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INTERNATIONAL JOURNAL OF LEPROSYolume 64, Number I rinted in the U S

A Survey of Leprosy Impairments and DisabilitiesAmong Patients Treated by MDT in Burkina Faso'

Alexandre Tiendrebeogo, Idrissou Toure, and Petit-Jean Zerbo 2Burkina Faso, a West African country,has elaborated and carried out a NationalLeprosy Control Program (NLCP) since1989 (Ministere de la Sante et de l'ActionSociale Burkina Faso. Programme NationalLepre-Tuberculose, Volet lutte antile-preuse, Dec., 1989). In this control pro-gram, treatment of leprosy cases consisted

essentially of multiple drug therapy (MDT)recommended by the World Health Orga-nization (WHO). Between 1990 and 1994,this MDT program treated nearly 12,000persons, two thirds of whom had receiveddapsone monotherapy. Thus, leprosy reg-istered prevalence considerably decreasedduring this period from 13,000 to 2000 cases("). However, in this population treated byMDT, thousands of patients had leprosyimpairments either existing at the time ofdetection or occurring during the treatment.The information system set up with theNLCP did not allow us to estimate the num-ber of disabled cases nor to evaluate theneed for disability care (Ministere de la Santeet de l'Action Sociale Burkina Faso. Rap-port d'evaluation per operatoire de la lutteantilepreuse au Burkina Faso realise par A.S. Diallo, Consultant OMS, Dec. 1991 andRapport d'evaluation du Programme Na-tional Lepre du Burkina Faso. Travail con-joint Gouvernement/OCCGE/OMS, Mai,1993).The only leprosy hospital existing in thecountry is well equipped but was not op-erational due to the absence of trained staffand the lack of a physical rehabilitation pro-gram. That is why this survey was con-ducted in collaboration between the NLCPof Burkina Faso and the Marchoux Insti-

' Received for publication on 28 July 1995; acceptedfor publication in revised form on 26 October 1995.

= A. Tiendrebeogo, M.P.H., Unite Epidemiologie-Formation; I. Toure, Physiotherapist, Institut Mar-choux, B. I'. 251, Bamako, Mali. P.-J. Zerbo, M.P.H.,Manager, National Leprosy Program, Burkina Faso.

lute, a research and training center on lep-rosy in West Africa. The aims of the surveywere to: a) estimate the frequency of im-pairments and disabilities due to leprosyamong patients treated by MDT in BurkinaFaso; b) evaluate the needs for the care ofleprosy disabilities among these patients;and c) contribute to the planning for theactivities for physical rehabilitation anddisability prevention in this country. (In thefollowing text, we have used alternately theterms "impairment" or "disability" to des-ignate eye and nerve damage due to leprosywhich could result in a "handicap" as de-scribed by Srinivasan').

MATERIALS AND METHODSBurkina Faso is a sub-Saharan country of274,000 sq. km. with a population of 10million. It is divided into 30 provinces, and

the national health system is organized ac-cording to that administrative division. Ineach province a medical officer and a nursespecialized in leprosy control arc in chargeof the NLCP application. Information onleprosy patients is available in the followingdocuments kept at that level: leprosy reg-isters, MDT booklets, and leprosy clinicalforms.

For this survey on leprosy disabilities, wedecided to visit six provinces and to ex-amine 600 patients treated with MDT be-tween 1990 and 1995. To choose the sixprovinces, we clustered the 30 provinces ofthe country into six geographical regions offive provinces each (Fig. 1). In each geo-graphical region, we chose the province withthe greatest number of leprosy cases in 1990.The number ofleprosy patients in the regiondecided proportionally the number of pa-tients to be examined in each province (Ta-ble 1).

A month before the survey, we sent a cal-endar of the survey to the six provinces. Themedical officer of each province selectedrandomized areas which allowed us to reach15

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16nternational Journal of Leprosy99 6FIG. I. Map of Burkina Faso showing the six prov-

inces visited. 1 = Poni, 2 = Mouhoun; 3 = Boulkiemde;4 = Kouritenga; 5 = Soum; 6 = Oubritenga; =country boundary; = regional boundaries; = provincial boundaries; = province visited

the number of patients of the local sample.Nurses informed leprosy patients of theseareas to stay at home or to gather in thetreatment centers during the survey day intheir area.During the survey, we collected infor-mation on patients and leprosy disabilitiesexisting at the time of detection from lep-rosy registers, treatment booklets or the pa-tients' clinical forms. We used a question-naire to record information (Fig. 2, part one).We confirmed these data by interrogationof the patients found during the field visit.For actual disabilities due to leprosy, weobtained information by examination of the

