Lepr Rev ( 1 9 8 6 ) 57, Supplement 3, 5 3-59 Report of the Joint Leprosy - Tuberculosis Proj ect in Paraguay A E A L V A R E N G A Departmen to de Lepra, Min isterio de Salud Publica y Bienestar Social, A suncion , Paraguay Following a rewarding initial experience in the treatment of leprosy and tuberculosis with the combination of rifampicin and I s oprodian and taking into account the excellent results o f the M alta-Proj ect, the Paraguayan Government, through its Ministry of Health, resolved to initiate an eradication programme of both these diseases which constitute important public health problems in the country . The realization of the programme was made possible by means of an agreement of cooperation existing between the Government of Paraguay and the German Leprosy Relief Association (DAHW) of Wiirzburg, and in addition counting on the consultantship-on the technical level-of Professor E Freerk­ sen of the Medical and Biological Research I nstitute, B o rstel . For the execution of the mixed programme, use was made of the existing infrastructures for leprosy and tuberculosis contro l . Concerning t h e organization of t h e programme , a central directory, encom­ passing leprosy and tuberculosis control was created . The Director of the Department for Leprosy Control, M inistry of Health, i s i n charge of the programme coordinati o n . It should also be mentioned that the leprosy pro­ gramme i s a vertical programme and this proved to be the most efficient way of dealing with the maj o rity of problems at all levels . Meanwhile the tuberculosis programme i s of a horizontal nature, being integrated into the General Health Services . In the public health approach to both of these diseases there are common characteristics: Treatment i s predominantly ambulatory, leaving a small number of patients in need o f ho spitalizati o n . 1 . 1 For leprosy patients, under t h e M i ni stry of Health, there are many health centres all over the country, the Institute of Tropical M edicine in Asuncion, and for cases with advanced incapacities , the leprosarium Santa Isabel of Sapucai . 0 3 0 5 -7 5 1 8/86/0570 5 3 S + 07 $0 1 . 0 0 © British Leprosy R e l i e f Association 5 3 54 A E A lvarenga 1 . 2 Under the Faculty of M edicine; the relevant wards of the University Hospital in the capital . 1 . 3 Under private insti tutions; the M ennonite Hospital km. 8 1 and the ward of the Patronate for leprosy patients, also in Asuncion. 2 For tuberculosis patients: 2 . 1 Under the Mini stry of Health; the Sanatorium Juan Max Boettner. 2 . 2 Under the Faculty of M edicine, Asuncio n ; the Tuberculosis Service of the University Hospital . 3 In these and other centres patients are not subj ected to any kind of segregation and, if necessary, will be attended by other specialists like any other patient. This acceptance by official centres of leprosy patients inspires confidence, thus strengthening the voluntary examination of household contacts and most important, the regularity of treatment. 4 Therapy, including laboratory examinations, is free of charge . 5 The same combined drug therapy is used for both diseases, therefore the Leprosy Service is in charge of drug storage and distribution, safeguarding a close supervision on the utilization of medicaments . For the purpose of the day-to-day management of the j oint programme, this has been divided into two secti ons. First, a leprologist i s in charge of the leprosy section, and secondly, a tuberculosis specialist takes care of the TB sectio n . Both these specialists have their offices at the Ministry of Health . The leprosy section of the joint programme The following steps were taken during the preparatory phase: The provision o f intensive info rmation o n the efficiency of the combined therapy with I soprodian-rifampicin, mainly to the decision-taking levels of the Ministry of Health . Thus we try to assure the programme support by the highest national authority. Intensive theoretical and practical training of medical officers, laboratory and nursing staff collaborating with the programme . Organizing a central dermatological (including leprosy) clinic and a labora­ tory for clinical and bacteriological tests . These serve as a centre for treatment, training and reference for doctors, nurses , biochemi sts and laboratory tech­ nicians. Coordinating the programme with government health centres in order to establish skin and leprosy clinics, and, if needed , to provide hospitalization for leprosy patients . Safeguarding the provision of drugs . Report of jo in t L- TB project, Paraguay 5 5 I N I T I A T I O N O F T H E P R O G R A M M E Officially, the programme was initiated i n September 1 9 79 when the first clinic was opened in Asuncion for the treatment of leprosy patients with the combinati on I soprodian-rifampicin . This clinic, which happens to be the best developed one of the entire programme, functions full-time and i s situated in the same building as the Central Health Centre of the Government. Here, highly qualified dermatologists are taking care o f leprosy and other dermatological patients. A well-equipped laboratory i s functioning, also full-time, in an annex to this clinic and carries out the relevant tests for leprosy patient s . 