Evaluation of National Leprosy Eradication Program after Integration into General Health System in Rajkot District,Gujarat from 2003 to 2014

Background:National Leprosy Eradication Program (NLEP) was launched in 1983 with the goal of elimination of leprosy as a public health problem.Aim:To evaluate the NLEP performance after integration into general health system from April 2003 to March 2014.Results:The PR of leprosy per 10,000 populations was significantly declined (P < 0.001) from 0.44 in 2003–2004 to 0.15 during March 2014. Reduction in NCDR trend was statistically significant (P < 0.001). The proportion of female cases among newly detected cases showed fluctuation from 36.23% in 2003–2004 to 37.10% in 2013–2014 (P > 0.05). The proportion of child cases also showed significantly declining trend from 12.08% in 2003–2004 to 6.70% in 2013–2014 (P < 0.05). Significant number of MB cases decreased from 122 (2003–2004) to 69 (2013–2014) (P < 0.001). Grade II disability proportion was 1.45% in the year 2003–2004, increased to 5.2% in 2009–2010 and then again decreased to 3.4% in 2013–2014 (P > 0.05). Proportion of patients RFT showed fluctuation from 66.66% (2003–2004) to 45.68% (2009–2010) and then 64.66% (2013–2014) (P < 0.001).Conclusion:The NLEP is having a favorable impact on the problem of leprosy by maintaining the elimination level of leprosy in Rajkot district over a decade.     

Leprosy situation in endemic states of India and prospects of elimination of the disease

In India there is a dramatic fall in the prevalence rate (PR) of leprosy, but the new case-detection rate (NCDR) has not been reduced concomitantly. It is the operational efficiency of the National Leprosy Eradication Programme (NLEP) that has led to a significant reduction in the NCDR in Andhra Pradesh and Tamil Nadu. The ratio of PR to NCDR has been declining in these two states and it reveals that elimination could be reached even with the high NCDR level of 3 to 4 per 10000 population, particularly if single skin lesion (SSL) cases are discharged through single dose treatment of rifampicin, ofloxacin and minocycline (ROM). On the other hand, the significant number of cases detected in Bihar and Orissa during modified leprosy elimination campaigns (MLECs) reveals that there are lacunae in operational activities in new case-detection resulting in a large number of undetected cases in the community. Only one-third of the cases are reporting voluntarily. Awareness of leprosy is not adequate to motivate the patients to report voluntarily and complete their treatment, thus underscoring the need for relying on active case-detection so that transmission can be broken and elimination of leprosy achieved. In addition, the influence of socio-economic factors on continued occurrence of leprosy cannot be ruled out. The establishment of a sentinel surveillance system along with a computerized simplified information system to gain in-depth knowledge on the functioning of the NLEP will ensure operational efficiency. In view of this situation, the NLEP should adopt a more realistic approach towards reaching the elimination goal.     

Epidemiological trends of leprosy elimination in CLTRI rural field operation area, Tamil Nadu, India

The analysis of computerized data of patients in our Rural Field Operation Area (Kunrathur Taluk, Kancheepuram District, Tamil Nadu) from the start of MDT in 1986 has shown a decrease of leprosy prevalence from 275/10000 in 1986 to 0.7/10000 in 2005. Leprosy has been eliminated as a public health problem after 19 years of MDT implementation. Although the control programme was started in 1962, MDT implementation began only in 1986. The new case-detection rate has declined significantly from 27.3 in 1987 to 2.4/10000 in 2005 (y = -1.6x + 2325.1, p = < 0.05). The age-specific cumulative detection rates calculated showed highest case-detection at 10-14 years for total, 10-14 years for PB, 50-54 for MB, and 10-14 for both males and females. MB percentage was more among new cases in the last three years as compared to the initial three years, and this difference was found to be statistically significant, but there was no significant difference between the first three and the last three-year periods in child, male and disability rates (grade +/-2) among new cases. Thus, the declining trend in NCDR has not reflected any change in sex and age-groups of new cases. This analysis strengthens the hypothesis of sub-clinical cases possibly transmitting the disease and MB cases accruing after long incubation period.     

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.     

Case detection, gender and disability in leprosy in Bangladesh: a trend analysis.

