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

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

0.8

12.1

Thailand

2251

797

0.4

1.3

Total

488333

668658

3.2

43.7

Global Leprosy Situation in 2001* Region

Africa
Americas East Mediterranean South East Asia Western Pacific Europe World

Point Prevalence
45170 83101 7007 488333 7735 38 635404

Cases detected during the year 2001

39612 42830 4758 668658 4786 53 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.

PREVALENCE OF LEPROSY

1. Point Prevalence 2. 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
Examine

in a well-lit room
the whole body

Ask
Ask

since when the patch was noticed

what treatments have been tried

Test

for sensation
for any visible deformities

Look

How to diagnose leprosy

Examine Check Test

skin

for patches

for sensation the number of patches

Count 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

SKIN LESION AND SENSORY LOSS - LEPROSY

ONE SKIN LESION SLPB leprosy

2-5 SKIN LESION PB LEPROSY

More than 5 lesions MB LEPROSY

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 Dapsone

600 mg once a month

100 mg every day

MB

Adult

(12 blister packs) to be taken monthly within a maximum period of 18 months

Rifampicin

600 mg once a month 300 mg once a month 50 mg and dapsone 100 mg every day

Clofazimine Clofazimine SLPB Single

dose ROM 600 mgm 400 mgm

Rifampicin Ofloxacin

Minocyclin

100 mgm

Multi Drug Therapy

When treatment is completed

Congratulate Thank

the patient

family/friends for their support that MDT completely cures leprosy

Reassure Any

residual lesions will fade away slowly

Show

them how to protect anaesthetic areas and/or disabilities

Encourage Tell

to come back in case of any problem

that they are welcome to bring other members of family or friends for consultation
Remove

the patients name from the treatment

register

ORGANISING MDT SERVICES a) b) c) d) e) 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
to

means to provide comprehensive essential services from one service point

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 health

services are provided on a daily basis

workers are able to diagnose, cure and provide basic information about the disease
health

facilities are distributed equally in all

male/female, poor/rich, tribal/others, etc.

areas
urban/rural,

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 Leprosy Lack

disease (MB leprosy)

reactions which involve nerves

of information on how to protect insensitive

parts

Disabilities can be prevented

The

best way to prevent disabilities is:

diagnosis and prompt treatment with MDT

early

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