leprosy - one of the few diseases which can be eliminated leprosy meets the demanding criteria for...
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Leprosy - one of the few diseases which can be eliminated
Leprosy meets the demanding criteria for elimination practical and simple diagnostic tools: can be
diagnosed on clinical signs alone; the availability of an effective intervention to
interrupt its transmission: multidrug therapy a single significant reservoir of infection:
humans.
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Why integrate leprosy into the general health services?
Integration means to provide “comprehensive” essential services from one service point to improve patients’ access to leprosy services and
thereby ensure timely treatment to remove the “special” status of leprosy as a
complicated and terrible disease to consolidate substantial gains made to ensure that all future cases receive timely and
correct treatment to ensure that leprosy is treated as a simple disease
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Why is coverage so important?
Good coverage means that: health facilities are easily accessible to every
member of the community health services are provided on a daily basis health workers are able to diagnose, cure and
provide basic information about the disease health facilities are distributed equally in all areas
urban/rural, male/female, poor/rich, tribal/others, etc.
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Advantages of Integrating Leprosy Services
Patients detected early Patients treated early Transmission of infection
interrupted early Development of
deformities prevented Stigma reduced further
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Diagnosing a case of leprosy
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We must follow good practices Good practices are:
be friendly give correct information about the disease answer questions /doubts keep confidentiality keep up to date records give choice to patient to decide when and where to
come back use MDT in a flexible manner provide leprosy services free of cost avoid unnecessary investigations
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How to diagnose leprosy
Examine skin Check for patches Test for sensation Count the number of patches Look for damage to nerves
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Signs of leprosy
Pale or slightly reddish patch Definite loss of sensation in the patch Signs of damage to nerves
definite loss of sensation in hands/feet weakness of muscles of hands/feet/face visible deformity of hands/feet/face
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What is not leprosy
Skin patches which have normal feeling are present from birth cause itching are white, black, dark red or silver coloured show scaling appear and disappear periodically spread quickly
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What is not leprosy (cont.)
Signs of damage to hands/feet/face without loss of sensation due to other reasons like injury, accidents,
burns, birth defects due to other diseases like arthritis due to other conditions causing paralysis
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How to examine for leprosy?
Examine in a well-lit room Examine the whole body Ask since when the patch was noticed Ask what treatments have been tried Test for sensation Look for any visible deformities
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Check for loss of sensation
Take a pointed soft object (feather, cotton wick) Lightly touch alternately the patch & normal skin Ask the person to point where they were
touched Ask them to close their eyes and repeat the
procedure In case of loss of sensation the person will be
able to point to where they were touched on the normal skin but not on the patch
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Treating a case with MDT
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Classification for treatment
The diagnosis is made based on finding definite loss of sensation in one or more patches.
When you have examined the whole body, count the number of patches.
1-5 patches is paucibacillary (PB), more than 5 patches is multibacillary (MB) leprosy
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Standard WHO-MDT for the treatment of leprosy
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Steps to start MDT Classify as PB or MB leprosy Inform the patient about the disease Explain the MDT blister pack - show drugs to be
taken once a month and every day Explain possible side effects (e.g. darkening of
skin) and possible complications and when they must return to the health centre
Ask the patient when it is convenient for him/her to come back to the health centre. Give enough MDT blister packs to last until the next visit.
Fill out the patient treatment card
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Treatment regimens
PB Adult (6 blister packs)
Rifampicin 600 mg once a month Dapsone 100 mg every day
MB Adult (12 blister packs)
Rifampicin 600 mg once a month Clofazimine 300 mg once a month Clofazimine 50 mg and dapsone 100 mg every day
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Multi Drug Therapy
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Multi Drug Therapy
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Keeping good records Good records include:
Patient identification (name, age, sex, address) Remark on history of complaint (what, how long,
progress) Remark on history of previous treatment (what, where,
how long, result) Current treatment (diagnosis, classification, any visible
disability, date of first dose, date of next appointment) Record of special events (what event, date, how
managed, referral) Date of cure
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Information to patientsAbout the disease
Caused by a bacteria Affects skin and sometimes nerves Progresses slowly Easy to diagnose and cure Lead normal life, do not change life style
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Information to patientsAbout the treatment
MDT will cure you completely MDT is free of cost MDT is available in all health centres MDT should be taken as advised (regular,
full course) If you have problem or questions contact
your health centre
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Information to patientsAbout possible problems
Skin discoloration due to clofazimine Urine discoloration due to rifampicin In case of fever, pain in the nerves,
muscle weakness, joint pains they must return immediately to the health centre
In case of eye problems Appearance of new skin patches How to protect insensitive hands/feet
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What is Accompanied MDT (A-MDT)? A patient receives
a full course of MDT at the outset receives information (verbal and printed materials) about the
disease, its treatment and when and where to come for follow up, and
someone close to or important to the patient assumes the responsibility of ensuring that the patient completes a full course of treatment.
