Guidelines & Practice
Technical Bulletins
1. BASIC REQUIREMENTS FOR THE IMPLEMENTATION OF MULTIDRUG THERAPY
The current strategy for leprosy control is early diagnosis and the provision of effective chemotherapy in order to cure the patient, to interrupt transmission and to prevent leprosy-related disabilities.
At present, regular and complete course with Multidrug Therapy (MDT) of all known leprosy cases and early diagnosed new cases is the best available effective approach to achieve leprosy control and its use must be the top priority for leprosy control programmes. Using this approach will. decrease the need for social, psychological and economic rehabilitation of the leprosy patient.
2 RECOMMENDATIONS TO ILEP MEMBER-ASSOCIATIONS FOR THE USE OF BLISTER CALENDAR PACKS IN LEPROSY CONTROL PROGRAMMES
ILEP Member Associations are quite frequently invited to supply Blister Calendar Packs to governments for their leprosy control programmes. The response to such a request is a very difficult decision, particularly when the extra cost is taken into account. A working group of the Leprosy Control Expert Discipline has reviewed the advantages and disadvantages of the Blister Calendar Packs and formulated some recommendations to help Member Associations make the best decision.
3 IMPROVING SKIN SMEARS & THE READING OF THE BACTERIOLOGICAL INDEX IN MDT LEPROSY CONTROL PROGRAMMES
Reliable skin smear tests are essential for the confirmation of the diagnosis of leprosy, the correct classification into Paucibacillary (PB) leprosy and Multibacillary (MB) leprosy of newly-diagnosed patients, the duration of treatment in MB leprosy in the majority of control schemes which treat ‘until smear negativity’, and the diagnosis of MB leprosy relapse. They may also be of help in the correct classification according to the Ridley-Jopling 5-point spectrum, in the assessment of progress, and in the anticipation of the further course of chronic severe Erythema Nodosum Leprosurn (ENL). Yet the 5th Expert Committee on leprosy of WHO (1977) commented on ‘...the extremely low standard of the bacteriological examination techniques used in many leprosy control projects’. The WHO 6th Expert Committee (1988) was forced, not on theoretical grounds but by reason of operational feasibility, to amend the classification of MB leprosy and PB leprosy recommended by the WHO Study Group on the Chemotherapy of Leprosy (1982), so that all smear-positive patients were included in MB leprosy.
4 PRELIMINARY RECOMMENDATIONS ON THE USE OF SURGERY FOR THE TREATMENT OF LEPROSY NEURITIS: CAUTION CONCERNING THE USE OF SURGERY IN PREVENTION OF DEFORMITIES
Deformities and disabilities are the consequence of leprosy neuritis, thus the best prevention of deformities is:
- First, the early detection and treatment of as many patients as possible.
- Then, the early detection and appropriate treatment of reactions which involve the nerves.
The therapy of leprosy now uses well tried MDT regimens and new drugs for treatment of both uncomplicated disease and leprosy reactions. Unfortunately, chemotherapy is not always used early enough, is not always well conducted, well tolerated or well followed.
5 WORKING PROCEDURES TO AVOID HIV INFECTION - ADVICE TO HEALTH STAFF INVOLVED IN LEPROSY CONTROL ACTIVITIES
Since the first cases were diagnosed in 1981, the HIV/AIDS epidemic has created millions of victims. Not a single country in the world is unaffected, and the estimates on the extent of the problem published by UNAIDS, the specialized United Nations Agency, are terrifying: by December 2003, about 40 million people, including 2.5 million children under 15 years, were living with HIV/AIDS. During the year 2003 alone, 5 million people were newly infected with HIV, and 3 million people died of AIDS. Sub-Saharan Africa is by far the most badly stricken area. In some countries, particularly in the southern part of the continent, more than 30% of the adult population is thought to be infected. The spread of the infection is also alarming in other parts of the world, particularly South- and South-East Asia and Latin America.
6 POSSIBLE CHEMOTHERAPY OF RIFAMPICIN-RESISTANT LEPROSY
The emergence of secondary rifampicin resistance in multibacillary leprosy is well documented (1, 2). Although only 24 cases of confirmed rifampicin-resistant leprosy Have been reported so far, others have occurred in different countries (3, 4). From an epidemiological point of view, patients harbouring rifampicin-resistant M. leprae are of great importance because of their potential ability to transmit such organisms in the community. The majority of the documented rifampicin-resistant patients are also resistant to dapsone, because rifampicin was added to the treatment of these patients only after they had relapsed from dapsone monotherapy. Consequently, neither rifampicin nor dapsone should be prescribed to rifampicin-resistant cases of leprosy. Furthermore, in order to interrupt as soon as possible the transmission of rifampicin-resistant M. leprae within the population and minimize the risk of relapse, the strategy for the treatment of rifampicin-resistant leprosy should be different from the treatment of rifampicin-susceptible patients.
