EPIDEMIOLOGY AND RECENT ADVANCES IN LEPROSY WITH NLEP - HARIMU.pptx

The presentation contains epidemiology of leprosy and the recent updates related to leprosy and its control programmes.

1. EPIDEMIOLOGY AND RECENT ADVANCES IN LEPROSY WITH NLEP HARIMU BARGAYARY POST-GRADUATE RESIDENT DEPARTMENT OF Community medicine llrm medical college, meerut

2. Your best quote that reflects your approach… “It’s one small step for man, one giant leap for mankind.” - Neil Armstrong Introduction Historical Background Problem statement Epidemiology of Leprosy Control of Leprosy Recent Advances National Leprosy Eradication Program Summary CONTENTS 2

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4. HISTORICAL BACKGROUND Leprosy is an age-old disease and has been described in the literature of ancient civilizations. In India , it was first described in Sushruta Samhita as “KUSHTA ROGA” (derived from a Sanskrit word- ‘ Kushanti ’ = eating away ). 4

5. HISTORICAL BACKGROUND 1873 - “ Mycobacterium leprae” was identified by Dr Gerhard Armauer Hansen. 1943 - Dapsone drugs introduced for treatment. 1955 - GOI launched National Leprosy Control Programme (NLCP). 1982 - Multidrug Therapy (MDT) introduced. 1983 - NLCP renamed as National Leprosy Eradication Program (NLEP). 1991 - World Health Assembly (WHA) resolution to eradicate leprosy by 2000AD. 2005 - India achieved elimination status Nationally. 5

6. Problem statement – global and india Number of New Leprosy cases, 2022 6

7. New Leprosy case detection rate per 1000000 population, 2022 7 Problem statement – global and india

8. Number of leprosy cases registered for treatment (prevalence), 2022 8 Problem statement – global and india

9. Leprosy Prevalence rate (Uttar Pradesh & Meerut) Uttar Pradesh: 0.4 per 10000 population (Jan. 2023) Meerut district: 0.27/ lakh population (March 2023) 9

10. Epidemiology of leprosy 10

11. Mode of transmission 11

12. Incubation period Long incubation period. Average of 3 to 5 years or more. 12

13. Pathogenesis of leprosy 13

14. Classification 14 INDIAN Indeterminate type Tuberculoid type Borderline type Lepromatous type Pure neuritic type MADRID Indeterminate type Tuberculoid type Borderline type Lepromatus type RIDLEY AND JOPLING Tuberculoid (TT) Borderline Tuberculoid (BT) Borderline (BB) Borderline Lepromatous (BL) Lepromatous (LL)

15. CLINICAL CLASSIFICATION FOR CONTROL PROGRAMME (who): 15 CHARACTERISTICS PAUCIBACILLARY LEPROSY MULTI BACILLARY LEPROSY Skin Lesion 1 to 5 skin lesion 6 and above Nerve involvement No nerve / only one nerve involvement > 1 nerve irrespective of no. of skin lesions Skin smear Negative at all sites Positive at any site

16. DIAGNOSIS OF LEPROSY 16 Leprosy is clinically characterized by one or more of the following cardinal features :- Hypo-pigmented patches Partial or total loss of cutaneous sensation in the affected area Presence of thickened nerves Presence of acid-fast bacilli in the skin or nasal smear

17. SIGNS OF ADVANCED DISEASE Lumps or nodules in the skin of the face and ears Plantar ulcers Loss of fingers or toes Nasal depression Foot drop and claw toes Other deformities - Leonine faces - Lagophthalmos 17

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19. Clinical examination 19 Case history: - Name, sex, age, address, occupation, etc. - Presenting complaints - H/o Recurrence - Any deformity with onset and h/o progression - Treatment history - Associated illness - Family and Close contact Physical examination: - Thorough Inspection - Testing the sensation over the skin Nerve examination: - Palpation of nerves - Assessment of Nerve function

20. BACTERIOLOGICAL EXAMINATION A. Skin Smears : Sites: Ear lobe, Forehead, Gluteal region, Active edge of patch. B. Nasal Smears or blows : Best prepared from early morning mucus material. C. Nasal Scrapings : Not recommended as routine. Smear on a slide, air dried & fixed followed by ZN staining 20

