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National Rural Health Mission (NRHM) is widely heard and
talked about but less understood by many they may be
working under or for National Leprosy Eradication
Programme (NLEP With this presumption in mind we
considered it a good opportunity to update our readers as to
what this NRHM is and how it is related to NLEP. In this write
up components of NRHM which are relevant to us, are only
highlighted.
The National Rural Health Mission (2005-12) seeks to provide
effective healthcare to rural population throughout the
country with special focus on 18 states, which have weak
public health indicators and/or weak infrastructure. These 18
States are Arunachal Pradesh, Assam, Bihar, Chhattisgarh,
Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur,
Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa,
Rajasthan, Sikkim, Tripura, Uttarakhand and Uttar Pradesh
NRHM is in different stages of implementation in different
States
NRHM is basically a strategy, a mission an umbrella under
which all public health activities will be managed It envisages
improvement in Sanitation and Safe drinking water,
Reproductive and Child Health, National Disease Control
Programmes (NDCP) including National Leprosy Eradication
Programme (NLEP) and Integrated Disease Surveillance
Project (IDSP). NRHM will also enable the mainstreaming of
Ayurvedic, Yoga, Unani, Siddha and Homeopathy Systems of
Health (AYUSH).
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National Rural Health Mission an opportunity forNational Leprosy Eradication Programme
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Institutional Framework of NRHM
National level: Mission Steering Group
State level: State Health Mission
District level: District Health Mission
Under the Chairmanship of the Union Minister
for Health & Family Welfare
Led by the Chief Minister
Led by the Chairman, Zila Parishad or District Magistrate/collector
To provide policy guidance and operational oversight at
the National level. Ministerial / Secretary level
representatives, of Planning Commission, Rural
Development, Panchayati Raj, Human Resource
Development and Health and Family Welfare.
Secretaries, of four States and ten public health
professionals nominated by the Prime Minister, will be the
members
Co-chaired by the Health Minister with the State Health
Secretary, and representation from related Departments,
NGOs, private professionals etc.
Managed by the District Head of the Health Department
i.e. CMO, CS etc. with representation from all relevant
Departments, NGOs and private professionals.
Editor :
Associate Editor :
Advisers :
Dr. P. Krishnamurthy
Mr. D.V. Premkumar Velu
Dr. P. Vijayakumaran
Dr. N. Manimozhi
Dr. M.A. Arif
Mr. B. Vijayakrishnan
(DFIT)
(DFIT)
(DFIT)
(AIFO)
(NLR)
2 UPDATE
CONTENTS
Under NRHM local governments will be empowered to manage, control and be accountable
for public health services at various levels.
The District Health Mission DHM will be led by the Zila Parishad and will
control, guide and manage all public health activities, including activities under NLEP of the
district. States will be encouraged to devolve greater powers and funds to Panchayati Raj
Institutions PRIs
Committees are formed at the grass root level i e The Village Health &
Sanitation Committee (VHC), the standing committee of the Gram Panchayat (GP) which
will provide oversight of all NRHM activities including activities related to NLEP, at the village
level and be responsible for developing the Village Health Plan including leprosy, with the
support of the ANM, ASHA, AWW and Self Help Groups Block level Panchayat Samitis will
co ordinate the work of the Gram Panchayat in their jurisdiction and will serve as link to the
District Health Mission
will be bottom up, need based, result
oriented and participatory in nature i.e. the planning should start well in advance
including consultations with village, block and district level stakeholders. These
consultations will highlight the problems will be identified, objectives/results
which are expected to be achieved, in the programme, will be listed o achieve these
objectives/results t will be proposed. Plans
developed under NLEP will be submitted to District Health Mission after
incorporating it in the integrated plan, will send the integrated plan to State Health
Mission Under
NLEP, guidelines decentralized planning, have been issued by the Central Leprosy
Division (CLD), GOI
For this purpose
As and MIS specialists will be appointed on contract basis at State and District level in
18 priority states of India
primarily a woman resident of the
village, with formal education up to 8 one each for 1000 population
a link person between community and the health system, to
strengthen the public health service delivery infrastructure, and to facilitate
particularly at village, primary and secondary levels EP
involvement of ASHAs is envisaged.
Incentive has been foreseen for the involvement of ASHA in NLEP.
this will be done by making provision of two rooms in each CHC for bringing AYUSH
practitioners under the same roof.
