(WP)CHD/ICP/LEP/001-E
3 May 1988 ENGLISH ONLY
REPORT ~GIONAL
WORKSHOP ON
THE IMPLEMENT.-tION OF MULTIDRUG THERAPY FOR LEPROSY
Convened by the REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Cebu City, Philippines 21 September - 2 October 1987
Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines May 1988 WHO' wPKr1 LIBRAR'J
1'+
J t.J N 1988
The views expressed in this report are those of the participants and me.bers of the facult.1 of the Regional Workshop on the Implementation of Mu1tidrug Therapy for Leprosy and do not necessarily reflect the policies of the Organization.
This report has been prepared by the Regional Office for the Western Pacific of the World Health Organization for governments of Member States in the Region and for the participants in the Regional Workshop on the Implementation of Multidrug Therapy for Leprosy, which was held in Cebu Cit.1. Philippines, from 21 September to 2 October 1987.
CONTENTS
1..
INTRODUCTION .................................
10 ..
.. ..
.. .. ..
.. ..
.. .. ..
.. .. ..
.. .. .. .. .. .. . . . . .. ..
•
.. ..
1
2. 3.
OBJECTIVES. • • • • • • • . • . . . • • • • . • • . . • . . • • • • • . . • . . . . . • • • • . • • • • • . • • SUMHARY OF DISCUSSIONS....................................... 3.1 3 .. 2 3.3
1 1 1
Leprosy situation in the Western Pacific Region •••••••• Epidemiology .................................................................................... ..
2
Microbiology and immunology ....•.......•.•••.....•..••.
3.4 3.5 3.6
Pathology .••.•.....•.•••.•.•...••.••••..•••••••.••.•••• Demonstration of pathological and skin smears slides ••• Clinical leprosy .......................................................................... ..
2 3 3
3.7 3.8 3.9 3.10 3.11 3.12
Historical development of leprosy chemotherapy .•••••.•. Multiple drug therapy (MDT) regimens recommended by WHO study group...............................................................................
3 3 .3 4
Reactions and management of reactions.................. Leprosy control programmes in the Philippines.......... MDT experience in Ilocos Norte......................... Steps in planning MDT implementation in a country / communi ty.. . . . . .. .. . . . . . . . .. . . . . . .. .. .. .. . .. . .. .. .. .. .. .. .. .. .. .. ..
4 4
3.13 Health information system in leprosy................... 4. 5. FIELD VISITS IN CEBU PROVINCE............................... EVALUATION OF THE WORKSHOP ••••••••.•••..•••••••••.••••••••••
4 4 5 5/6
ANNEXES: ANNEX OPENING REMARKS OF THE REGIONAL DIRECTOR, WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC •••.••••••••••••..••••• LIST OF PARTICIPANTS, TEi-1PORARY ADVISERS AND SECRETARIAT .••••...••..•.••••••••.•.••.••• PROGRAMME. • • . . . . . . • • • . . • • • . . • . • • • . • • • • • • • • . • • • SUMMARY OF EVALUATION ON THE REGIONAL WORKSHOP ON THE IMPLEMENTATION OF MULTI DRUG THERAPY FOR LEPROSY •..••..••.••••••.•••••••••• RESULTS OF EVALUATION QUESTIONNAIRES •.•••••••• GLOBAL LEPROSY SITUATION AND WHY GENERAL HEALTH SERVICES SHOULD BE ENTRUSTED TO Ir-1PLEMENT MDT - DR YO YUASA, EXECUTIVE AND MEDICAL DIRECTOR, SASAKAWA HEALTH FOUNDATION, TOKYO ............ ........ ........
7
ANNEX 2 ANNEX 3 ANNEX 4 -
9 13
17 19
ANNEX 5 ANNEX 6 -
21
1•
INTRODUCTION
The Regional Workshop on the Implementation of Multidrug Therapy was held at Leonard Wood Memorial Health Foundation in Cebu, Philippines, from 21 September to 2 October 1987. The local administrative arrangements were undertaken by the starf of the World Health Organization in collaboration with Leonard Wood Memorial Health Foundation and the office of Region 7, Department of Health, Government of the Philippines. All of the nineteen nominees frOIl nine countries and areas in the Western Pacific Region were able to participate in the workshop. The workshop was opened with a lIessage from Dr Hiroshi Nakajima, WHO Regional Director for the Western Pacific, read by the WHO Representative frOIl Manila, Philippines. The workshop was also addressed by the Director of Technical Service Division on behalf of Dr Felicito Aniceto, Director of Region 7, Department of Health, Philippines.
2.
OBJECTI'nS
It was expected that, at the end of the workshop, participants would be able to: (1) (2) (3) understand the clinical and public health aspects of leprosy control; organize field activities for multidrug therap,y implementation; and formulate field activities for multidrug therap,y implementation in their respective leprosy control programmes.
3.
SUMMARY OF DISCUSSIONS
3.1
Leprosy situation in the Western Pacific Region
The epidemiological situation of leprosy in the Region was presented. It was pointed out that, because each country has different interpretations on registered cases, the number of registered cases on the table should be read with the understanding of the different criteria applied in the respective countries.
