Fitness to Work in a Hansen’s Disease Worker With a Disability: A Case Report
2024 Volume 46 Issue 2 Pages 215-220
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2024 Volume 46 Issue 2 Pages 215-220
Hansen’s disease not only causes problems for patients in the workplace, but also increases the possibility of transmission to other workers. This case report discusses the fitness-to-work assessment for a Hansen’s disease patient with a disability. A 19-year-old female, who worked as an online shop warehouse staff, presented at our hospital with a wound on her left hand accompanied by numbness. The patient’s activity indicated mild limitations with a SALSA score of 25. A seven-step process for evaluating fitness to work was conducted. These steps involved assessing the patient’s medical condition, disability, job demands, risks, and tolerance to determine the appropriate work status. This patient was declared fit to work with a note as online shop warehouse staff. She must take care of herself by maintaining good personal hygiene and consulting a doctor regularly, in addition to educating other workers about her condition and avoiding stigma. Routine examinations are also an important part of treating leprosy in the workplace.
Leprosy, also known as Hansen’s disease, is a chronic infectious disease caused by the Mycobacterium leprae (M. leprae) [1, 2]. This condition predominantly impacts the peripheral nerves and skin, but it may also extend its involvement to the ocular and upper respiratory tract mucosa. Multidrug therapy (MDT) regimens have contributed to a decline in the number of leprosy cases [1–3]. Nonetheless, the effective management of leprosy remains a challenge due to obstacles such as delayed detection, prolonged treatment period, patient non-compliance, and the occurrence of defects and leprosy reactions. Beyond its medical implications, leprosy presents far-reaching effects on the social, economic, cultural, and resilience aspects of a nation [4].
Based on the data provided by the World Health Organization (WHO) in 2020, a total of 127,558 new cases of leprosy were reported across 139 countries [3]. As of 2021, the prevalence rate of leprosy in Indonesia stands at 0.45 cases per 10,000 population. Remarkably, Indonesia successfully achieved leprosy elimination status, defined as a prevalence rate of less than one case per 10,000 population, since the year 2000. Despite this overall achievement, certain provinces in eastern Indonesia continue to encounter challenges in attaining leprosy elimination status [5].
One of the primary challenges in leprosy management is in the potential development of disabilities among affected individuals. Despite undergoing comprehensive treatment, there remains a risk of permanent disability, leading to a cycle of discrimination and social isolation for patients. In the workplace, leprosy not only causes problems for patients but also increases the possibility of transmission to other workers [6]. Workers with leprosy are therefore very vulnerable to being unemployed and living in deprivation, particularly when clinical manifestations and disability appear.
A 19-year-old female presented at our hospital with a wound on her left hand accompanied by numbness, which had been persistent for the past 2 weeks. She also reported the presence of lumps on her left leg for approximately 1 month, also accompanied by numbness. The patient had also been suffering clawing on the little finger and ring finger of the left hand since about 4 months before. Multiple ulcers with surrounding erythematous macules were observed in the dorsal region of the left hand, along with hypoesthesia and clawing of digits IV–V. In addition, there was erythema nodosum with hypoesthesia in the lateral area of the left foot.
Nerve thickening was identified in the ulnar nerve and the left posterior tibial nerve. The patient’s activity limitation was assessed using the SALSA (Screening Activity Limitation and Safety Awareness) score, which yielded a score of 25, indicating mild limitation [7, 8]. The results of an Acid-Fast Bacilli (AFB) examination were negative, while a gram stain examination showed positive gram coccus findings in the area of the ulcer wound. The patient was diagnosed with Hansen’s disease Borderline Tuberculoid type with a bacterial ulcer on the left hand. She was treated using the MDT combination with an MB (Multi Bacillary) regimen, once daily for 12 months. The patient was right-handed and was working as an online shop warehouse staff. Her duties included collecting data, maintaining an inventory of items, preparing orders, and also packing goods. Regarding her medical condition, the supervisors advised her to take medication and consult with a doctor before starting work again.
