World Health Organization
Representative to India
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World Health Organization Representative to India |
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Leprosy Situation in India
July 2003
II. Epidemiological situation in India
As on 1st April 2003, eleven endemic states (Andhra Pradesh, Bihar, Chhattisgarh, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Orissa, Tamil Nadu, Uttar Pradesh and West Bengal) contributed for 93% of registered cases, during the year 2002-2003.
On 1st April 2003, the number of leprosy registered was 346 000, down from 439 782 the previous year, a decrease of 93 782 cases.
Out of 35 States/Union Territories, 15 had a PR below 1/10,000. Out of 590 districts, 212 (35.9%) had achieved the elimination level; 6 other states and 87 districts (14.8%) are near elimination with a current PR well below 2/10,000. The 11 most endemic states contributed for 94% of all new detected cases during the year 2002-2003.
A total of 476 000 cases were detected during the year 2002-2003, a decrease from the 618 041 cases detected during the previous year. On 1st April 2003, the Annual New Case Detection Rate was 4.5 per 10,000. Among the new detected cases, the proportion of MB cases was 35.2% (167 750 cases), the proportion of children under 15 years old was 14.8% (70 686 cases), the proportion of female was 33.8% (160 998), and the proportion of cases with visible deformity (grade-2) was 1.8% (8526 cases). The Schedule Caste cases represented 14.6% and the Schedule Tribe cases 7.9% of the total new detected cases.
The proportion of children cases is still high. This is a result of either high transmission or intense elimination activities targeted to this age group (school survey). Surprisingly, the highest child proportions came from states with lower prevalence rates (e.g. Andhra Pradesh 24.5%, Karnataka 21.3%, Maharashtra 19.8%, Tamil Nadu 17.8%, as opposed to Bihar 16.1% and Uttar Pradesh 8.3%). It is probably due to intense school survey activities in those states.
Among the top endemic states, the proportion of female varied from 44% in Maharashtra, to 26% in West Bengal. It is not clear why such variations occurred. It might be due to a lower awareness and/or access to health care within the female community. It was noted that during the MLEC active search, the ratio of male to female was close to one.
The proportion of new detected cases with visible deformity continued to decrease steadily in the year 2002-2003, at 1.8%, from 2.1% during the previous year. It showed that early diagnosis is taken place for most of the cases. This proportion has been decreasing steadily from 1998 when it was 3.7%.
Regarding detection, a major step taken in 2003 by the Central Leprosy Division, GoI, was to discourage all active search activities (e.g. school surveys, contact surveys, etc.), but to encourage voluntary reporting through increased awareness.
Trends in prevalence and detection
Prevalence has decreased steadily in India, since the introduction of MDT in 1985. By March 2003, the prevalence was reduced by 93%. From 1998 to 2001, the prevalence showed a declining trend with a slight increase in 2002, due to a higher number of cases detected during this year. In 2003, the trend continued to decrease to 3.2 from 4.2 per 10,000 in 2002.
Trends in detection increased in 1999, mostly due to the first Modified Leprosy Elimination Campaign (MLEC), which was also carried out in 2000. In 2001, there was no MLEC conducted in India. The third campaign was carried out in 2001-2002, and MLEC-IV in 2002-2003. It is planned that the fourth MLEC was the last one.
The significant decline in case detection in 2002-2003, despite the MLEC-IV, represented a decrease of 142 041 cases detected, compared to the previous year. Despite this improvement, it is believed that the still high detection rate is due to contradictory factors. On one hand, the intensified detection activities such as MLEC and the increase in geographical coverage of MDT services during the integration phase contributed to the relatively stagnant detection rates. In the other hand, operational factors, such as detection targets given by the Central Leprosy Division, GoI, re-registration of old cases as new cases, and wrong diagnosis also contributed to the detection rates.
Due to strong advocacy from WHO, the Central Leprosy Division has decided from April 2003, to stop giving detection targets to the States. In addition, a validation of leprosy diagnosis study has been planned during July 2003, in order to quantify the level of wrong diagnosis and re-registration of cases.
Modified Leprosy Elimination Campaign - MLEC-IV
During the MLEC-IV, 102 153 cases were detected, of which 76 138 (74%) through active search and 26 015 (26%) by voluntary reporting. As expected, data showed that the number of cases detected through consecutive MLECs had decreased steadily from MLEC-I (463 594 cases), MLEC-II (213 732), MLEC-III (164 993) to MLEC-IV (102 153 cases). This declining trend shows that the campaigns have steadily cleared most of the backlog cases. On the other hand, due to the nature of leprosy and its transmission pattern, it is surprising that so many cases were still detected during the consecutive campaigns. It could have be the results of multiple factors. Either the coverage was low during the first campaigns with a high proportion of suspect cases that did not show up for the confirmation, or the number of newly detected cases was inflated by wrong diagnosis and re-registration of old cases.
In any case, the proportion of cases detected through the routine detection (mostly voluntary reporting) has significantly increased over the past 5 years, as described in the graph below. In 2002-2003, the number of cases detected through MLEC-IV represented 21.5% of the total detection, compared to 1999 when it was more than the half.
Note: No MLEC conducted in 2000-2001
As mentioned above, wrong diagnosis and re-registration of cases pose a problem of accuracy of data. Several studies highlighted this issue. In 2000, an independent evaluation of MLEC data, conducted in 5 endemic states, reported that wrong diagnosis was between 6 to 13% and recycling of cases (cured, defaulters or re-registration of old cases as new) varied from 36 to 82%. An evaluation of MLEC-III by DFIT in Jharkhand found that wrong diagnosis was 8% and recycling 9%.
Theoretically, the verification of diagnosis of a sample of newly detected cases should be carried out systematically by NLEP supervisors and District Technical Support Teams (DTST) of ILEP agencies. Unfortunately, this activity is not done regularly, which hampers the quality of the case detection data. |
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