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At District level:
At Village level:
Decentralized village and District level Health planning and management
Under NRHM it is envisaged that the planning
needs
T
activities will be planned and budge
and DHM
and SHM after scrutiny will send the plan to Centre for approval
for
which could be referred in states and districts
Improved management capacity skilled professionals like CAs
MB
to organize health systems and services in public health
emphasizing evidence based planning and implementation through improved
capacity and infrastructure They should be roped in to be sensitized to leprosy
as a public health problem
Accredited Social Health Activist (ASHA)
standard She is
identified to act as
access to
health services Under NL
Mainstreaming Ayurvedic, Yoga, Unani, Siddha and Homeopathy (AYUSH
Promoting the non profit sector to increase social participation and
community empowerment
Promoting healthy behaviours, and improving inter sectoral convergence.
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Core strategies under NRHM
Contd. in page 3
National Rural Health Mission
an opportunity for National Leprosy
Eradication Programme 1-3
Support to NLEP in Delhi by NLR India 3-4
Experiences with Self Care Groupsin NLR supported States 5-6
RCS in Jharkhand 7
The anguish of a young couple 7
A tale of woes 8
Back on the road 8
Operational guidelines forLeprosy control activities 9-10
Belgium Ambassador visitsDamien Foundation Project 10
Technical Session Meeting of ILEP 11
Different Presentations of Leprosy 12
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3ILEP-INDIA /OCTOBER 2008
How NLEP can use this opportunity?•
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Since monitoring and review meetings will be conducted
under SHM and DHM SLOs/acting SLOs and
DLOs acting DLOs should take this opportunity to keep
leprosy on high agenda and ensure good discussion on
problems and solutions during state and district level
review meetings.
Expertise available for IEC activities under NRHM should
be utilized in planning, and propagating correct messages
on leprosy & messages and activities to reduce stigma and
discrimination.
ASHAs could be involved in case detection, referral,
follow up, spreading correct messages and involving more
& more people in the programme.
Prednisolone & other supportive material i.e. aids and
appliances could be procured through Rogi Kalyan Samiti
National Rural Health Mission an opportunity for National Leprosy Eradication Programme - Contd. from page 2-
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Pachayati Raj Institutions could be involved in keeping
leprosy on high agenda in advocacy for reduction of
stigma and discrimination in IEC activities
Village Health Samiti Committees could be involved in
reducing stigma and discrimination against Leprosy. They
could also be involved in spreading correct messages.
The flexible fund available under NRHM could be used in
adhoc needs, supply of aids & appliances, advocacy etc.
Other logistics like computers, internet and other facilities
provided under NRHM could be utilized for leprosy
control programme.
Facility of e-banking should be utilized for electronic
transfer of funds at state and district level.
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Dr. M. A. Arif,Country Representative,
NLR India
Source: www.mohfw.nic.in
Introduction:
The National Capital Territory (NCT) of Delhi is spread over
1483 sq km and is a home to over 17 million people. Delhi has
population density of 12000 persons/ Sq Km; highest among
other metropolis of India. Among all the States and Union
territories, the NCT of Delhi is most urbanized with only 7% of
population in the rural area of Delhi i.e. about 165 villages.
About 19% of urban population lives in slums. In addition to
the State government, Delhi is governed by three local civic
bodies, the New Delhi Municipal Council (NDMC), the
Municipal Corporation of Delhi (MCD), and the Delhi
Cantonment Board. The leprosy services are now provided
through general health care system (dispensaries and
hospitals).
Delhi reported 3146 new cases of leprosy during 2007-08,
with 5.91 % of cases with disability grade II among new cases.
MB, Female & child proportion is 58.3%, 18.5% & 4.39 %,
respectively. The high case load in Delhi can be attributed to
the migrants who migrate from leprosy endemic states either
in search of better means of livelihood or to avail better health
facilities.
International Federation of Anti-leprosy Associations (ILEP)
comprising of ten agencies has been supporting the national
leprosy eradication programme of NCT of Delhi for many
years. A new Memorandum of Understanding (MOU) was
signed between ILEP agencies (including Netherlands
Leprosy Relief (NLR) - India) and GOI in October 2007 for a
period from 2007-2012. The MOU describes the areas of ILEP
support such as “Capacity building of DN staff” and “Support
and improvement in supervision and monitoring by the DN
team”. The strategy adopted by NLR-India in Delhi is
described here.
Support to NLEP in Delhi by NLR India
Strategy:
Preparation:
NLR-India has placed Leprosy Programme Advisors (LPA)
with mobility at regional level to cover a group of 5-7 districts
in the 6 states supported by it, including LPAs Delhi. These
LPAs are medical officers with experience in leprosy and other
public health activities. These LPAs will impove skills of
supervision of DN staff by providing on the job training.
