Infectious apathy

THE NUMBER of contagious leprosy cases in the State is reportedly on the rise. According to figures given by the Directorate of Health Services, 2,364 cases were reported between April 2002 and February 2003. Of these, 1,022 were contagious.

These account for 43.23 per cent of the total number of cases. For the year 2001-2002, of the 2,420 reported cases, 986 were contagious -- that is, 40.74 per cent. In 1997-98, this figure was only 26.45 per cent -- that is, only 1,243 cases of the 4,699 cases reported were contagious. The national average remains at 35 per cent.

While the total number of leprosy cases has reduced by half over a period of six years, the same cannot be said of contagious cases. However, the State Leprosy Officer, Dr. M. Thampi, said it was difficult to scientifically conclude that contagious or Multibacillary leprosy cases were on the rise, for the diagnosis of leprosy was based on clinical signs and symptoms detected by health workers. Only the morphological index and bacteriological index -- the two indices that are based on the observation of Mycobacterium leprae, the disease-causing bacillus, in smears from skin or nose -- helped determine the amount of infection and the viability of the organisms, he added.

More than a century after the Norwegian physician, Dr. Gerhard Armauer Hansen, discovered leprosy in 1873, it continues to evade complete eradication.

The first formal attempt to estimate the global leprosy burden was made by the World Health Organisation (WHO) in 1966, pegging the estimated number of cases at 11 million, 60 per cent of which was not registered. Monotherapy using the drug, Dapsone, had started to fail in the 1970s. Resistance to Dapsone was observed and it didn't control transmission of M. leprae. But a combination of drugs (Multi-drug therapy -- MDT), recommended by the WHO, resulted in dramatic change. MDT, a combination of Rifampicin, Clofazimine and Dapsone, was systematically introduced in 1982. By the beginning of 2002, more than 12 million cases had been treated and cured. Due to substantial progress, the World Health Assembly in 1991 was prompted to call for the "elimination of leprosy as a public health problem by the year 2000", defining elimination as attaining a level of prevalence below one case per 10,000.

While the defined elimination level was attained at the global level at the end of the year 2000, India, together with Brazil, Madagascar, Mozambique, Myanmar and Nepal, represent 90 per cent of the global leprosy burden. The number of registered cases in India comes to 62 per cent of the global burden. The WHO says it is clear that some countries will not reach the elimination target at the national level by the end of the year 2005.

The Government of India had begun the National Leprosy Control Programme (NLCP) in 1955 with the objective of controlling leprosy with the help of the drug, Dapsone. The NLCP was redesignated as the National Leprosy Eradication Programme (NLEP) in 1983, as a Centre-sponsored scheme, after MDT became available.

The NLEP was first implemented in the State in Alapuzha district in 1987 and subsequently introduced in the other districts in a phased manner. The first phase of the programme ended on September 30, 2000. The second phase started on October 1, 2000 and is scheduled to end on March 31, next year. The prevalence rate of one in 10,000 has already been achieved by the State in March 2000. The WHO says the integration of leprosy eradication into the general health services is a key component in the strategy for leprosy elimination, especially for communities at risk, which are often the poorest. General health services are more widely available and in close touch with the local community. Case-finding and case-holding activities will improve and make the programme more cost-effective. Integration will also help reduce stigma and increase awareness about the disease.

So, when the prevalence rate in the State reduced to one per 10,000, the Centre instructed that the State too take up the campaign. But after March 2004, no financial help from the Centre will be forthcoming. Therefore, the Government intends to integrate the highly specialised vertical staff into the general health services.

With this aim in mind, the 500-odd vertical staff were sent for a health inspector course by the Government in 2002. But sources say, no further steps have been taken in this direction. This has affected the leprosy eradication campaign as well.

The Health Secretary, K. Ramamoorthy, said though the vertical staff wanted to be integrated, the general health workers were resisting every effort in this direction.

He said the meetings convened to facilitate a smooth integration process were not being attended by them.