patients during the visit. In our sample weincluded 46 patients with recorded infor-mation on impairments at diagnosis andwho were missing during the review. Infor-mation on actual disabilities of these pa-tients was not available.The physiotherapist of the survey teampracticed sensory and muscle tests on eyes,hands and feet of those patients seen. Heused a ballpoint pen for sensory testing onthe hands and feet as usually practiced bynurses at the time of diagnosis. We used theWHO scale of 1988 in three grades (0, 1, 2)to score the disabilities 2 ). According tothe nature of the impairments, we evaluatedthe needs for disability care during exami-nation of the patients in the field. Two class-es of care grouped these needs: a) primarycare that could be delivered by nurses incommon health centers, including healtheducation, training in skin and deformitycare of hands and feet, delivery of protectivemeans (footwear, gloves, sunglasses), non-complicated ulcers treatment; and b) sec-ondary care to be delivered by physiciansor physiotherapists in equipped health cen-ters: complicated ulcer care, training in lidstrengthening, excision or salvage surgery,reconstructive and palliative surgery withpreoperative and postoperative physiother-apy. All patients in need of secondary carealso required primary care. For reconstruc-tive or palliative surgery, all indicated pa-tients were not real surgery candidates butneeded to be reviewed by a surgeon for pos-sible treatment. Information on actual dis-ability and care needs was recorded on a

TABLE1 Number of cases included in the study by province in Burkina Faso.

Region No. casesin 1990 ProvinceNo. planned tobe include& No. effectivelyincluded To CasesincludedTotal FC Ne Total FC NC

South 2,635 Poni 12 0 80 40 12 0 62 58 10 0West 1,479 Mouhoun 66 44 66 47 19 10 0Middle-West 1,617 Boulkiemd 72 48 24 71 51 20 99Middle-East 2,631 Kouritenga 12 0 80 40 99 84 15 82.5North 1,569 Soum 70 47 23 64 29 35 91Center 3,381 Oubritenga 15 2 101 51 180 127 53 118Total 13,312 6 600 400 20 0 600 400 200 10 0

Based on examining 600 total cases, the overall ratio of 600 to total cases (13,312) yields a weighted proportionfor each province, e.g., 2635 patients in Poni province x 600/13,312 = 120 patients to be examined in Poni.

FC = Former cases treated with DDS before MDT.NC = New cases treated with MDT alone.

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64, 1iendrebeogo et al.: Survey of Impairments and Disabilities7questionnaire for each reviewed patient (Fig.2, part two).We used Epi-info software to analyze allof these data.

RESULTSCharacteristics of survey sample. In thesample of 600 patients, there was a predom-

inance of females with 360 cases (60%). Theaverage age was 47.9 years with a standarddeviation of 16.2. Twenty-one percent ofthe cases were multibacillary (MB) patientsand 67% were former cases of leprosy treat-ed by dapsone (DDS) before MDT.During the field visit, we found 554 casesfor examination among the 600 cases in-cluded in the study. The 46 missing patientshad either died or were absent from theirvillage during our visit. The differences be-tween the sample of 600 cases and the 554patients reviewed during the study were notsignificant for the frequency distribution bythe different variables (Table 2). This al-lowed the comparison between disabilitiesat detection time and actual disabilitieswithout a previous adjustment. The distri-bution of the sample by type of leprosy andby treatment received was similar to theentire leprosy case distribution in BurkinaFaso. This allowed extrapolation of our re-sults for all leprosy cases treated by MDTin this country.Disabilities at time of d etection. Amongthe 600 cases of the sample, the frequencyof impairment was 21.3% with a 95% con-fidence interval (CI) between 18% and24.6%. Considering grade 2 disabilities, thefrequency was 19% with a 95% CI between17.5% and 20.5%. The frequency distribu-tion of disabilities by sex, age, type of lep-rosy and treatment showed a predominancefor males, older patients, MB form and for-mer cases treated by DDS before MDT, evenafter adjustment for other variables: a) males= 32.1% with disabilities compared to fe-males (14.2%, p < 0.001); compared to fe-males, the relative risk for males was 2.26.b) older patients = 29.6% for those 50years, 13.4% for those between 15 and 50years old and 0% for children

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18nternational Journal of Leprosy996SURVEY ON LEPROSY DISABILITIES IN BURKINA FASO

Identification number/ate :rovince :Part 1: INFOR MA TION on leprosy clinical form, leprosy register arid treatmentbookletNANIE and Surname :Register number : Vllage :Year of birth :Leprosy form : /Year of diagnosis : /

