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Urban Leprosy Elimination Dr. CR Revankar. MD, DPH
Public Health & Leprosy specialist
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Contact address: 3-15-14, Garden View Society,
Bhavani Nagar, Marol, Andheri-East, Mumbai , India
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How important -Urban Leprosy
% of the global population is in urban areas & % of global leprosy case load is likely to be in urban areas (guestimate) 2.Increased transport facilities, scope for employment, attraction for tourism -resulted in increased population movement across the globe Continued
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Issue of Global Leprosy
Population movement responsible for Infectious disease transmission across the globe-eg. SARS, TB, Leprosy and any other infectious disease. Leprosy should not be considered as a problem of developing countries. Should be considered as a global issue
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Objectives After this lecture, one should be able to:
Understand the epidemiological trend of leprosy, influencing factors, public health principles and possible strategies to eliminate leprosy in relation to urban population.
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Influencing Factors 1.Rapid Industrialization
2.Population migration- Permanent/temporary 3.Migration -intra and inter -slums/residential areas Continued
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Influencing factors 4.Increase in population 5.Slum/shanty town growth
6.Congestion, poor hygiene 7.Daily commuters for work from neighboring areas Continued
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Influencing factors 8.Socio-economic-cultural aspects
9.Health seeking behavior 10.Complex-health service delivery -Public & Private,modern/traditional, Non-profit health organizations Continued
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Influencing factors 11.Catastrophes-Violence, fire, earthquake, demolition of slums for urban planning 12.Fall in economic growth-shifting of labour force to other cities/towns
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Special features in slums/shanty towns
Fig.1. Demolition Fig.2.Violence Fig.1,2,3 from Bombay Leprosy Project,Bombay Fig.3. Accidental fire
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Outcome 1.These environmental and population factors influence the efforts of leprosy elimination in urban areas 2.Continuous growth of urban localities, maintain low level of disease transmission Continued
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Outcome 3.Survival of causative organisms, poor living conditions & poor nutrition 4.Difficulty in finding new cases especially-infectious type, relapse 5.Low adherence rate and drop-out from treatment, treatment failure etc.
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Recommendations 1.International Leprosy Association-pre-congress workshops: 1973, 1978, 1984, 1988, 1993 2.German Leprosy Relief Association-Urban Leprosy Panel, India: 1975 3.WHO: 1988, 2001 4.Sasakawa Memorial Health Foundation -Singapore International Leprosy Workshop: Continued
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Recommendations 5.Damien Foundation, India: 1998
6.Danida Assisted National Leprosy Eradication Program(DANLEP) and National Leprosy Eradication Program, India: 2000 7.The Leprosy MissionInternational(TLMI), NewDelhi: 2000 8.Indian Association of Leprologists(IAL): 2001
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Urban Population Growth
Increasing Urban agglomerations with >5 million inhabitants ( ) in the World. (UN population data, 1999) ___________________________________ Year No Population (million)
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Urban Population Growth
23 megacities by 2015 with more than 10 million population Urban agglomerations (>5 million) endemic for leprosy Bombay, Delhi, Kolkatta, Hyderabad, Chennai, Banglore, Pune, Ahmedabad, Dhaka, Sao Paulo, Rio de Janeiro, Jakarta
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Urban slum growth 1.It is estimated that more than 50% of the 12 million population (2001) in Bombay(Mumbai) live in the slums/shanty towns. 60% of them are migrants from other states of India. 2.Poor socio-economic conditions lead to slum/shanty town growth in all towns/cities/metropolitan areas
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Impact of MDT PR/10 000(2002) : 3.45 NCDR/100 000(2001) : 44.86
Dhaka city -Bangladesh PR/10 000(2002) : NCDR/ (2001) : 44.86 Smear +ve : 131/2532(5%) (new cases) Migrants : 25% (Jalal Uddin, 2002)
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Impact of MDT PR/10 000(2001) : 4.3 NCDR/ 100 000(2001) : 38.0
Delhi-India,2001 PR/10 000(2001) : 4.3 NCDR/ (2001) : 38.0 Migrants (%) : 40.0 Smear +ve (%) : 9.0 (new cases) Bhagotia, 2002
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Impact of MDT NCDR/100 000 (2000): 33.0 Migrants : 50%-60%
Bombay-India,2001 PR/ : 2.3 NCDR/ (2000): 33.0 Migrants : 50%-60% Smear +ve : 560/5131(11%) (new cases) ADHS,Bombay, 2001
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Impact of MDT NCDR/100 000 (2001) :16.30 Migrants : NA
Rio de Janeiro-Brazil,2001 PR/ (2001) : 1.84 NCDR/ (2001) :16.30 Migrants : NA Smear +ve : 252/962 (26.2%) (new cases) Tardin, 2002
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Impact of MDT PR/10 000 : 0.85 NCDR/100 000 : 2.6
Sao Paulo, Brazil, 2001 PR/ : 0.85 NCDR/ : 2.6 Migrants :Not available Lafratta, 2002
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Trend in Leprosy rate in Bombay
12000 10000 8000 No.of cases 6000 4000 2000 1992 1993 1994 1995 1996 1997 1998 1999 2000 Prevalenc Detection Infectious ADHS,Bombay,2002
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Significant observations
1.New Case detection rate in these megacities/cities has not shown significant reduction for the past 5 years even though prevalence rate showed significant reduction.This is similar to rural leprosy program. continued
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Status of infectious leprosy
Skin smear positive cases (of public health importance ) from Bombay does not show any significant reduction over the past 5 years (out of annual new case detection) new infectious leprosy cases are recorded inspite of low prevalence.40-60% are migrants from other parts of India. (ADHS, Bombay, 2001).
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Untreated Lepromatous leprosy cases
2 1 Fig.1,2 from Yawalkar,2002 These cases discharge 240million leprosy germs in 24 hours through nose if untreated (Davey & Rees,1974)
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Leprosy Trend in Dharavi slum, Bombay
500 400 300 200 100 1981 1979 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 New case Infectious Ganapati R,2002
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Ganapati R,2002
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Migration & Leprosy More than 60% of the skin smear +ve patients(infectious) are migrants to Bombay - maintaining low level of transmission. North America - more than 80% of new leprosy patients are immigrants from other countries maintaining low level of transmission (NHDP Report, 2002).
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Leprosy-Migrant population
Examination of migrant population to different cities/ towns in Maharashtra state,India revealed a detection rate of 194 per , even though overall Prevalence Rate is coming down in 32 cities/towns (NLEP-Maharashtra,India 1998).
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Leprosy- Disability Prevention of Disabilities is not finding its place in the program that it deserves. WHO-AIFO (2000) estimated 3 million leprosy patients with disabilities (including impairments) in the world. Disability case load in urban areas is still not available.
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Integration of Leprosy
Urban Health services : Public - Private mix programme 1.Government, Municipal medical colleges, hospitals, dispensaries 2.Railway, Industrial hospitals 3.Private hospitals, private doctors 4.Non-profit community organizations
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