Medical care delivery through leprosy clinics--consumer's perception, experiences and suggestions

Randomly selected 500 adult leprosy patients, registered for treatment with six Sectors of a Leprosy Control Unit in Chingleput District of Tamil Nadu (India) were interviewed to study their perception, and experiences with medical care being delivered to them through leprosy clinic(s), and their suggestions to improve the system. About 14% patients did not perceive their disease as leprosy. And 8% of the total patients were taking treatment outside their sector leprosy clinics. The services like physiotherapy, rehabilitation, health education etc. were known to only 3-8% patients, perhaps on account of their non-availability and or non-practice. On an average, a patient had to cover a distance of 2.1 +/- 2.5 KMs (one side) in 24 +/- 49 minutes to reach clinic spot, mostly by walk (83.2%), and spent 58.9 +/- 32.2 minutes at clinic, of which two third in waiting for service(s). Each patient had consulted 1.23 +/- 0.55 medical agencies for treatment of leprosy. The average man-day and wage losses to a patient, due to monthly clinic attendance, were estimated to be 0.48 +/- 0.49 days and Rs. 2.28 +/- 3.06, respectively. Only 10.6% of the 500 patients got admitted 1.55 +/- 0.89 times in leprosy hospital for a duration of 63 +/- 69.30 days and lost wages of Rs. 126.4 +/- 85.64 per month of stay in hospital. Availability and efficient delivery of comprehensive medical care through well organized and regularly conducted leprosy clinic, by considerate and sympathetic staff was much emphasised by patients. Various factors influencing medical care delivery and its utilization by patients, are discussed in this communication.     

Die Dermatologische Universitätsklinik und -poliklinik Bern

The history of the university dermatology clinic in Bern can be followed back into the 13th century to the founding of the Siechenhaus (hospice for incurable patients) in 1283. The hospice was moved in 1491 to the Breitfeld before the gates of the city, where over the next four centuries it expanded greatly and served patients with leprosy and later syphilis and other skin diseases. In the beginning of the 19th century teaching in dermato-venerology was carried out here. In 1891/82 one of the earliest dermatology clinics was established, as a professorship was established and the clinic moved to a new building on the grounds of the Inselspital, the university hospital. Through the efforts of the first chairmen, E. Lesser and J. Jadassohn, as well as their successors, dermato-venerology has remained well-established in Bern. We review the important dates, individuals and institutions and their role on the long development of dermato-venerology in Bern from its early roots until today.     

Capture-recapture method to assess the prevalence of disabled leprosy patients.

The capture-recapture technique was applied in estimating the prevalence of disabled leprosy patients in four States in Northern Nigeria. A two-sample capture-recapture method, using data from hospital admissions during 1997 and 1998 in three leprosy referral hospitals, and from a sample survey on leprosy patients with disabilities in the clinics in 1999. In the sample, 1395 (ex) leprosy patients were found, 393 with a disability. Of these 393 patients, 47 had been admitted during 1997 and 1998 to one of three leprosy referral hospitals. In these hospitals, 151 individuals from the 24 study Local Government Areas (LGA) in four states of Northern Nigeria were admitted in 1997 and 1998. Using the Peterson estimator, we calculated the number of unknown disabled leprosy patients in the studied LGAs to be 1262 (95% confidence interval 991-1533). This was nearly four times greater than the field reported figure. The capture-recapture method can be applied in a leprosy care programme. Limitations of the method are the completeness of reporting after invitation in the field, as well as the probable biased sample of leprosy patients admitted to hospital. Our finding implies that relying on patients to report for prevention of disabilities and rehabilitation to the clinics, causes the real size of the problem to be underestimated by a factor of 3-4. We recommend the use of a special 'care' register for disabled leprosy patients to better address their needs for prevention of disabilities and rehabilitation.     

Studies on mode of detection of leprosy in China during the years 1981-1998.

