Hanseníase e COVID-19: repercussões na vida de pessoas afetadas e promoção de intervenções / Leprosy and COVID-19: repercussions on the lives of affected people and promotion of interventions / Lepra y COVID-19: repercusiones en la vida de las personas afectadas y promoción de intervenciones

Objetivo: analisar as repercussões da COVID-19 na vida das pessoas afetadas pela hanseníase e promover intervenções de enfrentamento aos problemas vivenciados pelos usuários. Método: estudo qualitativo do tipo pesquisa participante, realizado de dezembro de 2021 a junho de 2022 na região metropolitana de Recife em oito serviços de saúde de referência para hanseníase. Realizaram-se entrevistas semiestruturadas, telemonitoramento e intervenções nos grupos de autocuidado com usuários acometidos pela hanseníase, e oficinas com profissionais e gestores. Resultados: observaram-se repercussões financeiras, no acesso aos serviços de saúde e na socialização dos usuários. As intervenções realizadas com usuários promoveram melhores práticas de conhecimento sobre a patologia, empoderamento e autocuidado. As oficinas com gestores e profissionais propiciaram a retomada e implementação de novos grupos de autocuidado, atividades comprometida na pandemia. Conclusão: a COVID-19 trouxe repercussões na situação financeira, socialização e acesso a serviços de saúde, com piora da situação de vulnerabilidade social e isolamento, já presentes no contexto da hanseníase.

Objective: to analyze the repercussions of COVID-19 on the lives of people affected by leprosy and to promote interventions to cope with the problems experienced by users. Method: qualitative study of the participant research type, carried out from December 2021 to June 2022 in the metropolitan region of Recife in eight reference health services for leprosy. Semi-structured interviews, telemonitoring and interventions were carried out in self-care groups with users affected by leprosy, and workshops with professionals and managers. Results: there were financial repercussions, on access to health services and on the socialization of users. Interventions carried out with users promoted better knowledge practices about the pathology, empowerment and self-care. The workshops with managers and professionals facilitated the resumption and implementation of new self-care groups, activities compromised in the pandemic period. Conclusion: COVID-19 had repercussions on the financial situation, socialization and access to health services, with a worsening of the situation of social vulnerability and isolation, already present in the context of leprosy.

Objetivo: analizar las repercusiones del COVID-19 en la vida de las personas afectadas por la lepra y promover intervenciones para el enfrentamiento de los problemas vividos por los usuarios. Método: estudio cualitativo de tipo investigación participante, realizado de diciembre de 2021 a junio de 2022 en la región metropolitana de Recife en ocho servicios sanitarios de referencia para la lepra. Se realizaron entrevistas semiestructuradas, telemonitoreo e intervenciones en grupos de autocuidado junto a usuarios afectados por lepra y talleres con profesionales y gestores. Resultados: hubo repercusiones financieras en el acceso a los servicios de salud y en la socialización de los usuarios. Las intervenciones realizadas con los usuarios promovieron mejores prácticas de conocimiento sobre la patología, empoderamiento y autocuidado. Los talleres con directivos y profesionales facilitaron la reanudación e implementación de nuevos grupos de autocuidado, actividades comprometidas en la pandemia. Conclusión: el COVID-19 tuvo repercusiones en la situación económica, socialización y acceso a los servicios de salud, con empeoramiento de la situación de vulnerabilidad social y aislamiento, ya presente en el contexto de la lepra.

Descrição do seguimento farmacoterapêutico de pacientes com hanseníase em município hiperendêmico do estado de Mato Grosso / Pharmacotherapy follow-up of patients with leprosy in a hyperendemic city in the state of Mato Grosso

Introdução: A hanseníase é uma doença crônica, infectocontagiosa e considerada um problema de saúde pública no Brasil. O objetivo deste estudo foi descrever o seguimento farmacoterapêutico de pacientes com diagnóstico de hanseníase. Métodos: Estudo descritivo, com pacientes com hanseníase multibacilar do município de Rondonópolis, Mato Grosso. O seguimento farmacoterapêutico foi realizado a partir de uma versão adaptada do Método Dáder. Para análise de dados aplicou-se a estatística descritiva e o teste Qui-quadrado de Pearson.Resultados: Uma frequência de 95,6% dos participantes apresentou problemas relacionados aos medicamentos, 59,1% apresentaram 3 ou mais problemas, os mais frequentes foram administração errada do medicamento e interação medicamento/nutriente. A inefetividade não quantitativa foi o resultado negativo associado ao medicamento mais evidenciado. Os indivíduos acompanhados em um serviço especializado apresentaram menor número de problemas relacionados aos medicamentos quando comparados àqueles da Estratégia Saúde da Família (p = 0,027).Conclusão: A maioria dos pacientes acompanhados apresentou problemas relacionados ao uso de medicamentos. O método Dáder possibilitou realizar o seguimento farmacoterapêutico de indivíduos com hanseníase.

