National Leprosy Program

Presented byMamata Manandhar

M Sc NursingBatch 2011.

Content• Introduction of Leprosy• Background• Vision• Mission• Goal• Objectives• Strategies• Targets• Major Activities• Analysis of Achievement

Introduction of Leprosy

• Also known as Hansen's disease (HD), is a chronic disease caused by the bacteria Mycobacterium leprae and Mycobacterium lepromatosis.

• Named after physician Gerhard Armauer Hansen, leprosy is primarily a granulomatous disease of the peripheral nerves and mucosa of the upper respiratory tract; skin lesions are the primary external sign.

• Left untreated, leprosy can be progressive, causing permanent damage to the skin, nerves, limbs and eyes.

Leprosy contd..

• Secondary infections, in turn, can result in tissue loss causing fingers and toes to become shortened and deformed, as cartilage is absorbed into the body.

• Leprosy has affected humanity for over 4,000 years, and was recognized in the civilizations of ancient China, Egypt and India.

• The age-old social stigma associated with the advanced form of leprosy remains a major obstacle to self-reporting and early treatment.

World scenario

Leprosy contd..

• Effective treatment for leprosy appeared in the late 1930s with the introduction of dapsone and its derivatives.

• Leprosy bacilli resistant to dapsone soon evolved .

• It was not until the introduction of multidrug therapy (MDT) in the early 1980s that the disease could be diagnosed and treated successfully within the community.

Leprosy contd..

• Since 1995, WHO has supplied MDT free of cost to leprosy patients in all endemic countries.

• The drugs used in WHO-MDT are a combination of rifampicin, clofazimine and dapsone for MB leprosy patients and rifampicin and dapsone for PB leprosy patients.

Leprosy contd..• MDT for multibacillary leprosy consists of rifampicin, dapsone,

and clofazimine taken over 12 months.

• Dosages adjusted appropriately for children and adults are available in all HF.

• Single dose MDT for single lesion leprosy consists of rifampicin ,ofloxacin, and minocycline.

• The move toward single-dose treatment strategies has reduced the prevalence of disease in some regions, since prevalence is dependent on duration of treatment.

Background

• Leprosy has existed in Nepal since time immemorial and was recognized as a major Public Health problem as early as 1950.

• Khokana Leprosarium near Kathmandu was established more than 160 years ago to provide services to the leprosy patients.

Background contd…

• Leprosy has been a priority of the government of Nepal.

• Thousands of people have been affected by this disease and many of them had to live with physical deformities and disabilities.

Background contd…

• Activities to control leprosy in an organized and planned manner were initiated only from 1960.

• According to a survey conducted in 1966, an estimated 100,000 leprosy cases were present in Nepal.

• Dapsone monotherapy treatment was introduced as a Pilot Project in the Leprosy Control Program.

• Nepal Leprosy Control Program was started in the country in 1966.

Background contd…

• Multi Drug Therapy (MDT) was introduced in 1982 in few selected areas and hospitals of the country.

• By this time, the number of registered leprosy cases had reached 21,537 with a Prevalence Rate (PR) of 21 per 10,000 population.

• Sixty two districts of the country had PR of over 5, ‐while only three districts had PR less than 1 per 10,000 inhabitants.

Background contd…

• The program was integrated into the general health services in 1987.

• By 1996 MDT was expanded to all 75 districts.

• The country conducted Leprosy Elimination Campaign in 1999 (LEC 1) and again in 2001 (LEC 2) which was ‐ ‐an active case detection activity.

• In high endemic pockets special interventions were undertaken for case finding.

Background contd…

• Community mobilization and participation during LEC contributed to voluntary case reporting due to reduction of stigma and discrimination against leprosy affected persons.

• High cure rates through flexible and patient friendly ‐drug delivery systems were ensured.

• Monitoring and supervision of the activities were undertaken to keep track of progress towards elimination.

Background contd…

• All initiatives were coordinated amongst the national, international and local non governmental ‐organizations.

• Specialized care for leprosy affected persons was provided in Leprosy hospitals and referral clinics run by NGOs and the government.

Background contd…

• WHO and other major partners supporting the program are Sasakawa Memorial Health Foundation, The Nippon Foundation, Netherlands Leprosy Relief, The Leprosy Mission, International Nepal Fellowship and Nepal Leprosy Trust.

Background contd…

• Leprosy Control Division, the guiding body for leprosy control activity in Nepal, functions in close coordination with the Regional Health Directorate, District Health System, donor agencies and all the supporting partners.