2 P R O G R A M M E D E V E L O P M E N T There was a gradual extension of the programme, linked t o the existing public health infrastructure . At this time we have three treatment centres in Asunci o n and 1 2 centres in t h e interior of t h e country . During t h e present year, the programme is further expanded to additional towns and village s . To this end, medical officers of government health centres are undergoing a specific training which will enable them to diagnose and treat leprosy patients living inside their area o f responsibility. 3 THE C H E M O T H E R A P E U T I C C O M B I N A T I O N U S E D During the period 1 979- 1 9 8 4 , the combination I soprodian-rifampicin w a s used in the presentation o f two separate dragee s . I n October 1 9 84, a four-drug combination, namely I soprodian-R M P was introduced , i n one single tablet with the following compositi o n : rifampicin, 1 50 · 0 mg; isoniazid , 8 7 · 5 mg; prothiona­ mide, 8 7 · 5 mg; and dapsone (DDS) 2 5 · 0 mg. This new form of presentation offers the following practical advantage s : the combinati on of substances i n adequate proportions inside a single tablet facilitates optimum dosage . The regular ingestion of the medication by the patient is greatly eased by the fact that he only has to take one tablet at a time . 3 . 1 The dosage This scheme , which depends on the body-weight, is shown below: Patients up to Patients up to Patients up to Patients up to Patients up to 1 5 kg 3 0 kg 4 5 kg 60 kg 7 5 kg and above take take take take take 1 tablet daily 2 tablets daily 3 tablets daily 4 tablets daily 5 tablets daily. Drug ingestion i s daily, from M o nday to Saturday, with a break on Sunday . 56 A E A lvarenga Duration of therapy is variable, depending upon the clinical and bacteriologi­ cal progress of each patient. Disregarding in this context the clinical forms (1-B-T­ L) o f leprosy, the minimum period of treatment i s 6 months with an average of about 1 4 month s . 3 . 2 The supply of Isoprodian-RMP The Department of Leprosy provides I soprodian-RMP directly to each health centre in accordance with the number of patients on treatment. The drug is deposited under the care o f the nursing services and is i ssued on medical order to the patient at the time of his check-up. Each supply covers a period of 3 0 days when the patient returns for his clinical and bacteri ological controls. The daily drug intake i s not supervised since the patient takes medication at home . The good results we are having with this method of administration are demonstrated by the following facts : the high regularity o f patients attending at the clinic or health centre; the favourable clinical and bacteriological evolution of the disease; and the low rate of absconding case s . 4 N U M B E R , D I S T R I B U T I O N A N D F O L L O W - U P O F L E P R O S Y P A T I E N T S T A K I N G P A R T I N T H E P R O G R A M M E A total of 6000 c<:J.ses are estimated to exist in the country. F o r the development o f the programme it w a s taken into account that the country h a s 3 2 5 8 million inhabitants and that 4957 leprosy patients are in the active register; of these, some 3 1 % of the population and 34% of registered cases are concentrated inside an area of 2 8 5 2 sq km comprising the city of Asuncion and the Central Department . In the first instance, in September 1 9 79, the work started in these two areas from where it was gradually extended to those parts of the country having the highest demographical concentratio n and a well-developed public health infra­ structure . In time the programme was expanded to other departments . Since the beginning of the programme, the results obtained with the combination I soprodian-RMP have been most rewarding, particularly regarding the fast cure of patients followed by the reduction of endemic foci . The specific programme output has been highly satisfactory . This is best evidenced by the following data: total of estimated cases, 6000; total o f registered cases, 49 5 7 ; under treatment with Isoprodian-RMP, 1 62 3 (27 % ) . O f these 1 623 cases, admitted t o the programme, the situation i s summed u p in Table 1 . Of the 794 cases on o bservation, 343 were released and taken off the register having completed 3-6 years of post-therapy observatio n . It should be mentioned t h a t there a r e several cases t h a t have been under observation for more than 6 years since ceasing treatment without having Report of join t L- TB project, Paraguay 5 7 Table 1 Case situation Under post- treatment observation Receiving treatment Absconders Deaths Interruptions of therapy Tota l : Number 794 687 8 0 27 35 1 623 ( % ) (49 ' 0 ) (42-4) ( 5 · 0 ) ( 1 , 6 ) ( 2 ' 0 ) ( 1 0 0 ' 0 ) relapsed . The excepti on i s one patient for whom therapy had to be re-started. Of the 27 deaths, not one can be attributed to the specific antileprosy treatment. The 35 cases which interrupted chemotherapy with I s oprodian-RM P , are accounted for either because of a premature change o f medication in a few, mo stly private clinics, or of other intercurrent diseases requiring an interruption of specific antileprosy therapy . The tuberculosis section of the programme O B J E C T I V E S The high aims of this programme required the creation of a national tuberculosis register . At present, this covers 5 3 % o f the country population incorporating the most populous sanitary regi o n s . New areas are being added in acco rdance with the planned extension of the programme . The immediate programme o bj ective is a speedy reducti on of the morbidity and mortality rates, aiming at the cure o f all case s . Doubtless, this a i m , whose realization i s subj ect to availability o f funds, implies a relatively fast programme extension in order to achieve a total population coverage . 