WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU REGIONAL DU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONDIALE DE LA SANTE
RIDIONAL COMMITTEE
Eighth Session Hong Kong
vVP/RC8/TD5 8 September 1957
5-11 September 1957
DISCUSSION GROUP REFORTS ON LEPROSY
Monday. 9 September at 2.30 p.m. COlTTENTS
1 2
Report of Group I •.•.•...••...••.••.•.•••.•••.•••.••••••• ' 2 Report of Group II ••••••••••••••••••••••••••••••••••••••• Report of Group III......................................
4 8
3
4
Report of Group IV ••••••••••••••••••••••••••••••••••••••• 11
WP/RC8/TD5 Page 2 REroRT OF GROUP I
ORIGJNA.L: FRENCH
The members of this group are Dr. Le van 10lai (Viet Nam) Chairman Dr. Ber Keng Hean (Cambodia) Dr. Phav Sany (Cambodia)
Medecin-Colonel H.Demange (France) Rapporteur Dr. Thongphet Phetsiriseng (Laos) Dr. Phony Phoutthasak (Laos) Dr. G.M.Thomson (UK) Dr. Tran van Bang (Viet Nam) Dr. Nguyen Tang Nguyen (Viet Nam) Miss C. del Rosario (IUHEP) Dr. Thos. C. Lonie (spc) Sir Alexander MacFar~ (TAB) Dr. Harmen (Hong Kong Dr. M. Giaquinto (WHO Mr. L. Keyes (WID) The
members of Group I explained how the control of leprosy in their Following this dis-
respective countries was envisaged and implemented.
cussion the items mentioned below emerged as starting points for leprosy control measures:1 Treatment (a) An overall epidemiological survey leading to early case finding. (b) Quick implementation. of chemotherapy. (c) Mass treatment at a dispensar,y or at the homes of non-isolated cases. 2 Preventive Treatment (a) Temporar,y and selective i~olation (b) Health education of the public
3
Rehabilitation Programme (a) Development of measures facilitating the physical and social rehabilitation of the leper.
WP/RC8/TD5 Page 3
(b) Revision of leprosy legislation
4
The members of the Group wish to malte the following suggestions
to the Regional Committee (a) WHO should intervene with the UNO to draw its attention to the importance of the social problems arising from leprosy control and the advantage of tackling them at the same time as campaigns sponsored by international assistance. (b) WHO should provide information on mass treatment on the basis of observations already made and proceed with research in order to determine the highest possible <pick recovery. (c) Help should be provided for Member states on the training of specialized staff for leprosy control and physical rehabilitation of lepers. degree of sulfonaemia for ).
Pagel,.
WP/RC8/ID5 ORIGJNAL: ENGLISH
REPORT OF GROUP II Th
members of this group are:Dr. Dr. Dr. Mr. Mr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. Dr. 'W. Glyn Evans (UK) Chairman
Y. Danvoye (Cambodia) Y.T. Kuo (China) A. Saita (Japan) Yu Sun Yun (Korea) Jesus A. Nolasco. (Philippines) P.W. Dill-Russell (UK) Leroy Burney (USA) Ra:pporteur G.C. Dansey-Browninf? tIAPB) Heil D. Fraser (lLA) Tsang Fuk Cho (rJFUNA) T.C. Lau (VlFUNA) C.Y. Shu (mIO) S~1.0g::..
;)r. I-l..
(,(l.ao)
The members of Group II highly commended the Leprosy Control Programme
of Hong Kong and the institutional programme of Hay Ling Chau, where an eff ctive rapport and co-ordination is demonstrated between the control activities of a governmental agency and an institutional service subsidized both by government and voluntary tunds. It is apparent this effective relation-
ship is a result, largely, of the stimulating and dedicated leadership of Dr. G. Graham-Cumming and Dr. N.D. Fraser. 1 Objective The members determined that their objective was to present general principles of leprosy control for the guidance of governments and their staffs. In the discussions, it was apparent that each countr,y had certain problems and needs peculiar to each, but the comments and recommendations resulting from the discussion present broad administrative guidelines with which all could agree. 2 Control Measures It Vias decided to comment upon the following control measures:
Page 5
WP/RC8/TD5
2.1 2.2
Case finding Orsanization of treatment (a) Out - patient (b) In - patient
2.3
Rehabilitation of Eatients (a) During treatment (b) In his community
2.4- Health Education
(a) Patient (b) Professional (c) Public 2.5 2.1
Training Needs
Case finding Members discussed the services in their cOWltries regarding cas finding. Korea mentioned the value of medical clinics. In the Philippines I mobil
clinics are used in areas of high incidence, especially for visiting towns and schools. Many members mentioned the importance of follow-up of contacts of known
cases. Recommendations: The following procedures were recommended, in order of priority, as having the greatest effectiveness in case finding: (a) Follow-up of contacts of known cases; (b) as an adjunct to regular services, such as B.C.G. and venereal diseas ; and (c) the use of clinic visits for other purposes as a method of screening and case finding.
