1. Leprosy - one of the few diseases which can be eliminated
Leprosy meets the demanding criteria for elimination
practical and simple diagnostic tools: can be diagnosed on clinical signs alone;
the availability of an effective intervention to interrupt its transmission: multidrug therapy
a single significant reservoir of infection: humans.

2. Why integrate leprosy into the general health services?
Integration means to provide “comprehensive” essential services from one service point
to improve patients’ access to leprosy services and thereby ensure timely treatment
to remove the “special” status of leprosy as a complicated and terrible disease
to consolidate substantial gains made
to ensure that all future cases receive timely and correct treatment
to ensure that leprosy is treated as a simple disease

3. Why is coverage so important?
Good coverage means that:
health facilities are easily accessible to every member of the community
health services are provided on a daily basis
health workers are able to diagnose, cure and provide basic information about the disease
health facilities are distributed equally in all areas
urban/rural, male/female, poor/rich, tribal/others, etc.

4. Advantages of Integrating Leprosy Services
Patients detected early
Patients treated early
Transmission of infection interrupted early
Development of deformities prevented
Stigma reduced further

5. Diagnosing a case of leprosy

6. We must follow good practices
Good practices are:
be friendly
give correct information about the disease
answer questions /doubts
keep confidentiality
keep up to date records
give choice to patient to decide when and where to come back
use MDT in a flexible manner
provide leprosy services free of cost
avoid unnecessary investigations

7. How to diagnose leprosy
Examine skin
Check for patches
Test for sensation
Count the number of patches
Look for damage to nerves

8. Signs of leprosy Pale or slightly reddish patch
Definite loss of sensation in the patch
Signs of damage to nerves
definite loss of sensation in hands/feet
weakness of muscles of hands/feet/face
visible deformity of hands/feet/face

9. What is not leprosy Skin patches which have normal feeling
are present from birth
cause itching
are white, black, dark red or silver coloured
show scaling
appear and disappear periodically
spread quickly

10. What is not leprosy (cont.)
Signs of damage to hands/feet/face without loss of sensation
due to other reasons like injury, accidents, burns, birth defects
due to other diseases like arthritis
due to other conditions causing paralysis

11. How to examine for leprosy?
Examine in a well-lit room
Examine the whole body
Ask since when the patch was noticed
Ask what treatments have been tried
Test for sensation
Look for any visible deformities

12. Check for loss of sensation
Take a pointed soft object (feather, cotton wick)
Lightly touch alternately the patch & normal skin
Ask the person to point where they were touched
Ask them to close their eyes and repeat the procedure
In case of loss of sensation the person will be able to point to where they were touched on the normal skin but not on the patch

13. Treating a case with MDT

14. Classification for treatment
The diagnosis is made based on finding definite loss of sensation in one or more patches.
When you have examined the whole body, count the number of patches.
1-5 patches is paucibacillary (PB), more than 5 patches is multibacillary (MB) leprosy

15. Standard WHO-MDT for the treatment of leprosy

16. Steps to start MDT Classify as PB or MB leprosy
Inform the patient about the disease
Explain the MDT blister pack - show drugs to be taken once a month and every day
Explain possible side effects (e.g. darkening of skin) and possible complications and when they must return to the health centre
Ask the patient when it is convenient for him/her to come back to the health centre. Give enough MDT blister packs to last until the next visit.
Fill out the patient treatment card

17. Treatment regimens PB Adult MB Adult Rifampicin 600 mg once a month
(6 blister packs)
Rifampicin 600 mg once a month
Dapsone 100 mg every day
MB Adult
(12 blister packs)
Clofazimine 300 mg once a month
Clofazimine 50 mg and dapsone 100 mg every day

18. Multi Drug Therapy

19. Multi Drug Therapy

20. Keeping good records Good records include:
Patient identification (name, age, sex, address)
Remark on history of complaint (what, how long, progress)
Remark on history of previous treatment (what, where, how long, result)
Current treatment (diagnosis, classification, any visible disability, date of first dose, date of next appointment)
Record of special events (what event, date, how managed, referral)
Date of cure

21. Information to patients About the disease
Caused by a bacteria
Affects skin and sometimes nerves
Progresses slowly
Easy to diagnose and cure
Lead normal life, do not change life style

22. Information to patients About the treatment
MDT will cure you completely
MDT is free of cost
MDT is available in all health centres
MDT should be taken as advised (regular, full course)
If you have problem or questions contact your health centre

23. Information to patients About possible problems
Skin discoloration due to clofazimine
Urine discoloration due to rifampicin
In case of fever, pain in the nerves, muscle weakness, joint pains they must return immediately to the health centre
In case of eye problems
Appearance of new skin patches
How to protect insensitive hands/feet

24. What is Accompanied MDT (A-MDT)?
A patient receives
a full course of MDT at the outset
receives information (verbal and printed materials) about the disease, its treatment and when and where to come for follow up, and
someone close to or important to the patient assumes the responsibility of ensuring that the patient completes a full course of treatment.
Note: In some areas (difficult to access, poor security etc) or for some patients (students,workers etc), this will ensure that all patients have adequate supply of MDT at home.

