National Leprosy Eradication Programme – Delhi
WHAT
IS LEPROSY?
Leprosy/Hansen’s disease is an infectious disease
that causes severe, disfiguring skin sores and nerve damage in the arms, legs,
and skin areas around the body. The incubation period is 3 to 5 years / till 20
years. Leprosy is caused by mycobacterium lapre it is not so contagious but if
one come into close and repeated contact with nose and mouth droplets from
someone with untreated leprosy.
Children are more likely to get leprosy than
adults. It primarily affects the skin and nerves outside the brain and spinal
cords (peripheral Nerves). Eyes and the thin tissue lining the inside the nose.
Loss of sensation occur on the affected area of skin with muscle weakness.
What are types of Leprosy?
Leprosy is characterized according to the number
and type of skin sores you have. Specific symptoms and your treatment depend on
the type of leprosy you have. The types are:
Paucibacillary/tuberculoid.
A mild, less severe form of leprosy.
People with this type have only one or a few patches of flat, pale-coloured
skin (paucibacillary leprosy). The affected area of skin may feel numb because
of nerve damage underneath. Tuberculoid leprosy is less contagious than other
forms.
Multibacillary/lepromatous.
A more severe form of the disease. It
involves widespread skin bumps and rashes (multibacillary leprosy), numbness
and muscle weakness. The nose, kidneys and male reproductive organs may also be
affected. It is more contagious than tuberculoid leprosy.
Borderline. People with this type of leprosy have symptoms of
both the tuberculoid and lepromatous forms
|
S. No.
|
Characteristic
|
PB (Pauci bacillary)
|
MB (Multi bacillary)
|
|
1.
|
Skin
lesions
|
1
– 5 lesions
|
6
and above
|
|
2.
|
Peripheral
nerve involvement
|
No
nerve / only one nerve with or without 1 to 5 lesions
|
More
than one nerve irrespective of number of skin lesions
|
|
3.
|
Skin
smear
|
Negative
at all sites
|
Positive
at any site
|
How do you diagnose?
If patients have a suspicious skin sore, your
doctor will remove a small sample of the abnormal skin and send it to a
laboratory to be examined. This is called a skin biopsy. A skin smear test may
also be done. With paucibacillary leprosy, no bacteria will be detected. In
contrast, bacteria are expected to be found on a skin smear test from a person
with multibacillary leprosy.
What is treatment of Leprosy?
Leprosy
can be cured. In the last two decades, more than 14 million people with leprosy
have been cured. Treatment depends on the type of leprosy that patients have. The drugs used are dapsone, rifampicin
and clofazimine - different combinations of these drugs are recommended
depending on whether a person has paucibacillary or multibacillary leprosy.
Public Health England (PHE) reports that since the introduction of multi-drug
therapy (MDT) in 1982, the number of leprosy cases has been dramatically
reduced.Before the introduction of MDT, many leprosy patients could expect to
take medicine for life. MDT has been made available free to all leprosy
patients in the world by the World Health Organisation.
Ø Rifampicin:
10 mg/ kg body weight, monthly once
Ø Clofazimine:
1 mg /kg body weight daily and 6 mg/kg body weight, monthly once
Ø Dapsone:
2 mg /kg body weight daily.
Duration of treatment: Leprosy
persons with PB leprosy need 6 months treatment that must be completed in
maximum of 9 consecutive months. This means PB leprosy person cannot miss a
total of more than 3 pulses during treatment. MB leprosy person needs 12 months
treatment that must be completed in 18 consecutive months. All the efforts must
be made to complete 6 pulses in 6 months for PB cases and 12 pulses in 12
months for MB cases. Note: Rarely, specialists may consider treating a person
with high bacterial index for more than 12 months; decision is based on
clinical and bacteriological evidence.