Before deploying LPAs in the field, they were given orientation
in relation to their role. In addition, they were also equipped
with desirable knowledge & skills. This was done through
following trainings/workshops:
Orientation/induction training,
NLR Branch office, Delhi - 15 Days
Communication/Training skills,
BIKASH, Pokhara (Nepal) - 14 Days
International leprosy congress (ILC)
at Hyderabad - 06 Days
Supervision workshop, Agra - 05 Days
Harmonization workshop
before deploymen - 03 Days
Review meetings/workshops (continuing)
Situational Analysis of the DN and the district by the LPAs
Identification of needs out of situation analysis
To provide support on the basis of needs identified
To enable the DN to conduct classroom trainings
On the job training to District Leprosy Officer and DN staff
during LPAs' visits to the DN office or during supervisory
field visits with DN team.
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Support to NLEP:
Contd. in page 4
Outcome:
Situational analysis was completed in all five districts in
Delhi supported by NLR- India (Table.1). During visits to the
DN of their respective districts, LPAs' of Delhi persuaded the
DN to carry out the activities, which were either not carried out
or done inadequately. Untiring efforts and perseverance of
LPAs' had brought about following changes in these five
districts.
Table 1. Comparison of functioning of DN staff before and after introduction of LPAs'
S. Identified Needs Status
As on 30th April 2008 As on 30th September 2008
1. Preparation of Advance tour programme (ATP) DN have started preparing ATP, but still it is not a regular feature.
2. Preparation of Activity Undertaken Report (AUTR) Some of the DN have started preparing AUTR.
3. Use of Supervisory checklist during supervision Some of the DN have started using Supervisory checklist.
4. Preparation of Supervisory Report DN have started preparing Supervisory Report, but still it is not a
regular feature.
5. Maintenance of Master Register at District level. All DN have started maintaining the Master Register at the district
level.
6. Preparation of reports
6.1 Quarterly Performance Assessment (QPA) Some of the DN have started preparing QPA.
6.2 Cases from outside states Some of the DN have started preparing “Cases from other states”
report.
6.3 Monthly Reporting Form for District Nucleus Team To be started.
7. Preparation of Plan of Action (POA) based on Training to DN teams in supervision, monitoring and planning in a
Logical Framework Approach. workshop held at Dehradun. All DN prepared POA for the year
2008-09.
8. Management of MDT stock Improvement in the status of MDT stock and supply in some
of the districts.
9. Frequency of supervisory field visits by DN Yet to achieve.
10. Case validation activity Not yet started.
11. Training skills of the DN staff Their training skills are being honed by demonstrating the training
skills during field visits and state level quarterly review meetings.
12. Referral system In our opinion, this can not be effectively implemented unless
primary level medical officers and specialist at secondary/tertiary
level health facilities are formally introduced to each other at the
time of training sessions and the use of referral slips becomes a
regular feature.
13. Treatment Completion Rate Training to Non Medical Supervisors, Para Medical Workers and
Leprosy Assistants. DN have started doing cohort analysis for the
year 2008-09.
Conclusion:
It is important that how the supporting agency responds to the needs of implementers. In our opinion, all we need to do is to provide
the right guidance and whole hearted support to the DN teams in their endeavor to render quality leprosy services to our fellow
citizens. Change for the better/improved functioning of the DN can be perceived after the deployment of LPAs.
Dr. V. Gautam & Dr. J. B. Singh,Leprosy Programme Advisors, Delhi, NLR India
4 UPDATE
Support to NLEP in Delhi by NLR India - Contd. from page 3
Introduction:
Objective:
Methodology:
Loss of sensation in extremities leads to ulcers due to trauma
which usually occur without patients knowing them.
Undetected trauma is often untreated trauma; if left untreated
for long, these simple ulcers can have potentially threatening
consequences such as bone infection, bone destruction and
even amputation. Major issue in management of leprosy is
prevention and treatment of ulcers so as to prevent the further
worsening of disability. Patients with planter ulcers tend to
depend on health services, which for various reasons may not
be easily accessible or advisable in many situations.
Furthermore, social stigma to which leprosy affected persons
are subjected is generally because of the deformities and
unsightly ulcers.
Simple self care procedures if practised regularly will prevent
majority of the problems. Self-care for the prevention or
management of disabilities in leprosy is an intervention of
increasing importance. Experiences have suggested that these
disabilities can be best managed by practicing self care
practices by affected persons themselves in a group.
To ensure that the Persons with disability (PWD) residing in
leprosy homes are empowered with skills to enable them to
take care of their disability.