Along with the nationwide economic reform initiated in the early 1980s and the rapid decrease of leprosy endemic after the implementation of multi-drug therapy (MDT), the leprosy programme changed from 'vertical' to 'horizontal'. An evolution in the mode of detection of leprosy cases has consequently taken place. Based on the nationwide registration of newly detected cases, the profile of patients at detection has been studied. The proportions of cases corrected significantly with calendar years in detection by dermatological clinics, contact checks, 'clue survey' and mass survey, showing a significant increase in percentage of cases detected through dermatological clinics and contact checks, and decreases through 'clue survey' and mass survey. Detection of cases through dermatological clinics and voluntary reporting have become the main modes of case-finding during 1997-1998, accounting for 37.3% and 28.6%, respectively, where contact check accounts for only 9.1%. In areas with good dermatological services, a significantly higher proportion (75.9%) of cases was detected through dermatological clinics, where voluntary reporting and 'clue survey' were the main modes of detection in endemic areas. As regards confirmation of diagnosis, the great majority of cases were confirmed by leprosy units, even though they were detected in various other situations. Only 6.5% of leprosy cases were detected and subsequently confirmed by doctors in dermatologic clinics. The present modes of detection and their relation to demographical, epidemiological, clinical factors and health services are discussed. This study emphasizes the cardinal importance of the dermatological clinics in the detection of leprosy cases in China at the present time and hence the need to strengthen the training of doctors in these clinics, while continuously encourage their involvement in leprosy control.     

Impairments in multibacillary leprosy; a study from Brazil

This is a retrospective cohort study of 103 multibacillary leprosy patients (18% BB, 48% BL and 34% LL) followed during and after treatment, in a tertiary referral centre with an outpatient clinic in an endemic area in Brazil, for an average period of 65 months since the start of multidrug therapy (24-dose MDT). The objective of the study was to identify the role of overt neuritis (presence of pain in a peripheral nerve trunk, with or without enlargement or neural function damage), in the development of impairments. They were evaluated using the World Health Organization disability grade before treatment, at the end of the treatment, and at the end of the follow-up period. Thirty-four percent of patients presented overt neuritis during MDT, and 45% had overt neuritis episodes during the follow-up period; the most commonly affected nerves were ulnar, fibular and posterior tibial nerves, and the neuritic episodes were carefully treated with steroid therapy and physiotherapy. Impairments were associated with: affected (painful and/or thick) nerves at diagnosis (P < 0.005); delay in diagnosis (P = 0.010); impairments already present at the start of treatment (P = 0.00041 at the end of MDT, and P = 0.000013 at the end of follow-up); occurrence of overt neuritis episodes during MDT (P = 0.0016) or the whole follow-up (P = 0.015). These data draw attention to the importance of early diagnosis and of good neurological examination throughout the follow-up, as well as suggest the importance of neuritis in the induction of impairments in multibacillary leprosy.     

Childhood leprosy in an urban clinic,Hyderabad, India: clinical presentation and the role of household contacts

A retrospective case note study was done of children below the age of 14 years who attended Dhoolpet Leprosy Research Centre (DLRC) over the decade 1990-1999. The aim of the study was to describe the pattern of clinical presentation, the role of household or near neighbour contacts and the incidence of neuritis and reactions. In all, 3118 leprosy patients were registered during this period, of whom 306 were children [182 (60%) male]; 95 children had a single patch, 159 had five or fewer than five patches and 37 had multiple patches. The youngest case detected was 9 months old. The spectrum of leprosy in these children was: TT 62 (20.3%); BT 203 (66.3%); BB 3 (1%); BL 23 (7.5%); LL 5 (1.6%) and PNL 10 (3.3%). Twenty-nine cases (9.4%) were smear positive. Ninety-one children (29.7%) developed a reaction, 86 type I and five type II. A history of contact was present in 119 (38.8%) cases, family contact in 113 (95%) and other than family in six (5%). Classification of the contact was available in only 60 patients. Among the contacts of the index case, 21 (35%) suffered from PB leprosy and 39 (65%) from MB leprosy. All contacts were from the immediate family. This study shows that childhood leprosy cases continue to present in significant numbers to this outpatient clinic. There is a high level of family contact with leprosy in these cases, strengthening the strategy of screening children in leprosy-affected households. The high incidence of reactions and nerve damage in children emphasizes the importance of early detection and treatment.     

