sense of ownership.
    Advocacy projects strive to change the project environment. Besides consideration of activities and output, evaluation should therefore look for changes in the social environment that favour PWDs.
    Projects should have ways and means of growing and developing in response to own experiences, changing needs of clients and changing professional views. These include a sound information system, availability of literature, mechanisms for feed back of evaluation findings, availability of literature and contact with colleagues in the field of rehabilitation.

     

    OPOD 5

    AVALIAÇÃO DA FORÇA DE PREENSÃO PALMAR COM O USO DO DINAMÔMETRO JAMAR® EM PACIENTES PORTADORES DE HANSENÍASE ATENDIDOS EM NÍVEL AMBULATORIAL NO DISTRITO FEDERAL
    Prof.ª. Ms. Demóstenes Moreira; Prof.ª Drª. Rosicler Rocha de Aiza Alvarez.
    Universidade de Brasília - UnB. Campus Darcy Ribeiro - Asa Norle - Brasília/DF - CEP. 70910-900

    As funções básicas dos membros superiores nos pacientes portadores de hanseníase, depende basicamente da integridade sensitiva e motora da mão. A mão tem papel primordial na atividade humana, através de suas funções básicas de preensão e sensibilidade, sendo inclusive considerada como a extensão efetora do córtex cerebral. A capacidade manual (preensão), desenvolve-se gradativamente através dos sistemas sensório-motor até atingir a acuidade necessária para que o indivíduo se adapte às atividades de vida diária. Nos indivíduos portadores de hanseníase, a capacidade de realizar a preensão manual pode se apresentar com limitações que podem variar de acordo com a forma clínica e grau de incapacidade da mão. O objetivo do presente estudo foi avaliar o comprometimento do mecanismo de preensão palmar em indivíduos portadores de hanseníase atendidos em nível ambulatorial no Distrito Federal. O presente trabalho compreende um estudo de delineamento transversal comparativo, onde avaliou-se a preensão palmar de um grupo de 50 pacientes portadores de hanseníase inscritos no Programa de Controle da Hanseníase do Distrito Federal e comparou-se com um grupo de 50 indivíduos normais. Após a determinação do grau de incapacidade dos pacientes hansenianos foi realizado a avaliação da preensão palmar com o uso do dinamómetro Jamar®. Durante a avaliação da força de preensão palmar, os participantes do estudo foram orientados a permanecerem sentados, com o ombro na posição neutra, cotovelos a 90° e punho na posição neutra (intermediária entre pronação e supinação) sem que houvesse desvio radial ou ulnar, enquanto o examinador sustentava o dinamômetro. Os pacientes realizaram três tentativas para cada mão (com duração de 5 segundos para cada tentativa) na posição de pegada dois, preconizada no aparelho, alternado a movimentação para o teste, sendo inicialmente testada a mão direita e logo em seguida a mão esquerda, seguindo criteriosamente a instrumentação do aparelho: o intervalo entre uma tentativa e outra foi de 1 minuto. Todos os participantes do estudo foram informados através de um Termo de Consentimento Livre e Esclarecido, sobre os procedimentos e objetivos da pesquisa.

     

    OPOD6
    COMMUNITY BASED REHABILITATION IN RURAL AREA

    Malhura prasad mahato; Sudhakar Bandyopadhyay
    Gandhi Memorial Leprosy; German Leprosy Relief Association-India
    Foundation, Balarampur
    This study is based ou an action programme undertaken at lhe Balarampur Control unit of Gandhi

    Memorial Leprosy Foundation in purulia district of west Bengal. The unit covers a rural population of 300.000 in 341 villages. A list of beneficiaries was prepared for financial rehabilitation. From 1998 to 2001, total 124 persons were supported with interest free loans, which ranged from Rs.500/- to Rs. 2000/-(US$12 to 50), The loans were distributed in presence of the social leadership. The criteria for selection were financial condition, visible deformity and helpless women. While selecting the trades, traditional and familial trades like bamboo craft, shop keeping (stationary and Grocery), shoe making, goatery, selling rice and paddy, selling of vegetables, piggery and mechanical shop were given priority. Total Rs. 100.000/- was disbursed. The beneficiaries were guided and supported by the leprosy workers including initial collection of raw materials and marketing of products. Social acceptance was ensured through community awareness programme. It was observed that except three persons all beneficiaries were paying the installments regularly. Average monthly income of each person was Rs. 1.000/- -Rs.2.000/-. Some of the beneficiaries have developed their own capital. Involvement of the grass-root level workers and the social leadership is mandatory to run the programme. It is suggested that small trades are worthy enough in the rural area for solution of the financial rehabilitation problem keeping the persons in the community.

     

    OPOD7

    DETECTION OF EARLY SENSORY NERVE FUNCTION IMPAIRMENT IN THE FEET OF LEPROSY PATIENTS USING 2GM SEMMES WEINSTEIN (SW) MONOFILAMENTS.

    Syed Muzaffarullah1; Rajgopal Reddy1; Suman Jain1; Robert S Jerskey1, Sujai Suneetha2; D.K. Desikan1

    1. LEPRA India - Blue Peter Research Centre, Cherla-pally, Hyderabad - 501301, India.
    2. American Leprosy Mission. IALM Way, Green valley.SC. 29601, USA

    The SW monofilaments are important tools in leprosy for the detection of early sensory nerve function impairment. Its use in the hand has been largely standardised but experiences of its use in the feet are few. The aim of the study was to detect early nerve function impairment in the feet comparing different grades of SW monofilaments. This study was carried out between Jan. 1997-Dec. 2000.
    Sensory assessment was carried out by a single examiner using the 0.2gm, 2gm, 4gm and the 300gm SW monofilaments. 8 sites were tested on each feet, 4 in the forefoot, 2 in the mid foot, 1 in the heel and 1 on the dorsum of the great toe.
    A total of 418 leprosy patients (M 293 F 125) were registered during this period (TT 24(5.74%); BT 168(40.19%); BL 162(38.75% ): LL54(12.91%) and PNL 10(2.39%)).
    It was found that 0.2gm monofilament was felt by 11(2.6% ) patients; 2gm fell by 223 (53.34%); 4gm by 66 (15.78%) and 300gm by 118(28.22%). More than half the patients were able to feel the 2gm monofilament and about 16% the 4gm monofilament. A small proportion (2.6%) mainly children could feel the 0.2gm monofilament.
    This study shows that to delect early sensory changes in the feet we can use the 2 and 4gm monofilaments in adults and the 0.2gm filaments in children. It helps to detect early changes in sensation, thereby preventing the complication of nerve damage through early initiation of steroids.

     

    OPOD 8

    DEVELOPMENT OF AN ACTIVITY LIMITATION SCALE FOR PERSONS WITH SENSORY LOSS
    Alison Anderson1; Catherine Benbow2; Jannine Ebenso3; Priscila Fuzikawa4; Hanna Melchior5; Angelika Piefer6; Paul Rajkumar7; Johan P. Velema8

    1. International Nepal Fellowship. Pokhara.
    2. The Leprosy Mission Internatonal. London.
    3. The Leprosy Mission Nigeria.
    4. Municipal Prefecture of Betim-MCi. Brazil
    5. Israel Leprosy Control Centre. Jerusalem;
    6. Ministry of Health & Institute of Dermatology. Shandong. PR. China.
    7. SLR&TC Karigiri. India;
    8. Evaluation & Monitoring Service. The Leprosy Mission International. PO Box 902. 7301 BD Apeldoorn. Netherlands.

    An international collaboration of occupational therapists and people skilled in research methods aims to develop two instruments for the assessment of activity limitation and risk of increasing impairments in people affected by leprosy or other peripheral neuropathies. One will be a screening tool for use at the primary care level, while the second will examine activity limitation in more depth.
    Collaborators in five countries interviewed persons affected and unaffected by leprosy or diabetes to generate lists of activities of daily living. Over 1250 activities were identified which were commonly practiced by at least 30% of the people at risk of leprosy or diabetes. These were pooled, duplications removed and a unified format of asking and recording developed. The resulting questionnaire included 348 items covering all domains of the ICF. It was administered to 779 persons aged 15-65 affected by leprosy or diabetes; approximately 40% were also assessed for activitiy limitation by an occupational therapist who was blinded to the content of the questionnaire.

     

     

     

    Based on the data collected, the questionnaire will be reduced to a minimal set of items giving the best discrimination between individuals with different degrees of activity limitation, the best reliability in comparison with expert opinion and the best applicability in the different cultural settings. Other considerations will be the duration of the interviews, the ability of the scale to identify areas requiring further intervention and the calculation of summary scores. The resulting draft scale will be presented. Further testing is planned in each centre. For test-retest and inter-rater reliability.
    The draft screening tool will be a subset of items from the draft scale, aiming for maximum sensitivity to identify patients in need of referral.

     

    OPOD 9

    DISABILITY, SOCIAL AND ECONOMIC SITUATION OF THE PEOPLE AFFECTED BY LEPROSY IN SHANDONG PROVINCE, THE PEOPLE'S REPUBLIC OF CHINA
    Chen Shumin; Liou Diangehang; Liou Bing; Zhang Lin; Yu Xioulu
    Shandong Provincial Institute of Dermatovereneology. Jinan, Shandong. PR. China 250022. E-mail: chenshm@public.jp.sd.cn

    As the decline in prevalence of leprosy, social and economic rehabilitation (SER) has become a major priority in leprosy control programme in Shandong Province. In the preparative phase of a SER programme, a province-wide survey was conducted with a semi-structured questionnaire in order to provide policy makers and programme managers with some basic information on the disability, and social and economic situation of the people affected by leprosy. In this paper the results of the study for the people affected by leprosy living in the communities were presented.

     

    OPOD 10

    EFFICACY OF SURGICAL NEURAL DECOMPRESSION WITHOUT NEUROLYSIS IN LEPROSY PATIENTS WITH PERSISTENT POST-TREATMENT NEURITIS
    Souza. G.M.; Goulart, I.M.B.; Bizinoto, S.P.; Lacerda, E.C.; Martins, C.A.L.; Nishioka. S.A.
    Centro de Referência Estadual em Hanseníase/Dermatologia Sanitária. Faculdade de Medicina. Universidade Federal de Uberlândia. Av Pará 1720. 38400902 Uberlândia. MG. Brazil. Fax: +55-34-321X 2349. E-mail: imbgoulart@ufu.br

    Background: Surgical neural decompression in patients with leprosy has been increasingly recommended for the treatment of neuritis that persists after multidrug therapy and fails to respond to steroid therapy.
    Patients and Methods: Forty-six patients (mean age 44.3 years; 34 males) previously treated for leprosy and with persistent post-treatment neuritis who were referred to our service from December 1999 to July 2001 were submitted to surgical decompression without neurolysis of the ulnar (44 cases), tibial (14), median (12) and lateral popliteal (4) nerves. The surgical procedure included anterior transposition in the cases of ulnar nerve decompression These patients had their pain, motricity and sensitivity associated with nerve involvement assessed with standard scores before and six months or over after surgical decompression was undertaken. The dose of prednisone that was necessary to alleviate their symptoms was also assessed.
    Results: Daily prednisone (mean decrease of 34.9 mg), ulnar nerve pain, motricity and sensitivity, and tibial, median and lateral popliteal nerves pain improved significantly (p < 0.05. paired t test) after the surgical decompression.
    Conclusion: Surgical decompression without neurolysis was successful for the treatment of post-multidrug therapy neuritis that was unresponsive to high-dose steroid therapy in this series. Failure to improvement of motricity and sensitivity of the involved nerves was probably due to the late referral of these patients and consequent delay of the surgical intervention

     

    OPOD 11

    IMPORTANCE AND TIMINGS OF NERVE DECOMPRESSION IN LEPROSY
    A. Salafia, G. Chauhan. Vimala
    Dermatological Centre- Yari Road Versova, Bombay. India

    Leprosy is a disease of the peripheral nerves. The earliest pathology is oedema, which, in theory, can be controlled by steroids. However oedema can perpetuate itself by compressing the venous return.
    Repeated reactions cause fibrosis of the peri-neural structures leading to adhesion and mechanical compression. More than 5 thousand cases of neuritis have been referred to us: of these. 1217 cases where operated (mostly done under microscope). A brief analysis of the operated cases:

    a) Almost all cases had been treated, unsuccessfully, with steroids for various periods of time, therefore surgery was considered. Surgery helped in relieving pain and preventing further damage.
    b) In 76.8% (935) there was evidence of mechanical compression (photodocumented): thick paraeurium. bands, muscles (normal and anomalous), abscesses, lymph nodes. Twelve patients (1%) with complete neural loss had nerves that - under microscope and naked eye vision- looked normal and felt normal.
    c) Among 648 long-term follow-up cases, we noticed improved sensory modalities in about 34.7% of patients within 6-2 months, and motor function in about 7 % after 9-24 months.
    d) Circa 32% of patients had total neural loss before surgery. None of the operated patients had worsening of neural function following surgery.
    e) Eight BT patients had a new granuloma at the same operated site 1 -2 years after surgery.
    f) Two LL patients reported with small abscesses on the same site, 10 years after large abscess had been excised.
    g) 106 patients had abscesses in only sensory nerves, no motor trunks involved.
    h)  In the presence of motor damage, sensory nerve damage too was observed in all cases except two, where there was motor damage but no sensory loss.

    The authors believe that more importance has to be paid to early surgery: and surgery should not be considered as the last recourse, more so when mechanic compression is suspected. Statistics will be presented to prove the superiority of surgery over steroids in dealing with chronic/ repeated neuritis.

     

    OPOD 12

    INCREASED RISK FOR DISABILITY IN MULTI-BACILLARY LEPROSY PATIENTS WITH NEURITIS
    Rangel. E.; Duppre, N.C.; Nery, J.A.C.; Sales. A. M.; Gallo. M.E.N
    Leprosy Laboratory, Oswaldo Cru/ Foundation (FIOCRUZ). Rio de Janeiro. R.J., Brazil

    Introduction: The elimination of infection through MDT is the main objective of the program of leprosy. However prevention and management of impairments and disabilities have long been recognized as essential components in order to avoid sequels and stigmatization.
    Objective: To evaluate the degree of disability in our patients from the moment they start the treatment up to five years of follow-up after discharge from treatment.
    Material Methods: A retrospective study involving 190 multibacillary patients selected submitted to the routine in andour service. Patients were evaluated both the beginning, and at the end of treatment, during the five years of follow-up as well as whenever it was necessary because of the occurrence of reactional states. The evaluation of the degree of disability followed the criteria recommended by the Brazilian Ministry of Health.
    Results: At the beginning of treatment the degree of disability was equal to zero in 99 patients (52.1%), equal to 1 in 47 patients (24.7%), and equal to 2 in 44 patients (23.3%). At the end of treatment 123 patients (64.7%) maintained the initial degree, 49 patients (25.8%) improved and 18 patients (9.5%) got worse. In general, the relative risk (RR) for worsening the degree of disability among reactional patients was 3.01 (95% CI 2.03 - 4.46) for those with neuritis when compared to those without neuritis. Noteworthy, patients with initial degree of incapacity equal to zero that exhibited reactional states with neuritis had an increased risk (RR = 7.62; 95% CI 1.87-31.02) of worsening the degree of disability at the end of the treatment, when compared to those that did not exhibit reactional states. Of those 91 patients with some physical disability established at the beginning of treatment, 39 patients (42.9%) remained stable and 49 patients (53.8%) improved. After 5 years of follow-up, 7 patients (21.2%) with degree 1 at the end of treatment improved their disability degree and 7 patients (20.6%) of those with degree 2 did the same.
    Conclusion: Reactional states with neuritis seems to be responsible for worsening the degree of disability, mainly in those with initial degree equal to zero. There has been a highly significant improvement of the disability degrees both at the end of treatment, as well as 5 years after therapy discharge.

     

    OPOD 13

    IS THE, SURGICAL CORRECTION OF FOOT DROP A MORF EFFECTIVE METHOD TO REDUCE PLANTAR ULCERATION THAN CONSERVATIVE METHODS?
    Hugh Cross; Stuart Eergusson
    Lalgadh Leprosy Services Centre, Lalgadh. Dhanusha District. Nepal

    Findings from an archival study of 107 case files relating to subjects with fool drop are presented. A study was conducted at Lalgadh Leprosy Services Centre, Nepal. Within the parameter of a defined time span it was found that 67 subjects had accepted surgical foot drop correction (tibialis posterior transfer) and 40 subjects had been supplied with fool drop springs. Both groups had been supplied with protective footwear. Using standard non-parametric analysis (chi-square) it was found that the difference between the groups, when compared on post intervention plantar ulceration rates, was not significant. Compared with pre intervention ulceration, the site of ulceration on surgically corrected feet was more likely to be different than it was for feet assisted by foot drop springs (p < 0.05). An implication of this study is that where cost constraints are an issue and the prevention of ulceration is a primary objective, conservative treatment may be as useful as surgical intervention.

     

    OPOD 14

    PLANTAR ULCERS IN LEPROSY: PATIENTS' PERCEPTIONS AND TRADITIONAL PRACTICES OF CURE.
    Sabita Ohimirc; Madan Ghimire; Joanne Roberts; Niru Shrestha; Ruth Butlin.
    Anandaban Leprosy Hospital, PO Box 151. Kathmandu, NEPAL. E-mail: anandaban@mail.com.np

    Plantar foot ulcers are a major reason for hospital admission among leprosy patients. Self-care of anaesthetic feet is a significant health education challenge and many patients with anaesthetic feet have recurrent ulcers despite repeated health education.
    Aim: To seek to understand leprosy patients' own perceptions about the causes and care of foot ulcers, and to investigate traditional practices used in the treatment of these.
    Methods: One hundred and twenty (60 male, 60 female) patients admitted for plantar ulcer management at Anandaban Leprosy Hospital during the period March 2000- December 2001 were interviewed using a pre-tested semi-structured questionnaire. Data analysed using Epilnfo version 6.04.
    Results: Approximately 90% of respondents believed leprosy ulcers to be different from other kind of ulcers; 607 thought leprosy ulcers should be treated differently, with 42% believing they needed leprosy medicine for ulcer healing. Almost one third of respondents (32%) thought recurrent ulcers were due to their disease not yet being cured. Only 3% said the healing time of a leprosy ulcer is the same as other ulcers. Of 120 respondents. 74 (62%) used traditional materials to treat their ulcers: 59 kinds of plant product, 18 kinds of animal product, and 15 other kinds of materials were considered helpful in healing ulcers (1 oral use, 66 external use and 7 both external and oral use).
    Conclusion: This study will assist health educators and ulcer care workers in identifying commonly held beliefs and practices which may aid or impede foot ulcer care.

     

    OPOD 15

    SOCIAL IMPLICATIONS OF DISABILITY AND NEED OF INTENSIVE POD PROGRAMME IN URBAN AREA
    Dr. Gitanjali saha; Sudhakar Bandyopadhyay
    German Leprosy Relief Association-India

    Disability-care in urban set-up is a complex problem associated with socio-Economic, psychophysical, migratory and occupational implications. While some persons suffer from the consequences of deformity and disability, others capitalize it as their means of livelihood. Similarly one group is careful enough to adopt self-care while other group were found to be negligent. The major cause of reporting with deformity was ignorance on early signs and subsequently negligence in treatment. Inspite of adequate services provided, due to migration, hard labour and excessive movement, condition of many disabled persons were worsened. This was revealed in a 20 years retrospective study conducted at GRECALTES in Kolkata. Data were analyzed from 1981-2000 A.D.During this 20 years, total 6331 leprosy patients were detected, 415 were deformed among new cases. Total 630 patients were put under deformity care services, conditions improved for 74 cases, conditions remained static and not further deteriorated for 375 and conditions aggravated for 181 patients. It is suggested that intensive community education programme, patient and patients' family members' education is necessary to curve new case reporting with deformity and to check further worsening. The strategy of recently launched POD programme should be continued and intensified. Disability care is important but prevention of disability is the necessity.

     

    OPOD 16

    SKIN TEMPERARURE ASSESSMENT BY PALPATION OF NEUROPATHIC FEET OF LEPROSY PATIENTS
    W.R. Faber1; A.F. Hoeksma 2

    1. Department of Dermatology, Academic Medical Center.
    2. Department of Rehabilitation Medicine, Jan van Breemen Institute and Slotervaart Hospital, Amsterdam, The Netherlands.

    Complications of the neuropathic foot as ulceration, bacterial infection and neuroosteoarthropathy (Charcot foot) are accompanied by signs of inflammation. Of the inflammatory signs pain sensation is diminished or absent due to loss of sensory function. Increased temperature, in a part or in the whole foot, can be assessed by thermometry or, as in clinical practice, by palpation.
    We have already reported a high inter-observer reliability (Kappa = 0,79) and a high correlation of palpation with thermometry (Spearman's rank correlation coefficient 0.82; p << 0,002). (Int J Leprosy 2000;68:65-7)
    Consequently, in three field studies it was investigated whether skin temperature could be assessed reliably by palpation by leprosy patients, their family and leprosy staff.
    In Ethiopia 69, in India 64 and in Brazil 76 persons participated in the study. Spearman's rank correlation coefficients between palpation and infrared thermometry ranged from 0,36 to 0,60. Correlation was highest on the dorsum of the foot, higher when performed by patients than by their family, and higher by experienced than inexperienced staff.
    In the last study the assessment was repeated after one month, and an improvement was found.
    The results of these studies indicate that assessment of skin temperature by ons in neuropathic feet of leprosy patients.

     

    OPOD 17

    THE REHABILIATION OF CURED IN COMMUNITY NEED FOR REHABILITATION OF LEPROSY PATIENTS
    Abdul K. Chauhan

    A in other diseases or conditions associated with disability and/or deformity, rehabilitation services are also needed for leprosy patients. The introduction of effective methods of treatment-medical, surgical and physical has brightened the prospects of cure of the disease. As a result, rehabilitation of a leprosy patients has now become practicable. Cure of the disease does not have much meaning for the patients if he still remains socially and economically dislocated.
    The general principles of rehabilitation of leprosy handicapped persons are no doubt the same as those for other handicapped persons, However, there are two significant and vital differences. First, while other handicapped persons do not carry any stigma and/or are not socially dislocated, leprosy is unfortunately associated with a stigma and patients suffering or having suffered from this disease are apt to be socially ousted and considered as out casts from society.
    In other diseased, the question of rehabilitation is considered after the treatment of the patient has been completed, but in leprosy the process of rehabilitation should start as soon as a diagnosis of the disease has been made. Because of the immense difficulties in rehabilitation after he has been socially and economically dehabilitated or dislocate, efforts should be made to prevent dehabilition.
    There are vasd number of leprosy patients representing an enormous waste of human resources who are disabled physically, socially, spiritually, vocationally or economically. We are to prevent this from occurring in the first place.

     

    OPOD 18

    THE SELF-CARE KIT: AN AID TO EMPOWER PATIENTS IN CARE OE FEET
    Atul Shah; Neela Shah
    Comprehensive Leprosy Care Project & Medical Aid Association
    Novartis India Ltd. F 701. Goregaon (E), Mumbai, 400063. India

    The authors have developed and introduced the CLCP self-care kit to heal ulcers, improve the ichthyosis and cracks in feet by empowering patients. Empowering patients to care for their feet at home is the only practical and sustainable solution to reverse the trophic changes, heal minor wounds or plantar ulcers and prevent disabilities. The self-care kit can help trigger this change. The empowerment program with lhe self-care kit is carried out as a camp approach where patients are taught how to use the kits in groups. The self care kit contains a foot scraper, antiseptic solution and ointment, moisturising cream, sterilised gauze packets, bandages and scissors. Patients also receive a plastic tub and MCR footwear. The use of the self-care kit is demonstrated and patients also understand and discuss how ulcers develop and what they can do to prevent their recurrence. The health care staff provide patients replacement kit during the monthly follow up visits. Results assessed at 4 to 6 months later clearly demonstrate that 85 % of patients had improvement of which nearly 50 % cases had complete healing of their ulcers. The results document the impact of the self-care kit as an effective tool to empower patients to heal ulcers, improve the ichthyotic skin and cracks in feet. Considering the magnitude of ulcer cases and the substantial improvement in the quality of life for persons affected by feet ulcers, the new CLCP modality of the "self-care kit" could make a significant contribution to reduce the burden of foot related disabilities in leprosy.

     

    OPOD 19

    TIBIALIS POSTERIOR TRANSFER (TPT) - CIRCUMTIBIAL vs INTEROSSEUS ROUTES
    Dr. Premal Das ; Victor Paul; Julius Kumar; Karthikeyan; Dr. Cornelius Walter
    TLM Hospital, Naini, Allahabad, 211008, Uttar Pradesh, India. tlmnaini@sanchernet.in

    Objective: To compare the functional outcomes of Circumtibial and Interosseus routes of foot drop deformity correction.
    Design: A prospective study conducted at The Leprosy Mission Hospital, Naini. Allahabad, from 1998 to 2001.
    Setting: The Leprosy Mission Hospital, Naini, is a 110-bed referral Hospital with leprosy and non-leprosy medical facilities
    Participants: 119 people affected by leprosy with more than one year duration of foot drop deformity.These people are from the rural community and residents of nearby small towns and cities.
    Procedure: For several years there has been a debate over the functional outcomes and risk of inversion deformity of one procedure to correct foot-drop versus another. In the first year all patients were operated using only the Circumtibial route for correction of foot drop. The following 3 years, patients with peroneus muscle grade 3 or more underwent Circumtibial route and those with less underwent Interosseus route of correction of foot drop. The results of 55 TPT surgeries using the Interosseus route and 64 using the Circumtibial route were analysed at 1 month, 3 - 6 months and 1 - 3 year follow-up periods movements and inversion. Factors such as Surgeon, Physiotherapist. Physiotherapy technician and pre and post-operative exercise regimen were constant.
    Outcome measures: The percentage of people with good outcomes (>90%) following Circumtibial and Interosseus routes of foot drop correction
    Results and conclusions: The analysis is in progress and the results will be presented at the Conference.

     

    OPOD 20

    "USE OF A MULTIDISCIPLINARY ASSESSMENT TOOL IN THE PREVENTION AND MANAGEMENT OF IMPAIRMENT AND CONSEQUENCES (PAMIC) IN LEPROSY"
    Dr. Mannam Ebenezer; Dr. Patheebarajan; Dr. Anil Thomas; Dr. M.V. Thomas; Mrs. Helen; Mrs. Valsa Augustine; Mr. Paul Rajkumar
    Schieffelin Leprosy Research and Training Centre, Karigiri, India

    PAMIC is a multidisciplinary approach in which professionals from the medical, occupational therapy, social sciences and clinical psychology combine to prevent and manage disability issues in leprosy. The programme is hospital based and is held in the outpatient department. An assessment form based on the WHO ICIDH concept is used to identify impairments, activity limitation and participatory restriction.
    The disability issues are prioritized according to patient's perception and possible interventions are identified. About 250 patients were assessed using this tool and the results are presented. 84% of patients had activity limitation and 82 % participatory restriction. As far as activity limitation is concerned approximately 95% of patients were able to perform Activities of Daily Living. 61 % had to change their vocation with 34% adapting to their vocation with the disability. 20 % of perceived participatory restriction in their domestic life. 19% had participatory restriction with relatives and about 36 % had participatory restriction in societal roles including vocations.
    The main advantage of the assessment tool is that disability issues are seen in the light of patient's perception and interventions are drawn according to his/her priorities. The assessment form brings out liner details of activity limitation and participatory restriction so that specific interventions can be decided upon. Interaction between professionals helps to arrive at the best possible way to implement interventions taking into consideration social and economic issues

     

    SOCIAL ASPECTS

    OSA 1

    A HEALTH PROMOTING INTEGRATIVE COMMUNITY DEVELOPMENT PROGRAMME
    Derek Browne
    Health Promotion Specialist Agency Southampton
    Merrival Lodge Rhinelield Road Brockenhurst Hampshire S042 7SW UK

    Social stigma and ostracism affect those with and 'cured' leprosy, and others in a community who have persons with disabilities, inequalities and loss of social capital. Community integration and community involvement using community resources and facilities can enhance social esteem, improve quality of living and help integrate those with physical, mental and social disabilities. Partnerhips between the statutory, voluntary and private organisations within a community may be facilitated through the services of a paid community co-ordinator.
    Healthy Communites which include Healthy Cities and Healthy Villages are part of the World Health Organisaiotn plans to promote healthy and active communities in developed and developing countries. Health Care systems vary in many countries of the world from a Health Service funded mainly through Taxation as in the UK, to combinations of Tax based insurance and private funding in other countries. Many 'cured' patients of leprosy or Hansen Disease carry the stigma with their associated disabilities with them throughout life independent of any corrective surgery that may have been performed.
    In our village in the UK we demonstrated a posotive 72% uptake of resources and 70% improved quality of living.

     

    OSA 2

    A IMPORTÂNCIA DA AVALIAÇÃO DA QUALIDADE DE VIDA EM PACIENTES COM HANSENÍASE
    Rodrigo Sestito Proio; Lúcia Mioko Ito; Ferrucio Fernando Dall'Áglio; Fábia Oppido Secalch; Simone Santos; Maurício P. Paixão.
    Departamento de Dermatologia da Faculdade de Medicina do ABC.
    Av Príncipe de Gales, 821- -09060-650-Santo Andre -SP- Brasil.

    Introdução: A hanseníase, se não tratada, resulta em graves distúrbios psicológicos, físicos e sociais. Devido ao estigma que a doença causa, os índices de qualidade de vida desses pacientes decai consideravelmente.
    Casuística: Foi aplicado o questionário de avaliação da qualidade de vida da Organização Mundial da Saúde (OMS), adaptado para as condições dos pacientes com hanseníase. Foram analisados 30 pacientes (16 homens e 14 mulheres), na faixa etária de 18 a 72 anos, que estão em registro ativo e acompanhamento pós- alta, no Centro de Saúde Escola Capuava (ambulatório de hanseníase). O questionário explora os seguintes itens: físicos, psicológicos, nível de independência, relacionamento social, religião e lazer.
    Resultados: O nosso estudo revelou que a qualidade de vida diminui com a evolução e progressão da doença, principalmente em relação aos fatores psicológicos, relacionamento social, nível de independência e alteração da imagem corporal. Os pacientes com as formas avançadas da doença relatavam exclusão social, incapacidade ao trabalho e diminuição da atividade sexual.
    Discussão: A hanseníase pode ser vista corno uma doença que leva à alterações psicológicas, socioeconômicas e espirituais que vão progressivamente afetando as pessoas que não estão preparadas para encararem esses fatos. Apesar de multidroga terapia anti-hansênica ter proporcionado um certo otimismo em relação às perspectivas de eliminação da doença e prevenção das incapacidades, observa-se que os estigmas da doença ainda permanecem e os centros de tratamento não estão preparados para auxiliar estes conflitos. Conseqüentemente, o grau de declínio da qualidade de vida precisa ser revisado e correlacionado com vários fatores ambientais e sócio-demográficos, incluindo-os no protocolo de atendimento aos doentes com hanseníase.

     

    OSA 3

    A IMPORTÂNCIA E A NECESSIDADE DO ACOLHIMENTO AO PACIENTE COM HANSENÍASE: UM ENFOQUE BIOÉTICO
    Letícia Maria Eidt
    Ambulatório de Dermatologia Sanitária / Secretaria Estadual da Saúde e do Meio Ambiente do Estado do Rio Grande do Sul. Rua Mostardeiro, 920. Porto Alegre, Rio Grande do Sul, Brasil, CEP: 90430-000. FONE: 0-51 33331590; 0-51 33333085 - E-mail: leticia.eidt@globo.com

    A Hanseníase, doença ainda hoje lembrada como nos tempos bíblicos com todos os seus estigmas e preconceitos, gera vários sentimentos e angústias que contribuem para a diminuição da auto-estima em seus portadores. Os pacientes quando procuram atendimento chegam fragilizados, necessitando, além do tratamento medicamentoso poliquimioterápico, sobretudo, de um tratamento humanizado. O presente trabalho apresenta os resultados de uma pesquisa qualitativa fenomenológica, realizada com hansenianos em acompanhamento no Ambulatório de Dermatologia Sanitária, localizado na cidade de Porto Alegre, centro de referência para tratamento da Hanseníase no Estado do Rio Grande do Sul, Brasil. Os dados foram coletados por meio de entrevista semi-estruturada e dialogada, posteriormente transcrita para aplicação do método fenomenológico. A importância do respeito ao ser humano hanseniano, o acolhimento e o carinho por parte da equipe de saúde, contribuindo para o resgate da auto-estima e para a adesão ao tratamento, são alguns dos aspectos abordados pelos pacientes. A autora reflete, ainda, sobre a necessidade de tratar os doentes na sua integralidade e sobre a preocupação em não se descuidar da dignidade humana como medidas necessárias à humanização do atendimento aos portadores de Hanseníase.

     

    OSA 4

    A QUESTION OF JUSTICE: REHABILITATION OF PERSONS AFFECTED BY LEPROSY
    Chukwu, J.N.; Onojorhovwo, I.
    German Leprosy Relief Association, 35 Hillview, Independence Layout. Enugu-Nigeria

    The German Leprosy Relief Association (GLRA) supports leprosy control services in 14 states in the south-east and south-west of Nigeria. About one third of Nigeria's population of 120 million live in this area. As the backlog of leprosy cases requiring treatment declines, the GLRA has increased the profile of social and economic rehabilitation of persons affected by leprosy. In the new spirit of partnership with persons affected by leprosy, the GLRA in Nigeria has adopted the motto: "nothing about you, without you". To operationalise the concept, a series of meetings and consultations was held with field officers and representatives of persons affected by leprosy. The consultation with persons affected by leprosy was the first of its kind in Nigeria. It was a most rewarding and revealing experience. Data on the focus groups and their recommendations are presented and discussed. The paper concludes on the following note: that most persons affected by leprosy are asking for a hand-up, not a hand-out. That main-stream socio-economic field is heavily tilted against persons affected by leprosy that 'affirmative action' is necessary to bridge the gaps and assist persons affected by leprosy in the 'normalisation' process. That ILEP in collaboration with IDEA International is best positioned to play 'advocate-extraordinaire' on behalf of the affected persons and to raise the considerable sums of money needed for effective and sustainable rehabilitation. That a world without 'LEPERS' is attainable in this century, long before a world without leprosy. That the pursuit of this goal is not a favour to persons affected by leprosy but a question of justice for all.

     

    OSA 5

    A STUDY ON THE SETTLEMENTS OF THE LEPROSY AFFECTED IN INDIA
    C.S. Cheriyan; T. Jayaraj Devadas
    India Co-ordinator, IDEA International. No.4, Gajapathy Street, Shenoy Nagar, Chennai-600 030

    Introduction: As soon as IDEA's activities were established in India, an all embracing study covering more than three hundred self settlements of persons affected by HD was launched in India for the first time, to find out the occupational requirements of the inmates and to assess their living conditions, family setups and all about their lives. It was a massive study covering as many as nine endemic states in India.
    Objectives:
    1. To study the living conditions of the inmates in the settlements.
    2. To study the occupational stattis of the inmates.
    3. To find out the needs and requirements of the inmates.
    4. To offer suitable remedial measures.
    Operational Modalities: A detailed questionnaire was worked out and the settlements were visited by a team comprising of a health educator, social worker and a physio-technician. Exhaustive interviews were carried out to get the required data.
    Conclusion: After the collection of the data, they were analyzed and a comprehensive relief package was worked out and the same was administered among the inmates at the behest of IDEA in the various settlements spread out in different parts of the country which had helped to enhance their integration with the general public, dignity through self reliance and economic advancements through occupational gains.

     

    OSA 6

    ASSESSMENT OF DISABILITY, SOCIAL AND ECONOMIC SITUATIONS OF THE PEOPLE AFFECTED BY LEPROSY IN SHANDONG PROVINCE, PEOPLE'S REPUBLIC OF CHINA
    Chen Shumin; Liu Diangchang; Liu Bing; Zhang Lin; Yu Xioulu
    Shandong Provincial Institute of Dermatology and Vereneology, 250022, Jinan. China

    As the decline in prevalence of leprosy, social and economic rehabilitation (SER) has become a major priority in leprosy control programme in Shandong Province. In the preparative phase of a SER programme, a province-wide survey was conducted with a semi-structured questionnaire in order to provide policy makers and programme managers with some basic information on the disability, and social and economic situation of the people affected by leprosy. In this paper the results of the study for the people affected by leprosy living in the communities were presented

     

    OSA 7

    CONHECIMENTO CIENTÍFICO E CONTROLE SOCIAL: A INSTITUCIONALIZAÇÃO DO CAMPO DA HANSENÍASE (1897-2000)
    Zoica Bakirtzief
    PUC- SP, Cx Postal 1527, 18041-970 Sorocaba, São Paulo, Brasil

    Pesquisa realizada para obtenção de título de doutorado analisa as concepções e práticas de controle social da hanseníase, mediante estudo das fontes documentais de domínio público na perspectiva da Psicologia Social. O processo de institucionalização da hanseníase é enfocado a partir da noção de campo científico de Pierre Bourdieu e dos conceitos e definições cristalizadas em produtos científicos como livros, revistas e índices bibliográficos. A perspectiva diacrônica aponta as transformações ocorridas ao longo dos anos: do paradigma da hereditariedade ao bacteriano e à imunogenética atual. A série histórica analisada (1879-2000) mostra que o discurso hegemônico, excluindo os discursos marginais, tratou a doença, não o doente, ao qual não deu voz. A institucionalização do campo da hanseníase ocorreu por movimento mais amplo da Medicina Social que objetivava a promoção da saúde mediante o controle dos doentes por meio de estratégias de governamen-talidade. A especialização progressiva do campo da hanseníase reduziu as possibilidades de reflexão sobre a doença pela hegemonia discursiva.

     

    OSA8

    DELAY IN PRESENTATION: IDENTIFYING CONTRIBUTING FACTORS USING BASIC QUALITATIVE METHODS
    P.G. Nicholls; W.C.S. Smith
    Department of Public Health. University of Aberdeen, UK

    In leprosy, the variety of help-seeking actions in a great diversity of pathways by which individuals finally present and star treatment. Many of these contribute to delay and so increase the risk of disability.
    To identify the factors contributing to delay requires an analysis of decision making relating to help-seeking actions. We adopted this approach, using a variety of qualitative methods in seven centres in three continents. We used semi-structured interviews and organised group activies with patients currently receiving MDT. We validated our findings through interviews with field staff, and with project managers, teachers, political leaders, religious leaders and practitioners in alternative medicine.
    The presentation will contrast the relative importance of different causes of delay between centres and suggest ways in which these may be addressed. We will comment on the effectiveness of the methods used and their implication for skills and resources. A Handbook describing our field methods and case studies will be available at the Congress.

     

    OSA 9

    DELAY IN PRESENTATION -RESULTS F FIELD-WORK IN PARAGUAY
    C. Wiens; P.G. Nicholls; W.C.S. Smith.
    Hospital Mennonita Km 81, C.d.c. 166 Asunción. Paraguay

    We used qualitative methods to explore the factors contributing to delay in presentation in Paraguay -semi-structured interviews with patients and others and free listing with stall.
    Interviews with patients and focused on help-seeking actions. We asked staff to list the normal responses of patients to (1) the diagnosis of leprosy and (2) the need to inform the family members of the leprosy diagnosis.
    Staff identified the most common responses to the leprosy diagnosis as denial, fear of rejection and punishment from God. In our second series of interviews (total 14) two young women had been excluded from school and had returned to treatment after a ten year break. One young woman had twice tried to commit suicide. One man said he had cried much at the diagnosis. An older woman asked several friends to pray for her as she felt suicidal.
    Responses from staff to the need to inform family members of the leprosy diagnosis included concealment, giving a different diagnosis and fear of endangering children. In the first series of interviews 18 of 36 patients expressed fears. These included fear of the response of neighbors (9), fear of the response of the family (4) and fear for the impact on the family (3).
    In our presentation we will expand these findings and discuss their contribution to delay in presentation.

     

    OSA 10

    DEVELOPMENT OF A SCALE TO MEASURE PARTICIPATION
    Alison Anderson; Ulla-Britt Engelbrektsson; Ishwor Khawas; Sarah Kinsella-Bevan; Megan Grueber; Ramachandra Mutatkar; Zoica Bakirtzief; Wim van Brakel
    INF-RELEASE. PO BOX 28. Pokhara. Nepal

    Improvement in social participation should be an important outcome of interventions in socio-economic rehabilitation. Up to now, no standard, simple, measure of participation has been available for use in the context of Nepal and other leprosy-endemic countries. Different individuals visiting a client/patient see the situation differently, and simple comparison between people or measurement of change within a situation has been difficult. Given the increasing interest in and importance accorded to rehabilitation of people affected by leprosy worldwide, development of an instrument to measure participation has become an urgent need.
    Based on observed and spoken indicators of participation from observational studies, a scale is being developed to simplify and standardise measurement of participation (or restrictions in participation), particularly in the context of clients who previously had leprosy. The conceptual framework of the scale is based on the International Classification of Functioning. Disability and Health ((ICF), WHO. 2001 ). 'Participation restrictions' are defined as "problems an individual may experience in involvement in life situation". The scale is intended primarily for use in assessment of socio-economic rehabilitation and therefore will emphasise domains of participation which reflect this aspect.
    The scale is being designed, developed and tested according to standard principles for health measurement scale development. Items were generated and piloted in Nepal: the programme has since been extended to include six centres in India and two in Brazil, in an attempt to produce a culture free scale. The methodology used in design and a draft scale ready for psychometric testing will be presented.

     

    OSA 11

    DEVELOPMENT OF SOCIAL WELFARE AND REHABILITATION SYSTEM FOR LEPROSY PATIENTS IN LEPROSY COLONY. CHANTHABURI
    Supharh Krussaeng B.Sc (Psychology)
    Office of Communicable Diseases Control Region 3, Chonburi Province. Thailand

    The author has conducted an evaluative research on development of social welfare and rehabilitation system for Leprosy patients in Phrangkayang Leprosy rehabilitating colony at Chanthaburi province.
    The study was based on descriptive research and qualitative research using participatory observation, focal group discussion and in-depth interview. Overall findings revealed total 911 members comprising registered in-patients, unregistered in-patients and relatives. Problems of high deformity resulted in limitation and disadvantages for further development. Focus was made on development of social welfare and rehabilitation system which were facilitated by intersectoral collaboration such as establishment of water resources, vocational promoting funds, guidance and support on agricultural promotion, health care. etc.. These result in better mutual cooperation and formation of self-help groups which promote interactive self-reliance and increase community participation. The author has made relating recommendation including better care of disable and old aged patients, protection of land invasion, restructuring of leprosy colony into cooperative colony in order to be more independent and decrease financial burden of the government. These will lead to total elimination of Leprosy as public health and social problems.

     

    OSA 12

    DO NEEDS VARY AMONG PEOPLE WITH LEPROSY, PEOPLE WITH DISABILITY AND OTHERS FROM THE SAME RURAL AND URBAN AREAS?
    Robert K. Das-Pattanayak; Wim H. van Brakel; Cornelius S. Walter
    The Leprosy Mission Research Resource Centre. 5 Amrita Shergill Marg. New Delhi - 11003. India: robertp@tlm-india.org

    Aim: To assess and compare observed and felt-needs among people affected by leprosy, people with disability and others living in the same rural and urban localities.
    Methods: 14 slums in and around the leprosy control area of 'The Leprosy Mission' in Calcutta, and 20 nearby rural villages were selected for an in-depth survey. 1400 respondents were randomly selected from both rural and urban areas, including 400 with leprosy-related problems, 300 with other disabilities and 700 from the same rural and urban areas, but without leprosy-related problems or disability. The latter group consisted of people with no cultivable land, marginal farmers who own only a small piece of land and other slum-dwellers.
    Results: Few significant differences were found between the three groups of respondents regarding some of the key indicators such as employment status and community facilities. They agreed about their fundamental needs, although the priority ranking was slightly different between the groups. Employment and income generating activities were most frequently cited as a first choice, whereas toilet facilities were the most common second choice. Basic amenities remain a major problem for the majority of our respondents in both villages and slums. Health care also ranked among the top five required services. Respondents showed interest in schemes that would require their direct involvement and own contributions.
    Conclusion: No remarkable differences were found regarding observed or felt-needs between people affected by leprosy, disability or general poverty. Their needs appear to be determined by their socio-economic conditions rather than the differences in disability and disease status. The results show a desire for self-sufficiency among the respondents. Future programme activities should take this into account and programme staff should adopt a role of facilitator, rather than service provide

     

    OSA 13

    EXPERIENCES OF GENERAL PATIENTS ATTENDING GENERAL OPD IN GMLF'S LEPROSY REFERRAL HOSPITAL
    Iayashree B.1; M.S. Raju2; V.V. Dongre3
    Gandhi Memorial Leprosy Foundation, Ramnagar, WARDHA-442 001 (Maharashtra Slate) INDIA

    1. P.M.W.
    2. Project Officer
    3. Director.

    It is necessary to know the reactions of public towards the process of integration, where they need to take treatment along with leprosy patients. As such, 300 persons with general ailments but not afflicted by leprosy, attending General OPD started in GMLF leprosy referral hospital have been interviewed to understand their experiences and attitude towards attending the OPD.
    The results show that the reasons for taking treatment from a clinic situated in leprosy hospital include several socio-economic factors. While, majority of the patients come to GOPD because, fee is less, few attended GOPD because it is near by. There are some patients who attended because they don't know that it is a leprosy hospital and some have adequate knowledge about leprosy and attend GOPD with scientific conviction. Patients with different complaints of minor nature only attended the GOPD. Majority came voluntarily and the remaining were motivated through friends and the Social Worker appointed by the GOPD, who visited the field to create awareness. Majority of the patients were satisfied with the medicine and die cost. As a result repeated attendance is observed.

     

    OSA 14

    GENTE PREVENINDO GENTE
    Rosarina de F. Sampaio da Silva
    Presidente da Associação das Prostitutas do Ceará

    Atualmente a Hanseníase faz parte do conteúdo programático das oficinas da Associação das Prostitutas do Ceará (APROCE). Voluntários do MORHAN junto com nossa equipe de educadoras sociais, estão participando de treinamentos em conjunto. Até o momento, nossas programações incluíam apenas DST e AIDS. Com a hanseníase. discutimos o que é a doença, como identificar a doença e esclarecimentos sobre a importância do tratamento para a cura definitiva. Após 15 oficinas realizadas percebemos que as profissionais do sexo tem demonstrado muito interesse pelo novo tema. Todas as 300 profissionais do sexo que participaram das oficinas pediram que fossem realizadas outras oficinas e mais de 80% demonstraram terem assimilado como suspeitar da doença. Cientes da presença de um significativo número de casos da doença cm nossa cidade e com a experiência na prevenção das DST/AIDS há alguns anos, queremos também colaborar a diminuir o preconceito que tanto atrapalha a identificação, tratamento e cura da Hanseníase. Unindo as forças de todos um dia a Hanseníase será coisa do passado. Outros resultados serão apresentados

     

    OSA 15

    HOW THE NUMB FEET SYMPTOM IS SEEN BY THE LEPROSY SUFFERERS
    Sônia Marília Matsuda Lessa; Diltor Vladimir Opromolla; Fernando Lefèvre
    Universidade de São Paulo - Faculdade de Saúde Pública
    Instituto Lauro de Souza Lima
    Universidade de São Paulo - Faculdade de Saúde Pública

    This study explores the relationship between leprosy sufferers and what perception they have of the numb feet symptom and how much they know and do about the resources available in order to prevent and cure plantar ulcers. Three different opinions have resulted from this research. The first group saw their feet as being normal, the second said their feet were kind of dead and the third one thought they were vulnerable. The first two ways of perceiving the problem are cause for concern since they don't raise the appropriate awareness about the risk factor and adequate self- treatment practices. However, the image of vulnerability the third group has can be positive because it can prevent the onset and aggravation of the ulceration process, although the existence of both external and internal factors make it difficult for some to adopt and carry out care practices at home, on a day to day basis. It has been concluded from this research that health orientation, health education and the availability of accurate information about the disease, alongside awareness about how to take care of their own bodies could play an invaluable part on the prevention and cure of plantar ulcer. Furthermore, a good relationship between patients and health workers as well as psico-social help to patients, and to their relatives, are the basic requirements for the quick identification and overcoming of the disease, helping to improve the patient's trust on the treatment and leading to a better understanding of the necessity for the continuity of treatment at home.
    [Key words] Leprosy, numb feet, self-treatment and plantar ulcer.

     

    OSA 16

    IMPACT OF SOCIO-ECONOMIC REHABILITATION INTERVENTIONS FOR 25 YEARS- AN ANALYSIS
    G.R.Srinivasan. G. Isaac. Anand David
    German Leprosy Relief Association-India
    No.4, Gajapathy Street, Shenoy Nagar, Chennai-600 030

    German Leprosy Relief Association Rehabilitation Fund (GLRA-RF) was instituted in 1974 at Chennai, India to promote socio economic rehabilitation of those displaced leprosy affected persons by offering the following services such as financial assistance for self employment and micro enterprises. Housing programmes. Referrals for Training cum career guidance. Placement services. Educational sponsorships. Supply of mobility aids and appliances. Empowerment through 'Resource Link' a quarterly circular and Networking and lobbying.
    The services of GLRA-RF were carried out through 52 Non Governmental Organisations situated in 11 States in India. During the period of 25 years an amount of Rs.5.914.274 was advanced by GLRA-RF and an amount of Rs.4,59I 714 was mobilised through banks as loans towards self employment scheme to help 7401 leprosy affected persons needing economic assistance. The housing scheme benefited 1055 persons affected by leprosy. Through training and job placements, 6502 persons were ben-elited. One of the encouraging results of the loan scheme as part of the economic reinstatement is the high rate of repayment. Micro enterprises were started out of the self help groups so that the efficiency of individuals are pooled together.
    After analysing the response of the beneficiaries it is revealed that the rehabilitation interventions have enhanced their normalization process of the individuals

     

    OSA 17

    IMPORTANCE OF IMPLEMENTING PUBLIC RELATION TECHNIQUES IN RESOURCE MOBILIZATION AND IMAGE BUILDING OF NGO WORKING FOR LEPROSY ELIMINATION
    D.J. Sathe; V.V. Dongre
    Gandhi Memorial Leprosy Foundation, Ramnagar, Wardha44200l Maharashtra State) India

    By every passing year, scene in the field of leprosy is changing quite rapidly, from medical point of view. Leprosy has become a curable disease and it is quite possible that many of the states in India will declare themselves as a leprosy free state in near future.
    However reality indicates that although to a great extend, it may be true but lot of ground is yet to be covered to eliminate leprosy in its true sense, and asa result of this it is quite important to have more and more programs for elimination of leprosy by involving people's active participation.
    It is well known fact that no program can be effectively implemented without availability of sufficient-funds and other resources which can be made available by pursuing people to contribute for the cause.
    It is understood that there are nearly 200 N.G.O.'s engaged in anti-leprosy programs in India but it is also a very alarming fact that only a very few of them are really in a position to carry out their routine functions in a perfect manner while others are facing a very serious financial crisis.
    To overcome this serious problems it is absolutely necessary to apply the practices of good public relations in the working of every non-governmental organization to improve its local funding source by doing good work and also projecting it before the society with the help of print and electronic media. While working in the field of leprosy for the last 11 years I have observed that in India many organizations are doing a commandable work, however they are not very serious about image building activity which can help them to solve many of their important problems like resource, human resource, peoples' co-operation and so on.

     

    OSA18

    LEPROSY IN CARIOCA CONTEXT: PATIENTS EXPERIENCES IN RIO DE JANEIRO, BRAZIL
    Cassandra White
    Tulane University, Department of Anthropology, New Orleans, Louisiana 70118 USA

    Leprosy continues to be a problem throughout Brazil. High incidence and prevalence rates of leprosy can be found in neighborhoods of the North Zone (Zona Norte) of Rio de Janeiro and of the Baixada Fluminense, the lowland floodplain outside of Rio. For 11 months in 1998-1999,I interviewed patients at public health posts and hospitals in Rio de Janeiro about their experiences with leprosy and leprosy treatment. I attempted to identify elements of national and local culture that might shape or construct these experiences. I also examined problems that patients experienced within their socioeconomic and cultural milieu. Patient narratives revealed that gender, occupation, religious beliefs, living conditions, concepts of the body, and folk models of leprosy all contributed to how this disease was experienced by patients.

    OSA 19

    LEPROSY VILLAGE/LEPROSARIA IN SHANDONG PROVINCE - PAST, PRESENT AND IN FUTURE
    CHEN Shumin; LIU Diangchang; LIU Bing; ZHANG Lin; YU Xioulu
    Shandong Provincial Institute of Dermatology and Vcreneology, 250022. Jinan, China

    In the late phase of the leprosy control programme in Shandong Province, there are a few old and disabled ex-patients affected by leprosy in the 54 leprosy villages/leprosaria. This makes the running of these leprosy villages/leprosaria more costly. In this paper, we reviewed the history and the role of leprosy village/leprosarium in the care of leprosy patients and in the leprosy control programme in Shandong province, the People's Republic of China. And then we analyzed the present situation of leprosy-affected people living in these leprosy villages/leprosaria, using the information collected from a questionnaire-based survey. Finally, we made some suggestions and recommendations for policy makers concerned and leprosy control managers, in order to improve the present situation and better use of exiting resources

     

    OSA 20

    O ESTIGMA NA REALIDADE INTRAFAMILIAR DO ADOLESCENTES COM HANSENÍASE
    Maria Francelina dos Santos; Zulene Maria de Vasconcelos Varela
    Centro de Dermatologia Dona Libânia - SESA- CE.
    Rua Pedro I, 1033 - Centro Fortaleza - CE.

    Objetivou-se como o estigma se expressa na realidade intrafamiliar do adolescente portador de hanseníase, com incapacidade física, manchas visíveis, hiperpigmentação pelos efeitos colaterais da clofazimina e suas reações desde o diagnóstico até a alta. A pesquisa foi realizada no Centro de Saúde D. Libânia - Fortaleza - Ceará. Entrevistaram-se 22 adolescentes de 13 a 21 anos. Os procedimentos envolveram entrevistas, grupos de encontro e consulta aos prontuários. Referencial Teórico usado - Modelo de Kübler-Ross (1920). Percebeu-se a presença do estigma subjetivo e intrafamiliar centrado em alguns familiares; estigma social em parentes/contra-parentes, vizinhança e escola. Cinco dos entrevistados apresentaram idéia de suicídio, abandonaram estudos e emprego. Das falas emergiram 3 eixos temáticos com temas e sub-temas: HANSENÍASE E SEUS SIGNOS (manchas e neu-rites: abominação do corpo, vergonha, deterioração da auto-imagem, estigma subjetivo). HANSENÍASE: REAÇÕES PÓS-DIAGNÓSTICO (Reação dos adoleseantes: estágios de Kübler-Ross negação, raiva, isolamento, depressão, barganha e aceitação. Reação dos conviventes: apoio, proibições, estigma familiar; Reação do Grupo social: estigma social): HANSENÍASE: ESPACIALIDADE E TEMPORALIDADE (processo de diagnóstico tratamento - expectativa de alta, alta) Conchu-se que os adolescentes necessitam de suporte psico-sócio-sanitário para enfrentar a doença em todas as manifestações e aderir ao tratamento para evitar a emergência e incapacidade tísicas, o que pode afastá-lo da convivência social, da escola e do trabalho. Sugere-se formar grupos de auto-ajuda, promoção da auto-estima, combate aos estágio depressivos que possam levar ao abandono do tratamento e depreciação da imagem corporal.

     

    OSA 21

    O IMAGINÁRIO RELIGIOSO DE PACIENTES DE HANSENÍASE
    Andre Gonçalves Mellagi; Yara Nogueira Monteiro
    Instituto de Saúde (SES/SP). Rua Santo António, 590 (Núcleo Memória). 01314-000 - São Paulo - SP. tel: (11) 32092849. E-mail: andregm90@hotmail.com

    O foco da pesquisa são as relações entre a religiosidade tio paciente portador de hanseníase com o processo saúde-doença. Como a hanseníase ainda se vê mesclada dos preconceitos e medos em torno da "lepra", estigmatizada desde os tempos bíblicos, este estudo tem por finalidade compreender as características destas relações a partir do mundo vivenciado pelos hansenianos, tanto pelos que tiveram este mundo limitado pelas instituições asilares da primeira metade do século XX quanto pelos hansenianos que são hoje tratados pela terapêutica vigente. Elaboramos dez entrevistas semi-estruturadas, cinco com ex-internos e cinco com atuais hansenianos, além de cinco questionários com profissionais que atendem portadores de hanseníase sobre as influências da religião no tratamento dos pacientes. Observamos que a religião possui diversos papéis diante da situação de doença de acordo com a história que o indivíduo traça. Os ex-internos freqüentavam a religião institucionalizada imposta pela gerência asilar, ao mesmo tempo em que exerciam sua religiosidade mais particular diante das questões próprias da doença e do mundo em que viviam, mesmo este confinado pela instituição total. Os atuais hansenianos sentem o peso do estigma da hanseníase na impossibilidade de comentar a doença ao grupo religioso ao qual pertencem, salvo os casos onde houve a necessidade de esclarecê-la aos membros do grupo. A religião pode tanto dar respostas ou servir de refúgio, fornecer meios de enfrentamento ou mudar os hábitos. Os profissionais de saúde assinalaram a confiança na reabilitação e ajuda da comunidade religiosa como aspectos positivos da religião e o abandono do tratamento e a culpa como aspectos negativos.

     

    OSA 22

    O SIMBOLISMO DA HANSENÍASE NA VIDA DAQUELES QUE A VIVENCIAM
    Prisla Ücker Calvetti; Maria da Graça Raimundo; Marisa Canipio Muller; Letícia Eidl
    Ambulatório de Dermatologia Sanitária de Porto Alegre. Endereço Completo: Av. Azenha. 165 / 207 -Porto Alegre/RS- Brasil 90160-000

    A Hanseníase é uma doença milenar carregada de estigma e preconceitos desde os mais remotos tempos. O presente trabalho leve como objetivo desvelar quais as repercussões e o simbolismo desta doença na vida daqueles que a vivenciam. Utilizando para tal, uma abordagem qualitativa fundamentada na fenomenologia. Participaram do estudo seis pessoas com a doença Hanseníase em idade compreendida entre 57 e 75 anos, de ambos os sexos, moradores no Hospital Colônia Itapoã na cidade de Viamão, antigo centro para internação e tratamento da doença de Hansen, no Estado do Rio Grande do Sul, Brasil. O instrumento utilizado foi a entrevista semi-estruturada com uma questão norteadora central: "Qual o significado da Hanseníase na sua trajetória de vida?". A entrevista gravada foi posteriormente transcrita para a aplicação do método fenomenologia). A análise dos dados revelou os sentimentos e experiências destas pessoas em relação a Hanseníase como sendo um processo de crescimento pessoal muito importante em suas vidas. Dentre os relatos, destacou-se o sofrimento pelo afastamento das pessoas devido ao medo do contagio, porém, muita força e luta marcaram a superação da doença

     

    OSA 23

    O SUJEITO E A HANSENÍASE
    Rosângela Alves de Carvalho Patrício
    Instituto de Especialidades de Mato Grosso - Ambulatório de Dermatologia Sanitária - Secretaria de Estado da Saúde. Av. Rubens de Mendonça. 1826, sala 806. Bairro Bosque da Saúde. Cuiabá-MT. Telefones: (065) 642-4405 / 613- 2689 / 9982-4606

    Afinal, quem é o sujeito portador do mal de Hansen? Ele é um sujeito, sr. ou sra, fulano de tal. ou é um hanseniano? A questão que pretendo polemizar, se é que isso e possível, é: - qual é o estatuto de sujeito assujeitado ao mal de Hansen? Quando ouço dizer sobre "analisar o perfil" ou fazer um "estudo sobre a personalidade" dos hansenianos percebo aí uma visão comportamcnialista e unilateral desse sujeito. A patologia passa então a defini-lo, dando-lhe uma condição única de existência: um SER de hanseníase. E tudo passa a girar em torno desse mal avassalador (avassala-dor).Tenho observado cm alguns casos que há um histórico, anterior ao diagnóstico, de alguma dor emocional, decepção ou raiva, que fez apresentar os sintomas que, posteriormente, foram identificados com hanseníase. Os pacientes reagem contra esse mal como se precisassem atacar o inimigo, e na maioria tias vezes sentem-se impotentes diante de tanta crueldade que esse mal causa. É como se o mal de Hansen encarnasse uma entidade mobilizadora que sugasse, que ceifasse a existência deles, roubando-lhes até mesmo a dignidade. Raiva, dor e hanseníase passam a ser sinônimos para dizer o quanto a vida é injusta, o quanto são desgraçados (e o são!) e o quanto a vida lhes deve. Sentem dó de si mesmos e se vitimizam do próprio sintoma, acontecendo o que Freud chamou "ganho secundário".

     

    OSA 24

    PARTICIPATION RESTRICTION: A QUALITATIVE STUDY OF INTEGRATED AND VERTICAL APPROACHES TO LEPROSY.
    Shobha Arole; Ramaswamy Premkumar; Raj Arole; Mathew Maury; Paul Saunderson.
    Comprehensive Rural Health Project. Jamkhed -413 201, Maharashtra. India.

