WORLD HEALTH ORGAN I ZATION
ORGANISATION MONDIALE DE LA SANT~
REGIONAL OFFICE FOR
THE WESTERN PACIFIC
BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL
REGIONAL COMMITTEE Fourteenth Session Port Moresby 5-10 September 1963
TECHNICAL DISCUSSIONS WP/RC14/TD6 26 June 1963 ORIGINAL: ENGLISH
CASE-FINDING, FOLLOW-UP AND MANAGEMENT OF LEPROSY CASES WITH PARTICULAR ,REFERENCE TO THE INTEGRATION OF THESE ACTIVITIES INTO THOSE OF THE ESTABLISHED HEALTH SERVICES by Dr. D. A. Russell Senior Specialist Medical Officer (Leprology) Department of Public Health Territory of Papua & New Guinea
CONTENTS
1. 2.
INTRODUCTION
............................................. .
1
INVESTIGATIONS FOR THE PREVALENCE OF LEPROSY
2 2
3. LEPROSY CAMPAIGNS
4.
........................................ . LEPROSY IN PAPUA AND NEW GUINEA ........................... CASE-FINDING
4
5· 6. 7. 8.
9· 10. 11.
.............................................. ISOLATION OF PATIENTS ..................................... OUT-PATIENT TREA'lMENT ................................... . CHEMOTHERAPY ............................................. REHABILITATION OF CRIPPLED PATIENTS ....................... PROPHYLAXIS AND PROTEm'ION OF CONTROLS ................... . TEACHING AND TRAINING IN LEPROSY AND HEALTH EDUCATION ••••••• FUTURE GUIDE LINES
4
5 6
7 7
8 8 8 9 11
12.
13.
...................................... . CONCWSION .............................................. . ANNEX ....................................................
,
. WP/RC14/TD6 page 1 1. INTRODUCTION
~..
The epidemiology of leprosy varies in different countries and may be different in different parts of the same country. The WHO Expert Committee on Leprosy at its first session expressed the view that "leprosy is not a disease apart; it is a general public health problem in the countries in which it is endemic, and that therefore specific control work must be undertaken by staffs working within the general framework of the health administration of a country an~ must confOI1ll with the generally accepted public health principles." The detailed manner in which this is to be effected is not specified but left rather to the individual country concerned. At its second session, the Expert Committee supported this view fUrther by stating in its report that "the methods to be adopted for anti-leprosy campaigns will differ, according to the prevalence rates and economic and social conditions, and tha~ each country will adopt the method suited to its own circumstances." The Committee, however, was very explicit that, wherever a campaign is to be undertaken, it is essential to establish a central leprosy service, and that the ultimate trend of the leprosy campaign should be towards its integration within the general health services. Where this is to be the case then the leprosy patients can get no better treatment than the general population is afforded by the medical services. In Papua and New Guinea, at the present time, less than 20% of sick people receive medical attention by fully trained medical personnel. The need for a separate leprosy service is still particularly necessary in this territory because experience up to date has shown that case-finding and the treatment of leprosy are not effective when they.are dependent on the general health services only. The health agencies commonly concerned in the detection and treatment of leprosy are: (1) (2) Federal and State Public Health Services Private bodies devoted to leprosy work: (a) (b) Foundations Missions
The general principle governing leprosy campaigns starts with defining leprosy into "open" or "closed" cases, according to whether leprosy bacilli are detectable by smears for bacteriological examination or not. "Open" cases include all lepromatous and borderline cases, many of the reactional tuberculoid and a small but varying percentage of others. "Closed" cases are not thought to play an important part in the spread of the disease. It is this distinction
~ld Hlth
Org. techno Rep. Ser., 1953, 71
2W1d Hlth Org. techno Rep. Ser., 1960, 189
WP/RCI4/TD6 page 2 .
between the two classes of leprosy ca~es which is the basis of the policy of confining segregation to "open" cases.
2.
