Evaluation of National Leprosy Eradication Program after Integration into General Health System in Rajkot District, Gujarat from 2003 to 2014.

BACKGROUND: National Leprosy Eradication Program (NLEP) was launched in 1983 with the goal of elimination of leprosy as a public health problem. AIM: To evaluate the NLEP performance after integration into general health system from April 2003 to March 2014.
MATERIAL AND METHODS: A retrospective record based study was conducted by obtaining data from Rajkot district leprosy center. Prevalence rate (PR), new case detection rate (NCDR), proportion of female cases, child cases, multibacillary (MB) cases, Grade II disability among new cases and release from treatment (RFT) cases were evaluated from April 2003 to March 2014 and analyzed by using Chi-square for trend analysis test.
RESULTS: The PR of leprosy per 10,000 populations was significantly declined (P < 0.001) from 0.44 in 2003-2004 to 0.15 during March 2014. Reduction in NCDR trend was statistically significant (P < 0.001). The proportion of female cases among newly detected cases showed fluctuation from 36.23% in 2003-2004 to 37.10% in 2013-2014 (P > 0.05). The proportion of child cases also showed significantly declining trend from 12.08% in 2003-2004 to 6.70% in 2013-2014 (P < 0.05). Significant number of MB cases decreased from 122 (2003-2004) to 69 (2013-2014) (P < 0.001). Grade II disability proportion was 1.45% in the year 2003-2004, increased to 5.2% in 2009-2010 and then again decreased to 3.4% in 2013-2014 (P > 0.05). Proportion of patients RFT showed fluctuation from 66.66% (2003-2004) to 45.68% (2009-2010) and then 64.66% (2013-2014) (P < 0.001).
CONCLUSION: The NLEP is having a favorable impact on the problem of leprosy by maintaining the elimination level of leprosy in Rajkot district over a decade.

What was known?

The National Leprosy Eradication Program was launched in 1983 with the goal of elimination of leprosy as a public health problem.

Introduction

Leprosy, one of the most ancient, feared, and disabling diseases of mankind is on the verge of defeat.[1] The word leper comes from a Greek word meaning scaly. The disease comes with many myths which compel the patients to hide the disease resulting in manifestation of deformities. A common belief is that leprosy is due to past sins committed by the person. There is also a belief that it is hereditary and incurable.[2] The global prevalence rate (PR) of the leprosy has dropped by 90% from 21.1 cases per 10,000 population in 1985 to <1 per 10,000 in year 2000. Leprosy has been eliminated from 119 of 122 countries where the disease was considered as a public health problem in 1985.[3] The global PR of leprosy further reduced to 0.33 per 10,000 by end of first quarter of 2013.[4] The South-East Asia region accounts for 66% of the global prevalence at the beginning of 2013.[4]

India contributes to more than 50% of new cases of leprosy detected globally every year.[5] It is estimated that approximately 25% of the patients who are not treated at an early stage of disease develop anesthesia and/or deformities of the hands and feet.[6] The National Leprosy Control Program was launched in Indian in 1955, using surveys, education and dapsone monotherapy to detect and treat leprosy cases. The program was re-launched as the National Leprosy Eradication Program (NLEP) in 1983 with the goal of elimination of leprosy as a public health problem (<1 case per 10,000).[7] In 1981, PR of India was 57.6 per 10,000 which was brought down to <1 per 10,000 by December 2005,[8] and declined further to 0.73 per 10,000 population.[5] Gujarat state contributed 6% of leprosy cases in India by year 2012.[5] In Gujarat state, the PR reduced to elimination level by 2004[9] and now it is 0.96 per 10,000 populations in early 2013.[8]

The core strategy to eliminate leprosy is to identify all leprosy cases and cure them with multi drug therapy (MDT). The responsibility for identifying new cases of leprosy was held solely by specialized leprosy services and it was provided by vertical leprosy staff before integration. The disadvantage of such system was relatively poor coverage of population resulting in large number of patients remaining undetected. Hence, the integration of specialized leprosy services into general health system (GHS) was essential to reach remote area of community.

Analysis of trends of leprosy in a well-defined geographical population over a period provides useful information on how the disease has evolved over the years.[10] The present study was conducted to evaluate the NLEP performance after integration into GHS for eleven years from 2003 to 2014 in Rajkot district of Gujarat state.

