Report on Status of Leprosy Elimination Global, Regional
Dr Derek Lobo Regional Advisor –Leprosy and Other Priority Diseases(LF,Yaws,STH) World Health Organization South East Asia Regional Office India
“MEDICINE MUST HAVE ITS TRIUMPHS BUT THE NEEDS OF THE MAJORITY MUST PREVAIL UPON THE NEEDS OF THE FEW.”
Mrs. Indira Gandhi
GLOBAL LEPROSY CASE-LOAD : 1985 VS 2000 VS 2003
1985 12 Million 1998 < 1 Million 2000 0.6 Million 2003 0.5 Million
The dramatic decline is attributed to the effective use of multi-drug therapy(MDT) Parameter 1. Number of Countries with Prevalence Rates of > 1/10,000 population 2. Global Prevalence 3. Patients on MDT 4. Patients Cured 5. Drug Resistance 1985 122 2000 14 2003 9
10/10,000 < 10% Accurate Data Not Available High-since single drugdapsone was given for long periods, in low doses
1/10,000 100% 11.2 million NIL- Multi-Drug Resistance following MDT is NOT reported
< 1/10,000 100% 13.5 million NIL - Multi-Drug Resistance following MDT is NOT reported
GLOBAL LEPROSY SITUATION IN JANUARY 2004
Prevalence as of 1 January 2004
GLOBAL LEPROSY SITUATION IN 2003*
69%
1% 19%
Africa South-East Asia Americas Western Pacific
2% 9% 0%
East Mediterranean Europe
GLOBAL LEPROSY SITUATION IN 2004
Annual new case detection 2003
1% 81% 0%
Africa Americas East Mediterranean South-East Asia Western Pacific Europe
7% 1% 10%
Leprosy Situation in South-East Asia Region
Annual new case detection 2003
91.0%
2.4% 0.0%
Bangladesh India Maldives Nepal Thailand Bhutan Indonesia Myanmar Sri Lanka Timor-Leste
0.0% 1.9% 0.1%
2.7% 0.4% 0.2%
1.4%
Leprosy situation in SEA Region, latest available figures
for 2003-2004
Country Population in 1,000 Registered leprosy cases
6754 42 265,781 18,337 19 2,742 5899 1,301 1,775 210 302,860
Prevalence rate/10,000
New cases detected in 2003
NCDR/ 100,000
Cumulative cured with MDT
150,771 953 10,967,571 287,570 1,163 233,530 104,939 36,784 57,443 N.A 11,840,724
Year of reaching elimination target
1998 1999 2005 2000 1996 2003 2005 1995 1994 2005 2005
Bangladesh Bhutan India* Indonesia** Maldives Myanmar Nepal Sri Lanka Thailand*** Timor-Leste SEA REGION
132,146 659 1,088,355 211,907 270 53,642 24,516 19,086 61,879 914 1,593,374
0.51 0.64 2.44 0.87 0.70 0.51 2.41 0.68 0.29 2.30 1.90
8712 18 367,143 15,913 29 4,083 6,958 1,912 705 136 405,609
6.59 2.73 33.73 7.51 10.74 7.61 28.38 10.02 1.14 14.88 25.48
Data for all countries are as on December 2003, except: * India figures are for the period: 01 April 2003 to 31 March 2004-fiscal year; ** Nepal figures are for the period: July 2003 to July 2004-fiscal year; *** Thailand figures are for the period 1st October 2002 – 30 Sept 2003-fiscal year
LEPROSY PREVALENCE IN SOUTH-EAST ASIA REGION - DECEMBER 2003
3 2.5 2 1.5 1 0.5 0
Bangladesh
Sri Lanka
Bhutan
Nepal
Indonesia*
Thailand*
Prevalence rate/ 10,000
Timor-Leste
Maldives
Myanmar
India
Countries yet to reach elimination at the beginning of 2004
Countries Number of registered cases Number of new cases at the beginning of 2004 detected during 2003 (%) (%) 3,776 (1.0%) 79,908 (20.8%) 952 (0.2%) 2,933 (0.7%) 49,206 (11.0%) 542 (0.1%)
Angola Brazil Central African Rep.
