Sistemas de interpretación, itinerarios y repertorios terapéuticos de pacientes con lepra en un país con baja prevalencia / Interpretation systems, therapeutic itineraries and repertoires of leprosy patients in a low prevalence country

RESUMEN Objetivos: En Perú, a pesar del escaso número de casos, existe evidencia de un diagnóstico tardío y prevalencia oculta de la lepra. En este contexto el objetivo del estudio fue conocer los sistemas de inter pretación sobre la lepra, itinerarios y repertorios terapéuticos de pacientes con diagnóstico de lepra que se encuentren en tratamiento o con tratamiento culminado. Materiales y métodos: Se realizó un estudio cualitativo, aplicando entrevistas semiestructuradas a pacientes con diagnóstico de lepra de las regiones de Loreto y Ucayali. Resultados: Se entrevistaron a 30 pacientes. La mayoría no conocía el mecanismo de transmisión de la lepra. En relación con los itinerarios terapéuticos, los pacientes generalmente acudie ron a los establecimientos de salud por recomendación de terceros que conocían la enfermedad. En al gunos casos, el personal de salud realizó un mal diagnóstico. Se reconoce la importancia del tratamiento indicado por el Ministerio de Salud; sin embargo, factores económicos y la distancia a los establecimien tos de salud afectan de forma negativa la adherencia al tratamiento. Además, se evidenció que persiste el estigma de la enfermedad. Conclusiones: Los pacientes reconocen la importancia del tratamiento, sin embargo, manifiestan ideas equivocadas sobre la patogenia de la lepra, además se identifican debilidades en el sistema de salud. Estos problemas conllevarían al retraso en el diagnóstico y tratamiento. Se reco mienda fortalecer las estrategias de control y descentralizar la atención de la lepra con la participación de la comunidad, pacientes, personal de salud y curanderos, considerando las barreras identificadas y un probable infradiagnóstico en la mujer.

ABSTRACT Objectives: In Peru, despite the small number of cases, there is evidence of late diagnosis and hidden prevalence of leprosy. In this context the objective of the study was to know the interpretation systems on leprosy, itineraries and therapeutic repertoires of patients diagnosed with leprosy who are in treatment or who have finished treatment. Materials and methods: A qualitative study was carried out, applying se mi-structured interviews to patients diagnosed with leprosy from the Loreto and Ucayali regions. Results: 30 patients were interviewed. Most did not know the mechanism of leprosy transmission. In relation to therapeutic itineraries, patients generally went to health facilities on the recommendation of third parties who knew the disease. In some cases, health personnel made a bad diagnosis. The importance of the treatment indicated by the "Ministerio de Salud" (Ministry of Health) is recognized; however, economic factors and the distance to health facilities negatively affect adherence to treatment. In addition, it was evidenced that stigma persists towards the disease. Conclusions: Patients recognize the importance of treatment; however, they express misconceptions about the pathogenesis of leprosy, and weaknesses in the health system are also identified. These problems would lead to delay in diagnosis and treatment. It is recommended to strengthen control strategies and decentralize the care of leprosy with the participa tion of the community, patients, health personnel and healers, considering the identified barriers and a probable underdiagnosis in women.

Lepra lepromatosa no erradicada en el perú / Leprosy lepromatosa not eradicated in peru

RESUMEN En este estudio del caso, los autores discuten la presentación de un varón de 56 años, con lepra lepromatosa multibacilar, localizado en un hospital del distrito de Trujillo. La biopsia de una de las lesiones, demostró infiltraciones difusas por macrófagos espumosos en toda su extensión; con la tinción de Ziehl - Neelsen se encuentran: bacilos ácido-alcohol resistentes sueltos o empaquetados en grupos, con índice bacilar: 6. La condición se manejó inicialmente en la comunidad como un "pénfigo ampolloso", sugiriendo que las barreras locales actualmente impiden la detección de la lepra en este sistema de atención primaria, en desarrollo. La lepra es una enfermedad multisistémica y el paciente demostró alteraciones neurológicas periféricas evidentes. Promover el conocimiento de estas manifestaciones sistémicas, evitará un retraso en el diagnóstico, a su vez disminuirá las complicaciones y eludirá la morbilidad a largo plazo. Los esfuerzos para optimizar los sistemas de detección, gestión, educación pública y profesional son esenciales, para impulsar la erradicación en estas poblaciones en riesgo.

SUMMARY In this case study, the authors discuss the presentation of a 56-year-old male in a hospital in the Trujillo district with lepromatous multibacillary leprosy. The biopsy of one of the lesions showed diffuse infiltrations by foamy macrophages in all its extension, with the stain of Ziehl - Neelsen bacilli acid resistant alcohol loose or packaged in groups, the bacilar index: 6. The condition was initially managed in the community as a "bullous pemphigus" that suggests that local barriers currently prevent the detection of leprosy in this developing primary care system. Leprosy is a multisystem disease and the patient demonstrated evident peripheral neurological alterations. Promoting the knowledge of these systemic manifestations will avoid a delay in the diagnosis, in turn will reduce complications and avoid long-term morbidity. Efforts to optimize detection systems, management and public and professional education are essential to promote eradication in these populations at risk.

Diffuse Multibacillary Leprosy of Lucio and Latapí with Lucio's Phenomenon, Peru.

Diffuse multibacillary leprosy of Lucio and Latapí is mainly reported in Mexico and Central America. We report a case in a 65-year-old man in Peru. He also had Lucio's phenomenon, characterized by vascular thrombosis and invasion of blood vessel walls by leprosy bacilli, causing extensive skin ulcers.