• RHD supervises and monitors the program in all districts within the region.

Background contd…

• Disease control activities including leprosy control activities are headed by respective officer as appointed by Regional Director in RHD.

• Regional Tuberculosis and Leprosy Officer/Assistant (RTLO) is the focal person of leprosy in RHD.

• In addition, District TB & Leprosy Officer/Assistant (DTLO), implement the program in respective district.

Background contd…

• MDT service is being delivered through all the public health facilities in Nepal.

• Majority of health care providers serving at community based health facilities have undergone Comprehensive Leprosy Training (CLT) and are effectively providing MDT service.

Background contd…

• In addition more than 90 percent FCHVs have received orientation on leprosy and referring suspected cases to the nearest HF for confirmation of diagnosis and treatment.

• Capacity building is a key intervention area and is conducted with support from the WHO and INGOs.

• In addition to capacity building INGO supported referral centres also provide primary, secondary and tertiary level care to leprosy patients.

Vision

• To usher in a leprosy free society where there are no new leprosy cases and all the needs of existing leprosy affected persons having been fully met.

Mission

• To provide accessible and acceptable cost effective quality leprosy services including rehabilitation and continue to provide such services as long as and wherever needed.

Goal

• Reduce further the burden of leprosy and to break channel of transmission of leprosy from person to persons by providing quality service to all affected community.

Objectives

1. To eliminate leprosy (Prevalence Rate below 1 per 10,000 population) and further reduce disease burden at district level;

2. To reduce disability due to leprosy;3. To reduce stigma in the community against leprosy;

and4. Provide high quality service for all persons affected

by leprosy.

Strategies1. Early case detection and prompt treatment of

cases.2. Enable all general health facilities to diagnose and

treat leprosy.3. Ensure high MDT treatment completion rate.4. Prevent and limit disability by early diagnosis and

correct treatment.5. Reducing stigma through information, education,

and advocacy by achieving community empowerment through partnership with media and community.

6. Sustain quality of leprosy service in the integrated set up.

Targets• Reduce NCDR by 25 percent at national level by the

end of 2015 in comparison to 2010(1.15).• Reduce PR by 35 percent at national level by the end

of 2015 in comparison to 2010(0.77).• Reduce by 35 percent GII disability amongst newly

detected cases per 100,000 population by the end of 2015 in comparison to 2010(2.72).

• Additional deformity during treatment <5 percent by EHF score.

• 80 percent health workers are able to recognize and manage /refer reaction/complications.

• Promote POD and Self care.

Major Activities

1. MDT Service Delivery:

• During the FY 2067/68, 3,142 new leprosy cases were detected and 5362 cases received treatment with MDT.

• 2979 cases completed treatment and were made RFT in the fiscal year.

• Secondary and tertiary care was provided to the needy leprosy pts through the existing network of referral centres through the support of supporting partners.

• MDT and anti reaction drugs were freely available in the country throughout the year.

2. Capacity Building

• Comprehensive Leprosy training was provided to new recruits.

• Refresher Training was provided to health workers providing service in the endemic and low endemic districts.

• Similarly, orientation to FCHVs is an ongoing activity. • At present, each and every health facility has more

than one staff trained in leprosy.

3. Information Education and Communication

• To enhance community awareness, passive case detection and to reduce stigma, IEC activities were undertaken on a regular basis using electronic and non electronic media.

• During the year, relevant messages were broadcasted using mass media.

• Posters and leaflets were printed and distributed from national. Likewise, Leprosy message were disseminated, broad casted through 300 flex boards and 144 Street Drama.

• Similarly 1200 times leprosy messages broadcasted in local language through FM, Radio at district level.

4. World Leprosy Day

• World Leprosy Day is observed internationally on January 30 or its nearest Sunday to increase the public awareness of the Leprosy.

• This day was chosen in commemoration of the death of Gandhi, the leader of India who understood the importance of leprosy.

• This year World Leprosy Day ~ 27th January 2013.

• This 60th World Leprosy Day will give particular emphasis to those under-served and marginalized communities that are most at risk from leprosy - those who are often the poorest of the poor.

4. World Leprosy Day contd..

• World leprosy day was celebrated in national level by releasing message of Honorable President, Honorable Prime Minister, Health and Population minister, Secretaries for Health & other official dignity through national news paper.

• Interaction with Journalists and celebration interaction program with stake holders jointly organized by LCD & Leprosy Net Work Nepal.

