Knowledge on leprosy and its management among primary healthcare providers in two districts of Bangladesh.

BACKGROUND: In 2013, Lepra Bangladesh (a non-government organization) and the National Leprosy Programme of the Directorate General of Health Services under the Ministry of Health and Family Welfare, Bangladesh implemented a 3 years project entitled "2015 and Beyond: Poverty Reduction through Strengthened Health Systems". The aims of this Health System Strengthening (HSS) project were to improve quality of leprosy services through service delivery, capacity development, curriculum development, improved collaboration, coordination, operational research and knowledge sharing to identify and treat leprosy in order to contribute to strengthen existing health systems. We evaluated the changes in knowledge of primary and community level healthcare providers about cardinal signs, course of leprosy treatment, and drug use for paucibacillary (PB) and multibacillary (MB) leprosy cases. METHODS: We conducted two surveys using purposive sampling technique in two pilot districts: Bogra and Moulvibazar. The first survey was conducted before implementing the HSS project from March to June 2014 among 98 providers. The end-line survey was conducted in November 2015 and included 49 providers. The interview was conducted using the same pre-tested structured questionnaire. Descriptive statistics followed by further analysis was done including proportions, 90% confidence intervals, and p values were calculated for the selected variables. RESULTS: The primary and community level healthcare providers demonstrated significant increases in knowledge on one cardinal sign (definite loss of sensation in a pale -hypopigmented- or reddish skin patch), doses and courses for the adult PB and MB cases and duration of Multi-Drug Therapy (MDT) course at the end line compared to the beginning of the project. All the providers except TB and Leprosy Control Assistants demonstrated statistically significant decreases in knowledge at the end-line compared to the baseline about supportive counseling. CONCLUSIONS: HSS activities including training and capacity building of the providers recorded significant increase of knowledge on types of leprosy, one cardinal sign, courses of MDT and drug use for the adult PB and MB cases and use MDT for leprosy treatment among the service providers at the end-line. Any health systems strengthening project should incorporate a capacity building approach within the programme all through.

Worldwide experience with the robotic navigation system in catheter ablation of atrial fibrillation: methodology, efficacy and safety.

INTRODUCTION: The Hansen Robotic system has been utilized in ablation procedures for atrial fibrillation (AF). However, because of the lack of tactile feedback and the rigidity of the robotic sheath, this approach could result in higher risk of complications. This worldwide survey reports a multicenter experience on the methodology, efficacy, and safety of the Hansen system in AF ablations. METHODS AND RESULTS: A questionnaire addressing questions on patient's demographics, procedural parameters, ablation success rate and safety information was sent to all centers where more than 50 robotic AF ablation cases have been performed. From June 2007 to December 2009, 1,728 procedures were performed at 12 centers utilizing the Hansen robotic navigation technology. The overall complication rate was 4.7% and the success rate was 67.1% after 18 ± 4 months of follow-up. In 5 low volume centers there appeared to be a learning curve of about 50 cases (complication rate 11.2% for the first 50 cases vs 3.7% for the 51-100 cases; P = 0.044) and a trend showing a decrease of complication rate with increasing case volume. However, in the remaining 7 centers no learning curve was present and the complication rate was stable over time (3.7% for the first 50 cases vs 3.6% for the 51st case thereafter; P = 0.942). CONCLUSION: The Hansen robotic system can be used for AF ablation safely. In low volume centers, there appeared to be a learning curve of the first 50 cases after which the complication rate decreased. With a higher case volume, the success rate increased.

Medicinal plants and formulations used by the Soren clan of the Santal tribe in Rajshahi district, Bangladesh for treatment of various ailments.