Netherlands Leprosy Relief- India (NLR-India) started
rendering support to the Self Care Projects in six states viz.
Uttarakhand, Jharkhand, Delhi, Bihar, Uttar Pradesh, & W.
Experiences with Self Care Groups in NLR supported States
Bengal. Establishment and running of SCG is being done in
the lines of the guidelines developed by NLR-India. This
whole process was divided into three stages.
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Identification of Facilitator - Non Medical Supervisor
(NMS)/Physio Therapy Technician (PTT) from District
Nucleus Team (DNT) by DLO.
Identification of homes occupied by leprosy affected
persons.
Organisation of stake holders meeting by DLO.
Sensitization meeting of inhabitants of selected LAP
home.
Training of Facilitators with practical demonstration by the
SCG coordinator from NLR-India.
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Profile & disability assessment of each SCG member by
facilitator.
Compilation of assessment by the facilitator.
Group formation & the selection of Group leader by the
SCG members themselves.
Training of Group leaders by Facilitator.
Self care practices in presence of facilitator (in the initial
stages).
Provision of Protective aids & appliances to the needy
persons by DLO.
Organisation of cultural activities.
1. Preparatory stage
2. Implementation stage
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5ILEP-INDIA /OCTOBER 2008
Contd. in page 6
6 UPDATE
Experiences with Self Care Groups in NLR supported States - Contd. from page 5
3. Monitoring & Supervision stage:-
Observations:
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Group leader will maintain a SCG attendance register and assess the regularity of self care practices by PWDs.
Facilitator will monitor SCG practice monthly/ quarterly and assess progress of each member and mention the problems
etc.
Facilitator will prepare report and send it to the concerned DLO.
DLO will organize half yearly stakeholders meeting to assess progress, to seek solution of identified problems & prepare
the future plan.
Till now, SCG are established and being run in 36 of 78 LAP homes present in 70 districts of six states of India, supported by
NLR-India. The findings of the SCG started in Uttarakhand and Delhi are presented. These SCG were established (Mar
2008) in 4 LAP homes i.e. 3 LAP homes in Haridwar district of Uttarakhand and 1 in west district of Delhi. A total of 160 LAP
agreed to be part of the self care groups in these 4 LAP homes. Analysis was done of the baseline data and data available at
the end of six months of self care practices by the SCG members. Mid-term review at the end of six months of running of SCG
revealed that a total of 137 LAP had followed self care practices, regularly and all of these reported softening of the skin.
Progress of the 160 enrolled LAP is depicted in the following flow diagram :
During the process of formation and running of SCG, we have observed that not only LAP have shown great interest
in the self care practices but also they have practiced self care practices in an organized manner in their respective groups.
There has been remarkable coordination amongst the stakeholders throughout the process. In addition, District Nucleus has
been instrumental in providing dressing material and protective aids like MCR chappals/shoes to the needy,
which could possibly be the reason of enthusiasm amongst LAP towards self care practices. Besides these,
there were some negative observations such as, LAP continuing the begging in order to earn the living. A total of 23 LAP
not practicing self care could be attributed to the fact that the time was not fixed for the activity.
Self care group (SCG) is a medico-social association of people with similar problems who are empowered to take care
of their own problems through group support. It is essential for the success of the SCG model that productive
interactions take place between appropriately informed and trained patients/clients and the multidisciplinary teams of
health workers. It is also essential that all members are appropriately informed, motivated, and prepared with 'skills'
necessary to manage the conditions in question. These self care practices would bring positive change in their
physical condition and social life.
Ghanshyam DikshitSelf Care Group Coordinator,
NLR India
Conclusion:
7ILEP-INDIA /OCTOBER 2008
Facility for Reconstructive Surgery (RCS) has been available
only in a few leprosy institutions unevenly distributed in the
country. The present DPMR plan of the Government of India
envisages rectifying this by the active involvement of non-
leprosy institutions especially the Government Medical
Colleges in different states. ILEP including DFIT has taken an
initiative in this endeavour. The Preventive & Medical
Rehabilitation (PMR) department of Patna Medical College
Hospital (PMCH), Patna, Bihar, was the first to introduce this
activity in 2005 with the help of DFIT for the first time. Only
after prolonged negotiations and repeated visits for over a
period of one year, agreement was finally reached. After 3 or 4
demonstration-cum-training visits, the surgeons started to
operate on their own. Since then, PMCH has done over 175
corrections till date. Darbhanga Medical College, Bihar, was
the next institution DFIT helped to introduce corrective
surgery for the leprosy disabled and has done over 20
procedures so far.
