Jan Swasthya Sahyog

Leprosy Project

JSS Health Centre Ganiyari, Bilaspur District

Chhattisgarh

Background on JSS• Jan Swasthya Sahyog (JSS) is a long term partner of AID and has been working on

healthcare in the Bilaspur District, Chattisgarh– Founded by AIIMS doctors

• JSS caters to patients at 3 levels-Main Hospital at Ganiyari, via 3 mobile clinics/subcenters and through the village health workers in 53 villages.

– Accessed by people from about 1500 villages in Bilaspur and the neighbouring districts of Chhattisgarh, as well as some adjoining districts of Madhya Pradesh state

• They are also working on sharing their findings from rural India including highlighting issues of access, chronic hunger levels, cost of drugs and the link between poverty and disease.

• Dr Jonathan Fine recently visited their site and gave us an update at GBM 2010 (visiting again in Q3)

– Multiple AID chapters have supported several projects from JSS over the years – AID Portland had also funded JSS from 2006-2008.

• http://www.youtube.com/watch?v=4yY_JSO-Dqg ( if time permits)

JSS: Focus Area• Bilaspur district, state of Chattisgarh

(statehood in Nov’00)• Area details:

– Mainly rural population– Forest cover and mainly dominated by

Adivasis– Literacy: 52%– Health conditions:

• IMR (Infant Mortality Rate) = 99/1000 (1993) with rural being 110. Under 5 IMR is 20/100

• 57% of children under 5 are malnourished• Malnutrition is twice as common as the

urban areas• Other health problems: Leprosy,

falciparum malaria, water-borne diseases, TB

– Average family size = 5.6

JSS Activities• Community health care center in Ganiyari – outpatient,

clinical & research lab, low-cost pharmacy, imaging facilities, OTs, training facilities for workers– Coverage >1500 villages in surrounding areas

• Village health program covers 53 tribal villages • Development, adaptation and validation of low-cost health-

related technology • Field-based research into public health problems • Providing technical support to voluntary organisations in the

field of public health

Leprosy – Prevalence in India

Leprosy is endemic in the state of Chhattisgarh. The current official prevalence level is about 2 per 10,000 population.

Leprosy was eliminated as a public health problem by WHO in 2000 ( less than 1 case per 10,000 persons)

CAUSELeprosy is a chronic disease caused by a bacillus, Mycobacterium leprae (Mycobacterium leprae). M. leprae multiplies very slowly and the incubation period of the disease is about 5 years.

TRANSMISSION    Leprosy is transmitted by air through droplets from the nose and mouth, during close and frequent contacts with untreated cases. Leprosy is one of the least infectious diseases, because:      • Over 99% of the population has adequate natural immunity;     • Over 85% of the clinical cases are non-infectious, and     • An infectious case is rendered non-infectious within one week, most often after the very first dose of treatment. 

SYMPTOMS     Leprosy mainly affects the skin and peripheral nerves.     If left untreated, it can lead to progressive and permanent damage of nerves, leading to loss of sensation and sweating in the extremities and paralysis of muscles in the hands, feet and face.     

The disease is classified as paucibacillary (PB) or multibacillary (MB), depending on the bacillary load.     

LEPROSY- KEY FACTS

Leprosy – Govt Attitude & Treatment

• Cases of leprosy report initially to both the Government public health system and also to the private practitioners in the area.

• Public health system often unwilling to recognize and register new cases of leprosy reported by field workers

– Artificial attempt to keep the prevalence of the disease at a low level. – Early cases of leprosy with only one or two skin lesions are simply ignored. Oral

instructions to this effect are given to all Government doctors. – The few cases that are registered are not followed up adequately for compliance, side

effects of drugs, lepra reactions and other complications.

• The private health care system charges are high for the examination, diagnosis and treatment of leprosy patients.

– The leprosy patients are also often wrongly diagnosed as suffering from other skin diseases. Their complications are often not recognized and treated in time.

Leprosy Care at JSS

• Referred (but new) cases from other doctors in Bilaspur and beyond.

• Cases who have taken treatment partially from other private doctors, with or without complications.

• Cases who have taken partial or complete treatment from the Government public health system, with or without complications and / or side effects.

Number of new cases of leprosy seen at JSS for the last few years:

2007.........121 cases2008.........149 cases2009.........180 cases

Although the JSS Health Centre at Ganiyari is not a leprosy hospital or treatment centre, it has attracted and continues to attract a large number of leprosy patients, most of them completely new cases. Some of the other kinds of leprosy patients are:

Leprosy Care at JSS – Cont’d

• A leprosy patient typically requires treatment for the disease for about one year.

• Some patients require additional treatment for complications like lepra reactions, ulcers, other co-existing diseases etc.