A process report on physical and psychological determiners of social functioning in leprosy patients

Management and rehabilitation of leprosy patients needs information aoout the social acceptance and its association with physical and psychological problems of the affected person. Ninety three leprosy patients (72 male and 21 female) were selected from outpatient department of the hospitals/clinics and their demographic and clinical informations were recorded. The patients were screened for common menta diseases using GHQ-60 (Bengali version). The social functioning was assessed using SSFI. Mean age was 35.19 +/- 12.5 years, 69.9% of the subjects were from urban areas. Multibacillary cases accounted for 60.2% of the cases, 21.5% of the patients had deformity, 53.8% of the patients screened positive for common psychiatric diseases. Social functioning impairment of mild, moderate and severe level was 9.7%, 82.8, and 7.5% respectively. On Univariate analysis, presence of deformity was the only variable showing significant association with moderate to severe degree of social impairment. Using decision tree (Exhaustive CHAID) analysis, presence of deformity along with urban residence was strongly predicted severe social functioning impairment. The results of the study show the need to formulate suitable psychosocial intervention strategy especially in the context of high psychiatric morbidity.     

Patterns of Chlamydia trachomatis testing and follow-up at a University Hospital Medical Center.

OBJECTIVE: Although testing for Chlamydia trachomatis is encouraged and increasingly practiced at sexually transmitted disease (STD) and family planning clinics, patterns of testing and follow-up in other settings are not well described. To begin to address these issues, we performed a chart review of patients with a positive laboratory test for C. trachomatis at a major university medical center. METHODS: Chart review of medical records for all patients with positive laboratory tests for C. trachomatis during calendar year 1996. RESULTS: Of 326 patients with positive tests, 95% were female and 5% were male. Median age was 22 for females and 25 for males. Most positive C. trachomatis test results were from the emergency room (ER)/walk-in clinic (55%) or patients receiving obstetric/gynecologic (OB/GYN) care (31%). While most C. trachomatis tests performed were on patients who had symptoms, patterns of treatment varied between sites. Fifty-seven percent of ER/walk-in patients received empiric antibiotics at the initial visit versus 36% of patients under OB/GYN care. Among patients with positive screening tests seen in the ER/walk-in clinic, 32% of patients had no treatment documented versus 14% of OB/GYN patients. Four percent of women with positive tests who did not receive therapy at the time of their initial evaluation developed pelvic inflammatory disease in the interval between testing and return to the medical center. CONCLUSIONS: Of the patients with positive chlamydial screening tests, the proportion not treated was similar to that found in studies performed in STD clinics.     

The INFIR Cohort Study: assessment of sensory and motor neuropathy in leprosy at baseline

AIM: To compare different method(s) to detect peripheral neuropathy in leprosy and to study the validity of the monofilament test (MF) and the voluntary muscle test (VMT) as standard tests of nerve function. DESIGN: A multi-centre cohort study of 303 multibacillary (MB) leprosy patients. METHODS: Newly registered MB patients requiring a full course of MDT were recruited in two leprosy outpatient clinics in North India. Controls were people without leprosy or neurological conditions, attending the dermatological outpatient departments of the same clinics. Nerve function was evaluated electrophysiologically using standard parameters for sensory and motor nerve conduction (NC) testing, warm and cold detection thresholds (W/CDT), vibration perception thresholds, dynamometry, MF and VMT. The latter two defined the outcomes of sensory and motor impairment. RESULTS: 115 patients had nerve damage or a reaction of recent onset at diagnosis. Sensory and motor amplitudes and WDTs were the most frequently abnormal. Among the nerves tested, the sural and posterior tibial were the most frequently impaired. In the ulnar nerve, sensory latencies were abnormal in 25% of subjects; amplitudes in 40%. Ulnar above-elbow motor conduction velocities were abnormal in 39% and amplitudes 32%. WDTs were much more frequently affected than CDTs in all nerves tested. The thresholds of all test parameters differed significantly between controls and patients, while only some differed between patients with and without reaction. Good concordance was observed between MF results and sensory latencies and velocities (direct concordance 80% for the ulnar). However, a proportion of nerves with abnormal MF results tested normal on one or more of the other tests or vice versa. Concordance between VMT and motor conduction velocities was good for the ulnar nerve, but for the median and peroneal nerves, the proportion impaired by VMT out of those with abnormal motor conduction was very low. CONCLUSIONS: Concordance between monofilaments and other sensory function test results was good, supporting the validity of the monofilaments as standard screening test of sensory function. Concordance between VMT results and motor nerve conduction was good for the ulnar nerve, but very few median and peroneal nerves with abnormal conduction had an abnormal VMT. A more sensitive manual motor test may be needed for these nerves. Of the nerve assessment tests conducted, NC amplitudes and warm sensation were the most frequently affected. Therefore, nerve conduction studies and WDT measurements appear to be most promising tests for early detection of leprous neuropathy. The pattern of concordance between tactile and thermal sensory impairment failed to support the hypothesis that small fibre neuropathy always precedes large fibre damage. Warm sensation was more frequently affected than cold sensation. This could indicate that unmyelinated C fibres are more frequently affected than small myelinated Asigma fibres.     