Seeing the success of this in the neighbouring state, the State
NLEP Coordinator and the State Leprosy Officer of
Jharkhand, have now approached DFIT to assist them in
establishing the same in Mahatma Gandhi Medical College in
Jamshedpur, Jharkhand. This was accepted and the
preliminary round of talks with the Superintendent of the
Hospital, the District Leprosy Officer (DLO) and NLR State
Coordinator, is over. The understanding among all concerned
was that after the few initial inputs by the visiting surgeon and
physiotherapists, they would withdraw from the programme
and would make only occasional monitoring / consultative
visits thereafter. An Orthopaedic & a Plastic surgeon have
volunteered to carry out the operations. A Physiotherapist has
been assigned to this task from the DLO's Office, and another
has been identified from a nearby PHC as support.
DFIT will depute two trained and experienced
physiotherapists from their projects to train the
Physiotherapists. Separate wards for male and female patients
have been earmarked and potential leprosy affected persons
needing correction of their deformities are being identified
and mobilised. The Physiotherapy department is being
restocked with the necessary equipment and furniture by the
government and DFIT has promised to donate the essential
instruments needed. The government has also agreed to
provide all consumables for this programme including
medicines and food for the patients. Identified patients will be
admitted 10 days before surgery for their pre-op.
physiotherapy and the first demonstration-cum-training in
reconstructive surgery will take place in the first week of
December 2008.
RCS in Jharkhand
The anguish of a young couple
Hirna & Dinesh (names changed) were a very happily married
couple. He was a highly qualified computer engineer working
with a well known computer advisory firm in a neighbouring
country. They had known each other from their school days.
Hirna noticed some vague patches on her body when she was
14 years old but neglected them since they were not
troublesome. Years later, she married her childhood
sweetheart and life was good for her.
Eight years ago she noticed small painful swellings over her
upper and lower limbs with swelling of her legs. She was seen
by many doctors and given various types of treatment, but
nothing proved helpful. A close family friend and Physician of
the leprosy programme in the country finally submitted her to
a skin biopsy and diagnosed leprosy. She was put on MB MDT
for 2 years. Meanwhile, she continued to get the swelling of her
legs and arms with nodules frequently. For nine years she was
treated with various types of steroid to combat her reaction,
including 1000 mgs. of intravenous Methyl Prednesolone. She
was given 2 courses of Thalidomide with a warning not to get
pregnant, but her reaction never abated. The doctor then tried
something none of us would have even thought of! She was
exposed to 2 pulses of Cyclophosphomide (an anti-cancer
drug)! Being sleepless at nights she was on regular sedatives.
Exposure to all these drugs over years started taking its toll on
her body. She developed severe Diabetes and within a couple
of years had bilateral cataract surgery done. She became
severely anaemic and was promptly started on haematinics.
Then Osteoporosis set in and at the young age of 30, she
acquired a stoop, the bodies of her thoracic vertebrae were
giving way and she had severe backache! The Physician
started her on Calcium and other supplements. Then came
the news that Dinesh was being deputed to India on
promotion, to set up their regional office in Chennai. There
was joy within the family but anguish between them because
of the uncertainties of treatment for her. They scoured the
internet for some answers before starting for Chennai and
came up with the ALM website. They were then directed to
visit DFIT.
A stooped, small fragile-looking lady in extreme pain,
supported by her husband walked into our office early this
year. All unnecessary drugs were stopped, the standard
treatment for reaction was started and she was referred to a
local NGO leprosy hospital since there might be need for in-
patient treatment for her. Now, she is free of any of those
painful swellings and reaction-free. She is regaining her
confidence and the couple seem to be seeing happy days
again.
8 UPDATE
A tale of woesJanarthanan (name changed), aged 40 years and unmarried
hailing from Chennai, is living with his sister and her family.
A Dermatologist in Chennai referred him to DFIT for expert
opinion. His story was that he had gone to the Dermatologist
for the treatment of his ulcers in both the feet which
he had noticed since May 2008. He was not aware of his
disease and admitted that he had not been treated for the
disease before.
On examination he had multiple skin lesions over his trunk
and infiltration over face and both earlobes. There were
Icthyotic, anaesthetic lesions over his limbs. He had bilaterally
enlarged ulnar, median, radial cuteneous, ulnar cutaneous,
lateral popliteal and musculocutaneous nerves. Sensory
testing showed impairment of touch sensation over
Right hand, loss of sensation over both feet and ulcers over
great toes of both feet. Skin smear was positive (3+) for AFB.
