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LEPROSY AND
LEPROSY
PROGRAM
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Leprosy existed in the Philippines long
before the arrival of the Spanish in the16th century and was known locally by
such terms as 'ketong' and 'cizaro'.
In the early 1900s, there was a fairly high
incidence of leprosy in the Philippines. TheAmerican colonial administration was keen
to implement health and sanitation
programmes, influenced by popular fieldsof public health and tropical medicine .
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Given the absence of any known cure andinspired by numerous positive reports about
the colony in Molokai in Hawaii, an activecampaign for the segregation of lepers wasinitiated. One such leper colony was locatedon Culion Island and opened in 1906. In order
to provide a legal framework for the activecollection and incarceration of peoplesuspected of leprosy throughout thearchipelago, a segregation law, that
practically criminalized the harbouring andnon-voluntary submission of lepers, wasenacted in 1907. At its peak, Culion was hometo over 5,000 people.
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When the Philippines National Leprosy
Control Program (NLCP) was established in
1986, there were 38,570 registered leprosypatients in the country. According to WHO
statistics, there were 2, 514 new cases
detected in 2007.
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What is Leprosy?
Leprosy (also known as Hansens
Disease) is a chronic, infectious
disease involving the skin and nervesof infected individuals. Pale patches
on the skin are usually the first sign of
the disease they are painless and donot itch, so are often ignored by the
patient.
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In the past, nerve damage and other
complications occurred as the disease
progressed. The numbness and lack of
feeling in the limbs often led to
festering wounds on the hands and
feet, and then to the characteristic
deformities of the face and limbs. In
many communities this led to stigma
towards those affected and theirfamilies, causing them to be shunned
and even excluded from everyday life.
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Fortunately, antibiotics can now quickly killthe bacteria (germs) that cause leprosy, so
the disease can be completely cured with afew months of treatment. If this is started atan early stage, most patients need neversuffer the terrible complications which used
to be common. Nerve damage does still occurin some patients, but it can often be reversedwith other medical treatment. When it cannotbe reversed and the person remains with
some disability, there are many differentstrategies of rehabilitation to help them liveas normal a life as possible.
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How do you catch leprosy?
Leprosy is probably spread like the
common cold, but is much less contagious
than the cold, or influenza. You really have
to live for some years in an endemic area,where new cases of leprosy are continuallybeing detected, to run the risk of catching
it. In a study of new cases being put ontreatment in the United Kingdom, it wasfound that all of them had lived abroad in a
country with leprosy for at least eight
years.
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Transmission and Control of
Leprosy Leprosy is caused by a bacterium,
Mycobacterium leprae, which is closely
related to the organism causing tuberculosis.The mechanism of infection is not fully
understood, but it is generally thought to be
by droplet spread through the upper
respiratory tract. The incubation period islong, usually between 2 and 8 years, but it
can be up to 20 years in some cases.
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Casual contact with a person affected by leprosydoes not seem to lead to infection. The evidencesuggests that residence for several years in an
endemic area is needed before the risk of infectionbecomes appreciable. The current strategy tocontrol leprosy involves early case finding andtreatment with antibiotics, with the aim of stopping
transmission of the disease to new contacts. WHO gives an overview of leprosy and leprosy
control activities around the world. ILEP MemberAssociations support leprosy activities on a country-by-country basis throughout the world. In the USA,
the Center for Disease Control (CDC) , gives generalinformation about leprosy. The Report of the ILATechnical Forum (394KB), held in Paris in 2002,reviews much of the scientific evidence underpinningcurrent efforts to control leprosy.
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The Diagnosis of Leprosy Leprosy is essentially a clinical diagnosis,
although a laboratory test (the slit skin
smear) is important in some cases. Normally,
the diagnosis rests on finding any one ofthree cardinal signs,
one or more hypopigmented, anaestheticskin patches, typical of leprosy;
one or more thickened peripheral nerves; or
a positive skin smear.
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WHO emphasizes the first of these signs for useby junior health workers in endemic areas and
gives a clear description of how to examine theskin.
As with many diseases, the most accuratediagnostic test is a biopsy, with subsequent
staining and histopathologicalexamination ofthe tissues.
One major topic for research at present, is thedevelopment of new diagnostic tests, which mayallow leprosy to be diagnosed with confidence ata much earlier stage; this would mean thattreatment could begin early, resulting in lessdisability and probably also in less transmissionof the disease to contacts.
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The Classification of
Leprosy Cases Leprosy exhibits quite a wide range of
clinical features in different people and
this is now thought to be due to
differences in the body's immune responseto the infection. Most people have an
effective response which completely
prevents the disease, while others haveonly a moderate response which allows
the disease to appear, but limits it to only afew skin patches.