INVESTIGATIONS FOR THE PREVALENCE OF LEPROSY
The WHO Inter-Regional Leprosy Conference at Tokyo (1958)lhas described the various types of investigations of the prevalence of leprosy and as they are relevant, they are quoted as follows: (a) (b) (c) "Preliminary Investigation" "Case-finding Programme" "Epidemiological Survey"
A "Preliminary Investigation" means an investigation by one or more trained workers to obtain a picture of the distribution of the disease and the size of the problem in a given territory. The object is to find areas of high prevalence and choose a site for a case-finding programme. Use should be made of all available information. A "Case-finding Programme" means a detailed search for leprosy and for contacts with a view to placing every patient under treatment, and household and family contacts under surveillance. An "Epidemiological Survey" means a study properly planned and carried out, with expert statistical advice, including the recording of all relevant epidemiological information (e.g., climate, age and sex, distribution, diet, type of dis~ase, etc.) to obtain an ~ccurate analysis of the total leprosy problem, and of its true prevalence.
3.
LEPROSY CAMPAIGNS
Leprosy campaigns usually have three phases: attack, consolidation and integration. The attack phase is one of case-finding and treatment. Case-finding is achieved by mass examination, house-tohouse Visiting, contact tracing or the examination of particular groups of the population such as military or police recruits, factory workers and school children. Mass gatherings of the population for other purposes e.g., mass campaign against yaws, trypanosomiasis surveys, smallpox vaccination, could be used for leprosy case-finding provided trained workc;rs ,'C1re available. Contact tracing is more suitable in areas of medium or low prevalence of leprosy, as in areas of high endemicity of the disease practically the entire population must be regarded as contacts, and the cost of contact tracing then becomes prohibitive. The consolidation phase follows immediately after the completion of case-finding. lunpublished document WHO/Lep.Conf./21
(a)
WP/RC14/Tif:> page 3
As leprosy is a chronic disease requiring long years of treatment, the problem that now presents itself is that of case-holding. Regular treatment of the patients registered can now be conducted by:
mobile circuits e.g., automobile, bicycle or other transport. This is usually impossible in the terri tory. Less than 15% of the population can be reached by road; out-patient hospital treatment clinics conducted on fixed days, either for leprosy specifically or general medical examination including dermatology; travelling out-patient clinics (mobile units); clinics in leprosy villages in countries of scattered population where the use of mobile units is impracticable. This measure will have to be considered in the border and upper Fly River areas of the Western District where there are scattered foci of leprosy in small hamlets in extremely primitive country; a unit for survey, health education and treatment (S.E.T.) which carries out work around a general hospital dispensary or health centre. This work may be carried out in difficult situations by para-medical personnel directed by a doctor. This.is most suitable to present circumstances in most of this territory; a working group, as established in Brazil, directed by a leprologist who supervises the work of nonspecialized physicians and some other health workers; all existing non-governmental medical institutions in the country concerned, which could be enlisted in the leprosy campaign, if they accept the policy and direction of the health authorities.
(b)
(c) (d)
(e)
(f)
(g)
The third phase of integration is achieved when the health centres have been sufficiently developed to truce over the treatment of the leprosy patients as part of their regular work. At the beginning, surveys for case-finding and regular fo11owup for new cases should be performed by specialized leprosy personnel but when integration is complete it is thought that these duties could be part of the general health service, working fram health centres. However, even in countries with highly developed health services, this policy leads to great delays in diagnosis. Where diagnostic skill is limited, as in the Territory of Papua and New Guinea, such a policy may lead to the missing of many cases in the early stages of the disease, which respond best to treatment.
WP/RC14/TD6 page 4
To aid the development, as well as assessment of a leprosy campaign, pilot areas of operation should be first established and then gradually extended. The pilot area should be sited where the estimated prevalence of leprosy is higher than average and where there is a hospital or leprosarium for the admission of infectious, as well as acutely ill, patients and a laboratory equipped to carry out bacteriological examinations. The prOvision of treatment close to the homes of the people r and in the area where the disease occurs, is essential for the su~cessfUl treatment of leprosy in this terri tory. The people of Papua and New Guinea resent being removed too far fram their homes or even beyond their language groups, of which there are same 600.