- 2 -
3.2
Epidemiology
DR CELWNA gave slide presentations on the distribution or lepro"1, such as geographic, age, sex and by ethnic ractors. The current knowledge on the mode or transmission or lepro"1 was presented. Microbiology and immunology General characteristics or M. leprae (1) (2)
(4)
(3)
(5)
Gram-positive Acid-rast Rod-shaped (1-8 mm x 0.3 mm) Non-cultivable in vitro but limited multiplication on mouse rootpad. Obliga te intracellular organism, particularly in macrophage. Biological properties
3.3.2 (1)
or
M. leprae
Generation time 11-13 days Optimum temperature requirements. The optimum in vivo temperature in the mouse root-pad is 27-30 C Minimal inrective dose About 40 solidly staining bacteria on mouse root-pad. Viability and pathogenicity (a) Viability is retained ror 7-10 days in tissue stored in 4 C (b) No dii'i'erence in growth pattern or pathogenicity in mice or armadillos or M. leprae irrespective or type or lepro"1, race or geographic origin. (c) Continuous serial passage or M. leprae in nol"lllll mice does not change their pathogenicity. Chemical composition or M. leprae
(2) (3)
(4)
3.3.3
Cell walls:
peptidoglycan polysaccharide chains bearing mycolic acids phoahatidyl inositol oligiomannosides phthiocerol demycocerosate (PDIM) phenolic glycolipid
Lipids
In vitro CUltivation No M. leprae haa been cultivated in vitro
- 3 -
3.3.5 An immunological portrait of the infections was illustrated in terms of the relationship between the cell mediated immunity and clinical spectrua of leproB1. 3.4 PathologY
DR ABALOS gave a slide presentation on the pathological characteristics of leproB1. The following points wsre emphasized: (1)
M. leprae has low toxicity. The histopathological response ref'lects the illlllll1nological state of the patients. Most iaportant site of multiplication is the nerve. The low optimum temperature deteraines distribution in the body. The long generation time determines chronicity of infection. Deaonstration of pathological and skin suars slides
(2) (3) (4) 3.5
The pathological and skin smears slides were displayed together with microscopes. 3.6 Clinical leprosy
DR FAJARDO gave presentation on clinical leproB1 according to the following topics: (1) (2) (3)
(4) (5) (6) (7) (8)
infection, inaubation period, and onset of the disease earl,y lesions and presenting 8111Ptoms oardinal signs of leproB1 pb;ysical examination clinical features of leproB1 across the spectrum oomplioations of leproB1 leprae reactions differential diagnosis Hi storical develo1!!Bn t of leprosy chemotherapy
3.7
DR CARILLO described the historical development of chemotherap,y in leproB1 acoording to the pre-~dnocarp,yus, ~dnocarpus, dapsone, and MDT era. Multiple drug therapy (MDT) regimens recommended by WHO study DR J.W. LEE gave presentations on the above topic using information WHO Technical Report Series 675, Cheaotherap,y of leproB1 for control progr8lllles. frOIl
- 4-
3.9
Reactions and management of reactions
DR VIARDO gave presentations on the precipitating factors, cltnical manifestations and management of Type I and II reactions. Reactions can be regarded as an emergency in the management of leprosy cases that should be recognized and treated early so as to prevent permanent nerve dallllge. 3.10 Leprosy control prograDllles in the Philippines DR CARILLO presented ths national leprosy control programme in the Philippines (NLCP). The national leprosy control programme targeted 12 000 cases in 1987, and 16 000 cases were under MDT treatment in 1988. At the end of a three-year period , 38 000 cases will have completed multidrug therapy. The financial cost for five years was estimated at '80 million. 3.11 MDT experience in Ilocos Norte
DR CABANOS gave a presentation on the experience of the MDT pilot project in Ilocos Norte. The study started with 917 patients in Jul¥ 1985 and with the intake of 400 cases, a total of 1317 cases were at various stages of multidrug therapy as of August 1987. It is expected that the lessons learnt from this pilot study will be applied nationwide for the operation of national leprosy control programme. 3.12 Steps in planning MDT implementation in a country!comaunity
DR GALVEZ gave presentations on the above topic in the following order: (1) (2) (3) Determination of workload of the leprosy service Screening of registered cases and case-finding Simnltaneous with the screening activities, training of the field health personnel on the cltnical aspects of leprosy, management of the programme, logistics and evaluation, and health education of the public Information, education and communication Determination of drugs and supplies Determination of the most effective supplf distribution system. Determination of the most convenient but effective supervisioD system The built-in evaluation system Health information systsm in leprosy
(4) (5) (6) (7) (8) 3.13
DR LIM IWAN JOO gave presentations on the principle of the health information system in general and its application in leprosy. The importance of an effective information system through case detection, holding, and case releasing was emphasized. The information collected through the information system should be analfsed and reported for evaluation and improvement of the programmes.
- 5/6 -
4.
FIELD VISITS IN CEBU PROVINCE
The participants and resource persons were divided into three groupe, and assigned to the following districts: Group I Group II Group III Danao District Lapu-lapu district Minglanilla District
Each group in the assigned district observed the MDT programme at the
baranw, municipal, and district level. The participants discussed the following with the health workers: (1) (2) (3)
activities undertaken in relation to MDT implementation; role of the health personnel, patients, family, and community, in general in MDT implementation; problems encountered in the dif1'erent phases of implementation and how they were solved.
