Survey of leprosy in unapproachable and uncovered areas.

Leprosy surveys in tribal population, fishermen and labourers engaged in construction work revealed prevalence rates of 32/10,000, 109/10,000 and 20/10,000 respectively, suggesting that systematic surveys have to be carried out in such population groups, to reach the goal of a "World without leprosy".

"Outside project area" leprosy cases in 'A' ward of Mumbai.

Analysis of newly registered smear-positive cases in a ward of the metropolitan city of Mumbai, which has a railway terminus during 1990-97 revealed that 72% of the patients came from outside the project area, most of them arising from the States of Uttar Pradesh, Bihar and Orissa. They had unstable and temporary residences in the area and were employed in low income hard labour jobs. Nevertheless, it was found that their treatment completion rate was high. Using different approaches, e.g. through the community leaders of footpath dwellers and railway platform dwellers, and those of different state language groups' colonies, the new entrants were examined periodically and simultaneously proper rapport was maintained with the medical practitioners of the ward for more referrals to leprosy clinic. Such special approach may have to be developed to tackle such situation in other metropolis in the country.

Socioeconomics of a global leprosy eradication programme.

In the absence of evidence in the literature on cost factors in the management of leprosy, a reference is made to the sporadic attempts to study costs of case detection and treatment. Such studies indicate that in the currently declining phase of leprosy endemicity, employing a conventionally trained, salaried class of paramedical staff for field surveys is prohibitively expensive if cost per case detected is computed. Involving primary healthcare and community derived workers is cost effective. Likewise, short course chemotherapy with newer drugs under trial, administered under supervision by community volunteers, reduces the expenses considerably. Community-based disability services using inexpensive tools may cut costs by 90%. Operational research on cost effectiveness of rehabilitation comparing 'integrated' with 'vertical' approaches is, unfortunately, still in a primitive stage. It is urged that in view of the changing logistics, manpower costs and financial implications should be given serious consideration by health planners. Post-elimination problems such as: (i) unearthing hidden cases; (ii) community-based supervised treatment with highly promising newer drugs; (iii) identification of reactions and relapses; and (iv) field management of disabilities resulting from acute and silent neuritis etc could be solved in a much cheaper manner. Integration of leprosy into general healthcare services and community-based rehabilitation of leprosy patients along with those disabled by other diseases will be the major task in future as these procedures are expected to reduce management costs and eliminate stigma.

Hidden sources of infection in unapproachable areas.

The population living in the hilly terrains of Panvel taluka, District Raigad of Maharashtra State was examined in a special campaign carried out during a time when the majority of the population will be stationed at the hills. Examination of 10499 persons revealed 108 leprosy cases (PR 10.3/1000) of which 72 were paucibacillary (PB) and 29 were multibacillary (MB) cases. Among the PB cases, only two had single lesion type and among the 29 MB cases, 14 were smear-positive, having BI more than 4. These untreated advanced leprosy cases, in view of their frequent migrations in order to earn their livelihood, may be responsible for transmitting the infection in the plains areas where multidrug therapy is practiced since 1990. In order to achieve early leprosy elimination, it is necessary to cover populations in difficult areas like the one mentioned by special action programmes.

The pattern of 'drop-out' of smear-positive cases at an urban leprosy centre.

One hundred nineteen smear-positive leprosy cases registered at an urban leprosy centre in Bombay in 1991 were followed for three years to study the 'drop-out' pattern in them and judge the utility of some corrective measures for the same. The measures included having maps showing exact location of the patient's residence, paying home visits on registration days and subsequent persuasion and counselling both at the clinic and at the residence of patients. The results were compared with 'drop-out' in smear-positive cases registered at the same centre in 1989, 1990, 1992 and 1993. By introduction of the special measures, the 'drop-out' rate was significantly reduced from 52% (for other years) to 36% (1991). The expenses incurred for the successful recovery of 'drop-out prone' patients and ensuring regularity in drug intake was Rs. 659/- per patient. This study of 'drop-out' patient shows that there are three categories of the so-called drop-outs: (i) the false 'drop-outs' (51%): these patients get transfer as per their convenience to other leprosy centres or medical services (private practitioners or consultants) within the city (ii) drop-outs due to migration: the migration is forced on them due to some genuine reason, and (iii) persistent offenders: this is a group of adamant, non co-operative, or, distressed patients. For the first two category of patients it is advisable to introduce a good referral system. For the recalcitrant defaulters, supervised short-term drug therapy will probably be the best option.