Introduction: Leprosy is a chronic, infectious, and contagious disease considered a public health problem in Brazil. The objective of this study was to describe the pharmacotherapy follow-up of patients diagnosed with leprosy. Methods: We conducted a descriptive study of patients with multibacillary leprosy in the city of Rondonópolis, state of Mato Grosso, Brazil. Pharmacotherapy follow-up was conducted based on an adapted version of the Dáder method. Data were analyzed using descriptive statistics and Pearson's chi-square test. Results: Drug-related problems (DRP) were reported in 95.6% of patients, among whom 59.1% had 3 or more problems DRPs. The most common DRPs were incorrect drug administration and drug-nutrient interaction. Nonquantitative ineffectiveness was the most common drug-related negative outcome. Patients monitored in a leprosy treatment center had fewer DRPs than those monitored by a Family Health Strategy team (p = 0.027). Conclusion: Most patients had DRPs. The Dáder method allowed pharmacotherapy follow-up of patients with leprosy.

Hanseníase e atenção primária: um estudo avaliativo sob a ótica do médico / Leprosy and primary care: an evaluation study from a medical perspective / La lepra y la atención primaria: un estudio evaluativo desde la óptica médica

RESUMO Objetivo Avaliar a presença e extensão dos atributos essenciais e derivados da atenção primária em saúde no programa de controle da hanseníase, sob a ótico médica. Métodos Trata-se de um estudo de avaliação de programas de saúde, com foco na hanseníase, tendo como púbico alvo os médicos atuantes nas ações de controle do programa de hanseníase nas unidades de saúde da atenção primária. Foi utilizado um questionário, elaborado e validado em outro estudo, para medir a presença e a extensão dos atributos da atenção primária à saúde no controle da doença. Os dados foram inseridos em um banco de dados e posteriormente receberam uma análise estatística e descritiva. Esse estudo foi aprovado sob o parecer CEP n° 1.128.385. Resultados Na análise dos escores gerais e dos atributos essenciais observou-se que o município do estudo apresentou alta orientação para as ações de controle da han-seníase. Os atributos acesso, orientação comunitária e orientação profissional receberam médias abaixo do ponto de corte, demonstrando fragilidades existentes nos itens que compõe esse atributo. Conclusão Apesar das fragilidades identificadas, o município de estudo apresenta alta orientação para o desenvolvimento das ações de controle da hanseníase, segundo a avaliação dos médicos atuantes na atenção primária.(AU)

ABSTRACT Objective To assess the presence and extent of essential attributes derived from primary health care in a leprosy control program. Materials and Methods This is an assessment of health programs, focused on leprosy and targeted at doctors working on control actions in a leprosy program of primary health care units. A questionnaire developed and validated in another study was used to measure the presence and scope of primary health care attributes in disease control. Data were entered into a database and statistical and descriptive analysis was carried out. This study was approved within the framework of CEP No. 1.128.385. Results Overall scores and essential attributes of leprosy control actions showed a high exposure to leprosy control actions in the studied city. Community's access, orientation and guidance attributes averaged below the cutoff point, demonstrating the existing weaknesses in the items that make up these attributes. Conclusion Despite the weaknesses identified, the study showed high orientation towards the development of leprosy control actions, according to the assessment made by doctors working in primary care.(AU)

RESUMEN Objetivo Evaluar la presencia y alcance de los atributos esenciales derivados de la atención primaria de la salud en el programa de control de la lepra, desde la óptica médica. Métodos Se trata de una evaluación de los programas de salud, centrados en la lepra, teniendo como público objetivo los médicos que trabajan en las acciones de control de la lepra en el programa de las unidades de salud de atención primaria. Se utilizó un cuestionario desarrollado y validado en otro estudio, para medir la presencia y alcance de los atributos de la atención primaria de salud en el control de la enfermedad. Los datos se introdujeron en una base de datos y más tarde se realizó el análisis estadístico y descriptivo. Este estudio fue aprobado en el marco del CEP N°. 1.128.385. Resultados Las puntuaciones globales y los atributos esenciales de las acciones de control de la lepra tuvieron una puntuación alta, en la ciudad del estudio. Los atributos de acceso, orientación y guía de la comunidad tuvieron un promedio por debajo del punto de corte, lo que demuestra las deficiencias existentes en los elementos que componen estos atributos. Conclusión A pesar de las debilidades identificadas, el estudio mostró una alta orientación en el desarrollo de acciones de control de la lepra, de acuerdo con la evaluación de los médicos que trabajan en atención primaria.(AU)