    Background: Integration of leprosy into the general health system is very much emphasized by health care planners. One prime reason stated for this is to reduce participation restrictions that are attached to this disease. This study was conducted in India, to compare the level of participation restriction towards leprosy in communities with a vertical and an integrated programme.
    Methods: The data were collected in three areas of live villages each. The first two areas were in an integrated programme to test for internal consistency and the third in a vertical programme. All the leprosy patients with visible deformities in these villages were enrolled in the study, and an in-depth participation restriction measurement scale was administered. In addition, focus group discussions (FGD) were conducted among the family members of leprosy patients and participative rural appraisal (PRA) was done in the communities. The data were analysed using qualitative methods.
    Results: A total of 24 leprosy patients with visible deformities participated in the in-depth participation restriction measurement exercise from 15 villages. 15 FGDs were conducted with families of leprosy patients and an equal number of PRAs with communities were done. The results show that participation restriction was virtually non-existent among the communities with the integrated approach and minimally experienced by leprosy patients in this model. However, a high level of self-stigmatization among leprosy patients was observed in the vertical approach and equally a high level of participation restriction was found in their communities, which led to reduced interaction between the leprosy patients and their communities. This presentation also discusses the integrated community based - primary health care adopted in the study villages.

     

    OSA 25

    PSYCHIATRIC MORBIDITY AMONG LEPROSY PATIENTS IN NEPAL
    Sakalananda Shrestha; Niru Shrestha; Sanju Ruchal; Ruth Butlin; R. Jonathan Quimpo; Wim Theuvenel; Paul Roche; Murdo Macdonald
    Anandaban Leprosy Hospital, PO Box 151. Kathmandu. NEPAL. E-mail: anandaban@mail.com.np

    Aim: To assess the psychiatric and social problems caused by the stigma associated with leprosy, and to measure the extent of these problems.
    Methods: In 1991, more than 400 Nepali leprosy patients were interviewed using a WHO self-reporting questionnaire (SRQ20), designed to delect non-psychotic disorders. The questionnaire was supplemented with questions about the patient's family and social situation. The same questionnaire was used in interviews with 150 leprosy patients in 2000/01. In addition. 166 non-leprosy affected people were interviewed to assess the levels of psychiatric stress in the local population.
    Results: Psychiatric morbidity in this assessment is indicated by a score of greater than 11 of 20 in the SRQ20. The 1991 data showed a low but significant level of menial health problems among leprosy patients, and identified significant factors predisposing to psychiatric "stress". Our results indicate an increase in the psychiatric morbidity among leprosy patients in the 10-year period between the assessments using the SRQ20, from 16% (67/411) in 1991 to 31% (46/146) in 2001. Interestingly, non-leprosy affected individuals assessed on our study also appeared prone to high levels of psychological stress, as indicated by their scoring highly in the SRQ20.
    Conclusions: While the perceived 'curability' of leprosy and the decline in deformity undoubtedly improved individual and social acceptance of the disease, leprosy patients remain vulnerable to psychiatric morbidity and depression

     

    OSA 26

    REHABILITATION IN THE EYES OF INSTITUTIONALISED LEPROSY PATIENTS
    Kishore Landae
    National Organization For Community Welfare. 8, Srinivas Colony. Wardha (Maharashtra) India

    There are thousands of leprosy patients staying in colony today and new patients are also coming to the colony for their rehabilitation. This fact is disturbing in connection with the community-based rehabilitation of leprosy patients.
    In this direction a study is undertaken to know the opinion of Institutionalized leprosy patients in nine Districts of Vidarbha Maharastra India. A data is collected from 175 Institutionalized leprosy patients and analyzed. In this study, the knowledge of leprosy patients their experiences in the families anil with society, the reasons for their rehabilitation from normal social environment, their opinion about their rehabilitation their educational economical and own status in the family and Society etc. such factors are studied in detail
    However, it is also found that not only old or deformed patients are settled in colony but the patients with no visible deformities are also coming today in colony for stay and this is disturbing. It is also found that qualified patients have more psychological problems and today on the verge of elimination the patients are facing familial social physical economical psychological and medical problems. These patients have no hope about their acceptance in the family and society as one of them and don't believe that the concept of community-based rehabilitation will be seen in reality in future completely

     

    OSA 27

    SELF HELP GROUPS OF PEOPLE WITH DISABILITIES IN NEPAL-AN EVALUATION
    Chhabi Gaudel; Karen Baxter; Mukti Sharma
    Partnership For Rehabilitation. INF-RELEASE, PO BOX 28, Pokhara, Nepal

    Partnership For Rehabilitation is a socio-economic rehabilitation programme of the International Nepal Fellowship, based in Pokhara, Nepal. The programme has been working with people affected by leprosy for over 20 years. In 1997. PER started to establish self-help groups of people with disabilities with dual aims of the improvement of the economic status of the members and improvement in social participation. Most group members were affected by leprosy, but people with other disabilities were also included. The format of the self-help groups was based on UN ESCAP guidelines [1991], and included the principles of a comprehensive model of disability and methods of introducing micro credit schemes. However, the functioning of each group has varied in response to priorities set by the group members.
    The first three groups set up in three communities of western Nepal have completed four years of operation ami the outcome of the initiative has been evaluated.
    The evaluation had two parallel aims:
    1) To evaluate progress against the objectives set by PFR prior to group establishment.
    2) To assess the current ability of disabled people, their families and communities to include people with disabilities into the communities represented by the self-help groups.
    The results of the evaluation, which uses qualitative participatory techniques including focus group discussions and indi\ idual interviews with group members and community leaders, will be presented.

     

    OSA 28

    SOCIETY'S ATTITUDE TOWARDS REHABILITATION OF LEPROSY AFFLICTED AFTER 2000 A.D.
    R.B. Dole; Kishor Landge; M.D. Deshpande
    Gandhi Memorial Leprosy Foundation. Ramnagar Wardha (Maharashtra State) India

    In connection with leprosy programme, India is trying to achieve the goal of elimination of leprosy in the country. In coming years the case load may be reduced but as long as leprosy is there leprosy afflicted persons may have to face social problems. Therefore, it is the real difficult task to change the attitude of the society in general towards leprosy afflicted. In this direction a study is undertaken and data is collected from various personalities having different qualificational status, age group and occupations. A questionnaire was designed and information about their knowledge, attitude towards acceptance of the patients, their involvement in social and religious programmes, their rehabilitation etc. is collected. The data is tabulated and analysed.
    It is observed that there are still 35% people who have shown negative attitude. They have shown their inability to accept the material prepared by leprosy afflicted and 15% have suggested to keep leprosy patients away from normal social environment.
    It is most surprising to receive such opinions from general public on the verge of elimination of leprosy, which are indicating to have need of continuous and consistent efforts on health educational programmes especially for many years in future.

     

    TEACHING & TRAINING-ORAL

    OT&T 1

    A ATUAÇÃO DO PRECEPTOR DE ENFERMAGEM DO PSF/SOBRAL NO PROCESSO DE DESCENTRALIZAÇÃO DAS AÇÕES BÁSICAS EM HANSENÍASE.
    Bezerra, Francisca Marlene de Sousa; Flor, Sandra Maria Carneiro; Barreto, Ivana Cristina de Holanda Cunha; Andrade, Luis Odorico de
    Secretaria de Desenvolvimento Social e Saúde de Sobral.

    A atuação da preceptoria de enfermagem do PSF de Sobral, iniciou-se no processo de descentralização das ações básicas de hanseníase, para as 35 equipes do Programa Saúde da Família em 25 unidades, por acreditar que um dos fatores que impede a eliminação a eliminação da hanseníase é a dificuldade de acesso às pessoas doentes e profissionais capazes de realizarem o manejo dos casos.
    Em agosto de 1999, iniciou-se o processo de descentralização da atenção às pessoas atingidas pela hanseníase para os Centros de Saúde da Família de Sobral, município, com uma prevalência de 11,9,alta endemicidade.
    Na efetivação da descentralização da atenção básica aos casos de MH, as seguintes iniciativas foram tomadas pela preceptoria de Enfermagem: 1) a análise do banco de dados do SINAN, com distribuição dos 285 casos ativos por área de residência e vinculação com o Centro de Saúde da Família (CSF); 2) organização de livros de registro de casos por CSF; 3) entrega dos prontuários individuais por área de residência e vinculação a cada CSF; 4) acompanhamento semanal do atendimento aos casos em conjunto com a equipe do PSF através da preceptoria de enfermagem da RSF; 5) realização do I Encontro de Usuários e trabalhadores para eliminação da Hanseníase.
    Como atividades de suporte para a descentralização e preceptoria, foram realizados treinamentos para capacitação das equipes- PSF, mobilização social c/ resadeiras e benzedeiras, I encontro de usuários e trabalhadores e a criação do núcleo do MORHAN.
    Como resultado observamos uma queda na taxa de abandono ao tratamento e aumento na proporção de casos detectados pelas equipes do PSF, envolvimento de familiares e comunidade com a preocupação de eliminar hanseníase de suas respectivas áreas.

     

    OT&T2

    ALERT's ORGANIZATIONAL CHANGE! WILL IT SUSTAIN INTERNATIONAL TRAINING FUNCTIONS?
    S.A.R. Krishnan.
    All Africa Leprosy, Tuberculosis and Rehabilitation Training Centre (ALERT), PO.Box 165, Addis Ababa, Ethiopia.

    All Africa leprosy, tuberculosis and rehabilitation training centre [ALERT] started its activities in 1965 in Princess Zenebework's Hospital in an old leprosy settlement from the beginning of 20th century at AddisAbaba, Ethiopia. ALERT constituted three major divisions: training division, leprosy and tuberculosis control division, and the hospital division. The TBL control division was taken over by the government and the control programme was integrated into the general health service. At present the International training division is being changed into a 5 years project. The purpose of this study is to have a holistic view of the organizational change and its impact with an aim of sustaining the international training functions. All available information was collected and analyzed from the board meeting minutes, annual reports, annual budget financial returns and annual training brochures. The changes made in the organizational goals, structure, responsibilities, authorities, the process of organizational change and the probabilities of sustaining the organization's international training functions will be discussed.

     

    OT&T 3

    ANALYSIS EFFECTS OF INTEGRATIVE TRAINING PROJECT OF LEPROSY CONTROL AND COMMUNITY CONTROL
    PAN Chunzhi1; XU Chunmao2; NU Jianping3; WU Jing3

    1. China Leprosy Association, 100055. Beijing, China.
    2. Gansu Control Disease Centre, 730030, Lanzhou, China
    3. Qinghai Leprosy Association. 810000, Qinghai, China..

    Objective: To analysis effects of leprosy control and community control training in Gansu, Qinghai, Shanxi, Xinjiang Province, which have subsidized from Holland Leprosy Association in recent years, discuss new mode fitted for stability development of Chinses leprosy control in low epidemiological phase.
    Method: The information come from Leprosy Control Association of Chinaj's work summary and training acceptance report 1 year later which have executed Integrative training of leprosy control and community control in Hanzhong prefecture of Shanxi, Gannan prefecture of Gansu.Yushu and Tongren prefecture of Qinhai,Hetian prefecture of Xinjiang from 1999 to 2000, more 2000 members of common medicine staff which receive integrative training project in three step sanitation control net from eounty.town.burg, which grasp knowledge of leprosy control and make use of practical work and carry through leprosy control in these regions,will go on synthesis analysis.
    Results: The training staff have already achieved average SO score in elemental knowledge of leprosy control via intensive training a day (The intensive training is average 30 to 40 score ago).
    Conclusion: At present,our country have already been better sane medical sanitation control net of community.the many leprosy patients have still been mistaken and leaked diagnosed, the disabilities rate of leprosy in newly detected cases is still high from 20 to 40%,which shows many medicine staff in grass-root control net can not quite understand control know ledge of leprosy.We should make the best of medcial staff; role in three step of control net.and strenghen popularity knowledge of science in community group,should be possible to diminish mistaken and leaked diagnosis rate.Early detect,diagnosis.treatment of leprosy will conduce control infection and prevention disabilities.Meanwhile, we are possible to eliminate terrible and prejudice of community group to leprosy patients,and will mobilize everyone taking active part in caring action of leprosy patients.
    [Key words] leprosy control and community control; training;effects analysis.

     

    OT&T4

    CAPACITY BUILDING OF GENERAL HEALTH CARE FUNCTIONARIES IN LEPROSY-AN ENTRY POINT FOR ELIMINATION.
    Murugesan. N. Dr1; Tamil Nadu, India2; Mahniood. K. Dr.2

    1. State Project Co-Ordinator, DANIDA/DANLEP
    2. State Leprosy Officer. Tamil Nadu

    Integration of leprosy services with General Health Care (GHC) system is the only alternative to provide comprehensive medical services under one roof and to eliminate leprosy. For realizing this objective, the GHC functionaries have to be fully trained to have adequate skills in- diagnosis of leprosy and classification, treating a case with adequate Multi Drug Therapy (MDT) regimen, managing complications, stocking of adequate drugs, giving information to people on simple facts about leprosy, educating patients on regularity of treatment and sensitizing and involving community members, local volunteers, special groups and leaders in all leprosy elimination efforts, monitoring the programme through simple patient card, treatment register with simplified reporting system.
    With a remarkable decline in Prevalence rate from 118/10,000 ( 1983) to 7/10.000 (1997).
    Tamil Nadu State integrated leprosy with general health care system.
    In order to equip the GHC functionaries at various levels a core group was formed at the state level with clear terms of reference to work on. They are assigned with the following lasks: to define the job responsibilities of various staff, to design curriculum for different functionaries as per job responsibilities, to develop training support materials for various categories. The outcome of the core group was very productive.
    Cascade method of training was followed to cover the entire state in a short period. Functionaries from district down to the periphery were trained as per the time frame.
    This paper highlights the training methodology, number of personnel trained, duration of training, contents, training methods and media and the training outcome.

     

    OT&T5

    LEPROSY TRAINING IN THE CHANGING SCENARIO
    P. Sarkar; Dr. V.V. Dongre
    Gandhi Memorial Leprosy Foundation. Ramna-gar.Wardha (Maharashtra State) India.

    The changing scenario has created a need for reorganisation of the existing training programmes in leprosy and also introducing new training courses according to the need of the situation. Seventyfive persons belonging to various categories such as, experts, programme managers, field workers in leprosy including general health staff responded through a mailed questionnaire and also through personal interviews. We intend to analyse their opinions in this paper regarding the training needs, duration of training, contents and syllabi and such other factors to impart systematic and effective training to various categories of workers for successful integration of leprosy work with general health services.

     

    OT&T 6

    REVIEW OF KNOWLEDGE AND SKILLS OF TRAINED HEALTH WORKERS IN THE CENTRAL REGION OF NEPAL
    Madan Ghimire; Jonathan Quimpo; Gopal Pokhrel; Uddhav Raj Pant; Ram Babu Bista; Kapil Dev Neupane and Rewali Tilmilsina
    Anandaban Leprosy Hospital, PO Box 151. Kath-mandti. NEPAL. E-mail: anandaban@mail.com.np

    The Leprosy Mission-Nepal provides training to Basic Health Services (BHS) staff of Nepal's Central Region (CR) using a standard curriculum-based course (CLT-B) and a refresher (CLT-R). A systematic post-training evaluation using a standardised checklist was used from July 2000.
    Aim: To assess the levels of post-training core knowledge and skills of BHS staff trained at the Training Centre at Anandaban Leprosy Hospital.
    Methods: A post-training evaluation was done in selected Central Region districts, using the same standardized post-training checklist, enrolling a total of 150 staff. Knowledge was assessed by interview and skills by demonstration of procedures. Analysis was done using Epi Info 2000.
    Results: Knowledge and skills were correlated with 3 variables: (a) years interval between training and evaluation (1-8 yrs); (b) whether they dealt directly with patients post-training (DP+) or not (DP-); and, (c) whether they had CLT-R (R+) or not (R-). Results suggest a decrease in knowledge and skills as the time interval widened (knowledge: 1 yr. (A)= 50% to 8 yrs (H)= 14.3% (p= 0.53)); skills: A= 20% to H= 7% (p= 0.38)). Those dealing with patients appeared to do better (knowledge DP+= -38%, DP-= 20%: (p= 0.13); skills: DP+= 17%, DP-= 3% (p = 0.32)). Those who had CLT-R appeared to do better (knowledge: R+= 47%, R-= 30% (p=0.018); skills: R+= 12%. R-=4% (p= 0.12)).
    Conclusions: This study will help in the planning of future courses, with particular attention to the need, content, timing of refreshers, and the qualifications of participants for each course batch

     

    OT&T 7

    TRAINING IN CHANGING CIRCUMSTANCES:
    S.A.R. Krishnan
    All Africa Leprosy. Tuberculosis and Rehabilitation Centre. ALERT, P.O.Box 165, Addis Ababa, Ethiopia.

    All Africa Leprosy Tuberculosis and Rehabilitation Training Centre (ALERT) initiated Leprosy teaching and training during the early 70's to develop manpower to light against Leprosy in Africa and the rest of endemic countries in the world. Since then many changes in training have taken place at ALERT.
    The aim of this study on "Training in changing circumstances" is to observe changes, made in various training related issues by using Alert's annual international training calendar from 1991 till date, statistics on International and National trainee weeks, changes made in training programmes which were offered by ALERT in the past and to plan future training.
    The results of the study shows significant changes made in international and national courses, increased the number of trainees weeks in all structured international courses, gradual decrease in all international in service training programmes and a very significant increase of participants in national courses etc. The study relates the present institutional changes in order to challenge and take advantage of the changing circumstances and to improve the international training within and outside ALERT

     

    TREATMENT

    OT 1

    A COMPARISON OF 12 AND 24-MONTH MDT/WHO REGIMENS WITH MULTIBACILLARY LEPROSY PATIENTS
    Sales. A.M; Sabroza, P.C.; Nery, J.A.C.; Duppre, N.C.; Fialho, M.B.; Gallo, M.E.N.; Sarno, E.N.
    Leprosy Laboratory. Oswaldo Cruz Foundation. Rio de Janeiro. R. J., Brazil.

    Introduction: The adoption as of 1982 of a standard, fixed-duration, multidrug therapy regimen under the recommendation of the World Health Organization (MDT/WHO) requiring 24 consecutive monthly doses of MDT followed by patient discharge regardless of Bacteriologic Index (BI) was a landmark step in controlling leprosy worldwide. Over time, however, it was seen that duration of treatment proved to be an obstacle for the public health care sector. Short treatment regimens allow for easier patient compliance and, perhaps even more importantly, facilitate the implementation and sustainability of national leprosy programs. Based on a growing body of evidence, in 1998. WHO recommended that MDT be reduced for multibacillary (MB) leprosy patients to 12 instead of 24 monthly doses.
    Objective: To ascertain and compare the bacillary load, grade of disability, and frequency of reactions of a group of MB patients who received 12 monthly doses of MDT to a group who received the full 24-dose regimen and compare both at both the end of one year and the end of two years.
    Material and Methods: 213 MB patients who began MDT between 1995 and 2000 were evaluated. Eighty-five patients received the full 24-dose regimen while 128 received treatment for 12 months. The latter group was then examined at the end of the following year. All patients were submitted to clinical and dermatológical examinations at the beginning of treatment and at the end of the 12 and 24-month periods, at which time grade of disability and Bl were also determined.
    Results: At the end of 24 months, the rate of BI decline was almost identical for both groups. Moreover, reactional episode frequency was not significantly different between the two groups.
    Conclusion: A reduction in treatment from 24 to 12 monthly doses of MDT did not prejudice BI status in that it similarly declined in both groups of MB patients, and the frequency rate of reactional episodes remained stable.

     

    OT2

    ANT1LEPROSY ACTIVITY OE SOME DERIVATIVES OF DITHIOCARBAMATE
    G. Urlyapova; A.D. Daudova
    Leprosy Research Institute, Astrakhan, Russian Federation

    Despite effective antileprosy drugs available and success of multidrug therapy, searches for new drugs with potent antimycobacterial activity remain to be continued. In mice, experimentally infected with M. leprae according to Shepard's method, compounds belonging to a group of dithiocarbamates were investigated for their antileprosy activity. Untreated animals were taken as controls, and DDS as a drug of comparison. Test compounds were introduced per os via probe at doses of 10 and 30 mg/kg five times a week. Mice were sacrified in 7,5 months after inoculation. M. leprae counts in soft tissues of foot pads (C.C.Shepard. D.H.McRae, 1968) were (3,91 0,33) × 105 in control animals. (0,27 0,07) × 105 in mice taken dapsone at 10 mg/kg and (0,22 0,04) × 105 in mice received 30 mg/kg, the difference being statistically significant (p<0.01 ). Amount of M. leprae in soft tissues of foot pads from animals received compound 1 10026127 at a dose of 10 mg/kg equaled (0,56 0,1l) × 105. With 3-fold increase of the dose of the compound average number of mycobacterial cells decrease ten times, and mycobacterial population counted (0,06 0,01) × 105 (P<0,01). In mice administered compound 1 10026068 at a dose of 10 mg/kg the number of M. leprae was significantly less than in control animals (0,83 0,15) × 105 (p<0.0l) but higher than in animals introduced dapsone and compound 1 10026127. Three times increase of the dose did not result in decrease of M. leprae amount at the site of inoculation (0,77 0,1) × 105. Average number of mycobacteria in foot pads of mice received compound 1 9926126 at a dose of 10 mg/kg was (2,13 0,28) × 105 and at a dose of 30 mg/kg - (1,83 0,2) × 105, being significantly less than in control group (p<0.01) but more than in animals received other compounds and dapsone. Thus, the data obtained suggest good prospects of further study of the above compound for antileprosy activity. Among test compounds belonging to dithiocarbamates 110026127 showed the highest activity to inhibit mycobacterial growth.

     

    OT3

    AVALIAÇÃO DA SEGURANÇA, EFICÁCIA E COMPARAÇÃO DE DOSES DE TALIDOMIDA, ADMINISTRADA POR DUAS SEMANAS NO TRATAMENTO DO ERITEMA NODOSO DA HANSENÍASE (ENH)
    Gerson Oliveira Penna; Celina M.T Martelli; Mariane Stefani; Vanize de Oliveira Macedo
    Universidade de Brasília em parceria com a Universidade Federal de Goiás com apoio da Celgene Corporatio

    Os autores apresentarão e discutirão o protocolo da investigação, aprovado pelo Comitê Nacional de Ética em Pesquisa (CONEP) do Ministério da Saúde, que está sendo desenvolvido em Goiânia e Manaus. Serão enfatizados na discussão os critérios de inclusão, de exclusão, as vantagens do uso da talidomidy em detrimento dos corticosteróides, e sobretudo as perguntas que se buscam responder a partir desse protocolo.

     

    OT4

    CLINICAL PROFILE OF PATIENTS EXHIBITING DRUG RESISTANCE TO MDT DRUGS
    Geetha S. Rao; Gift Norman; Gigi J. Ebenezer; Sheela Daniel; P.S.S. Rao
    Schieffelin Leprosy Research and Training Center, Karigiri. India

    The multidrug therapy (MDT) recommended by the World Health Organization for the treatment of leprosy was designed to prevent emergence of drug resistance, while providing shortened and affordable treatment required in developing countries. Emergence of drug resistant strains of Mycobacterium leprae could undermine current gains toward global elimination of leprosy. Twenty years after MDT has been in use, there is very little information on the profile of resistance to drugs used in the present MDT regimen. The Schieffelin Leprosy Research and Training Centre (SLRTC), Karigiri has carried out comprehensive leprosy control activities in an entire Taluk (Gudiyatham) since 1955. The institution has facilities to study drug resistance using mouse footpad inoculation (MFP). It receives skin specimens not only from the control area, but from other institutions as well. In a period 1988 - 1998, 122 biopsies from patients belonging to the control area were sent for drug resistance studies using MFP. Of the 122 biopsies 21 (17%) showed drug resistant strains. Of these, 10 (47.6%) were resistant to Dapsone alone and 2 (9.5%) were resistant to Clofazimine alone and 2 (9.5%) to Rifamipicin alone. Five patients (23.8%) were resistant to both Dapsonc and Clofazimine and 1 (4.8%) to Rifamipicin and Clofazimine and 1 (4.8%) to Rifampicin and Dapsone. Of the 21 showing drug resistant strains, 9 (42.9%) exhibited primary drug resistance and 12 (57.1%) secondary resistant strains. The demographic information, treatment history and current clinical status of the above patients will be presented.

     

    OT5

    COMBINED 12 MONTHS WHO MDT MB REGIMEN AND MYCOBACTERIUM w VACCINE IN MULTIBACILLARY LEPROSY: A FOLLOW UP OF 136 PATIENTS
    Bhushan Kumar; Inderjeet Kaur; Sunil Dogra; B. D. Radotra Department of Dermatology, Venereology & Leprology and Department of Pathology*
    Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.

    Multidrug therapy (MDT) was introduced in the treatment of leprosy in 1980s which lead to a significant change in leprosy scenario at the global level. The success with MDT administered to the MB patients has encouraged leprosy experts to shorten the regimen from 24 months to 12 months. One hundred and thirty six multibacillary patients having BI > treated with WHO MDT MBR (12 months) on regular follow up were included in the study. Clinical assessment and slit skin smears were carried out in all the patients. At the baseline 69% patients had Bl of >3. All patients were also given 4 doses of Mw vaccine at 3 monthly intervals. All patients showed excellent clinical response. A large proportion of patients, 39/42 (92.8%) with BI of <3 had become smear negative, whereas, only 10/36 (27.7%) patients with BI between 3.1-4 and 5/58 (8.6% ) highly bacillated patients having initial BI of > 4 had become smear negative at the end of 2 years follow up. Thirty four percent of all reactional episodes and 27% of all nerve function impairments developed in the follow up period after slopping MDT. Relapse rate was 0.36/100 PYAR at 2 years and 1.38/100 PYAR at the end of 3 years follow up. All 4 relapses occurred in patients having initial BI of > 4. All the relapsed patients responded to the retreatment with the same drug combination. Dapsone hypersensitivity, induced urticaria and flu like syndrome were noted in 5. 3 and 1 patients respectively. Although the results of this limited period follow up are satisfactory, a long term follow up in larger number of patients will settle the issue of safely and efficacy of shortened MDT MB regimen and the place of immunotherapy with Mw vaccine in multibacillary patients

     

    OT6

    CYCLOSPORIN A (CYA) PHARMACOKINETICS IN ETHIOPIAN AND NEPALI PATIENTS WITH LEPROSY TYPE 1 REACTIONS (T1R).
    Sharon N.S. Marlowe; Terence D. Lee; Atholl Johnston; Diana N.J. Lockwood; David W. Holt
    Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, Keppel. Street, London, WC1E 7HT, United Kingdom.
    St George's Hospital Medical School, London, SW17 0RE

    Background: Levels of cyclosporin A (CyA) show high inter-and intra-subject variability as a result of poor oral absorption and also its hepatic metabolism.
    Genetic variation and the ability to metabolise CyA differently have been noted in some ethnic groups, but the pharmacokinetics of all ethnicities has not been elucidated.
    Aims: To assess inter- and intra- subject variability. To assess the pharmacokinetics of CyA in leprosy Type 1 reaction (T1R) patients. To determine an appropriate dose of CyA to be used. To identify any ethnic variation.
    Study: 10 Ethiopian and 10 Nepali patients with severe Tl R were recruited. All patients were started on CyA (Indian generic formulation) at 5mg/kg/day. 2 mls blood was taken at intervals (0, 0.5, 1.0, 2.0, 2.5, 3.0, 4.0, 5.0, 6.0, 8.0, 12 hours) after the first CyA dose.
    Analysis: Concentration of CyA was assayed by liquid-chromatography tandem mass spectrometry. The maximum whole blood concentration (Cmax ) and time of its occurrence (tmax ) was plotted graphically and the area under the curve (AUC) calculated.
    Results: The cyclosporinc Cmax ranged between 328 and 1734µg/L, the tmax varied between 1 and 6 hours and the AUC between 1831 and 9704µg/L.h. The mean Cmax, 935µg/L and AUC, 5000µg/L.h, and median tmax , 2.5h, were similar to those seen in transplant patients at a dose of 5mg/kg. Although variability was high, again it was similar to that of transplant patients immediately following the first dose.
    Conclusions: In this small number of Ethiopian and Nepali patients with leprosy T1R. cyclosporin pharmacokinetics are not markedly different from those seen in transplant patients.

     

    OT 7

    DAPSONE HYPERSENSITIVITY SYNDROME: SYSTEMATIC REVIEW OF DIAGNOSTIC CRITERIA
    Graziela Leta; M Esther dos Santos; M Leide Oliveira; M Katia Gomes
    Federal University of Rio de Janeiro

    The awareness of pharmacovigillance is increasing, even in undeveloped countries. In this context, the Dapsone Hypersensitivity Syndrome (DHS), an unusual but potentially serious side effect of dapsone (DDS) which is used in large scale for leprosy treatment, must be considered. Still, there is a consensus about the drug safety. In order to ascertain the diagnosis criteria, a world literature systematic review was done analysing reports from fifteen endemic countries since 1956 to 2001. The authors found 108 reported cases, 96.2 % occurred after 1980. From those, 57.4 % presented complete DHS symptoms -fever, rash, lymphadenopathy, and hepatitis - and 42.6 %, expressed an incomplete form. Fatal outcomes were 12.96 % of the total. An intriguing point is the 9.6% rate of mortality within the group which fulfills the criteria of complete DHS (6/62 patients) and the fact that no statistical association to death or hepatic injury can be attributed. This may express the poor quality of the information collected and reinforces the importance of its reliability.

     

    OT8

    DOUBLE RELAPSE AFTER TREATMENT WITH RIFAMPICIN-CONTAINING MULTIDRUG REGIMENS AMONG MULTIBACILLARY LEPROSY PATIENTS
    Samba O. Sow; Abdoulaye Fomba; Issa Traore; Augustin Geudenon; Pierre Bobin; Jacques Grosset; Baohong Ji
    Centre National d'Appui a la lutte contre la Maladie du Mali (CNAM), BP 251, BAMAKO, MALI

    We present herewith 12 cases of multibacillary (MB) leprosy who had relapsed twice after treatment with various rifampicin (RMP)-containing multidrug regimens. Because these patients were derived from different cohorts, it is difficult to define the denominator for calculating the frequency of double relapse.
    Relapse was defined as followings: i) occurrence of definite new skin lesions and/or reactivation of preexisting lesions; and ii) the bacterial index (BI) at any single site was found to have increased by at least 2+ over the previous value, or the new lesions had a BI greater than that in any pre-existing but non-reactivated lesions.
    The durations of the first treatment with RMP-containing multidrug regimens ranged from a single dose to 2 ± 4 months. Patients began treatment with a mean BI of 4.2 ± 1.0. At the end of treatment, despite none of the 12 cases were BI negative, the BI continued to decline after stopping treatment and became negative in 9 cases after 5 ± 3 years of follow up. The first relapse occurred 6 ± 3 years after completion of treatment. The major clinical signs of relapse were occurrence of macules in 2 cases, diffuse infiltration in 4 cases, nodules and/or lepromas in 6 cases; with a mean BI of 4.1 ± 1.2. All relapses have been confirmed by histopathology, and viable M. leprae were demonstrated from skin biopsies of 10 cases by mouse foot pad inoculation; drug susceptibility test indicated that all 10 strains of M. leprae remained susceptible to RMP. All relapsed cases were retreated with WHO/MDT regimen for 24 months, and administration of the monthly doses was supervised at our institute. At the end of 24 months of treatment, none of the 12 cases were BI negative, but after 4 ± 2 years of follow-up, 8 of them became BI negative.
    The second relapse occurred at 6 ± 1.5 years after stopping treatment with WHO/MDT. The major clinical signs of relapse were macules in 3 cases, nodules and/or lepromas in 9 cases, with a mean BI of 4.3 ± 0.9. Again all relapses were confirmed by histopathology, and viable M. leprae were demonstrated in skin biopsies of 8 cases by mouse foot pad inoculation; all 8 strains of M. leprae remained susceptible to RMP. After the second relapse, all these patients were treated with another course of MDT for 24 months; they are being followed-up, and so far without any sign of relapse.
    The results clearly confirmed our earlier findings that MB relapse does exist, and in certain patients, they may even relapse more than once. The results also clearly indicate that after treatment with any RMP-containing regimen, the average incubation period of MB relapse is at least five years after stopping treatment; therefore, attempt to detect individual relapsed case and to define the magnitude of MB relapse, patients must be followed up with a minimum duration of five years after stopping treatment.

     

    OT 9

    DRUG RESISTANCE IN THE TREATMENT OF LEPROSY -STUDY IN THE RELAPSED CASES FOUND IN SANATORIA
    Masako Namisato; Mamoru Matsubayashi; Masaaki Higashi; Motoaki Ozaki; Masanori Matsuoka; Yoshiko Kashiwabara; Hideoki Ogawa
    National Sanatorium Kuryu-Rakusenen 647. Kusatsu-machi. Gunman-ken, 377L-1711, Japan
    Amagasaki Prefectural Hospital
    Leprosy Research Center, National Institute of Infectious Diseases
    Department of Dermatology, Juntendo University School of Medicine

    We studied 14 relapsed cases of leprosy that have once cured with various anti-leprosy drugs. Genomic DNA was prepared with M. leprae isolates harvested from skin biopsy samples. Mutations of genes involved in resistance to DDS, RFN and OFLX were examined. Mutations related to DDS-resistanee were found in 9 out of 11 cases, the same to RFP were found in 9 out of 11, and the same to OFLX were found in 2 out of 3. Seven cases had mutations related to 2 or 3 drugs. In many cases, these drugs were given with small dosage. No mutation was found in the cases without history of administration of particular drug(s). The method used in this study is considered to be a Unstable and effective to find drug-resistance. Application of simple molecular tests to assess the drug-related mutations in M. leprae may offer another strategy to the leprosy control in the endemic areas where the decrease in the new case incidence has not been apparent. (This work was supported by an Emerging and Remerging Infectious Disease Promotion grant from the Ministry of Health, Welfare and Labor in Japan.)

     

    OT 10

    EFICACIA DE LA PENTOXIFILINA COMO COADYUVANTE TERAPÉUTICO DE LAS VASCULITIS NECROTIZANTES EN REACCIONES REVERSALES (TI)
    Giménez, Manuel F.
    Centro Dermatológico. Ameghino 1205. (CP 3500) Resistencia- Chaco Argentina.

    Dentro de los episodios reaccionales (ER), la reacción Tipol conocidad con las denominaciones de reacción reversal (RR), reacción de reversa, reacciones limítrofes ó reacción dimorfa; predomina en enfermos de lepra dimorfa o borderline, usualmente "upgrading"; causadas por un incremento de la inmunidad mediada por células (CD4 activadas, elevación de IL2, y aumento de IFNã y del Factor de necrosis tumoral alfa(FNTá). Clínicamente se expresa por edemas aciales, infiltración de lesiones, aparición de lesiones nuevas, neuritis, neuralgias, disestesias y vasculitis necrotizantes. El daño neural se debe al edema, la infiltración del axón por el granuloma la trombosis de los vasa-nervorum y la fibrosis post-inflamatoria.
    El tratamiento convencional es continuar con la Poliquimioterapia (PQT) si aún no completó el esquema OMS, agregar precozmente corticosteroides y se han ensayado aumentar la dosis de clofazimina, también innumosupresores (azatioprina) y cielosporina A. La pentoxifilina (Ptx) se ha usado con éxito en la Reacción tipo 2 ENL y en el fenómeno de Lucio en Lepras difusas.
    Nosotros realizamos el tratamiento asociado de corticosteroides y Ptx en cuadros de severas vasculitis necrotizantes que aparecieron en el curso de reacciones reversales en lepras dimorfas y que no cicatrizaban con el uso convencional y prolongado de corticosteroides. Presentamos tres pacientes en los que utilizamos una dosis de 1200 mg diarios con una mejoría evidenciable en la cicatrización de las ulceras en las primeras 4 semanas de tratamiento. Paralelamente se observó un mejoramiento de la neuralgia. Los efectos inmunopatológicos de la Ptx justifican su uso en éstos cuadros

     

    OT 11

    ENSAIO TERAPÊUTICO: AVALIAÇÃO DA ASSOCIAÇÃO DE OFLOXACINA COM RIFAMPICINA POR 28 DIAS EM PACIENTE DE HANSENÍASE VIRCHOVIANA.
    João Carlos Regazzi Avelleira; Larissa Mitraud Alves; Francisco Reis Vianna; Alfredo Marques Boechat; Raul Negrão Fleury
    Instituto Estadual de Dermatologia Sanitária do Rio de Janeiro.

    Introdução: O esquema poliquimioterápico (PQT/ OMS) representou notável progresso na luta contra o M. leprae. Entretanto, novas drogas continuam sendo testadas, com o objetivo de aumentar a eficácia destes esquemas, e diminuir o tempo de tratamento. As quinolonas são derivadas do ácido nalidíxico, que tiveram atividade antibacteriana aumentada com a introdução de um átomo de flúor no anel quinoleico. Agem inibindo a enzima responsável pelo enovelamento do DNA bacteriano. A quinolona com melhores resultados contra o M.leprae, foi a Ofloxacina.
    Material e métodos: Paciente do sexo masculino, de 54 anos, que apresentava quadro clínico compatível com Hanseníase Virchoviana: face e pavilhões auriculares infiltrados, madarose, tubérculos disseminados, extremidades edemaciadas e com sensibilidade diminuída. A hipótese de Hanseníase foi confirmada pela baciloscopia positiva e histopatologia. Em regime hospitalar o paciente foi tratado por 28 dias com 400 mg de ofloxacina, e 600 mg de Rifampicina em dose diária supervisionada. Recebeu alta e passou a ser observado pela clinica, histopatologia e baciloscopicamente por um período de 2 anos, sem nenhuma medicação específica. Foi posteriormente foi introduzido no esquema PQT/MB/OMS.
    Resultados: A evolução do paciente mostrou, gradativa desinfiltração do tegumento, redução do tamanho e número dos tubérculos, acompanhado de baciloscopia decrescente, após a suspensão do tratamento, enquanto o índice morfológico mostrava ausência de bacilos íntegros.
    Comentários: O esquema Otloxacina e Rifampicina mostrou ação eficaz, contra o M. Leprae, apontando a possibilidade de que a associação entre as duas drogas possa potencializar a poliquimioterapia anti-hansenica

     

    OT 12

    LEPROSY PATIENTS DESERVE A PROPER FOLLOW-UP!
    Ben Naafs
    Dept. Dermatology Leiden University Medical Centre (LUMC) and IJsselmeerziekenhuizen Emmeloord/Lelystad, The Netherlands; Instituto Lauro de Souza Lima (ILSL) Bauru SP Brazil; the Regional Dermatology Training Centre (RDTC) Moshi. Tanzania: c/o Gracht 15 8485 KIN Munnckehuren. The Netherlands

    During a recent GAEL meeting it was proposed to treat all leprosy patients, independent of classification, with six months MB-MDT. It was suggested to hand out blister packs for six months at the time of diagnosis, cautioning the patient to report back when complications occur. From public health point of view it is essential that infectious leprosy patients are made non-infectious. The presently proposed treatment will certainly do so in over 95% of the patients, thus satisfying i nfectiologists.
    Nerve damage and as consequence deformities lead to the leprosy stigmata. In over 30% of the patients this damage will occur during and even after the proposed new treatment regime. The patient will be disappointed and the reputation of the leprosy control program damaged. However adequate treatment could have been instigated, provided a careful follow-up was available. To neglect such a follow-up and to believe that a patient after only one contact with the health worker will report back in time is at least naive. Simple methods of follow-up which can be handled by the peripheral health worker and which can detect early and treatable damage are available. In this presentation these will be presented.

     

    OT 13

    MANAGEMENT OF REACTIONS IN LEPROSY
    Ben Naafs
    Dept. Dermatology Leiden University Medical Centre (LUMC) and IJsselmeerziekenhuizen Emmeloord/Lelystad, The Netherlands; Instituto Lauro de Souza Lima (ILSL) Bauru SP Brazil; the Regional Dermatology Training Centre (RDTC) Moshi. Tanzania: c/o Gracht 15 8485 KIN Munnckehuren. The Netherlands

    Nerve damage leadingto impairments is still the major problem in the course of a leprosy infection. Were it not for this damage, leprosy would be a rather innocuous skin disease, whereas even today it is one of the most feared diseases, often associated with social repercussions. Since there is no change in the number of detected cases and if any, it is an increase, leprosy will remain one of the main causes of peripheral nerve damage. Nerve damage may occur before anti mycobacterial treatment, during treatment and even in patients released from treatment.
    In borderline leprosy (BT, BB and BL) such damage usually develops during a so-called reversal reaction (RR), type I leprosy reaction. When this happens, the peripheral nerve trunks at specific sites may become swollen and tender and may show deterioration of function, which is generally rather gradual, taking weeks or even months to become irreversible. Occasionally, severe nerve damage may occur overnight.
    In lepromatous leprosy (BL, LLs and LLp) the damage may take years to develop or may increase suddenly during a reactional episode, called erythema nodosum leprosum (ENL), type II leprosy reaction. Since lepromatous leprosy is a generalised disease other organs may be involved as well, skin, joints, lymphnodes, eyes, testicles, liver and kidney. The patient can be extremely ill and the reaction may become chronic.
    Reactions must be diagnosed early and treated appropriately if permanent disability is to be avoided. Ideally the reactions should not occur at all, being prevented by treatment. To achieve this, it is of utmost importance to understand the mechanisms behind reactional states and principles of management. This will be discussed, taking the latest developments in account

     

    OT 14

    OFLOXACIN BASED REGIMENS IN LEPROSY - LONG-TERM OBSERVATIONS
    R. Ganapati; V.V. Pai; C.R. Revankar; H.O. Bulchand; S. Kingsley
    Bombay Leprosy Project; Sion-Chunabhatti; Mumbai - 400 022, India

    The inclusion of Ofloxacin in regimens in leprosy for research trials (RO and ROM) and recommendation of ROM as a single dose for the treatment of PB Single Skin Lesion Therapy (SSL-PB) formed a landmark in the chemotherapy of leprosy.

     

     

    The pattern of clinical problems in the two groups indicates lack of any correlation between the problems encountered and the chemotherapy interventions adopted. All clinical problems including reactions are manageable. Relapse rate is less than the reported rates with PB-MDT.

     

     

    It ias already been documented that the rate of decline of BI after RO over 8 years is identical to MB MDT (WHO) administered for 24 or 12 months (Ganapati et al, 1997). Continued follow-up of a total sample of 189 patients confirms these observations.

     

     

    RO group is associated with relatively far higher risk of relapse than expected. The rates however compare favourably with those encountered in Tuberculosis.

     

    OT 15

    PANCITOPENIA OBSERVADA DURANTE POLIQU1MIOTERAPIA PARA MHD-T, REVERTIDA COM A SUSPENSÃO DA DAPSONA
    Ana Regina Coelho de Andrade; Andrea Machado Coelho Ramos; Marcelo Grossi Araújo; Marilda Helena T. Brandão
    Hospital das Clínicas da Universidade Federal de Minas Gerais. Alameda Alvaro Celso, 55 Santa Efigênia- Belo Horizonte MG CEP 30150-260. E-mail: adermato@hc.ufmg.br

    Relata-se a ocorrência de pancitopenia em paciente portadora de hanseníase dimorfo-tuberculóide, em tratamento com poliquimioterapia (PQT) esquema 2 (rifampicina, dapsona e clofazimina). A paciente fazia uso prévio de ácido valpróico, hidroclorotiazida e amilorida, enalapril, amitriptilina e diazepam. O quadro hematológico instalou-se subitamente, no segundo mês de tratamento, quando o hemograma revelou hemoglobina de 6,5g%, 48.000 plaquetas e o leucograma 4.900 leucócitos com desvio escalonado à esquerda com a presença de 10% de blastos. A PQT foi suspensa imediatamente, e não obstante a paciente tenha mantido o uso dos outros medicamentos, o quadro reverteu-se e na terceira semana já estava normalizado. A impressão diagnóstica foi de pancitopenia secundária a drogas, em resolução. Considerando os efeitos hematológicos da dapsona, foi reiniciada a PQT sem a mesma. O seguimento da paciente com hemograma mensal desde novembro de 2001 não ter) mostrado novas alterações hematológicas.

     

    OT 16

    PERSISTÊNCIA DE BACILOS EM PACIENTES DE HANSENÍASE MULTIBACILARES APÓS 12 DOSES DO ESQUEMA PQT/OMS. RESULTADOS PRELIMINARES
    João Carlos Regazzi Avelleira; Francisco Reis Vianna; Larissa Milraud Alves; Alfredo Marques Boechat; Suzana Madeira
    Instituto Estadual de Dermatologia Sanitária, Rio de Janeiro e Instituto Lauro de Souza Lima, Bauru, São Paulo

    Introdução: Recentemente o Ministério da Saúde, baseado nas conclusões da reunião de peritos em Lepra da OMS, recomendou que o esquema poliquimioterapico para tratamento da hanseníase, em pacientes multibacilares poderia ter sua duração reduzida para 12 doses.
    Material e métodos: Participaram do trabalho, 4 pacientes do sexo masculino, virgens de tratamento, com diagnóstico clinico, e confirmação baciloscópica e histopatológica de hanseníase virchoviana, realizado no ambulatório do Instituto de Estadual de Dermatologia. Todos os pacientes apresentavam índice baciloscópicos maiores que 5, com presença de bacilos íntegros, em todos os casos. Foi instituído em todos o tratamento com o esquema padrão PQT/OMS para Multibacilares (Rifampicina em dose mensal supervisionada, Dapsona e Clofazimina autoadministradas diariamente), com duração de 12 doses, que todos os pacientes concluíram em 12 meses. Ao término do tratamento foram retirados através de biópsia, material para inoculação em camundongos no Instituto Lauro de Souza Lima, Bauru/SP, conforme a técnica de Shepard.
    Resultados: Foi constatada a presença de crescimento de bacilos álcool ácido resistentes em apenas um paciente dos 4 que haviam sido inoculados.
    Discussão: Os estudos apresentados em que foram baseadas as recomendações para a diminuição da duração do tratamento, fundamentam-se principalmente na possibilidade que o novo esquema seja eficaz na grande maioria dos pacientes multibacilares. No entanto, é real a possibilidade de que entre pacientes com carga bacilar elevada, um grupo venha a recidivar. Uma melhor avaliação destes achados deverá ser realizada com o aumento da amostra.

     

    OT 17

    RELAPSES AMONG LEPROSY PATIENTS TREATED WITH 2 - YEAR MULTIDRUGTHER-APY.VIAB1LITY OF THE ORGANISMS AND DRUG SUSCEPTIBILITY.
    Maria da Graça S. Cunha; Suzana Madeira; Paula F. Bessa Rebello; Sumara N. Pennini.
    Fundação de Dermatologia Tropical e Venereología "Alfredo da Malta" Rua Codajás nº 24, Cachoeirinha - CEP 69.065-130, Manaus - Amazonas - Brazil.

    In this prospective study multibacillary (MB) leprosy patients were treated with 2- year multidrug therapy (MDT) and had been followed up for 8-10 years after released from treatment (RET). The relapse rate was the most important parameter for assessing the efficacy of the therapeutic regimen. The viability of M. leprae organisms and drug susceptibility had been tested whenever clinical relapse was detected.
    From 1987 to 1992, 424 MB leprosy cases where included. None of the patients had been treated previously and all had bacterial index (BI) of at least 2+ in any site. Relapse was suspected on the appearance of new lesions of multibacillary leprosy and if the BI at any site was found to have increased by at least 2+ over the previous value. The demonstration of viable M. leprae and drug susceptibility were tested by mouse footpad inoculation. Simultaneously the patients who relapsed had been retreated with the standard 2-year MDT for MB leprosy.
    Treatment was completed for 337 patients and during surveillance period 6 cases of relapse were detected. The relapse rate was 1.78% and the shortest interval between the end of MDT and the occurrence of relapse was 70 meses. The available results of drug susceptibility testing of the organisms recovered from the relapsed lesions were susceptible to both rifampin and dapsone. Clinical improvement was observed in all 6 patients and the mean BI continued to decline after patients had been retreated. No further relapses have been detected during the same period.

     

    OT 18

    RELAPSES IN MULTIBACILLARY LEPROSY AFTER 2 YEARS TREATMENT WITH WHO-MDT REGIMEN
    Cellona. R.V.; Balagon, M.F.; Dela Cruz, E.G.; Abalos. R.M.; Walsh, D.S.
    Leonard Wood Memorial Leprosy Research Center. P.O. Box 727. Cebu City 6000, Philippines.

    The objectives of this study are to determine the frequency of relapses in MB leprosy patients completing the 2 years WHO-MDT regimen and to determine whether the relapses that occur are due to drug-resistant or persister organisms using the mouse-footpad technique of Sheppard.
    500 MB leprosy patients who completed the 2 years WHO-MDT regimen were recruited sequentially and followed up. Duration of surveillance now range from 8 to 15 years. Surveillance includes yearly clinical examinations and skin smears. Criteria for probable relapse are the appearance of new/active lesions and an increase in Bl of at least 2+ at any site compared to the lowest Bl taken at the same site. Those with probable relapse are biopsied and tested for growth in mouse footpads to confirm relapse. The organisms are then passaged to groups of mice given the 3 drugs composing the WHO-MDT regimen to determine whether the relapse is due to drug-resistant or persister organisms.
    So far, 15 patients were found to have a probable relapse occurring 6 to 12 years after the end of their WHO-MDT regimen. No relapses were noted within 5 years after end of treatment. Twelve of the 15 relapsed patients with complete mouse footpad test results were all due to persister relapse. There were no drug-resistant relapses.
    The clinical, bacteriological and histopathological characteristics of the patients in the study including the mouse footpad results will be discussed

     

    OT 19

    RESULTADOS PRELIMINARES DE COORTE DE PACIENTES MULTIBACILARES TRATADOS COM 12 MÊSES DE POLIQUIMIOTERAPIA MB/OMS
    Gerson Oliveira Penna; Ana Maria Costa Pinheiro; Lucas Nogueira; Daniela Cardoso
    Trabalho desenvolvido no Hospital Universitário da Universidade de Brasília UnB

    Os autores apresentarão e discutirão os resultados preliminares de uma coorte aberta de pacientes multibacilares tratados com esquema poliquimioterápico preconizado pela Organização Mundial de Saúde por 12 meses.

     

    OT 20

    RESULTS OF POST ROM (SINGLE DOSE) FOLLOW-UP OF 332 SINGLE SKIN LESION (SSL) CASES IN THE N, S, T WARDS OF GREATER MUMBAI, INDIA
    Sachin R. Salunkhe; Joy Mancheril; P.R. Dewarkar; A. Antony Samy
    ALERT-OIndia, B-9 Mini Mansion, Sion (West), Mumbai - 400 022, India

    ROM has been introduced as an effective short-term Chemotherapy for SSL cases to reduce the period of treatment in leprosy elimination campaigns. ALERT-INDIA in its leprosy control areas of Greater Bombay has treated 332 SSL cases from Jan. 1998 to Dec. 1999. Of these 302 cases have been followed up for 24 months and the remaining 30 cases have been followed up for 18 months. Ten of these eases presented a clinical picture that warranted further treatment. Five of these were confirmed histo-pathologically. These cases were put on regular PB MDT for 6 months, and subsequently showed good clinical improvement. Hence we confirm satisfactory results of single dose ROM therapy in majority of SSL cases and also suggest proper surveillance to detect cases that do not im prove clinically.

     

    OT 21

    SCENAR-THERAPY FOR LEPROSY PATIENTS WITH CHRONIC NEURITIS
    E.I. Shats; O.A. Bezrukavnikova
    Leprosy Research Institute, Astrakhan. Russian Federation

    Scenar (Self-Controlled Energoregulator) devices are portable autonomous electric apparatus operating in the mode of biological feedback circuit with a patient. The operation of the device is based on a physical factor representing an individually modulated electric signal similar to nervous impulse in its form. Advantages of scenar-therapy include non-invasiveness, a wide spectrum of indications, and absence of age limitations. General course of treatment consists of 10-15 procedures on alternate days. If necessary, treatment courses may be repeated after three-four weeks. Treatment of peripheral nerve damages, especially chronic ones remains to be an urgent problem. Methods of therapy available are of little effect. The results of scenar-therapy of 20 patients with leprosy (12 males and 8 females) aged 30-65 years and suffering from chronic peripheral neuritis are presented. Before treatment patients complained of sharp pains in extremities, thickening and painfulness in ulnar and peroneal nerves at palpation, amiotrophies and flexion contractures of lingers. Against the background of scenar-therapy arresting of painful syndrome and increase in muscle strength (by 10% in average) was noted. All the patients noted a significant improvement of their general state, appetite and sleep. Electropuncture testing of biologically active points located in zones under stimulation performed before and during seenar-treatment revealed increase in nerve conduction suggesting functional improvement of peripheral nerves

     

    OT 22

    TRATAMENTO ÚNICO PARA PACIENTES DE HANSENÍAS
    Gerson Oliveira Penna; Ana Maria Costa Pinheiro; Lucas Nogueira; Daniela Cardoso
    Trabalho desenvolvido no Hospital Universitário da Universidade de Brasília UnB

    Os autores apresentarão e discutirão o protocolo de investigação aprovado no Comitê de Ética em Pesquisa (CEP) da Universidade de Brasília, que objetiva instituir tratamento Poliquimioterápico -Multibacilar - padronizado pela Organização Mundial da Saúde, para todos os doentes de hanseníase independentemente da forma clínica.
    Medicamentos utilizados: Todos os pacientes - Independentemente da forma clínica - receberão Rifampicina 600 mg/mês, Dapsona 100 mg/dia e Clofazimina 300 mg/mês e 50mg/dia.
    Tempo de Tratamento: Todos os pacientes - Inde-pendentement da forma clínica - serão tratados por seis meses
    Serão discutidos:
    - o critério de inclusão, que será baseado unicamente na definição clínica de Caso de Hanseníase;
    - a justificativa para a não utilização de nenhuma das classificações de pacientes de hanseníase para fins terapêuticos;
    - os parâmetros de acompanhamento;
    - o uso da baciloscopia como parâmetro de acompanhamento laboratoril
    - a dificuldade para estabelecer Gold standart laboratorial

     

    OT 23

    TREATMENT OF MB LEPROSY PATIENTS U1NSG CONVENTIONAL AND NEWER DRUGS MINOCYCLINE AND OFLOXACIN
    Kiran Katoch; M. Natrajan; V.D. Sharam; H.B. Singh; U.D. Gupta; V.M. Katoch; Raj Kamal
    Centrla JALMA Institute for Leprosy (ICMR), Taj Ganj, Agra, India

    This study has been carried out to study the effect of regimen comprising of conventional drugs used in MDT along with newer drugs like Minocycline and Ofloxacin. One hundred, untreated, smear positive
    BB, BL and I.I. patients were treated with a regimen comprising of supervised. 600mgs of Rifampicin, 300mg of Clofazimine, 100 mg of Minocycline and 400mg of Ofloxacin once a month in addition to 50 mg of Clofazimine and Killing of Dapsone daily for 12 months. The treatment was then stopped and patients were followed up on placebo. This study reports the follow-up of these patients up to 5 years after stoppage of therapy. The drugs were well tolerated, there was a good clinical response and there was no case of treatment failure during the treatment period. At the end of one year of treatment 25 of the 70 (patients available for follow-up) were still smear positive. No bacterial growth was observed in the foot pad of mice and no bacillary ATP was detected in the tissue biopsies one year alter therapy. The patients continued to progress satisfactorily, and by 2 years only 4 patients were still smear positive. However 4 patients have relaped in the follow-up of 5 years. The results have been compared with patients treated with WHO MDT for one year. The details findings and their implications in the therapy of leprosy of MB patients will be discussed.

     

    OT 24

    ULTRA-HIGH DOSE COBALAMIN FOR TREATMENT OF LEPROSY NEUROPATHY
    Márcia R. Jardim; Ximena Illarramendi; Patricia S. Penna; José A.C. Nery; Nádia Duppre; Euzenir N. Sarno

    Neurological damage may persist after completion of multidrug therapy (MDT). Corticoidsteroids have been proved successful for the improvement of recent motor deficit but are little effective for sensitive alteration.
    Objective: An open controlled clinical trial was done in order to evaluate the effects of ultra-high dose of cobalamin (Cb) for persistence of motor and/or sensory nerve deficit alter MDT and steroid treatment.
    Method: Nineteen patients (13 males, 6 females) aged 44 ± 16.7 years were divided into 2 groups of treatment: 10 patients (treatment group) received l000µ g of intra-muscuilar Cb, 3 times per week, and 9 patients (controls) received 1 dose of Cb per month. Clinical and nerve conduction (ENMG) evaluations were performed by 2 neurologists before, at 3 months (only clinical) and after the 6 months of treatment.
    Results: Nine patients were MB and 10 patients were PB. Grade of disability 0 was present in 60% of the patients, bul 27% had GD 2 at the end of MDT. Muscle strength and vibratory sensation were little affected but improvement was observed in twice the number of nerves on thermal, tactile and pain evaluation in the treatment group compared to the controls. In addition, significant worsening of sensation was observed in the control group (pain p=0.026; tactile p=0.006; thermal p=0.031). On ENMG, the evaluation of the amplitude of motor and sensory conduction showed worsening of twice the number of nerves in the control group than in the treatment group and a slight improvement was seen in the latter.
    Conclusion: Axonal nerve lesions diagnosed by ENMG have a slower recovery than clinical alterations. In this preliminary study we observed some beneficial effects of the use of ultra-high doses of Cb for the treatment of peripheral neuropathy.

     

    ABSTRACTS OF POSTER PRESENTATIONS

     

     

    CLINICAL ASPECTS

    PCA 1

    17-YEAR SURVEILLANCE OF 657 MB CURED CASES RETREATED BY MODIFIED MDT
    Jing ZhiChun; Zhou DaoHai; Chen JiaKun; et al
    Shanghai Skin Disease & STD Hospital, 200435. Shanghai, China

    Objective: To investigate the role of MDT retreating in decreasing relapse rate of cured cases with DDS monotherapy. Methods: 657 cured cases with DDS monotherapy were retreated with modified MDT for one year, had been monitored for 17 years by clinical and bacteriological aspects, and were analyzed statistically.
    Results: 620(94.74%) of them completed course, and toxic and side-effects were slightly. There was 1 leprosy relapse patient after 14 years follow up; relapse rate was 0.21 % or 0.15/1000 person-years. The relapse rate of the cases retreated was lower compared with non-retreated cases (P<0.001).
    Conclusion: the retreating was more effective to reduce relapse rate of the cured with DDS monotherapy. However, the MDT retreating was recommended in high relapse rate and good economic areas due to expenses of retreating. Moreover we should not ignore later relapse by persistence.
    [Key words] Leprosy;Retreat

     

    PCA 2

    A CASE REPORT OF II LEPROSY REACTION WHICH LEADING TO HARM INTERNAL ORGANS
    Luo Liangkui
    The Station for dermatosis control of Jiangxi, Chongyi County, Jiangxi, China

    The female Leper, 33 years old. The BL Leprosy. She had been cured with MDT Scheme of MB Leprosy. There were II Leprosy reaction with nephritis, arthritis Sclerritis and others internal organs being harmed in her body 7 months later. After taking tabellae mulligiycosidorum tripterygu uilfordll and tripterygium wilfordiif prednisonum and curing comprehenly complication, we controlled and healed the complication in a short time.
    [Key words] The II Leprosy reaction Nephritis Arthritis Sclerritis

     

    PCA 3

    A CLINICAL AND EPIDEMIOLOGICAL PROFILE OF MULTIBACILLARY LEPROSY PATIENTS WITH A SINGLE SKIN LESION
    Vieira, G.A.; Sales, A. M.; Duppre N.C.; Pereira. R.M.O.; Albuquerque. E.; Nery. J.A.C.; Gallo. M.E.N.
    Leprosy Laboratory, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro, R.J., Brazil

    Introduction: In multibacillary leprosy, the existence of a single skin lesion, whose precise pathogenesis is still unclear, is a rare occurrence. A single skin lesion in itself is not a symptom of a more benign form of the disease. In light of the uncommon nature of this lesion, the leprosy research community welcomed the decision of WHO that all patients with a positive BI regardless of the clinical form of the disease would be considered multibacillary.
    Objective: To determine the frequency rale of MB patients with a single skin lesion as well as trace their clinical and epidemiological profile.
    Material and Methods: A retrospective study was carried out in the Leprosy Outpatient Clinic between 1987 - 2001 based on the clinic's databank and the patient records of the 14 MB patients who presented a single skin lesion. The patients were submitted to routine examinations at diagnosis.
    Results: During the study, of the 1,707 patients registered in the Clinic, 14 MB patients, mostly residents of Rio de Janeiro (71.4%), (5 females and 9 males) ranging from 11 to 66 years of age, presented a single skin lesion. Batches (57.2%) were the most commonly-occurring skin lesions followed by macula (42.8% ). BIs varied from 0.16% to 4%. Thirteen patients showed a negative Mitsuda test, which was positive in only one patient (7mm). The most commonly-found clinical form was borderline-lepromatous (BL) at 64.3% (9 patients).
    Conclusion: In this study, the incidence rale of MB patients with a single skin lesion was 0.82%, which corroborates the rarity at which a single skin lesion occurs as has been reported in the literature.

