1 leprosy in cambodia - niph€¦ · it was also described in detail by the time of king jayavarman...

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TsSnavdþIsuxPaB elx25 | ExFñÚ qñaM2005Health Messenger Issue 25 | December 2005

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mü:ageTot eK)anKitfaCMgWXøg;)anqøgedaypÞal;mkBIRbeTs\NÐa. edayeyageTAtam Madeleine Giteau

mankareFIVcMNakRsukd¾FMsem,ImCaeRcInBIRbeTs\NÐa)anekIteLIgrvagstvtSTI1 nig4. ehIyk¾mankareFIVcMNakRsukBIextþnanaenAPaKxagt,ÚgénRbeTscin enAedImstvtSTI12pgEdr. extþTaMgenHRtUv)aneKcat;TukfaCaRbPBd¾sMxan;EnCMgWXøg;.The History of Leprosy in Cambodia

Leprosy has been known in Cambodia for many centuries however it is impossible toapproximate when it exactly appeared. Old Chinese writings mention that it was common inSouth-China and Cambodia by the 4th and 6th centuries.

It was also described in detail by the time of King Jayavarman VII. The statue of the leprous kingin Angkor Thom is considered to represent a Khmer king who died of leprosy. The legend saidthat the king was punished by the Dragon God for not performing a rite. The dragon spat out fireon the king's face who became leprous.

Another legend mentions an old leprous woman who, avenging her daughter, jumped on theKing who then became leprous. Most modern scholars consider the statue as that of PreahCiva.

It is thought that Leprosy may have come directly from India. According to Madeleine Giteaumassive migrations from India happened between the I and IV centuries. There was also amigration from the southern provinces of China at the beginning of the XII century. Theseprovinces were considered as the hotbed of leprosy.


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The Current Situation

The National Leprosy Control Programme ofCambodia achieved the goal of “elimination”of leprosy as a public health problem, with aprevalence of less than 1 case per 10,000people by 1998.

Approximately 17,000 people have beentreated with MDT and cured of leprosy in thelast 15 years, which is a commendable effort.

Although the prevalence rate has fallen belowthe WHO defined target of 1 case per 10,000people, we are currently finding 400-500 newcase a year.

461 new cases were detected on 2004 and wesuspect that a similar number will be found forseveral years to come.

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There are two very worrying problems inCambodia:

1. A high number of children contract leprosy.This shows that there is ongoing and activetransmission of the disease.

2. 18.3% of people have an obvious disability(Grade 2) at diagnosis, such as an ulcer or aclawed hand. This means that people arepresenting for treatment too late and aredeveloping disability as a result.


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What do people think about leprosy?

In 2004, NLEP, in conjunction with theNational Institute for Public Health, conducteda survey to find out what people really thinkabout leprosy.

As you can see there is a low level ofknowledge in the community about theavailability of free and effective treatment,and often a great deal of prejudice towardsaffected persons. This can lead to tragicconsequences, such as late diagnosis, highdisability and discrimination.

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KitfaXøg;KWCaCMgWsYrBUCThink leprosy is hereditary

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35°min[kUneTAeronkñúgsalaCamYykumarekItCMgWXøg;35% will not send their children to schoolwhere there is a child with leprosy

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et I RbCaCneyIgyl;y:agd Ucem þcG MB IC Mg WX øg ;? What do people think about leprosy?

KitfaCMgWXøg;ekItedaysarcMNIGaharThink leprosy caused by food

KitfaCMgWXøg;KWCaCMgWkameraKThink leprosy is an STD

mindwgGMBImUlehtuénCMgWXøg:Do not know what causes leprosy

85°minbriePaKGaharCamYyGñkCMgWXøg;85% will not share a meal with a leprosypatient

mUlehtuénCMgWXøg;The Causes of Leprosy

Gkb,kiriyacMeBaHGñkCMgWXøg;Attitudes Towards Leprosy Patients

enAkñúgRbeTskm<úCa mmanRbCaCnEt45/5°b:ueNÑaH EEdldwgfaCMgWXøg;Büa)alCaOnly 45.4% of people in Cambodia know leprosy is curable.


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The most common misconceptions are thatleprosy is hereditary and that is is incurable.These are not true, and information needs tobe spread to communities about how leprosyis spread and the availability of free andeffective treatment. Intense fear of leprosy stillexists in communities, leading tostigmatisation of affected persons and theirfamilies.

Rejection and stigmatization can only bedecreased through effective communicationand education in the communities. Peopleneed to understand that leprosy is hard tocatch but easy to cure. Leprosy patients shouldbe related to in a normal manner, and shouldbe encouraged and allowed to participate inlife as usual.

A Disease of Poverty

Leprosy is a leading cause of permanentdisability in the world. Although not fatal, thechronic symptoms often afflict individuals intheir most productive stage of life andtherefore impose a significant social andeconomic burden on individuals, families andtheir communities. Patients are often shunned,stigmatized, isolated and sometimes displacedfrom their work, marriage and social set-up,needing care and financial support leading tofurther insecurity, shame, and consequenteconomic loss.

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The National Leprosy EliminationProgramme

Diagnosis and treatment is now available in allprovinces through the Operational DistrictLeprosy Supervisor. There are alsorehabilitation centres providing support topeople affected with leprosy in someprovinces, and in Phnom Penh Kien KhleangLeprosy Rehabilitation Centre provides avariety of free services where leprosy pateitnscan be referred; including ulcer and reactioncare, education and reconstructive surery. Italso provides technical support and trainingfor health professionals and students.

The key elements of the national strategyare:

Integration of leprosy services into thegeneral health services to improve accessto treatment.Capacity building to enable general healthcare staff to diagnose and treat leprosy.Improve logistics to ensure adequatestocks of MDT at health centres.Change society's perception of leprosy andmotivate people to seek timely treatment.Ensure high cure rates through flexible andpatient-friendly drug delivery systems.Simplify monitoring to keep track ofprogress towards elimination.

Health staff should be able to:Diagnose and classify a case of leprosy onclinical groundsTreat a leprosy patient with the appropriateMDT regimenManage or refer cases with complicationsMaintain simple patient cards and atreatment register, and submit reportsregularlyKeep adequate stocks of drugs for MDTProvide appropriate information about thedisease to patients, community members,and decision-makers.

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karBinitüsrésRbsaTelIGñkCMgWXøg;Examination of the nerves of a leprosypatient


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Facts About LeprosyBy Dr Lai Ky (NLEP) and Health Messenger

How is leprosy transmitted?

There is only one source of infection:untreated, infected human beings.

Leprosy is not highly infectious. It istransmitted via droplets, from the nose andmouth, during close and frequent contact withuntreated cases. Circumstances like hygieneand living conditions play a role in thetransmission.

The mechanism of infection is not fullyunderstood, but it is generally thought to be bydroplet spread through the upper respiratorytract. Several risk factors have been identifiedin the process of transmission and thedevelopment of the disease. These are relatedto the host (genetic, immune status, nutritionalstatus, pregnancy), socio-economic conditions(poverty, housing,), and factors related to themicro-organism (bacterial load, frequency ofexposure). It is clear that a combination ofthese factors defines the conditions fortransmission and the development of thedisease.

The period between infection and diseaseranges from a few months to many years. It isnot known at what stage an infectious patientstarts sending out bacilli, nor how long thiswould continue in the absence of treatment.

However, most people who are infected withMycobacterium Leprae will never know thatthey have been infected. The response of theimmune system determines the kind ofleprosy they will develop: Paucibacillary (PB)or Multibacillary (MB) leprosy. Because MBpatients harbour many more bacilli, they aremuch more infectious, develop more skinlesions and require longer treatment. We willexamine the different types of leprosy later inthis issue.

Leprosy (also known as Hansen’sDisease) is a chronic infectiousdisease caused by Mycobacterium

Leprae. Leprosy mainly affects the skin, theperipheral nerves, mucosa of the upperrespiratory tract and the eyes, but has awide range of clinical manifestations.

Leprosy can affect all ages and both sexes.Incubation can last anywhere between threemonths and 40 years, with the averageincubation period lasting three to five years.

Among communicable diseases, leprosy is aleading cause of permanent physicaldisability. Timely diagnosis and treatment ofcases, before nerve damage has occurred, isthe most effective way of preventing disabilitydue to leprosy. In addition effectivemanagement of leprosy complications,including reactions and neuritis, can preventor minimize the development of furtherdisability.

Leprosy can be diagnosed on clinicalsigns alone.

Leprosy is curable and if detected early andtreated with a prescribed duration of multidrugtherapy (MDT), leprosy is less likely to causeany permanent disability.


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Effective anti-leprosy treatment usuallymakes a patient non-infectious within a fewdays.

Fortunately, antibiotics can now quickly kill thebacteria (germs) that cause leprosy, so thedisease can be completely cured with modernmedicines. If this is started at an early stage,most patients need never suffer the terriblecommon complications.

Nerve damagedoes still occur insome patients, butit can sometimesbe reversed withother medicaltreatment. When itcannot be reversedand the personremains with somedisa-bility, thereare many differentstra-tegies ofrehab-ilitation tohelp them live asnormal a life aspossible.


10

CMgWXøg;b:HBal;dl;GI Vx øH?

eKaledAsMxan;²rbs;CMgWXøg;KWsrésRbsaT nigEs,k CaBiesssrésRbsaTenARbGb;éd RbGb;eCIg nigEPñk.RbsinebIBMu)anBüa)aleT Es,k srésRbsaT Gv³yv³ nigEPñknwgmankarxUcxatkan;EtxøaMgeLIg²nigCaGcié®nþy_.Leprosy mainly targets the nerves and skin - in particular, the nerves of the hands, feet and eyes. Ifuntreated, there can be progressive and permanent damage to the skin, nerves, limbs and eyes.

What leprosy does?

cugrbs;srésRbsaTenAEPñkNerve endings in the eye(5th cranial nerve)

srsrésRbsaThVasüal;Facial nerve(7th cranial nerve)

xYrk,al BRAIN

srésRbsaTq¥wgxñgSPINAL CORD

ra:DIya:l;Radial Nerve

TIb‘Íya:l;;Tibial Nerve

Kuyb‘ÍtalUlner Nerve

emDIy:g;Median Nerve

sIuya:TikPeroneal Nerve

(minb:HBal;edaysarkarxUcsrés RbsaTeT)(NOT affected by nervedamage)


11

plv i ) akénC Mg WX øg ; Consequences of leprosy

CCMMggWWXXøøgg;;GGaaccbb::HHBBaall;;eeTTAAmmnnuussSSeeyyIIggttaammvviiFFIIeeppSSgg²².. vvaaCCaakkaarrssMMxxaann;;NNaass;;kkññ úúggkkaarrvvaayyttMMééllGGññkkEEddllmmaannCCMMggWWXXøøgg;; bb¤¤GGññkkEEddllmmaannBBiikkaarrPPaaBBeeTTAAeellIIbbBBaaððaa33yy::aaggeeppSSgg²²KKññaa..

Leprosy can affect people in different ways. It is uself toassess someone who has leprosy (or other disabilities) inthree different areas.

11>> BBiikkaarrPPaaBB - bbBBaaððaaeeppSSgg²²éénnddMMeeNNIIrrkkaarrbb¤¤rrccnnaassmm<<½½nn§§rrbbss;;rraaggÁÁkkaayykñúgCMgWXøg; bBaðaenHEtgEtTak;TgeTAnwgkarcuHexSayéndMeNIrkarrbs;srésRbsaT EdlmansrésRbsaTm:UT½r srésRbsaT jaNdwgb¤srésRbsaTsVy½t. ]TahrN_ karxUcdMeNIrkarrbs;srésRbsaTGacbNþal[manPaBBikar dUcCaRkj:g;Rmaméd b¤Føak;RbGb;eCIg ¬sUmGanGtßbT CMgWXøg; nigBikarPaB¦. 1) Impairments - problems in body function or structure. In leprosy this usually relates to impairments in nerve function -including motor, sensory or autonomic nerve function. For example,nerve function damage can cause impairments such as clawing of thehands or drop foot. (Please see the article on Leprosy and Disabilityfor more information)

22>> sskkmmµµPPaaBBmmaannkkMMrriitt - kkaarrllMM))aakkeeppSSgg²²EEddllbbuuKKÁÁllmmññaakk;;GGaaccCCYYbbRRbbTTHHkkññúúggkkaarrGGnnuuvvttþþnn__kkaarrggaarrRRbbccaaMMééff¶¶eeddaayyssaarrBBiikkaarrPPaaBB..karlM)akxøH dUcCakareFVIclna karEfTaMxøÜn kargarkñúgRKYsarnigkarR)aRs½yTak;TgepSg². ]TahrN_ karexSaysac;duMGacbNþal[mankarlM)akkñúgkaredIr ehIykar)at;bg;jaNdwgGacbNþal[mankarlM) akkñúgkarcab;kan;vtßútUc².RtUveFVIkarvaytMélbBaðaenHedaysYrGñkCMgWfa “etIskmµPaBsMxan;²GVIxøHkñúgCIvitrs;enARbcaMéf¶ EdlGñkminGaceFVI)anb¤EdlGñkmankarlM)ak?”2) Activity limitations - difficulties an individual may have incarrying out activities because of impairments. Difficulties can include movement, self-care, household duties andcommunication. For example muscle weakness may cause difficultiesin walking, and sensory loss may cause difficulties in holding smallthings. Assess this by asking the client - “what are important activitiesin your life that you cannot do anymore or that have become difficult?”


12

33>> kkaarrccUUllrrYYmmkkññúúggkkaarrggaarreeppSSgg²²mmaannkkMMrriitt - bbBBaaððaaeeppSSgg²²EEddllbbuuKKÁÁllmmññaakk;;GGaaccCCYYbbRRbbTTHHkkññ úúggkkaarrccUUllrrYYmmkkññ úúggkkaarrggaarreeppSSgg²²kkññ úúggCCIIvviittrrss;;eennAARRbbccaaMMééff¶¶ddUUccCCaakkaarrRRbbkkbbrrbbrrcciiBBaa©©wwmmCCIIvviitt kkaarrggaarrssggÁÁmm nniiggRRKKYYssaarrbb¤¤sshhKKmmnn__..CaTUeTA bBaðaenHbNþalmkBIkarmak;gay. GñkekItCMgWXøg;b¤GñkmanBikarPaBepSg²)anniyayerobrab;karlM)akrbs;BYkeKkñúgkarcUlrYmkñúgBiFIepSg² GaBah_BiBah_ kareRbIR)as;meFüa)aydwkCBa¢ÚnsaFarN³ nigkareRbIR)as;sßab½nsuxPaB. BYkKat;Gac)at;bg;kargarEdlmann½yfa BYkKat;minGacRTRTg;RKYsar)an.

3) Participation limitations – problems an individual mayexperience in involvement in life situations such as work, socialfunctions and family or community life. This is usually due to stigma. People with leprosy or other disabilitieshave described difficulties in participating in ceremonies, marriage,use of public transport and use of health facilities. They may losetheir jobs, which means that they cannot support their families.

cUrcgcaMfa enAEtmankarmak;gay nigkarP½yxøacCaeRcIn GMBICMgWXøg;. GñkmantYnaTId¾sMxan;kñúgnamCabuKÁlikCMnajkñúgkarCYyeFIVeGayRbCaCn RkumRKYsar nigshKmn_rbs;BYkeK yl;dwgGMBICMgWXøg; nigkñúgkaredaHRsaykarP½yxøacrbs;BYkeK. CaTUeTA RbCaCneyIgEtgEtmanCMenOnigeKarBtamCMerIsrbs;buKÁliksuxaPi)alrbs;eyIg. dUecñHehIyviFIl¥bMputmYykñúgcMeNamviFIl¥CaeRcIn edIm,Ikat;bnßykarP½yxøac nigkarmak;gay KWkarbgðajkareKarBdl;GñkEdlmanCMgWXøg; edayniyayCamYyBYkeK nigb:HBal;BYkeK.

REMEMBER that there is still much stigma and fearabout leprosy. You have a vital role as the healthprofessional in helping people, their families andcommunity understand leprosy and in addressingtheir fears. Health professionals are generallytrusted and their opinions respected. Therefore oneof the best ways to decrease fear and stigma issimply by showing respect to people with leprosy,talking with them and touching them.