Age:Sex:Class:Disease duration:

IMPAIRMENTS OR DISABILITIES AT DIAGNOSISS ITE S ID E NAT URE GRAD E MAXIMUMGR A DEEYES RightLeft

H ANDS RightLeftFEET RightLeft

CHEMOTHERAPYDDSuration/PCTuration /PRESCRIBED CARE: NW cular care/Health education /rotective care of hands and feetFootwearurgery/PhysiotherapyUseful information to fetch the patient :District :illage :Parents :Marital status :thnic origin :eligion :Occupation :Address :

FIG. 2. Questionnaire form used during the survey.

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64, 1iendrebeogo et al.: Surrey of Impairments and Disabilities9Part 2: INFORMATION during patient reviewACTUAL CI ,INICAL STATUS

Curedon mDT

ACTUAL, IMPAIRMENTS O R DISABILITIESSITE SIDE NATURE GRADE MAXIMUMGRADEEYES Right

LeftHANDS RightLeftFEET RightLeff

Year of impairments occurrence if after leprosy diagnosis:

RECEIVED CARE

H ealth e ducation /Footwear

Ocular care /protective care of hands and feet;Surgery/Physiotherapy

ACTUAL NEEDS OF CARE

SITE SIDE : Pr imary l ai econdary care Global careEYES i Right

e t t HANDS Right Left FEET Right Left 1

FIG. 2. Continued.Actual disabilities were seen more fre-quently with hands (25.1%) than with feet(18.1%) and eyes (5.8%) (Table 7). Grade 2disabilities were seen more frequently at allsites (eyes, hands and feet) and reached92.1% of disabled patients. Actual plantarulcers (live cases) represented 0.9% of ex-amined patients (Table 8), but we noted that

five patients with a plantar ulcer at diagnosishad salvage surgery and wore artificial legs;three other cases with an ulcer recorded ontheir leprosy forms were missing during thereview. Only five patients with grade 1 dis-abilities at detection did not show actualimpairment; 52 patients representing 11.9%of the nondisabled cases at detection de-

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2 nternational Journal of Leprosy996TABLE 2. Distribution of eases by sex age leprosy type and treatment and comparison

between sample cases and patients finoul fin- physical examination.Se xge (yrs.)eprosy typereatmentM49BDT MDTCases insurvey sample (600)p value

Cases foundduring visit (554)

40 6024060

NS2183639.4 60.6 3.5 44.7 51.8 1 9 6.7 33.321681126740000NSSS214093144079753.8 43.3 52.9 0.6 79.4 8.4 31.6

veloped impairments (Table 9). Many for-mer cases previously treated with DDS werefound among the 436 patients who devel-oped disabilities after detection (73%).However, their association with actual dis-abilities compared to cases treated by MDTalone was not significant (x test p > 0.05)(Table 10). The treatment received (DDS +MDT or MDT alone) did not seem to mod-ify the risk of disability occurrence.Disability care needs. The disability careneeds were greater for hands (25.1"/o of cases)than for feet (18.2%) and eyes (6.3%) (Table11). Those in need of care were found morefrequently among cases previously treatedwith DDS (35.9%) than those treated byMDT alone (15.4%). Primary care repre-sented 82.8% of the needs and concerned24.4% of the patients seen during the sur-vey. Secondary care represented 17.2% ofthe needs for only 5% of the patients who

were visited. Compared to the care receivedestimated by patient questioning (5.4%), allcare needs (29.4%) were very important.Health education of patients and theirfamilies and patient training for skin anddeformity care were the most frequent needsfor all patients with impairments (Table 12).Among secondary care, we counted only fivecomplicated ulcers to be surgically treated.Five other cases of plantar ulcer were al-ready cured by salvage surgery which couldpartially explain the small number of com-plicated ulcers found in the field.

DISCUSSIONFrequency of disabilities. The frequencyof disabilities at detection in our study is

near to those of Ponnighaus, et al. in Malawi 7 ). Those authors found 20% of disabilitiesat detection for patients detected before

TABLE 3. Distribution of disabilities at leprosy detection by sex age leprosy type andtreatment.

Disabilities at detection Grade 2 disabilities at detectionNo. p Value No. p Value

MalesFemales

7751

32 114.2 p < 0.001

6549

27.113.6 p < 0.001

49 years 92 29.6 80 25.7MBPB

5573

43.615.4 p < 0.001

5064

39.713.5 p < 0.001

DDS MDTMDT alone

10820

27I p < 0.001

10113

25.26.5 p < 0.001

Total 128 21.3 114 19

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64, 1iendrebeogo et al.: Surrey of Impairments and Disabilities1TABLE 4 Distribution of disabilities at leprosy detection for eyes hands and feet.