     

    PCA 4

    A FIELD TRIAL OF DETECTION AND TREATMENT OF NERVE FUNCTION IMPAIRMENT IN LEPROSY-REPORT FROM NATIONAL POD PILET PROJECT
    Juan Jiang; G.C. Zhang; X.Y. Wei
    Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, 12 Jiangwangmiao Street, Nanjing, 210042, People's Republic of China

    As part of the national pilot project on leprosy rehabilitation and prevention of disability (POD), a total of 1407 patients were monitored for possible nerve function impairment (NFI) through standardized clinical nerve function assessment between May 1995 and February 1998. Of these, 191 patients were found to have NFI and were put on a fixed regimen of prednisolone. In this study. 36,7% of NFI occurred before diagnosis of leprosy, 35,6% developed during MDT and 25,7% after their release from MDT. Overall, 7,5% (105 out of 1407) of all patients, or 55,9% 01 patients with NFI, suffered from silent neuropathy.
    Of the affected nerves, 62,6% had silent neuropathy. Sensory impairment responded to prednisolone satisfactorily, giving a recovery rate of 73,8%, 76,5% and 81,0% in ulnar, median and posterior tibial nerve, respectively. Sensibility in patients even with a NFI duration longer than 6 months made significant improvement (p<0,05). Motor function improvement was less satisfactory, especially in ulnar and c. popliteal nerve. The possible reasons are analysed. Our findings with regard to sensibility changes con
    firm that once it becomes clinically detectable, NFI is no longer at the 'early' stage. More sensitive tests are necessary to detect real 'early' sensory impairment in the field. Our study also indicates that with well-trained field staff and proper equipment for nerve function assessment, early detection and treatment of NFI can be practical and effective.

     

    PCA 5

    A SPECIAL CASE - A LEPROSY PATIENT WITH 2 RELAPSES AFTER MULTIDRUG THERAPY
    Dr. Dao Manh Khoa
    Dermato-venereology Center of Haiphong City
    Place of the subject implementation: Haiphong
    Dermato-venereology Center, 50 Tran Phu, Haiphong, Vietnam

    Introduction: After 18 years introducing multidrug therapy (MDT) Haiphong City has helped reduce the leprosy prevalence rate to 0.033/10,000 population. But the city is now facing with a great problem: resistance to MDT.
    Objective: Patient: Pham Van Dap, born in 1957, Sex: Male
    Methodology: Supervise and record the development of clinical aspects, tests and photos.
    When there were signs of relapse, consultation was conducted with Vietnam Dermato-venereology Institute.
    Summary: The patient was detected with BL type in 1993 and was selected as a patient for the study under the joint project between Vietnam and WHO with MDT + ofloxacin from 1993 to 1994. In 1998 he was found with the first relapse with special and rare symptoms. Thousands of small infiltrations were found scattered on the face, hands, feet, and body interwoven with reddish papules. The patient felt very itchy. Tests showed that BI rose to 4+. This time he was treated with MDT regimen MB for 24 months. After 24 months of treatment, his condition was stable clinically and in tests. But one year later the disease relapsed second time in December 2001. This time he was treated following a special regimen combining 3 kinds of medicine ofloxacin, minocine and lamprene for two years.
    Result and comment: The disease relapsed twice after eight years. The first relapse showed special and rare clinical symptoms: very itchy. The second relapse occurred more quickly and seriously. At present, after one month's treatment with the special regimen his condition is changing for the better. But whether it will relapse will take some time to answer. The patient is going to be Healed for two years. Will there be any side-effects that might badly affect the patients health?
    Conclusion: Patient Dap is the first case in Haiphong suffering from two relapses with special and rare symptoms. We should not be subjective with the disease relapse after MDT. It is suggested that WHO and leprosiologists continue to research so that they can work out a more perfect regimen to solve the current problem of medical resistance.

     

    PCA 6

    ALTERED SKIN WRINKLING IN LEPROSY PATIENTS AND CONTACTS.
    Ximena Illarramendi; Anna Maria Sales; José Augusto Costa Nery; Einar Wilder-Smith; Euzenir Nunes Sarno; Annelies Wilder-Smith
    Laboratório de Hanseníase, Dept. Medicina Tropical, Instituto Oswaldo Cruz. Av. Brasil 4365, Manguinhos. Rio de Janeiro, RJ. CEP.21045-900, Brazil.

    There is evidence that Leprosy patients and their contacts have autonomic dysfunction, but current electrophysiological methods for autonomic assessment are expensive and require extensive training. We therefore investigated the simple bedside test of skin wrinkling as a potential test for autonomic nerve function in leprosy.
    Method: Forty-nine leprosy patients and 13 contacts attending the Leprosy Referral Centre in Rio de Janeiro were evaluated. Following inspection, both hands were immersed in water at 40º C for 30 minutes and examined for wrinkle formation on the fingertips. A grading scale for each linger was used as follows: 0=no wrinkle, l=discrete wrinkles, 2= one-two wrinkles/valleys and 3= three or more wrinkles. According to this scale, a normal hand would have a value of 15 points.
    Results: Skin wrinkling in patients was more affected than in contacts (median values: patients right=7, left=8; contacts right=12, left=11). Sixty nine percent of the patients had moderate to severe alteration (0-19 points) in both hands, while 61.5% of the contacts had normal to slightly affected skin wrinkling (20-30 points). The prevalence of moderate to advanced abnormality was similar in the patients already treated (70%) and in those under MDT (67%). Advanced impaired skin wrinkling in leprosy patients was 34% and in contacts 23%. Eleven patients hail absence of wrinkles in either one or both hands, and 1 contact had bilateral absence of wrinkles.
    Conclusion: Skin wrinkling test is easy to perform and is useful in the evaluation of leprosy patients. The abnormal skin wrinkling observed in contacts confirm previous studies that found sub-clinical alterations in peripheral autonomic function of healthy contacts, the significance of which needs to be further investigated.

     

    PCA 7

    AN ANALYSIS OF 11 MULTIBACILLARY LEPROSY RELAPSES PRESENTING TO AN OUTPATIENT REFERAL CENTRE IN HYDERABAD. INDIA.
    Rajgopal Reddy; Suman Jain; Syed Muzaffarullah; Diana NJ Lockwood*; Sujai Suneetha
    LEPRA India - Blue Peter Research Centre. Cherlapally, Hyderabad - 501301. India
    *London School of Hygiene & Tropical Medicine. London, UK

    Blue Peter Research Centre is an extension of Dhoolpet Leprosy Research Centre (DLRC) in Hyderabad which has been carrying out out-patient based management of leprosy for over 2 decades. The aim of this study was to analyse the nuiltibacillary (MB) relapses presenting to our centres since January 2000 to December 2002. Relapse in MB leprosy was defined as the reappearance of lesions and positive skin smears after completion of a full course of treatment and a reasonably long disease/symptom free intervening period.
    11 patients (M6, F5) presented as MB relapses during this period. All of them presented with appearance of new lesions/symptoms after stopping treatment with durations ranging from less than 5 years in 1 patient (3 years); 5 to 10 years in 3 patients and >10 years in 7 patients. The patients were originally classified as BT in 1 patient. BL in 3 and LL in 7.
    On relapse they were classified as BL in 1 and LL in 10 patients. A histological support for the diagnosis was available in 9 patients. 1 BT patient relapsed as LL and one BL patient relapsed as BL. The remaining 2 BL patients and all the LL patients relapsed with lepromatous disease. The relapse BI was ≤3+ in 2  patients and > 3+ in 9 patients.
    History of past treatment revealed that 6 patients relapsed after DDS monotherapy, 3 patients relapsed after completing a full course of MB MDT. 1 patient of LL relapsed after 27 doses of Dapsone and Rifampicin (prior to availability of Lamprene) and 1 BT patient relapsed as LL after a full course on PB MDT.

     

    PCA 8

    AN OBSERVATION ON THERAPEUTIC EFFECTS ON PLANTAR ULCERS OF 11 CURED LEPROSY CASES WITH DISABILITIES
    LUO Jingwen1; CHEN Zihong2; NONG Haibo2; LI Quanyue3

    1. Chongzuo Station Tor Prevention and Treatmen of Skin Diseases, Guangxi, China
    2. Chongzuo People Hospital, Guangxi, China
    3. Liberation Army 303 Hospital, China

    Objective: To study the causes of plantar ulcers of leprosy, as well as x-ray check, histopathological changes and treatment.
    Methods: 11 cured cases with serious plantar ulcers were chosen to make enlarged wound operation.
    Results: Out of 11 cases with plantar ulcers which had been treated with antibiotics for 30 days after operation, 12 ulcers in 8 cases became dry and 9 ulcers in 6 cases had little effusion. Followed up in 3 months, 4 ulcers 3 cases healed and scars appeared. 15 ulcers in 9 cases improved and 2 ulcers in 1 case were infected.
    Conclusions: Because the nerves and blood vessels of the skin are damaged by M. leprae, the skin has no feeling, which results to ulcers finally. The effective therapy includes controlling the appearance of the ulcers, thorough operation, enough antibiotics, self-care and reduction of activities.

     

    PCA 9

    ANÁLISE COMPARATIVA DE RESULTADOS HISTOPATOLÓGICOS COM DIAGNÓSTICOS CLÍNICOS EM HANSENÍASE NA URE MARCELLO CANDIA, MARITUBA. PARÁ
    Carlos Alberto Vieira da Cruz1; Cláudio Guedes Salgado2

    1. URE "Marcello Candia", Secretaria Executiva de Saúde do Estado do Pará; End. Av. João Paulo II, 113. Bairro Dom Aristides. Marituba, Pará, Brasil. 67200-000.
    2. Laboratório de Dermato-imunologia UEPA/MC. Universidade do Estado do Pará. e URE "Marcello Candia".

    A histopatologia é um dos exames complementares utilizados no diagnóstico de hanseníase (MH). Realizamos uma análise retrospectiva comparando as hipóteses diagnosticas (HD), os resultados histopatológicos (RH) e o diagnóstico final do clínico, através da avaliação dos prontuários da URE Marcello Candia no ano de 2001. Como a histopatologia somente é realizada em caso de dúvida após testes de rotina, o número de prontuários é pequeno e o diagnóstico clínico é realmente duvidoso. De 34 pacientes avaliados, 16 (47%) tiveram a forma clínica do RH compatível com a HD, enquanto 9 (26,5%) foram incompatíveis e 9 (26,5%) foram inconclusivos. Entre os incompatíveis, os resultados HD/RH foram os seguintes: I/T (4); T/D (1); V/l (1) e; D/T (3). Os RH inconclusivos tinham as seguintes HD: I (2); T (1) e D (6). Em 22 de 25 RH com forma clínica definida, o clínico manteve o diagnóstico final compatível com o RH. Nos 9 casos com RH inconclusivo manteve-se a HD inicial. Considerando a classificação operacional, dos 34 casos, 6 (17.64%) sofreram modificações após o RH, sendo que 3 mudaram de PB para MB e 3 de MB para PB. Dos 17 (50%) casos com HD de MB, apenas 5 (29,41%) tiveram RH de MB, 3 (17,64%) tiveram RH de PB e 9 (52,95%) tiveram RH inconclusivo. Os dados acima sugerem que apesar da alta incompatibilidade (26,5%) entre HD e RH na classificação de Madri, a maioria dos casos com classificação operacional em PB 14/17 (82,3%) mantiveram-se como PB, enquanto que 12 (70.58%) dos 17 casos MB diferiram da HD ou não foram conclusivos. Todos os casos relacionados aqui realizaram PQT com melhora. Conclui-se portanto que a histopatologia pode auxiliar no diagnóstico de MH, principalmente nas formas PB, e que o contato entre o clínico e o patologista é necessário para o melhor esclarecimento dos casos com HD de MB.

     

    PCA 10

    ANALYSIS ON NERVE IMPAIRMENT OF THE UPPERLIMB IN 8578 LEPROSY PATIENTS
    Pan Liangde; He Xinguo; Kuang Yanfei; Gao Xiaoling; Di Xiaodan; Mo Jiangling
    Hunan Institute of Dermatology Venereology, Changsha, Hunan Province, 225700 China

    In order to make clear the situation of nerve impairment of the upper limb in leprosy cases, we selected 8578 leprosy non-active and active cases who are still living in Hunan province as the study samples. The result showed that about 40.29% of the upper limb in all cases developed nerve impairment. The lateral nerve impairment was 23.15%. It is higher than that of bilateral nerve impairment (17.14%). The verve impairment among active and relapsed cases was 54.03%. It is higher than that of non-active cases (19.51%). The MB cases developed more nerve impairment (50.15%) which is higher than that of PB cases (21.15%). We also find that 36.55% of the ulna nerve developed nerve impairment, the medium nerve, 16.68% and the radial nerve, 1.64%. The claw hand with the stiff fingers was seen in 73.03% of cases. The nerve impairment has relation with leprosy reaction counted for 41.06%. Most of active and relapsed leprosy cases have the single nerve impairment. The frequency of nerve impairment developed is as following. The first is in ulna nerve, The second, medium verve and radial nerve.
    Two third of nerve impairment is in reversible. The nerve impairment in upper limbs is significantly different due to delay of diagnosis of leprosy, leprosy reaction and different type of clinical leprosy

     

    PCA 11

    ANALYSIS OF BLOOD SERUM CR1STALLIZATION IN LEPROSY
    A.A. Juscenko; A.K. Ajupova; N.G. Urlyapova
    Leprosy Research Institute, Astrakhan. Russian Federation

    Peculiarities of crystalline structure of blood serum (BS) were studied in leprosy with using a new laboratory method based on wedge-shaped dehydratalion (V.N.Shabalin, S.N.Shatokhina, 1996). BS drop at 0,02 ml was placed on a slide surface and allowed to dry at t 18-25oC during 6-8 hours. Then samples were studied in stereomicroscope MZ 12 (firm "Leica"). In the process of drying on the open surface of BS drop a thin film ("faciens".Lat.) is formed. The main structural elements of the faciens include segments, separates, cracks, concretes. Microstructures of the type of Arnold's tongues, wrinkles, plates, leaflike structures and others are considered as pathological formations We studied faciens of BS from 80 patients with lepromatous leprosy (12 patients with active leprosy and 68 with regressed leprosy) aged 35-78 years old. Faciens of BS from healthy donors aged 25-35 years served as controls. It was found out that a pattern of structure of BS in the process of its dehydratalion was of certain peculiarities in leprosy. Noted changes in main structures of faciens of BS as well as pathological formations depended on the severity of leprosy, presence of complications, concurrent illnesses and age of a patient. The intensity of disturbances noted reflected severity of pathological processes. All this, as well as observed in vitro effects of biological preparations (tuberculin, lepromin) on pattern of BS structure suggested a high informative value of the method of wedge-shaped dehydratalion for more accurate defining disease activity and differential diagnosis of specific processes.

     

    PCA 12

    ANALYSIS OF DROP-FEET OF LEPROSY IN 2235 CASES
    Yan Lianghin; Zhang Guocheng; Chen Xiangsheng; et al.
    Institute of Dermatology, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for STD and Leprosy Control, Nanjing 210042

    To understand situation of drop-feet cased by leprosy in order to provide scientific basis for formulation of preventive strategies. All alive cured and active leprosy cases in 11 counties in Jiangsu Province were investigated. Data were entered into computer for analysis. Among investigated cases, prevalence rate of drop-feet was 15.7%, the rate in single foot (13.62%) being higher than double feet (2.07%), rate in active or relapsed cases (31.28%) being higher than cured cases (15.07%), and rate in BT and BB leprosy cases (23.56%) being 23.56% and 20.96%. Within duration of less than 5 years, prevalence rate of drop-feet in PB cases (72.41%) was higher than that in MB cases (50.47%); and the rate in cases who had leprosy reactions was 33.75%. In patients with drop-feet the prevalence rates of plantar ulcers (21.21 %), bone damage (19.17%) and foot disability (27.43%) were higher than those in patients without plantar ulcers (15%), bone damage (15.09%) and foot disability (20.19%). Among 989 drop-feet, only 30% could be reconstructed with operation. Drop-feet are more common among active or relapsed cases and predominately occurred on single foot. The plantar ulcers and foot disabilities are more frequently occur in drop-feet. Two-thirds of drop-feet have not chance to be reconstructed, and 70% of cases with drop-feet have not confidence to do such reconstructive surgery. Occurrence of drop-feet is associated with delay of diagnosis and treatment, leprosy reactions and leprosy classification.

     

    PCA 13

    ANALYSIS OF NEWLY DETECTED LEPROSY CASES FROM 1990-1998 IN CHINA
    Li Wenzhong; Shen Jumping; Chen Xiangsheng; Jiang Cheng; Yu Meiwen; Zhu Chengbin
    Institute of Dermatology, Chines Academy of Medical Sciences, Nanjing, P. R. China 210042

    Since implemented multi-drug therapy on leprosy recommended by WHO, the leprosy prevalence decreased significantly in China and the world. But the annual leprosy incidence seems not to parallel with the decrease of the leprosy prevalence. The Leprosy incidence decreased slowly in the recent years in China, and sometimes showed the rebounding situation in leprosy incidence. We selected the data on leprosy newly detected cases from 1990~1998 from database of leprosy surveillance system. National Center for STD and Leprosy Control to analyze the situation and the trend of leprosy transmission in China. Hoping to gel the information to establish the working priority on leprosy control.
    Materials and methods: The data came from database of leprosy surveillance system, National Center for STD and Leprosy Control. The diagnosis, classification and skin smear test of leprosy is based on the Handbook of Leprosy Control in China. The disability grating system is based on the 7th report of WHO Leprosy Expert Committee. The population calculation in provinces is the median of every three years.

     

     

     

     

     

     

    Discussion and conclusion
    The leprosy prevalence in 1998 decreased by 74% than 1990 in China, and showed a continually declining trend, hut the detection rate of leprosy in the recent 5 years decreased not significantly, and fluctuated between 0.14~0.16/100000. Based on theory that if all leprosy cases treated with MDT in time, leprosy transmission could be decreased, and the detection rate of leprosy declined. Our study showed that the detection rate did not decreased significantly. It may be related with many leprosy cases who were not detected in time, and as the leprosy transmission sources existed a long time Incidence
    The results showed that the average age of new leprosy cases at diagnosis from 1990~1998 is 37 years old, the average delay time of new cases at diagnosis is 34.4 months and the child leprosy cases counted for 4% of all cases. It indicated that although the leprosy control has achieved a great success in the past years in China, the leprosy problem could not be neglected in some provinces.
    There were 5656 cases developed leprosy due to contacting the active eases within the family which counted for 29.1% of all cases. About 8115 (41.7% ) cases developed leprosy due to contacting the active cases out of the family. There were a total of 13771 (70.8%) cases who had the definite sources of leprosy. The result showed that it is of great importance to us in following up the contacts of leprosy.
    The 95% of all new cases were detected by the methods of skin clinic, disease reporting, clue survey and follow up contacts. About 13355 leprosy new cases were detected by the passive methods (Skin clinic and disease reporting) which counted for 68.7% of all cases. But 5991 cases (counted for 30.8%) were detected by the active case-finding methods (Clue survey, spot survey, group survey and so on). It suggested that active cases finding with passive methods should be recommended.
    Among 19453 cases, about 12228 cases were skin smear positive that counted for 62.9% of all eases. About 2208 cases were BI more than 4.0 which counted for 11.4% of all cases. The skin smear test is also of great importance to diagnosis and treatment of leprosy in the field. Now above the level of county in China, almost every leprosy unit has established the reliable skin smear laboratory. We suggest that the skin smear test should be maintained in the leprosy control program.
    There were only 2161 cases with the single lesion which counted for 11.1% of all cases from 1990~1998 in China. We agree with WHO's review that some operational factors in the field could influence the specificity of diagnosis on leprosy such as rewarding on reporting of leprosy and political pressure. We consider that the leprosy cases with the single lesion must be diagnosed with caution and must be avoid to over-diagnosis on leprosy.
    The result showed that among the 19453 eases. 86.7% of cases had nerve damage. The cases with the disability grade 2 counted for 24% of all cases. This is much higher than that of 32 leprosy epidemic countries (5.43%~9.63%) in the world from 1985-1997 reported by WHO. We think that there is a problem in leprosy early cases linding due to the traffic difficulty and lack of leprosy service in the mountain areas.

     

    PCA 14

    ANALYSIS ON 93 RELAPSED LEPROSY CASES
    Fu Zhizhi; Liang Jianxiu; Huang Peiyong
    Guangxi Institute of Dermatology, 530003, Nanning, China

    Objective: to provide guidance for leprosy control at the grass-roots level through studying the relapse situation of leprosy in Guangxi Autonomous Region during recent years. Methods: the relapse situation was analyzed by Chinese statistical software of leprosy.
    Results: Out of 93 relapsed cased detected during 1990 to 2000,82 cases relapsed after DDS monotherapy (88.17% ) and 11 cases after MDT (11,83%).The mean duration from cure to relapse and after MDT to relapse was respectively 15.62 years and 8.27 years. The proportion of new case to relapsed case was 1.09:1. Most cases were delected in dermatology clinic and some others by follow-up visit and self-report.
    Conclusions: There is a relapse in different degree after both DDS monotherapy and MDT, which indicate that in a low epidemic situation, to detect relapsed cases in time should be regarded as one of the most important tasks.
    [key words] leprosy, relapse, MDT

     

    PCA 15

    ANALYSIS ON DETECTION OF NEW LEPROSY CASES BEFORE, DURING AND AFTER THE YEAR OF LEPROSY ELIMINATION CAMPAIGNS
    Shen Jianping; Li Wenzhong; Yu Meiwen; Yang Jun; Zhou Longchao; Wang Rongmao; Hu Lufang; Mou Hongjiang; Ye Fuchang; He Xinguo; Pan Liangde
    Institute of Dermatology, Chinese Academy of Medical Sciences, 12 Jiangwangmiao Road. Nanjing. P. R. China 210042

    In order to analyze the impact on the situation of case linding after Leprosy Elimination Campaigns, the data of newly detected leprosy cases in the leprosy high endemic area have been collected before, during and after the year of carrying out Leprosy Elimination Campaigns. The result showed that the number of new leprosy cases detected during the year of leprosy elimination campaigns was significantly high. The number of newly detected cases after the year of Leprosy Elimination Campaigns was similar to that of detected before the year of carrying out Leprosy Elimination Campaigns in counties with persisting case linding activities. But the number of newly detected cases after the year of Leprosy Elimination Campaigns significantly decreased in counties without active case finding activities. The average distance from the house of leprosy cases detected during Leprosy Elimination Campaigns to the leprosy control unit al the count town is 62.8 kilometer which is farther more than that of other leprosy cases detected before and after the year of Leprosy Elimination Campaigns. The average disease delay-time of leprosy cases detected after the year of LEC shortened. The results also showed that carrying out Leprosy Elimination Campaigns will have no the significant impact on the trend of cases finding within a short time in local areas. But it may improve some indicators of leprosy patients and so promote the leprosy control in local areas.

     

    PCA 16

    ANALYSIS ON NERVE IMPAIRMENT OF THE UPPER LIMB IN 641 LEPROSY PATIENTS
    Pan Shu; Pan Xiao-feng; Liu Tong-kui
    Xinghua Station of Skin Diseases Control. 225700. Xinghua, Jiangsu Prouince, China

    In order to make clear the situation of nerve impairment of the upper limb in leprosy cases, we selected 1575 leprosy non-active and active cases who are still living in Xinghua city as the study samples. The result showed that about 40.7% of the upper limb in all cases developed nerve impairment. The lateral nerve impairment was 23.1%. It is higher than that of bilateral nerve impairment (17.52%). The nerve impairment among active and relapsed cases was 69.23%. It is higher than that of non-active cases (40.46%). The MB cases developed more nerve impairment (55.94%;) which is higher than that of PB cases (38.46%.). We also find that 36.63% of the ulna nerve developed nerve impairment, the medium nerve, 16.95% and the radial nerve, 2.35%. The claw hand with the stiff lingers was seen in 73.03% of cases. The nerve impairment has relation with leprosy reaction counted for 43.37%. Most of active and relapsed leprosy cases have the single nerve impairment. The frequency of nerve impairment developed is as following, the first is in ulna nerve, the second, medium nerve and radial nerve, Two third of nerve impairment is inreversible. The nerve impairment in upper limbs is significantly different due to delay of diagnosis of leprosy, leprosy reaction and different type of clinical leprosy.
    [Key words] leprosy; nerve of upper limbs; impairment

     

    PCA 17

    ANATOMICAL AND CLINICAL STUDY OF THE SUPERFICIAL BRANCH OF RADIAL NERVE -A CONTRIBUTION FOR THE DIAGNOSIS OF LEPROSY.
    Rosemari Baccarelli; João A.C. Navarro; Diltor V.A. Opromolla; Marcos C.L. Virrnond; Somei Ura
    Instituo Lauro Souza Lima. CP 3031, Bauru - SP - Brasil, CEP 17034 - 971

    The purpose of this paper is to contribute to the diagnosis of leprosy and to evaluate the possibility of a misdiagnosis based on superficial branch of radial nerve (SBRN) palpation and its anatomical relationships. A clinical study was conducted based on the results obtained by three leprologists. Each examiner performed SBRN palpation at the radius dorsal tubercle level on a total of 70 upper extremities of 25 Hansen's disease patients and 10 healthy controls. All test subjects were adult males. The data collected regarding the SBRN thickness, consistency and shape were statistically analyzed to evaluate agreement using Kappa statistics and association through chi-square test. Macro and microscopic observations of the anatomical relationships of the thickest branch of the SBRN with surrounding tendons and veins, at the radius dorsal tubercle level, were also performed. A total of 20 formalin ( 10%) preserved adult male human cadavers upper extremities were studied macroscopically and 22 upper extremities of 10% formalin preserved adult male human cadavers, microscopically. Results indicated that palpation of SBRN is subject to considerable inter-observer variation. Chi-square results show a statistically significant association between SBRN thickness and clinical group, as well as of SBRN thickness and consistency. Anatomical aspects of SRBN demonstrated some findings that can lead to erroneous clinical assessment of its thickness, consistency and surface. Difficulties in evaluating the SBRN by palpation and the anatomical variations observed suggest caution when interpreting results, and that inclusion of this nerve during routine field work neurological evaluations be considered with reservations.

     

    PCA 18

    APPROACHES TO IDENTIFICAI ION OF RISK GROUPS FOR LEPROSY NEURITIS
    E.S.Balybin
    Leprosy Research Institute, Astrakhan. Russian Federation

    Searches for criteria to consider a patient as having risk of development of leprosy neuritis are of urgency. In the work presented we discussed the main scientific developments in this direction and our own attempts aimed at elucidation of pathogenesis of leprosy neuritis and estimation of prognostic value of the data obtained as well. The most part of investigations unravel the most significam aspects of mechanism of peripheral nerve damage in leprosy (molecular, iilirastructural and cell-cooperative neurotropism oi M. leprae). Bul application of lhe dala obtained for prognostic aims is unlikely. In this regard, methods of detection of antineural antibodies (anAb) seem lo be more promising. At the same time data obtained by various investigators are rather contradictory. One might suggest (hat some part of free anAbs in blood scrum is not caught because they seem to be bound with immune complexes and directly with antigens of peripheral nerves. According to our observations, intersystem approach to prognosis of development of leprosy neuritis is promising. It is based on simultaneous evaluation of intensity of proliferation of lepronin-stimulated lymphocytes and state of cortisol-producing function of adrenal cortex.

     

    PCA 19

    ASSOCIAÇÃO DE HANSENÍASE NEURAL PURA E CONTRATURA DE DUPUYTREN: RELATO DECASO.
    Souza, G.M; Manze, CJS; Goulart, IMB; Sales, MAG; Pereira, JE
    Centro de Referência Estadual em Hanseníase/Dermatologia Sanitária. Faculdade de Medicina. Universidade Federal de Uberlândia. Av. Pará. 1720- Bloco 2H, CEP 38400-902 - Uberlândia - MG, Brasil.; imbgoulart@ufu.br.

    Introdução: A neurite do nervo ulnar é a forma mais comum de neuropatia hansênica. Clinicamente apresenta-se com dor, espessamento do nervo ulnar, atrofia de musculatura interóssea e região hipotenar e garra do 4° e 5° dedos, enquanto que a "Contratura de Dupuytren" consiste numa fibrose da fáscia palmar com retração de pele e flexão da articulação metacar-pofalangeana e/ou interfalangeana proximal, porém sem acometimento neurológico.
    Relato de caso: Paciente masculino, 47 anos, foi encaminhado ao nosso serviço por apresentar quadro de dor intensa em trajeto de ulnar direito, com irradiação para 4º e 5º dedos da mão, com garra dos respectivos dedos, atrofia discreta de musculatura interóssea e espessamento do nervo ulnar ao nível do cotovelo, sendo diagnosticado Hanseníase Tuberculóide (TT) Neural Pura e iniciado terapêutica com poliquimioterapia paucibacilar (PB) e Prednisona 60mg/dia. Na reavaliação após 30 dias, o paciente apresentava melhora do quadro álgico e do espessamento do nervo ulnar. Nesta ocasião, foi evidenciada uma retração da pele na face palmar da mão direita sobre a região dos tendões flexores do 4º dedo, sendo feito o diagnóstico clínico de "Contratura de Dupuytren" e o paciente encaminhado para tratamento cirúrgico com liberação da fáscia palmare descompressão com transposição do nervo ninar.
    Conclusão: Este caso ilustra a importância de um exame físico minucioso para confirmar a ocorrência de duas patologias, que podem ser consideradas como diagnósticos diferenciais em um mesmo paciente, podendo levar a fatores de confusão na confirmação do diagnóstico de formas neurais puras de hanseníase

     

    PCA 20

    AVALIAÇÃO DA NEURITE HANSÊNICA ATRAVÉS DA ULTRA-SONOGRAFIA
    Erika Suenaga; Renato Sernik; Leontina C. Margando; Giovanni Guido Cerri
    Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Rua Dr. Enéas de Carvalho Aguiar. 250, São Paulo - SP.

    O estudo ultra-sonográfico permite uma avaliação estrutural dos nervos periféricos, possibilitando o acompanhamento da neurite hansênica.
    Foram avaliados sistematicamente os nervos radial, mediano, ulnar, fibular comum e tibial bilateral de pacientes em diferentes estágios da doença, utilizando-se o aparelho Logic 700, GE, com transdutor linear com freqüência de 9-13 MHz. Os aspectos ecográficos avaliados incluíam: espessura do nervo, padrão fascicular, extensão do acometimento neural, compressão por túneis osteofibrosos e estudo da vascularização intraneural através do Doppler colorido.
    Verificou-se que pacientes de hanseníase apresentam maior espessura dos nervos periféricos, os quais, de acordo com o tempo de doença, podiam se apresentar com perda do padrão fascicular normal.
    Conjuntamente aos aspectos clínicos e à eletroneuromiografia, o ultra-som adiciona informações sobre os aspectos estruturais dos nervos periféricos e desta forma permite uma análise confirmatória do acometimento neural, do grau e da extensão do comprometimento, além de poder auxiliar no acompanhamento da eficácia terapêutica reacional, através da comparação desses dados, e do uso do Doppler colorido, durante ou após o tratamento.

     

    PCA 21

    AVALIAÇÃO DO ACOMETIMENTO UNGUEAL NA HANSENÍASE
    Carla Wanderley Gayoso; Mohamed A. Azouz; Francisca Estrela Maroja Dantas; M° das Graças Videres A. Almeida; Francimary de Sousa Buriti
    UFPB/Hospital Universitário Lauro Wanderley

    Avaliamos meticulosamente as unhas das mãos e dos pés de 60 doentes portadores de hanseníase. Os doentes foram avaliados no ambulatório da UFPB e em clínica privada no decorrer de 2000 e 2001. De um modo geral, a faixa etária mais acometida foi a de 31-60 anos. Foram avaliados um total de 60 doentes com hanseníase, onde observamos que 24 pacientes eram portadores de alterações ungueais. Destes, 20.83% estavam na faixa etária de 11-30 anos, 54,17% tinham de 31-60 anos e 25% tinham mais de 60 anos.

     

    PCA 22

    AVALIAÇÃO DO COMPORTAMENTO CLÍNICO DOS HANSENIANOS NO INSTIUTO LAURO DE SOUZA LIMA NO PERÍODO DE 1930 A 1990.
    Noemi Garcia de Almeida Galan; Edson Eiji Nakayama; Vitor Soares
    Instituto Lauro de Souza Lima (ILSL) - Bauru - SP-Brasil.

    Foram estudados retrospectivamente 1984 pacientes portadores de hanseníase falecidos no ILSL no período de 1930 a 1990. Os resultados dos dados clínicos e laboratoriais foram expressos em média ± erro padrão quando paramétricos, em mediana e percentil quando não paramétricos. A comparação foi realizada utilizando-se ANOVA ou teste "t"; Kruskall-Wallis e teste do χ2. As curvas de sobrevida actuarial foram determinadas através do método de Kaplan Meyer, e comparadas pelo "log rank test".
    Resultados: Houve predomínio do sexo masculino e raça branca, não sendo observada diferença estatisticamente importante (p>0,05) entre as décadas. A idade média dos pacientes no período do diagnóstico da Hanseníase (MH) foi 39,75 ± 0,36 anos, sem diferença entre as décadas (p > 0,05). A idade média do óbito foi de 52,02 ± 0,36 anos; observando-se um aumento significativo das décadas de 40 (46,36 ± 0,61 anos) para 50 (52.54 ± 0.95 anos) (p < 0,001), de 50 (52,54 ± 0,95 anos) para 60 (57,15 ± 0,74 anos) (p < 0,01) e de 70 (58,59 ± 0,75 anos) para 80 (64,83 ± 1.19 anos) (p < 0,01). A mediana de uréia foi 63,5 mg/dl (P25 =36 mg/dl; P75 = 140 mg/dl) e de creatinina 2,17 mg/dl (P25 = 1,47 mg/dl; P75 = 6,05 mg/dl). As principais causas de óbito foram: doenças infecciosas (48.50%); doenças renais (24,50%); cardiovasculares (17.50%); neoplásicas (4,30%); digestivas (3,20%); respiratórias (0,60%) seguida de outras causas (1,50%). A sobrevida actuarial da hanseníase foi: na década de 30 de 5 anos; na de 40, 7 anos; na de 50, 10 anos; na de 60, 16 anos; e nas décadas de 70 e 80/90 foram 20 anos. Estatisticamente observou-se aumento na sobrevida actuarial nas décadas subjacentes (P < 0,05).
    Conclusões: O aumento da sobrevida actuarial das respectivas décadas coincidiu com a implantação de inn tratamento eficaz e diagnóstico precoce, enquanto que as complicaões renais decresceu significantemente

     

    PCA 23

    BACTERIOLOGICAL STATUS OF LEPROSY AFFECTED BEGGARS AND ITS EPIDEMIOLOGICAL SIGNIFICANCE
    Sumian Jain; Rajgopal Reddy; Shaik Yousuf Jani; Sujai Suneetha
    LEPRA India - Blue Peter Research Centre, Cherlapally, Hyderabad - 501301

    A recent publication has indicated that about 20 percent of leprosy affected beggars were smear positive and may be a hidden source of infection to the community. The aim of this study was to estimate the bacteriological status of leprosy affected beggars at our centre in order to assess the epidemiological significance for the spread of infection.
    We used 2 approaches - one, we screened all leprosy affected beggars who attend our centre and second, we identified 3 leprosy colonies where such beggars reside and carried out a clinical and bacteriological assessment on site. Slit skin smears were taken from a minimum of three sites (Right earlobe, Left forehead, Left arm) and sometimes from the skin lesions.
    A total of 127 beggars were screened (M 70, F 57). The duration of disease ranged from 5 to >40 years. 102 of them had deformity of hands and or feet. 45 patients gave a history of taking Dapsone Monotherapy for durations ranging from 5 years lo 10 years. 44 patients had completed MDT. In 38 patients a clear history of past treatment could not be ascertained, but most of them said they had taken treatment at different leprosy centres.
    Slit skin smear examination revealed 4 cases that were positive out of the 127 tested (3.1 % ). The average BI ranged from 0.5 to 5.4 with the individual site BI ranging from 1+ to 6+. A detailed analysis of these 4 patients revealed that they had either taken only monotherapy and had relapsed or had taken treatment irregularly.
    This study help allay the fears in the general public to the possibility of "Catching the disease" through casual exposure to leprosy affects beggars in society

     

    PCA 24

    BORDERLINE LEPROMATOUS LEPROSY IN A PAT IENT TREATED WITH INFLIXIMAB (A TUMOR NECROSIS FACTOR INHIBITOR)
    M. Patricia Joyce; David M. Scollard.
    National Hansen's Disease Programs. 1770 Physicians Park Drive. Baton Rouge, LA, 70816, USA.

    Chimeric monoclonal antibodies directed against tumor necrosis factor alpha (TNF) have been developed for use in rheumatologic conditions. Agents such as infliximab and etanercept interfere with T-lymphocyte functions and have been associated with reactivation of infections controlled by cell-mediated immunity. Active tuberculosis has been reported in persons receiving infliximab recently, raising concern for the need for prophylaxis to treat latent disease.
    We report the first case of leprosy in a person receiving infliximab. A 60-year-old man with a five-year history of rheumatoid arthritis developed a skin rash, lie had previously been treated with methotrexate, hydroxychloroquine, and steroids without relief. One month following his first infliximab injection, he developed skin lesions that worsened following his second injection. Infliximab was discontinued. Biopsy of the lesions showed BL leprosy with skin smears positive to 3+ with globi. Normal skin was present in the dermis between the affected areas. He has received standard MDT, with good results and no signs of reaction to date. His arthritis remains in control with only nonsteroidal medications.
    Screening for latent infections should be considered for patients receiving immunosuppressive drugs. Use of TNF inhibitors has been associated with the activation of latent mycobacterial infections, tuberculosis and now the lirst case of leprosy

     

    PCA 25

    CHALLENGES OF IMPLEMENTING A SKIN TEST TRIAL FOR LEPROSY UNDER PRESENT DAY CIRCUMSTANCES
    Becks L. Rivoire; Stephen M. TerLouw; Paul W. Roche; Murdo Macdonald; Patrick J. Brennan
    Department of Microbiology, Colorado State University, Fort Collins, Colorado 80523, U.S.A.
    Anandaban Leprosy Hospital. The Leprosy Mission. P.O. Box 151. Kalhmandu. Nepal

    The elaborate and multifaceted process of testing two new leprosy skin test antigens (MLSA-LAM and MLCwA) in clinical studies began in 1992. The quest for regulatory approval from the FDA and other authorities has heightened our awareness of the stringent regulations in the U.S. and abroad for research on humans. Familiarization with regulatory requirements, resources, training in human research, document creation and approval processes was integrally critical to manufacturing antigens in a GLP/GMP pilot facility and running a Phase I clinical study at CSU. Each element was addressed and skin test antigens were manufactured in May, 1997. Concurrently, working in concert with our NIAID, NIH Project Officer, our Human Research Committee (HRC) and Phase I Principal Investigator. FDA approval for the Investigational New Drug (IND) application and Phase I clinical study was approved in December 1998. The Phase I trial was successfully completed in December 1999. Preparations for the Phase II clinical trial were greater in magnitude. Foremost was the identification of the trial site (Anandaban Leprosy Hospital, Kathmandu, Nepal)(see related abstract). In addition, approvals from CSU HRC. Nepal Health Research Council (NHRC) and the Office for Human Research Protection (OHRP) were required before study documents could be submitted. The Phase II protocol and consent forms were extensively reviewed before approval. Comparably, standard operating procedures, study guidelines and case report forms have been created in Nepal, reviewed and approved. Finally, and most importantly, a safety monitoring committee was established to oversee the study as it progresses. Although challenges of implementing a skin test trial have been intense and difficult, with teamwork and perseverance the process is Hearing final approval. The Phase II study is expected to begin in March 2002.

     

    PCA 26

    CHARACTERISTICS OF PATIENTS WITH HANSEN'S DISEASE SEEN AT A PRIVATE MEDICAL CENTER IN HAWAII, 1998 AND 1999
    Nina M. Teruya1; Richard I. Frankel2; Ronson J. Sato3
    The Queen's Medical Center and the University of Hawaii John A. Burns School of Medicine, 1356 Lusitana Street. #724. Honolulu, Hawaii.

    1. M.S.
    2. M.D., M.P.H.
    3. B.A.

    Hansen's disease has occurred in Hawaii since the 1830's. Since 1984, all medical care for Hansen's disease has been provided in the private sector. We reviewed the charts of all 37 patients who were seen at The Queen's Medical Center in 1998 and 1999 in whom Hansen's disease was listed as a diagnosis.
    The mean age was 59 years, with 35% being younger than 50 years. 78% were male. 30% were Hawaiian, 24% Filipino, 14% Samoan, and 14% Micronesian. In 30%, the record stated that the patient had lived or still lived at Kalaupapa.
    Aside from Hansen's disease, the 2 most common primary diagnoses were gastrointestinal disease, and infection. 76% of the visits/admissions were for problems other than Hansen's disease.
    The Ridley-Jopling classification was included in only 38% of cases, 14% had LL disease, 8% BL/BB, 5% BL, 5% BB and 5% BT. 35% were known to be receiving antimicrobial therapy for Hansen's disease, and 45% of those receiving therapy were receiving more than one drug for Hansen's disease.
    18 patients were stated to have comorbidity. 6 had foot ulcer, and 5 each had hand deformity, foot deformity, and neuropathy.
    We will discuss the significance of these findings in relationship to the epidemiology of Hansen's disease in Hawaii.

     

    PCA 27

    CLINICAL AND EPIDEMILOGICAL EVALUATION OF PATIENTS WITH HANSEN'S AGED BETWEEN 0 TO 14 YEARS.
    Chaves, M.S.R.; Araújo, P.L.M.: Sailaja, K.S.; Ingred; Nery, J.A.C.; Azulay, R..D.
    Department of Leprosy. Instituto de Dermatologia da Santa Casa da Misericórdia. Rio de Janeiro, Brazil.

    Introduction: Hansen's was considered as a hereditary disease in the past. Since it was thought because of higher incidence in infancy. In Brazil 10% of the cases were delected in children. In relation with clinical aspects, the infantile Hansen's has got same characteristics like in adult Hansen's with some peculiarities.
    Material and Methods: In this study 219 patients were included from January 1998 to December 2000 at the Out patient department of Dermatology (hygiene) of Santa Casa. On analyzing the patient records 16 patients (7%) were between the 0 to 14 years age. These patients were classified as per the Madrid classification (1953) and lab exams were performed. After confirming the diagnosis multiple drug regime was started where as 2 patients (12.5% ) were managed conservatively.
    Results: Out of 219 patients registered, 16 patients (14%) were children between 0 to 14 years age group, out of this 15 were males and I was a female. 14 patients (87.5% ) had paucibacillary type. On evaluation of the relation between the diagnosis and duration of the disease we observed 7 (44% ) patients were diagnosed within 6 months of the beginning of the symptoms. The Basciloscope was negative in 15 (94%) patients. In one patient reaction (reverse reaction) was noted. In relation with the treatment 11 patients (69% ) treated with PTQ/PB, 1 patient treated (6% ) with ROM, 2 patients (12.5%) treated with PTQ/MB.
    Conclusion: This study in relation to age with clinical type showed thai paucibacillary type is more common than the multibacillary type, but later does exist.

     

    PCA 28

    CLINICAL ANALYSIS OF 111 LEPROSY PATIENTS WITH TYPE 1 LEPRA REACTION
    Hu Lufang; Luo Jiusi; Jian Darning; Ning Yong; Wu Xinsheng
    Sichuan Institute of Dermatology, I2Sidao Street. Chengdu. 610031, China

    To investigate the incidence, clinical features and management of type I reaction (RR) in the leprosy patients treated with WHO-MDT regimen.
    Methods: To analyze the incidence, relation with classification, clinical features, occurrence and persistence of RR in 111 patients with RR.
    Results: Among 2004 leprosy patients treated with MDT, 111 cases are diagnosed to have RR (5.54%) and 73.83% of them are borderline patients (BT, BB and BL). Of 111 patients with RR, there are 4 cases with skin lesions (3.60%), 93 cases with skin lesions and nerve impairment (83.78%) and 14 with nerve impairment (12.61%). 102 patients are diagnosed to have RR before and during MDT (91.89%), including 58 cases occurred in the first year of MDT (52.25%), and 69 cases with RR persisted for 6 months (62.167). Conclusion: Among leprosy patients treated with MDT, the incidence of Type I reaction is 5.547, most cases are the borderline patients occurred in the first year of MDT. Type I reaction causes nerve impairment and persists lor long time. Sufficient doses and course of steroid therapy can prevent and decrease occurrence of deformity.
    [Key words] Multidrug therapy Type I reaction

     

    PCA 29

    CLINICAL AND DIAGNOSTIC ASPECTS OF THE PURE NEURAL VARIETY OF LEPROSY
    José A Garhino; Andrea F F Belone; Lúcia H S C Marciano; Raul N Fleury
    Instituto Lauro de Souza Lima. CP 3021, Bauru - SP, CEP 17034-971

    Aim of investigation: Contribution to the knowledge of pure neural variety of leprosy, the diagnostic approach.
    Methods: A total of 25 patients with peripheral neuropathy suspicious of leprosy, without detectable skin lesion or positive skin baciloscopy were studied during the period of 1994-01. They, were submitted to dermatological and neurological examination, sensory mapping, electrophysiologic tests, Mitsuda reaction and biopsy of the sural nerve. The histological studies were applied with hematoxiline-eosine, Fite-Faraco and imunohistochemical study with policlonal antibodies ant-BCG antigen.
    Results: The age range was from nine to 87 years old, 20 of them were male and live female, in 72% of patients the symptoms developed above the fourth decade. The clinical picture of polineuropathy occurred in 80% of the patients while 20% were mononeuropathy multiplex. The Mitsuda reaction was possible to read in 20 patients, being positive in 15 and negative in five. The histological routine examination, hematoxiline-eosine and Fite-Faraco, was conclusive for leprosy in seven patients. Five of them were borderleine or tuberculoid and two were borderleine lepromatous, accomplished 28% of confirmed diagnosis cases.
    The imunohistochemical study was introduced in order to increase the diagnosis and help to discharge this hipothesis. The test was positive in nine patients; all of them previously confirmed leprosy, one with inespecilic inflamatory process and another arteriopathy (36%). Among the remaining 16 patients, two patients had leprosy confirmed and in 14 it was excluded in the follow-up, pulling the diagnosis to 44%.
    Conclusion:The imunohistochemical study is an accurate instrument to be added to the routine histological examination of the peripheral nerve in the suspicious cases of leprosy, but the clinical follow-up also has an important role in this investigation.

     

    PCA 30

    CLINICAL EVALUATION OF' INFANTILE NODULAR HANSEN'S (1N1I).
    Baraúna, S.; Barcelos. D.L.; Mendonça I.P.T.; Orofino, R.R.; Abreu, F.; Nery. J.A.C.; Azulay, R. D.
    Department of Leprosy. Institute of Dermatology, Santa Casa de Misericórdia. Rio de Janeiro, Brazil.

    Introduction: The Infantile Nodular Hansen's (INH) is a variety of Tuberculoid Hansen's. Clinically it can present in various types. The lesions are usually few but yet times multiple. Lesions are commonly noticed in the exposed areas but they heal spontaneously.
    Material and Method: Out of 103 patients evaluated at the out patient department of Dermatology (hygiene), 8 patients (8%) had fulfilled all the criteria of clinical and epidemiological features of Infantile Nodular Hansen's (INH). The variables of sex, age, number and location of lesions, mode of contact and type of treatment were correlated. The treatment was given according to the Brazilian national program of Hansen's control. (PQT/PB & ROM).
    Results: Out of 103 patients registered, 8 patients (8%) had INH type and out of this only one male patient (12.5%) and 7 patients (87.5%) were females. The average age is 6.5 years. As per the study of number of lesions 4 patients (50%) had only one lesion and one patient (12.5%) had more than 10 lesions. Face is very often affected i.e. in 6 patients (75%) 3 patients had this by the way of domestic contact. In relation with the treatment 3 patients (37.5%) were treated as per the scheme of PQT/PB, 1 (12.5%) with ROM and 4 (50%) with conservative treatment.
    Conclusion: All though INH had been stated many times in the literature as a single lesion seen on exposed areas, the interesting point noted in this study is that we found one case with disseminated lesions. In the major group of patients the mode of contact could not be identified well.

     

    PCA 31

    COMPARISON BETWEEN ML OF TISSUE FLUID SMEAR AND THAT OF PATHOLOGIC SECTION BEFORE AND AFTER MDT ON MB LEPROSY PATIENTS
    Cun-Xin HE; Xiao-Ying WANG; Xiu-Lian ZHANG
    Hanzhong Sanatorium, 723000, Hanzhong, Shanxi Province, China

    The article has made a comparison between ML of skin tissue fluid and that of tissue pathologic section on 142 new patients of MB leprosy. Those patients have finalized the process of MDT, undergone continual monitor, and met the treating requirement. This article aims to discuss the change of bacteria of these two inspecting means on different steps of MDT.
    The 142 cases have proved to be positive on the bacteriological inspection before MDT. The averages of BI and BIG are 3.55 and 3.27 respectively, much close to each other. But under MDT, those two figures decrease sharply. ML of tissue fluid decreases far greater than that of pathologic section. The difference is obvious (P<0.001). BI and BIG have dropped to 0.0953 and 0.7404 at the end of MDT. ML of tissue fluid has transformed into negative after 42 months, while that of pathologic section into negative after 54 months. The result shows the decreasing rate of link ratio for BI is irregular. Big decrease regularly. Thus it can be concluded that ML of pathologic section is more exact than that of tissue fluid smear. BIG can represent the bacteriological change of leprosy even more accurately and objectively. It can also make a more reliable inspection to judge the treatment and to prevent the leprosy recrudesce.

     

    PCA 32

    COMPROMETIMENTO DA MUCOSA ORAL EM PACIENTES VIRCHOVIANOS TRATADOS COM PQT E ROM
    Marcelo Araújo Opromolla; Somei Ura; Diltor Vladimir Araújo Opromolla
    Instituto Lauro de Souza Lima

    Na forma virchoviana, desde o seu início há disseminação hematogênica do M. leprae que se localiza na pele, mucosas, nervos, ossos e vários órgãos. As mucosas nasal, da boca e da laringe são geralmente comprometidas e isso faz com que as vias aéreas superiores constituam uma via de eliminação dos bacilos muito importante. Pacientes com lesões específicas bem evidentes nas mucosas, em particular na mucosa oral, são menos freqüentes hoje, em que o diagnóstico é feito em uma fase não muito avançada. Contudo, as lesões específicas, embora não aparentes, devem continuar existindo. Qualquer solução de continuidade nesse nível poderia eliminar uma quantidade muito grande de bacilos que contribuiriam para a disseminação da doença. Neste trabalho foi estudada a mucosa oral de dez pacientes virchovianos em tratamento com PQT e com baciloscopia positiva. Em todos eles foi realizada uma biópsia do palato mole que é o local mais freqüentemente acometido pela doença c o resultado foi o encontro do infiltrado específico e a presença de bacilos álcool-ácido resistentes nesses pacientes.

     

    PCA 33

    CONCURRENT LEPROSY AND HIV INFECTION - SHORT TERM OBSERVATIONS - TWO CASE REPORTS
    V V Pai; H.O. Bulchand; R. Ganapati
    Bombay Leprosy Project, Sion-Chunabhatti, Mumbai - 400 022, India

    The coexistence of mycobacterial diseases including tuberculosis and HIV infection is a well-known fact. However, there is no conclusive evidence to show any significant correlation between HIV and Leprosy. We report two case reports on the progress on the coexistence of HIV infection
    Case 1: DS, unmarried, male, 22 years.
    Promiscuous individual. Past history of genital ulcer disease Diagnosed as BT leprosy (B.I. negative). Treated with ROM - 3 doses intermittently from September to December 1997. Developed Type - I reaction in April 1998, treated with corticosteroids. HIV confirmed by Western Blot in March 1999. LEPROMIN negative in September 2000 Silent neuritis in right ulnar nerve, treated with steroids. Leprosy lesions regressed completely in July 2001.
    Case 2: BN, married, male, 32 years Promiscuous and alcoholic individual.
    Past history of genital ulcer disease. Diagnosed as BL leprosy (B.I. was 2+) in October 2000 and treated with ROM - 12 intermittent doses till September 2001. Reported HIV (ELISA) positive in December 2000. Developed Type - 1 reaction in January 2001 and treated with steroids. Developed Herpes Zoster in March 2001 and hepatitis in April 2001. Repeated reaction in August 2001 with acute neuritis, treated with steroids. In December 2001, he was hospitalized for ulcer care. Patient expired (Suspected due to Pulmonary Kochs) in January 2002. Spouse tested HIV positive. HIV status of 2 children is unknown.
    It is observed that in both these cases, though the follow up is short, clinically they have been regressing well. Long-term follow-up is necessary to observe the behaviour of clinical pattern (Case - 1), however it seems that it may not be feasible due to mortality on account of opportunistic infection as seen in case - 2.

     

    PCA 34

    DEVELOPMENT OF A SCALE TO MEASURE THE SEVERITY OF REACTION IN LEPROSY
    Alison Anderson; Himalaya Sigdel; Friedbert Herm; Jukka Knuutlila; Rachel Hawksworth; Wim van Brakcl; Sharon Marlowe
    Green Pastures Hospital & Rehabilitation Centre, INF-RELEASE, PO BOX 28, Pokhara. Nepal

    Reaction is a common complication of leprosy. It is associated with a variety of signs and symptoms, including skin signs, systemic effects such as fever, and peripheral neuropathy. Reaction differs in its severity, from mild reaction with minimal effects to severe reaction that may lead to irreversible tissue damage. Each of the signs and symptoms are associated with their own clinical test and grading method. There is however, no single, validated assessment drawing together this information. For programme, treatment, and research outcome evaluation, a single quantifiable scale measuring the severity of reaction was desired. For the purposes of the INFIR 2 project, (pilot clinical trials to evaluate alternative drugs as treatment for leprosy reactions), it was decided that a scale was needed to identify patients with severe reaction for recruitment and as a numerical way of monitoring drug response.
    Scale development and validation was carried out at Green Pastures Hospital & Rehabilitation Centre. Items for the draft scale and potential gradings were collected through consultation with a team of experts from within Nepal and abroad, and by review of a cohort of patients from the hospital to identify presenting characteristics. The items were rationalised into dermatological, systemic and neurological features and include all available tests and clinical examinations. A four-point response scale was chosen. The scale was developed by classical scale development techniques, validated in the hospital against a clinical assessment made by a team of experienced physicians and will be psychometrically tested. Results of the scale development and validation process will be presented.

     

    PCA 35

    DIAGNÓSTICO DA HANSENIASE: O EXAME CLÍNICO ASSOCIADO A BACILOSCOPIA PARA UMA TERAPEUTICA ADEQUADA.
    Alexsandro C. Dias; lara Pessoa Sant'ana; Vera Rejane. do Nascimento Gregorio
    Universidade de Pernambuco - UPE
    Centro Integrado de Saúde Amaury de Medeiros-CISAM
    Rua, Visconde de Mamanguape s/n, Encruzilhada. Fone:3427-3911 Ramal-259. Recife-PE; CEP: 52030-010

    A hanseníase, é uma patologia infecciosa que afeta principalmente a pele, os nervos periféricos, tem causado medo a humanidade por muitos anos. Porém O Mycobcterium leprae, descoberto na Noruega por Armauer Hansen em 1873, foi a primeira bactéria a ser identificada como causadora de uma doença humana. Hoje os pacientes são tratados em ambulatórios, e necessitam de um diagnóstico adequado (exame clínico e baciloscópico).O objetivo do estudo é avaliar a importância do exame clinico associado ao exame baciloscópico (BAAR) para o diagnóstico e classificação da hanseníase. Estudo transversal e retrospectivo, que utilizou dados secundários retirados dos prontuários dos pacientes matriculados no Centro Integrado de Saúde Amaury de Medeiros -CISAM-UPE referência no diagnóstico e tratamento da hanseníase na cidade do Recife-PE, no período de janeiro a dezembro de 2000 e revelaram a importância da realização do exame baciloscópico em pacientes com hanseníase, devido a sua relevância para o diagnóstico e controle da evolução da doença, é como parâmetro indispensável no auxilio da conduta a ser instituída nas reações e recidivas.

     

    PCA 36

    DIFICULDADE DIAGNOSTICA NA LESÃO GRANULOMATOSA DA FACE NA CRIANÇA
    Abulafia-Azulay, Luna; Azulay, R.D.; Sodré, C.T.: Leal. FR.P.C; Nery, J.A.C.
    Instituto de Dermatologia da Santa Casa de Misericórdia do Rio de Janeiro. RJ., Brasil

    Introdução: A hanseníase e uma doença infecto-contagiosa causada pelo Mycobacterium leprae com alta prevalência em nosso país. Exterioriza-se de diversas maneiras clinicas comprometendo diversas faixas etárias. Nas crianças existe uma peculiaridade conhecida como hanseníase nodular infantil que se acredita ser bastante freqüente.
    Objetivo: Chamar a atenção para as lesões na face em crianças.
    Material e Métodos: TVB, sexo feminino, quatro anos, branca, natural e residente no Rio de Janeiro. Referindo lesão na face há 06 meses, foi submetida ao exame dermatoneurologico e exames complementares (Biopsia, mitsuda e baciloscopia) finalizando diagnostico de hanseníase tuberculoide (hanseníase nodular infantil).
    Resultados: Exame dermatológico: Lesão papulo-tuberosa de coloração levemente ocre, menor que 1cm, localizada na asa nasal direita e sulco nasogeniano esboçando bordas policiclicas com discreta depressão central. Biopsia (granuloma tuberculóide). Mitsuda 4 mm. Teste de sensibilidade sem alteração.
    Conclusão: Incluir este tipo de lesão clinicamente como diagnostico diferencial de hanseníase mesmo sem historia epidemiológica, devido a variedade de apresentações clinicas da hanseníase nodular infantil que pode se apresentar como nódulo, papula ou macula.

     

    PCA 37

    DOENÇA AUTO-AGRESS1VA HANSÊNICA
    Alexandre Lima de Barros; Bruno Eduardo Pedroso Balbo; Maria Alice Ribeiro Ozório; Marina Lemos Carvalho; Roberta Leste Motta;, Rosana Barbosa Silva; Rozana Castorina da Silva; Silvia Helena Lyon de Moura; Sandra Lyon
    Fundação Hospitalar do Estado de Minas Gerais, Hospital Eduardo de Menezes, Centro Colaborador de Referência em Dermatologia Sanitária.
    Av. Doutor Cristiano Rezende 2213. Bonsucesso, Belo Horizonte, MG.

    A doença aulo-regressiva hansênica, descrita em 1978 pelo Prof. Azulay, corresponde a quadro clínico e imunopatológico de auto-agressão que ocorre na Hanseníase da forma Virchowiana e, menos freqüentemente, na forma diforma que tende para o pólo virchoviano devido à grande quantidade de múltiplos anticorpos às custas de uma estimulação de linfócitos B. Os autores apresentam o caso de um paciente, sexo feminino, 68 anos de idade, com diagnóstico de artrite reumatóide em julho/98, usando Diclofenaco de Sódio 20mg, Prednisona 5mg, Disfofato de Cloroquina 250mg, sem melhora clínica. História de ter iniciado com quadro de lesões em placas eitêmatohipoerônicas disseminadas no corpo, dores articulares e queda do estado geral dois anos antes do diagnóstico. Em Dezembro/98, teve o diagnóstico de hanseníase Virchoviana IB=5,2. A sintomatologia só teve melhora com o início da poliquioterapia. Ao exame dérmato-neurológico apresentava perfurante plantar no Hálux direito. Os exames complementares realizados em 12/04/99 mostraram: Fator reumatóide muito aumentado: 2560 UI (<5); Proteína C Reativa: 198mg/dl (<5): VHS 60 min: 18. Os exames realizados em 08/06/2000 mostraram: Células LE: negativo; FAN: positivo; VHS 60 min: 14; Fator Reumatóide: 1280 UI (Ref.: < 25 UI/ml): Proteína C Reativa: 48 mg/LL: VDRL: não reativo: ASTO: 80,0; Urina Rotina: normal. O tratamento instituído foi a poliquimioterapia multibacilar e Talidomida 400 mg/dia com melhora completa da sintomatologia.
    Motivo da apresentação: Alertar para a existência da doença auto-agressiva hansênica em país endêmico e muitas vezes confundida com outras doenças auto-imunes

     

    PCA 38

    DORMANT LEPRA BACILLI IN THE OCULAR TISSUE IN PRE MDT DAPSONE ERA AND POST MDT ERA.
    Swapan K. Samanta; I.S. Roy; Jyotirmoy Biswas
    B.S. Medical College, Bankura, West Bengal, PIN 722101, and Shankar Nethralaya, Chennai, India

    The Lepra Bacilli was searched in the iris tissue of the leprosy sufferers who was declared Released From Treatment (RFT). The aim of this study was to evaluate the status of bacillary clearance from the body as well as to correlate/postulate the presence of the bacilli as one of the causes/sources of relapses or the evolution of the ocular complications. Two such studies were undertaken in Eastern India in between 1979 to 1981 and in the year 2000. This iris tissue or the other ocular tissue was collected from the leprosy patients (RFT) during cataract surgery where an iridectomy was performed routinely as a part of the surgery or enucleation was done to remove a painful blind eye.
    Dormant Lepra Bacilli was found to be present in the iris tissue in the Dapsone Era (1982) amongst the MB leprosy sufferers with a Negative Skin Smear report for the Acid Fast Lepra Bacilli. Again Dormant Lepra Bacilli had been encountered along the Optic Nerve sheath in "RFT" MB patient in the MDT era (2001 ).The histo pathological picture of the skin tissue of these patients had not revealed any Lepra Bacilli. So the big question lies in the fact of the presence of these bacilli in a dormant state and the bactericidal efficacy of MDT. Is it one of the risk factor for relapse.

