elimination of leprosy dr. c.r.revankar md, dph public health physician & leprologist
TRANSCRIPT
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Elimination of Leprosy
Dr. C.R.RevankarMD, DPH
Public Health Physician & Leprologist
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Contact :
3-15-14, Garden view Society, Bhavani Nagar, Marol, Andheri-
East, Mumbai(Bombay) - 400059, India
Email: [email protected]& [email protected]
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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)
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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
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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
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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
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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)
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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)
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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)
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Global public health strategy-1
To achieve leprosy elimination
• Adequate, regular MDT
• Leprosy awareness
• Leprosy Elimination campaign
• Special Action Projects for difficult areas (SAPEL)
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Global public health strategy-2
• Action plan, review meetings• Resource mobilization, technical support, Capacity building, drug supply, monitoring, evaluation & documentation
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Transmission
Organism: Mycobacterium leprae
Source: Untreated infectious patients (Multibacillary type)
Exit: Nasal mucosa, ulcerated skin
Entry: Airborne like TB
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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
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Epidemiology-2
Geographic variation
Lepromatous (MB type) -18% (Tanzania) to 63% (West Malaysia)
Neuritic leprosy-18% in India
Lucio type - Mexico
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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
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Epidemiology-4
Prevalence rate/10000
Agewise 1-5 5-14 >14
(slums) 47 150 247
slums non-slums schools
119 52 66
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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
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Leprosy: top 6 countries-2001
0100000200000300000400000500000600000700000
India
Brazil
Nepal
Mya
nmar
Mad
gas'r
Moz
a'que
Prevalen Detection
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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)
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Magnitude of Disabilities (1995)
0
500000
1000000
B'desh China India IndonesiaThailand Vietnam Guinea Nigeria
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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
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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.
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Paucibacillary leprosy(PBL)
From “Leprosy” book by Yawalkar 2002
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Multibacillary leprosy(MBL)
From “Leprosy” book by Yawalkar 2002
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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)
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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
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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)
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Trend of Leprosy :1985-2001 -32 countries (WHO)
0500000
10000001500000200000025000003000000350000040000004500000
1985 1987 1989 1991 1993 1995 1997 1999 2001
Prevalenc Detection
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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
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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
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Cumulative disabled leprosy cases -32 countries-1985-1997
0500000
100000015000002000000
25000003000000350000040000004500000
1985 1987 1989 1991 1993 1995 1997
Prevalenc Disabled
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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
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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
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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
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Post-Leprosy Elimination issues-2
• Early detection & treatment of
reactions in 30%-40% of cases
• Prevention of nerve damage
• Prevention & Care of disabled
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Post-Leprosy Elimination issues-3
• Patients dissatisfaction for residual
signs after MDT
• Immunoprophylaxis
• Chemoprophylaxis
• Immunotherapy
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Partners in Leprosy Elimination
WHO, Nippon Foundation,
Novartis, World Bank, Danida,
ILEP agencies
National Governments &NGOs endemic countries