Table showing recommended dose of MDT
for person affected by leprosy
|
Type of leprosy
|
Drugs used
|
Frequency of Administration Adults
(children in bracket)
|
Dosage (adult) 15 years & above
|
Dosage (Children 10-14 years)#
|
Dosage Children Below 10 years*
|
Criteria for RFT
|
|
MB
leprosy
|
Rifampicin
|
Once
monthly
|
600
mg
|
450mg
|
300mg
|
Completion
of 12 monthly pulses in 18 Consecutive months
|
|
Clofazimine
|
monthly
|
300
mg
|
150
mg
|
100mg
|
|
Dapsone
|
Daily
Once
|
100
mg
|
50
mg
|
25mg
|
|
Clofazimine
|
Daily
for adults (every other day for children)
|
50
mg
|
50mg
(alternate day, not daily)
|
50mg
(weekly twice)
|
|
PB
leprosy
|
Rifampicin
|
Once
monthly
|
600
mg
|
450
mg
|
300mg
|
|
Dapsone
|
Daily
|
100
mg
|
50
mg
|
25mg
daily or 50 mg alternate day
|
Completion
of 6 monthly pulses 9 consecutive months
|
Advantages of Multi Drug Therapy (MDT)
•
MDT kills bacilli (M. leprae) in the
body. It stops the progress of the disease, prevents further complications and
reduces chances of relapse.
•
As the M. leprae are killed, the patient
becomes non-infectious and thus the spread of infection in the body is reduced.
Moreover, chances for transmission of infection to other persons are also
reduced to a considerable extent.
•
Using a combination of two or three
drugs instead of one drug ensures effective cure and reduces chances of
development of resistance to the drugs.
•
Treatment with multi-drug therapy
reduces duration of the treatment.
•
Duration of treatment is short and
fixed.
•
MDT is safe, has minimal side effects
and has increased patient compliance.
•
Available in blister pack; easy to
dispense, store and take.
Indications
for prescribing MDT
New case of
leprosy: Person with signs of leprosy who have never received treatment before.
Other cases: Under NLEP all previously treated cases, who need further
treatment are recorded as “other cases”. It has been decided that all migrant
cases from another state reporting at any state Health Institution will also be
grouped under this category. Other cases include both PB & MB cases.
Cases
from outside the state & Temporary migration or cross border cases.
Before
deciding a case to be recorded as from other state, the residential status at
the place of diagnosis is carefully examined. A person who has migrated and is
residing for more than six months, is likely to stay till completion of
treatment, and recorded as indigenous case and will not be categorized under
“other cases”. Information regarding other cases is shown separately in the monthly
progress reports. Once it has been decided that a person needs treatment,
register the person in Leprosy Treatment register and make the Leprosy Record
Card. Take care to indicate type of patient (new/others) correctly. Decide the
regimen and counsel the person
Assessing
fitness of a leprosy
Patient
for MDT before starting treatment, you must look for the following: Jaundice:
If the patient is jaundiced, wait till jaundice subsides. Anemia: If the
patient is anaemic, start treatment for anaemia simultaneously along with MDT.
Tuberculosis: If the patient is taking Rifampicin, ensure that he continues to
take Rifampicin in the dose required for the treatment of tuberculosis along
with other drugs in the regimen required for the treatment of leprosy. Allergy
to sulpha drugs: If the patient is known to be allergic to sulpha drugs, avoid
Dapsone. Refer person for prescription of alternate drug regimen.
Assigning
appropriate MDT regimen Based on the grouping, the patients may be given any
one of the standard MDT regimen mentioned below. In children, the dose must be
adjusted suitably. When the patient has completed the required number of doses
the treatment is stopped and RFT (Released from Treatment) is written against
the name of the person in the leprosy treatment register.
Treatment
of leprosy during pregnancy Why to treat?
MDT
is safe and can be continued during pregnancy.
Treatment
of leprosy & tuberculosis:
MDT
is continued but rifampicin is omitted from MDT for leprosy and is given in the
doses recommended as per guidelines of RNTCP
Treatment
of leprosy in HIV positive patients
MDT
for leprosy can be safely given to HIV affected persons and to those on
antiretroviral therapy.