A trend analysis is presented of all newly detected leprosy cases over an 18-year period (1979-1996) in a highly leprosy endemic area of Bangladesh. A total of 23,678 new cases were registered, with an average of 860 new cases per year in the first 12 years, and increasing to around 3000 in 1996. The male:female (M:F) ratio decreased from 2.3 to 1.4. The proportions of newly detected cases with MB leprosy and of newly detected cases with any disability decreased over time. These reductions were more marked in the higher age groups of both sexes. The reduction in disability was primarily attributable to a decline in grade 2 disability. New case detection rates (NCDR) of all leprosy patients per 10,000 general population increased for males from 3 to 6; and for females from 1 to 4, while the NCDR of MB leprosy decreased in males from 1.4 to 0.6, and in females fluctuated around 0.45. The NCDRs of leprosy patients with disabilities showed an initial decrease in the first period, especially in males, but later showed an increase. The NCDR of males with disability was about twice as high as that of females. Finally, female NCDRs in the ages between 15 and 30 were low by comparison with the male NCDRs at the same time. This may be due to the sociocultural characteristics of the Bangladeshi society, with gender differences in exposure, health seeking behaviour and opportunities for case detection. Operational changes in the control programme have contributed to the changed profile of newly detected cases. This study shows that the application of general population statistics is essential for understanding the dynamics in leprosy control programmes under changing operational conditions. Combining case detection figures with such statistics helps to identify population groups that are possibly not benefiting sufficiently from the services provided, and to clarify the dynamics in control programmes and the future trends and programme requirements.     

Epidemiological shift in leprosy in a rural district of central India following introduction of multi-drug therapy (April 1986 to March 1992 and April 1992 to March 2002)

This study compares the epidemiological pattern of leprosy in pre- (April 1986 to March 1992) and post- (April 1992 to March 2002) multi-drug therapy (MDT) periods by retrospective analysis of 3274 registered leprosy cases in the rural field area of Regional Leprosy Training & Research Institute (RLTRI), situated in Raipur district of Chattisgarh province of Central India. The area has high endemicity for leprosy. In the post-MDT period, prevalence rate (PR) came down to less than 1 in 10, while New Case Detection Rate (NCDR) remained almost static during the two periods. Of the total new registered cases, 30.1% were registered during the pre-MDT period and the remaining 69.9% during the post-MDT period. Comparison of key leprosy variables among new registered cases showed a 2-fold rise in the proportion of MB cases (14.8 versus 27.6%), 3.0% increase in proportion of child cases (15.3 versus 18.6%) and cases with deformity grade II (3.1 versus 5.9%) and 4.0% increase in female proportion (41.4 versus 45.7%) during the post-MDT period. A decline was noted in mean age of registration for both MB (6.4 years) and PB (5.7 years) groups in the post-MDT period. While comparing treatment and outcome related variables, a marked fall of 25.8 months was recorded in treatment duration in the post-MDT period. The defaulter rate came down by 45.0% and relapse rate by more than 12.0% during the same period. The study shows that MDT is effective operationally, but continued ongoing transmission of infection and delayed diagnosis needs corrective action.     

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.     

Perspectives of leprosy patients on MDT services after integration of NLEP functions into primary health care

Sixty-five leprosy patients residing in rural Digapahandi block of Ganjam district were studied during July-August 2001 in order to ascertain their perspectives regarding different MDT services after NLEP functions were integrated into primary health care (PHC) in Orissa after September 1999. They included 43.08% multibacillary (MB) cases and 61.92% paucibacillary (PB) cases. Assessment was done by personal interviews of adult patients and the parents of child cases after verification of their treatment cards at the sub-centre. Patient's knowledge regarding the availability of MDT services under PHC services and utilization of these services were highlighted. Influence of different socio-demographic factors was also studied. Basing on the study results, recommendations were made for sustained NLEP functions through PHC in order to improve the utilization of MDT services, which will help in the elimination of leprosy.     