13

eraKv in ic ä ½y nigeraKsBa Ø ad Mb UgénC Mg WX øg ;eroberogeday³ TsSnavdþIsuxPaB

kareF I V er aKv in ic ½ äyC Mg wX øg ;

11>> BBiinniittüüeellIIRRbbvvttþþ iissuuxxPPaaBBeeddaayyBBiiPPaakkSSaaCCaammYYyyGGññkkCCMMggWW ³³RbsinebIGtifiCnrbs;GñkmansñampÞa Mg²enAelIEs,k sMnYrdUcxageRkam KWCacMNuccab;epþImd¾l¥edIm,IsMercfaetIBYkeKGacqøgCMgWXøg; b¤ya:gNaenaH³

aarrBBüü aa))aallCC MMgg WWXXøøgg ;;mmaannRRbbssiiTT ii §§ PPaaBBxx <<ss;;eehhIIyyPPaaBBBBiikkaarrGGaaccbbggááaarr))aann RRbbssiinneebbIICCMMggWWeennHHRRttUUvv))aannrrkkeeXXIIjjeennAAddMMNNaakk;;kkaallddMM

bbUUgg.. RRbbssiinneebbIIBBMMuu))aannBBüüaa))aalleeTT CCMMggWWXXøøgg;;nnwwggnnaaMMeeGGaayymmaannbbBBaaððaaBBiikkaarrCCaaeeRRccIInn RRBBmmTTaaMMggeeFFII VVeeGGaayysskkmmµµPPaaBBnniiggkkaarrccUUllrrYYmmkkññ úúggkkaarrggaarreeppSSgg²²mmaannkkMMrriitt.. kkaarrrrkkeeXXIIjjCCMMggWWXXøøgg;;eennAAkkññúúggddMMNNaakk;;kkaallddMMbbUUgg nniiggkkaarreellbbffññaaMMMDT yy::aaggRRttwwmmRRttUUvv GGaaccbbggááaarrBBiikkaarrPPaaBB))aann..

kareFIVeraKvinic½äyTan;eBl

karBüa)alRtwmRtUv

karEfTaMedayxøÜnÉg karbgáarBikarPaB =+

+

etIsñampÞa Mg²enAelIEs,kenaH)anekIteLIgry³eBlb:unµanmkehIy? etIsñampÞaMg²enaHmankarERbRbYlEdrb¤eT?etIsñampÞaMg²TaMgenaHmanrmas;b¤mankarQWcab;Edrb¤eT?

etIbuKÁlenaHmanGarmµN_faenAelIRbGb;éd b¤RbGb;eCIgrbs;Kat;manlkçN³xusBIFmµtaEdrb¤eT dUcCakars<wkRsBn; karQWeqob² b¤mankarekþAeral?etIbuKÁlenaHKitfa RbGb;éd b¤RbGb;eCIgrbs;Kat; kan;EtexSayeTA²Edrb¤eT? etIBYkeKmanbBaðakñúgkarkan;yYr b¤elIkrbs;rbr nigkñúgkarkMerIkRbGb;éd b¤RbGb;eCIgEdrb¤eT? etImanRbvtþiCMgWenHenAkñúgRkumRKYsar b¤etIbuKÁlenaHFøab;CYbRbTHbBaðasgÁmxøHEdrb¤eT? Cajwkjab; CMgWXøg;qøgkñúgsmaCikRKYsar.

CaFmµta sñampÞaMg²enAelIEs,kedaysarCMgWXøg;elceLIgyWt². sñamTaMgenaHBMuekItmantaMgBIkMeNItmkenaHeT. sñampÞaMg²enAelIEs,kedaysarCMgWXøg;BMurmas;eLIyehIyCaFmµta BMumankarQWcab;eT.karmanGarmµN_xusBIFmµtaenAelIRbGb;éd b¤RbGb;eCIgGacCaeraKsBaØamYyEdleFVI[sgS½yfamanCMgWXøg;.

kar)at;bg;kMlaMgenARbGb;éd b¤RbGb;eCIg GacCaeraKsBaØamYyEdleFVI[sgS½yfamanCMgWXøg;.

bBaðasgÁmeRcInEtGacekItman RbsinebIbuKÁlenaH )anekItmanBikarPaBrYcehIyedaysarCMgWXøg;.


14

Diagnosis and Early Signs of Leprosy By Health Messenger

Leprosy treatment is effective, anddisability may be prevented if thedisease is identified at an early stage.

Untreated, leprosy can lead to problems ofimpairment, as well as activity andparticipation limitations. Recognisingleprosy in the early stages and taking MDTcorrectly can prevent disability.

Diagnosing Leprosy

1. Take a medical history by talking to thepatient:If you have a client with a patch on their skin,the following questions are a good startingpoint to decide if they could be infected withleprosy:

Early diagnosis

Correct treatment

Self-care

++

Prevention of disability=

How long has the skin patch been there? Has itchanged?

Do the patches itch, or are they painful?

Does the person have unusual sensations intheir hands or feet, such as numbness, tinglingor a burning feeling?

Does the person think that their hands or feethave become weaker? Do they have problemswith holding or lifting things and with movinghands or feet?

Is there a history of disease in the family, or hasthe person ever experienced any socialproblems

Leprosy patches usually appear slowly, they arenot there at birth.

Leprosy patches do not itch and are not usuallypainful.

Unusual sensations in the hands or feet can bea sign of a leprosy suspect.

Loss of strength in hands or feet can be a signof a leprosy suspect.

Leprosy is often transmitted between familymembers. Social problems may be more likely ifthe person already has some disability due toleprosy.

kareFVIeraKvinicä½ynigBüa)alTan;eBlbgáarBikarPaBEarly diagnosis and treatment preventsdisability


15

2. Examine the skinIn order to carry out a complete examination,the whole body must be looked at. Tell theclient what you are going to do, and find aprivate room with good light. Examine theskin from head to toe - on the front and theback of the body.

You are looking for any skin patches. Leprosypatches are usually lighter than thesurrounding skin, they may be reddish incolour and can have a raised edge. Leprosypatches are found in many shapes.

22>>>> BBiinniittüüEEss,,kkedIm,IGnuvtþkarBinitüeGay)aneBjelj eKRtUvBinitüemIlelIragkayTaMgmUl. sUmR)ab;GtifiCnnUvGIVEdlGñknwgeFIV ehIyrkbnÞb;dac;edayELkmYyEdlmanBnøWRKb;RKan;. RtUvBinitüemIlEs,kcab;BIk,alrhUtdl;cugeCIg - TaMgxagmux nigxageRkayénragkay.

GñknwgRtUvBinitürkemIlsñampÞa Mg²enAelIEs,k.CaFmµta sñampÞaMg²enAelIEs,kedaysarCMgWXøg;manlkçN³PøWCagEs,kEdlenACMuvijenaH eBalKWvaGacmanBN’Rkhm² nigGacmanEKmx<s;bnþic. sñampÞaMg²enAelIEs,kedaysarCMgWXøg;RtUv)aneKrkeXIjfamanRTg;RTayCaeRcIny:ag.

RKUeBTükMBugBinitürkemIlsñampÞaMgelIEs,krbs;GñkCMgWmñak;EdlsgS½yfamanCMgWXøg;Health staff examining the skin of asuspected leprosy patient to look for skinpatches


16

]TahrN_x øH²énsñamp Þ a MgenAelIEs,kk ñ úgC Mg WXøg ;

CaFmµta CMgWXøg;cab;epþImeLIgedaykarmansñampÞaMg²enAelIEs,k. sñampÞaMg²enAelIEs,kedaysarCMgWXøg;EtgEt ³

GacekItmanenARKb;EpñkénragkayelceLIgyWt²GacmanBN’esøk b¤RkhmGacFM b¤tUcminEmnmantaMgBIkMeNItmkenaHeTminrmas;KµankarQWcab;manlkçN³s¶ÜtmankarfycuHjaNdwg

Examples of leprosy skin patches

Leprosy usually starts as a patch on the skin.Leprosy skin patches usually:

can be in any part of the bodyusually appear slowlycan be pale or redcan be big or smallare not present from birthare not itchyare not painfulare dry to touchhave decreased feeling


17

b:uEnþ sUmcgcaMCanic©fa³ eK)anrkeXIjfa enAeBlxøH CMgWXøg;eFIVeGayEs,keLIgRkas; nigBMumansñampÞaMg²enAelIEs,keLIy. Es,kGacmanlkçN³PøWrelag nigs¶Üt. vaGacmanBN’RkhmCagEs,kEdlenACMuvij. enAeBlxøH CMgWXøg;bNþaleGaymanduMBktUc²enAelIEs,k. CaFmµta duMBktUc²TaMgenH CasBaØaénkarbgáeraKF¶n;F¶r.

But, always bear in mind that:Sometimes leprosy is seen as thickening of the skin and there are no skin patches. The skin can beshiny and dry to the touch. It may be redder than the surrounding skin. Leprosy sometimes causes nodules or lumps on the skin. They are usually a sign of a serious infection.

33>> eeFFIIVVeettssþþeeTTAAeellIIjjaaNNddwwggrrbbss;;EEss,,kk)ak;etrICMgWXøg; eFVIeGayjaNdwgmankarfycuH.GaRs½yehtuenH kareFIVetsþy:agsamBaØeTAelIjaNdwgrbs;Es,k RtUv)aneKeRbIR)as;sMrab;kareFIVeraKvinic½äy.

muneBlcab;epþImeFIVetsþenH RtUvbgðajR)ab;GñkCMgWnUvGIVEdlGñknwgRtUveFIV. sMueGayBYkeKbiTEPñkdUecñH BYkeKminGacemIleXIjfa Gñkb:HenARtg;kEnøgNaenaHeT. bnÞab;mk GñkRtUvb:HsñampÞaMg²enAelIEs,kenaHya:gRsal²edayeRbIeramstV b¤cugb‘íc b¤vtßúEdlmanlkçN³Rbhak;RbEhlKñaenH.

sMueGayGñkCMgWenaHcg¥úlR)ab;kEnøgEdlGñk)anb:HKat;.

eFIVetsþemIljaNdwgelIEs,kEdlmansñampÞaMg²nigelIEs,kEdlmanlkçN³Fmµta. GñkCMgWenaHGacmanCMgWXøg; RbsinebIKat;BM umanGarmµN_dwgTal;EtesaH enAeBlEdlGñk)anb:HsñampÞaMg²TaMgenaH. RbsinebImankar)at;bg;jaNdwg enaHGñkCMgWGacmanCMgWXøg;ehIy.

RbsinebIsñampÞaMg²enaHenAxñg b¤enAkEnøgEdlBi)akcg¥úlR)ab;RtUvsMueGayGñkCMgWrab;enAeBlBYkeKmanGarmµN_dwgfa Es,krbs;xøÜnRtUv)anb:Hmþg².RbsinebImankar)at;;bg;jaNdwg enaHBYkeKnwgrab;xuscMnYnkEnøgEdl)anb:HenA tMbn;TaMgenaH.

cMeBaHkarBinitüTaMgBIrEbbenH GñkKYrEtb:HEs,kedayBMumanlMnaMKMrUeLIy ehIypøas;bþÚrel,Ón nigkEnøgb:H.


18

3. Test the sensation of the skinLeprosy bacteria causes decreased sensation.Simple sensation tests are therefore used fordiagnosis.

Before starting, show the patient what you aregoing to do. Ask them to close their eyes, sothat they cannot see where you touch. Thenvery lightly touch the skin patch with a featheror tip of a pen, or similar object.

Ask the person to point to where you touchedthem.

Test the feeling in the skin patches, and in theskin that looks normal. If the person cannotfeel anything when you touch the patches, thepatient may have leprosy.

If there is a loss of sensation, thepatient may have leprosy.

If the patch is on the back or somewheredifficult to point to, ask the patient to counteach time they feel their skin is being touched.If there is loss of sensation they will misscounting those areas.

With both tests you should touch the skinwithout a pattern and vary your speed andplace.


19

4. Test the sweating of the skinBecause leprosy bacteria cause nerve damageto the nerves that control sweating, leprosyskin patches usually remain dry when thesurrounding skin sweats.

Explain this to the patient, and ask the patientto stand outside in the sun for a few minutes.When the skin has started to sweat, run afinger over the leprosy patch - is it dry ormoist? Leprosy patches are usually dry.

44>> kkaarrBBiinniittüüeemmIIllkkaarrEEbbkkeejjIIssrrbbss;;EEss,,kkedaysarEt)ak;etrICMgWXøg;bNþaleGaymankarxUcxatdl;srésRbsaTEdlRtYtBinitükarEbkejIseTIbsñampÞa Mg²enAelIEs,kedaysarC Mg WXøg ;EtgEtmanlkçN³s¶Üt enAkñúgxN³EdlEs,kenACMuvij mankarEbkejIs.

sUmBnül;bBaðaenHdl;GñkCMgW nigsMueGayGñkCMgWQrenAxageRkAbnÞb; enAkNþaléf¶ry³eBlBIrbInaTI. enAeBlEs,k)ancab;epþImEbkejIs sUmykRmamédsÞabelIsñampÞa Mg²Ta MgenaHemIlfaetIvas¶Üt b¤esIm? CaTUeTA sñampÞaMg²enAelIEs,kedaysarCMgWXøg; manlkçN³s¶Üt.

RbsinebIGñkCMgWmansñampÞaMg²enAelIEs,k minsUvEbkejIs nigmanjaNdwgfycuH sUmbBa¢ÚnKat;CabnÞan;eTAeGayGñkbnÞúkCMgWXøg;enARsukRbtibtþi edIm,IbBa¢ak;bEnßm nigpþl;fñaM MDT .

pþl;RbwkSadl;GñkCMgWGMBIsar³sMxan;énkarcab;epþImBüa)aledayfñaM MDT eGay)anqab;EdlGaceFIVeTA)an. pþl;karGb;rMGMBICMgWXøg; nigpþl;RbwkSaGMBIkarEfTaMedayxøÜnÉgeTAtamkMriténkar)at;bg;jaNdwg.

If the patient has skin patches, decreasedsweating and decreased sensation, refer themimmediately to the Operational District LeprosySupervisor for confirmation and prescription ofMDT.Counsel the patient on the importance ofgetting MDT as quickly as possible. Provideeducation about leprosy and counsel on self-care with regard to the level of loss ofsensation.

The disease is classified as paucibacillary ormultibacillary, depending on the bacillaryload.

1. Paucibacillary leprosy is a milder diseasecharacterized by few (up to five)hypopigmented, anaesthetic skin lesions(pale or reddish). It affects none or onlyone nerve trunk.

2. Multibacillary leprosy is associated withmultiple (more than five) skin lesions,nodules, plaques, thickened dermis or skininfiltration, and in some instances,involvement of the nasal mucosa, resultingin nasal congestion and epistaxis.Involvement of certain peripheral nervesmay also be noted, sometimes resulting inthe characteristic patterns of disability.


20

CMgWXøg;RtUv)anEbgEckCaRbePT Paucibacillary

(PB) b¤ Multibacillary (MB) Ep¥kelIbnÞúkemeraK.

1 > CMgWXøg;RbePT PB CaRbePTCMgWXøg;RsalEdlEsþgeLIgedaymansñampÞa MgBIrbIelIEs,k¬rhUtdl;5kEnøg¦manBN’x© In igs< wk¬esøksøaMgb¤RkhmeRBOg²¦. vaminb:HBal;dl;tYsrésRbsaTb¤b:HBal;dl;tYsrésRbsaTEtmYy

2> CMgWXøg;RbePT MB CaRbePTCMgWXøg;EdlmansñampÞaMgCaeRcInelIEs,k ¬eRcInCagR)aMkEnøg¦manduMBktUc² bnÞH² RsTab;Es,keLIgRkas; b¤CaMEs,k nigkñúgkrNIxøH mankarb:HBal;eTAnwgRsTab;PñasenAkñúgRcmuHEdlnaMeGaytwgRcmuHnighUrQamtamRcmuH. eKk¾GacsegáteXIjmankarb:HBal;eTA elIsrésRbsaTxageRkAmYycMnYnEdr EdlenAeBlxøH vabNþaleGayBikareTotpg.

ddMMeeNNIIrrkkaarréénnkkaarreeFFVVIIeerraaKKvviinniiccää½½yy Diagnosis Procedure

kar)at;bg;jaNdwgSensory Loss

CMgWXøg;Leprosy

mansñampÞaMgelIEs,krhUtdl;5kEnøg

Up to 5 skin lesions

mansñampÞaMgelIEs,keRcInCag5kEnøgMore than 5 skin lesions

CMgWXøg;RbePT PBPB Leprosy

CMgWXøg;RbePT MBMB Leprosy

mNÐlsuxPaB: BinitürksñamelIEs,kEdlRbhak;RbEhlnwgCMgWXøg; nigeFIVetsþrkkar)at;bg;jaNdwgHealth Centre: Look for lesions comparablewith leprosy and test for sensation loss

GñkTTYlbnÞ úkCMgWXøg;enARsukRbtibti þ:eFIVeraKvinic½äyOperational District LeprosySupervisor: Diagnose

EbgEckRbePTtamlkçN³KøInikClassify


21

karEbgEck Classification Paucibacillary (PB) Multibacillary (PB)

sñamelIEs,k ¬rYmTaMgsøaksñamG uc²dUcG utsVay BgRkhmelIEs,k nigduMBktUc²¦

• BI1 dl; 5kEnøg • ekIteL IgedayminsIu emRTIKña

• )at;bg;jaNdwgTaMgRsug

• eRcInCag5kEnøg • ekIteL IgedaysIuemRTIKña • )at;bg;jaNdwg

Skin lesions (includes macules -flat lesions, papules-raised lesions and nodules)

• 1-5 lesions • asymmetrically

distributed • definite loss of sensation

• more than 5 lesions • distributed more • symmetrically • loss of sensation

karxUcsrésRbsaT ¬EdlnaMeG aymankar)at;bg;jaNdwg b¤ exSaysac;dMuEdlTTYlbBa¢aB I srésRbsaTEdl)anxUcxat¦

• Kµanb¤mantYsrésRbsaT EtmYyKt ;

• tYsrésRbsaTCaeRcIn

Nerve damage (resulting in loss of sensation or weakness of muscles supplied by the affected nerve)

• none or only one nerve trunk

• many nerve trunks

mnÞIrB iesaFn _

• minGacrkeXIj M. Bacterium

• M. Bacterium RtUv)anrkeXIj

Laboratory No M. Bacterium can be seen

M. Bacterium can be seen and identified.

kkaarrsseeggççbbGGMMBBIIkkaarrEEbbggEEcckkRRbbeePPTTCCMMggWWXXøøgg;;Summary of classification

kMeb:HKUfCakEnøgEdleRcInEtmansñampÞaMg²énCMgWXøg;. dUecñHkMuePøcBinitüenAkEnøgenHenAeBleFVIeraKvinicä½y nigeFVIkarEbgEckRbePTCMgWXøg;. sUmcgcaMkarrkSakarsMgat;enAeBlBinitü.The bottom is a common site for leprosy skin patches - sodon’t forget to examine during diagnosis and classification!Remember about confidentiality during examinations!


