STRATEGY FOR ELIMINATION OF LEPROSY IN INDIA..skp

STRATEGY FOR ELIMINATION OF LEPROSY IN INDIA: 

STRATEGY FOR ELIMINATION OF LEPROSY IN INDIA DR.SUDHIRA KUMAR PARIDA

INTRODUCTION: 

WORLD : Over past 20 yrs, 14 million pts cured;4million since 2000. PR has dropped by 90%(1985:21.1/10,000 .2000:1) Globan burden has declined dramatically(1985:5.2million cases,2009:2.04lakh) Has been Eliminated from 119 of 122 countries. To date,there has been no resistance to MDT Efforts currently focus on eliminating leprosy at a national level in remaining endemic countries & at a sub-national level from others. INTRODUCTION

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2009: 2,44,796 new cases Registered prevalence at the beginning of 2010:2,11,903 No. of new cases in 2009 in 16 countries that reported 1000 new cases accounted for 93% of all new cases Among new cases in 2009: MB-67.93%(SEAR:42.89% in Bangladesh to 82.43% in Indonesia) Proportion of females among newly detected cases in 2009 was 43.71%(SEAR:33.13% in Timor to 43.52% in Sri Lanka) Proportion of children15 yrs was 10.97%(SEAR:3.67% in Thailand to 12% in Indonesia) Proportion of new cases with grade2 disability was 7.04%(SEAR:3.08% In India to 14.9% in Myanmar) No. of relapses remained low at 1.52% SEAR : 58.8% of global prevalence at the beginning of 2010 67.8% of all new cases in 2009

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As on 1981 PR: 57.60/10,000 As on Mar.2001 PR: 3.74/10,000 As on Mar.2007 PR: 0.72/10,000 Elimination achieved in 32 out of 35 States/Union Territories As on Mar 2004 PR:2.44/10,000 As on Mar 2009 PR:0.72/10,000

PREVALENCE vs ANCDR: 

PREVALENCE vs ANCDR

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INDIA : By the end of March 2009: 0.86 lakh cases were on record PR: 0.72/10,000 1.34 lakh new cases were detected in 2008-09 ANCDR:1.119/10,000 New cases in 2008-09: 48%-MB,10.1%-child,35.2%-females,2.8%-visible deformity After introduction of MDT,case load has come down from 57.6/10,000 in 1981 to 1 at national level in DEC 2005 . 32 states/UTs have achieved the status of elimination. Only 3 states/UTs: Bihar,Chhatisgarh & D&N Haveli with PR 1-2.5/10,000 ARE YET TO ACHIEVE(10.4% 0f country’s population,20% of new cases)

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MP 5% Odisha 5% TN 4% Karnataka 3%

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ODISHA : By Mar 2011, Total population-4.19 crores PR-0.85/10,000 (13 districts: 1,highest- Nuapada 1.58,lowest-Gajapati 0.22,Sambalpur-1.45) ANCDR-1.61/10,000. (Sambalpur-1.45) Among newly detected cases, Gr.I deformity-3.71%,Gr.II-3.87%,MB-46.48%,Child cases-9.34%,females-36.62%,SC -20.26%,ST-26.22%

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Leprosy meets the demanding criteria for elimination: practical and simple diagnostic tools: can be diagnosed on clinical signs alone; the availability of an effective intervention to interrupt its transmission: MDT a single significant reservoir of infection: humans.

MILESTONES OF NLEP IN INDIA: 

1955 – Launched National Leprosy Control Programme 1983 – Launched National Leprosy Eradication Programme and introduced MDT 1991 – WHO declaration to eliminate leprosy at global level by 2000 . 1993 – World Bank supported NLEP – I 2001 – World Bank supported NLEP – II Integration of Leprosy services with General Health Care System 2002 - National Health Policy Statement : Elimination of Leprosy by 2005 Dec.2005 – Elimination of leprosy as public health problem at National level. Since Jan 2005 - Programme continues with GOI support MILESTONES OF NLEP IN INDIA

NLEP: 

Funding-GOI Technical support-WHO & ILEP(International federation of anti-leprosy association) NLEP

STRATEGIES FOR ELIMINATION OF LEPROSY IN INDIA: 

Decentralization of NLEP services Integration of NLEP with General Health Care System Capacity building of GHS functionaries Early diagnosis & prompt MDT Intensified IEC using Local and Mass Media Prevention of Disability & Medical Rehabilitation (DPMR) Monitoring & Evaluation STRATEGIES FOR ELIMINATION OF LEPROSY IN INDIA

DECENTRALIZATION OF NLEP SERVICES: 

STATE LEVEL SOCIETIES are formed & funding to districts is done by these. In smaller states/UTs-district societies DECENTRALIZATION OF NLEP SERVICES

