Leprosy poses serious challenge for Sri Lanka

20 August 2013 08:14 pm - 0     - {{hitsCtrl.values.hits}}

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Most Sri Lankans including the professionals believe that Leprosy does not exist in Sri Lanka today. Some believe that it has been eliminated. A small group of people feel that the disease has been eradicated. Yet for a remaining group, the disease is here with us, but not in a worrisome scale.

To refresh our minds, Leprosy is an infectious disease caused by a bacterium. So far as present knowledge goes, it is transmitted from one human to another through the nose and mouth. Bacteria from a person with leprosy are spread from the mouth or nose, through the same routes to a healthy person. Some of us have the immunity and therefore a random exposure to few bacteria will not cause the disease, but if we did not have the immunity, we are at risk of getting it following an exposure.

"Modern medicine tells us that Leprosy is caused by a bacterium that affects the human skin and the nerves mainly. The causative bacterium multiplies slowly and thrives well in part of the body where oxygen supplies are poor"

Leprosy’s incubation periods which is the time taken by the bacteria to show the symptoms since entering the body, could be years, preventing health workers tracking the source of infection. This makes the victims theorize on the aetiology, suspect the diagnosis and even run away from treatment. “No one in my family ever had it, so how can I have it?” is the usual complaint of such worried patients.

Body’s immunity against the invading bacteria plays a big role and determines the nature of subsequent unfolding of the disease. Some do not get it at all, while others end up with a controlled version of the disease called the ‘Pausibacillary’ type in which the number of lesions is limited. When there is less immunity or no immunity in the body at the time of exposure there is a likelihood that the more severe kind known as the ‘Multibacillary’ type to manifest. It is this condition and not the former, which is infective and leads to the transmission of the disease to otherwise normal people. Both types of course need to be treated.

Most Sri Lankans are possessed with several layers of memories as a response to the trigger word Leprosy, ‘Laduru’ in Sinhala and ‘Thola Noi’ in Tamil. “Dreadful disease” is one such response. Handela or Manthiev Leprosarium is another. Disability and disfigurement is yet another. Seclusion, criminality and moral degradation are also ideas that surface in during discussions. Except for the few enlightened people exposed to medical knowledge, the above constitutes the “knowns” for leprosy for the ordinary folk.

Such ordinary discourses contribute to the construction of what the health people refer to as Stigma. Stigma is a set of ideas and perceptions of common people and they determine the individual and societal response to the disease. Such stigmatising ideas shape the illness experiences of these patients, their compliance with the treatment and subsequently with coping of any resulting disability. Stigma operates subconsciously in the minds of patients, their family members and with the society at large that does not exclude the health workers.

"Leprosy’s incubation periods which is the time taken by the bacteria to show the symptoms since entering the body, could be years, preventing health workers tracking the source of infection. This makes the victims theorize on the aetiology, suspect the diagnosis and even run away from treatment. “No one in my family ever had it, so how can I have it?” is the usual complaint of such worried patients"

Modern medicine tells us that Leprosy is caused by a bacterium that affects the human skin and the nerves mainly. The causative bacterium multiplies slowly and thrives well in part of the body where oxygen supplies are poor. This explains the preponderance of the lesions in the peripheries of the body or the extremities. Most of the time, the disease is limited to a single skin patch that is ignored by many patients. But among those with the multibacillary type of the disease, multiple lesions are common. This type of the disease affects the nerves as well causing numbness, loss of sensation and subsequently resulting in functional disabilities known as “claw hand” and “foot drop”. When such disabilities manifest, patients need special medical interventions. But the common single lesion can be treated easily.

Leprosy medication comprises of prescribing to patients a combination of antibiotics. This treatment is known as, Multi Drug Therapy, or MDT. The duration of treatment varies with the type of Leprosy and sometimes with the severity of the disease. Research has shown that most of the harmful bacteria can be eliminated with a month or two of MDT treatment. The ‘’Multibaccillary’ type should receive at least twelve months of treatment. MDT comes in blister packs and is provided free of charge at the government hospitals. Although MDT clears all the bacteria, it will not bring back functional disabilities caused by the bacteria. Effective MDT treatment will put a stop to transmission of the disease. Medical treatment of disabilities requires prolonged specialized attention that will be costly to both the patients and to the health system. Leprosy will only be a simple skin condition if not for the disabilities caused by nerve damage.

