Dr. CR Revankar. MD, DPHPublic Health & Leprosy specialistUrban LeprosyElimination

Contact address:3-15-14, Garden View Society,Bhavani Nagar, Marol, Andheri-East, Mumbai-400059, IndiaEmail: drrevankar50@vsnl.com, macnir@bom3.vsnl.net.in

How important -Urban Leprosy1.20-25% of the global population is in urban areas & 20-25% of global leprosy case load is likely to be in urban areas (guestimate)2.Increased transport facilities, scope for employment, attraction for tourism -resulted in increased population movement across the globe Continued

Issue of Global LeprosyPopulation movement responsible forInfectious disease transmission across the globe-eg. SARS, TB, Leprosy and any other infectious disease.Leprosy should not be considered as a problem of developing countries. Should be considered as a global issue

ObjectivesAfter this lecture, one should be able to:Understand the epidemiological trend of leprosy, influencing factors, public health principles and possible strategies to eliminate leprosy in relation to urban population.

Slums/Shanty towns-A gift of Urbanization

Store house for causative germs-leprosy,TB, HIV & other infectious diseases

Fig.1,2 from Bombay Leprosy Project,Bombay,2002

Fig.1

Fig.2

Influencing Factors1.Rapid Industrialization2.Population migration- Permanent/temporary3.Migration -intra and inter -slums/residential areas Continued

Influencing factors4.Increase in population5.Slum/shanty town growth6.Congestion, poor hygiene7.Daily commuters for work from neighboring areas Continued

Influencing factors 8.Socio-economic-cultural aspects 9.Health seeking behavior10.Complex-health service delivery-Public & Private,modern/traditional,Non-profit health organizations Continued

Influencing factors11.Catastrophes-Violence, fire, earthquake, demolition of slums for urban planning12.Fall in economic growth-shifting of labour force to other cities/towns

Special features in slums/shanty townsFig.1. DemolitionFig.2.ViolenceFig.3. Accidental fireFig.1,2,3 from Bombay Leprosy Project,Bombay

Outcome 1.These environmental and population factors influence the efforts of leprosy elimination in urban areas2.Continuous growth of urban localities, maintain low level of disease transmission Continued

Outcome3.Survival of causative organisms, poor living conditions & poor nutrition4.Difficulty in finding new cases especially-infectious type, relapse5.Low adherence rate and drop-out from treatment, treatment failure etc.

Recommendations1.International Leprosy Association-pre-congress workshops: 1973, 1978, 1984, 1988, 1993 2.German Leprosy Relief Association-Urban Leprosy Panel, India: 19753.WHO: 1988, 20014.Sasakawa Memorial Health Foundation -Singapore International Leprosy Workshop: 1983 Continued

Recommendations5.Damien Foundation, India: 19986.Danida Assisted National Leprosy Eradication Program(DANLEP) and National Leprosy Eradication Program, India: 20007.The Leprosy MissionInternational(TLMI), NewDelhi: 20008.Indian Association of Leprologists(IAL): 2001

Urban Population GrowthIncreasing Urban agglomerations with >5 million inhabitants (1950- 2015) in the World. (UN population data, 1999)___________________________________Year No. Population (million)___________________________________1950 8 541975 22 1942000 41 4172015 59 622___________________________________

Urban Population Growth23 megacities by 2015 with more than 10 million populationUrban agglomerations (>5 million) endemic for leprosy

Bombay, Delhi, Kolkatta, Hyderabad, Chennai, Banglore, Pune, Ahmedabad, Dhaka, Sao Paulo, Rio de Janeiro, Jakarta

Urban slum growth1.It is estimated that more than 50% of the 12 million population (2001) in Bombay(Mumbai) live in the slums/shanty towns. 60% of them are migrants from other states of India.2.Poor socio-economic conditions lead to slum/shanty town growth in all towns/cities/metropolitan areas

Impact of MDT Dhaka city -Bangladesh

PR/10 000(2002) : 3.45 NCDR/100 000(2001) : 44.86 Smear +ve : 131/2532(5%) (new cases) Migrants : 25%

(Jalal Uddin, 2002)

Impact of MDT Delhi-India,2001

PR/10 000(2001) : 4.3 NCDR/ 100 000(2001) : 38.0 Migrants (%) : 40.0 Smear +ve (%) : 9.0 (new cases) Bhagotia, 2002

Impact of MDT Bombay-India,2001

PR/10 000 : 2.3 NCDR/100 000 (2000): 33.0 Migrants : 50%-60% Smear +ve : 560/5131(11%) (new cases) ADHS,Bombay, 2001

Impact of MDT Rio de Janeiro-Brazil,2001

PR/10 000 (2001) : 1.84 NCDR/100 000 (2001) :16.30 Migrants : NA Smear +ve : 252/962 (26.2%) (new cases) Tardin, 2002

Impact of MDT Sao Paulo, Brazil, 2001

PR/10 000 : 0.85 NCDR/100 000 : 2.6 Migrants :Not available

Lafratta, 2002

Trend in Leprosy rate in Bombay020004000600080001000012000199219931994199519961997199819992000No.of casesPrevalencDetectionInfectious ADHS,Bombay,2002

Significant observations1.New Case detection rate in these megacities/cities has not shown significant reduction for the past 5 years even though prevalence rate showed significant reduction.This is similar to rural leprosy program.

continued

Status of infectious leprosySkin smear positive cases (of public health importance ) from Bombay does not show any significant reduction over the past 5 years. 400-500 (out of 4000-5000 annual new case detection) new infectious leprosy cases are recorded inspite of low prevalence.40-60% are migrants from other parts of India. (ADHS, Bombay, 2001).

Untreated Lepromatous leprosy cases

These cases discharge 240million leprosy germs in 24 hours through nose if untreated (Davey & Rees,1974)

Fig.1,2 from Yawalkar,200212

Leprosy Trend in Dharavi slum, Bombay0100200300400500197919811983198519871989199119931995199719992001New caseInfectious Ganapati R,2002

Ganapati R,2002

Migration & LeprosyMore than 60% of the skin smear +ve patients(infectious) are migrants to Bombay - maintaining low level of transmission. North America - more than 80% of new leprosy patients are immigrants from other countries maintaining low level of transmission (NHDP Report, 2002).

Leprosy-Migrant populationExamination of 72 436 migrant population to different cities/ towns in Maharashtra state,India revealed a detection rate of 194 per 100 000, even though overall Prevalence Rate is coming down in 32 cities/towns (NLEP-Maharashtra,India 1998).

Leprosy- Disability Prevention of Disabilities is not finding its place in the program that it deserves. WHO-AIFO (2000) estimated 3 million leprosy patients with disabilities (including impairments) in the world. Disability case load in urban areas is still not available.

Integration of LeprosyUrban Health services : Public - Private mix programme1.Government, Municipal medical colleges, hospitals, dispensaries2.Railway, Industrial hospitals3.Private hospitals, private doctors4.Non-profit community organizations