Qualidade da atenção as pessoas com hanseníase na rede pública de saúde / Quality of assistance provided to people with leprosy in the public health network

O estudo avaliou os serviços de saúde na assistência à Hanseníase a partir da percepção de todos os pacientes diagnosticados em um biênio em um município com baixa prevalência e incidência da doença de acordo com parâmetros da Organização Mundial de Saúde. Os entrevistados responderam a um questionário validado para o Brasil sobre a organização e o desempenho desses serviços. Destacam-se como fatores facilitadores: porta de entrada do serviço; vínculo com os profissionais e atuação profissional. Domínios que mesclaram pontos de satisfação e insatisfação entre os entrevistados: serviços prestados durante as consultas; falta de interesse pelas condições socioeconômicas do doente e de sua família; e participação da família no tratamento. Aspectos que foram consideradas dificultadores: iniciar o acesso ao diagnóstico e ao tratamento, falta de resolutividade dos profissionais quanto aos problemas gerais de saúde, que não relacionados à hanseníase e dificuldade no acesso às especialidades médicas, ausência de visitas domiciliares e orientação à comunidade com ações de educação em saúde.

This study evaluated leprosy care services from the view point of all patients diagnosed during one bienniumin a city with a low prevalence and incidence of the disease according to World Health Organization parameters. Leprosy patients answered a questionnaire validated in Brazil on the organization and performance of services provided. Access to services,relationship with professionals and performance of professionals were considered facilitating factors. Domains of mixed satisfaction and dissatisfaction among those interviewed were the service provided during consultations, lack of interest in the socioeconomic conditions of the patient and their family and family participation in treatment. The factors considered problematic were initial access to diagnosis and treatment, lack of determination of professional sin respect to general health problems not related to leprosy, difficulties to access medical specialties, and lack of home visits and community guidance with health education initiatives.

In sickness or in health: TDR's partners. 8. Kenya Medical Research Institute (KEMRI).

PIP: Since its establishment in 1979, the Kenya Medical Research Institute (KEMRI) has been one of the partner agencies working with the UN Development Program/World Bank/World Health Organization Special Program for Research and Training in Tropical Diseases (TDR). KEMRI consists of a secretariat and eight separate research centers devoted to alupe leprosy and skin diseases; biomedical, clinical, virus, microbiology, and medical research; vector biology and control; and traditional medicines and drugs. KEMRI also has a model clinic, an animal house, a library, a conference area, and a computer center serving 250 technical staff and 600 administrative staff. TDR has supported about 30 trainees, and KEMRI conducts research programs on all TDR diseases except trypanosomiasis, which is the responsibility of a sister institution. KEMRI's malaria research focuses on the vector, on control through the use of bednets impregnated with insecticide, and on clinical management. KEMRI is currently researching development of hard-wearing and cheaper bednets and alternatives to chloroquine. TDR has provided funding for KEMRI studies that focus on schistosomiasis treatment, prevention, and control; the distribution and impact of filariasis as well as treatment with ivermectin and anthelminthics; and control and treatment of leishmaniasis. Research into leprosy is seeking better drugs, better diagnostic tools, and ways to increase patient treatment compliance.^ieng

Health promotion in South East Asia.

PIP: The countries of the South East Asia region, which includes Bangladesh, Bhutan, Pakistan, Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, and Thailand, have undertaken a variety of strategies to address the health challenges in the region. The ever-growing pressure of population in the region has allowed rapid transmission of communicable diseases like malaria, tuberculosis (TB), leprosy, and HIV/AIDS. One of the innovative community-based health initiatives in response to this problem is Indonesia's Primary Health Care Project. This project aimed to develop a sustainable health infrastructure by training medical staff, coordinators, village cadres, midwives and those working for TB programs; provision of ongoing guidance and education in this area; and provision of medicines and funds. The project has pioneered a process towards positive changes. Another strategy is the collaboration of youth groups, island development committees, and health workers in Maldives which has led to the declaration of two islands (Madifushi and Haa Alif Berinmadhoo) as 'no smoking' islands. In addition, Sarvodaya has successfully developed a methodology to involve Buddhist monks in AIDS prevention and control through "the Buddhist approach to AIDS prevention in Sri Lanka."^ieng

Study on the detection of leprosy reactions and the effect of prednisone on various nerves, Indonesia.

