Antileprosy measures in Bombay, India: an analysis of 10 years' work*

Antileprosy measures in Bombay, India: an analysis of 10 years' work* K. K. KOTICHA1 & P. R. R. NAIR 2 Leprosy control measures adopted in Bombay consist of health education, case- detection, and treatment, and are carried out mainly by the Acworth Leprosy Hospital and its subsidiary, the Greater Bombay Leprosy Control Scheme. Although the data collected on different aspects of leprosy during the 10-year period 1963-72 are hospital-based and retrospective, their analysis provides a useful indicator of the possible situation in the field. Health education is provided by medical social workers, field staff, andphysicians, and the significance of this activity in relation to early detection of leprosy is analysed. It is shown, however, that case-holding is a more urgent priority than case-detection. Trials have confirmed the effectiveness of chemoprophylaxis with dapsone for contacts of infectious index cases in crowded households. Comparison of annual expenditure per outpatient in leprosy clinics with that for inpatients in a leprosy hospital demonstrates greater cost- effectiveness ofoutpatient treatment. Some practical recommendations are madefor leprosy control. In Bombay antileprosy work is carried out mainly through the Acworth Leprosy Hospital (ALH) and its subsidiary, the Greater Bombay Leprosy Control Scheme (GBLCS). Centres operated by the Control Scheme are spread throughout the city area; the ALH clinic coordinates the various activities. Leprosy control measures in Bombay consist chiefly of health education, case-detection and treat- ment. No time-limited, prospective field projects have been carried out but the clinic-based data collected during the 10-year period 1963-72 should serve as baseline data for reflecting the possible situation in the field, quantifying the magnitude of the future problem, and planning a project of leprosy control through time-oriented schedules. The importance of health education for early and in- creased detection of the disease, the effectiveness of prolonged therapy, and the role of chemoprophy- laxis are emphasized. In this paper, prevalence and detection rates are considered, data on education, case-detection, treat- ment, and prophylaxis are presented and expendi- * The first author held aWHO Fellowship in 1973-74 and wishes to acknowledge the value of the training received during its tenure in carrying out this analysis. 1 Superintendent, Acworth Leprosy Hospital, Bombay 400 031, India. 2 Statistician, Acwortb Leprosy Hospital. ture per patient per year in different establishments is analysed. Notes are included on integration of leprosy work into the general health service and on assessment of antileprosy programmes. Unless stated otherwise, the data are taken from annual reports of the Acworth Leprosy Hospital and the Greater Bombay Leprosy Control Scheme. PREVALENCE The approximate prevalence rate for leprosy in Bombay is obtained in the following way: if A = number of resident, registered patients up to 1972, including the number of patients " out of con- trol "; a B = the number of dead patients; b and C = the mid-year population of Bombay in 1971, then the approximate prevalence rate is given by A-B x 1000 = 71 835-477 x 1000 = 11.96.C 5 968 546 A resident patient is defined here as a patient who had resided in Bombay for at least 2 years at the a A term used for registered patients who have not been under control for two or more years. See WHO Technical Report Series, No. 459, 1970 (Fourth report of the WHO Expert Committee on Leprosy), p. 6. b The number of patients released from control could not be identified. 3488 - 67 BULL. WORLD HEALTH ORGAN., Vol. 54, 1976 K. K. KOTICHA & P. R. R. NAIR time of registration. The census figures are those for the year 1971, while the number of cases is the cumulative total for the 10-year study period. A marginal correction can be made by deducting the number of patients who have died (as reported by relatives or friends; this will be an underestimate as the clinics are not always informed of deaths of patients). The number of patients registered but non- resident is not included; however, among these are some patients who might subsequently have become resident but for whom revised information was not available. Likewise, resident patients who have sub- sequently migrated away from Bombay have not been excluded. The numbers of inactive or arrested or cured cases have not been excluded for want of uniform definitions. Similarly, patients who have completed their treatment have not been excluded for lack of uniformity of views about the period of Wf'HO 76646 Fig. 1. Prevalence of leprosy in Bombay City and the Greater Bombay area, 1963-72: Bombay City, 42 035 cases; Greater Bombay, 29 800 cases; total number of cases 71 853. WHO 76647 Fig. 2. Prevalence of leprosy in Bombay City, 1963-72: total number of cases, 42 035. 