Trends in new case-detection leprosy in Bihar, India

Multi-drug therapy (MDT) has been successfully implemented in all leprosy endemic countries. Prevalence of leprosy has declined remarkably after the introduction of MDT. Detection of new cases did not show expected decline in many endemic and low endemic situations. Bihar in India started implementing MDT in 1993. The Damien Foundation India Trust (DFIT) supported the leprosy control programme in Bihar by providing a district technical support team (DTST) for each district assigned to DFIT. Effective coverage was achieved in 1996-98. Data for the period 1996-2004 from 10 districts are presented in this paper. The total population in these districts was 29.4 million. Deformity among newly detected leprosy patients declined to 1% indicating effective early case-detection. Intensive new case-detection activities were in vogue contributing to high new case-detection rate (NCDR). The NCDR remained high during the 9-year period reported here and did not show any declining trend.     

Progress towards elimination of leprosy as a public health problem in India and role of modified leprosy elimination campaign

India (population 943 million) has seen a highly significant decrease in the prevalence of leprosy since the introduction of multi-drug therapy (MDT) in 1981. From a prevalence rate of 57/10,000 of the population in March 1981, the figure has declined to 5.2/10,000 in March 1999. This was possible due to the creation of a completely vertical (specialized) infrastructure for leprosy control in the 218 endemic districts of the country and skeleton vertical staff in the remaining districts, coupled with the recruitment of additional staff on contract basis to provide MDT through vertical staff in endemic districts and mobile treatment units in the moderate and low endemic districts. Despite all efforts, however, new case detection has not shown a decline over the last 14 years due to the presence of hidden (and undiagnosed) cases. Therefore, in order to intensify and hasten progress towards elimination (less than 1 case per 10,000 of the population) in the whole country, it was decided to implement a massive leprosy elimination campaign (LEC) in all the States/Union Territories (UTs). The reports of 22 States/UTs indicate that 415 out of the total of 490 districts in the country were covered by modified LEC (MLEC), with 85% coverage of the population. The campaign used in India was modified from the pattern previously described by the World Health Organization. The detection of hidden or suspected cases took place within a short, intensive period of 6-7 days and relied heavily on house-to-house searches by General Health Care staff trained in leprosy detection and confirmation was made by appropriately trained staff. This MLEC received widespread Government and public support, resulting in the detection of 454,290 hidden cases of leprosy, whilst providing training to a large number of General Health Care staff and volunteers and creating widespread awareness about leprosy and the availability of treatment free of charge for all cases. This programme proved to be one of the most successful health care interventions undertaken in India in recent years, particularly in the states of Bihar and Orissa. Although a few states in India are unlikely to reach the current WHO goal of elimination before end of the year 2000, the results of the MLEC strongly support the possibility that elimination levels will be achieved in the majority of states by the end of the year 2000 and at national level by the end of the year 2002.     

"Instant" new leprosy case-detection: an experience in Bihar State in India

The National Leprosy Eradication Programme (NLEP) is based on survey, education and treatment, including coverage of all the registered cases with multi-drug therapy (MDT). The Government of India introduced MDT in all leprosy endemic districts through a vertical set-up, and through mobile leprosy treatment units in low endemic districts. Anti-leprosy work has not been uniform in all the states and needed push-start in some, such as Bihar. There have been spurts of leprosy elimination activities and the entire populations of the regions have not been covered because of various administrative reasons and logistic problems. In Singhbhum district of Bihar, a successful attempt was made to cover the maximum population by campaign approach. The strategy was to involve all the field workers of the leprosy programme in the district, supported by a small group of experienced personnel. The campaign, lasting for 39 working days, resulted in detecting leprosy cases equivalent to 64% of cases detected during the previous one full year. The entire operation helped the local staff to gain experience that would be useful for the future of the NLEP, and also provide an insight into working practices. Similar campaign approach can be used in situations where case-detection activities are feeble and the implementation of MDT is slow. If such campaigns are repeated at appropriate intervals, it will be a great support to achieving the goal of leprosy elimination.     

