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WHO Goodwill Ambassador's Newsletter For The Elimination Of Leprosy

SRI LANKA REPORT: Keeping an Eye on Leprosy

Health ministry working to improve monitoring, focus on disability care.

Sri Lanka was one of the first countries in the WHO's Southeast Asia Region to eliminate leprosy as a public health problem at the national level. It reached this milestone - a prevalence rate of less than 1 case per 10,000 people - in 1995, 12 years after multidrug therapy (MDT) was introduced to the country in 1983.

Contributing to this achievement was a social marketing campaign launched in 1990 with the support of the Novartis Foundation for Sustainable Development. The aim was to change the image of leprosy and portray it as just another disease, in order to encourage persons with skin lesions to come forward for treatment and dispel the stigma associated with the disease.

The campaign made use of television and radio spots, TV soap operas, buses, billboards and more. It drummed home the message that leprosy is 100% curable and that skin patches are an early sign of the disease. Even today, people still sing songs from those TV dramas.

The year following the social marketing campaign, case detection increased by 150%. Self-reporting rose from 9% in 1989 to 50% in 1991, and has since become the norm.

Postage stamp commemorates tricentenary of Hendala Leprosy Hospital in 2008.
Postage stamp commemorates tricentenary of Hendala Leprosy Hospital in 2008.

Current situation

Sri Lanka is divided into nine provinces and 25 districts. Each district is further divided into administrative units known as Divisional Secretariat Divisions (DSDs). Health care is provided through Medical Officer of Health (MOH) areas that for the most part follow DSD boundaries. Each MOH office includes Medical Workers (MWs) and Public Health Inspectors (PHIs). On average, there is one MW for 3,000 people and one PHI for 10,000 people.

In 2009, 1,875 new cases of leprosy were detected nationwide. Almost half of these (47%) were found in Western Province, which includes the capital Colombo. There is one leprosy hospital in Hendala, outside Colombo. Established in 1708, it is home to 47 persons affected by leprosy. Compulsory admissions to the hospital were stopped in 1977, and admissions ceased altogether in 1982.

Full integration

Leprosy control was fully integrated into the general health services in 2001. It is coordinated at the central level by a team of four doctors headed by Dr. Tilaka Liyanage, director of the Anti-leprosy Campaign (ALC) under the Ministry of Healthcare and Nutrition (see Interview). The team is responsible for policy making, planning, monitoring, evaluation, training and research.

Since integration, it is mandatory for a diagnosis of leprosy to be made by a dermatologist. There are 48 dermatologists in the country.

However, although dermatologists may diagnose and treat patients, the follow-up is left to the patients themselves, and because of this there is a rather high number of defaulters. Treatment completion is difficult to confirm. Reaction and disabilities cannot be followed up.

Dr. Liyanage assumed her position last year. Since then, she and her team have been redesigning the system to improve defaulter tracing, contact tracing and health education of patients, including released-from-treatment (RTF) cases.

They have updated all registered cases since 2001 so that the trends of various indicators can clearly be seen. These indicators show that there is no reduction in case detection, even though Sri Lanka has achieved the elimination milestone; the number of patients with multibacilliary leprosy as a proportion of all cases is increasing; the number of child cases remains static, indicating active transmission in certain pockets; and Grade II disability rates are still high in some districts, a sign of late diagnosis.

The ALC team have also revised Individual Patient Forms (IPFs) to make follow-up easier and to avoid duplicate registration. The forms also include 'relapse' and 'defaulter' information.

Disability Care Session

Starting this year, ALC has begun a series of Disability Care Sessions, with a focus on districts where there are cured cases of leprosy that have not been followed up on. Dr. Liyanage feels the disability aspect of leprosy has been neglected and that people have not been educated in selfcare or made aware of the possibility of having corrective surgery.

At a Disability Care Session in Colombo in May, around 15 people with varying degrees of disability attended. This was out of 30 who had been contacted about the session by postcard. Some came with family members. The session consisted mainly of teaching with the aid of PowerPoint presentations and foot-soaking exercises for people with ulcers.

There were talks by Dr. Liyanage and Dr. Kaushalyo Kastisaratchi of the ALC team, and by a physiotherapist and a nurse. A surgeon also attended as an observer. Participants received self-care kits containing medicine and bandages, as well as a pair of sandals made from microcellular rubber (MCR). The MCR is imported from India and the sandals are made locally. Each patient with foot wounds gets two pairs a year. The program is funded by FAIRMED, a Swiss-based NGO working for Health for the Poorest.

At time of writing, 10 of these Disability Care Sessions had taken place, and more are planned, especially in districts where there are known to be cases that have been cured but where there has been no follow-up.