The Santals form the largest tribal community in northern Bangladesh reside primarily in Rajshahi and Rangpur Divisions, where they live in the districts of Rajshahi, Rangpur, Thakurgaon, Dinajpur, and Panchagarh. Although they are fast losing their traditional medicinal practices, they still have their own medicinal practitioners who rely mostly on medicinal plants for treatment of a variety of ailments. The traditional medicinal practices vary quite extensively between the twelve clans of the Santals. The objective of the present study was to conduct an ethnomedicinal survey amongst the Soren clan of the Santal community residing in two villages of Tanor Santal Para in Rajshahi district to collect information on their use of medicinal plants. Interviews were conducted of the two existing Santal traditional medicinal practitioners of the Soren clan with the help of a semi-structured questionnaire and using the guided field-walk method. Plant specimens as pointed out by the practitioners were collected and pressed on the field and identification completed at the Bangladesh National Herbarium. Information on 53 medicinal plants distributed into 32 families was obtained in this survey. Ailments treated by these plants included skin disorders, respiratory tract disorders, gastro-intestinal disorders, sexual dysfunctions, sexually transmitted diseases, diabetes, helminthiasis, pain, urinary problems, filariasis, leprosy, tuberculosis, epilepsy, snake bite, enlarged heart, and paralysis. The medicinal plants used by the Santals merit further scientific studies for some of their formulations are used to treat diseases like diabetes, paralysis, enlarged heart, tuberculosis, and filariasis for which modern medicine has no known cure or medicines have developed resistant vectors.

The status of tuberculosis infection control measures in health care facilities rendering joint TB/HIV services in "German Leprosy and Tuberculosis Relief Association" supported states in Nigeria.

OBJECTIVE: To assess the status of tuberculosis (TB) infection control practice in health care facilities implementing joint TB/HIV activities. MATERIALS AND METHODS: A descriptive survey triangulating self-administered questionnaire (facility survey to Infection Control Officer, individual health worker to general health workers), review of facility case notes and participant observation techniques was carried out. Twelve health facilities from southern Nigeria were assessed. RESULTS: (1) Administrative and work practice control measure: Only 1 (8.3%) facility had a documented TB Infection control policy; 2 (16.7%) facilities had Infection Control Committee; 5 (41.7%) facilities had Infection Control Officer; 2 (16.7%) asked questions at the health records about cough; 1 (8.3%) facility had health workers intermittently checking for patients with cough in the waiting hall; and 2 (16.7%) facilities had Infection Control Officers who have attended some training on infection control. No facility had Information, Education and Communication (IEC) materials reminding patients and health workers of the possibility of TB transmission in the health care setting. While 86.4% of TB patients were screened for HIV, only 54.7% of HIV patients were tested for TB. (2) Environmental control measures: All the waiting halls were well ventilated. Though 66.7% of the consulting rooms were well ventilated, 25% of them were over crowded; 58.3% of the facilities managed sputum smear positive TB patients in the same ward with HIV-positive and other vulnerable patients; no facility had air cleaners. CONCLUSION: Implementation of the different aspects of the administrative control and work practice component of TB infection control measure range from 8.3% to 41.7% of the facilities. Urgent measures should be taken to reverse this trend in the face of TB burden due to HIV.

Public awareness on integration of leprosy services at primary health centres in Uttar Pradesh, India.

Leprosy services were integrated into the general health a decade ago but it seems that a majority of public are still ignorant of this development. Hence, a study was done in Uttar Pradesh, India to determine the awareness about integration and its relationships to various socio-demographic factors. A multistage representative random sample of 3000 persons was chosen in Faizabad district, selecting a sample of 3 villages each situated within 1 km, 1-3 km and beyond 3 km of a PHC. A systematic random sample of 10% of households was chosen from selected villages and an adult male and an adult female from each household interviewed by a qualified investigator. Data were computerized and cross- tabulated against distance from the PHC, sex, age, education and occupational status. Only 45.7% in Uttar Pradesh are aware of the availability of leprosy treatment facilities at PHC but most knew that MDT was free. A smaller proportion was also aware of other facilities such as ulcer dressing and treatment of complications. Family members and health workers and PHC were the main source of information. It is concluded that massive efforts are urgently needed to educate the rural public on integration.

Managing type II and type IV Lauge-Hansen supination external rotation ankle fractures: current orthopaedic practice.