• Similarly World Leprosy Day was celebrated by interaction with different groups, procession, rally, and talk program etc.

5. Program Monitoring and Follow up Workshop at ‐PHC/HP Level

• During the year, 3 monitoring workshops were organized in 19 endemic Terai districts once in every four months.

• Personnel from SHPs/HPs/PHC met at Ilaka level to compile and aggregate data, discuss problems faced in the field and to share their experiences.

• Facilitators from LCD, district/regional health directorates, supporting partners assisted the staff in these meetings.

• Presentations on relevant topics were also made during these meetings.

6. District and Regional Review Meetings

• Regular Review Meetings were held once in every 4 months at district and regional level.

• During these meetings aggregated data was presented and discussed. Administrative issues were attended too.

• Activities that are to be undertaken in near future were presented and the details regarding their implementation were discussed and agreed upon.

7. Four Monthly Performance Review Workshop at Central Level

• The workshop is held every four months at LCD to assess the outcome & monitoring of the program.

• The workshop is chaired by Director of the Leprosy Control Program. RTLOs, representatives from LMD and HMIS section, regional statistical officers, INGO partners and WHO attend the workshop.

• During the workshop hindering factors are identified (if any) and measures are suggested to address it.

8. Patients and Their Neighbor Family Examination

• This activity is in the Index case based approach HW/ FCHV's visit every household of a newly detected leprosy case and their neighbor using the chase card (pictorial card).

• They examine all household family members for any signs and symptoms of leprosy and refer suspected case of leprosy to nearest HF.

• During this year 130,000 family member were examined which is 67 percent of annual targeted. Among total detected of new cases 5 percent of cases were found through this activity.

9. School Health Education

• This activity target mainly secondary level school students.

• The main objective of this activity is to aware students and teachers about early sign and symptoms of leprosy, benefits of early treatment and options of treatment available at treatment facilities.

• During this FY 2380 Schools had given health education among targeted 2500 schools.

10. Procurement of Anti Reaction Drugs and MDT ‐Logistic

• Nippon Foundation and the Novartis Foundation provides MDT free of cost for all patients through WHO.

• The Leprosy Control Division supply of MDT through Regional Medical Store with general drug delivery system at the district levels.

• Health facilities where leprosy cases are diagnosed and treated must have been assured supply of MDT drugs.

Contd..

• Cases should start MDT at the centre where diagnosis is confirmed, and treatment should continue at the health facility nearest to the pt’s residence.

• Accompanied MDT may be given to certain categories of patients— those from hard to reach or ‐ ‐distant areas, migrant laborers, nomads, those with jobs which entail constant travel, etc.

Contd..

• Where necessary, the referral centre that first treats a case should provide the MDT drugs to the local unit that will continue the treatment.

• The drugs and materials for treating complications such as reactions, wounds and plantar ulcers should be made available from the pharmacies of general health facilities.

• MDT stock management remained satisfactory throughout the year though some districts managed the shortage by neighboring districts.

11. Publications

• During the year, Leprosy Control Division published its annual report 2066/67 (2009 10) containing the ‐salient features of the current leprosy situation, activities undertaken during previous year, achievements and obstacles faced by the program.

12. Health Management Information System (HMIS)

• Data generation, compilation, aggregation, and report submission were timely done throughout the year.

• Consolidated data was received at every 4 months at districts, regions and centre.

• Feedback on vital issues that had emerged was provided to specific program area during the review meetings.

13. Skin Camp

• This activity was focused in high endemic districts to detect early leprosy cases.

• During fiscal year, 16 camps were conducted in 16 different endemic districts.

14. Disadvantage Group Program

• This activity was conducted to access the unreached community.

• Stigma reduction and motivation for active participant in the leprosy control activity and services of the community were focused.

• During this fiscal year this activity was conducted in 145 places of different districts. In some places and the community identified suspected cases and refer them.

15. Case Validation and Updating of Records

• This activity was designed to correct operational errors like over diagnosis, re registered, removal of ‐non existing cases from the prevalence pool, and over stay in treatment.

16. Supervision and Monitoring

• To provide technical guidance to the staff at peripheral health facilities and district health offices, supervisory visits were undertaken regularly by the staff of LCD, Regional Health Directorate (RHD) and District Health Offices (DHO).

• A part from the budget made available by GoN for this activity, additional funds were also provided by WHO, NLR and other supporting partners.

• Additional technical support through supervisory visits was also provided by the staff of WHO, NLR, NLT, INF, Anandaban Hospital & other supporting partners.

