Leprosy Training Module for Medical Officers

NLEP
Leprosy
Training Module
for Medical Officers
Dr.A.S.sanghvi & State Leprosy Cell
Commissionerate of Health, Medical Services and Med. Ed. ( H )
Gandhinagar, Gujarat.

Index
C h a p t e P g
T a s k o f M e d i c a l O f f i c e r s f o r N L E P
T h e D i s e a s e L e p r o s y
3 E p i d e m i o l o g y
D i a g n o s i s & C l i n i c a l E x a m i n a t i o n
5 C l a s s i f i c a t i o n o f L e p r o s y
6 T r e a t m e n t o f L e p r o s y
7 R e a c t i o n s i n L e p r o s y
8 D i s a b i l i t i e s i n L e p r o s y 5
P r e v e n t i o n o f D i s a b i l i t i e s ( P O D ) 6
E l i m i n a t i o n o f L e p r o s y & I n t e g r a t i o n 8
S i m p l i f i e d I n f o r m a t i o n S y s t e m ( S I S ) 8 6
Sr.No. r . No.
1. 1
2. – 2
. 4
4. 9
. 24
. 40
. 46
. 9
9. 9
10 . 2
11.

Task of Medical Officers for NLEP
( A ) CLINICAL :
1. To make the diagnosis & classification of all Leprosy cases .
2. To decide type of treatment and supervise the same.
3. To diagnose drug reactions.
4. To define and grade the disabilities.
5. To counsel the patient regarding regular and complete treatment.
( B ) MANAGERIAL :
1. To plan for MDT services from PHC and sub-Centres .
2. Management of MDT logistics.
3. Requisition of MDT from DLO .
4. To supervise maintenance of patient treatment register and MDT drug
register.
5. To identify problems and difficulties of staff.
6. To monitor staff performance.
7. To monitor NLEP situation in PHC area through NLEP indicators
8. To verify validity of information and records.
9. To prepare action plans to eliminate Leprosy in PHC area.
10. To prepare action plans for IEC activities.
1

The Disease
Leprosy

The Disease – Leprosy
Leprosy is a chronic infectious disease caused by the bacteria
known as Mycobacterium leprae. The disease mainly affects the
peripheral nerves, skin, and occasionally some other structures.
All systems and organs can be involved in leprosy except the Central
Nervous System .
Though it is highly infectious disease , but we are not getting too many
cases in the society , because these bacilli are having very low pathogenicity
( capacity to produce clinical form of disease ).
Leprosy, with long incubation period between 9 months to 20 years after
infection can affect all age groups. The signs and symptoms may vary
between PB to MB depending upon the degree of patient’s immunity to
M. leprae, the causative agent. Nevertheless, 95 % of the people in our
community are immune to Leprosy. Since the Leprosy bacilli affect the
peripheral nerves, and if not properly cared, the patients lose sensation by and
large, in their hands, feet and eyes, and injuries to these insensitive parts may
lead to disfigurement, which is the main consequence of this disease, that
generates fear and stigma. The early detection and prompt treatment of
Leprosy with prescribed MDT not only cures Leprosy but also interrupts its
transmission to others.
However, the social picture of Leprosy over the last decades. Now, it is
being regarded as a public health disease just like many others, and patients
are being treated by general health services. All countries have officially
adopted the out patient clinic as the base for treating Leprosy, while old and
stigmatising leprosaria are being phased out. This optimistic approach
deserves strong support from health personnel and others at all levels in order
to guarantee patients adequate treatment as well as self respect.
2

N
The Causative Organism – M. leprae
Leprosy is caused by Mycobacterium leprae, which was discovered
in 1873 by Hansen at Bergen in Norway. These Mycobacterium leprae
are pleomorphic, straight or slightly curved, rod – shaped gram positive
micro - organisms. They may appear like solid rods, fragmented or
granular. They are acid fast bacilli ( AFB ), because they are stained red
by a dye called carbol fuschin , and this red colour can not be removed
either by acid or alcohol. M. leprae is less acid fast than M. tuberculosis.
The presence of the bacilli can be demonstrated by taking skin
smears, and after staining with Zeihl Neilson stain , these bacilli can be seen
under microscope. They are seen lying singly, in clumps or in compact
masses known as globi. The living Leprosy bacilli appear as solid staining,
i.e., bright pink rods with rounded ends and uniformly stained through
their entire length. Although the discovery of Leprosy bacilli reported as early
as 1873, they could not yet be grown in artificial culture media. The generation
time of M. leprae in the mouse footpad is 12 – 14 days ( longest of any known
bacterium ). In comparison with this, the generation time of M. tuberculosis is
only 20 hours.
Leprosy
Patients
Skin Smear
Positive
Infective
Skin Smear
Negative
o n
Infective
As per GOI and WHO guidelines , skin smear examination has
now been stopped.
3

Epidemiology

Epidemiology
In 1991, the World Health Assembly took a measure initiative towards
global elimination of Leprosy, an age old public health problem with
devastating effects on its sufferers. The WHO’s leadership, strong
commitment of endemic countries and active support of NGOs / VOs as well
as donor agencies have jointly helped in reducing the global situation of
Leprosy by about 90 % and the elimination level achieved in more than a
hundred countries.
Currently, only a dozen countries have Leprosy as a major problem, and
India contributes a large proportion ( 66 % ) of global Leprosy burden as
Leprosy had been widely prevalent in this vast and populous country for
centuries.
With efficient implementation of well – planned efforts since 1953 – 54,
India has also very substantially controlled Leprosy. During 1981, our country
recorded a prevalence of 57.6 cases / 10000 population, whereas, in March
2004, the prevalence had been brought down to 2.4 cases / 10000 population.
Situation at the
time of start of
NLEP - 1983
Situation as on
31. 03. 2004
1
P.R. :
57.6 cases 2.4 cases
/ 10000 Pop. / 10000 Pop.
2
Total Cases
registered
29.2 lakh
1
3.45 lakh
3
India has 66 % of the global case load .
4

30
25
25.9
Prevalence Rate of Leprosy - India
20
15
10
5
2.4
0
1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
Prevalence Rate of Leprosy - Gujarat
25.00
20.00
21.1
15.00
10.00
5.00
0.00
84-85
85-86
86-87
87-88
88-89
89-90
90-91
91-92
92-93
5
93-94
94-95
95-96
96-97
97-98
98-99
99-00
00-01
01-02
02-03
03-04
Oct. 04
0.95

District wise case load of Leprosy – March 2004
Rest 16 Districts
22%
Bharuch
9%
Dahod
8%
Dangs
1%
Narmada
1%
Valsad
13%
Navsari
11%
Godhra
8%
Vadodara
10%
Surat
17%
Districtwise Prevalence Rate (PR) of Leprosy (Nov-04)
3.50
3.00
3.38
3.18
3.00
2.50
3.05
2.56
2.00
2.01
1.50
1.50
1.00
0.50
0.00
Dangs
Navsari
Dahod
Valsad
PM
Bharuch
Vadodara
Surat
Narmada
Junagadh
Anand
1.10
5
Kheda
Bhavnagar
6
Jamnagar
Porbandar
Rajkot
G'Nagar
SK
A'Bad
S'Nagar
Amreli
Katchchh
Mehsana
Patan
BK

Spread of Leprosy
Source of Infection :
Man is the only known source for M.leprae. Among human beings it is the
untreated MB leprosy patient who acts as a source of infection.
The occurrence or the non – occurrence of the disease is closely
associated with the cell – mediated immune response of the host , to the
challenge by the Leprosy bacillus.
Transmission of Leprosy :
Leprosy is transmitted from one untreated Multibacillary patient to another
person via mainly the respiratory tract or skin.
Portal of Exit :
The major sites from which bacilli escape from the body of an infectious
patient are the nose and mouth.
Lepromatous patients in their nasal secretions can excrete as
much as 10 million viable organisms per day.
Viability of M. Leprae outside the human host :
M. Leprae can survive up to 7 to 9 days in nasal secretions , in shady
places .
Portal of Entry :
As such portal of entry of M. Leprae into human body is not definitely
known, the two portals of entry seriously considered are the skin and the
upper respiratory tract. Although entry through respiratory route appears most
probable, other routes, particularly broken skin, cannot be ruled out.
7