     

    PCA 39

    ER1TEMA NODOSO NECROTIZANTE- RELATO DE CASO.
    Andréia Castanheiro da C. Barbosa; Lúcia Mioko Ito; Rodrigo Sestito Proto; Ferrueio Fernando Daill'Áglio
    Departamento de Dermatologia da Faculdade de Medicina do ABC.
    Av Príncipe de Gales, 821 - -09060-650-Santo André -SP- Brasil.

    Relato do caso: Os autores relatam um caso de hanseníase dimorfo virchoviana em paciente adolescente, masculino, branco, 15 anos, natural do Ceará e procedente de Mauá, com início do quadro há 1 ano. Realizado o diagnóstico e instituída a terapia multibacilar específica, evoluiu com vários episódios reacionais do tipo II (eritema nodoso), controlados parcialmente com talidomida e prednisona, porém apresentando neurites intensas que culminaram com formação de garra fixa de nervo ulnar bilateralmente. Há 30 dias, apresentou novo surto reacional de nódulos eritematosos em membros superiores e inferiores, encimados por bolhas hemorrágicas e necrose central, que após tratamento específico evoluiu com cicatrizes atróficas.
    Discussão: O eritema nodoso é uma reação de hipersensibilidade tipo III de Coombs, que ocorre em pacientes DV e V, virgens de tratamento, mas em geral durante e após terapêutica (mais comum após os primeiros seis meses de tratamento). Caracteriza-se clinicamente por nódulos eritematosos, dolorosos que eventualmente podem ulcerar e necrosar. Os sintomas constitucionais são importantes. Sugerindo uma relação mais provável com a presença de bacilos fragmentados que surgem após tratamento específico, a reação localiza-se em vasos mais calibrosos da derme profunda e tecido celular subcutâneo, primariamente nos granulomas. Os principais diagnósticos diferenciais são: fenômeno de Lúcio, síndrome do anticorpo antifosfolípide e eritema polimorfo. Apesar do diagnóstico e tratamento precoce, incapacidades graves podem se desenvolver.
    Motivo da apresentação: Raridade e exuberância do caso.

     

    PCA 40

    ERYTHEMA NODOSUM LEPROSUM (ENL) POSSIBLY TRIGGERED BY LEVOFLOXACIN 3 YEARS AFTER COMPLETION OF MULTIDRUG THERAPY (MDT)
    Nishioka. S.A.; Goulart, I.MB.
    Centro de Referência Estadual em Hanseníase/Dermatologia Sanitária, Faculdade de Medicina. Universidade Federal de Uberlândia. Av. Pará 1720, 38400902 Uberlândia. MG. Brazil. Fax: +55-34-3218 2349. snishioka@umuarama.ufu.br

    Background: ENL, commonly found in multibacillary leprosy patients, can occur after exposure to drugs that are active against Mycobacterium leprae. It is known that viable, dormant bacilli (persisters) can survive for many years after-leprosy therapy.
    Case Report: A 57-year-old male treated for BL leprosy with MDT for 2 years, required treatment of ENL and neuritis with thalidomide and/or prednisone for additional 20 months and was then lost to follow-up for 12 months. In November 2001, while self-medicated with daily 20-mg prednisone and free of ENL-related manifestations for 1 year, he developed cryptococcal meningitis that was successfully treated with amphotericin B (2110 mg over 2 months); prednisone was withdrawn. Each daily dose of amphotericin B was administered with 25 mg hydrocortisone as co-medication to prevent infusion-related side effects (a common practice in Brazilian hospitals). In January 12. 2002. the patient developed sinusitis that was treated with a daily 500-mg dose of levoflaxacin. In January 28, 16 days after the introduction of hydrocortisone, he developed an episode of ENL.
    Discussion: It is possible that ENL was triggered by levolloxacin, which is the active isomer contained in ofloxacin, a fluroquinolone that is active against M. leprae. If this is so, it is an evidence that the patient still had viable bacilli after taking BDT for the recommended 24 months. Withdrawal of steriod is an alternative explanation that is debatable given the low dose schedule used by the patient for over 2 months before the episode of ENL.

     

    PCA 41

    ESTUDO CLÍNICO-PATOLÓGICO DE 461 NOVOS CASOS DE HANSENÍASE
    Dra. Greicianne Ferreira Nakamura; Dr. Antônio Schettini; Dra. Maria das Graças Cunha
    Fundação "Alfredo da Matta". Avenida Codajás nº 25. Cachoeirinha CEP 69065-130, Manaus-Amazonas-Brasil

    Apesar de nos últimos anos estar ocorrendo um importante declínio da Hanseníase como endemia em todo o mundo, a persistência de níveis elevados de casos novos em áreas geográficas pontuais e a necessidade de se manter os profissionais com experiência no diagnóstico e tratamento da doença mobilizados nos programas de controle, tem estimulado a realização de estudos no âmbito da clínica e epidemiologia. O Brasil permanece sendo o segundo país do mundo com maior número de pacientes e o Estado do Amazonas ainda apresenta taxas de prevalência e de detecção de casos novos consideradas com representativas de alta endemicidade. No presente estudo os autores fazem uma revisão de prontuários de pacientes atendidos na Fundação "Alfredo da Matta" (FUAM), que é Centro de Referência para tratamento da Hanseníase e faz o diagnóstico e tratamento de 70% dos casos da cidade de Manaus, demonstrando os dados demográficos, epidemiológicos e clínicos observados. O perfil clínico-patológico e epidemiológico deste grupo de pacientes é comparado com os descritos na literatura científica mundial.

     

    PCA 42

    ESTUDO DA EVOLUÇÃO DAS FORMAS CLÍNICAS DA HANSENÍASE E TENDÊNCIA CRESCENTE PARA A FORMA DIMORFA, NO CENTRO DE REFERÊNCIA DONA L1BANIA -FORTALEZA CEARÁ - 1995 - 2001
    Oliveira, Z. R.; Tavares, C. M.; Lopes, M. N. B.; Santos. M. F; Pereira, E. M. S. F;
    Rua Pedro Primeiro, Centro, Fortaleza- CE

    Ao analisar a evolução das formas clínicas da Hanseníase e a tendência das formas dimorfas no Centro de Referência Dona Libânia Fort. Ce. no período de 1995 - 2001, pereebe-se no cotidiano desta unidade de saúde uma tendência crescente no diagnóstico na forma tuberculóide, porém, observa-se na clínica que está havendo um aumento do número de casos de hanseníase na forma dimorfa e um comportamento diferente da doença para as formas multibacilares, especificamente a dimorfa com altos índices baciloscópicos. O objetivo deste trabalho é estudar a tendência da forma dimorfa entre todas as formas clínicas da hanseníase, verificar o índice baciloscópico da forma clínica dimorfa no momento do diagnóstico. Os dados parciais foram obtidos através das fichas de notificação e investigação dos pacientes de hanseníase e processadas no SINAN / EPINFO. Será realizado um estudo retrospectivo, descritivo e analítico de uma serie histórica de casos de hanseníase nos últimos 7 anos. A casuística é constituída de todos os casos notificados do período (1995 - 2001). Analisando os dados do período de 1995 a 2001, acharam-se os seguintes resultados: a partir do ano de 1995, observa-se um aumento de casos dimorfos de 133 em relação ao totat de 614 casos com o aumento de 22% no primeiro ano avaliado (1995). No ultimo anos avaliado (2001) encontramos 433 casos na forma dimorfo entre 840 de todos os casos, alcançando um percentual de 55%. O período analisando 1995 a 2001, inclui marcos importantes na evolução da endemia hansênica e do enfoque das políticas de controle da hanseníase, melhoria no diagnostico clínico. Concluí-se portanto, que é de grande importância a realização deste trabalho para um maior conhecimento do comportamento desta endemia no nosso estado.

     

    PCA 43

    ESTUDO DA VALIDADE DA CLASSIFICAÇÃO CLÍNICA DE HANSENÍASE RECOMENDADA PELO MINISTÉRIO DA SAÚDE DO BRASIL
    Iara Lacerda Ferreira Crippa; Antônio Pedro Mendes Schettini; Silmara Navarro Peninni; Paula Fracinetti Rebello; Maria da Conceição Schettini
    Fundação Alfredo da Matta (FUAM). AV. Codajás, 25. Cachoeirinha. 69065-130. Manaus. Amazonas. Brasil.

    A classificação dos pacientes de hanseníase baseada no resultado do exame baciloscópico da linfa é fundamental para a determinação do esquema terapêutico adequado. Pacientes que apresentam baciloscopia positiva serão tratados com o esquema de poliquimeoterapia mullibacilar e os que apresentam baciloscopia negativa recebem o esquema paucibacilar. No entanto, para os locais que não dispõem da baciloscopia, o Ministério da Saúde do Brasil recomenda que seja feita uma classificação baseada no número de lesões: até cinco lesões de pele e/ou um tronco nervoso acometido, é considerado paucibacilar e mais de cinco lesões de pele e/ou comprometimento de mais de um tronco nervoso é considerado hanseníase multibacilar. Neste estudo, os autores comparam a classificação clínica baseada no número de lesões e troncos nervosos acometidos com o resultado da baciloscopia e da pesquisa de bacilos ao exame histológico, em um grupo de 530 pacientes portadores de hanseníase. diagnosticados na FUAM, no período de janeiro de 2000 a março de 2001.

     

    PCA 44

    ESTUDO DE CASOS CLÍNICOS: DIFICULDADES ENCONTRADAS NA CONDUÇÃO DO TRATAMENTO DAS REAÇÕES HANSENÍCAS
    Fernanda da Silva Alves Costa; Juliana Maria Vicente; Roberto Cláudio Correia; Rosemary Aparecida Passador Sanches De Giuli
    Secretaria Municipal de Saúde de Vilhena - RO
    Secretaria Municipal de Saúde de Pimenta Bueno-RO
    Introdução: A Hanseníase é sabidamente endêmica no estado de Rondônia, constituindo um sério problema de saúde pública apesar de esforços da Coordenação Estadual, priorizando programações específicas desde 1992, objetivando detecção precoce de casos e conseqüentemente a prevenção de incapacidades.
    Objetivos: Apresentar e discutir casos de hanseníase, com pontos em comum, sob os aspectos psicossocial e clínico, em dois Municípios do Estado, Pimenta Bueno e Vilhena, identificando falhas na condução dos mesmos e buscando uma reflexão embasada na realidade local, visando assegurar uma assistência adequada aos portadores deste estigmatizante mal.
    Materiais e Métodos: Estudo de dois casos clínicos ocorridos em diferentes Municípios. O trabalho tem como fonte, dados coletados dos prontuários dos pacientes e entrevistas.
    Apresentação dos Casos- Pacientes jovens, mesma faixa etária e classe social, portadores da doença na forma multibacilar que apresentaram estados reacionais intensos (Eritema Nodoso Necrotizante) aliado à intercorrências clínicas adversas, exigindo terapêutica agressiva sem resposta satisfatória.
    Resultados: A experiência foi importante para reflexão de alguns pontos básicos:
    -necessidade urgente de Referência Técnica Descentralizada (Pimenta Bueno dista 510 Km e Vilhena 700 Km da capital Porto Velho);
    -revisão e complementação do Manual de Normas do Programa de Controle da Hanseníase, prevendo situações adversas não tão raras como mostra a casuística.
    Conclusão: Faz-se necessário realizações de reuniões com o intuito de promover discussões técnicas, estudo de casos e troca de informações entre as equipes municipais e/ou estaduais, o que contribuirá também para revisão das Normas Técnicas do Programa, alem de tornar as equipes coesas e seguras

     

    PCA 45

    ESTUDO DO COMPROMETIMENTO NEURAL EM HANSENÍASE
    Elisete S. Pedrazzani; Mariangela Pedroso Piolo; Isabella G. Oliveira; Ingrev G. Vanella; Edna S. Uati
    Secretaria Municipal de Saúde de São Carlos. R. Cap. Adão P. S. Cabral. 457- São Carlos/SP. Brasil.

    Os problemas das neurites, do dano neural e das incapacidades na hanseníase continuam sendo relevantes no que se refere à sua detecção precoce, ao seu tratamento e às suas repercussões psicossociais para o indivíduo e para a sociedade.
    Foi realizado um estudo prospectivo com todos os casos inscritos no programa de controle e eliminação da hanseníase no período de 01 de janeiro de 1998 a 31 de dezembro de 2001 no município de São Carlos, São Paulo, Brasil. Foram monitorados 30 pacientes, sendo 17 multi e 13 paucibacilares, mensalmente ou quinzenalmente, quando necessário, quanto à evolução do comprometimento neural durante a fase de tratamento e posteriormente à sua alta clínica trimestralmente durante 2 a 3 anos. As ações básicas de prevenção de incapacidades foram parte integrante deste trabalho para a totalidade dos pacientes acompanhados.
    Os resultados mostraram que:
    O Nervo Tibial seguido pelo Nervo Ulnar foram os nervos mais freqüentemente comprometidos:
    A maioria apresentou pelo menos um tronco nervoso em estágio de envolvimento neural no momento do diagnóstico;
    82.3% evoluíram para perda da sensibilidade protetora plantar dos pés durante e/ou no período pós-alta.;
    A maioria apresenta, neste momento, Estágio I de comprometimento neural, ou seja, perda sensorial incompleta para um ou mais troncos nervosos;
    A detecção precoce do dano neural e o monitoramento sistematizado e periódico da função neural foram fundamentais para evidenciar e tratar os nervos acometidos;
    Nenhum paciente evoluiu para perda sensorial e motora completas bem como para deformidades instaladas.

     

    PCA 46

    EVALUATION OF LEPROSY PATIENTS PRESENTING LIVER ALTERATIONS DUE TO LEPROSY MDT/WHO TREATMENT
    Costa. M.D.; Macedo. A.K.; Hosken. F.C.; Rosa. T.F.L.; Sales. A.M.; Nery. J.A.C.; Gallo. M.E.N.
    Leprosy Laboratory / IOC - FIOCRUZ - Rio de Janeiro - Brazil.
    Introduction: The Fiocruz leprosy Laboratory (Collaborating Center of the Ministry of Health for the Program of Leprosy Control), among the several activities developped, one of them is to serve as a back-up to patients from other institutions coming lo present side effects due lo MDT.
    Objective: Calling attention to some clinical indications which may wrongly ascribed to MDT.
    Material and Methods: There have been evaluated 6 (six) patients with MDT. Treatment, clinically suspected of medicative hepatitis (disconfort, jaundice, abdominal pain and laboratory alterations), during the period of March to May 2001. At the moment of consultation, patients were examined by the general practitioners in charge of the service and laboratory exams (complete hemogram, liver function tests, lipid profile and sorology for A. B, C viruses of hepatitis) were performed. Not having been found unfavourable laboratory results in the subsequent consultations, drugs have been introduced again in different moments, been always followed by laboratory and clinical evaluation. All the laboratory exams have been done at the Evandro Chagas Hospital (CPqHEC).
    Results: Among six patients having been studied, two of them were male and lour female. The ages range from six to seventy years old. Five patients presented normal laboratory results and only one patient presented symptomatology compatible lo medicative liver disease and developped into anaemia when dapsone was introducted. Patients who did not present laboratory and clinical alterations alter reintroduction of drugs have been oriented towards maintaning their MDT. Original schemes, in relation to the patient who had been unable to continue with the medication (Dapsone), the alternative scheme have been introduced (Clofazimine 100 mg/day), based on the orientation of the Ministry of Health.
    Conclusion: With the MDT. Introduction is general consensus that this one is quite safe and effective, although it demands a greater consideration on the part of its handling by health professionals.

     

    PCA 47

    EVALUATION OF THE FREQUENCY OF THE REACTINAL STATES AMONG PAUCIBACILLARY LEPROSY PATIENTS.
    Duarte, S.K.; Nery, J.A.C.; Machado. A.M.; Lyra. M.R.; Sales A.M.; Pinto, J.M.N.; Gallo. M.E.N.

    Introduction: Investigative works about the frequence of leprosy reactional states have been showing varying results among the pauci and multibacillary groups. In Brazil, publications on these date are still rare, mainly in the paucibacillary group.
    Objective: The main objective of this study was to analyze the frequency of reactional states in paucibacillary leprosy patients.
    Methods: We studied 300 paucibacillary leprosy patients, classified according to Ridley and Jopling, including the pure neuritic clinical form, with a methodical assessment of this group. The reference time was the start of specific paucibacillary treatment (WHO) and we didactically classified the reactions in three clinical types, reversal reaction without neuritis (R1), reversal reaction with neuritis (R2) and isolated neuritis (R3).
    Results: The results demonstrated that the reactional states happen in 14.6% of patients and the recurrence was 4,5% of paucibacillary patients. It was verified that 70.4% of patients developed reversal reaction before the start of specific treatment, 25% during the treatment and 4.6% after the treatment. Reversal reaction without neuritis was observed in 56.8% of patients. "Borderline "-Tuberculoid" clinical form has the most incidence of reversal reactions (84.1%).
    Conclusion: We have presented herein date that reinforce previous studies, showing that reaction episodes in paucibacillary patients occur less frequently than reaction episodes.

     

     

    PCA 48

    EVOLUÇÃO DA HANSENÍASE NA FORMA INDETERMINADA PARA A FORMA TUBERCULÓIDE APÓS O TRATAMENTO - RELATO DE 2 CASOS.
    Ana Regina Alencar Santos; Clarisse Zaitz; Juliana Rogério Prado; Clarice Marie Kobala

    Foram observados 2 casos de pacientes que se apresentaram inicialmente com máculas hipocrômicas na pele e alteração de sensibilidade local, tendo sido diagnosticados e tratados como Hanseníase na forma paucibacilar, com esquema poliquimioterápico (rifampicina e dapsona) por 6 meses. Evoluíram num curto período de tempo com viragem da reação intradérmica de Mitsuda. sendo revelado no exame anatomo-patológico a formação de um granuloma, caracterizando a forma tuberculóide da doença.
    Caso 1: paciente C. S., 55 anos, masculino, branco, natural de Arcalva - SP, procurou nosso ambulatório há 2 anos com queixa de lesões bolhosas e perda da sensibilidade no 2º quirodáctilo da mão direita, apresentando previamente síndrome do túnel do carpo nesta mão, tratada com cirurgia há 1 ano. Feita hipótese de Hanseníase forma neural, realizado eletromiografia sem alterações, baciloscopia e mitsuda negativos, e orientado tratamento em posto de saúde com poliquimioterapia paucibacilar (rifampicina e dapsona). Evoluiu com surgimento de lesões em braços e pé direito, com perda de sensibilidade, onde foi realizado biópsia, revelando Hanseníase tuberculóide.
    Caso 2: paciente S. D. A., 23 anos, masculino, branco, natural de São Paulo, procurou nosso ambulatório com lesão em perna direita caracterizada por mácula hipoerômica, área de alopeica e perda de sensibilidade térmica, dolorosa e tátil no local. Realizado biópsia revelando processo inflamatório crônico cutâneo. Mitsuda e baciloscopia negativos, prova da pilocarpina alterada, enquadrando-se o caso numa Hanseníase indeterminada e iniciando o esquema poliquimioterápico paucibacilar por 6 meses. Evolui no pós-tratamento com infiltração da lesão pré-existente e aparecimento de lesão nodular em lábio inferior. Realizado biópsia que evidenciou processo granulomatoso.

     

    PCA 49

    EVOLUTION TIME PRIOR TO DIAGNOSIS AND DISABILITIES AT THE INITIAL EXAM IN MULTIBACILLARY LEPROSY PATIENTS.
    Pimentel, Maria Inés Fernandes; Nery, José Augusto da Costa; Borges, Esther; Gonçalves, Rosângela Rolo; Sarno, Euzenir Nunes
    Laboratório de Hanseníase, Fundação Oswaldo Cruz. Avenida Brasil no. 4365 - Manguinhos - Rio de Janeiro - RJ CEP: 21045 - 900.

    In an effort to determine the influence of the evolution period prior to diagnosis in the presence of disabilities detected at the initial examination of multibacillary leprosy patients, one hundred patients (18% BB, 47% BL and 35% LL) were asked in anamnesis to ascertain the evolution period of the disease before the diagnosis was made. The patients were evaluated in respect to physical disabilities al the time of the diagnosis through the disability grade before treatment (DGBT), using voluntary muscle test (VMT) and nylon-monofilament sensitivity test (Semmes-Weinstein test).
    The diagnosis was made up to 6 months of evolution of the disease in 29% of the patients, while more than 2/3 of them (71% ) had diagnosis in a time period of over 6 months of evolution. In relation to the disabilities presented al diagnosis, 44% presented DGBT = 0; 33% presented DGBT = 1; 22% presented DGBT = 2; and 1% presented DGBT = 3. When lhe period of time of disease evolution before diagnosis was correlated with DGBT, we obtained a significant correlation (p = 0.019428). Patients with bigger evolution periods before diagnosis presented bigger disability grades before treatment, while patients whose diagnosis was made up to 6 months of disease evolution presented less disabilities related to leprosy. These data show the importance of early diagnosis in the prevention of disabilities related to leprosy.

     

    PCA 50

    EXPLORACIÓN NEUROLÓGICA COMPLETA EN PACIENTES CLÍNICA Y BACTERIOLÓGICAMENTE INACTIVOS DESDE HACE MÁS DE 10 AÑOS
    Dr. José Ramón Gómez Echevarría (Sanatorio Fontilles); Fátima Molí Cervera (Sanatorio Fontilles)
    Sanatorio San Francisco de Borja. CP. 03791 FONTILLES (ALICANTE); sanatorio@fontilles.org

    Aunque para el diagnóstico de la enfermedad no sea necesario una exploración neurológica completa, intentamos recoger los resultados de esta exploración realizada a 81 pacientes inactivos controlados por el Sanatorio san Francisco de Borja (Fontilles). Se evalúa tanto la sensibilidad superficial (térmica, dolorosa y táctil) como la sensibilidad profunda en miembros superiores e inferiores. Se valora la fuerza muscular de los Sistemas neuromusculares más comúnmente afectados. Se exploran los reflejos osteotendinosos y cutáneos y se estudian las alteraciones tróficas secundarias a la enfermedad.
    Con el estudio se demuestra que, a pesar de ser posterior a la afectación de la sensibilidad superficial, también la profunda se ve afectada tras años de evolución de la enfermedad.

     

    PCA 51

    EYE IN MDT- LONGITUDINAL FOLLOW-UP 1982-2002
    Muthiah Arokia Rajan
    Sacred Heart Leprosy Centre, Karaikal Road. Sakkottai - 612 401. Kumbakonam, Tamil Nadu - India.

    Regular Eye Examinations were done from start of treatment till last date of attendance. 1033 were followed for a minimum period of 5 years to 20 years.
    Follow-up period and cases:
    5- 10 years 308
    11-15 years 449
    > 15 years 276
    They consisted of Tuberculoid 83, Borderline 384, Borderline Lepromatous and Lepromatous 566. The treatment was according to WHO regimen. In Tuberculoid and Borderline patients 441 had no eye complication while 26 patients had Lagophthalmos only. In BL-LL patients 507 had no eye complication while 59 had eye complications.
    In those with short duration of disease eye complications subsided within a year and did not recur again. In those with long duration of disease eye complications lasted for years and even in those who did not have eye complications initially developed them later alter years of MDT. Blindness occurred in 4 patients who had severe pre-existing eye complications. Steroid Cataract was common. Cataract and IOL surgery outcome was good.
    Early detection of the disease and MDT prevent eye complications. All BL-LL patients need routine Slit Lamp examination for early detection of Iritis. Early detection of Reversal Reaction will prevent Lagophthalmos. Treatment of ENL with Thalidomide will reduce Steroid Cataract. Benefits of ophthalmic surgery including IOL should not be denied to the patients.

     

    PCA 52

    FACIAL LESIONS IN LEPROSY - AN ANALYSIS
    V V Pai; V Gaikwad; R Ganapati
    Bombay Leprosy Project. Sion-Chunabhatti, Mumbai - 400 022, India

    Face lesions in leprosy have a potential and a propensity to develop Type I Reaction and disability. Several studies published in literature supports this theory. In our experience, particularly patients with face lesions report with anxiety related to persistence of the lesions and attribute to the incurability of the disease.
    In this study a total of 89 patients with lace lesions were analysed from the available records of registered patients in our urban clinics located in Bombay over the past 5 years. 46 were adults and 43 were children, 22 were male adults and 24 were female adults, 19 were male children and 24 were female children.
    The face lesions were analysed with reference to (i) distribution of lesions, (ii) clinical presentations and (iii) treatment of clinical problems. All these patients were either treated with standard WHO MDT or with intermittent therapy consisting of Rifampicin, Ofloxacin and Minocycline (1/3/6/12 doses)
    It was observed from the analysis that 14 patients had lesions around the eye, 59 had lesions on the cheek, 10 had lesions on the cheek and forehead while 6 had the lesion on the nose. Among these 8 patients were found to have Type I Reaction, 6 reported with watering of the eyes and 1 with Type II Reaction. Incidentally none were found to have lagophthamos, though 6 patients had watering of the eyes indicating early nerve function impairment. All patients with Type I Reactions were managed with a standard course of steroids for 3 months, 2 patients who did not respond to steroids were put on a course of Clofazimine in anti-inflammatory schedule for six months. In view of persisting erythema in 8 patients, despite the standard steroid course, they had to be put on topical sunscreen consisting of Titianium dioxide 1%, Calamine 6 % along with strict advice to avoid sunlight. The response was good and satisfactory.

     

    PCA 53

    FENÔMENO DE LÚCIO NA GESTAÇÃO
    Luciana Pessoli Bufíbn, Reinaldo Leal. Paulo Ricardo Criado, Maria do Rosario Vidigal. Thais Romero Gatti
    Complexo Hospitalar "'Padre Bento" de Guarulhos - Serviço de Dermatologia Prof. Dr. Mário Cezar Pires
    Av. Emílio Ribas nº 1573 - Tranqüilidade - Guarulhos -SP

    A gravidez, associa-se a uma maior freqüência dos estados reacionais relacionados à hanseníase. Um destes, o fenômeno de Lúcio, é observado entre os portadores da variedade difusa de Lúcio e Alvarado, sendo raro em nosso meio. Ilustrando esses fatos, relatamos um caso de fenômeno de Lúcio na gestação marcante por sua raridade, exuberância e evolução dramática.
    Sem diagnóstico prévio de hanseníase; veio ao nosso serviço por apresentar áreas de necrose cutânea seca com contornos poligonais e estelares na face, tronco, membros superiores e em toda extensão dos membros inferiores; lesões eritêmato-violáceas infiltradas com bordas irregulares na face, além de madarose e rarefação ciliar. Não havia evidências de comprometimento sistêmico nem fetal. O exame histopatológico foi compatível com fenômeno de Lúcio. Instituímos o tratamento específico para hanseníase, imunossupressão com doses altas de corticóides e antibioticoterapia de amplo espectro. Debridamentos cirúrgicos. No 39º dia de internação, após o óbito fetal seguido por abortamento espontâneo, a paciente desenvolveu insuficiência respiratória, evoluindo com óbito.

     

    PCA 54

    FENÔMENO DE LÚCIO: RELATO DE 2 CASOS.
    Rodrigo Sestito Proto; Lúcia Mioko Ito; Ferrucio Fernando Dall'Áglio; Andréia Castanheiro Barbosa; Antonio José Tebcherani; Maurício Paixão
    Departamento de Dermatologia da Faculdade de Medicina do ABC.
    Av Príncipe de Gales, 821- -09060-650-Santo André - SP- Brasil.

    Introdução: Os autores relatam 2 casos de fenômeno de Lúcio em pacientes com hanseníase virchoviana.
    Relato dos casos: Caso 1: JMF, branco, masculino, 52 anos, apresentou quadro súbito em membros inferiores e superiores de máculas livedóides e purpúricas que evoluíram para lesões ulcero-necróticas, ascendentes e dolorosas, evoluindo com septicemia. Apresentava infiltração difusa da face e madarose ciliar.
    Negava afecção e tratamentos prévios para qualquer patologia. O exame histopatológico das lesões revelou proliferação endotelial focal dos vasos dérmicos, vasculite rica em bacilos (BAAR) e oclusão vascular por trombos. Caso 2: JAS, 78 anos, branco, natural do Piauí. Procurou o Posto de Saúde do Serviço Universitário com quadro de aparecimento repentino de áreas de necrose cutânea ascendentes, dolorosas em membros inferiores, superiores e lóbulos de orelhas. Ao exame dermatológico, apresentava infiltração da região frontal, com destruição do septo nasal. Negava doenças e tratamentos prévios. O exame histológico da face evidenciou hanseníase virchoviana e o quadro dos membros inferiores e superiores foi com patível com o de fenômeno de Lúcio.
    Discussão: o fenômeno de Lúcio, também denominado de eritema necrotizante, foi descrito pela primeira vez por Lúcio e Alvarado como uma reação necrosante, ocorrendo em pacientes com hanseníase virchoviana e não nodular. Em 1948, Latapi e Zamora, reconheceram-na como sendo o estado reacional da forma difusa, ocorrendo em doentes com infecção avançada, sem tratamento específico adequado ou precedendo o início deste.nos dois casos descritos, o fato da doença de base até então não ter sido detectada e tratada, favoreceu o diagnóstico, pois o fenômeno geralmente acomete indivíduos nesta situação.
    Motivo da apresentação: Raridade e exuberância dos casos.

     

    PCA 55

    FIRST DOCUMENTATION OF HISTOID FROM YEMEN
    Abdul Samid Al-Kubati; Abdul Rahim Al Sarnie; AbduAli
    Office of the National leprosy control programme, P.O.Box. No.55722, Taiz, Republic of Yemen, Tel: 967 4 242306/7/9 Fax: 967 4 242308 Mobile 967 7928976

    Histoid type of Lepromatous leprosy was first reported and described by Dr.Wade in 1963, Dr.Ramanujam, Dr.Ramu in 1969, Dr.Rodxigues in 1969 and Dr.Chaudhary in 1971. It is a variant of L.L. Clinically characterized by cutaneous and subcutaneous nodules with a distinctive histopathology or plaque like lesions. The typical cutaneous lesions are reddish, shiny, round, well-defined, firm and non-tender nodules, arising from normal skin, resemblance to neurofibromatosis. Histoid leprosy occurs in patients, whose disease is relapsing on behalf of the discontinued treatment prematurely, or due to the causative organism, M.leprae, has become drug resistant. In this subject we are reporting the first case of Histoid leprosy from Yemen after intake of MDT for 5 months, and discontinuing for 10 years.

     

    PCA 56

    FREQUENCY OF ANEMIC PROFILES IN PATIENTS WITH LEPROMATOUS LEPROSY UNDER DAPSONE TREATMENT
    Dirceu Dalpino
    Instituto Lauro of Souza Lima of Bauru - SP Brazil

    The anemia can be defined as the presence of hemoglobin rates lower 13 grams/dl in the man and 12,0 grams in the woman. It's great variety for the appearance of an anemic picture, however in our study, two factors has larger relevance. The leprosy is a disease of chronic evolution ami the dapsone, a drug oxidizer, used in your treatment. The anemia of chronic disease may also present as a microcytic anemia.

    In a retrospective rising of 148 lepromatous leprosy patients assisted at this Institute in the year of 2001 and submitted to hematology's exams, we observed the presence of lower hemoglobin rates above to the limits described in 37,1% of these patients, and this rate was 11,1% in a group control of 144 patients. There was not difference significant statistics in relation to the patients' sex.

     

     

    There was not difference significant statistics as in the anemia presence when compared in relation to the sex. We found significant statistical difference (p < 0.001) when we compared the patients' group with the group control in the presence of hemoglobin rates lower the minimum levels.

     

    PCA 57

    HANSEN'S DISEASE IN CHILDHOOD: A STUDY OF PHYSICAL DISABILITY
    Maria de Fátima Marója; Adriana C. Saraiva; Valderiza Pedrosa; Maria Anete Queiroz; Lúcio T. Ihára
    Fundação Alfredo da Matta - Rua Codajás, 25, -Manaus - Amazonas

    In the State of Amazonas, Hansen's disease still represents a very important public health problem. The prevalence, comparing the coefficient of 127,6/10.000 inhabitants in 1988 and 10.3/10.000 inhabitants in 2000, has reduced significantly, however it has still not reached the elimination aim. Detection of new cases, has shown it to be hyper-endemic, with a coefficient of 4,4/10.000 inhabitants in 2000. Amongst the new cases detected, 82.1 % presented disability Level 0, only 6.5% presented level II and
    III. considered medium by national standards. In children younger than 15, the detection coefficient may be considered hyper-endemic, with a coefficient of 1.2/10.000 inhabitants. Hansen's disease in childhood reflects up lo a certain point the aspects of this disease in the adult. The project's general objective is to evaluate Physical disability in children younger than 15, diagnosed with Hansen's disease. 216 patients were evaluated, diagnosed anD treated at the "Fundação Alfredo da Malta" between January 1998 and January 2001, of these 57.4% were male. The age group most affected was between 11 and 15 years (60.6%). Paucibacillary forms represented 59.7% of the cases. 90.4% presented disability level 0,4.8% I and 4.8% II and III. Of the 134 patients that were given discharge during the study, 63.4% were not evaluated for disability at discharge. Of those cases evaluated, 89.8% presented disability level 0, 6.1% level I and 4.1% level II and III. The disability level at diagnosis compared lo that at discharge, show a worsening of 4.08%. However, this value is probably sub estimated, due to the high percentage of cases not evaluated at discharge.

     

    PCA 58

    HANSEN'S DISEASE RELAPSE IN THE CONTROL PROGRAMME OF AMAZONAS STATE
    Maria de Fátima Marója; Valderiza Pedrosa; Emilia Santos Pereira; Maria Del Pilar Berbegal; Maria da Graça Souza Cunha; Antonio Pedro Schetinni
    Fundação Alfredo da Matta - Rua Codajás, 25 -Manaus - Amazonas

    Hansen's disease represents an important public health problem in the State of Amazonas with a detection co-efficiency of 4.4 / 10.000 inhabitants and Prevalence of 10.3/10.000 inhabitants, having reduced significantly. One of the contributing factors for this reduction in prevalence was the introduction of multi-drug therapy in 1982, with patients receiving discharge as cured in shorter periods. Relapse after MDT may occur, according to the World Health Organisation in very low percentages, according to WHO. in 0.7% for multi-bacillar cases and 1.07% for paucibacillar. Our study's objective was to determine the percentage of relapse in Hansen's disease in patients registered in the Amazonas State Control Programme. A descriptive study was carried out with evaluation of notified cases of relapse from Manaus and the interior, between 1982 and 2001. Of the total number of patients given discharge as cured. 226 cases of relapse were notified, representing 0.95%. Relapse was more frequent in MB forms. The mean period between discharge and relapse was 7 years in MB cases and 4 for PB. In relapse, the slit skin smear index in MB presented a mean of 3.25. The disability level worsened between discharge and relapse in 32.6% of the cases.

     

    PCA 59

    HANSENÍASE ASSOCIADA À FEOHIFOMI-COSE
    Heitor de Sá Gonçalves; Ricardo Américo de A. Uma; Ana Célia de A. Mesquita; Ruth Helena O. Menezes; Rose Mary P. Guilhon
    Centro de Dermatologia Dona Libânia - SESA - CE
    Av. Redro 1. 1033 - Centro - Fortaleza - CE

    MMF, 48 anos, masculino, branco, eletrotécnico, natural e procedente de Fortaleza - CE. Paciente em tratamento para MHBV há 22 meses, com queixa de '"caroços no pé" há 7 meses, referindo ter feito drenagem do mesmo em serviço de Cirurgia, apresentando laudo histopatológico inconclusivo. Ao exame dermatológico: lesões inativas de MH e lesões nodulares, eritematosas, em número de três (03), medindo 5 cm no maior diâmetro, pouco dolorosas, eliminando secreção vermelha, localizadas em pé esquerdo. Exames microbiológicos: pesquisa e cultura para BK e germes piogênicos - negativas; micológico direto - hifas demáceas septadas com aspecto toluróide; cultura para fungos - Exophiala ieanpelnei. Histopatológico: compatível com micologia. Tratamento: Cetoconazol e exérese cirúrgica. Motivo da apresentação: raridade da associação.

     

    PCA 60

    HANSENÍASE COM PSORÍASE
    Sabrina L.C. Maciel; Suzana Kally M.B. Rapozo; Jaison Antonio Barreto; Deise Ap. dos Santos Godoy; Raul Negrão Fleury
    Instituto Lauro De Souza Lima
    Rod. Cte. João Ribeiro de Barros, km 225/226, Bauru - SP. CEP: 17034-971, Cx. Postal: 3021, Fone: (14) 221 5900. FAX: (14) 221 5914. E-mail: ensino@ilsl.br
    Sabrina Lacerda Cardoso Maciel: Fone: (14) 230 5392, E-mail; sahrimaciel@hotmail.com

    JC, 72 anos, masculino, leucodérmico, casado, lavrador, natural de Botucatu - SP, residente em Itapuí-SP.
    HMA: Há três anos notou manchas vermelhas em dorso e abdome '"adormecidas". Há um ano, somaram-se ao quadro placas eritematodescamativas em membros inferiores e antebraços que pioravam quando o paciente sente-se nervoso e melhoram quando se expõe ao sol.
    AP: Tratamento em centro de saúde por dez anos, a partir de 1956.
    Parou de fumar há mais ou menos cinquenta anos. Hipertensão arterial em tratamento irregular.
    AF: Nega outros casos semelhantes na família.
    Exame Dermatológico: Máculas hipocrômicas residuais em tronco, ombros e abdome ao lado de máculas hipocrômicas com eritema e infiltração marginal e placas eritematopardacentas mal delimitadas.
    Placas eritematodescamativas com descamação lamelar e sinal do orvalho sangrante em membros inferiores e em menor número nos antebraços. Nas coxas, observa-se placas eritematopigmentares planas, entremeadas com áreas de pele normal.
    Amiotrolia hipotenar e de primeiro interósseo dorsal na mão direita, retratação móvel de quarto quirodáctilo e fixa de quinto quirodáctilo direitos.
    Exames Realizados: Hemograma: hemácias 4.97 mi, Hb: 52% (morfologia normal), leucócitos 6700 (diferencial sem alterações), plaquetas 265.000, glicemia de jejum 103 mg%, Mitsuda= negativo, Baciloscopia: IB: 1.5; IM: 0.
    Histopathológico: placas eritematopardacentas - infiltrado multifatorial, de pequena extensão, constituído de células epitelióides pouco diferenciadas e linfócitos. Baciloscopia 3+, (presença de bacilos típicos); placa eritematodescamativa de membro inferior- hiperplasia epitelial característica com hiper-queratose, paraqueratose e pequenos acúmulo de neutrófilos fragmentados em capa córnea. Focos de exocitose neutrofílica com espogiose. Baciloscopia: bacilos em macrófagos não diferenciados e em ramos nervosos.
    Tratamento e Evolução: indicado PQT para multi-bacilar por vinte quatro meses 9fará tal tratamento em posto de saúde de região); prescrito liquor carbonis detergens (LCD) 10% em gel para lesões dos membros inferiores.

     

    PCA 61

    HANSENÍASE DIMORFA E AIDS - APRESENTAÇÃO DE 4 CASOS
    Marli Izabel Penteado Martini; Maria Ângela Bianconcini Trindade; José Homero Masetti; Mirian Aparecida Leite; Marcos Alberto M. Nogueira
    Instituição: Divisão de Hansenologia e Dermatologia Sanitária da Secretaria da Saúde do Estado de São Paulo

    Introdução: A influência da AIDS na evolução clínica e na resposta ao tratamento da hanseníase não está esclarecida.
    Relato dos casos: Os quatro indivíduos manifestaram hanseníase dimorfa durante o tratamento da AIDS. Três do sexo feminino e 1 do masculino. As idades variaram de 27 a 44 anos. No momento do diagnóstico da hanseníase, dois indivíduos apresentaram baciloscopia positiva e reação de Mitsuda entre 7 e 10 mm. Todos apresentaram no exame histológico células epitelióides com baciloscopia positiva. A reação tipo 1 (resposta imune celular) ocorreu em um indivíduo no momento do diagnóstico da hanseníase e em outro durante a evolução do tratamento da hanseníase.
    Motivo da apresentação: Demonstrar as características clínicas, histológicas e a evolução do tratamento da hanseníase em casos desta co-infecção.

     

    PCA 62

    HANSENÍASE DIMORFA E VIRCHOWIANA EM MENORES DE 15 ANOS - APRESENTAÇÃO DE 8 CASOS
    Marli Izabel Penteado Manini; Maria Ângela Bianconcini Trindade; José Homero Masetti, Mirian Aparecida Leite; Marcos Alberto M. Nogueira; Maria Denise Takahashi.
    Divisão de Hansenologia e Dermatologia Sanitária da Secretaria da Saúde do Estado de São Paulo

    Introdução: A hanseníase em menores de 15 anos é pouco freqüente e muito pouco estudada. As formas bacilíferas (V e D) e as reações que podem ocorrer nestas formas podem gerar incapacidades que acarretarão muitas dificuldades na vida destes menores.
    Relato dos casos: Os menores foram diagnosticados nos últimos 5 anos como hanseníase dimorfa ou virchowiana com baciloscopia positiva. A idade variou de 9 a 14 anos, 3 eram do sexo feminino e 5 masculino. Quatro apresentaram reação tipo 1 e 3 tipo 2. Todos apresentavam incapacidades sendo três com deformidades.
    Motivo da apresentação: Realçar a importância do diagnóstico precoce em menores de 15 anos.

     

    PCA 63

    HANSENÍASE DIMORFA REACIONAL E LESÃO NEURAL
    Patrícia Araújo; Ademir Figueiredo
    Serviço de Dermatologia-FCM/HUPE - UERJ

    Introdução: Os episódios agudos extracutâneos com acometimento neural periférico são frequente no grupo Dimorfo, após as manifestações cutâneas, embora é citado por vários autores, a presença precípua dos bacilos nos nervos periféricos, nas formas disseminadas do grupo dimorfo.
    Relato do caso: Paciente masculino, pardo, 39 anos, casado, pedreiro, desempregado, residente no Rio há 15 anos. Há 4 meses apresentou "dormência" no 1º e 2º pododáctilos e dorso do pé direito. Em seguida, refere intensa dor no joelho direito durante 15 dias, que melhorou com antiinflamatórios, mas que evoluiu com dificuldade de mobilização do pé direito. Após um mês destes sintomas, surgiram "manchas avermelhadas" no tronco, que se "espalharam" pelo corpo, com queixa de "formigamento" nestas lesões. Apresentava placas eritemato-infiltradas, urticariformes, algumas com pigmentação violácea, localizadas no tronco, braços, coxas e pernas, poupando a face. Hiperestesia bilateral do nervo fibular (mais à dir.) e parestesia. Défice motor com abolição da dorso-flexão do pé direito (pé caído). Pesquisa de BAAR foi positiva 2+ com raras globias e a biópsia foi compatível com HDVr e a coloração para bacilo positiva 4+(Fite).
    Motivo da apresentação: HDV reacional com neurite do libular direito e paresia muscular flexora do pé direito. Sintomas e sinais neurológico, que antecederam as manifestações cutâneas.
    Comentário: A presença da grande quantidade de histiócito com citoplasma abundante e vacuolizado neste caso.é proporcional a uma multiplicação bacilar.tanto â nível de pele e nervo.mostrando uma degradação progressiva da imunidade celular, evoluindo para o polo V. Job.C.K. (1996). Nerve in reversal reaction. Indian J. Lepr. 68( 1 ):43-7.

     

    PCA 64

    HANSENÍASE EM PACIENTE AIDÉTICO COM ANTECEDENTES DE CRIPTOCOCOSE CUTÂNEA E NEUROLÓGICA
    Rodrigo Sestito Proto; Lúcia Mioko Ito; Ferrucio Fernando Dall'Áglio; Eduardo Lacaz Martins; Maurício Zanini
    Departamento de Dermatologia da Faculdade de Medicina do ABC.
    Av Príncipe de Gales, 821- -09060-650-Santo André -SP- Brasil.

    Relato do caso: Os autores relatam um caso de paciente masculino, branco, 45 anos, aidético, tendo como manilisteção inicial criptococose cutânea, evoluindo para a forma cerebral, com resolução total do quadro após internação. Um mês após alta, notou diminuição da sensibilidade em membro inferior direito, seguido do aparecimento de placa eritemato-descamativa, infiltrada de 20 cm de diâmetro, bordas ulceradas e acompanhado de neurite e topografia do nervo ciático poplíteo externo. O exame histológico foi compatível com o de hanseníase dimorfo- tuber-culóide.
    Discussão: Nos pacientes com AIDS, nunca foi encontrado um aumento maior da prevalência de hanseníase. Embora um paciente aidético possa ter evidências laboratoriais típicas de uma imunossupressão, a resposta imunológica ao M. leprae é essencialmente desconhecida. Considera-se que o M. leprae não causa a doença em pacientes com infecção previa ao HIV, posto que a hanseníase necessita de uma imunidade celular funcionante para causar a doença clínica. Estudos epidemiológicos fuimos serão necessários para compreendermos esta co-infecção.
    Motivo cia apresentação: Raridade e exuberância do caso.

     

    PCA 65

    HANSENÍASE EM SACO ESCROTAL - RELATO DE UM CASO
    Sousa, A.R.D.; Aires, M.A.P.; Lima, R.A.A.; Mesquita, A.C.A.; Lima, S.M.E.S.
    Centro de Dermatologia Dona Libânia - SESA - CE
    Av. Pedro I. 1033 - Fortaleza - CE

    A hanseníase é doença crônica contagiosa, causada pelo M. leprae , bacilo de alta infectividade, com baixa patogenicidade e virulência. Constitui-se num grande problema de saúde pública em países subdesenvolvidos, pelas graves sequelas consequentes ao não tratamento da moléstia. Os autores relatam um caso de hanseníase tuberculóide em saco escrotal. AFR, 36 anos, há um ano com placa eritêmato-infiltrada, de bordas elevadas, medindo 7cm no seu maior eixo, localizada em saco escrotal, relatando o paciente, dormência local. Realizada investigação diagnostica que mostrou baciloscopia negativa e histopalológico compatível com MHT. Iniciado PQT/PB em agosto/2000, com acompanhamento ambulatorial, obtendo-se boa resposta terapêutica. Motivo da apresentação: raridade de localização e exuberância da lesão.

     

    PCA 66

    Cládio de Lélis Filgueiras de Souza; Avani Soares Almeida Magalhães; Elisa Oliveira Gonçalves Antunes; Mariza Bárbara Rissulo; Wendel Antônio Fagundes
    Serviço de Hanseníase da S.M.S. de Afenas (MG)
    Pça. Dr. Fausto Monteiro, 300 Centro Alfenas-MG CEP 37130-000

    Os autores apresentam a história da família do paciente A.G.S., 27 anos do sexo masculino, apresentando quadro de hanseníase virchowiana, sua esposa M.A.S., 25 anos e seus três filhos B.G.S., 3 anos, S.G.S., 5 anos e E.G.S., 6 anos de idade vindos da regão norte de Minas Gerais, cidade de São Sebastião do Maranhão, onde segundo os dados da Secretaria de Estado da Saúda não houve casos registrados de hanseníase no ano de 2001.
    Motivo da Apresentação: Reforçar a importância do exame dos contratos como forma de diagnóstico precoce.

     

    PCA 67

    HANSENÍASE HISTÓIDE: RELATO DE 2 CASOS
    Lúcia Mioko Ito; Rodrigo Seslito Proto; Andréia Castanheiro Barbosa; Antonio José Tebcherani; Nobuo Matsunaga; Fábia Oppido Schalch
    Departamento de Dermatologia da Faculdade de Medicina do ABC.
    Av Príncipe de Gales, 821- -09060-650-Santo André - SP- Brasil.

    Relato dos casos: Os autores relatam 2 casos de pacientes com hanseníase históide.
    Caso 1: IMR, 65 anos, branca, feminina, natural e procedente de Santo André, apresentava há 4 meses, pápulas e nódulos eritemato-brilhantes em membros inferiores, nádegas e dorso, assintomáticas de 0,5 a 1,0 centímetro de diâmetro. Não havia espessamento de nervos ou infiltração da face. Negava qualquer tratamento anterior para hanseníase. O exame histológico evidenciou proliferação de histiócitos fusiformes de forma estoriforme, com inúmeros bacilos. Instituído tratamento específico para multibacilar, houve boa evolução com regressão das lesões em número e tamanho.
    Caso 2: MJS, 52 anos, branca, natural c procedente de São Bernardo do Campo. Há 2 meses passou a apresentar pápulas e nódulos normoerômicos, superfície brilhante, "dermatofibroma like", assintomáticos, em membros inferiores e abdome. O exame histológico evidenciou hanseníase históide. Relata ainda que há 2 anos, apresentou placas eritematosas em face, tórax, membros e foram diagnosticados como hanseníase virchowiana, mas a paciente não realizou tratamento instituído.
    Discussão: Hanseníase históide foi inicialmente descrita por Wade como uma variante da forma virchowiana em 1960, embora outros autores a considera como uma entidade distinta. Pode ocorrer em pacientes que já tinham sido submetidos a tratamento anterior com sulfona, ou virgens de tratamento. Lesões históides também foram descritas em pacientes com hanseníase dimorfa e indeterminada. Caracteriza-se por pápulas, placas e nódulos bem delimitados, brilhantes. Segundo alguns autores, as características histológicas do nódulo históide poderiam ser agrupadas em um espectro englobando 3 categorias baseadas na presença de células fusiformes e histiócitos vacuolizados.
    Motivo da apresentação: Raridade e exuberância dos casos.

     

    PCA 68

    HANSENÍASE HISTÓIDE

    Dalila Filomena Mohalem; Maria do Rosário Vidigal; Mônica Nóbrega Cunha; Ederli Assunção Ruiz; Antonio José Tebcherane
    Centro de Saúde Tranqüilidade
    Secretaria de Saúde de Guarulhos
    Av. Emílio Ribas, nº 1845 - Guarulhos - SP.

    Paciente havia feito cirurgia de varizes dos MMII com aparecimento de lesão elevada na cicatriz cirúrgica. O estudo anatomopatológico desta lesão mostrou laudo de dermatofibroma. Foi submetida à infiltração com corticóide sem melhora. Posteriormente surgiram lesões semelhantes em MMSS quando foi encaminhada ao Centro de Saúde e realizada nova biopsia com o resultado de hanseníase Virchowiana. Solicitado coloração de Ziel Nielsen da primeira lâmina (lesão inicial) que mostrou globias.

     

    PCA 69

    HANSENÍASE HISTÓIDE
    Francisca Estrela Dantas Marója; Flávia Estrela Maroja; Maria Das Graças Videres De Almeida; Mohamed Azzouz; Carla Wanderley Gayoso; Carlos Alberto Fernandes Ramos; Germana Brígida Queiroga Estrela
    Universidade Federal Da Paraíba. Hospital Universitário Lauro Wanderley.

    Os autores apresentam o caso de J.P.S., 27 anos, faiodérmico, natural e procedente de Mamanguape-PB que ao exame apresentava lesões nodulares endurecidas, algumas eritematosas, outras de coloração normal da pele, algumas ulceradas de fundos lisos, isoladas e localizadas no tronco, membros inferiores e superiores com início há 04 anos. Apresentava ainda pavilhões auriculares infiltrados, nervos ulnar e fibular espessados e não dolorosos. Diagnóstico: Hanseníase Históide confirmada pelo anátomo-patológico. Foi instituído tratamento com poliquimioterapia com boa evolução e melhora das lesões.
    Motivo da Apresentação: exuberância das lesões

     

    PCA 70

    HANSENÍASE INFANTIL NA PARAÍBA
    Francisca Estrela Dantas Maroja; Tereza Cristina Moura Rodrigues; Dulce Emília Ataíde Estrela; Flávia Estrela Maroja; Germana Brígida Queiroga Estrela; Francimary De Souza Buriti
    Universidade Federal Da Paraíba. Hospital Universitário Lauro Wanderley
    Pam De Jaguaribe
    Centro De Estudos Dia. Francisca Estrela Dantas Maroja

    Os autores analisaram os dados epidemiológicos da evolução da hanseníase infantil na Paraíba no período de 1976 a 2001, com idade de 0 a 14 anos, avaliando o tratamento instituído, o acompanhamento clínico, a cura ou abandono da terapêutica, avaliação da incapacidade física, reações que possam ter ocorrido durante a evolução e seguimento dos casos.

     

    PCA 71

    HANSENÍASE MULTIBACILAR EM BEBÊ DE 13 MESES - EVOLUÇÃO APÓS 7 ANOS DO DIAGNÓSTICO
    Alexandre Castelo Branco1; Luiz Cosme Cotta Malaquias2; Francisco Carlos Félix Lana3; Regina Lúcia Barbosa Cypriano1; Francisco Carlos Pereira1; Mara Firmato Esteves1; Simone Teixeira4; Andressa Masiero Santos4; Maria Cristina Souza Felipe da Silva5; Jorge Eduardo Tavares de Lima1; Sebastião Fontes Santiago1

    1. Policlínica Central Municipal de Saúde. Gov. Valadares. MG, Brasil.
    2. Faculdade de Ciências. Educação e Letras/UNI-VALE. Gov. Valadares. MG. Brasil.
    3. Escola de Enfermagem/UFMG. Belo Horizonte. MG. Brasil.
    4. Secretaria Municipal de Saúde, Gov. Valadares, MG. Brasil.
    5. Diretoria Regional de Saúde, Gov. Valadares. MG. Brasil.

    Expõe-se o quadro clinico inicial de hanseníase multibacilar em um bebê de treze meses, apresentado por ocasião do IX Congresso da Associação Brasileira de Hansenologia e IV Congresso do Colégio de Hansenologia dos Países Endêmicos, em Foz do Iguaçu, e o quadro apresentado cinco anos após ter concluído tratamento PQT-MB de 24 doses.

     

    PCA 72

    HANSENÍASE NA INFÂNCIA
    Antônio Renê D. de Sousa; Rose Porto O. Guilhon; Francisco José D. Branco; Maria Luci Landin T. Ferreira
    Centro de Dermatologia Dona Libânia - SESA - CE Av. Pedro I, 1033 - Centro - Fortaleza - CE

    De um total de 878 casos novos detectados pelo serviço no ano de 2001, 78 (8.8 %) pertenciam à faixa etária de menores de 18 anos. Destescasos, 3 (0.3 %) tinham 5 anos ou menos; 19 (2.1 %) tinham 10 anos ou menos; e 64 (7.2 %) tinham 15 anos ou menos. Quanto ao sexo. 47 (57.3 %) eram masculinos; e 35 (42.7 %) eram femininos. No que se refere às formas clínicas, 2 (2.4 %) eram indeterminadas (I); 37 (45%) eram tuberculóides (T); 34 (41 %) eram dimorfas (D); 8 (9.8 %) eram virchowianas (V); e 1 (1.2%) foi não-especilicado. De acordo com a classificação operacional, 89 (47.6% ) eram paucibacilares e 43 (52.4%) eram multibacilares., sendo 22 (26.8%) portadores de baciloscopia positiva, 58 (70,7 %) portadores de bacilioscopia negativa e 2 (2,4 %) com bacilosvopia não especificada. Quanto ao grau de incapacidade física, 67 (81.7 %) tinham grau zero; 8 (9.8%) tinham grau I e 7 (8.5 % ) tinham grau II no início do tratamento.

     

    PCA 73

    HANSENÍASE NA INFÂNCIA NO MUNICÍPIO DE CURIONÓPOLIS - SUDESTE DO ESTADO DO PARÁ - RELATO DE CASO
    S. Amador1; V.R. Barros1; P.J.B.S. Albuqueruque1; M.I.F. Buna1; J.M. Campos2

    1. Instituto Evandro Chagas, Rodovia BR-316, Km 07, Ananinideua-Pará.
    2. Centro de Saúde Enfermeira Silvina da Paz - Av. Brasil S/N CEP=68-523-000

    Hanseníase na infância, especialmente casos polarizados demonstram a magnitude do problema e refletem a intensidade de exposição ao Mycobacterium leprae, em determinada região. Apesar de não ser freqüente, requer intervenção criteriosa e gera questionamentos sobre a opeiacionalização das atividades para o controle desta nosologia milenar. Os autores relatam um caso de hanseníase dimorla clássica em menor de três anos de idade, contato de hanseníase virchowiana (o pai), inclusive com suspeita de resistência primária e hanseníase dimorfa (o irmão). A menor, com baixo peso para a idade, não exibia nenhuma cicatriz de BCG ao diagnóstico, embora fosse contato. O resultado do exame histológico revelou: "Infiltrado inflamatório difuso, linfohistiocitário, respeitando o limite dermo-epidérmico." A coloração especial (Fite-Faraco) revelou raros bacilos álcool-ácido resistentes (BAAR).
    Palavras-chave: Hanseníase, Epidemiologia, Pediatria

     

    PCA 74

    HANSENÍASE NEURAL PURA EM CRIANÇA DE 12 ANOS
    Dalila Filomena Mohalem; Maria do Rosário Vidigal; Aldo Sarpieri; Antonio José Tebcherane
    Centro de Saúde Tranqüilidade. Secretaria de Saúde de Guarulhos
    Av. Emílio Ribas, nº 1845 - Guarulhos - SP.

    Paciente de 12 anos de idade foi encaminhado pelo neurologista em decorrência de amiotrolia de interósseos da mão esquerda com reabsorção óssea da falange distal do 5º quirodáctilo. O paciente era goleiro e sofria traumatismos freqüentes. Mitsuda de 6 mm, baciloscopia negativa, biópsia de nervo: processo inflamatório granulomatoso, eletroneuromiografia apresentando processo neurológico periférico acometendo nervo mediano. E ao nível do punho e intensamente no nervo ulnar E ao nível do cotovelo.

     

    PCA 75

    HANSENÍASE NO BRASIL: ESTUDOS DE ENFERMAGEM E TENDÊNCIAS DAS PUBLICAÇÕES NA ÚLTIMA DÉCADA
    Alessandra Maria Alves De Sousa

    Trata-se de um estudo retrospectivo, exploratório descritivo, onde objetivamos fazer o levantamento das publicações da Associação Brasileira de Enfermagem (ABEn) em livros de resumos de congressos, dissertações, teses e artigos da Revista Brasileira de Enfermagem, sobre a temática Hanseníase. Estas publicações no total de quarenta e seis, foram distribuídas em dois grupos situando os trabalhos e autores. Os dados foram agrupados por tipos de publicações, procedência e ano, apresentados em gráficos, quadros e tabelas. Os resultados destacam estudos descritivos concentrados, principalmente, no Estados de São Paulo, com ênfase para estudos qualitativos sobre assistência, pontuando aspectos relacionados à humanização do "cuidar" ao doente de Hanseníase.

     

    PCA 76

    HANSENÍASE NODULAR DA INFÂNCIA: EVOLUÇÃO EM 20 ANOS.
    Fátima MoRabay; Márcia Orso; Ivonette Silva; J.L. Cardoso
    Universidad de Taubaté. Serviço de Dermatologia; Centro de Saúde da Lapa, SP.
    Av Granadeiro Guimarães 270, Taubaté (SP)

    Intodução: São escassos os relatos de Hanseníase Nodular da Infância (HN1). OPROMOLLA (2000: 52), ressalta a ocorrência em crianças de 1 a 4 anos, com lesões que regridem espontaneamente, deixando cicatriz atrófica. O Mitsuda é positivo e geralmente não deixam seqüela.
    Relato do Caso: EGF, masc, 11 anos, procedente de Capital (SP), em 1982 foi à consulta com "carocinho na barriga há muito tempo". Pai e mãe com diagnóstico de MHV. Ao exame, lesão sarcoídica única na região supra umbilical. A histopatologia revelou estruturas tuberculóides. O Mitsuda foi fortemente positivo. Com diagnóstico de UNI, sem indicação de tratamento, foi acompanhada em ambulatório por 5 anos, tendo alta definitiva com 2 lesões cicatriciais nas regiões supra umbilical e na face medial do braço E. Após 20 anos, ainda apresentava 2 lesões atróficas.
    Motivo Apresentação: registro iconográfico de UNI, com evolução de 20anos.

     

    PCA 77
    HANSENÍASE: O NÚMERO DE LESÕES CUTÂNEAS E OS EXAMES BACILOSCÓPICOS

    Gallo, M.E.N.; Novaes, A.; Albuquerque, E.C.A.; Nery, J.A.C.; Sales, A.M.
    Centro Colaborador Nacional em Hanseníase -FIOCRUZ - RJ

    A integração das ações de controle da hanseníase nas ações básicas de saúde, fundamentou a atualização das normas da legislação sobre o controle da doença. A classificação operacional visando a alocação na poliquimioterapia seja a recomendada pela OMS, baseada no número de lesões cutâneas. São paucibacilares (PB) os casos com até 5 lesões de pele e multibacilares (MB) os com mais de 5 lesões de pele. Com o objetivo de avaliar esle método clínico de classificação, correlacionou-se os resultados das baciloscopias cutâneas com o número de lesões cutâneas. A fonte de informações foi o banco de dados com informações epidemiológicas, clínicas e laboratoriais dos pacientes. Eoi selecionado o dado referente a baciloscopia de 837 casos no período de 1986 a 1999. Comparou-se o item número de lesões tomando como método padrão referência o resultado das baciloscopias cutâneas. A partir desta comparação foram calculadas a sensibilidade e a especificidade relativas bem como os valores preditivos positivo e negativo do critério lesão cutânea e avaliada a concordância entre o numero de lesões e a baciloscopia através do cálculo do índice Kappa (k). Entre os 837 casos avaliados, 652 apresentavam baciloscopias positivas e 185 negativas; destes 30 (16,0%) apresentavam mais do que 5 lesões cutâneas. Entre os 652 baciloscópicamente positivos. 68 (11.4%) apresentavam menos de 5 lesões cutâneas. Em relação a sensibilidade e especificidade do método clínico encontramos o valor preditivo negativo foi de 30.5% enquanto que o valor preditivo positivo foi de 95%. O método clínico baseado no número de lesões apresenta limitações que não invalidam a sua operacionalidade, porém há necessidade de novos critérios que possibilitem uma melhor acurácia na alocação dos pacientes nos esquemas poliquimioterápicos.

