Leprosy

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 Point Prevalence 45170 83101 7007 488333 7735 Cases detected during the year 2001 39612 42830 4758 668658 4786 Europe World 38 635404 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 Ask Ask Test in a well-lit room the whole body since when the patch was noticed what treatments have been tried for sensation for any visible deformities Look How to diagnose leprosy Examine Check skin for patches Test 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 meets the demanding criteria for elimination practical Leprosy 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 Clofazimine Clofazimine SLPB Single 300 mg once a month 50 mg and dapsone 100 mg every day dose ROM 600 mgm 100 mgm 400 mgm Rifampicin Ofloxacin Minocyclin 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 patient’s 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 to consolidate substantial gains made 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: facilities are easily accessible to every member of the community health 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? such as loss of sensation and deformities of hands/feet/eyes occur because: Late Disabilities diagnosis and late treatment with MDT disease (MB leprosy) Advanced Leprosy Lack 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