This paper presents a retrospective study on the detection of the treatment of leprosy reactions in a field situation, and the effect of prednisone on the various affected nerves. Two patient cohorts were analysed. The leprosy control programme in the testing area is not backed up by a specialized referral leprosy hospital, but patients are treated on an ambulatory basis at peripheral health centres by trained multipurpose health workers supervised by the health centre doctors. For operational purposes the guidelines and procedures for reaction management in the field were adjusted and partially simplified. In both studies it appeared that the time of the occurrence of severe reactions was the same: 80% or more of the severe reactions occurred in the first year of treatment, the majority in the first few months after the start of the multidrug (MDT) treatment. One third of all reaction patients suffered from a silent neuritis. Well-instructed fieldworkers proved to be competent in detecting and treating leprosy reactions. Treatment of severe reactions with prednisone in the field situation can preserve or considerably improve the functions of the affected nerves. It is interesting that often the motor function of a nerve was found to be impaired without any loss in sensibility, which was tested using the ballpoint pen method.

PIP: A retrospective study of two patient cohorts in Central Sulawesi, Indonesia, analyzed the detection of the treatment of leprosy reactions in a field situation and the effect of prednisone on the affected nerves. In Indonesia, leprosy patients are treated on an outpatient basis at peripheral health centers by trained multipurpose health workers supervised by the health center doctor. The first cohort included 69 patients with severe reactions (125 affected nerves) and the second was comprised of 85 patients with severe reactions (180 affected nerves). Both groups were treated with the minimum standard dose of prednisone for 10 weeks. 81% of severe reactions occurred in the first year of treatment. 27% appeared to suffer from a severe reaction at the time of first contact. The ulnar nerve was most frequently affected. 33% of all reactors suffered from a silent neuritis. 75-80% of affected nerves improved either partially or totally. Treatment of severe reactions with prednisone appears to preserve or considerably improve the functions of the affected nerves. In many cases, the nerve's motor function was impaired with no loss in sensitivity. These findings confirm that well-instructed leprosy field workers are capable of detecting severe reactions on a timely basis and are competent to treat these complications adequately.

Tuberculosis prevention: where do we go from here?

PIP: The Karonga (Malawi) Prevention Trial revealed that repeat BCG vaccinations did not protect against pulmonary tuberculosis (TB) but appeared to provide some protection against glandular TB. They increased protection against leprosy. In fact, a single BCG vaccination conferred 50% protection against leprosy and a repeat BCG vaccination increased protection by another 50%. This trial's findings confirm the need for maintaining BCG vaccination programs in countries where leprosy is a public health problem, for individuals at high risk of leprosy (i.e., contacts of leprosy cases), and because BCG provides some protection against severe forms of TB (i.e., miliary disease and TB meningitis). An alternative TB vaccine needs to be developed, however. The protective efficacy of BCG against pulmonary TB is higher at latitudes far from the equator (80% in northern Europe vs. 0% in India and Malawi). It appears that the immunologic effects of environmental mycobacteria compromise BCG's protective effect against pulmonary TB. There is heterologous immunity between various mycobacterial infections. Low-level delayed-type hypersensitivity (DTH) to tuberculin in non-BCG vaccinated people reflects exposure to environmental mycobacteria. These people are at lower risk of TB than are people with either no DTH or strong DTH to tuberculin. Intradermal exposure to different mycobacteria provides varying degrees of protection against TB in guinea pigs. The warmer and the wetter the environment, the more widespread is colonization by mycobacteria. An area of future research is mapping the distribution of environmental mycobacteria, correlating it with the pattern of DTH responses to tuberculin, and then laboratory work to isolate relevant antigens of the mycobacteria. Another approach is identifying mycobacterial antigens that elicit protective immune responses in vitro so researchers can then identify which antigens and responses are associated with patterns of DTH known to reflect low risk of TB and which response patterns are elicited by BCG against leprosy but not TB antigens. New vaccines are not on the imminent horizon, however.^ieng

Tuberculosis control programme in rural area: experiences from the field.

