HOW BIG OR SMALL LEPROSY IN BANGLADESH:

A Country Situation Analysis, Epidemiology, Programme and Policy Implications

ILC 2016 ─ Shahed Hossain1, Rezia Akhter2, Aprue Mong3, SA Hadi3, Humayun Kabir1, David Pahan3, Safir Uddin Ahmed2, Nafisa Huq1
1
International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 2National Leprosy Elimination Programme, Bangladesh, 3Lepra Bangladesh
Beijing, China

1993 1985
Background 2012 1999

Bangladesh Situation 1985-2012 Bangladesh Situation 1985-2012, programmatic

Indicators 1985 1993 1999 2012 Indicators 1985 1993 1999 2012
Pre MDT MDT Post New Pre MDT MDT Post New
extension elimination Strategy extension elimination Strategy
Cases self reported (%) Not available Not available 31 29.1
Population (in millions) 100 110 125 155
Programme approach Vertical Integrated Integrated Integrated
Prevalence (Number) 52161 22334 11091 3459
MDT services centre Not available 120 625 640
Prevalence rate / 10,000 5.2 2.3 0.89 0.22 MDT completion rate (%) Not available Not available Not available >90% (2010 & 2011 cohort)
New Case detection (Number) 4834 6943 14338 3576
NGO involvement Limited Limited 10 NGO partners 10 NGO partners
Detection Rate/ 100,000 4.8 6.3 11.5 2.3 Recording and reporting None Poor/ Standard/ Standard/
Grade 2 deformity (%) 35.6 21.4 8.7 11.0 systems Inadequate Annually Annually
produced/ produced/
MB (%) 44.6 60.4 37.8 43.9
Paper based paper based
Children < 15 Years (%) 7.9 11.7 15.4 5.6
General Health Staff Not available 416 36000 40,000
Female (%) N/A N/A N/A 38.6 Leprosy trained*

* At least received one day orienta�on once, No QC done

Objectives Materials and methods Study Sites

To understand the current situation of leprosy in Bangladesh in ○ Disease mapping Sites were selected in a stratified cluster sampling design.
terms of burden of disease, service provision and gaps in the service ○ Case validation study
provision.  ○ Districts are clusters
○ Facility assessment
○ Stratified according to the prevalence of leprosy cases in 2012 into
Specific objectives: ○ Providers survey High/ Medium / Low areas
  ○ In-depth interview (IDI) ○ Total 10 districts were selected in a PPM mechanism randomly
○ To analyze current situation and trend of leprosy from 2008 to & Group discussion with managers from each strata
2014 (Data further updated to 2015 for this presentation)
○ Informal care providers interview ○ (Bogra and Moulvibazar were pre selected)
○ To assess performance of NLEP and implementing partners ○ Community survey
including, technical and management activities
○ Exit interview and survey
○ To provide recommendations for a better management and with people affected by leprosy
appropriate intervention plan for leprosy programme ○ Individual case study
○ Stakeholder analysis

Findings
 Disease mapping  Provider’s Perspectives  People’s Perspectives  Patient's Perspectives

Trends in Prevalence & New case detection Trends in case detection: Community Survey
Child, G2D, MB, Female cases With modes of case detection
Among Community People:
○ >70% answered anyone could be affected by Leprosy
New case detection rate /100,000 population

Prevalence rate /10,000 population

CH Dis MB Female CT Vol

4.00 0.27 0.28 0.30 70
○ 78% knew that leprosy is curable
0.24 0.24
3.61 3.55 0.22 0.22 0.25
3.00 0.20
0.21 ○ 8.8% aware about the mode of transmission
6 2.97 0.20 60
2.60 2.5 ○ <1% knew about cardinal signs and symptoms
2.00 2.30 2.3 0.15
Prevalence rate /10,000 population

1.99
5 0.10 50
1.00

4
0.05
40
Prevalence of Leprosy cases
0.00 0.00
2008 2009 2010 2011 2012 2013 2014 2015
Leprosy is more common among the
3 New case detection rate Prevelance rate 30
○ poor (70.5%),

2 20 ○ less educated (40.2%) and

Decline or plateau ○ male (71.3%) Population
1
MDT 10

Elimination
0 0
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 2013 2015 2008 2009 2010 2011 2012 2013 2014 2015

Prevalence Panchagar
Incidence Provider’s perspectives 100
97.1
Nilphamari in 2015 Nilphamari in 2015 100

Rangpur Rangpur

50.0 45.3 43.9

Gaibandha Gaibandha 44.6 41.7 Knowledge on leprosy signsand
33.3
27.2 symptoms inadequate
Percentage

Percentage

22.8 22.8
Varying responses on where to refer,
and when to refer
Moulvibazar Moulvibazar Physician TLCA Others All Physician TLCA Others All

Paucibacillary + Multibacillary MDT for 6 months of PB MDT for 12 months of MB

Dhaka Dhaka
Stigma and other consequences
○ Low self esteem- often self created isolation from participating in social activities
○ Reported drop out from school
○ Neighbor refused to receive cooked meal by patient
○ Afraid of getting married (unmarried female patient)

Bandarban Bandarban
○ Mother is isolated from children and joint family separated
Prevalence (per 10,000 population) Incidence (per 100,000 population) ○ Geographical variation in terms of social stigma- common in Northern part and hilly areas of Bandarban
No Case Low Medium High No Case <5 5-10 >10

Exit point interview:

Way forward
○ To undertake measures to effective integration of leprosy services in to general health services
Patients’ knowledge about disease transmission
○ Development of effective tools for detecting cases early, including tools for early recognition and
management of leprosy reactions
Patients knew that Mode of transmission Perception on curability ○ Effective referral systems
leprosy is contagious
○ Strong Monitoring and evaluation
7% 3%
 Continuous disease surveillance
13.3% 20% 23.3% - Effective recording reporting
- more in-depth epidemiological analysis
76.7%  RFT, disability grade 0 and 1 cases
66.7% 90%  A strong central monitoring mechanism
○ Innovative and strong IEC to create demand in the community
 Scope of M-health and E-health
Yes No Don’t Know Bacteria /Air/Cough Other causes Curable Not curable Don’t Know
○ Needs to strengthen prevention of disabilities and rehabilitation

This project has been funded Our partners were icddr,b thanks its core donors for their on-going support