22

er aKv in ic ½ äyepSg²B IK ñ aeroberogeday³ Dr. Sally Duke, CIOMAL

CYnkal kareFVI skin smear GacCYybBa¢ak;bEnßmeTAelIkareFIVeraKvinic½äyrkCMgWXøg;)an CaBiessenAeBlmaneraKsBaØaminc,as;las; dUcCa krNImanCaMEs,k b¤duMBktUc²enAelIEs,kenaH.

enAqñaMenH GñkTTYlbnÞúkCMgWXøg;enARsukRbtibtiþd¾Qøasévmñak; )aneFIVeraKvinic½äyGñkCMgWXøg;mñak;EdlkalBImunKat;RtUv)aneKR)ab;fa Kat;manEtCMgWpSitenAEs,kEtb:ueNÑaH. bursenHmanCMgWTaMgBIrya:genH. vaBMuR)akdeTfa etIbursenaHRtUv)aneFIVeraKvinicä½yRtwmRtUvEdrb¤eT rhUtTal;EtGñkTTYlbnÞúkCMgWXøg;enaH)aneFIVetsþeTAelIjaNdwgenARKb;sñampÞaMgelIEs,kTaMgGs;. cUrcgcaMfa GñkRtUvEteFIVetsþemIljaNdwgrbs;RKb;sñampÞaMgelIEs,kTaMgGs;.

ggWWEEss,,kkCCaabbBBaa ðð aaEEddlleekkIIttmmaannCCaajjwwkkjjaabb;;eennAAkkññúúggRRbbeeTTsskkmm<<úúCCaa.. ssßßaannPPaaBBEEss,,kkeennAA

kkññ úúggCCMMggWWXXøøgg;;GGaaccmmaannllkkççNN³³ddUUccKKññaaeeTTAAnnwwggllkkççNN³³EEss,,kkéénnCCMMggWWEEss,,kkeeppSSgg²²eeTToott eehhIIyyllkkççNN³³EEss,,kkéénnCCMMggWWEEss,,kkeeppSSgg²²eeTToottkk¾¾GGaaccmmaannllkkççNN³³ddUUccssßßaannPPaaBBEEss,,kkkkññúúggCCMMggWWXXøøgg;;EEddrr..

CYnkal CMgWXøg;GacmansñamCaM² b¤duMBktUc² nigGacKµankar)at;bg;jaNdwgBitR)akdeT dUecñH GñkRtUvEtyl;fa CMgWXøg;GacEsþgecjCaeraKsBaØaepSg²CaeRcIn.

vamansar³sMxan;Nas;kñúgkarBinitüEs,k nigsrésRbsaTeGay)anhµt;ct;.

RbsinebIGñkmankarsgS½y sUmsaksYrGñkTTYlbnÞúkCMgWXøg;rbs;Gñk b¤Rkumfñak;Cati.

eyIgRtUvcgcaMfamnusSmñak;GacmanbBaðaEs,keRcInya:gkñúgeBlEtmYy. RbsinebIGñkminR)akdeTsUmeFVIkartamdanGñkCMgWenaH b¤RtUvbBa¢ÚnKat;.

RtUveFVIetsþrkjaNdwgenAsñampÞaMgelIEs,kCanic©.kareFVIetsþenHGacCYy[GñkdwgfaGñkCMgWmanCMgWXøg;b¤eT.


23

Differential Diagnosis By Dr Sally Duke, CIOMAL

Skin conditions are very common inCambodia.Leprosy can look likemany other skin conditions and other

skin conditions can look like leprosy.

Sometimes leprosy can be infiltrative ornodular and may not have defined sensory lossand so you must be aware that leprosy canpresent in many different ways.

It is very important to make a thoroughexamination of skin and nerves.

If you are in doubt then ask your leprosysupervisor or National team.

Sometimes a skin smear can help confirm thediagnosis of leprosy particularly when thesigns are unclear like in the more infiltrativeor nodular types.

This year a clever operational districtsupervisor diagnosed a patient with leprosywho had previously been told he just had afungal infection. This man had both! It wasnot until the supervisor tested all skin lesionsfor sensation that he was correctly diagnosed.

These are just a few commonly confusedlesions

Vitiligo: Unlike leprosy, sensation will be normalin the lesion and when fully developed itwill have complete depigmentationSkin lesions themselves are not harmful.This is thought to be an autoimmunedisorder

Tinea / pityriasis versicolor:Common skin disease caused by yeastCharacterized by superficial pigmentedscaly irregular patches often on the trunkand neck. The patches are normally asymtomatic.The sensation will be normal.Treat with topical antifungal or anti-dundruff shampoo (selenium sulphide).

Tinea corporis:Caused by a fungal infectionCan look like leprosy patches but areusually itchy and will have normalsensation.Treat with topical antifungal

Psoriasis:Chronic disease that is not infectious.Usually plaques with shiny silvery scaleson the surface. The removal of the scales may revealsmall bleeding points. The lesions are usually itchy. Sensation is normal

Remember that people may have morethan one skin condition. If you are notsure then make sure you follow -up thepatient or refer.

Always test sensation in skin lesions. Itwill help you know whether the patienthas leprosy or not!


24

xageRkamenH KWRKan;EtCaCMgWesIrEs,kxøH²EdleRcInEtnaMeGaymankaryl;RclMCMgWXøg;el<A (Vitiligo):

miindUcCMgWXøg;eT³ sñamEs,kenAmanjaNdwgCaFmµta ehIyenAeBlva)anvivtþn_eBjelj vanwgmankar)at;bg;BN’sMburEs,kBIkMeNItTaMgRsugBMumanviFIBüa)aleT ehIyenAkEnøgEs,kEdlmanbBaðaenaHKµankarxUcxatCMgW wenHRtUv)aneKKitfabNþalmkBIPaBminRbRktIénsV ½yGgÁbdibkç

Tinea / Pityriasis Versicolor :

CMgWEs,kEdlekItmanjwkjab; EdlbNþalmkBIemeraKpSitmankarelcecjnUvsñampÞaMg²EdlmanBN’sMburminRbRktInigmanlkçN³CaRkm:resþIg² EdleRcInEtekItenAelIxøÜnnigksñampÞaMgEs,kTaMgenaHKµaneraKsBaØaeTenAkEnøgEs,kEdlmanbBaðamanjaNdwgCaFmµtaGacBüa)aledaykareRbIfñaMlabRbqaMgnwgemeraKpSit b¤eRbIsabUkk;sk;EdlRbqaMgnwgemeraKpSit

Tinea Corporis :

EdlbNþalmkBICMgWpSitGacmanlkçN³dUcsñampÞaMg²kñúgCMgWXøg;Edr b:uEnþCaFmµtavaeFIVeGayrmas; ehIyEs,kEdlbBaðaenaH enAmanjaNdwgCaFmµtaGacBüa)aledaykareRbIfñaMlabRbqaMgnwgemeraKpSit

Psoriasis :

CMgWraMuér:Edlminqøgdl;GñkdéTCaFmµtaCaRsTab;Rkm:reRkom²PøWrelagdUcR)ak;enAépÞxagelIkarykRkm:recj GacbgðajeGaymancMnuchUrQamtUc²EtgEtrmas;enAkEnøgEs,kEdlmanbBaðaenaHEs,kEdlmanbBaðamanjaNdwgCaFmµta.

Vitiligo

Tinea Corporis

Psoriasis

Tinea / Pityriasis Versicolor


44

KK))aannKKiittffaaRRbbmmaaNN2255%éénnGGññkkCCMMggWWXXøøgg;;EEddllBBMMuu))aannBBüüaa))aalleennAAddMMNNaa kk;;kkaallddMMbbUUggéénnCCMMggWWeennHH

eekkIIttmmaannPPaaBBss<<wwkkRRssBBnn;; nniigg¼¼bb¤¤mmaannkkaarrxxUUccRRTTgg;;RRTTaayyRRbbGGbb;;éédd bb¤¤RRbbGGbb;;eeCCIIgg.. bbBBaaððaaBBiikkaarrPPaaBBPPaaKKeeRRccIInnkkññ úúggccMMeeNNaammGGññkkCCMMggWWXXøøgg;;))aanneekkIItteeLLIIgg BBIIeeRRBBaaHHttYYssrrééssRRbbssaaTT ))aannTTTTYYllrrggppllbb::HHBBaall;;eeddaayyssaarrCCMMggWWeennHH.. CCaajjwwkkjjaabb;; ssrrééssRRbbssaaTTEEddllmmaanneennAARRbbGGbb;;éédd RRbbGGbb;;eeCCIIgg nniiggEEPPññkkRRttUUvv))aannTTTTYYllrrggppllbb::HHBBaall;;..ddUUeeccññHH EEppññkkTTaaMMggeennHHEEttggEEttCCaakkEEnnøøggEEddllrrggrrbbYYss nniiggxxUUccRRTTgg;;RRTTaayy EEddllbbNNþþaalleeGGaayymmaannBBiikkaarrPPaaBB..CCaaTTUUeeTTAA ttYYssrrééssRRbbssaaTTEEddll))aannTTTTYYllrrggppllbb::HHBBaall;;eeddaayyssaarrCCMMggWWXXøøgg;;RRttUUvv))aannbbggððaajjeennAAkkññúúggrrUUbbPPaaBB..

C Mg WX øg ; n igB ikarPaB eroberogeday³ TsSnavdþIsuxPaB

smasPaBént YsrésRbsaT

tYsrésRbsaT KWCasrésRbsaTcMruH. tYsrésRbsaTman)ac;srésRbsaTEdlbBa¢aEs,k nigsac;dMu. srésRbsaTTaMgenH KWCaGñkbBa¢Únsarb¤sBaØaepSg²³1 > BIEs,keTAxYrk,al EdleFVI[Es,kGacman

jaNdwg.2> BIxYrk,aleTARkeBjejIs enAkñúgEs,keday

CMruj[RkeBjejIsTaMgenHdMeNIrkar nigeFIV[Es,kesIm ehIyTn;.

3 > BIxYrk,aleTAsac;dMu edayCMrujeGaysac;dMudMeNIrkar.

tYsrésRbsaTFmµtaA normal nerve trunk


45

Leprosy and Disability By Health Messenger

Composition of nerve trunks

Nerve trunks are mixed nerves. They carrynerve fibers which supply the skin and themuscles. These fibers convey messages orsignals: 1. From the skin to the brain, providing the

ability to feel sensations in the skin2. From the brain to the sweat glands in the

skin, stimulating these glands to functionand keep the skin moist and supple

3. From the brain to the muscles, stimulatingthe muscles to function.

It is thought that approximately 25% ofpatients who are not treated at an earlystage of the disease develop anaesthesia

and/or deformities of the hands or feet.Most disability problems in leprosy patientsoccur because the nerve trunks are affectedby the disease. The nerves supplying thehands, feet and eyes are frequently affected.Thus, these parts are often the sites ofimpairments and deformities, which causedisability. The nerve trunks commonlyaffected in leprosy are shown in the picture.

srésRbsaTemDIy:g;Median nerve

kEn§cemédmin)anLoss of thumb opposition

srésRbsaTKuybÍtal;Ulnar nerve

Rkj:g;RmamédClaw fingers

srésRbsaTr:aDIy:al;Radial nerve

Føak;kédDrop wrist

srésRbsaTsuIy:aTikPeroneal nerve

Føak;RbGb;eCIgDrop foot

srésRbsaTTIbÍy:al;Tibial nerve

Føak;RmameCIgClaw toes

srésRbsaThVasüal;Facial nerve

biTEPñkminCitLagophthalmos


46

Effects of damage to nerve trunks

When a nerve trunk is damaged at a particularsite, messages do not pass across the damagedsite. This means that the normalcommunication between the brain and an areaof skin as well as a group of muscles isinterrupted.

This results in:

1. Impairment of sensibility over the area ofskin supplied by the nerve trunk, becausemessages from the skin do not reach thebrain.

2. Dryness of the skin, because messagesfrom the brain do not reach the sweatglands.

3. Weakness or paralysis of the musclessupplied by the nerve trunk and paralyticdeformities, because messages from thebrain do not reach the muscles.

\T § iBlénkarx Ucxatdl;t YsrésRbsaT

enAeBltYsrésRbsaTmankarxUcxatenAkEnøgCak;lat;NamYy sarBMuGacbBa¢Únqøgkat;tamkEnøgEdlxUcxatenaH)aneLIy. enHmann½yfa TMnak;TMngFmµtarvagxYrk,al nigEs,k RBmTaMgsac;dMumYycMnYn RtUv)ankat;pþac;.krNIenHbNþaleGayman³1 > karxUcxatdl;jaNdwgenAelIépÞEs,kEdl

bBa¢aedaytYsrésRbsaTenaH BIeRBaHsarBIEs,kmin)aneTAdl;xYrk,aleLIy.

2> Es,ks¶Üt BIeRBaHsarBIxYrk,alBMu)aneTAdl;RkeBjejIseLIy.

3 > karcuHexSayb¤xVinsac;dMuEdlbBa¢aedaytYsrésRbsaTenaH nigkarxUcRTg;RTayedaykarxVin BIeRBaHsarBIxYrk,alBMu)aneTAdl;sac;dMuTaMgenaH.

tYsrésRbsaTEdlxUcxatA damaged nerve trunk


47

Impairment of sensibility Sensibility is the ability to feel sensation in theskin. When a nerve trunk is damaged, thisability is altered, giving rise to:

Abnormal sensations, e.g. burningsensations, numbness and tingling Dryness of the skin supplied by the nerveLoss of sensibility or inability to feel in theaffected skin

Muscle weakness and paralytic deformity When a nerve trunk is damaged, the nervesupply to the muscles may also be affected,usually some time after the supply to the skinis affected. The muscles initially become weakand later paralysed, giving rise to paralyticdeformities.

Joints are normally held in balance by theforces produced by the muscles around thejoint. Paralysis of some muscles upsets thisbalance of forces causing these joints to moveinto new positions. These new positions of thejoints are seen as deformities.

kkaarrxxUUccjjaaNNddwwggjaNdwg KWCasmtßPaBEdlEs,kGacmanGarmµN_dwg. enAeBltYsrésRbsaTmYyRtUv)anbMpøajsmtßPaBenHRtUv)anxUcxatehIynaMeGayman³

jaNdwgminRbRktI ]TahrN_ manGarmµN_ekþAeral PaBs<wk nigmanGarmµN_QWeqob².PaBs¶ ÜténEs,kEdlbBa¢aedaytYsrésRbsaTEdlxUcenaH.kar)at;bg;jaNdwg b¤GsmtßPaBkñúgkardwgenAkEnøgEs,kEdlxUcxatenaH.

kkaarreexxSSaayyssaacc;;ddMM uu nniiggkkaarrxxUUccRRTTgg;;RRTTaayyeeddaayyssaarrkkaarrxxVViinnenAeBltYsrésRbsaTmYyRtUv)anbMpøaj enaHsrésRbsaTEdlbBa¢aeTAsac;duMk¾RbEhlCaTTYlkarxUcxatEdr enABlNamYybnÞab;BIkarbBa¢aeTAsac;duMenaHRtUv)ankat;pþac;. CadMbUg sac;dMu)ancuHexSay bnÞab;mkeTACaxVin ehIybNþal[eTACamankarxUcRTg;RTayedaysarkarxVin.

CaFmµta snøak;q¥wgmanlMnwgedaysarkMlaMgrbs;sac;dMuEdlenACMuvijsnøak;q¥wgenaH. karxVinsac;dMuxøH)anb:HBal;dl;kMlaMglMnwgenH ehIyeFVI[snøak;q¥wgenHgakeTArksßanPaBfµImYy. sßanPaBfµIénsnøak;q¥wgenHehIy EdleyIgemIleXIjfaCakarxUcRTg;RTay.