Leprosy control activities in India: integration into general health system

Integration of leprosy control into the general health system is an essential element of a leprosy elimination strategy. In India, the process has been undertaken with the assistance of World Bank in a phased manner. In the first phase (2001-2002), 24 low/moderately endemic provinces for leprosy were targeted. Operational research was undertaken in these low/moderate endemic provinces to assess the progress of integration of leprosy control in general health system using defined categories, viz. structural integration, training status, availability of MDT and recording/reporting of cases. Selection of nine provinces, 18 districts, 86 health facilities and 108 sub-centres was performed using multistage stratified random sampling technique. Data were collected by interviewing GHS/vertical staff, scrutiny of records and spot checking of MDT stock by Health officers of three leprosy institutions of the Government of India. The result showed that district leprosy nuclei had formed in 16 of 18 districts. In 56% of health facilities vertical staff were redeployed for delivering general health care. Forty-five percent of medical officers, 71% of health supervisors and 75% of multipurpose workers were trained in leprosy. MDT treatment was available in >80% of health facilities. In only 2% of health facilities 3 months MDT stock of all types was present. Forty-four percent of sub-centres were delivering subsequent doses (second dose onward) of MDT. Reporting through a simplified information system was universal. This study emphasizes the need for reorientation training of Medical Officers, better MDT stock management and decentralized management of cases up to sub-centre level.     

Integration of leprosy control into general health care system: observations from a state with low endemicity

The study was undertaken as part of operational research to assess the level of integration of leprosy services into general health care system in 24 low or moderately endemic states/union territories by the Ministry of Health and Family Welfare, Government of India. Himachal Pradesh was one of the nine randomly selected states for the study. Out of the 12 districts in the State, 2 were selected randomly for the study. In each of the selected districts, 8 health facilities (that included a district hospital, an urban hospital/urban health centre, an Employees' State Insurance Hospital, a community health centre and a primary health centre) and 9 sub-centres were surveyed. Selection was done randomly at each stage. Data were collected on training in leprosy of general health care staff, availability of drugs for MDT in the system and maintenance of leprosy records by the staff of the system. The study showed mixed results. About half (53.2%) of the existing medical officers, 83.9% of health supervisors and 96.8% of multi-purpose workers were trained in leprosy. But only 31.3% of medical officers were able to diagnose leprosy and most of them were relying on vertical staff and skin specialists for confirmation. MDT services were provided by 20% of rural and 66.7% of urban health facilities that were acting as treatment centres. None of the health facilities had 3 months' stock of all types of blister packs, as per the guidelines of the Government of India. None of the sub-centres was involved in MDT delivery. However, reporting as per SIS formats was universal. The study emphasized the need for training and better management of MDT drug stock.     

Modified leprosy elimination campaign (MLEC) in the State of Orissa, India

As part of a country-wide modified leprosy elimination campaign (MLEC) carried out in 21 selected States in India in 1998, the State of Orissa launched activities in early January of that year, during which 28.9 million people were examined, giving 85% coverage of the enumerated population. Using general health care staff and volunteers, 416,604 suspect cases were identified and 62,804 of these were confirmed as leprosy by experience observers. The period of intensive search activity lasted 1 week only, but this was preceded by several months of community mobilization and involvement, health education, training of government and voluntary staff, media messages and the involvement of all relevant health departments, officials and politicians. Both this and the intensive search period were characterized by a high level of interest and cooperation by all concerned. The total of new cases detected and put on treatment (multi-drug therapy; MDT) during the period of only 7 days was approximately equal to that which, on routine population survey by the leprosy services, would be recorded over a period of 2 years. The MLEC in Orissa is judged to have been not only an historic step forward in the control of leprosy in a State previously classified as highly endemic for leprosy, but also one of the most successful State health interventions ever mounted. In the 5 months after completion of the campaign, the voluntary reporting rate increased from 50 to 90%. As a direct result of the campaign, facilities for the diagnosis and treatment of leprosy are now available daily in an additional 1639 institutions, over and above those in existence before the campaign was launched. The achievements in terms of detecting hidden (and thus undiagnosed and untreated) cases exceeded the outset predictions, underlining the importance of continued vigilance and the need to maintain involvement of general health care staff. It is anticipated that the rise in prevalence due to the addition of 62,884 cases will be reduced by the implementation of MDT by 80% by about March 1999. Overall the results of the MLEC in Orissa strongly support the likelihood that an elimination level of less than 1 case per 10,000 of the population will be reached in this State by the year 2000.     