25. Curing the disease
Provide the correct blister packs (MB/ PB/ Child/ Adult) for correct duration (6 for PB & 12 for MB)
Explain how to use the blister pack (MB or PB)
Give the first dose at soon as diagnosis is made
Explain about the importance of regular treatment
Encourage to ask questions and remove doubts
Check when it is convenient to come back to the centre
Give enough blister packs to cover the interval
Encourage patients to come in case of problems/ doubts

26. MDT side-effects Red coloured urine Darkening of skin
This is due to rifampicin. Lasts only for few hours Reassure the patient that this is harmless
This is due to clofazimine. Reassure the patient that this will disappear after treatment is completed
This is due to allergy to one of the drugs (commonly to dapsone). Stop all medicines and refer to hospital
Red coloured urine
Darkening of skin
Severe itching of skin

27. How to manage complications

28. Some patients may develop complications
Leprosy reactions
Side-effects
Disabilities

29. Leprosy reactions 1 or 2 patients in 10 may develop reactions
Reactions are not a side effect of MDT. They are the body’s response to leprosy
More commonly seen in MB cases (more than 5 lesions)
Signs and symptoms include
Skin: patch/s becomes reddish and/or swollen; sometimes painful reddish nodules appear
Nerves: pain in the nerve and/or joint; loss of sensation and weakness of muscles (commonly of hands, feet and around eyes)
General: fever, malaise, swelling of hands/feet

30. Managing reactions (1)
Early diagnosis and prompt treatment of reactions
Every patient should be informed about the signs and symptoms of reactions
Inform them to go as soon as possible to the health centre
Reassure patients that:
reactions can be treated
they are not a side-effect to MDT
does not mean that MDT is not working

31. Managing reactions (2) Rest is very important:
Help to get leave from work or school for a few days (e.g. medical certificate)
Control of pain and fever
Aspirin or paracetamol
Continue MDT regularly

32. Managing reactions (3) Reactions which only involve the skin:
rest and pain-killers are usually sufficient.
If there is no improvement within few days or worsening, then specific treatment is needed
Reactions which involves the nerves
start treatment with a course of corticosteroids (e.g. prednisolone) as soon as possible
will control all signs/symptoms of reaction

33. Before starting treatment with prednisolone
Make sure that you have adequate stock
One course will require 336 tablets of 5 mg each
The course lasts for 12 weeks
It is better to examine the patient once every 14 days and reduce the dose
Advise to take the total daily dose every morning
If you do not have adequate stock, then start treatment and refer to another centre/hospital
Always send a written note with the patient, when you refer

34. Suggested course of prednisolone
40 mg (8 tablets) every morning for 14 days
30 mg (6 tablets) every morning for 14 days
20 mg (4 tablets) every morning for 14 days
15 mg (3 tablets) every morning for 14 days
10 mg (2 tablets) every morning for 14 days
5 mg (1 tablets) every morning for 14 days
Note: Continue rest and aspirin or paracetamol as required
Examine the patient every 14 days before reducing the dose
If there is no improvement or worsening, refer to hospital
Continue MDT regularly

35. Why do disabilities occur?
Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because:
Late diagnosis and late treatment with MDT
Advanced disease (MB leprosy)
Leprosy reactions which involve nerves
Lack of information on how to protect insensitive parts

36. Disabilities can be prevented
The best way to prevent disabilities is:
early diagnosis and prompt treatment with MDT
Inform patients (specially MB) about common signs/symptoms of reactions
Ask them to come to the centre ASAP
Start treatment for reaction ASAP
Inform them how to protect insensitive hands/ feet /eyes
Involve family members in helping patients

37. Care of feet Cracks and fissures Blisters Simple ulcer Soak in water
Apply cooking oil/Vaseline
Use footwear
Do not open blister
Apply clean bandage
Clean with soap & water
Rest and clean bandage

38. Care of feet (2) Infected ulcer Clean with soap & water
Wounds/injury
Weakness/paralysis
Clean with soap & water
Rest & apply antiseptic dressing
Soak in water
Apply cooking oil/Vaseline
Clean and apply clean bandage
Protect when working/cooking
Oil massage
Exercises
Refer

39. Care of eyes Redness and pain Injury to cornea
Difficulty in closing eye
Aspirin or paracetamol
Atropine and steroid ointment
Cover with eye pad
Apply antibiotic ointment
Refer
Tear substitute eye drops
Exercises
Dark glasses to protect

40. When treatment is completed
Congratulate the patient
Thank family/friends for their support
Reassure that MDT completely cures leprosy
Any residual lesions will fade away slowly
Show them how to protect anaesthetic areas and/or disabilities
Encourage to come back in case of any problem
Tell that they are welcome to bring other members of family or friends for consultation
Remove the patient’s name from the treatment register