"With the end of the conflict in Sri Lanka, there is more movement of people. Some of the displaced people are returning from India. Given this, the number of new cases detected in areas where traditionally only a few cases were found, is likely to increase. In Jaffna district alone such an increase has been observed in 2012"

World over the number of new cases of Leprosy has diminished. In the West this reduction came long before the MDT was invented. Living conditions, overcrowding and poor socio-economic conditions seem to contribute to the spreading of the disease. Improvements in such areas contributed to the decline of Leprosy in the West. Close human contact and poor immunity are the contributing factors for rapid transmission of the disease in such contexts.

Sri Lanka is one of the few countries in world that still produces over one thousand new cases a year. In 2012, the number of new cases detected over 2000 new cases. Half of them have been detected from the affluent Western Province. The rest came from districts such as Batticaloa, Ampara, Matara, Puttalam, Hambantota and Polonnaruwa. In Sri Lanka all diagnoses are confirmed by consultant dermatologists who later treat them. A yearly average of 1800-2000 new cases has been detected in Sri Lanka for the last decade and the challenge to reduce this rate has continued. Children below 15 years are not spared and the proportions of children affected are high in Sri Lanka. The disease seems to affect men and women equally.

What worries the health authorities is the continuous, uncontrolled detection of a 2000 cases more or less each year. There is no indication that it will take a downward turn any sooner.
The health authorities are also worried that only a half of the patients who got MDT treatment got it within six months of observing a lesion. The rest of the patients took more than a year to obtain proper treatment. Patients reporting for the first time with a deformity due to leprosy clearly are the victims of this delay in getting the proper treatment. They had waited until the bacterium caused them nerve damage that will be difficult to correct. For a country with high literacy, good health service, good accessibility to health facilities and free health service, this is unacceptable. The deformity rates among new patients at the time of diagnosis, is also high for Sri Lanka.
With the end of the conflict in Sri Lanka, there is more movement of people. Some of the displaced people are returning from India. Given this, the number of new cases detected in areas where traditionally only a few cases were found, is likely to increase. In Jaffna district alone such an increase has been observed in 2012.

What worries the leprosy worker most is the general apathy shown towards this disease by the common citizens, politicians and the officials. While most of the attention is now drawn to control of Dengue, Kidney Disease and Obesity, in the minds of officials and public, Leprosy is no more — eliminated- taken care of. Meanwhile, each year about 250 individuals join the disability group because of Leprosy. In a period of 10 years it will be 2500 Sri Lankans who will probably need lifelong disability care. By making suspecting cases of Leprosy to access MDT treatment as soon as possible, such a burden can be minimized. This means that denial of correct treatment has many consequences that go beyond the misery of the individual patient.

While early diagnosis and treatment is an important step towards spreading of the disease, it is also important to diagnose as much cases as possible. The “risk group” in Leprosy is close contacts to whom a patient may have given the disease or have got the disease from the same primary source. It is therefore very important for all contacts of patients such as family members, neighbours and significant others to be checked for signs and symptoms of Leprosy by doctors and have them treated if found to be infected. It is also important for patients who are on treatment to continue the treatment according to medical advice without making their own decisions about the possible outcomes. All patients found with disabilities need specialized care and will be referred to such treatment centres. Leprosy is a disease for which no benefit is likely to come by changing doctors.

Making the suspected cases come for treatment, making the patients on treatment to continue treatment to its conclusion and making patients to bring their contacts for medical examinations will play a major determinant role in the fight against Leprosy. All this could only be enhanced with an effective counselling process.
Anti-Leprosy Campaign has now developed a three year national plan of action. Organizations such as FAIRMED FOUNDATION and the World Health Organisation have offered technical and financial support to the national programme. All what is now needed is the public and the officials to take the challenge on their shoulders and the Sri Lankans across board to assist the public health staff to do their job. The disease can be curtailed by breaking the transmission lines by providing treatment as early as possible - although this might take some time to see the results.

To curb the spreading of the disease, Sri Lanka has many favourable factors at her disposal. A good and an effective public Health system, highly trained staff, medical professionals as district administrators, epidemiologists and a network of medical officers of health, well equipped health facilities and easy accessibility to health institutions using buses or three wheelers and what more, -a free health service.
Given all this, it will be a shame if Sri Lanka could not curtail the transmission of Leprosy and even eradicate the disease for her 20 million islanders.
Email: fairmedcolombo@yaho.com
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