Grading impairment in leprosy.

The aim of the paper is to discuss the concept of 'severity grading' in relation to impairment in leprosy, and to describe the use of an impairment sum score, the Eyes, Hands, Feet (EHF) score, as an indicator of the severity and the evolution of impairment over time. The use of an impairment sum score, the EHF score, is illustrated using data on impairment at diagnosis and after a 2-year interval from MB patients released from MDT in the Western Region of Nepal. The WHO 1988 'disability' grading scale (0-2, for both eyes, hands and feet--six sites) was used as a measure of impairment. For the analysis, the WHO grades for the six sites were summed to form an EHF score (minimum 0, maximum 12). The sensitivity to change over time of the EHF score was compared with that of the 'method of maximum grades'. Using the 'method of maximum grades', 509/706 patients (72%) appeared not to have changed in impairment status, compared with only 399 (56.5%) with the EHF score. Improvement or deterioration of impairment status was missed in 113 patients (16%). In 216/706 patients (30.6%), the changes detected with the EHF score were bigger than those revealed by the method of maximum grades. The six components of the WHO impairment grading may be added up to form a EHF sum score of impairment. This score can be used to monitor changes in impairment status in individuals or in groups. It should be recorded and reported at least at diagnosis and release from treatment. Reporting could be done as the 'proportion of patients with improved EHF score', 'stable EHF score' and 'EHF score worse', and 'proportion of patients without impairment', 'proportion with WHO grade 1' and 'proportion with WHO grade 2'. It is recommended that the concepts and terminology of the WHO International Classification of Impairments, Activities and Participation (ICIDH-2) be adopted in the field of leprosy, particularly for the areas of prevention of impairment and disability and rehabilitation. The 'WHO disability grade' should be renamed 'WHO impairment grade'.