Strategy for elimination of leprosy in india..skpPresentation Transcript
DR.SUDHIRA KUMAR PARIDA
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.
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
As on Mar As on Mar.2001 2004As on 1981 PR: 3.74/10,000 PR:2.44/10,00PR: 57.60/10,000 0 As on Mar.2007 As on Mar 2009 PR: 0.72/10,000 Jammu& Kashmir PR:0.72/10,000 Punjab Chandigarh Himachal Pradesh Pradesh Elimination achieved in 32 out of 35 Uttaranchal Haryana Delhi Sikkim Arunachal Pradesh Uttar Pradesh Rajasthan Assam Nagaland States/Union Territories Bihar M eghalaya Manipur Jharkhand Tripura Gujarat MadhyaPradesh West Bengal Mizoram Chhattisgarh Daman &Diu Orissa Dadra& Nagar Haveli Maharashtra Andhra Pradesh Goa Karnataka Pondicherry Lakshadweep Tamil Kerala Nadu Andaman &Nicobar Islands
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)
Statewise distribution K a r UP TN 4% n a Bihar Odisha 5% t a UP 20% Maharashtra k MP 5% a WB 3 % AP Others 6% GujaratChhatisgarh 6% Chhatisgarh Bihar 14% Others Gujarat 6% MP Odisha AP 7% Mah arashtra 11% TN WB 9% Karnataka
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%
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.
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
Funding-GOI Technical support-WHO & ILEP(International federation of anti-leprosy association)
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
STATE LEVEL SOCIETIES are formed & funding to districts is done by these. In smaller states/UTs-district societies
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
ADVANTAGES: Patients detected early Patients treated early Transmission of infection interrupted early Development of deformities prevented Stigma reduced furtherNRHM & NLEP: Link person-ASHA Performance based incentive:
Training centers …CLTRI,Chengalputtu 3RLTRI(Raipur,gauripur,aska) Routine …. Diagnosis and MDT Specialised … RCS in Medical colleges Management training to DLOs
Proper history Thorough clinical exam. Lab confirmationNEW 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
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.
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.
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.
OBJECTIVES: Active participation of communities & clientsTARGETS & 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/impOTHER ACTIVITIES:o Women mobilizationo Old leprosy peoples‟ associationo Complain: toll-free no.
o Remedial & redressal measures.o Awareness within ptso Village level meetingso Health campso Cultural program:street theatre,folk music,puppet show,dance theatre,rallies & house visitso Community feasto Advocacy meetingso Sensitization of the media pesonso Motivate the youth to come forward & educate the community about leprosyo Inviting budding writers to write positive & motivational stories on leprosyo Door to door contact & counsellingo Advertisements through local newspapers,posters,wall writings
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
. WHO DISABILITY GRADING WHO Grade 0 1 2EYES Normal vision,lid Corneal reflex Reduced gap,blinking. weak vision,lagophthal mos.HANDS Normal sensation Loss of feeling in Visible & m.power. the palm damage:wounds, claw hand,loss of tissue etc.FEET Normal sensation Loss of feeling in Visible & m.power. the sole damage:wound,f oot drop,loss of tissue.
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.
- 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.
PRIMARY INDICATOR:- Annual New Case Detection Rate (ANCDR)- Treatment Completion Rate (cohort analysis)
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.
„‟REFERRAL SYSTEM IN NLEP‟‟
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. 5th MLEC: Feb-Mar‟04 in 8 high endemic states. Specific strategy is varied as per endemicity of region.
Carried out for 15 days in identified priority areas during Sep-Nov each yr. Made huge impact on:o Hidden case detectiono Better case mgto Imrovement in spreading the awarenesso Bringing down PR in high endemic areas.
For people living in special difficult to access areas or situation or neglected communities. Strategies: early detection & prompt MDT with proper IEC.
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
ILEP Members ILU LEA National Level NGOs: GMLF HKNS Local Voluntary Organisations
AREAS OF SUPPORT: Capacity Building Technical Support Referral services Rehabilitation IEC and Advocacy Infrastructure development Research Urban leprosy
WHO, Nippon Foundation, Novartis, World Bank, DANIDA, ILEP agencies National Governments &NGOs of endemic countries.
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
• 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
o Further reduce leprosy burden in the countryo Provide quality leprosy services through GHC systemo Enhance DPMR serviceso Enhance advocacy to reduce stigma and discriminationo Capacity building of GHC staffo Strengthening monitoring & supervision
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
www.who.int J.Kishore‟s national health programmes of india,9th ed. Park‟s text book of preventive & social medicine,21st ed. A guide for public health doctors(ALERT- INDIA:LEAP PUBLICATION)