How can the private practitioners support leprosy elimination in India.

The private providers especially private practitioners are the first contact points for any types of ailments both in the urban and rural situations. From 2001 onwards, the services for National Leprosy Eradication changed to integrated system involving general healthcare system. Special emphasis is laid on correct diagnosis of leprosy cases before declaring and putting them under multidrug therapy. The government doctors were provided repeated training for this capacity building to diagnose and manage all diagnosed cases. Government of India also arranged practice of giving orientation programme to the private practitioners through IMA in the year 2004-05. The private practitioners can support the programme through case diagnosis, continuation of treatment and spreading awareness.

National Leprosy Eradication Programme and progress towards elimination of leprosy in India.

The World Health Assembly in May 1991 made the declaration to eliminate leprosy at global level by the year 2000. Complete coverage of all the districts with MDT was possible in the year 1996. Very good results were obtained and the case lead came down to 0.51 million by December 2000. A new goal has been set to reach leprosy elimination at national level in India by December 2005. The challenges to eliminate leprosy and to bring prevalence rate 0.9/10,000 by December 2005 are to be taken at epidemiological, operational and at administrative levels.

Progress towards elimination of leprosy as a public health problem in India and role of modified leprosy elimination campaign.

India (population 943 million) has seen a highly significant decrease in the prevalence of leprosy since the introduction of multi-drug therapy (MDT) in 1981. From a prevalence rate of 57/10,000 of the population in March 1981, the figure has declined to 5.2/10,000 in March 1999. This was possible due to the creation of a completely vertical (specialized) infrastructure for leprosy control in the 218 endemic districts of the country and skeleton vertical staff in the remaining districts, coupled with the recruitment of additional staff on contract basis to provide MDT through vertical staff in endemic districts and mobile treatment units in the moderate and low endemic districts. Despite all efforts, however, new case detection has not shown a decline over the last 14 years due to the presence of hidden (and undiagnosed) cases. Therefore, in order to intensify and hasten progress towards elimination (less than 1 case per 10,000 of the population) in the whole country, it was decided to implement a massive leprosy elimination campaign (LEC) in all the States/Union Territories (UTs). The reports of 22 States/UTs indicate that 415 out of the total of 490 districts in the country were covered by modified LEC (MLEC), with 85% coverage of the population. The campaign used in India was modified from the pattern previously described by the World Health Organization. The detection of hidden or suspected cases took place within a short, intensive period of 6-7 days and relied heavily on house-to-house searches by General Health Care staff trained in leprosy detection and confirmation was made by appropriately trained staff. This MLEC received widespread Government and public support, resulting in the detection of 454,290 hidden cases of leprosy, whilst providing training to a large number of General Health Care staff and volunteers and creating widespread awareness about leprosy and the availability of treatment free of charge for all cases. This programme proved to be one of the most successful health care interventions undertaken in India in recent years, particularly in the states of Bihar and Orissa. Although a few states in India are unlikely to reach the current WHO goal of elimination before end of the year 2000, the results of the MLEC strongly support the possibility that elimination levels will be achieved in the majority of states by the end of the year 2000 and at national level by the end of the year 2002.

Operational research in malaria--why and how?

Research studies conducted so far have had little bearing on the National Malaria Eradication Programme implementation for want of operational component. In India there is no dearth of scientific knowledge and technical know-how but dearth of operational research of direct relevance to the programme. The rationale for research under the operational conditions of the NMEP is discussed in this paper.

Comparative efficacy of chloroquine and amodiaquine in Plasmodium falciparum strain of north-eastern India.

The present study describes the comparative efficacy of chloroquine and amodiaquine in two different presumptive therapy areas of north eastern India. The study recorded insignificant differences in respect of Mean Parasite Clearance Time (MPCT) of sensitive cases, MPCT and Mean Parasite Recrudescence Time (MPRT) of RI resistant cases and recrudescence rate in chloroquine and amodiaquine therapy areas. It is concluded that amodiaquine is not a superior drug as compared to chloroquine. In the chloroquine resistance area, Plasmodium falciparum developed cross resistance to amodiaquine and this phenomenon appears to be unidirectional. However, amodiaquine may help to slow-down the rate of precipitation of higher grade of resistance.

A longitudinal study to monitor chloroquine-resistant P. falciparum malaria in Bokajan and Manja PHC areas of Karbi Anglong District, Assam.

In-vivo as well as in-vitro studies were carried out at regular intervals from 1979 to 1988 to monitor chloroquine resistance in P. falciparum in Bokajan and Manja PHC of Karbi Anglong district, Assam. The results showed no significant change in resistance status in the area. Intensified antivector measures, withdrawal of chloroquine pressure and prompt detection and treatment of P. falciparum cases with alternative drugs helped bring down the higher grades of resistant parasites by 1984, which however could not be maintained. The results of in-vitro tests correlated well with those of in-vivo tests. The Karbis seemed to have better immunity against the strain of P. falciparum than the non-Karbis residing in the area. However, there was no difference in the rate of sensitive and resistant cases detected amongst the two groups.