Note: In some areas (difficult to access, poor security etc) or for some patients (students,workers etc), this will ensure that all patients have adequate supply of MDT at home.
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Curing the disease
Provide the correct blister packs (MB/ PB/ Child/ Adult) for correct duration (6 for PB & 12 for MB)
Explain how to use the blister pack (MB or PB) Give the first dose at soon as diagnosis is made Explain about the importance of regular treatment Encourage to ask questions and remove doubts Check when it is convenient to come back to the
centre Give enough blister packs to cover the interval Encourage patients to come in case of problems/
doubts
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MDT side-effects
Red coloured urine
Darkening of skin
Severe itching of skin
This is due to rifampicin. Lasts only for few hours Reassure the patient that this is harmless
This is due to clofazimine. Reassure the patient that this will disappear after treatment is completed
This is due to allergy to one of the drugs (commonly to dapsone). Stop all medicines and refer to hospital
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How to manage complications
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Some patients may develop complications
Leprosy reactions
Side-effects
Disabilities
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Leprosy reactions
1 or 2 patients in 10 may develop reactions Reactions are not a side effect of MDT. They
are the body’s response to leprosy More commonly seen in MB cases (more than 5
lesions) Signs and symptoms include
Skin: patch/s becomes reddish and/or swollen; sometimes painful reddish nodules appear
Nerves: pain in the nerve and/or joint; loss of sensation and weakness of muscles (commonly of hands, feet and around eyes)
General: fever, malaise, swelling of hands/feet
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Managing reactions (1)
Early diagnosis and prompt treatment of reactions Every patient should be informed about the signs and
symptoms of reactions Inform them to go as soon as possible to the health
centre Reassure patients that:
reactions can be treated they are not a side-effect to MDT does not mean that MDT is not working
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Managing reactions (2)
Rest is very important: Help to get leave from work or school for a
few days (e.g. medical certificate) Control of pain and fever
Aspirin or paracetamol
Continue MDT regularly
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Managing reactions (3)
Reactions which only involve the skin: rest and pain-killers are usually sufficient. If there is no improvement within few days or
worsening, then specific treatment is needed
Reactions which involves the nerves start treatment with a course of corticosteroids (e.g.
prednisolone) as soon as possible will control all signs/symptoms of reaction
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Before starting treatment with prednisolone
Make sure that you have adequate stock One course will require 336 tablets of 5 mg each The course lasts for 12 weeks It is better to examine the patient once every 14
days and reduce the dose Advise to take the total daily dose every morning If you do not have adequate stock, then start
treatment and refer to another centre/hospital Always send a written note with the patient, when
you refer
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Suggested course of prednisolone 40 mg (8 tablets) every morning for 14 days 30 mg (6 tablets) every morning for 14 days 20 mg (4 tablets) every morning for 14 days 15 mg (3 tablets) every morning for 14 days 10 mg (2 tablets) every morning for 14 days 5 mg (1 tablets) every morning for 14 days Note: Continue rest and aspirin or paracetamol as required
Examine the patient every 14 days before reducing the dose
If there is no improvement or worsening, refer to hospital Continue MDT regularly
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Why do disabilities occur?
Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because: Late diagnosis and late treatment with MDT Advanced disease (MB leprosy) Leprosy reactions which involve nerves Lack of information on how to protect
insensitive parts
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Disabilities can be prevented
The best way to prevent disabilities is: early diagnosis and prompt treatment with MDT
Inform patients (specially MB) about common signs/symptoms of reactions
Ask them to come to the centre ASAP Start treatment for reaction ASAP Inform them how to protect insensitive hands/
feet /eyes Involve family members in helping patients
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Care of feet
Cracks and fissures
Blisters
Simple ulcer
Soak in water Apply cooking
oil/Vaseline Use footwear
Do not open blister Apply clean bandage
Clean with soap & water Rest and clean bandage
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Care of feet (2)
Infected ulcer
Wounds/injury
Weakness/paralysis
Clean with soap & water Rest & apply antiseptic dressing
Soak in water Apply cooking oil/Vaseline Clean and apply clean bandage Protect when working/cooking
Oil massage Exercises Refer
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Care of eyes
Redness and pain
Injury to cornea
Difficulty in closing eye
Aspirin or paracetamol Atropine and steroid
ointment Cover with eye pad Apply antibiotic ointment Refer
Tear substitute eye drops Exercises Dark glasses to protect Refer
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When treatment is completed
Congratulate the patient Thank family/friends for their support Reassure that MDT completely cures leprosy Any residual lesions will fade away slowly Show them how to protect anaesthetic areas and/or
disabilities Encourage to come back in case of any problem Tell that they are welcome to bring other members of
family or friends for consultation Remove the patient’s name from the treatment register