He came with his sister and friend the next day. His sister was
curious about his illness and was worried about spread of
infection from his brother to the other members of her family.
She was counselled about the disease and the treatment.
He was advised about regular self care for his ulcers. The sister
had an old prescription of 2007 of his, given by a Medical
College Hospital. He was prescribed only Rifampicin with
other Vitamin tablets for a short period and stopped, saying
that the patient need not come again!
He was referred to a NGO hospital with a prescription for
MB – MDT and management of ulcers.
Back on the roadMr. Arunachalam belongs to a town near Salem, he is an auto
rickshaw driver by profession. He was a Hansen's disease
Patient (MB) who had been treated with Mono and MDT. He
was released from Treatment (RFT) a few years back after
treatment. The disease left with ulnar claw and ulcers on both
feet. As a result of this, his wife divorced him and he was forced
to live a lonely life rejected by his family and the society.
Chronic recurrent ulcers forced him to dress his ulcers on his
own with cotton and bandages. He was unable to concentrate
on his driving job as the ulcers forced him to stop going for
work frequently, but he did not loose hope. He was on look out
for a ray of hope at the end of the tunnel.
He approached a Leprosy hospital run by a NGO at Salem.
The NGO trained him on self care activities and SSOD for
protecting his hands and feet. He began to practice self care
regularly and made it a regular routine in his life. He was more
careful on the use of his feet and gave it a lot of rest whenever
possible. In six months he was totally free of his ulcers. He
became a changed man. He looked forward to a life of new
verve.
He got married again and became proud father of three
children. The NGO which supported his remarkable change
arranged for a loan to purchase an auto under rehabilitation
scheme. He paid the dues regularly and cleared the loan and
became the owner of the auto.
His attitude and persevering nature was liked by his fellow
auto drivers in the auto stand. He was soon elected as a leader
for the auto-rickshaw owners association which boasts of 200
members in Salem Town. This social recognition was well
appreciated by the local community. He got his eldest
daughter married and the other two daughters are studying.
He is a man with a happy family. He is a sterling example for
others and especially the disabled patients that one should
never give up hope and look at life with a positive attitude.
Contd. from July 2008 Issue
As soon as someone misses an MDT appointment, action
should be taken to find out why the patient has not attended
and, if necessary, to remind the patient of the importance of
taking treatment regularly and of finishing the full course of
MDT. If this proves insufficient, a home visit by a local
community worker should be arranged to find out why the
patient has stopped visiting the clinic and, if necessary, to
motivate him or her to resume treatment. Such a home visit
should be undertaken preferably within one month of the first
missed visit date.
If the person has difficulty in attending the clinic, it is possible
for them to receive several blister packs at once, so that the
visits to the clinic are less frequent. It is advisable in such cases
to involve another responsible person to supervise the
treatment (a community volunteer, a family member or
neighbour), to help the patient to continue the treatment
properly at home (this is called Accompanied MDT, or A-
MDT). Counselling and information about the importance of
regularity of drug intake are essential. They should also be
advised to report to the clinic in case of any problem.
Although every effort must be made to ensure that PB patients
complete their treatment in six months and MB patients in
12 months, the six months of treatment for PB leprosy must be
completed within a maximum period of 9 months. Similarly,
the 12 months of treatment for MB leprosy must be completed
within a maximum of 18 months.
A defaulter is an individual who fails to complete treatment
within the maximally allowed time frame. Thus, whenever a
PB patient has missed more than three months treatment or an
MB patient more than six months treatment, it is not possible
for them to complete treatment in the maximum time allowed
and they should be declared as defaulters from treatment; this
should be indicated in the Leprosy Treatment Register under
“Treatment Outcome”.
If a patient returns after defaulting, examine him/her in the
same way as you would examine a new patient and record
your findings.
If the returning patient was previously a PB case:
• Count the number of patches to confirm the original
classification (section 4.3)
If the classification is now MB (more than five lesions),
register the patient as a return from default, not as a new
case, and treat with a full course of MB-MDT (12 months)
If the classification remains PB, register the patient as a
return from default, not as a new case, and give a full
course of PB-MDT
If there are signs of a reaction (section 5.8), manage
appropriately
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5.4 Who is a defaulter and what should be done for
people who return to the clinic after defaulting?
If the returning patient was previously an MB case:
Register the patient as a return from default, not as a new
case and not as a relapse (a relapse can only occur after
fully completing the first course of MDT)
Treat with a full 12-month course of MB-MDT
Remember that a reaction may mimic a return of the
disease (sections 5.8 and 5.9)
Any defaulter, particularly one who remains very irregular on
treatment and repeatedly defaults despite every effort on the
part of the health staff, may be referred, so that a more
experienced person can decide if further treatment is required
and if so, how much.