7 ACHIEVING MDT FOR ALL LEPROSY PATIENTS
The ILEP Technical Bulletin No. 1 of September 1990 stated the Medical Commission’s view that Multidrug Therapy (MDT) should be given to all leprosy patients in need of chemotherapy (1). Because of the danger of drug resistance there is no justification to treat patients with any monotherapy.
8 PREVENTION OF DISABILITY IN LEPROSY
The overall aim of leprosy control programmes is to prevent disabilities. This current point in time presents a unique opportunity to implement specific disability prevention activities as a result of the successful implementation of MDT. Stigma is reducing and the hand over to integrated programmes allows the possibility of POD being introduced at a primary care level.
9 THE MANAGEMENT OF ERYTHEMA NODOSUM LEPROSUM
Immunologically mediated episodes of acute or subacute inflammation known as a reaction, may occur in any type of leprosy except indeterminate. Unless reactions are promptly and adequately treated they can result in permanent deformity. Most reactions belong to one of two major types, erythema nodosum leprosum (ENL) or type 2 reaction or reversal reaction (type 1 reaction).
10 PRIORITIES FOR LEPROSY RESEARCH
The priorities for research in leprosy have changed as a result of the success of the multidrug Therapy (MDT) programme. In December 1995, the ILEP Medical Commission produced a list of leprosy research topics. It was developed from the experience of members of the Commission and from a reading of the literature. The research topics which were identified reflected the interests of ILEP Member Associations in leprosy control and patient care and thus they may differ from topics recommended by other groups. There was however no detailed attempt to prioritise the topics except to rank the general research themes as follows: reactions and recent nerve damage, prevention of disabilities, chemotherapy and early diagnosis of disease, incidence and transmission.
11 DETECTING HARD TO REACH LEPROSY PATIENTS
At the beginning of 1997, about 890,000 leprosy patients were registered for chemotherapy, globally. The World Health Organisation estimates that the true prevalence of patients in need of chemotherapy is about 1,150,000 patients. This estimate was reached through information provided by national programme managers from endemic countries, taking into account registered figures, health service coverage and MDT implementation. This means that there would presently be a gap of about 260,000 undetected patients. This is an approximate figure, since population surveys conducted in different areas often showed that there were two to three times more patients than reported through the registered figures.
12 EARLY DETECTION AND TREATMENT OF REVERSAL REACTION UNDER FIELD CONDITIONS
Leprosy reactions are the main cause of acute nerve damage and disability in leprosy. Reactions are caused by changes in the immune response of the patient to the mycobacteria. There are two types of reaction, reversal reaction or type 1 reaction and erythema nodosum leprosum (ENL) or type 2 reaction. (ILEP Technical Bulletin 9 describes the management of ENL reaction).
Reversal reactions often occur in the first 6 months of multidrug therapy (MDT) and may occur in both paucibacillary (PB) and multibacillary leprosy (MB), but more commonly in MB. Sometimes patients are found to have reversal reactions at the time of diagnosis and it may be the symptoms of the reaction which makes the patient aware of the disease. A reversal reaction may occur after completion of MDT, particularly when short duration regimens are used.
13 PLANNING HEALTH EDUCATION INTERVENTIONS
Health Education activities have an important role to play in leprosy control programmes. The changing epidemiological situation of leprosy in different geographical areas of the world may mean that the strategies for Health Education need to be reviewed.
14 OPERATIONAL GUIDELINES FOR THE INTRODUCTION OF NEW MDT REGIMENS FOR THE TREATMENT OF LEPROSY
In June 1997, the WHO Expert Committee on Leprosy made several recommendations on possible ways to improve the treatment of leprosy (1). Two have been endorsed by WHO and one or both are being implemented in many national programmes.
15 GUIDELINES FOR IDENTIFYING PATIENTS FOR REFERRAL SURGERY
These guidelines are designed for programme managers as a framework for training their staff in identifying individual patients affected by leprosy, who would benefit from reconstructive surgery or other forms of surgery. It is important that centres doing reconstructive surgery in leprosy liaise with field workers in developing local criteria and arrangements for the referral of appropriate patients.
16 THE ILA TECHNICAL FORUM - IMPLICATIONS FOR LEPROSY CONTROL PROGRAMMES
The International Leprosy Association (ILA) convened a Technical Forum in Paris in February 2002, which brought together a group of experts to examine in detail the scientific basis for current guidelines and recommendations in the field of leprosy. A number of important issues were discussed at length during the 4-day meeting. In preparation for the Forum, a comprehensive review of published and ‘grey’ literature from 1966 onwards was carried out, enabling conclusions to be reached and recommendations to be made based on evidence. Where evidence is lacking, recommendations for best practice were made. Matters requiring further research were also identified.