Squamous cell carcinoma in plantar ulcers in leprosy: a study of 11 cases

The objectives of our study were to describe and analyse the malignancies that occurred in plantar ulcers of leprosy patients. The possible predisposing conditions, duration and extent of the spread of the tumour were also studied. All patients with trophic ulcer of the foot attending the urban leprosy clinic in our hospital from January 1998 to January 2003 were screened for change to malignancy. During the study period, 79 cases of plantar ulcers in leprosy were seen. The mean age of these cases was 39.9 years with male-to-female ratio of 4:1. Eleven cases with plantar ulcers and malignant change were diagnosed in our hospital during the study period. The male-to-female ratio was 4.5:1. The mean age of these patients was 60.6 years. Their age ranged from 46 to 75 years. Nine of the cases were treated cases of borderline tuberculoid leprosy, while two had treated lepromatous leprosy. In our study, two distinct morphological types of malignant changes were seen. Histopathologically, all cases, except one, were of well-differentiated squamous cell carcinoma variation; one case had verrucous carcinoma. Though trophic ulcers are common in leprosy cases, only long-standing and neglected ones undergo malignancy.     

Incidence of HIV infections among the patients of the outpatient clinic of the Institute of Venereology

The presence of anti-HIV antibodies was sought in 1061 patients (818 men and 243 women) with various sexually transmitted diseases; the group of men contained 29 homosexuals (3.5%) and 26 were bisexual (3.2%). Together these deviants accounted for 7.1% of the group. EIA test confirmed with the Western-blot test gave positive result in 11 patients, including 10 homosexual and bisexual men, that is in 18.2% of the subgroup of men with this deviation, and in 1 heterosexual man (0.13%). Over one-half of them had or had had syphilis, and in the subgroup of homosexuals the patients with syphilis amounted to 36%. The proportion of HIV infections in homosexuals, patients of outpatient clinics for sexually transmitted diseases, is much higher than in heterosexual patients in these clinics and homosexuals not treated in these clinics. Patients in outpatient clinics for sexually transmitted diseases are a high risk group for HIV infection (especially homosexuals with syphilis) and should be tested for the presence of anti-HIV antibodies.     

Histoid leprosy: a retrospective study of 40 cases from India

Background Rare variants of leprosy pose a diagnostic challenge even to astute clinicians and histoid leprosy is one such form of disease with unique clinical and histopathological features. There are very few large series on this entity, mainly reported from India. Objectives To study the epidemiological and clinical characteristics of patients with histoid leprosy. Methods We undertook this retrospective study including patients registered with the leprosy clinic of our tertiary care referral centre from January 1991 to December 2006. Data regarding demographic details, clinical features, treatment, complications and course following treatment were extracted from the records of the leprosy clinic. Results The incidence of histoid leprosy among the registered patients of our clinic was 1·8% (40 of 2150). There was a significant male preponderance with a male/female ratio of 5·7 : 1. The anatomical areas of involvement were thighs/buttocks (67·5%), arms (62·5%), back (52·5%), face (47·5%), forearms (47·5%) and legs (35%) in descending order of frequency. This variety of leprosy was found most commonly in patients with a primary diagnosis of lepromatous leprosy (40%). De novo histoid lesions, i.e. lesions of histoid leprosy developing without evidence of lesions of other types of leprosy in the Ridley–Jopling classification, appeared in 12·5% of patients only. Only three patients had received antileprosy treatment before presentation. Episodes of erythema nodosum leprosum (ENL) had occurred in 40% of patients, although only one patient manifested ENL after the diagnosis of histoid leprosy. The disease responded satisfactorily to the respective World Health Organization multidrug therapy regimens in all except in one patient who relapsed with borderline lepromatous leprosy. Conclusions As the bacillary load is very high in these patients, they can form a potential reservoir of the infection in the community especially in the postleprosy elimination era. Contrary to the earlier belief in the dapsone era, most of our patients manifested disease without any history of inadequate or incomplete antileprosy therapy.     