Relapse is defined as the re-occurrence of the disease at any
time after the completion of a full course of treatment. Relapse
is indicated by the appearance of new skin lesions and, in the
case of an MB relapse, by evidence on a skin smear of an
increase in BI of two or more units. It is difficult to be certain
that a relapse has occurred, as new lesions may appear in
leprosy reactions (section 5.8), and in many programmes
evidence from smears is not available.
MDT is a very effective treatment for leprosy. If a full course of
treatment has been taken properly, relapse is generally rare,
although continued vigilance is important. Patients who start
treatment with a high BI are more likely to suffer a relapse later;
most relapses occur long after the treatment was given –
sometimes over 10 years later. Fortunately, the use of a
combination of drugs has prevented the development of drug
resistance in leprosy, so relapse cases can be treated effectively
with the same drug regimen – MDT.
PB relapses are difficult to differentiate from reversal reactions
(section 5.9). If there are signs of recent nerve damage, a
reaction is very likely. The most useful distinguishing feature is
the time that has passed since the person was treated: if it is less
than three years a reaction is most likely, while if it is more than
three years, a relapse becomes more likely. A reaction may be
treated with steroids, while a relapse will not be greatly affected
by a course of steroids, so using steroids as a 'therapeutic trial'
can help clarify the diagnosis.
MB relapses should be investigated by using skin smears and
histopathology, if at all possible.
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5.5 What is a relapse? How is it recognized and
managed?
Peripheral level
Suspected relapses should be referred for further
investigation at a referral centre.
Contd. in page 10
9ILEP-INDIA /OCTOBER 2008
The Ambassador of Belgium, Mr. Jean M. Deboutte visited
Holy Family Hansenorium on 27.09.2008. He was received
by Dr. Krishnamurthy, Secretary, DFIT, Chennai and Dr. Rita,
Project Holder,
While visiting the wards, the Ambassador showed concern
and enquired about the well being of the inmates of leprosy,
TB and HIV/AIDS wards. He patiently stopped at some of the
beds of both the male and female wards and interacted with
them. He also visited the Out patient section, Laboratory,
Physiotherapy, and the Shoe department. The crèche, the
children's hostel, weaving unit were the other facilities he was
shown. He was impressed at the rehabilitation done for the
patients and visited some of the rehabilitated patient's houses
outside the campus in Fathimanagar.
Holy Family Hansenorium in Fathimanagar
Belgium Ambassador visits Damien Foundation Project
There was a Press Meet along with Secretary, DFIT, for about
20 minutes. On the whole, the Ambassador's visit was as
inspirational to all the staff and the patients as it was an eye-
opener to him.
His comments in the Visitors' Book when asked to record his
visit to Fathimanagar:
“Thank you very much for the warm welcome and the way
you have made me understand the work you are doing
helping and caring for the most needy people, done with a
very warm human approach. It is a wonderful experience and
a principle to be able to witness your action. Thank you and
wish you courage and good luck in your endeavours!”
10 UPDATE
Referral level
Suspected PB relapse: the diagnosis of a PB relapse can
never be absolutely certain. A skin smear should be
carried out, if at all possible, to ensure that an MB case is
not being misclassified as PB. The evidence for either a
relapse or a reaction must be weighed up and a decision
made. If it is decided to treat someone as a PB relapse,
they are given a normal sixmonth course of PB-MDT.
MB relapse: criteria for diagnosing a relapse are the
presence of new skin lesions and an increase by two or
more units of the Bacillary Index.
Drug resistance is a potential problem when treatment has
been irregular. Although resistance to dapsone was a serious
problem in the past, when leprosy was treated with dapsone
alone, clinically important drug resistance has not been
reported with MDT. Failure to respond to treatment, especially
the treatment of a relapse, should lead to suspicion of drug
resistance. Because of the seriousness of the development of
drug resistance, any suspicious case should be thoroughly
investigated at a referral centre.
The complications of leprosy can be categorized as:
Leprosy reactions (section 5.8)•
5.6 Is drug resistance a problem?
5.7 What complications occur in leprosy and how are
they managed?
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Effects of nerve damage (section 6.2)
Adverse effects of MDT
Complications of advanced disease
Psycho-social problems
MDT is remarkably safe and serious adverse effects are very
rare.