INTRODUCTION: Differentiating supination external rotation (SER) type II and IV ankle injuries is challenging in the absence of a medial malleolar fracture or talar shift on radiographs. The accurate differentiation between a stable SER-II from an unstable SER-IV injury would allow implementation of the appropriate management plan from diagnosis. The aim of this study was to ascertain the practice of orthopaedic surgeons in dealing with these injuries. MATERIALS AND METHODS: A postal survey was undertaken on 216 orthopaedic consultants from three regions. RESULTS: In the presence of medial-sided clinical signs (tenderness, swelling, ecchymosis), 22% of consultants would perform surgical fixation. 53% would choose non-operative treatment and the majority would monitor these fractures through serial radiographs. The remaining 25% of consultants would perform an examination under anaesthesia (EUA; 15%), request stress radiographs (9%) or an MRI scan (1%). Without medial-sided signs, 85% would advocate non-operative treatment and, of these, 74% would perform weekly radiographs. Interestingly, 6% would perform immediate surgical fixation. Stress radiographs (6%) and EUAs (2%) were advocated in the remaining group of consultants. Foot and ankle surgeons utilised stress radiographs more frequently and were more likely to proceed to surgical fixation should talar shift be demonstrated. CONCLUSIONS: Clinical practice is varied amongst the orthopaedic community. This may lead to unnecessary surgery in SER-II injuries and delay in diagnosis and operative management of SER-IV injuries. We have highlighted the various investigative modalities available that may be used in conjunction with clinical signs to make a more accurate diagnosis.

Assessment of needs and quality care issues of women with leprosy.

OBJECTIVES: Leprosy causes not just physical but psychosocial and economic problems which are further magnified in women due to gender disadvantages especially in developing countries. In order to determine the needs and quality care issues of women leprosy patients attending a hospital/health care facility, a research project was done. DESIGN: All women leprosy patients attending a Leprosy Referral Hospital in Kolkata, India during 2006 were interviewed in depth and clinically assessed, using a standardised proforma. FINDINGS: Of 104 women studied, half below 40 years of age and 70% above 40 years, had visible disability, and some had diabetes, low back pain etc. Nearly 60% preferred to hide their disease but even so, some had social problems. Most women delayed going to hospital, until their husband/guardian felt it was necessary. They had to complete their household chores before setting out for the hospital, and after their return. A considerable amount of time was spent waiting at various service points which conflicted with their domestic work, and lowered their social worth if they were away too long. This de-motivated them from visiting hospitals, even for follow up visits. Medical advice given--such as avoiding prolonged walking and standing, working with hot utensils etc., was not practical. CONCLUSION: Hospitals can do much to address the needs of women leprosy patients and. provide quality services. National programmes should give a higher priority to offering culturally acceptable health education to promote early reporting.

Integration of leprosy into GHS in India: a follow up study (2006-2007).

In India leprosy services, were integrated into the General Health Services (GHS), in a phased manner, in different provinces, from 2001 to 2004. This study reports the findings from a follow-up operational research undertaken in 2006-2007, to assess the level of integration, on predetermined indicators related to: referral services, training of health functionaries, availability of diagnosis, treatment, MDT dispersal and counselling guidelines in health facilities, recording and reporting by GHS staff, MDT stock management and involvement of health sub-centres in different Indian provinces. Nine provinces, 18 districts, 88 health facilities and 108 sub-centres were selected, by using multistage stratified random sampling techniques. Reverse integration, as reflected by the training and deployment of vertical staff in GHS, was also assessed. Data was collected by medical officers experienced in leprosy, with the assistance of state health functionaries, and recorded on separate schedules for health facility and sub-centre levels. The study also touched on the issue of client perception towards MDT services by interviewing 149 under treatment/cured leprosy cases (who had completed treatment within the last year), in the community with the help of local interpreters. Results showed wide variations across the selected provinces in various parameters. District leprosy nuclei were understaffed in 12(66.7%) districts, and district hospitals were not working as referral institutions anywhere. The training status of medical officers and multi-purpose workers in leprosy was low in Andhra Pradesh (6.9 and 22.4%), Madhya Pradesh (26.3 and 14.5%), Rajasthan (19.7 and 40.9%) and Kerala (25.5 and 65.7%). MDT stock availability as per the National Leprosy Eradication Programme (NLEP) guidelines was not adequate in all provinces. Availability of patient counseling guidelines was nil/low in Kerala, Karnataka, West Bengal, Orissa, Rajasthan and Andhra Pradesh. The involvement of sub-centres, in case referral, recording and dispensing MDT was nil Kerala and Rajasthan and poor in Andhra Pradesh. Ninety percent of clients in Kerala and 38.0% in Andhra Pradesh and Madhya Pradesh did not get MDT in the nearest health facilities or sub-centres.

Knowledge, attitude and practices regarding leprosy among general practitioners at Hyderabad.