WP/RCB/TDS Page
6 Organization of treatment (a) Thesulphones have made it possible to conduct treatment of milder or controllable cases on an out-patient basis. This keeps the
2.2
patient in his communit,y and decreases rehabilitation problems. (b) Institutional care, in most of the vrorld, is the exception rather than the rule. Hovrever, economic factors rather than available
treatment most often determine type of care given. It vras generally a,greed that correct thinking demands an open door to non-institutional, yet controlled, treatment, as a natural constructive development. It was suggested that (i) Compulsory segregation hides oases.
(ii) Leprosy should be part of communicable disease regulations giving local health authorities power to act in individual oases. 2.3 RehAbilitation of Patients This includes physical, mental and vocational aspects, whioh begin in the institution and is continued upon return to the community • The question of acceptance upon return home is an important problem.
.
The longer the stay in hospital, the more difficult is rehabilitation. Centres for the physically handicapped were suggested where the leprosy patient cOuld be treated together with other disabled persons so as to minimize the stigma. Health officials were urged to use voluntary groups to assist in other problems 'and it was further agreed that governments should assume leadership in employment of leprous and other handicapped patients. The possibility of
resettlement of lepers on the land was suggested, where they could contribute to their own welfare and remain productive.
WPjRCB/TD5 Page 7
2.4
Health Education It was agreed that there is a need for all health personnel to be
alert and knowledgeable, in order to assume their proper role of leadership.
2.5 / Training /
Needs
RecommendatioA§: (a) Greater training for medical students in leprosy in those countries where the problem is serious. (b) Public health schools should add training in leprosy to their curricula. (c) Each country with a real problem of leprosy should provide training courses for physicians, public health nurses, midwives and other ancillary health personnel, preferably in conjunction with a medical school. (d) WHO should establish at intervals a training course, where patients are readily available, for those health personnel concerned with the' treatment and control of leprosy, includ-
ing, but not limited to, such activities as occupational therapy and orthopaedic rehabilitation.
Page 8
WP/RC8/TDS
ORIGlli.AL :ENGLISH
REPORT OF GROUP III The members of this group are:-
L.J. Clapham (U-.1\:) Chainnan H.E. Downes (Australia) Wu Ching (china) M. Yamaguchi (Japan) Mohamed Din bin Ab.ll1o.d (HalaY£l.) Rapporteur Dr. J. Paiva Hart ins (Portugal) Dr. G. Graham-C\.u:uning (m~) lUss Mary Chow (Icn) Mrs. D.C.C. Trench (LRCS) Dr. Wong (Hay Ling Chau leprosarium, Hong Kong) Dr. E. Croapbell (ICA) Dr. L.O. Roberts (rmo) Dr. Dr. Dr. Dr. Dr. This group, after decidinG to limit the discussions to the public heal th angle and control of lepl"Osy by heal-(;h officers, spent SOiae time in obtaining Jche vie~'{s
of the membe-_'s as to the existing practice of
leprosy control in their respective cO'Lmtries. It immediately became apparent that greatly divergent opinions on the methods of control are nO\v prevalent in this Region. 1 (a) It was noted that:Segregation. This v~-ied
fl"Oll '(;he most rigid compulsory segreBation to Jchat In the fOl~er
of almost no segregation.
instances there seems
little likelihood of any early relaxation of this policy. However, certain countries are preparing to revert to nonsegregation in view of improved current treatnent as ,Tell as reduction in costs. (b) Notification of cases. A marked variation was again a feature, ranging from comPulsory
Page 9
WP/RC8/TD5
notification to none at all.
Even where notification is
compulsory by lay, it is not possible to enforce it. (c) Case Finding. (i) (ii) General individual practi-Cioners contributed little. Self-diagnosis by patients on themselves, relatives and friends Ylas prominent.
(iii) (iv)
Health visitors tracing contacts clairled some S'L:ccess. Special survey teams had been utilised to look for leprosy.
(d)
Leprosaria. In general they appeared to "fork on simila:i~
line s to Hay Ling
Chau Leprosarium. supported their
Whilst certain governments financially leprosaria, voluntary organizations assisted
~7n
considerably in others. (e ) Prevention. There has been insufficient experience as yet as to wheJ~her
BeG
is protective against leprosy and whether protective sulphetrone is of any value. 2 (a) Furthermore many members are of the opinion that ignorance and fear have formed a strong ba..--rier against the control of leprosy; (b) many believe, too, that there h..'lS
been a marked fall in the
incidence of leprosy in certain modern countries throughout the years, which could perhaps be attributed to bet"Ger living
conditions, improved sanitution
ro1d good nutrition.