Incubation Period
The period between the time of entry of the organism and the time of
onset of clinical signs is called incubation period.
As such, in Leprosy, these two reference points for measuring the
incubation period are difficult to define. The former ( time of entry of the
organism ) because of the lack of adequate immunological tools and the latter
( time of onset of clinical signs ) because of the insidious nature of the onset of
Leprosy.
The incubation period in Leprosy in variable. It could be as small as 6
months or as long as 30 years. It is believed that the incubation period could
be an average of 2 – 5 years.
Summary
1. Leprosy is a chronic infectious disease caused by Mycobacterium leprae.
2. It is a public health problem because of the disabilities it produces in a
few patients.
3. India contributes to about 66 % of case load in the world.
4. The bacteria enter and exit the body through nose and mouth.
5. The incubation period is long and variable.
8

Diagnosis
&
Clinical Examination

Diagnosis of Leprosy
A case of Leprosy is diagnosed by eliciting cardinal signs of Leprosy
through systematic clinical / bacterial examination.
Diagnosis of leprosy can be done on the basis of the following cardinal
signs. Presence of any one of the cardinal signs is sufficient to diagnose a
case as a Leprosy case.
1. Hypo pigmented or reddish colour skin patch(es) with
definite loss of sensation
2. Thickness and / or tenderness of peripheral nerves, resulting
into damage to them, demonstrated by loss of sensation and
weakness of muscles of hands, feet or face .
3. Demonstration of acid-fast bacilli in skin smears .
The Skin Lesion can be single or multiple, usually less pigmented than
the surrounding normal skin. Sometimes, the lesion is reddish or copper –
coloured. A variety of skin lesions may be seen but macules ( flat ),
papules ( raised ) or nodules are common. Sensory loss is a typical feature of
PB Leprosy. The skin lesion may show loss of sensation to pin prick and / or
fine touch.
Nerve Damage, mainly to peripheral nerve trunks, constitutes another
feature of Leprosy. There may be loss of sensation in the skin and weakness
of muscles supplied by the particular peripheral nerve affected. In the absence
9

of these signs, nerve thickening by itself without sensory loss and / or muscle
weakness is often not a reliable sign of Leprosy.
Positive Skin Smear : In a small proportion of cases, rod shaped, red
stained Leprosy bacilli, which are diagnostic of the disease, may be seen in
the smears taken from the affected skin when examined under microscope
after appropriate staining.
NEVER diagnose leprosy when you are in doubt .
Ethical responsibilities in Leprosy diagnosis
It is important to remember that the diagnosis of Leprosy
is a very serious matter for the individual and his / her family.
If you are in the slightest doubt, avoid making diagnosis
and categorize the individual as ‘ suspect ’. Inform the
individual about the common signs and symptoms of the
disease and ask him / her to report back after six months, or if
there is any worsening of the signs and symptoms.
Alternatively, the individual may be referred to other
specialists.
10

Clinical Examination
Clinical Examination includes :
A. Interview of patient to get detailed history – case history.
B. Skin examination
C. Nerve examination
( A ) Case History :
• Introduction – Name, age, sex, address, occupation etc.
• Presenting complaints and their duration – A patch of a few days or
present since birth is unlikely to be Leprosy.
• History of recurrence – A recurrent lesion which comes and goes will not be
due to Leprosy.
• Deformity – if any , the time of its onset & nature of its progress
• Treatment History – Treatment taken : Yes or No, Which drugs and for how
long ?
• Associated illness – if any jaundice, cough, swelling of feet at present or in
the recent past.
• Family History – Any other person in the family having similar disease or
had the disease and was treated.
11

( B ) Skin Examination :
Remember the cardinal sign :
Hypo pigmented or reddish colour skin patch(es)
with definite loss of sensation .
Principles of Skin Examination :
1. Choose a spot where good light is available.
2. As far as possible, choose a spot where there is privacy.
3. Always examine the whole skin from head to toe.
4. Compare both sides of the body.
Examine the skin for presence of patch, and if present, following features must
be noted :
1. Site : Useful for follow – up.
2. Number : The number of lesions indicates the severity of the disease. Also
useful for classification and follow – up.
3. Colour : Maybe hypo – pigmented ( lighter in colour than the rest of the skin ) or
erythematous ( red ). Lesions of Leprosy are never de – pigmented.
4. Sensory Loss : This is useful both for diagnosis and classification of Leprosy.
Loss of sensation over a patch is a cardinal
sign of Leprosy ( mostly PB Leprosy ) .
12

5. Tenderness on gentle tapping : In reactional states.
6. Presence of infiltration :
This term refers to skin which is :
thickened ,
shiny and
erythematous.
All three features must be present in the same area. This may be seen in severe
forms of Leprosy.
Test for Anaesthesia
The simplest and quickest way to test for anaesthesia is to use
the tip of your finger to touch the patient. Using your ring or little
finger pulp, touch the patient very gently. If you can feel it, he should
be able to do so also.
Remember :
• Generally, testing for anaesthesia is done with the help of a feather, a
fine wisp of cotton , or the tip of ball - pen.
• Touch only, do not brush across the skin.
• Touch only once in each site tested.
• The testing for anaesthesia is required in two situations :
Presence of patch on skin – Test the anaesthesia over the patch for
fine touch.
Nerve Damage – In case of nerve damage, test for anaesthesia over
the skin supplied by the affected nerve. Test for fine touch, pain and
hot & cold ( by one tube containing hot water and other containing
old water ) sensations. Never do cold testing alone by spirit or spirit
swab. All three modalities of sensation should be tested ad
sometimes only one is affected (dissociated anaesthesia).
13

Method for testing anaesthesia :
First, explain to the patient what you will be doing and how you will
be doing it.
Then, keeping his eyes open, touch on the normal skin of the forehead,
neck and hands, which perceive any sensation the better than any other part
of the body.
The patient now will be able to perceive the touch sensation. Now, ask
the patient to close his eyes. Then, first touch the same normal skin spots
and ask him to indicate the exact points. After this, he will be able to
perceive the touch sensation fully even with his eyes closed.
Now, having his eyes still closed, examine the patch for anaesthesia.
Ask him to indicate the exact location of the point, where the feather has
been touched. Failure to do so shows anaesthesia on the spot.
Note : If he feels it but cannot touch the exact point, it is called misreference,
and this is the earliest sign of anaesthesia.
The normal range of accuracy of his indication of the point
- on the hand is within 1 cm.
- on the face is 2 cm.
- on the back and buttocks is 7 cm.
Remember :
1. The innervation of the face is from multiple sources so that it is not often
anaesthetic.
2. Always proceed from normal skin to abnormal.
3. Give only one stimulus at a time.
4. Vary the pace of testing.
14

( C ) Nerve Examination :
Remember the cardinal sign :
Involvement of peripheral nerves, as demonstrated by
definite thickening with loss of sensation and
weakness of the muscles of hands, feet or face.
Principles of Nerve Examination :
Examination of nerves in all the patients is very important for
prevention of deformity. This involves two aspects :
1. Palpation of Nerves for thickening or tenderness.
2. Assessment of Nerve function.
1. Palpation of Nerves for thickening or tenderness :
Nerve damage, mainly to peripheral nerve trunks, constitutes another feature
of Leprosy. There may be loss of sensation in the skin and the weakness of
muscles supplied by the affected nerve. In the absence of these signs, nerve
thickening by itself, without sensory loss, and / or muscle weakness is often not
a reliable sign of Leprosy.
Remember :
In a healthy subject, most peripheral nerves are palpable.
• When palpating the nerves, you should look for thickening and / or
tenderness.
• When palpating the nerves, the patient should be properly positioned. The
examiner should also be positioned correctly.
• Always compare both sides to assess thickness.
15

• Look at the patient’s face while palpating the nerve to illicit tenderness.
• Always palpate across the course of the nerve.
• Feel along the nerve as far as possible, in both the directions.
• Palpate gently with the pulp of the finger and not the tip.
The ‘ sites of predilection ’ at which the peripheral nerves are
most commonly enlarged and palpable in Leprosy.
16

