Vasculitic neuropathy in a patient with inactive treated lepromatous leprosy.

A 46 year old Asian male with previously treated lepromatous leprosy developed a stepwise multifocal sensory disturbance 25 years later. Neurophysiology demonstrated marked deterioration from previous studies. Sural nerve biopsy disclosed a vasculitic process superimposed on inactive lepromatous leprosy. Immunocytochemical stains for mycobacterial antigen showed deposits within nerve and vessel walls. A delayed vasculitic neuropathy precipitated by persisting mycobacterial antigen is proposed.

The contribution of "cure by dapsone monotherapy' to the reduction of prevalence of leprosy in the State of Orissa, India, 1983-1993.

The implementation of multiple drug therapy (MDT) in the State of Orissa, India, started in early 1983 and was extended in a phased manner to nine out of the then total of 13 districts by 1993. As part of a programme to bring the remaining four districts under MDT, an intensive screening of the registers was carried out in early 1993. From a total of 28,855 cases registered in these districts, 26,113 (90.5%) were examined and 18,008 (69.9%) deleted. The deleted included patients who had died, emigrated, double (or occasionally treble) entries for the same patient and those in whom careful re-assessment suggested that the original diagnosis of leprosy had been wrong. In addition, however, 8,260 (45.8%) of the 18,008 cases deleted were considered to have been cured by dapsone monotherapy. This figure, from districts with a relatively poor development of services for leprosy control, prompted a retrospective examination of data from the other (more privileged) nine districts. This revealed that from a total of 264,000 patients screened, prior to the implementation of MDT from 1983 onwards, 75,590 (28.6%) were removed from the registers, and that of these, 63,562 (84.0%) were considered to have been cured by dapsone monotherapy. Thus from a total of 93,598 patients removed from registeres in this State since 1983, 71,822 (76.7%) have been assessed as cured by dapsone monotherapy. The significance of this finding and its apparently considerable contribution to the overall reduction in the prevalence of leprosy in Orissa, 1983-1993, is discussed.

An evaluation of the contribution of the Swedish International Development Authority (SIDA) to leprosy control in India based on the implementation of multiple drug therapy (MDT) 1981-1993.

The Swedish International Development Authority (SIDA) first supported the National Leprosy Control Programme in India in 1978. In 1981/82 priority was given to the implementation of multiple drug therapy (MDT), starting in two high-endemic districts, and gradually extending to a total of 19 districts in the years by 1993. SIDA then decided to undertake a detailed evaluation of its 12-year contribution and this was carried out by an international team between November 1993 and April 1994. In terms of epidemiological and public health impact, the main results were impressive and clear-cut; 837,519 cases (old and newly arising) were successfully treated, with few complications and a low rate of relapse. The voluntary reporting rate had improved significantly. Data relating to new case detection, child and disability rates were, however, less clear and difficult to interpret. Deficiencies were also identified in the areas of health education, community participation, gender issues, disability prevention and management, rehabilitation, operational research and assessment of cost-effectiveness. These problems should not, however, detract from the contribution of SIDA, from 1981 onwards, in establishing the implementation of MDT in two 'pilot' districts at an early and important stage in the history of the MDT programme in India. SIDA also made significant contributions in other areas, namely pre-MDT 'screening' of registers in 45 endemic districts in 1990-1993, appointment of consultant leprologists at district level, group education activities, annual meetings of voluntary agencies and the development of a monitoring and information system, with computer facilities, at national level. This paper describes the design and methodology, main findings and conclusions of the evaluation, based on the final report and the appendices submitted to SIDA in Stockholm in April 1994.

Long-term active surveillance of leprosy suspects--what are the likely returns?

Data are presented from the Karonga District in Northern Malawi on the long-term follow up of 277 leprosy suspects who were not given antileprosy treatment or kept on active surveillance. Individuals who were started on antileprosy treatment within a year after leprosy was first suspected, usually on the basis of histopathology results, are excluded from this analysis, because their active surveillance would not usually cause an organizational or financial problem for leprosy control projects. After an average follow-up period of 4.5 years 35 of the 277 suspects included in the analysis (13%) were diagnosed with what we consider to be 'unequivocal' leprosy, and 3 of the 35 had developed disabilities. In 211/277 (76%) all signs of leprosy had disappeared completely. Comparing clinical certainties at first and last examinations and comparing clinical with histopathological certainties at last examinations it is estimated that up to 50% of the 35 cases of unequivocal leprosy which 'arose' in this group were attributable to misdiagnosis at the 1st or 2nd examination rather than to genuine progression of the disease. This estimate is compatible with an overall sensitivity of 90% and an overall specificity of 95% at each examination. Leprosy suspects with 1 cardinal sign of leprosy, either a typical lesion without loss of sensation, or loss of sensation in an otherwise untypical lesion, should be considered a high-risk group in that approximately 25% of such suspects (19/78) were later found with unequivocal leprosy. Policies towards such suspects should be formulated by leprosy control projects.