5. EVALUATION OF THE WORKSHOP
An evaluation 01' the workshop was conducted through a questionnaire distributed to the participants. A total 01' nineteen participants received the questionnaires (summary 01' questionnaire in Annex 4). With regard to the attainment 01' objectives, seventeen indicated that objectives 1 and 2 were attained, two indicated that they were not. With regard to objective 3, all but one confirmed attainment 01' the objective. With regard to partiCipation in the discussions, four noted that there _s not enough time for exchange 01' knowledge and experience. Apart from the time constraints, it was observed that several participants needed further improvement in English pro1'iciency which might have been the cause 01' the above observation. With regard to the administrative aspects, eighteen participants were satisfied with the arrangements. The majority of participants expressed satisfaction with the workshop. However, it was observed that more time should be allocated 1'or them to study the working papers, and participants should be encouraged to take part in the discuasion.
- 7 -
ANNEX 1
OPENING REMARKS OF THE REGIONAL DIRECTOR, ,SORLO HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC, MANILA
Distinguished Participants, Guests, Ladies and Gentlemen, I have pleasure in welcoming you all on behalf of the Regional Director to the Regional Workshop on the Implementation of Multidrug Therapy for Leprosy. In the five years that have passed since the WHO study group introduced multiple drug regimens for leprosy treatment, most countries in the Western Pacific Region have used them completely or in part in their leprosy programmes. Considerable experience has also been gained in streamlining the control programmes to meet the new operational demands of MDT implementation. We consider that the time has come to mobilize all available resources in order to accelerate MDT implementation. With this in view WHO has set the target of covering at least 75% of all cases needing treatment in the Western Pacific Region by MDT regimens by 1993, and 100% by year 1997. This of course, will require considerable outlays but we believe that the financial requirements ca~ be met through good management of the combined resources that governmental, non-governmental and intergovernmental organizations allocate for this purpose. As most of the countries in the Western Pacific Region are achieving remarkable improvements in the status and since the estimated number of cases in this Region is less than 5% of the estimated global number, we are in a good position to reach this target schedule. Our goal is to detect all cases of leprosy in all countries in the . Region and put them on multidrug therapy. It is to help attain this goal that this workshop on MDT implementation has been organized. Its objectives are: to enable participants to: (1) (2) (3) understand the clinical and public health aspects of leprosy control; organize field activities for multidrug therapy implementation; formulate a plan for multidrug therapy implementation in heir own leprosy control programmes.
- 8 -
Annex 1
During this workshop, among other activities, you will have an opportunity to observe and take part in MDT field activities in Cebu. You may find some of the methods used in Cebu applicable in the country, while some may not be. As you are already experts in your respective countries, please voice your opinions freely concerning everything that you see, as this will be to our common benefit. Last but not least, we wish you a pleasant and memorable stay in Cebu. We should also like to thank the Region No. 7 Office, the Eversly Childs Sanitarium and the Leonard Wood Memorial Foundation for cooperating with WHO in various ways to make it possible for this workshop to be held in Cebu.
- 9 -
ANNEX 2
WPR/LEP(2)/IB/2
LIST OF PARTICIPANTS, TEMPORARY ADVISERS AND SECRETARIAT
1. CHINA
PARTICIPANTS
Dr Cheng Shumin Vice-Head Leprosy Control Department Shandong Provincial Institute of Dermatology Shandong Province Dr Shen Pengzhang Officer-in-Charge National Leprosy Control Chronic Disease Division Endemic Disease Bureau Ministry of Public Health Beijing Dr Li Qiang Vice-Head Leprosy Control Department Guizhou Provincial Institute of Dermatology Guizhou Province
HONG KONG
Dr Tam Shiu Tong Medical and Health Officer Medical and Health Department 9th Floor, Sunning Plaza 10 Hysan Avenue Hong Kong Dr Sayaphet Bountu Directeur adjoint de l'hopital dermatologique Ministre de la Sante publique Vientiane
LAO PEOPLE'S DEMOCRATIC REPUBLIC
- 10 -
Annex 2 WPR/LEP(2)/IB/2
Dr Rangsi Souphanthavong Directeur de l'hopital dermatologique Ministere de la Sante publique Vientiane MACAO Dr Joao Larguito Claro Dermatologist Praca Lobo de Avila No. 8-6 A Macau Dr T. Ganesapillay Consultant DerI!latologist General Hospital 10990 Penang Dr Suraya Rani bte Tun Hussein Dermatologist Skin Department General Hospital 50586 Kuala Lumpur PAPUA NEW GUINEA Dr Clement Malau Senior 11edi cal Officer Communicable Diseases Disease Control Department of Health P.O. Box 3991 Boroko, N.C.D. Dr Gemma Cabanos Medical Officer Ilocos Norte Skin Clinic Iloc05 Provincial Health Office Laoag City Ilocos Norte Dr Vicente Guzman Jr Medical Specialist II Regional Health Office No.2 Tuguegarao Cagayan
MALAYSIA
PHILIPPINES
- 11 -
Annex 2 WPR/LEP(2)/IB/2