68 ANTILEPROSY MEASURES IN BOMBAY cna, co .)0 6 z 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 WHO 76648 RESI DENT GBLCS clinics L......c :.ALH clinicU;." Fig. 3. Distribution patients, 1963-72. NON-RESI DENT GBLCS clinics ALH clinic of newly registered cases of leprosy in Bombay according to residential status of treatment required. Further, since no field projects, prospective studies, or sample surveys were under- taken in the city, a correction factor of 300% could be applied to obtain the estimated prevalence rate, as proposed by Bechelli & Martinez Dominguez (1). In spite of these reservations, Bombay can be considered a hyperendemic area for leprosy. The prevalence rate for the whole of India was estimated in 1965 as 6 per 1000 (2) and for the state of Maharashtra (of which Bombay is the capital) in 1963 as 8 per 1000 (3). The distribution of prevailing leprosy cases in the Greater Bombay area and in the city of Bombay are shown in Fig. 1 and 2. DETECTION RATE New cases detected every year at the various leprosy clinics from 1963 to 1972 are shown in Fig. 3. In all, 56 777 new cases were registered during the 10-year period 1963-72. The average annual case-detection rate was 0.95 per 1000 popula- tion in Bombay. Of the new patients, 60.7% were resident and 39.3% non-resident. Among the resident population the number of new cases in 1963 was 3309 and this increased to 3880 in 1972. For a chronic disease like leprosy incidence rates, understandably, have a cumulative effect, i.e., the work-load involved in providing regular treatment for newly registered patients and examining their family contacts, etc., must increase. INFECTIOUS CASES The annual number of infectious (i.e., bacterio- logically positive) cases among all newly detected cases for the period 1963-72 is presented in Fig. 4. 7 -i 6 c o 5 4 4 r_ o3 0 6 2 z 1 0 WHO 76649 Fig. 4. Distribution of new infectious cases of leprosy among total new cases, 1963-72. l 69 70 K. K. KOTICHA & P. R. R. NAIR This shows that about 25-32% of new cases are infectious. FORMS AND STAGES OF THE DISEASE Fig. 5 shows the distribution of resident new leprosy patients in relation to the forms (leproma- tous, tuberculoid, and intermediate) a and stages (early and advanced) of the disease in the years 1963, 1968 and 1972. These years are selected arbitrarily. The lepromatous proportion, i.e., the number of lepromatous cases per 100 cases of leprosy of all forms for the years 1963, 1968, and 1972, respec- tively, was 17.3, 14.6 and 13.2. The lepromatous proportion for the whole of India was 12 in 1958 (5). The lepromatous rate varies widely from country to country, the lowest rate recorded being 4 in Upper Volta and the highest 63 in Cuba (4). Early cases, i.e., the percentages of early cases registered in the years 1963, 1968, and 1972 were, respectively, 31.9, 25.9 and 24.7. The significance of early case detection is discussed later. 1963 1968 1972 TUBERCULOID INTERMEDIATE LEPROMATOUS Early E3 Early m Advanced m Advanced [] WHO 7Ie30 Fig. 5. Distribution of new cases of leprosy by form and stage of the disease for the years 1963, 1968, and 1972. " Intermediate "includes all forms of leprosy with the exception of lepromatous and tuberculoid. HEALTH EDUCATION In Bombay health education in leprosy is provided by the following personnel. (1) A medical social worker specially appointed for the purpose of delivering lectures illustrated with slides in schools and colleges, showing documentary films on leprosy in factories, etc., for industrial workers, arranging broadcasts and television pro- a " Intermediate " includes all forms of leprosy with the exception of lepromatous and tuberculoid. grammes, writing for the press, and arranging for displays on leprosy at general exhibitions, science fairs, etc. (2) Two medical social workers at the clinics who interview patients routinely and disseminate infor- mation on leprosy to patients, relatives, friends, or neighbours who accompany patients to the clinic. They also train students of the social sciences and supervise their work. (3) Physicians teaching undergraduate and