In determining the fitness-to-work status of this patient, a comprehensive analysis was required in the form of a seven-step approach to assess the fitness to work and return to work. The Indonesian Association of Occupational Medicine Specialists’s Guidelines for fitness to work as shown in Figure 1, was used to assess this patient [9].
Seven-step fitness to work and return to work assessment.
In the first step, the job description for this patient should be elaborated on. Arriving at work, the patient tidied up and prepared the work area in the computer room and coordinated with superiors and other colleagues. The patient would collect data and take an inventory of existing items. The patient did this by taking notes in a book, which were then inputted into the computer. After that, the patient helped prepare orders and pack goods in the warehouse area. There was plastic to wrap the inside of the packing, which was then wrapped again with another piece of plastic before applying adhesive tape. Items that were at risk of damage were wrapped using cardboard material or bubble wrap to protect them.
For the second step, we need to understand about the job demand. In the physical aspect, based on the 2011 Compendium of Physical Activities, the patient’s activities include standing, light (bartending, store clerk, assembling, filing, duplicating), standing and talking at work, which required 3.0 METs of sustained work [10]. Other aspects that need to be assessed in job demands include muscle strength, motor, sensory aspects, mental, work environment, organization, and temporal aspects.
The third step would be the assessment of the patient’s medical status. Currently, the patient’s physical condition was skin abnormalities with multiple ulcers, an irregular shape, a widest diameter of 3 cm in the dorsal region of the left hand, interphalangeal digits IV–V with hypoesthesia, an erythematous macula, and claw hand digits IV–V. On the lateral side of the left foot there was a lump, hyperemic, with hypoesthesia but no wounds or ulcers.
She had a decrease in muscle strength accompanied by a decrease in motor skills in the little and ring fingers of the left hand, associated with claw hands. The findings were that the activity limitations were only mild and the patient was still able to carry out most of her activities independently. Steps two and three of the assessment are shown in more detail in Table 1.
| Job Demand | Health Condition | |
|---|---|---|
|
Physical Capacity |
|
|
Muscle strength |
|
|
Motor |
|
|
Audiovisual |
|
|
Mental |
|
|
Work Environment |
|
|
Organization |
|
|
Temporal |
|
SALSA: Screening Activity Limitation and Safety Awareness
Impairment, disability, and handicap assessment is the fourth step in assessing a patient’s fitness to work. The impairment in this patient was related to Hansen’s disease borderline tuberculoid (BT) type with bacterial ulcers and claw hands on the left hand. In the aspect of disability, there was impaired function of the fingers IV–V of the left hand and disturbances in grasping or reaching for objects, based on the WHO category, including disability level 2 with the discovery of ulcers and claw hands on the extremities. The patient depends to others for only a small part of her work activities.
The fifth step in assessing a fitness to work is determining the risks for the patient, her colleagues, and the working environment. If the patient continues to work under the current conditions, there will be a risk of the ulcers getting worse if the wound is open, and a potential risk of psychological disorders due to discrimination from her co-workers. This condition will also increase the risk of transmitting infection to co-workers and superiors.
The sixth step is to determine the worker’s tolerance as well as that of the workplace. Currently, the patient is still enthusiastic about working, despite a slight decrease in performance due to the decreased function of the left hand’s IV–V digits. Supervisors and co-workers support her by suggesting treatment and consulting a doctor before resuming work. In the seventh step, based on considerations from the previous steps, the patient was declared fit with notes. Activity adjustments are needed so this patient does not lift or pack large items herself, and risk control is also needed to prevent disease transmission to co-workers.
A medical fitness for work assessment’s main goal is to determine if a person is healthy enough to carry out the tasks at hand without risk to their own or others’ health and safety. Workers with disabilities are commonly found to be highly motivated, often with excellent work and attendance records. When medical fitness for work is assessed, the loss of function that results from the ailment typically matters more than the actual medical illness. Unsafe working conditions may be a direct cause of illness and poor health. Improvements in health and safety risk management could prevent much avoidable sickness and disability [11].