     

    PCA 78

    HANSENÍASE: RECIDIVAS PÓS POLIQUIMIOTERAPIA COM DURAÇÃO FIXA
    Nery, J.A.C.; Lopes. A.C.S.; Albuquerque, E.C.A; Machado, A.M.; Gallo, M.E.N.
    Centro Coloraborador Nacional cm Hanseníase -IOC - FIOCRUZ RJ.

    A Poliquimioterapia com duração fixa para hansenianos é utilizada em nosso serviço, desde 1986. A alta terapêutica é fundamentada nos critérios número de doses supervisionadas e tempo de tratamento. Apresentamos características clínico-epidemiológicas de hansenianos que recidivaram após terem sido submetidos a PQT/OMS. O estudo abrange um total de 1.584 pacientes tratados no período de 1986 à 2000 que receberam alta obedecendo os critérios de regularidade ao tratamento. Os casos diagnosticados como paucibacilares (PB) foram tratados com Rifampicina (REM) 600mg, uma vez ao mês supervisionadas associadas a Dapsona (DDS) 100mg diárias auto-administradas com duração de 06 doses em até 09 meses. Os diagnosticados como multibacilares (MB) receberam REM 600mg e Clofazimina (CFZ) 300mg, uma vez ao mês supervisionadas e DDS 100mg e CFZ 50mg, diárias auto-administradas com duração de 24 doses em até 36 meses. Um total de 03 casos (0.18%) foram diagnosticados clinicamente como recidiva, sendo 2 submetidos ao esquema preconizado para os PB e 1 do esquema para os MB. Os pacientes foram submetidos a exames laboratoriais cujos resultados confirmaram o diagnóstico clínico. A presença de reação hansênica pós alta foi observada em todos os casos. O tempo decorrido entre a alta e a recidiva variou de 3 à 8 anos. O estudo demonstrou que apenas um pequeno percentual de casos recidivou e o longo tempo decorrido entre a alta e o diagnóstico de recidiva. Todos os pacientes foram reintroduzidos nos esquemas poliquimioterápicos indicados e estão sendo acompanhados criteriosamente e nos que já completaram o novo ciclo de tratamento a evolução foi satisfatória, afastando a possibilidade de quimioresistência, sugerindo terem as recidivas ocorrido por persistência bacilar.

     

    PCA 79

    HANSENÍASE TUBERCULÓIDE SIMULANDO NECROBIOSE LIPOÍDICA
    Gustavo Alonso Pereira; Maria Helena Garrone; Leontina da Conceição Margando
    Departamento de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo(USP).

    Introdução: Necrobiose lipoídica é uma dermatose caracterizada pela presença de placas amareladas e centro atrófico, localizadas preferencialmente nos membros inferiores. Está associada ao diabetes melitus, sendo que 2/3 dos doentes apresentam diabetes e 0,3% dos diabéticos apresentam esta dermatose.
    Relato de caso: Os autores relatam um caso dc uma doente feminina, 27 anos, natural e procedente de São Paulo que apresentava ao exame dermatológico placas eritêmato-amareladas, de bordas bem definidas e superfície levemente papulosa em ambas as pernas. A paciente negava antecedente pessoal ou familiar de diabetes melitus. Ao exame complementar as ilíacas apresentam áreas de anestesia e hipoestesia térmica, estando preservada a sensibilidade tátil e a dor. Realizado teste de pilocarpina-iodo que resultou incompleto. A paciente foi então, submetida a uma biópsia por punch, que evidenciou infiltrado inflamatório linfohistiocitário perivascular na derme papialr e reticular média, ectasia vascular com extravasamento de hemácias, além de presença de bacilos álcool ácido resistentes íntegros.
    Discussão: A Moléstia de Hansen pode ter diversas apresentações clínicas, contudo, simulando necrobiose lipoídica é uma apresentação clínica rara. É descrito o fato da necrobiose lipoídica apresentar anestesia cutânea, não somente térmica, como também tátil. Isto poderia inicialmente confundir o diagnóstico e dificultar a diferenciação com a forma tuberculóidc da Hanseníase, contudo, o achado de bacilos álcool-ácido resitentes íntegros no material submetido a exame histopatológico não deixa dúvidas quanto ao diagnóstico.
    Conclusão: Hanseníase é doença de alta prevalência na nossa comunidade, podendo se apresentar clinicamente de diversas formas. Portanto, o diagnóstico de Hanseníase, deve ser lembrado sempre que a clínica for compatível. O teste de sensibilidade térmica é simples e de fácil aplicação, podendo descartar ou aumentar as suspeitas quanto ao diagnóstico da Moléstia de Hansen. Sempre que houver suspeita clínica e hipoestesia ou anestesia térmica da lesão, uma biópsia deve ser obtida, além dos testes de pilocarpina ou histamina, visando o diagnóstico de Hanseníase.

     

    PCA 80

    HANSENÍASE VIRCHOV1ANA - REATIVANDO COMO HANSENÍASE DIMORFA REACIONAL
    Sabrina L.C. Maciel; Suzana Kally M.B. Rapozo; Somei Ura; Deise Ap. dos Santos Godoy; Raul Negrão Fleury
    Instituto Lauro de Souza Lima
    End. Rod. Cte. João Ribeiro de Barros, km 225/226, Bauru - SP, CEP: 17034-971, Cx. Postal: 3021, Fone: (14) 221 5900, FAX: (14) 221 5914, E-mail: ensino@ilsl.br

    FS, 45 anos, masculino, branco, procedente de Bauru - SP.


    HMA: Atendido neste Instituto em 10/77, com lesões cutâneas características de hanseníase virchoviana (infiltração difusa, sobre a qual se notavam placas, pápulas e tubérculos, alguns de um tom ferruginoso), sobrancelhas estavam preservadas, baciloscopia eram de 5+ com até 18% de bacilos íntegros, histologia com aspecto típico de hanseníase virchoviana, reação de Mitsuda negativa. Iniciou tratamento com rifampicina e sulíona durante 6 meses, após este período, continuou tratamento monoterápico com sulfona. Teve vários surtos de eritema nodoso han-sêmico, neurites e artrites. Foi medicado com talido-mida e/ou corticosteróides para controle das manifestações reacionais em vários momentos.
    Ultima baciloscopia positiva foi em 10/84, 1+, mas até 10/88 apresentava manifestações reacionais (artrite, neurite).
    Fez uso de sulfona regularmente por quatorze anos, depois de forma irregular (2-3 vezes/ semana) e há seis anos não usa sulfona. Em 1989, era considerado branqueado (sem lesões cutâneas ativas, baciloscopia negativa). Neste ano, foi submetito à imunoterapia (vacina do Convit).
    Há um mês e meio (setembro de 2001), notou manchas avermelhadas praticamente assintomáticas no tronco. Ao exame apresentava lesões cicatriciais hipertróficas em regiões escapulares (cicatriz da vacina), lesões cicatriciais e anetodérmicas em face posterior de braços, antebraços, pernas e joelhos. Placas eritemalosas, algumas bem delimitadas outras nem tanto, número moderado em tronco, membros e lesões papulares eritematopigmentares esparsas em tronco e membros. Na face há placa eritematosa não bem delimitada na fronte e há também eritema malar. Nas coxas há laivos ferruginosos. Índice baciloscópico (IB: 1,6). A histopatologia da lesão eritematosa, em placa bem delimitada, mostra focos inflamatórios de pequena moderada extenção em todos os níveis do derma, constituídos por hístiócitos modificados, com núcleos vesiculosos e citoplasma finamente vacuolado entremeados por difuso infiltrado linfocitário, delaminação do perinervo e penetração do endonervo por células inflamatórias. Baciloscopia 5+ (presença de bacilos típicos).
    AP: etilista, teve vários episódios de gastrite alcoólica e síndrome de abstinência. Há cinco anos não bebe (sic); diabetes mellitus diagnosticado há 5 anos; pneumonia há 1 ano.

     

    PCA 81

    HANSENÍASE V1RCHOWIANA - MANIFESTAÇÃO CLÍNICA ATÍPICA
    Ana Paula de Almeida Costa, Jane Ventury Leal, Leandro Ourives Neves, Maria Alice Ribeiro Ozório, Moisés Salgado Pedrosa, Roberta Leste Motta, Rozana Castorina da Silva, Sandra Lyon
    Fundação Hospitalar do Estado de Minas Gerais, Hospital Eduardo de Menezes, Centro Colaborador de Referência em Dermatologia Sanitária.
    Av. Doutor Cristiano Rezende 2213, Bonsucesso, Belo Horizonte, MG

    A Hanseníase é uma doença infecto-contagiosa, curável, de evolução crônica causada pelo Mycobacterium leprae, endêmica em várias regiões do mundo e se caracteriza principalmente por manifestações dermatológicas e neurológicas atingindo nervos periféricos podendo levar a deformidades e mutilações. Uma das formas clínicas de hanseníase é a forma virchowiana que apresenta como característica numerosas lesões eritemato-violáceas, infiltradas, brilhantes, coalescentes e mal definidas. Pode ocorrer infiltração difusa com formação de tubérculos e nódulos ocasionando a perda definitiva de pêlos. E uma doença sistêmica com manifestações viscerais importantes, os distúrbios sensitivos cutâneos e o acometimento de troncos nervosos estão presentes, mas não são tão precoces e marcantes como nas lesões tuberculóides e dimorfas. Os autores apresentam o caso de um paciente, 29 anos, com uma lesão eritêmalo-infiltrada com o centro necrótico, perifolicular localizada em face médio-anterior de coxa esquerda há alguns meses que evolui com lesões satélites com o mesmo aspecto e também lesões similares em membro inferior direito e membro superior direito. Queixava-se de prurido nas lesões. Havia feito uso de medicamentos tópicos sem melhora clínica. Negava alteração de sensibilidade, dormência, perda de força muscular ou ainda perda de pêlos ou sinais de infiltração. O exame histopatológico mostrou a epiderme com acantose irregular e hiperceratose, a derme com denso infiltrado inflamatório linfo-plasmo-histiocitário rico em células espumosas (células de Virchow) de distribuição perivascular, perineural e perianexial. A pesquisa de BAAR (WADE) foi positiva com grande número de bactérias intracelulares formando globias. O diagnóstico histopatológico foi de Hanseníase Virchowiana. No retorno o paciente já apresentava em mão E uma lesão nodular sugestiva de hansenoma. O índice baciloscópio foi de 4.2. O tratamento instituído foi a poliquimioterapia multibacilar.
    Motivo da apresentação: Manifestação clínica atípica de uma doença endêmica.

     

    PCA 82

    HANSENÍASE VIRCHOWIANA HISTÓIDE
    Ana Cláudia Lyon de Moura; Dayse Vidal D'Avila; Maria Alice Ribeiro Ozório; Moisés Salgado Pedrosa; Paula Pimentel Carvalho; Roberta Leste Motta; Rozana Castorina da Silva; Sandra Lyon
    Fundação Hospitalar do Estado de Minas Gerais. Hospital Eduardo de Menezes. Centro Colaborador de Referência em Dermatologia Sanitária.
    Av. Doutor Cristiano Rezende 2213, Bonsucesso, Belo Horizonte, MG

    A Hanseníase é uma doença infecto-parasitária, curável, de evolução crônica causada pelo Mycobacterium leprae, endêmica em várias regiões do mundo e se caracteriza principalmente por manifestações dermatológicas e neurológicas que podem acarretar deformidades e mutilações nos portadores da doença. A doença pode se manifestar através de quatro (indeterminada, tuberculóide, diforma e virchowiana). A forma virchowiana apresenta ainda diversas variedades de apresentação clínica, dentre elas a variedade históide que se caracteriza por lesões nodulares múltiplas, consistentes, pardacentas semelhantes a quelóides. A hanseníase virchowiana históide é considerada por alguns autores como característica de casos sulfono-resistentes, com reativação da doença, mas existem relatos de casos em pacientes virgens de tratamento. Os autores apresentam caso de paciente, sexo masculino, 39 anos, com história de ter tido o diagnóstico de hanseníase virchowiana em 1992 e ter sido adequadamente tratado por 24 meses com poliquimioterapia multibacilar (janeiro de 1992 a março de 1994) sem nenhuma reação hansênica durante o tratamento e com alta por cura. Conforme relatório médico paciente iniciou o tratamento com índice baciloscópico (IB:5) e recebeu alta com IB: 3,75. Apareceu com lesões nodulares, consistentes, cor da pele, difusas em toda a superfície corporal, com seis meses de evolução, sete anos após o tratamento inicial. Realizado novamente IB: 6. Ao exame histopatológico, a epiderme evidenciou área de atrofia com retificação das cristas interpapilares, a derme mostrou denso infiltrado inflamatório mononuclear rico em histiócitos espumosos (células de Virchow), formando nódulo subepidérmico e manguitos perivasculares/perineurais. A pesquisa de BAAR (coloração especial de WADE) foi positiva, com numerosos bacilos intracelulares íntegros e fragmentados formando globais. O diagnóstico clínico e anátomo-patológico foi de Hanseníase Virchowiana Históide. O tratamento proposto foi a repetição da poliquimioterapia multibacilar.
    Motivo da apresentação: Raridade da patologia e evolução pouco comum em pacientes tratados adequadamente com poliquimioterapia multibacilar.

     

    PCA 83

    HANSENÍASE X COLAGENOSE
    Ricardo Américo de Araújo Lima; Heitor de Sá Gonçalves; Francisco José D. Banco; Maria Araci P. Aires; Maria Ruth Salgueiro
    Centro de Dermatologia Dona Libânia - SESA- CE
    Av. Pedro I, 1033 - Centro - Fortaleza - Ce

    BBCP, 31 anos, feminino, secretária, natural e procedente de Fortaleza/Ce. Há 16 anos apresentou quadro de artrite em tornozelos, febre, perda de peso. alopécia, e FAN positivo. Nesta época recebeu o diagnóstico de Lupus eritematoso sistêmico (LES), iniciando o uso de prednisona. Em outubro de 1996, passou a apresentar hipoestesia em região plantar direita, com progressão lenta. Em agosto de 1998 surgiram placas eritemalosas na região torácica anterior, associadas a parestesias e dores nos membros inferiores, sendo feito o diagnóstico clínico de hanseníase, com posterior confirmação histopatológica de MHV, com índice baciloscópico de 5,0. Iniciou esquema poliquimioterapia para multibacilar da OMS, tendo apresentado quadro reacional tipo I, com neurite e edema dos membros superiores e inferiores, seguido de eritrodermia, o que levou à suspensão da Dapsona e da Carbamazepina que a paciente fazia uso. Após melhora do quadro de farmacodermia, foi reintroduzido o esquema PQT/MB, sem intercorrências.
    Motivo da apresentação: Hanseníase simulando colagenose.

     

    PCA 84

    HEPATITE CRÔNICA GRANULOMATOSA HANSÊNICA X HEPATITE MEDICAMENTOSA: DIFICULDADE DIAGNOSTICA
    Rosa Maria Cordeiro Soubhia; Geysa Canarim; Juliana Caroni Bozola Bosi; Denise Rodrigues; Maísa Zumerli Vasconcelos; Raquel Fukuti; João Roberto Antonio
    Faculdade Estadual de Medicina de São José do Rio Preto. Ambulatório de Dermatologia do Hospital de Base. Av. Brigadeiro Faria Lima n.º 5416 São José do Rio Preto - Brasil.

    RMS, 51anos, casado, motorista, natural de Jales e procedente de São José do Rio Preto. Paciente com diagnóstico de Hanseníase Virchowiana há 7 meses com baciloscopia 2+, em tratamento com PQT-MB, evoluiu após sexta dose com adinamia, icterícia, emagrecimento de 21 kg associado a elevação das enzimas hepáticas (TGO= 86 U/L:TGP= 93 U/L) e anemia (Ht= 25,2 %; Hb= 7,9 g/100ml). Com hipótese diagnostica de Hepatite Medicamentosa foi optado pela suspensão da Dapsona e da Rifampicina e manutenção da Clofazimina 50 mg/dia. Encaminhado para a Gastroenterologia, que solicitou ultra-som, TC de abdômen, endoscopia digestiva alta, sorologias para hepatite B e C, alfa feioproteína e ceruloplasmina; todos normais. Encaminhado a Hematologia com hipótese diagnostica de anemia hemolítica medicamentosa. Foi solicitado Coombs direto e indireto, eletroforese de hemoglobina e reticulócitos; todos normais. Após dois meses em uso de monoterapia com Clofazimina (50mg/dia), não apresentou mudança do quadro clínico e dos níveis das enzimas hepáticas. Introduzido esquema alternativo com Minociclina 100mg/dia, Ofloxacina 400mg/dia e suspenso a Clofazimina por um mês, sem melhora clínica e laboratorial, tendo em vista esse quadro, foi suspensa toda terapêutica, realizada biópsia hepática percutânea, sendo compatível com hepatite crônica granulomatosa de etiologia Hansênica, BAAR positivo. Evoluiu com normalização das enzimas hepáticas sendo reintroduzida terapia alternativa com Minociclina 100mg/dia, Ofloxacina 400mg/dia, Clofazimina 50mg/dia com monitorização da função hepática semanalmente. MOTIVO DA APRESENTAÇÃO: Dificuldade do diagnostico diferencial entre hepatite crônica Hansênica e hepatite medicamentosa em paciente com Hanseníase Virchowiana em tratamento com PQT

     

    PCA 85

    HEPATITIS B AND C INFECTION AMONG LEPROSY PATIENTS ATTENDING THE SANATORIUM OF FONTILLES (SPAIN)
    P. Torres1; J.R. Gomez1; J.J. Camarena2; J.M. Nogueina2; J.C. Navarro2

    1. Sanatorium San Francisco de Borja, Fontilles.
    2. Servicio de Microbiología. Hospital Universitario Dr Peset.

    A possible association between infection by hepatitis viruses B (HBV) and C (HCV) and leprosy has been proposed. Hepatitis B (HBV) and hepatitis C (HCV) viruses are transmitted by blood (transfusions, parenteral injections) possibly sexual contacts and probably other unknown routes. They can cause chronic liver disease. Populations with increased risk of these viral infections, especially patients with hemophilia and on hemodialysis have been identified. Patients with leprosy possibly also form a high risk group because of skin lesions, blood transfusions and confinement in institutions during prolonged periods of time. Some consider that the 2 polar forms of leprosy (tuberculoid and lepromatous) provide a model of interaction between cellular immunity and the hepatitis viruses.
    In this study, the distribution of HBV and HCV virus markers were evaluated in 214 leprosy patients mostly long term institutionalised in the Sanatorium of Fontilles and compared with matched controls, using the same protocols required for screening of blood donors. Initially, two third generation microparticle enzyme immunoassays and positive results were confirmed by PCR methods.
    The HBsAg and HCV positivity rates were 6% and 35% respectively, significantly higher than in the corresponding control groups (2% and 3.5%). The influence of possible risk factors (blood transfusion, confinement in leprosaria during prolonged periods of time, open skin lesions etc.,) on this group of patients is discussed.

     

    PCA 86

    HEREDITARY NEUROPATHY MISDIAGNOSED AS LEPROSY
    M. Patricia Joyce; David M. Scollard
    National Hansen's Disease Programs. 1770 Physicians Park Drive. Baton Rouge. L.A. 70816, USA.

    Hereditary neuropathies (HN) comprise a group of syndromes which may present early in life with various symptoms, including decreased or absent sensation in extremities. Persons affected suffer repeated trauma to hands and feet, resulting in neuropathic sequelae including ulcerations, fractures, osteomyelitis, and disabling deformities. Despite a lack of rash, these disorders may be confused with leprosy, particularly the paucibacillary or neuritic forms. Several family cohorts have been evaluated at NHDP for suspected leprosy but finally diagnosed with HN.
    Two siblings in one family from Mississippi were admitted in the 1960's with "bacillary negative" leprosy and treated without improvement in neuropathy. More recently we evaluated a family whose index case is a 14 year old boy from Mexico with severe neuropathic deformities. Extensive evaluation showed no evidence of leprosy, bin a severe end stage peripheral neuropathy involving all extremities, with minimal central disease. Nerve biopsy revealed almost complete loss of myelinated fibers and endoneurial fibrosis. Nerve conduction studies revealed severe demyelinating disease. The patient and two other siblings appear by history to have HN, with two other siblings unaffected (as are four other half-siblings). The patient's mother was studied and appeared unaffected.
    Neuropathies other than leprosy can be confusing, especially in a young patient lacking skin rash.

     

    PCA 87

    HEREDITARY SENSITIVE AUTONOMIC NEUROPATHY TYPE I (HSAN-1) AS A DIFFERENTIAL DIAGNOSIS FROM LEPROSY
    Stravogiannis A.; Miron, B.G.; Stump, G.V.; Cezar, L.T.S.; Stump, PRNAG; Mariano, LHSC
    lnstituto Lauro de Souza Lima, CP 3031. Bauru - SP. Brasil, CEP 17034-971

    Aims: Clinical features' comparison between HSAN I and Leprosy.
    Methods: Clinical, neurological and psychological assessment of lour patients with HSAN I, initially diagnosed and treated as Leprosy carriers and regularly accompanied for over 23 years. The patients were two sisters, whose parents were first degree cousins, and two brothers. Their ages ranged from 42 to 50 years,Tactile (Semmes-Weinstein's monofilaments), painful, thermal and vibratory sensibilities have been mapped.
    Results: Disease initiation began in the 2nd decade of life. Inferior limbs have been more precocious and seriously affected than the superior ones, with symmetrical sensitive deficits. Anhidrosis, leading to skin fissures, and cold extremities denoted autonomic neuronal damage. Plantar pressure ulcers and osteomyelitis had developed, resulting in amputations and osteolysis. The patients didn't present any motor impairment such as amiotrophy; neither the central nervous system nor other non-neural tissues have been affected. The interoceptive sensibility has been preserved. One of the sisters and one of the brothers have presented asymmetric sensory hearing loss, smaller intellectual level and a higher number of disabilities.
    Conclusion: The clinical resemblance to Leprosy, including sensitive deficits and complications such as amputations, may underestimate HSAN I's prevalence, many carriers may still be managed as lepromatous patients. We can exclude the diagnosis of leprosy from HSAN I by the absence of amiotrophy and claw hands and claw feet.

     

    PCA 88

    HETEROGENOUS HISTOPATHOLOGICAL PRESENTATION OF TWO MORPHOLOGICALLY DIFFERENT SKIN LESIONS IN BORDERLINE LEPROSY
    Sunila Anbarasu; C.K. Job; S. George; S.M. Chanily
    Christian Medical College Hospital. Vellore-632004. Vellore District. Tamilnadu, India.

    Borderline leprosy is immunologically unstable and tends to downgrade towards lepromatou send of the spectrum especially if left untreated or upgrade towards the tuberculoid end of the spectrum with or without treatment. The skin histopathology plays a major role to appreciate the shift in the classification of leprosy and the histopathology varies in morphologically different skin lesions. Twenty untreated borderline leprosy patients with two morphologically different lesions were chosen. After clinical assessment they were classified according to Ridley-Jopling classification. They were subjected to bacteriological and histopathological examination. Lepromin lest was done in all cases. Nine patients (45%) showed different histopathological features in the two lesions and four patients (20%) showed histologically similar features but with marked difference in the intensity of granuloma. Seven patients (35%) showed identical histopathological features. This study confirms that morphologically different skin lesions may show different histopathological features. The interpretation and the significance of the observations will be discussed.

     

    PCA 89

    HISTOLOGICAL STUDY OF HYPOAESTHESIC SKIN AREA IN PRIMARY NEURITIC LEPROSY
    Lais Abreu Menicucci1; Alice Miranda1,2; Jose Augusto da Costa Nery1; Euzenir Nunes Sarno1
    Leprosy Laboratory, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil

    The characteristic clinical skin lesion are absent in primary neuritic leprosy (PNL). Nevertheless, poor delimited hypoaesthesic areas are often found on clinical examination. Few data are avaiable concerning the histological changes in this altered skin.
    In this preliminary study we attempt to define the modifications in biopsies taken from apparently normal skin of 33 clinically diagnosed PNL patients showing sensory deficit.
    Histological changes due to leprosy were seen in 21.2% of the patients, consisting in borderline tuberculoid form (4 cases) and the indetermined form (3 cases). 36,3% of the patients showed mild non-specific mononuclear cell infiltrates around blood vessels within papillary and reticular dermis and 42,4% showed no significant lesion.
    Our results suggest that not all patients with PNL are similar, but the histological examination of skin can disclose early leprosy cases and anticipate the specific therapy. Further, in some cases, the nerve biopsy could be postponed.
    We intend to extend this work by using immunohistochemical methods to show the presence of M. leprae antigens in non-conclusive cases to further improve the diagnosis of leprosy.

     

    PCA 90

    HISTOLOGY OF NERVE BIOPSIES IN LEPROSY PATIENTS PRESENTING NEUROLOGIC RELAPSE LONG TERM AFTER COMPLETION OF TREATMENT
    Yohannes Negesse
    Armauer Hansen Research Institute (AHRI) and All Africa Leprosy and Tuberculosis Training and Rehabilitation Center (ALERT). P.O.BOX 1005, Addis Ababa, Ethiopia.
    Introduction: Although the peripheral nerves are well recognized to be the seat in leprosy, decisions regarding diagnosis and therapy are largely based on skin manifestations. Our study is intended to evaluate the histologic findings of nerve biopsies from patients considered clinically as relapse.
    Materials and Methods: From January 1990 to December 1998, nerve biopsies (cutaneous branch of the radial nerve or the sural nerve) were taken from 82 patients diagnosed clinically as neurological relapse two years or more after completion of Multidrug Therapy (Rifampicin, Clofamizine and DDS).
    We have compiled the original classification of these patients and the histologic findings.
    Results: The results are summarized in the following table:

     

     

    Discussion: Bacteriological relapse may be evoked in only 1 % of all the patients.
    The vacuolated macrophages infiltrate and the fibrotic change may indicate that the healing and scarring processes may cause clinical nerve function alteration.
    The tuberculoid granuloma raises the problem of differential diagnosis between relapse and late reaction.
    The diffuse lymphohistiocytic infiltrate without dectectable bacilli may indicate the mechanism of nerve damage out side the classical episodes of reaction and may be an explanation of the concept of "silently arising clinical neuritis" (without episodes of reaction).
    Defining relapse for MDT re-treatment purpose has to be reconsidered.

     

    PCA 91

    HISTOLOGY OF SKIN BIOPSIES IN LEPROSY PATIENTS PRESENTING NEW LESIONS LONG TERM AFTER COMPLETION OF TREATMENT
    Yohannes Negesse
    Armauer Hansen Research Institute (AHRI) and All Africa Leprosy and TB Rehabilitation & Training Center (ALERT), P.O.Box 1005, Addis Ababa, Ethiopia.

    Introduction: New skin lesions are considered as sign of relapse in leprosy. Histologic finding is also taken as the basis to diagnose relapse. Our study is intended to assess the histology of new lesions.
    Materials and Methods: From January 1990 to December 2000, skin biopsies were taken taken from 238 patients presenting "new" lesions one year or more alter completion of MDT(Rifampicin, Clofamizine, DDS). We have compiled the histologic findings and the original classification of these patients.
    Results: The results are summarized in the following table:

     

     

    Discussion: 1-Bacteriological relapse may be envisaged in 8% of the cases.
    2- The tuberculoid granuloma found in IX'< of all the patients raises the problem of relapse or late reaction
    3- The histological features ol perivascular infiltrate, indeterminate pattern and vacuolated macrophages infiltrate raise the possibility of persisting inflammatory reaction in leprosy maintained by dead bacilli.
    4- The concept of "new'" lesions on clinical assessment ami the histological examination have their own limitations in allowing taking decision for retreating patients.

     

    PCA 92

    HISTOPATHOLOGICAL STUDY OF NERVE BIOPSIES IN PATIENTS SUSPECTED CLINICALLY PRESENTING PURE NEURITIC LEPROSY.
    Yohannes Negesse
    Armauer Hansen Research Institute (AHRI) and All Africa Leprosy and TB Rehabilitation and Training Center (ALERT), P.O. BOX: 1005, Addis Ababa, Ethiopia. E-mail: ahri@telecom.net.et

    Introduction: Primary neuritic leprosy is defined as leprous neuritis with no visible skin lesions and skin smears negative for AFB. Our study is intended to see the histological changes in the nerve of patients suspected clinicallv presenting as pure neuritic leprosy.
    Materials and Methods: During the study period. January 1993 to December 2000, two hundred and twenty patients, suspected clinically to present pure neuritic leprosy, were sent from ALERT to AHRI for nerve biopsy and histological examination.
    The biopsied nerves were the cutaneous branch of the radial nerve or the sural nerve. Fasicular biopsies were taken and processed routinely for histological examination. Systematic tissue Ziehl-Neelson staining was done for all the biopsies.
    The demographic data and type of observed lesions of all the patients were compiled.
    Results: There were 134 males (61%) and 86 females (39%). Fifty six percent of the patients were between the ages of 20 years and 50 years.
    The histological linding was as follow: lymphohistiocytic infiltrate with high BI was found in 40 patients (18%); tuberculoid granuloma in 11 cases (5%): fibrotic change and lymphohistiocytic infiltrate in 102 patients (47%); foamy macrophages infiltrate in 7 cases (3%) normal in 60 patients (27%).
    Conclusion: 1- The normal biopsies may indicate that the clinical manifestations were caused by other conditions or that the small nerve biopsies may not be representative of the nerves lesion.
    2- The high male to female ratio and the age distribution of the patients correlate to data of previous studies on pure neuritic leprosy.
    3- The classification of pure leprous neuritis for practical purpose seems to be better accommodated into paucibacillar and multibacillary leprous neuritis, than tuberculoid and lepromatous leprosy since only in 5% of the cases typical tuberculoid granulomatous reaction was found and typical lepronialous type lesion as in skin lesion was not found.
    4- For treatment purpose the problem of classification is raised: long term treatment for the multibacillary lesions and short regimen for the paucibacillar?.
    5- It seems that al the time when patients seek for medical care advanced nerve lesions have already occurred and the presence of large foamy macrophages without detectable bacilli may indicate that some multibacillary patients can possibly clear the bacilli but the inflammatory reaction triggered by the dead bacilli will continue to damage the nerve structures.
    6- The appropriateness of only antibacillarv treatment in pure neuritic leprosy is also debatable.

     

    PCA 93
    HISTOPATHOLOGICAL STUDY OF SKIN BIOPSIES FROM LEPROSY PATIENTS PRESENTING "NEW" SKIN LESIONS LONG TERM AFTER COMPLETION OF MULTIDRUG THERAPY

    Yohannes Negesse
    Armauer Hansen Research Institute (AHRI) and All Africa Leprosy and IB Rehabilitation & Training Center (ALERT). P.O.Box 1005. Addis Ababa, Ethiopia. E-mail: ahri@telecom.net.et

    Introduction: Leprosy is essentially a disease of the skin and peripheral nerves. Skin lesions are the basis for the classification and for the treatment purpose of leprosy.
    Criteria for relapse regarding skin manifestations have been more or less clearly defined and histological examination is also one diagnostic method of relapse.
    Our study is intended to assess the contributions of histological examinations in the work-up of patients presenting "new" lesions one year or later after completion of WHO MDT. We think also that our study will contribute towards better understanding of the pathogenesis of M. leprae infection disease.
    Materials and Methods: Our retrospective study covers the period from January 1990 to December 2000. We have compiled the initial classification and histological findings of skin biopsies of all patients sent from ALERT to AHRI as presenting new skin lesions one year or more after completion of WHO MDT. Regarding the initial classification patients were grouped into paucibacillary and lepromatous.
    Results: During the study period skin biopsies were taken from 238 such patients. For these 238 patients the pre-treatment classification was as follow: 100 patients were classified as paucibacillary, 80 as lepromatous and the initial classification was not found for 58 patients.
    The histological findings were as follow:

     

     

    Discussion:
    1- Histologically detected possible bacteriological relapse (re-infection or bacilli starting to multiply again) may be envisaged in 8% of all patients.
    2- The tuberculoid granulomatous reaction found in ihe patients with a pre-treatment classification of paucibacillary and as well in the intially lepromatous patients raises the difficult differential diagnosis between relapse and reaction.
    3- The histological features of perivascular infiltrate, indeterminate pattern and vacuolated macrophages infiltrate raise the possibility of continuous inflammatory reaction in leprosy.
    4- The concept of "new" lesions on clinical assessment and the histological examination have their own limitations in allowing taking decision for retreating patients.
    5- ln general the concept of relapse in leprosy considered as re-infection or bacilli starting to multiply has to be taken with caution.

     

    PCA 94

    HIV E HANSENÍASE: ASPECTOS CLÍNICOS E TERAPÊUTICOS DE 05 CASOS ACOMPANHADOS NO HC DA UFMG
    Ana Regina Coelho Andrade; Andréa Machado Coelho Ramos; Dalton Nogueira Moreira; Jacqueline G. Ferreira de Oliveira; Marcelo Grossi Araújo; Maria Ester Massara Café; Mark Drew Crossland Guimarães
    Hospital das Clínicas da Universidade Federal de Minas Gerais/Centro de referência e treinamento em doenças infecciosas e parasitárias Orestes Diniz
    Alameda Alvaro Celso 55 Santa Efigênia Belo Horizonte MG CEP 30150-260

    A co-infecção HIV/hanseníase tem motivado muitos trabalhos e várias hipóteses têm sido levantadas em relação a possíveis repercussões na epidemiologia da hanseníase e na evolução clínica dos casos.A letalidade era elevada nos primeiros anos da epidemia do HIV, dificultando o seguimento dos pacientes. As novas modalidades de tratamento anti-retroviral combinado tem melhorado a sobrevida dos pacientes, e permitido seguimento mais longo dos casos de co-infecção.
    Apresenta-se casuística de 05 casos acompanhados nos serviços de Dermatologia do HC-UFMG e CRT - DIP Oresles Diniz. Ressalta-se o diagnóstico de hanseníase borderline- tuberculóide em reação como primeira manifestação da hanseníase em 03 casos, nos quais o quadro eclodiu poucos meses após o início da terapia anti-retroviral combinada. Nestes, observou-se a concomitância da recuperação na contagem de CD4 com a reação. Discute-se se a mudança na condição imunológica dos casos seria fator favorecedor do aparecimento da reação reversa e se esses quadros reacionais seriam parte da nosología que compõe a Síndrome de Recuperação Imunológica descrita desde a introdução do tratamento anti-retroviral combinado.
    A resposta clínica à poliquimioterapia e aos corti-costeróides aparentemente tem sido semelhante àquela observada nos pacientes imunologicamente competentes.

     

    PCA 95

    HYPERGLYCAEMIA IN LEPROSY AN OBSERVATION FROM 1993 TO 2001
    Rajenderen, M.; Suri Babu, C. S. S.; Ravi, P.; Narasimha Moorthy, P.; Sathish Kumar, E.
    Central Leprosy Teaching & Research Institute. Tiru-mani, Chengalpattu - 603 001. Tamil Nadu, India.
    Changes in human behavior and life style over the last century have been resulted in a dramatic increase in the incidence of Hyperglycemic siatus (or) Diabetic World wide. The associated conditions are Diabesity and metabolic syndrome. The global figure of 151 million people with Hyperglycemic status currently estimated in the year 2000, most cases might be of Metabolic syndrome and it is multi-factorial. Especially in Asia 84.5 million Hyperglycemic patients are distributed.
    The important debate today is on the reasons for Hyperglycaemic status in leprosy. The present observations are made from the Central Leprosy Teaching & Research Institute's, in-patients admitted in wards. Out of 7145 patients Multi Bacillary (MB) and Pauci Bacillary (PB) admitted during the year march 1993 to December 2001. 2358 patients were referred lo Biochemistry Laboratory for various Bio chemical investigations. Among 1670 patients with and without anti-diabetic drugs were investigated for Blood glucose level, either during fasting or after food, (including Post Pradial samples) Blood glucose levels in short ranges will be tabulated in percentage, age, sex wise distribution and presented for discussion.

     

    PCA 96

    INFILTRADO LINFOCÍTICO SIMULANDO RECIDIVA EM HANSENÍASE - RELATO DE CASO
    Hercules, FM; Stenzel, D; Britto, R. A. S; Souza, M.A.J.; Abulalia, A.L.; Oliveira, M.L.W.D.R.
    Centro Municipal de Saúde de Duque de Caxias

    O Infiltrado Linfocítico caracteriza-se por uma ou mais placas ou nódulos eritematosos, na face, pescoço, tronco superior, ou braços, sendo mais incidente nos adultos. Alguns consideram variante do Lúpus Eritematoso, ou menos comumente, Erupção Lumínica, Hiperplasia Linfóide Cutânea ou Linfoma Linfocítico. As opções de tratamento são: corticóide tópico, antimalárico e talidomida. Paciente, fem., 51 anos, parda, RJ, solteira, do lar. Início em 1994 com 4 lesões eritemato-infiltradas, tricofitóides. no pescoço, cotovelo direito, punho esquerdo e dorso. A baciloscopia foi negativa c o grau de incapacidade zero. Biopsia cutânea evidenciou MHT. Iniciado tratamento com PQT PB, tendo evoluído com diversos episódios reacionais tipo reação reversa (RR), tratados com corticóide. Em 09/1997 foi rebiopsiada a lesão, sendo compatível com MHI, e então diagnosticado recidiva e reiniciado PQT PB sem DDS (suspeita de alergia a sulfa). Novamente cumpriu as 6 doses com vários episódios de RR. Em 04/ 1999 nova biopsia cutânea mostrou infiltrado linfocítico. Desde então, associou-se talidomida à prednisona, sem impedir o surgimento de novas lesões. Em 01/ 2001 foi internada no HUPE para esclarecimento do quadro, onde nova biopsia indicou Infiltrado Linfocítico de Jessner. Após exames de rotina, iniciou cloroquina 250mg/dia; entretanto após 5 meses, foi suspensa devido a edema de mácula. Em 12/2001, a cloroquina foi substituída pelo uso diário de DDS, sem melhora até o momento. O diagnóstico de recidiva paucibacilar merece muita atenção, uma vez que não existem critérios laboratoriais confirmatórios e diferenciação segura de reação na biópsia. Este caso evidencia uma situação onde a Histopatologia foi fundamental para afastar recidiva e diagnosticar Infiltrado Linfócítico.

     

    PCA 97

    INITIAL NEUROLOGICAL EXAMINATION IN MULTIBACILLARY LEPROSY: CORRELATION WITH DISABILITIES AT DIAGNOSIS AND OVERT NEURITIS
    Pimentel, Maria Inês Fernandes; Nery, José Augusto da Costa; Borges, Esther; Gonçalves, Rosângela Rolo; Sarno, Euzenir Nunes
    Laboratório de Hanseníase. Fundação Oswaldo Cruz. Avenida Brasil no. 4365 - Manguinhos, Rio de Janeiro - RJ. CEP: 21045-900.

    One hundred and three patients with multibacillary forms of leprosy (18.4% BB, 47.6% BL, and 34% LL) were studied, aiming to correlate the presence of thickened and/or painful peripheral nerves with physical disabilities at the initial examination, considering the disability grade before treatment (DGBT), as well as to correlate with the development of overt neuritis episodes, during and after multibacillary multidrug therapy. The detection of affected peripheral nerves at diagnosis correlated significantly (p < 0.005) with the occurrence of physical disabilities (DGBT > 0). Also, it correlated significantly with the development of overt neuritis in the follow-up (average of 64.6 months from diagnosis, during and after multidrug therapy). We can stress the necessity of careful palpation of peripheral nerve trunks in multibacillary patients at the initial examination, in order to call attention to physical disabilities already present, and specially to prevent further or worsening of disabilities by careful follow-up of patients at risk of developing overt neuritis.

     

     

    PCA 98

    KNOWLEDGE, ATTITUDE AND PRACTICE QUESTIONNAIRE SURVEY THROUGH FOCUS GROUP DISCUSSION ON LEPROSY. COX'S BAZAR. BANGLADESH
    Dr. Aprue Mong; Mr. David Baidya; Mrs. Jayontee Baroi; Mr. Atlanta Chakma.
    Chittagong leprosy Control project (CLCP), House # 16, Road # 4, Khulshi. Chittagong 4000, Bangladsesh

    Objective: The main objective was to assess the knowledge and changing attitude and practice towards leprosy patient through focus group discussion, to identify opportunities for intervention and their relative impact due to focus group discussion.
    Study design: It is an intervention study at Pre-FGD and Post-FGD questionnaire survey. Study subject were randomly selected from rural population and pre and post participants were matched.
    Methods: Focus group discussion (FGD) conducted by trained Leprosy Control Assistant (LCA) and a group of Health Educator from National Leprosy Coordinating Committee. During the FGD data collection done by asking questionnaire to the participants and socio-demographic characteristics also collected during the discussion.
    Result: A total of 607 participants in both pre and post focus group discussion, in which 374 (61.6%) male and 233 (38.4%) were female. Pre-FGD participants were 281 and age range from 10 to 80 years mean age 31.81 years and standard deviation 15.6. In Post-FGD group participants were 326, age ranged from 12 to 85 years, mean age 32.85 and standard deviation 15.53.
    There are improving of knowledge and practice average 30%, on leprosy disease due to present health education methods, which is highly significant, p value <0.001. But the attitude not much changes as knowledge, risk difference seen average 5% and p value = 0.25. In conclusion knowledge of the community is changing very fast but altitude does not change much.

     

    PCA 99

    LEPRA EN LA INFANCIA
    Dr. José Luis Gómez
    Médico De Planta Del Hospital Nacional "B. Sommer". General Rodríguez, Praça De Buenos Aires, Rep. Argentina.

    - Definicion
    - Características de la lepra cm la infancia
    - Variedades clíncias cm la infância (com 6 fotografias)


    - Histopatologia de los tipos polares (com 2 fotografias)

     


    - Diagnóstico

     


    - Tratamento

     


    - Referencias.

     

     

    PCA 100

    LEPROSY AND AIDS: REPORT OF TWO CASES IN THE BEGINNING OF HAART AND INFLAMMATORY REACTIONS
    Pignataro, P.E.; Nery, J.A.C.; Miranda, A; Santos Rocha, A.; Sales, A. M.
    Leprosy Laboratory - FIOCRUZ- Rio de Janeiro - Brazil

    Introduction: Several authors have reported inflammatory reactions in patients infected with HIV-1, who were under the first two months of highly active antiretroviral therapy (HAART). This condition may represent progression of previously quiescent infections to symptomatic diseases and is associated with pronounced reductions in plasma HIV-1 viral load and increase CD4 T lymphocyte counts. Clinical presentation is often different from untreated H1V-1 infection probably because of restored immunity. Clinical information: two patients with AIDS and about few weeks of HAART presented ulcerated skin lesion, positive Mitsuda reaction, epithelioid granuloma in the biopsy. CD4 less then 500 cells/mm3. One of them were AFB-positive on the smear and on the paraffin-embedded biopsy section (4+), showing a drastic decrease of bacillary load before specific antibiotic therapy and after reversal reaction. The other patient had his diagnosis confirmed with PCR and presented persistent reversal reaction. Comments: Leprosy has long been known to present paradoxical reactions shortly after beginning antimycobacterial therapy. Both patients presented lesion worsening before specific treatment and increased number of CD4 cell counts as a result of the HAART. In addition, they improved with corticotherapy and antymycobacterial therapy.

     

    PCA 101

    LEPROSY NEURITIS: DEVELOPMENT OF PHYSICAL DISABILITIES IN MULTIBACILLARY LEPROSY PATIENTS THAT INITIATE MDT WITHOUT THEM
    Pimentel, Maria Inês Fernandes; Nery, José Augusto da Costa; Borges, Esther; Gonçalves, Rosângela Rolo; Sarno, Euzenir Nunes
    Laboratório de Hanseníase, Fundação Oswaldo Cruz. Avenida Brasil no. 4365 - Manguinhos - Rio de Janeiro - RJ - CEP: 21045 - 900.

    We studied 45 multibacillary leprosy patients (22.2% BB; 46.7% BL; and 31.1% LL) that initiated multidrug therapy (MDT) without disabilities (disability grade and index before treatment equal to zero), aiming to study the influence of overt neuritis in the development of physical disabilities. They were followed-up during MDT and after treatment, for an average period of 64,6 months from the start of the treatment. The overt neuritis episodes (pain, spontaneous or at palpation, in peripheral nerves) were noted, during and after MDT. Physical disabilities were evaluated at the end of treatment (24 doses) and at the end of the follow-up period through disability grade and index. Nineteen patients presented overt neuritis episodes during follow-up (15 patients while receiving MDT). There was a significant correlation between the occurrence of overt neuritis during MDT and the presence of disabilities al the end of treatment, by disability grade (p = 0,013246) an by disability index (p = 0.010989). We found a also significant correlation between the developmenl of overt neuritis during follow-up period and the stablishment of physical disabilities al the end of the accompaniment period, evaluated through final disability grade (p = 0.022933) and through final disability index (p = 0.026420). These data show the importance of neuritis in the induction of disabilities in multibacillary leprosy, suggesting that we must pay attention to its early diagnosis, aiming prompt treatment and adequate physiotherapy.

     

    PCA 102

    LESÕES ORAIS NA HANSENÍASE
    Ana Líbia Cardozo Pereira; Ana Paula Pucci da Costa Nery; José Augusto da Costa Nery; Maria Leide Wan-del-rey de Oliveira; Tullia Cuzzi Maya: Márcia Ramos e Silva
    Hospital Universitário Clementino fraga Filho-UFRJ. Serviço de Dermatologia
    Av. Brigadeiro Trompowsky s/ número - Ilha do fundão- 5 Andar

    As lesões orais na hanseníase são pouco freqüentes, entretanto acredita-se que a sua ocorrência possa ser uma possível fonte de infecção com a presença de bacilos viáveis. No presente trabalho foram estudados 26 pacientes sendo 18 homens e 8 mulheres com idade entre 16 e 71 anos com diagnóstico de hanseníase, virgens de tratamento ou até a segunda dose de tratamento. Os pacientes foram provenientes dos ambulatórios de hanseníase do HUCFF/UFRJ e da FIOCRUZ e submetidos a exame clínico da cavidade oral, biópsia da lesão, caso houvesse, e da mucosa jugal à esquerda onde foi realizado Wade e HE.
    Resultados: 11 pacientes foram classificados como MHV, 14 MHB e 1 paciente MHT. O exame clínico da mucosa oral desses pacientes mostrou:
    enantema de pilares anteriores - 5/ enantema de úvula - 3/enantema de palato- 2/enantema de mucosa jugal - 3/ exulceração da mucosa jugal -1/exulceração de palato duro - 1/ infiltração do palato - 2/ nódulos no palato - 1.12 pacientes não apresentavam lesões orais e 4 pacientes tiveram dois tipos de lesões simultaneamente.
    No exame histopatológico da mucosa jugal ao HE, 16 pacientes não apresentavam alterações, 10 apresentavam infiltrado inflamatório inespecífico e 3 apenas congestão e ectasia vascular. No Wade todos foram considerados negativos. Já na histopatologia da lesão, todos os pacientes apresentavam anormalidades no HE que variavam de infiltrado inflamatório inespecífico (3); congestão e ectasia vascular (3) e infiltrado inflamatório com células xantomizadas (2). Na coloração de Wade. 5 pacientes apresentavam positividade, a maioria com lesão no palato.

     

    PCA 103



    LESÕES ULCERADAS NA HANSENÍASE
    Abulafia-Azulay, Luna; Baraúna, S.; Bonalumi, A.F.; Leal, F.R.P.C.; Nery, J.A.C.; Kac, BK.
    Instituto de Dermatologia da Santa Casa de Misericórdia do Rio de Janeiro. RJ., Brasil

     

    Introdução: A hanseníase e uma doença infecto contagiosa de alta infectividade e baixa patogenicidade mantendo-se em temica no nosso pais. Apresenta expressão clinica variada dependendo da resposta imune.
    Material e Métodos: foram avaliados pacientes que apresentavam clinicamente lesões ulceradas em varias fases evolutivas da doença: antes, durante e após o tratamento especifico com também quadro clinico sugestivo de reação (Tipo 1 ou Tipo 2).
    Resultados: A involução dos quadros ulcerativos muitas vezes foi devido não só da medicação para estado reacional como também da introdução da poliquinioterapia.
    Conclusão: As lesões ulceradas representam uma dificuldade diagnostica quanto não interpretadas no contexto do quadro clinico global do paciente, significando muitas vezes conduta terapêutica inadequada.

     

    PCA 104

    LEVANTAMENTO DAS DERMATOSES DF INTERESSE SANITÁRIO MAIS FREQUENTES EM REGIÕES CARENTES DO ESTADO DE MINAS GERAIS - ÊNFASE EM HANSENÍASE
    Ana Paula de Almeida Costa; Dayse Vidal D'ávila; Jane Ventury Leal; Juliana Fonseca Valadão; Leandro Ourives Neves; Luciana Paione Carvalho; Maria Alice Ribeiro Ozório; Paula Pimentel Carvalho; Moisés Salgado Pedrosa; Raquel Virgínia Rocha Vilela; Roberta Leste Motta; Rozana Castorina da Silva; Sandra Lyon
    Fundação Hospitalar do Estado de Minas Gerais. Hospital Eduardo de Menezes, Centro Colaborador de Referência em Dermatologia Sanitária. Av. Dr. Cristiano Rezende 2213, Bonsucesso, Belo Horizonte, MG.

    Em 1991 a Organização Mundial de Saúde - OMS propôs a eliminação da Hanseníase como problema de saúde pública do mundo até o ano 2000, com a intenção que até essa data, todos os países endêmicos alcançassem uma taxa ele prevalência de l/l0000 habitantes. A meta proposta, apesar dos esforços, não foi atingida no Estado de Minas Gerais, e o principal fator associado foi a permanência de casos não diagnosticados (permanência oculta), responsável pela manutenção de fontes de contágio na população, Este problema pode estar relacionado a baixa cobertura e a falta de informação da população. Dentre as várias regiões do Estado de Minas Gerais, destacam-se a região do Vale do Jequitinhonha e do Vale do Mucuri pela carência do setor de saúde e conseqüente ineficiente assistência médica a população. Foi devido a essa carência e o contato prévio com as prefeituras de várias cidades dessas regiões que o trabalho de levantamento da prevalência das dermatoses de interesse sanitário com ênfase na Hanseníase pode ser viabilizado. Foram realizados 2 multirões com equipe multiprofissional e interinstitucional composta por 44 pessoas das mais diversas áreas (dermatologistas, oftalmologistas, dentistas, psicólogos, enfermeiros, bioquímicos, veterinários, auxiliares de enfermagem, assistente social, dentre outros). A equipe realizou atendimento durante 3 dias em cada uma das regiões em julho e dezembro de 2001 com avaliação da população com lesões de pele, unhas e couro cabeludo, cadastradas por agentes de saúde. Para cada paciente foi preenchida uma ficha com dados pessoais e sócio econômicos pertinentes ao inquérito epidemiológico. Durante o curto tempo de atendimento no Vale do Jequitinhonha, 4 novos casos diagnosticados em 1330 atendimentos, sendo todos eles no município de Itaobim cuja prevalência da doença era zero até então. Os dados obtidos com relação a hanseníase foram tão positivos que motivaram a continuidade desse trabalho pela equipe com uma periodicidade semestral com expansão para outras regiões já neste ano.

     

    PCA 105

    LINFOMA NÃO-HODGK1N SIMULANDO HANSENÍASE VIRCHOWIANA - RELATO DE CASO
    Vanessa Barreto Rocha; Marcelo Grossi Araújo; Antônio Carlos Martins Guedes; Saôny Victor de Carvalho; Cláudia de Souza
    Serviço de Dermatologia do Hospital das Clínicas -UFMG. Al. Álvaro Celso, 55 - Santa Efigênia - Belo Horizonte - MG. CEP 30l50-260.Telefax: (31) 3226-3066

    Apresentamos caso de Linfoma não-Hodgkin em que chamamos atenção para o diagnóstico diferencial com formas multibacilares de hanseníase, dificultando principalmente o diagnóstico de campo. Além de achados clínicos passíveis de confusão, a histologia mostrava infiltrado inflamatório perineural.
    Relato do Caso: Trata-se de paciente feminina. 28 anos, natural e residente no interior de MG, atendida pela primeira vez no serviço em setembro de 2000 com relato de ter se mantido hígida até fevereiro, quando iniciou com lesões hipercrômicas no abdome e dorso, assintomáticas, que, após biópsia feita na mesma cidade, foram diagnosticadas como MH1, sendo tratada com PQT II por 6 meses, quando evoluiu com anemia importante, atribuída à hemólise por dapsona, e com "quadro reacional" descrito como edema poliarticular, piora das lesões de pele e surgimento de nódulos cervicais, para o qual iniciou-se prednisona 50 mg/dia. Ao chegar ao ambulatório, apresentava-se com estado geral comprometido, placas ictiósicas e várias lesões esclerodermiformes disseminadas: a face se mostrava infiltrada, de modo marcante os pavilhões auriculares, não se notando madarose. Não apresentava neurite ou espessamento neural, nem alteração de sensibilidade. Apresentava, ainda, linfadenomegalia muito importante em várias cadeias, com linfonodos endurecidos, confluentes, aderidos, esplenomegalia. Adenomegalia hilar importante ao Rx de tórax. Fizemos, assim, biópsia de 5 locais da pele e obtivemos o diagnóstico de linfoma não-Hodgkin. Pesquisa de BAAR em lesões, lóbulos de orelha e cotovelos negativa. Constatada leucemização em mielograma, foi submetida á quimioterapia com regressão importante das lesões e melhora clínica.

     

    PCA 106

    LONG STANDING SINGLE LESION ON THE FACE CONSISTENT WITH LEPROSY AND RESPONSIVE TO MULTIDRUG THERAPY
    Alba Valeria de Melo1; Alice Miranda1,2; José Augusto da Costa Nery1; Vania Valentim1; Ziadir Francisco Coutinho1

    1. Leprosy Laboratory, Oswaldo Cruz Foundation, Rio de Janeiro. Brazil
    2. Deparlament of Pathology and Laboratories, FCM. UERJ, Brazil

    Leprosy is a chronic disease, infecting 1.5 millions persons in undeveloped countries. Brazil has about 78 000 patients under multidrug therapy classified according to clinical characteritics and epidemiological data.
    However, atypical or incipient presentations occur that do not fulfill the classic criteria for the diagnosis of leprosy and can be of difficult management even for well trained medical teams.
    In this retrospective study we present the clinical and histopathological data from six female patients with long standing (2 to 7 years) single lesion located on the face, without clinical and laboratorial conclusive diagnosis. All patients responded to paucibacillary multidrug therapy (MDT/PB or ROM protocols), with clinical subside of lesions. Sarcoidosis, Lupus erythematous-like lesión. Borderline tuberculoid leprosy. Jessner's Iymphocytic infiltration and Annular Elastolitic Granuloma were the proposed histological differential diagnosis, after excluding infectious diseases.
    In conclusion, we suggest that the diagnosis of leprosy should always be questionned in long standing solitary nodule or plaque on the face, mainly in endemic countries like Brazil. In addiction, a specific leprosy chemotherapy should be initiated as a therapeutic and diagnostic procedure.

     

    PCA 107

    MANIFESTACIONES OrateS DE LA LEPRA
    Juan Manuel Núñez Martí; Mª Dolores Marrero Calvo
    Sanatorio San Francisco de Borja. Fontilles.
    03791 Fontilles - Vall De Laguart (Alicante), España Teléfono: 96 558 33 50. Fax- 96 558 33 76. E-mail: fontilles.org

    La Lepra conlleva una serie de efectos secundarios indeseables, que condicionan la tolerancia y la calidad de vida del paciente. Así, dentro de la esfera oro-facial, la boca puede ser asiento de lesiones, que pese a su accesibilidad, pueden por ignorancia pasar desapercibidas y dificultar el adecuado tratamiento de un proceso, que hasta ese momento, había producido pocas lesiones corporates.
    Las lesiones en la cavidad oral suelen aparecer en forma lepromatosas y más raramente en dimorfas y tuberculoides. Las lesiones específicas de los lepromatosos a nivel oral son fundamentalmente alteraciones dentales, periodontales, de la mucosa oral y lengua. El diagnóstico precoz de estas lesiones puede disminuir considerablemente el daño oral que esta grave enfermedad puede llegar a causar.
    Presentamos el estudio de estas lesiones en un grupo de 76 pacientes con enfermedad de Hansen de la Colonia Sanatorio San Francisco de Borja de Fontilles (Alicante) España.

     

    PCA 107

    MANIFESTACIONES OrateS DE LA LEPRA
    Juan Manuel Núñez Martí; Mª Dolores Marrero Calvo
    Sanatorio San Francisco de Borja. Fontilles.
    03791 Fontilles - Vall De Laguart (Alicante), España Teléfono: 96 558 33 50. Fax- 96 558 33 76. E-mail: fontilles.org

    La Lepra conlleva una serie de efectos secundarios indeseables, que condicionan la tolerancia y la calidad de vida del paciente. Así, dentro de la esfera oro-facial, la boca puede ser asiento de lesiones, que pese a su accesibilidad, pueden por ignorancia pasar desapercibidas y dificultar el adecuado tratamiento de un proceso, que hasta ese momento, había producido pocas lesiones corporates.
    Las lesiones en la cavidad oral suelen aparecer en forma lepromatosas y más raramente en dimorfas y tuberculoides. Las lesiones específicas de los lepromatosos a nivel oral son fundamentalmente alteraciones dentales, periodontales, de la mucosa oral y lengua. El diagnóstico precoz de estas lesiones puede disminuir considerablemente el daño oral que esta grave enfermedad puede llegar a causar.
    Presentamos el estudio de estas lesiones en un grupo de 76 pacientes con enfermedad de Hansen de la Colonia Sanatorio San Francisco de Borja de Fontilles (Alicante) España.

     

    PCA 108

    MANIFESTAÇÕES GENITAIS EM PACIENTE COM HANSENÍASE MULTIBACILAR SOB POLIQUIMIOTERAPIA
    Eduardo de Azevedo Nunes; Fanny Xiomara Trigo Gusmán; Profa. Dra. Leontina Margarido Márchese
    Departamento de Dermatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Rua Enéas de Carvalho, São Paulo -SP - Brasil. Tel/Fax: 011 66841527.E-mail: edu1000@uol.com.br

    Os autores relatam características clínico-patológicas de paciente masculino de 37 anos, com hanseníase multibacilar, dimorfa-virchowiana, segundo a classificação de Ridley- Jopling. Apresenta discreto espessamento difuso na pele; rarefação discreta e caudal dos supercílios. Lesões pápulo-nodulares amarelo-acastanhadas, isolados ou confluentes nas orelhas e no corpo peniano, onde a consistência era mais endurecida; e, em menor tamanho e maior número, no abdomem. A palpação dos testículos e epididimo revelou aumento de volume doloroso e bilateral [orquie-pididimite], sem sinais de eritema nodoso hansênico, na pele. Anidrose nas extremidades; espessamento neural assimétrico pouco doloroso à palpação. O exame histopatológico dos nódulos os identifica como hansenomas constituídos pelas clássicas células vacuolizadas de Virchow contendo globias bacilares e bacilos isolados. Após 15 meses de multidrogaterapia (rifampicina, dapsona e pirazinamida) o exame histopatológico dos nódulos, inclusive penianos, revelou tecido fibroso com intenso infiltrado de histiócitos com citoplasma vacuolizado, com numerosos bacilos álcool ácido resistentes graiuilosos, por vezes em globias no citoplasma de macrólagos. Discussão: Foi notável que o exame clínico da genitália, diversamente do resto do tegumento, apresentava múltiplas lesões nodulares grandes, amarelo acastanhadas, bem delimitadas, endurecidas no prepúcio. As manifestações genitais hansênicas são observadas numa frequência que varia entre 6 e 12% dos casos de hanseníase em pacientes masculinos, sendo mais prevalentes nos multibacilares {dimorfo-virchowianos e virchowianos}. O doente de hanseníase multibacilar dimorfa-virchowiana, ora em discussão, foi surpreendente pela relativa pobreza de manifestações clínicas cutâneas hansênicas extragenitais e a exuberância das mesmas na genitália, caracterizadas pelos múltiplos hansenomas descritos e orquiepididimite bilateral. Okada e cols, 1978, observou, por microscopia eletrônica, bacilos de Hansen em queratinócitos da epiderme íntegra. Provavelmente, os bacilos que conseguiram atingir as células na zona da membrana basal, através dos desmossomas se espalham; e, podem ser eliminados na camada córnea, mesmo com a pele íntegra. Portanto, é plausível, que os hansenomas ou pele especificamente espessada dos genitais, principalmente após atrito, possam transmitir bacilos de Hansen. Há que se pensar na hanseníase como doença sexualmente transmissível (DST); situação já reconhecido na literatura específica e clássica; e, atualmente relegado a plano secundário provavelmente pela emergência de outras DSTs.

