Leprosy and lymphatic filariasis comorbidity: the case for an integrated functional limitation grading system.

Worldwide, both lymphatic filariasis (LF) and leprosy are major causes of morbidity and functional limitation. Despite an abundance of data on the impairment caused by these infections in isolation, there is little data on disability in patients unfortunate enough to be affected by both infections. We present two cases of patients with LF and leprosy comorbidity. Both cases suffer from Grade 2 disability and chronic lymphedema in the same limb (left and right leg, respectively). These morbidities cause significant functional limitation in the patients' activities of daily living. Both LF and leprosy are endemic in India and their comorbid conditions contribute to functional limitation. However, there is still currently no integrated scale for assessment of interventions for functional limitation in these patients. Investigating and managing impairment and functional limitations individually is the least cost effective and sustainable strategy. Considering the similarities of caring for functional limitations in both diseases and assuming its efficacy, augmentation of LF care services with leprosy referral centres may be beneficial. Integrated approaches have been pilot tested at district level in states in India under the title 'Integrated Prevention of Deformity project' (IPoD). Further work is required to identify a reliable, holistic, functional impairment scoring system, which allows for comparison between diseases. This may help promote greater understanding of impairments and functional limitations these cause and allow effective monitoring and evaluation of all aspects, activities and stages of similar programmes.

Leprosy and tuberculosis concomitant infection: a poorly understood, age-old relationship.

Historically, archaeological evidence, post-mortem findings and retrospective analysis of leprosy institutions' data demonstrates a high observed incidence of concomitant infection with leprosy and tuberculosis (TB). However, reports of concomitant infection in the modern literature remain scarce, with estimates of annual new case detection rates of concomitant infection at approximately 0.02 cases per 100,000 population. Whilst the mechanism for this apparent decline in concomitant infections remains unclear, further research on this topic has remained relatively neglected. Modelling of the interaction of the two organisms has suggested that the apparent decline in observations of concomitant infection may be due to the protective effects of cross immunity, whilst more recently others have questioned whether it is a more harmful relationship, predisposing towards increased host mortality. We review recent evidence, comparing it to previously held understanding on the epidemiological relationship and our own experience of concomitant infection. From this discussion, we highlight several under-investigated areas, which may lead to improvements in the future delivery of leprosy management and services, as well as enhance understanding in other fields of infection management. These include, a) highlighting the need for greater understanding of host immunogenetics involved in concomitant infection, b) whether prolonged courses of high dose steroids pre-dispose to TB infection? and, c) whether there is a risk of rifampicin resistance developing in leprosy patients treated in the face of undiagnosed TB and other infections? Longitudinal work is still required to characterise these temporal relationships further and add to the current paucity of literature on this subject matter.

Forehead plaque: a cutaneous marker of CNS involvement in tuberous sclerosis.

BACKGROUND: Tuberous sclerosis complex (TSC) is a neurocutaneous genodermatosis characterized by hamartoma formation in multiple organs. There are no definite cutaneous markers suggestive of central nervous system (CNS) involvement in TSC. AIMS: To study association of forehead plaque seen in tuberous sclerosis patients and CNS involvement in TSC. METHODS: This is a retrospective study of 15 cases of tuberous sclerosis in varying age groups - from 1.5 to 50 years. All the cases were thoroughly evaluated with detailed history; clinical examination; and relevant investigations like X-rays of chest, skull, hands and feet; ultrasound abdomen and computed tomography of brain. RESULTS: Out of the 15 cases, CNS involvement was seen in 8 cases. Seizures were present in 8 cases (53.33%) and mental retardation was seen in 6 cases (40%). Computerized tomography of brain revealed subependymal nodules (SENs) in eight cases (53.33%). In addition to SENs, subependymal giant cell astrocytomas and cortical tubers were seen in 2 cases each. Out of these 8 cases having CNS involvement, in 7 cases forehead plaque was observed. In 1 case, no forehead plaque was observed (X 2 = 1.07, P < 0.05). CONCLUSION: This study shows that there is a statistically significant relationship between the presence of a forehead plaque and CNS involvement in TSC. Therefore, forehead plaque may be considered as a novel cutaneous marker to know the CNS involvement in TSC at an early stage.