4.
LEPROSY IN PAPUA AND NEW GUINEA
It is the purpose of this paper to d~scribe the prevalence and management of leprosy in the Territory of Papua and New Guinea. Leprosy appears to be endemic in most parts of the territory and has been known and treated for many years, but it was not until the Suppression of Hansen's Disease Ordinance in 1952-53 that segregation of "open" cases became compulsory. However, in the Territory of Papua and New Guinea, the enforcement of segregation has never been attempted. It would be fUtile. In the Territory, there was only one leprosy officer until
January
1963, when another Administration medical officer and a medical assistant were seconded for the special purpose of anti-leprosy work, and a unit known as the Regional Highlands Leprosy Control Unit was established at Mount Hagen. It is hoped that this unit will be the precursor of other similar units in the major regions of the Territory.
5.
CASE-FINDING
Cases are found in order of statistical importance, in the following ways: (a) special case-finding surveys conducted by the Administration Leprologist or other medical officers; detection on medical patrols performed by doctors, nurses, medical assistants; detection during routine medical examination for some other conditions; voluntary presentation of the patient for medical examinations;
(b) (c) (d)
'I,'lP/RCI4
/TOO
page 5
(e)
detection during routine medical inspection of schools, prisons, labour lines or recruits for labour forces.
It can be seen that at the present time specific surveys for leprosy case-finding are the most efficient. Although comprehensive epidemiological surveys of the nature described earlier have not been made in most areas, case-finding surveys nevertheless have revealed prevalence of the disease in all areas selected for investigation. The areas mentioned above were specially chosen because of the reported high prevalence of leprosy. It is estimated that there are about 10 000 cases of leprosy in the Territory and that about 6000 of these are untreated. The estimated prevalence of the disease is 5.71 per 1000 in the Territory as a whole. These surveys show that all forms of leprosy occur in the Territory but that the tuberculoid form predominates. This differentiation is true in the case of adults as well as children. The fi~xres quoted further indicate that the disease occurs in both coastal and highland areas, and that the coastal distribution appears hea~~er in prevalence as well as in the incidence of the lepromatous form. (See Annex 1.)
6.
ISOLATION OF PATIENTS
The isolation of patients is effected through Hansenide Colonies subsidized by the Administration, but under the administrative care of various Mission organizations. The subsidy is either total or partial. In the former case, the Administration meets the entire cost of land, bUilding, maintenance, staff salaries, all food and drugs for the patients. In the latter case, the Administration supplies only the salaries of the staff and the food and drugs for the patients, while the cost and maintenance of buildings become the responsibility of the individual Mission concerned. Under this system, there are eleven such colonies in the Territory (Papua four, New Guinea seven) but, in addition, treatment for leprosy is also available at Administration and Mission general hospitals, and aid-posts under supervision. The distribution of the various institutions and the areas that they serve can be appreciated by studying the accompanying map. During the year 1961-62, the number of patients in the various colonies and hospital wards was 2375. There were 1007 admissions and 777 patients discharged from the various institutions.
WP/RC14/TD6 page 6 .
7. ,
OUT-PATIENT TREMliENT
I~ recent years (1956 onwards), in keeping with modern trends in the pol~cy of the management of leprosy, an attempt has been made to encourage the non-infectious patient to receive out-patient treatment at his own village in the areas where the disease occurs. The records indicate that some 1387 patients are receiving out-patient treatment. The adoption of out-patient treatment has been recommended to the health services in general but the maximum effort at present is confined to four endemic areas, one in Papua and three in New Guinea. In the Wabag and Bogia SUb-districts, the out-patient treatment scheme functions through the co-operation of the Hansenide Colony in the area, the Administration and Mission hospitals and aid-posts. At two other places, namely Orokolo and Begasin, both areas of pronounced endemicity of leprosy, special clinics have been established from which treatment and village-visiting are being developed.