Nerves in Hand
Ulnar Nerves :
Best palpated at the inner aspect of the elbow in the olecranon grooves with
the elbow semi – flexed. Feel for thickening, irregularity, hardness and
tenderness. Run your hands down the ulnar border of the forearms and the
hands, feeling for dryness of skin and wasting of hypothenar muscles.
Median Nerves :
It may be felt proximal to the wrist, deep to the palmaris tendon when the
wrist joint is semi – flexed.
Radial Nerves :
The radial nerve should be rolled in its groove on the humerus posterior to
the deltoid muscle insertion.
Nerves in Feet
Lateral Popliteal Nerves :
It should be palpated behind the neck of the fibula while the knee joint is
semi – flexed.
Posterior Tibial Nerves :
It should be palpated near the medial malleolus of the tibia.
Nerve in Neck
Great Auricular Nerve :
To examine this nerve, the head should be turned to the opposite side,
thus stretching the nerve across the sternomastoid muscle.
17

2. Assessment of Nerve Function :
Nerve function assessment is useful to identify any impairment of nerve function.
Identification and management of impaired nerve function is important
for prevention of disability in leprosy patients.
Nerve function assessment includes two things :
1. VMT – Voluntary Muscle Test : Testing for involvement of muscles supplied
by the nerve.
2. Sensory test ( S.T. ) : Testing for sensory loss in the area supplied by the
nerve.
Both VMT and ST should be done for :
a ) All patients with nerve thickening
b ) All patients with multibacillary Leprosy
Voluntary muscle testing is done by checking the range of movement to see
whether it is normal, reduce or absent due to muscle paralysis.
If movement is normal, a test for resistance is then done. Press gently in the
opposite direction while asking the patient to maintain the position, resisting
pressure as strongly as possible. Then gradually press more firmly and judge
whether resistance is normal, reduced or absent. Always compare the right side
with the left. The grading of results can be done as follows :
S ( Strong ) = Able to perform the movement
against full resistance
W ( Weak ) = Able to perform the movement
but not against full resistance
P ( Paralysed ) = Not able to perform the
movement at all
18

VMT – Ulnar Nerve
Ask the patient to push his
little finger outwards .
To test for weakness, try to
push the little finger towards
the hand , while the patient
tries to hold it in the test
position .
Grade the muscle power as
S / W / P .
VMT – Median Nerve
Ask the patient to hold his
thumb pointing up to the sky,
while keeping palm parallel to
the ground .
To test for weakness, try to
push the thumb downwards,
while the patient must try and
hold it in the test position.
Grade the muscle power as
S / W / P .
19

VMT – Radial Nerve
Ask the patient to hold his hand
as shown in the figure .
To test for weakness , try to
press the hand in the direction of
the arrow , while the patient tries
to hold it in the test position .
When the patient tries to resist ,
press on the back of the hand
and not the fingers .
Grade the muscle power as
S / W / P .
VMT – Lateral Popliteal Nerve
Ask the patient to pull up his foot
fully , as shown in the figure .
To test for weakness , try to
push the foot downwards as
shown in the figure , while the
patient tries to hold it in the
test position .
Grade the muscle power as
S / W / P .
20

VMT – Facial Nerve
Ask the patient to close his eyes
and keep them lightly closed as if
in sleep. If there is a gap visible
between the upper and lower
eyelids ( Lagophthalmos ) ,
measure the gap.
If there is no gap, ask him to
close the eye tightly, and try to
pull the lower lid down and see
whether the patient is able to
keep his eyes closed against
resistance.
If he is able to do so, the grade is
S, else the grade is W.
If there is a gap when he closes
his eye, the grade is P.
Also note whether the upper
eyelid is able to cover the cornea
completely.
21

ST – Sensory Test – Hand
Ulnar
Median
Radial
ST – Sensory Test – Leg
Posterior Tibial
Lateral Popliteal
22

Points for ST in Palms & Soles
Summary
• Cardinal signs that help Leprosy are :
1. Hypo – pigmented or reddish skin lesion(s) with definite ( complete or
partial ) loss of sensation.
2. Involvement of peripheral nerves as demonstrated by definite thickening
with loss of sensation and weakness of the muscles of hands or feet.
• Examination of skin and nerves helps in identifying cardinal signs and
complications.
• One should examine the patches on the skin for site, number, colour, size
and sensory loss. These characteristics help in diagnosis of the disease and
grouping.
• One should examine the nerve for thickening, tenderness and loss of
function. Loss of function is identified by doing VMT and ST for the specific
nerves.
23

Classification
of
Leprosy

Classification of Leprosy
As per WHO classification, Leprosy is classified
purpose of treatment .
into two types for the
This classification is based on the number of skin lesions and
involvement .
nerve
1. Paucibacillary Leprosy ( PB )
2. Multibacillary Leprosy ( MB )
Skin Lesions :
Includes
Macules - Flat
lesions
Papules – Raised
lesions
Nerve Damage :
Resulting in loss of
sensation or
weakness of muscles
supplied by the
affected nerve
Paucibacillary Leprosy
( PB )
• 1 to 5 lesions
• Big to medium
• Asymmetrical
• Definite loss of
sensation
• Dryness over the
patch present
• Loss of hair over the
patch
• Only 1 nerve involved
Multibacillary Leprosy
( MB )
• > 5 lesions
• Small
• Symmetrical
• Loss of sensation
( May be / May not be )
• Dryness over the
patch absent
• No loss of hair over
the patch
• 2 or more nerves
involved
24

Examples showing WHO classification :
1 Skin Patch + No nerve = Lesions - 1 PB
2 Skin Patch + No nerve = Lesions - 2 PB
5 Skin Patch + No nerve = Lesions - 5 PB
6 Skin Patch + No nerve
=
Lesions - 6 MB
4 Skin Patch + 1 nerve =
Lesions - 5
PB
4 Skin Patch + 2 nerve = Lesions - 6 MB
5 Skin Patch + 1 nerve = Lesions - 6 MB
3 Skin Patch + 2 nerve = Lesions - 5 MB
25

Pure Neural Leprosy :
In all forms of leprosy , at least one peripheral nerve is attacked by M.
Leprae , though this may not have any clinical evidence .
Leprosy can involve nerves without any skin changes. This unusual
occurrence is called Pure Neural Leprosy .
26

PB Leprosy
PB Leprosy :
Small Solitary
• Well – defined margins with
flat slightly atrophic central
area , insensitive to pain
• Hypo pigmented macule
PB Leprosy :
• Small Solitary
• Well – defined margins,
completely anaesthetic .
• Hypo pigmented macule
27

PB Leprosy :
• Clear border
• Anaesthetic
• Hypo pigmented macule
PB Leprosy :
• Hypo pigmented macule
• Well defined slightly raised
borders
• Dry surface
• Completely anaesthetic
28

PB Leprosy :
• Rounded lesion with wide
slightly brownish and scaly
elevated well defined margins .
• Centre clear area
• Clear hair loss
• Anaesthetic
29

MB Leprosy
MB Leprosy :
• Well defined margins .
• Anaesthetic
• Big to small in size
• Asymmetrical
MB Leprosy :
• Raised well defined margins
• Erythemato-hypochromic patch
with dry surface
• Presence of small satellite
lesions
• Anaesthetic
30

MB Leprosy :
• One of many patches
• Large patch
• Margins are well defined,
raised, sloping towards clear
centre of lesion
• Central portion anaesthetic
MB Leprosy :
• Large plaque
• Borders are clear and sharp .
• Anaesthetic
31

MB Leprosy :
• Multiple subsiding lesions
showing large clear centre
areas surrounded by well
defined slightly raised inner and
outer margins .
• Centres are anaesthetic
MB Leprosy :
• Plaque , with sharply
demarcated clear central area
• Peripheral edges sloping into
surrounding normal skin
• Central uninvolved area is
anaesthetic
• Geographic appearance .
32

MB Leprosy :
• Several Punched out lesions
• Central areas are anaesthetic
MB Leprosy :
• Irregular erythematous bends
around a large anaesthetic
central area
• Inner margins of lesion tend to
be better defined than the outer
margins
33

MB Leprosy :
• Classical punched out lesions
• Central clear areas are
anaesthetic
MB Leprosy :
• Numerous, widespread plaques
• Annular lesions
• Papules and macules
• Centre of large lesions show
some loss of sensation
34