21. BACTERIAL INDEX (BI) Only objective way of monitoring benefit of treatment . Indicates the density of leprosy bacilli in smears and includes both living (solid staining) and dead (fragmented or granular) bacilli. BI ranges from 0 To 6+ and is based on the no. of bacilli seen in an average microscopic field. 21

22. 22 Ridley’s logarithmic scale No bacilli in any of the 100 oil-immersion fields 1+ 1-10 bacilli on average, in 100 oil-immersion fields 2+ 1-10 bacilli on average, in 10 oil-immersion fields 3+ 1- 10 bacilli, on average, in each oil-immersion field 4+ 10- 100 bacilli , on average , in each oil-immersion field 5+ 100-1000 bacilli, on average, in each oil-immersion Field 6+ More than 1000 bacilli, on average, in each oil-immersion field

23. MORPHOLOGICAL INDEX (MI) It is the Percentage of solid staining bacilli in a stained smear. Calculated after examining 200 pink-stained free standing (i.e. not in clumps) bacilli. It is Valuable indicator of the patient’s response to treatment during the first few months and helps to signal drug resistance. 23

24. MOUSE FOOT-PAD CULTURE Only certain way of identifying M. leprae 10 times more sensitive at detecting the bacilli than slit-skin smears. Used for: - Detecting drug resistance - Evaluating the potency of anti-leprosy drugs - Detecting the viability of the bacilli during treatment Drawback: Time consuming (requires 6 to 9 months). 24

25. HISTAMINE TEST Reliable test for detecting at an early stage peripheral nerve damage. 25 Normal Nerve damage present

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27. LEPROSY CONTROL MEDICAL MEASURES - Estimation of the problem - Early case detection - Multidrug therapy - Surveillance - Immunoprophylaxis - Chemoprophylaxis - Deformities - Rehabilitation - Health education SOCIAL SUPPORT PROGRAMME MANAGEMENT EVALUATION 27

28. MEDICAL MEASURES 1. Estimation of the problem: Random sample surveys to collect baseline data Roughly the total prevalence will be about 4 times the number of cases found a mong school-age children. 11. Early case detection: CONTACT SURVEY: In areas with < 1 case/1000 population. GROUP SURVEY: In areas with prevalence of > 1/1000 or higher. MASS SURVEY: In areas with prevalence > 10/1000 population. 28

29. 111. Multidrug therapy Objectives of Multidrug Chemoterapy : To interrupt transmission of the infection in the community. To ensure early detection and treatment of cases to prevent deformities. To prevent drug resistance. 29

30. WHO RECOMMENDED REGIMENS 30 DRUGS ADULT CHILDREN(10-14yrs) MULTI BACILLARY PAUCI BACILLARY MULTI BACILLARY PAUCI BACILLARY DURATION 12 months to be completed within 18 months period. 6 months to be completed within 9 months period. 12 months to be completed within 18 months period. 6 months to be completed within 9 months period. RIFAMPICIN 600mg once monthly under supervision 600mg once monthly under supervision 450mg once a month under supervision 450mg once a month under supervision DAPSONE 100mg daily self administered 100mg daily self administered 50mg daily self administered . 50mg daily self administered . CLOFAZIMINE 300mg once monthly under supervision, 50mg daily self-administered 150mg once monthly under supervision 50mg alternate day self-administered

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32. For Children under 10 years of age Rifampicin: 10 mg/kg bodyweight Clofazimine: 1 mg/kg bodyweight daily and 6 mg/kg bodyweight monthly Dapsone: 2 mg/kg bodyweight daily. The standard child blister pack may be broken up so that the appropriate dose is given to children under 10 years of age 32

33. IMPORTANT INSTRUCTIONS FOR PATIENTS ON MDT Skin discoloration due to Clofazimine. Urine discoloration due to Rifampicin. Must return immediately to the health centre, in case of - - Fever, pain in the nerves, muscle weakness, joint pains. - Eye problems. - Appearance of new skin patches. - Severe itching of skin ( allergic reaction to drugs sp. Dapsone ) How to protect insensitive hands/feet. 33

34. defaulters Defaulters who returns to the health centre for treatment should be given a new course of MDT when he/she shows > 1 of the following signs: Reddish and/or raised skin lesions Appearance of new skin lesions New nerve involvement Lepromatous nodules Signs of reversal reactions or Erythema Nodosum Leprosum (ENL) The returning defaulters are not considered as newly detected cases for registration. 34

35. Important points About MDT Not contra-indicated in patients with HIV infection. Leprosy is exacerbated during pregnancy, it is important that MDT is continued. MDT is safe during pregnancy. Drugs are excreted in breast milk but no reports of adverse reaction except for mild discoloration of infants skin by Clofazimine. 35

36. Medical measures ( contd …) 36 1V. Clinical Surveillance of cases after Treatment completion: PB Leprosy: Clinical examination atleast once/year for min. 2yrs. MB Leprosy: Clinical examination atleast once/year for min. 5yrs. V. Immunoprophylaxis : High BCG vaccination coverage. VI. Chemoprophylaxis: Further research needed.