     

    PCA 109

    MEDIDA DA ATIVIDADE DA ADENOSINA DEAMINASE NAS DIFERENTES FORMAS CLÍNICAS DA HANSENÍASE
    Chubert Bernardo Castro de Sena1; Gisele Pacheco1; Mário Rogério Santos1; Marília Brasil Xavier2; Claudio Guedes Salgado3; José Luis Martins do Nascimento1

    1. Laboratório de neuroquímica molecular e celular. Universidade Federal do Pará. End. Rua Aaugusto Correa, 1. Campus Guamá. UFPA. 66075-110.
    2. Departamento de saúde comunitária. Universidade do Estatlo do Pará.
    3. Laboratório de Dermato-imunologia UEPA/MC, Universidade do Estado do Pará. e URE "Marcello Candia"

    Objetivo: Padronização da técnica de medida da enzima Adenosina Deaminase (ADA), para servir como um bioindicador nas diferentes formas clínicas de Hanseníase.
    Métodos e Resultados: A atividade da ADA, em U/L, foi determinada através de método espectrofotométrico, para caracterização da cinética enzimática e de sua atividade em pacientes com hanseníase. A concentração de l,55mM do substrato (adenosina), mostrou-se mais eficaz em expressar a velocidade máxima da enzima. Os pacientes foram divididos em três grupos: grupo controle (não portadores) e grupos de portadores com e sem espessamento de nervos, sendo estes subdivididos conforme sua classificação (MHI; MHT; MHD e MHV)
    Conclusão: Nossos resultados indicam que a atividade da ADA está baixa em todas as formas clínicas, exceto a forma dimorfa, quando comparada ao controle e pode ser um bom indicador da resposta imune em pacientes com diferentes formas clínicas da Hanseníase.

     

     

    PCA 110

    MULTIFORM ERYTHEMA: RETROSPECTIVE ANALYSIS
    Garcia Afonso, M.C.Z; Sales, A.M.; Coutinho, Z.; Vieira, L.M.M.; Nery, J.A.C; Gallo, M.E.N.
    Leprosy Laboratory - Oswaldo Cruz Institute -FIOCRUZ - Rio de Janeiro - RJ.

    Introduction: Multiform Erythema (ME) - like lesions are manifestation of a reactional episode in lepromatous patients and can delay its recognition as a leprosy reaction. Its early diagnosis is crucial to present disabilities due to the peripheral neuropathy that complicate these acute inflammatory episodes.
    Objective: Evaluate the distribution of Multiform Erythema as part of reaction episodes of leprosy.
    Materials and Methods: This study has included a retrospective analysis of 56 patients with reactional patient condition of a multiform erythema type in patients with leprosy submitted to multibacillar multidrugtherapy (MDT) according to the scheme of the WHO. All those patients who presented this reactional patient condition, whether during the period when they received the PCT or during the observation period after therapeutic discharge, were selected for this study. Sex, age, bacilloscope indices (BI), incapacity degree (ID) as well as the classifications of patients with reference to clinical form, moment the first episode occurred, number of episodes and occurrence of episodes, whether associated or not to other patient conditions.
    Results: We have observed a predominance of the reactional patient condition of the multiform erythema type in the male sex (87,5%) and in the age group between 20 and 39 years old (55.4%). There has been a tendency of a multiform erythema occurring in association with higher BI indices as well as a decrease of BI after treatment. There has been an improvement in ID, should we compare the initial ID with the final ID (51,8%) degree at the beginning of treatment and 63,4% degree zero at the end of treatment. 76% of the patients presented only one episode of multiform erythema, 40% presented their first episode after medication discharge and 17,9% presented it before having begun therapy (at the moment of diagnosis). 41% of the patients presented multiform erythema in association with nodal erythema, 1,8% presented association with reverse reaction, and 26,8% of patients presented isolated multiform erythema.
    Conclusion: M.E. episodes were not frequently found in multibacillary patients. However, those episodes are very important for identification of leprosy patients and in several occasions, they are the main reason for patients to seek medical care.

     

    PCA 111

    Mycobacterium leprae-HIV CO-INFECTION: RELEVANT CLINICAL ASPECTS AND PROGRESSION
    Gomes, A.P.; Sales, A.M.; Nery, J.A.C.; Sampaio, E.P.; Galhardo, M.C.G.; Sarno, E.N.
    Introduction: To date, published research regarding M. leprae -HIV co-infection has been scarce. Leprosy is endemic in Brazil and HIV infection rates, while, generally speaking, have been kept somewhat under control, require constant vigilance. Even so, co-infection has remained a largely ignored subject.
    Objective: To evaluate the evolution of leprosy in co-infected HIV patients. Material and Methods: This is a retrospective descriptive case study of 30 patients with M. leprae -HIV co-infection that were treated in 1991 to 2000 at the leprosy Outpatient Clinic, Oswaldo Cruz Foundation, Rio de Janeiro. R.J., Brazil. Statistical analyses were performed via EPIINFO 2000 (CDC). The Qui-square Test and Fisher Exact lest were also carried out.
    Results: there was no indication in this study that HIV was a risk factor for the development of the multbacillary forms (60% of the cases under treatment in the clinic were paucibacillary). Reactional episodes occurred in 70% of patients (57,1% had reversal reaction). It can, therefore, be postulated that the capacity for reactivation of the cell-mediated immune response remained strong regardless of existing CD4+ levels. All 30 patients responded satisfactorily to multidrug therapy despite their being co-infected and having an altered immune slate (AIDS/HIV). Moreover, no relapses were seen to occur.
    Conclusions: None of the patients demonstrated an increased susceptibility to M. leprae or progression toward a multibacillary or disseminated form of leprosy. In addition, there was likewise no indication of impairment in the immune response to M. leprae in spite of the AIDS co-infection.

     

    PCA 112

    NERVE CONDUCTION STUDIES OF MULTI-BACILLARY-LEPROSY PATIENTS: ANALYSIS OF 35 PATIENTS AT THE BEGINING OF MULTIDRUG THERAPY
    Patricia S. Penna; Marcia M. R. Jardim; Osvaldo J.M. Nascimento; Jose A.C. Neri; Anna M. Sales; Euzenir N. Sarno
    Fundação Oswaldo Cruz and Dept of Neurology. Universidadc Federal Fluminense (UFF), Rio de Janeiro, Brazil.

    Objective: To observe the frequency of evidences of nerve damage in multibaccilary (MB) leprosy patients at the beginning of multidrug therapy (MDT).
    Background: We did not found at the literature any study that determine how are frequency of peripheral neuropathy at the beginning of MDT in MB patients and when the axonal or demyelinated lesions appear during these treatment.
    Design/method: We examined 35 patients classified as having the MB form of leprosy. These patients were submitted to clinical and neurological examination followed by nerve conduction studies at the beginning of multidrug therapy. We divided these patients into groups: Group I A - Patients with signs and symptoms of peripheral nerve lesion; Group I B - Patients without complain of paresthesias or pain, but with signs of peripheral nerve lesion; and Group 2 - Patients without peripheral nerve complaints and without signs. Nerve conduction studies were done according to standard techniques.
    Results: Out of the 35 multibacillary leprosy patients. 11 (31%) were female and 24 (69%) male. The mean age was 39,5 years. The neurological examination revealed sensory alterations in 22 (66%) cases; motor alterations in 7 (20% ) of and nerve thickeness in 19 (54%) patients. Nerve conduction studies (NCS) were normal in only 50% of group 2 patients. Out of the 28 remaining patients only in 1 (3.5%) from group 1A there were findings consistent with purely demyelination with conduction block, without reaction. Most of the patients (62.8%) has purely axonal alterations in NCS and 2 (5.7%) patients have axonal ami demyelinating findings in NCS.
    Conclusions: Leprosy neuropathy in multibaccillary patients is typically of the axonal type, and the small libers are primarily involved, even in most of the patients with no neurological alterations at the beginning of die MDT. Nevertheless, in rare cases we can verify superimposed demyelinating features with conduction block, an alteration frequently observed in demyelinating neuropathies

     

    PCA 113

    NEUROCRIPTOCOCOSE EM PACIENTES COM HANSENÍASE VIRCHOWIANA
    Ana Cláudia Lyon de Moura; Dayse Vidal D'ávila; Jane Venlury Leal; Maria Alice Ribeiro Ozório; Paula Pimentel Carvalho; Raquel Virgínia Rocha Vilela; Roberta Leste Motta; Rosimeire Arcanjo Hosken; Rozana Castorina da Silva; Samira Lyon
    Fundação Hospitalar do Estado de Minas Gerais, Hospital Eduardo de Menezes, Centro Colaborador de Referência em Dermatologia Sanitária, Av. Dr. Cristiano Rezende 2213. Bonsucesso, Belo Horizonte - MG.

    A hanseníase é uma doença infecto-contagiosa causada pela Mycobacterium leprae que acomete pele e, sobretudo, nervos periféricos, levando a neurites muitas vezes severas. Essas neurites são tratadas durante sua vigência e nos surtos reacionais através da corticoterapia, que pode se prolongar por meses. As reações adversas do uso sistêmico dos corti-costeróides tornam-se inevitáveis. Os autores apresentam o caso de um paciente do sexo masculino, 45 anos, encaminhado da cidade de Prata, MG, para tratamento de neurites persistentes, pós tratamento de Hanseníase multibacilar em uso de 80 mg de Prednisona há 2 anos. O paciente relatava que há 1 ano e 6 meses vinha apresentando quadros repetitivos de "abscessos" em cotovelos, drenando secreção expontaneamente, recebeu antibióticos várias vezes, com períodos de melhora e de exacerbação do quadro. Durante a internação, o paciente apresentou cefaléia persistente. O exame neurológico e a tomografia computadorizada de crânio foram normais. O exame micológico direto e a cultura de fungos do líquido cefalorraquiano identificaram a presença de Cryptococus neoformans. Foi iniciado Anfotericina B, mas o paciente evoluiu para o óbito no 7° dia após o início do tratamento.
    Motivo da apresentação: alertar para as possíveis complicações com a corticoterapia prolongada em pacientes hansenianos.

     

    PCA 114

    NEUROPATIA PERIFÉRICA SENSORIAL CONGÊNITA SIMULANDO HANSENÍASE VIRCHOVIANA
    Thomas de Aquino Paulo Filho
    Universidade Federal do Rio G. do Norte - Natal - RN - Brasil. thomasfi@uol.com.br

    Criança de 10 anos do sexo masculino que desde os 5 anos de idade vem apresentando diminuição da acuidade visual com opacificação das córneas, auto-mutilações nas extremidades dos membros com formação de úlceras plantares, destruição da pirâmide nasal, distúrbios de comportamento, anemia crônica e infecções secundárias nas lesões úlcero-tróficas nos membros. Não há relato de casos semelhantes na família.
    O autor apresenta este caso clínico raro com todas as suas manifestações clínico-laboratoriais simulando caso de Hanseníase Virchoviana e comenta a dificuldade de abordagem terapêutica neste caso

     

    PCA 115

    NUTRIÇÃO E HANSENÍASE
    Gubert, Muriel B.; Alvares, Rosicler R.A.
    Hospital Universitário de Brasília, UnB- Avenida L2 Sul, Quadra 605 norte - Brasília DF

    Introdução: Uma alimentação inadequada está relacionada a doenças carenciais (1) e em um aspecto mais amplo, a imunidade de um indivíduo é diretamente influenciada pelo seu estado nutricional (2, 3, 4). Pesquisadores mostraram que a desnutrição proteica está relacionada com alterações na imunidade mediada por células, função fagocítica. atividade sistema complemento, ação das imunoglobulinas secretórias e produção citocinas e citam como nutrientes envolvidos com sistema inume o zinco, selênio, ferro, cobre. Vit. A, Vit. C, Vit. E, Vit. B6 e ácido fólico (2). Estudos mostram, ainda, que a desnutrição proteica afeta mais IMC do que imunidade humoral. Torna-se, portanto, evidente a relação entre Hanseníase e Nutrição.
    Objetivos: Este trabalho tem como objetivo relacionar Hanseníase e Nutrição. Metodologia: Foi feita revisão da literatura entre os anos 1960 a 2000, nos bancos de dados MEDLINE e LILACS.
    Resultados: Rees (1981) mostra que a desnutrição protéica diminui a resposta mediada por células e aumenta o risco para MH e que em experimentos com ratos (com défict calórico/protéico) verificava-se a maior disseminação da doença. Existem relatos que na segunda Guerra, em Leprosário na Malásia (com 2500 doentes) submetidos a uma dieta com menos de 700 Kcal/dia houve maior mortalidade (IVA) contudo, desapareceram estados reacionais neste período (5). Rao e cols (1986) demosntram que a desnutrição não está relacionada com a doença e sim com a pobreza e privação de comida. Pesquisadores como Rao e Saha (1986; 1987 e 1988). Chattopadhya e cois (1992); Mennem e cols (1993). Vidal et al (1993) e Foster et al (1988) demostraram que pacientes de MU tem níveis séricos alterados pia alguns micronutrieiites. Em experimentos com ratos, verilicou-se que a gordura da dieta relacionada com multiplicação do M.leprae(6).AIém dos aspectos alimentares levantados, cabe ainda ressaltar a importância dos efeitos adversos da PQT para estes pacientes (7), o que pode levar a um estado de desnutrição, se não controlados.

     

    PCA 116

    OCORRÊNCIA DE ERITEMA NODOSO HANSÊNICO
    Lastória, J.C.; Maccharelli, C.A.; Puttinatti, M.S.M.A.
    Faculdade de Medicina de Botucatu- UNESP, Depto de Dermatologia.

    A evolução crônica da hanseníase em pacientes portadores da forma multibacilar pode ser interrompida por surtos reacionais denominados tipo 2 ou de Eritema Nodoso Hansênico (ENH),principalmente após o início do tratamento. Com o intuito de se observar a ocorrência destes surtos, avaliou-se 40 pacientes multibacilares em tratamento no Ambulatório de Hanseníase da Disciplina de Dermatologia da Faculdade de Medicina de Botucatu- UNESP, no período de 3 anos, sendo 18 da forma dimorfa (D) e 22 da forma virchoviana (V). Observou-se que 18 (45%) pacientes apresentaram surtos de ENH, sendo 3 (7,5%) D e 15 (37,5%) V. Os surtos ocorreram em número de vezes variável de 1 a 8 por paciente, sendo que 8 (44,4)% pacientes apresentaram apenas um surto; 1 (5,5%), 2 surtos e 9 (50%) pacientes mais de 2 surtos; 22 (55%) dos pacientes não apresentaram surtos reacionais. Estes surtos ocorreram entre a 1ª. e a 23ª. dose da PQT, sendo a maior freqüência entre a 1ª. e a 12ª. dose, em 8 (22%) pacientes. Observou-se, ainda que 12 (30%) pacientes apresentaram surtos após a alta, com variação de ocorrência de 1 a 52 meses, até o momento, sendo que 5 (12,5%) apresentaram apenas uma vez; 2 (5%) duas vezes e 5 (12,5%) apresentaram mais de dois surtos. Em 2 (5 %) dos pacientes o ENH manifestou-se antes mesmo do início do tratamento. Interessante notar que os pacientes que apresentaram surtos após a alta foram praticamente os mesmos que apresentaram durante o tratamento e, ainda, que em 6 (15%) destes, que não haviam apresentado durante o tratamento, o fizeram a partir do 6° mês após o mesmo, sendo em 3 deles, cerca de 40 meses após a alta. Os autores chamam a atenção para a alta freqüência de surtos de ENH e que muitos pacientes continuam a apresenta- los após a alta, ou seja, após o término do tratamento, por longos períodos, além do fato dos mesmos poderem ocorrer, também, após longos períodos após a alta em pacientes que não os apresentaram durante o tratamento.
    Houve ou não correlação do número de surtos com o IB, tanto durante o tratamento como após.

     

    PCA 117

    OCORRÊNCIA DE HEPATITES B E C EM PACIENTES COM PATOLOGIAS PASSÍVEIS DE TERAPÊUTICA COM IMUNOSSUPRESSORES
    Joel Carlos Lastória; Milena Cerchiaro; Fábio C. Iuan, Nádia R. Carvalho
    Faculdade de Medicina de Botucatu - UNESP

    Dentre as diversas etiologias da hepatite crônica, temos a infecção pelo vírus da hepatite C (HCV), na qual a cronicidade da infecção é a regra, como sugerido por estudos de hepatite pós-transfusional. A condição de portador assintomático para formas graves da doença pode ser modificada pela terapia com imunossupressores como, da mesma forma que pela infecção pelo HIV. Esse fato motivou o presente estudo em pacientes com doenças dermatológicas passíveis dessa terapêutica mas que. no entanto, poderiam, eventualmente, serem tratados com medicamentos alternativos, entre as quais a psoríase, a micose fungóide e a hanseníase virchoviana reacional. Como a hepatite C parece ser transmitida de uma forma semelhante à da hepatite B, realizou-se a sorologia para ambas em 54 pacientes portadores dessas doenças dermatológicas. A mesma foi positiva em 4 (7,41%) pacientes. Destes, apenas 1 (1,85%) apresentava o vírus para hepatite C, sendo que os outros 3 (5,56%) apresentavam apenas o contato com o vírus da hepatite B ou eram falso positivos, o que não acarretaria problemas com o uso desse tipo de medicação. Embora em pequeno percentual (7.41%), os autores defendem a realização do teste sorológico para hepatite em geral, pois nos casos positivos, poder-se-ia optar por medicações alternativas, analisando-se, evidentemente, o fator risco-benefício, não incorrendo em possível prejuízo ao paciente. Além disso, diante de situações de impossibilidade da realização dos testes, sugerem a avaliação das condições epidemiológicas associadas ao risco da doença, antes da introdução dessas medicações.

     

    PCA 118

    OCULAR LESIONS AMONGST THE MB LEPROSY SUFFERERS UP TO TWENTY FIVE YEARS OF AGE GROUP WITH THE DURATION OF THE DISEASE UNDER FIVE YEARS
    Swapan K Samanta; I S Roy; Asim K Dey; Amitava Chattaraj
    B.S.Medical College & Gouripore State Leprosy Hospital, Bankura, West Bengal, PIN 722101, India

    One hundred MB leprosy sufferers up lo twenty five years of age group with the duration of the disease under five years were examined randomly between July 2001 to January 2002 in Eastern India in search of the ocular lesions most probably related to the disease process. Two third of them were under active treatment and the rest hail completed the scheduled MDT regime. 20 of them were from the leprosorium, 25 of them were the residents of the alter care leprosy colonies and the other 55 leprosy sufferers were in the society. 70% of the patients were male and 30% female. Only 2% of them had minor physical deformity arising out of leprosy. 11% of this group of patients had ocular complications most probably related to leprosy. The ocular leprosy included Lagophthalmos in 3%, Peresis of Orbicularis Oculi in 1%, Complicated Cataract amongst 3%, and Recurrent Uveitis in 3% and Episcleritis in 1%. Otherwise non specific ocular lesions like Pterygium, Chronic Conjunctivitis, Pinguicula, Chronic Dacryocystitis, Refractive errors and Bitots Spots were encountered in 12% of the patients of the group. Here lagophthalmos was not associated with any exposure keratitis and responded well with a course of systemic steroid for six weeks. Uveitis responded effectively with local ocular medication along with a course of systemic steroid. The Cataract had a good visual out come following Extra Capsular Cataract Extraction with Intra Ocular Lens Implantation.
    Ocular Leprosy in MB patients of younger age group is not an uncommon phenomenon in this era of MDT but it is well controlled by appropriate therapy keeping aside the dread full complications of incurable blindness.

     

    PCA 119

    ONE MONTH PREVALENCE OF MENTAL DISTRESS AMONG PEOPLE AFFECTED BY LEPROSY AT ALERT. ETHIOPIA. 2002
    Ruth Leekassa; Elizabeth Bizuneh; Atalay Alem
    ALERT (All Africa Leprosy Rehabilitation Training Centre) P.O. Box 165, Addis Ababa, Ethiopia.

    Leprosy is a disease that results in handicap as a result of nerve damage. The society has negative feeling towards the affected people. The disability and the negative feeling of the society affect patients' emotional state and behaviour. Many patients attend clinic frequently without specific medical reason and the hypothesis was that they might be doing so because of psychological problems.
    Objective: To estimate the prevalence of mental distress in people affected by leprosy and to suggest ways to deal with this problem.
    Subjects: 471 persons affected by leprosy attending the different clinics at ALERT were systematically sampled and interviewed using The Self Reporting Questionnaire (SRQ).
    Instrument: SRQ is an instrument developed by WHO to detect mental health problem in primary health care attendees in low-income countries. Twenty questions that contain emotional and somatic symptoms were used to identify emotional problems.
    Result: Those who had at least 11 positive scores out of twenty symptoms from SRQ were regarded as having mental distress. The prevalence of mental distress in the study subjects was 51%. Those patients with handicap reported symptoms of mental distress more often than those without handicap. Over 18 % had suicidal ideation over the past one month.
    Conclusion: These findings are much higher than findings of similar studies done in Ethiopia and elsewhere, both in clinical and community settings. People affected by leprosy seem to have more mental distress than the general population and people attending clinics for other diseases. The findings emphasize the great need for addressing Ihe psychosocial aspect of the problem with the medical treatment to help these people. Training in leprosy work should also include this as an important component in the management of leprosy. Since SRQ is meant to detect the presence of symptoms of general mental ill health, another study needs to be done to diagnose specific mental disorders in this population.

     

    PCA 120

    OUR EXPERIENCE OF ANTILEPROSY PREVENTIVE TREATMENT
    A.A. Juscenko; N.G. Urlyapova; V.V. Anokhina; V.V. Duiko
    Leprosy Research Institute, Astrakhan, Russian Federation

    In Astrakhan endemic zone leprosy incidence among relatives of leprosy patients, long living together with index cases and having no preventive treatment, was 8- 10% in pre-sulphonic era. Since the 50th of the 20th century preventive antileprosy treatment was introduced in Russia. Preventive treatment was administered to persons aged 2-60 years old and having a close household contact with index leprosy case as well as with relapsed case of leprosy with high BI. As preventive treatment DDS was used at doses, usually administered to leprosy patients. Duration of preventive treatment was 6-12 months. In the period of 1958-1998 preventive treatment was given to 531 persons, among them 13 (2.4%) developed leprosy (7 females and 6 males). It should be noted that 12 out of the 13 cases accounted for the 60th-70th years. All the diseased had close household contacts with lepromatous leprosy patients. Index cases were as follows: mother - 4 cases, father, son, and brother-by 2 cases each, husband - 3 cases. By Ridley-Jopling classification patients were distributed as follows:. LL- 3-, BL-1, TT-7, I- 2. i.e. paucibacillary forms of leprosy prevailed. During preventive treatment no complications were observed. Intolerance of sulphones was rare. In control group (contacts having no preventive treatment) leprosy was developed in 8%. The data obtained suggested rather high effect of preventive treatment. While in the 50th in Astrakhan zone populated about 1 million 50—60 cases were registered annually, now, thanks to a set of antileprosy measures, including preventive treatment of leprosy contacts, prevalence of leprosy infection sharply decreased and primary incidence of leprosy has become sporadic

     

    PCA 121

    OVERT NEURITIS INFLUENCING THE INDUCTION AND/OR WORSENING OF PHYSICAL DISABILITIES IN MULTIBACILLARY LEPROSY PATIENTS
    Pimentel, Maria Inês Fernandes; Nery, José Augusto da Costa; Borges, Esther; Gonçalves, Rosângela Rolo; Sarno, Euzenir Nunes
    Laboratório de Hanseníase, Fundação Oswaldo Cruz, Avenida Brasil no. 4365 - Manguinhos - Rio de Janeiro - RJ - CEP: 21045 - 900.

    With the goal of studying the role of the overt neuritis (pain, spontaneous or by palpation, in peripheral nerves) in the development and / or worsening of physical disabilities in multibacillary leprosy patients, 103 patients (18.4% BB; 47.6% BL; and 34% LL) were followed-up for an average period of 64.6 months, from the start of multidrug therapy (MDT), 24 doses. They were evaluated in relation to physical disabilities through disability grade and through disability index, before treatment, at the end of the treatment, and at the end of the follow-up period.
    Forty six patients (44.7%) had overt neuritis episodes during follow-up (34% during MDT). The overt neuritis episodes were associated mainly with erythema nodosus leprosus reactions (55.3%), when compared to reversal reactions (33.3%), although this was not statistically significant. There was a significant correlation between the occurrence of overt neuritis and the development of disabilities, evaluated through disability grade at the end of treatment (p = 0.000274), as well as al the end of whole follow-up period (p = 0.006886). Similarly, disabilities measured through the disability index at the end of the treatment (p = 0.002165) and through the final disability index (p = 0.006274) were significantly correlated with the occurrence of overt neuritis. These data suggest that health professionals must pay attention to the early diagnosis of oven neuritis, giving prompt and adequate therapy, to prevent the development of physical disabilities in multibacillary leprosy patients.

     

    PCA 122

    PALPAÇÃO DE RAMO NERVOSO CUTÂNEO COMO UMA ESTRATÉGIA PARA A REDUÇÃO DA PREVALÊNCIA OCULTA DA HANSENÍASE
    Alexandre Castelo Branco1; Luiz Cosme Cotta Malaquias2; Francisco Carlos Félix Lana3; Regina Lúcia Barbosa Cypriano1; Francisco Carlos Pereira1; Mara Firmato Esteves1; Simone Teixeira4; Andressa Masiero Santos4; Maria Cristina Souza Felipe da Silva5; Sebastião Fontes Santiago1

    1- Policlínica Central Municipal de Saúde, Gov. Valadares. MG, Brasil.
    2 - Faculdade de Ciências. Educação e Letras/UNlVALE. Gov. Valadares, MG. Brasil.
    3 - Escola de Eníermagem/UFMG. Belo Horizonte, MG, Brasil.
    4 - Secretaria Municipal de Saúde. Gov. Valadares. MG. Brasil.
    5 - Diretoria Regional de Saúde. Gov. Valadares. MG, Brasil.

    Expõe-se o quadro clínico inicial encontrado em contato de hanseníase descoberto a partir da palpação de ramo nervoso cutâneo. Enfatizam a utilização também da palpação de ramos nervoso cutâneos associado com a utilização do exame com monolila-mentos como uma estratégia para a detecção precoce e redução da prevalência oculta da hanseníase.

     

    PCA 123

    PAUCIBACILLARY HANSEN'S: COMMON CLINICAL TYPES
    Melo. S.; Chaves, M.S.R.; Sailaja, K.S.; Souza, P.F.; Cavalcante, CM.; Abreu. F.; Nery, J.A.C.; Azulay. R. D.
    Department of Leprosy. Institute of Dermatology. Santa Casa de Misericórdia. Rio de Janeiro, Brazil.

    Introduction: Hansen's is an infectious disease with an inconsistent incubation period. The peripheral nerves are affected frequently and cause physical deformities. The incidence of the disease by mycobacterium leprae can be determined by two factors i.e. by the resistance of the patient and by the quantity of the bacilli.
    Materials and Methods: 938 patients had been evaluated in the out patient department and out of that 103 were diagnosed as paucibacillary. All the patients were submitted for the following clinical examinations Neurodermatological, Bacilloscope, Lepromin test. Histopathological examination of skin. All of them received the Hansen's treatment for the lirsl time in their life. A study was done on the basis of age, sex, clinical classification, type and number of lesions.
    Results: Out of 103 patients evaluated, 70 patients (68%) were females and 33 patients (32%) were males; the age incidence was from 1 year to 75 years. As per the clinical presentation 76 patients (74%) were tuberculoid type, 17 patients (16.5%) were inderminate type. 8 patients (8%) were infantile nodular, 2 patients (2%) were absolute neural type. As per the types of lesions 62 patients (60%) were macular, 30 patients (29%) were plaques, 8 (8%) were nodular and 2 (2%) were with out any dermatological lesions but presented with neurological deficit. In relation with number of lesions 61 patients (59%) had single lesion and 18 patients (17%) had two lesions.
    Conclusion: In spite of the sound clinical knowledge of paucibacillary Hansen's type, the similar features are seen in the other types of clinical manifestations of the cutaneous plaques, infantile nodular Hansen's and absolute neural type. A keen attention should be given to the paucibacillary form, which has typical characteristics with other existing variable clinical entities.

     

    PCA 124

    PEROXIDASE AND SUPEROXIDE DISMUTASE LEVELS IN THE LYMPHOCYTES OF LEPROSY PATIENTS
    Ravi, P.; Suribabu. C.S.S.
    Central Leprosy Teaching & Research Institute. Tirumani, Chengalpattu - 603 001.
    Tamil Nadu, India.

    Leprosy become more complicated due to acute inflammatory episodes called "Reactions" during the natural course of the diseases while treatment and even after treatment. It is known that CMI is defective in infection with M. leprae . This abnormality has been correlated with defect in both numbers and proliferation of T-lymphocytes. The change that occurs in the physiology of Lymphocytes might be one of the reasons for the depressed functions, especially in the effector limb. We have studied a number of enzymes like LDH, Arginase, ADA. Aldolase besides rate of translation by labeled amino acids. In the present study we have studies SOD and Peroxidase levels in leprosy patients throughout the spectrum. We have analysed the above enzyme levels in both RBC as well as purified lumphocytes using standard procedures. These enzymes showed varying trends in both RBCs and Lymphocytes. Results will be presented and discussed.

     

    PCA 125

    POSSIBLE FACTORS AND THEIR COUNTER-MEASURES OF LEPROSY MISDIAGNOSIS AND MISSED DIAGNOSIS
    Chen Jiakun; et al.
    Shanghai Skin Disease & STD Hospital. 200435, Shanghai, China.

    Abstract: The disability resulted from leprosy make the public develop apprehensiveness and discrimination on leprosy. Therefore it is very important to diagnoses early and accurately. Never establish diagnosis unless there are enough evidences. If it happen, the distress will drop the patients and their relatives mentally and physically. Once patients are misdiagnosed or missed diagnosed, irreversible disability and social public problem will be produced. Possible factors include 1) low precautions of leprosy presence, 2) absence of leprosy knowledge and do not master main points of diagnosis. 3) imperfect, careless or not enough synthetic analysis for examination. 4) leprosy with other skin diseases or peripheral nerve diseases. 5) variation of leprotic symptoms and signs. 6) incorrect preliminary diagnosis results in return visit as usual, especially for senior. 7) taboo leprosy and hide the truth. We discuss their countermeasures.

     

    PCA 126

    POST RELEASE REACTIONS AND SKIN SMEAR RESULTS
    Albuquerque, E.C.A.; Gallo. M.E.N.: Nery, J.A.C.; Vieira, D.M.
    National Collaborating Center in Leprosy -FIOCRUZ - RJ
    The occurrence of reaction manifestations following release from treatment in leprosy patients remains as one of the most worrisome matters and of difficult solution. With the objective of better understanding the problem, we correlated the skin smears results with the presence of reactions in cases submitted to multidrug therapy destined to multibacillary leprosy patients (WHO/MDT). 164 cases were evaluated that presented reactions following release, where 124 cases had received 24 doses and 40 cases had received 12 doses of WHO/MDT. In the evaluation of the results, we used the system of Word processing, data bank and statistics for epidemiology in microcomputers EPI INFO 6.01. From the total of cases, 51.2% (84/164) presented positive skin smears at the moment of reaction. When we separately evaluated in relation to the number of doses, we observed that, following 24 doses. 53.2% (66/124) and after 12 doses, 45.0% (18/40) developed post release reactions with negative skin smears. The statistical tests showed no significant statistical difference between positive and negative skin smears and the occurrence of reactions in leprosy patients following release from WHO/MDT for multibacillary signaling the need for treatment with anti-inflammatory drugs and strengthening the participation of the immune system in the etiology of reaction episodes.

     

    PCA 127

    PREVALENCE OF OCULAR COMPLICATIONS IN NEWLY DIAGNOSED AND RELAPSED LEPROMATOUS PATIENTS
    Ebenezer Daniel; Sheena Koshy; P S S Sundar Rao
    Schieffellin Leprosy Research and Training Center, Karigiri, India - 632106

    Results on the ocular complications of 301 lepromatous patients, newly diagnosed (238) and relapsed (63), male (213) (71%) and female (88) (29%), polar lepromatous (LL) (41) (14%) and borderline (BL) (260) (86%) with age ranging from 7 to 78 years with 41.5 (14) mean (SD) and duration of disease from 1 year to 32 years with 6.2 (7.8) mean (SD), belonging to a geographically defined leprosy control area program in South India who had base-line anterior-segment ophthalmic examination is presented.
    Ocular complications, categorized as leprosy related complications (lagophthalmos, ectropion, entropion, trichiasis, corneal opacities, corneal sensory impairment, corneal ulcer, episcleritis, scleritis, iridocyclitis and iris atrophy) (LRC) and general complications (nasolacrimal duct block, pterygium and cataract) (GC), were found in 213 (71%) patients. 88 (29%) patients had no ocular complications. 30 (10%) had only GC. 111 (37%) had only LRC and 72 (24%) had both. More elderly patients had ocular complications (P=0.000) as did LL patients (85%) compared with BL (68%) (P=0.03). Limb deformity (P=0.000) and smear positivity at any one site at enrollment (P=0.02) and visual loss (P=0.()()2) were associated with ocular complications. Ocular complications were not significantly different in relapsed patients compared with newly diagnosed lepromatous patients. Similar associations were found when LRC were analyzed separately. More cataract was present in those who had LRC (30%) than those who did not (12%)(P=0.000). GC were associated with increasing age (P=0.000), were more in LL patients (49%) than BL(32%) (P=0.03) and were associated with increased limb deformity (P=0.006). Corneal opacity with vision loss was more in patients with GC (P=0.01).

     

    PCA 128

    PRIOR THE START AND AFTER TREATMENT WITH MULTIDRUG THERAPY IN LEPROSY: A HISTOLOGICAL AND IMMUNOHISTOCHEMISTRY STUDY
    M.C. Floriuno; J. Tomimori-Yamashita; O. Rotta
    Department of Dermatology, Paulista School of Medicine - Federal University of São Paulo, Brazil.
    Rua Botucatu, 740. Vila Clementine-. São Paulo (SP), Brasil.

    The fixed-duration multidrug therapy (MDT) has been of a great value in the control of leprosy. Its effectiveness is basically shown through clinical and bacterioscopic parameters. The goal of this study was tissue analysis by histological and immunohistochemistry techniques for populations of lymphocytes T helper, lymphocytes T suppressor, macrophages and Mycobacterium leprae antigens on the patients undergone MDT.
    Twenty-eight patients with leprosy were studied. They were classified according Madri classification. Seven out of them were tuberculoid leprosy (T) and they were classified as paucibacillary group to be treated. Twenty-one were classified as multibacillary group, twelve of the borderline leprosy (B) and nine of the lepromatous leprosy (L). All patients were treated with MDT.
    Skin biopsies were made alter the end of the treatment at same site that it had been made before lhe beginning of the therapy and histological and im-muhistochemistry analysis with anti-OPD4, anti-CD8, anti-CD68 and anti-BCG antibodies were made.
    The decrease of the inflammatory cells in the infiltrate was noticed of leprosy after the treatment. The CD4+cells were more expressive in T leprosy than in B and L leprosy before treatment. After treatment this difference was not noticed.
    The distribution of CD8+ cells and CD68+ cells was similar in different forms of leprosy, before as well as after treatment.
    The demonstration of the mycobacterial antigens in lhe tissues through the BCG+ cells was more sensitive than the demonstration of acid-fast bacilli in the tissue through the Fite-Faraco stain.

     

    PCA 129

    REAÇÃO DE REVERSÃO REVELANDO DOENÇA DE HANSEN
    Mohamed A. Azzouz; Francisca Estrêla Maroja Dantas; Carla Wanderley Gayoso; Mª das Graças V. A. Almeida; Francimary de Souza Buriti; Carlos Alberto F. Ramos
    UFPB/ Hospital Universitário Lauro Wanderley.

    R.M.S. 32 anos, masculino, branco, casado, natural e procedente dc João Pessoa- Pb, apresentava há 1 ano lesões no corpo tipo urticariana, que melhorava com corticoide sistêmico e com aparecimento das lesões após a suspensão da medicação. Ao exame apresentava nervos espessados e lesões em placa eritematosas e infiltrada em tórax e abdome. Confirmado o diagnostico através da biopsia. Baciloscopia negativa, iniciamos tratamento com o esquema paucibacilar e corticoterapia. Trata-se de manifestação aguda da Doença de Hansen. Cerca de 20% da doença é diagnosticada a partir da reação.

     

    PCA 130

    REAÇÃO HANSÊNICA TIPO I EXUBERANTE SIMULANDO FENÔMENO DE LÚCIO
    Ana Célia de A. Mesquita; Heitor de Sá Gonçalves; Ana Fátima P. Teixeira; Francisco José Dias Branco; Maria Araci P. Aires Centro de Dermatologia Dona Libãnia - SESA - CE Av. Pedro I. 1033 - Centro -Forateza - CE

    AMS, masculino, 71 anos, agricultor, procedente de Quixadá - CE. Paciente portador de hanseníase virchoviana, diagnosticada pela associação de clínica com a baciloscopia (IB = 2.5), além de hislopatologia compatível. Na consulta inicial apresentava extenssa placa eritêmato-infiitrada, com ausência de sensibilidade térmica e dolorosa na lace medial do braço esquerdo, e inúmeras lesões semelhantes, am menores dimensões, disseminadas pelo tegumento, predominando em tronco e membros superiores. Iniciou esquemaq poliquimioterápico para mutlibacilares da OMS, e cerca de 15 dias após, apresentou exuberante quadro de ração tipo I, com aumento da infiltração de numerosas lesões. Foi medicado com prednisona, na dose de 0,8 mg/kg/dia, evoluindo com resposta terapêutica bastante satisfatória. Motivo da apresentação: exuberância dc reaçã tip I em hanseníase, sumulando fenômeno de lúcio, e a pronta responsta terapêutica á doses moderadas de corticoterapia.

     

    PCA 131

    REAÇÃO TIPO I GRAVE, COM LESÕES INCOMUNS EM CRIANÇA DE 7 ANOS COM HANSENÍASE DIMORFA - RELATO DE CASO
    Grossi, M.A.F.; Freire, H.B.M.; Teixeira. M.L.G.; Villarroel. M.F.; Pires. R.P.; Lyon. S.
    Centro Geral De Pediatria (Cgp) and Hospital Eduardo De Menezes (Hem) Fundação Hospitalar Do Estado De Minas Gerais. Alameda Ezequiel Dias N° 345 Cep: 30130 110 Belo Horizonte, Mg - Brasil

    Relato de Caso: D.N.L.C., 07 anos, sexo masculino, faioderma, natural e procedente de Teófilo Otoni, Minas Gerais, internado no C.G.P em 10/01, com história de há 03 anos ter apresentado mácula hipocrômica no tórax, com posterior aumento do número das lesões. Diagnóstico de Hanseníase Dimorfa em 09/01, com Grau Zero de Incapacidade, no Centro de Saúde de sua cidade, aonde iniciou PQT/MB. Passou a apresentar exacerbação das lesões que ficaram eritemato-infiltradas e edematosas, com posterior necrose e ulceração em face, orelhas, tronco e membros. Enviado para o Centro de Referência do HEM em Belo Horizonte quando foi feito o diagnóstico de Reação Tipo 1 Necrótica com infecção secundária e encaminhado para o CGP, aonde manteve a PQT/MB, iniciou Prednisona, Oxacilina e Cloranfenicol, limpeza e proteção da pele com Ácidos Graxos Essenciais e Curativos Interativos com Hidrocoloide nas lesões ulceradas. A criança evoluiu com melhora progressiva das lesões cutâneas e piora sensitiva e motora em Ulnares e Tibiais, comprovada pelo monitoramento da função neural: força muscular, estesiometria e eletroneuromiografia, sendo indicada Neurolise de Ulnares, Medianos, Fibulares e Tibiais. Após cirurgia e melhora inicial a criança vem sendo acompanhada pelo serviço de origem e pelo CGP.
    Motivo da Apresentação: Caso pouco usual e grave da Reação Tipo I em criança de 7 anos.

     

    REAÇÕES ADVERSAS À PQT. NUM PERÍODO DE DEZ ANOS.
    Dalila Filomena Mohalem; Maria do Rosário Vidigal; Mônica Nóbrega Cunha
    Centro de Saúde Tranqüilidade. Secretaria de Saúde de Guarulhos.
    Av. Emílio Ribas, n° 1845 - Guarulhos - SP.

    Uma Avaliação Da Incidência De Reações Adversas A Poliquimioterapia Ocorridas Num Período De Dez Anos (1992 A 2002), No Centro De Saúde Tranquilidade; Entre Elas: Anemia Hemolítica, Hepatite, Insuficiência Renal, Síndrome Pseudo Gripal, Vômitos Incoercíveis E Púrpura Trompocitopênica.

     

    PCA 132

    REAÇÕES ADVERSAS À PQT. NUM PERÍODO DE DEZ ANOS
    Dalila Filomena Mohalem. Maria do Rosário Vidigal, Mônica Nóbrega Cunha
    Centro de Saúde Tranqüilidade
    Secretaria de Saúde de Guarulhos
    Av. Emílio Ribas, n" 1845 - Guarulhos - SP.
    Uma Avaliação da Incidência de Reações Adversas à Poliquimioterapia ocorridas num período de dez anos (1992 a 2002), no centro de saúde tranquilidade: entre elas: Anemia Hemolítica. Hepatite. Insuficiência Renal, Síndrome Pseudo Gripal, Vômitos Incoercíveis e Púrpura Trompocitopênica.

     

    PCA 133

    REACTIONAL STATES IN CO-INFECTED LEPROSY X HIV POSITIVE PATIENTS
    Nery, J.A.C.; Sá, R.P; Guatierrez, M.C.; Sales. A.M.; Machado, A.M.; Gomes, A.P.; Sampaio, E.P.
    Leprosy Laboratory - Oswaldo Cruz. Foundation -RJ - Brazil.

    Introduction: Although endemic in Brazil, leprosy disease is uncommon in HIV+ individuals. HIV+ patients present the same stable forms and reactional episodes described in the HIV negative leprosy patients. As the disease develops into HIV-positive individuals, a variety of other opportunistic infections may develop, some of which are directly related to deficiencies in the cellular immune response. However, leprosy does not seem to be related to the immune status of HIV+ patients.
    Objective: Describe the reactional episodes among the co-infected leprosy × HIV+ patients.
    Methods: With the intent to evaluate the frequency of reactional episodes in co-infected leprosy × HIV+ patients, we followed 38 patients. They were treated at Outpatient Unit of Leprosy Laboratory / Oswaldo Cruz Foundation / Rio de Janeiro / Brazil with multidrugtherapy (OMS).
    Results: Out of 38 cases, 24 (63%) patients were paucibacillary (PB) and 14 (37%) were multibacil-lary (MB). Eighteen patients (47%) were male and 20 (53%) were female, ranging from 17 to 64 years of age. Twenty-three (60%) patients presented reactional episodes, and 20 patients developed type 1 reaction and 3 developed type II reaction. Among the PB patients, 21 (87%) presented reactional states and in the MB, 11 (78% ) patients. Nineteen (825) developed a reaction during the first 6 months of treatment, 3(13%) during the first year and only 1 (4%) after this. Only 8 (34%0 patients presented more than one episode of reaction.
    Conclusion: The HIV co-infection does not seem to change the natural course of leprosy, nor to interfere on the specific immune response to M. leprae , but the frequency of reaction in PB patients is higher than in HIV negative patients.

     

    PCA 134

    REACTIONS IN LEPROSY: AN EPIDEMIOLOGICAL STUDY OF 2600 PATIENTS FROM NORTH INDIA
    Bhushan Kumar; lnderjeet Kaur; Sunil Dogra
    Department of Dermatology, Venereology & Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh-160012, India.

    Although leprosy reactions are a very common phenomenon, very limited data has been published on their epidemiology from India, which harbours the largest number of case load in the world. This paper presents epidemiological data over a period of 15 years on reversal reactions (RR) and erythema nodosum leprosum (ENL) from retrospective analyses of 2600 new leprosy patients registered and followed up at our clinic. Average period of follow up was for 72 months (range 24-156 months). There were 1634 males (mean age 37 ± 3.2years) and 966 female patients (mean age 4 ± 12.3years). 1494 (57.4%) of them had multibacillary and 1106 (42.5%) had paucibacillary disease labelled on the basis of slit skin smear.
    The prevalence of RR at registration was 24% and that of ENL was 6.8%. The overall incidence rates among patients available for follow-up were 8.2%/100 persons years (PYAR) at risk for RR and 4.1%/100 PYAR for ENL. The most significant risk factor for RR was extent of clinical disease measured by count of body areas involved. The observation of other investigators that most RRs occur during first year of treatment was confirmed in our study. Lepronialous disease and high bacteriological index (BI≥3) were significant risk factors for INL reactions. A total of 226/507 (26.4% of all LNL cases) patients had > 4 episodes over a period of > 3 years and the reactions continued to occur in decreased frequency till 7.2 years in lew patients. Late RR was seen in 7.1% of all leprosy patients. The incidence of RR declined steadily after the start of the treatment but recurrent episodes continued to occur even up to 6 years after diagnosis.

     

    PCA 135

    RECIDIVA PAUCIBACILAR - RELATO DE UM CASO
    Flávio Marcondes Hercules; Mónica Duarte da Cunha; Maria Leide Wand Del Rey de Oliveira
    Serviço de Dermatologia do Hospital Universitário Clementino Fraga Filho - UFRJ.

    Os novos esquemas terapêuticos para hanseníase e redução no tempo da poliquimioterapia (PQT), torna a recidiva um tema cada vez mais importante. A OMS (1994) detectou coeficiente cumulativo de recidiva paucibacilar de 1,7% . Segue a descrição de I caso de recidiva paucibacilar: paciente, feminina, 46 anos. parda, MG. do lar. Início do quadro em 07/1990 com surgimento de 3 lesões eritemato-infiltradas, hipoestésicas, situadas nas regiões malares, acompanhadas de espessamento ulnar bilateral. A biopsia cutânea evidenciou hanseníase tuberculóide, o Mitsuda foi positivo (10mm), e a baciloscopia negativa. Foi iniciado tratamento com PQT PB, sem intercorrências até o seu término. Permaneceu assintomática, porém 9 anos após surgiu nova lesão eritemato-infiltrada e hipoestésica, na região frontal, associada à neurite fibular direita. Foi submetida a 60mg de prednisona com melhora da lesão (hipercromia residual) e desaparecimento da neurite. A biopsia revelou denso infiltrado linfoplasmocitário e histiocitário, circundando nervo com células epitelióides c gigantes formando granulomas. A baciloscopia foi negativa. Desde então evoluiu com períodos de piora e melhora da lesão, de acordo com curso oscilante de corticoterapia. Não apresentou surgimento de novas lesões ou recidiva da neurite. Em 01/2002 foi reiniciado tratamento com esquema PQT MB. Ressalta-se que pelas regras aluais do Ministério tia Saúde esla paciente deveria ler sitio tratada no primeiro episódio com esquema multibacilar. pois apresentava acometimento neural de 2 troncos.

     

    PCA 136

    RECOMBINANT HUMAN PLATELET-DERIVED GROWTH FACTOR FOR TREATMENT OF NEUROPATHIC ULCERS IN LEPROSY PATIENTS
    Winnie Ooi
    Lahey Clinic. Burlington. MA USA

    Data from the World Health Organisation indicates that the global prevalence rate for leprosy at the end of 2000 has been reduced to less than 1 per 10.000: an eighty nine percent drop over the past 15 years. This has been achieved through early detection and free effective multidrug therapy (MDT). Leprosy remains a public health problem however, in six endemic countries that represent approximately eighty three percent of prevalence worldwide. Nerve lesions, which are often progressive and irreversible may develop in one third of patients despite effective multidrug therapy. Therefore, clinicians treating leprosy patients will continue to have to deal with the complications from nerve damage including deformities and anaesthetic ulcers for many years to come.
    Recombinant human platelet derived growth factor (PDGF) gel has been shown to increase the healing of diabetic neuropathic ulcers through fibroblast activation and stimulation of granulation tissue formation. A small number of patients in our clinic with lower extremity neuropathic ulcers secondary to leprosy were treated successfully with PDGF after failing to respond to conventional therapy including topical or oral antibiotics. All four patients had successfully completed MDT for lepromatous leprosy but had significant residual peripheral neuropathy and deformities. Three patients developed full thickness plantar ulcers from chronic pressure and one had a traumatic ulcer in an anaesthetic area on the lower leg. All four ulcers were rendered free of necrotic and infected tissue after debridement and were treated with once daily topical application of 0.01% PDGF gel and good wound care until complete wound closure for three patients. The fourth patient had a marked decrease in ulcer size but was temporarily lost to follow up for nine months. The duration of treatment ranged from 8 weeks to 7 months in which no side effects were observed. None of the ulcers has recurred after a follow-up of 8 to 30 months. Our results support the use of PDGF in nonhealing neuropathic ulcers in leprosy patients and it warrants further study.

     

    PCA 137

    REVERSAL REACTIONS IN AN OUTCOME LEPROSY CLINIC IN SALVADOR/BAHIA
    Vitória Rêgo; Isabela Martins; Paulo Machado

    Serviço de Imunologia e Serviço de Dermatologia. Hospital Universitário Prof. Edgard Santos, Universidade Federal da Bahia.
    293 patients with leprosy were followed between 4 to 9 years after start of multidrugtherapy (MDT), to characterize reversal reactions (RR). RR were documented in 79 patients (27%), and begun during treatment in 47 patients (59.5%). Twenty patients (25%) had clinical presentation of RR alter MDT and during the follow-up period. Neuritis with or without skin involvement occurred in 73% of patients, and cutaneous manifestations without neuritis were found in 27%. The majority of the patients (49/79) were paucibacillary, while the average bacillary index was 2.4 in the 27 multibacillary patients. Our data shows that the beginning of MDT is an important risk factor for the development of RR, which presents with neuritis in the majority of the patients. Due to the morbidity associated with neuritis, all leprosy patients should be carefully monitored during MDT in order to provide an early detection of reversal reactions.

     

    PCA 138

    REVIEW OF 100 PATIENTS WITH CHRONIC AND RECURRENT NEURITIS TREATED IN A SPECIAL NEURITIS CLINIC
    Elizabeth Bizuneh; Ruth Leekassa; Ronald Kazen
    All Africa Leprosy Rehabilitation Training Center (ALERT), P.O. Box 165. Addis Ababa, Ethiopia. Fax: 251 1711 199.

    Leprosy is a chronic disease that affects skin and nerves. Nerve damage is the main cause of disability and stigma. Therefore, prevention and management of nerve damage is pivotal in leprosy control. ALERT as a referral center deals with a large number of leprosy patients with complications. Most of them present with recurrent and chronic neuritis. A group of these patients were managed with individualized dose regimen of steroid in a special neuritis clinic. One hundred patients with an average of two years follow up were reviewed. Of these, 59 were'males and the age of these cases ranged from 15 to 70. Thirty-seven were PB and 63 MB according to WHO classification. Ninety-eight of the cases were released from MDT and 2 were on MDT at the time of review. The outcome of treatment was measured by VMT/STG; 75 improved, 20 remained the same and live deteriorated. Of the 75 who improved. 20 had only motor improvement, 30 improved in only sensory function and 25 had both motor and sensory nerve function improvement. The results indicate thai leprosy patients with recurrent and chronic neuritis cold be better managed with individualized dose steroids and long tern follow up.

     

    PCA 139

    SECUELAS DE LA LEPRA EN EL ÁREA OTORRINOLARINGOLOGICA
    Menchades Guardiola, MI; Lafarga Vázquez, J; Gómez Echevarría, JR
    Sanatorio San Francisco de Borja. Dirección: Sanatório San Francisco de Borja. 03791 FONTILLES -VALL DE LAGUART (ALICANTE) ESPAÑA Telefono: 96 558 33 50 Fax: 96 558 33 76. E-mail: sanatoria@fontilles.org

    La Lepra afecta al territorio otorrinolaringológico con frecuencia. La lesión nasal aparece hasta en el 90% de los casos en las formas multibaciles. También se afecta la apófisis alveolar anterior del maxilar, la laringe, etc. Se revisan los enfermos del Sanatorio San Francisco de Borja, 80 internos y 150 externos, realizándose una exploración otorrinolaringológica completa. Se trata de enfermos inactivos actualmente en su mayoría, y en los cuales sólo hallamos las secuelas de la enfermedad. Se presenta iconografía de las secuelas más representativas y los resultados de la revisión.

     

    PCA 140

    SERUM ZINC LEVEL AND LEPROMIN (MITSUDA) TEST IN NONREACTIONAL MULTIBACILLARY LEPROSY PATIENTS
    lndah Handayani; Sri Linuwih; A. Djuanda; Retno W Soebaryo; I.M. Wisnu and Emmy Sjamsoe
    Dep. of Dermato-venereology Faculty of Medicine University of Indonesia Jakarta

    Serum zinc level in leprosy patients is lower than in healthy people. The decreasing level is in accordance with clinical spectrum and cellular immune response in leprosy. It is still not clear whether people with Zn deficiency are more susceptible to leprosy or M. leprae metabolism will cause low serum Zn level, and whether leprosy treatment can increase serum Zn level and cellular immune response. A cross-sectional study was done on 1999. The subjects were non-reactional MB leprosy patients which are divided into 3 groups, each group consists of 20 patients i.e. untreated patients, 6-12 months therapy and more than 18 months. Determination of serum Zn level and a lepromin test were conducted in all subjects. Sixty live percent of the subject were between 14-30 years old, male were more common (78.33%) than female. There were no statistically significant differences in distribution of starling treatment age, sex, leprosy type, body mass index, and duration of illness among the three groups. The serum Zn level of the 3 groups were not signilcantly different (p = 0.998), neither were the lepromin test result between the subjects with and without treatment (p > 0.05). Serum Zn level and lepromin test result were not influences by the duration of leprosy treatment. The serum Zn level was in accordance and significantly correlated with the lepromin test result (p = 0.045).

     

    PCA 141

    SILENT NEURITIS IN MULTIBACILLARY LEPROSY: STUDY OF PATIENTS DURING AND AlTER MULTIDRUG THERAPY
    Pimentel, Maria Inês Fernandes; Nery, José Augusto da Costa; Borges, Esther; Gonçalves, Rosângela Rolo; Sarno, Euzenir Nunes
    Laboratório de Hanseníase, Fundação Oswaldo Cruz. Avenida Brasil no. 4365 - Manguinhos, Rio de Janeiro - RJ - CEP: 21045 - 900

    In an effort to evaluate the frequency of silent neuritis, 103 multibacillary leprosy patients (18.4% BB, 47.6% BL, and 34% LL) were followed-up during an average period of 64.6 months from diagnosis, during and alter multidrug therapy (24 doses), in relation to physical disabilities, according to the disability grade. Studying twelve patients'who presented a worsening of the disability grade at the end of the treatment, or at the end of the follow-up, in comparison with the disability grade before treatment, we found two patients who experienced a worsening of physical disabilities without overt neuritis. We further analysed in detail four patients who developed final disability grade of 2, who had no disabilities or had disability grade of 1 at the beginning of the treatment, and we observed two other patients with silent neuritis. Three patients who presented a worse disability grade at the end of follow-up, in comparison with the end of treatment, were studied, and one of them had also silent neuritis. We found that five patients (4.9% ) developed silent neuritis, during or alter multidrug therapy. We recommend a careful neurological examination during the whole follow-up of multibacillary patients, aiming the detection and prompt treatmenl of silent neuritis

     

    PCA 142

    SOME LABORATORY INDICES IN LEPROSY NEUROPATHIES
    M.N. Dyachina; Y.G. Androsjuck; O.V. Degtyarev; E.I. Shats
    Leprosy Research Institute, Astrakhan, Russian Federation

    Exacerbations of leprosy neuroparthies often occur without clinical manifestations, but they result in decreased functional ability of the damaged extremities and accelerated invalidization. Over 3 years 97 patients with leprosy duration of 5-20 years and clinically proved neuropathies were under study (74 patients with MB and 23 patients with PB-leprosy). According to the degree of nerve damage patients under study were divided into two groups: 1) patients with deep invalidizing disturbances (contractures, mutilations, neurotrophic ulcers), and 2) patients with minimal clinical manifestations limited by hypertrophy of nerve trunks and pain syndrome. For prognostic assessment of course of leprosy neuropathies certain clinical and laboratory indices were studied. With using ELISA in blood sera antibodies towards PGL-1 and protein antigens of M. leprae as well as against sonicate of rabbit sciatic nerves (AgPN) were determined. Besides, concentrations of lactoferrin (LF) and C-reactive protein (CRP) were estimated. Conduction velocity in skin areas supplied with leprosy-damaged nerves was estimated according to Nakatani. Active clinical manifestations of neuropathies are the most often correlated with increased levels of antibodies against M. leprae antigens and AgPN as well as with high concentrations of LF in blood serum. These indices are correlated with the results of testing biologically active skin /ones. CRP levels are widely varied in patients and did not always correspond lo other indices. Thus, a set of laboratory and clinical tests: levels of antibodies against M. leprae antigens, AgPN, blood LF as well as conduction velocity in /ones innervated by damaged nerves might be used for prognosis of the course of leprosy neuropathies.

     

    PCA 143

    SQUAMOUS CELL CARCINOMA AND CHRONIC LOWER LEG ULCER IN LEPROSY
    YU Aim
    Zhejiang Provincial Institute of Dermatology, 313200. Deqing. Zhejiang. China

    Objective: To further determine the epidemiological status, clinical features and prognosis of neuoplastic transformation in chronic lower leg ulcers of leprosy.
    Methods: Cases with neuoplastic transformation in chronic lower leg ulcers of leprosy, which were diagnosed and admitted to a provincial leprosy hospital for operation, in the recent 20 years were retrospectively reviewed anil analyzed.
    Results: Between Jun 1980 and Sep 2001, 21 cases were diagnosed and treated. There were 15 males and 6 females with average age of 59.1 years (48-71 years) and mean ulcer duration of 16.2 years (8-30 years; tumors located 16 in sole, 4 in leg and 1 in ankle. Squamous cell carcinoma was the only neoplasia in this group with well to moderate tumor differentiation (grade 1-2), however metastasis is common (10 cases) and fatal. Above-knee amputation had been performed on all cases (10 cases) before Sep 1993, and in the remaining cases below-knee amputation were performed on. By Sep 2001. there were 10 alive, 9 died of cancer metastasis and .3 lost follow-up. fhe average postoperative survial was 37.1 months.
    [Key Words] Squamous Cell Carcinoma; Ulcer; Lower Leg; Leprosy

     

    PCA 144

    STUDY OF REACTION IN THE HANSEN'S -AGED BETWEEN 0 TO 14 YEARS
    Barcelos, D.L.; França JR.; Spinelli, L.P.; Silva, R.T.; Cavalcante, CM.; Melo S.; Nery, J.A.C.; Azulay. R.D.
    Department of Leprosy, Institute of Dermatology, Santa Casa de Misericórdia, Rio de Janeiro, Brazil.

    Introduction: Hansen's is an infectious disease; it is well known that it can present as acute and sub-acute types according to reaction state. Various authors has investigated and inferred about this. How ever very few studied in the age group between the 0 to 14 years. In this study we observed the incidence of reaction in children and followed up them from June 1992 to June 1998.
    Materiasl and Methods: Out of total 938 patients with Hansen's, 55 patients were in this particular age group of 0 to 14 years. According to the classification of Madrid these were divided into infantile nodular and tuberculoid types. All the patients were treated for the first time in their life for the Hansen's and all of them had the laboratory examinations before the treatment.
    Results: Out of 55 patients studied 9 (16%) had episodic reactions. 5 (56%) had Type-I reaction, 2 (22%) had Type-11 reaction and 2 (22%) had localized neuritis. As per these statistics males and females are equally affected and reactions were frequently noted in the more than 5 years age group. Out of 9 patients who had reactions, 6 (67%) were multibacillary. Significant reactions noted in the patients with disseminated cutaneous lesions. At the first consultation none of them presented with any reaction where as during the treatment period. 3 patients showed up with episodic reactions.
    Conclusion: All though the risk of having these episodic reactions in children are very low but this should be always considered as a factor of morbidity during the treatment.

