Does Leprosy Need a Stronger Surveillance System Now? A point of view article.

Multi Drug Therapy (MDT) for leprosy was introduced by WHO in 1982 and the programme has been implemented for more than 3 decades. The main presumption out of the PR based elimination was that with reduction of disease load below 1 per 10000 persons, the transmission of leprosy would be arrested resulting in disappearance of the disease. MDT made the disease description, definition and epidemiological indicators so different that it ceases to be like any other disease. To eliminate the leprosy totally from the country needs following activities: 1. Scaling up of some sentinel sites (SS) to surveillance units (SUs), 2. Source of information, 3. Authentication and standardisation, 4. Generation of own data, 5. Need for a skin smear laboratory, 6. Promoting referral of suspects for DST.

Trend in decline in leprosy disabilities of a LEPRA project in Malkangiri district, Odisha, India.

This a retrospective analysis of the changes in 646 disabilities occurred amongst 3979 cases registered during 19 years from 1992 to 2010 in Malkangiri district. This amounted to 16.2% of cases with disability segregated to 310 (48%) Grade 1 and 336 (52%) Grade 2. In this project, managed by LEPRA India, POD care was in practice from the year 1992 and records were updated regularly. An analysis of the annual records showed that the next year-end balance increased up to the year 2001 followed by gradual decline. Within this period the total cases with disabilities declined by about 369 (57%) due to death by aging 204 (55%), migration from the area 77 (21%) and reversing to normal 88 (24%) in cases. Deletion due to recovery to normal especially with sensory impairment is fairly good with or without steroid. Disability percentage in new cases declined steadily especially Grade 2 from 30% to 1%, initial high rate attributed mostly to backlog cases. In later years the rate is erratic high amongst low number of new cases. Absolute number indicates the situation better. Such study helps to roughly extrapolate the existing disability load in a particular area and assists in planning for care and prevention.

Transfer of disability care of leprosy to the affected persons and the community members.

Bargarh district in the western Orissa had high leprosy burden and LEPRA India supported in control activities. Its main focus was on POD care with community participation. After motivation and capacity building, it transferred the responsibility of POD care to affected persons, family, community partners and GHS staff in 2006. The effectiveness of this approach was evaluated in 2009. With personal contact responses from 112 (17%) persons with disability and 18 stakeholders were obtained. Result shows 98% affected persons are staying with family; 92% are practicing self-care; 92% felt self-care is beneficial; 57% and 36% are using commercial and MCR footwear respectively. Surgical correction of deformity is maintained in 80% of cases. Difficulty in activity and in community participation was experienced in about one third of affected persons the latter is mostly due to self stigma. The facilitators were happy with their beneficiaries.

Can the skin smear examination in NLEP be reconsidered?

Slit and skin smear examination is an important laboratory test which was made optional in the NLEP. In a laboratory managed by LEPRA Society, this test was provided to voluntary reporting cases and those referred by the general health service institutions of the area. Total cases tested were 1180, out of which 152 (12.9%) were positive. Of the 152 smear reports, 121 were from Koraput district and constitute the sample for this study. Regarding the spread of site wise highest BI, 56% cases had BI of 3.1+ to 6+. Of the 121 cases, 112 (92.6%) cases completed 12 doses of MDT. Seventy patients, from whom detailed information was collected by personal contact, responded well to MDT resulting in regression of lesions. Out of them, 46 cases had repeat smear showing negative smear in 39% and decline of 81 in the rest of cases. There are 16 contact cases with 2 family clusters. A rough block-wise mapping showed 4 strata with a dense clustering in the urban area where the laboratory facility is available. The probable reasons for uneven distribution of cases and causes for late diagnosis were discussed. The study reflects the leprosy problem in urban pockets which high infection pool. Together these two factors remain unexposed due to winding up of smear labs and pose a potential threat to elimination. The paper also emphasized on the reasons for past failure of the test along with suggestions to revive this facility with minor modifications.

Satisfaction of leprosy patients on integrated MDT services: as evaluated by Bargarh Integrated Community Health Project (BICHP).

Functional integration can be viewed successful if general health system (GHS) delivers services to the satisfaction of leprosy patients. The study elicits responses from 307 leprosy cured persons of 3 blocks and one town covering a population of about 3,50,000 in district Bargarh, Orissa. 229 (74.6%) MB and 78 (25.4%) cured PB cases were the respondents. About 80% patients diagnosed and received treatment within half an hour, 89.9% respondents spent adequate time with providers for clarifying different aspects of leprosy, 85.0% felt the discussion very useful. About 94% had comfortable time at the health institutions. About 97% of persons were regular and completed FDT in time while 25.0% experienced some discrimination mostly at the health institutions. Trunk nerves were involved in 57% cases at detection which subsided during treatment in 33% of cases. Skin patches disappeared in 74.6% and became inactive in the rest. Majority (90.2%) were convinced about cure by MDT. Clients' satisfaction in terms of quality treatment and cordial patient provider relation in GHS should be a strong indicator for successful integration.

Response of thickened nerve trunks and skin lesions of leprosy patients to MDT.

This paper indicates the responses of thickened nerve trunks in leprosy patients to MDT. Out of 1625 cases, 557 (34.2%) cases had thickened nerve trunks at the time of registration. From these cases, 175 (31.4%) were randomly selected and re-examined by personal visit about 5 years after RFT. Follow-up showed persistent thickening in 96 (54.8%) cases. Persistence of nerve thickening was higher in MB leprosy. Additional nerve thickening appeared in 8 (4.6%) cases. New disability developed in 6 (3.4%) cases after RFT but these persons did not come for check up voluntarily. Reaction occurred in 6 during follow-up. Both MB and PB considered together thickening continued in as high as 96 (54.8%) compared to persisting skin lesions in 24 (13.7%) cases. Persons with thickened nerve trunks require more counseling to report for check up at the earliest sign of nerve function deficit.