37. vii. disability It is estimated that approx. 25% of the patients who are not treated at an early stage of disease develop anaesthesia and/or deformities of the hands and feet. Patients at high risk of developing disability: MB Leprosy Past/present thickened/painful/tender nerve trunk Skin lesion on face Adolescents, pregnancy, old age Any inter-current infection 37

38. Disability ( contd …) 2 types of disabilities in leprosy: Primary : Occur as a result of nerve damage – eg. Loss of sensation, paralysis, dryness, etc. Secondary : Occur as a result of Neglected primary disability – eg. Ulcer, contracture. 38 Deformities occurring in Leprosy

39. Medical measures ( contd …) 39 V111. Rehabilitation Community based rehabilitation with coordinated efforts by the Department of Health, Education and Social Welfare and Voluntary organizations. IX: Health education To patient and his family. To general public.

40. Leprosy control ( contd …) 40 2. Social Support To reduce social stigma. To provide social assistance and social support. 3. Programme Management Long-term activity. National Leprosy Eradication Programme (NLEP) 4. Evaluation Epidemiological indicators Indicators for monitoring progress Quality of service indicators

41. Leprosy control programmes 41

42. THE GLOBAL LEPROSY STRATEGY 2016-2020: "ACCELERATING TOWARDS A LEPROSY-FREE WORLD" Released in April 2016 Key Targets (1) Zero grade 2 disability (G2D) among children diagnosed with Leprosy (2) the reduction of new leprosy cases with G2D to < 1 case per million population (3) zero countries with legislation allowing discrimination on the basis of leprosy 42

43. Progress report Impact indicator 2020 target 2019 status Newly detected child cases with G2D Zero Reported: 370 Estimated: 400 – 500 G2D rate in newly detected cases < 1/million population 1.4/million population Number of laws allowing discrimination on the basis of leprosy Zero countries with discriminatory laws 127 discriminatory laws in 22 countries 43

44. Strategic AIMS and 4 pillars: I mplement integrated, country-owned zero leprosy road maps in all endemic countries; S cale up leprosy prevention alongside integrated active case detection; M anage leprosy and its complications and prevent new disability; and C ombat stigma and ensure human rights are respected. Interruption of transmission and elimination of disease are at the core of the Strategy. 44 TOWARDS ZERO LEPROSY - GLOBAL LEPROSY (HANSEN’S DISEASE) STRATEGY 2021‒2030

45. Global targets for 2030 120 countries with zero new autochthonous cases 70% reduction in annual number of new cases detected 90% reduction in rate per million population of new cases with grade-2 disability (G2D) 90% reduction in rate per million children of new child cases with leprosy 45

46. NATIONAL LEPROSY ERADICATION PROGRAM (NLEP) 46

47. nlep emblem S ymbolizes beauty and purity in lotus : Leprosy can be cured and a leprosy patient can be a useful member of the society in the form of a partially affected thumb , a normal fore-finger and the shape of house . T he symbol of hope and optimism in a rising sun . The Emblem captures the spirit of hope positive action in the eradication of Leprosy. 47

48. Historical BACKGROUND 1955: National Leprosy Control Programme (NLCP) launced . 1969-74: (4 th Five year plan) Became a Centrally sponsored programme. 1980: Working group constituted to “eradicated” leprosy by year 2000. 1982: Recommended revised strategy on Multi-drug Chemotherapy. 1983: Control from NLCP redesignated to Eradication, thereby renaming it to National Leprosy Eradication Programme (NLEP) 48

49. Historical BACKGROUND ( contd …) 1993: Introduced first World Bank supported project. 2002-03: Integrated with general Health care system. 2005: Achieved the goal of leprosy elimination at national level as set by the National Health Policy (2002). 2012-13: 209 high endemic districts identified for special action. 2017: Sparsh Leprosy Awareness Campaign launched. 2019: ASHA based surveillance for leprosy suspects (ABSULS) launched. 49