     

    PCA 145

    STUDY OF REACTIONAL STATES IN CHILDREN UNDER 15 YEARS OF AGE
    Maria de Fátima Marója; Angelila Akemi Nakamuta; Valderiza Pedrosa; Lúcio Tshuyoki Ihára
    Fundação Alfredo da Malta - Rua Codajás, 25 -Manaus - Amazonas

    Detection of Hansen's disease in children under 15 years of age in the State of Amazonas, has presented a gradual reduction comparing the co-efficiencies of 3.52/10.000 inhabitants in 1988 and 1.29/10.000 inhabitants in 2000. However, it still remains hyperendemic. Reactional states occur frequently in Hansen's disease, especially in it's multi-bacillar forms. Hansen's disease in childhood shows the same aspects of the disease as in the adult. However, few studies on reactional states in Hansen's disease-have been related in known literature in age groups below 15 years. Reactional States represent a great problem in the management of patients receiving treatment and after discharge. They are also the largest cause of nerve damage, and consequently incapacity. The general objective of this work is to study reactional states in children under 15 years of age diagnosed with Hansen's disease, determining the frequency of Type 1 and Type 2 reaction, relationship with clinical forms and evolution of treatment. A descriptive study of Hansen's disease in children under 15 years of age. diagnosed and treated at the Fundação Alfredo da Malta between January 1998 and January 2001 was carried out using Patient's notes of 216 patients, of these 57,4% were male and 42.6% female. The most frequent age group was between 11 and 15 years old, representing 60.6% of the patients. In relation to clinical form. 59.7% were indeterminate and tuberculoide forms, 17.5% Borderline Tuberculoide, 7.4% Borderline Borderline, 8.3% Borderline Virchoviana and 6.9% Virchoviana. Of the 216 cases studied, 55 presented reactional episodes, representing a frequency of 25.4%. Hansen's reaction was the most frequent in dimorphic forms. Pure Neuritis had a frequency of 58.6% and was associated with other types of reaction in 31.0%. These episodes appeared most frequently during treatment. The drug most frequently used was prednisilone with a moan period of use being 4 months. In odier patients who used prednisilone only I presented a decrease in growth.

     

    PCA 146

    SURTO REACIONAL TIPO MACULOSO EM HANSENÍASE DIMORFA
    Ana Paula de Almeida Costa; Jane Ventury Leal; Maria Alice Ribeiro Ozório; Roberta Leste Motta; Rosimeire Arcanjo Hosken; Rozana Castorina da Silva; Sandra Lyon
    Fundação Hospitalar do Estado de Minas Gerais. Hospital Eduardo de Menezes, Centro Colaborador de Referência em Dermatologia Sanitária. Av. Dr. Cristiano Rezende 2213, Bonsucesso, Belo Horizonte. MG.

    A hanseníase e uma doença granulomatosa inflamatória crônica causada pelo Micobacterium leprae, também denominado bacilo de Hansen, e acomete pele e nervos periféricos. Evolui lenta e insidiosamente, sendo, muitas vezes, interrompida por episódios inflamatórios agudos e subagudos, cutâneos ou extracutâneos, chamados surtos reacionais, que guardam relação com o terreno imunológico do indivíduo. São fenômenos reacionais do tipo I e II. As reações tipo 1 são mediadas por células (imunidade celular) e ocorre nos tuberculóides e dimorfos. As reações tipo II são mediadas por anticorpos (imunidade humoral). Nos pacientes dimorfos ocorre edema e eritema de lesões preexistentes e o aparecimento de lesões novas, pápulas e placas eritematosas em pequeno número, na maioria das vezes em sua vizinhança. Pode haver comprometimento neural acentuado com possibilidade de graves neurites. Quando a reação regride, as novas lesões podem persistir e a doença retoma seu curso. Os autores apresentam o caso de uma paciente de 43 anos, sexo feminino, com o diagnóstico clínico e histopatológico de hanseníase da forma diforma (Índice Baciloscópico = zero) tratada com esquema de poliquimioterapia multibacilar por 12 meses. A partir desse período, começou a apresentar lesões maculosas hipocrômicas localizadas na face. tronco, nádegas e coxa direita c também neurite dos nervos periféricos. A paciente foi medicada com Prednisona I mg/kg/dia até a regressão total das lesões, quando se iniciou a retirada gradativa do corticóide.
    Motivo da apresentação: as reações hansênicas fogem muitas vezes do padrão habitual.

     

    PCA 147

    SURVEILLANCE ON UVEA DISEASE IN LEPROSY
    Yan Lianghin; Zhang Guocheng; Ye Ganyun; et al.
    Institute of Dermatology. Chinese Academy of Medical Sciences and Peking Union Medical College. National Center for STD and Leprosy Control. Nanjing 210042

    To determine the prevalence and characteristic of the uvea disease in leprosy, 1045 persons cured of leprosy and active cases of leprosy in Taixing, Jiangsu were checked by specially trained ophthalmologists. Uvea disease caused by direct invasion of M. leprae, Type-2 reaction, and secondary corneal disorders were found in 7.85% of the all investigated cases. The prevalence rate of the disease was found significantly higher in active cases (25% ), multi-bacillary cases (24.47% ) and those with long duration of the disease (38.93% ). It was characterized by granulomatous iridocyclitis, with presenting of redness of the cilary body (18.29%), irregular pupil (56.1%). diminished light reaction (50%), irisposterior synechiae (43.9%), small pupil (36.59), blocked pupil (23.17%), synechia iridis anterior (20.73%), de-pigmentation (20.73%), and iridoleptynsis (19.51% ). Secondary cataract was found in 81.54% of those with chronic iridocyclitis, of which 60% with reduced vision, 40.24% blindness, and 52.73% curable blindness. The uvea disease in leprosy could be caused either by direct invasion of the M. leprae or type-2 reaction. It was commonly found in active cases, multi-bacillary cases and those with long duration of the disease. Granulomatous iridocyclitis is its clinical characteristic, and most of them develop cataract and loss of vision

     

    PCA 148

    THE ASSOCIATION OF SKIN PATCHES OVER SUPERFICIALLY LOCATED NERVE TRUNKS AND NEURITIS IN LEPROSY
    Rajgopal Reddy; Suman Jain; Syed Muzalfarullah; Sujai Suneetha
    LEPRA India - Blue Peter Research Centre. Cherlapally, Hyderabad - 501301

    We have previously shown the strong association between facial patches located over the eye and the development of lagophthalmos. The aim of this study was to identify any such association between the presences of skin patches over superficially located trunk nerves at known sites of prediliction and the development of neuritis/nerve damage.
    All the records of leprosy patients registered at the centre over a 2 year period (Jan. 2000 to Dec.2001) were analysed with regard to the location and size of skin patches over the trunk nerves and the presence of nerve damage. The areas considered were the skin over the olecranon fossa at the elbow (for ulnar nerve), the front of wrist (for Median nerve), the head of fibula (for lateral popleteal nerve) and around the eyes (for facial nerve). The patches were arbitrarily divided into small patches (≥5 cm) and large patches (> 5cm). Neuritis was defined in terms of motor nerve damage as evidenced by a weak VMT score (≥4/5). 92 patient charts were analysed (TT4, BT 43, BB 2. BL 34 and LL 9). Overall it was observed that neuritis was present in 135 nerves. Out of this 126(93.3%) had associated patches over the trunk nerve, 65 (51.6%) of them were large patches and 61(48.4%) were small patches. 19 of the patients also had type I reaction. In these 19 patients 37 nerves were involved as result of the RR in the overlying skin patches. This association between the presence of skin lesions and the development of neuritis was highest in the ulnar nerve followed by the lateral popleteal nerve, facial nerve and median nerve.

     

    PCA 149

    THE EFFECT OE THE ACTIVITY OF MICROSOMAL ENZYMES AND ACETILATION ON METHEMOGLOBIN RATE IN LEPROSY PATIENTS
    V.Z. Naumov; VP. Tsemba; E.A. Zadneprovskaya;
    Leprosy Research Institute, Astrakhan, Russian Federation

    As it is known, dapsone at certain doses may induce hemolysis, especially in persons with glucose-6-phosphate dehydrogenase (G6PDH) deficiency, occurring in about 10% of leprosy patients. However, DDS-induced hemolysis might be due to other factors among which peculiarities and intensity of drug metabolism, including rate of sulphone acctylating and hydroxylation, play an important role. Patients with lepromatous leprosy were given various schemes of MDT with dapsone 100 mg daily as a main component. Activity of microsomal enzymes by the time of antipyrine half-secretion (T1/2) and acetylation rate of sulfadimizine was studied. All the patients studied had no G6PDH-deficiency. It was observed that in patients showing rather high activity of microsomal enzymes (Tl/2 =12.5 h in average) blood methemoglobin rate was significantly higher (P<0,05) than in those with low activity of these enzymes (T1/2=23,5 h in average). Though methemoglobin rate in the most patients did not exceed 1.5%, it approached 2.5-3.9% in persons with a combination of low acetylating rate and high activity of microsomal enzymes. It might be a consequence of increase in derivatives of N-hydroxylation of dapsone with methemoglobin-forming properties in persons with predominance of oxydative phenotype of xenobiotic biological transformation.

     

    PCA 150

    THE FOLLOWING OBSERVATION FOR EFFECT OF 251 LEPER CASES IN THE MONITOR PRIOD AFTER MDT
    LI Long
    Shangrao station for dermatosis and venereal disease control, 334000, Jiangxi, China

    Objection: analysis 251 leper cases which is cured jointly and finish monitoring the observation of curative effect from clinicopathology, bacteriology, histopathology. Ways: We analysis comprehenly from clinicopahology, bacteriology, histopathology according to 251 leper cases which is cured jointly and the changes of curative effect in the monitor period. Conclusion: The rate of basically curing in clinical reaches 81.27%. The marked progress and the common progress are 18.73% after the course. The MB rates of basically curing in clinical, which are monitored 5 years, have reached 88.85%. The PB has been cured after their monitor period of five years.
    The evaluation of bacteriology: The average BI about 2.80¡ À 1.5 of 118 cases of MB has come down to 65 cases after the course. It covered 55.08% of all and decreased 0.98 average annual. The BI of 48 cases of PB. which infected covered 39.33%. has come down to 32 cases, covered 66.67% of all. and the decrease rate of bacteria was 60% after course. The BI of MB has come down to 87 cases, covered 73.73% of all and decreased 0.09 average annual after finishing monitoring in 3 years later. The BI of 45 cases of PB has come down to zero, covered 93.75% of all after monitoring in 3 years later. They all revered after finished monitoring 5 years later. The 103 cases of MB has come down to zero, covered 87.29% of all, decreased 0.11 average annual after finishing monitoring 6 years later. The bacteria revered after finishing monitoring 10 years later.
    The curative effect evaluation of histopathology: we cured 103 cases and it covers 41.04% of all, 73 case of curing nearly covered 29.08% of all, 75 cases have gone down partly and greater partly and it covered 29.88%. The rate of curing and nearly curing reached 86.26% after monitoring 3 years later. 32 cases have gone down in early period, middle period and later period and it covered 13.74%. The rate of curing and nearly curing has reached 94.35% after monitoring 6 years later, 13 cases have gone down incompletely and it covered 5.65% of all. They all revered after monitoring in 10 years.
    The indication of the article is that jointly curing is the best clinical curative effect to PB and MB. and the plan of jointly curing is the best valuable and feasible way to control leprosy according to changes of the bacteriology and histopathology.
    [Key words] Leprosy. MDT Bl. Histopathology, Curative effect

     

    PCA 151

    THE REPORT FOR THE SKIN SMEARS QUALITY CONTROL ON LEPRESY IN SICHUAL PROVINCE IN THE PAST 15 YEARS
    WANG Rongmao; LIU Xueming; ZHENG Yiqiang; YU Linchong
    Sichuan Institute of Dermatology, Chengdu, 610031, China

    The skin smears quality control on leprosy was implemented in the leprosy epidemic counties in Sichuan Province, in order to improve the quality of skin smears and implementation of MDT. 10% of skin smears, came from the leprosy epidemic counties, were selected randomly with double-blind method and evaluated in smears, stain and diagnosis in Sichuan Leprosy Laboratory on the basic of the criterion of the skin smears quality on leprosy in the Handbook of MDT on Leprosy. Meanwhile, the skin smears came from Sichuan Leprosy Laboratory were also checked and contrasted by the paramedical workers. In the past 15 years, the skin smears quality control was implemented and the quality of skin smears was improved between 17 and 97 leprosy epidemic counties in Sichuan. 4529 pieced of skin smears were checked. The average qualified rate of smears, stain and diagnosis was 96.88%, which was 86.97% in 1986. The implementation of skin smears quality control could improve professional level of paramedical workers and the quality of leprosy control

     

    PCA 152

    THE REPORT OF HISTOID LEPROMA 1 CASE
    ZHANG Jianlin; HUANG Ganjun; LIAO Yanzhen; et al.
    Hezhou Skin Hospital, 542800 Hezhou, Guangxi, China

    A sick man is fifty years old. He has been sick for four years. The clinical appearance is just like a drunk with universal infiltrated lupus, various sized and shaped nodules. There is a "fointed met" which like a hemisphere in each of the elbow joint. He has "ape-hands," elcosis at the bottom of his feet. Shallow nerve is bulky all over the body. Mycobacterium leprae is found from the eruption (2+- 5+). Pathological diagnosis conform to HL.
    Key words LLp HL

     

    PCA 153

    THE USE OF PILOCARPINE TEST FOR DIFFERENTIAL DIAGNOSIS BETWEEN TUBERCULOID LEPROSY AND GRANULOMATOUS DISEASES
    Authors: Miranda, J.A.P.P.; Chumpitaz, S.A.; Lyra, MR.; Lima, R.B.; Valle, H.A.; Coutinho, Z.; Nery. J.A.C.; Lowy, G.
    Dermatology Department of Gaffrée e Guinle University Hospital; Leprosy Laboratory/IOC-FIOCRUZ. Rio de Janeiro, Brazil.

    Background: Tuberculoid leprosy is often easily diagnosed on clinical aspects, but in some situations the signs and symptoms are not clear enough bringing difficulties and consequently delayed diagnosis, which may facilitate the installation of chronic disabilities. For this reason, the use of complementary procedures becomes fundamental for early diagnosis.
    Subject and methods: we have studied six patients presenting a long term unique lesion suggesting granulomatous diseases in which several tests were made to elucidate the diagnosis. All of the patients had had previous topical treatments without improvement.
    Results: the patients were between the ages twenty-eight and sixty-nine years, five of them were female, three were white and three were dark skin colored. All of them presented with infiltrated erythematous annular lesions with a variable course from two months top three years. The histopathological examination's findings were unspecific granulomatous inflammation. Four patients with facial lesions had incomplete pilocarpine test on suspected area. All of the six patients who receive paucibacillary therapy achieve great improvement.
    Conclusions: pilocarpine test seems to be a very helpful complementary diagnostic method when differential diagnosis between Tuberculoid leprosy and other granulomatous diseases is not possible through clinical and histopathological examinations.

     

    PCA 154

    TRABALHO EM UMA COMUNIDADE DE EX-HANSENIANOS COM INTEGRIDADE DA PELE PREJUDICADA E COM ISOLAMENTO SOCIAL
    Noemi Garcia de Almeida Galan
    Instituto Lauro de Souza Lima (ILSL) - Bauru - SP.-Brasil.

    Trabalho do enfermeiro desenvolvido há 4 anos em uma comunidade que possui um grupo de pessoas com sequelas da Hanseníase caracterizadas por úlceras crônicas.
    Objetivos: Identificar os fatores interferentes na recuperação da integridade da pele prejudicada relacionada a sequelas da hanseníase caracterizados por úlceras em MMII. Campo de trabalho e instrumentos utilizados: desde 1997; em Bauru/SP- Centro Comunitário do Parque Santa Terezinha, 27 adultos com sequelas de Hanseníase (úlceras de MMII): compromisso social do Instituto Lauro de Souza Lima (fornecedor de material); teoria do autocuidado de Orem; Histórico, diagnóstico, intervenção e evolução de enfermagem.
    Resultados: o trabalho permitiu a investigação de vários fatores interferentes na cicatrização das úlceras crônicas. Esses foram agrupados nos seguintes diagnósticos dc enfermagem propostos por NANDA (North American Nursing Diagnosis Association): 1-Integridade da pele prejudicada. 2-Risco para Integridade da pele prejudicada. 3-Isolamenlo social. 4-Perfusão tissular alterada periférica.5-Risco para infecção. 6-Nutrição alterada menos do que as necessidades corporais. 7-Risco para trauma. 8-lntegridade tissular prejudicada. 9-Mobilidade física prejudicada. 10-Andar prejudicado. 11-Intolerância a atividade. 12-Dor crônica. 13-Medo. 14-Disfunção sexual. 15-Processos familiares alterados. I6-Enfrentamento comunitário ineficaz. 17-Controle ineficaz do regime terapêutico. 18-Déficit de atividades de recreação. 19-Distúrbio da imagem corporal.
    Conclusão: a cicatrização das úlceras crônicas constitui um grande desafio aos profissionais dc saúde em decorrência da imensidade tios fatores interferentes.

     

    PCA 155

    TREATMENT OF MILD SENSORY IMPAIRMENT IN LEPROSY: A RANDOMISED CONTROLLED TRIAL (TRIPOD 2)
    W.H. van Brakel; A.M. Anderson; S.G. Withington; R.P. Croft; P.G. Nicholls; J.H. Richardus; W.C.S. Smith
    TLM Research Resource Centre, 5 Amrita Shergill Marg, New Delhi - 11003

    Aim: To investigate whether leprosy patients diagnosed with mild sensory impairment have a better prognosis when treated with steroids than similarly impaired patients treated with placebo.
    Methods: A multicentre, randomised, double-blind, placebo-controlled trial was conducted in Nepal and Bangladesh. Patients were eligible if they had a confirmed leprosy diagnosis, were between 15 and 50 years old, had mild sensory impairment of the ulnar or posterior tibial nerve of less than 6 months duration and did not require steroids for other reasons. 'Mild impairment' was defined as "impaired on the Semmes-Weinstein monofilament (SWM) test, but testing normal on the ballpen sensory test". Subjects were randomised to either prednisolone treatment starting at 40 mg per day, tapering over 4 months, or placebo. Nerve function was monitored monthly. Any patient who deteriorated was taken out of the trial and was put on full-dose steroid treatment. Outcome assessment was done at 4, 6, 9 and 12 months from the start of the treatment. Outcome measures were the proportion of patients needing full-dose prednisolone and the SWM sum scores. Each patient contributed only one nerve to the analysis.
    Results: 75 patients had nerves eligible for analysis, of whom 41 (55%) and 34 (45%) were allocated to the prednisolone and placebo arms, respectively. At 4 months, 3 patients in the prednisolone arm (7%) and 6 in the placebo arm (18%) had an outcome event requiring full dose steroids. At 12 months, these proportions had almost reversed, 11 (27%) and 6 (18%) in the treatment and placebo arms, respectively. In the latter group, 15 (44%) recovered completely without treatment.
    Conclusions: Treatment of mild sensory impairment of the ulnar and posterior tibial nerves with prednisolone does not improve the long-term outcome in terms of recovery, nor does it reduce the risk of leprosy reactions or nerve function impairment beyond the initial 4-month treatment phase.

     

    PCA 156

    TREATMENT WITH CORTICOSTEROIDS OF LONG-STANDING NERVE FUNCTION IMPAIRMENT IN LEPROSY: A RANDOMISED CONTROLLED TRIAL (TRIPOD 3)
    J.H. Richardus; S.G. Withington; A.M. Anderson; R.P. Croft; P.G. Nicholls; W.H. van Brakel; W.C.S. Smith
    Department of Public Health, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR Rotterdam, The Netherlands

    Aim: Some leprosy patients with long-standing nerve function impairment (NFI) appear to have responded favourably to treatment with corticosteroids. This study investigated whether patients with untreated NFI between 6 and 24 months duration and who are given standard regimen corticosteroid therapy, will have a better treatment outcome than a placebo group.
    Methods: A multicentre, randomised, double-blind placebo-controlled trial was conducted in leprosy control programmes in Nepal and Bangladesh. Treatment with prednisolone started with a dose of 40 mg/day, tapered by 5 mg every 2 weeks, and completed after 16 weeks. Outcome assessments were at completion of treatment at 4 months, and at 6, 9, and 12 months after the start of treatment.
    Results: A total of 92 MB patients on MDT were recruited, of which 40 (45%) received prednisolone and 52 (55%) placebo treatment. No demonstrable additional improvement in nerve function, or in preventing further leprosy reaction events was seen in the prednisolone group. Overall, improvement of nerve function at 12 months was seen in about 50% of patients in both groups. Analysis of sub-groups according to nerve (ulnar and posterior tibial), duration of NFI, and sensory and motor function, also did not reveal any differences between the treatment and placebo groups.
    Conclusion: The trial confirms current practice not to treat long-standing NFI with prednisolone. Spontaneous recovery of nerve function appeal's to be a common phenomenon in leprosy. Leprosy reactions and new NFI occurred in a third of the study group, emphasising the need lor regular nerve assessment.

     

    PCA 157

    ULCERATED LESIONS IN LEPROSY
    Solange M. Maeda; Marcos C. Floriano; Alessandra Yoradjian; Jane Tomimori-Yamashita
    Department of Dermatology - UNIFESP- Escola Paulista de Medicina

    Erythema Nodosum Leprosum (ENL) or type II reaction is believed to be an immune complex reaction seen in multibacillary leprosy in which the dead bacilli and their products react with antibody in the tissue or blood. Although ENL occasionally develops in untreated patients, it occurs more commonly alter initiation of therapy. This presents most commonly as small papules or larger nodules which are painful and tender to touch. In some cases they may ulcerate, and the histological analysis may show vasculitis pattern affecting superficial and mid-derma vessels, leading to epidermal necrosis, bulla formation and ulceration. Therefore it has been proposed that ENL is a manifestation of immunecomplex-mediated vascular injury. A clinical and histopathological overview of ulcerated lesions in lepromatous leprosy patients will be presented. These patients had necrotizing lesions on the limbs similar as described in "Lucio's phenomenon" and also acute eonstitucional symptoms. The Lucio's phenomenon is observed in diffuse nonnodular lepromatous leprosy most commonly in Mexico and Central America. Histopathologic studies of Lucio's phenomenon have shown leucocytoclastic vasculitis, endothelial cell proliferation, thrombosis, ischemic necrosis. Is Lucio's phenomenon and Type II reaction a unique variant of cutaneous vasculitis separated only by distinctive clinical settings?

     

    EPIDEMIOLOGY

    PE 1

    A ENDEMIA HANSÊNICA NO NOROESTE DO ESTADO DE SÃO PAULO
    Ferreira. E.A.R.; Mencaroni, D.A.; Oliveira, M.H.P.; Pinto Neto, J.M.; Villa, T.C.S.
    Escola de Enfermagem de Ribeirão Preto/ Universidade de São Paulo
    Av. Bandeirante, 3900, Campus Universitário - Ribeirão Preto - CEP 14040-902 São Paulo, Brasil.

    O Brasil após onze anos da implantação da MDT ocupa a segunda posição mundial em relação a prevalência com 4,6 casos /10 mil habitantes. A distribuição da endemia é irregular. O estado de São Paulo, considerado um dos mais desenvolvidos do país, apresenta uma prevalência de 1,6 casos/10 mil habitantes. Há regiões dentro desse estado com prevalências maiores, como por exemplo a região noroeste. Essa região serviu de cenário para esse estudo descritivo, tendo como objetivo analisar a endemia de acordo com alguns indicadores. Foram analisados dados epidemiológicos do período de 1994 a 2001 de 99 municípios "totalizando 1.311.763 habitantes (76,9% dos municípios com até 10 mil habitantes) que compõem uma das 24 regiões administrativas da Secretaria de Estado da Saúde de São Paulo, denominada Direção Regional de Saúde XXII. Em 2001, o coeficiente de detecção variou de zero (47.5% dos municípios) a municípios com 10 casos/ 10 mil habitantes. O coeficiente de prevalência variou, no período, de 6,58 a 2,40 casos/10 mil habitantes, encontrando municípios acima de 10 casos/ 10 mil habitantes. As formas clínicas polarizadas representam atualmente mais de 80% dos casos. Do total dos casos, 95% estão em MDT. Há necessidade de intensificação das ações de controle na região, especialmente o diagnóstico precoce.

     

    PE2

    A MULTICENTRIC TRIAL FOR TREATMENT OF 2-5 LESIONS PB LEPROSY WITH SINGLE DOSE OF ROM
    M.D. Gupte; B. Nagaraju; S.Balasubramaniam; V.N. Mahalingam; S. Anitha; K. Sarojamma; S.V. Subbaroyulu; N.K. Nanda; Margery Emmanuel; Jayarama; Subbaiah
    National Institute of Epidemiology (ICMR). Chenna, 31. Tamil Nadu, India. Chennai & CLT&RI in Tamil Nadu.

    Our experience in conducting a multicentric trial for treatment of 2-5 lesions PB leprosy with single dose of ROM and under programme conditions is discussed. This study is a double blind randomized controlled clinical trial.
    The objective of the study is to evaluate, the efficacy of a combination of Rifampicin, Ofloxacin and Minocycline (ROM) administered as a single dose for the treatment of skin smear negative 2-5 lesions PB leprosy compared to the standard 6 monthly doses of WHO PB MDT regimen.
    Six centres for 2-5 lesions PB leprosy had been selected. 1596 skin smear negative patients with not more than one peripheral nerve trunk involvement (adults 1 167; children 429) were included.
    The total duration of the study is 48 months (six months of intake phase, six months of treatment phase and 36 months of post treatment follow-up).
    During intake phase Medical Officers from NIE helped the investigators in selection of patients and documentation. Frequent visits to the participating centres by Medical Officers and Statisticians from NIE are made in order to help the staff in clinical examination, data collection.
    Detailed report with reference to the progress of the study will be discussed.
    Collaborating Centres: National Institute of Epidemiology (ICMR) and WHO
    Participating Centres: Chittoor and Cuddapah districts in Andhra Pradesh: Naini (TLM) in Uttar Pradesh; Champa (TLM) in Madhya Pradesh

     

    PE 3

    A MULTICENTRIC TRIAL FOR TREATMENT OF MONO LESION PB LEPROSY WITH SINGLE DOSE OF ROM
    M.D. Gupte; B. Nagaraju; S. Balasubramaniam; V.N. Mahalingam; S. Anitha K. Sarojamma; S.V. Subbarayulu
    National Institute of Epidemiology (ICMR). Chennai -31, Tamil Nadu. India.

    NIE is conducting an open trial for treatment of mono lesion PB leprosy with single dose of ROM in order to find out relapse rate under programme conditions. A total duration of the study is 48 months. The intake phase commenced in April 1998 and the study is expected to be completed by January 2003.
    1263 untreated smear negative single skin lesion leprosy patients (adults 820; children 443) were included and followed up once in six months after completion of treatment. During intake phase Medical Officers from NIE helped the staff in participating centres in clinical examination, selection of patients, documentation of clinical findings and related research methodology. Monitoring is done by making field visits by Medical Officers and Statisticians from NIE to assess the progress of the trial. During follow-up patients who developed new lesions are examined by Medical Officers from NIE. The detailed report on progress of the trial will be discussed.
    Collaborating Centres: National Institute of Epidemiology (ICMR) and WHO
    Participating Centres: Chittoor and Cuddapah districts in Andhra Pradesh

     

    PE4

    A MUNICIPALIZAÇÃO DA SAÚDE E O CONTROLE DA HANSENÍASE
    Cintra, Ivete A.1; Altuy, Leni P.2; Bertolini, Maria S.3
    Direção Regional De Saúde De Araçatuba. Rua Oscar Rodrigues Alves, 1296, Vila Mendonça. CEP 16015031. Araçatuba, SP - Brasil

    1. Médica Sanitarista.
    2. Enfermeira.
    3. Educadora De Saúde Pública.

    Este trabalho pretende analisar o impacto da municipalização dos serviços de saúde nas ações de controle da hanseníase.
    O universo a ser abordado é constituído pelos quarenta municípios que compõem a área de abrangência da Direção Regional de Saúde de Araçatuba-DIR VI-SP.
    O estudo pretende verificar o grau de variação de alguns indicadores epidemiológicos e operacionais e o comportamento da endemia no período de 1990 a 2000.
    Dentre esses serão focalizados, principalmente, coeficiente de detecção, coeficiente de prevalência, taxa de abandono e alta por cura.
    A observação desse quadro comparativo tem como principal finalidade a verificação da interferência da mudança do modelo assistencial no desenvolvimento das ações de controle da hanseníase.

     

    PE 5

    A RECIDIVA DA HANSENÍASE NOS DADOS OFICIAIS DO RJ: VALIDAÇÃO NO ARQUIVO LOCAL DA UNIDADE DE REFERÊNCIA DO MUNÍCIPIO DE DUQUE DE CAXIAS
    Hercules. F.M.; Cunha. M.D.; Oliveira. M.L.W.
    Curso de Pós-Graduação em Dermatologia /FM/ HUCFF / UFRJ e SMS-DC

    O presente trabalho compara base dados de nível central e local do Município de Duque de Caxias no Sistema de Informações de Agravos de Notificação (SINAM). A variável do estudo foi a recidiva de casos de hanseníase, analisada através do modo de entrada no arquivo central e validada com as informações dos prontuários dos respectivos pacientes, no registro local. De acordo com a análise dos dados secundários de nível central municipal, no período de 1990 á 2001, foram registrados no banco de dados 3.112 casos de hanseníase residentes e tratados em DC. Dos 191 casos de recidiva registrados no banco de dados da SMS-DC no período de 1990 à 2000, um total de 180 casos (94,2%) tinham no registro local (prontuario) modo de entrada como caso novo. A grande maioria, correspondendo a 165 (91.6%), tinha ficha de notificação antiga na qual não existe uma formatação compatível com a ficha atual de notificação do SINAN. Apenas 11 casos foram diagnosticados como recidiva (5,8%) de fato, e todos foram casos recentes.
    Ao que parece a mudança da ficha de notificação, parece justificar os erros na entrada dos dados. Esse trabalho permitiu a correção do dado oficial de recidiva no município, de 6.1% para 0,0035%, reforçando o baixo percentual geral de recidiva dos esquemas oficiais de tratamento de hanseníase. Faz-se ressalva ao fato de que outros casos de recidiva tratados no município estejam sendo diagnosticados em unidades de referência da cidade do Rio de Janeiro, não constando no registro municipal. Esse dado portanto pode não mostrar a magnitude do problema, especialmente tratando-se de evento raro. E importante que as três esferas de atuação governamental adotem diretrizes e práticas que permitam a utilização das informações existentes nos três segmentos e, o livre fornecimento de dados, de modo a contribuir, para a ampliação e aperfeiçoamento do relacionamento entre as estruturas que compõem o SUS.

     

    PE 6

    A SURVEY OF THE KNOWLEDGE AND ATTITUDE TOWARDS LEPROSY OF THE HEALTH WORKER IN THE EPIDEMIC AREA
    Wu Xinsheng; Wang rongmao; Ning Yong; Hu Lufang; Li Binyu; Wang Kai; Shi Ling; Hei Lu
    Sichuan provincial Institute of Dermatology & Venereology. China

    Objective: in order to find out the knowledge and altitude towards leprosy of the health workers in the epidemic area and the factors influence on it.
    Methods: Health workers are surveyed in the field by questionnaire at county, district and village level, analyzed the data by computer.
    Results: 292 received valid questionnaire showed that health workers fear leprosy in different extent, and detest the leprosy patients.
    Conclusion: Health workers who are not belonging to the professional leprosy control have wrong knowledge and attitude on leprosy. It is the major step to train these workers about the knowledge of leprosy, changing the pattern in order to eliminate leprosy.
    [Key words] health workers leprosy knowledge attitude

     

    PE7

    A SURVEY OF THE KNOWLEDGE AND ATTITUDE TOWARDS LEPROSY OF THE RESIDENTS IN THE EPIDEMIC AREA
    Wu Xinsheng; Wang rongmao; Ning Yong; Hu Lufang; Li Binyu; Wang Kai; Shi Ling; Hei Lu
    Sichuan provincial Institute of Dermatology & Venereology, China

    Objective: in order to find out the knowledge and attitude towards the leprosy from the residents in the epidemic area and try to find the best method of health education on leprosy.
    Methods: 300 random residents are selected to fill the questionnaire out in the field. Analyzed the data by computer.
    Results: 292 received valid questionnaires, showed that it is common phenomenon for the residents to fear leprosy and discriminate against leprosy patients and many factors influence on it.
    Conclusion: We should carry out the health education, widely and deeply, focus on that leprosy is preventable and curable, not fearful, let the patients and cured patients return to the community. This is the basic condition as well as important procedure to eliminate leprosy as a social problem.
    [Key words] residents, leprosy, knowledge, attitude

     

    PE8

    AN ANALYSIS OF THE BENEFITS OF PREVENTION AND TREATMENT OF LEPROSY IN SAN-MING CITY
    Zheng Xingzhao1 Wu Xianming1 Dai Yansheng2 Chen Qiujin3

    1. Sanming Dermatology Hospital (365001).
    2. Sanming Epidemic Prevention Station.
    3. Sanming Municipal Health Bureau

    Situated in the Northwestern part of Fujian Province, Sanming City is part of the inland mountainous region; during the reformation of institutions in 1983, the Municipal Dermatology Prevention Institute was formed and a prevention and treatment network established. Beginning from 1986, it implemented MDT scheme and adopted such various means as "live checks", outpatient service and disease reporting to discover patients at an early stage; it also extensively conducted such comprehensive measures of prevention and treatment as health education; as a result, the prevention and treatment were stepped up and the goal of basically eradicating leprosy was reached in 1993. The benefits were quite obvious. We herewith make the following report so as to valuate the economic benefits of the prevention and treatment of leprosy in a scientific way and provide useful economic information: we selected the benefits of the two situations in the periods of 1973~1982 and 1983~1992 for evaluation and made calculations using such methods as cost-profit and cost-benefit. Financial investment: in the period of 1983~1992, the allocation of fiscal fund totaled 1,248,400 yuan, which was a 114.66% increase from that in the period of 1973~1982. Social benefits: the adoption of comprehensive prevention and treatment resulted in significant drop in "three rates", reduction in epidemic range and early achievement of goals. Compared with the previous period, the period of 1983~1992 saw a reduction of 169 patients in incidence. Economic benefits: The reduction in the incidence of 169 patients saved 1,334,400 yuan in the cost of providing health service and receiving health service and 1,827.100 yuan of non-incidence earning; a reduction of disabilities for 59 patients due to prevention and treatment and 1.350,900 yuan of economic loss due lo disease and disability. Since the MDT scheme was promoted, a total of 320 patients were cured during the period of 1983~1992, shortening courses of treatment and saved treatment expenses of 1,114,000 yuan and 5,766,100 yuan was earned by shortening the courses of treatment. In summary, the economic benefits created by the prevention and treatment of leprosy in the period of 1983~1992 totaled 11,392,500 yuan, excluding the invisible expenses in the economic losses resulted from diseases, i.e. the losses—social expenses resulted from such life quality issues as pain, depression, sadness and social segregation suffered by the patients and their relatives. Therefore, this paper is based on an underestimation of calculation. The ratio of total benefits and total investment reported by this paper is 7.48:1, BCR>I. This manifests that the benefits of prevention and treatment service of leprosy are tremendous and the prevention of leprosy is an undertaking with effective investment and high benefits. However, the basic eradication of leprosy is not the ultimate goal and further efforts need to be made. Therefore, the authors suggested that:
    1. Increase the investment for fund of prevention and treatment.
    2. Enhance follow-up monitoring of prevention and treatment and strengthen such work as rehabilitation.
    3. Consolidate the construction of teams of leprosy prevention personnel, elevate professional proficiency and improve the work quality of service and prevention and treatment.
    [Key words] leprosy prevention and treatment analysis of benefits

     

    PE9

    ANÁLISE DA IMPLANTAÇÃO DA ESTRATÉGIA DO CONASEMS NA ELIMINAÇÃO DA HANSENÍASE NO MUNICÍPIO DE PALMAS -TOCANTINS
    Eliane Ignoiti; Joaquim Gonçalves Váleme; Vera Andrade
    Universidade Estadual de Mato Grosso/Escola de Saúde Pública -MT; eignotti@uol.com.br
    Escola Nacional de saúde Pública/Universidade Estadual do Rio de Janeiro; jvalene@ensp.fiocruz.br.br
    OMS: vandrade@sade.gov.br

    Avaliação da implantação da intervenção do CONASEMS na eliminação da hanseníase no município de Palmas (TO), por meio de enfoques epidemiológico e operacional desenvolvidos em séries de tendências temporal; acompanhamento do nível de autonomia em gestão, de mudanças estruturais que possam modificar a assistência ao doente de hanseníase. Ressalta a importância dos indicadores da redução no coeficiente de detecção em menores de 15 anos e da taxa de prevalência em conseqüência da detecção precoce principalmente nos casos com lesão única. A intervenção do CONASEMS resulta na articulação entre os gestores municipais em assumir o atendimento ao doente de hanseníase como ação básica de saúde. Tem como hipótese o fato de O "grau de autonomia" técnico-gerencial e financeira na gestão do Sistema Único de Saúde, em nível local condicionar a integralidade da implantação da Estratégia de Aceleração da Eliminação da Hanseníase em nível municipal. Intervenção é considerada uma variável dependente em relação âs características contextuais tio meio de implantação. Se o contexto é favorável â intervenção, será possível fazer a predição do tempo necessário para a eliminação tia hanseníase. Nesse caso, o grau de implantação da intervenção é a variável independente e as variáveis dependentes serão os resultados ou efeitos esperados. As informações foram colhidas na perspectiva de três metodologias diferenciadas em função do propósito a que foram elaboradas:
    1. Indicadores epidemiológicos e operacionais propostos como instrumento no controle da endemia (MS. 2000);
    2. Indicadores-chave para o monitoramento de eliminação da hanseníase (OPAS, 1998);
    3. Indicadores do Independem Evaluatitm of Indían Leprosy. (WHO, 2000).
    Palavras-chave: avaliação, eliminação, hanseníase.

     

    PE 10

    ANÁLISE EPIDEMIOLÓGICA DOS CASOS NOVOS DE HANSENÍASE RESIDENTES NO MUNICÍPIO DE BELO HORIZONTE, MINAS GERAIS, BRASIL, NO PERÍODO DE 1999 A 2001
    Paulo De Tarso Silveira Fonseca; Renato César Ferreira
    Secretaria Municipal Da Saúde - SMSA-BH.
    Av. Afonso Pena 2336, 5° Andar, Atenção Saúde Do Adulto. CEP: 30.130-007. Belo Horizonte -Brasil. Telefone: (31) 3277-9532. Fax: (31) 32779530. E-mail: ptsf@bol.com.br

    São apresentados e analisados os dados epidemiológicos dos casos novos de hanseníase, residentes em belo horizonte, no período de 1999 a 2001, utilizando-se as informações do SINAN (sistema de informação nacional de agravos notificáveis), implantado nesta secretaria no final do ano 2000.
    Esta análise é feita com relação à idade, sexo, forma clinica da doença, grau de incapacidade e baciloscopia ao diagnóstico.

     

    PE 11

    ANALISIS ON NERVE IMPAIRMENT OF THE UPPERLIMB IN 8578 LEPROSY PATIENTS
    Pan Liangde; He Xinguo; Kuang Yanfei; Gao Xiaoling, Di Xiaodan; Mo Jiangling
    Hunan Institute of Dermatology Venereology, Changsha, Hunan Province. 225700 China

    In order to make clear the situation of nerve impairment of the upper limb in leprosy cases, we selected 8578 leprosy non-active and active cases who are still living in Hunan province as the study samples. The result showed that about 40.29% of the upper limb in all cases developed nerve impairment. The lateral nerve impairment was 23.15%. It is higher than that of bilateral nerve impairment (17.14%). The verve impairment among active and relapsed cases was 54.03%. It is higher than that of non-active cases (19.51%). The MB cases developed more nerve impairment (50.15%) which is higher than that of PB cases (21.15%). We also find that 36.55% of the ulna nerve developed nerve impairment, the medium nerve. 16.68% and the radial nerve, 1.64%. The claw hand with the stiff lingers was seen in 73.03% of cases. The nerve impairment has relation with leprosy reaction counted for 41.06%. Most of active and relapsed leprosy cases have the single nerve impairment. The frequency of nerve impairment developed is as following. The first is in ulna nerve, the second, medium verve and radial nerve. Two third of nerve impairment is in reversible. The nerve impairment in upper limbs is significantly different due to delay of diagnosis of leprosy, leprosy reaction and different type of clinical leprosy

     

    PE 12

    ANALYSIS OF NEWLY FOUND LEPROSY PATIENT FORM 1990 TO 2000 YEAR IN GANSU PROVINCE
    WANG Deving; MU Taojun; QIU Yaowen
    Center of Prevention and Control Disease of Gansu, 730030, Lanzhou. China

    Objective: To explore epidemological feature of newly found leprosy patient and relapse leproy patient in low endemic areas.
    Methods: A retrospective epidemiological date of leprosy from 1990 to 2000 year in Gansu Province was made.
    Results: The data analysis showed that newly found leprosy patient 138 cases and the average annual found rate was 0.058/100000, of which MB was 116 cases and PB was 22 cases, MB:PB rate was 5.6:1.The relapse leprosy patient was 52 cases and the relapse rate was 2.64% during 1990 and 2000 year, of which MB was 46 cases and PB was 6 cases. MB:PB rate was 7.7:1. 50 cases were relapsed after cure with DDS monotherapy and 3 cases were relapsed after cure with MDT.
    Conclusion: The found rate in the early of 1990's was a little higher than that then and it has declined tendency. Leprosy patients should be timely detected and treated so as to eliminate infiectious resource.
    [Key words] Multibacillary Paucibalillaryt!» Newly found leprosy patient£» Relapse leprosy patient

     

    PE 13

    ANALYSIS OF QUALITY CONTROL OF LEPROUS BACILLI MICROSCOPY
    Liu Zuosheng
    Institute of Dermatosis Prevention and Control. Hubei Provincial Academy of Medical Sciences 430079

    Objective: To understand the quality status of Leprous Bacilli Microscopy.
    Method: 2594 specimens smear were detected at lower level and checked by provincial laboratory during 1990-2001.
    Result: The quality rate of smear membrane, quality rate of stain, quality rate of BI, medium quality rate of three indices were 94.48%. 94.63%. 93.52%, 94.20%.
    Conclusion: The quality of leprous bacilli microscopy was high, and the results were creditable in our province. This was favorable to diagnose leprosy and evaluate the treatment effect.
    [Key word] Leprosy microscopy quality control

     

    PE 14

    ARREST OF LEPROSY MORBIDITY AND DISEASE TRANSMISSION IN URBAN AREAS - A MOP UP OPERATION
    V.V. Pai; S. Kingsley; H.O. Bulchand; V. Gaikwad; R. Ganapati
    Bombay Leprosy Project. Sion-Chunabhatti, Mumbai-400 022, India

    Currently available chemotberapeutic agents undoubtedly have offered bacteriological cure to leprosy patients in the shortest possible time. But the sporadic occurrence of relapses in small numbers has been a matter of concern in the context of disease transmission. Transmission due to relapses adds a new dimension to the disease burden and delays the goal of elimination. Relapses are encountered in all types of treatment regimens including the short course chemotherapy regimens with newer drugs. In addition about 10 % of PB leprosy patients develop delayed clinical problems and about 20 - 30 % present with reaction and neuritis leading to nerve damage. This phenomenon increases the morbidity and poses a challenge to the programme managers. Therefore, mopping up of all 'cured' leprosy patients, particularly MB patients, is necessary to identify the complications likely to be encountered so that proper interventions can be taken to minimize the morbidity. We conducted a mopping-up exercise in urban areas mainly to identify relapses and related clinical problems among the cured leprosy patients.
    The clinical details of 2664 leprosy patients registered with the clinics of Bombay Leprosy Project from 1-3-2001 to 28.2.2002 and who have completed treatment were collected from the patients' records. An attempt was made to contact these patients. Community Volunteers were given task-oriented training with the help of a pocket card to suspect clinical problems in the field, to be confirmed later by supervisory staff, 968 patients (37%) were physically assessed to identify relapses and other clinical events in the field. Skin smears and skin biopsies were done in 605 cases. Twelve relapses were detected and all of them were confirmed by investigations. 143 (15%) patients had signs of reaction. These were treated with a standard course of steroid therapy. Patients with physical disabilities were provided with necessary disability services.
    This mopping-up exercise indicates that patients cured earlier tend to have the risk of developing late reaction as well as relapses, especially in a long-term follow-up. Since this is not a population-based study, one cannot derive any epidemiological observations. It is concluded that leprosy patients who have completed treatment may develop clinical problems and can be assured of relief, if they are given prompt attention at the appropriate time, through a mopping-up exercise. Such an exercise is particularly more relevant in view of relaxation of active surveillance in the leprosy programmes.

     

    PE 15

    ARTICULAÇÃO DAS AÇÕES DE CONTROLE DA HANSENÍASE AO PROGRAMA SAÚDE DA FAMÍLIA NO MUNICÍPIO DE SÃO JOÃO DO PIAUÍ. BRASIL
    Maria Goretti S. Pereira ; Márcia L. Amorim; Sônia M. Oliveira; Vânia C. Santos; Virgílio M. Miranda; Adriana V. P. Assunção; Alberto N. Ramos Jr.
    Núcleo de Vigilância Epidemiológica da Secretaria Municipal de Saúde de São João do Piauí. Rua Rodrigo Carvalho s/n°, Centro. São João do Piauí, Piauí, Brasil - CEP: 64760-000.

    Introdução: O Ministério da Saúde vem adotando como estratégica a implantação do PSF objetivando ampla mudança do modelo assistencial em saúde. Neste sentido, programas verticais, como o de Controle da Hanseníase (PCH), também vêm passando por intensas modificações que necessitam serem avaliadas de forma contínua.
    Objetivo: Descrever o processo da implantação e os primeiros resultados da inserção do PCH no PSF do Município de São João do Piauí, visando otimizar a assistência integral ao paciente com hanseníase.
    Métodos: Estudo descritivo, operacional, baseado nos dados epidemiológicos e de serviço do Município de São João do Piauí, no período de 1999 a 2001.
    Resultados: O PCH foi implantado no Município no início dos anos 90,centralizando suas ações no Hospital Regional (Estado) e, posteriormente, alcançando o nível municipal. Mesmo a este nível, apenas em meados dos anos 90 foi possível estabelecer estratégias para avaliação clínica geral, diagnóstico baciloscópico, realização de PQT e prevenção de incapacidades de forma efetiva. Em 2001, com a articulação com a SES, deslocaram-se as atividades do nível Estadual para as duas unidades do Município. Como resultado, observou-se: maior número de profissionais envolvidos (incluindo agentes comunitários de saúde), aumento da detecção de casos, maior cobertura da PQT, melhor abordagem dos estados reacionais e menor grau de incapacidades no diagnóstico.
    Conclusões: Esta primeira avaliação mostra que ainda é precoce para se ter uma resposta mais clara sobre o impacto deste novo modelo assistencial em saúde. Mesmo assim, importantes mudanças foram alcançadas no Município e trazem uma perspectiva positiva da intensificação das ações do PSF. Estão sendo programados estudos a longo prazo para uma avaliação mais acurada deste processo

     

    PE 16

    ASPECTOS EPIDEMIOLÓGICOS DA HANSENÍASE NO ESTADO DA PARAÍBA
    Rose Mary Barros Araújo Madruga; Clélia Albino Simpson de Miranda; Teresa Cristina Moura Rodrigues

    O estudo trata de uma seria historia compreendida entre 1990 - 2001 salve Hanseníase. Teve como objetivo analisar a situação epidemiológica da hanseníase no estado da Paraíba, com vistas a estabelecer ações prioritárias que possibilitem a intervenção buscando a eliminação.
    Os dados foram obtidos através do SINAM (sistema de informação de agravos e denotifícação), no total de 5.621 fichas, obedecendo ao fluxo: serviço de saúde, Séc. municipal de saúde, coordenação de vigilância epidemiológica da Séc. estadual de saúde, onde está inserido o núcleo de dermatologia sanitária.
    A analise dos dados deu-se a partir dos coeficientes de detecção de prevalência e avaliação do grau de incapacidade física da casuística analisada. Conclui-se que na Paraíba a hanseníase distribui-se de forma heterogênea em aproximadamente 50% dos 223 municípios do estado, com áreas de concentração em municípios do litoral agreste e sertão. Apresentando assim uma media endêmicidades com palavras chaves: hanseníase. epidemiologia, eliminação.

     

    PE 17

    AVALIAÇÃO CLÍNICA EPIDEMIOLÓGICA DE PACIENTES COM HANSENÍASE ACOMPANHADOS EM UM AMBULATÓRIO DE DERMATOLOGIA SANITÁRIA
    Nery, J.A.C.; Novellino, A.B.C.; Tanaka, R.M.; LEAL, .F; Turiel. A.F.A.H.L.; Twardowski, G.; Melo, S.; Azulay, RD.
    Ambulatório de Dermatologia Sanitária do Instituto de Dermatologia da Santa Casa de Misericórdia do Rio de Janeiro. Chefia: Prof. Rubem David Azulay. Secretaria Municipal de Saúde / Superintendência de Saúde Coletiva / Hanseníase - Rio de Janeiro - Coordenação Drª Raquel Tardin

    Introdução: A hanseníase é uma doença infecciosa considerada problema de saúde pública em nosso país, sendo o quarto no mundo em número de casos, ficando atrás apenas da índia. Birmânia e Nigéria.
    Objetivo: Conhecer a distribuição epidemiológica dos pacientes com hanseníase acompanhados no Ambulatório de Dermatologia Sanitária do Instituto de Dermatologia da Santa Casa de Misericórdia.
    Material e Métodos: Participaram do estudo todos os pacientes de ambos os sexos com o diagnóstico clínico e/ou laboratorial de hanseníase baseados na classificação de Madrid, que estavam em acompanhamento no Setor de Dermatologia Sanitária, no período entre janeiro de 1999 a dezembro de 2001. Todos os pacientes foram avaliados pelos médicos residentes e quando disponível, foram realizados alguns dos seguintes exames: biópsia cutânea, teste de mitsuda e baciloscopia. Após confirmação diagnostica foram tratados com esquema poliquimioterápico (PQT).
    Resultados: Foram avaliados 184 (100%) pacientes, sendo 89 (48,3%) provenientes do Município do Rio de Janeiro e 95 (51.6% ) de outros municípios: sendo classificados nas seguintes formas clínicas: 79 dimorfo (42,9%); 11 indeterminado (6,0%); 1 não classificado (0,5%); 62 tuberculóides (33,7%); 31 virchovianos (16.8% ); totalizando 94 (51.1 %) pacientes do sexo feminino e 90 (48,9%) do sexo masculino. Dos casos novos detectados foram observados os seguintes graus de incapacitação: grau 0- 137 casos (74,5%); grau 1-18 casos (9,8%); grau 2- 18 casos (9,8%); grau 3-1 caso (0,5%); NC-10 casos (5.4%).
    Comentários Finais: No Brasil a hanseníase ainda mantém-se endêmica, e o controle desta doença deve ser realizado por todos profissionais da saúde, sua divulgação portanto, se faz necessária principalmente nos meios universitários onde acreditamos ser um ponto fundamental deste conhecimento e divulgação.

     

    PE 18

    AVALIAÇÃO DO PREENCHIMENTO DO GRAU DE INCAPACIDADE NA FICHA DO SINAN
    Maria Ana A. Leboeuf ; Maria Aparecida de Faria Grossi: Eni S.B. Magalhães
    Secretaria de Estado da Saúde de Minas Gerais - hanseniase@saúde.mg.gov.br
    Avenida Afonso Pena 2300 - CEP: 30130-007 - Belo Horizonte - Mg, Brasil

    Introdução: O Grau de Incapacidade - GI que o caso de Hanseníase apresenta na detecção é o indicador mais importante para avaliar a endemia, por falar da precocidade do diagnóstico, da endemia oculta e da necessidade de medidas de combate à principal causa do estigma social da Hanseníase. A avaliação e o registro do GI, já estão incorporados à rotina na detecção de quase 100% dos casos. O correto registro desta informação na Ficha do Sistema Nacional de Agravos de Notificação - SINAN, padronizada no Brasil, que utiliza codificação que pode induzir a erros de preenchimento, onde o grau Zero recebe código 1, o I é = 2 e o II = 3, foi o principal motivo que nos levou realizar o presente estudo.
    Metodologia: Foram comparados o GI registrado no Quadro de Avaliação e a informação registrada na Ficha do SINAN de 6.774 notificações ocorridas em Minas Gerais de 06/1999 a 12/2001.
    Resultados: Das 6.774 Fichas, 99% tinham o Quadro de GI preenchido e destes 1995 tinham a anotação incorreta do GI no SINAN. Das 1.297 preenchidas com erro, 43% informaram o Grau no lugar do Código, 36% deixaram em branco e 21% preencheram outro código. Dos que não preencheram o Quadro de GI, 82% informaram algum código no SINAN. Por esta possibilidade de erro recomendamos que o SINAN apresente alternativa de informar o GI e não o Código e o Quadro do GI na própria ficha.

     

    PE 19

    AVALIAÇÃO DO PROGRAMA DE CONTROLE DA HANSENÍASE NO MUNICIPIO DE CARUARU/PE
    Aílton Romero dos Santos1, Maria Jesus Barbosa1, Erika Virginia Lima1, Otamires Alves da Silva2

    1. Centro de Saúde Amelia de Pontes/CSAP - Caruaru/PE
    2. Centro de Pesquisas Aggeu Magalhães/ CPqAM/ FIOCRUZ- Recife/PE

    A hanseníase é uma doença infecto-contagiosa, e endêmica em varios países, causada pelo Mycobacterium leprae ou bacilo de Hansen, um parasita intracelular obligatorio que apresenta afinidade por células cutâneas e nervos periféricos. A hanseníase é um sério e importante problema de saúde pública por causar incapacidade física e permanente, apresentando altos índices de prevalência em diferentes regiões do Brasil, com mais de 12 milhões de casos reconhecidos em todo mundo e cerca de 600 mil casos novos por ano. Trata-se de uma doença de transmissão interpessoal cuja fonte principal é o homem, através das formas contaminantes, que não estejam em tratamento, dificultando assim o controle epidemiológico. Procuramos avahar o programa de controle da hanseníase no Centro de Saúde Amélia de Pontes/CSAP, referência em dermatologia sanitária localizado no agreste pernambucano. Trata-se de um estudo realizado a partir do levantamento de dados comidos nos prontuários dos pacientes tratados e em tratamento no CSAP, compreendendo um período de cinco anos (1996 à 2000). Foram revisados 474 prontuários de pacientes atendidos por demanda espontânea ou indicados. Destes, 133 com residência fixa no município (28.05%), sendo 121 na zona urbana (90.97%) e 12 na zona rural (9.02%). Observamos que indivíduos apresentando boa resposta imunológica exibem lesões em menor quantidade e bem delimitadas, ao contrário dos pacientes com comprometimento da capacidade imunológica que apresenta lesões numerosas e sem limites precisos. Graças ao trabalho multidisciplinar exercido na comunidade, o diagnóstico precoce e o início do tratamento imediato fazem com que a população busque com maior freqüência o serviço de referência em hanseníase.

     

    PE 20

    AVALIANDO A COBERTURA DE BCG EM CONTATOS DE HASENÍASE, NO BRASIL
    Maria da Conceição Cavalcanti Magalhães
    ATDS / SPS / DAB / MS

    A vacina BCG confere proteção contra hanseníase em todas as populações estudadas. Os últimos estudos, sobre vacinas para hanseníase,realizados mostram que o BCG ainda é a melhor opção disponível, no momento. Deste 1993, a norma nacional através da portaria n° 814/GM de 22 de julho de 1993, recomenda a aplicação de duas doses de vacina BCG intradérmica a lodos os contatos intradomiciliares dos casos de hanseníase independente de forma clínica.
    Objetiva-se neste trabalho, avaliar a cobertura de vacina BCG, no Brasil, no período de 1993 a 2001.
    Utiliza-se como fonte de dados o Programa Nacional de Imunizações. Os resultados mostram que a cobertura da vacina BCG tem aumentado no período, porém o nível atingido parece ser insuficiente para interferir no aparecimento de casos novos da doença. A baixa cobertura da vacina BCG esta relacionada a um baixo percentual de contatos examinados, atividade que necessita ser priorizada nas ações de controle da hanseníase.

     

    PE 21

    BCG EM COMUNICANTE: EFICÁCIA E SUSCETIBILIDADE
    Nakahodo, P; Tanno, L. K.; Techelsk, A.
    Unidade Básica de Saúde 4 (UBS) - Município de Itapevi - São Paulo
    Av. Nove de Julho, n° 39 - Itapevi (Rainha) - São Paulo.

    A Hanseníase é uma doença infecto-contagiosa ainda presente em nosso meio. Muitos casos não são notificados levando a uma desatenção por parte da vigilância sanitária e da população.
    Como uma das profilaxias da Hanseníase, utiliza-se a vacinação com BCG.
    Neste trabalho fizemos um levantamento de todos os casos de pacientes comunicantes hansênicos da Unidade Básica de Saúde IV no município de Itapevi (São Paulo) no período de 1997 â 2001.
    Foram registrados 214 prontuários de comunicantes neste período de 6 anos procurando definir e separar nas famílias estudadas a eficácia do BCG dentro da mesma.
    Por este trabalho concluímos que: 1 dose parece ser suficiente para a profilaxia da Hanseníase, no entanto aconselhamos manter a imunidade ativa fazendo um reforço (segunda dose); dos casos que receberam BCG e desenvolveram a patologia, concluímos que possivelmente já estavam no período de incubação ao receberem a vacinação; quando separados por grupos etários, observamos que os comunicantes que receberam BCG e desenvolveram a moléstia tiveram forma paucibacilar (90% deste grupo); e, para finalizar, concluímos com a população estudada, que a vacinação com BCG continua eficaz na profilaxia da Hanseníase.

     

    PE 22

    BCG REVACCINATION ON LEPROSY CONTACTS: PRELIMINARY RESULTS
    Duppre, N.C.; Nery, J.A.C.; Sales. A.M.; Pereira, R.M.O; Matos, H.; Sarno, E.N.
    Leprosy Laboratory, Oswaldo Cruz Foundation (FIOCRUZ), Rio de Janeiro. R.J., Brazil

    Introduction: Studies of large-scale field trials on BCG carried out in Uganda, Burma, Papua New Guinea and India demonstrated that BCG was indeed capable of preventing leprosy, but that its protective efficacy varied widely from about 207 to more than 80%. In Venezuela, studies indicated that the protective efficacy of BCG was directly proportional to the number of doses given. In a 1996 study realized in Africa. Fine postulated that an initial BCG vaccination imparted a minimum 50% protection rate, while two-doses increased protection to around 75%. The Brazilian Ministry of Healthy has recommended two doses of BCG-ID in household contacts of leprosy patients since 1990, however, to date no studies on the efficacy of BCG in preventing leprosy have been carried out.
    Objective: Evaluate the efficacy of BCG revaccination in conferring protection against leprosy disease in contacts of leprosy patients.
    Material and Methods: All the contacts (4,055) aged 1 to 75 examined during 10 consecutive years (June 1987 - December 1999) were enrolled in the study. The healthy contacts, numbering 1.927, who were examined before 1991 were not administered a BCG vaccination at their initial exam irrespective of the presence/absence of a BCG scar. Another 2,128 contacts were examined after 1991. The contacts in this group who upon examination were found to have a BCG scar were then revaccinated with BCG. On the other hand, the contacts without a previous BCG scar were given their first dose at the initial exam and scheduled to receive a second six months later, in accordance with the Brazilian Ministry of Health guidelines.
    Results: The vaccine efficacy rate among contacts without a previous BCG scar was 70% (95% CI 29.6-87.3) whereas among contacts with previous BCG scar, it was 55%. (95% CI 8.76-77.8). The protective effect of BCG was higher for the multibacillary forms of leprosy, at 89.2 % (95% CI 57.0 - 97.3) than for the paucibacillary forms of the disease, at 81,2% (95%. CI 70,4-88,0).
    Conclusion: In view of the results, a second dose of the BCG vaccine confers protection against leprosy among household leprosy contacts.

     

    PE 23

    CAMPANHA DE COMBATE A HANSENÍASE -SÃO CARLOS - SP - 2001: ANÁLISE DOS DADOS
    Ana Cláudia Cianflone; Edeltraut N. Zóia; Elisete S. Pedrazzani; Isabela Geriu de Oliveira; Maria Tereza Claro; Mariangela Pioto
    Secretaria Municipal de Saúde - Divisão de Vigilância Epidemiológica. Rua Conde do Pinhal, n° 2161 - Centro. Fone/Fax: 016 - 270-7405. E-mail: salvepi@saocarlos.sp.gov.br

    O município de São Carlos - SP, participou da Campanha Estadual de Combate a Hanseníase de 23 a 27 de abril de 2001, desenvolvendo atividades de divulgação e estratégias de detecção de casos novos, envolvendo diversos segmentos da comunidade local.
    A Campanha teve início com reuniões da equipe de saúde para planejamento e organização das ações e posteriormente com alunos dos cursos de graduação na área de saúde e professores do Departamento de Enfermagem da Universidade Federal de São Carlos, representantes das associações de bairros e das indústrias, profissionais da saúde, religiosos entre outros, com o objetivo de uma grande mobilização social. Os alunos receberam treinamento para aplicação do teste de sensibilidade para atendimento da população durante a Campanha.
    Foram desenvolvidas ações educativas na comunidade, testes de sensibilidade em qualquer mancha na pele nos Postos de Saúde e exames clínicos com Dermatologistas, para as pessoas encaminhadas após avaliação sensorial.
    Os resultados foram: de 290 pessoas examinadas com manchas, 112 foram encaminhadas para consulta com Dermatologista, dos quais 48 foram avaliados na semana, sendo que 46 foram negativos, 01 positivo e 01 com suspeição diagnóstica.
    Espera-se com esta campanha dar continuidade ao processo de divulgação da doença e desta forma contribuir para a melhoria dos indicadores epidemiológicos, sendo que o município de São Carlos, apresentou em 2001 um coeficiente de prevalência de 0.9 por 10.000 habitantes, enquanto que no Estado, no ano de 2000 foi de 1.74.