Sources also claim that the second stage of the campaign is hardly operational in some districts of the State. While the vertical staff were highly active in districts such as Thiruvananthapuram, it was not so in others.

The State president of the Kerala Leprosy Eradication Staff Association, K. Bhuvanendran Chettiar, raised the issue of the role of Block Primary Health Centres, Community Health Centres and District Leprosy Units after the integration is over and done with. "If quality eradication work has to go on, these have to be retained, at least for some time."

But the core issue remains something else.

The Government is convinced that the campaign has succeeded in bringing down the prevalence rates (PR) to levels that do not require concentrated efforts anymore.

But its claim is questionable. Sources say a sample survey and assistance unit, which monitors the work done, assesses and evaluates it, has not been set up in the State ever -- not even at the height of the campaign in the 1980s and 90s.

They also allege that the campaign is in full force in Thiruvananthapuram, Ernakulam and Alapuzha.

But the same cannot be said of the other districts. For instance, in Wayanad, of the five posts of Leprosy Inspectors (LIs), only one is occupied. In Kasaragod, only 5 of 40 posts are occupied. In stark contrast, in Thiruvananthapuram, of the 75 posts, 75 are filled.

This, they say, is a pointer to the fact that where the staff deployed is more, the detection rates are higher. Where their number is low, detection levels too remain low. For instance, in Wayanad, 3 of the 3 cases detected in January 2003 are of contagious leprosy. The number is 14 and 16 in Thiruvananthapuram and Ernakulam, respectively.

This is substantiated by figures from the CAG's audit review for the year 2000-2001.

The report says that "lack of manpower resulted in non-coverage of entire population at least once in three of the six districts checked".

It also says all hidden cases can be detected only when the same population is covered repeatedly. And with the available manpower, this was not possible. For instance, against the required strength of 1344 LIs, only 622 were sanctioned and 396 personnel were in position.

The Government claimed that the vacancies were not filled up because the programme was proposed to be integrated with the general health services. The review, however, held that "the reply was not tenable as the vacancies had remained in existence since 1991 and the programme of integration had not been carried out till March 2001."

The review further says that the target fixed by the Centre vis-�-vis achievement for the State, was low. It held that the reason for the low target was the "defective classification of districts based on wrong PR, as a result of which achievement exceeded the target set for three of the five years during 1996-2001. For instance, in 1996-97, the target was 4,000 while achievement was 5795. Similarly, in 1999-2000, the target was 3,000 and achievement 4809.

The report says the annual reports on the coverage of population were highly inflated and the prevalence rate, calculated on the basis of case detection and population coverage, was incorrect. In Kollam, the range as shown as 7.36-14.59 but with the available manpower, it could not have been more than 5.05, for the period 1996-97 to 2000-01, it says. In Kozhikode, as against the shown range of 10-18.42, the possible coverage could only be 4.75.

The method for calculating PR, the review says, was also defective. The PR rate was to be worked out based on the incidence of disease per population of 10,000 with reference to population actually covered and new cases detected in a year. But PR was actually calculated by the department by adopting the incidence as at the close of the year (number of new cases detected minus the number of cases in which treatment was completed), for the whole population of the districts and projecting the incidence to a population of 10,000 population resulting in unrealistic projection of PR.

In Kottayam, the range of PR as per the department was 0.40 to 2.59 but as per the audit, it came to 10.90 to 57.78 between 1996-97 and 2000-01.

Moreover, the classification of the districts into hyper endemic (five districts), endemic (five districts), and low endemic (four districts), based on prevalence rates arrived at on the basis of inflated figure of coverage of population, low coverage of population and unscientific method of calculation of PR, was defective and unrealistic.

In the light of these facts, the Government's claim that elimination levels have been achieved in the State rings hollow. The drive necessary for covering the entire population of the state in a foolproof manner is imperative to make the campaign a true success story.

Graphics: C. R. Sasikumar

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