Side
effects of anti-leprosy drugs and its management
•
Anaemia
•
Abdominal symptoms
•
Severe skin complication (Exfoliate
dermatitis) Sulphone hypersensitivity, Haemolytic anaemia
•
Liver damage (Hepatitis)
•
Kidney damage (Nephritis)
Dapsone:
Dapsone
may cause haemolysis of red blood cells. People with glucose-6- phosphatase
dehydrogenase deficiency are more susceptible to haemolysis. It is usually mild
and symptom less. Methaemoglobinaemia may also occur due to dapsone therapy.
Lips and nails may develop blue hue that may disappear spontaneously or on
reducing the dose and is not an indication to interrupt therapy. Both are rare
in therapeutic doses used for leprosy.
Rifampicin
•
Red discoloration of body fluids
•
Flu like illness
•
Abdominal symptoms
•
Hepatitis (liver damage)
•
Allergy
Ensuring
regularity of treatment:
Counsel
the person adequately regarding the disease, its curability, duration of
treatment and importance of regular & complete treatment. Encourage the
person constantly to complete the treatment.
•
Tell the basic facts about the disease
e.g. disease is curable, skin patches may not disappear or take some time to
disappear after the completion of the treatment
•
Explain the method of taking drug. Ask
person to swallow first dose in front of the health worker / doctor (Assign a
person to observe intake of first dose)
•
Tell them that medicine is to be
collected every 28 days (better to collect 1-2 days in advance).
•
Tell the person about possible side
effects and when to report.
•
Encourage person to ask questions
•
Ask person to bring the previous blister
pack Every time patient comes to collect medicine, examine and assess for any
complication or worsening of disability Contact the person who has not reported
to collect the monthly blister pack with the help of your team members or
members of the community. Find out the reason and try to find a solution to the
patient’s problem. Reasons for interruption of treatment may be many like:
§ Poor
accessibility of the clinic (Distance/ connectivity / timings)
§ Difficulty
in taking time off work
§ Lack
of understanding about disease and importance of regular treatment
§ Stigma
often fed by negative attitude and fear in the community
§ A
poor relationship with health care providers Adopt, accompanied MDT, whenever
it is essential Ensure timely release from treatment of MDT
Encourage regular and complete treatment
Patients who are not
collecting drug on time should be contacted immediately to identify the reasons
and take corrective actions. ? Flexibility in MDT
delivery (more than one pulse at a time) may be adapted whenever it is
essential.
Follow
up of patient on MDT
Whenever
a patient comes to the PHC, reassure the patient, ensure regularity of
treatment, and look for side effects of MDT or sign /symptoms of reaction/
Neuritis.
Completion
of treatment with MDT:
Skin
lesions due to leprosy may not disappear immediately on completion of fixed
duration treatment with MDT. In some people, light-colored patches remain on
the skin permanently. Persons with residual patches at the time of completion
of treatment must be told this, otherwise, they may not understand why their
treatment has been stopped and may try to take treatment from somewhere else.
Loss of sensation, muscle weakness and other nerve damage may also remain.
Educate the patient about the difference between persistence of light-coloured
patches or loss of sensation despite successful therapy as an expected outcome,
appearance of new lesions or new sensory loss, nerve involvement, ocular
involvement or other signs and symptoms of reaction as danger signs for which
the person should report immediately. Ensure that person with disability knows
about “self care” for prevention of disability or it’s worsening. (For self
care refer POD) Ask persons with low risk for development of reaction/
disability to report immediately on appearance of any of the signs/ symptoms
and people with high risk to come for follow up after three months for first
year after completion of treatment and every six months for next two years.
Those taking steroid therapy are asked to come after two weeks.
After
completion of treatment, a very small number of patients may get new skin
patches because of relapse. Refer such PAL to referral center for confirmation
of relapse and treatment. 7.3.16 Criteria to restart course of MDT On relapse
of disease, MDT is restarted. Relapse must be differentiated from Leprosy
Reaction. Drop out cases that discontinued MDT for more than three months in PB
and more than six months in MB leprosy regimen, restart treatment as other
cases Any new lesion reappears after completion of full course of MDT. Refer the case to identified referral center for confirmation
of relapse.
What
are the complications of not treating?
