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TRAINING MANUAL FOR
MEDICAL OFFICERS
National Leprosy Eradication Programme
Directorate General of Health Services
Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi
i
Contents
Forewords
Preface
Acknowledgement
National Rural Health Mission
1. Introduction
1-1
2. Job responsibility
2.1 Medical officers
2.2 Health supervisor / health Assistant
2.3 Health worker / multipurpose worker
2.4 Pharmacist at sector PHC
2.5 Pharmacist at block PHC / CHC
2.6 Accredited Social Health Activist / Anganwari worker / other volunteers
3-4
3. Epidemiology of leprosy
3.1 Introduction
3.2 Distribution of leprosy
3.3 Determinants of leprosy
3.4 Control and prevention of leprosy
5-7
4. Natural History of the Disease
4.1 Natural history of Leprosy
9-9
5. Pathogenesis of Leprosy
5.1 Introduction: M. lepra
5.2 Pathogenesis of Leprosy
5.3 Clinical presentation of the disease
5.4 Skin lesions
5.5 Involvement of nerves
5.6 Reactions in leprosy (Lepra Reaction)
5.7 Disabilities & deformities
5.8 Involvement of other tissues
5.9 Leprosy and pregnancy
5.10 Leprosy and HIV Infection
11-22
6. Confirmation of diagnosis of leprosy & Examination of leprosy affected
person
6.1 Introduction
6.2 Suspecting Leprosy
6.3 Cardinal signs for confirmation of leprosy
6.4 Assessment of person affected by leprosy
6.5 Eliciting detailed History
6.6 Examination of skin lesions
6.7 Examination of Nerves
6.8 Examination of individual important nerves of the face and the neck
6.9 Examination of nerves of the limbs
23-54
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6.10
6.11
6.12
6.13
6.14
6.15
6.16
6.17
6.18
Examination of individual nerves
Grading of disability
Assessment of risk status
Interpretation of signs and symptoms - assessing disease activity
Recording of findings
Slit Skin smear examination
Diagnosis of relapse
At confirmation of diagnosis of leprosy
Ethical responsibility while diagnosing leprosy
7. Classification & Management of leprosy
7.1 Introduction
7.2 Grouping of leprosy
7.3 Treatment of leprosy
55-65
8. Lepra Reaction and its management
8.1 Introduction
8.2 Risk for developing reactions
8.3 Types of reactions
8.4 Diagnosis & examination of the person with lepra reaction
8.5 Management of reactions
8.6 Precautions during treatment with systemic steroids
Counselling PAL in reactions / steroid therapy
Referral of patient in reaction
Management of person with interruption of steroid therapy
Assessment of requirement of prednisolone tablets for leprosy reactions
67-80
9. Ocular leprosy
81-94
9.1
9.2
9.3
9.4
9.5
9.6
Introduction
Causes of ocular involvement in leprosy
Causes of blindness in leprosy
History & Examination of eye
Management of ocular lesions in leprosy
Self - Care of eye
10. Prevention of disability & Medical rehabilitation
10.1 Introduction
10.2 Definitions of Impairment, deformity, Disability
10.3 Disabilities associated with leprosy
10.4 Prevention of Disability & Impairment
10.5 Protection/Care of body part with nerve function impairment
10.6 Care of Insensitive Limbs
10.7 Care of the limbs with weakness/paralysis of muscles (Physiotherapy)
10.8 Prevention and Management of ulcers
10.9 Disintegration of the anaesthetic foot (without associated ulceration)
10.10 Conditions managed at referral centre
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95-126
10.11 Surgical treatment for Persons Disabled by Leprosy
10.12 Support to PAL with disability
10.13 Community based Rehabilitation
11. IEC & Counseling
11.1 Introduction
11.2 Job responsibilities related to IEC of leprosy
11.3 Messages to generate awareness
11.4 Planning IEC activities
11.5 Leprosy Awareness Activities
11.6 Counselling
127-135
12. Planning
12.1 Introduction
12.2 Steps in Planning: ‘Planning Cycle’
12.3 Planning Document
137-146
13. Monitoring
13.1 Introduction
13.2 Monitoring the Planned Activities
13.3 Monitoring the Programme
13.4 Sample register for session on recording and reporting
147-153
14. Supervision
14.1 Introduction
14.2 Process of supervision
14.3 Skills of supervisor
14.4 Do’s for effective supervision
14.5 Sample supervisory checklists
155-160