Reduction in caseload after multidrug therapy in an urban leprosy control programme--a retrospective study in Bombay

A fall in the active registered case prevalence rate together with a fall in the active caseload per worker after the introduction of multidrug therapy (MDT) is becoming a managerial issue in leprosy control. A retrospective analysis was undertaken to assess the caseload per paramedical worker with reference to active cases for treatment (3341), cases for surveillance (2227) and cases for care after cure (165) at the end of December 1989. All these cases were under the care of 24 paramedical workers. The analysis showed that the caseload per worker was 239 (active cases 139, plus surveillance cases 93, plus care after cure cases 7), though active registered case prevalence rate declined from 1.82/1000 (before starting MDT) to 0.79/1000 by the end of December 1989. The case detection rate was 0.49/1000 by the end of 1989. So, although the active registered case prevalence rate declines, the worker will have enough to do because of the need for surveillance and the detection of relapses, early neuritis, early disabilities and care after cure. Simultaneously, new case detection and treatment must be continued. All these aspects need to be considered when programme managers are reviewing leprosy control strategy.     

Integration of leprosy into GHS in India: a follow up study (2006-2007)

In India leprosy services, were integrated into the General Health Services (GHS), in a phased manner, in different provinces, from 2001 to 2004. This study reports the findings from a follow-up operational research undertaken in 2006-2007, to assess the level of integration, on predetermined indicators related to: referral services, training of health functionaries, availability of diagnosis, treatment, MDT dispersal and counselling guidelines in health facilities, recording and reporting by GHS staff, MDT stock management and involvement of health sub-centres in different Indian provinces. Nine provinces, 18 districts, 88 health facilities and 108 sub-centres were selected, by using multistage stratified random sampling techniques. Reverse integration, as reflected by the training and deployment of vertical staff in GHS, was also assessed. Data was collected by medical officers experienced in leprosy, with the assistance of state health functionaries, and recorded on separate schedules for health facility and sub-centre levels. The study also touched on the issue of client perception towards MDT services by interviewing 149 under treatment/cured leprosy cases (who had completed treatment within the last year), in the community with the help of local interpreters. Results showed wide variations across the selected provinces in various parameters. District leprosy nuclei were understaffed in 12(66.7%) districts, and district hospitals were not working as referral institutions anywhere. The training status of medical officers and multi-purpose workers in leprosy was low in Andhra Pradesh (6.9 and 22.4%), Madhya Pradesh (26.3 and 14.5%), Rajasthan (19.7 and 40.9%) and Kerala (25.5 and 65.7%). MDT stock availability as per the National Leprosy Eradication Programme (NLEP) guidelines was not adequate in all provinces. Availability of patient counseling guidelines was nil/low in Kerala, Karnataka, West Bengal, Orissa, Rajasthan and Andhra Pradesh. The involvement of sub-centres, in case referral, recording and dispensing MDT was nil Kerala and Rajasthan and poor in Andhra Pradesh. Ninety percent of clients in Kerala and 38.0% in Andhra Pradesh and Madhya Pradesh did not get MDT in the nearest health facilities or sub-centres.     

Delivery of MDT through blister calendar packs in leprosy eradication programmes--a multicentre field study (phase I). Multicentre Study Group

To overcome operational problems and improve patient compliance in leprosy programmes, DANIDA introduced blister calendar packs (BCP) to deliver MDT in four districts in India. A questionnaire study of 1470 patients from these districts showed that more than 90% accepted BCP and found them to be very convenient for domiciliary treatment. A similar study of 127 treatment providers indicated that delivery of MDT through BCP was found convenient to overcome logistic problems.     

Management of simple plantar ulcers by home based self-care.

Seeking a solution to bring down the prevalence of simple plantar ulcers in the field, Damien Foundation India Trust (DFIT), Chennai, developed a curriculum to teach the field staff of all its projects. The purpose was to make patients self-reliant in the care of their plantar ulcers in their homes. The strategy used was to make patients take care of their ulcers using tools found in their homes and surroundings and become responsible for the care of their limbs. This strategy was implemented in eight projects of DFIT and the programme was followed regularly for one year. Regular monitoring and evaluation showed that under this strategy the prevalence of plantar ulcers was reduced by about 50%.     