Problem of antimalarial drug resistance in Plasmodium falciparum in Mizoram.

Studies conducted in Mizoram during 1981 to 1990 have shown areas with increasing RIII level of chloroquine resistance. These foci need urgent liquidation. Sulfalene-pyrimethamine drug combination was found suitable for treatment of P. falciparum cases in these areas with only 5.3 per cent cases showing RI level of Plasmodium response. Quinine combined with sulfalene-pyrimethamine showed 100 per cent success. Amodiaquine however was similar in response to chloroquine though the mean parasite clearance time with amodiaquine was slightly better.

Importance of mean parasite clearance time and recrudescence time and their role in gradation of Plasmodium falciparum resistance.

The present paper describes the relationship of Mean Parasite Clearance Time (MPCT) and Mean Parasite Recrudescence Time (MPRT) in the epidemiology of Plasmodium falciparum. The role of MPCT in grading the resistance of an area has been discussed. Further, MPRT revealed a positive correlationship with the percentage of RI resistant cases, and showed an increase with age. The ratio of MPRT/MPCT is an indicator of stability status of the resistance.

Efficacy of a low dose oral quinine therapy in Plasmodium falciparum cases of Assam, Meghalaya and Arunachal Pradesh in India.

A low dose oral quinine schedule with 1050 mg in two divided doses daily for five days was tried for treatment of Plasmodium falciparum cases in Assam, Meghalaya and Arunachal Pradesh, in areas where resistance to chloroquine was confirmed. The drug schedule was found effective in 76.92 per cent cases. The treatment was also found effective in 45.55 per cent of the known chloroquine resistant P. falciparum cases. The drug in this low dose was well tolerated and clinical response was quick.

Changing response of Plasmodium falciparum to chloroquine in West Bengal during 1980-1988.

A total of 314 cases of Plasmodium falciparum malaria studied during 1980-88 in nine times monitoring revealed three RIII foci i.e. two in Jalpaiguri and one in Purulia districts. The studies showed a parasite clearance of 40 per cent and 32 per cent of P. falciparum cases within seventh day in Purulia and Jalpaiguri districts respectively, with a dosage of 25 mg per kg body weight, spread over three days in divided doses. Increase in transmission potential and prolonged drug pressure with single drug have been noted in association with development of resistance. Malaria parasite clearance time (MPCT) value of sensitive and resistant cases reach parallelism and malaria parasite recrudescence time (MPRT) value starts declining, giving an indication of stabilisation of genetic change in the parasite.

Plasmodium falciparum--chloroquine in vivo test in northeast India: reclassification and extended follow-up till day 14.

In vivo test for the susceptibility of Plasmodium falciparum to chloroquine was carried out in 390 patients. Parasite density was analysed by calculating the mean of each day's parasite count and the value was expressed per microliters of blood. Majority of sensitive and resistant infections attained minimal values on day 4. Further more, this value provides a clear-cut, statistically significant difference between sensitive and RI cases (Z = 2.14, P less than 0.05) RII, RIII cases (Z = 3.86, P less than 0.001). It is proposed that assessment of sensitivity should be based on D-4 parasite density per microliters of blood considering D-0 as base i.e., (proportionate reduction of parasite density on D-4 as compared to that on D-0) utilising the present criterion. In endemic areas, where reinfection is possible, patency on D-14 will nearly always be due to resistance. It is therefore, suggested that a better, more economical and an epidemiologically viable result can be obtained by extension of in vivo test upto D-14.

Efficacy of sulfalene and pyrimethamine combination drugs alone and with quinine in treatment of P. falciparum cases in chloroquine resistant areas of north east India.

Studies were carried out in some areas of Assam, Nagaland, West Bengal and Mizoram where chloroquine resistant strains of Plasmodium falciparum were present during 1983 and 1984, to see the efficacy of treatment of P. falciparum cases with SLP alone or with quinine sulphate. The findings have indicated that SLP in the dosage of sulfalene (1000 mg) + Pyrimethamine (50 mg) is suitable for treatment of P. falciparum cases not responding to chloroquine therapy in N.E. India. Treatment with sulfalene (1500 mg) + Pyrimethamine (75 mg) has no advantage over the SLP (1000 + 50) mg. Combination of quinine (1000 mg x 3 days) + SLP (1000 + 50) mg is better with 100 per cent cure rate. In Karhi Anglong district (Manja PHC) of Assam response to these drug combination is however less.