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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 ii 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 iii 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 v 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 vii 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. viii 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 ix 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 x