Leprosy - one of the few diseases which can be eliminated

1. Leprosy - one of the few diseases which can be eliminated • Leprosy meets the demanding criteria for elimination • practical and simple diagnostic tools: can be diagnosed on clinical signs alone; • the availability of an effective intervention to interrupt its transmission: multidrug therapy • a single significant reservoir of infection: humans.

2. Why integrate leprosy into the general health services? • Integration means to provide “comprehensive” essential services from one service point • to improve patients’ access to leprosy services and thereby ensure timely treatment • to remove the “special” status of leprosy as a complicated and terrible disease • to consolidate substantial gains made • to ensure that all future cases receive timely and correct treatment • to ensure that leprosy is treated as a simple disease

3. Why is coverage so important? • Good coverage means that: • health facilities are easily accessible to every member of the community • health services are provided on a daily basis • health workers are able to diagnose, cure and provide basic information about the disease • health facilities are distributed equally in all areas • urban/rural, male/female, poor/rich, tribal/others, etc.

4. Advantages of Integrating Leprosy Services • Patients detected early • Patients treated early • Transmission of infection interrupted early • Development of deformities prevented • Stigma reduced further

5. Diagnosing a case of leprosy

6. We must follow good practices • Good practices are: • be friendly • give correct information about the disease • answer questions /doubts • keep confidentiality • keep up to date records • give choice to patient to decide when and where to come back • use MDT in a flexible manner • provide leprosy services free of cost • avoid unnecessary investigations

7. How to diagnose leprosy • Examine skin • Check for patches • Test for sensation • Count the number of patches • Look for damage to nerves

8. Signs of leprosy • Pale or slightly reddish patch • Definite loss of sensation in the patch • Signs of damage to nerves • definite loss of sensation in hands/feet • weakness of muscles of hands/feet/face • visible deformity of hands/feet/face

9. What is not leprosy • Skin patches which • have normal feeling • are present from birth • cause itching • are white, black, dark red or silver coloured • show scaling • appear and disappear periodically • spread quickly

10. What is not leprosy (cont.) • Signs of damage to hands/feet/face without loss of sensation • due to other reasons like injury, accidents, burns, birth defects • due to other diseases like arthritis • due to other conditions causing paralysis

11. How to examine for leprosy? • Examine in a well-lit room • Examine the whole body • Ask since when the patch was noticed • Ask what treatments have been tried • Test for sensation • Look for any visible deformities

12. Check for loss of sensation • Take a pointed soft object (feather, cotton wick) • Lightly touch alternately the patch & normal skin • Ask the person to point where they were touched • Ask them to close their eyes and repeat the procedure • In case of loss of sensation the person will be able to point to where they were touched on the normal skin but not on the patch

13. Treating a case with MDT

14. Classification for treatment • The diagnosis is made based on finding definite loss of sensation in one or more patches. • When you have examined the whole body, count the number of patches. • 1-5 patches is paucibacillary (PB), more than 5 patches is multibacillary (MB) leprosy

15. Standard WHO-MDT for the treatment of leprosy

16. Steps to start MDT • Classify as PB or MB leprosy • Inform the patient about the disease • Explain the MDT blister pack - show drugs to be taken once a month and every day • Explain possible side effects (e.g. darkening of skin) and possible complications and when they must return to the health centre • Ask the patient when it is convenient for him/her to come back to the health centre. Give enough MDT blister packs to last until the next visit. • Fill out the patient treatment card

17. Treatment regimens • PB Adult • (6 blister packs) • Rifampicin 600 mg once a month • Dapsone 100 mg every day • MB Adult • (12 blister packs) • Rifampicin 600 mg once a month • Clofazimine 300 mg once a month • Clofazimine 50 mg and dapsone 100 mg every day

18. Multi Drug Therapy

19. Multi Drug Therapy

20. Keeping good records • Good records include: • Patient identification (name, age, sex, address) • Remark on history of complaint (what, how long, progress) • Remark on history of previous treatment (what, where, how long, result) • Current treatment (diagnosis, classification, any visible disability, date of first dose, date of next appointment) • Record of special events (what event, date, how managed, referral) • Date of cure

21. Information to patientsAbout the disease • Caused by a bacteria • Affects skin and sometimes nerves • Progresses slowly • Easy to diagnose and cure • Lead normal life, do not change life style

22. Information to patientsAbout the treatment • MDT will cure you completely • MDT is free of cost • MDT is available in all health centres • MDT should be taken as advised (regular, full course) • If you have problem or questions contact your health centre

23. Information to patientsAbout possible problems • Skin discoloration due to clofazimine • Urine discoloration due to rifampicin • In case of fever, pain in the nerves, muscle weakness, joint pains they must return immediately to the health centre • In case of eye problems • Appearance of new skin patches • How to protect insensitive hands/feet

24. What is Accompanied MDT (A-MDT)? • A patient receives • a full course of MDT at the outset • receives information (verbal and printed materials) about the disease, its treatment and when and where to come for follow up, and • someone close to or important to the patient assumes the responsibility of ensuring that the patient completes a full course of treatment. • Note: In some areas (difficult to access, poor security etc) or for some patients (students,workers etc), this will ensure that all patients have adequate supply of MDT at home.