INTEGRATION OF NLEP WITH GENERAL HEALTH CARE SYSTEM: 

Integration means to provide “comprehensive” essential services from one service point: to improve pts access to leprosy services and thereby ensure timely Tt to remove the “special” status of leprosy as a complicated and terrible disease to consolidate substantial gains made to ensure that all future cases receive timely and correct Tt to ensure that leprosy is treated as a simple disease INTEGRATION OF NLEP WITH GENERAL HEALTH CARE SYSTEM

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ADVANTAGES : Patients detected early Patients treated early Transmission of infection interrupted early Development of deformities prevented Stigma reduced further NRHM & NLEP : Link person-ASHA Performance based incentive:

CAPACITY BUILDING OF GHS FUNCTIONARIES: 

Training centers … CLTRI,Chengalputtu 3RLTRI( Raipur,gauripur,aska ) Routine …. Diagnosis and MDT Specialised … RCS in Medical colleges Management training to DLOs CAPACITY BUILDING OF GHS FUNCTIONARIES

EARLY DIAGNOSIS & PROMPT MDT: 

Proper history Thorough clinical exam. Lab confirmation NEW CASE : a person having skin patch( es ) with a definite loss of sensation & has not received a course of MDT. Classification for Tt : (WHO CLASSIFICATION/FIELD CLASSIFICATION) PB MB EARLY DIAGNOSIS & PROMPT MDT

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PB MB

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 95% of cases can be diagnosed clinically even by paramedical workers Skin smears for M.leprae would assist in detecting suspected infectious cases Biopsy/PCR may be needed rarely Detection of 5-10% skin smear  ve leprosy pts is more imp. as they infect others. If no smear facility, detect 30-40% of infectious cases with multiple skin lesions but intact sensation.

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LEPRA REACTION : May occur before/during/after MDT. Not caused by MDT. Do not stop MDT. Type1 (Reversal reaction) Type2 (ENL) Treat ‘Reaction’ as a Medical Emergency : Rest & Analgesics DOC- Prednisolone (40-60 mg) Taper gradually over 12-16 wks. All need a detailed Neuromuscular assessment by a physiotherapist.

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RELAPSE: a pt who has completed the required course of MDT & who is taken as having been treated, but in whom s/s of leprosy reappear either during surveillance period or thereafter. A Confirmed case should be treated with MDT again depending upon classification. DEFAULTER: a pt who has not collected MDT for 12 consecutive months . Adequate efforts should be made to trace & persuade each to return for assessment & Tt before their removal from register.

INTENSIFIED IEC USING LOCAL & MASS MEDIA: 

OBJECTIVES: Active participation of communities & clients TARGETS & PRIORITIES : Community-at large & selected communities where stigma is more deep rooted Leprosy pts General health care staff Local NGOs & CBOs DPOs(Disabled peoples organizations) IPC-m/imp OTHER ACTIVITIES : Women mobilization Old leprosy peoples’ association Complain: toll-free no. INTENSIFIED IEC USING LOCAL & MASS MEDIA

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Remedial & redressal measures. Awareness within pts Village level meetings Health camps Cultural program:street theatre,folk music,puppet show,dance theatre,rallies & house visits Community feast Advocacy meetings Sensitization of the media pesons Motivate the youth to come forward & educate the community about leprosy Inviting budding writers to write positive & motivational stories on leprosy Door to door contact & counselling Advertisements through local newspapers,posters,wall writings

PREVENTION OF DPMR: 

The best way to prevent disabilities is: Secondary prevention i.e.,early diagnosis and prompt treatment with MDT Inform patients (specially MB) about common s/s of reactions Ask them to come to the centre (as soon Start treatment for reaction as possible) Inform them how to protect insensitive hands/ feet /eyes Involve family members PREVENTION OF DPMR

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. WHO Grade 0 1 2 EYES Normal vision,lid gap,blinking . Corneal reflex weak Reduced vision,lagophthalmos . HANDS Normal sensation & m.power . Loss of feeling in the palm Visible damage:wounds,claw hand,loss of tissue etc. FEET Normal sensation & m.power . Loss of feeling in the sole Visible damage:wound,foot drop,loss of tissue. WHO DISABILITY GRADING

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Disabilities such as loss of sensation and deformities of hands/feet/eyes occur because: Late diagnosis and late treatment with MDT Advanced disease (MB leprosy) Leprosy reactions which involve nerves Lack of information on how to protect insensitive parts.