The allocation of leprosy patients into paucibacillary and multibacillary groups for multidrug therapy, taking into account the number of body areas affected by skin, or skin and nerve lesions.

In Nepal, the setting up and maintaining of reliable services for slit-skin smears has proven difficult. A clinical classification system for leprosy has therefore been developed to assist in the allocation of patients to either paucibacillary or multibacillary groups for the purpose of multiple drug therapy (MDT), using 9 body areas: head (1), arms (2), legs (2), trunk (4). Patients with more than two areas of the body affected are grouped as multibacillary (MB) and those with only one or two areas affected are paucibacillary (PB). Using a computer simulation model and the data of 53 patients registered at Green Pastures Hospital (GPH) in Pokhara and 703 field patients from the Western Region, different clinical classification systems were evaluated with regard to their sensitivity, specificity, and predictive value for MB or PB classification, as compared with the histological classification for the GPH cases and the bacteriological classification for the field patients. The sensitivity and specificity of the body area system in present use were 93% and 39%, respectively. The low specificity is due to MB overclassification. The sensitivity of the WHO classification system without skin smear facilities is 73% (the difference with the body area system is significant: p < 0.05, McNemar's test). Our histology findings confirm previous publications indicating that, while some borderline-tuberculoid (BT) patients may outwardly have a 'PB appearance' and be skin-smear negative, their nerve biopsy and sometimes skin biopsy may show a 'MB' picture. This is the first publication discussing a 'body area system' for the purpose described, including diagrams of the areas used. In Nepal it has proved easy to use and teach and its use may be justified in other control programmes which implement MDT, particularly if slit-skin smear services are unreliable or nonexistent.

Leprosy: an urgent need to step up use of MDT in Africa.

PIP: 10-12 million people in the world have leprosy. India claims about 4 million of these cases. Overall at least 20% of the cases are children. In the 1940s, dapsone was the only drug used to treat leprosy. By the early 1970s, dapsone did not perform as expected and Mycobacterium leprae were beginning to exhibit resistance to dapsone. In 1982, WHO published results of its study which recommended fixed and relatively short duration regimens of multiple drug therapy (MDT) for all people with leprosy. It also listed recommendations on diagnosis, classification, and distribution of patients to either pauci or multibacillary groups. MDT depends on what type of leprosy patients have. For example, patients with multibacillary leprosy receive rifampicin, clofazimine, and dapsone whereas those with paucibacillary leprosy receive only rifampicin. In many African countries, however, MDT is not used. Yet cases of leprosy exist in 94% of Africa's countries. Moreover 37% have highly prevalent leprosy and the lowest percentage of patients on MDT (18% vs. world average of 56%). In fact, Nigeria is included in the group of 5 countries with 84% of all cases. Until the various countries in Africa can satisfy the ideal requirements for establishing a MDT program, they should begin MDT at least on a small scale. They do need, however, an adequate supply of the drugs. The other requirements include a good plan of action, laboratory facilities, transport, and referral centers. If the period of time needed to meet these requirements is long, then physicians should conduct pre MDT screenings to diagnose cases and determine who needs chemotherapy. The best way to diagnose cases is from clinical experience and paying particular attention to dermatological and neurological findings. Early identification is needed since leprosy cases are stigmatized. This article includes MDT dosages in adults and children.^ieng

ALERT-India 1981-89: nine years' experience of leprosy control in the slums of Bombay.

Bombay has a population of about 8 million people, one-half of whom live in slums. In 1981, ALERT-India started its first leprosy control project in N, S and T Wards of Greater Bombay Municipal Corporation covering an area of 122 sq km in the north-eastern suburbs of Vidhyavihar, Ghatkopar, Vikhroli, Kanjurmarg, Bhandup and Mulund, with a total population of 1,100,000 according to the 1981 census. In the 9 years of operation, over 12,000 patients have been registered and treated and of these 7425 have been released from treatment, having satisfactorily completed courses of chemotherapy. However, over 1000 cases are still identified every year by house-to-house or school surveys, or by self-reporting, including a considerable percentage in children. The origin, development, staff structure, operational procedure, administration and recording system of ALERT-India are described in detail, with emphasis on what has been accomplished with purely outpatient facilities, using paramedical workers, all of whom have received inservice training from Government recognized training centres for their specific tasks. The account includes a brief description of an expansion of the organization's work into townships in New Bombay, where preliminary surveys in 1988 confirmed the presence of leprosy cases and the need for treatment facilities. The discussion addresses: 1, the better use of the large volume of statistical information which has been collected by ALERT-India during the past 9 years, with emphasis on its value in assessing the impact on the control programme and modifying future policy; 2, the need to radically examine the present policy of survey, versus an 'education campaign approach' with regard to increasing early case-detection and self-reporting; 3, the establishment of a central coordinating body for leprosy control in Bombay to exchange information, coordinate efforts and formulate a future plan of action, the latter in association with the National Leprosy Eradication Programme; and 4, the development of a health education resource centre in association with the Bombay Municipal Corporation.