post- graduate students of nursing, students of micro- biology, physiotherapy, and occupational therapy; undergraduate medical students and postgraduate students of dermatology/venereology and preventive and social medicine. These physicians also conduct refresher courses for general medical practitioners, physicians in municipal and government service, etc. The hospital also receives WHO fellows for specialist training in leprosy control and related fields. (4) Field staff (16 field visitors) who, besides providing treatment and examining contacts at the homes of patients, give individual and group talks to patients, relatives, and other persons in the neigh- bourhood. Channels employed for the dissemination of infor- mation on leprosy in Bombay are shown in Fig. 6. Assessment of educational efforts aimed at medical students and physicians Assessments are made in two ways. (1) For medi- cal students competitive tests in leprosy are held annually and prizes are awarded. This activity began in 1972 and, on average, 18-20 students from 4 medi- cal colleges in the city take part. (2) Early cases referred to clinics by practising physicians in the city are analysed. For the year 1964 (arbitrarily selected) about 70% of the new resident patients were " refer- red " and 30% attended a clinic on their own initiative. Among the " referred " patients, 38.7% of cases were in early stages. The most significant observation is that even among these early cases 5.4% were of the early lepromatous form, which can be diagnosed only by bacteriological examination. This shows the diagnostic skill and awareness of referring physicians-a result directly attributable to educational activities in Bombay. Assessment of educational efforts aimed at the lay public in Bombay Assessments can be made in three ways. (1) Essay- writing competitions on the subject of leprosy are ANTILEPROSY MEASURES IN BOMBAY 71 Educational activity Illustrations Written material Lectures, seminars, Films shown in schools Radio talks and Exhibitions (stands): for publication in and talks for physi- and colleges, cinemas, television pro- displays of models, newspapers, magazines, cians, students, and factories, grammes charts, posters medical periodicals, welfare workers, and especially in endemic and "goodwill" others areas advertisements 1. Posters displayed in 2. Folders, leaflets, hospitals, clinics, schools and booklets for patients and colleges, exhibitions, and relatives, schools and at railway stations and colleges, and bus stops exhibitions Fig. 6. Educational activities in leprosy. held for schoolchildren, and prizes are awarded. This activity began in 1967. (2) New patients with early cases of leprosy who attend a clinic on their own initiative can be asked how they knew about, or suspected, the possibility of leprosy. The responses to this questioning were unfortunately discontinued in the clinics' records. (3) Finding out the occupa- tions of patients with early cases of leprosy attending clinics on their own initiative and relating this information to educational activities. For the year 1964 30% of new patients attended of their own accord and 67% of these were found to have leprosy (see Fig. 7). Among these cases 25.2% were in early 4 02 W, 6 1963 1968 1972 WHO 76651 Referred NOT LEPROSY Attending on LEPROSY own initiative Fig. 7. Distribution of patients referred by a physician or attending a clinic on their own initiative according to whether they were found to be suffering from leprosy or were free of the disease, for the years 1963, 1968, and 1972. stages, which means that those patients had ade- quate information about the disease. Schoolchildren and industrial workers formed the majority of these patients. Since the medical social worker concen- trated her efforts on those two groups, it can safely be assumed that the majority of patients with early leprosy attend clinics on their own initiative as a result of educational efforts. CASE DETECTION The groups of people to be screened for leprosy is decided by the prevalence of the disease in a parti- cular area. When the prevalence rate is less than 1 per 1000 only household contacts of infectious cases may be examined; when the rate is between 1 and 10 per 1000 both contacts and special groups such as schoolchildren and military personnel should be examined; for rates above 10 per 1000 mass surveys are recommended.a According to those recommendations, the survey- ing of more than 7 million people in Bombay is essential; however, this is unlikely to be