Rate of relapse in multibacillary patients after cessation of long-course dapsone monotherapy supplemented by a final supervised single dose of 1500 mg of rifampin

When multidrug therapy was implemented in Senegal, 406 multibacillary (MB) patients who had been treated for more than 10 years by dapsone alone, and who had become clinically inactive and skin-smear negative, were released from treatment. Of these 406 patients, 298 were given a supervised single dose of 1500 mg of rifampin. Subsequently, 302 of them (229 who had been given rifampin and 73 who had not) were followed up by means of annual clinical and bacteriological examinations. Of the former 229 followed up for a mean period of 4.9 years, 34 patients relapsed (22 males and 12 females), giving a crude relapse rate of 15% and an overall risk of relapse of 3.1 per 100 patient-years. Of the latter 73 followed up for a mean period of 2.4 years, 5 relapsed (4 males and 1 female), giving a crude relapse rate of 6.8% and an overall risk of relapse of 2.9 per 100 patient-years. Such results, which are in agreement with those of a similar study conducted recently in Mali, indicate that the intake of a single dose of 1500 mg of rifampin by MB patients when they are released from long-course dapsone monotherapy does not result in a decrease of the relapse rate. Therefore, MB patients who have been treated with dapsone alone, even for long periods, should be put under multidrug therapy prior to their release from control.

[Multi-drug therapy trials for leprosy in Senegal: first observations relative to liver tolerance of multibacillary patients. Therapeutic consequences]

The authors have studied tolerance of multibacillary patients to 4 MDT regimens. These 4 regimens consist of: One supervised part in which RMP-ETH combination in once-monthly administered; furthermore, in 2 of these regimens, is included one "starter phase" with daily doses of that combination for 2 months. One self-administered part during which CLO is associated either to DDS for new cases, or to ETH for relapses. Clinical Supervision: Out to 310 multibacillary patients, 7 cases of hepatitis with or without icterus, but no death due to the treatment. Interruptions of MDT have been temporary and have been observed in 0.9 to 5.6% of the patients according to the therapeutic regimen. Checking SGOT: The SGOT were abnormally high in 16.3% of the patients before treatment. These pre-existing liver damages do not favour the appearance of intolerance disorders. During MDT, abnormal increases in SGOT are observed in 27% of the patients but there is no exact correlation between the absorbed doses of ETH and the frequency in SGOT increases. The clinical or biological evidence of liver damages occur rather early (1st, 2nd month) in regimens with "starter phase", and later (4th-8th month) in those without "starter phase". But introduction of "Starter phase" does not increase the global frequency of such intolerance accidents. ETH combined with RMP, must be used under steady clinical and biological supervision. Recalling the results of a previous survey, the authors consider that a long duration of MDT is not necessary. For the multibacillary leprosy treatment, they propose a diphasic regimen, more easily applicable in the field than the WHO protocols. In this diphasic regimen, the only part which must be supervised is the initial "starter phase" of 2 month. It consists of daily administration of 3 antibacillary drug among which RMP and ETH. The second phase is a relay treatment using 2 drugs, CLO combined with DDS or ETH, self-administered until smear negativity.

[A trial of polychemotherapy of leprosy in the Dakar region. Initial observations on the acceptability of the protocols used]

Since 1982, in Dakar, a controlled essay tests the suitability of several short protocols of multidrug therapy (MDT), some of them being close to those advised by the WHO, others showing a starter stage of a two month daily MDT. In three years, 198 paucibacillary and 123 multibacillary patients have been treated. The short duration of these treatments leads to an important decrease in the load of the Department. The total rate of those who have not attended for the treatment is of 15.2% whereas it was of 52% with DDS monotherapy for a similar treatment duration. Those who gave up don't seem to live in Dakar. To judge by the diligence of the patients, the compliance seems excellent even for the protocols requiring a daily dose of ethionamide: 95% of paucibacillary, 76% of multibacillary patients have maximal attendance. The authors think that any MDT program: must be preceded by a retraining of staffs; must give a priority to the health education of the patients; must involve a home patient search for system.

[Prevention of perforating plantar ulcers: trial directed by a mobile team]

AIMS

to prevent the appearance of plantar ulcerations and then mutilations, by going in the field in order to: make suitable footwear, educate the patients, train the paramedical staff. Means: 1 fitted lorry, 1 physiotherapist, 1 shoemaker, and 1 educator.

RESULTS

In one year, 206 patients have been provided with shoes and followed up. Advice have been taken exactly in the leper villages in which the attendance rate is of 98%; this rate varies between 47 to 70% in the all-purpose dispensaries. Paramedical workers of all-purpose Health Centers did not take great interest in this action. After 6-12 months under observation: 84% of good results for the feet without deformity or slightly deformed; 51% for the deformed feet. The results are quite satisfactory for the feet without plantar ulcer at the beginning, and that whatever the food deformity stage. But for the feet wounded by plantar ulcer at the beginning, 33% of recovery have been reported after wearing these shoes.