PIP: According to the Indian National Tuberculosis Program (NTP), only 30% of tuberculosis (TB) patients receiving conventional treatment and 52% of those receiving short-course chemotherapy (SCC) complete the treatment. Incompletely cured patients return to the community, and each sputum-positive case can infect 10-14 people in the course of a year. Direct monitoring of chemotherapy is a must for success, especially if rifampicin is used after accurate diagnosis based on bacteriological examination. The National Leprosy Eradication Program, which has involved voluntary organizations, provides an example to be followed by NTP. This example was considered when the Karuna Trust, a voluntary organization, launched a TB control program on January 1, 1992, for Yelandur taluk, covering a population of 69,484 in 40 villages. A staff consisting of a medical officer, a supervisor, a smear technician, and paramedical workers had undergone training at the National TB Institute in Bangalore. Detection of cases was carried out by house-to-house visits, which could detect about 65% of cases. It was also found that TB treatment had been started without a sputum examination, sputum-positive cases had been on rifampicin, and data recording was incomplete. Up to October 1994, a total of 231 cases were registered and compliance was ensured by home visits. Private practitioners were carrying out harmful activities by not enforcing full patient compliance and thereby contributing to the increasing number of drug-resistant cases. In contrast, this program had a default of only 19.1% among sputum-positive cases, but even these can be recovered with an interaction with private practitioners. Treatment failure amounted to 10.1%, all having been on rifampicin. Retreatment requires more expensive second-line drugs. Drug collection will be decentralized for the convenience of patients; and an adequate supply of drugs was secured. Some suggestions were also made concerning adequate resources, integration of the program, monitoring, and involving nongovernmental organizations in implementation and evaluation.^ieng

Integrating leprosy control into primary health care: the experience in Ghana.

Integration of leprosy control into primary health care is the most comprehensive and permanent system of delivering care to leprosy patients. But so far only a few countries have adopted this approach, largely on account of a fear of failure. Over the past decade Ghana has developed a model approach towards the transition from a vertical to an integrated programme. The highlights of our approach included the development of the leprosy service as part of the overall development of the health service, increasing capacity building for leprosy control at the district and subdistrict levels as well as the establishment of a regular and effective monitoring to identify and correct operational problems early. This paper describes the principles behind the integration, the strategies adopted and how they were implemented. It also includes the achievements made as well as the problems that were encountered and how they were solved.

PIP: During the period from the late 1940s to the mid-1980s, the Ghana Leprosy Control Programme was a vertical program based out of Ankaful Leprosy Hospital. It has four other leprosy hospitals. The administrative and technical aspects of the program, once handled by the program's Senior Medical Officer, are now handled at the regional, district, and subdistrict levels. Headquarters' responsibilities now include development of national leprosy control policies, monitoring and evaluation of regional programs, technical advice and support, intermediary between the Ministry of Health (MOH) and donors, development of health education materials, and training of trainers in leprosy control. Events leading to integration of leprosy control into primary health care include: the 1978 Alma Ata Conference and resultant reorganization of the MOH; 1981 termination of training of specialized leprosy technical officers and training of multipurpose technical officers for epidemiology; and the economic crisis in the early 1980s. Since the mid-1980s, the MOH has introduced various initiatives to strengthen health care management at the district level (e.g., establishment of district health management teams). Once the MOH set the foundation for integration at the district level, in phases, it devolved the program's administrative functions to regions and some functions to district and subdistrict levels; prepared health care managers and providers for management of leprosy control within their regions; clarified roles of specialized leprosy technical officers vis-a-vis nonspecialized leprosy care providers; set up systematic monitoring and evaluation of programs at all levels; and strengthened the capacity of district hospitals to recognize and manage leprosy complications. Headquarters oversees the regions two times per year. The leprosy technical officer monitors each district four times per year. The district technical officer oversees each subdistrict once a month. Each level provides feedback. Donors were amenable to the transition's changing needs.

China aims to improve health of newborn by law.

PIP: Effective June 1, 1995, China will have a new law covering aspects of maternal and infant health care. The controversial law provides for improvements in perinatal health care, but it also mandates a premarital physical examination for couples to determine if either person has a genetic or infectious disease or a mental disorder which would have an adverse effect on marriage and childbearing. Marriage must be postponed if any of the defined infectious diseases (including AIDS, gonorrhea, syphilis, and leprosy) or a mental disorder is detected. In cases of genetic diseases, the couple must agree to adopt longterm contraceptive measures or to become sterilized. When a serious genetic defect is uncovered during a pregnancy, physicians are to advise abortion. Whereas the law stipulates that consent must be obtained before an abortion or sterilization is performed, there is concern that the law will lead to forced sterilization. Also, medical experts are still trying to devise a list of "serious genetic disorders" in a social climate which has little tolerance for any type of disability. The new law forbids the use of prenatal testing to determine the sex of a fetus unless there are medical indications for such a determination. In some areas of China, selective abortion of female fetuses has resulted in a birth ratio of 131 boys to 100 girls.^ieng

Communicable disease control as a Caribbean public health priority.