MB Leprosy :
• Thick erythematous plaque on
face and ears
• Lesions are not sharply
delimited
• No sensory loss.
MB Leprosy :
• Bilaterally distributed
• Irregularly shaped
• Erythematous
• Infiltrated patches
• Not anaesthetic
35

MB Leprosy :
• Symmetrical
• Infiltrated
• Note punched out patches.
MB Leprosy :
• Infiltrated
• Erythematous macules
36

MB Leprosy :
• Extensive
• Symmetrical , Infiltrated
• Coalescent macules & plaques.
• Lesions are not anaesthetic.
• Note small round plaque on the
left lumber area.
MB Leprosy :
• Diffused Infiltration all over face
and ears.
37

MB Leprosy :
• Lepromatous Leprosy
• Diffuse Infiltration all over face
and ears.
• Nodule on ear lobules
MB Leprosy :
• Symmetrically distributed
Diffused Infiltration
• Nodules on face and ears
• Madarosis
38

MB Leprosy :
• Marked Diffused Infiltration
• Nodules over eyebrows, cheeks,
nose , chin , and ear lobes.
MB Leprosy :
• Nodules over Ear lobes.
39

Treatment

Treatment for Leprosy
MDT Drugs : These drugs are used in WHO – MDT and are a combination of
Rifampicin, Clofazimine & Dapsone for MB patients, and of Rifampicin &
Dapsone for PB patients. Among these, Rifampicin is the most important drug
and highly bactericidal. Therefore, it is included in the treatment of both types of
Leprosy. Clofazimine and Dapsone are mainly bacteriostatic drugs but they have
very very low bactericidal action also.
For PB
Rifampicin
Dapsone
Rifampicin
For MB
Clofazimine
Dapsone
Treatment of Leprosy with only one
anti – Leprosy drug will always result
in development of drug resistance to
that particular drug. Treatment with Dapsone
or any other anti – Leprosy drug used as
monotherapy should be considered as
unethical practice.
40

Before starting treatment with MDT , you must look for the following :
1. Jaundice : If the patient has jaundice, you will have to wait till the jaundice
subsides.
2. Anaemia : If the patient is anaemic, treat the anaemia simultaneously.
3. Tuberculosis : If the patient is taking Rifampicin, ensure that he continues
to take Rifampicin in the dose required for the treatment of Tuberculosis
along with other drug regimen required for the treatment of Leprosy.
4. Allergy to Sulpha Drugs : If the patient is known to be allergic to Sulpha
drugs, Dapsone should be avoided.
Before starting the treatment, following basic facts regarding the treatment
must be explained to the patient :
1. Explain that Leprosy is curable like all other diseases.
2. Ask the patient for his ideas about Leprosy, and if any is false, then
correct it.
3. Explain that contacts of the patient could develop the disease.
Arrange to have the examination of the contacts.
4. Treatment must be taken regularly.
5. Explain the doses.
6. Explain about possible side effects ( red colouration of urine, darkening of
skin, skin rashes etc ).
7. If a patient has sensory loss, explain that continued self care is needed to
prevent disability.
8. At the end of treatment, explain to the patient that treatment has been
completed but self care is still important, and if further problems arise, to
come back for treatment.
41

Advantages of MDT
MDT kills the bacteria ( M. leprae ) in the body and thus, stops the
progression of the disease, and prevents further complications.
As the M. leprae are killed, the patient becomes non – infectious and thus,
the spread of infection in the body is reduced. Moreover, spread of
infection to others is also reduced.
Using a combination of 2 or 3 drugs instead of 1 drug alone will ensure
effective care. There are no chances of development of resistance.
Reduces the period of treatment .
Well accepted by patients.
Easy to apply in the field.
Prevents disabilities.
Treatment for Leprosy
PB
MB
PB MDT
1. Rifampicin
2. Dapsone
MB MDT
1. Rifampicin
2. Dapsone
3. Clofazimine
6 months
Duration of
treatment
1 year
42

PB MDT ( Adult ) :
Supervised dose on day 1
Rifampicin
Dapsone
600 mg
100 mg
Unsupervised dose :
Dapsone
100 mg daily for
27 days
MB MDT ( Adult )
Supervised dose on day 1
Rifampicin
600 mg
Clofazimine 300 mg
Dapsone
100 mg
Unsupervised dose :
Clofazimine 50 mg daily
Dapsone 100 mg daily ,
both for 27 days
43

PB MDT ( Child 10 –14 yrs. ) :
Supervised dose on day 1
Rifampicin
Dapsone
450 mg
50 mg
Unsupervised dose :
Dapsone
50mg
daily for 27 days
MB MDT ( Child 10 –14 yrs. ) :
Supervised dose on day 1
Rifampicin
450 mg
Clofazimine 150 mg
Dapsone
50 mg
Unsupervised dose : for 27 days
Clofazimine 50 mg
on alternate days
Dapsone
50 mg daily
44

Side Effects of Anti – Leprosy Drugs
Dapsone
Anaemia
Severe Skin Complication
( Exfoliate dermatitis )
GIT Symptoms
Jaundice
Kidney Damage
Give anti – worm treatment and iron
tablets. Continue Dapsone.
Stop Dapsone and refer to hospital
immediately. Never restart.
Symptomatic treatment . Reassure the
patient.
Stop Dapsone. Refer to hospital. Restart
after the Jaundice subsides.
Stop Dapsone. Refer to hospital.
Rifampicin
Reddish colouration of urine,
saliva and sweat
Jaundice, Loss of Appetite &
vomiting
Flu – like illness
Allergic Rashes
Reassure the patient.
Stop Rifampicin. Refer to hospital. Restart
after the Jaundice subsides.
Symptomatic treatment.
Stop Rifampicin.
Clofazimine
Brownish red discolouration of
skin, urine and body fluids
Ichthyosis ( Dryness and thickening
of skin )
GIT problems
Reassure the patient, it will go after the
completion of the treatment.
Apply oil to the skin. Reassure the patient.
Symptomatic treatment . Reassure the
patient.
45

Reactions
in
Leprosy

Reactions in Leprosy
Definition : Leprosy reaction is an acute inflammatory
event occurring in the course of the disease, which
produces painful symptoms.
Reactions can occur at any time :
• Before treatment ,
• During treatment or
• After treatment.
The occurrence of Leprosy reactions does not mean that MDT drugs are not
being effective, and therefore, MDT should not be stopped during the reaction.
Reactions are the part of the natural course of the disease and can occur
frequently and may be severely damaging in untreated Leprosy. Treatment with
Leprosy significantly reduces the frequency and severity of the reactions.
Possible occurrence of reactions need to be explained to the patient
since signs and symptoms of reactions could be misunderstood by them
as adverse effects of the drugs they are taking.
Leprosy reactions must be promptly diagnosed &
properly treated to prevent any disability.
46

Patients with following characteristics are more likely to develop lepra
reactions :
• Many lesions
• Lesions close to the Nerve
• Lesions on face
• Pregnancy
These patients should be monitored more
frequently by doing clinical examinations
including VMT and ST for early detection of
nerve damage.
Predisposing factors :
1. Vaccination
2. Infections like viral fever, malaria etc
3. Anaemia
4. Mental and / or physical stress
5. Puberty
6. Pregnancy
7. Delivery
8. Surgical Intervention
These factors do not precipitate reaction in all patients.
47

Types of Lepra Reactions :
Lepra reactions are of two types :
1. Type I Lepra Reaction :
• Upgrading Type I Lepra reaction
• Downgrading Type I Lepra reaction
2. Type II Lepra Reaction ( ENL reaction )
Common Factors :
Type I Reaction
1. Also known as reversal reaction.
2. May occur both in PB & MB
Leprosy.
3. Occurs usually during first 6 months
of treatment.
4. It is because of any alteration in
CMI.
5. Skin : Existing lesions suddenly
become red, swollen, warm and
tender. New lesions may appear.
Lesions, when subsiding, may
show scales on the surface.
6. Nerves : Nerves may become
enlarged, tender and painful
( neuritis ) with loss of nerve
function.
7. Other organs : Not affected.
8. General Symptoms : Not common.
Type II Reaction
1. Also known as ENL reaction.
2. Occurs in MB Leprosy
only.
3. Can occur before, during and after
treatment.
4. It is because of humoral immune
response.
5. Skin : Red, painful, tender and
subcutaneous nodules ( ENL )
appear commonly on face, arms
and legs. They appear in groups
and subside within a few
days.
6. Nerves : Nerves may be affected,
but not as common as in Type I.
7. Other organs : Eyes, joints,
bones, testes and kidneys may be
affected.
8. General Symptoms : Are common.
48

