Elimination of Leprosy Dr. C.R.Revankar MD, DPH Public Health Physician & Leprologist
Jan 01, 2016
Contact :
3-15-14, Garden view Society, Bhavani Nagar, Marol, Andheri-
East, Mumbai(Bombay) - 400059, India
Email: [email protected]& [email protected]
Leprosy : How important for you
Leprosy(Hansen): Easy to diagnose, treat and cure.
3 million people are with leprosy related disabilities in the world.0.76 million new cases were identified in 2001(WHO 2002)
Objectives
After this lecture one should be able to-
Describe epidemiology of leprosy disease including disability in terms of time trends, impact of leprosy elimination strategies etc
Leprosy (Hansen’s) Disease
Chronic infectious disease caused by Mycobacterium leprae, affects nerves, skin and mucosa
Causes nerve damage & disabilities
- leading to social stigma, ostracism
& denial of human rights
Leprosy Case
A patient with active signs of leprosy- need or is under MultiDrugTherapy (WHO 1988)
Patients with residual signs are Inactive and Cured & should not be included for prevalence rate
Leprosy Elimination
Leprosy Elimination:Reducing Prevalence Rate (PR) to less than one active leprosy case per 10,000 population as a Public Health problem (WHO1991)
Priority:Communicable part of the disease (Transmission)
Leprosy Eradication/Extinction
Eradication: Absence of disease agent in nature in a geographic area after deliberate control measures (WHO2002)
Extinction: Specific disease agent no longer exists in nature or laboratory(WHO 2002)
A World Without Leprosy
Concept encompasses - early diagnosis, treatment, physical, socio-economic, psychological and rehabilitation of leprosy patients
No problems related to Leprosy in the world (ILA 1998)
Global public health strategy-1
To achieve leprosy elimination
• Adequate, regular MDT
• Leprosy awareness
• Leprosy Elimination campaign
• Special Action Projects for difficult areas (SAPEL)
Global public health strategy-2
• Action plan, review meetings• Resource mobilization, technical support, Capacity building, drug supply, monitoring, evaluation & documentation
Transmission
Organism: Mycobacterium leprae
Source: Untreated infectious patients (Multibacillary type)
Exit: Nasal mucosa, ulcerated skin
Entry: Airborne like TB
Epidemiology-1 • 1%-2% exposed population develop clinical disease• Incubation period: 3-5 years, can occur after several years
• Male:Female ratio: Generally 2:1
Epidemiology-2
Geographic variation
Lepromatous (MB type) -18% (Tanzania) to 63% (West Malaysia)
Neuritic leprosy-18% in India
Lucio type - Mexico
Epidemiology-3
• Deformities - 80% in Taiwan
7.6% in Cameroon
• Higher rate of Foot drop in
India and wrist drop in Japan
Prevalence rate—varies from
10-2500 per 10000 population
Epidemiology-4
Prevalence rate/10000
Agewise 1-5 5-14 >14
(slums) 47 150 247
slums non-slums schools
119 52 66
Global Leprosy Situation-2001
No.of cases registered: 635404Prevalence rate: 1.4 /10000New cases detected: 763317Detection rate: 11.9/100 000South-East Asia region contributed 76.9% of the global case load
Leprosy: top 6 countries-2001
0100000200000300000400000500000600000700000
India
Brazil
Nepal
Mya
nmar
Mad
gas'r
Moz
a'que
Prevalen Detection
Leprosy: 6 top countries
•6 top endemic countries: India, Brazil, Myanmar, Madgascar, Mozambique, Nepal contribute
85% of global case load:
(69% from India)• 91% of global case new cases
(81% from India)
Magnitude of Disabilities (1995)
0
500000
1000000
B'desh China India IndonesiaThailand Vietnam Guinea Nigeria
Diagnosis of Leprosy
More than 95% of cases can be diagnosed clinically even by paramedical workers
Skin smears for M.leprae would assist in suspected infectious cases
Biopsy/PCR may be needed rarely
Diagnosis- infectious leprosy
Detection of 5%-10% skin smear positive leprosy patients is more important as they infect others.
If no smear facility, detect 30%-40% of cases with multiple skin lesions.
Classification for Treatment
•Multibacillary(MB) leprosy: >5 skin lesions:39%•Paucibacillary(PB) leprosy: 2-5 skin lesions:52%
•Single skin lesion PB:9%
(WHO 2002)
Multi Drug Therapy
•Kill all viable bacteria & make a patient non infectious
•Cure an active leprosy patient quickly from a public health point
Residual signs of inactivity may persist including persister bacilli in the deeper tissues
Impact of MDT Program
Cases cured: 12 million (2002)Fall in case load: 12 million (1977) to 0.64 million (2002)Deformities prevented:1-2 million
Relapse rate: < 1 /1000(WHO 2002)
Trend of Leprosy :1985-2001 -32 countries (WHO)
0500000
10000001500000200000025000003000000350000040000004500000
1985 1987 1989 1991 1993 1995 1997 1999 2001
Prevalenc Detection
Child case /Total new cases-32 countries: 1985-1997 (WHO)
0
100000
200000
300000
400000
500000
600000
700000
800000
1985 1987 1989 1991 1993 1995 1997
Detection Children
Disabled among new cases-32 countries:1985-1997 (WHO)
0
100000
200000
300000
400000
500000
600000
700000
800000
1985 1987 1989 1991 1993 1995 1997
Detection Disabled
Cumulative disabled leprosy cases -32 countries-1985-1997
0500000
100000015000002000000
25000003000000350000040000004500000
1985 1987 1989 1991 1993 1995 1997
Prevalenc Disabled
Urban Leprosy Issues-1
• Leprosy Elimination in urban areas is challenged by -
Rapid increase in population, migration, slum/shanty towns, density, poor living conditions and violence
Urban Leprosy Issues-2
• Favorable to maintain reservoir of infection and transmission
• Difficulty in finding hidden cases, relapse and treatment completion, private health care participation
Post-Leprosy Elimination issues-1
• Continued transmission
• Early detection of MB case,
relapse, rifampicin resistance
• Sub clinical infection, carriers
• Eradication model, integration
• Uniform MDT for six months
Post-Leprosy Elimination issues-2
• Early detection & treatment of
reactions in 30%-40% of cases
• Prevention of nerve damage
• Prevention & Care of disabled
Post-Leprosy Elimination issues-3
• Patients dissatisfaction for residual
signs after MDT
• Immunoprophylaxis
• Chemoprophylaxis
• Immunotherapy