Complications of leprosy can include:
·
Blindness or glaucoma
·
Disfiguration of the face (including
permanent swelling, bumps, and lumps)
·
Erectile dysfunction and infertility in
men
·
Kidney failure
·
Muscle weakness that leads to claw-like
hands or an inability to flex the feet
·
Permanent damage to the inside of the
nose, which can lead to nosebleeds and a chronic, stuffy nose
·
Permanent damage to the peripheral
nerves, the nerves outside the brain and spinal cord, including those in your
arms, legs and feet.
·
Nerve damage can lead to a dangerous
loss of feeling. A person with leprosy-related nerve damage may not feel pain
when the hands, legs, or feet are cut, burned or otherwise injured.
·
Approximately one to two million people
worldwide are permanently disabled because of leprosy.
What
is National/State Programme?
The programme was started in last year
of 1st five year plan. The mile stones of the programme are as
follows:
1955 - National Leprosy Control
Programme (NLCP) launched
1983 - National Leprosy Eradication
Programme launched
1983 - Introduction of Multidrug therapy
(MDT) in Phases
2005 - Elimination of Leprosy at National
Level
2012 - Special action plan for 209 high
endemic districts in 16 States/UTs
2016-Leprosy case Detection Campaign in
high endemic Area
2017-Sparh Leprosy Campaign
What
are its objectives?
• Decentralization
of NLEP responsibilities to States/ UTs through State/ District Leprosy
• Societies.
• Accomplish
integration of leprosy services with General Health Care System (GHS) and
• Achieve
elimination of leprosy at National level by the end of the Project
• Provide
good quality leprosy services,
• Enhance
Disability Prevention and Medical Rehabilitation,
• Increase
advocacy towards reduction of stigma and stop discrimination and Strengthen-
• Monitoring
and supervision.
• To
achieve elimination of leprosy at national level by the end of the project
• To
accomplish integration of leprosy services with general health services in the
27 low endemic states
• To
proceed with integration of services as rapidly as possible in the 8 high
endemic states
How
to achieve these objectives?
A large number of voluntary
organizations have been playing a pioneering role in anti-leprosy work in
India. While some of them were engaged in training, education and research,
others were also engaged, in case detection, treatment, rehabilitation and
control work. A large number were voluntary, while some received grants from
governmental organizations and others from international agencies.
10. What are the Strategies?
•
To eliminate the following strategy
adopted:
•
Modified leprosy elimination campaigns (
MLEC): organizing camps for 1 or 2 weeks duration for case detection, treatment
and referral
•
Special action projects for the
elimination of leprosy ( SAPEL): initiative for providing MDT services in
special difficult to access areas or to neglected population groups.
•
Early detection of leprosy cases
•
Intensified health education and public
awareness campaigns
•
Regular treatment of leprosy cases
providing multi- drug therapy( MDT) at fixed centres near the patient
•
Disability prevention and medical
rehabilitation
•
Multi-bacillary leprosy is labeled when
there are 6 or more skin patches and/or 2 or more nerves affected. Skin smear
is positive.
•
Paucibacillary leprosy is labeled when
there 5 or less than 5 skin lesions and/or 1 more nerve affected. Skin smear do
not show bacilli
•
Rifampicin is given once a month. No
toxic effects have been reported in the case of monthly administration. The
urine may be coloured slightly reddish for a few hours after its intake, this
should be explained to the patient while starting MDT.
•
Clofazimine is most active when administered
daily. The drug is well tolerated and virtually non-toxic in the dosage used
for MDT. The drug causes brownish black discoloration and dryness of skin.
However, this disappears within few months after stopping treatment. This
should be explained to patients starting MDT regimen for MB leprosy.
•
Dapsone: This drug is very safe in the
dosage used in MDT and side effects are rare. The main side effect is allergic
reaction, causing itchy skin rashes and exfoliative dermatitis. Patients known
to be allergic to any of the sulpha drugs should not be given dapsone.
What is prevalence and New case
detection?
Prevalence Rate (PR):
Number of cases on record at a given point of time per 10000 populations.
New Cases Detection Rate:
Number of new cases detected during the year per 100000 populations.