D. R. Congo
India Madagascar Mozambique
6,891 (1.8%)
265,781 (69.2%) 5,514 (1.4%) 6,810 (1.8%)
7,165 (1.6%)
367,143 (82.1%) 5,104 (1.1%) 507 (0.1%)
Nepal
Tanzania Total
7,549 (2.0%)
7,063 (1.8%) 384,244 (100%)
8,046 (1.8%)
6,497 (1.5%) 447,143 (100%)
Number of new cases detected during 2003
YEAR GLOBAL SOUTH EAST ASIA INDIA
2003
500,730
405,150 (81%)
367,143 (73%)
IN THE GLOBAL LEPROSY SCENARIO, INDIA STANDS SPECIAL & SEPARATE
WHY ??
GENETIC FACTORS ?
EPIDEMIOLOGICAL FACTORS ??
TECHNICAL FACTORS ??? OPERATIONAL FACTORS ????
LEPROSY ELIMINATION MAJOR ACHIEVEMENTS IN SEAR
EIGHT COUNTRIES HAVE ACHIEVED THE LEPROSY ELIMINATION GOAL AT THE NATIONAL LEVEL i.e. PREVALENCE <1/10,000 POPULATION INDIA, NEPAL & TIMOR LESTE ARE YET TO ACHIEVE ELIMINATION BUT HAVE SUBSTANTIALLY REDUCED THE PREVALENCE RATE AND ARE MAKING CONCERTED EFFORTS TO ATTAIN ELIMINATION BY 2005 THERE HAS BEEN A 92% REDUCTION IN PREVALENCE OVER A 16 YEAR PERIOD: 1987-2003 OVER 11.8 MILLION CASES HAVE BEEN CURED ALL COUNTRIES HAVE INTEGRATED LEPROSY SERVICES INTO GENERAL HEALTH SERVICES EXTENSIVE ADVOCACY and IEC ACTIVITIES HAVE RESULTED IN GREATER AWARENESS AND REDUCED STIGMA DEFORMITY RATE AMONG NEW CASES HAS DRAMATICALLY DECLINED
Leprosy Prevalence in India as on March 2004
National PR-2.44/10,000
PR >5 – 1 State/1 UT 2-5 – 7 States/2 UTs 1-2 – 7 States <1 – 14 States/3UTs
PR/10,000 population <1 1-2 2-5 5 - 10 >= 10
Proportion of Leprosy Cases in India Proportion of Leprosy Cases in India
Karnatka, 3% Others, 11% Tamil Nadu, 4% Chattisgarh, 5% MP, 4% Bihar, 22%
Jharkhand, 5% Andhra Pradesh, 6% West Bengal, 6% Orissa, 8% Uttar Pradesh, 21% Maharastra, 6%
March 2004
National Leprosy Eradication Programme Leprosy Prevalence : 31 March 2004
Chhattisgarh Bihar Jharkhand Delhi Uttar Pradesh Orissa West Bengal Maharashtra Andhra Pradesh Goa Madhya Pradesh Karnataka Tamil Nadu Gujarat
5.91 4.97 4.06 3.92 3.52 3.49 3.06 2.87 1.99 1.88 1.6 1.4 1.38 1.29
0 1 2 3 4 5 6 7
MAJOR ACHIVEMENTS OF NLEP - INDIA
1. Over 10 Million Cases Detected/cured
2. Integration of Leprosy Services with GHS
3. Effective Implementation of Focused Activities
4. Decentralization
5. Involvement of Partners
Trends of Leprosy Prevalence and Detection Rates per 10,000, India, 1991-2004
30 25 20 15 10 5 0 25.9 NCDR 20 13.7 10.9 8.4 5.9 5.9 6.2 6.4 5.7 4.9 5.8 5.5 5.6 4.6 5.1 8.9 7 5.5 5.9 4.4 PR
5.3 5.3
3.6 2.4
3.7 4.2 3.2
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
LEPROSY ELIMINATION
OPERATIONAL FACTORS INFLUENCING PREVALENCE & NEW CASE DETECTION 1. Setting case detection targets and basing performance appraisal on target achievement 2. Over-diagnosis and re-registration of cases due to
a) Non-adherence to WHO-recommended case definitions b) Active search & surveys c) Repeated Leprosy elimination campaigns in same area d) Lack of “Quality” and “Accuracy” of diagnosis
3. Delayed treatment and over-treatment e.g. 24 doses for MB cases 4. Job insecurity among staff involved in Leprosy services
A COMBINATION OF DETECTION TARGETS, ACTIVE SEARCH AND REPEATED LEPROSY ELIMINATION CAMPAIGNS WITHOUT ANY CONTROL ON THE QUALITY, ACCURACY AND SPECIFICITY OF DIAGNOSIS… IS LIKELY TO INFLATE THE CASE-LOAD AND DELAY ELIMINATION OF LEPROSY
Summary of Over-reporting (%) of leprosy cases, India 2003
Madhya Pradesh Andhra Pradesh Uttar Pradesh
indicator
West Bengal
9.9 30 0 39.9
80
Maharashtra
Tamil Nadu
Chattisgarh
Jharkhand
Karnataka
Orissa
Bihar
Delhi
