Abstract
Leprosy care has been integrated with peripheral health services, away from vertical programmes. This includes the diagnosis and management of leprosy reactions, which cause significant morbidity. We surveyed patients with leprosy reactions at two leprosy hospitals in Nepal to assess their experience of leprosy reaction management following integration to identify any gaps in service delivery.MethodsDirect and referral patients with leprosy reactions were interviewed in two of Nepal's leprosy hospitals. We also collected quantitative and qualitative data from clinical examination and case-note review to document the patient pathway.ResultsSeventy-five patients were interviewed. On development of reaction symptoms 39% presented directly to specialist services, 23% to a private doctor, 17% to a district hospital, 10% to a traditional healer, 7% to a health post and 4% elsewhere. Those who presented directly to specialist services were 6.6 times more likely to start appropriate treatment than those presenting elsewhere (95% CI: 3.01 to 14.45). The average delay between symptom onset to commencing corticosteroids was 2.9 months (range 0–24 months). Obstacles to early presentation and treatment included diagnostic challenge, patients' lack of knowledge and the patients' view of health as a low priority. 40% received corticosteroids for longer than 12 weeks and 72% required an inpatient stay. Treatment follow-up was conducted at locations ranging from health posts to specialist hospitals. Inconsistency in the availability of corticosteroids peripherally was identified and 41% of patients treated for leprosy and a reaction on an outpatient basis attended multiple sites for follow-up treatment.ConclusionThis study demonstrates that specialist services are necessary and continue to provide significant critical support within an integrated health system approach towards the diagnosis and management of leprosy reactions.
Highlights
Leprosy reactions play a significant role in the morbidity associated with the disease
Two types of reactions are recognized: type 1 (T1R, known as reversal or downgrading) and type 2 reactions. They can occur at presentation, during treatment for leprosy with multi-drug therapy (MDT) and occasionally following completion of MDT [3]
We aimed to identify any gaps in current service delivery in order to help strengthen future services to ensure effective management of leprosy reactions
Summary
Leprosy reactions play a significant role in the morbidity associated with the disease. These immune-mediated complications, seen in up to 50% of patients [1], can cause rapid nerve damage resulting in anaesthesia and weakness, which in turn increases risk of injury and deformity [2]. Two types of reactions are recognized: type 1 (T1R, known as reversal or downgrading) and type 2 reactions (erythema nodosum leprosum, ENL). They can occur at presentation, during treatment for leprosy with multi-drug therapy (MDT) and occasionally following completion of MDT [3]. Prompt and appropriate treatment is essential to prevent permanent neurological deficit with observed recovery rates of 60–70% in those identified and treated within six months of onset [3]
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