Laterial planternerve

Medial planternerve

Calcaneal nerve

Ulnar nerve

Median nerveRadialnerve

kEnøgénkar)at;bg;jaNdwgenA)atéd nigxñgédkñúgkrNIxUcsrésRbsaTSite of sensory loss in palm and sole in thecase of damage to nerves


48

karxUcxatepSg²eToteRkayBIxUctYsrésRbsaTOther impairments following nerve trunk damage

kareRbH nigdMe)AEdlKµankarQWcab;³ Es,kFmµtamansMeNImCanic©edaysarkarEbkejIs. Es,kFmµtamanlkçN³Tn;CagEs,ks¶Üt ehIyEs,ks¶ÜtmanlkçN³puyRsYyCagEs,kFmµta. Es,kEdls¶Üt gaydac;rEhkenAkEnøgEdlbt;cuHbt;eLIg ehIybegáIt)anCakareRbHEs,k.Es,kEdlKµanjaNdwg BMumanGarmµN_QWcab;eLIyenAeBlvargrbYsGaRs½yehtuenH rbYsenaHEtgEt minRtUv)anykcitþTukdak;. kareqHrlakkarmut nigdMe)AepSg²eTotEdlekIt eLIgenARbGb;édnigRbGb;eCIgEdlKµanjaNdwg EtgEtmin)anykcitþTukdak;edaysarEtmUlehtuenHÉg.Cracks and painless wounds: Normal skin keeps moist by sweating.Dry skin is less supple and more brittle than normal skin. The brittle,dry skin breaks where it is repeatedly bent and straightened, and askin crack develops. Unfeeling skin does not feel pain when it isinjured, therefore the injury is always neglected. Burns, cuts and otherwounds occurring in unfeeling hands and feet are often neglected forthe same reason.

dMe)ArlYyenA)ateCIg³ edaysarGñkCMgWKµanGarmµN_QWcab; eTIbdMe)AnigkareRbHEs,kminRtUv)anykcitþTukdak;nigKµankarCasHes,Iy. pÞúyeTAvijvakøay eTACadMe)ArlYy. dMe)ArlYyk¾GacekItedaysarkarsgát;xøaMg²nigdEdl² eTA elIEpñkNamYyénRbGb;eCIg b¤RbGb;édEdlKµanjaNdwg.cMeBaHRbGb;eCIg karsgát;xøaMghYsehtuTaMgenH ekIteLIgenAeBledIr.dMe)ArlYyRbePTenH eRcInekItmanjwkjab;bMputenA)ateCIg.Plantar ulcers: As the patient does not feel pain, the wounds andcracks are neglected and they do not heal. Instead, they becomeulcers. Ulcers may also arise because of repeated excessivepressure over certain parts of an unfeeling foot or hand. In the foot,these excessive pressures occur during walking. This kind of ulcer isseen most often on the sole of the foot.

kardac;Rmam (Rmaméd nigRmameCIg)³ CalikaGacmankarxUcxat b¤RtUv)anbMpøajedaykarbgáeraK b¤karmanrbYsEdlnaMeGayRmamTaMgenaHdac;. Shortening of digits (toes and fingers): Tissues may be damaged ordestroyed by infection or injury leading to shortening of the digits.

karrwgsnøak;q¥wg³ enAeBlCalikaEdlxUcxatedaysarkarrgrbYsb¤karbgáeraKCasHes,Iy vanwgbegáIt[mansmøakmYycMnYn. smøakEdlenACitsnøak;q¥wgnig smøakEdlTak;TgeTAnwgsrésBYr raraMgclnarbs;snøak;q¥wgehIysnøak;q¥wg enaHk¾køayeTACarwg. Joint stiffness: Tissues damaged by injury or infection heal with theformation of scars. Scars located close to joints and those that involvetendons prevent joint movement and the joint becomes stiff.


49

kkaarrkkMMNNtt;;kkMMrriittBBiikkaarrPPaaBBDisability grading

vamanGtßRbeyaCn_Nas;kñúgkarvaytMélBikarPaBEdlGñkCMgWmñak;man enAeBlcab;epþImeFIVkarBüa)alnigkñúgeBlBüa)al.RbB½n§kMNt;kMritBikarPaBEdlRtUv)aneRbIR)as;jwkjab;CageK ¬karkMNt;kMritBikarPaBrbs;GgÁkarsuxPaBBiPBelak¦ KWmanenAkñúgtaragxageRkam ³It is very useful to assess the disability that a person has at the start of treatment and then later duringtreatment. The most widely used grading system (the WHO Disability Grading) is in the following table.

KMrit 0

Grade 0 KMrit 1

Grade 1 KMrit 2

Grade 2 EP ñk Fmµta EP ñkRkhm kar)at;bg;jaNdwg

enARKab;EP ñk ¬Gacrab;RmamédenA cMgay6Em:Rt)an¦

emIlminsUveXIj ¬minGacrab;Rmaméd enAcMgay6Em:Rt)aneL Iy¦. minGacbiTEP ñkCitTaMgRsug.

Eyes Normal Red eyes, loss of feelin g in the eyeball (able to count fingers at 6 meters)

Reduced vision (unable to count fingers at 6 meters). Lagophtalmos.

RbGb;éd Fmµta kar)at;bg;jaNdwgenA)atéd karxUcxatCak;EsþgenARbGb;éd dUcCa dMe)A Rkj:g;RbGb;éd b¤mankar)at;bg; Calika

Hands Normal Loss of feeling in the palm of the hand Visible damage to the hands, such as wounds, claw hand, or loss of tissue.

RbGb;eCIg Fmµta kar)at;bg;jaNdwgenA)ateCIg karxUcxatCak;EsþgenARbGb;eCIg dUcCa dMe)A kar)at;bg;Calika b¤Føak;RbGb;eCIg

Feet Normal Loss of feeling in sole of the foot Visible damage to the foot, such as wounds, loss of tissue, or drop foot.

vtþmanénkarxUcxatTaMgenH bnÞab;BIGñkCMgWXøg;mñak;)anTTYlBüa)al minEmnmann½yfakarBüa)alenaHKµanRbsiTi§PaBenaHeT b¤k¾minEmnmann½yfaGñkCMgWenHGaccMlgemeraKXøg;dl;GñkdéTeTot)aneLIy. enHKWCakaryl;RclMmYyEdlekIt manCajwkjab;.RbCaCneyIgGacmankarP½yxøacedayyl;RclMminh‘anb:H sÞab b¤Büa)alGñkEdlmandMe)ArlYy b¤manrbYseRBaHBYkeKKitfaGñkenaHGac qøgCMgWXøg;BIdMe)AEdlmanmuxcMhenaH. The presence of these impairments after someone has been treated for leprosy does not mean that thetreatment has not been effective nor does it mean that this person is contagious. This is a commonmisconception. People can be mistakenly afraid of touching or treating people with ulcers or injury as theythink they may catch leprosy from the open wounds.


50

mUlehtuepSg²eTotEdlbNþal[manCMgW Neuropathic foot

Neuropathy KWCaCMgWEdlb:HBal;eTAelIsrésRbsaTmanmUlehtuCaeRcInEdlbNþal[manCMgW Neuropathic foot. eTaHbICamUlehtuGIVk¾eday k¾mnusSeyIgnwgRbQmmuxnwgbBaðadUcKñakñúgkarrgrbYs nigkarekItmandMe)ArlYyenARbGb;eCIg BIeRBaHkarQWcab;CYykarBareyIgBIkarrgrbYs.

GIVEdlGñk)anyl;dwgBIkñúgGtßbTsþIGMBIkarEfTaMCMgW neuropathic foot rbs;mnusSEdlmanCMgWXøg; k¾GaceRbIR)as;)ancMeBaHmnusSEdlmanCMgW neuropathy edaysarmUlehtuepSgeTotEdr.

CMgW neuropathy edaysarCMgWTwkenamEp¥m kMBugekItmanCajwkjab;enAkñúgRbeTskm<úCa. \LÚvenH enAkñúgRbeTsxøHCMgWenHKWCamUlehtujwkjab;bMputEdlbgáeGaymandMe)ArlYyenARbGb;eCIg nigkarkat;eCIg. TMrg;jwkjab;CageKénCMgWneuropathy edaysarCMgWTwkenamEp¥m KWCamUlehtuénkar)at;bg;jaNdwg. srésRbsaTesIr²minrIkFMeT. eRkABIkarBüa)aldUcEdl)anbgðajenAkñúgGtßbT karEfTaMedayxøÜnÉg karRtYtBinitüCatisárenAkñúgQamk¾mansar³sMxan;Edr.RtUvBinitüemIlkMritCatisárkñúgQamenAeBlRBwk RbsinebIGñkKitfaGñkCMgWGacmanCMgWTwkenamEp¥m.

mUlehtuepSg²eTotEdlGacbNþaleGaymanCMgW neuropathic foot rYmman³ Hereditary sensory neuropathy,

amyloidosis, emeraKeGds_ karexSaytMrgenamruaMér: kareRbIfñaMepSg² GñkpwkRsaeRcIn karxVHCIvCati B-complex

sMN b¤karBuledayCatiGaesnik.

Other Causes of a Neuropathic FootNeuropathy - a disease affecting the nerves

There are a number of other causes of a neuropathic foot.Whatever the cause, people will face the same problem of footinjury and ulceration because pain helps protect us from injury.

What you learn in this article about the care of the neuropathicfoot in people who have had leprosy can be also applied topeople who have neuropathy from other causes.

Diabetic neuropathy is becoming more common in Cambodia. Insome countries it is now the most common cause of footulceration and amputation. The most common form of diabeticneuropathy is the distal symmetrical “glove and stocking” patternof sensory loss. The peripheral nerves are not enlarged. Inaddition to the treatment outlined in the following articles on self-care, blood sugar control is also important. Check someone’sfasting blood sugar level if you think they may have diabetes.

Other possible causes of neuropathic feet include: hereditarysensory neuropathies, amyloidosis, HIV, chronic renal failure,medications, alcohol, vitamin B-complex deficiency, lead orarsenic poisoning.


51

MMggWWXXøøgg;;GGaaccCCaaCCMMggWWEEddllbbggáá[[mmaannBBiikkaarrPPaaBB..ddUUeeccññHH eeRRkkAABBIIkkaarrbbBBaaÄÄbb;;kkaarrccMMllggeemmeerraaKK M.

Leprae nniiggkkaarrBBüüaa))aallGGññkkCCMMggWWXXøøgg;;[[CCaakkmmµµvviiFFIIRRbbyyuuTT§§nnwwggCCMMggWWXXøøgg;;RRttUUvvEEtteeppþþaatteeTTAAeellIIkkaarrkkaatt;;bbnnßßyyBBiikkaarrPPaaBB.. ddUUeeccññHHkkaarrbbggááaarrBBiikkaarrPPaaBBKKWWCCaaeeKKaallbbMMNNggyy::aaggssMMxxaann;;mmYYyyeennAAkkññúúggRRKKbb;;kkmmµµvviiFFIIRRbbyyuuTT§§nnwwggCCMMggWWXXøøgg;;..

BikarPaB KWCamUlehtuEdlbNþal[mankarRBYy)armÖya:gxøaMgkñúgbBaðaCMgWXøg; BIeRBaHvaGacnaM[mankarQWcab;xagrUbragkay pøÚvcitþ nigesdækic©-sgÁm dl;GñkCMgWnigRkumRKYsarrbs;BYkeK.

b:uEnþ eyIgGackat;bnßybBaðaTaMgGs;enH)an tamry³viFankarsamBaØ² EdlGñkCMgWGacGnuvtþ)anedayxøÜnÉg.

karbg á arB ikarPaBrbs;G ñkC Mg WX øg ; dkRsg;BI “Essential Action to Minimise Disability in Leprosy Patients, by Jean M. Watson”

smasPaKk ñ úgkarbg á a rB ik a rP aB

karbgáarBikarPaB GacsMerc)aneCaKC½ytamry³karbgáarkarxUcxat nigBikarPaB RBmTaMgkarbgáarmin[BikarPaBmansPaBkan;EtF¶n;F¶reLIg².

11>> kkaarrbbggááaarrkkaarrxxUUccxxaatt nniiggBBiikkaarrPPaaBBkic©GnþraKmn_nanaEdlepþateTAelIkarbgáarBikarPaBfµI²eTot b¤karxUcRTg;RTayepSg²EdlBMuTan;ekItmanenAeBlEdlCMgWXøg;RtUv)aneFIVeraKvinicä½y.karqab;rkeXIjCMgWTan;eBlevla nigkarBüa)alRtwmRtUvEdlRbkbedayRbsiTi§PaB KWCaviFankard¾manRbsiTi§PaBbMputkñúgkarbgáarBikarPaB. b:uEnþ edaysarGñkCMgWxøHGacekItmankar)at;bg;jaNdwgnigxUcxatkMlaMgclkrkñúgeBlfµI²eTotenAkñúgeBl b¤bnÞab;BIkarBüa)aleday MDT dUecñHkarqab;rkeXIjRbtikmµ nigkarxUcdMeNIrkarrbs;srésRbsaT)anTan;eBlevla RBmTaMgkarBüa)alCabnþbnÞab; k¾mansar³sMxan;Nas;Edr.

22>> kkaarrbbggááaarrmmiinn[[BBiikkaarrPPaaBBmmaannssPPaaBBkkaann;;EEttFF¶¶nn;;FF¶¶rreeLLIIggEEffmmeeTToottkic©GnþraKmn_nanaEdlepþateTAelIkarbgáarmin[BikarPaB b¤karxUcRTg;RTayEdlmanRsab;enAeBlCMgWXøg;RtUv)aneFIVeraKvinicä½y mansPaBkan;EtF¶n;F¶reLIg². RKb;GñkCMgWTaMgGs;EdlmankarxUcxatxøH² KYr)anTTYlkarGb;rMGMBIv iFIedIm,Ibgáarmin[karxUcxatEdlmanRsab;kan;EtxUcxatxøaMgeLIg.

karbgáarBikarPaBtamry³karkarBarRbGb;eCIgPrevention of disability through protectingthe feet

TsSnavdþIsuxPaB elx25 | ExFñÚ qñaM2005Health Messenger Issue 25 | December 2005TsSnavdþIsuxPaB elx25 | ExFñÚ qñaM2005Health Messenger Issue 25 | December 2005

52

Prevention of Disability in Leprosy Patients Adapted from Essential Action to Minimise Disability in Leprosy Patients, by Jean M. Watson

2. Prevention of worsening of disability(POWD)Interventions that are aimed at preventing theworsening of disabilities or deformitiesalready present when the disease is diagnosed.All patients with impairments should betaught methods to prevent further impairmentsand residual impairments.

Leprosy can be disabling disease.Hence, besides interrupting thetransmission of M. leprae and curing

patients, control programmes must aim atminimising disability. Prevention ofdisability is therefore a key objective in anyleprosy control programme.

Disability is cause of great concern in leprosy,because it can bring physical, psychologicaland socio-economic suffering to patients andtheir families.

It is possible to minimise these problemsthrough simple measures which can beundertaken by the patient themselves.

Components of prevention of disability(POD):

Prevention of disability can be achieved byprevention of impairments and disabilities(POID) and prevention of worsening ofdisabilities (POWD).

1. Prevention of impairments and disability(POID)Interventions that are aimed at preventing theoccurrence of a new disability or deformitynot already present at the time when thedisease is diagnosed.

Early case detection and effectiveappropriate treatment are the mosteffective measures to prevent disability.

But since some of the patients will developnew sensory and motor impairments during oreven after MDT, early detection of reactionsand nerve function impairment andsubsequent treatment are also of vitalimportance.

karbgáarBikarPaBtamry³karEfTaMedayxøÜnÉgd¾l¥Prevention of disability through good self-care


53

karEfrkSakarBard MeNIrkarrbs;srésRbsaT

ral;GñkCMgWTaMgGs;Edl)aneFIVeraKvinicä½yfamanCMgWXøg; KYryl;GMBIkarEdlGacmankarb:HBal;dl;srésRbsaT nigKYr)anTTYlkarGb;rM edIm,IsÁal;GMBIsBaØadMbUg²énPaBminFmµtaéndMeNIrkarrbs;srésRbsaTdUcCa karQWRsekor²enAsrésRbsaT karERbRbYlEpñkjaNdwg ¬kar)at;bg; karQWcab;dUccak;nwgm¢úlRBmTaMgkarRkhay¦ b¤karcuHexSayénsac;dMu. GñkCMgWKYrRtUv)anBinitüy:aghµt;ct;Ep¥ksrésRbsaT erogral;6ExmþgedayGñkTTYlbnÞúkEpñkCMgWXøg; ehIyKYrRtUv)anBinitüedaybuKÁlikCMnajerogral;3Exmþgya:gtic.

Preservation of nerve function

All patients who have been diagnosed with leprosy should be aware of the possible involvementof nerves and taught to recognize the early signs of nerve dysfunction such as tender nerves,sensory changes (loss, pins and needles, burning) or muscle weakness. The patient should bethoroughly examined neurologically every 6 months by the OD leprosy supervisor and seen bya health professional at least every 3 months.

kareFVIetsþemIldMeNIrkarminFmµtarbs;srésRbsaT nigkMlaMgsac;duMrbs;GñkCMgWXøg;Testing nerve dsyfunction and muscle strength in leprosy patients


KKbb;;GGññkkCCMMggWWXXøøgg;;TTaa MMggGGss;;KKYYrrRRttUUvv))aannBBiinniittüüyy::aaggllMMGGiitteeTTAAeellIIssrrééssRRbbssaaTT eennAAeeBBll

eeFFVVIIeerraaKKvviinniiccää½½yy eerrooggrraall;;66EExx (CCMMggWWXXøøgg;;RRbbeePPTT PB nniiggMMMB) nniiggeerrooggrraall;;1122EExx (CCMMggWWXXøøgg;;RRbbeePPTT MB EEttbb::uueeNNÑÑaaHH).. RRttUUvvkktt;;RRttaakkaarrBBiinniittüüeennHHeennAAkkññúúggkkaattrrbbss;;GGññkkCCMMggWW..