The impact of leprosy control on the transmission of M. leprae: is elimination being attained?

In 1991 the World Health Assembly decided to 'eliminate leprosy as a public health problem' by the year 2000. Elimination was defined as reducing the global prevalence of the disease to less than 1 case per 10,000. In 2000 the World Health Organization (WHO) announced that elimination was reached globally. Conventionally control of disease is defined as the reduction of disease burden to a locally acceptable level. Elimination of disease is defined as the reduction to zero of the incidence in a defined geographical area, and eradication is defined as the permanent reduction to zero of the worldwide incidence of infection caused by a specific agent. In leprosy however, WHO limited elimination to control instead of transmission, by using prevalence instead of incidence of disease. Leprosy statistics usually report on prevalence and new case detection. Prevalence is linked to length of treatment, which has changed over time. Trends in new case detection rates only reflect trends in incidence rates when no changes occur in case detection, but in the past 25 years case detection in leprosy has been determined strongly by operational factors. For the leprosy elimination strategy it was assumed that MDT would reduce transmission of M. leprae, but there is no convincing evidence for this. Data for evaluating the impact of MDT on transmission are not readily available because leprosy has a long incubation period. Also declines in case detection may have other causes, such as BCG vaccination. Mathematical modelling of the transmission and control of leprosy showed that the elimination strategy reduces transmission slowly, with a predicted annual decline in incidence ranging from 2% to 12%. Early case finding was the key factor to attain this decline. Future projections of the global leprosy burden indicated that 5 million new cases would arise between 2000 and 2020, and that in 2020 there would be 1 million people with WHO grade 2 disability. It is concluded that substantial progress has been made to control leprosy, but when elimination of disease is defined as the reduction to zero of the incidence, leprosy is definitely not eliminated. To attain elimination of leprosy it is necessary to find effective interventions to interrupt transmission of M. leprae and practical diagnostic tools to detect levels of infection that can lead to transmission. This requires extensive research in the areas of epidemiology and microbiology.     

Sustainable leprosy related disability care within integrated general health services: findings from Salem District, India

The main focus of leprosy control has been case detection and treatment delivery with relative neglect of prevention of disability. Absence of reliable data and lack of research have added to the problem. This raised concerns about the capacity of the general health system to address the needs of people living with leprosy-related disabilities. In this prospective study appropriate services for people living with leprosy-related disabilities were introduced in the form of self-care training, guidance and monitoring by the general health staff facilitated by a non-governmental organisation leprosy centre in a district in south India with a population of 3.1 million (estimated in 2005). The staff identified 1232 people with leprosy-related disabilities and trained them in self-care. Follow-up assessments indicated that 86% were found to be practising self-care regularly and all the 239 general health workers were found to be actively involved. The most heartening outcome was the healing of plantar ulcers in 70% of people at the 1-year follow up. This intervention is sustainable because of the simplicity of the procedures and the involvement of all health staff including supervisors.     

Trends in detection of new leprosy cases at two centres in Himachal Pradesh, India: a ten-year study

An impressive decline in leprosy prevalence rate (PR) in all endemic districts of India is seen in the post-MDT era. However, the new case-detection rate, an important statistical indicator in leprosy control programmes, has not shown significant decline in spite of all efforts. In Himachal Pradesh, a decline in PR from 7.8 to 0.56/10000 between 1991 to 2000 is seen, and recently the State has won national acclaim for having achieved the goal of elimination of leprosy in all the districts. The vertical leprosy programme has been integrated into general health services of the state. An analysis of data from 1991 to 2000 of two leprosy control units of Himachal Pradesh, the Urban Leprosy Clinic in Shimla (ULC-S) and the District Leprosy Control Unit in Mandi (DLCU-M), showed no significant decline in the new cases detected. 277 and 271 new cases were detected at these centres respectively; these included 2.2% and 1.5% children of less than 14 years of age. Almost 75% of these cases were males and of MB type. A steadily increasing trend in the annual detection of new cases was seen at both the centres during the decade. The cases registered at DLCU-M were mainly indigenous to the district. At ULC-S, 45 migrant cases from other endemic areas-mainly from Nepal, Bihar, and Uttar Pradesh-had also contributed to the increased number of new cases. Other possible causes discussed for this higher new case detection, e.g. overdiagnosis, detection of backlog "hidden cases" and voluntary reporting of patients, do not differ from those seen in other parts of the country or the world.     