15. Annexure
Annexure
Annexure
Annexure
Annexure
I
II
III
IV
National Leprosy Eradication Programme
Referral system for persons affected with leprosy
Differential Diagnosis for leprosy
Clinical aspects of the Ridley-Jopling classification of Leprosy
according to immunity
Annexure V Bacterial Index (BI) and Morphological index (MI)
Annexure VI Referral of PAL with reaction before starting steroids
Annexure VII Stigma in Leprosy
Annexure VIII Process of counselling
Annexure IX Block Leprosy Awareness Campaign (BLAC)
Annexure X Rehabilitation services for disabled persons
i)
Institutions under Ministry of Social Justice& Empowerment
ii) Provisions for ‘Persons with Disability (PWD)
iii) Main types and definitions of disabilities
iv) DDRCS Implemented Through 10 DRCs
iv
i-v
vii-ix
xi-xiii
xv
xvii-xviii
xix-xx
xxi- xxvi
xxvii-xxix
xxxi
xxxiii-li
v)
vi)
vii)
viii)
ix)
x)
List of District Rehabilitation Centers
List of The Addresses Of The Special Employment Exchanges
List of vocational rehabilitation centers for handicapped
List of Special Employment Exchanges and Special Cells for the
Handicapped
List of Existing Functional RCS & Medical Rehabilitation Institutions
(ILEP)
Names of Govt. Institutions performing Re-constructive Surgery (RCS)
Annexure XI
Annexure XII
Annexure XIII
Annexure XIV
Annexure XV
Annexure XVI
Annexure XVII
Guidelines for “Other-cases” under NLEP
Guidelines on Quarterly assessment of New Case Detection Rate
(NCDR) under NLEP
Revised Guidelines for streamlining the MDT Supply
Management in States/ UTs
Guidelines for Treatment completion rate under the NLEP
Formats for Recording and reporting
Terms abbreviations and Definitions
References
16. Self assessment
Case Studies
Answers (Hints): Case Studies
Pre / post questionnaire
Answers
liii-lv
lvii-lix
lxi-lxvi
lxvii-Ixxi
Ixxiii-xcv
xcvii-ciii
cv
i- x
xi – xxii
xxiii – xxxv
xxxvi
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Directorate General of Health Services
Government of India
Ministry of Health & Family Welfare
Dr. R.K. Srivastava
Director General of Health Services
FOREWORD
I am happy to learn that the Central Leprosy Division has for the first time prepared a
detailed training manual for the Medical Officers working under the Primary Health Care
system, to train them on the National Leprosy Eradication Programme. The manual prepared
in consultation with the experts from partner organizations like the WHO, ILEP, Novartis,
and others included all the standard technical material required for training of the General
Health Care Services Medical Officers.
Availability of this Training manual along with the facilitators guide prepared, should
help in standardizing the training given to the Medical Officers, who in turn have to provide
service to the persons affected by leprosy and also to teach the Health Workers under him.
This book also should remain as a referral material for NLEP including the recent
developments after introduction of the National Rural Health Mission.
I am sure the manual will be used profitably by the Medical Personnel working in the
General Health Care services and make practical use of the same.
(Dr. R.K. Srivastava)
Dated:
December 2008
vi
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Directorate General of Health Services
Government of India
Ministry of Health & Family Welfare
Dr. P.L. Joshi
Deputy Director General (Leprosy)
PREFACE
Learning material on leprosy used for training of Medical Officers was first developed
by a group of selected experts from Leprosy and General Health Care Institutions in the year
1999. The booklet was printed by the International Federation of Anti Leprosy Association
(ILEP) and supplied to all the States and UTs. The booklet was again updated and modified
in consultation with various experts in the years 2005, which was printed and supplied by
ILEP again to all the Health Institutions.
The National Leprosy Eradication Programme has undergone various changes in its
concepts and approaches over the years and particularly after the elimination of leprosy as a
public health problem was achieved in India at the National level in December 2005.
