Leprosy elimination in NepalLeprosy elimination in Nepal

Dr B N Reddy

WHO Country Office Nepal

HeadlinesHeadlines

Control / Eradication / Elimination / EradicationFew relevant historical factsWhere are we nowJourney so farObstacles to eliminationProposed solutionsSummary

Leprosy: Control / Eradication / Leprosy: Control / Eradication / Elimination / EradicationElimination / Eradication

Purposeful reduction in the number of cases to such a low level that

It is acceptable (Contr.)

PR is < 1. (Elim.) (No public health problem ?)

Transmission ceases. (Erad.)

IndicatorIndicator

Point Prevalence rate

- Estimated prevalence rate.

- Registered case prevalence rate.

From 1 / 1000 to 1 / 10 000

“ 1 ” Arbitrary or epid. & oper significant !!!

Programme Strategy Programme Strategy

Primordial Prevention X

Primary Prevention ???

Secondary Prevention + + +

Tertiary Prevention + +

BCG unintentional ?

Early detection and prompt treatment

Limitation of disabilities Rehabilitation

Few historical factsFew historical facts

Countries have eliminated leprosyWith no effective chemotherapy.With Dapsone mono therapy.With Indefinite MDT.With fixed MDT.

MDT is most important factor in leprosy transmission reduction but not the only

factor

Where are we now ?Where are we now ?

CDR38%

EDR25%

FWDR11%

MWDR12%

WDR14%

CDR40%

EDR28%

WDR15%

MWDR8%

FWDR9%

Two thirds are from EDR & CDR.Over 80 % of the cases are from terai region.

R C 3786

N C 4317

Where are we ? Case distributionWhere are we ? Case distribution

Prevalence rate > 1 in all regions. Highest in FWDR Least in WDR

Number of reg. cases Highest in CDR in Least in FWDR

Regionwise PR (14/7/07

1.56 1.58

1.05

1.321.45

1.68

EDR CDR WDR MWDR FWDR Nepal

Registered cases939

542449 419

1427

EDR CDR WDR MWDR FWDR

Where are we? Case distributionWhere are we? Case distribution

NCDRHighest (2) in EDRLeast (1.07) in WDR

New case DetectionMaximum (1689) CDRMinimum (364) MWDR

Regionwise NCDR 2006/07

1.86

1.281.07

1.59 1.65

2

EDR CDR WDR MWDR FWDR Nepal

New case detection 2006/07

1206

661

364 397

1689

EDR CDR WDR MWDR FWDR

Where are we? District wise Where are we? District wise endemicity endemicity

> 31%

2 to 317%

< 157%

1 to 225%

Journey so far: 3Journey so far: 3rdrd qrtr trend qrtr trend

Why increased?

No surprises from disabled bacteria

Data from additional source.

Social factors

-6.2

-13.5

10.7

-11.7

Qrtr 1 Qrtr 2 Qrtr 3 2006/07

Percentage change in PR

Journey so far: Trends in Journey so far: Trends in PR & NCDRPR & NCDR

4.4

5.73

3.04

2.412.02

1.65 1.45

1.651.962.4

2.84

3.24

2001/02 2002/03 2003/04 2004/05 2005/06 2006/07

PR NCDR

Average reduction in PR was 0.4 /10 000 per year except during 2006/07 where it is only 0.2

Journey so far: Indicator TrendsJourney so far: Indicator Trends

Female proportion has come down significantly during 2006 / 07. Other indicators had remained stable.

7.7 6.5 6.8 6.6 6.16

34.431.829.6

41.2

30.2

51.2 50.9 52.3 51.3 55.13

2002/03 2003/04 2004/05 2005/06 2006/07

Female % Child % MB %

Obstacles: Epidemiological factorsObstacles: Epidemiological factors

Agent related factors

Host related factors

Environmental factors

Social

Physical

Biological

Agent

Environ Host

Obstacles: Technical factorObstacles: Technical factor

Limitation of disease control technology namely early diagnosis and prompt treatment.

Absence of an effective specific protection tool (primary prevention). Immuno & Chemo prophylaxis have limited application.

Obstacles: Operational factorsObstacles: Operational factorsaffecting detectionaffecting detection

Wrong diagnosis

Leprosy91%

No leprosy

9%

Varied from 5.5 to 20.45 % in districts studied

Obstacles: Operational factorsObstacles: Operational factorsaffecting detectionaffecting detection

Re- registration varied from 0 to 28 % in the districts studied

Proportion of cases reregistered

Cases89%

Re reg.11%

Obstacles: Operational factorsObstacles: Operational factorsaffecting detectionaffecting detection

Cases94%

Nonexist6%

Obstacles: Operational factors Obstacles: Operational factors affecting affecting duration of diseaseduration of disease

C Gr87%

W Gr13%

Obstacles: Operational factors Obstacles: Operational factors affecting affecting duration of duration of disease disease

Smear examination

False positives. = Unnecessarily 12 months

False high positives. = - do - 24 months

Wrong calculation = - do - 24 months

Highest single site reading

< 4 +53%

> 4 +47%

Average reading of all sites (BI)

< 4 +99%

> 4 +1%

Obstacles: Operational factors Obstacles: Operational factors affecting affecting DDuration of diseaseuration of disease

Overstay beyond 6 / 12 / 24 months.

Irregular patients.

6 / 9 and 12 / 15 or 18 flexibility

Obstacles: Operational factorsObstacles: Operational factors Increasing PD ratioIncreasing PD ratio

Region 05 – 06 06 – 07

EDR 0.73 0.78

CDR 0.82 0.85

WDR 0.80 0.82

MWDR 1.08 1.23

FWDR 1.04 1.06

National 0.84 0.88

Obstacles: System factorsObstacles: System factors

Frequent Change of guard (4 times in one year)

Low priority accorded by system.Inappropriate Attitude of managerial

staff.Inexperience of first line manager.

Obstacles: OthersObstacles: Others

Maoist movement

Madeshi movement

Floods

Proposed solutionProposed solution

Reduce detection !!!

Reduce duration !!!

Reduce errors in compilation.

Legal, ethical & acceptable to all & Patients interest is guarded!!!

Proposed activitiesProposed activities

Examine, Detect Discuss and Delete all

in appropriately registered cases:

Wrong diagnosis.

PB wrongly grouped as MB and has completed 6 pulses.

Indian patients.

Overstay patients.

Motivate DTLAs !!!Motivate DTLAs !!!

To Update registers promptly.Ensure correct data aggregation.Ascertain error free report generation.

Quality laboratory services??Quality laboratory services??

Work shop of technicians so as to ensure that a standard, correct and uniform smear examination procedure is followed in the country.

Revision of national guidelines.

What is new ???What is new ???

Activities are not new.Activities are not obstacle specific.To be implemented properly &

immediately over a short period of time.

Aimed primarily at PR reduction.

Estimated declineEstimated decline

Natural decline 15 %

Control of OFs: Detection 10 % Duration 10%

New case detection 5%

30 % net reduction Wishful thinking !!!

SummarySummary

Both NCDR and PR are declining.Elimination is inevitable.Minimizing proactively the operational

factors will expedite elimination.Additional resources (money and men) need

to be mobilized over a very short period.

Thank you