Thursday, January 11, 2007

LEPROSY REVISITED FIVE YEARS AFTER INTEGRATION OF LEPROSY SERVICES INTO THE GENERAL HEALTH SERVICES (GHS) IN SRI LANKA

Sri Lanka has been in the fore front of the elimination of leprosy, which has been extant since ancient time, as a public health problem in the world. It reached the elimination target of less than one case for 10000 population, a half decade before the year targeted by the WHO. Though the country has achieved a significant progress in this regard, few more issues remain to be settled in the final phase of its elimination. Current strategies addressing these issues are consistent with the global strategy for further reducing the leprosy burden and sustaining leprosy control activities outlined by the WHO which aims at addressing the remaining challenges that endemic countries are likely to face in providing services to people affected by leprosy under conditions of low prevalence.

To overcome these challenges, Sri Lankan Ministry of Health took a bold decision to integrate leprosy services carried out by the vertical campaign to the hierarchical institutions in the General Health Structure( GHS) in 2001. This strategy was adopted with a view to detecting and managing still remaining leprosy cases in the population and providing a better and easy access to these services to patients in a low prevalence scenario in the country. Furthermore, this was seen as a cost-effective approach of providing services for the ministry in a changing epidemiological situation.

Global leprosy situation

Leprosy is no longer a public health problem in a vast majority of countries in the world.
The global registered prevalence of leprosy at the beginning of the year 2006 was 219826 cases. There were 296499 new cases detected during 2005. .According to the WHO, there was a 27% decline in newly detected cases in 2005 in comparison to the preceding year. However, our region, South East Asia was the biggest contributor to the global leprosy burden. Sixty eight percent (201635 new cases) of the global case load was reported in the South-East Asian region. The lowest number of 3133 new cases (0.01%) was reported in the Eastern Mediterranean region.

Worldwide, there has been a declining trend in newly detected cases during the period spanning from of 2001 to 2005. This decline was 38%. The percentage decrease for African, American , South East Asia, Eastern Mediterranean, Western Pacific regions were respectively 7.6%, 2.5%, 70%, 34.2%, 3.7%. The most notable decline in new cases is reported from the South East Asian region.

There were six major endemic countries namely Brazil, Congo, Mozambique, Madagascar, Nepal and Tanzania, which had not been able to reach the WHO elimination target by the end of 2005. Registered prevalence of Leprosy in Nepal was 1.8/10000 while New Case Detection Rate (NCDR) was 2.27/10000 population in 2005.

Seventeen countries had reported more than 1000 new cases during the year 2005.These countries accounted for 94% of the new cases detected globally. Though, Sri Lanka has reached the WHO‘s target of elimination, it occupied the 14th position in terms of the number of new cases detected during the year 2005. India’s contribution of 161457 (54.5%) new cases was phenomenal in this list.

One of the important parameters for a leprosy epidemiologist is the proportion of Multi Bacillary (MB) cases among newly detected cases .This varied from WHO regions to region. The highest proportion (94.3%) was reported from the Philippines while the lowest was from Comoros in the African region which was 22.6%. The other important parameter from the transmission point of view of the disease is the proportion of children less than 15 years among the newly detected cases (Child rate). Comoros in the African region had reported the highest child rate of 39.1% while Argentina had the lowest reported rate of 1%. Grade II disability rate which is the indicator of delayed detection of leprosy was reported to be the highest in Benin (21.7%) followed by China (21.3%). Federated state of Micronesia reported the lowest disability rate of 0.8%.


Sri Lankan situation.

Since integration of leprosy services into the GHS, diagnostic, treatment, MDT distribution and rehabilitative services have been fully taken over by the hierarchical institutions in the GHS. Organisation and implementation of the leprosy elimination activities at the field level are within the jurisdiction of the respective Provincial Health Ministries.

Recent analysis carried out by the ALC reveal that there is a statistically significant drop in the trend of newly detected cases at the Central Leprosy Clinic(CLC) indicating the effect of the integration. It reflects the gradual taking over of the case detection and treatment by the institutions in the GHS. Currently, the CLC caters mainly to the people residing in the Colombo Municipal area. Among the institutions in the GHS, institutions above Base Hospitals have been instrumental in detecting more than three quarter of cases every year since integration. This is consistent with the existing trend of bypassing minor health facilities for other disease in Sri Lanka. Another striking feature in pattern of detection of leprosy in the GHS following integration is the significantly increasing proportion of leprosy cases detected at hospitals with specialised dermatological services. However, in remote districts where specialised dermatological services were not available, the role of lower echelon institution such as Central dispensaries in detecting cases was noteworthy of mention. The comparatively higher proportion of Grade II deformities among patients detected in lower echelon institutions suggests the detection of cases hidden in the community mainly in rural areas until the services became more wide spread and accessible as a result of the integration.