Material and Methods

The present study was conducted in Rajkot district of Saurashtra region in Gujarat state from January 2014 to May 2014 to evaluate the NLEP after integration into GHS. As per the data available for PR in Gujarat (March 2013), 16 districts reported PR <1 per 10,000 populations; 2 districts reported PR between 1 and 2/10,000; 6 districts reported PR >2–5/10,000 and 2 districts reported PR >5–10/10,000.[8] The Rajkot district is currently reporting PR <1/10,000. The population of Rajkot district is 3,804,558 and population of Rajkot city is 1,286,678 as per Census 2011 data.[11] There are 14 talukas in Rajkot district namely – Dhoraji, Gondal, Jam Kandorna, Jasdan, Jetpur, Kotda Sangani, Lodhika, Maliya, Morbi, Paddhari, Rajkot, Tankara, Upleta and Wankaner [Figure 1]. The Rajkot city is having an almost one-third population of the Rajkot district.

Figure 1

Map showing Rajkot district in Gujarat state

The NLEP was integrated into GHS from year 2003 in Rajkot district. The program data were collected for last 11 years from April 2003 to March 2014 from district leprosy center, and a retrospective analysis of NLEP was done. The data was collected and analyzed from 1st April to 31st March of every year as per the reporting format of leprosy under the program. As the study was record based only, there was no specific sample size but the study included all the registered cases with health authority in analysis during the study period. The study data were collected with: (1) Inclusion criteria – all data records of below mentioned program indicators which were complete and available for the study period, and (2) exclusion criteria – data with incomplete information for program indicators were excluded.

For evaluation, information was collected on program indicators[12] including PR per 10,000 population, new case detection rate (NCDR) per 10,000, proportion of female cases, of child cases among new cases, of multibacillary (MB) cases, of Grade II disability among new cases, and percentage of cases released from treatment.

Some of the important operational definitions[1314] used in the study includes: (1) New case – a person having skin patch or patches with definite loss of sensation and has not received a course of MDT, (2) MB leprosy – when there are six or more patches and/or 2 or more nerves get affected with skin smear positive for Mycobacterium leprae at any sites, (3) NCDR – number of new cases detected during given year per 10,000 estimated mid-year population, (4) PR – number of balance cases under treatment as on 31st March of given year per 10,000 estimated mid-year population, (5) child case – a child below 15 years of age detected as a new case of leprosy, and (6) Grade II disability[15] – visible deformity or damage present in hands and feet and in case of eyes it is severe visual impairment (vision worse than 6/60, inability to count fingers at 6 meters), lagophthalmos, iridocyclitis, and corneal opacities.

The data was entered and analyzed by using Epi Info 7 software (version 7.1.3.10, release date 03/11/2014) from Centre for Disease Prevention and Control, Atlanta, USA.[16] The data was analyzed and expressed in terms of proportion and percentages. Statistical analysis was done by using Chi-square for the trend to analyze and interpret the data.

Results

The Rajkot district reported 207 new cases during year 2003–2004 which were then reduced to 116 in year 2009–2010 and further declined to 89 in year 2013–2014 [Table 1 and Figure 2]. Reduction in trend of NCDR was statistically significant (χ2 trend = 138.85, P < 0.001). The PR of leprosy per 10,000 population was 0.44 in the year 2003–2004, which was then decreased to 0.26 during year 2009–2010, and further declined to 0.15 during March, 2014. Significant reduction in trend of PR was reported (χ2 trend = 66.89, P < 0.001). More than one-third of newly detected cases were reported from Rajkot city.

Table 1

NCDR and PR of Leprosy in Rajkot district from 2003-2014

Figure 2

Trend of new case detection rate and prevalence rate of leprosy in Rajkot district from 2003 to 2014

Over a period of 11 years, total number of female cases reported showed a decline with statistically insignificant (χ2 trend = 1.38, P > 0.05) trend from 75 in year 2003–2004 to 33 in 2013–2014, but the proportion of female cases among newly detected cases showed fluctuation over a period of time from 36.23% in 2003–2004 to 44.83% in 2005–2006, 33.9% in 2008–2009, 42.2% in 2010–2011 and 37.10% in 2013–2014 [Figure 3]. The number of child cases also showed significantly declining trend from 25 (12.08%) in year 2003–2004 to 6 (6.70%) in year 2013–2014 (χ2 trend = 3.95, P < 0.05). The proportion of child cases among newly detected cases also reported fluctuation over a period of 11 years.