CARE OF EYES: 

CARE OF EYES

CARE OF HANDS: 

CARE OF HANDS

CARE OF FEET: 

CARE OF FEET

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- Measurement of persons with disabilities - Comprehensive approach to rehabilitation in co-ordination with MOSJ&E - Community based rehabilitation - Increased access to DPMR services at first, second and third level Institutions. - Payment of Rs. 5000/- to poor patients for each major RCS to compensate for wage loss. - Reimburse funds upto Rs. 5000/- for each surgery to Govt. Hospitals to facilitate RCS operations.

MONITORING & EVALUATION: 

PRIMARY INDICATOR: Annual New Case Detection Rate ( ANCDR ) Treatment Completion Rate (cohort analysis) MONITORING & EVALUATION

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INDICATORS FOR CASE DETECTION: Proportion of new cases with Gr II disability Proportion of child cases( 15yrs) among new cases Proportion of MB cases among new cases Proportion of Female cases among new cases INDICATORS FOR QUALITY OF SERVICE: Proportion of new cases correctly diagnosed. Proportion of defaulters. Number of relapses during a year. Proportion of cases with new disabilities.

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‘’REFERRAL SYSTEM IN NLEP’’

MODIFIED LEPROSY ELIMINATION CAMPAIGN(MLEC): 

Organising camps for 1 or 2 wks duration Services available: case detection,Tt & referral Mass media Quite effective in case finding & has been employed during phase-II. 5 th MLEC: Feb-Mar’04 in 8 high endemic states. Specific strategy is varied as per endemicity of region. MODIFIED LEPROSY ELIMINATION CAMPAIGN(MLEC)

BLOCK LEPROSY AWARENESS CAMPAIGNS (BLAC): 

Carried out for 15 days in identified priority areas during Sep-Nov each yr. Made huge impact on: Hidden case detection Better case mgt Imrovement in spreading the awareness Bringing down PR in high endemic areas. BLOCK LEPROSY AWARENESS CAMPAIGNS (BLAC)

SPECIAL ACTION PROJECTS FOR THE ELIMINATION OF LEPROSY(SAPEL) : 

For people living in special difficult to access areas or situation or neglected communities. Strategies: early detection & prompt MDT with proper IEC. SPECIAL ACTION PROJECTS FOR THE ELIMINATION OF LEPROSY(SAPEL)

LEPROSY ELIMINATION CAMPAIGNS(LEC) FOR URBAN AREAS: 

GOI provides assistance to urban areas with 1lakh population. Urban areas:townsship I,medium cities I&II,Mega cities. Leprosy Elimination in urban areas is challenged by - rapid increase in population, migration, slums, density, poor living conditions and violence, favorable to maintain reservoir of infection and transmission difficulty in finding hidden cases, relapse and Tt completion, private health care participation LEPROSY ELIMINATION CAMPAIGNS(LEC) FOR URBAN AREAS

INVOLVEMENT OF NGOs: 

ILEP Members ILU LEA National Level NGOs:  GMLF  HKNS Local Voluntary Organisations INVOLVEMENT OF NGOs

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AREAS OF SUPPORT : Capacity Building Technical Support Referral services Rehabilitation IEC and Advocacy Infrastructure development Research Urban leprosy

PARTNERS OF NLEP: 

WHO, Nippon Foundation, Novartis, World Bank, DANIDA, ILEP agencies National Governments &NGOs of endemic countries. PARTNERS OF NLEP

FACTORS HELPED IN REACHING ELIMINATION: 

Strong political commitment. Availability of adequate resources. Support from partners in NLEP like WHO, World Bank, ILEP, The Nippon Foundation, Novartis, and NGOs. Strategic planning and timely implementation of the activities. Special campaigns in vulnerable areas : MLEC/BLAC FACTORS HELPED IN REACHING ELIMINATION

POST ELIMINATION ISSUES: 

Continued transmission Early detection of MB case, relapse,R resistance Sub clinical infection, carriers Eradication model Early detection & treatment of reactions Prevention of nerve damage Prevention & Care of disabled Patients Dissatisfaction for residual signs after MDT Immunoprophylaxis Chemoprophylaxis Immunotherapy POST ELIMINATION ISSUES

11TH PLAN(2007-12): 

Further reduce leprosy burden in the country Provide quality leprosy services through GHC system Enhance DPMR services Enhance advocacy to reduce stigma and discrimination Capacity building of GHC staff Strengthening monitoring & supervision 11 TH PLAN(2007-12)

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NEW PARADIGMS ARE IN CONFORMITY WITH WHO OPERATIONAL GUIDELINES 2006-2010: Providing quality services Sustainable Leprosy services through the PHC System . Referral services and long term care

REFERENCES: 

www.who.int J.Kishore’s national health programmes of india,9 th ed. Park’s text book of preventive & social medicine,21 st ed. A guide for public health doctors(ALERT-INDIA:LEAP PUBLICATION) REFERENCES

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