50. NLEP VISION: “Leprosy-free India” MISSION: To provide quality leprosy services free of cost to all sections of the population, with easy accessibility, through the integrated healthcare system, including care for disability after cure of the disease. 50

51. OBJECTIVES a) To reduce Prevalence rate less than 1/10,000 population at sub national and district level b) To reduce Grade II disability % < 1 among new cases at National level c) To reduce Grade II disability cases < 1 case per million population at National level d) Zero disabilities among new Child cases e) Zero stigma and discrimination against persons affected by leprosy. 51

52. COMPONENTS Case Detection and Management Disability Prevention and Medical Rehabilitation (DPMR) Information, Education and Communication (IEC) including Behaviour Change Communication (BCC) Human Resource and Capacity building Programme Management 52

53. STRATEGIES UNDER NLEP Integrated anti-leprosy services through General Health Care system Early detection and complete treatment of new leprosy cases Carrying out household contact survey for early detection of cases Involvement of Accredited Social Health Activist (ASHA) in the detection and completion of treatment of Leprosy cases on time Strengthening of Disability Prevention and Medical Rehabilitation (DPMR) services 53

54. ACTIVITIES UNDER NLEP 1. Diagnosis and treatment of leprosy – Free of cost Services for diagnosis and treatment (MDT) including reconstructive surgeries at all public health care facilities like PHC, Govt. dispensaries, CHC, DH and Medical colleges throughout the country 54

55. Activities 2. Capacity building - Training of general health staff like Medical Officer, health workers, health supervisors, laboratory technicians and ASHAs conducted every year to develop adequate skills for diagnosis and management of leprosy cases. 3. IEC and counselling - Intensive IEC activities conducted to generate awareness which will help in reduction of stigma and discrimination associated with persons affected with leprosy. 55

56. 4. Disability Prevention and Medical Rehabilitation – For prevention and management of disability, dressing material, supportive medicines and micro-cellular rubber (MCR) footwear provided to leprosy patients. The patients trained in self-care procedure for preventing aggravating disability to the insensitive hands/ feets . Free reconstructive surgeries (RCS) for correction of permanent disability through GOI identified 112 institutions 56 Activities

57. Activities 5. Supervision and Monitoring – Monitored at different level through analysis of monthly progress reports, through field visits by the supervisory officers and programme review meetings held at central, state and district level Emphasis is put on assessment of New Case Detection and Treatment Completion Rate and proportion of grade II disability among new cases. 6. Incentive to patient – Rs 12000/- to all leprosy affected patients undergoing major reconstructive surgery. 57

58. NGO services under SET scheme NGOs are getting grants from Govt. of India under Survey, Education and Treatment (SET) scheme. Various activities undertaken by the NGOs are IEC Prevention of Impairments and Deformities Referral of Suspected cases Referral for Reconstructive surgery (RCS) Research and Rehabilitation 58

59. 59 Referral System In NLEP

60. 60 NLEP Patient Card

61. Recent developments New Operational strategy for Active Case Detection and Regular Surveillance introduced in both rural and urban areas in order to ensure detection of leprosy cases on regular basis and at an early stage in order to prevent grade II disabilities. Leprosy has been converged under Rashtriya Bal Swasthya Karyakram (RBSK) and Rashtriya Kishore Swasthya Karyakram (RKSK) for screening of children (0-18 years). 61

62. Recent developments ( contd …) Population based screening of women and men of age > 30years included in Comprehensive Primary Health Care under Ayushman Bharat at the Health and Wellness Centres . Welfare allowance raised from Rs 8,000 to Rs 12,000 to Patients for Reconstructive Surgery Central Leprosy Division has introduced guidelines for certification and award to the well performing Districts for achieving potential leprosy elimination status. 62

63. Achievements India has achieved enormous success in leprosy control, particularly in the last four decades. Leprosy elimination, which means Prevalence Rate <1 case/ 10,000 population, was achieved at the National level in 2005. The MoHFW is constantly taking steps to achieve elimination of Leprosy at the sub-national level, i.e. upto the district level. 63