Dr Erlandino Albaytar OIC, Regional Leprosy Consultant Regional Health Office No.5 Legaspi Ci ty Albay Dr Erlinda Provido Regional Leprosy Consultant Regional Health Office No.6 Mal1durriao Iloilo Ci ty Dr Jaime Regional Regional Tacloban Leyte REPUBLIC OF KOREA Miralles Leprosy Consultant Health Office No.8 Ci ty
Dr Sung-Jun Choi Dermatologist/Medical Chief Institute for Leprosy Research Korean Leprosy Control Association Seoul Dr Tran Quang Vinh c/o National Institute of Dermato-Venereology Hanoi Mr Nguyen Ki~chi c/o National Institute of Dermato-Venereology Hanoi 2. TEMPORARY ADVISERS
VIET NAM
Dr Yo Yoosa Executive and Medical Director Sa sakawa Memorial Health Foundation The Sasakawa Hemorial Health Foundation The Sa sakawa Hall 6F 3-12-12 Mita, Minato-ku Tokyo 108 Japan
- 12 -
Annex 2 WPR/LEP(2)/IB/2
Dr Cesar Viardo Chief Eversly Childs Sanitarium Mandaue Ci ty Dr Marcial P. Carillo Leprosy Control Services Communicable Disease Control Services Department of Health San Lazaro Compound Manila Ms Monina G. Madarang Chief of Technical Services Leonard Wood Memorial Center for Leprosy Research Eversly Childs Sanitarium P.O. Box 727 Cebu City Dr Tranquilino Fajardo Officer-in-Charge Leonard vlood Memorial Center for Leprosy Research Eversly Childs Sanitarium P.O. Box 727 Cebu City 3. SECRETARIA T
I
P
I I
I
Dr Andres A. Galvez Regional Adviser in Chronic Diseases WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines Dr Jong-Wook Lee (Operational Officer) Medical Officer Regional Leprosy Control WHO Regional Office for the Western Pacific P.O. Box 2932 Manila Philippines
l'
j I I
;
- 13 -
ANNEX 3
WPR/LEP (2) IIB/3
PROGRAMME Monday. 21 September 0830 - 0900 0900 - 0930 0930 - 0950 0950 - 1010 1010 - 1100 1100 - 1200 1200 - 1400 1400 - 1520 1520 - 1540 1540 - 1700 Registration Opening ceremony Group picture taking COFFEE BREAK Leprosy situation in WPRO Presentation of paper on MDT implementation LUNCH BREAK Presentation of paper on MDT i~plementation (continuation) ::;OFFEE BREAK Presentation of paper on MDT implementation (continuation)
Tuesday. 22 September 0800 - 0900 0900 - 0950 0950 - 1010 1010 - 1100 1100 - 1200 1200 - 1400 Epidemiology Microbiology and immunology COFFEE BREAK Pathology Demonstration of pathological and skin smears slides LUNCH BREAK
- 14 -
Annex 3 WPR/LEP(2)/IB/3
1400 - 1520 1520 - 1540 1540 - 1615 1615 - 1700
Clinical leprosy (symptoms and signs, complications of leprosy, reactions) COFFEE BREAK Clinical leprosy (differential diagnosis) Historical development of leprosy chemotherapy
Wednesday. 23 September 0800 - 0900 0900 - 0950 0950 - 1010 1010 - 1100 1100 - 1200 1200 - 1400 1400 - 1520 1520 - 1540 1540 1700
Pharmacology of MDT drugs: rationale
MDT regimens
Reactions and management of reactions COFFEE BREAK Control programmes in leprosy Control programme in the Philippines LUNCH BREAK Operational consideration in MDT programmes COFFEE BREAK MDT experience in Cebu and Ilocos Norte
Thursday, 24 September Visit of leprosy programme at provincial, municipal and barangay levels
- 15 -
Annex 3 WPR/LEP(2)/IB/3
Friday. 25 September Assignment to field clinics Monday, 28 September Assignment to field clinics Tuesday. 29 September Assignment to field clinics Wednesday. 30 September 0800 - 0850 0850 0950 Planning MDT implementation Presentation and discussion of experience from field assignments - each group COFFEE BREAK
0950 - 1010 1010 1200
Presentation and discussion of experience from field assignments - each group (continuation) LUNCH BREAK
1200 - 1400 1400 - 1520
Group exercise on the formulation of a multidrug therapy programme (simulated health situation paper will be distributed in time) COFFEE BREAK
1520 - 1540 1540 - 1700
Group exercise on the formulation of a multidrug therapy programme (continuation)
- 16 -
Annex 3 WPR/LEP (2) / IB/3
Thursday. 1 October 0800 - 0950 0950 - 1010 1010 - 1100 1100 - 1130 1130 - 1200
Oral and written presentation on the group eXercise COFFEE BREAK Oral and written presentation on the group exercise (continuation) Evaluation Closing ceremony
J ,
I I
f I
- 17 -
ANNEX 4 SUMMARY OF BVALUATION ON THB RBGIONAL WORKSHOP ON THE IMPLBMENTATION OF MULTIDRUO THERAPY FOR LBPROSY Cebu, Philippines 21 September - 2 October 1981 An eYaluation questionnaire was distributed to each of the 19 participants of the workshop. All 19 rsspondents completed the questionnaire and information furnished was ussd to asssss the results and conduct of ths workshop.
"
The responses to the queries on the educational gains, administrative and technical aspects of the workshop, are tabulated in Annex 1. In the questionnaire, two alternatives wsre provided for each query: "Yes" for the first column, and the second, "No". A column for "No Repl)," was added in Annex 1. The responses for the educational-gains (which include the objectives of the workshop, aa well as the skills and concapta learned, were tabulated aa follows: No Repl)'
Educational gaina Objectives Skills or concepts learned Applications of skills or concepts The objectives of the workshop were: (1) (2) (3)
Yea
No
100.0~ 100.0~
to review the clinical and laborator), aspect of leprosy; to participate in field activities in pilot areas; and to conduct an exercise on multidrug therapy for leprosy control programme.
89.5~
The above mentioned objectives were met to a great extent according to of the replies, a "No" answer 8.8~ and no answer 1.1~.
