CHALLENGES IN PREVENTING DISABILITIES AMONG CHILDREN AFFECTED BY - - PowerPoint PPT Presentation

CHALLENGES IN PREVENTING DISABILITIES AMONG CHILDREN AFFECTED BY LEPROSY -

FINDINGS FROM A REFERRAL HOSPITAL IN NORTH INDIA The Leprosy Mission Trust India tlmshahdara@tlmindia.org M Sethi ⃰ PSS Rao *Presenting

author

Symposium- Promoting Early diagnosis 18th September 2013

Introduction

• India had declared elimination of leprosy in December

2005 and leprosy services have been integrated into general health services

• There is still high incidence of disabilities in children

which poses a major challenge to the society and leprosy services

• If the nerve function impairment (NFI) is < 6 months

duration , further disabilities can be prevented by early intervention

 The Leprosy Mission (TLM) Community Hospital established in 1984 is located in the north-eastern part of Delhi , India  Annually 300- 400 new leprosy cases are detected and 5,000 people affected by leprosy are treated  It has an in-patient ward of 45 beds

Background

Objectives

• To estimate the burden of disabilities due to

leprosy among untreated children brought to this referral hospital

• To Identify measures to prevent them

Material and Methods

• All untreated children affected

by leprosy (<15 years) brought to the OPD in TLM Hospital Nandnagri Delhi, India during January 2009 to Dec 2012 were included

• Patients were classified into

WHO deformity Grade 0 , 1 and 2

• All data was collected , analysed

through SPSS software

Clinical history Clinical examination

Lab investigation (CBC, Slit Skin Smear , HPE)

Findings

• N=94

15 PB

Grade 0 15 Grade 1 Grade 2

79 MB

Grade 0 47 Grade 1 9 Grade 2 23

7 Female 8 Male 50 Male 29 Female

34% patients with disabilities (grade 1 & grade 2) and 24.5% with grade 2 disabilities

Findings→

10 20 30 40 50 60 70 80 90 100 < 5 6 to 10 11 to 15 100 65 56.5 5 14.5 30 29

Percentage of deformity with age ( in yrs )

Age in years

Incidence of disabilities by age ( in years )

Grade 0 Grade 1 Grade 2

Among the MB cases the disabilities increased with increasing age; there were no disabilities among children < 5 years of age

10 20 30 40 50 60 70 80 90 100 TT BT BL LL 100 60 78 100 10 11 30 11

Percentage of patients with deformity

Ridley Jopling (RJ )Classification

Incidence of disabilities by RJ Classification

Grade 0 Grade 1 Grade 2

Majority of disability cases were reported among BTHD patients

10 20 30 40 50 60 70 80 90 100 No known contact Household contact Other Contacts 64 70 100 8 15

28 15 Percentage of patients with deformity

History of contact

Incidence of disabilities by history of household contact

Grade 0 Grade 1 Grade 2

It was noted that there were less number of cases with disability in children who had familial or extra familial contact.

10 20 30 40 50 60 70 80

Reaction No Reactions

48 73 26 3 26 24 Percentage of patients with deformity

Reaction at the time of presentation

Incidence of disabilities by reactions at the time of presentation

Grade 0 Grade 1 Grade2

Nerve involvement Grade 0 Grade 1 Grade 2 Total 9 (100%) 9 1 10 (100%) 10 >1 43 (57%) 9 (12%) 23 (31%) 75 Total 62 9 23 94

The incidence of disabilities by number of nerve lesions

• There were no disability cases in patients with no nerve trunk involvement
• Among the disability cases 65% had NFI >12 months duration , 15% had 6-12

months and 20% < 6 months duration

10 20 30 40 50 60 70 80 2 to 3 4 to 5 >5 76 43 34 9 16 9 15 40 55 Percentage of patients with disability

Number of Nerve lesions

Incidence of disabilities with multiple nerve trunk involvement

Grade 0 Grade 1 Grade 2

• Among all disability cases there was direct relationship with multiple nerve trunk

involvement

• It was noted that the disability cases had ipsilateral nerve trunk involvement

Grade 2 disability in children

Ulnar Clawing (70%) Lagopthalmos (10%) Plantar Ulcer (20%)

10 20 30 40 50 60 70 80 0-5 6 to 10 >10 73 67 50 8 21 19 33 29 Percentage of patients with disability

Number of Skin lesions

Incidence of disabilities by number of skin lesions

Grade 0 Grade 1 Grade 2

There was no relation of Grade 2 disability with number of skin lesions

Reasons for delay

Reasons for delay Percentage of pts with delay (%) Total (%) Misdiagnosis Indigenous medications 23% 43% PHC 10% Private practioners 10% Ignorance 28% 28% Financial constraints 20% 20% Stigma 9% 9%

Conclusion

• These rates of disability in young children are worrying as

they point to considerable delay in diagnosis of leprosy.

• Lack of family/ household contact could mislead the parents /

health practitioners in misdiagnosis leading to delay in seeking the right treatment

• Lack of association of disabilities with number of skin lesions

is significant as only skin patches are counted for classification in the field which can lead to misdiagnosing / wrong classification

Recommendation for parents / guardians

• Families need to be motivated for early reporting as

children cannot be expected to go on their own to a health facility

• It is important for them to know tell tale signs of leprosy,

reaction and neuritis

Recommendation for teachers

• Educating teachers not only about early signs of

leprosy but also early signs of neuritis, and prompt reporting in suspected cases

Recommendations for health service providers and health professionals

• Further studies need to be carried out to determine the reasons for

delay in seeking correct treatment through detailed interviews and questionnaire

• It would help in developing practical strategies to prevent the

complications

• Supplementing the voluntary reporting through special school

surveys as dependence only on it alone at integrated centres is inadequate to detect early cases of leprosy, especially among children

Any amount of medical care is futile when the children are not brought to the treatment centre early enough before irreversible damage

• ccurs

References

• Joshi P. National scenario, National Leprosy Eradication Programme and new paradigms.IAL text book of
• leprosy. New Delhi: Jaypee Brothers Medical Publishers; p.35-43(2010)
• Kar BR, Job CK. Visible deformity in childhood leprosy--a 10-year study. Int JLepr Other Mycobact Dis.

2005 Dec;73(4):243-8

• Rao R, Balachandran C. Multiple grade II deformities in a child: tragic effectof leprosy. J Trop Pediatr.

2010 Oct;56(5):363

• WHO.A guide to eliminate leprosy as a public health problem , 1st edn.Geneva:WHO,1995,p.48
• Mahato ME. Disability prevention and medical rehabilitation (DPMR)--preventionof disability and timely

referral in leprosy. J Indian Med Assoc. 2006Dec;104(12):682-5

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WHO classification of leprosy? Indian J DermatolVenereol Leprol. 2008 Jul-Aug;74(4):327-30

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Dec;81(4):306-17

• Daniel S, Arunthathi S, Rao PS. Impact of integration on the profile of newly diagnosed leprosy patients

attending a referral hospital in South India. Indian J Lepr. 2009 Apr-Jun; 81(2):69-74

• Singal A, Sonthalia S, Pandhi D. Childhood leprosy in a tertiary-care hospital in Delhi, India: a reappraisal

in the post-elimination era. Lepr Rev. 2011Sep;82(3):259-69

Acknowledgements

• The leprosy Mission Trust India , Staff and all

concerned patients