64. major achievements under NLEP : Prevalence rate 0.69/10000 (2014-15) => 0.45/10,000 population (2021-22). Annual New Cases Detection Rate per 1 lakh population: 9.73 (2014-15) => 4.58 (2021-22). Child cases % among new cases detected: 6.86% (2019-20) => 5.76% (2020-21.) % of G2D among new cases detected: 3.05% (2018-19) => 2.39% (2019-20) => 2.48% (2020-21). The G2D amongst new cases per million population: 1.94/million (2019-20) => 1.14/million (2020-21). District level Representatives from 34 States/UTs have been trained for data entry into NIKUSTH web-based reporting system for leprosy cases. A total of 1822 participants have been trained. 64

65. ANNUAL REPORT 2021-22 65 New cases detected Prevalence Cases discharged as cured Cases on record under treatment Number % Per 10,000 Number Number India 61942 0.41 54649 60077 Uttar Pradesh 8743 0.32 7806 7705

66. SPARSH Leprosy Awareness Campaign Special Annual Mass Awareness campaigns launched on 30th January, 2017. Carried out through Gram Sabhas with the help of Panchayat and Village Health and sanitation Community. AIM: To generate awareness, reduce stigma and improve self-reporting of cases. 66

67. Sapna – the mascot SAPNA is a concept (mascot) designed and developed keeping in mind a common girl living in community, who will help spread awareness in the community, through key IEC messages. Who can be “Sapna”: A local school going girl who is willing to be ‘Sapna’, preferably from the same locality. There can be any number of Sapnas in a village 67

68. Mycobacterium indicus pranii Vaccine Developed at National Institute of Immunology, New Delhi. Launched as part of pilot program in 5 districts of Gujarat and Bihar in 2017 under NLEP. 2 doses given 6 months apart to both cases and contacts. 68

69. POST-EXPOSURE PROPHYLAXIS On 2 nd  October 2018, NLEP started post-exposure prophylaxis for all contacts of leprosy cases. Contact :- A person aged ≥ 2yrs, who has been living/ working / having social activities with a newly detected case of leprosy for period of >3months and 20hrs/week in the last 1year. 69

70. 70 Age/Weight Rifampicin (Single dose) 15 years and above 600mg 10–14 years 450mg Children 6–9 years (weight ≥ 20 kg) 300mg Children <20 kg (≥ 2 years) 10-15mg/kg POST-EXPOSURE PROPHYLAXIS REGIMEN

71. National Strategic Plan & Roadmap for Leprosy (2023-27) to achieve zero transmission of leprosy by 2027 Launched on 30 th  January, 2023 . T o achieve zero transmission of leprosy by 2027 i.e. three years ahead of the Sustainable Development Goal (SDG) 3.3. C ontains implementation strategies, year-wise targets, public health approaches and overall technical guidance for the programme . F ocuses on awareness for zero stigma & discrimination, promotion of early case detection, prevention of disease transmission by prophylaxis (Leprosy Post Exposure Prophylaxis) and roll out of web-based information portal ( Nikusth 2.0) for reporting of leprosy cases. 71

72. Celebrated globally on last Sunday of January every year . In India , it is observed on 30 th January “Death Anniversary of Mahatma Gandhi” . 2024 Theme : “ Ending Stigma, Embracing Dignity ”. This theme encapsulates the dual objectives of the day: - to eradicate the stigma associated with leprosy and - to promote the dignity of people affected by the disease. 72

73. SUMMARY Leprosy/Hansen’s disease/ Kusth rog is alteast 4000years old, making it one of the oldest diseases known to humanity. It is curable with a combination of antibiotics known as MultiDrug Therapy (MDT). This treatment is available for free across the world. If not treated, it can lead to serious complications. Often known as a “social disease”, it is attached with social stigma. Community awareness regarding the disease and its curability is essential to remove leprosy associated stigma. 73

74. references: Park’s Textbook of PREVENTIVE AND SOCIAL MEDICINE 27 th Edition by K. Park. DK Taneja’s Health Policies & Programmes in India 16 th Edition. https://www.who.int/news-room/fact-sheets/detail/leprosy https://pib.gov.in/ https://main.mohfw.gov.in/documents/publication/publication-archives Mikami , Mariko & Tanigawa , Kazunari & Kawashima, Akira & Kiriya , Mitsuo & Nakamura, Yasuhiro & Fujiwara, Yoko & Suzuki, Koichi. (2022). Pathogenicity and virulence of Mycobacterium leprae. Virulence. 13. 1985-2011. 10.1080/21505594.2022.2141987. 74