Evaluation of Leprosy Case Detection Campaign (LCDC) in Jharkhand: The Way Forward for Elimination of Leprosy.

Bhagat VM

India launched National Leprosy Control Programme in 1955 with Dapsone domiciliary treatment and IEC through vertical staff as the main strategies. The major breakthrough achieved when Multi-Drug Therapy was identified and recommended by World Health Organization (1981) for treatment of leprosy. In the light of recommendations by Dr. M.S. Swaminathan Committee (1981) National Leprosy Eradication Programme (NLEP) was launched in 1983. NLEP led a great success in bringing down the burden of newly detected leprosy cases from 3.95 Million (1981) to 88,833 (2015).[1]

Three countries India, Brazil and Indonesia account for 81% of the newly diagnosed and reported patients globally during 2014.[2] During 2014-15, total 125785 new cases were detected which gives Annual New Case Detection Rate (ANCDR) of 9.73 per 100 000 population and the Prevalence Rate (PR) was noted to be 0.69 per 10000 population. Both these indicators were almost static since last since (2006-07) last 10 years. The proportion of Multi-Bacillary (MB) cases among the newly diagnosed patients increased from 48.4% in 2008-09 to 52.82% in 2014-15. Also Grade II Disability (G2D) among new cases was increased from 3.10% (2010-11) to 4.61% (2014-15).[1]

The above scenario indicates that there are significant numbers of cases in the community those do not report to the health facility and that he newly detected cases are diagnosed late therefore providing longer time for spreading the disease, increasing propensity for disabilities etc.

Therefore, Leprosy Case Detection Campaign (LCDC) was implemented during January to April, 2016 in seven high endemic states of the country viz. Bihar, Chhattisgarh, Madhya Pradesh, Maharashtra, Jharkhand, Orissa, and Uttar Pradesh covering selected blocks of fifty districts with following objectives.[3]

The present research article is a set of compilation of some of the observations during monitoring and supervision of the LCDC activity in the state of Jharkhand.

Study area and population
Jharkhand is 28th state of Indian Union, brought into existence by Bihar Reorganization Act Nov. 15, 2000. It hosts a population of about 33 million. The state is known for its rich mineral reserve and unique flora and fauna. Spread over 7.97 Million Hectares, the state is divided into 24 districts and 260 blocks.[4]

The state is endemic for leprosy and 74936 cases were detected during previous five rounds of MLEC from 1997 to 2005.

Therefore Jharkhand was one of the states selected for active case detection through LCDC in 2016. Based on the reported and estimated prevalence of leprosy the LCDC activity was conducted in selected forty seven blocks, spread across six high endemic districts of Jharkhand.

Study design: The current cross sectional observational study was conducted in four districts as a part of the monitoring LCDC activities in Jharkhand.

Settings: The study was conducted in four out of six districts of Jharkhand namely East Singhbhum, Dumka, Godda and Ranchi.

LCDC institutional framework: Central Operational Group was formed to support, coordinate and monitor the implementation of LCDC. Various coordination committees were set up at state district and tehsil/ block level.

Information Education Communication (IEC): State leprosy awareness media committee was established with ILEP partners, representatives of Association of Persons Affected by Leprosy, local Non-Governmental Organizations, Akashwani and Doordarshan Kendras to develop media plan & timeline utilizing available resources to deliver simple and clear information to the committee, monitor the implementation of IEC/social mobilization activities. For Jharkhand the state media cell coordinated IEC activities, after finalizing the prototype of print IEC material by State Leprosy Officer (SLO) the printing of IEC material was carried out by the Dist. IEC cells. The IEC activity was carried out two days prior and three days after starting the h-t-h case search.

Training: Two days state level training was conducted one month prior to the activity for Civil Surgeons, District Leprosy Officers (DLOs), District Leprosy Consultants (DLCs) Block/Municipal Medical Officers (MO). Training of Accredited Social Health Activists (ASHAs), local volunteers and the supervisors was conducted at Block/Ward level capacity building of the staff in identification of leprosy suspects. Inter-personal-communication was also incorporated one of the important component of the activity.