Variables influencing regularity of leprosy patients in attending treatment clinics.

Regularity in attending clinics as well as taking drugs assume a very significant place in leprosy control programme since irregularity of leprosy patients can lead to poor disease control, drug resistant disease, and development of physical deformities and disabilities thus leading to programme failure. Further, these complications also create socio-economic and psychological problems to the victims as well as their families in myriad ways. This paper reports a study aimed at identifying the variables, among a set of 29 selected demographic, socio-economic and disease-related variables, having significant association with regularity of leprosy patients in attending treatment clinics. It was found that age of the patients, type of family, duration of the disease, time lag between diagnosis of the disease and starting treatment and knowledge of patients and their families about the disease were significantly associated with treatment regularity.     

The associated diseases with leprosy

The prevalence of cutaneous, medical and surgical disorders was studied in 846 leprosy patients. Common cutaneous disorders among leprosy patients were pityriasis versicolor, tinea, pyodermas, warts, acquired ichthyosis, scabies, pediculosis and callosities. Only pityriasis versicolor had higher incidence when compared to general population. Common medical diseases were tuberculosis, infective hepatitis and diabetes mellitus. The epidemiological importance of their co-existence with leprosy is discussed and relevant literature of other diseases found to be frequently associated with leprosy is reviewed.     

Pattern of drug compliance in leprosy patients attending urban centres--a longitudinal study

The pattern of drug compliance in 485 leprosy patients attending urban leprosy centres in Bombay was studied for 2 years. The study subjects included 113 patients with paucibacillary leprosy under dapsone monotherapy, 241 patients with paucibacillary leprosy under multidrug therapy and 131 patients with multibacillary leprosy under multidrug therapy. Their urine samples had been checked at least 6 times during the 2 years by DDS tile test at the time of their clinic attendance. The urine test results were not disclosed to the patients, but patients showing negative results were counselled about the need for regular drug intake. 35% of the patients were "Regular through out", 13% were "Irregular through out" and the other 52% who "Tended to be irregular" in their drug intake became "Regular" after counselling. Regularity in drug compliance was better in patients on multidrug therapy than in those on monotherapy. It is suggested that periodic testing of urine for checking for regularity of drug intake and subsequent counselling of patients should be made a routine practice to maintain drug compliance at a high level.     

HIV infection--a sexually transmitted disease

In the light of literature reports and own experiences and observations the most important epidemiological aspects of HIV infection acquired through sexual contacts are discussed, including the likelihood of infection during heterosexual or homosexual intercourse, factors increasing the infection risk in homosexuals intercourse and the more or less safe forms of sexual intercourse. The combination of HIV infections with infections with other sexually transmitted diseases is discussed on the basis of own observations which showed that HIV infection was acquired much more frequently by homosexuals treated in outpatient clinics for venereological diseases (19.7%) as compared to other homosexual groups (2.7%), and the risk was even lower in heterosexuals treated in these clinics for sexually transmitted diseases (0.2%). Over half the patients infected with HIV had or had had syphilis. HIV infection was sought for in Warsaw prostitutes, and 0.6% of them were found to be infected, two-thirds of the infected ones were drug addicted prostitutes. The importance of the sexual route of infection in drug addicts and transmission of this infection to the heterosexual population are considered. The principles of prophylaxis, the directions of health education, and the importance of screening for HIV infection prevention are considered. Attention is called to the harmful effects of all types of restriction of the infected people which lead to trials of infection concealment.     