Type I Lepra Reactions
Type I Lepra reaction may occur in both MB & PB Leprosy. The patient may
be present with one or more following features :
• Inflammation in skin patches, i.e., skin patches become reddish and swollen.
• Painful, tender and swollen peripheral nerves.
• Signs of nerve damage, i.e., loss of sensation and / or muscle weakness.
• Fever and malaise ( sometimes only ).
• Hands and feet may be swollen.
• Rarely, new skin lesions may appear.
Type 1 Lepra Reaction – Inflammation in existing
patches and / or nerves
Type 1 Lepra Reaction is due to change in CMI
Type 1 Lepra
Reaction
Reaction in skin
patch only
Reaction in nerve
only
Reaction in both
skin patch & nerve
Inflammation in
skin patch
Inflammation in
nerve , i.e. ,
neuritis
Inflammation in
both skin patch
and nerve
No deformity Risk of deformity Risk of deformity
49

Type I Lepra Reaction
• Inflammation in existing
patch.
• Borders are raised and
clear.
Type I Lepra Reaction
• Inflammation in existing
patches.
• Borders are raised and
clear.
• Oedema over hands.
50

Type I Lepra Reaction
• Inflammation in existing
patch.
• Borders are raised and
clear.
Type I Lepra Reaction
• Inflammation in existing
patches
• Borders are raised and
clear .
• Inflammation in great
auricular nerve also .
51

Type II Lepra Reactions
No changes in existing skin patches
Clinical Features : Symptom – complex
One or more symptoms may be present in a patient .
1. ENL ( Erythema nodosum leprosum ) :
- Crops of brightly erythematous, slightly raised nodules
- Fresh crops appear in the evening.
- Commonly occur on face, arms and thighs ( the flexor aspects of forearms
and the medial aspects of thighs are favoured )
- Variable in size but usually small
- Usually bilaterally, symmetrical
- Blanch with light finger pressure ( the red colour immediately after pressure
is released )
- Evanescent ( lasting only for 2 – 3 days, rarely longer )
- Tender and warmer than the surrounding skin
- When they fade, they leave a blue stain in the skin
- Numerous ENL – fever and malaise
- Desquamate as they subside
2. Fever and malaise
3. Nerve pain
4. Bone pain, especially over the sheen of tibia
5. Muscle pain
6. Pain in joints
7. Rhinitis
8. Epistaxis
9. Acute iritis ( iridocyclitis )
10. Tender Lymph nodes
11. Epididymo – orchitis
Combination of any of these constitute the Type 2 Lepra Reactions.
52

Type II Lepra Reaction
• ENL nodules on face
Type II Lepra Reaction
• ENL nodules on face
53

Type II Lepra Reaction
• Pink coloured ENL
nodules on both hands
• Few ENLs show
desquamation
IRIDOCYCLITIS
Patients may present with Iridocyclitis during
Type II Lepra reaction. The main symptoms of
Iridocyclitis are :
• Pain
• Redness
• Watering of the eyes
On examination, circumcorneal congestion
with small irregularly shaped pupils which
respond sluggishly to light.
54

Difference between
Type I Lepra Reaction ( Reversal Reaction ) & Relapse
Features
1. Onset
2. Time of onset
3. Old lesions
4. New lesions
5. Ulceration
6. General
Condition
7. Response to
Corticosteroids
8. Drug
Compliance
Type I Lepra Reaction
1. Sudden, within a few
hours.
2. Generally occurs during
treatment or within 6
months of stopping
treatment.
3. Become red, swollen and
shiny.
4. May develop in some
cases.
5. Ulceration sometimes.
6. Fever & malaise unusual.
7. Excellent.
8. May have been good.
Relapse
1. Slow and insidious.
2. Generally, occurs a long
time after treatment.
3. Margins of some may
become red.
4. Few.
5. Unusual.
6. Not affected.
7. Lesions subside but
reappear. Corticosteroids
are not indicated in
relapse.
8. Poor.
55

Management of Lepra Reactions
Principles of Management of Reactions :
1. Continue anti – leprosy treatment
2. Rest
- Physical rest
- Mental rest
- Rest to the affected part ( nerve )
3. Care of the pain : Analgesics & Anti – inflammatory
4. Corticosteroid Therapy
5. Other anti – reactional drugs :
Clofazimine , Thalidomide
6. Surgery : For recurrent neuritis not responding to
corticosteroid
For mild reactions :
• Rest
• Analgesics & Anti – inflammatory
For severe reactions :
• Rest
• Rest to the affected part ( for neuritis )
• Analgesics & Anti – inflammatory
• Corticosteroid Therapy
56

Corticosteroid Therapy :
• Corticosteroids are the treatment of choice for the Type 1 reaction since
neuritis and ulceration frequently occur in these patients.
• They are having immunosuppresent, anti – inflammatory and anti – fibrotic
actions, which are useful.
• The dosage varies with severity of reactions.
• Abrupt cessation of prolonged high doses is associated with significant risk of
adrenal insufficiency of sufficient severity to become life threatening.
Give doses of corticosteroid in single morning dose. Avoid drug
administration on empty stomach.
• The drug of choice is Prednisolone.
WHO Corticosteroid Regimen used in fields :
The standard 12 week oral prednisolone treatment for an adult patient is as
follows :
Dose/ day
Duration in Weeks
40 mg 1 and 2
30 mg 3 and 4
20 mg 5 and 6
15 mg 7 and 8
10 mg 9 and 10
5 mg 11 and 12 , &
then stop the drug
Other Anti – Reactional Drugs :
1. Clofazimine :
• Anti – leprosy drug also having anti – inflammatory effect. Hence, useful as
anti – inflammatory drug in recurrent Type 2 Lepra reactions and to wean off
patients from corticosteroids.
57

• Doses required :
- 100 mg 3 times a day for 1 month
- 100 mg 2 times a day for 1 month
- 100 mg daily for 1 month and then stop the drug
2. Thalidomide :
• It was marketed as a sedative – hypnotic in 1957.
• Withdrawn from the market several years later because of teratogenecity.
• Also effective for the treatment of severe ENL and chronic recurrent ENL
reactions as an anti – inflammatory drug.
• Useful in weaning patients off corticosteroids.
• Because of teratogenic effects, thalidomide should never be given to women
of child bearing age.
• Doses required :
- 400 mg a day in 4 divided doses for 1 – 2 weeks
- 300 mg a day in 3 divided doses for 1 week
- 200 mg a day in 2 divided doses for 1 week
- 100 mg a day for 1 week and then stop the drug
• Combined treatment with Clofazimine and Thalidomide ( both 300 mg daily )
controls the reactional state of corticosteroid – dependent lepromatous
patients more rapidly than monotherapy with thalidomide alone.
Management of Other Complications :
• Iridocyclitis – Mild cases of iridocyclitis may be treated with topical
application of Atropine and Steroid eye drops or ointments .
More severe cases should be referred to the nearest hospital.
58

Disabilities
in
Leprosy

Disability in Leprosy
Leprosy is associated with intense stigma because of the disabilities
and deformities that result from Leprosy.
Most of the disabilities that occur in Leprosy are
preventable. Therefore, it is very important to
prevent these disabilities from occurring.
DeFORMity : It is an alteration in the form, shape or appearance of a
part of the body, i.e., anatomical changes, for example, depressed
nose.
DisABILITY : It is deterioration in one’s ability or capacity, i.e.,
physiological change, for example, anaesthesia of hand.
Treatment of Leprosy as with that of any other infectious disease has
two main aims :
1. To destroy all the infecting organisms in the body of the patient.
2. To prevent and treat the complications that result directly or indirectly
from the disease.
Reactions and Nerve Damage are two most important complications
that directly result from Leprosy. Of these, nerve damage is far more
common than reactions, and it is also mostly responsible for the
deformities, disabilities and dehabilitation that many Leprosy affected
persons experience.
59

