DR. I. SELVARAJ I. R. M. S B. Sc. ,M. B. B. S. ,D. P. H. ,D. I. H DR.I.SELVARAJ I.R.M.S B.Sc.,M.B.B.S.,D.P.H.,D.I.H.,PGCH&FW/NIHFW/NEW DELHI Senior Divisional Medical Officer, Railway Hospital, Chennai Division, Southern Railway, India.

LEPROSY It is a chronic infectious disease caused by M.leprae, an acid fast, rod shaped bacillus. It mainly affects the skin, peripheral nerves, and mucosa of the respiratory tract etc., It has left behind a terrifying image in history and human memory of mutilation, rejection and exclusion from society.

Global Leprosy Situation 1998  

Leprosy Situation in South East Asia 2001   Leprosy Situation in South East Asia 2001 Thailand 2251 797 0.4 1.3 Country Point Prevalence Cases detected during the year 2001 Prevalence per 10000 Detection per 100000 Bangladesh 8537 10740 0.6 8.2 Bhutan 40 19 0.2 0.9 India 439782 617993 4.3 60.1 Indonesia 17259 13286 0.8 6.2 Myanmar 8237 9684 1.8 21.0 Nepal 10657 13830 4.4 56.5 Sri Lanka 1570 2309 12.1 Total 488333 668658 3.2 43.7  

Global Leprosy Situation in 2001*   Global Leprosy Situation in 2001* Region Point Prevalence Cases detected during the year 2001 Africa 45170 39612 Americas 83101 42830 East Mediterranean 7007 4758 South East Asia 488333 668658 Western Pacific 7735 4786 Europe 38 53 World 635404 763317 * As reported by 106 countries.

Prevalence of Leprosy in SEA Region as of April 2001     

GOAL AND OBJECTIVE OF LEPROSY ERADICATION PROGRAMME Goal: elimination of leprosy i.e.to reduce the prevalence rate to less than I per 10000 population by the year 2000 AD. Objective: To arrest disease activity in all the known cases of leprosy by the year 2000AD Strategy: The elimination strategy

CONTROL OF LEPROSY It means no longer to be a public health problem

ERADICATION OF LEPROSY It is defined as interruption of transmission of leprosy to attain a stage of zero level

ELIMINATION OF LEPROSY The elimination of leprosy as a public health means reducing the prevalence of leprosy to below on case per 10000 population. Elimination of leprosy will be achieved by: Making MDT accessible to all communities and areas. Treating all registered cases with MDT Diagnosing and promptly treating all new cases Improving quality of patient care, including disability prevention and management Ensuring reqularity and completion of treatment Enlisting community support for the programme

INCIDENCE OF LEPROSY Incidence is the number of new cases (only the new cases) of a particular disease that occur in a defined population over a defined period of time. The time period used is conventionally one year.

Point Prevalence Period Prevalence PREVALENCE OF LEPROSY Point Prevalence Period Prevalence

Point prevalence The number of persons with a disease at a specified point in time in a defined Population

Period prevalence The number of persons with a disease in a defined population within a specified period of time

SUSPECT CASE OF LEPROSY One or more suggestive skin patches with normal sensation Extensive loss of sensation in the hands or feet with no other evidence of leprosy One or more grossly enlarged peripheral nerve trunks with no sensory loss or skin lesion Painful nerves with no other evidence of leprosy Painless ulcers on hands and/or feet with no other evidence of leprosy Nodules on the skin with no other evidence

WHO IS LIKELY TO REPORT TO THE HEALTH CENTRE Leprosy cases who were never treated before Leprosy cases who had treatment with dapsone in the past Leprosy cases who had treatment with MDT in the past Suspect cases With other skin lesions Other conditions causing nerve damage Contacts of leprosy patients for check up Normal individual for information

How to examine for leprosy? Examine in a well-lit room Examine the whole body Ask since when the patch was noticed Ask what treatments have been tried Test for sensation Look for any visible deformities

How to diagnose leprosy Examine skin Check for patches Test for sensation Count the number of patches Look for damage to nerves

DIAGNOSIS OF LEPROSY Hypopigmented or reddish skin lesion(s) with definite loss of sensation Damage to the peripheral nerves, as demonstated by loss of sensation Weakness of the muscles of hands, feet or face Positive skin smear

FLOW CHART FOR DIAGNOSIS AND CLASSIFICATION

Leprosy - one of the few diseases which can be eliminated 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: multidrug therapy a single significant reservoir of infection: humans.

Elimination strategy Providing domicillary MDT to all communities and areas Breaking the chain of transmission by intensive case detection and promptly treatment activities Improving quality of patient care, including disability prevention and management Ensuring regularity and completion of treatment Encouraging and ensuring community participation Providing rehabilitation to the needy patients Organising health education to patients , their families and community.