possible in the near future. An increase in the numbers of personnel, particularly field staff, social workers, physicians, registration clerks, etc. would contribute significantly towards the control of leprosy. At present contacts are being examined at the ALH and GBLCS clinics and at the homes of patients. The numbers examined as well as the numbers of contacts requiring to be examined are a Guide to leprosy control. Geneva, World Health Organ- ization, 1973 (unpublished document LEP/73.1), p. 24. K. K. KOTICHA & P. R. R. NAIR Table 1. Examinations of contacts of leprosy patients conducted in Bombay leprosy clinics and in the field, 1963-72 No. of N.o Yer contacts No.efofnYear examined cnasesfound c (old and new) inctas 1963 4548 305 1964 4538 175 1965 11 251 310 1966 11 967 279 1967 12 440 376 1968 12700 342 1969 12 022 354 1970 13 317 426 1971 14 508 481 1972 14135 485 Total 111 426 3 533 a It is estimatea that the average number of house in Bombay is 4 per patient. shown in Table 1. The table shows that 111 426 contacts were examined during th study period. However, 137 932 estimate should have been examined, not only repeatedly, for a varying number of years on the forms of leprosy occurring in pa This represents a cumulative work load; number of contacts examined is below rec It is considered that more personnel are examine a larger number of contacts. The leprosy cases detected-namely 30 per tacts-shows the importance of examinir as a priority. To obtain an approximate estimate of through prospective studies, the compara venient procedure of screening schoolcl leprosy was started. A total of 50 69, representing about 10% of the child po] Bombay municipal schools, were surv making a selection of schools by randor The prevalence rate was 3 per 1000 (6). veys have been restarted but the contint activity depends on the funds available. this is a very inexpensive method of case the examination of 100 children costinl US$ 6. Further, it is proposed to screer workers for leprosy if the cooperation o Estimated number of ontacts who should be examined a 13 236 13 636 physicians and managements is obtained. This work is important because of the magnitude of the leprosy problem. Bechelli & Martinez Dominguez (4) found that of the estimated 10 407 200 cases of leprosy in the world in 1970 (which may be an underestimate), only 2 887 481 were registered in 124 countries. TREATMENT 13 608 From the point of view of public health, chemo- therapy reduces the quantum of infection in the14096 community. Figueredo et al. (7) state, "Treatment 12 516 of infectors reduces the risk of infection to contacts 13 352 and this independently of the age at which the 10 504 contact started and the period of contact." An 14 448 11-year study of 609 lepromatous cases of leprosy (8) revealed that a majority of the patients who received 17 016 dapsone treatment for a period of 41/2 years, uninter- 15520 rupted by reactions, became bacteriologically nega- tive irrespective of age, sex, or the stage of the 137 932 disease. Maintenance treatment is given for further 4-5 years to prevent relapses. This long period of shold contacts treatment leads to defaulting. The numbers of patients who attended public clinics or received private treatment and those who a total of defaulted from control during the 10-year study te 10 years' period are given in Table 2. Defaulting is a serious ,d contacts problem. New, and even early, case-detection loses once, but much of its value if case-holding is poor. As an depending example of the extent of the problem, Bechelli & Ltients, etc. Martinez Dominguez (1) found in 1966 that 82% of hence the the estimated, or 32% of the registered, patients in luirements. the world were not receiving any treatment. required to It has been found that patients default from number of treatment for various reasons. Surty (9) investigated 1000 con- the causes of non-attendance of some 3830 patients ig contacts in Bombay. Of these, 945 patients were receiving private treatment and belonged to upper socio- prevalence economic strata. The majority of the patients did Ltively con- not attend the clinics for various reasons such as hildren for disbelief in the diagnosis, lack of faith in the 7 students, treatment, lack of time to attend for treatment, pulation in indifference, or a belief that a cure was obtained ,eyed after after a few months' treatment. i sampling. It was further found that patients, particularly These sur- those from lower socioeconomic strata, who suffered iity of this