Replies to questions relating to the process and outcome or the technical aspects (interaction among the participants, documentation, presentation of topics and discussions, etc.) were as follows: 82.1~ of the respondents replied favorably, 12.1~ gave a negative reply, and 5.8~ did not reply. With regard to the organization of the workshop, 13.1~ of the respondents replied that the duration and scheduling of different activitiea/lectures, group diacussiona, etc., are satisfactory, 15.8~ did not agree, while lO.5~ of the respondents did not give a reply. Eighteen respondents or 94.1~ of the replies rated the adminiatrat1ve aspects (which include organization arrangement a for travel, accommodation, per diem, meeting room, sscretarial support and interpretation) as aatisfactory. Field viaite as part of the meeting were ussful to msst objectives of the workahop to 94.1~ of the repliea.
- 18 -
Annex 4 The unfavourable replies on the follows: Unsatisfactory technical aspects 1. Workshop objectives were not met: (a) to review the clinical and laboratory aspect of leprosy (b) to participate in field activities in pilot areas (c) to conduct an exercise on multidrug therapy for leprosy control programme 2.
technical aspects were distributed as Replies
5 or 8.8! 2
2
1
Participants Not enough participation in discussions Documentation (a) Working papers were not satisfactory (b) Not enough time to study working papere
4 or 21.1%
3.
11 or 28.9% 1 10
4.
Methode of introduction and presentation were not satisfactory
1 or 5.3%
In summary, the components of the administrative aspects were rated as satisfactory by 94.7!. The components of the technical aspects wsre rated as satisfactory (-Yes") as follows: seminar objectives by 93.7%, procees and outcome (participants and documentation) by 82.1!. I t can, therefore, bs said that the Workshop on the ImplellBntat10n of Multidrug Therapy for Leprosy was successful. However, the deficienCies listed by the participants on both the administrative and technical aspects should be taken into account in planning future workshops of this nature.
- 19 -
ANNEX
5
RESULTS OF EVALUATION QUESTIONNAIRES· Regional Workshop on the Implementation of Multidrug Therapy for Leprosy 21 September - 2 October 1987 Cebu, Philippines Number Yes 1. Educational lains §.2 No No Reply Yes ~
No 5.3 8.8
No ReplY 1.0 1.7
..2. ..2. 2 2 1
...! ...!
93.7 89.5
1.1 Were the folloWing objectives met? (a) to review the clinical and laboratory aspect of leprosy (b) to participate in field activities in pilot areas (c) to conduct an exercise on multidrug therapy for leproey control programme
2! 17 17 17 19 19 156 14 19
89.5 10.5 89.5 10.5 1 89.5 100.0 100.0 5.3 5.3
1.2 Have new skills or concepts been learned at the lUeting? 1.3 Can these skills and concepts be appl1ed your country? 2. Process and outcome
n
11
82.1 12.1 73.7 21.0 100.0
5.8 5.3
2.1 Were you able to express your ideas or problems at the meeting? 2.2 Was there enough opportunity to exchange knowledge and experience with other participants? 2.3 Were you satisfied With all working papers provided? 2." Specify which of the working papers distributed for the meeting are euitable for Wider distribution. 2.5 Did you have enough time to study the working papers? 2.6 Were methods of introduction and presentation of different topics satisfactory? 2.7 Were you tully satisfied with discussions (a) at the plenary sessions? (b) at the group session? 'Bo. of Questionnaire replies received • 19
" 1
1
18 15
94.7
5.3 21.1
" 10 1 ~
78.9
9 17
47.4 52.6 1
89.5
5.3
5.3 5.3 5.3 5.3
~
18 16
1
2 1
2
89.5 5.3 94.7 84.2 10.5
- 20 -
Annex 5
Number Yes No No Reply Yes
~
No
No Reply
2.8 2.8.1
Field visits If
...lQ
..2
there were field visits as part of the meeting, vere they useful to mset the objectives? consider field vieits would have been useful to meet the meeting objectives?
18
...l 1
78.9 13.2 94.7
7.9 5.3
2.8.2 If there vere no field visits, do you
12
5
2
63.2 26.3
10.5
3.
Orsanization of the workshop Were the duration and. scheduling of different activities/lectures, group discussions, etc. satisfactory?
14 14
...l 3
~
73.7 15.8 73.7 15.8
10.5 10.5
2
4.
Administrative aspect Are organization or administrative arrangements for travel, accommodation, per diell, lIeeting room, secretarial support and interpretation satisfactory?
18 18
1 1
94.7 94.7
5.3 5.3
5.
Your ovsrall conclusion
68
~
.J.
89.5 100.0 100.0 84.2 73.7
1.3
9.2
Do you feel that (a) the recommendations/conclusions reflected the meeting consensus? (b) such workshops should be held regularly? (c) your attendance was worthwhile to you personally? (d) your participation was worthwhile to your country?
19 19 16 14 4 15 1 2 5
5.3
10.5 26.3
6. 7.
Is there any better vay to achieve the meeting objectives? What follow-up activites, if any, would lOU recommend: (a) by national government (b) by WIll (cl bl other agencies
21.1 78.9
12 7
l!! 12 12 14 3
33.3 36.8 36.8 26.3 84.2
66.7 63.2 63.2 73.7
7
5 16
8.
How many have you capacity the laat
meetings - WHO and others attended in your professional outside your country over twelve months?