The two most important measures for preventing Nerve Damage in
Leprosy patients :
• Early case detection
• Starting of appropriate Multi Drug Therapy ( MDT ) without delay
However, in a good proportion of cases, by the time the condition is
recognised as Leprosy, the extent of nerve damage has already
progressed to such levels as to cause clinical symptoms and signs. It is
important to understand that it is not too late even then, for, in many
cases, the damaged nerve can recover or with proper management of
condition, nerve damage can be prevented from becoming permanent.
Now, after integration, the responsibility of to provide treatment to
Leprosy patients lies with general health services. It is essential that
personnel from general health services should have clear guidelines so
as to prevent nerve damages and occurrence of deformities and
disabilities.
There are two types of disabilities in Leprosy :
1. Primary – These disabilities occur as a direct result of a nerve
damage.
E.g. loss of sensation , claw hand etc.
2. Secondary – These occur as a result of neglected primary
disabilities.
Non healing planter ulcer , contractures etc.
E.g.
60

Disability
Primary
Secondary
Direct result of
Result of
Nerve Damage
OR
Bacterial
Invasion
Neglected Primary
Disability
WHO Grading of Disability
Hands & Feet
Eye
Grade I
Anaesthesia present but
no visible deformity or
damage.
Eye problem due to
Leprosy present but
vision not affected due to
it.
Grade II
Visible deformity or
damage present.
• Severe visual
impairment ( Vision
worse than 6 / 60,
inability to count fingers
at 6 metres )
• Lagophthalmos
• Iridocyclitis
• Corneal Opacities
61

Primary Disability
Primary
Disability
Bacterial
Invasion of
tissues
M a y o c c u r I n
Nerve Damage
Saddle Nose
Loss of eyebrow
Loss of eyelashes
Motor
fibres
Sensory
fibres
Autonomic
fibres
Leonine Face
Leads to
Leads to
Leads to
Thickened Earlobes
Paralysis
Anaesthesia
Dryness
Primary Disabilities due to nerve Damage
Site
Face
Nerve
Facial Nerve
Trigeminal
Feature
Inability to close the eye ( lagophthalmos )
Loss of sensation over cornea
Ulnar
Clawing of 4 th and 5 th finger
Loss of sensation and sweat over the little finger
and the inner half of the ring finger
Hand
Median nerve
alone
Inability to move the thumb away ( abduction )
and touch the tips of other fingers (opposition)
Ulnar & Median
Clawing of all five fingers
Loss of sensation and sweat over the whole
palm
62

Site
Nerve
Feature
Hand
Radial
Wrist drop
Loss of sensation and sweat over the back of the
hand
Foot
Common
peroneal
Posterior tibial
Foot drop
Loss of sensation over the lower leg and the
dorsum of the foot
Claw toes
Loss of sensation and sweat over the sole of the
foot
Illustrations of Primary Disability
Lagophthalmos :
• Inability to close the eyes due
to paralysis of zygomatic
branch of facial nerve.
63

Ulnar Claw
• Clawing of little and ring finger,
due to involvement of ulnar
nerve.
Total Claw Hand
• Clawing of all the fingers, due
to involvement of ulnar nerve,
and median nerve.
64

Wrist Drop
• Dropping of wrist , due to
involvement of radial nerve.
Claw Toes
• Clawing of all the toes due to
involvement of posterior tibialis
nerve.
65

Secondary Disability
Primary disability, when neglected, results in Secondary disability.
E.g. Planter Ulcers , Contractures .
( A ) In the Hands and Feet :
Nerve
Damage to
Autonomic
Fibres
Sensory
Fibres
Motor
Fibres
Loss of sweat
Loss of sensation
Paralysis
leads to cracks
leads to injury / pressure
leads to contracture
ulcers
ulcers
Pri.Disability
Sec.Disability
( B ) In the Eyes :
Damage to Facial
Nerve
Damage to Trigeminal
Nerve
1. Lagophthalmos Primary Disability 2. Corneal anaesthesia
Exposure keratitis
corneal ulcers
Exposure keratitis
Blindness
S e c o n d ary Disability
Blindness
66

Ulcers in hand :
• Patient is having
anaesthesia in hand,
and therefore has
developed ulcers
due to contact with hot
objects .
Non healing ulcers in
feet :
• Patient is having
anaesthesia in soles
of feet , and therefore
has developed ulcers
due to pressure on
pressure points .
67

Prevention of Disabilities
( POD )

Prevention of Disabilities ( POD )
Why POD is critical …
Leprosy
Disability
Preventable
Social
Stigma
The Objectives of POD are :
1. Prevention of development of Primary
Disability.
2. If the patient suffers from Primary
Disability at diagnosis, then
- To improve Primary Disability
- To stop the worsening of Primary to
Secondary Disability
3. If the patient has already developed
Secondary Disability, then
- To ensure that proper management of
Secondary disability is done to
prevent any structural damage.
68

Three Levels of Interventions for POD
MDT & Early diagnosis
of reactions & their
Use of eyes & mind
69
Leprosy
proper trt.
Early Detection of Nerve
Damage by VMT & ST and
trt. with Prednisolone
Before deformity develops
Primary
Disability
To prevent worsening of Pri.disability
Hands, feet & eye care
Splints
MCR
Secondary
Disability
Care of Secondary disability
Protective
Wear
Treatment
Self Care
RCS
Foot Wear
RCS
Exercises
Active
Passive
Level 1
Level 2
Level 3

1. Early Case Detection, before disabilities and deformities can set in.
2. Proper Counselling : Give the patient proper advice and explanation.
At the time of starting treatment, we must discuss the following with patient.
• The nature of the disease, the type of the disease & duration of
treatment.
Prevention of Primary Disability
• The importance of regular treatment.
• Possible signs and symptoms of reaction and the need to report
immediately in case of nerve pain, loss of sensation, weakness
and tingling in the hand, face and foot.
3. Detect loss of nerve function early.
Check muscle strength and sensation ( VMT & ST ) regularly to detect
complications early.
4. Manage early loss of nerve function appropriately.
If the patient has early nerve function loss ( less than 6 months ), he
should be given a course of steroids.
Early Case
Detection
Educate
the patient
Lepra
Reactions
Patient
Reporting
Regular
visits
Early Nerve
Damage
detection
VMT
ST
Disease
Treatment
Signs & Symptoms
of Reactions
Motivation to report
on occurrence of
nerve pain
Prednisolone
No Disability
Manage
immediately
No
Prednisolone
Disability
1
70

Care of Primary Disability
to prevent
Secondary Disability
It is the responsibility of the clinicians that a patient
should not develop Primary disability during and after the
treatment.
But if he / she does develop it, then ample proper care
should be taken to ensure that no Secondary disability
develops as care of Primary disability is the best way to
prevent Secondary disability.
The three basic principles involved in the prevention of
worsening of disability are :
1. Self care practices.
2. Provision of protective aids.
3. Regular monitoring of patient to ensure
patient’s compliance with self care.
71

Loss of Sweat in Hands & Feet ( Primary Disability )
Aim : Loss of sweat makes the skin dry and cracked. Such dry cracked skin is
more prone to injury. The aim is to moisten and soften the skin so that it becomes
soft and does not crack.
Method : Soak the hands or feet in water for 20 minutes. Scrap off the callused
skin with a any clean stone leaving a smooth surface. Soaking helps the skin to
absorb water. With the hands / feet still wet, apply oil over the surface. Oil helps to
keep the water in the skin.
Hands
Loss of
Sweat
&
Feet
Dryness
of Skin
Soaking
of Hands
& feet in
Water
Soft &
moist skin
Cracks
No Cracks
Injury
No Injury
72