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In these patients, the number of leprosy bacilli inthe body is quite small (less than a million) and
they don't show up on the skin smear test, whichis negative; the disease is classified aspaucibacillary (meaning 'few bacilli'). A verysmall minority of people, on the other hand,
have such a weak immune response to theleprosy bacillus that it can multiply almostwithout any check and spread to almost all partsof the skin and the peripheral nerves.
In these patients the skin smear is positive andthe disease is classified as multibacillary(meaning 'many bacilli').
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For the purposes of treatment, all patients areput into one category or the other (eitherpaucibacillary - PB - or multibacillary - MB), butthis is somewhat arbitrary. The disease should beseen as a more or less continuous spectrum fromhigh to low immunity. It should be pointed outthat people who get multibacillary leprosy have
no other immune deficiencies and have noparticular susceptibility to any other disease.
The straightforward classification of leprosy intotwo treatment groups (PB/MB)is described by
WHO. The older, but more detailed, classificationof leprosy is known as theRidley/Joplingclassification.
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The Treatment of Leprosy
As a bacterial infection, leprosy can
be very effectively treated with
certain antibiotics; the bacillus can be
easily killed. If there has already beendamage to the nerves, however,
antibiotics alone will not restore
function and other forms oftreatment will be needed, including
physiotherapy.
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The first antibiotic to be widely used for leprosywas dapsone, from around 1950 onwards.Dapsone meant a major breakthrough for
millions of patients who, until then, had beenconsidered incurable. However, many patientsstill had to take medicines for life.
In 1981, when resistance to dapsone wasbecoming widespread, WHO introduced Multi-Drug Therapy (MDT)which consisted of tworegimens: rifampicin and dapsone for PB leprosyand rifampicin , clofazimine and dapsonefor MBleprosy. (Note: rifampicin is also known asrifampin, especially in the USA). MDT has beenremarkably successful: there have been very fewside effects associated with its use and over 13million people have been cured of leprosyfollowing its introduction.
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Prevention of Disability
Nerve involvement starts quite early in a fewcases, but in others occurs only late in thedisease, especially if it is left untreated. Itcommonly leads to weakness of various
muscles and loss of sensation in the handsand feet, so that the person no longer feelshot or cold, or even pain - this leads tounintentional damage, ulceration, infection
and eventual destruction of fingers and toes,and the well-known deformities of untreatedleprosy.
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The muscles around the eye may also beaffected and blindness is another importantcomplication of untreated disease. Efforts toprevent disability in people who already havesome nerve damage due to leprosy thereforeconcentrate particularly on the eyes, hands andfeet.
Fortunately, the complications of leprosy, suchas nerve involvement and eye damage, canthemselves be treated, so that the problem maysometimes be reversed completely, or, if that is
no longer possible, further deterioration can beprevented. As may be expected, more severedamage requires more complex and lengthytreatment, and is more likely to leave some
residual disability or deformity.
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Rehabilitation
Some people who get leprosy areunfortunately left with some residual
disabilities after the infection itself
has been cured. The eyes, hands andfeet are the parts commonly affected.
In addition, many also face long-term
problems within their family andcommunity, simply because they
once had leprosy.
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Rehabilitation involves a whole range ofinterventions that attempt to restore the person
affected to as normal a life as possible.
There are two major categories of rehabilitation:
1. Firstly, physical rehabilitation seeks to help
people with their normal daily activities; themethods include physiotherapy andoccupational therapy, and sometimesspecialized forms of reconstructive surgery to
improve the functioning of the hands or feet;special treatment of certain eye problems mayalso be possible. The aim is to help with thephysical demands of daily life.
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2. The second major category is socio-economic
rehabilitation, which seeks to help peoplerebuild their lives, including their relationshipsand household economies, both of which areoften severely disrupted by having leprosy.
Many people with leprosy face the loss of their
jobs and divorce or other forms of rejection bysociety. Rehabilitation involves informing andreassuring the families and communities of thefacts about leprosy, as well as developingspecific interventions that help to restore
dignity to those affected. One of the majoraims is to empower individuals, enabling themto have more control over their own situations.
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The International
Classification of Functioning
Health
This WHO program has attempted, with
considerable success, to standardize the
terminologyused in relation to health anddisability. The ICF uses a conceptual
framework for long term consequences of
health conditions that is very helpful in thecase of POD and rehabilitation of peopleaffected by leprosy.
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Leprosy Control Program envisions to eliminate Leprosyas a human disease by 2020 and is committed to eliminateleprosy as a public health problem by attaining a nationalprevalence rate (PR) of less than 1 per 10,000 population by
year 2000. Its elimination goals are: reduce the national PRof