Leprosy case detection using schoolchildren

An innovative method that combined awareness creation with screening of high school students by their peers was undertaken in 26 randomly selected schools in the project area of the Schieffelin Leprosy Research and Training Center, Karigiri, Vellore, India. This method entailed educating teachers and student leaders in grades 8-12 about leprosy and how to suspect leprosy among their peers. The student leaders in turn conducted a similar awareness programme for their peers and encouraged them to report if they suffered from any skin problem or skin lesion. Based on the reporting by their peers, the class leaders prepared a 'suspect list'. Within a fortnight of the awareness program, a trained leprosy worker visited the school and examined all the students on the 'suspect list'. Those diagnosed to have leprosy were referred to a medical officer, who then confirmed the diagnosis and initiated treatment. Among the 23,125 students enrolled in the 26 randomly selected schools, 234 student leaders were educated about leprosy and trained to detect suspect lesions among their peers. A total of 2200 (9.5%) children reported with skin lesions to their leaders and after screening by a leprosy supervisor and confirmation by a medical officer, 14 new cases (NCDR 6.05/10,000) were detected. This rate was found to be comparable with case detection rates of annual school surveys done during the National Leprosy Eradication Programme (NLEP), when all schoolchildren were examined. The paper suggests that schoolchildren can be used effectively in leprosy case detection and this method has the additional advantage of creating awareness among them, their teachers and communities.     

Leprosy elimination campaigns in Orissa

Four Modified Leprosy Elimination Campaigns (MLECs) were conducted in Orissa by March 2003. Their impact on various leprosy indicators was analyzed. More than 70% of the people of the State were examined during these campaigns. The suspect rate decreased from 1.44% to 0.37% towards the fourth MLEC. About 15% of the suspects were clinically confirmed to be having leprosy. The total number of new cases detected during the MLEC years was on the decrease. A marked fall in new case-detection rate was observed during inter-MLEC years. This has resulted in fluctuation in the prevalence rate during the MLEC years, but the overall PR/10,000 population decreased from 12.18 in 1996-97 to 7.3 in March 2003. More than 40% of the total new cases and about 45% of total new child cases for the corresponding year were detected during the MLECs, and the proportion of total new case-detection was as high as 60.8% during the first MLEC. The proportion of female cases detected during succeeding MLECs improved and an almost equal number of female cases were detected during MLECs III and IV. Considering the present leprosy situation in Orissa and the effectiveness of MLECs in case-detection, it was recommended that such campaigns should be undertaken in select high prevalent blocks of the State at regular intervals, along with the strengthening of the integration of NLEP activities into primary health care activities.     

An interventional strategy to strengthen integration of NLEP into primary health care

The Government of Orissa implemented the Revised Operational Strategy in September 1999 to integrate the NLEP functions into primary health care activities. An interventional strategy, in the form of consensus on job responsibilities and capacity-building through training of PHC staff, was developed and adopted in a rural block under the Department of Community Medicine to strengthen the integration process. The impact was studied six months after the intervention by comparing it with the leprosy situation in the pre-intervention period. Data were collected by verification of registers at the block PHC and sub-centre levels. Analysis was done using different leprosy indices, such as new case-detection rate (NCDR), child rate, deformity rate, profile of leprosy cases and patient compliance, etc. This integrated approach was found to be more community-oriented and effective in early case-detection in children and women. It also helped in providing continuous MDT services because of the involvement of primary health care functionaries in the post-intervention period.     

Imported leprosy in Italy

Background Leprosy is far from being eliminated with more than 200 000 new cases detected (NCD)/year. Objective Retrospective analysis between 2003 and 2009 to compare the New Case Detected Rate (NCDR) observed in Italy in the immigrant population with the NCDR of the same population in their country of origin to verify if the cases observed are those expected or not. Methods Leprosy statistics were retrieved from the Italian leprosy register and from official WHO data. Results The NCD in Italy were lower than expected, from 2003 when the expected number of NCD was 40.5 between the legally resident immigrants, but only one case was diagnosed (98% of lower from the expected), to 2009 when four NCD were diagnosed and 41 were expected (90% lower from expected). Conclusions This study points out a discrepancy between the observed and the expected cases of leprosy in Italy. Specifically, the number of NCD was less than expected for each studied year. Of course our data do not represent a validation, but only an indication of the leprosy diagnosis in Italy. Difficulty in accessing the health systems, fear of segregation, ignorance and illegal immigrant status with consequent fear of police arrest are possible explaining factors. The critical issue anyhow is the medical expertise. The role of the dermatologist is fundamental. For these reasons, there is still a need for wide spread leprosy teaching programmes. Although with few limitations, this study represents a first approach to validate the accuracy in leprosy diagnosis in Italy.     

