DR.I.SELVARAJ I.R.M.S B.Sc.,M.B.B.S.,D.P.H.,D.I.H.,PGCH&FW/NIHFW/NEW DELHI

1. DR.I.SELVARAJ I.R.M.SB.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.

2. 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.

3. Global Leprosy Situation 1998

4. 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

5. 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.

6. Prevalence of Leprosy in SEA Region as of April 2001

7. 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

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

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

10. 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

11. 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.

12. PREVALENCE OF LEPROSY Point Prevalence Period Prevalence

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

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

15. 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

16. 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

17. 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

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

19. 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

20. FLOW CHART FOR DIAGNOSIS AND CLASSIFICATION

21. 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.

22. 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.

23. 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

24. 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

25. 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 • Rifampicin 600 mg once a month • 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

26. Multi Drug Therapy

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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.

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

35. 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

36. 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

37. 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

38. 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