deformities attended the clinics regularly since the However, deformities affected their earnings. An attempt is :-detection, being made to minimize defaulting by providing g less than domiciliary treatment for patients who have no time l industrial to attend clinics. Concerted educational efforts also f industrial help to increase case-holding. In spite of these 72 ANTILEPROSY MEASURES IN BOMBAY Table 2. Number of patients receiving home or private treatment, attending a clinic, or during the 1 0-year study period in Bombay defaulting from treatment (1 ) (2) (3) (4) (5) (6) (7) (8) No. of patients No. of patients No. of Dead receiving who should Actual trted Defaulters Year registered peatint treatment at receive Acul Rsatd Dflerpainspatients home or treatment attendance treatment (5-(6 +I 7)) privately (2- (3 + 4)) 1963 40108 28 1 133 38 947 15110 242 23 595 1964 43417 33 1 093 42291 16184 200 25907 1965 46826 40 1 188 45598 14590 244 30764 1966 50228 59 1 297 48872 14869 247 33756 1967 53 357 62 1 373 51 922 15302 236 36 384 1968 56 695 49 1 386 55 260 15133 168 39959 1969 60066 38 1 248 58780 13 559 173 45048 1970 63 688 65 1 374 62249 16794 212 45243 1971 67942 64 1 357 66521 18730 561 47230 1972 71 835 39 1 242 70554 19407 1 110 50037 measures, however, a small minority of patients, especially those with a poor educational back- ground, seem unwilling to accept regular treatment. The strengthening of educational efforts for this group of patients would be particularly rewarding. CHEMOPROPHYLAXIS Bombay 1954 trial Dapsone prophylaxis of contacts was first begun in Bombay in 1954, and the results were reported in 1967 (7). The results obtained with chemoprophy- laxis are shown in Table 3. Dapsone prophylaxis is prescribed for a period of 2 years for contacts of bacteriologically negative index cases; if the index case is positive, the period of prophylaxis should continue until 2 years after the index case becomes negative. This is arbitrary and based on the assump- tion that, on average, the incubation period is 2 years in the majority of cases though it varies considerably. Experimental and control groups are not strictly Table 3. Chemoprophylaxis with dapsone of leprosy contacts in Bombay, starting in 1954 a Households Contacts Secondary cases Index case No. of Total Prophy- Controlhouseholds No. laxis Prophy- Prophy-laxis laxis Control irregular regular Lepromatous 2 191 2 963 942 2021 7 - 36 Intermediate b 428 679 295 384 3 - 3 Tuberculoid 4 136 6 306 2 187 4 119 10 - 41 Total 6 755 9 948 3 424 6 524 20 - 80 a Periods of observation range from 3 months to 19 years. b ' Intermediate " includes all forms of leprosy with the exception of lepromatous and tuberculoid. 73 74 K. K. KOTICHA & P. R. R. NAIR comparable. Contacts were asked whether they would like to take a preventive drug or not since evidence for the prophylactic value of dapsone is conflicting and ethics demanded that they should be informed about this. According to their reply, con- tacts were allocated to the two groups. Though there was no randomization, the absence of any case of leprosy in a contact who had taken adequate pro- phylaxis as compared with 80 cases in contacts in the control group and 20 in the group of contacts who received inadequate prophylaxis is noteworthy. The protection rate was 52.4%. Prophylaxis was consid- ered adequate if it continued over 3 years or more with an average of 8 months per year and when there was no long break during the first 3 years. Table 3 also shows that cases of leprosy among contacts do occur even when the index case is of the tuberculoid form of leprosy. Other trials A chemoprophylaxis study reported by Wardekar (10) covered 54 villages with a total population of around 40 000 and lasted for 41/2 years. About 11 000 persons received dapsone and a similar num- ber were given a placebo. The prophylaxis protection rate was 48.1 %. Noordeen (11) obtained a protec- tion rate of 52.5% in a chemoprophylaxis study involving 718 contacts and lasting 5½/2 years. Both these results compare favourably with our findings reported above and in Table 3. The prophylactic value of intramuscular injections of acedapsone given once every 75 days is under investigation (12). EXPENDITURE The annual expenditure per patient (in rupees) a at the Acworth Leprosy Hospital clinic, the ALH inpatient facilities and the Greater Bombay Leprosy Control Scheme clinics for the years 1963-72 are shown in Fig. 8 and 9. The proportional expendi- tures for these three establishments in the year 1972 are shown in Fig. 10. (a) At the ALH clinic expenditure per patient has doubled in the last 10 years. This is commensurate with the rise in costs. The actual expenditure of Rs 17.80 per patient in the year 1972 compares well with that of Rs 23 per patient in a control project in Aska, Orissa, India (13). (b) In the ALH inpatient facilities almost half of a Conversion rate: USS 1 = Rs 8 approx. 