Figure 3

Trend of the proportion of female cases* and child cases† among new cases of leprosy in Rajkot district from 2003 to 2014. *χ2 trend = 1.38, P > 0.05, †χ2 trend = 3.95, P < 0.05

The number of MB leprosy cases decreased from 122 in the year 2003–2004 to 85 in the year 2009–2010, and further down to 69 in the year 2013–2014. Though cases of MB leprosy decreased from 122 to 69, its proportion showed significantly increasing trend from 58.94% in year 2003–2004 to 77.52% in year 2013–2014 (χ2 trend = 39.22, P < 0.001) [Figure 4]. Cases with Grade II disability reported during the study period showed little fluctuation in number, but its proportion showed fluctuating and insignificant trend (χ2 trend = 3.23, P > 0.05) over 11 years period. It was 1.45% in the year 2003–2004, increased to 5.2% in year 2009–2010 and then again decreased to 3.4% in year 2013–2014.

Figure 4

Trend of the proportion of multibacillary cases* and cases with Grade II disability† among new cases of leprosy in Rajkot district from the year 2003 to 2014. *χ2 trend = 39.22, P < 0.001, †χ2 trend = 3.23, P > 0.05

Total 234 patients were released from treatment during the year 2003–2004 which were declined to 97 during the year 2013–2014 [Table 2]. The proportion of patients released from treatment [Figure 5] showed fluctuation from 66.66% in 2003–2004 to 45.68% in 2009–2010 and 64.66% in 2013–2014. The percentage rate of release of cases after treatment was satisfactory (χ2 trend = 10.41, P < 0.001). Table 2 shows various other services like number of reconstructive surgeries (RCSs) done, number of microcellular rubber (MCR) shoes distributed and ulcer kits provided to the leprosy patients.

Table 2

Various services provided to the leprosy patients of Rajkot district from 2003-2014

Figure 5

Trend of the proportion of cases released from treatment release from treatment* out of total leprosy patients in Rajkot district from 2003 to 2014. *χ2 trend = 10.41, P < 0.001

Discussion

Since 1985, the prevalence of leprosy has been reduced globally by more than 90% and over 14.5 million patients have been cured through MDT. The strategy to eliminate leprosy is twofold: (1) Improving access to diagnosis through the integration of leprosy control services into existing public health services, and (2) providing effective drugs free of charge. Early detection of cases has dramatically reduced the risk of deformities and disabilities among patients, ensuring that leprosy sufferers can lead normal lives with dignity.[1]

Integration is considered more cost-effective and feasible within national resources, thereby ensuring sustainability of leprosy services,[17] and it also offers anonymity to patients in attending purely leprosy clinics.[18] In an integrated setup, leprosy diagnosis and treatment is available on all working days in all the health facilities up to primary health center level, and not on fixed day as in a vertical setup. Doses of MDT for treatment completion were distributed by multipurpose workers of nearby sub-centers. For quality diagnosis and treatment, capacity building of GHS staff by proper training and supply of drugs was essential elements of strategy. The Central Leprosy Division of the Ministry of Health and Family Welfare, Government of India, has given the responsibility of training of Medical Officers and other GHS staff to state health authorities. The technical support and other necessary inputs were provided by the Government and District Technical Support Teams. A free supply of MDT has been ensured through World Health Organization and NLEP. Responsibility for stock management and streamlining 3-month supply of each type up to district and health facility level again lies with state health authorities. Leprosy surveillance and monitoring were undertaken by the establishment of Simplified Information System, with the use of standardized formats such as a patient card, treatment register, drug register, and reporting format.[19]

The present study was conducted in Rajkot district after NLEP integration into general health services from the year 2003. The PR of leprosy in the present study showed declining trend from 0.44/10,000 population (year 2003) to 0.15/10,000 population (year 2014) over 11 years of the study period. The Rajkot district has already achieved the elimination status during year 2003 (0.44) and reported a further decline in PR to 0.15 (March 2014). It indicates that integration of program into general health services from 2003 further helped in reducing the PR of leprosy in Rajkot district. Similar declining trend was reported by different authors in neighbor district Jamnagar from 1.84/10,000 population to 0.34/10,000 population during year 1992 to 2001,[20] and 0.72 in 2000–2001 to 0.23/10,000 in year 2010–2011.[10] Various other studies reported from Gujarat state[2122] and also from other states[2324] also reported declining PR in their respective studies.