PIP: The English-speaking Caribbean is in transition toward communicable disease health patterns seen in the more developed world. Structural adjustment policies in recent years have weakened control measures, such as water supply and sanitation, as illustrated by recent outbreaks of typhoid fever in Jamaica (1990-1991), increased malaria incidence in Suriname and Guyana (with temporary importation into southern Trinidad in 1991), an upswing in tuberculosis in some countries, and the occurrence of cholera outbreaks in Belize, Suriname, and Guyana. The emergence of epidemic cholera throughout most of Latin America in 1991, and Caribbean mainland countries in 1992, aroused concern. Deteriorating socioeconomic conditions and the consequent communicable disease risk underscored the absence of communicable disease control in the Caribbean Cooperation in Health (CCH) strategy which was adopted in 1986 by the countries of the Caribbean Community. The Caribbean Epidemiology Center (CAREC) offered the following analysis: At least four out of seven CCH priorities already directly address critical aspects of communicable disease control, and therefore the question arises whether communicable disease control should be recognized as an explicit CCH priority. Beyond cholera and the diseases already represented in the CCH strategy, there are only a few other communicable diseases that warrant specific attention at this time: tuberculosis; leprosy, which CAREC member countries may want to eradicate; and leptospirosis, a zoonosis (communicable disease of animals transmissible to humans) thought to be the most frequent disease of this type in the Caribbean. These three conditions are insufficient to justify a distinct communicable disease grouping within CCH. However, if all communicable diseases of public health importance were to be grouped together (AIDS/STD, vaccine-preventable diseases, food- and waterborne diseases, vector-borne diseases), such a group would be important enough to justify a distinct priority category, with several major subcategories.^ieng

[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.

Health and development of mothers through system of ICDS.

PIP: In order to accelerate welfare and nutrition programs for women and children in tribal, hilly, and backward areas of India, the government of India has accepted the National Program of Integrated Services. Delivery of these services is coordinated by the Integrated Child Development Services (ICDS). The package of services for prenatal women include physical and obstetrical exams; serial recording of weight, blood pressure, hemoglobin, and urinalysis; tetanus immunization; iron (60 mg) and folic acid (.5 mg) tablets; food supplements; identification and referral of high-risk mothers; and health education on antenatal care, breast feeding, child rearing, and family planning. Postnatal women received 2 home visits within 10 days of delivery and make 1 visit after 1 month of delivery. These visits cover general health, breast feeding, delivery records, infant health, and birth control measures. Food supplementation continues for nursing mothers. All women 15-44 years of age receive health and nutrition education. Specially organized courses, campaigns, home visits by anganwadi workers, cooking demonstrations, and mass media emphasize simple messages regarding health and nutrition. Areas that are covered include family welfare; antenatal, intranatal, and postnatal care; breast feeding; immunization; prevention of such common communicable diseases as malaria, tuberculosis, and leprosy; weaning and supplementary feeding; improvement of children's nutritional status; balanced diet; food storage, preparation, cooking, and serving; eye and ear care; personal and environmental hygiene; sanitation; management of acute respiratory infections; management of diarrhea; and control and treatment of internal parasites. The mobile food and extension units of the Department of Food are utilized. Pregnant and nursing mothers belonging to families of landless agricultural laborers, of marginal farmers, of the scheduled caste, of the scheduled tribe, and of poorer sections of the community are chosen for this program. Special care is given to pregnant women who: are pregnant for the 1st, 3rd, or 4th time; have gained less than 6 kg; are younger than 18 or older than 35; have had frequent or twin pregnancies; have a history of miscarriage or preterm delivery; are anemic; or have a history of edema, hypertension, or seizure. Personnel, who are monitored, receive training supplemented by reorientation and continuing education.^ieng

Traditional healers and community health.

A review of projects in various countries suggests that traditional healers, if properly trained, can contribute significantly to the work of primary care teams. Recommendations are offered with a view to making the best possible use of this valuable resource.