22 20 18- 14 10~~~~~~~~~~~~~~~~~~~~~~0\0 Fi. 8. -ALHacxedtrlprotaienicRsa GreaterBombay eprosy o -trol Lchm clinicsan 1412 GraerBmayLpos otrlS Hem clinics n 14- 212 10 uJ6 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 WHO 76652 Fig. 9. Annual expenditure per inpatient (Rs) at the Acworth Leprosy Hospital, 1963-72.Q ~~~~~~~~~~ALH clinic 1- GBLCS clinics Fig. 10. Proportional expenditure per patient at the Greater Bombay Leprosy Control Scheme clinics, the Acworth Leprosy Hospital clinic, and the Acworth Leprosy Hospital inpatient facilities for the year 1 972. the total annual expenditure of all three establish- ments is incurred by 500 leprosy inpatients. A developing country can ill afford expenditures of this kind. The segregation of 500 patients contributes ANTILEPROSY MEASURES IN BOMBAY 75 little towards leprosy control and inpatient admis- sions should therefore be restricted to those suffering from acute complications, those needing plastic sur- gery, and those helping in research. (c) At the GBLCS clinics the total expenditure has doubled but, since the number of patients has also doubled, the cost per patient has remained the same for 10 years, which is commendable. INTEGRATION Integration of antileprosy activities in the general health services is desirable. This would mean that the personnel of municipal and government health ser- vices, as well as local and village health centre personnel, would receive adequate training in lepro- sy for confidently diagnosing and treating the major- ity of leprosy patients. These personnel should also be trained to maintain proper records and to educate the public about leprosy. They should conduct domi- ciliary examinations and provide treatment in the patient's home. From the point of view of practicality, it should be remembered that these health workers are also re- quired to diagnose and treat, and to take part in control activities against, tuberculosis, filariasis, smallpox, malaria, trachoma, and other diseases. They also carry out family planning activities, main- tain records of births and deaths, and provide immunizations for the population for which they are responsible. They should therefore have received a good grounding in all these health activities and will in addition be expected to know how to collect samples of blood, urine, stools, etc., for transport to health laboratories. If health workers are to carry out all these tasks effectively the work load per worker will have to be reduced. In many villages in India the health worker often has to travel long distances through difficult terrain from one house to another. Until the health infrastructure of the country is strengthened both qualitatively and quantitatively, the involvement of the general health services in specialized, vertical programmes will be premature and only partially effective. We concur with Shri- vastava (14) and Walter (15) that unless the endemi- city of the disease has diminished to a reasonably low level, or the general health services of a country are in a position to undertake leprosy control mea- sures, integration will not be beneficial. In Bombay, integration will be started on an experimental basis in a pilot area. TOTAL ASSESSMENT The entire leprosy control programme in an area at a particular time can be assessed through certain indices. (a) Prevalence rate. The disadvantages of prevalence rate are (1) difficulty of recording migrations of patients in and out of the area; (2) lack of uniformity of views on the period of treatment required; (3) difficulty in defining arrested or cured cases, etc. Hence, prevalence rate is not considered to be an ideal index for assessment. (b) Incidence rate. This is preferably termed " case- detection rate ". It will depend on three conditions. (1) Health education efforts for both the public and the medical profession: the more intensive the edu- cation, the greater the awareness about leprosy and the higher the case-detection rate. (2) The size of population groups surveyed and their composition. (3) The diagnostic abilities of the personnel: the amount of underdiagnosis, or of