     

    PE 24

    CAN WE PREVENT LEPROSY AMONG HOUSEHOLD CONTACTS OF LEPROSY PATIENTS ? -A PRELIMINARY REPORT FROM INDIA
    Vijayakumaran P; Krishnamurthy P; Etienne Declercq; Prabhakar Rao T
    Damien Foundation India Trust, 27, Venugopal Avenue, Spurtank Road, Chennai 600 031 India. E-mail: damienin@vsnl.com

    Studies indicate that the relative risk of leprosy among household contacts varies from 4 to 9 when compared to the population who do not have household contact with leprosy patient. This randomised double blind controlled trial is undertaken to determine protective efficacy of single dose of Rifampicin as chemoprophylaxis to household contacts in reducing the risk of developing clinical leprosy among them. The protective efficacy is measured in terms of reduction in incidence of leprosy among household contacts. Nine NGO leprosy projects supported by Damien Foundation India Trust (DFIT) are participating in the study. All the newly registered leprosy patients during the years 2000 and 2001 were considered as index cases and their houlsehold contacts were examined for clinical evidence of leprosy. Families allocated randomly lo study and control groups. The followup examination (reexamination) is done annually. There were 1958 newly registered leprosy patients. Among these, 14.8% of families had more than one case at intake and 23.8% of the families had MB cases. A total of 8063 household contacts were enrolled till Dec 2001. Among them 391 had leprosy (previously treated and new) at the time of intake. There were 7672 eligible contacts. The first group of eligible contacts (3271) was re-examined in April 2001 and three new eases were detected giving an overall New Case Detection Rate of 0.9 per 1000. Details of methodology and updated re-examination findings will be presented.

     

    PE 25

    CASE DETECTION AMONG NON-HOUSEHOLD CONTACTS OF NEW SMEAR POSITIVE MB CASES
    Pratibha Kathe2; U.H.Thakar; Dnyanshwar Kholgade1; W.S. Bhatki2.

    1. Kushtarog Niwaran Samiti. Shantivan. Taluka Panvel.
    2. Acworth Leprosy Hospital Society for Research. Mambai.

    Household contacts of smear positive MB cases are generally considered as high-risk population and hence covered in routine case detection activity. However, leprosy cases like other people also spend much more time outside their homes, thereby having contact with people residing in surrounding houses, at the place of work and at the place of social activities. In taluka Panvel, 7946 people have been indentified for having contacts with 46 new smear positive MB cases by virtue of their slaying in the surrounding houses (4612 people), working with the index cases (1548 people) and having social contact' with the index cases (1786 people). Of these 7324 (92%) had been examined to reveal 27 new cases (4 SSL. 16 PB and 7 MB). The New Case Detection Rate) NCDR), observed among extra-household contacts of smear positive MB cases (37/10000) was found to be much higher than that is seen in routine surveys. Among three categories of non-household contacts, the maximum NCDR of 66 cases per 10000 population was observed among the people having social contacts with smear positive MB cases. The results suggest that the non-household contacts of smear positive MB cases should also be considered as high-risk population.

     

    PE 26

    COMPARE OF NEWLY DETECTED LEPROSY CASES BETWEEN BEFORE MDT AND AFTER MDT IN NANKANG CITY
    ZHANG Shengwei; HE Shengxing; LIAO Qinyan; ZHANG Xiaocheng
    Nankang Institute of Dermatology, 341400. Nankang, China

    Objective: To compare the profiles of case-finding and the clinicale characteristics of new leprosy cases detected after MDT with that before MDT.
    Methods: Materials of cases detected before MDT and after MDT in Nankang City were compared.
    Results: In comparison with before MDT, detection rate has decreased dramatically (0.75/100000) after MDT. The rate of early detection cases in newly detected patients has increased (57.41%). The rate of cases with positive skin smears was higher (74.07% ) than that before MDT£"53.72%£©. The rates of cases with single skin lesion and with Grade II disability were similarities between before MDT and after MDT. The way that cases were detected through dermatologic clinic was main mode yet.
    Conclusion: Detection rate has decreased dramatically after MDT. It suggests that extensive health education of leprosy is the main one of measures on early detection of cases.

     

    PE 27

    COMPORTAMIENTO DE LA LEPRA MUNICIPIO CAMAGUEY. CUBA 1984 - 1998
    Dra Nieves Atrio Mouriño; Dr. Rene David Sifontes Mejias; Lic. Iris Vidal Camero.; Dr. Miguel Rivero Sánchez
    Asesora Programa de Lepra Centro Provincial de Higiene y Epidemiología Camagüey. Cuba.

    Se realizó un estudio descriptivo transversal del comportamiento de la lepra en el municipio Camagüey durante los últimos quince años (1984 - 1998), el universo de estudio estuvo representado por 260 casos, diagnosticados como tal en las historias clínicas familiares e individuales. Como registro primario se utilizaron los informes anuales del departamento municipal de estadísticas de Camagüey y el modelo de encuesta epidemiológica del enfermo de lepra, con los datos obtenidos, se confecciono una encuesta según bibliografía revisada la cual una vez llenada pasó a ser el registro primario de datos. Los aspectos analizados fueron, la incidencia de la enfermedad su tasa × 100 000 hab, la distribución según grupo etáreo, sexo, color de la piel, nivel de escolaridad, ocupación, condiciones de la vivienda, formas clínicas, primeros síntomas y signos referidos de la enfermedad, localización de los mismos, modo de detección, grado de incapacidad, fuente de infección, tiempo de diagnostico y los resultados de la situación del enfermo con relación al foco.
    Entre los resultados obtenidos se observó una tendencia hacia la disminución de la incidencia y su tasa, ligero predominio del sexo femenino, bajo nivel escolar, mayor numero de desocupados y de pacientes mayores de 35 años, porcentaje superior de las formas clínicas multibacilares y predominio de la LD y LL.
    En los casos de LL predominan los nodulos cutáneos y en la LD. LI y LT las manchas anestésicas. El modo de detección espontáneo y el diagnóstico tardío aportaron el mayor porcentaje, la fuente de infección fue desconocida en el mayor número de enfermos. Predominaron los casos sin incapacidades en el momento del diagnóstico y en los casos discapacitados predominó el Grado I.

     

    PE 28

    CONSTRUÇÃO DO PERFIL EPIDEMIOLÓGICO DE PACIENTES DE 0 A 14 ANOS, COM HANSENÍASE, EM UM HOSPITAL ESCOLA NO RECIFE
    Lea Fradique Lucena; Marta Ribeiro da Silva; Tatiana Luciano Freire; Vera Rejane do Nascimento Gregório
    Universidade de Pernambuco - UPE. Centro Integrado de Saúde Amaury de Medeiros- CISAM. Rua, Visconde de Mamanguape s/n, Encruzilhada. Fone: 3427-3911 Ramal-259. Recife-PE; CEP: 52030-010

    A Hanseníase, uma das mais antigas doenças humanas, ainda é um problema de Saúde Pública no Brasil, as condições sanitárias e de nutrição deficientes são responsáveis pela pré disposição em crianças. Este trabalho, trata-se de um estudo quantitativo do tipo descritivo e retrospectivo, cujo objetivo é conhecer o perfil da hanseníase em crianças de 0 a 14 anos de idade diagnosticadas num hospital escola do Município de Recife, no ano de 2001. As variáveis estudadas foram idade, sexo, forma clínica, basciloscopia, grau de incapacidade, modo de detecção e situação atual desses pacientes. Os dados coletados estão cm processo de análise.

     

    PE 29

    DADOS CLÍNICOS E DEMOGRÁFICOS DE UM SERVIÇO DE ATENÇÃO PRIMÁRIA A HANSENÍASE EM RIBEIRÃO PRETO-SP
    Dr. Stenio Miranda: Maria Luiza Freires Lopes: Elisabete Paganini; Liliane Batista Franco; Adriana Teixeira Renosto; Rute Aparecida Casas Garcia
    Programa de Hanseníase da UBDS - Vila Virgínia

    Nosso objetivo é apresentar dados clínicos/demográficos dos pacientes em tratamento de Hanseníase, de janeiro de 1998 a dezembro de 2001 e as peculiaridades do serviço que estão relacionadas aos resultados obtidos. O trabalho é desenvolvido na Unidade Distrital de Saúde - Zona Sul, da Secretaria Municipal de Saúde, responsável por 81.541 habitantes. Neste período incluímos 37 pacientes, 28 (75,6%) homens e 9 (24.4%) mulheres, com idade média de 37 anos (menor = 6 anos e maior = 70 anos), sendo 94.5% de Ribeirão Preto, a maioria migrantes (67.5% de outros estados e 27% de outras cidades do Est.S.Paulo). Em relação às formas clínicas, 16 (43.2%) com Hanseníase virchowiana, 6 (16,2% ) foram dimorfos, 9 (24.4% ) tuberculóides e 6 (16.2% ) indeterminados, conforme diagnóstico apoiado em características clínicas, baciloscópicas e anátomo-patológicas (59.4% multibacilares e 40.6% paucibacilares). Apresentaram grau de incapacidade zero 23 pacientes (62,2% ), grau de incapacidade I 9 pacientes (24.4% ), grau de incapacidade II 2 (5.4% ) e grau III 2 pacientes (5,4%). Do total 12 pacientes (32.4% ) apresentaram alguma forma de reação durante o tratamento e 5 (13.5% ) persistiram com sintomas reacionais, fazendo uso contínuo de medicação específica após alta medicamentosa. No encerramento dos casos em 31.12.2001 tínhamos alta cura em 23 (62.2% ) pacientes, tratamento em curso para 13 (35.1% ), onde uma paciente foi transferida (2.7% ) foi transferida e nenhum abandono. Consideramos que os bons resultados obtidos pelo serviço, notadamente o índice de abandono zero nos 4 nos incluídos resultam de metodologia de trabalho participativa desenvolvida a partir da abordagem abrangente do paciente e de seus familiares, com efetivo acolhimento pelos membros da equipe.

    PE 30

    DETECTION OF Mycobacterium leprae DNA BY PCR IN BLOOD AND SKIN FROM NINE BANDED ARMADILLO (Dasypus novemcinctus): PRELIMINARY RESULTS
    Patrícia Deps; Adalberto Rezende; Jane Yaniashita Tominiori
    Santa Casa of Misericórdia Hospital, Vitória - ES. Leprosy Laboratory, Oswaldo Cruz Foundation, Rio de Janeiro - RJ. AV. Nossa Senhora da Penha, 2190, CEP 29045-402, Vitória - ES, Brazil.

    Introduction: and purpose: The multiple drug therapy (MDT) is highly effective in killing M. leprae in this human reservoir, i.e infected person. In many countries and in spite of a dramatic fall in prevalence, the number of new cases detected annually does not show a marked decline, maybe, because the sources didn't eliminate. Wlash et al (1974) described a leprosy-like infection in seven armadillos form Lousiana (EUA). We studied the wild armadillos from Espirito Santo State, Brazil, a hyperendemic leprosy area
    Methods: Fourteen armadillos, Dasypus novemcintus species, were examined. Blood samples were collected. For amplification of specific M. leprae DNA, a set of primers ML-1 and ML-2.
    Results: Those animals were assymtomatic and none of them presented clinical diagnose of leprosy. Blood from five of fourteen animals had a positive PCR.
    Conclusion: These are first results in the medical literature and are in accordance with that from American resercher's that also reported the presence of M. leprae in armadillos from Texas and Lousiana States of USA. Anyway, these preliminary results suggest that in the Espírito Santo Slate, Brazil, the nine-banded armadillos could be considered a natural reservoir of M. leprae.

     

    PE 31

    DISTRIBUIÇÃO DA HANSENÍASE SEGUNDO O SEXO NO MUNICÍPIO DE GOVERNADOR VALADARES - MINAS GERAIS / BRASIL
    Lana, F.C.F.; Meléndez, JGV; Lanza, F.M.; Branco, A.C.; Teixeira, S.; Malaquias, L.C.
    Escola de Enfermagem da UFMG, Av. Alfredo Balena, 190, Santa Efigênia, CEP 30.130-100. Belo Horizonte, Minas Gerais. Brasil, xicolana@enf.ufmg.br
    Introdução: A hanseníase em Governador Valadares é considerada hiperendêmica. O nosso pressuposto é o de que a taxa de detecção se distribui desigualmente nos espaços urbanos e também entre os sexos.
    Objetivo: Analisar a distribuição da hanseníase segundo o sexo em Governador Valadares.
    Metodologia: Estudo epidemiológico de natureza descritiva de tipo operacional.
    Resultados: Observamos uma maior proporção de casos em mulheres do que homens, respectivamente 55.3% e 44,7%. Proporção confirmada pela maior taxa de detecção em mulheres, 10,20/10.000 contra 9,27/10.000 em homens. Verificamos que 56.6% dos casos diagnosticados por demanda espontânea são de mulheres. Observamos que o número de casos de hanseníase no sexo feminino é maior nas formas tuberculóide, dimorfa e indeterminada e a virchoviana no sexo masculino. Isto justifica a maior proporção encontrada de casos com incapacidade nos homens, 19.7% contra 9% nas mulheres. Estes dados confirmam a ocorrência de uma maior proporção de diagnóstico tardio em homens.
    Conclusão: A hanseníase em Governador Valadares incide desigualmente entre homens e mulheres, acarretando maior repercussão nos homens em termos de incapacidades físicas. Desta maneira, este estudo aponta para a necessidade dos serviços de saúde deste município implementarem estratégias que considerem as diferenças de necessidades biológicas e sociais entre homens e mulheres de modo a proporcionar equidade no acesso e proteção à saúde.

     

    PE 32

    DISTRIBUIÇÃO GEOGRÁFICA DOS CASOS NOVOS DE HANSENÍASE DIAGNOSTICADOS NO MUNICÍPIO DE BELO HORIZONTE, MINAS GERAIS. BRASIL, NO PERÍODO DE 1999 A 2001
    Paulo de Tarso Silveira Fonseca; Renato César Ferreira
    Secretaria Municipal da Saúde. Av. Afonso Pena 2336. Belo Horizonte. Minas Gerais, Brasil. CEP: 30.130-007

    Os pacientes de Hanseníase diagnosticados em Belo Horizonte, no período de 1999 a 2001, foram distribuídos geograficamente segundo os respectivos Distritos Sanitários de residência.
    Utilizou-se o banco de dados do Setor de Epidemiologia da Secretaria Municipal da Saúde de Belo Horizonte (Sistema de Informação Nacional de Agravos Notificáveis), e o programa Map-Info da Prefeitura Municipal de Belo Horizonte.
    Foram analisados os aspectos socioeconômicos dos Distritos Sanitários em relação ao diagnostico da Hanseníase.

     

    PE 33

    EFFECTIVENESS OF BCG VACCINATION IN PROTECTING AGAINST LEPROSY IN VIETNAM
    Tran Hau Khang; Le Kinh Due
    National Institute of Dermato-Venereology

    In order to assess the effectiveness of BCG vaccination in protecting against leprosy, a prospective case-control siudy was carried out in the North of Vietnam. The objective of the study was to determine the frequency of positive reaction to the BCG vaccine in the patients and in the control groups. If leprosy cases were found to have BCG reactions, this would be evidence lor a protection against leprosy by successful immunization with BCG.
    90 leprosy patients and ISO controls (2 controls for one case) were paired according to their identical parameters. All patients was investigated by the same clinician. Laboratory tests (BI, Histopathology) was also done for all cases. Patients and controls was matched first for height, weight and sex, living condition, changes of residence. The main feature checked for was the presence or absence of a vaccination scar, this being the physical manifestation of a positive reaction to vaccination with BCG in the past.
    The results obtained are shown as below:
    1. BCG vaccination seems to provide protection against non-lepromatous leprosy in the North of Vietnam.
    2. The BCG vaccine does not have any clear protective effect against lepronialous leprosy.

     

    PE 34

    EPIDEMIOLOGIA DA HANSENÍASE EM MAIORES DE 60 ANOS, MUNICÍPIO DO RECIFE-PE DE 1995/2001
    Márcia L.G. De Melo; Miguel Vasconcelos C. De Melo
    Centro De Saúde Lessa De Andrade. Est. Dos Remédios 2416 Benfica, Recife -Pe.

    A Hanseníase é considerada um importante problema de saúde pública para o municipio do Recite. Na década de 90, o coeficiente de prevalência da hanseníase manteve-se em níveis elevados, variando entre 12.48 e 32.90/10.000 hab. com tendência linear crescente. Na mesma década o coeficiente de detecção da doença manteve-se elevado, variando de 4.47 a 8.61/10.000 hab. sendo o municipio considerado hiperendêmico para hanseníase, segundo parâmetros do Ministério da saúde. Considerando que o número de idosos vem aumentando em todo o país, esta apresentação tem por objetivo focalizar as características epidemiológicas da hanseníase em maiores de 60 anos, em uma unidade de referência do município do Recife-Pe, no período de 1995 a 2001, através de informações obtidas de prontuários de pacientes acima de 60 anos no período, tendo sido consideradas as seguintes variáveis: sexo: modo de detecção; comunicantes; forma clínica: grau de incapacidade física: classificação operacional e Baar.

     

    PE 35

    EPIDEMIOLOGIA DAS FORMAS DE HANSENÍASE NUM PERÍODO DE TRÊS ANOS EM UM MUNICÍPIO DO ESTADO DE SÃO PAULO (1999/2001)
    Lima, S.S.; Oliveira, M.C.F.; Matsubayashi, HM.; Sousa, M.A.S.; Romanini, E.
    USB 4 - Itapevi (Rainha)

    Os autores mostram a distribuição da patologia HANSENÍASE nas suas diversas formas, na população de um município da Grande São Paulo: segundo a classificação de Madri, isto é, formas indeterminadas dimorfas tuberculóides e vischovianas. Estudaram-se neste período assinalado 52 casos com a seguinte distribuição:

    • formas instáveis: 36.5%
    • formas estáveis: 63.5%

      Mostram, os autores que as formas bacilíferas correspondem a 50% de todos os casos, compreendendo-se assim, a importância do paciente multibacilar na manutenção da endemia.
      Especificamente os 52 casos revistos apresentam a seguinte freqüência absoluta:
       
    • forma 1:13 casos
    • forma BD: 6 casos
    • forma T: 1 3 casos
    • forma V: 20 casos

     

    PE 36

    EPIDEMIOLOGIA DO PROGRAMA DE HANSENÍASE DO MUNICÍPIO DE ROSÁRIO OESTE - MT. NO PERÍODO DE 1992 A 2001
    José Luiz Rainho Cunha
    Centro De Saúde De Rosário Oeste - MT.

    A hanseníase constitui importante problema de saúde pública no Estado de Mato Grosso apresentando elevados índices de prevalência e de detenção anual de casos. Este estudo objetiva a apresentar as características epidemiológicas do Programa de Controle da Hanseníase do município de Rosário Oeste - MT, no período de 1992 a 2001, através de levantamento de informações obtidas do registro do total de 504 prontuários de pacientes diagnosticados e inscritos no referido programa, sendo consideradas as seguintes variáveis: forma clínica, idade, sexo, árcade residência, modo de detecção, tempo de aparecimento de sinais e/ou sintomas, número de pacientes examinados e com BCG id 2ª dose, grau de incapacidade, ocorrência de reações e situação de registro ativo.


    PE 37

    EPIDEMIOLOGICAL ANALYSIS IN THE URBAN AREA OF WUHAN DURING THE PERIOD FROM 1949 TO 1999
    Liu Daozhong
    Dermatology Institute of Wuhan City, China

    2441 leprosy patients have been accumulated in the urban area of Wuhan from 1949 to 1999, during which two periods have dominated the peak of onset. The first peak reached 29.04 1/100000 in 1949, incidences before 1949 included.The second one was seen within the years from 1950 to 1957 with the average incidence of 8.76/100,000. Since 1957, the incidence has shown a tendency of decrease every year. By the end of 1999, 2.296 patients have been totally cured.
    With the development of MDT in 1987, it has shortened the duration and raised the cure rate. And only 14 present MB patients have been detected by the end of 1999. Incidence and prevalence in 1999 was reported respectively as 0.05/100.000 and 0.006. The aim of "leprosy elimination" has been accomplished after the examination and evaluation given by Health Department in Hubei Province and Evalution Group from Provincial Dermatology Research Department. Pour years watch leads to a constantly decreasing tendency of incidence and prevalence in Wuhan.
    [Key Words] Leprosy Epidemiological Analysis

     

    PE 38

    EPIDEMIOLOGICAL ANALYSIS OF ACTIVE LEPER IN HEILONGJIANG PROVINCE FROM 1990 TO 1999
    Qian Liu; Yi Zhang; Jianhua Li
    Heilongjiang Institute of Dermatology, 150001, Haerbin, China

    Heilongjiang province is situated in the north of China and its average temperature is 1.3¡æ which belongs to frigid temperate zone. 1.034 lepers had been diagnosed by the end of 1999 since leprosy ease was registered in 1949, so it is part of the non-prevalent area. 891 patients had been cured after fifty-year positive prvention and cure, and now only 24 patients were still in active, morbidity of the leper was 0.006/10000. Recent five-years average morbidity was less than 0.00l/l00000, but also it throughoutly kept a lower level in recent ten years. Now we will make a epidemiological analysis of lepers detected from 1990 to 1999 year as follow:
    During ten years, 37 cases (male 23 cases, female 14 cases; M:F= 1.57:1) were reported, which contained 29 new patients and 8 relapsed patients and relapse rate was 21.6%. Among them the youngest sufferer was 13 years old, the oldest was 69 years old and the average was 40.1 years old. Main profession were peasants (22 cases,75.9%), the others were workers (2 cases), cadres (2 cases) and the resident of city(3 cases). Of 29 new patients, 3 cases were LL. 19 cases were BL, 4 cases were BB, 3 eases were BT and nobody was TT. the ratio of type was 89.6%; moreover. 19 patients were diagnosed within six years. 8 patients were diagnosed whinthin six to ten years and 2 patients were detected more than ten years. Before they were reported, the shortest course was 1 year, the longest was 12 years, and the average was 4.6 years. There were 28 patients who had got disability in varying degrees when they detected, accounting for 96.3%. 25 sufferers had ever been to different levels medical units (including countryside, county city and province), accounting for 86.1%. 16 persons of them had been to the provincial rank hospitals and 12 persons had been to the several provincial rank hospitals. Of the reported ways, multiple hospitals diagnosed 16 cases (11 cases in the provincial rank hospitals and 5 eases in the city rank hospitals). 11 cases were reported by the special medical institution and 8 cases in the provincial rank institution and 8 cases in the city rank institution), and two persons were reported by themselves. 29 new patients were distributed over 2.3 countries (or cities) in Heilongjiang province, which were highly scattered condition. Those who were born in other province accounted 89.6 percentage. The minimum times that patients lived in ancestral home was 8 years, the maximum times was 55 years and the average times was 28.9 years. In ten years, the lowest yearly diagnosed number was I case, the most was 6 cases and the average was 2.9 cases. There was only one who got leprosy in family. There were 8 patients who relapsed in all in ten years, of which 7 lepers recurred after the treatment or D.D.S and 1 leper recurred after the treatment of D.D.S+R.F.P. The type of relapse were respectively 2 cases of LL. 4 cases of BB, but also they were all polybacteria kind of lepers. The youngest lepers who recurred was 43 years old, the oldest was 65 years old, and the average was 52 years old. Among 29 new lepers, 8 sufferers had family history, 17 sufferers had contacted with lepers before, and 4 sufferers were unknow contact history.
    Heilongjiang province is non-prevalent region of leprosy in history and its character of distribution has close correlation with migration. On one hand leprosy highly scattered, on the other hand, the number of patients is close correlate with number of migration. Polybacteria kind of patients are absolutely predominance, which show that polybacteria kind of patients are chief in low prevalent condition. Average age of attacking leprosy rose, it was 32.9 years old in 1980s, however, it rose to 40.1 years old in 1990s.
    lepers can not be detected for long time after leprosy came on shows that medical personnels are generally short of the ability of early cognition to leprosy in our province, which is quite disadvantage to diagnosing lepers earlily. Training medical personnels for leprosy's knowledge is an important task of preventing and curing leprosy in heilongjiang province.

     

    PE 39

    EPIDEMIOLOGICAL ANALYSES OF CHILDREN LEPROSY IN GANSU PROVINCE (19492001)
    Xu ChunMao; Qui Yaowen; Bai Li et al.
    Control Disease Center of Gansu, 730030, Lanzhou, China

    Objective: To study epidemiological features of children leprosy in Gansu province.
    Methods: The data of children leprosy from 1949 to 2001 in Gansu province were analyzed in terms of gender, age, duration of the disease, infection source, detection modes, regional distribution, incidence.
    Results: A total of 4801 leprosy cases were detected during 1949-2001, of which 518 (10.79%), lucre child cases (324 males and 194 females).Average delay in detection was 3.91 years. The main source of infection was directly contact with families, accounting for 94.58%,MB were 399 cases,and PB were 119 cases, the chief age of children were 14 years. The majority of cases were detected through active modes. There have been different degree epidemiological of 12 regions in 14 regions of Gansu province. Epidemiological features of children leprosy in Gansu province were basic respondence with epidemiological trends of adults leprosy in Gansu province, the top of incidence was 1.01/100 000 in 1954, the degression of incidence was I case in 2001.
    Conclusion: The present study shows the proportion of children leprosy is one of the sensitive indicators of leprosy endemicity, which is one of reference according as evaluation of effectiveness of leprosy in one region.
    [Key words] Children Leprosy Duration of Disease

     

    PE 40

    EPIDEMIOLOGICAL ANALYSIS OF LEPROSY IN JIANGX1 PROVINCE
    Wang Lamei; Li Zhiyi; Qiu Yingxi; et al.
    Jiangxi Province Leading Group of Leprosy Control, Nanchang 330046, China

    Objective: To summarize the achievement and experience in leprosy control in Jiangxi Province and provide scientific basis for formulation of leprosy strategics.
    Methods: Based on the National Leprosy Recording and Reporting System. Epidemiological data of leprosy in Jiangxi Province were analyzed using computer.
    Results: Jiangxi Province was a leprosy medium endemic area with a higher distribution of leprosy in the south than the north. The prevalence, incidence and detection rates were highest in the 1959s or 1960s and had decreased annually since then. Average incidence rate for the recent 5 years (0.1604 per 100 000) and prevalence rate (0.049 per 10 000) in 1998 reached the criteria of basic elimination of leprosy at provincial level, however, still 15 counties of cities not reaching the criteria.
    Conclusion: The comprehensive measures including early detection of cases, immediate treatment with multidrug therapy and effective health education arc helpful and important for leprosy control.
    [Key words] Leprosy Incidence Prevalence Epidemiologic factors

     

    PE 41

    EPIDEMIOLOGICAL ASPECTS OF THE LEPROSY'S TRANSMISSION AND ARMADILLO MEAT CONSUME
    Patricia Deps; Lorena V. Faria; Christini G. Ventura; Débora A. Silva; Valéria C. Gonçalves
    Dermatology, medical School of Anta Casa Of Misericórdia.
    Av. Nossa Senhora da Penha, 2190, CEP 29045-402, Vitoria - ES- Brazil.

    Introduction: and purpose: The leprosy transmission still now a days is a polemic question. Some authors demontred the possibility of the armadillos. Dasypus novemcinctus species, be a environmental source of Mycobacterium leprae. The epidemiologic inquiry realized to check the correlation between the being human's contact with armadillos and the incidence of leprosy.
    The objective of this research is check the frequence of the leprosy cases contacts with armadillos and also the interhuman contact before of the own diagnose.
    Methods: The inquiry was realized with 107 patients ex-leprosy cases (leprosy cases that had tineshed the treatment with PQT) thai lived in Pedro Pontes Colony - Hospital, in Cariacica, Espirito Santo State. Brazil 29 leprosy cases and 173 no leprosy case from Dermatology Service of the Santa Casa Hospital. Vitoria- Brazil. The inquiry included Batas about the armadillo meal consume before own diagnosed, the existence of known cases and/or familial leprosy cases. It was realized Qui-square test, correlation and Exact Fischer Test.
    Results: 90.4% of the leprosy's cases or ex-leprosy's cases had ever eaten armadillo meat in their diet before their leprosy diagnose, while 9.6% of the no leprosy's cases had ever eaten armadillo meal. It didn't have correlation between the armadillo meat consume and it has familial and know cases of leprosy before the leprosy diagnose.
    Conclusion: This research revealed a direct correlation between the armadillo meat consume and leprosy cases.

     

    PE 42

    EPIDEMIOLOGICAL TRENDS OF LEPROSY IN GUIZHOU PROVINCEE

    Li Jinlan; Ye fuchang; Bao xia. Ke wei
    Guizhou provincial institute of dermatology, 550001. Guiyang, China

    Objective: To analyze the epidemiological trends of leprosy and evaluate the effectiveness of leprosy control with fixed duration MDT in Guizhou province.
    Methods: used for the National leprosy data annual report and computer recording system of leprosy in Guizhou province, each epidemiological data were analyzed.
    Results: Leprosy endemic areas had obviously changed in Guizhou. All 87 counties prevalence were >0,01% and 66 counties were >0,01% among them in 1986. ln 2000, only 3 counties were >0.1% prevalence.49 counties prevalence were during 0.01-0.1% and others were <0.01%.The detection rate decreased from 0.22/10 000 in 1986 to 0.066/10 000 in 2000. The prevalence decreased from 0.24% in 1986 to 0.021% in 2000. During 1986-2000, there were 7 405 leprosy patients treated with faxed duration MDT, regular rate of MDT 95.88%. Three were 18 leprosy relapsed with a relapse rate of 0.24%. The incidence of leprosy in children and the disability rate of new case were still no change trends.
    Conclusion: The faxed duration MDT was effective to treat leprosy patients. The endemic of this disease has been evidently under control in Guizhou.
    [Key words] Leprosy, Incidence, Prevalence, Recurrence

     

    PE 43

    EPIDEMIOLOGICAL TRENDS OF LEPROSY IN SEVAGRAM CONTROL UNIT
    Avinash Kale1; Dr. V.V. Dongre2, P.C. Sarkar3
    Gandhi Memorial Leprosy Foundation. Ramnagar. WARDHA-442 001 (Maharashtra State) INDIA

    1. Statistical Assistant
    2. Director
    3. Asstt. Director

    Sevagram Leprosy Control Unit has been the first control unit in the country started in 1952. Since the inception till 2001 a total of 2050 cases have been detected from a population of 27875. This paper is intended to present the epidemiological scenario of the control unit, after implementation of MDT programme for two decades which needs serious attention while declaring the elimination of leprosy.
    The prevalence rate of leprosy was 234/10.000 in the year 1952 which declined to 12.9/10,000 (94.5% reduced) in the year-2001. The deformity rate declined from 9.1% to 2.4% (73.6% reduced). Percent MB cases which include LL, BL & BB also declined from 21.8 to 15.6 (28.4% reduction), while percent PB cases which include TT, BT, IND & PN increases 78.2% to 84.4%. While number of positive cases with BI- 1&2 is decreased the number of cases with BI-3 and above increased from 2.1% to 5.2%. The new case detection rate also declined from 54/10,000 to 13.6/10,000 (74.8% reduced). It is recent observation that NCDR is more than PR and NCDR has been almost static since last two decades.
    The above observations show that the MDT could reduce the number of accumulated active cases in the society but could not hinder the occurrence of new cases and suggest the need for further epidemiological and bacteriological studies which may throw some light on transmission mechanism of leprosy

     

    PE 44

    EPIDEMIOLOGIST AS THE DISTRICT LEPROSY MANAGER: THE SRI LANKAN EXPERIENCE
    Nimal D. Kasturiaratchi; Sunil Settinayake, Penny Grewal
    University of Peradeniya (Sri Lanka), Anti-Leprosy Campaign (Sri Lanka), Novartis Foundation (Switzerland)

    Integrating leprosy in the general health services represents an immense organizational and logistical challenge. Sri Lanka, like many other countries, only has a small leprosy team who were responsible for the vertical programme. It was crucial to identify a counterpart within the regional health services to help carry out the numerous activities planned. The regional epidemiologists were selected as the "managers" of the integration process as well as for the monitoring of the integrated programme in their respective district. It was envisaged that they would work in close collaboration with the leprosy worker of the area. A goal oriented project planning workshop was conducted to actively seek their input in formulating the detailed plan.
    This paper discusses how and why the epidemiologists were identified as the most appropriate counterparts. The paper will also critically examine the expectations al the outset and the reality of their role alter 18 months experience. It will also discuss the challenges faced in translating the concept of empowerment and teamwork into reality. It also addresses the problems encountered in shifting responsibility from a highly committed small team to new players.

     

    PE 45

    EPIDEMIOLOGY ANALYSIS OF LEPROSY IN ZHEJIANG PROVINCE
    YAO Jianjun; XU Yaping; LUO Chi; et al.
    Zhejiang Provincial Institute of Dermatology. Wukang, 313200£-China

    Objective: To evaluate the effectiveness of leprosy epidemic and control in Zhejiang Province.
    Methods: To adopt the analysis of retrospective sluily.
    Results: By the end of 1999, 16461 leprosy patients have been registered, of which 11935 had been cured and only 97 were still active cases. Compare 1999 with 1973, active cases decreased 99.0291. The main character of epidemiology: the mean age of attack increased, the value of type ratio increased, and the incidence of children decreased, accorded with the character of leprosy control later stage.
    Conclusion: The tendency of leprosy epidemic dropped continuously in Zhejiang province, effect of control is notable and fruit is solid.
    [Key words] Leprosy, Epidemiology, Analyze

     

    PE 46

    EPIDEMIOLOGY AND CONTROL OF LEPROSY IN VIETNAM
    Tran Hau Khang; Nguyen Thi Hai Van
    National Institute of Dermato-Venereology, Hanoi. Vietnam

    In Vietnam, leprosy is considered as one of social diseases which must be eliminated before the year 2000. Before 1982 (the year of MDT implementation), the prevalence rate was very high and the distribution of leprosy patients was uneven. In mountainous areas, the prevalence was 20 per 10.000, while in the delta provinces, the rate was only 2 per 10.000. The proportion of children and women cases was 8% and 36% respectively. However, after implementation of MDT, the National Leprosy Control Programme has proved to be very fruitful. The epidemiological status of the disease has remarkably also changed. The national prevalence rate has considerably decreased from 6.7 per 10,000 in 1982 to 0.2 per 10,000 in 2001. By the end of 2001, all provinces of the country have reached already the goal of leprosy elimination.
    However, while the prevalence rate has continued to reduce in the recent years, the number of newly detected cases has remained steadily ranging from 1500 lo 2000 with a detection rate less than 3 per 100.000. In order to attain the final goal, the national criteria for leprosy eradication are set up and implemented in 2002.

     

    PE 47

    ESTADOS REACIONAIS NAS DIFERENTES FORMAS CLÍNICAS DE HANSENÍASE
    Rosa Maria Cordeiro Soubhia; Geysa Canarim; Denise Rodrigues; Prof. Dr João Roberto Antônio
    Faculdade Estadual de Medicina de São José do Rio Preto. Ambulatório de Dermatologia do Hospital de Base. Av. Brigadeiro Faria Lima n. 5416 São José do Rio Preto - SP Brasil.

    Os estados reacionais (ER) são intercorrências comuns no curso da hanseníase, sendo fundamental para o manejo e prevenção de incapacidades o diagnóstico precoce e a conduta terapêutica adequada. O objetivo deste estudo foi analisar os tipos de ER mais freqüentes em cada espectro da doença, bem como a época do aparecimento dos mesmos. Neste contexto, foram estudados retrospectivamente 87 pacientes com diagnóstico histopatológico de hanseníase, submetidos a poliquimioterapia (PQT). Os pacientes foram classificados, de acordo com os critérios de Ridley-Jopling (1962), em 29% de tuberculóide-tuberculóite (TT). 1% de dimorfo-tuberculóide (DT), 15% de dimorfo-dimorfo (DD). 5% de dimorfo-virchowiano (DV). 35% de virchowiano-virchowiano (VV) e 15% de forma indeterminada. Veriticou-se que os ER foram complicações freqüentes (64%), sendo classificados com base nos dados clínicos e histopatológicos em: tipo I (27% reação reversa): tipo II (28% eritema nodoso hansénico e 3% fenômeno de Lúcio); e 47% neurite isolada. A reação tipo I predominou entre os pacientes portadores de forma DD (80%), a reação tipo II nos VV (68%), enquanto a neurite isolada na forma TT (83%). Quanto ao aparecimento do primeiro episódio reacional, veriticou-se que 46% dos pacientes (50% neurite isolada: 27% tipo I: 23% tipo II) já se encontravam com reação no momento da admissão: em 37% (42% neurite isolada, 33% tipo II, 25% tipo I) a reação surgiu no primeiro ano de PQT. Apenas 1 paciente (4%) apresentou reação tipo II (Fenômeno de Lúcio) durante o segundo ano de PQT e após PQT 2 pacientes (8%) apresentaram reação, sendo uma do tipo I e outra do tipo II, De acordo com estes dados clínicos, pode-se concluir que os estados racionais são complicações comuns nas diferentes formas clínicas de hanseníase, havendo predomínio de reação tipo I na forma DD, reação tipo II nos VV e neurite isolada nos TT. Cabe ressaltar que, devido ao risco aumentado de alterações permanentes nos sistema nervoso periférico durante a reação tipo I e a neurite isolada, estas são consideradas condições emergênciais na hanseníase necessitando portanto de diagnóstico e tratamento precoces.

     

    PE 48

    ESTUDIO COMPARADO DE LA ENFERMEDAD DE HANSEN Y TUBERCULOSIS PULMONAR EN LA SEGUNDA MITAD DEL SIGLO XX EN ESPAÑA
    Almela Vich, Fernando; Vilata Corell, Juan José; Alfonso Sánchez, José Luis; Terencio de las Aguas, José; Salazar Cifre, Antonio; Navarro Gosalbez, María
    Organismo Público Valenciano de Investigación (OPVI) - Instituto de Medicina Tropical. C/ Salamanca N° 68, pta lª, 46005-Valencia, España

    Objetivo: Evaluar la asociación entre hanseniasis y tuberculosis determinando si sus evoluciones siguen un patrón en sus presentaciones, que puede ser competitiva hacia el mismo nicho ecológico, o paralela en cuanto que comparten factores de riesgo.
    Material y métodos: El material ha sido el conjunto de anuarios del Instituto Nacional de Estadística de España, los informes del Registro Estatal de Lepra y los Registros de Enfermedades de Declaración Obligatoria. Para la recogida de datos y presentación de resultados se ha utilizado el programa informático Excel y para el análisis estadístico el PSPS. La metodología estadística ha consistido, en una primera fase, presentación descriptiva: Comparacion de medias globales anuales entre las Comunidades Autonoma de España en el periodo 1950-2000 para incidencia de lepra e incidencia de tuberculosis respiratoria y evolución comparada de ambas incidencias a lo largo del periodo señalado, en una segunda fase, análisis estadístico de las variables utilizando la pruebas de correlacion, regresion lineal simple con tranformacion logaritmica y valoracion previa de requisitos de normalidad de distribucion y homogeneidad de la varianza.
    Resultados: Los datos han sido recogidos por provincias, comunidades autonomas y globales para España. Mostraremos los resultados correspondientes a las tasas anuales nacionales presentadas a intervalos de 5 años. La lepra se expresa como incidencia acumulada cada 5 años dado el impreciso periodo de incubación y la baja incidencia. Se ha encontrado un Coeficiente de Determinación R2 de 0,64, y un valor p < 0,01.
    Conclusiones: La asociación encontrada entre ambas variables es significativa a mas del 1 %, y es de es carácter directo, con presentación gráfica en paralelo, por lo que apuntaría, en nuestro caso, hacia la segunda hipótesis de coparticipación de mismos factores de riesgo. Sin embargo, hay amplias variaciones entre provincias y comunidades autónomas.

     

    PE 49

    ESTUDIO ESTADÍSTICO Y EPIDEMIOLÓGICO DE CASOS DE LEPRA DETECTADOS EN CONTACTOS EN UN PERÍODO DE 5 AÑOS EN SANTA FE
    Dras. Mónica Recarte; Silvia Paredes; Silvia Barraza; Alejandra Kervin; Dra. Est. Isabel Janulevicius
    Programa de Dermatología Sanitaria de la Provincia de Santa Fe. Bv. Avellaneda 1400 – (2000) Rosario –: Santa Fe ̵ I: Argentina: Tel. 54-341-4804155; Fax 54-341-4516882; E-mail: mcrecarte@hotmail.com

    Santa Fe es una provincia situada en el área endémica de lepra de la República Argentina. La distribución de los casos no se dan de manera uniforme y las tasa de prevalência y detección a fines del 2001 fueron de o.6 × 10.000 y 2.2 × 100.000 respectivamente, habiendo bolsones epidemiológicos que superan tasas de 4 × 10.000 hab. Dentro de la provincia.
    A la luz de los conocimientos actuales se sabe que la mayoría de los casos nuevos detectados provienen de contactos tanto intra como extra domiciliarios. Es por ello que nuestro objetivo es conocer el porcentaje de contactos que han enfermado después del diagnostico del foco principal.
    Se presenta un trabajo estadístico y epidemiológico, realizado entre los casos detectados desde enero de 1996 hasta diciembre de 2000, que arrojó cifras significativas, por lo que se propone “ el control de convivientes “, como estrategia destacada para arribar a la meta de la eliminación de la Lepra como problema de Salud Pública.

     

    PE 50

    ESTUDIO SEROEPIDEMIOLOGICO DE UN FOCO DE LEPRA EN EL HOSPITAL "CELIA SANCHEZ MANDULEY", MUNICIPIO MANZANILLO, GRANMA
    Dr. Leonel Alejo Gutierrez.; Dr. Eduardo Rodes Santiesteban
    Centro Provincial de Higiene, Epidemiología y Microbiología de Granma, Parada # 6 e Martí y Marmol. Municipio: Bayamo Provincia: Granma.

    Se realizó un estudio en el Hospital "Celia Sanchez Manduley" del Municipio Manzanillo donde fueron estudiadas 447 personas contatos extradomiciliarios compañeros de trabajo de 6 pacientes de Lepra multibacilar mediante estudio serológico con el antígeno PGL-I por el método Ultramicroanalitico (SUMA) y de acuerdo a los resultados e la serología, prueba de Lepromina y Baciloscopia. El 19.2% de los estudiados mostró niveles de anticuerpos superiores al nivel de corte establecido. Los resultados fueron analizadosd en relación al sexo, la edad, el tiempo de relación con los enfermos. Se naliza la conducta seguida al final de la Investigación, concluyendo que estos studios resultan de gran utilidad en el control de la Lepra.

     

    PE 51

    ESTUDO DE INCIDÊNCIA E PREVALÊNCIA DE HANSENÍASE EM MENORES DE 15 ANOS NO MUNICIPIO DE PARACATU-MG DURANTE UM PERÍODO DE CINCO ANOS
    Isaias Nery Ferreira; Rosicler Rocha Aiza Alvarez.
    Fundação Nacional de Saúde/MS. Av. Olegario Maciel 660 - Centro. 38600-00 Paracatu - MG

    Paracatu/MG é considerada pela Secretaria Estadual de Saúde como município prioritário para o controle da hanseníase devido aos altos coeficientes de incidência e prevalência desta nosología em sua população. Foi realizado um estudo de incidência e prevalência de hanseníase em menores de quinze anos diagnosticados e tratados neste município por um período de cinco anos. analisando diversas variáveis como forma clínica, idade, sexo, grau de incapacidade, escolaridade, cicatriz vacinal, contatos, entre outras. O objetivo deste estudo é obter um panorama epidemiológico desta doença visando subsidiar os serviços e secretarias de saúde municipal e estadual em suas ações, contribuindo para eliminar a hanseníase como doença de saúde pública

     

    PE 52

    ESTUDO RETROSPECTIVO DA OCORRÊNCIA FAMILIAR DA HANSENÍASE EM UNIDADE DE REFERÊNCIA NO MUNICÍPIO DE ITAPEVI - SP
    Lima, S.S.; Kanagusuko.T; Techelsk, W.; Becker, O. M.; Gloria, I
    Instituição: UBS IV - Rainha. Av. Nove de Julho, 39, Itapevi - São Paulo. Fone: (11) 426-3555 - ramal 45.

    A hanseníase é uma moléstia que nos acompanha desde a antiguidade e ainda está longe de ser erradicada.
    O Brasil é responsável por 85% dos casos das Américas, ocupando o 2lugar em número de doentes em todo o mundo.
    Praticamente o único reservatório é o homem, dificultando pesquisas laboratoriais e fazendo com que o contato pessoal seja a principal forma de transmissão. Estudos epidemiológicos tornam-se então instrumentos importantes para compreensão da doença.
    Este é um trabalho retrospectivo que se baseou no levantamento de dados de prontuários de doentes e seus respectivos familiares, acompanhados durante o período de 1996 a 2001 no UBS Rainha, unidade de referência para hanseníase, localizada no município de Itapevi - São Paulo. Enfatizamos os comunicantes familiares como integrantes do principal ambiente de propagação da moléstia. Avaliamos 78 casos com 642 comunicantes. A maioria destes últimos era assintomática. Porém. 9% apresentou hanseníase. Destes comunicantes doentes, 66% possuíam forma infectante (Borderline ou Virchoviana) perpetuando assim a transmissão domiciliar.
    Variáveis como sexo, relação familiar dos comunicantes e forma do caso índice (multibacilar ou paucibacilar) foram analisados como fatores de risco para aquisição da doença.

     

    PE 53

    EVOLUÇÃO DA DETECÇÃO E PREVALÊNCIA DA HANSENÍASE REGISTRADAS DO CENTRO DE SAÚDE DONA LIBÂNIA- REFERÊNCIA EM DERMATOLOGIA SANITÁRIA - FORTALEZA -CEARÁ PERÍODO 1995 - 2001
    Tavares, C. M.; Ferreira, M. L. L. T.; Alencar, T. M.; Araujo, M. A.; Santos. R.
    Centro De Saúde Dona Libânia - Referência Em Dermatologia Sanitária - Fortaleza - Ceará

    Ao realizar este trabalho, acerca de evolução da endemia hansênica utilizando indicadores de morbidade (incidência e prevalência) no município de Fortaleza, não podemos deixar de pensar na situação preocupante da referida endemia em algumas secretarias regionais de Saúde da capital cearense. Hanseníase, doença endêmica em todo território nacional, tem colocado o Brasil na incômoda posição de segundo país do mundo e primeiro das Américas em número de casos registrados. A meta preconizada pela OMS para o ano 2000 e postergada para 2005 é redução de 1 caso de hanseníase para cada 10.000 habitantes. O objetivo deste trabalho é estudar a situação epidemiológica e operacional da hanseníase no município de Fortaleza registrados no centro de referência Dona Libania no período 1995 - 2001.
    A metodologia utilizada é de um estudo descritivo e analítico de uma série histórica, no período de 1995 - 2001. A casuística é constituída de todos os casos notificados no período. Os dados foram obtidos do S1NAN. Os resultados parciais encontrados foram que a média de casos por ano era de 700 casos e a distribuição por secretarias regionais de saúde -SER, observa-se um grande número de casos na regional VI (30% dos casos da capital), região do Conjunto Ceará e Grande Bom Jardim.
    Concluímos que é imperativa a implantação de todas as ações de eliminação de hanseníase, previstas na Norma Operacional de Assistência a Saúde - NOAS para todas as unidades básicas de saúde do município de Fortaleza, e a unidade de referência apoiando esta descentralização, ficando a referência ocupando o seu verdadeiro papel de apoio para - Unidades Básicas de Saúde da Família - UBASF nos municípios de Fortaleza nos casos de difícil diagnóstico e controle.

     

    PE 54

    EVOLUCIÓN COMPARADA DE EL PRODUCTO INTERIOR BRUTO Y LA INCIDENCIA DE HANSENIASIS EN LA SEGUNDA MITAD DEL SIGLO XX, EN ESPAÑA
    Almela Vich, Fernando; Vilata Corell, Juan José; Alfonso Sánchez, José Luis; Terencio de las Aguas, José; Salazar Cifre, Antonio
    Organismo Público Valenciano de Investigación (OPVI) - Instituto de Medicina Tropical. C/ Salamanca Nº 68, pta 1ª, 46005-Valencia, España

    Objetivo: Determinar si el Producto Interior Bruto y la lepra presentan una asociación en su evolución, haciendo especial hincapié en el análisis por Comunidades Autónomas.
    Material y métodos: El material ha sido el conjunto de anuarios del Instituto Nacional de Estadística de España, el Registro de Enfermedades de Declaración Obligatoria y el Registro Estatal de Lepra del Instituto de Salud Carlos III. Para la recogida de datos y presentación de resultados se ha utilizado el programa informático Excel y para el análisis estadístico el PSPS.
    Resultados: Los datos han sido recogidos por provincias, comunidades autónomas y globales para España. Mostraremos los resultados correspondientes a las tasas anuales nacionales presentadas a intervalos de 5 años. La lepra se expresa como incidencia acumulada cada 5 años dado el impreciso periodo de incubación y la baja incidencia. Se ha encontrado una correlación de Pearson de 0,82. El valor de p es < 0,01.
    Discusión y Conclusiones: La correlación encontrada entre ambas variables es significativa a mas del 1 %, y es de es carácter inverso. Por tratarse de un estudio ecológico, no podemos considerar la asociación como causal; así mismo es necesario considerara la posibilidad de sesgos y factores de confusión.

     

    PE 55

    FATORES QUE INFLUENCIARAM A INADEQUAÇÃO DO DIAGNÓSTICO E DO ACOMPANHAMENTO DAS REAÇÕES EM PACIENTES COM HANSENÍASE EM RONDÔNIA, BRASIL
    Carmelita R. Oliveira; Maria de Jesus F. Alencar; Sônia C. Santana; Gerson F. Nascimento; Sebastião A. Sena Neto; Alberto N. Ramos Jr.
    Coordenação Estadual de Controle de Hanseníase e Tuberculose do Estado de Rondônia - Avenida Padre Ângelo Cerri s/n°. Porto Velho - Rondônia - CEP: 78903-400 - E-mail: hanse-ce-ro@ronet.com.br

    Introdução: Os episódios reacionais em hanseníase mantêm-se como um grande desafio para os PCH. Apesar de se conhecerem os aspectos clínicos das reações e sua relação com lesão neural, ainda persistem questões a respeito de sua epidemiologia, o que dificulta a definição de estratégias para o controle efetivo.
    Objetivo: Caracterizar os fatores que influenciaram a inadequação do diagnóstico e acompanhamento dos pacientes com hanseníase com reações e que tiveram alteração ou não do grau de incapacidade.
    Métodos: Estudo descritivo, operacional, baseado nos casos novos diagnosticados em 1997 em Rondônia e com alta por cura. Estudaram-se 684 casos, dados demográficos e informações sobre a evolução da doença, considerando início da PQT e alta. Realizou-se pesquisa em prontuários para avaliação da conduta e caracterização de reações. Para a entrevista foram selecionados pacientes com reações apenas após a alta e os com progressão do grau de incapacidade durante tratamento, com avaliação clínica. Foi avaliada a estrutura do PCH nos municípios selecionados.
    Resultados: Apesar dos avanços gerais obtidos pelo PCH no Estado, mantêm-se as dificuldades da abordagem dos estados reacionais. Foram identificadas falhas em vários aspectos operacionais da conduta das reações. A caracterização desta situação no Estado reflete a predominância de casos novos classificados operacionalmente como PB. Identificou-se a centralização do PCH e a necessidade de articulação com o PACS e PSF. As entrevistas refletem a inadequação dos serviços e mostram a necessidade de trabalho articulado para o efetivo controle das reações.
    Conclusões: Faz-se necessária a redefinição de prioridades no Estado incorporando a abordagem das reações como medida estratégica para se alcançar a atenção integral dos pacientes.

    PE 56

    GENDER ISSUES AND LEPROSY FROM THE SLUM OF DHAKA
    (The effectiveness of female LCA and volunteers in increasing urban slum population)
    Christopher A. Baroi; David Khan; Prince Das
    Dhaka leprosy Control Project, 9/4 Iqbal Road Mohammadpur Dhaka 1207 Bangladesh

    Background: Dhaka leprosy Control Project was initialed by the Leprosy Mission to improve the quality of life of the people residing in the city of Dhaka. It is a joint venture by the government of Bvangladesh and the Leprosy Mission. The Lepropsy Mission is working in half of the Dhaka city. This project was initiated in 1996 where 80% of the leprosy control assistants were male. Later on it was felt that the workers mainly the male workers were going under difficulty to enter into the houses as during their visits mainly the témale portion of the population were in the house and the male were either working or roaming about. And we felt that female wlorkers/volunters should be recruited for smooth efficient and effective leprosy control activities.
    Observation: The statistics of the years from 1996 to 2001 were observed and the following statistical reports were found regarding the achieved activities.

     

     

    Result: A differtiation was before and after 1997. And athe results show clearly that percentage of diagnosis of new cases are quite high after 1997. This was due to the female 5-6 female volunteers, to make the balance of gender among the field workers. The increase in the per head of the new patients were some times 50-70% of the previous years. The disability rate came down from 12% to 5-6 % . The involvement of the female in credit proghram are 70% and which has resulted much improvement in their family economy.
    Conclusion: Inclusion of female worker in the control services of leprosy bis critically important as it helps the group of workers easy access into the houses of the slum dwellers where female members of the family mainly in the houses. Involvement of the female workers has resulted in per head diagnosis of new patients, decreased the disability rate, ami increase in treatment compliance.

     

    PE 57

    GENDER, LEPROSY AND LEPROSY CONTROL: FOUR CASE STUDIES IN ACEH, INDONESIA; PLATEAU STATE, NIGERIA: PAR WEST AND EASTERN NEPAL; AND RIO DE JANEIRO STATE, BRAZIL
    C.M. Varkevisser, O. Alubo, K. Burathoki; C. Idawani; P. Lever; P. Patrobas; T.A.M. Moreira; M. Yulizar;
    Royal Tropical Institute, PO Box 95001. Amsterdam, The Netherlands

    This study was carried out in the four countries to identify to what extent biological, sociocultural/economic and health service factors played a role in gender differences in case finding of leprosy patients. The quantitative part of the study consisted of analysis of a cohort of at least 500 patients registered in 1994 and followed up till declared cured in ultimately 1998. Qualitative interviews and FGDs with patients, RFTs. relatives, community leaders and leprosy staff followed in 1998-99. The M/F ratio was 1.5 and 1.7 in Indonesia and Nepal but roughly 1 in both Nigeria and Brazil. Despite these differences, males in all four countries were more seriously affected than females with MB leprosy, deformities and reactions. Biological (hormonal) factors appear to protect women. Only in the Ear Western Region of Nepal where services are rather inaccessible, both sexes were equally seriously affected. Where services had invested in decentralisation of treatment (Brazil, Indonesia) more women started reporting. Other service factors were sensitivity of stall in treating patients of opposite sex (80% F staff in Brazil; 75-80% M staff in the other countries), and adequate health education to community and patients', responding to their needs and stressing the strong points of MDT.
    Mobility of men (financial and social) appeared in all four countries a positive factor in case finding, but women scored better in alertness to bodily signs. Yet, this not necessarily resulted in early case finding, because women opted sometimes for the 'wrong' healer: untrained private practitioner (Brazil), traditional healer (Nepal). In Aceh. where beliefs in traditional causes are strong, visits to dukun delayed men and women alike. In all four countries leprosy is a stigmatising disease at community and (less) family level, but predominantly in case of deformity and reactions. Involving well-coping, non-deformed ex-leprosy patients in community education proved a powerful instrument in combating the stereotypes of leprosy and promoting early case finding.

     

    PE 58

    GEOGRAPHICAL INFORMATION SYSTEMS AND LEPROSY CONTROL: USEFUL TOOL OR GIMMICK?
    Jacques van den Broek; J.S.R.K. Sastry; Erica Hackenitz
    Netherlands Leprosy Relief (NLR), The Netherlands, E-mail: jacvdbroek@planet.nl
    Enviplan. Health-GIS Consultant, Hyderabad, India. E-mail: enviplan@vsnl.com
    SBW INFRA. The Netherlands. E-mail: eha@shwinfra.nl

    Concept and capabilities of Geographical Information Systems (GIS)
    Significance in health care systems and (infectious) disease control, with special emphasis on leprosy control.
    Review of the most important characteristics of some commonly used GIS software packages and GIS applications.
    A GIS is a computer-based system for data input, data management, data manipulation and analysis, and display of all and any type of geo-referenced data.
    Therefore, in leprosy control a GIS is a useful tool for planning and management (decision support); Epidemiology and surveillance; Education, persuasion and lobbying (advocacy): Complex analysis and research.

     

     

    With the advent of Internet Mapping Servers (IMS) like ARCIMS, it is now possible to have the data at a central server and the GIS data can be accessed, queried and printed over the internet on the local computer.

     

    PE 59

    HANSENÍASE EM MUNICÍPIO DA GRANDE SÃO PAULO: CASOS AUTÓCTONES X CASOS IMPORTADOS
    Anunciata F. S. Toniolo; lsabela M. Vincenzi; Raphael S. Campolim Almeida; Sidney Souza Lima; Teresa C. S. Ribas
    Serviço De Dermatologia Do Hospital Darci Vargas - SP. Rua Dr. Seraphico De Assis Carvalho; 34: Morumbi; São Paulo

    Objetivo: Demonstrar a prevalência e incidência de pacientes hansênicos num município da grande São Paulo- Itapevi - com população de 162.421 habitantes (IBGE 2000) com ênfase para os virchovianos, comparando os casos nativos (autóctones) o os "importados" e analisar sua influência sobre a população atual.
    Método: Os autores examinaram 96 prontuários de pacientes matriculados no setor de hansenologia no município de Itapevi-SP num período de 6 anos, analisando fatores como: sexo, idade, naturalidade e procedência.
    Resultados: Observou -se que 52 % dos casos são oriundos de outras localidades, em sua maioria de outros estados, sendo que 48% são casos autóctones. O índice de prevalência para os autóctones no ano de 2000, quando o número total de casos era de 41, foi de 1,6: 10.000 Hab e para os "importados" 1,3: 10.000 Hab.
    Conclusões: Considerando-se, e tendo como média de 5 anos o período de incubação para a hanseníase, traduzindo esta média talvez um período mais curto para o pólo T e mais longo para 0 pólo L, estamos mostrando, no município de ltapevi- SP, como a influência de imigrantes hansênicos, sobretudo os virchovianos, interfere nos coeficientes de incidência e prevalência da patologia, aumentando aqui os números absolutos e relativos e diminuindo estes na sua origem. Este fato também indica a eficácia dos nossos indicadores de detecção.

     

    PE 60

    HANSENÍASE NA INFÂNCIA: ASPECTOS CLÍNICOS- EPIDEMIOLÓGICOS EM UMA ÁREA INDUSTRIAL
    Lúcia Mioko Ito; Ferrucio Fernando Dall'Áglio; Rodrigo Sestito Proto; João C. S. Chiti
    Departamento de Dermatologia da Faculdade de Medicina do ABC. Av Príncipe de Gales. 821- -09060-650-Santo André - SP- Brasil.

    Introdução: O objetivo deste estudo é considerar deforma concisa os aspectos clínicos o epidemiológicos da hanseníase na infância na região do Grande ABC. As crianças parecem ser mais susceptíveis sendo que estas correm o risco pela presença de hanseníase pela família. Quase 60% dos adultos desenvolvem a moléstia na infância ou no início da idade adulta, portanto, relatos de longo período de incubação devem ser encarados com cautela, pois sinais físicos iniciais, podem ser discretos, além de que muitas lesões podem desaparecer espontaneamente.
    Casuística: Foi realizado um estudo transversal retrospectivo, de casos de hanseníase na infância, abrangendo doentes de 0 a 14 anos, através da análise das notificações compulsórias e prontuários médicos arquivados no Centro de Vigilância Epidemiológica e Postos de Saúde credenciados nos municípios da região tio Grande ABC, no período de janeiro de 1990 a 1999.
    Resultados e discussão: Nesse período, foram registrados um total de 571 casos novos de hanseníase, sendo que destes, 35 correspondiam a crianças de 0 a 14 anos. Notou-se que no período de 1990 a 1997, a hanseníase infantil permaneceu com uma incidência estável e após 1997, houve um aumento significativo do número de crianças acometidas, correspondendo à perda do poderio econômico da região, caracterizando assim a correspondência de hanseníase e pobreza.

     

    PE 61

    HANSENÍASE NA INFÂNCIA E ADOLESCÊNC1A
    Lima S.S.; Balizardo D.; Caldeira F.P; Mendes M.S.; Valencio M.C.S.
    Departamento de Dermatologia, Hospital Infantil Darcy Vargas, Rua Dr. Seraphico de Assis Carvalho 34, Morumbi, SP. Brasil.

    Foram revisados 308 prontuários de comunicantes e doentes do dispensário de hansenologia de uma Unidade Básica de Saúde do município de Itapevi no período de 5 anos (1997 à 2001), constatando-se o diagnóstico de 94 casos de pacientes com Hanseníase distribuídos nas formas paucibacilares e multibacilares. Deste total, 16 eram crianças e adolescentes, constituindo elas 17% do total dos casos. Dos 214 comunicantes, 110 eram menores de 18 anos. Dos 16 menores hansênicos, 60% apresentavam pelo menos contato com um familiar portador da patologia, geralmente multibacilar. 32% destes menores receberam duas doses de BCG id e desenvolveram, mesmo assim, Hanseníase; porém sempre foram de formas paucibacilares. Conclusões: A) H