Leprosy - one of the few diseases
which can be eliminated
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Leprosy meets the demanding criteria for
elimination
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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.
Why integrate leprosy into the
general health services?
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Integration means to provide
“comprehensive” essential services from one
service point
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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
Why is coverage so important?
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Good coverage means that:
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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
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urban/rural, male/female, poor/rich, tribal/others, etc.
Advantages of Integrating
Leprosy Services
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Patients detected early
Patients treated early
Transmission of infection
interrupted early
Development of
deformities prevented
Stigma reduced further
Diagnosing a case of
leprosy
We must follow good practices
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Good practices are:
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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
How to diagnose leprosy
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Examine skin
Check for patches
Test for sensation
Count the number of patches
Look for damage to nerves
Signs of leprosy
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Pale or slightly reddish patch
Definite loss of sensation in the patch
Signs of damage to nerves
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definite loss of sensation in hands/feet
weakness of muscles of hands/feet/face
visible deformity of hands/feet/face
What is not leprosy
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Skin patches which
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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
What is not leprosy (cont.)
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Signs of damage to hands/feet/face
without loss of sensation
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due to other reasons like injury, accidents,
burns, birth defects
due to other diseases like arthritis
due to other conditions causing paralysis
How to examine for leprosy?
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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
Check for loss of sensation
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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
Treating a case
with MDT
Classification for treatment
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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
Standard WHO-MDT for the
treatment of leprosy
Steps to start MDT
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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
Treatment regimens
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PB Adult
(6 blister packs)
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Rifampicin 600 mg once a month
Dapsone 100 mg every day
MB Adult
(12 blister packs)
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Rifampicin 600 mg once a month
Clofazimine 300 mg once a month
Clofazimine 50 mg and dapsone 100 mg every day
Multi Drug Therapy
Multi Drug Therapy
Keeping good records
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Good records include:
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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
Information to patients
About the disease
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Caused by a bacteria
Affects skin and sometimes nerves
Progresses slowly
Easy to diagnose and cure
Lead normal life, do not change life style
Information to patients
About the treatment
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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
Information to patients
About possible problems
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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
What is Accompanied MDT (A-MDT)?
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A patient receives
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a full course of MDT at the outset
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receives information (verbal and printed materials)
about the disease, its treatment and when and where
to come for follow up, and
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someone close to or important to the patient assumes the
responsibility of ensuring that the patient completes a full
course of treatment.
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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.
Curing the disease
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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
MDT side-effects
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Red coloured urine
Darkening of skin
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This is due to rifampicin. Lasts
only for few hours Reassure
the patient that this is harmless
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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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Severe itching of skin
How to manage
complications
Some patients may develop
complications
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Leprosy reactions
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Side-effects
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Disabilities
Leprosy reactions
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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
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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
Managing reactions (1)
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Early diagnosis and prompt treatment of
reactions
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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:
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reactions can be treated
they are not a side-effect to MDT
does not mean that MDT is not working
Managing reactions (2)
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Rest is very important:
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Control of pain and fever
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Help to get leave from work or school for a
few days (e.g. medical certificate)
Aspirin or paracetamol
Continue MDT regularly
Managing reactions (3)
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Reactions which only involve the skin:
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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
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start treatment with a course of corticosteroids (e.g.
prednisolone) as soon as possible
will control all signs/symptoms of reaction
Before starting treatment with
prednisolone
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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
Suggested course of
prednisolone
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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
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Examine the patient every 14 days before
reducing the dose
If there is no improvement or worsening, refer to hospital
Continue MDT regularly
Why do disabilities occur?
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Disabilities such as loss of sensation and
deformities of hands/feet/eyes occur
because:
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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
Disabilities can be prevented
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The best way to prevent disabilities is:
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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
Care of feet
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Cracks and fissures
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Blisters
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Simple ulcer
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Soak in water
Apply cooking
oil/Vaseline
Use footwear
Do not open blister
Apply clean bandage
Clean with soap & water
Rest and clean bandage
Care of feet (2)
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Infected ulcer
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Wounds/injury
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Weakness/paralysis
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Clean with soap & water
Rest & apply antiseptic dressing
Soak in water
Apply cooking oil/Vaseline
Clean and apply clean bandage
Protect when working/cooking
Oil massage
Exercises
Refer
Care of eyes
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Redness and pain
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Injury to cornea
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Difficulty in closing eye
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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
When treatment is completed
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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