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As integration of leprosy control programmes proceeds, general health staff will have responsibility for the diagnosis of most new cases of leprosy. The training required by these workers has not yet been set out in detail. In this paper the criteria for making the diagnosis of leprosy in the AMFES cohort of 594 new cases are examined. Since this study does not include details of suspects in whom leprosy was excluded on clinical grounds, true sensitivity and specificity values cannot be calculated, but the positive predictive value of the diagnostic criteria can be measured. Sensory loss in a typical skin patch is the most important sign of early leprosy, but was not present in 132 (49%) of the 268 cases with a positive skin smear. Thickening of the ulnar nerve is a valuable sign of leprosy in Ethiopia. It can be taught to health workers, who can practise by examining their own ulnar nerves. It is more likely to be present than nerve function impairment and is particularly important when skin smears are difficult to do or are unreliable. We recommend that five basic signs are used, the presence of any two being diagnostic of leprosy: Skin lesion(s) consistent with leprosy. Loss of sensation in such a lesion. Thickening of either ulnar nerve. Loss of sensation in the palm of the hand or the sole of the foot. The presence of acid-fast bacilli in skin smears. Exact policies for the diagnosis of leprosy should be worked out and validated for each national programme.

Which physical signs help most in the diagnosis of leprosy? A proposal based on experience in the AMFES project, ALERT, Ethiopia