17. Other Significant Events of the Year

During the FY 2067/68 various events took place in LCD among which following are the major ones that took place at the central level:

• The Health Education Advisory Committee was held at LCD.

• DTLO seminar for Dissemination of New National Strategy 2011 2015 at Bharatpur.‐

Activities carried out in high endemic districts with the assistance:

• Supported community awareness and participatory program at different level

• Orientation to different community members• Provision of Primary, secondary and tertiary care

through referral centres• Capacity building of GoN staff• Technical support through supervision• POID and Rehabilitative services• Support in IEC activities

Analysis of Achievement

1. Prevalence

• By the end of FY 2067/68 there were 2,210 cases receiving treatment for leprosy in the country.

• Leprosy elimination has also been achieved at regional level.

2. New Case Detection Rate

• During 2067/68, a total of 3,142 new leprosy cases were detected. One third of these new cases were female and the children constituted 5 percent of the new cases registered.

• About 52 percent of these new cases were grouped under multi bacillary leprosy.

WHO grading of EHF score: 1998Hands and feet• Grade 0: no anesthesia, no visible deformity or damage.• Grade 1: anesthesia present, but no visible deformity or

damage.• Grade 2: severe visual deformity or damage present.

Eyes• Grade 0 : no eye problem due to leprosy, no evidence of visual

loss.• Grade 1: eye problems due to leprosy present, but vision not

severely affected ( vision:6/60 or better; can count fingers at 6m)

• Grade 2: severe visual impairment ( vision: 6/60; inability to count fingers at 6m) also includes lagophthalmos, iridocyclitism, and corneal opacities.

2. Disability Rate

3. Outcome of the Cases Registered

• During the Fiscal Year 2067/68 a total of 2979 (MB 1507 and PB 1472) cases had completed treatment and were removed from treatment.

• The remaining cases are undergoing treatment. • Total transferred out cases were 54, number of

defaulter cases was 31 and other deductions were 122, which include death, double registration and wrong diagnosis.

• The number of patients who restarted MDT in the current year was 42.

4. Treatment Compliance (Cohort Analysis)

• The proportion of new patients who complete their treatment on time is an indication of how well the leprosy patients are being served by the health services.

• The rate is calculated separately for PB & MB patients as a cohort analysis.

Treatment Compliance contd..

• During the fiscal year 2064/65 (2007/08) total of 2,302 MB patients and 2,380 PB patients were registered.

• Among the registered MB cases 2,174 (94.4%) and 2,286 (96.9%) PB have completed treatment within the given time frame.

• In this period 33 MB & 34 PB cases defaulted. The treatment completion rate this year is satisfactory.

Problem/Constraints

• Non existing (cross border issues) cases on ‐prevalence pool

• Double reporting of cases at the place of diagnosis & at residence HF level

• Still high prevalence in some districts

Action Taken

• Patients verification, case validation (Bara, Rautahat, Rukum, Morang, Jhapa, Sunsari)

• Updating records/reports (Quarterly, on the spot, Fax, Tel.)

• Patients counseling, intensification of contact examination has done

• Post Elimination Strategy Finalized

Impression

• Elimination continued – RPR has increased• 12 Districts – Still remain high Prevalence, PR

increased to >1 in eliminated district Rautahat and Chitwan

• Increased – Disability Grade II• Child proportion and Female proportion Remarkably

decreased

Strength• Trained manpower serving in all health facilities.• Accessible network of public health and services provided by

partner organization.• Free leprosy service.• Minimum stigma and discrimination against people and

families affected with leprosy• Regular review meetings.• Uninterrupted MDT supply.• Elaborate data base of good quality.• Good communication and collaboration with supporting

partners

Weakness

• Low priority of program at periphery.

Challenges

• To sustain leprosy elimination at all level.• To maintain quality of services in low endemic

mountain and hilly districts situations.• To strengthen surveillance, drug supply, logistic,

information, and job oriented capacity building for ‐general health workers and an efficient referral network.

• To assess the magnitude of the disability burden due to leprosy.

• To further reduce stigma and discrimination against affected persons and their families.

Future Course of Action

• Intensive IEC activities to raise the community awareness about leprosy and its treatment.

• Strengthen regular new case detection activities in cluster area of Endemic districts.

• Promote community participation in National Leprosy Elimination Program.

• Improve access of unreached group.

Target for FY 2068/69

• Annual report 2067/68 : 152

THANK YOU…!!