PIP: Positive outcomes, constraints, and future involvement of traditional healers in community health projects is reviewed. 17 projects of which 2 were nongovernmental were included in the analysis of traditional practitioners trained in implementing 1 or more primary care (PHC) activities. Traditional medical persons were, for instance, herbalists, diviners, spiritual or faith healers, traditional midwives, and birth attendants, who worked well with other staff and were willing to contribute to PHC. Skills were taught in promotion of 1) health education and prevention relevant to local problems; 2) improving nutrition and food supplies (breast feeding, weaning foods balanced diets, kitchen gardens); 3) safe drinking water supplies and sanitation; 4) maternal and child health care and family planning (pregnancy monitoring, risk referral, contraceptive distribution); 5) prevention and control of local endemic diseases (diarrhea and oral rehydration therapy--ORS, tuberculosis, leprosy, malaria, malnutrition) and referral for treatment; 6) immunization and referral of children 5 to clinics for vaccination; and provision of 7) treatment of common diseases and injuries (1st aid and accident prevention); and 8) essential drugs and maintenance of a basic dispensary. Examples are given for Ghana, Swaziland, Nepal, and brazil and show the high level of interest of healers. There was increased use of ORS and decreased use of purges, use of handwashing in basins, construction and use of latrines, increased referrals, and increased use of midwives for birthing. 7 projects showed improvements in attitudes, knowledge, and behavior of healers; in the health status of population; and in attitudes and behavior of health staff. Constraints were the lack of government recognition of the value of traditional healers, of government commitment, and of dialogue between healers and government staff. Clearly defined roles and tasks are important for deterring problems. Harmful practices of healers can interfere with proper medical care. Recommendations were to stimulate government action to incorporate traditional healers into health services, to define carefully the role of healers, to engage in evaluation research with other sectors, to tailor training programs to the needs of local traditional healers, and to develop effective strategies to integrate healers. Traditional healers are a valuable resource in PHC.

Care and development of children in tribal areas.

PIP: About 53 million people (8% of the population) of India belong to various tribes in about 400 tribal communities. These groups live in different ecological geoclimatic conditions throughout India ranging from the Sub-Himalayas to the islands in the Bay of Bengal and in the Arabian Sea. They also differ in distinct biological traits and cultural and socioeconomic background. Due to cultural patterns which vary from tribe to tribe, they are all at different stages of social, cultural, and economic development. Since the tribes live in isolated and inaccessible areas, it is hard to implement health care and nutrition activities, elementary education, and preventive promotive health care. The government does plan to provide rural day care for 0-3 year old children. The Integrated Child Development Services (ICDS) Scheme reaches 2197 of 5143 tribal development blocks. ICDS activities include immunization of children and mothers, health education, and supplementary nutrition. The government also promotes primary health care in tribal areas. Despite these efforts, child welfare and development in tribal areas have not improved. Recently nongovernmental organizations have joined child welfare and development efforts in tribal areas. The Jigyansu Tribal Research Center has compiled a long list of recommendations to improve child welfare and development efforts in tribal areas including improving preventive activities especially those that target specific local diseases such as cerebral malaria and leprosy, introduction of traditional herbal medicines, and comprehensive data collection.^ieng

The relationship of training programs to public health nurses' competencies in primary health care.

PIP: The objective was to determine the types of training programs that Philippine public health nurses participated in, and to determine whether this participation contributed to their competencies in primary health care. Subjects consisted of 110 public health nurses. 44 of them were graduates of the 3-year nursing program (GN). 65 were graduates of the 4-year nursing program. The number of years in service ranged from 1 month to 37 years. All the subjects, except one, were graduates of the more cure-oriented and hospital-based traditional curriculum. 26 (23.64%) never participated in any training program, 29 (26.36%) participated in 1-3 programs, 45 (40.91%) participated in 4-6 programs; 9 (8.18%) participated in 7-9 programs and 1 (.91%) participated in 10 training programs. Approximately 75% of the programs involved health services about diarrhea, tuberculosis, acute respiratory, infections, vitamin-mineral deficiency diseases, cardiovascular diseases, leprosy, psychiatric emergencies, disaster preparation, first aid, family planning, child survival, and immunization. The first hypothesis was the there is no significant difference in the competencies of public health nurses who participated in less than 4 (group I) training programs and those who participated in 4 or more training programs (group II). The mean number of training programs for the entire group was 3.45; 1.24 for group I and 5.65 for group II, a significant difference (p 0.05). The mean score of Group I was 2.78 vs. 2.85 for Group II. The t-test (t=1.10) showed no significant difference between the 2 means. Thus the competencies of the 2 groups were equivalent. The 2nd hypothesis was that there is no relationships between competencies and number of training programs. Pearson's r test indicated r equal to t. 145, therefore a positive but weak relationship existed between the 2 variables. The above findings reveal that the training programs were not comprehensive enough to produce the expected competencies measured by the instruments used.^ieng

Drug supply in Nigeria.