Epidemiological situation

Prevalence of leprosy has been nearly unchanged in the five year period from 2000(0.68/10000) to 2005(0.65/10000). The absolute number of newly detected cases was 1924 in 2005 in comparison to 1700 in 2000. NCDR was 8.9/100000 and 9.6/100000 in 2000 and 2005 respectively. There has not been substantial decrease in the number of new cases detected during the five year period with the reported figure being around 2000 cases. Sri Lanka, despite its elimination of leprosy as a public health problem occupies the 14th position among the 17 countries which reported more than 1000 newly detected patients annually. Nearly half of the newly detected leprosy patients (44.5%) are reported from the Western province followed by 15% in Eastern and 12% in Southern province. Five districts (Colombo, Batticaloa, Polonnaruwa, Matara, Ampara) have consistently reported a prevalence above the WHO elimination target

There has been a clearly visible trend of a reduction in the deformity rates in comparison to 2000.The relevant rate was 5.7% in 2005 while it was 9.8% in 2000. This reflects the reduction of pool of previously undetected, hidden cases in the community and the relevance of shifting to NCDR (incidence) as a more appropriate epidemiological measure of quantifying the disease than the prevalence.

There were 803 (43%) multi bacillary (MB) patients in 2006. Increasing trend of the detection of MB rates augers well for the control of disease as early case detection and treatment with MDT remains the cornerstone of leprosy control. The child rate has been in the range of 10-12% during the five year period. Exceptionally higher rates in endemic Batticaloa (18%), Ampara(10%) and Colombo(14%) districts suggest the continuing transmission in these regions. However, one caution in interpreting these data is the possibility of over diagnosis of child cases.

Challenges for the future

Though Sri Lanka has achieved the elimination target at the country level, the sub national level elimination remains a high priority considering the consistent detection of nearly 2000 new patients annually with higher concentration in some districts. Integrated approach is the most cost effective approach to address the remaining problems and therefore, strengthening and sustaining the provision of quality leprosy services at institutional level in the GHS is essential. It ensures the easy access of services to patients closer to their homes.
Re-registration and recycling of previously detected patients still occur in certain areas. This has to be corrected as it may affect the quality of data. The other important problem is the over diagnosis of hypo pigmented patches in children. It is a known fact that sometimes diagnosis of leprosy may be difficult in children leading to over diagnosis. Validation of the diagnosis and support of the dermatologists to the medical officers in peripheral institutions in better diagnosis may prove to be handy in this situation.

Though many of the patients are cured without sequalae , some may not be so fortunate. Lepra-reactions occur in a few patients after the MDT and relapses may occur from time to time. These patients need timely intervention as negligence may lead to disabilities such as nerve impairment and permanent loss of the function of the nerve. These patients need the specialists support in referral centres. Neglecting such patients leading to permanent disabilities may impact negatively on the programme in a low prevalence situation. Improvement of the quality of life of these patients remain the biggest challenge to the ALC in a low prevalence scenario. Identification of mechanisms of counselling and provision of services to these long suffering patients stands out high priorities for district leprosy managers.

The global strategy for elimination of leprosy is based on further monitoring of MB rates, child rates and deformity rates even in a low prevalence setting. It is essential to estimate the hidden prevalence based on the delay in case detection to successfully launch programmes to detect possible remaining cases in the community. However, in Sri Lanka, the lack of the culture of local level data analysis and targeted intervention on the basis of evidence remain a big obstacle to further expand leprosy elimination activities. This lack of culture and non availability of REs have forced compulsory involvement of the ALC in planning and execution of leprosy elimination activities even after integration in certain areas.

Careful considerations of these challenges are essential to further consolidate gains achieved so far and to reach the goal of the campaign to achieve elimination of leprosy at the sub-national level.
References
1. W.H.O. Global leprosy situation-2006. Weekly Epidemiological Record, august 2006, August. Also available on URL: http: www.who.int/entity/wer/2006/wer8132.pdf
Wijesinghe PR, Settinayake WAS. An analysis of the pattern of detection of leprosy patients by the General Health Services (GHS) in Sri Lanka after the integration of leprosy services into GHS. Leprosy Review. 2005; 76: 296-304.
3. World Health Organization. Report of the inter country meeting of the National Programme Managers of Leprosy Elimination at Kathmandu, Nepal on 6-8 January, 2005.WHO/ICP CPC 600.
4. Anti Leprosy campaign. Annual National and District Leprosy Statistics in Sri Lanka. Central Leprosy Clinic, NHSL, Colombo. 2000-2005.

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