Epidemiological trends of leprosy in an urban leprosy centre of Delhi: a retrospective study of 16 years

This study was done by collecting the retrospective data from 1994 to 2009 of patients attending the urban leprosy centre attached to the department of dermatology, STD & leprosy of PGIMER & Dr. R M L Hospital, New Delhi. The data was analysed according to age, sex, type of leprosy, leprosy reactions, deformities and relapse and compared with the national figures by comparison of proportions after taking the national data per 10,000 population. A total of 3659 patients attended our ULC (Urban Leprosy Centre) among which 2741 were male and 945 females (M:F-3:1). 669 patients (18.2%) were children. The data analysed show a gradual decline in new case detection rate with a marginal rise in 2005 and 2008. Percentage of MB cases was falling consistently till 2005 after which it showed an abrupt rise. The incidence of type 1 reaction varied from 21% in 1994 to 10% in 2009 in PB patients and from 6% in 1994 to 8% in 2009 in MB patients. The trend of type 2 reactions in MB patients showed a slow declining trend. MDT completion rate showed an impressive improvement from 56% in 1994 to 90% in 2009. The number of patients revisiting the ULC with features of relapse also showed a decrease in number. The pattern of visible deformities showed an almost constant trend similar to national figures. Improved MDT completion rate helps in reducing the disease transmission, severity, reactions and disabilities.     

浙江省1995-2020年麻风流行特征分析

目的：了解1995-2020年浙江省麻风流行特征,为“十四五”麻风防治规划的制定提供可靠的依据。方法：收集整理浙江省各地上报的各类麻风疫情报表、国家麻风防治管理信息系统（LEPMIS）中浙江省1995-2020年所有新发麻风病例、可疑症状监测系统以及浙江省消除麻风病危害规划终期评估的相关资料并进行描述性流行病学分析。结果：1995-2020年浙江省新发现麻风病例493例,年平均发现率0.04/105,患病率0.19/105,均呈下降趋势;2011-2020年新发病例与1995-2010年相比,平均年龄小,户籍分布以流动人口病例为主;新发病例五级分类法以LL最多（33.87%）;联合化疗多菌型占比由72.41%上升到93.68%,平均延迟期由34.1个月降至20.7个月,早期发现比由46.71%上升到70.69%,皮肤科就诊者占比由80.56%上升到91.95%;新发病例完成治疗率89.7%,2015年后新发病例中未出现氨苯砜综合征。结论：浙江省麻风流行呈下降趋势,防治工作取得显著成效,但仍面临人口流动造成的输入性病例,导致难以发现和监测等问题,因此需继续加强麻风可疑症状监测、完善防治网络、稳定防治队伍及加强麻风核心知识的宣传,尽早发现患者,及时诊断治疗。     

An epidemiological analysis of leprosy from 1951-1996 in Sichuan

Through the leprosy surveillance system established in 1990s the authors analysed the epidemiology of leprosy in Sichuan province from 1951 to 1996. By the end of 1996, the total number of registered cases was 32,772, the peak incidence rate (2.44/100,000) was in 1958. The annual average progressively decreasing speed (AAPDS) of the number of new cases, incidence rate, incidence rate among children, number of newly detected patients, detection rate, number of registered cases and registered prevalence rates were 4.7% (xg = 0.9534), 5.9% (xg = 0.9407), 7.4% (xg = 0.9263), 6.7% (xg = 0.9326), 8.1% (xg = 0.9195), 10.9% (xg = 0.8913) and 11.7% (xg = 0.8828) respectively. Among newly detected cases, the proportion of children gradually declined with an AAPDS of 2.9% (xg = 0.9712), but that of household contacts gradually increased, showing a gradual decline of source of infection. The multibacillary (MB) rate among new cases, newly registered cases and active cases also increased gradually. The MB rate among child cases was much lower than that among adults. The disability rates among newly registered cases tended to decline. The peak incidence was in the 20 to 35 years age group, the average age at onset being 31.92 years. Average age at onset gradually increased to 34.19 during 1991-1995. The average interval between onset of symptoms and diagnosis was 4.89 years and that had reduced gradually to 3.24 years during 1991-1995. The authors conclude that: (1) the epidemiological trend of leprosy in Sichuan province shows decline; (2) the case-finding activities have improved and intensified; but (3) the disability rate among newly detected cases is still high (> 20%) and the average delay in diagnosis is still too long, showing that early case finding is still not satisfactory.     