Observations on reactions of leprosy in the field.

In order to assess the incidence of reaction in leprosy, it would be necessary to examine the data from a field control unit. In this study, it was found, at a fully monitored control unit, that Type I reaction occurred in 3.9% of borderline cases and Type II in 23.7% of LL and BL cases. Even so, the load of reaction is not high since reaction of Type I and Type II together are seen only in 3.7% of all types of cases. A majority of them are of mild or moderate degree and could be treated as out-patients. Of the borderline cases, the BB type showed maximum rate of reaction. The BL type can present with both Type I and Type II reactions with a total incidence of 12.8%. While the BT type constituted 74% of total cases, reaction of Type I occurred in 3.1% of cases. Reaction also occurred in 0.8% of RFT cases.

Knowledge, attitude and practices about leprosy among medical officers of Hyderabad urban district of Andhra Pradesh.

In India, MDT was implemented through vertical programme staff of the National Leprosy Eradication Programme till the year 2001, when it was integrated into general health services (GHS). Human resource development of GHS is a vital, preparatory action for successful integration of leprosy into GHS. District Technical Support Teams (DTST) have been formed with responsibility for building the capacity of medical and paramedical staff of urban health posts (UHPs). In this context, it is necessary to know the current levels of Knowledge, Attitude and Practices (KAP) about leprosy prevailing among health staff at a given point in time, so that required knowledge and skills can be imparted, if need be. The present study is an attempt in this direction for assessing the KAP status of health staff working in Hyderabad city. 402 staff members (352 females and 50 males) working in urban health posts, the Employees State Insurance Corporation and the Central Government Health Services dispensaries in Hyderabad urban district in Andhra Pradesh were included in the study carried out in 2004 in order to assess KAP, and some operational parameters. A questionnaire was used to elicit responses of 110 medical officers in urban Hyderabad and the data were analysed and discussed. Medical officers have shown consistent higher knowledge on leprosy, followed by nursing staff as compared to other paramedical workers Only 40% of the medical officers had the opportunity of seeing at least 1 case of leprosy in their practice. Medical Officers who received training in leprosy and possessed reference material on leprosy have shown higher knowledge and practice. More than half of the study subjects did not have specific training in leprosy. Two major operational problems expressed by the medical officers were managing big crowds in OPD and time lost in meetings. 96 (87.3%) of 110 medical officers felt integration of leprosy services into general health services can be effectively implemented. 78 (71%) expressed that a leprosy patient with severe reaction needed priority attention at the out-patient department indicating good understanding of reactions in leprosy and a positive attitude towards such patients. There is a need to organize training at regular intervals to cover new persons as well as reinforcing and updating the knowledge of those already trained.

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.

Clinical diagnosis of leprosy cases.

The principle of leprosy control is based on secondary prevention with early detection of all cases and treatment with multidrug therapy. Eradication of leprosy warrants detection of all cases. Hence diagnosis of leprosy is of paramount importance to eradicate the cases. History taking gives all important information about the patient. Presenting complaint and contacts in family give useful guidelines to clinicians to arrive at the diagnosis. The objective of clinical examination is to elicit cardinal signs of leprosy through a systemic examination. Sensory testing, examination of nerves and examination of hands, feet and eyes are helpful in establishing diagnosis. Laboratory examination is not essential. Slit-skin smear examination for acid-fast bacilli shows positive results in a few cases. Diagnosis is complete once the clinical signs are established through clinical examination.

An outbreak of cutaneous anthrax in a non-endemic district--Visakhapatnam in Andhra Pradesh.