A contrary
view is upheld by one or -I..,-ro members.
WP/RC8/TD5 Page 10
3 (a)
After some discussion ti1is group agreed:that the ideal public health measure would be to take the infective case out of the community ,dthout offence or (b) fe~;
that more research would be required to determine when a case oould be considered infective. . (A case may be infectious even before any signs appear);
(c)
that the control of leprosy should be centralized at the national level in a country;
(d)
that it was satisfactory to treat non-infectious cases in outpatient departments and that in certain countries it was an economic necessity to do so;
(e)
that there might be an advantage in the injection of sulphones as op)osed to tablets by mouth for reasons of economy; blood. levels and less frequent attendances;
(f)
that the follow-up of cases should continue throughot'.t the patient's life - less often in later years;
(g)
that the education of the patient and the public, particularly school children, should be encouraged j
(h)
that it was desirable to find an effective prophylactic because . of the universally accepted desire to protect children.
4.
The group noted, too, that some very interestinG vfork on leprosy
appeared to have been undertaken outside the TIestern Pacific Region and it was suggested that an inter-regional seJ:linar, vlith particular emphasis on the public health aspects of leprosy, could be beneficial to all concerned.
i"IFjRC8/ID5
Page 11 ORIGrnAL: :ENGLISH
REPORT OF GROUP IV
The members of this group are:Dr. R.K.C. Lee (USA) Chairman
Dr. C.H. Yen (China) I,ledecin-Colonel M. Demange (France) Dr. J. Bierdrager (Netherlands) Dr. Antonio Ejercito (~I) Dr. M. Doraisingham (U!() Rapporteur Dr. P.R. Teng (UK) Dr. Walter C. Allwright (mF) Dr. Marie Hui-hsi Feng (I.1\UA) Mr. Brian J one s (UHICI!F) Dr. Eugene Campbell (US-ICA) Dr. H.P.L. Ozorio (VIFSA) Professor F.E. Stock (\TI~) Dr. J.N. Rodriguez (PI) Dr. O.K. Skinsnes (HK University) The grouping comprising 15 persons met under the chairmanship of Dr. R.K.C. Lee.
Dr. H. Doraisingham was designated to be Rapporteur.
The group at the outset realized that demands and conditions must vary from one place to another by reason of the nature of the terrain, the availability or othervdse of adequate medical and social services and the differing social arui cultural patterns. It agreed to concentrate on the
theme of Control as opposed to eradication, or curative measures. The main headings under vmich the problem was discussed were as follows:1
Case finding Among the numerous measures possible, the group listed the
following as the more important for this Region:-
VVP,/.RC8/ID5 Page 12
(i) Examination o£ family contacts. (ii) (iii) Examination of organized groups particularly school children. Where static (fixed) centres do not exist, travelling or mobile clinics should be provided. (iv) Where by reason of mal\Y known cases, an area is thought to be highly endemic, case :rinding. surveys should. be carried out with a view to
(v) The cooperation and support of the G.P., in order to assist in the case finding pro gt"amme, should be enlisted and. to further this medical education in Leprosy should form an essential part of the curriculum.
( vi)
The case finding potential of other medical institutions such as clinics, O.P. services and hospitals should receive attention.
( vii)
The education o£ the public and. through it, the leprosy patient, tha.t the disease is curable, would encourage sufferers to report fortreatment more readily.
2
Case Holding
(i)
It should. not rest on the idea of compulsion except in places where eradication is possible.
(ii) (iii)
Emphasis should be on domiciliary or out-patient services. Institutions for those needing hospital treatment should be provided.
wPjRc8/TD5 Page 13
(iv)
In suitable areas the creation of settlements and villages would be an additional advantage, and may even be necessary.
(v)
Persons disabled on account of leprosy, but declared cured or arrested, and requiring care, should be admitted to institutions for the disabled (as a whole).
(vi)
Babies of leprous mothers should be separated and where possible fostered.
3
Mass Treatments as an instrument of Public Health (i) (ii) As far as possible, it should be on a voluntary basis.
Treatment must be sustained, regular and adequate with a sufficient concentration of the drug in the blood.
(iii)
Health visiting is essential -in order to persuade patients to continue regular treatment. should be inareased. If such staff
is inadequate, it
4
Health Education There is great need to provide Health Fducation of the publiC, the
patient and the profession on a sustained and repetitive basis.
The Public The
should be taught to accept leprosy as it does almost all other diseases. group emphasized the importance .of this item and recommended that it be pursued vigorously. Furthermore , it should be remembered that leprosy is
only one ailment to which human! ty is subject.
5
Legislation The group is of the opinion that since there is adequate legislative
cover in most countries, there is little or no need for new legislation.