The health situation in Nigeria is typical of tropical Africa. It is characterised by high childhood and maternal mortality and a relatively short life expectancy. Mortality in childhood in due mainly to diseases like malaria, measles, poliomyelitis, tetanus, diarrhoea and acute respiratory tract infections. Diseases like filariasis, schistosomiasis and leprosy which are now readily controlled by drugs cause considerable morbidity in later life. Although the technology and tools (particularly vaccines and drugs) for the control of most of these diseases are now available, it has not been possible to make optimal use of them in Nigeria and other tropical African countries because of unfavourable social and economic conditions. The non-availability of drugs most needed for healthcare and disease control has been found to be due not only to insufficient funds but also to the use of the limited funds on expensive drugs that have little bearing on the disease pattern. The Essential Drug Programme initiated by the World Health Organisation, now adopted by Nigeria and about 100 other countries mostly in the Third World, aims to correct this unsatisfactory drug supply situation by ensuring that the available funds are used to provide those drugs needed by the large majority of the people and are made available at all times at prices that most people can afford. The Bamako Initiative in the African Region of the World Health Organization is also designed to ensure regular availability of drugs particularly to primary healthcare facilities. Seed drugs are provided to the health institutions either by the National Government or through external aid. These are sold to patients at a small profit margin. The proceeds are then used to replenish stocks and the small profit used to improve services in the health centre. The introduction of these programmes in Nigeria has improved drug availability considerably in the past couple of years and should soon start yielding further dividend in the form of measurable improvement in the health situation.

Status of health in India and its future prospects.

PIP: This overview of health programs and conditions in India reveals that health is related to economic development antipoverty measures, food production and distribution, drinking water supply, sanitation, housing, environmental protection, and education. There are urgent requirements for effective intersectorial coordination. Unprecedented growth of 1 million a year has resulted in slums and shanties--a place of epidemics; urbanization has contributed to environmental pollution impacting on health, and water pollution to water-born diseases. Health services are still insufficient to meet the needs. Sanitation practices contribute to cholera, dysentery, diarrhea, enteric fevers, and malaria. Indian Systems of Medicine and Homeopathy must be active in preventive and health care. Accomplishments include in 1987/8 a decline in leprosy cases attributed to the existence of leprosy control units. 40 AIDS Surveillance Units are actively treating and screening. The Naval Goitre Control Programme's goal is replacement of iodized salt for edible salt by 1992, thereby reducing mental retardation and low birth weight babies. The Family Welfare Programme, targets a New Production Rate of Unity before 2000. A National Technology Mission on immunization and the Universal Immunization Programme plans to be operational in all districts by 1990. Oral rehydration therapy programs dispense free packets to fill the needs of 1 million children under 5 who suffer from diarrhea 3 times a year with 3 million facing death. The Primary Health Care Programme provides iron and folic acid to women with nutritional anemia and Vitamin A to children. Health service developments have been increased.^ieng

Pattern of STDs at Davangere.

PIP: The distribution of sexually transmitted diseases (STDs) among 450 patients attending the Department of Skin, STD and Leprosy of JJM Medical College, Davangere, India, from May 1984-December 1988, is discussed. All patients had clinical exam, wet and stained smears of discharge and lesions, dark microscopy, culture and histopathology. The patients were 87.3% male, predominantly aged 21-30 years, and 54.5% middle-income, reflecting the fact that this is an urban, for-profit hospital. The distribution of STDs in order of prevalence was: balanoposthitis 19.3%, donovanosis 15.3%, gonorrhea 10.7%, syphilis 12.2%, lymphogranuloma venereum 10.1%, vulvo-vaginitis 6.9%, non-gonococcal urethritis 6.22%, herpes genitalis 4.89%, venereal warts 4.00%, and chancroid 1.33%. The vulvo-vaginitis was accounted for by bacterial, candidal and trichomonal infections, and 16.1% labeled nonspecific. The high incidence of donovanosis was noted in the discussion.^ieng