NCDR in Rajkot district reported decline from 0.62/10,000 population in 2003 to 0.22/10,000 population in March, 2014. Similar declining trend was reported in other studies also.[102122232425] The declining trend in NCDR was probably due to implementation of modified leprosy elimination campaign (MLEC) and block leprosy awareness campaign (BLAC) during last decade, increased coverage of MDT, and voluntary reporting of cases, as reported by others,[10212426] but study from Bihar reported high NCDR and did not show any declining trend.[27] Decline in NCDR may be due to increased coverage of MB cases with MDT, which ultimately reduces disease load in the community.[223]

Almost one-third of newly detected leprosy cases were reported from Rajkot city, that is, one of the major urban areas in the district. Rajkot city is having one third of the total district population. It is mainly industrial hub of the Saurashtra region in Gujarat state and so, attracts people from surrounding area to settle in Rajkot city that might be the reason why Rajkot city is reporting more cases than any other talukas of Rajkot district.

Proportion of female cases among newly detected cases showed a fluctuating trend in a present study like previous studies.[22124] This may indicates the health seeking behavior of women in accessing the health services.[10] The study has reported rapid fall in female specific NCDR in Orissa.[28] The declining trend was observed among child cases from 12.08% in year 2003–2004 to 6.70% in 2013–2014. Only 1 child case was reported during the year 2011–2012 which may indicate the underreporting of child cases. Peat et al. found child ratio difficult to interpret in their study.[29] Different studies have reported either similar findings[22430] or increasing or fluctuating change.[1021]

Though cases of MB leprosy decreased from 122 to 69, its proportion showed increasing trend from 58.94% in year 2003–2004 to 77.52% in year 2013–2014. Various authors reported such decreasing trend of MB cases in their respective studies.[21024] MB Leprosy will increase with a decline in total cases because these are hard to treat and will cluster in the numerator while denominator decreases. As PR decreases, paucibacillary cases also decreases and so, MB cases are on the increase which suggests decreasing trend of leprosy in the community.[2]

The proportion of cases with Grade II disability was 1.45% in year 2003–2004, increased to 5.2% in year 2009–2010 and then again decreased to 3.4% in year 2013–2014. Different studies have reported different findings in reporting Grade II disability cases in India.[2213132] Cases with Grade II disability shows that the program has failed to reach out to that section as the proportion is more than doubled from 1.45% in 2003–2004 to 3.4% in 2013–2014. Field studies will probably show more such cases which the program has still not reached. The present study reports decreasing the number of RCSs though increase in the proportion of Grade II disability cases was observed. The number of RCSs should be increased by the authority for these patients that would help them in rehabilitation.

The proportion of patients released from treatment showed fluctuation from 66.66% in 2003–2004 to 45.68% in 2009–2010 and 64.66% in 2013–2014. Various other studies have reported high number and percentage of cases released from treatment due to MLEC and good coverage of cases with MDT.[2024] Various services have been provided to leprosy patients such as RCSs for rehabilitation, MCR shoes distribution, and ulcer kits provision.

Limitations

There are some limitations in present study like: (1) The study included data from only one district of the state, (2) it is a record based study only and no case interview was conducted to know the patients perception about disease, treatment and program, (3) some hidden cases may remained unreported in the district which may affect the PR of leprosy, (4) the study not included data of MLEC, BLAC, and voluntary reporting of cases which may affect the trend of leprosy.

Conclusion

Considering the findings and analysis of the program indicators, it can be concluded that the NLEP is having a favorable impact on the problem of leprosy by maintaining the elimination level of leprosy in Rajkot district over a decade. Improving surveillance activities, IEC activities, cases released from treatment will definitely help in further reducing the prevalence of leprosy.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

What is new?

The National Leprosy Eradication Program has a favorable impact on the problem of leprosy after integration into GHS.