BACKGROUND: Anthrax is a disease of herbivorous animals, and humans incidentally acquire the disease by handling infected dead animals and their products. Sporadic cases of human anthrax have been reported from Southern India. METHODS: Five tribal men presented with painless ulcers with vesiculation and edema of the surrounding skin on the extremities without any constitutional symptoms. There was a history of slaughtering and consumption of a dead goat ten days prior to the development of skin lesions. Clinically cutaneous anthrax was suspected and smears, swabs and punch biopsies were taken for culture and identification by polymerase chain reaction (PCR). All the cases were treated with intravenous followed by oral antibiotics. Appropriate health authorities were alerted and proper control measures were employed. RESULTS: Smears from the cutaneous lesions of all five patients were positive for Bacillus anthracis and this was confirmed by a positive culture and PCR of the smears in four of the five cases. All the cases responded to antibiotics. CONCLUSION: We report five cases of cutaneous anthrax in a non-endemic district, Visakhapatnam, Andhra Pradesh, for the first time.

Introducing operations research into management and policy practices of a non-governmental organization (NGO): a partnership between an Indian leprosy NGO and an international academic institution.

This paper reports on a partnership between LEPRA, a non-governmental organization (NGO), and the London School of Hygiene and Tropical Medicine (LSHTM) to explore the feasibility and appropriateness of incorporating operations research into the management and decision-making of a leprosy NGO. A pilot study in Orissa was used to determine the advantages and disadvantages of introducing operations research to assist in decision-making and programme implementation within the organization. The results highlight the difficulty and complexity of the process, but point to several important themes: partnership, changing perspectives, use of time and priority-setting, identification of gaps in systems, and building institutional and personal capabilities. The results of the study provide support to encourage NGOs to become actively involved in research. Because of their work and service to local communities, NGOs have the opportunity to collect information about the perceptions, resources and constraints of individuals, families and the communities themselves in accessing appropriate care. Their proximity to communities gives them a feeling of responsibility for ensuring that this information is translated to the district, national and ultimately international level. This will help to ensure the creation of appropriate infectious disease control policies that support the needs of patients. 'Outside' academic institutions can help NGOs to facilitate this up-stream flow of information from the local to the national and international level, to help to ensure that international disease control policies are appropriately serving local communities.

Lessons in integration--operations research in an Indian leprosy NGO.

Since the Alma Ata Declaration in 1978, health systems supporting the treatment and control of infectious diseases like leprosy and tuberculosis have been encouraged to 'integrate' into the primary health care structure within countries. Now, more than 20 years later, countries are still grappling with the concept of integration and looking for ways to achieve it. This study reports findings from a leprosy/Tuberculosis/AIDS awareness pilot project conducted by LEPRA India, a leprosy non-governmental organization (NGO), between 1996 and 2000 in Koraput district, Orissa. The project addressed the issue of integration on two levels. On the one hand LEPRA used the context of the project to explore ways in which to integrate TB services into their existing leprosy control structure. On the other hand, lessons from the pilot study were intended to help the organization find ways of linking with the government health care structure. Following a 'qualitative approach', this operations research project assessed the perceptions of communities and providers about leprosy and tuberculosis services. Providers across the spectrum of this plural healthcare system were asked to provide comment on developing stronger networks with each other, with NGOs and with government, while patients and communities were asked to describe the resources available to them and the constraints they face in accessing health care in general, and for leprosy and TB in particular. LEPRA staff from top management to the outreach workers were also approached for their views. Patients and communities noted that physical access to treatment was a major constraint, while the existence of local providers and family support structures facilitated health and health care. Providers expressed a willingness to collaborate (with LEPRA and the government), but lacked training, adequate staff support and the appropriate equipment/technical resources. Also lacking were adequate information campaigns to inform the public about these diseases and their treatment. This information has provided LEPRA with an understanding of how they might best fill gaps in the existing system and therefore assist in the process of integrating services in their own organization and through the primary health care structure. To achieve this aim, LEPRA will increasingly become involved in developing relationships and partnerships with government in the delivery of training and services and in infrastructure development.

Initial experiences of implementation of functional integration (FI) in LEPRA India projects in Orissa.

