LEPROSY ELIMINATION AND ROLE OF DERMATOLOGIST IN LOW CASE SCENARIO

The leprosy control services were integrated into general health services in the year 1987 to provide wider coverage. Since, 1982/83 multi drug therapy (MDT) was introduced in few areas and some Hospitals, replacing mono therapy i.e. dapsone and gradually covering all 75 districts of Nepal by 1996. After the introduction of multi drug therapy (MDT) drugs treatment duration was reduced from life long to few years and this therapy has been found to be effective and acceptable to the leprosy patients.

Leprosy control activities started in Nepal since 1960AD with leprosy surveys.In 1966, about 100,000 cases were estimated in the country with a hyper endemicity in western and far western region.A pilot project was started in 1966, based on dapsone mono therapy and gradually extended to more areas under vertical leprosy control program.
The leprosy control services were integrated into general health services in the year 1987 to provide wider coverage.Since, 1982/83 multi drug therapy (MDT) was introduced in few areas and some Hospitals, replacing mono therapy i.e. dapsone and gradually covering all 75 districts of Nepal by 1996.After the introduction of multi drug therapy (MDT) drugs treatment duration was reduced from life long to few years and this therapy has been found to be effective and acceptable to the leprosy patients.
After the introduction of multi drug therapy (MDT), the prevalence rate in the country has declined significantly.At the end of July 1982, registered leprosy cases in the country were 31,537 with PR 21 per 10000 populations that have been reduced to 5899 with PR 2.41 in 10000 populations by mid July 2004 depicting PR by 88.52% deduction.multi drug therapy (MDT) has been proved to be safe, effective in curing disease, reducing the period of treatment, well accepted by leprosy patients, easy to apply in the field, prevents development of drug resistance, reduces the risk of relapse and improves the community attitude towards leprosy patients.

ROLE OF DERMATOLOGIST IN LOW CASE (POST ELIMINATION) SCENARIO
Leprosy will not remain as a public health problem in the country at nation level after set time frame of elimination.But there will be still endemic pockets in different region and districts even after reaching the goal at national level.So the leprosy activities should be focused to the remaining high endemic cluster pocket areas.
Even after disease elimination is declared, diagnosis of new ?????
cases, relapsed reporting and complication management will remain the major challenges.This needs to be tackled by basic health servic (BHS) staff, medical officers and dermatologists respectively.In post elimination scenario and in such integrated health service system the role of dermatologists will be more responsible for diagnosis, differential diagnosis, treatment, management of complication as well as capacity building of basic health service (BHS) staff and medical officers.Therefore, department of dermatology should be developed in each regional hospitals and referral centers keeping view of management of complicated cases and rehabilitation part (medical surgical and physical).
It may be that leprosy can be considered as low priority program, some of the donors may withdraw their support from this field and as in existing integrated approach leprosy activities may run as regular activities, but the community aspects and natures of the disease may remain the same.Case diagnosis and putting them in multi drug therapy (MDT) is not a very big problem in the field level, but patients suffering with recurrent leprae reactions, ulcer, neuritis and other complications are entirely different mode of the disease leprosy.
There are still certain queries and assumptions in leprosy that, more researches and studies need to be held to get the clear answers.In low case scenario dermatologists and leprosy field workers may have sufficient time to explore best efforts in all these essential fields.
After the introduction of multi drug therapy (MDT) leprosy prevalence has been found continually declining but new case detection rate is about stagnant over the years.In the absence of any standard laboratory test for diagnosis of leprosy, validation studies are useful to assess the accuracy of diagnosis.Dermatologists, as leprosy experts, can play vital role for the conduction of several such studies in low case scenario.
At policy level, strategies need to be focused on to sustain leprosy control activities at all level.Precautions can be taken on roll back of disease burden as well as continue interruption of disease transmission.Since, leprosy is regarded as one of the chronic infectious disease, the disfigurement that leprosy causes & the mystery surrounding its transmission have always given rise to fear, and fear has generated discrimination -not just towards those with the disease, but their families as well.
Hence full fledged community awareness rising information education & communication (IEC) activities are always the major issues.Major strategies of supporting agencies need to be diverted towards this line.A strong coordination and commitment of HMGN organizations, dermatologists, supporting partners and others would fortunately the major achievement for the sufferers with Hansen's bacilli!

LEPROSY ELIMINATION AND ROLE OF DERMATOLOGIST IN LOW CASE SCENARIO
To improve accessibilities of services in the 058/059 a decision was taken to transfer out the retained patients from the referral centers to nearby health institutions of respective districts as per issued guidelines by His Majesty Government (HMG) Leprosy Control Division (LCD) to concerned referral centers of respective regions of the country.This guideline was implemented by all concerned referral centers showing good treatment compliance, involvement of peripheral health institutions as well as better coordination & cooperation among the supporting partners.Some operational problems are identified that is over diagnosis, re-registration and delayed treatment compliance in leprosy elimination program, which needs to be tackled effectively through appropriate capacity building of BHS staff responsible for diagnosis of cases & more liberal use of flexible multi drug therapy (MDT) to facilitate prompt treatment completion.
th January 1996.The evaluation team appreciated the plan activities.In spite of this two round leprosy elimination compaign (LEC) were also implemented, first leprosy elimination compaign (LEC) in the year 1999 & second leprosy elimination compaign (LEC) in the year 2001 for endemic districts which brought most of the backlog and hidden cases from the community for treatment compliance.The information education & communication (IEC) that is electronic and non electronic media has also played a vital role in community awareness as well as reduction in social stigma in the community.Addressfor correspondence : Dr. M. C. Jain World Health Organization, Nepal Email: jainm@who.org.npFig. 1 : Prevalence Rate (PR) & New Care Detection Rate (NCDR) Trend of Nepal