25. Curing the disease • Provide the correct blister packs (MB/ PB/ Child/ Adult) for correct duration (6 for PB & 12 for MB) • Explain how to use the blister pack (MB or PB) • Give the first dose at soon as diagnosis is made • Explain about the importance of regular treatment • Encourage to ask questions and remove doubts • Check when it is convenient to come back to the centre • Give enough blister packs to cover the interval • Encourage patients to come in case of problems/ doubts

26. Red coloured urine Darkening of skin Severe itching of skin This is due to rifampicin. Lasts only for few hours Reassure the patient that this is harmless This is due to clofazimine. Reassure the patient that this will disappear after treatment is completed This is due to allergy to one of the drugs (commonly to dapsone). Stop all medicines and refer to hospital MDT side-effects

27. How to manage complications

28. Some patients may develop complications • Leprosy reactions • Side-effects • Disabilities

29. 1 or 2 patients in 10 may develop reactions Reactions are not a side effect of MDT. They are the body’s response to leprosy More commonly seen in MB cases (more than 5 lesions) Signs and symptoms include Skin: patch/s becomes reddish and/or swollen; sometimes painful reddish nodules appear Nerves: pain in the nerve and/or joint; loss of sensation and weakness of muscles (commonly of hands, feet and around eyes) General: fever, malaise, swelling of hands/feet Leprosy reactions

30. Managing reactions (1) • Early diagnosis and prompt treatment of reactions • Every patient should be informed about the signs and symptoms of reactions • Inform them to go as soon as possible to the health centre • Reassure patients that: • reactions can be treated • they are not a side-effect to MDT • does not mean that MDT is not working

31. Managing reactions (2) • Rest is very important: • Help to get leave from work or school for a few days (e.g. medical certificate) • Control of pain and fever • Aspirin or paracetamol • Continue MDT regularly

32. Managing reactions (3) • Reactions which only involve the skin: • rest and pain-killers are usually sufficient. • If there is no improvement within few days or worsening, then specific treatment is needed • Reactions which involves the nerves • start treatment with a course of corticosteroids (e.g. prednisolone) as soon as possible • will control all signs/symptoms of reaction

33. Before starting treatment with prednisolone • Make sure that you have adequate stock • One course will require 336 tablets of 5 mg each • The course lasts for 12 weeks • It is better to examine the patient once every 14 days and reduce the dose • Advise to take the total daily dose every morning • If you do not have adequate stock, then start treatment and refer to another centre/hospital • Always send a written note with the patient, when you refer

34. Suggested course of prednisolone • 40 mg (8 tablets) every morning for 14 days • 30 mg (6 tablets) every morning for 14 days • 20 mg (4 tablets) every morning for 14 days • 15 mg (3 tablets) every morning for 14 days • 10 mg (2 tablets) every morning for 14 days • 5 mg (1 tablets) every morning for 14 days • Note: Continue rest and aspirin or paracetamol as required • Examine the patient every 14 days before reducing the dose • If there is no improvement or worsening, refer to hospital • Continue MDT regularly

35. Why do disabilities occur? • Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because: • Late diagnosis and late treatment with MDT • Advanced disease (MB leprosy) • Leprosy reactions which involve nerves • Lack of information on how to protect insensitive parts

36. Disabilities can be prevented • The best way to prevent disabilities is: • early diagnosis and prompt treatment with MDT • Inform patients (specially MB) about common signs/symptoms of reactions • Ask them to come to the centre ASAP • Start treatment for reaction ASAP • Inform them how to protect insensitive hands/ feet /eyes • Involve family members in helping patients

37. Cracks and fissures Blisters Simple ulcer Soak in water Apply cooking oil/Vaseline Use footwear Do not open blister Apply clean bandage Clean with soap & water Rest and clean bandage Care of feet

38. Infected ulcer Wounds/injury Weakness/paralysis Clean with soap & water Rest & apply antiseptic dressing Soak in water Apply cooking oil/Vaseline Clean and apply clean bandage Protect when working/cooking Oil massage Exercises Refer Care of feet (2)

39. Redness and pain Injury to cornea Difficulty in closing eye Aspirin or paracetamol Atropine and steroid ointment Cover with eye pad Apply antibiotic ointment Refer Tear substitute eye drops Exercises Dark glasses to protect Refer Care of eyes

40. When treatment is completed • Congratulate the patient • Thank family/friends for their support • Reassure that MDT completely cures leprosy • Any residual lesions will fade away slowly • Show them how to protect anaesthetic areas and/or disabilities • Encourage to come back in case of any problem • Tell that they are welcome to bring other members of family or friends for consultation • Remove the patient’s name from the treatment register