In this territory, out-patient treatment of leprosy is open to considerable criticism on the grounds of impracticability, as well as of weaknesses in the aid-post system as it functions at present. Only in the four specific areas mentioned has there been any effective, as well as regular out-patient treatment (about 80% attendance on the part of the patients), .whereas in other parts of the countr,y where sltilled supervision is not available response to such treatment has been meagre and generally unsatisfactory. The reasons for this are many. Leprosy is a rural disease and the rural areas of the Territory present tremendous problems regarding terrain, transport, the development of health facilities and general education of the people and the training of health personnel. Conditions which will require considerable improvement before outpatient treatment becomes satisfactory, in the Territory as a whole, are: (a) (b) the medical standards of the aid-post orderly; the standard of the aid-post facilities and the supervision of the treatment by medical assistants and medical officers. These officers themselves need training; the general education of the people.
(c)
Except in special circumstances, already mentioned, where outpatient clinics are under the control of medical personnel trained in leprosy work, it has been found that aid-post orderlies and medical assistants are not capable of providing an effective leprosy service in the rural areas.
WP/RC14/TD6 page 7
Therefore, there is still a if out-patient treatment is to be alread~ been demonstrated as very it has been planned and worked by and trained for it.
need for a separate leprosy service a success in this country. It has effective in the four areas in which specific people dedicated to the task
8.
CHEMOTHERAPY
The drug of choice is Dapsone as it has been found to be clinically effective and economical, as well as easy to administer and cont~ol even under rural or primitive conditions. Dosages of DDS in the Territory have varied from 400-800-1000 mg a week but experience has shown that relatively smaller doses.of 400-600 mg a week are better tolerated. In addition, drugs such as thiosemicarbazone, diaminodiphenyl sulfoxide (Medapsol) and Etisul cream and liquid and Ciba 1906 are also available, but the use of these latter drugs has been more limited due to unfavourable reactions. The results of treatment on the whole have been satisfactory where supervision is available, although there have been some serious cases of drug intolerance and marked frequency of lepra reaction, requiring the use of antimonial preparations and the steroids. The management of this phenomenon also requires special training and experience, because if lepra reaction is not treated promptly and effectively then this condition can cause a very damaging loss of morale in the patients. 9. REHABILITATION OF CRIPPLED PATIENTS
The assessment of defOrmity in patients in the Territory of Papua and New Guinea according to the classification of deformity as suggested in the report of the Scientific Meeting on Rehabilitation on Leprosy, held in India in 1960, revealed that theri are 2200 patients in need of specialised surgical assistance and care. At the present time, rehabilitation measures in leprosy patients cover simple physiotherapy and operations by our two surgeons competent to do routine orthopaedic procedures. There is also the fitting of prostheses through the artificial limb factory at Lae. About twelve patients have been fitted with artificial limbs. The figures quoted indicate the extent of the problem and the need for proper planning to relieve the situation. With this end in view, the Administration has sought a WHO fellowship award to enable a surgeon from the Territory to study the techniques developed by Mr. P. Brand at Vellore, South India. The treatment of leprosy ulcers is badly handled as a whole, except in special leprosy or surgical units.
lwld Hlth Org. techno Rep. Ser., 1961, 221
WP/RC14/TD6 page 8
10.
PROPHYLAXIS AND PROTECTION OF CONTROLS
BCG vaccination of new-boms in leprosaria is encouraged as a preventive measure, but BCG vaccination of the vulnerable members of the population as a whole is not done by the leprosy staff but left to the tuberculosis division. DDS is not administered as a routine measure to contacts because of the, at present, insuperable administrative problem and its equivocal results in other parts of the world.
11.