overdiagnosis, is closely related to the skill of the auxiliary health workers. Hence an increase or decrease in the case-detec- tion rate in an area may not truly reflect the antileprosy efforts made there. (c) Treatment rate. The treatment rate, i.e., the number of cases under treatment per 100 of the total registered leprosy cases or, better, per 100 of the total estimated cases, would indicate with a fair degree of accuracy the intensity of antileprosy activi- ties in that area. As a slight variation of this indicator, a rate could be calculated for the propor- tion of lepromatous cases under treatment in a year per 100 of the total estimated lepromatous cases in the area. The following tentative suggestions were made in 1969 by Noussitou.a For operational assess- ment of proportion of all lepromatous cases to estimated total number of such cases minimal indi- cators could be: by 2nd year 66% or more by 5th year 750% by 10th year 90% by 15th year 99% Assessment of the impact of health education on leprosy control is discussed above. a NouSSITOU, F. M. Preliminary suggestions for the defi- nitions of assessment measurements of leprosy control (WHO Regional Office for South-East Asia unpublished document SEA/Lep/37, 15 December 1969). K. K. KOTICHA & P. R. R. NAIR RECOMMENDATIONS (1) The definition of an active case of leprosy should be that adopted in the Fourth Report of the WHO Expert Committee on Leprosy (16). This will lead to uniformity in the prevalence rates and active case rates maintained in records. Individual institutions can improve upon their own information concerning the number of patients who have died or left the area or patients new to the area, etc. (2) Priority must be given to minimizing the default- ing rate. All patients who have dropped out of control, and of these, initially, the bacteriologically positive cases, must be persuaded to continue or restart treatment. In addition to providing for an adequate field staff, every effort must be made to educate patients, their relatives, and their friends at leprosy clinics. It is not known whether legislating for the compulsory treatment of leprosy patients is possible or even helpful. (3) Active case-detection can be increased by screen- ing different groups in the community. The most profitable group for screening, i.e., that yielding the greatest number of cases, consists of the household contacts of known cases (particularly those that are bacteriologically positive). Where regular surveil- lance is possible efforts may then be directed towards convenient, self-contained population groups such as schoolchildren, industrial workers, military person- nel, and government and municipal employees. (4) Chemoprophylaxis promises good results and may be instituted, particularly in children in over- crowded households where the infector is bacterio- logically positive. (5) Passive case-detection at clinics and hospitals is improved by increasing awareness about leprosy among medical and auxiliary health personnel and in the community generally. It is generally agreed that in hyperendemic urban situations, where surveillance of the whole community is not possible financially, physically, or organizationally, health education of the population is of supreme importance in increas- ing passive case-detection. (6) Integration of antileprosy activities in the gen- eral health services, which is very desirable, should first be started in a carefully selected pilot area and the results should be evaluated before integration is extended to the whole country. (7) While the necessity of making adequate budget provisions for leprosy control cannot be questioned, it must be emphasized that re-allocation of funds already budgeted for may be very advantageous. In a developing country this can be done by diverting funds from inpatient facilities, research, and plastic surgery to outpatient care, health education, and field activities. UMt MESURES ANTILEPREUSES A BOMBAY (INDE): ANALYSE DE 10 ANS DE TRAVAIL On peut considerer, qu'a Bombay, la lepre est hyperen- demique. Le nombre total de cas enregistres dans la ville de Bombay et le Grand Bombay depasse 71 000. Le taux de prevalence est d'environ 12 pour 1000 a Bombay contre 6 pour 1000 pour l'ensemble de l'Inde. En outre, le nombre estime de cas a Bombay est d'environ trois fois superieur a celui des cas enregistres. Au cours de la periode 1963-72, le taux moyen annuel de ddpistage des cas etait de 0,95 pour 1000 dans la population. Parmi les nouveaux cas detectes, 60%. environ representaient des personnes etablies 'a Bombay; 25 a 30% de ces nouveaux cas etaient bactdriologiquement positifs. Les mesures de lutte antilepreuse adoptees a Bombay sont: education sanitaire, depistage des cas et traitement. L'education est fournie par des medecins, des travailleurs sanitaires et des travailleurs sur le terrain. Les efforts en matiere d'education sont evalues par des concours annuels dotes de recompenses a l'intention d'etudiants en medecine et autres disciplines; a cet effet, on recherche aussi la source des informations qui ont conduit des malades presentant une infection lepreuse precoce a se presenter au dispensaire. Les enquetes intensives sont, sans aucun doute, particulierement indiquees pour le depistage des cas dans les zones d'hyperenddmie, mais elles ne sont generalement pas faisables et des enquetes de groupe sont donc recommandees. Le groupe qu'il est le plus utile d'examiner est constitue par les contacts familiaux de cas connus car le taux des cas de lepre decouverts parmi les contacts examines etait de 30 pour 1000. Les enfants des 6coles, les travailleurs de l'industrie et les habitants des bidonvilles representent d'autres groupes qu'il faut examiner en prioritd. Un nombre notable de malades abandonnent le traitement; or le depistage de cas nouveaux, et meme de cas precoces, perd beaucoup de son interet si l'on parvient mal a maintenir les malades sous traitement. On peut diminuer l'abandon de traitement en eduquant les malades et leurs familles. Le renforcement des efforts d'education sur le 76 ANTILEPROSY MEASURES IN BOMBAY 77 terrain est egalement essentiel. La prophylaxie par la dapsone a commence a etre appliquee aux contacts en 1954 a Bombay. Le taux de protection obtenu a ete de 52,4 %, et la chimioprophylaxie peut etre recommand6e dans les foyers surpeuples des cas initiaux infectants, a condition que la dapsone soit prescrite pendant une periode de deux ans apres la negativation de ce cas initial. L'integration des activites antilepreuses dans les services generaux de sante est souhaitable, mais cela peut etre prematur6 a moins que l'endemicite de la maladie ne soit reduite a un niveau raisonnablement bas et que l'infrastructure sanitaire gen6rale du pays soit amelioree quantitativement et qualitativement de maniere a permettre des programmes de lutte contre des maladies particulieres telles que tuberculose, paludisme et lepre. Cependant, on peut tenter l'int6gration sur une base experimentale dans un secteur pilote. La methode la plus precise pour evaluer le programme antilepreux dans une region a un moment particulier consiste a determiner le taux de traitements, qui peut etre defini comme suit: pourcentage des cas (ou mieux des cas infectieux) sous traitement par rapport au total estime des cas de lepre (ou du total estim6 des cas infec- tieux) dans cette region. Un accroissement des effectifs du personnel et une augmentation des fonds disponibles pour les activites antilepreuses faciliteraient considerablement la lutte contre la maladie. Faute de fonds supplementaires, un reajustement des cr6dits affect6s serait utile; par exemple, dans un pays en voie de d6veloppement, une partie des fonds si n6cessaires affect6s aux soins hospi- taliers, h la recherche et a la chirurgie plastique devrait 8tre consacree aux soins ambulatoires, a l'6ducation et a des activites sur le terrain. REFERENCES 1. BECHELLI, L. M. & MARTINEZ DONNGUEZ, V. Bulletin of the World Health Organization, 34: 811-826 (1966). 2. DIRECTORATE GENERAL OF HEALTH SERVICES, MINISTRY OF HEALTH AND FAMILY PLANNING, INDIA. All India leprosy directory, 2nd ed. New Delhi, Gov- emnment of India Press, 1965. 3. KAPOOR, P. Leprosy in India, 35: 83 (1963). 4. BECHELLI, L. M. & MARTINEZ DOMiNGUEZ, V. Bulletin of the World Health Organization, 46: 523-536 (1972). 5. WARDEKAR, R. V. Leprosy in India, 30: 97 (1958). 6. GANAPATI, R. ET AL. Leprosy in India, 45: 151 (1973). 7. FIGUEREDO, N. ET AL. Leprosy Review, 38: 92 (1967). 8. KOTICHA, K. K. ET AL. International journal of leprosy, 39: 829 (1971). 9. SURTY, T. Leprosy in India, 34: 82-83 (1962). 10. WARDEKAR, R. V. Leprosy in India, 41: 240 (1969). 11. NOORDEEN, S. K. Leprosy in India, 41: 247 (1969). 12. RUSSELL, D. A. ET AL. Internationaljournal ofleprosy, 42: 378 (1974). 13. Leprosy review, 42: 5 (1971). 14. SHRIVASTAVA, J. D. In: Proceedings of the 15th Meeting of the Indian Advisory Committee, New Delhi, 1973. 15. WALTER, J. Acta leprogica (Geneva), 44: 67 (1971). 16. WHO Technical Report Series, No. 459, 1970, p. 13.