RKb;GñkCMgWTaMgGs;KYrRtUv)anbeRgonGMBIeraKsBaØadMbUgéndMeNIrkarminFmµtarbs;srésRbsaT nigRbtikmµ edIm,I[BYkeKGacqab;RtLb;mkBinitüeLIgvij.

buKÁlikmNÐlsuxPaBGac)anCYbGñkCMgWy:ageTogTat; enAeBlBYkeKmkebIkfñaM MDT nigmkkñúgbMNgepSgeTot. dUecñH buKÁlikmNÐlsuxPaBedIrtYnaTIy:agsMxan;kñúgkarRsavRCavrkeraKsBaØadMbUgEdlTak;TgnwgsrésRbsaT nigvaytMélktþaRbQmmuxnwgBikarPaBrbs;GñkCMgW.

k a r v ayt M élkt þ a RbQmm uxn wgB ik a rP aBeroberogeday³ TsSnavdþIsuxPaB

manetsþsamBaØ²xøHEdlGaceFVI)anenAmNÐlsuxPaB edImI,vaytMéldMeNIrkarrbs;srésRbsaT.

RbsinebIGñksgS½yfadMeNIrkarsrésRbsaTrbs;GñkCMgWNamñak; mansPaBkan;EtF¶n;F¶rRtUvbBa¢ÚnKat;eTAGñkTTYlbnÞúkRsukRbtibtþiCabnÞan;.

kareF I V etsþjaNdwgrbs;RbGb;édn igRbGb;eC Ig

enAelIrUbPaBRbGb;édnigRbGb;eCIgEdlmanenAkñúgkatrbs;GñkCMgW sUmKUscMNaMkEnøgEdlmandMe)A kEnøgeRbHEbkb¤RmamEdldac;.

Tb;RbGb;éd¼RbGb;eCIgrbs;GñkCMgW edIm,I[Rmaméd¼RmameCIgrbs;Kat;)anRTRtwmRtUvehIyminRtUvkMerIkenAeBleFIVetsþ.

eRbIcugb‘íc nigbBaÄrva[Rtg;eTAelI ehIyKUsfµm²enAelIEs,kCacMnucmYyEdlmanmuxkat;RbmaN1sgÞIEm:Rt. cMNucTaMgLayenAkñúgrUbPaBbgðajGñknUvkEnøgEdlRtUvKUs.

eFI VdUcenHenAkñ úgeBlGñkCMgWkMBugsMLwgemIlehIysMu[GñkCMgWeRbIRmamédmYycg¥ úlR)ab;kEnøgEdlcugb‘íc)anb:HEs,krbs;Kat;. R)ab;GñkCMgWkMu[mankarRBYy)armÖ RbsinebIKat;mindwgkEnøgEdlRtUv)anb:H.


54


55TsSnavdþIsuxPaB elx25 | ExFñÚ qñaM2005Health Messenger Issue 25 | December 2005

Hand and foot mapping sensation tests

On the hands and feet drawn on the patientcard, mark any wounds, cracks orshortening.

Support the patient’s hand/foot so that thefinger/toes are well supported and do notmove during the test.

Use a ballpoint pen and keeping it uprightgently indent the skin, making a dimple ofabout 1cm across.

Do this while the patient is watching andask him or her to point with one finger tothe place that the pen touches the skin. Tellthe patient not to worry if he or she doesnot feel a touch.

When the patient understands the test welland is pointing clearly, ask him or her tolook away and close his or her eyes.

Continue testing the sensation spots, butthis time be irregular in the timing andplacing of dents. In this way, the patientcannot guess when or where you willtouch next.

If the patient never points and seems not tofeel, try denting a part of his arm that hassensation. This will keep him interestedand encouraged, and will let you know heor she has not fallen asleep or given uptrying!

Each time you dent the skin, record it onthe hand or foot map. Put a TICK wherethe patient feels and points, and a X if thepatient does not feel or points somewhereelse.

Don’t take too long over the test or thepatient will become tired and careless. Ifthis happens, stop for a rest.

All leprosy patients should have adetailed examination of nervefunction at least at diagnosis, 6

months (PB and MB) and 12 months (MPonly). This should be recorded on thepatients clinical card.

Patients should always be taught how torecognise early signs of nerve dysfunction andreactions, so they can come for review asquickly as possible.

Staff in health centres will tend to see patientsmore regularly, as they come to collect MDT(and for other reasons!) Therefore HealthCentre staff play a vital role in detecting earlyneurological symptoms and signs, and inassessing the patients risk of disability.

These are some simple tests which can bedone to at the health centre to asess nervefunction.

If you suspect a patient has deterioration innerve function then refer immediately to theOD leprosy supervisor.

Assessment of Risk of Disability By: Health Messenger



56

enAeBlGñkCMgWyl;dwgc,as;GMBIkareFIVetsþenHehIyGaccg¥úlR)ab;)anRtwmRtUv enAeBlenaHRtUvsMu[Kat;gakmuxecj ehIybiTEPñk.

bnþeFVIetsþemIlcMnucjaNdwgteTAeTot b:uEnþeBlenH RtUveFVImþgenAkEnøgenH mþgenAkEnøgenaHmineTogTat;. kareFVIdUecñH GñkCMgWminGacTay)anfa Gñknwgb:HKat;enAeBlNa b¤kEnøgNaeT.

RbsinebIG ñkC Mg Wcg ¥ úlR)ab ;m in)anRt wmRt UvehIyemIleTAhak;dUcCa mindwgfamaneKb:HeTsUmGñksakl,gKUsenAkEnøgNamYyénédrbs;Kat;EdlmanjaNdwg. kareFIVdUcenHnwgeFIV[Kat;cab;GarmµN_ nigCakarelIkTwkcitþKat;ehIyvanwgnaM[Gñkdwgfa GñkCMgWmin)anedklk;b¤min)ane)aHbg;ecalkarBüayameT.

e n A e B l G ñ k K U s e n A e l I E s , k m þ g ²sUmkt;RtaenA elIKMnUrEpnTIRbGb;édb¤RbGb;eCIg. sUmKUs sBaØa ( )

e n A k En ø g E dlG ñ kC M g W m a nG a r m µN _ d w gnigcg¥úlR)ab;)anRtwmRtUv ehIyKUssBaØa (×)

RbsinebIGñkCMgWBMumanGarmµN_dwg b¤cg¥úlR)ab;minRtwmRtUv.

minRtUveFVIetsþry³eBlyUreBkeT eRBaHGñkCMgWGacFujRTan; b¤minykcitþdak;. ebImanbBaðaenHekIteLIg RtUvQb;sMraksin.

BinitürkemIl nnigkt;RtanUvral;sBaØaénkarxUcxatsrésRbsaTkñúgeBlfµI²enAeBlrkeXIjfamanjaNdwg b¤kMlaMgcuHfyenARtg;kEnøgNamYyk¾eday RtUvsMueGayGñkCMgWKitedayykcitþTukdak;fa etIva)anekIteLIg b¤)anpøas;bþÚrenAkñúgry³eBl6ExEdrb¤Gt; ehIyRbsinebIva)anekIteLIg¼pøas;bþÚrkñúgry³eBl6ExEmn etIBYkeKGaccaM)aneTfaenAeBlNa. sUmkt;RtanUvGIVEdlGñkCMgWniyay.

cat;viFankar1. bBa¢ÚneTAeGayGñkRKb;RKgEpñkCMgWXøg;RbcaMtMbn;

RbtibtiþnUvGñkCMgWEdlman³karfycuHc,as;las;xagjaNdwg b¤kMlaMg

enAkñúgry³eBl6Exknøgmk eTaHbIBMumankarQWcab; b¤karQWRsekorsrésjaNk¾eday.

karQWcab;srésjaNEdlmansPaBF¶n;F¶r2. bNþúHbNþalGñkCMgWG MB IkarEfTa Medayxø ÜnÉg

(sUmemIlGtßbTxageRkam¦Check for and record any signs of recentnerve damageWherever reduced sensation or strength arenoted, ask the patient to think carefully whetheror not any of these occurred or changed withinthe past 6 months, and if so, can theyremember when. Record what the patient says.

Take action1. Refer to the OD leprosy supervisor anypatient who has:

definite decrease in sensation or strengthwithin the past 6 months, even where thereis no nerve pain or tendernessnerve pain that is severe

2. Train patient in self care (see followingarticle)


57

Test for strength in hands and feet

The first test is to check for normal movement,as shown by the black arrows. See if thepatient can perform the movement fully andwithout assistance. If stiffness limits themovement, make a note in the record.

If movement is full, or almost full, continuewith a test for resistance as shown by the redarrows in the illustrations that follow. Only dothis if the movement is full, or almost so.Apply resistance gradually, never suddenly.Don't force a change in position, just test o seeif the strength of a patient's resistance isnormal, reduced or nil.

kareF I V etsþem IlkMla MgenARbGb;édn igRbGb;eC Ig

etsþdMbUg KWRtUvBinitürkemIlclnaFmµta dUcEdl)anbgðajedaysBaØaRBYjBN’exµA. BinitüemIl faetIGñkCMgWGaceFIVclna)aneBjelj nigedayKµanCMnYy)anEdrb¤eT. RbsinebIclnaRtUv)anrMxanedaykarrwgsnøak;RtUvkt;RtaenAkñúgkMNt;;ehtu.RbsinebIGaceFVIclnaeBjelj)an b¤esÞIrEteBjelj sUmbnþkareFIVetsþemIlkMlaMgTb;Tl; dUcEdl)anbgðajedaysBaØaRBYjBN’RkhmenAkñ úgrUbbnÞab;enH. RtUveFIVdUcenHcMeBaHEtkrNIEdlGaceFVIclnaeBjelj b¤esÞIrEteBjeljb:ueNÑaH.RtUveRbIkMlaMgTb;Tl;bnþicmþg² minRtUvTb;Tl;xøaMgPøam²eT. minRtUvbgçMeGaymanclnaeT eBalKWRKan;EteFIVetsþemIlfa etIkMlaMgTb;Tl;rbs;GñkCMgWmanlkçN³Fmµta fycuH b¤Kµan.

Always compare the right hand or foot with theleft. Record if any muscle is strong, weak orparalysed.

RtUveFIVkareRbobeFobCanic©rvagRbGb;éd¼RbGb;eCIgxagsþaM CamYynwgRbGb;éd¼RbGb;eCIg xageqVg.sUmkt;Rta kMlaMgsac;duM xøaMg exSay b¤xVin.

eFVIetsþ ebImanclnaeBjeljTo test if movement is full

eFVIetsþ ebImankMlaMgTb;eBjeljTo test if resistance is full

kan;Rmaméd3[Rtg; ehIyR)ab;GñkCMgW[eFVIclnakUnédmkrkRmamédy:ageBjelj Hold three fingers straight.Ask the patient to closethe little finger fully.

eFVIetsþemIldMeNIrkarrbs;srésRbsaTKuybÍtal;Test of ulnar nerve function

ebIGñkCMgWminGacbiTkUnéd)an etIKat;GacKabkat1snøwkenAcenøaHkUnédnigRmamdéTeTot)aneT?If the patient can close thelittle finger, can they holda card between theirfingers?

etIGñkCMgWGackMerIkemédcuHeRkamnigeLIgelI enAeBldak;va[Rtg;Can the patient move thethumb up and down, whilekeeping it straight?

eFVIetsþemIldMeNIrkarrbs;srésRbsaTemDIy:g;Test of median nerve function

ebIGackMerIk)aneBjelj etIKat;GacTb;nwgkMlaMgBIcMehog)aneT?If movement is full, canthe patient resist at theside of the thumb?


58

Tests for the eye

Blink TestAs you talk with the patient, observe the eye.Remember that if the patient knows you arelooking at the eyes, he or she may stopblinking.

Watch for these problems:1. Lashes turning in and touching the eye2. Patient never or rarely blinks in one or

both eyes3. Incomplete closure during blink4. Redness and injury affecting the lower part

of the eye, especially if it is not covered bythe blink

5. Lower lid hanging away from the eye,overflowing tears.

kareF I V etsþEP ñk

kkaarreeFFIIVVeettssþþkkaarrRRBBiiccEEPPññkkenAeBlGñkkMBugniyayCamYyGñkCMgW sUmsegátemIlEPñkrbs;Kat;. RtUvcgcaMfa RbsinebIGñkCMgWdwgfaGñkkMBugsMLwgemIlEPñkrbs;Kat; eBlenaHKat;GacQb;RBicEPñk.

sUmRby½tñcMeBaHbBaðaTaMgenH³1 > eramEPñkEdlbt;eTAkñúg ehIyb:HnwgRKab;EPñk2> GñkCMgWminEdl b¤kRmRBicEPñkmçag b¤TaMgsgçag3 > karbiTEPñkminCitTaMgRsugenAeBlRBicEPñk4> kareLIgRkhm nigmanrbYsEdlb:HBal;dl;

EpñkxageRkaménEPñk CaBiess RbsinebIkEnøgenaHmin)anRKbCitenAeBlRBicEPñk

5> RtbkEPñkxageRkamFøak;q¶ayBIRKab;EPñkedaymanehorTwkEPñk

eFVIetsþ ebImanclnaeBjeljTo test if movement is full

eFVIetsþ ebImankMlaMgTb;eBjeljTo test if resistance is full

RTkédrbs;GñkCMgW ehIyBinitüemIlfaetIKat;GaceFVIclnakédeTAeRkay)aneBjeljeTSupport the patients wrist,and see if the patient canmove their wrist backfully.

eFVIetsþemIldMeNIrkarrbs;srésRbsaTr:aDIy:al;Test of radial nerve function

sgát;fñm²Etsgát;Cab;eTAelIRbGb;éd edIm,IietsþemIlkMlaMgTb;rbs;vaPress gently but firmly onthe back of the hand totest resitance.

edayRTkeCIg etIGñkCMgWGacbt;RbGb;eCIgeLIgelI)aneBjeljb¤eT?Suport the ankle. Can thepatient pull their foot upfully?

eFVIetsþemIldMeNIrkarrbs;srésRbsaTsuIy:aTikTest of Peroneal nerve function

sgát;elIxñgeCIgedIm,IietsþemIlkMlaMgTb;rbs;vaPress at the top of thefoot to test for resistance.


59

Vision test Make sure there is enough normal light to dothis test. Go outside, and ask the patient tostand still and cover one eye. Walk 6 metresaway and hold up any number of fingers onone hand. Ask the patient how many fingers heor she can see. Test again with the patientcovering the other eye.

If the patient cannot see at 6 metres, retest at 3meters.

Voluntary muscle testThis test measures the strength of the musclesin the eye lid. Ask the patient to close the eyesas if in sleep. Look to see if there is any gapbetween the top and the bottom lids. Use aruler to measure the gap, and record it inmillimetres on the patient card. Record "0mm"if closure is complete.

kkaarreeFFIIVVeettssþþkkaarreemmIIlleeXXIIjjRtUvFanafamanBnøWePø IgFmµtaRKb;RKan;sMrab;kareFIVetsþenH. edIrecjeTAeRkA ehIysMu[GñkCMgWQrenAes¶om nigRKbEPñkmçag. sUmedIrecjBIGñkCMgWcMgay6Em:Rt ehIyelIkédmçag edaybgðajRmamédcMnYnb:unµank¾)an. sYrGñkCMgWfaetIKat;GacemIleXIjRmamédb:unµan. sUmeFIVetsþ dUcKñaenHmþgeTotCamYyGñkCMgWenH edayRKbEPñkmçageTot.

RbsinebIGñkCMgWminGacemIleXIjkñúgcMgay6Em:RteT sUmeFIVetsþeLIgvijenAcMgay3Em:Rt.

kkaarreeFFIIVVeettssþþssaacc;;ddMMuussVV½½yyRRbbvvttþþkareFIVestþenH vas;kMlaMgrbs;sac;dMuRtbkEPñk.sMueGayGñkCMgWbiTEPñkrbs;Kat; edayeFIVhak;dUcCakMBugedklk;. BinitürkemIletImanKmøatrvagRtbkEPñkxagelI nigRtbkEPñkxageRkamb¤eT. sUmeRbIbnÞat;edIm,Ivas;KmøatenaH ehIykt;RtavaCamIløIEm:Rt enAkñúgkatrbs;GñkCMgW. sUmkt;Rtafa{0 mIløIEm:Rt} RbsinebIEPñkGacbiTCitTaMgRsug.

kareFIVetsþkaremIleXIjVision Test

kareFIVetsþsac;dMusV½yRbvtþVoluntary muscle test


60

bbssiinneebbIImmaannkkaarr))aatt;;bbgg;;CCaaGGcciiéé®®nnþþyy__nn UU vvddMMeeNNIIrrkkaarrrrbbss;;ssrrééssRRbbssaaTT EEddllbb::HHBBaall;;

eeTTAAeellIIEEPPññkk RRbbGGbb;;eeCCIIgg bb¤¤RRbbGGbb;;éédd eennaaHHeeKKRRttUUvvEEttGGbb;;rrMMGGññkkCCMMggWWGGMMBBIIvv iiFFIIEEffTTaaMMeeddaayyxxøø ÜÜnnÉÉgg eeddIImm,,IIbbggááaarrBBiikkaarrPPaaBBGGss;;mmYYyyCCIIvviitt..

eKalbMNgsMxan;énkarGb;rMGMBIkarEfTaMedayxøÜnÉgenH KWedIm,ICUndMNwgnigpþl;cMeNHdwgdl;GñkEdlmanCMgWXøg; dUecñHBYkeKGacbgáarmin[mankarxUcxatkan;EtxøaMgeLIgEfmeTot.

mankarTTYlxusRtUvCaeRcInsßitenAelIGñkCMgWpÞal;. buKÁliksuxaPi)alGacpþl;dMbUnµan CYynigelIkTwkcitþ b:uEnþminGacTTYltYnaTIenHTaMgGs;)aneT.

karGb ;r MG ñkC Mg WG MB IkarEfTa M edayx ø ÜnÉged Im, Ibg á arB ikarPaB

eroberogeday³ TsSnavdþIsuxPaB nig elak ehog eXog (CIOMAL)

eyIgRtUvEtmankarsgS½yeTAelIkarxUcsrésRbsaT RbsinebI³

karRBicEPñkmankarBi)ak EPñkbiTminCit EPñkRkhm b¤emIlmineXIjEs,ks¶Üt eRbH b¤dMe)AenAelI)atédnig)ateCIg)at;bg;jaNdwgenAelI)atéd nig)ateCIgmansñampÞaMg²enAelIEs,kEdlminEbkejIseTaHbIenAhaléf¶k¾edaymankarrwgsnøak;q¥wg ¬EdRkj:g; nigRbGb;eCIgFøak;¦

ebIGñkCMgWmanbBaðaNamYykñ úgcMeNambBaðaTa MgenH RtUvGnuvtþkarEfTaMedayxøÜnÉgCaRbcaM edIm,Ibgáar min[mankarxUcxat nigBikarPaBkan;EtxøaMgeLIgEfmeTot.Cajwkjab; GñkCMgWXøg;cMa)ac;RtUveFI VkarsRmbs RmYlsMxan;²mYycMnYneTAnwgrebobrbbrs;enArbs;BYkeK edIm,IbgáarBikarPaB. Gñkpþl;esvaEfTaMsuxPaB GacCYyGtifiCntamry³karbeRgonGMBI {karEfTaMedayxøÜnÉg }³

elIkT wkc it þGt if iCneGayGn uvt þkarEfTa MedayxøÜnÉgeGayGñkCMgWsakl,geFVIGnuvtþnUvGIVEdlGñk)anbeRgon cab;epþImeday]TahrN_l¥²

GtßbTxageRkamenHnwgpþl;nUvdMbUnµanl¥² nigmanRbeyaCn_ EdlGacpþl;eGaydl;GñkCMgWXøg;enAeBlbeRgonGMBIkarEfTaMedayxø ÜnÉgedIm,IbgáarBikarPaB.


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Patches of skin which do not sweat, even ifin the sunJoint stiffness is developing (clawing inthe hands and drop foot)

If the patient has any of theseproblems, self-care must beimplemented consistently, to preventfurther harm and disability.

Often leprosy patients need to make majoradjustments to their lifestyles in order toprevent disability. Health providers can helpclients by teaching “self-care”:

Encourage clients to practise self-care Let the patient do it Practise what you teach - lead by goodexample!

The following sections provide good anduseful advice which can be given to leprosypatients when teaching self-care to preventdisability.

If there has been irreversible nervefunction loss affecting the eyes, feet orhands, patients must be educated in

self-care to prevent the risk of lifelongdisability.

The main object of training in self care is toinform and empower the leprosy affectedperson so that they can act to prevent furtherdamage.

The responsibility primarily lies with theperson affected by leprosy.Healthworkers can advise, help andencourage but can not take over thisrole!

Nerve damage should be suspected if:Blinking is difficult, lagophthalmos,corneal scarring, redness or vision lossSkin is dry, cracked or ulcerated on palmsof hands and soles of feetLoss of sensation on palms of hands andsoles of feet

Training Patients in Self-Care to Prevent Disability By Hieng Kheang

]TahrN_xøH²éndMe)AEdlKµankarQWcab;rbs;GñkCMgWXøg;. dMe)ArlYydUcenAkñúgrUbenH Gacbgáar)antamry³karEfTaMxøÜnd¾l¥Examples of painless wounds in a leprosy patient. Ulcers like these can be prevented with good self-care.


62

karEfTa M RbGb ;édEdl)at ;bg ;Ba Ø aNdwg

RbsinebICMgWXøg;bNþaleGayxUcxatdl;srésRbsaTenARbGb;éd nwgmankar)at;bg;jaNdwg kar)at;bg;kMlaMg nigkar)at;bg;karEbkejIs ekIteLIg. karxUcxatTaMgenH KWCabBaðaGs;mYyCIvitdUecñH vamansar³sMxan;Nas;EdlGñkCMgWeFIVkarpøas;bþÚr rebobrbbrs;enArbs;xøÜn edIm,IEfTaMédenaHnigbgáarkarxUcxatEfmeTot.

TMlab;RbcaMéf¶kñúgkarEfTaMedayxøÜnÉg rYmman³TMlab;kñ úgkareCosvagmin[mankarrgrbYsédRKb;Ebbya:g.TMlab;kñúgkarBinitüemIléd karEfTaMEs,k nigkareFVIlMhat;éd.TMlab;kñúgkarEfTaMdMe)AeGay)anRtwmRtUv nigTan;eBlevla.

Care of hands with loss of sensation

If leprosy damages the nerves to the hand(s),loss of sensation, dryness and loss of strengthoccurs. These are lifelong problems, so it isvery important for the patient to change his orher lifestyle in order to care for the hand andprevent further damage.

Regular habits of self-care include:Habit of avoiding all hand injuriesHabit of hand inspection, skin care, exerciseHabit of early and correct wound care

RtUvRbugRby½tñerogral;éf¶cMeBaHvtßúb¤skmµPaBEdlGaceFIVeGayRbGb;édrbs;GñkrgrbYs nigeCosvagBIvtßúnigskmµPaBTaMgenaH. RtUvRbugRby½tñcMeBaHkMedA rbYstictYc b¤BgEbkelIEs,k nigRtUvEfTaMvaCabnÞan;. karbgáarRbesIrCagkarBüa)al ehIykarbgáarmanPaBgayRsYlCagkarBüa)al. Be on the watch all day for objects or activitiesthat could harm your hands - and avoid them!Be on the watch of your hands for warmth, smallwounds or blisters and look after themimmediately. Prevention is better than cure -and much easier!

dak ;RbGb;édeG ayq¶ayBIG VIEdlekþA b ¤ rMuk a rB a rBIG VIEdlekþA • eRbIeQIEvgeTArukb¤q áwHeP øIg • eRbIeRsamédRkas;²enAeBlcMG inG ahar • eCosvagkarsÞabb:Hdgkan;EdlekþA • ykExSrMuédqña M • eRbIRTnab;RTab;EdEBgkaehV

KEEP hands away from heat OR INSULATE against heat • use a stick to poke a fire • use thick gloves when cooking • avoid touching hot handles • cover pot handles with string

• use a holder for a coffee cup


63

How to avoid injuries The patient should learn which parts of thehand do not have sensation and watch out forthese areas.

Injuries from sharp objects - protection!Watch for and avoid rough, sharp objects

When working - ensure handles of toolsare smoothKeep hands away from tools, be careful!Wear protective gloves

Be aware of long periods of one type ofhand activity that could cause blisters:Try to change jobs, protect handles oftools with soft, cushioning materials

Keep a watch for heat patches on your hands.Feel and look. These are early warning signsthat the hand is being injured and needs rest.

vviiFFIIeeCCoossvvaaggkkaarrrrggrrbbYYssGñkCMgWKYrdwgfa EpñkNaxøHénRbGb;édBMumanjaNdwg ehIyKYrRbugRby½tñcMeBaHkEnøgTaMgenaH.

kkaarrrrggrrbbYYsseeddaayyvvttßßúúmmuuttRRssYYcc - kkaarrkkaarrBBaarr ¡¡Rbytñ½ nigeCosvagvtßúeRKIm nigmutRsYc

enAeBleFIVkargar³ RtUvFanafadg]bkrN_TaMgGs;manlkçN³relagRtUvdak;édeGayq¶ayBIdg]bkrN_nana³ sUmRby½tñRbEyg ¡RtUvBak;eRsamédedIm,IkarBar

RtUvdwgfakargarmYyEdleFIVedayédkñúgry³eBlyUr GacbNþaleGaymanBgEbkenA)atéd³ RtUvBüayampøas;bþÚrkargar b¤karBardg]bkrN_edayRTnab;Tn;²ehIyRkas;.

RtUvRby½tñcMeBaHsñamrlakenAelIRbGb;édrbs;Gñk. emIlehIyKit. TaMgGs;enHKWCasBaØadMbUgEdlR)ab;eGaydwgfa RbGb;édrbs;GñkkMBugmanrbYs nigRtUvkarsMrak.

sUmR)ab;GtifiCnrbs;Gñk³RtYtBinitüemIlRbGb;édCaeTogTat;Qb;eFIVkargar RbsinebIGñkeXIjmansBaØaénkarrgrbYssMrakRbGb;édrbs;Gñk[)anjwkjab;Tell your client:INSPECT hands regularlySTOP work if you see signs of injuryREST your hands often

karEfTaMxøÜnd¾l¥manrYmTaMgkarbgáarkarrgrbYsedayeRbIeRsamédkarBar b¤eRbIRkNat; nigkarBinitüemIlnigEfTaMrbYsGood self care incudes preventing injury by using protective gloves or clothes, frequent checking forinjury and care of injuries.


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Care of Feet with loss of sensation

AVOID INJURY - - Always wear protectivefootwear

Remember that walking too much is themost common cause of sole wounds andulcer on the foot. Avoid long walks. Rest. Learn from earlier wounds to your feet.Remember how they happened, andprevent them from happening again.

karEfTa M RbGb ;eC IgEdl)at ;bg ;jaNdwg

eCosvagkarrgrbYs³ RtUvBak;Es,keCIgkarBarCanic©© RtUvcgcaMfakaredIreRcIneBk KWCamUlehtujwk

jab;bMputEdlnaMeGaymanrbYsenA)ateCIgnigmandMe)AenARbGb;eCIg. RtUveCosvagkaredIrq¶ayRtUvsMrak.RtUveronsURtBIkarEdlRbGb;eCIgrgrbYskalBIelIkmun. RtUvcgcaMfaetIrbYsTaMgenaH)anekIteLIgedayviFINa ehIyRtUvbgáarkMu[manrbYseTot.

R)ab;GtifiCnfa RtUvRby½tñCanic©enAeBlGgÁúy³CYnkal GñkCMgWGgÁúyRtdusEs,kenAkEnøgq¥wgEPñkeKaledaymindwgxøÜn. pþl;dMbUnµan[GñkCMgWrbs;Gñk eRbIRkm:aRTab;q¥wgEPñkeKalkuM[b:HnwgkEnøgGgÁúy.kMuGgÁúysgát;elIRbGb;eCIgyUreBk. sßanPaBEdll¥bMputrbs;GñkCMgWXøg;KWGgÁúyelIKUfpÞal;.

Tell your client to take care when sitting:Patients sometimes rub the skin off their anklebones without knowing. Advise your client to usea krama to cushion their ankle bone from thefloor. Do not squat for too long. The best sitting positionfor a leprosy patient is on their bottom!

GñkCMgWTaMgGs;Edlmankar)at;bg;jaNdwgenA)ateCIgKYrEtBak;Es,keCIgkarBarCanic©Protective footware should be worn by allpatients with sensory loss in the soles ofthe feet


65

karpþl;Es,keCIgkarBarRbsinebIGñkCMgWmankar)at;bg;jaNdwgenARbGb;eCIg enaHvaCakarsMxan;EdlBYkeKRtUvBak;Es,keCIgEdll¥²RKb;eBlevlaTaMgGs; edIm,IkarBarRbGb;eCIgrbs;BYkeKBIkarrgrbYs. Es,keCIgl¥²³

RTnab;xagkñúgTn;² edIm,IkarBarRbGb;eCIgenAeBledIrRTnab;xageRkamrwgmaM edIm,ITb;sáat;mineGaydMufµ b¤bnøamutFøúHcUleTAkñúgEs,keCIgEdlRkv:at;P¢ab;nwgRbGb;eCIgedayExSRkvat;EkgeCIgRsYlBak;nigmanTMhMRtwmRtUvedIm,ITb;sáat;karkkitRbGb;eCIgCamYynwgEs,keCIg.

Provision of protective footware If patients have sensory loss of the feet, it isessential that they wear good shoes at all times toprotect their feet from injury.

Good shoes:

Soft on the inside to protect and cushion the foot

during walking

Strong on the underside to prevent stones or

thorns from going through the shoe

Tied on to the feet by back straps

Comfortable and the correct size, to prevent

rubbing of the foot against the shoe.

TsSnavdþIsuxPaB )anB¤erOgGñkCMgWmñak;EdlenAEteFVI[manrbYsdl;RbGb;eCIgTaMgBIrrbs;Kat; b:uEnþK at ; ) anFanaGHGagCam Yyb uK Ál iks uxaP i ) alfaKat;EtgEtBak;Es,keCIgenAeBledIrCanic©. enAeBlKat;)anmkdl;mNÐlsuxPaB RbGb;eCIgrbs;Kat;manCab;bMENkvtßútUc². dUecñH buKÁlikeyIgmanCMenOc,as;faKat;minBak;Es,keCIgeLIy. b:uEnþGñkCMgWenaH)anniyayfaKat;EtgEtBak;Es,keCIgenAeRkApÞH.enATIbBa©b; buKÁlikeyIg)anrkeXIjbBaðaenH. bMENkvtßútUc²TaMgenaH nigrbYsepSg²eTot )anekItmaneLIgenApÞH eBalKWenAkñúgpÞHeQIrbs;GñkCMgWenaH.

eday)andwgGMBIBt’manenHehIy - \LÚvenH GñkCMgWenH)anTukEs,keCIgmYyKUsMrab;karedIrenAeRkApÞHCaFmµta nigEfmTaMgmanEs,keCIgBiessmYyKUeTotsMrab;eBlKat;enAkñúgpÞH.

ExSRkv:at;keCIgHeal straps

RTnab;rwgRkas;Strong soles

Health Messenger heard a story about apatient who kept injuring his feet, but assuredthe health staff that he wore shoes wheneverhe went walking. When he appeared at thehealth centre with a splinter in his foot - thehealth staff was sure he could not be wearingshoes, but the patient said he always woreshoes outside. Eventually the health staffworked it out. The splinter and the otherinjuries were being obtained at home, insidethe wooden house.

On hearing this news - the patient now keepsone pair of shoes for walking outside, asnormal, and even has a special pair of shoesfor when he is in the house!


66

Care of the skin in neuropathic feet andhands

Soaking and scraping of hard skin every daywill keep the skin moist and supple which willhelp prevent callous build-up, cracks andulcers.

Patients have often found that creating aregular routine where they practise these self-care steps once or twice a day - first thing inthe morning and/or after dinner - helps keeptheir feet and hands ulcer free.

Remember - no callous, no ulcer.

karEfTa MEs,kkñ úgC Mg W Neuropathic feet and hands

karRtaMTwknigekasEs,krwgecjCaerogral;éf¶ nwgeFVI[Es,kmansMeNImnigTn; EdlGacCYybgáarkarekItmanRkm:r kareRbHEs,k nigdMe)A.GñkCMgWPaKeRcIn)anrkeXIjfa karbegáItTMlab;CaeTogTat;kñúgkarGnuvtþn_CMhanTaMgLayénkarEfTaMxøÜnmþgb¤BIrdgkñ úgmYyéf¶ CYymin[mandMe)AenAédnigeCIg. cUrcgcaM - ebIKµanRkm:rrwg k¾KµandMe)AEdr.

2

4

1

3

RtaMRbGb;édnigRbGb;eCIgenAkñúgTwkFmµta Soak hands and feet in normal water

BinitüRbGb;édnigRbGb;eCIgrkemIlEs,kRkinb¤dMe)AExamine hands and feet for hard skin or wounds

dusxat;Es,kEdlRkinecj Scrape off hard skin

labeRbg[)ansBVApply oil liberally and throughly


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karEfTaMdMe)ArlYyenAtampÞH³ GGIVEdlGñkCMgWKYryl;dwgCare for ulcers at home – what a patient should know

GñkCMgWcaM)ac;RtUvyl;dwgGMBIviFIEfTaMdMe)ArlYy edIm,I[vaGacCasHes,Iy)an.dMe)ArlYyFmµtaPaKeRcIn BMuRtUvkarfñaMGg;TIb‘ÍeyaTikBiesseLIy eBalKWdMe)ATaMgenaHRKan;EtRtUvkarkarlagsMGat nigsMrakb:ueNÑaH. Patients need to know how to look after an ulcer so that it can heal.Most simple ulcers do not need special antibiotics, they just need tobe kept clean and to rest.

1> RtaMdMe)ArlYyenaHenAkñúgTwks¥aterogral;éf¶. RtUvbEnßmGMbilmYysøabRBakaehVeTAkñúgTwkcMNuHmYylIRt ¬GMbilKWCaGñksMlab;emeraK¦. RbsinebIdMe)AenaHkxVk;eBk GñkCMgWGacRtaMvaenAkñúgTwksab‘UCamunsinmunnwgRtaMvaenAkñúgTwkGMbil.

1. SOAK the ulcer in clean water every day. Add one coffee spoon ofsalt to one litre of water. (Salt is a disinfectant). If the wound isreally dirty, the patient can soak in soapy water first, and then saltwater.

2> lagsMGatdMe)ArlYyenaHedayTwkGMbils¥at ¬dak;GMbilmYysøabRBakaehVeTAkñúgTwkcMNuHmYylIRt¦.

2. CLEAN the ulcer with clean salted water (1 coffee spoon to onelitre of water).

3> RKbdMe)ArlYyenaHedayRkNat;Tn;² b¤bg;rMurbYs ehIyrMuvaedayRkNat; b¤Rkmas¥atl¥. kareFIVEbbenH KWedIm,IkarBardMe)ArlYyenaHBIkarqøgeraK nigFUlI.

