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									Leprosy elimination in Nepal




                     Dr B N Reddy
                   WHO Country Office
                         Nepal
                  Headlines
 Control / Eradication / Elimination / Eradication
 Few relevant historical facts
 Where are we now
 Journey so far
 Obstacles to elimination
 Proposed solutions
 Summary
   Leprosy: Control / Eradication /
      Elimination / Eradication

Purposeful reduction in the number of
 cases to such a low level that

It is acceptable (Contr.)
PR is < 1. (Elim.) (No public health problem ?)
Transmission ceases. (Erad.)
                   Indicator
Point Prevalence rate
    - Estimated prevalence rate.
    - Registered case prevalence rate.

From 1 / 1000    to   1 / 10 000


“ 1 ” Arbitrary or epid. & oper significant !!!
             Programme Strategy
   Primordial Prevention
        X

   Primary Prevention         BCG unintentional ?
           ???

   Secondary Prevention       Early detection and prompt
          +++                   treatment

                             Limitation of disabilities
   Tertiary Prevention
            ++               Rehabilitation
        Few historical facts
Countries have eliminated leprosy
 With no effective chemotherapy.
 With Dapsone mono therapy.
 With Indefinite MDT.
 With fixed MDT.


  MDT is most important factor in leprosy
   transmission reduction but not the only
                   factor
           Where are we now ?
       FWDR                        FWDR
        11% EDR                MWDR 9%    EDR
    MWDR
            25%                 8%        28%
     12%
                  R C 3786      WDR
    WDR                                         N C 4317
                                15%
    14%
            CDR                       CDR
            38%                       40%


 Two thirds are from EDR & CDR.
 Over 80 % of the cases are from terai region.
       Where are we ? Case distribution
1.56    1.58                          1.68    1.45
                              1.32
                 1.05
                                                     Prevalence rate
                                                      > 1 in all regions.
        Regionw ise PR (14/7/07
                                                      Highest in FWDR
EDR     CDR      WDR      MWDR        FWDR   Nepal    Least in WDR
          1427

939
                         Registered cases
                        542
                                     449     419
                                                     Number of reg. cases
                                                      Highest in CDR in
EDR        CDR          WDR          MWDR    FWDR
                                                      Least in FWDR
  Where are we? Case distribution
                      2         1.86
NCDR                                                                1.59     1.65
                                         1.28

Highest (2) in EDR                                    1.07



Least (1.07) in WDR
                              Regionwise NCDR 2006/07
                      EDR       CDR      WDR          MWDR      FWDR        Nepal



                                  1689
                       1206

New case Detection                        New case detection 2006/07
                                                661

Maximum (1689) CDR                                            364          397



Minimum (364) MWDR     EDR         CDR          WDR          M WDR         FWDR
Where are we? District wise
             endemicity
                  >3
                  1%


         2 to 3
         17%




                        <1
        1 to 2
                       57%
        25%
         Journey so far: 3rd qrtr trend

                    10.7
                                       Why increased?

                                         No surprises from
                                         disabled bacteria
Qrtr 1     Qrtr 2   Qrtr 3   2006/07

-6.2
                                         Data from
           -13.5              -11.7
                                         additional source.
Percentage change
in PR                                    Social factors
   Journey so far: Trends in
         PR & NCDR
    5.73                                                PR                 NCDR
    4.4
                    3.24
                                 2.84
                                                  2.4
             3.04                                                   1.96    1.65

                              2.41
                                           2.02
                                                             1.65
                                                                             1.45




2001/02    2002/03         2003/04      2004/05         2005/06            2006/07


Average reduction in PR was 0.4 /10 000
per year except during 2006/07 where it is
only 0.2
Journey so far: Indicator Trends
     51.2        50.9        52.3      51.3     55.13


                                        41.2
                             34.4
     29.6       31.8                                30.2
       Female %          Child %         MB %
     7.7        6.5          6.8        6.6             6.16

 2002/03    2003/04     2004/05     2005/06     2006/07

Female proportion has come down significantly during
    2006 / 07. Other indicators had remained stable.
Obstacles: Epidemiological factors

                         Agent related factors


       Agent             Host related factors


  Environ      Host      Environmental factors
                              Social
                              Physical
                              Biological
    Obstacles: Technical factor
   Limitation of disease control technology
    namely early diagnosis and prompt
    treatment.

   Absence of an effective specific protection
    tool (primary prevention). Immuno &
    Chemo prophylaxis have limited
    application.
Obstacles: Operational factors
     affecting detection
                  Wrong diagnosis
           No
        leprosy
          9%

                            Leprosy
                             91%




Varied from 5.5 to 20.45 % in districts studied
 Obstacles: Operational factors
      affecting detection
                         Re reg.
                          11%




    Proportion of cases reregistered



                     Cases
                      89%




Re- registration varied from 0 to 28 % in the
                 districts studied
Obstacles: Operational factors
     affecting detection


                Non
               exist
                6%




       Cases
        94%
Obstacles: Operational factors
        affecting duration of disease


                   W Gr
                   13%



          C Gr
          87%
Obstacles: Operational factors
           affecting duration of disease
                                                >4+
                                                1%


        <4+           >4+
        53%           47%                             <4+
                                                      99%

     Highest single site reading   Average reading of all sites (BI)



                   Smear examination
  False positives.        = Unnecessarily 12 months
  False high positives.   =     - do -   24 months
  Wrong calculation        =    - do -   24 months
Obstacles: Operational factors
           affecting Duration of disease

    Overstay beyond 6 / 12 / 24 months.

    Irregular patients.

    6 / 9 and 12 / 15 or 18 flexibility
Obstacles: Operational factors
           Increasing PD ratio
Region     05 – 06   06 – 07
EDR          0.73    0.78
CDR          0.82    0.85
WDR          0.80    0.82
MWDR         1.08    1.23
FWDR         1.04    1.06
National     0.84    0.88
  Obstacles: System factors

 Frequent   Change of guard (4 times in
  one year)
 Low priority accorded by system.
 Inappropriate Attitude of managerial
  staff.
 Inexperience of first line manager.
       Obstacles: Others
 Maoist   movement

 Madeshi   movement

 Floods
             Proposed solution
                                     Reduce detection !!!

                                     Reduce duration !!!

                                     Reduce errors in
                                      compilation.



Legal, ethical & acceptable to all & Patients interest is guarded!!!
     Proposed activities

Examine, Detect Discuss and Delete all
  in appropriately registered cases:

   Wrong diagnosis.
   PB wrongly grouped as MB and has
   completed 6 pulses.
   Indian patients.
   Overstay patients.
         Motivate DTLAs !!!

To
 Update registers promptly.
 Ensure correct data aggregation.
 Ascertain error free report generation.
Quality laboratory services??
Work shop of technicians so as to ensure
that a standard, correct and uniform smear
examination procedure is followed in the
country.

Revision of national guidelines.
         What is new ???
 Activities are not new.
 Activities are not obstacle specific.
 To be implemented properly &
  immediately over a short period of
  time.
 Aimed primarily at PR reduction.
           Estimated decline

   Natural decline               15 %

   Control of OFs:      Detection 10 %
                         Duration 10%

   New case detection              5%

       30 % net reduction Wishful thinking !!!
              Summary
 Both NCDR and PR are declining.
 Elimination is inevitable.
 Minimizing proactively the operational
  factors will expedite elimination.
 Additional resources (money and men) need
  to be mobilized over a very short period.
Thank you

								
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