active case finding for leprosy elimination · leprosy: key aspects mostly affects rural poor...
TRANSCRIPT
1 |Scoping Meeting TB - 31 May 2011, Geneva
Active case finding for leprosy
elimination
D. Daumerie WHO/NTD
2 |Scoping Meeting TB - 31 May 2011, Geneva
Leprosy: key aspects
Mostly affects rural poor
Natural history and transmission poorly known
Long or very long incubation period
Chronic disease with acute episodes (dermatological and neurological)
Several types and classifications. WHO classification consists of 2 groups PB and MB
3 |Scoping Meeting TB - 31 May 2011, Geneva
In most situations diagnosis is clinical (anaesthetic skin patches, classification based on number of patches)
Skin smear examination difficult in most settings. Proportion of skin smear positive cases very low, even among MB cases
Epidemiology of the disease is not influenced by the HIV situation
Treatment with MDT is safe, effective and free of cost to the patient.
So far, no resistance to MDT
Leprosy: key aspects (2)
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Simplified diagnosis and treatment
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Elimination concept and introduction of
intensive active case finding
In 1991 leprosy elimination as a public health problem: below 1 per 10 000 population.
At that time reported prevalence was 5.4 million patients, estimated prevalence 11 million and coverage with MDT below 10%. Incidence was unknown.
Leprosy elimination campaigns (LECs) were introduced in 1995 with the aim of diagnosing and treating the large number of "hidden" cases in at risk communities.
Hidden cases were considered to be the main source of transmission.
6 |Scoping Meeting TB - 31 May 2011, Geneva
Main steps in LECs
• Development and local adaptations of guidelines for LECs implementation
• Identification of populations (or areas) that would benefit from LECs
• Information (decision-makers, health workers, community)
• Rapid training of volunteers and/or health workers for "identification of suspects"
• Referral system for diagnostic confirmation and treatment
• Recording, monitoring and evaluation
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Key elements of LEC
Community mobilization Mass media campaigns
Active case finding Treatment and recordingReferral for confirmation
Training
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Main achievements with LECsRef. Weekly Epidemiological Record 1999, 74, 329-336
LECs actively implemented in 24 high endemic countries.
India and Brazil covered large populations. BBC world
service did intensive media campaigns in these 2 countries
In 4 years, 500 000 health workers and 300 000 volunteers
have been trained.
More than one billion persons have been reached, and more
than half million cases have been confirmed.
9 |Scoping Meeting TB - 31 May 2011, Geneva
Salient features of LECs
Highly variable outcomes, mostly depending on the prevailing situation and infrastructure.
Main difficulties are logistical (organizing proper referral system, treatment supply at the right place)
Average cost per diagnosed patient: $97 (range 1 to 1,300).
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Global impact of LECs
The aim of detecting "hidden" cases and thereby reduce transmission has been achieved
Access to diagnosis and treatment has dramatically improved, especially for difficult-to-reach populations
Proper case management and adherence to treatment remain the main challenges
11 |Scoping Meeting TB - 31 May 2011, Geneva
Main limitations of LECs(Ref Leprosy Review, Vol 70 No 4)
Active case-finding hinders self reporting and integration
Unclear impact on stigma and discrimination
Rapid training leads to overdiagnosis and weak case management
Large number of cases could still be missed (LECs versus total population surveys)
Limited evidence on long term impact on the transmission of the disease
Lack of clarity on how frequently LECs should be repeated
Key issue: cost effectiveness, especially in low prevalence areas
12 |Scoping Meeting TB - 31 May 2011, Geneva
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Lessons learnt
Proactive strategies to improve access to early diagnosis and treatment are essential, and beneficial
The absence of "ideal" screening and diagnostic tools should not be an obstacle
Research and modelling should "accompany" implementation
Technical guidelines should be adapted to local situation
Disease specific active case finding is difficult to justify
Information to and participation of target population is crucial
Interventions should be free of costs for the target population, treatment should be regularly available
14 |Scoping Meeting TB - 31 May 2011, Geneva
Thank you