Micro-planning: District level meeting was organized for block/municipal medical officers with urban health planners, representatives from Social Welfare department and other organizations involved in social mobilization for preparing the micro-plan. Area was identified and allocated to each team. The h-t-h search team was comprised of ASHA and a male volunteer/field level worker. One team was designated to cover 15-20 houses in rural area and 20-25 houses in urban areas, the flexibility in area allocation and coverage was given to the local planning unit at Block/Primary Health Center depending upon the geographical situation. Day wise micro-plan, checklists & reporting formats, logistics (such as Chalk/geru, pamphlets etc.) was prepared and discriminated to the team and their supervisors.

Field activity: The timeline for each of the activity was prepared during planning phase by the districts and compiled by the state. Two days prior to starting h-t-h campaign, IEC activities were started and continued for five days. After a thorough micro-planning for h-t-h activity, a team comprising of ASHA and local field level worker /male volunteer visited the house.

A detailed description of Inter-Personal Communication with the respondents, seeking and noting the appropriate information of the families, examination of each member of the family inside the house was provided during the training and was expected to follow by the team. Depending upon the information provided by the respondent; the team noted the information into the tally sheet followed by marking of the house. The house was marked “L” if all the dwelling persons were examined and none of them remained. The house was marked “X” where the beneficiary was not available during the visit by the team and the remaining family members were re-examined by the team during the revisit. Detailed guidelines in conducting a best possible field activity were provided to the search teams.

Supervision: Supervisors were trained to identify and solve problems faced by the team, support, encourage and motivate search team members in carrying out high quality LCDC activities. A three tier supervision system was developed comprising of Public Health Nurse, Block Medical Officer (BMO) and District Leprosy Officer (DLO) at respective level. Supervisors assigned to assist BMO in reviewing and revising micro plans during planning phase and to ensure that search teams were working as per their micro-plan. A detailed map of the area was provided to the teams and supervisors to maintain the high quality LCDC activity.

LCDC in high risk area: A thirteen point agenda for identification of high risk area was provided in the guidelines including underserved, misinformed groups, brick kilns, construction sites and difficult to reach areas. Emphasis was given on urban slums, peri-urban areas and new settlements. Special concerned was provided for development of area specific micro-plans in high risk areas and to be covered in LCDC under intensified supervision.[3]

Methodology:
In line with Pulse Polio Campaign, Leprosy Case Detection Campaign was carried out in 50 districts of seven high endemic states of the country. In Jharkhand this activity was conducted in forty seven blocks of six districts viz. Ranchi, Dumka, Gumla, Chatra, E. Singhbhum and Godda. Out of the six districts, four of the districts Ranchi, Dumka, E. Singhbhum and Godda were selected for the study. Two visits were made to the state, first visit for assessment of planning of LCDC and second visit to assess the implementation of the campaign. The first visit to the state was conducted one month before starting of the campaign. In this visit planning of all the components of LCDC were assessed.

Assessment of Planning of LCDC activities was conducted according to following components:
1. Formation & operational updates of coordination committees at various levels: In this component the formation of coordination committees at state, district and block levels including state leprosy awareness media committee.
2. Training of staff working at various levels
3. Development & distribution of micro-plans
4. Development & distribution of various IEC materials at various levels
Assessment of implementation of the LCDC activities was conducted in second visit: Two of the blocks where LCDC activity was being carried out were selected randomly. These two blocks were visited and following components of LCDC were noted.
1. IEC: Appropriate dissemination, presentation at appropriate level & site was assessed.
2. Training: The central monitors provided a two days training to the district leprosy officers, block /municipal medical officers. Training at district and block levels were observed and sought feedback.
3. House-to-house (h-t-h) survey: While monitoring the district level house-to-house activity, two areas were selected randomly for assessing the coverage and quality of h-t-h search activity.
4. Supervision: The supervision of the LCDC activities by appropriate authorities at village level, block/PHC level and district level was assessed by visiting the area covered by the team for monitoring the quality of survey. The review of micro-plan, assessment of missed individuals, houses or area was monitored by thorough review at blocks/PHCs and Districts.
5. Reporting: At the end of the day, supervisor collected and reported the day’s work in prescribed format to the concerned block, where information of entire block was compiled and reported to the district level and further to the state level. The recording and reporting system was assessed at district and Block/PHC level with respect to timeliness, appropriateness and accuracy of reporting.