Initial experiences of implementation of functional integration (FI) in LEPRA India projects in Orissa

In 2000, the Government of the State of Orissa (population 37 million) in India decided to introduce functional integration for the control of leprosy, in place of the long-established vertical programme, using the general health services and the primary health care system. This paper describes the initial (9 months) experience of implementing this strategy in two projects run by LEPRA India. One of these, in the district of Koraput, was established in 1991 and covers a population of 1.5 million people. The other, in Kalahandi district, started in 1997 and covers a population of 600,000. Both projects operate under difficult conditions with regard to terrain, the use of numerous tribal languages, illiteracy, water shortage, poor roads and communications. The preparatory phase included intensive health education of the public on leprosy, using a wide range of educational media and techniques. At the same time, LEPRA India supported the Government in the training and orientation of trainers, medical officers, primary health care staff and female health workers at village level. In all, over 2000 were trained. This paper describes all aspects of the implementation of functional integration in these two areas. In the 9-month period, 4207 suspect cases were referred to medical officers by health workers, but only 256 (6%) were confirmed as having leprosy. There were 169 confirmed self-reporting cases. Despite the clearly understood intention to involve primary health staff in case detection, 67% of all cases were in fact detected by LEPRA India, possibly due to overlapping attendance at clinics by vertical and general staff. There is obviously a need for further training of the general staff since only 6% of cases referred by them were confirmed as having leprosy. Steps must also be taken to ensure that the emphasis on case detection, confirmation and treatment shifts from the vertical to the general health staff. The supply of anti-leprosy drugs and steroids to primary health centers needs improvement. Appropriate teaching and learning material is urgently needed for both field staff and medical officers.     

Study on integration of the National Leprosy Eradication Programme into primary health care services: a pilot project

The Central Leprosy Training and Research Institute, Chengalpattu, Tamil Nadu, undertook an interventional study, as a pilot project, on integration of the National Leprosy Eradication Programme (NLEP) vertical activities into the PHC system in two selected districts of Visakhapatnam and Krishna of Andhra Pradesh, between September 1997 and March 1999. The objective of the study was to assess the various operational aspects and implications of integrated implementation of the activities of the NLEP through the PHC system. 1,304,163 people (239,142 in the study group and 1,065,020 in the control group) were enrolled in the study. The methodology employed in carrying out the pilot project in the two selected districts is described. MDT was in operation for more than 5 years in these two districts through vertical approach. Prevalence has declined from >50/10000 at the start of MDT to about 3/10000 at the start of the project. During the implementation phase, 1459 new leprosy cases were detected (NCDR 5.39/10000 person-years) and 1458 cases were released from treatment (RFT rate: 93.04%) and towards the end of the project 450 cases were under treatment (PR 1.66/10000). Simple rates, ratios and proportions were used in the analysis of data and results were compared. The interventional study was designed to assess the implications and impact of implementation of NLEP activities through PHC staff. The study design, rationale, data collection, data processing, quality control methods employed in the study project and the results are discussed. The results of the study indicate that integrated implementation of the NLEP by PHC staff is feasible, if proper support is provided.     

Childhood leprosy in an endemic area.

A study was done on 794 new cases of leprosy among children (aged 0-14 years) detected and treated with MDT during 1990-1995 in Gudiyatham Taluk, South India. Incidence rates of leprosy and proportion of multibacillary cases increased with age, while bacillary + tuberculoid was most common. Over 80% had a single patch and most children were detected through surveys. Nearly 30% had history of household contacts with leprosy, mostly parents or grandparents. Reactions and relapses were not uncommon. The findings emphasize the need for more careful surveys for case detection and better follow-up in case management.     

Can social marketing be applied to leprosy programmes?