In 2000, the Government of the State of Orissa (population 37 million) in India decided to introduce functional integration for the control of leprosy, in place of the long-established vertical programme, using the general health services and the primary health care system. This paper describes the initial (9 months) experience of implementing this strategy in two projects run by LEPRA India. One of these, in the district of Koraput, was established in 1991 and covers a population of 1.5 million people. The other, in Kalahandi district, started in 1997 and covers a population of 600,000. Both projects operate under difficult conditions with regard to terrain, the use of numerous tribal languages, illiteracy, water shortage, poor roads and communications. The preparatory phase included intensive health education of the public on leprosy, using a wide range of educational media and techniques. At the same time, LEPRA India supported the Government in the training and orientation of trainers, medical officers, primary health care staff and female health workers at village level. In all, over 2000 were trained. This paper describes all aspects of the implementation of functional integration in these two areas. In the 9-month period, 4207 suspect cases were referred to medical officers by health workers, but only 256 (6%) were confirmed as having leprosy. There were 169 confirmed self-reporting cases. Despite the clearly understood intention to involve primary health staff in case detection, 67% of all cases were in fact detected by LEPRA India, possibly due to overlapping attendance at clinics by vertical and general staff. There is obviously a need for further training of the general staff since only 6% of cases referred by them were confirmed as having leprosy. Steps must also be taken to ensure that the emphasis on case detection, confirmation and treatment shifts from the vertical to the general health staff. The supply of anti-leprosy drugs and steroids to primary health centers needs improvement. Appropriate teaching and learning material is urgently needed for both field staff and medical officers.

Modified leprosy elimination campaign (MLEC) for case detection in a remote tribal area in the State of Orissa, India.

A leprosy project was established in a difficult to reach area under guidelines of Government of India. The leprosy services were provided by Koraput Leprosy Eradication Project (KORALEP) and general health services by Primary Health Care (PHC). Leprosy elimination campaigns (LECs) were suggested by WHO to detect more cases in the community. A modified leprosy elimination campaign (MLEC), carried out utilizing the services of primary health care workers is discussed in this paper. Apart from the trained health workers, Anganwadi workers along with some literate people from the district were also included in the search teams. In all, 1543 cases were shortlisted from the suspects identified and on re-examination 576 cases were confirmed as active cases. Sixty percent of the cases detected were very early cases with two to three skin lesions. This could be achieved with a very brief training of health workers and involving village voluntary workers. MLEC was found to be a useful tool for case finding in such areas.

Occupational Dermatoses Among the Cashew Nut Workers in Karnataka.

Seventy five female workers employed in the cashew nut industry in Karnataka to slice off the outer hard shells from the nuts and thus exposed to the chashew nut shell oil had a characteristic cauterization type of reaction manifesting as brownish-black, thickened sheets of dead skin covering the dorsal as well as the palmar aspects of hands including the fingers and feet. Smaller but similer lesions were also seen on these parts of the forearms, abdomen, neck and face which were not covered with clothes. The fingers were thinned and tapering and several nails of the hands and feet were thickened, discolored and eaten away. The other changes included loss of the dermatoglyphic patterns, maceration of the hands, small pits on the finger tips and pitted keratolysis seen in some cases only. Similar changes were also seen on the feet of both the male workers exposed to the same oil, in the section which extracts the oil from the sliced shells. In contrast 29, feamle wokers engaged to peel off the thin reddish covering on the cashew nut had normal hands and feet, except for the two callosities on the flexural aspect of the proximal phalanx of the right middle finger and proximal interphalangeal joint of the right index finger respectively, caused by the friction of the peeling knife. An open patch test with the cashew nut shell oil used as such in 17 workers produced a cauterization type of reaction in 32 workers irrespective of the nature of their duties, while the standard occluded patch test with 10% cashew nut shell oil in polyethylene glycol showed a mild cauterization type of reaction in only 6 workers. Patch tests with 1% and 0.1% concentrations of the shell oil were negative in all the workers. Two barrier creams tested to protect the workers from the cashew nut shell oil produced reasonably effective results within a week.