Maximum gradeGrades Eyesands Feet by patientNo. ,oo. No. No. 572 95.399 83.2 530 88.3 4728.71 5 2. 51. 5 9 1 .5 1 4.313 / /2 15 . 3 61 10.2 1 1 491 and 2 28 4.701 16 .8 70 11 . 7 1 281.3

TABLE 5 Distribution of 49 new case disabilities by delay time to detection.Disabilities at

detection TotalYes No

Delay to detection2 years 4 3 7Total 5 44 49

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22nternational Journal of Leprosy996TABLE 7. Distribution of actual disabilities for eves hands and feet.

Maximum gradeGrades Eyes Handseet by patientNo. No.o. No. Y o0 522 94.2 4154.954 81.9 389 70.26 1. 1 9.64 4.3 13 326 4.7 1 3 03.56 1 3 .7 1 5 2 27.4I and 2 3 2 5.8 1 395 .100 18.1 1 65 29.8

TABLE 8 ature and frequency of actual impairments among the 55 patients seenduringlield visit.

Site ofimpairments Nature No.Eyes Red eyes (anesthesia only) 6 1. 1Lagophtalmos, ectropion, with/or light loss of vision 20 3.6Great loss of vision, blindness 6 1. 1Hands Sensory loss alone 9 1 .6Ulnar or median clawing, finger stiffness 1 6 2.9Finger shortening/absorption, hand wounds 1 1 4 20.6Feet Sole sensory loss alone 24 4.3Toe stiffness, foot drop 6 1. 1Plantar ulcer 5 0.9Toe/foot shortening 65 11.7

patients already cured and did not exactlyfollow the current WHO definition of a caseof leprosy. Zhang, et al. in the YangzhouPrefecture in China, found 56%-97% ofcases with disabilities or deformities among14, 257 leprosy patients ( 14 ). We did nottake into account deformities of the face inour study.The more frequent disabilities seen inmales, older and MB patients were alsofound in other studies, and several reasonscould explain these facts: longer delay fordetection for men and MB patients, longerevolution of the disease in older patients,males working outdoors. These reasonsprobably explain the highest proportion ofdisabilities among cases treated with DDSbefore MDT. They were older and had alonger evolution of the disease than did pa-tients treated with MDT alone. On the otherhand, we found a low rate of plantar ulcersamong patients examined during the survey

(0.9%) compared to results found in neigh-boring countries [Benin = 7.3% among 5273cases ( ); Senegal = 5.3% among 190 cases 4 )]. Perhaps the desert climate in BurkinaFaso, very hot and dry, and the habit ofwalking without shoes since childhood in

TABLE9 Distribution of 554 seen pa-tients- by presence of disabilities at detectionand when examined on field visit.

Actual disabilitieswhen examinedotalYeso

Yes 1 1 3 5 1 1 820.4% 0.9% 21.3%No 5 2 384 4369.4% 69.3% 78.7%Total 1 65 389 55429.8% 70.2% 100

Disabilitiesat

detection

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64, 1iendrebeogo et al.: Survey of Impairments and Disabilities3TABLE 10 Distribution of 436 patients

without disabilities at detection by treatmentand actual disabilities when examined onfield visit.No.ctual

casesisabledalueFormer cases778(DDS + MDT)New cases5 94(MDT alone)Total362rural areas reduce the incidence of ulcers. Agreat majority of our cases had rough andthickened soles of their feet.

Extent of disabilities in Burkina F aso andcare needs. Extrapolating our results to theentire number of leprosy cases treated with

MDT in Burkina Faso (12,000), we couldestimate the number of disabled patients at3500. This number must be multiplied bythree if we take into account living leprosypatients cured by DDS between 1980 and1990 (nearly 30,000 cases). Thus, the num-ber of patients needing disability care couldreach 10,000, equaling a rate of 1 per 1000of the country's total population. The num-ber of patients in need of disability care isfivefold more numerous that those needingMDT. Physical rehabilitation and disabilityprevention must be added to the NLCP ( 12 ).Among these disabled patients 5% (nearly500 cases) would need treatment in a centerequipped for surgery and physical rehabil-itation. Giraudeau and Despinay ( 2 ) foundthe same results in 1979 among patientstreated by DDS in a rural area of Mali (aneighbor country of Burkina Faso). The na-tional leprosy hospital in Burkina Faso

13 . 78.8

11 . 9NS

TABLE 1 1. Distribution of disability care needs.Sitesreatment received

Care needEyesands Feet Former cases New casesotal(DDS+ MDT) (MDT alone)asesNone 522 41594.2% 74.9%Primary 6 12 71.1 22.9%Secondary 2 6 124.7% 2.2Total with needs 32 395.8% 25.1%

Patients in need of secondary care also require primary care, such as health education and protective measuresfor eyes, hands and feet (footwear).