Red urine Rifampicin Reassurance
Brown discoloration
of the skin Clofazimine Counselling
Gastro-intestinal upset All three Give drugs with food
Anaemia Dapsone Give iron & folic acid
Itchy skin rash Dapsone Stop dapsone, refer
Allergy, urticaria Dapsone or Stop both, refer
Rifampicin
Jaundice Rifampicin Stop rifampicin, refer
Shock, purpura,
renal failure Rifampicin Stop rifampicin, refer
Other drugs are available for use if one or more of the standard
drugs must be stopped, but serious adverse drug reactions are
complex problems and must be managed by a specialist.
Adverse effects of MDT
Minor problems Drug Management
More serious problems Drug Management
The participants were from GOI, WHO, ILEP, Leprosy
Institutions (CLTRI-Chengalput and SLR & TC- Karigiri),
State and Districts (TN).
The session was chaired by Dr. Pannikar from WHO and Dr. P.
L .Joshi from GOI. Dr.P.Krishnamurthy, as ILEP coordinator
for India, welcomed the participants and said that under the
new leadership the programme has witnessed a refreshing
change in direction and an exalted level of partnership with
major players. Dr. Joshi while extolling the commitment of
ILEP members to the programme, urged the NGOs to look
beyond leprosy and resonate their actions in consonance with
the strategy and the scheme of NRHM. He reiterated his
support to decentralized planning which he said was in synch
with the schema of NRHM. He sought the help and support of
partners in strengthening supervision and monitoring, in
operationalising DPMR, in reducing stigma and
discrimination. Mr. Doug Soutar, General Secretary, ILEP,
referred to the relevance and importance of the current Global
strategy which emphasizes equity, quality and sustainability
and assured of the continued ILEP commitment to it.
DLOs from Salem and Pudukottai districts in Tamil Nadu
presented their
It is not difficult to bring about change in the way POD was
perceived by the General Health staff and in the levels of
their involvement particularly with the active interfacing
by NGO centres.
For the sake of sustainability it is important to realize total
internalization of the plan after an initial period of
facilitation.
There were presentations from Dr. Arif - NLR & Mr. Ashish
Chakravarthy -TLM
Different approaches with similar results.
Need for disseminating best practices.
The word colony has derogatory connotation and does
not help in removing discrimination. Effort should be
made to convince the administrators to remove references
to colony.
Presentations from Dr. Jamesh- SLO, Tamil Nadu &
Dr. Vijayakumaran- DFIT.
Ethical issues in case selection
Minor Differences in study protocols (basic protocol being
the same)- in inclusion of control group, in case follow up
Higher occurrence of reactions and drug side effects MB
intake less than expected
Experience in Integrated POD being
implemented in the two districts.
Experiences in working with SCGs in leprosy
colonies.
U-MDT Study:
Lessons learnt:
Lessons learnt:
Lessons learnt:
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Technical Session Meeting of ILEP India Representatives9th September, 2008, New Delhi
Experiences from leprosy management workshop at
Gauhati:
Current Status of DPMR implementation in India:
Study of magnitude of leprosy-related disability in
India:
Establishment of a viable referral system :
Challenges and perspectives:
Experiences with Technical Resource unit / Leprosy
Programme Advisors:
Presentation by Dr. Manimozhi-AIFO
Modules to be used as such with some modification
Small changes in methodology to suit the needs of the
programme
WHO will print more copies and make the modules
available for use by the programme
Need for decision on how many trainings are required for
India
To what extent ILEP is willing to participate
Presentation by Dr. Manglani-Consultant(DPMR)
Need for an estimate of the magnitude of the problem of
leprosy-related disability
Need for sharing of information on various guidelines
produced by GOI (RCS guidelines, Self care manual,
Stigma removal and BCC)
Need for coordination with other Ministries to remove
discriminatory laws and promote the use of funds by
LAPs.
Presentation by Dr. P.K.Oommen-Director-CLT&RI-
Chengalpat
Need for a quick estimate of the magnitude of problem
of leprosy-related disability
Sharing of information on best practices from various
centres
Presentations from Dr. Pati- LEPRA Society & Mr. Antony
Samy- ALERT:
Good initiatives
Intervention within the framework of sustainability
Presentations from Dr. Pandey-
NLR, Dr. Pati- LEPRA & Dr. N.M. Rathi-TLM:
Good initiatives
Different strategies to reach the same result
Need for more focus on assessing treatment adherence
directly from patients and cross-checking the data in the
PHC record
Need for exchange/dissemination of positive field
experiences
Follow up action:
Points for contemplation:
Lessons learnt:
Lessons learnt:
Lessons learnt:
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11ILEP-INDIA /OCTOBER 2008
Different Presentations of Leprosy