OBJECTIVE: To assess the level of knowledge, social attitude towards patients, and diagnostic and management capabilities of general practitioners (KAP) regarding leprosy, practicing at Hyderabad, Pakistan. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Hyderabad, Sindh, Pakistan, during October to December 2007. METHODOLOGY: A pre-tested and well-structured questionnaire consisting of 54 questions was administered to general practitioners working at various areas in Hyderabad. The questions were grouped under different headings and covered clinical features, common and uncommon presentations, complications, referral practices and stigma. The sum of correct answers marked by doctors was taken to classify the respondents. The doctors who responded correctly for upto 10 questions were assigned level 1 (poor), from 11 to 25: level 2 (average), from 26 to 40: level 3 (good), while those who marked correct answers for more than 40 questions were assigned level 4 (excellent). Chi-square test was used to determine significance at p<0.05. RESULTS: A total of 200 doctors were surveyed. Fourteen doctors (7%) had poor knowledge of disease (number of correct answers less than 10), 32 (16%) had average (number of correct answers between 11 and 25), 140 (70%) doctors good (number of correct answers between 26 and 40) while 14 (7%) had excellent (number of correct answers more than 40) knowledge of the disease. CONCLUSION: There is inconsistency and deficiencies in the knowledge, referral pattern and treatment of leprosy among general practitioners, which needs to be improved by conducting awareness activities.

The sustainability of self-care in two counties of Guizhou Province, Peoples' Republic of China.

This paper presents the findings of a follow-up survey conducted in two rural counties of Guizhou Province, PRC where a programme to prevent disabilities amongst leprosy affected people had been conducted. An initial 3-year programme had been conducted. One year after the final evaluation of the programme, a team was deployed to conduct a survey in the area. The objective of the survey was to establish the level of adherence to self-care. It was found that 87% of the sample of people living in leprosy villages that were surveyed (n = 31) and 50% of the sample of people living in general communities (n = 50) had continued to apply self-care. Interviews with family members suggested that 18 of the 27 self-care practising subjects living in the leprosy villages received encouragement or active support from family members (9 were single people). Twenty three of the 25 self-care practising subjects living in the communities also received family support (2 were single people). Family support was a highly significant factor influencing adherence in the community (OR = 15.8, CI = 3.0 to 83) but it may not have been the primary motivating factor in the leprosy villages where single people were just as likely to have adhered to self-care than people who were living in families (OR 0.5, CI = 0.06 to 4.2). The prevalence of foot ulceration among that population was recorded but a hypothetical association between the prevalence of foot ulceration and self-care adherence could not be investigated due to insufficient data to address the potential effects of confounding variables. Thirty-eight percent of subjects who did not practice self-care presented with ulceration or foot cracks (n = 29) compared with only 25% of people who did (n = 52).

Delay in the diagnosis of leprosy in the Metropolitan Region of Vitória, Brazil.

This paper reports on the time between the onset of the first lesion and diagnosis, defined as delay, and is based on results obtained by interviewers from a survey carried out amongst 450 leprosy patients in a leprosy endemic area in the Metropolitan Region of Vitória (MRV), state of Espirito Santo, Brazil. The mean age at diagnosis in all cases was 41.47 years and the median was 42.5 years. The mean age at diagnosis in MB (42.9 years) was greater than in PB (38.5 years). The mean of the delay in all cases was 25.25 months, median 12 months and range 0-360 months. The mean of the delay in MB (27.2 months) was greater than in PB (21.3 months). The results of this study suggest that although the delay in leprosy diagnosis in this region of Brazil was not too long when it was compared with other studies in endemic countries, it is still a problem: 65.4% of patients were diagnosed after a delay of 6 months. The Leprosy Control Programme in this state needs more effective health education in order to reduce the current period of delay before diagnosis.

Assessment of the quality of leprosy services from the clients' perspective in Thailand.

