Efforts Towards Building a Leprosy-Free Bangladesh

It is estimated that Bangladesh presently has about 40,000 leprosy cases remaining to be detected. This gives a current prevalence of approximately 3.3 per 10,000 population.

The modern Multi-Drug Treatment (MDT) has revolutioned the Leprosy treatment and a complete CURE is assured in all cases at all stages. Though MDT was introduced in Bangladesh in a phased manner in about 100 endemic thanas since 1985, it is only in November, '93 that the project "Further Development of TB & Leprosy Control Services" (funds from Govt of Bangladesh, World Bank, IDA, Govt of Netherlands & technical assistance from WHO) started MDT implementation in a systematic and organised manner.

Though it is a combined TB and Leprosy project, it was decided that Leprosy expansions will proceed faster than TB in order to achieve the elimination goal.

The WHO has targeted LEPROSY for ELIMINATION as a Public Health Problem i.e. to reduce prevalence of the disease to less than 1 case per 10,000 population, by the year 2000. This means that in Bangladesh, the prevalence has to be reduced from the present 3.3 /10,000 to less than 1/10,000 within the next 2 years.

Goal and Objectives: The Goal of the National programme is the Elimination of Leprosy as a public health problem i.e. prevalence 1/10,000 population by the year 2000.

In order to achieve the elimination goal, the National Programme had set the following objectives:

a) To provide countrywide MDT facility with thana as the peripheral unit by the end of 1995. It was proposed to establish a total of 600 MDT facilities (units) countrywide.

b) To detect over 85 per cent of the estimated cases within 5 years of MDT implementation.

c) To provide MDT to all registered cases.

d) To achieve over 85 per cent Treatment Completion (cure) rates.

e) To reduce deformity rate (grade 2) among new cases to less than 5 per cent within 5 years of project implementation (21.4 per cent in 1993).

Main Strategies 
a) Integration of Leprosy control into the general health services of the country, in combination with TB control.

b) To provide WHO-recommended fixed duration MDT to all registered leprosy cases.

c) Intensive information, education, communication (IEC) activities to promote case detection, case holding and awareness in the community.

d) Training of general health staff, NGO staff, general medical practitioners, community volunteers and other target groups.

e) Involvement and strengthening of collaboration with NGOs in MDT implementation.

f) Development of an effective referral network.

g) Development of a simple and effective system of monitoring and supervision.

h) Involvement and participation of all sections of the community in the leprosy elimination activities.

Achievements as of 31 December 1997
Countrywide Expansion of MDT Facilities with Thana as the peripheral unit: The thana is the Sub-district administrative unit in Bangladesh. Each thana has an average population of 200,000 and is catered by a Thana Health Complex (THC) with outpatient and inpatient facilities (31 beds).

It was proposed to establish a total of 600 MDT facilities or units as follows:

i. One each in 460 thanas (sub-district) : 460

ii. One each in 103 Municipalities, including 60 (out of 64) district HQ towns (the remaining 4 are Metros): 103

iii. Thirty-seven units corresponding to 37 police thanas of 4 metropolitan cities - Dhaka, Chittagong, Rajshahi and Khulna: 37

iv. The total is: 600

By the beginning of 1996, All 600 Treatment Centres were established. This means that at least one Medical Officer and all the field staff are trained in leprosy and adequate stocks of leprosy drugs are available in all the centres.

It was decided to retain thana as the peripheral unit because it is easily accessible to the majority of patients for the monthly reporting to receive the supervised doses.

Thus the objective of countrywide expansion and geographical coverage and accessibility of MDT to all communities and areas has been achieved.

Training and Human Resource Development 

The programme has given high priority to Training and Human Resource Development.

Over a period of 4 years, commencing July 1993, over 30,000 general health and leprosy staff of various categories from the central, divisional, district and thana level have received training in leprosy and MDT implementation.

Since 1995, training was decentralised to the district and the thana level and the NGOs were also involved in conducting the training. It is observed that substantially more numbers could be trained and training becomes more cost-effective, when it is decentralised.

National Guidelines 

With the aim of uniformly applying the planned strategies and activities countrywide and to follow a standard system of implementation a technical and operational National Guideline entitled "Technical Guide and Operational Manual for Leprosy Control in Bangladesh" was developed and distributed to programme managers at all levels in 1994.

A revised edition of the guideline was printed and distributed in 1996 and third edition is under printing and is due for distribution shortly.

In the first half of 1997, a total of 5,516 new cases have been detected of whom 2,067 (40 per cent) are MB and 3,449 (60 per cent) are PB. Countrywide, a total of 34,934 new cases were registered for MDT and 34,445 cases completed MDT from January 1993 to December 1996.

The male/female ratio among new cases in 1996 was 1:0.6 and the child rate among new cases was 15.85 per cent.

MDT Coverage and Treatment Completion (Cure) Rates

Since 1994, all registered cases are provided with MDT. Thus the MDT coverage of registered cases is 100 per cent in Bangladesh, for the past 4 years.