TABLE 12 Nature of disability care needs.Eyesandseet

Primary care

Secondary care'

Health educationProtective care including skin and deformity

care, footwearNoncomplicated ulcer or wound careComplicated ulcer care (excision surgery)Training in lid strengthening and think blink(physiotherapy)Review for possible reconstructive or palliativesurgery with pre- and post-operative physio-therapy

627402740017921

454424 79181.9%3.8%4%0.2%841 433 715.2%0.1%3.2 4.7%1 6382.9%.1%.8%.1%1 003786 518.1%6.2%6 9.8%Patients in need of secondary care also require primary care, such as health education and protective measures.

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nternational Journal of Leprosy996would be insufficient to face these needs forsurgery and physiotherapy. Some generalsurgeons would need to be trained to dealwith these needs in the regional hospitals ofthe country. Considering the number of dis-abilities occurring after detection, nurses incommon health services must be trained inthe early diagnosis of leprosy and neuritisand for disability prevention.

SUMMARYSince 1990, Burkina Faso, a West Africancountry, has carried out a national leprosycontrol program treating with WHO/MDT

nearly 12,000 patients between 1990 and1994. A sample survey of 600 cases amongthese patients showed that 29.8% were dis-abled cases. There was a predominance ofmales, older patients, the multibacillaryform of leprosy, and former cases treatedwith dapsone before MDT. The actual rateincreased 8.5% compared to the frequencyof disabilities at detection (21.3%). The needfor disability care was estimated, respec-tively, at 24.4% and 5% for primary andsecondary grades of disability. These im-portant needs were so great that the authorsrecommend the planning and initiation ofa physical rehabilitation and disability pre-vention program in this country.

RESUMENDesde 1990, Burkina Faso, un pais Africano occi-dental, ha implementado un programa nacional dccontrol contra la lepra consistente en el tratamientocon PQT/OMS, de casi 12,000 pacientes entre 1990 y1994. Una exploraciOn de 600 casos entre estos pa-cientes mostrO que el 29.8% fueron casos discapaci-tados. Hubo un predominio de hombres, de pacientesviejos, de la forma multibacilar de la lepra, y de casostratados con dapsona antes de instituirse la PQT. Lafrecuencia de incapacidades aumentO en un 8.5% encomparaciOn con la frecuencia encontrada al moment()de su detecciOn (21.3%). Se calculO la necesidad deatenciOn de las incapacidades en un 24.4 y en un 5 ,para los grados primario y secundario de incapacidad,respectivamente. Estas neccsidadcs fueron tan grandesque los autores recomiendan la planeaciOn y la inicia-ciOn de un programa de rehabilitaciOn fisica y de pre-venciem de las incapacidades en este pais.

RESUMEDepuis 1990, le Burkina Faso, un pays d'Afriqueoccidentals, a realise un programme national de luttecontre la lepre, traitant par PCT/OMS pros de 12.000

=lades entre 1990 et 1994. Une enquete par &Ilan-tillonnage de 600 cas parmi ces patients a montre que29.8% d'entre cux etaient portcurs d'incapacits. II yavail une predominance d'hommes, de patients ages,de forme multibacillairc de lepre, et de cas traites an-terieurement par dapsone avant la PCT. Lc taux ob-serve etait plus eleve de 8.5 par rapport a la frquencedes incapacites a la detection (21.3%). Les besoins desoins pour incapacites ont etc estimes a respectivement24.4% et 5% pour les incapacites de grade I et II. Ce sbesoins &talent si grands que les auteurs recommande ntla planification et la miss en route d'un programme derehabilitation physique et de prevention des incapa-cites dans le pays.

Acknowledgment. The authors would like to expresstheir deep thanks to all who contributed to this survey:Association Francaise Raoul Follereau for its financialsupport, the Ministry of Health of I3urkina Faso andthe staff of the National Leprosy Control Programme,the physicians, nurses and nonmedical workers whoparticipated in the field visits, and all leprosy caseswho accepted examination by the survey team.

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