3. COVER the ulcer with a clean cloth or compress and bandagewith a clean cloth or kroma. This protects the ulcer from infectionand dirt.

4> sMrak³ vaCa»sfd¾sMxan;bMputkñúgkarBüa)aldMe)ArlYy[Ca. 4. REST – this is the most important medicine to heal an ulcer.

karvas;EvgemIldMe)ArlYymþgkñúgmYys)aþh_ Gacbgðaj[dwgfaetIvakMBugCasHes,IyEdrb¤eT. cUreRbIExSedIm,Ivas;EvgGgát;p©itrbs;va. Measuring an ulcer once a week can show if it is healing. Use apiece of string to measure the diameter.


68

kkaarreeGGaayyddMMee))AArrllYYyyssMMrraakksMrakKWCa»sfl¥bMputsMrab;Büa)aldMe)ArlYy.dMe)ArlYyPaKeRcIn GacCasHes,IyTaMgRsug RbsinebIva)ansMrak. etIkarsMrakmann½ydUcemþc?vamann½yfa {minRtUvCan;elIdMe)ArlYyTal;EtesaHkñúgmYyéf¶² }.

RbsinebIenAEtmankarsgát;CaRbcaMeTAelIdMe)ArlYy enaHkarCasHes,IynwgmankaryWtya:v b¤minGacCasHes,Iy. GñkCMgWEdlmanjaNdwgFmµta nwgmandMeNIrex©Ic²CasV½yRbvtþiedaysarmankarQWcab; ehtudUcenH vanwgKµankarsgát;eTAelIdMe)ArlYyenaHeLIy. GñkCMgWEdlmanjaNdwgfycuHBuMmankarQWcab;eT ehtudUecñH vanwgmankarsgát;eTAelIdMe)AenaHedaymindwgxøÜn. vamansar³sMxan;Nas;EdlGñkCMgWXøg;yl;fa minRtUvsgá\t;eTAelIdMe)ArlYy.

RbsinebIGñkCMgWcaM)ac;RtUvEtedIr enaHKat;KYreRbIeQIRct;Cadac;xat. RtUvsMueGayGñkTTYlbnÞúkCMgWXøg;enARsukRbtibitþCYypþl;eQIRct;[GñkCMgW.

Resting UlcersRest is the best medicine for ulcers. Mostulcers can completely heal if they are rested.What does resting mean? It means “NOT ONESTEP A DAY ON AN ULCER”.

If pressure is constantly applied to an ulcer,the healing process is slowed down orstopped. A patient with normal sensationwould automatically limp because of the pain– thereby pressure is not applied to the ulcer.

A patient with decreased sensationdoes not feel this pain, and pressurecan be applied without knowing. It isimportant for leprosy patients to beconsciously aware of not applyingpressure to an ulcer.

If a patient really needs to walk, crutchesshould be used. Ask your OD leprosysupervisor for help in obtaining crutches for apatient.


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This patient has an ulcer that has notdecreaed in size for three weeks.

Why is this ulcer not healing?

1. Usually the healing process slows down oris delayed because the patient is not restingenough. Even one step a day on an ulcer is toomuch. This patient may need to borrow somecrutches to ensure they rest this ulcer. Thepatient also needs counselling to ensure theyunderstand what is causing the ulcer and howthe ulcer can heal. Does the patient reallyunderstand the importance of rest?

2. There is a callus around the ulcer whichmay prevent healing. The patient should soakthe ulcer for 20-30 minutes a day, and thenscrape the callus away carefully.

Less commonly, the ulcer may have becomecomplicated or serious. Signs of a moreserious ulcer are swelling, heat and redness ofthe skin around the ulcer. Pus and infectioncan also be a sign.

If the ulcer is complicated, the patient shouldbe reviewed by the OD leprosy supervisorwith possible referral to Kien Khleang or adistrict hospital.

G ñkC Mg W enHmand Me)ArlYyEdlKµ ankarCasHes, Iybn þ icbn þ ÜcesaHGs;ry³eBl3s)a þh _

eettIIeehhttuuGGIIVV))aannCCaaddMMee))AArrllYYyyeennHHmmiinnCCaassHHeess,,IIyyeessaaHH??1 > CaFmµta karCasHes,IymanPaByWtya:v b¤

BnüareBl edaysarEtGñkCMgWBMu)ansMrakRKb;RKan;. sUm,IedIrEtedIrmYyCMhankñúgmYyéf¶Can;elIdMe)ArlYy k¾vaCakareRcIneBkEdr. GñkCMgWenHRtUvsMux© IeQIRct; edIm,IFanafaKat;GaceFVIeGaydMe)ArlYyenH)ansMrak. GñkCMgWenHk¾caM)ac;RtUvkarkarRbwkSapgEdr edIm,IFanafaKat;)anyl;GMBImUlehtuEdlbNþal[mandMe)ArlYy nigGMBIviFIEdlGaceFIV[dMe)ArlYyCasHes,Iy)an. etIGñkCMgWBitCayl;GMBIsar³sMxan;énkarsMrakEdr b¤eT?

2> karmanRkm:rEs,kRkinenACMuvijdMe)A GacraraMmin[dMe)ArlYyenaHCasHes,Iy)an. GñkCMgWKYrRtaMdMe)ArlYyenaHenAkñúgTwkry³eBlBI 20-30naTIkñ úgmYyéf¶ ehIybnÞab;mkRtUvekasRkm:rEs,kRkinenaHecjedayRbugRby½tñ .

CYnkal dMe)ArlYyGackøayCamanplvi)ak b¤kan;EtF¶n;F¶r. sBaØaéndMe)ArlYyF¶n;F¶rKW karehImmankMedA nigkøayCaRkhmenAelIEs,kCMuvijdMe)ArlYyenaH. karmanxÞúH nigkarkøayeraK k¾GacCasBaØamYyEdr.

ebIdMe)ArlYymYymanplvi)ak GñkCMgWenaHKYrTTYlkarBinitüeLIgvijBIGñkTTYlbnÞúkRsukRbtibtþi nigGacRtUv)anbBa¢ÚneTAeKonXøaMgb¤mnÞIreBTüRsuk.


70

karEfTa M EP ñkEdlmankarl M)akk ñ úgkarRB icEP ñk n igkarb iTEP ñk

CMgWXøg;GaceFVI[EPñkmanbBaðaCaeRcIn. b:uEnþ bBaðaEPñkEdlekItmanjwkjab;CageKkñúgGñkCMgWXøg; KWkarbiTEPñkminCit (lagophtalmos) nigs<wkRKab;EPñk (corneal insensitivity) .

RbsinebIGñkCMgWmanbBaðakñúgkarRBicEPñk b¤karbiTEPñk enaHvanwgmaneRKaHfñak;edaysarEPñks¶ÜtrlakRkhayb¤rgrbYs. bBaðaTaMgenHGacnaM[emIlmineXIj. dUecHvamansar³sMxan;Nas;EdlGñkCMgWRtUveronEfTaMEPñknigeCosvagbBaðaEdlGaceFIVeTA)an.

CYnkal GñkCMgWXøg;RbePT MB Gacman Iritis

edaymaneraKsBaØaénkarQWcab; kareLIgRkhmkarxøacBnøW nigkaremIlminsUveXIj. GñkCMgWenHKYrRtUv)anbBa¢ÚneTAEpñkCMnajEdlBüa)albBaðaEPñk.

kkaarreeCCoossvvaaggkkaarrss¶¶ ÜÜttEEPPññkk EEddllGGaaccnnaaMM[[eemmIIllmmiinneeXXIIjj nniiggkkaarrkkaarrBBaarrEEPPññkkBBIIFFUUllIInniiggkkMMeeTTcckkMMTTIIeeppSSgg²²³³KKiitt-RRBBiiccEEPPññkkkarRBicEPñkCYylagFUlInigkMeTckMTIsMramecjBIEPñk nigeFVI[EPñkesImCanic© dUecñHvaGacmankarRkhaybnþicbnþÜc. RbsinebIsac;dMuEPñkkøayCarwgenaHTMlab;FmµtakñúgkarRBicEPñkRtUv)at;bg;. GñkCMgWRtUveronTMlab;enaHeLIgvijedayKitGMBIva ehIyRBicEPñkjwkjab; eBalKWRtUvRBicEPñkeGay)aneRcIndgkñúgmYyéf¶².

etIGñkCMgWKYrcgcaMkarRBicEPñkenAeBlNa? - enAkñúgsßanPaBmanxül;bk;nigFUlIhuy.

Care of eyes with poor blink or closure

Leprosy can affect the eye in many ways.However the most common eye problems inleprosy are lagopthalmos and cornealinsensitivity.

If a patient has problems with blinkingor eye closure, there is a danger thatthe eye will become dry, irritated orinjured. These problems could lead tosome loss of vision. It is thereforeimportant that the patient learns to carefor the eyes and avoids these problemsas far as possible.

Occasionally patients with MB leprosy candevelop iritis with symptoms of pain, redness,fear of light, and poor vision. Patients shouldbe referred to specialized units that deal witheye problems.

karbeRgonGMBIkarEfTaMEPñkedayxøÜnÉg -GñkCMgWmñak;kMBugBinitüEPñkrbs;Kat;kñúgkBa©k;Teaching self care of the eyes - a patientinspects her eyes in the mirror


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RBicEPñkeGayxøaMg³ biTEPñkeGayCitenAeBl{Kit-RBicEPñk}. eTaHbIRtbkEPñkBMuGacbiT)ank¾¾edayk¾RKab;EPñknwgRkLab;cuHeLIg² ehIyRtUv)anCUtsMGatedayRtbkEpñkxagkñúg.

EEffrrkkSSaaEEPPññkkeeGGaayy))aannss¥¥aattRtUvbk;edjstVl¥it nigstVruyEdlmkEk,rmuxrbs;Gñkecj. minRtUvykédCUtjIEPñkrbs;GñkeLIy RtUvRKbEPñkenAeBlyb;edayRkNat;Tn;²b:uEnþRtUvRbugRby½tñkMueGayRkNat; enaHeTAb:HnigRtduHnwgEPñkenAkñúgeBledklk;.

Avoiding the eye dryness that can lead tovision loss, and keeping all dust and dirt outof your eyes: THINK - BLINK

Blinking helps wash away dust/dirt and keepsthe eye moist so there is little irritation. If themuscles of the eye have become stiff, thenormal blinking habit is lost. The patientneeds to relearn the habit by thinking about it,and blinking often, many times a day.

When should the patient especially rememberto blink? - dusty, windy conditions

Blink hard - close the eyes tightly when"think-blink". Even if the lids do notclose, the eyes balls will roll up and bewiped clean by the inner lid.

Keep the eyes cleanWave away insects and flies that comenear the faceDon't rub eyes with hands Cover eyes at night with a soft cloth, butbe careful that the cloth does not touch andrub the eye while sleeping

BBiinniittüüeemmIIlleerrooggrraall;;ééff¶¶nnUUvvssBBaaØØaaéénnkkaarrrrllaakkRRkkhhaayynniiggrrbbYYss ddUUeeccññHHGGññkkGGaaccEEffTTaaMMvvaaTTaann;;eeBBlleevvllaa nniiggEEssVVggrrkkCCMMnnYYyyeennAAeeBBllccaaMM))aacc;;eRbIkBa©k; b¤sMueGaysac;jatiBinitüEPñkrbs;GñkedIm,IrkemIlsñamRkhm nigkMeTcsMram. RtUvFanafa)anlagsMGatédCanic©muneFVIkarBinitü.

RbsinebIGñkCMgWman lagophtalmos (minGacbiTEPñkCitTaMgRsug) enaHkarvHkat;RbEhlCaGacCYy)an - sUmBiPakSaCamYyGñkTTYlbnÞúkenARsukRbtibtþiGMBIkarbBa¢ ÚnGñkCMgWenHeTAeFI VkarvHkat;enAmnÞIreBTüeKonXøaMg.

Checking daily for signs of irritation andinjury, so that you can look after theseproblems early, and seek help whereneeded.

Use a mirror, or ask a relative, to inspect theeyes. Check for redness and dirt. Always makesure the hands are clean first!

If a patient has lagophthalmos (unableto completely close their eye) thensurgery may be able to help - talk to theOD supervisor about referring thispatient for surgery at Kien Khleanghospital.

karBarEPñkrbs;GñkkarBarEPñkBIBnøWRBHGaTitü xül;nigFUlI³ eRbIRkm:aEvntaexµA. RbsinebIGacmanlT§PaB sUmBak;EvntaexµA EdlGacTb;BnøWRBHGaTitümineGaycUlBIcMehog)an. sUmBak;mYkEdlmanhamFM edIm,IkarBarEPñkrbs;GñkBIBnøWRBHGaTitü xül; nigFUlI.

Protect the eyesProtect the eyes from the sun, wind anddust - use krama's and sunglasses. If possible, get a pair of sunglasses withpieces that prevent the sun from coming infrom the sideWear a hat with a wide brim to protect youreyes from sun, wind and dust.

aarrGGbb;;rrMMssuuxxPPaaBBeeddIIrrttYYnnaaTTIIdd¾¾ssMMxxaann;;kkññúúggkkaarrBBüüaa))aall nniiggkkaarrRRbbyyuuTT§§nnwwggCCMMggwwXXøøgg;;.. kkaarrGGbb;;rrMMeennHH

mmaanneeKKaallbbMMNNggCCYYyyRRbbCCaaCCnn[[mmaannssuuxxPPaaBBll¥¥ttaammrryy³³sskkmmµµPPaaBBnniiggkkiicc©©xxiittxxMMRRbbwwggEERRbbggrrbbss;;BBYYkkeeKKppÞÞaall;;.. karGb;rMsuxPaBGMBICMgWXøg; mansar³RbeyaCn_sMxan;bI³1> karGb;rMshKmn_GMBIeraKsBaØadMbUgénCMgWXøg;³

eRBaHfakarqab;Büa)alTan;eBlevlaGacbgáarBikarPaB)an nigGacbBaÄb;karcMlgdl;GñkdéTeTotenAkñúgshKmn_enaH.

2> karbgáarPaBBikar¬nigkarbgáarBikarPaBmin[mansPaBkan;EtF¶n;F¶reLIgeTot¦. vamansar³sMxan;sMrab;GñkCMgWXøg;kñúgkaryl;dwgGMBICMgWXøg; BIeRBaHBYkeKRtUvEtedIrtYnaTId¾sMxan;enAkñúgkarBüa)alrbs;;BYkeK nigEfTaMxøÜnedayxøÜnÉg.


73

karGb;r Ms uxPaBGMB IC Mg WXøg ; eroberogeday³ TsSnavdþIsuxPaB dkRsg;nigEksMrYlBI “ A Guide to Health Education in Leprosy” by PJ. Neville

3> karkat;bnßykarmak;gaynigkaryl;RclM³ enAeBlshKmn_kan;Etmankaryl;dwgGMBICMgWenHGMBIkarcMlg nigkarBüa)al enaHkarmak;gaycMeBaHGñkCMgWXøg;kan;EtRtUv)ankat;bnßy.

karGb;r MsuxPaBsMrab;RkumRTRTg;suxPaBPUmishKmn _ n igG ñkC Mg Wf µ I

CMgWXøg;BMuEmnCaCMgWEdlKYreGayP½yxøacenaHeT.vamingaynwgqøg b:uEnþvagayBüa)alCa. manRbPBEtmYyb:ueNÑaHkñúgkarcMlg³ mnusSekItCMgWXøg;EdlKµankarBüa)al. RbsinebImankarpþl;karGb;rMenAtamPUmi enaHGñkCMgWXøg;Gacqab;)anTTYlkarBüa)almunnwgekItmanPaBBikar ehIyCMgWenHGacRtUv)anbM)at;BIPUmienaH.


74

Health Education in Leprosy By Health Messenger, adapted from "A Guide to Health Education in Leprosy" by PJ Neville MPH

3. Reduction of stigmatization andmisconceptions - The more thecommunity knows and understands aboutthe disease, the transmission and thetreatment, the less the stigma to leprosypatients.

Health education for VHSG, communitiesand new patients

Leprosy is not a disease to be feared. It is hardto catch and easy to cure. There is only onesource of infection: untreated, infected humanbeings. If education is provided to villages,cases can be treated quickly before disabilitiesresult, and the disease can be removed fromthat village.

Health education plays an importantpart in the treatment and control ofleprosy. It aims to help people

achieve good health by their own action andeffort.

Health education in leprosy has three veryimportant effects:

1. Educating the community about theearly signs of leprosy - as early treatmentprevents disability and stops transmissionto other people in the community.

2. Prevention of disability (and preventionof worsening of disability) - It is importantfor leprosy patients to understand leprosybecause they must play an important partin their own treatment and self-care.


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Bt’manTUeTAGMBICMgWXøg;General information about leprosy

CMgWXøg;bNþalmkBIemeraKmüa:g nigBüa)alCaTaMgRsug.Leprosy caused by a germ and is fully curable.