15.8
- 21 -
ANNEX 6
WPR/LEP(2}/87.23
GLOBAL LEPROSY SITUATION AND WHY GENERAL HEALTH SERVICES SHOULD BE ENTRUSTED TO IMPLEMENT MDT: (by: Dr Yo Yuasa, Executive and Medical Director, Sa sakawa Memorial Health Foundation, Tokyo)
According to WHO, there are 12 million estimated cases of leprosy in the world now, and this figure has not been changed over the past 30 years. Nearly half of them are still totally being neglected. While Only
the rest of them are presumably receiving some kind of treatment. about one million patients are under WHO recommended MDT, or its
modified regimens, as of five years after the recommendation of the WHO study group on chemotherapy of leprosy.
It is up to us to change this deplorable situation and we must do it now. We already possess adequate means to diagnose majority of
clinical leprosy and the drugs we use for MDT are reasonably effective. Any failure to spread MDT would not be due to the absence of suitable tools but basically due to the lack of determination and effort on our part, who are currently in cbarge of leprosy control activities in
various parts of the world.
"Health for all by the year 2000" could mean many things to many people, but for leprosy it must mean that all those 12 million patients will have received MDT before the end of this century, and by the year 2000, every new leprosy case, arising in whatever part of the world,
- 22 -
Annex 6
WPR/LEP(2)/87.23
should be able to receive adequate MDT without delay.
In other words, and
the slogans we proudly proclaim now, that "leprosy is curable"
"deformities could be prevented", should become a reality on the global scale at the start of the next century, to every leprosy patient. Leprosy is an infectious disease, and as such should be handled from public health point of view. Breaking the chain of transmission The only feasible
should be given the top priority in leprosy control.
way to achieve this, is to entrust existing general health services rather than vertical services to implement MDT in every endemic country, because no vertical service, perhaps with only possible exception of China, is extensive enough to reach every leprosy patient and maintain regular monthly contact for two years or more.
Why has this not been done up to now?
The larger share of the
blame for this failure should be put on to us, the traditional leprosy workers. Consciously or unconsciously, we have made leprosy a thing True,
apart from all other disease, and made its control complicated.
leprosy has large social and psychological components, but these are products of the failure of proper medical handling of the disease.
Before 1942, there was no effective treatment and measures to prevent the ievelopment of deformities. But we do already have
adequate means to diagnose the cases at an early stage and, by using available irugs, arrest the disease process before serious deformities
- 23 -
Annex 6 WPR/LEP(2)/87.23
develop in the majority of cases.
Leprosy can now be and should be
handled primarily as a straight medical problem by public health personnel in every country.
Fortunately, 1982 W.H.O. recommendation made the standard treatment by MDT rather simple, by accepting only two classifications of active leprosy, MB and PB, and assigning only one regimen for each of these two classifications, stating that 2 years for MB and 6 months for PB is adequate as a minimum effective treatment. Furthermore,
these treatment will be basically unchanged during that period, regardless of the clinical situation. These put the control of leprosy
very much in line with the control of other infectious diseases, specially that of T.B. Therefore, there no longer is a justification
to insist that leprosy control should be handled by a vertical service specially set up for leprosy. On the contrary, since the most serious
failure of leprosy work up to now is the severe limitation of coverage, there are all the reasons to ask general health services to take over MDT implementation in every leprosy endemic country. An idea, quite
common, that ordinarily health services personnel are unwilling to handle leprosy work is a myth perpetrated mostly by leprosy workers. It has been proven in a number of countries, that after a suitable training and with dependable logistic support, general health
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services can manage MDT quite well, and the field staff are happy because for the first time they can do something positive for leprosy patients within a population groups under their responsibility. In a hyper-endemic area of 3 per thousand or above, an extra MDT worker may Ae needed at the initial period of two years or so, but if the endemicity is below that level the majority of multipurpose workers now in existence are likely to be able to handle a few leprosy cases within their catchment area without feeling unduly overtaxed. To be objective, leprosy is not likely to be high in the health priorities in most of the developing countries. Some countries put a great emphasis on leprosy control, but it is more likely to be due to political rather than straight forward medical reasons. Then, what argument can one use now to get necessary understanding and administrative back-up for MDT program from senior officials in the healtn ministry? Leprosy is unique among infectious diseases that there is a large gap between the prevalence rate and incidence rate. In most of the leprosy endemic countries where some systematic control activities are currently being carried out. the P.R./l.R. ratio is likely to be 10-20/1, indicating that the vast majority of eXisting cases are accumulating cases who have not been properly treated in the past. This means that by implementing proper MDT. it is possible to lower the eXisting active leprosy case load to 1/5 or even 1/10 within a few years. Once all the existing cases are given MDT, all one has to do then on is to deal with the newly emerging cases and some relapses and the total number could no longer be a major public health burden. The above should be a persuasive enough reason to get MDT program started right now in any leprosy endemic countries, utilizing eXisting manpower of general health services. Of course, success of any public services depends not only on adequate training of the staff but also constant supervision and regular monitoring. The field staff to implement MDT should be the existing general health worker whose collective coverage is, usually nationwide. and they do have regular contact with the people in their areas of responsibility for variety of health activities. With a little ~lanning they should be able to do monthly clinic and one or more home visits for monitoring purposes mandatory for proper implementation of MDT, without greatly adding to their normal working hours. Even including occasional defaulter tracing. it 1s likely to be no more than
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The persons in charge of training, of their total work load. leprosy supervision, and monitoring should be technically competent specialists and if there is an existing vertical leprosy service, it should not be too difficult to find them and incorporate them at various levels of the general health services structure. ,~3%
I believe there is no room now for an argument on vertical versus integrated approach for MDT implementation. Integrated approach to utilize existing general health services is the only feasible way to achieve our goal, which is simply to reach all of 1, million cases and give them MDT before the year ,,000. It is important to realize that chemotherapy (MDT) is only a part of possible care of leprosy patients. However, it is equally important to recognize that it is the most essential component in leprosy control program, and if available resources are limited, the primary effort should be concentrated on to giving MDT to as many leprosy patients as soon as possible, even at the exclusion of all other activities. Active case finding, with possible exclusion of contact survey of household children, should not be attempted unless provision of MDT is assured to all the known cases. Prevention of diSabilities by simple health education should ideally be a part of MDT implementation program, but anything beyond this such as a surgical treatment or assistance to rehabilitation to leprosy patients should be in steps with an availability of such services in general, and in most of the leprosy endemic countries, at present they are unlikely to be available. we have been demanding an equal treatment for leprosy patients. What we should realize is that it means "no more" just as much as "no less" than what the patients of any other diseases are normally receiving.