2 T H E P R O G R A M M E D E V E L O P M E N T The above-mentioned programme aims imply a step-by-step extension, starting in 1 9 79 in the area of the capital and its surrounding populations as well as in several indigenous settlements in the vast Paraguayan area of the Chaco (western region) . In 1 9 8 1 the programme incorporated the Departments of Paraguari , Cordillera and the Alto Paran a . These areas correspond to the I and IX Sanitary Regi o n s . Other Departments will be added in due course . 5 8 A E A lvarenga In 1 9 84 the TB programme reached a population of about 1 · 6 million, some 5 0 % of the country ' s inhabitant s . 3 O R G A N I Z A T I O N The fight against tuberculosis is integrated into the general health services of the country, implying medical attention for the TB patient by the government health centres which provide the necessary human and material resources . Regarding the indigenous population, the anti -tuberculosis service can count on the collaboration of the National Association for the Help for the I ndigenous Population and, in some instances, i s also assisted by paramedical field workers (Promotores de salud) . Concerning the anti- TB service provided by health centres, a medical practitioner attends TB patients once weekly or more often if needed . In the smaller health units the anti-tuberculosis service naturally i s of a more limited nature; however it still includes investigations regarding respiratory symptoms, sputum collection and examination by the nearest reference laboratory. The Central Government Laboratory and the Institute of Tropical Diseases, both in Asuncion, serve as TB reference centres and provide the relevant training. In the interior of the country this function i s taken over by the Regional Health Centre s . T h e anti-tuberculosis programme n o w incorporates 3 8 localities, including 6 9 centres providing medical assistance, 2 2 of which a r e inside indigenous settle­ ments . 4 P E R I O D O F T R E A T M E N T The short-term therapy with Isoprodian-RMP s o far h a s shown good results . For the maj o rity of patients , treatment is ambulatory, controlled but self­ administered . The minimum period of treatment is five months but this can be prolonged if required by the clinical-bacteriological evoluti o n . This drug-combination is indicated for all forms of the disease, regardless of the extension or severity of the lesion, age, sex or pretreatment . The do sage i s the same as that for leprosy patients given and discussed in Section 3 . 1 . 5 C O L L A B O R A T I O N W I T H O T H E R I N S T I T U T I O N S The following associations and institutions collaborate together with the Ministry o f Health in the national tuberculosis programme : The Paraguayan Institute for the Indigenous popUlation (IND I ) ; The Paraguayan Association for the Indigenous population (API); The Mennonite Association or Cooperative Service to the I ndigenous populations (ASCI M ) ; The Anglican Church; The Report of jo in t L- TB project, Paraguay 5 9 German Association for Technical C ooperati on (GTZ); T h e Oblatos de Maria; and The Chair for Respiratory Diseases o f the Faculty of M edicine, University of Asuncio n . 6 R E S U L T S During the period 1 9 79- 1 984, 5 8 5 3 tuberculosis cases were detected, or in other words, 2 5 % o f the total estimated number of patients (22 , 8 1 2) existing in the country . This situation is summed up in Table 2 . The number o f patients that abandoned treatment and those who left the area ( 1 6 - 4 and 1 4 · 0 % respectively) , could be explained by the fact that there i s a high percentage of migrant people . Also it could be explained because the information system and the system of registration were not s o efficient at the beginning of the programme . The maj o ri ty of deaths are reported from specialized institutions and refer to advanced case s . The introduction of the combination Isoprodian-RMP constitutes a most important advance in the fight against leprosy and tuberculosis. Principally this i s because of its rapid action a n d outstanding efficiency , coupled w i t h relatively short periods of treatment. Table 2 Case situation Number ( % ) Cured 3 1 3 5 ( 5 3 · 5 ) Abandoned treatment 9 6 1 ( 1 6 - 4 ) Left the area 82 1 ( 1 4 · 0 ) Died 3 8 5 ( 6 · 7) Actually on treatment 5 5 1 (9·4) Total 5 8 5 3 ( 1 0 0 · 0 ) In the light of these promising results, the ambitious goal o f planned disease eradicati on which has no parallels in other programmes, imposes the need for continuing the ongoing programme until its final realizatio n . To fulfil this goal it is imperative that the j oint TB-Leprosy Programme can count on the continua­ tion of the invaluable support of the German Leprosy Relief Association (DAHW) . This great challenge has found the backing of the Paraguayan Government and its people almost from the onset of the programme .