To assess the quality of the leprosy service in health facilities from the clients' perspective, qualitative data collection methods, i.e. semi-structured interviews, focus group discussions (FGDs) and priority cards, were conducted in six health facilities located in all regions of Thailand. A total of 29 patients were interviewed and three focus group discussions involving 20 patients were carried out. In addition, six health staff and six community members were interviewed. The results show that patients delayed months to years before they went to a public health facility. This is due to the poor knowledge about leprosy. Most of the interviewed patients tried to get rid of the skin symptoms at home, using topical medicated cream or herbs. Distance was not regarded as a problem, because most patients go to nearby district hospitals. In district hospitals misdiagnosis is still common. More than half of leprosy patients said they did not receive any information about leprosy before they were diagnosed. Travel costs seem to cause problems for a few poor and aged patients who needed someone to accompany them. Patients at district and provincial hospitals complained that the waiting times to consult staff were too long. In most health facilities, privacy during examinations was not adequate. Patients placed a priority on health staff being friendly and respectful to them. When patients were asked to list their priorities of the quality of services, they considered the attitude of health staff, low costs to go to the leprosy services, adequate attention to POD and adequate information to leprosy patients on their disease, as their top four items. Important recommendations resulting from the study were: (1) health education to the public has to be strengthened; (2) training of health staff to minimize doctors' delay; (3) good attitude of health staff towards leprosy patients should be sustained; and (4) leprosy services in district and provincial hospitals should be improved as a one-stop service for leprosy patients.

An exploration of the views of people with leprosy in Nepal concerning the quality of leprosy services and their impact on adherence behaviour.

Based on a qualitative interview study conducted in eastern Nepal, this paper explores the quality of services received by people with leprosy and the impact of quality of services received on adherence behaviour. The study found that a person's status within the family and community influenced the quality of care, which in turn affected adherence to treatment. Five major types of deficiency in the quality of care experienced were identified, particularly by the poor people and by women. These were the attitude and behaviour of the health worker, the practitioner-centeredness of the care and lack of information sharing, the organization of the health services, barriers in accessibility of the leprosy services, and lack of, or carelessness in, patient referral. This paper explores these types of deficiencies and the way people affected by leprosy cope with them. People of a higher status had access to enabling factors which allowed them to continue treatment, people of a lower status had to endure many disadvantages which had a great influence on their adherence behaviour.

Assessment of knowledge and skills in early diagnosis of leprosy and attitudes towards leprosy amongst doctors working in dermatological services, Shandong Province, People's Republic of China.

After the leprosy control programme in Shandong Province, China, had declared elimination in 1994, it was no longer cost effective to rely on rapid surveys, population surveys and contact tracing for case detection, and since then most new cases have been diagnosed by the dermatological services. The dermatological services will continue to play an important role in diagnosis of the few incident leprosy cases scattered in wide geographic areas and in a population of 90 million. In order to better understand the knowledge and skills in early diagnosis of leprosy among doctors working in dermatological services around the province, doctors attending the dermatological annual meeting and a dermatological training workshop were assessed on their knowledge and skills in early diagnosis of leprosy and their attitude towards leprosy with a semi-structured questionnaire. The results showed that continuous training was needed for dermatologists from both general hospitals and the leprosy control programme. In particular, the training methods for the skills in nerve examination including palpation of peripheral nerves and nerve function assessment should be improved.

Integrating leprosy control into general health service in a war situation: the level after 5 years in eastern Congo.

South Kivu Province of the Democratic Republic of Congo, plagued by a turbulent civil war, started a process of integrating leprosy into general health services in 1995. A questionnaire survey was carried out in September 2000 to assess the level of structural and functional integration, after 5 years of the integration process, in nine of its 14 health districts. The survey revealed that a total of 76 clinic nurses remained of those trained in leprosy since 1993. In all, 33-6% of the total 226 health facilities had a trained nurse, but according to the district supervisors who filled the questionnaires, nurses in only 28.3% of health facilities could diagnose leprosy. Less than 40% of the total 226 health facilities were structurally integrated with MDT and other leprosy services. Functionally, the clinic nurses were involved in dispensing MDT drugs and keeping leprosy records in 90.8 and 81.6%, respectively, of the integrated facilities, and diagnostic activities in 43.7%. The degree of involvement put health facilities into four grades of functional integration: 1) fully-functional integrated, 2) semi-functional integrated, 3) semi-integrated (structural but not functional), 4) not integrated (vertical). On this scale, 80% of 107 health facilities reported by the supervisors had some form of integration and 20% were not integrated. Treatment activities were significantly more functionally integrated than the diagnostic and POD activities, which require more skills. The presence of a trained nurse in a health facility made no significant difference to the involvement of clinic nurses in dispensing MDT drugs and performing POD activities, but significantly affected their performance of diagnostic activities and records keeping. The endemic districts had higher levels of structural integration, were not more likely to be functionally integrated. The levels of structural integration after 5 years are considered low in South Kivu Province, and reflect the significant negative effect of civil conflicts on integration of leprosy programmes in Africa.