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OPERATIONAL CONSIDERATIONS IN MDT IMPLEMENTATION
The followings are more important factors which should be taken into considerations when planning MDT implementation. They are not in descending orders of importance, but more or less put in a logical sequence for planning. 1. When To Terminate Treatment:
V.H.O. recommendation suggests 6 months for PB. But for MB it says minimum of 2 years and whenever possible until B.I. becomes '0, without specifying If one accepts the principle of infecwhat it means by ·whenever possible". tiou. disease control, which is a maximum coverage to make many infectious cases non infectious as quickly as possible, it should only mean that one can think of extending MB treatment beyond 2 years only after every existing cases have been given the minimum treatment of 2 years in a given area. Any failure of treatment, in the forms of relapses, are simply dealt with together with new cases or old cases not yet treated. Remember that 15% relapse, which may sound alarming to some people, actually means 85% success, which as a public health measure is a quite creditable accomplishment. In absence of an ability to identifying those likely to relapse with any certainty, trying to extend MDT beyond 2 years for every MB case probably means a vast over treatment for many cases which any government can ill-afford. 2. Area of Coverage:
The larger the better, and should aim at the nationwide coverage as soon as possible. In reality, when expanding the area in a phased manner, it is likely to be based on an administrative unit, s~ch as province or district, or surrounding area of health institution such as a leprosy hospital, but if there 1s a constant flow of population in a given area, an attempt should be made so that the whole of that area will be covered, at once.
3.
~ogistic8:
Procurement in an international market of
a
large
quantity of
anti-
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leprosy drugs will take up to 6 months for delivery after placing a firm order so ·that it must be planned well in advance of MDT implementation. IdeallY, adequate quantity to complete the course of HDT of those started should be in stock at the national level. In any case peripheral health units at which the patient receive his monthly drugs should have some extra stock at hand at all times, because it is a paramount importance to keep drug supply to patients uninterrupted once the program starts. Do not start the program until all the stations are supplied with prearranged amount of drugs, such as supply of 2 months at the peripheral clinic, 4 montha supply at the intermediary station like district hospital, 6 months supply at the province and 12 months supply Adequate storage facilities is'a must to safeguard at tho national center. the drugs and keep them free of possible damage. 4. Blister Packs of MDT Drugs: in spite of added
Putting drugs into monthly calendar blister packs, cost, haa a number of important advantages:
1. Prevent loss of valuable drugs, specially Rifampicin, during atorage or transit to more peripheral health .tations, and allurel safe delivery to the patient. 2. Handling of drugs by busy multipurpose worker in the field is made easier and less time consuming so that MDT program is more readily accepted by general health services, Which did not handle leprosy work before. 3. Monitoring of the taking of unsupervised daily dosage by the patient could be accomplished at a glance to the pack, so it becomes much easier by family members or visiting health workers. 5. Financial Aspects:
At the moment, KB drugs for 24 months cost about US860.00 while PB drugs for 6 months will cost less than US83.00. Blister packing will add about US812.00 for 24 KB packs and US83.00 for 6 PB packs. Therefore the drug cost
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may come up to 40~50% of the total MDT program budget, provided salary of health workers are excluded from the calculation. Training, including production of suitable teaching material is the next largest item in the budget, unless it is a part of the regular training schedule for health workers. Expense for supervision and monitoring, specially travelling cost for these activities must be adequately provided. Some additional transport facilities, like cars or motorbikes, health education equipments and others are likely to be needed. Assuming the salaries of the personnel are already covered by the routine budget and assuming MB/PB ratio is 50/50, it is safe to allocate U5$80.00100.00 for each case in the MDT program in most of the endemic countries and this is likely to mean that a substantial contribution from outside is needed for most of the governments. 6. Updating of Registry and Clinical Assessment of Patient:
One of the first task we should undertake before starting a MDT program is to find out how many patients require such treatment. It is therefore essential to update existing Registry of leprosy patients which are likely to be out of date in most countries. To make an "Active list" it is necessary to actually locate the patients and do clinical and bacteriological examination. If a patient is judged to be an active case needing chemotherapy, that patient should be ClaSSified into either MB or PB and assigned to a suitable regimen It i l a good rule oe thumb to place a patient on according to the findings. ~ regimen if classification, but not diagnosis, is in doubt. Some countries adopt B.I. positive or negative al dividing line rather than B.l.+ 2. If the quality of skin smear is in doubt, rely on clinical judgement, and in any case never trust B.I. figures blindly. 7. Training:
Timing of various training should be carefully synchronized with procurement and distribution of drugs, 10 that there i8 a minimum gap ,between the end of the training and the start of the MDT implementation in the field. One mUlt be ready to embark on re-training or lupplementary training, once tho origlnal tralnlng II found to be insufficient.