Source of over-reporting % Wrong diagnosis 12.7 1.1 Re-registration 3 14.9 Non-Existent cases 0 14.5 Total 15.7 30.5
Delhi Karnataka West Bengal M adhya Pradesh Orissa Bihar Uttar Pradesh M aharashtra Tamil Nadu Andhra Pradesh Chhattisgarh Jharkhand 0
2.3 0 6.6 40.4 3.1 31.3 12 71.7
2 4.2 1.9 8.1
12.5 49.5 7 69
21.1 10.8 1.2 33.1
18.2 9.6 0 27.8
15.8 12.2 4.9 32.9
8.9 7.6 1.3 17.8
8.9 12.5 7.7 29.1
71.7 69
9.4 13.5 5 27.9
39.9 33.1 32.9 30.5 29.1 27.8 17.8 15.7 12 8.1 10 20 30 40 50 60 70
Total
Support! different situations by specific tools
Leprosy Elimination in SEA Region
Remaining Challenges
1.
Achieve elimination at regional level and in the remaining three countries India, Nepal, Timor-Leste; Sustaining political commitment and adequate resources; Sustaining elimination at national level and progress towards subnational elimination;
2. 3.
4. 5.
Detecting, treating and curing all new “TRUE” cases;
Prevent „operational factors‟ like wrong diagnosis, wrong classification, re-registration of cases, over-treatment, delayed treatment completion, delayed release from treatment;
6.
Extending multi-drug treatment (MDT) to under-served population groups eg. Hard-to-reach areas, urban slums, migrant labor
Integration of leprosy cured into the community
7.
Leprosy Elimination
Strengths
1. Free supply of leprosy drugs since 1995 to all endemic countries
– Pledged until 2005 – Likely to be extended up to 2010
2. Sustained funding from national governments, WHO, The Nippon and Sasakawa Foundations of Japan and ILEP
JOINT WHO/NLEP-INDIA MEETING 05 February 2003 : YANGON, MYANMAR
RECOMMENDATIONS
1. Since India has endorsed and accepted the policy of integration of leprosy services into the general health services, concrete plans for integration should be formulated and implemented and the process of integration accelerated.
2. The plans and processes of integration should include phasing out vertical structures, in a definite time-frame. 3. It is recognized that factors of "over-diagnosis" and "re-registration" of cases are responsible for static reporting of high level of new case detection in the country. The following measures are recommended to prevent these factors: a. b. Case definition laid by WHO should be strictly and uniformly applied.
Promotion of self-reporting of cases should continue to receive the highest priority and all active surveys except family contact examination should be discouraged.
Updating of leprosy registers should form part of routine activity.
c.
d.
Leprosy Elimination Campaigns (LECs) and SAPELs should be restricted to only the unreached and the known under-detected areas. Prescription of case detection targets should be replaced by performance targets such as achieving 100% cure rates. Case detection should be evaluated through a validation exercise on a sample basis. High Risk and Hard-to-reach areas should be identified and closely monitored.
e.
f.
g.
4. Under special and specific circumstances, Accompanied MDT should be considered. 5. In order to accelerate the elimination of leprosy as a public health problem in India (at national and sub-national levels), the following activities should receive high priority: a. 100% MDT coverage and accessibility; b. High treatment completion and cure rates; c. Involvement/strengthening of partnerships; and d. Inclusion of leprosy in the training curricula of the general health staff of all categories.
Not every presentation is successful