Cyclosporine A treatment of leprosy patients with chronic neuritis is associated with pain control and reduction in antibodies against nerve growth factor

OBJECTIVES: Chronic neuritis (CN) is still a major problem in leprosy and is difficult to manage in patients who do not respond well to prednisone. In this study we (i) evaluate the efficacy of cyclosporine A (CyA) in controlling CN patients, and (ii) analyse the presence of anti-NGF antibodies in the sera of leprosy patients, and their behaviour during CyA treatment. DESIGN: This was an open, prospective, non-comparative study. Sixty-seven leprosy patients in three different institutions in Pará, Brazil were studied from January, 2001 to January, 2004. Of these, 47 had no CN and 20 were leprosy patients suffering from CN and taking at least 40 mg/day prednisone to control nerve impairment and pain. Patients received 12 months reducing course CyA starting at 5 mg/kg per day. The outcome measure was sensory impairment, assessed using Semmes-Weinstein monofilament examination (SWME), muscular force and spontaneous or palpation-related pain. RESULTS: Antibodies against NGF were detected in the sera of leprosy patients, which may explain the depletion of NGF in leprosy contributing to neuritis, inflammation and loss of cutaneous nociception. The levels of these antibodies in CN patients were slightly lower than in patients with no CN. However, anti-NGF titres in CN patients treated with CyA were lowered to levels similar to those in the normal subjects. There was also improvement in sensory impairment, muscular force and pain. CONCLUSIONS: These data suggest that anti-NGF antibodies are present in the sera of leprosy patients and may influence the outcome of neuritis, and that CyA might be a useful drug in controlling nerve impairment and pain in leprosy patients.     

广东省韶关市1996～2015年新发麻风病例流行病学分析

目的:了解广东省韶关市1996~2015年麻风病例流行学特征,为低流行状态下麻风防治工作提供依据。方法:收集近20年新发现麻风病例资料,并对其流行病学特征进行分析。结果:20年来麻风病的发现率和患病率呈下降趋势,地区分布不均衡,南雄市新发病例数最多,占总数的64.46%。从发病到确诊的平均延迟期为(58.75±64.31)个月,以多菌型为主,占73.08%,2级畸残比为23.08%,出现2级畸残者的病期显著长于无畸残者(t=2.16,P<0.05)。病例发现以门诊发现等被动发现方式为主,约占67.31%。结论:近20年来韶关市麻风流行状况已经得到有效控制。     

HIV partner notification policy and practice within GUM clinics in England: where are we now?

OBJECTIVES: To evaluate the extent to which larger genitourinary medicine (GUM) clinics in England have established local clinic policies for HIV Partner Notification (PN) and to describe the process of HIV PN within this setting. DESIGN: A cross-sectional survey of HIV PN policies and practices within GUM clinics. SUBJECTS AND SETTING: Senior consultants in 59 GUM clinics in England. MAIN OUTCOME MEASURES: The presence of clinic policies for HIV PN, indicators of HIV PN activity (that is, its initiation, documentation, performance and evaluation) and factors hindering the acceptance of HIV PN into clinical practice. RESULTS: Only 18% (10/57) of respondents stated that their clinics had developed their own local policies for HIV PN. Fifteen percent (9/58) of clinics had audited HIV PN activity, 15% had provided specific HIV PN training for doctors and 47% (27/58) for health advisers. Within GUM clinics, health advisers play a key role in the HIV PN process, being responsible for initiating the discussion of partners, patient follow-up and documenting HIV PN activity in patients' notes. Notifying partners was primarily seen as the responsibility of the newly diagnosed HIV positive patient. Although 77% (43/56) of responding consultants believed that HIV PN had become an accepted part of their clinics' practice, the perceived unacceptability of HIV PN to patients and health care workers were seen as important limiting factors. CONCLUSION: In many GUM clinics, local policies on HIV PN have yet to be established and appropriate training for the health personnel provided. Nevertheless, there appears to be wide-spread acceptance of HIV PN in clinical practice with an acknowledgement of its limiting factors. Further research into the acceptability of HIV PN to health care workers and patients in this setting should be undertaken.     

重复开展消除麻风运动对当地新发现病人情况的影响

目的:观察贵州省兴义市重复开展消除麻风运动对当地新发现麻风病人的影响.方法:收集1996～2004年新发现麻风病人的有关资料进行比较分析.结果:9年共发现麻风病人166例,平均每年发现18.4例,年均发现率为2.65/10万.1999年首次开展消除麻风运动后3年,新病人中的2级畸残率和延迟期呈明显下降趋势,低于开展前3年的水平.两次开展消除麻风运动时的畸残率和平均延迟期均达较高水平,提示该地区虽两次开展消除麻风运动但麻风流行程度仍处于较高水平.结论:重复实施消除麻风运动可促进某些流行病学指标的好转,应反复多次开展.