" II
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Annex 6 WPR/LEP/(2)/87.23
It is important to limit the contents of the training to' the essentials, remembering that the majority of trainees are multipurpose workers and the leprosy is only one of many areas they are working. Over-training is often as bad as under-training, and it is waste of time and energy as well as of limited fund. It is also important to remember that it is performances at assigned duties and not the amount of knowledge which really counts, thus training on MDT implementation should be mainly practical and less theoretical. 8. Health Education of the Patients, Families and Community:
Proper understanding of the essential meaning and benefit of MDT by the patients, their families and community at large, is essential to gain their positive participation to MDT program, and as much effort as possible should be put into these activities. Not much details, such as dosage of drugs, are necessary, but the disadvantages or actual danger to the leprosy patients of not taking MDT drugs regularly should be emphasized. However, the main responsibility for proper implementation of MDT is squarely on the shoulder of tho health services, and we should never put blame on the patients or community for any failure of the program, as we tend to do often.
9.
Assignment of Clinic and Setting of Day for Monthly Clinic:
As a rule, a patient should be assigned to the GHS clinic located in the area of the patient's residence. However, it may be necessary to choose a clinic in other area, or even a private practitioner if the patient insists on it for the sake of anonymity or for any other reasonB., A little flexibility on this may be more productive. However, in Buch a case, proper supervision as well as proper reporting should be insisted on these clinics or pracU Uoners. It is advantageous to have a common monthly clinic day for all the patients at a clinic, which will save time for the staff and more convenient for visiting medical officers for clinical examination or medical technologists for skin smear taking. It could well be an advantage to the patients for mutual support and encouragement as well.
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10.
Supervision and Drug Intake!
Monthly supervised doses of drugs should be taken under actual supervision by a health worker at the clinic. Under some circumstances that supervised drug taking could be done at the patient's home again under the supervision of a health worker from the clinic. In a special'case, such as an extremely remote location of the patient, the supervision of monthly drug taking could be entrusted to someone trustworthy, such as a primary health volunteer, village chief, teacher, priest, or even a family member, but under no circu..tance. the patient .hould be allowed to take the monthly dose unsupervised. Daily unsupervised drug taking should be monitored by a lui table family member daily and at least once a month checked by the clinic staff by unanA primary health care worker, if available, should be nounced home visit. requested to make periodic visits as a support to the patient. End of the period pill count at the clinic is not much use since most of the patients quickly learn to empty the remaining pills from the pack or a bottle before coming to the next clinic, to avoid the displeasure of the staff for not taking all the drugs. The urine check is not warranted unless such facility i. readily available, and the collection of the sample should be done at the tim. of unannounced home visit and not at the time of the monthly clinic. 11. Clinical ASB.Bs••nt and Laboratory Check: The staff at the monthly clinic should make simple inquiries as to the patient's health, and at least make a quick clinical examination of skin and nerves. Apart from this, no routine clinical examination by a medical officer or skin smear examination by a medical technologist is indicated, since these findings will not alter the regimen given. End of MDT clinical examination and bacteriological examination must be thorough. Sometimel, a mild degree of
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Annex 6 WPR/LEP(2)/87.23
ENL is found without the patient being aware of having one. There is no point in telling and possibly alarming the patient, but it should be recorded. For the care of the patients with various complications associated with MDT, a proper referral system should be set up. There is a real danger of transmitting the viruses of AIDS and Hepatitis B if insufficiently sterilized instruments are used for skin smear, nerve testing or any other procedure which involves penetration of skin or mucus Therefore, when performing these procedures, adequate precaution membrane. should be taken, and unless essential, such examination should be avoided. Skin smear examination is indicated only at the start and the end of MDT and not in-between, since Whatever the result, no mid-course change of the regimen is indicated. 12. Recording and Reporting:
Careful recording and regular reporting is essential for efficient and adequate implementation of MDT. No actions performed or no findings noted will be recognized officially unless properly recorded. However, unnecessary duplication of recording and reporting should be avoided, since such work is time consuming and often causes slowing down of not only MDT program but whole Basically no recording nor reporting is inof the activities of the clinic. dicated unloss it leads to a decision making. 13. Monitoring of MDT Program:
There should be a built-in monitoring system so'that program manager at the national and intermediary levell could be kept up-to-date with the progress of the program. How to effect a remedial action when indicated, should be pre-planned in the program. 14. Conformity with Regular Pattern of Health Services Activities:
It il of great advantage if MDT program is made to fit into routine activities of health workers, speCially at the peripheral level. Timing of clinic or home visit, patters of recording and reporting forms to be filled in
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and timing of their dispatch, etc. should be the same or similar as much as possible to what they are normally used. MDT drug supply should also be a part of the routine drug distribution system. 15. Post MDT Surveillance: At present, when the true efficacy of V.H.O. recommended MDT is not yet established based on enough data from the field, it is essential to make sure that post MDT patients are regularly followed up at least annually for a period, say 3 years for PB and 5 years for MB. Perhaps more importantly, each patient who completed prescribed MDT course should be made to understand the signs and symptoms of relapse or lepra reactions, and to come back to a clinic without delay with any indications. The medical staff at the peripheral clinics should know exactly what to do for such cases.
B ND