Apreciaciones críticas a los programas de control y eliminación de la lepra en el Perú y sus consecuencias para el Perú y América / Critical appraisal about control programs and elimination of leprosy in Peru, and its consequences for Peru and America

Se presenta un análisis crítico de las medidas de control sanitario que, históricamente, se llevaron a cabo en el Perú hasta llegar a la situación actual, que sitúa al Perú en la fase oficialmente considerada de ôeliminaciónõ de la lepra como problema de salud pública. Se discute, además, su validación, señalándose que el descuido de la vigilancia sanitaria, la desarticulación de los organismos de control especializado, el olvido de parte del personal médico sanitario de su diagnóstico precoz, la presencia de casos lepromatosos bacilíferos no diagnosticados en la capital de la república y la indudable prevalencia escondida, permiten concluir que existe el peligro para el país y la región que se reproduzca una recrudescencia de la lepra, si no se toman las medidas sanitarias pertinentes y oportunas...

A critical analysis of health control measures that historically took place in Peru to the present which has led Peru to officially consider leprosy as an ôeliminatedõ public health problem. We will also discuss the validity of the status given the neglect of health surveillance, disbanded specialized control entities, health medical staff forgetting to account for leprosy in early stages, the presence of undiagnosed smear-positive leprosy in Lima and the undeniable hidden prevalence, suggest that there is a danger to the country and the region that a re-emergence of leprosy will occur, if relevant and appropriate sanitary measures are not taken...

Revisión Histórica del control de la Lepra en el Perú

Se hace una sumaria revisión cronológica de los hechos más destacados en la historia y el control de la lepra en el Perú, hasta llegar a la situación actual, señalándose las bases doctrinarias y las perspectivas futuras del Programa Nacional de Control de la Lepra, con el propósito de lograr la eliminación de esta enfermeclad en el país como problema de salud pública. Finalmente, se brinda información de la situación epidemiológica de esta endemia al año 2000.

A summary chronological overhaul becomes of the most outstanding facts in the history and the control of the leprosy in Peru, until arriving at the present situation, being indicated to the doctrinarias bases and the future perspective of the National Program of Control of the Leprosy, in order to obtain the elimination of this disease in the country like problem of public health. Finally, epidemiologist of this offers information of the situation enclemia to year 2000.

[Research in tropical medicine and primary health care in Peru]. / Investigación en medicina tropical y atención primaria a la salud en Perú.

Tropical medicine's fundamental task is to improve health in the tropics. By adopting primary health care strategies, it satisfies the real needs of the population while doing research, improving its effectiveness and social impact. We illustrate this with some examples drawn from our experience, where this potentiation is evident. A sanitary dermatology study, based on health auxiliaries and promoters, encompassed a whole jungle province, with 68,977 km2 and 103,681 inhabitants. It resulted in an excellent relationship with the populations, and findings of significance for early diagnosis and control of hanseniasis and other diseases. It also facilitated an extension of activities to include the entire Amazonian Region, with specific concentration on training of the health personnel. Clinico-epidemiological studies on leishmaniasis in Andean valleys incorporated activities of sanitary education, health care, aspects of community development, etc., and extended into other geographic areas. Migrant workers from high-altitude communities in Cusco who have been to the jungle and acquired cutaneous or mucocutaneous leishmaniasis formed Patient Associations. The latter now receive support for their health and development needs from health authorities and many institutions; our Institute contributes with improved therapeutic procedures and further epidemiologic studies to orient preventive and control measures.

PIP: Tropical medicine is characterized by its focus on targeted research, which has improved biomedical knowledge for application to diagnosis, treatment, and prevention of illness. The UN Development Program/World Bank/World Health Organization Special Program for Research and Training in Tropical Diseases is promoting research to improve application of the results of targeted research. Combining a primary health care strategy with tropical medicine can help ensure that the real needs of the population will be met while research continues, maximizing effectiveness and social impact. Three examples from Peru illustrate the efficacy of this combined approach. A sanitary dermatology study was conducted in Alto Amazonas, a province of the Department of Loreto with a 1980 population estimated at 103,681 living in 68.977 sq. km of jungle. An intensive training program was held for physicians, nurses, auxiliaries, and other health personnel as well as the prospective health promoters who would participate in the pilot program to diagnose and control Hansen's disease (leprosy). The training included preparation of specimens for serological and other studies and other diagnostic procedures. Two 4-member field teams covered the entire province in 18 months, during which they censused 57,927 persons and clinically examined 47,160. After diagnosis of Hansen's disease was confirmed, a project physician or nurse initiated treatment with the multidrug regimen recommended by the World Health Organization and instructed the patient in the procedures to be followed to avoid incapacity. The auxiliary in the nearest health post supervised treatment and referred the patient to a higher level if adverse reactions occurred. 45 patients with Hansen's disease were detected during the study, along with 784 with leishmaniasis, 290 with malaria, and 164 with tuberculosis. All patients diagnosed with these conditions received treatment. A clinical and epidemiological study of leishmaniasis in Andean valleys combined health education, treatment, community development, and other interventions. The incidence of leishmaniasis has been increasing in Peru, and 15,000 new cases are projected for 1992. Active collaboration with the populations involved was sought through the primary health care system. A number of different organizations participated in the work. Field studies conducted primarily in the Purisima Valley included a census, recruiting of promoters and other health workers to diagnose cases, surveillance of new cases, systematic study of leishmaniasis vectors in houses and outside, and observation of the activity patterns of the population that might increase risk of disease. Positive correlations were found with the concentration of vectors inside houses and with seasons of increased agricultural activity. The third example concerned migrant workers from the highlands who contracted leishmaniasis in the jungle. They formed associations to seek assistance from the health system.