PR
and NCDR for last seventeen years.
Migration: About
54% patients come to Delhi for treatment from neighboring states like UP,
Bihar, Haryana Madhya Pradesh and Jharkhand. UP alone contributes almost 28% of
new leprosy patients diagnosed in Delhi.
Proportion
of mobile patients from neighboring states
What is rehabilitation?
Leprosy
may have already permanently damaged the nerves. As they no longer feel
pain, a person is then at risk of injuring their hands and feet while
completing daily tasks such as walking and cooking. We train people
within communities to lead self-care groups which help minimize the risk of
injury.
We
have specialist shoemakers to build shoes to support a leprosy-affected
person’s damaged feet. These have thick soles, often made from old vehicle tyres,
so that they cannot be perforated by glass or debris and injure numb feet.
Recently more cosmetic MCR footwears are available for better acceptance.
Surgery
The most common leprosy-caused
disabilities that can be corrected by surgery are a clawed hand, foot drop and
a clawed toe. Movement can be restored by using a muscle transfer technique
where, with the help of a physiotherapist, a muscle is identified for transfer
and strengthened. After surgery and several weeks in plaster, the patient is
taught how to use their old muscle to do a new job and then apply the technique
subconsciously. The results can see a leprosy-affected person walk again
without dragging their foot on the ground or use their hand to grip items. In a
similar way, leprosy patients no longer able to close their eyes as a result of
nerve damage (called Lagophthalmos), can undergo Temporalis Muscle Transfer.
This sees a muscle used for chewing transferred to the eyes so that, after a
period of recovery, a person can close their eyes once again by clenching their
teeth. This protects the eyes and can spare a person from blindness.
Prostheses
The fitting of ‘life-like’
prostheses can transform the lives of people who have lost lower legs as a
result of leprosy. We offer this opportunity in many of the countries in which
we work. A particularly pioneering prosthetic limb service has been launched
in Myanmar (Burma). It sees a truck manned by
four physiotherapists touring the country making fitting prostheses for
leprosy-affected people.
Counseling:
Counseling and tending to the
spiritual and emotional needs of people affected by leprosy are an integral
part of our care and health services. Counselling is more important than the
drug treatment. It’s the heart and soul that matters. The body is temporary,
people can overcome physical challenges, but the spirit takes the longest time
to heal. For many people the diagnosis of leprosy has taken away all hope. I
allow people affected by leprosy to vent their feelings, to cry; emotional
healing is so important. Healing is not just medical, it’s a healing of the
heart and soul, empowering a person to achieve a life of dignity and worth.”
What services are
provided to the affected persons?
·
Providing treatment (MDT) to the leprosy
affected persons (LEP)
·
Deformity correction which are being
done in DFIT Goyla Dairy and The Leprosy Mission Hospital (TLM).
·
Rupees eight Thousand are being paid to
the patients who under goes for the correction of the deformity of Claw hands
and drop foot
·
To provide MCR footwear.
·
Free Medical Services/Medicines are
being providing to the LAP and other supported treatment if require.
·
Dressing materials are being provided to
the LAP having ulcer.
·
Weekly visit in the leprosy colonies by
NMS/LA/PMW.
·
Fortnightly visit in the leprosy
colonies by the Medical officer Incharge of the nearby dispensary.
·
Monthly visit in the leprosy colonies by
the District leprosy officers.
Budget approved in 2016-17—2.93 Crores
Budget
Proposed 2017-18—3.45 Crores
What activities are planned this
year?
·
Quarterly Review Meetings
·
State Level Workshop
·
IEC activities
·
Leprosy case detection campaign (LCDC)
·
Chemoprophylaxis are being provided to
the contact persons of newly diagnosed LAP
·
Focus Leprosy Campaign (FLC) for newly
detected grade two disabilities.
·
PIP meetings
·
Field level monitoring in leprosy colonies
by DLOs
·
Repeat Online reporting system training
shall be given to the NMS/LA/MIS experts.
How many activities already started?
•
Working on IEC activities’
•
Planning for quarterly review meeting
What is implementation structure at
district level?