TEACHING AND TRAINING IN LEPROSY AND HEALTH EDUCATION
Very limited work has been done in these fields. Medical assistants and medical students of the Bapuan Medical College have been given lectures on leprosy as well as clinical demonstrations at Gemo Island Hospital, and shown films on leprosy. We are fortunate that leprosy carries no social stigma among the indigenes in this country. There is no reason therefore to call leprosy clinics by any other name. To do so would create in the Territory a problem that now exists only in the minds of the expatriates. 12 • FUTURE GUIDE LINES
There is a need for a concentration of public health effort on the follOWing lines: 1. The organization of epidemiological surveys by trained persoIDlel to assess the true extent of leprosy in the Territory and to study any features that are peculiar to the disease in this country. The need for a separate leprosy service in order to meet the problem squarely and develop a campaign of control to a level compatible with its eventual absorption into the general health service, by way of the rural health centres. But the problem of leprosy cannot wait until the general health services have reached the necessary standard. The need for more extensive training of medical orderlies, medical aSSistants, nurses and doctors in the recognition and treatment of leprosy. the fullest extent practicable through rural leprosy clinics, hospitals and aid-posts.
2.
3.
4. The extension of supervised out-patient treatment to
5. The establishment of a reconstructive surgery unit as a specific feature in the treatment of leprosy.
WP/RC14/TD6
page 9/10
6.
It is our experience that where the treatment of leprosy has been effective, convenient and humane, the people have responded and shown no sense of shame about the disease. services to assist in the rehabilitation of expatients. 13. CONCLUSION
7. The possibilities of co-operation with welfare
Leprosy is an endemic disease fairly widespread throughout the Territory but fortunately the tuberculoid form of the disease is the more cammon one. Whilst this appears as an encouraging feature from the point of view of transmission of the disease to future generations, there remain the problems and difficulties that follow the mutilations and handicaps that are a feature of extensive nerve involvement. The prevalence of the disease, its control and the rehabilitation of those affected therefore require our fullest attention and a fir.m policy on these matters. should be our first and earnest concern. The health services provided to rural people, who comprise 90% of the total population, are not yet adequate to deal with the problems of leprosy, but in certain selected areas integration of leprosy control with the general health services has been achieved.
WP/ tilJl.LJ./,l'.Ub
ANNEX 1
page
11
RESULTS OF SPECIAL LEPROSY SURVEYS
Area Investigated by the Leprologist SOUTHERN HIGHLANDS TARI HAIBUGA MARSH WESTERN HIGHLANDS WABAG SUBDISTRICT WESTERN HIGHLANDS BAIYER RIVER EASTERN HIGHLANDS OKAPA EASTERN HIGHLANDS NORTH PORE CENSUS GULF & WESTERN DIST. ARAMIA BAM! FLY
Prevalence Prevalence of' No. of' People of Leprosy Tuberculoid per 1000 Leprosy Examined per 1000
Prevalence of' Lepromatous Leprosy per 1000 3.0
Prevalence Prevalence of' Prevalence of' of Neuritic Dimorphous Indeterminate Leprosy Leprosy Leprosy per 1000 per 1000 per 1000
1 999 15 071 2 876 5 416 4 576
16.5 3.66 6.67 4.61 3.93
13.5 3.58 6.67 4.22 3.49
0.066
0.36 0.21 0.21
RIVER AND COASTAL TOWNS GULF DISTRICT IHlJ & OROKOLO MADANG DISTRICT MADANG DISTRICT BOGASIN CENSUS DIVISION NEW BRITAIN KILENGILOLLO & BARIAI REGIONS DUKE OF yORK IS. AITAPE EAST COAST AND INLA1TD DIST. ----COASTAL VILLAG~S NEAR PORT MORESBY TOTALS f
7 578 9 439 l2 617 3 421 3 110 3 597 3 014
18.4 14.938 6.18 36.8 17.36 10.28
15.5 13.985 5.54 32.4 15.43 6.67 43.46 9.76
2.9 8.953 0.63
1.4 0.99 3.05
2.3 0.32
0.5
0.32
0.32 0.55
55.17 16.45 14.21 r·
5.38 4.62 .l.
0.33 0·51 {
5.97 1.54 -----
"
1 945 74 659 ;..
,1'
;.
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