Loss of Sensation in Hands & Feet ( Primary Disability )
Aim : Sensation of pain, heat / cold, pressure and touch helps us to protect
ourselves from injury. In the absence of such sensation, the patient must be taught
to use his eyes and conscious mind to protect himself from injury.
Method : The patient must be taught to :
1. Inspect the hands and feet daily looking for ( use of eyes ) :
- Blisters
- Red spots
- Warm spots
- Tender areas
2. Understand his / her limitations and learn how to avoid
injury ( use of mind ).
Hands
&
Loss of
Feet
Sensation
Taught
to use
eyes &
mind
No
sensation of
Pain,Touch
or heat
Inspect
Hands, Feet
daily for
Blisters, Red
spots etc.
Taught to
Understand
Limitations &
learn how to
avoid injury
Injury
Can prevent Injury
73

Advice for Anaesthetic Hands & Feet
Hands :
• Do not hold tools too tightly.
• Do not work too long without rest.
• Use protective implements.
• Tool Handles – Bandage with cloth.
• Practice safe procedures while cooking.
Feet :
• Walk slowly , with short steps. Avoid running.
• Avoid walking long distances, rest in between.
• Do not walk long distances if you can avoid it- Use any mode of
transport.
• Use protective Footwear.
Protective footwear for insensitive feet
Characteristics of ideal footwear :
1. Have a soft insole to provide padding / cushion.
2. Have a hard outer sole to prevent pins / thorns from piercing the foot.
3. Have adjustable straps.
4. Be well fitting.
5. Be culturally and cosmetically acceptable.
6. Deformed feet will require specially designed footwear.
74

Care of wounds – Simple Wounds
If the patient develops a blister or a very small wound, he can heal
himself by following a few simple rules :
it
1. Cleaning :
Keep the wound clean by soaking it daily for 20 – 30 minutes in water (
preferably soapy or salty ).
After soaking, cover the wound with clean strips of cloth.
2. Rest :
The part with ulcer must be rested completely . In case of feet, no
in case of hand, use a sling or a splint.
walking , &
3. Antibiotic Ointment :
Needed only when wound is infected.
Care of wounds – Wounds with complications
The majority of patients having planter ulcers on anaesthetic feet can be
managed at home through self care and rest.
Referral to specialist is needed in following cases :
1. Ulcers with bone involvement
2. Malignant ulcers
3. Ulcers with severe infections
4. Recurrent ulcers
75

Paralysis in Hands & Feet ( Primary Disability )
Aim : There are three main aims :
1. Prevent setting in of contracture
2. Decrease existing contracture
3. Strengthen weak muscle
Method : All the above aims can be achieved by doing exercises. There are two
types of exercises :
1. Active : In active exercise, patient uses his weak muscles to do the
exercise. This will
- prevent contracture and
- strengthen the weak muscle.
2. Passive : In passive exercise, patient is helped to move the paralysed
the part. This will
- prevent contracture but
- cannot strengthen the weak muscle.
Paralysis
Aims to
Hands
&
Feet
Prevent setting in of contracture
Decrease existing contracture
Strengthen weak muscle
Exercise
Active
Passive
Direct use of
weak muscle
Movement of
paralysed part
using help
76

Exercises for Paralysis / Weakness in Hands & Feet
Exercises for Ulnar nerve
Active : Straighten fingers in
the weak hand repeatedly .
Keeping the wrist straight ,
move the joint between the
hand and fingers repeatedly .
Passive : Straighten the
clawed fingers with the other
hand repeatedly .
77

Exercises for Median nerve
Active : Straighten the weak
thumb , and hold it straight
for a few seconds , using the
other hand to hold it
straight .
Passive : Straighten the weak
thumb using the other hand ,
for a few seconds .
78

Exercises for Lateral Popliteal nerve ( Foot Drop )
Active : Bend the foot upwards , and hold it steady for a few seconds.
Passive : ( given below ) Stand near a wall , with the arms straight out , and
hands resting on the wall.
Then bend the elbows and leans forward for a few seconds.
79

Eye care 1
Lagophthalmos
Patient must practise
regularly …
Eyes
Patient must check daily
and report on finding …
Avoid dryness of eye , by washing eyes
Blink several times an hour, with effort :
THINK AND BLINK
Use wetting drops to substitute for tears
Reduce evaporation of tears using sunglass or
head cloth , during day , and oily drops at night
Protect eye against injury
Avoid rubbing the eyes
Redness of eye , even without pain
Use a mirror / friend
Blurring of vision
Excess watering , Inability
tolerate bright light
to
Compare daily , looking at a fixed
object from constant distance
Check daily , and look for problems
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Eye care 2
Corneal
Anaesthesia
Patient must
practise
regularly …
Eyes
Patient must check
daily and report on
finding ...
Cover the eyes with glasses
during day , and eye – shield /
cloth at night
Keep eyes clean and free from
flies
Redness of eye , even
without pain
Blurring of vision
Use a mirror / friend
Compare daily , looking
at a fixed object from
constant distance
Indications to refer a patient for Reconstructive Surgery
• All patients who have deformities caused by Leprosy and fulfill the
following criteria may be referred to a hospital where RCS are routinely
done.
• The patient should have completed Multi Drug treatment.
• Deformities should be mobile.
• Deformities should be of at least one year duration.
• The patient should have been reaction – free for at least 6 months.
• The patient should be willing for surgery and should have realistic
expectations of result.
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Elimination of Leprosy,
&
Integration

Elimination of Leprosy
It is well known that two initiatives :
1. The introduction of WHO recommended MDT in the 1980s and
2. The 1991 resolution of World health assembly to eliminate Leprosy as a
public health problem
made possible the remarkable progress the world has seen in the battle against
Leprosy.
Elimination :
Now, our goal is to achieve elimination of Leprosy as a public health problem in
India.Elimination of Leprosy aims at reducing the disease burden to very low levels
so that after reaching such low levels the disease will disappear over a period of
time. This very low level has been defined by WHO as a level of prevalence of
less than 1 case per 10000 population.
Elimination vs. Eradication :
Elimination is the achievement of low levels of disease ( prevalence less than 1
case per 10000 population ) while eradication has a more precise meaning. Making
total disappearance of the organism for complete stopping of transmission of
disease is Eradication.
Eradication aims at : 1.
Zero disease
2. Zero transmission
3. Zero disease agent in the world
In the case of Leprosy, eradication is not possible in view of limitations of
technology, neither is it necessary as Leprosy, unlike other diseases like Small pox
and Poliomyelitis, is not likely to result in outbreaks and widespread dissemination
after reaching very low levels of prevalence.
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Why do we want to eliminate Leprosy ?
Leprosy is not a disease that kills people. Neither does it occur in as large
numbers as malaria, tuberculosis or many other diseases. Still, we look at Leprosy
elimination as a important priority for following reasons :
1. Leprosy is a communicable disease, i.e., if nothing is done, it will
continue to exist endlessly.
2. The disease causes huge suffering as a result of the disabilities it
produces, which are permanent and progressive.
3. The social stigma against Leprosy patients results in their discrimination and
social suffering.
4. The existence of Leprosy in any country or community produces a very
negative image of development.
5. One of the major reasons to eliminate Leprosy is the availability of
opportunities to do so at this period of time. Those opportunities are :
1. Technological - in the form of highly effective treatment through
MDT.
2. Epidemiological - in the sense that Leprosy is a disease on the
retreat in many areas.
3. Availability of sizeable resources.
4. International and national commitments co – ordinated
through WHO.
5. Strong political and administrative commitments.
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Integration
Why integration is essential ?
The core strategy for Leprosy elimination is :
1. To identify all Leprosy cases.
2. To cure them with MDT.
When we talk of the identification of all Leprosy cases, it is important to
recognise that in order to achieve Leprosy elimination, nearly every case in the
community should be identified. In practice, this does not happen in many
situations. The responsibility for identifying new cases of Leprosy was held solely
by specialised Leprosy services ( by vertical Leprosy staff ).
While this approach had certain advantages in certain situations, the major
disadvantage was relatively poor coverage of population resulting in large numbers
of patients remaining undetected. And hence, integration of specialised Leprosy
services into general health services becomes essential. We can reach even the
remotest areas of the state through the general health services only. It is necessary
to give importance to the role of individual, the family and the community in
suspecting Leprosy and reporting to the health services.
Now, major focus shifts to creating community awareness about the disease, its
curability and the availability of MDT services at all government health institutions
on all working days. To create awareness, we need to initiate a people’s movement
with full community involvement, which also includes social, religious and political
and institutions, such as panchayats, participations.
Unless and until community accepts its own responsibilities towards elimination
of Leprosy and works on it, it will not be possible to identify every case of
Leprosy.
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The second issue is the role of the general health services. Over the years, the
technology for diagnosis & treatment has been simplified to a great extent due
to initiatives taken by the WHO and GOI. Today, it is possible to provide the
necessary minimal skills and competence to deal with Leprosy to practically any
health worker. There is no need for specialised workers any more to deal with the
routine work in Leprosy. This means that Leprosy work, including diagnosis and
treatment, can be easily handled by general health care services.
It is true that quality of service provided by the general health services may be
less than perfect but no other service can match their outreach, familiarity with
community and acceptability.
To provide efficient MDT services, the general health services not only need
capacity building but also need support from local districts’ support teams through
their periodic visits, which would act as catalysts and facilitators to see to it that all
activities relating to Leprosy elimination are being carried out reasonably well.
Simplified Information System ( SIS )
85