CMgWXøg;GacRtUv)aneFIVeraKvinic½äyedayEp¥keTAelIeraKsBaØaKøInikEtb:ueNÑaH. sñampÞaMg²EdlmanBN’esøksøaMg b¤BN’RkhmenAelIEs,k ehIy)at;bg;jaNdwg KWCaeraKsBaØaEdlbgðajR)ab;eGaydwgGMBICMgWenH. Leprosy can be easily diagnosed from clinical signs alone. A pale or reddish skin patch that lackssensation is a tell-tale sign of the disease.

fñaM MDT sMlab;emeraK nigbBaÄb;karqøgraldalénCMgWXøg;bnÞab;BIdUsdMbUg. GñkCMgWEdlkMBugTTYlkarBüa)alBMuGaccMlgemeraKXøg;)aneLIy. Multi-Drug Therapy (MDT) kills germs and stops the spread of leprosy after the first dose. Patients ontreatment do not spread leprosy.

fñaM MDT pþl;CUnedayminKitéføenARKb;mNÐlsuxPaB nigGñkTTYlbnÞúkCMgWXøg;RsukRbtibtþi.MDT is available free of charge at all health centres and OD leprosy supervisors.

karqab;Büa)alTan;eBlevla nigCaeTogTat; GacbgáarkarxUcRTg;RTay)an.Early and regular treatment prevents deformities

GñkCMgWEdl)anbBa©b;karBüa)al KW)anCasHes,Iy100° eTaHCaBYkeKenAmansl;sñampÞaMg²enAelIEs,k b¤BikarPaBxøHkþI. Patients who complete treatment are totally cured, even if they have residual skin patches or disabilities.

vGñkCMgWGacrs;enAkñúgCIvitFmµta enAmuneBl enAkñúgeBlnigenAeRkayeBlBüa)al.Patients can lead completely normal lives, before, during and after their treatment.

karpþl;karGb;rMdl;GñkCMgWGacCYybgáarBikarPaBProviding education to a leprosy patientcan help prevent disabilities

karpþl;karGb;rMdl;shKmn_GacCYybgáarkarcMlgCMgWXøg; nigkat;bnßykarmak;gayProviding education to the communitycan help prevent transmission andreduce stigma


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karBitsMxan;²GMBICMgWXøg;Important facts about leprosy

mUlehtu³ CMgWXøg;KWCaCMgWraMuér:EdlbNþalmkBIemeraK eBalKWBMuEmnbNþalmkBIkardak;bNþasab¤exµacbisaceLIy.vaBMuEmnCaCMgWsYrBUC nigBMuqøgtamkarrYmePTenaHeT. The cause - leprosy is a chronic disease caused by a germ, not a curse or an evil spirit, it is nothereditary and not sexually transmitted.

karqøgraldalénCMgWXøg;³ Xøg;KWCaCMgWmYyEdlkMrqøgbMput. vacMlgtamry³dMNk;TwktUc²BIRcmuH nigmat; enAkñúgGMLúgeBlTMnak;TMngCitsñiT§nigjwkjab;CamYyGñkCMgWEdlKµankarBüa)al. CMgWXøg;mingaynwgqøg b:uEnþvagayBüa)al.Spread of leprosy - leprosy is one of the least infectious disease. It is transmitted via droplets, from thenose and mouth, during close and frequent contacts with untreated cases. Leprosy is hard to catch,but easy to cure.

karBüa)al³ GñkEdlmanCMgWXøg;RtUvEtelbfñaM edIm,IsMlab;)ak;etrI. karBüa)alnwgminGacBnøarRmamédEdlRkjg;b¤minGacBüa)aldMe)ArlYy)aneT. minRtUvKitfakareRbIfñaMcak;l¥RbesIrCagfñaMRKab;enaHeT. vaminl¥RbesIreLIy.The treatment - a person with leprosy must take tablets to destroy the bacteria. Treatment will notstraighten bent fingers or cure ulcers. Do not think that injections are better than tablets - they are not.

karCasHes,Iy³ CMgWXøg;Büa)alCasHes,Iy b:uEnþRbsinebIKµankarBüa)al GñkCMgWGacmanBikarPaBenAeBlcugbBa©b;.eBlevlal¥bMput edIm,IBüa)alCMgWXøg; KWenAeBlEdlCMgWenHeTIbEt)ancab;epþImekIteLIgfµI². The cure - leprosy is curable, but without treatment he may end up with disability. The best time to treatleprosy is when the disease has just begun.

mUlehtuénBikarPaB³ karxUcsrésRbsaT GacbNþalmkBICMgWXøg; ehIykarxUcxatenH Gacb:HBal;dl;RbGb;édRbGb;eCIg nigEPñk EdlebIKµankarBüa)alEfTaMTan;eBleT karxUcxatenHGaceFVIeGaymanBikarPaBkan;EtxøaMg. Cause of disability - nerve damage can result from leprosy, and this can affect the hands, feet and eyes,which, without due care can lead to further disability.

bBaðasgÁm³ GñkCMgWXøg;minRtwmEtrgkarQWcab;edaysarEtCMgWrbs;xøÜnenaHeT. CYnkal BYkeKTTYlrgkarQWcab;edaysarKµannrNamñak;niyayrkBYkeK nigKµannrNamñak;cg;hUbGahar b¤eFIVkargarCamYyBYkeK.Social aspects - leprosy patients do not only suffer because of their disease. Sometimes they sufferbecause people will not talk to them; sometimes they suffer because people may not want to eat, orwork with them.

cMeBaHGñkCMgWEdlTTYlkarBüa)aledayfñaM MDT sñampÞaMg²enAelIEs,k nwgminrlb;)at;Pøam²eLIy ehIyGacmankarpøas;bþÚrbnþicbnþÜc sUm,IenAeBlkarBüa)alRtUv)anbBaÄb;kþI. sñampÞaMg²TaMgenH nwgmansPaBl¥RbesIreLIg enAkñúgry³eBlmYyqñaM b¤BIrqñaM b:uEnþnwgminGacrlb;)at;TaMgRsugeLIy. For patients on Multi Drug Therapy (MDT) - skin patches will not suddenly disappear, and may showlittle change even when treatment is stopped. The patches will improve in a year or two more but maynever disappear completely.


77

karBnül;GMBIkar)at;bg;jaNdwgjaNdwgeFVI[eyIgdwgkarQWcab; nigsItuNðPaB.vakarBareyIgBIkarrgrbYsepSg². RbsinebImnusSeyIgKµanGarmµN_dwgkarQWcab; b¤sItuNðPaBeTeyIgGacrgrbYs b¤karrlakedaymindwgxøÜn. rbYsnigkarrlakenH GacbNþal[mandMe)ArlYy.

eraKsBaØaRbtikmµCMgWXøg;CYnkalGñkCMgWGacekItmanbBaðaEdleKehAfa“Rbtikmµ” eTAnwg)ak;etrIrhUtdl;vagab;.

vaGaceraKsBaØadUcxageRkam³kareLIgehIm b¤kareLIgRkhmenAsñampÞaMgelIenAEs,k mankarQWcab;enAsrésRbsaTmanRKunekþAsac;duMcuHexSaykñúgeBlfµI²)at;bg;jaNdwgkñúgeBlfµI²manbBaðaEPñk

CYnkal bBaðaenHekIteLIgenAeBlEdlkarBüa)alRtUv)anbBa©b;.

IvaCakarsMxan;Nas;EdlGñkCMgWyl;fa ebIsinCaBYkeKmaneraKsBaØaNamYykñúgcMeNameraKsBaØaTaMgenH BYkeKRtUveTAmNÐlsuxPaBCabnÞan; b¤eTArkGñkTTYlbnÞúkenARsukRbtibtþi. BYkeKminKYrQb;elbfñaMXøg;eT. cMEnkÉRbtikmµminEmnCaeraKsBaØafµIénCMgWXøg;eLIy.

Explanation about loss of feelingSensation allows us to feel pain andtemperature. This protects us from injury. Ifpeople do not feel pain or temperature, theymay have injuries or burns without knowing.This can lead to ulcers and wounds.

Signs of reactionSometimes people develop what are called“reactions” to the bacteria until it dies.

This may include any of the following:Swelling or redness of the skin patchesPain in teh nervesFeverNew muscle weaknessNew sensory lossEye problems

Sometimes this occurs even when treatment isfinsished.

It is very important that patientsunderstand that if they experience anyof these symptoms, go directly to thehealth centre or OD leprosy supervisor.They should not stop taking theirleprosy medicine and reactions are nota new symptom of leprosy.

kareFIVbgðaj KKWCakarbeRgond¾l¥bMputTsSnavdþIsuxPaBRtUv)anB£GMBIerOgrbs;GñkCMgWXøg;mñak;Edlrs;enAkgPUmimYy ehIyKµannrNamñak;enAkñúgPUmienaHniyayrkKat;eLIy. Kat;mankareRkomRkMcitþya:gxøaMg ehIyeTaHbICaKat;)anTTYlkarBüa)al nig)andwgfaKat;minGaccMlgemeraKeTAGñkdéTeTotk¾eday k¾GñkPUmiTaMgenHminh'aneTACitKat;eLIy. enAéfmYy manbuKÁlikenAmNÐlsuxPaBmYy)ancuHeTAPUmienaH ehIy)ansMerccitþeTApÞHrbs;Kat;. GñkPUmidéTeTot )anemIleXIjbuKÁlikmNÐlsuxPaBenaHcuHeTAsYrsuxTukçGñkCMgWXøg;enaH. BYkeK)anyl;eXIjfa RbsinebIbuKÁliksuxPaBenaHminxøacqøgCMgWXøg; nig)anyl;dwgGMBICMgWXøg;c,as;las; dUecñH k¾KµanehtuplGIVEdlBYkeKRtUvxøacCMgWXøg;Edr. eRkaymkbnþicmþg² GñkPUmik¾)ancab;epþImh'aneTAsYrsuxTukçGñkCMgWXøg;enaH>>>.Demonstration is the best teacherHealth Messenger were told a story about a leprosypatient who lived in the village and none of the othervillage members would talk to her. She was verydepressed, and although she was being treated andknew she was no longer contagious, the villagersrefused to go near her.

One day, the health centre staff were visiting thevillage, and decided to go to her house.

The other villagers saw the health centre staff visitingthe house. They realized that if a health staff was notafraid of getting leprosy, and knew all about leprosy,then there was no reason for them to be afraid either.Slowly the villagers themselves started visiting theleprosy patient…


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Bt’manbEnßmkarBinitüGñkCitsñiT§³ RbsinebIGñkCMgWrs;enACamYyRkumRKYsarrbs;Kat; sUmpþl;dMbUnµandl;Kat;[naMsmaCikRKYsarmkTTYlkarBinitüpgEdr.kareKarBRslaj;xøÜnÉg³ CMgWXøg;minEmnbNþalmkBI)abkmµeT. CMgWXøg;minEmnCaCMgWsYrBUCeLIy. CMgWXøg;Büa)alCasHes,IyehIyeKGacbgáarkarxUcRTg;RTay)an. GñkCMgWXøg;minxusEbøkBImnusSdéTeToteT.GñkmincaM)ac;cakecjBIRkumRKYsar b¤RsukkMeNIt b¤kargarrbs;GñkeLIy.

Additional informationExamination of contacts - if the patient is livingwith his family, advise him to bring them forexamination.Self-respect - leprosy is not the result of sin. Thedisease is not hereditary. Leprosy can be curedand deformity prevented. Patients are notdifferent from other people. You need not leaveyour family, or land or job.


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Preparation and delivery of health educationsession 1. Prepare each session carefully - a scheme

of talks should be planned ahead.2. A session should include: introduction,

teaching points, and summary.3. Put the content of each session into note

form.4. Never teach more than 3 new ideas.5. Look at the audience - do not look at your

notes all the time.6. Do not talk too fast.7. Check your visual aids before you start8. Prepare one or two questions related to the

most important teaching points.

The person giving the education should:be in a position to see all the audienceuse simple languagemake frequent pausesremember that facial expression isimportant. Make the audience understandthat you are enjoying giving the education.remember that enthusiasm is infectious.

Hints for group teaching 1. The audience should be seated comfortably

in a small group.2. Make sure that you can see each person.3. Create a friendly atmosphere by greeting

the group.4. The talk should be short and not contain

more than 3 new points.5. Leave time for questions and discussion.6. Encourage the audience to voice their

problems.7. Never make a person look foolish in public.8. Use visual aids as much as possible and

plan them carefully.

karerobcM nnigkarpþl;karGb;rMsuxPaB1> erobcMvKÁGb;rMnimYy²edayRbugRby½tñ³KYrerobcMCamun

nUvral;EpnkarsMrab;Gb;rM2> erobcMRbFanbTénvKÁGb;rMnimYy²KYrEtman³ esckþI

epþIm cMNucEdlRtUvbeRgon nigesckþIsegçb 3> sresrKMeragemeronsMrab;vKÁnimYy²4> minRtUvbeRgonGMBIKMnitfµI²eGayelIsBI3cMNuceLIy5> RtUvsMLwgemIleTAGñkcUlrYm³ minRtUvsMLwgemIl

KMeragemeronrbs;GñkRKb;eBleLIy6> minRtUvniyayelOneBkeT7> BinitüemIlrUbPaBCMnYysMrab;karbeRgonrbs;Gñkmun

eBlcab;epþImbeRgon8> erobcMsMnYrmYy b¤BIrEdlTak;TgeTAnwgcMNuc

sMxan;²bMputEdlRtUvbeRgon

GñkEdlpþl;karGb;rM KKYrEt ³³QrenARtg;kEnøgNamYyEdlGacemIleXIjGñkcUlrYmTaMgGs;eRbIPasasamBaØ²RtUvsMrak[)anjwkbnþic KYrcgcaMfakareRbITwkmux mansar³sMxan;Nas;.RtUveFIVeGayGñkcUlrYmyl;fa GñkmankarrIkraykñúgkarpþl;karGb;rMenH.KYrcgcaMfaesckþIsaTrGaccMlgdl;GñkdéT)an

KnøwHsMrab;karbeRgonCaRkum1> KYreGayGñkcUlrYmGgÁúy[)anRsYl CaRkumtUc²2> RtUvR)akdfaGñkGacemIleXIjRKb;GñkcUlrYmTaMgGs;3> begáItbriyakassñiT§sñal edayrak;Tak;GñkcUl

rYmTaMgGs;4> vKÁGb;rMnimYy²RtUvEtxøI nigBMuRtUvmanKMnitfµI²elIs

BI3cMNuceLIy5> TukeBleGay)anRKb;RKan;sMrab;sYrsMnYrnigkar

BiPakSa6> elIkTwkcitþGñkcUlrYmeGayelIkeLIgnUvbBaðarbs;

BYkeK7> minRtUveFIVeGayGñkcUlrYmNamñak;Gab;eGanenAkñúg

TIsaFarN³eLIy8> eRbIrUbPaBCMnYyeGay)aneRcInebIGaceFIV)an nig

erobcMvaeGay)anRtwmRtUv KarGb;rMCaRkumA group education session


80

k a r b M e B j X ø a

Each sentence in the first column canbe completed with a sentence/wordin the second column. Draw lines to

match them up. Answers are at the bottomof the page. We have done the first one foryou.

aanniimmYYyy²²kkññúúggCCYYrrTTIImmYYyyxxaaggeeRRkkaammGGaaccRRttUUvv))aannbbMMeeBBjjeeddaayyPP¢¢aabb;;CCaammYYyyXXøøaabb¤¤BBaakküüeennAAkkññ úúgg

CCYYrrTTIIBBIIrr.. ccUUrrKKUUss bbnnÞÞaatt;;PP¢¢aabb;;XXøøaaTTaaMMggGGss;;eennaaHH.. ccMMeellIIyyéénnkkaarrbbMMeeBBjjXX øøaaeennHHmmaanneennAATTMMBB½½rr >>>>>>.. eeyyIIgg))aannbbMMeeBBjjXXøøaaTTII11 eeddIImm,,IICCaa]]TTaahhrrNN__..

Complete the sentences

1> CMgWXøg;GacLeprosy can be

2> CMgWXøg;RbePT MB manMB leprosy has

3> karqab;cab;epþImBüa)albgáarEarly treatment prevents

4> karRtaMRbGb;édnigRbGb;eCIgSoaking hands and feet softens the

5> karBüa)alTreatment for MB leprosy takes

6> dMe)AGackarBaredayUlcers can be prevented by

7> CMgWXøg;RbePT PB b:HBal;eTAelIPB leprosy affects

8> RbtikmµCMgWXøg;minEmnCaReactions are not a new

9> karrlakEPñk (iritis) KWCaRbePTTI2énIritis is a type 2

10> karxUcsrésRbsaTKuybItal;GacbNþal[Ulner nerve damage can cause

11> søaksñamelIEs,kkñúgCMgWXøg;minLeprosy skin patches do not

12> karxUcsrésRbsaTGacbNþal[mankarfycuHNerve damage can cause decreased

i> jaNdwgSensation

ii. EbkejIsSweat

iii> RbtikmµReaction

iv> ticCag5kEnøg5 or more skin lesions

v> Es,kSkin

vi> BikarPaBDisability

vii> karbgáCMgWXøg;Leprosy infection

viii> CasHes,IyCured

ix> tYsrésRbsaTmYy1 nerve trunk

x> karEfTaMedayxøÜnÉgy:agl¥Good self care

xi> Rkj:g;RmamédClawed fingers

xii> ry³eBl12Ex12 months

cMelIy 1 = viii4 = v 7 =ix 10 = xi 2 =iv5 = xii 8 = vii11 =ii3 = vi 6 = x9 =iii12 =i

1 leprosy in cambodia - niph€¦ · it was also described in detail by the time of king jayavarman...

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