A review of trends in new case-detection in Subarnapur district of Orissa.

Trends in new case-detection are analysed by reviewing the demographic and leprosy epidemiological data and current indicators in Subarnapur district, Orissa State and India. Population-specific new case-detection rates were calculated for analysis. The trend of skin-smear positive cases over a period of 10 years was reviewed in respect of smear positive cases of 1991. During the years 2002 to 2004, a sudden fall was noticed in the new cases detected in both India and Orissa state, whereas the decline in Subarnapur district was more gradual. The fall in the female-specific new case-detection rates is found to be rapid from 11 to 2.5 over the last three years. This also indirectly indicated the health-seeking behaviour of women in accessing health services and hence required a changed strategy. A similar rapid decline was observed in child-specific new case-detection rates. On analysiS, the decline of highly bacilliferous cases from 1991 to 2001 was found to be statistically significant. The analysis also brought out the fact that cases with bacterial index of 1+, 2+ and 3+, though small in numbers, were detected during the last three years indicating continued presence of cases with low bacterial density in the community. The review indicates a definite decline in the occurrence of new cases in all groups. Caution needs to be exercised about continued presence of cases with low bacterial index though in small numbers. The rapid decrease of cases in all groups during the years 2004 and 2005 warrants meticulous surveillance. The surveillance activities could include monitoring of population-specific new case-detection rates and skin-smear positive cases at district and state levels in order to advise on leprosy eradication programme strategies.

Neural pathology in leprosy during treatment and surveillance.

The histological findings of 22 patients with neuritis, 14 developing pain, tenderness and swelling during treatment and 8 during surveillance are presented in this study. Seven patients' biopsies showed macrophage type and 14 had epithelioid cell type of granulomas. All biopsies showed evidence of active disease, except for two patients with macrophage granulomas where some regressive changes were evident. One biopsy showed fibrosis with lymphocytic infiltration. The histology of epithelioid cell granulomas had varied histopathological presentations ranging from non-reacting BT to those with severe type I reaction with caseation necrosis, liquefaction and calcification. Two macrophage granulomas showed partial regression though there was neuritis clinically and features of ENL in the biopsy sections. One biopsy showed histoid changes. All the biopsies showed similar histopathological features irrespective of whether neuritis appeared during treatment or surveillance. The features of reaction were severe in nerves, probably due to the adjuvant nature of lipid and myelin in the nerve tissue. The histopathological features of nerve biopsies from patients under surveillance appeared to be ongoing active disease rather than relapse.

Reaction cases treated at the Regional Leprosy Training and Research Institute, Aska, Orissa: a retrospective analysis.

This study is a retrospective analysis of 147 cases of leprosy reaction selected out of 942 cases of leprosy registered between 1992 and 2002 at the RLTRI, Aska (Orissa). The occurrence of reaction was about 16% with a slight increase over the years. There was a preponderance of males, with about 80% cases among males, and the peak occurrence of reaction was found in the age-group of 21-49 years. Reversal reaction (RR) was seen in 68.7% and ENL in 31.3% of cases. Single episode of RR and ENL reactions was seen in 61.2% and 43.5% respectively. In either type the last episode was seen even after about 32 months after RFT. There was a dissociation between nerve and skin manifestation, with both skin and nerve manifestation in 78.96%, skin lesions only in 21.1% and nerve lesions only in 50.9% of cases. About 88% of reaction was seen in MB patients, with a higher proportion of RR, because of inclusion of more borderline cases. Prednisolone was the drug of choice in both types of reaction, though in 17 cases of steroid dependency, thalidomide was proved to have an edge over steroids. Both types taken together, in half of the cases the first episode of reaction developed within 6 months of starting treatment. Multiple episodes were more common with ENL.

Practical problems in the management of leprosy.

The categorization of leprosy into paucibacillary or multibacillary depends on the report of slit-skin smears. Unfortunately, in many control programmes the quality of slit smears is below par. Taking the example of India, the main reasons were that the work of laboratory technicians was unrewarding as compared to serving in a general health care system. There was lack of equipment and an unrealistic patient to technician ratio. Future attempts were made by experienced workers to devise a clinical system for classifying leprosy as paucibacillary or multibacillary based on counting the number of lesions. However this method did not prove cost-effective because more paucibacillary patients were classified in the multibacillary group increasing the burden of treatment. A renewed attempt to improve slit-smear performance should be made by modifying the existing methods. This can definitely improve the situation. Patients with multiple macular lesions and those with neuritic leprosy are best treated with the MB-MDT regimen. The treatment for PB leprosy is to continue up to 6 months but in MB leprosy with a high bacterial index a longer duration of MDT may be required. Following completion of MDT many cases with deformity are accumulating and their care forms are a neglected part of many control programmes. In addition to strengthening the infrastructure, simple techniques must be imparted to those with deformities and disabilities. This involves the artful and innovative cooperation of the health worker, patient and the community. The leprosy worker should be motivated to promote such activities.

Cellularity of macrophage granuloma and morphological index.

In the present study, morphological index (MI) and average macrophage count per microscopic field in skin sections of 94 lepromatous (LL) patients is correlated. The subjects included 14 cases with some histoid features. The MI in the lepromatous cases varied from less than one to 40 and the corresponding macrophage counts ranged from 40 to 156. In cases with histoid changes the MI varied from 30 to 60 and the cell count ranged from 215 to 360. The histoid cases showed a higher MI and cell count compared to the other lepromatous cases. There was a positive correlation between MI and macrophage count and the hypercellular state appears to depend on living and multiplying bacteria.