Simplified Information System
( SIS )

Records
Maintenance of correct data is most essential element of a sound information
system. Reliability of data depends upon the staff that is involved in management
of people being treated and meticulously records the findings. Regular updating of
records is very important.
The following three records are to be maintained at PHC and sub – centre level
under simplified information system :
1. Patient Card – L. F. 01
2. Treatment Record – L. F. 02
3. MDT Drug Stock Register – L. F. 03
1. Patient Card ( L. F. 01 )
• Patient Card – L. F. 01 is to be filled for newly detected Leprosy cases and
to keep record of the patient’s treatment.
• Initially, Patient Card will be prepared by Medical Officer at the PHC,
where the patient has been diagnosed.
• The Medical Officer will then put his signature on the card and initiate anti –
Leprosy treatment with first dose of MDT.
• Then, the same card should be sent to concerned sub – centre from where
the patient can take subsequent doses.
• This card will be maintained at sub – centre, where the MPHW or FHW will
enter dates of subsequent monthly doses collected by the patient till the last
dose required.
• Every month MPHW / FHW will ensure updating of treatment register at PHC
on their next visit for any purpose.
• Then, MPHW / FHW will discharge the patient ( RFT ) on due date of
discharge and record accordingly.
• After achieving the end status ( RFT ), the MPHW / FHW should put his /
her signature on the Patient Card and retain the same at the sub –
centre for future reference.
87

2. Treatment Record ( L. F. 02 )
• It should be kept in a register form at all health facilities from where MDT
services are being provided.
• At first, Patient Card is prepared by the Medical Officer diagnosing the case
of Leprosy. The information will thereafter be filled up in the treatment
record.
• The annual serial number will also be available from this register. The
registration number will be changed every year, starting from 01 on first April
of the fiscal year ( for example, 1 st April, 2003 to 31 st March, 2004 ).
• The Medical Officer of health institution can give this responsibility to one of the
general health care staff working at the health centre.
• The information entered should be exactly similar to the one recorded in the
Patient Card.
• It is quite essential to update this treatment record every month.
• This treatment record will be retained at health institutions for future
reference.
3. MDT Drug Stock Register ( L. F. 03 )
• This is to be maintained in all health institutions where MDT services are
provided.
• Separate pages should be used for each of the four types of MDT blister
packs, for example, MB ( Adult ), MB ( Child ), PB ( Adult ), PB ( Child ).
• The Medical Officer of health institution can give the responsibility to
maintain this record to one of the general health care staff.
• Monthly update of this register is necessary.
• Drug stock records are important documents and hence, should not be
changed annually. Same register can be used for a number of years.
• The record will be retained in health institution for future reference.
88

Patient Card is to be attached here.
89

Treatment Record to be attached here.
90

MDT Drug Stock Record is to be attached here.
91

Reports
The simplified information system under NLEP has one reporting format to be
used to report from PHC / health institution to district level.
NLEP Monthly Reporting Form – PHC ( L. F. 04 )
• This reporting format will be utilised by primary health centres, which are the
basic units under NLEP.
• This simple form will be filled up from the data available in the treatment
record ( L. F. 02 ) and MDT drug stock record ( L. F. 03 ) maintained at the
PHC.
• The report is to be sent by the Medical Officer of the PHC to the District
Leprosy Officer every month regularly.
Validation Mechanism at different levels
The essence of a successful information system is the meticulous collection and
reporting of correct data. It is, therefore, important to regularly cross check and
validate the data collected and reported. To achieve this, there should be inbuilt
mechanism for validation of data within the system at all levels.
Validation of records at the sub – centre
• From the Patient Card, validate treatment completion.
• This has to be done by the Medical Officer / Supervisor at the PHC.
Validation of records at the Primary health centre
• Validate the diagnosis classification and treatment completion on a sample
of patients. Also, validate treatment register.
• Check the MDT drug record and physical verification of drugs.
• Validation should be done by District Leprosy Officer / Medical Officers of the
district nucleus.
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Elimination Indicators
Indicators are tools that are used to measure progress and achievement
under a programme. Following are the indicators which are essential for
monitoring of elimination of Leprosy :
1. Prevalence Rate ( P. R. )
2. Annual New Case Detection Rate ( N. C. D. R. )
3. Child proportion among new cases
4. Visible deformed case proportion among new cases
5. MB proportion among new cases
6. Female proportion among new cases
7. SC new case detection rate
8. ST new case detection rate
9. Patient month blister calendar packs stock
10. Proportion of health sub – centres providing MDT
11. Absolute number of patients made RFT
1. Prevalence Rate
Total number of Leprosy cases on treatment at a given point of time in a PHC
area is known as Prevalence rate.
Total no. of Leprosy cases on treatment
P. R. =
Total Mid – year population of PHC
X 10000
2. Annual New Case Detection Rate
The total number of cases newly detected during a year in an area is known
Annual New Case Detection Rate.
N. C. D. R. = X 10000
Total no. of Leprosy cases newly detected
Total Mid – year population of PHC
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3. Child proportion among new cases
Proportion ( % ) of new Leprosy patients upto 14 years of age among newly
detected patients is known as child proportion among new cases.
Child
Proportion
=
Total no. of new Leprosy cases detected upto 14 yrs. of age X 100
Total no. of newly detected Leprosy cases
4. Proportion of Visible Deformity among new cases
It is the proportion ( % ) of new Leprosy patients with visible deformity.
Deformity
Proportion
=
Total no. of newly detected cases with visible deformity X 100
Total no. of newly detected Leprosy cases
5. Proportion of MB among new cases
It is the proportion ( % ) of new Leprosy patients diagnosed as MB.
MB
Proportion
=
Total no. of new MB cases X 100
Total no. of newly detected Leprosy cases
6. Proportion of females among new cases
It is the proportion ( % ) of new Leprosy patients diagnosed as females.
Female
Proportion
=
Total no. of new female cases X 100
Total no. of newly detected Leprosy cases
94

7. SC New Case Detection Rate
area.
It is the total number of new SC cases detected among the SC population in an
SC
NCDR
=
Total no. of new SC cases detected X 10000
Total SC population in the given area
8. ST New Case Detection Rate
area.
It is the total number of new ST cases detected among the ST population in an
ST
NCDR
=
Total no. of new ST cases detected X 10000
Total ST population in the given area
9. Patient Month BCP’s Stock
It is stock of BCP in months according to number of patients expected to be
treated in the next quarter.
PBM =
No. of blister packs of each category
No. of cases detected during the
previous 3 months in each category
10. Proportion of Health Sub – centres providing MDT
It is proportion of Health Sub – centres providing MDT among all functional sub
– centres in PHC area.
Proportion of
Health SC
=
Health sub –centres providing MDT X 100
Total no. of sub – centres
11. Absolute number of patients made RFT
It is the number of patients released from treatment.
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National Leprosy Eradication Programme
Emblem for Leprosy Eradication
The ‘ Emblem ’ symbolises beauty and purity in lotus ;
Leprosy can be cured and a Leprosy patient can be a useful
member of the society in the form of a partially affected thumb
, a normal forefinger and the shape of a house ; the symbol of
hope and optimism in a rising sun. The Emblem captures the
spirit of hope and positive action in the eradication of Leprosy.