Contribution of mini-LECS to cluster approach case finding in Kaduna State, Nigeria

Mini-leprosy elimination campaigns (Mini-LECs) were carried out over a period of 5 years (2000-2004) in Kaduna State, Nigeria. After careful preparation, the campaign team visited areas with a high suspicion of hidden cases in 12 selected Local Government Areas (LGAs). During the years of the 12 campaigns, 156 new cases of leprosy were detected against an expected number of 70 within the same LGAs. The results of the mini-LECs were analysed to find out if this cluster approach contributed significantly to the overall leprosy case finding and change in the proportion of the multi-bacillary (MB) forms of leprosy among new cases in the State. The analysis shows that, at LGA level, the number of cases detected during the year of mini-LEC is statistically higher then the expected number of cases. The MB proportion at LGA level did not change due to the mini-LEC exercises. Due to the limited number of exercises, the impact at state level is insignificant. However, the experience at LGA level suggests that with an increase in number of mini-LEC campaigns per state per annum an impact at the state indicators can be expected. In addition the campaigns should be repeated for further yield of new leprosy cases.     

Oxidative stress and anti-oxidant status in leprosy patients

Severe oxidative stress has been reported in leprosy patients because of malnutrition and poor immunity. The purpose of this study was to investigate the serum lipid peroxidation products, serum LDH and important free radical scavenging enzymes, i.e. superoxide dismutase (SOD), and catalase and anti-oxidant glutathione levels and total anti-oxidant status, in different types of leprosy patients. The subjects for this study were normal human volunteers (NHVs, n=14), paucibacillary leprosy patients (PB, n=18), untreated MB patients (MB1, n=18), MB patients under treatment (MB2, n=19), and MB patients released from treatment (RFT) (MB3, n=28). The levels of lipid peroxidation product, malondialdehyde (MDA), and LDH increased significantly (p<0.001) in MB (MB1, MB2, MB3) patients, and both gradually decreased with clinical improvement following MDT. The levels of SOD, catalase and glutathione, and the total anti-oxidant status decreased significantly in MB (MB1, MB2, MB3) patients (p<0.001), in comparison with NHVs. They gradually increased with clinical improvement with MDT. There was no significant variation of these parameters in PB leprosy patients in comparison with healthy volunteers. High free radical activity and low anti-oxidant levels observed in MB (MB1, MB2, MB3) leprosy patients indicate that there is an oxidative stress in MB cases, irrespective of the treatment status and suggest a suitable anti-oxidant therapy to prevent possible tissue injury.     

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.     

Trends in prevalence and case finding in the ALERT leprosy control programme, 1979-1999

From 1979 to 1999, the ALERT leprosy control programme has covered a well-defined area in central Ethiopia using standardized case finding strategies. During this period, the leprosy prevalence has decreased more than 30-fold, there has been a 3-fold decrease in case detection and a 6-fold decrease in the case detection rate. The proportion of MB patients among new cases increased by around 80% and the proportion of children among new cases decreased by around 60%. Several factors may have contributed to these trends. The impact of the introduction of MDT and the shortening of the duration of the MB regimen are shown, but other factors are also discussed at length: an increase in the population of the area, cleaning up of the registers, changing case definitions, changes in staff motivation and fluctuations, even small ones, in case finding intensity and coverage. Do the observed trends reflect a reduction in the transmission of the leprosy infection? Because of the many confounding factors, it would be difficult to answer that question positively at present. Additional rigorous data collection and analysis is required.     

Multidrug therapy in leprosy can prevent relapse--a retrospective study

A retrospective study was done at the Leprosy Control Unit (LCU) in Durgapur of Burdwan district, West Bengal, to determine the relapse rate following multidrug therapy (MDT). A total of 1581 patients (1276 PB and 305 MB) completed MDT regimens during a period of 5 years as per WHO recommendations and National Leprosy Eradication Programme (NLEP) guidelines. The treated patients were kept under surveillance as per NLEP guidelines and searched for relapses. The results of MDT were compared with those of pre-MDT (monotherapy) era at the same centre (total: 405 patients; PB-373, MB-32) and also with those of the Leprosy Clinic in Gopalpur (only dapsone was given to a total of 189 patients, PB-167, MB-22). Following monotherapy, the relapse rate was 10.06% at the Gopalpur Leprosy Clinic and 12.4% at the Durgapur LCU during the 2 years (PB) and 5 years (MB) of surveillance, whereas following MDT no relapse case was encountered both in PB and MB cases during the surveillance periods recommended by WHO. The results of this study are comparable with those of other studies. Though a few studies showed relapses during long-term surveillance beyond the periods recommended by WHO, it is once again established that MDT can prevent relapse in leprosy.