The mechanism of leprosy transmission remains inadequately understood, with prevailing theories proposing inhalation of droplets containing M. leprae. Apart from that, some believe that this bacteria can also be transmitted through direct contact with the skin. Host immunity emerges as an important factor in disease progression and control, as evidenced by the fact that up to 95% of individuals exposed to M. leprae do not develop the disease. The incubation period varies widely, spanning from 2 to 20 years, or even longer [2, 12].
The WHO recommends treating leprosy with MDT regularly, with control from medical staff to assess adherence and side effects. Leprosy chemoprophylaxis in the form of a single dose of rifampicin is a drug intended for the prevention of leprosy that is given to vulnerable groups, including family and co-workers. Leprosy prevention is also associated with administering the BCG vaccine. Providing chemoprophylaxis and administering the BCG vaccine at birth can reduce the risk of transmission to contacts by 57–80%. Providing BCG re-vaccination in adults in combination with chemoprophylaxis has also been introduced and is expected to provide better protection to contacts as well as maintaining personal hygiene in patients [2, 13]. This issue is important to understand as a basis for making a fitness-to-work assessment regarding the risk of infection to other workers, in addition to the disability problems experienced by the patient.
A cross-sectional study by De Souza et al in 2016 showed that the WHO disability assessment system is related to limitations in functional activities but not to participation in leprosy patients. Participation is a complex matter with a wider influence than other factors, including psychosocial factors. The SALSA scale score was highly correlated with the level of disability (P<0·0001) but not with the participation score (P>0.05) [14].
Screening Activity Limitation and Safety Awareness is used as a valid instrument to assess activity limitations in leprosy patients. The scale presented here will produce an overall score called the SALSA score, which is an assessment of activity limitations and alertness/awareness of safety. A low score indicates that there are few difficulties faced in daily life activities, while a high score indicates a high level of activity limitations. This instrument, which has been validated in Indonesia, consists of 20 questions, covering mobility, self-care, and work/skills, answered according to the scoring listed below. Scores range from 0-80, with the following categories:
A study by Menaldi et al in 2022 showed that there were significant differences in SALSA scores based on age, with younger people (<30 years) having lower limitations (P=0.014). Other differences in SALSA scores were also found by level of education (P=0.005), occupation (P<0.001), and WHO disability level (P<0.001). Limited functional activity is also significantly correlated with unemployment, with an OR of 2.59. The study concluded that people suffering from leprosy tend to have limited functional activities, especially the elderly, the uneducated, the unemployed, and those with more severe disabilities. If they can overcome their barriers to functional activities, they will have better job opportunities [8].
Moreover, van Brakel’s study in 2012 highlighted that, apart from the severity of impairment, the primary determinant of social participation in individuals affected by leprosy is the stigma that comes from the social environment [16]. As a result, in addition to the physical aspects, the questionnaire assessment needs to be carried out immediately when the control patient seeks treatment at the next visit. Identifying any psychological or psychosocial issues experienced by patients is vital and necessary to provide better intervention and education to colleagues and superiors and the community.
This patient with Hansen’s disease, classified with level 2 disability according to WHO criteria and possessing a SALSA score of 25, indicating mild limitations, was declared fit with note as an online shop warehouse staff. Recommendations for the patient include maintaining personal hygiene, using surgical masks, and routinely consulting a dermatologist to evaluate treatment and side effects. Furthermore, education needs to be given to all workers regarding the patient’s condition to avoid stigmatization, along with the use of masks for workers. Routine screening of other workers based on symptoms or complaints, and recommending prophylactic treatment may be considered part of a comprehensive approach to managing leprosy in the workplace.
No sources of funding were present in this study.
The authors declare no conflicts of interest.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