The cumulative number of MDT completed cases: From 1985 to December 1996: 70,063; From 1985 to December 1992: 35,618; From January 1993 to Dec 1996: 34,445;

A cohort analysis of 4,657 Pauci-bacillary (PB) patients registered between April 1995 and March 1996, show that 4,318 out of 4,657 patients have satisfactorily completed their treatment, giving a cure rate of 92.7 per cent.

A similar analysis of 2,575 Multi-bacillary (MB) patients registered in 1993/94, show a Cure rate of 82.9 per cent, which is marginally short of the objective of 85 per cent Cure rate. The MB cohorts relates to patients registered prior to the intensification of leprosy activities under the present project.

The number Relapses after MDT recorded in Bangladesh is extremely low - less than 0.2 per cent of the total cases detected in 1996, thus proving the potency and efficacy of MDT.

Collaboration with NGOs 

The collaboration between the government and NGOs is a model and one of the strengths of the leprosy programme in Bangladesh. In July 1994, the GOB signed a memorandum of understanding (MOU) with the Leprosy Coordination Committee (LCC) of Bangladesh, which represents 10 NGOs. Through this MOU, 23 out of the 64 districts of Bangladesh and 7 urban areas are allocated to NGOs for MDT implementation. The 23 districts together have 195 thanas.

In our opinion the collaboration with NGOs is functioning well, with the scope to further strengthen it. NGOs are implementing MDT in all the districts/thanas and urban areas allocated to them and most of the NGO clinics are held in GOB facilities. NGOs are also assisting in the training of general health staff and in the implementation of special initiatives such as SAPEL and LEC in the areas allocated to them.

WHO-funded Special Activities 

Special Action Projects for Elimination of Leprosy (SAPEL) in Difficult Areas: The National Leprosy Programme in Bangladesh submitted a SAPEL proposal for the 3 districts of Chittagong Hill Tracts. WHO approved the proposal initially for one district-Rangamati.

As per the proposal, village level volunteers are being utilised to deliver MDT, since patients have problems of access and transport to reach health centres in these districts.

The SAPEL project is operating in Rangamati district since the beginning of 1997 and will be extended to Bandarban and Khagrachhari districts in 1998.

Leprosy Elimination Campaigns (LECs): WHO had initially allocated funds for 14 campaigns in 14 districts. However, we requested funds for implementing LECs countrywide, since the criteria prescribed for LEC applied to all the 64 districts. We are grateful to WHO for accepting our proposal for conducting LECs countrywide.

It was proposed to organise LECs in 21 districts in 1997. However due to various reasons, the campaigns could be fully completed in only 8 of the 21 districts and are expected to be completed in the remaining 13 districts by February 1998.

In the meanwhile, WHO has proposed to organise a nationwide Leprosy Elimination Campaign (N-LEC) in October 1998, in view of the need to accelerate detection of the remaining hidden and backlog cases and initiate their treatment. This National Leprosy Awareness and Case Detection Campaign will be organised for one week with the involvement of about 80,000 health workers and volunteers from both the government and NGO sectors countrywide.

Workshops for Medical/Nursing College Teachers and Seminars for Internees and Final-year Medical Students: Under the WHO regular budget for 1996/97 it was proposed to organise workshops for medical /nursing college teachers and seminars for internees/students. The aim of the workshops is to update the leprosy knowledge/skills of medical/nursing college faculty, improve the quality of leprosy teaching and improve the leprosy knowledge/skills of the future doctors/nurses, specially in early case-detection and MDT implementation.

We have completed this very useful activity in 13 Medical and 4 Nursing Colleges so far. A total of 502 medical/nursing faculty members and 1484 students/internees have been covered.

Drug Supply

Adequate quantities of loose anti-leprosy drug have been procured and supplied to all the district stores and peripheral MDT units.

The procurement was done through Local Competitive Bidding (LCB) in 1994/95 and through International Competitive Bidding (ICB) in 1996.

In addition to this procurement done jointly for TB and Leprosy drugs through funds from World Bank, the project received Blister packs for MB cases through WHO from the Sasakawa fund. Thus the present drug stocks and those in the pipeline will be sufficient up to December 1998.

Monitoring /Supervision 

Since the programme is now operating throughout the country, there is need to improve and strengthen the monitoring/supervision at all levels. We are aware that more attention is required in this area.

Independent Evaluation: The First Independent Evaluation of the National Leprosy Programme was performed recently i.e. 14-24 Sept 1997. The evaluation teams have identified the strengths as well as the weaknesses of the programme and made useful recommendations, which are bound to receive due attention and action by the government and the national programme.

Combined TB/Leprosy Porgramme: The national programme is a combined TB and Leprosy Control Porgramme with a minimal vertical set-up for both diseases, operated through the general health services of the country.

By combining the two mycobacterial diseases, the efforts to control these two major health problems of Bangladesh have been complementary and cost-effective.

Achievement of the Leprosy Elimination Goal: It is our hope that Bangladesh will be able to achieve the Leprosy elimination goal by the year 2000, provided the political will and support is sustained and the various activities especially those directed towards case detection, case holding, prompt treatment and community awareness are intensified in the next two years.

The achievement of this noble goal naturally requires the support from all sections of the community at every level.

The writer is Project Director, Further Development of TB and Leprosy Control Services in Bangladesh