Elimination of Leprosy Dr. C.R.Revankar MD, DPH Public Health Physician & Leprologist

Contact : 3-15-14, Garden view Society, Bhavani Nagar, Marol, Andheri-East, Mumbai(Bombay) - 400059, India Email: macnir@bom3.vsnl.net.in & macnir@juno.com

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 develop clinical disease Incubation period: 3-5 years, 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 7.6% in Cameroon Higher rate of Foot drop in 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: 635404 Prevalence rate: 1.4 /10000 New cases detected: 763317 Detection rate: 11.9/100 000 South-East Asia region contributed 76.9% of the global case load

Leprosy: top 6 countries-2001 700000 600000 500000 400000 300000 200000 100000 India Brazil Nepal Myanmar Madgas'r Moza'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) 1000000 500000 B'desh China India Indonesia Thailand 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.

Paucibacillary leprosy(PBL) From “Leprosy” book by Yawalkar 2002

Multibacillary leprosy(MBL) From “Leprosy” book by Yawalkar 2002

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)

Child case /Total new cases -32 countries: 1985-1997 (WHO)

Disabled among new cases -32 countries:1985-1997 (WHO)

Cumulative disabled leprosy cases -32 countries-1985-1997

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

Partners in Leprosy Elimination WHO, Nippon Foundation, Novartis, World Bank, Danida, ILEP agencies National Governments &NGOs endemic countries