The implementation of multidrug therapy (MDT) has been highly effective in curing patients and reducing leprosy prevalence. In some countries, however, a significant number of cases remain undetected or are detected late. Although compliance with drug therapy is generally good, a significant proportion still defaults treatment in countries where the leprosy burden is still high. This paper proposes that leprosy control or elimination efforts might be enhanced by the application of social marketing principles. It first outlines the principles of social marketing and then reviews a successful social marketing campaign in Sri Lanka to increase case detection and treatment. The paper concludes with a discussion of the opportunities for using social marketing principles to enhance the success of current leprosy community heath education programmes and leprosy treatment services.     

Leprosy control in 7 districts of south Sulawesi, Indonesia, 1986-91.

This paper describes the leprosy control programme in 7 districts of the South Sulawesi Province in Indonesia. This province is reported to have the highest prevalence of leprosy in the country. The programme started in 1986 with re-registration of all patients on the cumulative registers. Strict criteria for admission of patients to MDT were initially applied. In 1990 it appeared that these criteria had been too strict, thus necessitating a second re-registration of patients still on DDS monotherapy. More flexible criteria for admission to MDT led to an increase in MDT coverage from 45% to 78% within 6 months. By April 1991, 5 years after the start of the programme, the registered prevalence had decreased from 4.4 per 1000 in 1986 to 1.6 per 1000; the coverage with MDT had increased from 6% in 1986 to 78%, and the case detection rate remained stable around 4 per 10,000 after an initial increase at the start of the programme.     

Evaluation of the modified leprosy elimination campaign in a high leprosy endemic district of Jharkhand

An evaluation of the third Modified Leprosy Eradication Campaign (MLEC) was carried out in Potka block in the high endemic district of East Singhbhum, Jharkhand State, India, by our external evaluation team, from 29 October to 8 November 2001. The searchers in this block detected 389 suspects during the MLEC; of these, 181 (46%) were examined, and 69 (38%) of them were confirmed as cases by the Programme staff. The evaluators examined 189 (48.5%) of the total 389 suspects detected by the searchers, including 31 of the 69 cases confirmed by the Programme staff. Concordance of diagnosis of leprosy cases by the Programme staff and the evaluators was found to be high (90%). However, concordance of the type of leprosy was found to be variable (PB 38%, MB 72%, SSL 100%). Specificity and sensitivity of diagnosis by the Programme staff (as against those by the evaluators) were found to be 85.7% and 79.2% respectively. There was no case of re-registration. The evaluators examined 108 of the suspects detected by the Search Team, but not screened by the Programme staff, and diagnosed 47 cases (44%; PB 20, MB 9, SSL 18) from among them. The evaluators also diagnosed additional 30 new cases (PB 18, MB 5, SSL 7), during their visit. An assessment of knowledge about the disease and treatment among confirmed cases revealed that most of the patients did not know correctly about their disease. All the cases were referred by the searchers. About 45% of cases were aware of the duration for which they needed to take the treatment, 97% of cases showed the blister calendar packs and had taken the supervised dose. Availability of MDT to the patients and drug compliance were found to be adequate. Assessment of the impact of IEC activities on the awareness of leprosy among the community showed that about 50% of those interviewed were aware of the campaign. Most of them had information about the availability of leprosy drugs and knew that treatment was free. A majority of those aware of the disease said that they would refer suspects, if they come across any, to PHC centres for treatment.     

Treatment outcome and impact of leprosy elimination campaign in Sokoto and Zamfara states, Nigeria

A Leprosy Elimination Campaign (LEC) was implemented in 37 districts of Sokoto and Zamfara states, Nigeria from 13 August to 30 November 1998. The campaign utilized intensive community mobilization and training of local health personnel to detect hidden leprosy cases. During 8 weeks of case finding, 160,127 persons were screened; 353 new cases of leprosy were detected and placed on MDT; 236 (67%) of new cases detected were classified as MB, 64 cases (18%) suffered visible deformities and 24 patients (6.8%) were children. Follow-up in December 1999 of patients placed on MDT revealed 97% PB and 96% MB cure rates, respectively. Detection of cases in communities led some community leaders to ask for repeat surveys in their communities. Repeat surveys continue to yield new cases. The authors recommend that LECs be maintained for 3 years to accelerate leprosy elimination in the region. The cost effectiveness and impact of LEC in Sokoto-Zamfara are discussed.