ADVANTAGES OF MDT Highly effective in curing the disease Reduces the period of treatment Well accepted by patients Easy to apply in the field Prevents development of drug resistance Interrupts transmission of infection Reduces risk of relapse Prevents disabilities Improves community attitude

POINTS ON MDT TREATMENT Every leprosy patient should receive tratment with more than one antileprosy drug Standard MDT is very safe and effective It is available free of charge for leprosy patients Standard MDT is for a fixed duration At the completion of a full course of MDT the patient is cured Use clinical criteria to classify and decide the treatment regimen If in doupt of classification, give MB treatment regimen Active follow-up after completion of treatment is not necessary In case of relapse, re-treat with appropriate standard MDT regimen

Treatment regimens PB Adult (6 blister packs) to be taken monthly within a maximum period of 9 months Rifampicin 600 mg once a month Dapsone 100 mg every day MB Adult (12 blister packs) to be taken monthly within a maximum period of 18 months Clofazimine 300 mg once a month Clofazimine 50 mg and dapsone 100 mg every day SLPB Single dose ROM Rifampicin 600 mgm Ofloxacin 400 mgm Minocyclin 100 mgm

Multi Drug Therapy

When treatment is completed Congratulate the patient Thank family/friends for their support Reassure that MDT completely cures leprosy Any residual lesions will fade away slowly Show them how to protect anaesthetic areas and/or disabilities Encourage to come back in case of any problem Tell that they are welcome to bring other members of family or friends for consultation Remove the patient’s name from the treatment register

ORGANISING MDT SERVICES Updating register Screening patients Selecting MDT regimen Preparing treatment register Delivering MDT to patients Managing MDT supply estimating MDT requirements procuring storage Shelf life Keeping records

ASSESSING PROGRESS WITH MDT IMPLEMENTATION MDT COVERAGE Number of patients cured with MDT Defaulters MDT drug utilisation Regular and uninterrupted supply of drugs is very important for MDT programme

PROVISION OF EFFICIENT HEALTH SERVICES Diagnose leprosy and classify the disease clinically Recognise and manage the common complications of the disease Identify and refer serious complications To ensure regular supply of MDT Maintain proper recording and reporting Organise convenient locations and timing of the clinics Maintain cardial and friendly relations with all patients and the local community Ensure commitment and motivation to eliminate leprosy from the area

MONITORING INDICATORS Point Prevalence Rate – Indicator of magnitude of the problem Monthly&Annual New Case detection rate –Indicator of impact of the programme Proportion of children among new cases – Indicator of early detection Proportion of new cases with deformity – Indicator of effectiveness of programme implementation Proportion of MB among new cases – Indicator of late detection Prevalence discharge ratio – Indicator of progress of the programme related to cure Clinic attendance –Indicator of regularity of treatment

Why integrate leprosy into the general health services? Integration means to provide “comprehensive” essential services from one service point to improve patients’ access to leprosy services and thereby ensure timely treatment 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 treatment to ensure that leprosy is treated as a simple disease

Why coverage is important? Good coverage means that: health facilities are easily accessible to every member of the community health services are provided on a daily basis health workers are able to diagnose, cure and provide basic information about the disease health facilities are distributed equally in all areas urban/rural, male/female, poor/rich, tribal/others, etc.

Advantages of Integrating Leprosy Services Transmission of infection interrupted early Stigma reduced further Development of deformities prevented Patients treated early Patients detected early

Why disabilities occur? 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

Disabilities can be prevented The best way to prevent disabilities is: early diagnosis and prompt treatment with MDT Inform patients (specially MB) about common signs/symptoms of reactions Ask them to come to the centre Start treatment for reaction Inform them how to protect insensitive hands/ feet /eyes Involve family members in helping patients

MORE FACTS ABOUT LEPROSY-1 NATIONAL LEPROSY CONTROL PROGRAMME WAS STARTED IN 1955 NATIONAL LEPROSY ERADICATION PROGRAMME WAS RENAMED IN 1983 PREVALENCE OF LEPROSY IN INDIA WAS 57/10000 IN 1981 AFTER MDT INTERVENTION, IT WAS REDUCED TO 5.07/10000 IN MARCH,2000 A TOTAL OF 8.84 MILLION PATIENTS CURED WITH MDT 19 STATES HAVE ACHIEVED ELIMINATION BY 2000 8 STATES ARE LIKELY TO ACHIEVE BY 2002 5 STATES BY 2005 CURRENT STRATEGY IS (MLEC) COMPAIGN IN 30 STATES MLEC-1 WAS LAUNCHED IN 1997-1998 MLEC-2 WAS CONDUCTED IN 1999-2000 ABOUT 2,20,000 WERE DETECTED WHICH ARE NOW BEING TREATED 3,76,000 PARAMEDICAL PERSONNEL INCLUDING DOCTORS AND 3,78,000 VOLUNTEERS WERE TRAINED SAPEL PROGRAMME IN INACCESSIBLE AREAS

MORE FACTS ABOUT LEPROSY-2 FOUR LEPROSY VACCINES ARE CURRENTLY IN TRAIL 1)BCG –34.1% PROTECTION 2)BCG+KILLED M.LEPRAE – 64.0% 3)M.W – 25.7% 4)ICRC – 65.5% 70% LAI are concentrated in the states of Bihar,UP,WB,Orissa,and MP.Bihar alone is having 32% recorded cases of LAI IN INDIA The prevalence of leprosy in PUNJAB,NAGALAND,and HARYANA is 1 per 10000 7 CONTROLLED TRAILS AND 9 CASE –CONTROL STUDIES EVALUATING THE ROLE OF BCG IN PREVENTION OF LEPROSY WERE CARRIED OUT AROUND THE WORLD