At
district level NLEP is implemented through district leprosy societies. Each
district has a district leprosy officer to implement the programme.
What is reporting system?
Reports
are collected in SIS format, compiled and sent to government of India. The
system for sending Online Reports to the Central leprosy Division on regular
basis is under process.
In
this regards, the leprosy portal are being started on district level after the
training to MIS expert and DLOs of the districts by the ICMR trainers.
How frequently reports are
collected and sent to the government?
Monthly,
Quarterly and annual reports are being collected from eleven districts,
compiled and sent to state and Government of India.
What is the roll of International,
National and Local NGOs?
International
Federation of anti-leprosy Associations (ILEP) is providing technical support
from time to time. ILEP agencies are also helping in reconstructive surgeries and
provision of microcellular rubber footwear. They are also conducting
sensitization programme for hospital and district administrators.
Involvement of peripheral workers:
Monthly refresher
trainings are being imparted to the ASHAs in dispensaries of districts in which
a session about the leprosy shall be included.
ASHA is involved in
following areas:
•
Generating awareness in the community in local language to
reduce stigma.
•
Encourage self reporting of suspected patients for early case
detection and treatment.
•
Identify / suspect leprosy completions in the community and
refer them to the treatment centre.
•
Ensuring leprosy treatment regularity and its timely
completion.
•
Encouraging leprosy disabled persons to practice self care
(as advised by doctor / health worker).
•
Encouraging the leprosy affected persons for healthy contact
examination of their family.
•
AWW worker shall be trained for LCDC
activity to be held in 2017.
An
urban leprosy project in collaboration with Hind Kusht Nivaran Sangh is being
implemented under Bangkok declaration to fill the gaps NLEP. Initially three
districts (east, Shahdara and northeast) are selected to improve early case
detection, completion of treatment through retrieval of treatment defaulters
and prevention of further worsening of disabilities.
For
further information /suggestions write to:
Dr K S Baghotia
Addl.
Director/State Leprosy Officer
Govt.
of NCT of Delhi
DGHS,
Pt DCSS Bhawan, Sector-20
Dwarka-
New Delhi-110077
Email:
dghsleprosy@gmail.com
NATIONAL PROGRAMME FOR PREVENTION AND CONTROL OF DEAFNESS - DELHI
Hearing loss is the most common sensory deficit in humans today. As per WHO estimates in India, there are approximately 63 million people, who are suffering from significant auditory impairment; this places the estimated prevalence at 6.3% in Indian population. As per NSSO survey, currently there are 291 persons per one lakh population who are suffering from severe to profound hearing loss (NSSO, 2001). Of these, a large percentage is children between the ages of 0 to 14 years. With such a large number of hearing impaired young Indians, it amounts to a severe loss of productivity, both physical and economic. An even larger percentage of our population suffers from milder degrees of hearing loss and unilateral (one sided) hearing loss.
OBJECTIVES OF THE PROGRAMME
- To prevent the avoidable hearing loss on account of disease or injury.
- Early identification, diagnosis and treatment of ear problems responsible for hearing loss and deafness.
- To medically rehabilitate persons of all age groups, suffering with deafness.
- To strengthen the existing inter-sectoral linkages for continuity of the rehabilitation programme, for persons with deafness.
- To develop institutional capacity for ear care services by providing support for equipment and material and training personnel.
- To make the public aware about injuries and ear diseases that cause severe or profound hearing loss through IEC activities
STRATEGIES
- To strengthen the service delivery including rehabilitation.
- To develop human resource for ear care.
- To promote outreach activities and public awareness through appropriate and effective IEC strategies with special emphasis on prevention of deafness.
- To develop institutional capacity of the district hospitals, community health centers and primary health centers, selected under the project.
- During 2010-11 the project will be implemented in all the nine districts of Delhi involving major/district hospitals.
ACTIVITIES PROPOSED UNDER PIP:
Availability of man power, procurement of equipment capacity building and required budget proposed in financial year 2010-11 are as follows:-
1 Contractual services: The contractual staff will be engaged under NPPCD to carryout the job effectively.
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