Introduction of the National Rural Health Mission in India on 12th April 2005 also brought in
newer challenges in integrated service delivery. Widening the scope of the Disability
Prevention and Medical Rehabilitation activities under NLEP along with emphasis on
behavioural change communication to reduce stigma & discrimination against the disease
have increased the need to make the training material more comprehensive and yet simple to
use by the General Health Care staff. In view of these requirements, it was agreed with all the
partners in NLEP in India, to prepare the training Manual for the National Leprosy
Eradication Programme for use by the Medical officers of the General Health Care system.
While preparing the manual it was kept in mind that this can also be used as a
reference book subsequently by all persons working for the programme. A set of facilitators
guide was also prepared, so that the training by different trainers can be standardized.
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In preparing the manual and the facilitators guide, the Central Leprosy Division was
supported with man and material by our partners WHO, ILEP, Novartis and other experts
from the states. The names of the experts and the resource persons have been duly
acknowledged in the manual. I would like to express my heartfelt gratitude to each of these
persons and organizations for their support and contribution toward this important work.
Special words of thanks are due for Dr. S.J. Habayeb the WHO Representative to India for
supporting organization of a workshop to finalize the manual.
(Dr. P.L. Joshi)
Dated:
November 2008
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Acknowledgement
The Training Manual for the Medical Officers and the facilitators guide were prepared with
consultation and active support from a large number of persons engaged in the field of leprosy.
Experts for their contribution in various chapters of the manual;
 Dr. P. Krishnamurthy, Secretary, Damien Foundation India Trust & ILEP India Coordinator
 Dr. H.K. Kar, Consultant & HOD (Skin) RML Hospital, New Delhi
 Dr. S.N. Bhattacharya HOD of Dermatology UCMS & GTB Hospital, Delhi
 Dr. M. A. Arif, Country Representative, Netherlands Leprosy Relief
 Dr. D. M. Thorat, Deputy Assistant Director, General (L), NLEP
 Dr. P.K. Oommen Director, Central Leprosy, Training & Research Institute Chengalpattu
 Dr. P. V Ranganadha Rao, Chief Executive Lepra India
 Dr. Rajan Babu, Deputy Director, The Leprosy Mission
 Dr. P.K.B. Patnaik Assistant State Leprosy Officer, Bhubaneswar, Orissa
 Dr. Vijay Kumaran Director (Programme) Damien Foundation India Trust
 Dr. D. K. Sen, Director & HOD, (Ophthalmology) ; (Retd) MAMC New Delhi
 Dr. R. P. Mal, State Leprosy Officer (Retd) UP
 Dr. Mani Mozhi, Amici Di Raoul Follereau
 Dr. G. Lakshmi Rajan, Pathologist & Superintendent; The Leprosy Mission Hospital, N.Delhi
 Dr. Helen Roberts Ophthalmologist ; The Leprosy Mission Hospital, Kolkata
 Dr. Jerry Joshua Surgeon, The Leprosy Mission Hospital, Kolkata
 Dr. Atul Shah, Director, Novartis CLC Association
 Dr. Saurabh Jain, State Coordinator, NLEP, WHO
 Dr. B.K. Panda, State Coordinator, NLEP, WHO
Resource Persons for rendering support and feed back at various stages.







Dr. V. Pannikar, Global Leprosy Team Leader, WHO, SEARO
Dr. B. N. Barkakaty, National Consultant, NLEP
Dr. A. K. Puri, Deputy Assistant Director General (Leprosy)
Dr. Indranath Banerjee, National Professional Officer WHO India
Dr. Jeyakumar Denial, Director, The Leprosy Mission
Dr Sunil Hamilton, Consultant, NGO Noida
Mr. R.K. Verma, MDT Logistic & Supply Officer
Organizations for their various supports
 World Health Organization Representative to India, Nirman Bhawan, New Delhi
 ILEP organizations especially, Damien Foundation India Trust, The Leprosy Mission,
Alert India, German Leprosy Relief Association
Contribution of Dr. Meena Kapoor, Training Consultant, Dr. P.R. Manglani, DPMR
consultant and Mr. Kamaraj A. Devapitchai, National Consultant (Rehabilitation) WHO India;
who have worked hard to prepare the draft manual and then finalizing the document in time, along
with the support staff Miss. Aarti, Cycyliya M. I., Mr. Dipesh Kumar, Mr. Rajesh Kumar,
Mr Jaspreet singh is fully acknowledged.
Dr. P. L. Joshi
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