- Volume 70 , Number 4
- Page: 3–372
Abstracts of Congress for Papers and Posters
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