• Some patients do not get completely cured with one year's treatment and require a longer course of drugs.

• Some patients also require corrective surgery, protective footwear for deformed feet and so on.

Proposed Budget

Proposal – Vote on funding Rs 4,60,000 for 1 yearCan we take a vote ?

AID Bay Area approved– Rs 3,00,000 for JSS Leprosy Project[AID-BA already funded $14K this year to JSS projects]

AID Pittsburgh approved– Rs 1,80,000

Backup

JSS Leprosy Proposal – Q&A

• What is the long-term plan regarding the Leprosy project

We plan to continue treating leprosy patients with the following objectives:

• Demonstrate that leprosy is still very much a problem that needs the attention of the Government

• Provide good quality treatment to rapidly cure patients and prevent complications and deformities.

• Demonstrate that general health services can handle leprosy care successfully with few inputs.

• Leprosy will continue to be a problem for the foreseeable future, till socio-economic conditions improve.

JSS Leprosy Proposal – Q&A• What is the approximate population of the 50 villages that JSS caters to?• JSS caters to patients at 3 levels-Main Hospital at Ganiyari, via 3 mobile

clinics/subcenters and through the village health workers in 53 villages.

• The health centre at Ganiyari is accessed by people from about 1500 villages in Bilaspur and the neighbouring districts of Chhattisgarh, as well as some adjoining districts of Madhya Pradesh state.

• The population served by the health centre at Ganiyari is over 300,000 with 35% Dalits, 14% Tribals and 44% backward castes. The population served by the subcentres is around 75000 and by the village health workers (of 50 villages) around 26000, and over 72% are adivasis, 7% dalits, and 19% backward castes.

SUPPORT FOR JSS• Ministry of Health and Family Welfare, GOI• Dept. of Science and Technology, GOI• Sir Dorabji Tata Trust, Mumbai• Sir Ratan Tata Trust, Mumbai• AID-India and USA• NOVIB(Netherlands)• AIMMS, New Delhi• Hospital fÜr Indien, Emsdetten, Germany• Letzdream Foundation, Mumbai• Friends and Relatives

Referral Center/OPD• Located in Ganiyari – 20 km to the north of Bilaspur • Leased by Govt. of Madhya Pradesh in Nov 2000• Servers about 150-250 patients on a clinic day• Health center has access to approx 500 villages

The old godown in the Water Resources Department Colony

The same building converted to the ward and operation theatre

OPD (contd.)• Public health problems like

tuberculosis, falciparum malaria, leprosy, and childhood infections

• 650 patients of tuberculosis have been identified

• Leprosy and malaria most common • Equipments/lab: X-ray and

ultrasound machine, diagnostic laboratory, an electrocardiograph, two observation beds, oxygen cylinders, a dressing room for minor diagnostic procedures and a nebuliser for rapid relief of patients with asthma.

A child being positioned for an X ray examination

OPD (contd.)• Dispensary

– 100 essential drugs at affordable cost

– Drugs mainly purchased from LOCOST – known for 25 yrs to produce low cost drugs at 200-300% cheaper than open market

– Drugs are dispensed in pouches with pictorial prescription slips

The Dispensary Counter

OPD (contd.)• Inpatient Department

– 10 bedded wards and 2 OTs– High quality surgical services have

been provided to more than 750 needy patients at 25-30% of market rates

Inside the wardThe Operation Theatre: an elective and an emergency operation in progress at the same time

Outreach Clinic• Outreach clinics at Shivtarai, a forest-

fringe village about 50 km to the northwest of Bilaspur town, since March 2000.

• One doctor visits the clinic every Saturday along with laboratory technician, pharmacy assistant, village health coordinator and registration clerk and attends to 30-50 patients, depending on the season

• Serves up to villages in 15-20 km radius

• Two clinics already open in Semariya and Chappawara

Examining a patient at Semariya

Research• Goal: To develop medical

technology, which is low-cost, simple and accessible to the peripheral health worker

• Developed a simple and inexpensive reproductive health test battery for diagnosing – Anemia, urinary tract infections,

vaginal discharge etiology, diabetes, pregnancy

• Produced a low-cost kit for the detection of fecal contamination of drinking water

• Other achievements:– weighing scales for babies – stadiometers – electrophoresis equipment – breath counters

The kit for diagnosing urinary tract infection

Treatment / Cure

Current recommendations :

Pauci-bacillary leprosy(1-5 skin lesions):Treat with rifampicin and dapsone for 6 months

Multi-bacillary leprosy (>5 skin lesions):

Treat with rifampicin, clofazimine and dapsone for 12 months

MDT : Multi Drug Therapy- provided by WHO and Novartis for free to all patients in the world (agreement uptill 2010)