The monitoring of the activities of LCDC was carried out in the first half of the programme implementation, so that based on the feedback; the activities can be improved in the next half. Feedback was provided to the programme managers at appropriate levels.

Overall the LCDC activity in the state of Jharkhand was noted to be satisfactory. Out of total population, 53.46% persons were screened for leprosy, 5889 (0.14%) suspects identified by the survey team, among them 4660 (79.13%) were examined by the Medical Officers. Out of screened suspects, 513 (11.01%) were confirmed to be leprosy. Out of confirmed leprosy cases, maximum 207 cases were diagnosed in E. Singhbhum, followed (180 cases) by Godda districts (Table 1).

More than 3/4th (75.44%) cases were identified in Godda and E. Singhbhum districts. Among the confirmed cases of leprosy 40.55% were MB, 8.58 % were child cases and 0.97 % were cases of Grade II disability. As compared with cases detected during previous year, an increment due to LCDC was noted to be 48.53%. In Godda district the cases detected during LCDC surpassed annual case detection in previous year and registered the maximum increment (107.78%) in new case detection, while in E. Singhbhum and Dumka Districts; more than two third of the previous year’s annual new cases were detected (Table 2).

Table 3 and 4 shows the quality of various components of LCDC activities according to the guidelines. Overall the IEC, Trainings, Micro-planning, Field activities were conducted satisfactorily. Inadequate supervision resulting in delayed reporting of the activities was the major issues at most of the districts. The activities queued due to financial year closure on 31st March and newer appointments were constraints identified at Godda and Dumka districts. While non involvement of Anganwadi Workers (AWW) in urban areas and inadequate trainings were major constraints at E. Singhbhum and Ranchi districts. The constraints were communicated to the programme manager and corrected in the second half of the activity. Appreciable initiatives by the districts were also noted during monitoring. Advocacy of LCDC to the district level programme manager led to further improvements. Newly joined civil surgeons at Godda and E. Singhbhum districts supported and addressed the constraints identified by the monitor. In Ranchi, ASHA supervisor (Sahiya Sathi) supervised the LCDC activities. Being former ASHA and currently their immediate supervisor; Sahiya Sathi was observed to be the most appropriate supervisor for house-to-house activity.

Out of total population 53.46% persons were screened for leprosy, among those 5889 suspects were identified, 4660 (79.13%) screened and 513 (11.00%) persons were confirmed to have leprosy (Table 1). Raganadha Rao et. al[7] observed that during MLEC activity for case detection in a remote tribal area in Orissa, the survey team identified 13907 suspects out of which 576 (4.14%) cases of leprosy were confirmed. the performance of search teams during LCDC was noted to be excellent as compared to the MLEC.

The proportion of confirmed cases among suspects was 11.01%. During the previous rounds of active case detection in MLEC in the concerned districts the overall proportion of confirmed cases to suspects was ranging from 50.92% during first MLEC (1997-99) in Godda to 13.20% in Dumka during fifth MLEC (2003-05).[5] As the prevalence of leprosy decreased over a period of time, the proportion of confirmed cases to suspects was decreased. The programme staff in Jharkhand possesses good diagnostic accuracy already studied by B Sekar et al while evaluating Third MLEC during 2003.[6]

Among the confirmed cases of leprosy more than one third were MB (34.83%), 8.75 % were child cases and 0.85 % were cases of Grade II deformity (Table 2). These all indicators were less as compared to the state level indicators during same time which showed MB (47%), Child cases (9.21%) and Grade II deformity (2.30%) proportion among new cases.[8]

Overall the IEC, Trainings, Micro-planning, field activities were conducted satisfactorily. B Sekar et al[6] evaluated impact of IEC activities on the awareness of leprosy and the programme in the Jharkhand State (2003).

Inadequate supervision leading to delayed reporting of the activities was the major issues at most of the districts. The importance of constant supervision and guidance by the supervisors at various levels was already reiterated by Ashok Kumar et al.[9] To better performance of managerial role by Medical Officers, District and State administrators modern management methods for efficient and effective implementation of the activity. Besides supervision, a refresher training of the administrative staff was also suggested.