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A Study of Newly Detected Leprosy Patients in Guizhou Province, People’S Republic of China

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A Study of Newly Detected Leprosy Patients in Guizhou Province, People’S Republic of China Lepr Rev (2016) 87, 23–31 How to improve early case detection in low endemic areas with pockets of leprosy: a study of newly detected leprosy patients in Guizhou Province, People’s Republic of China JINLAN LI*, LILI YANG*, YING WANG*, HANG LIU*, JIE LIU* & HUGH CROSS** *Guizhou Provincial Center for Disease Control and Prevention, Guiyang, Guizhou Province, P. R. China **American Leprosy Missions, 1 ALM Way Greenville, USA Accepted for publication 20 January 2016 Summary Although leprosy in China is controlled at a low endemic level, the number of new cases in Guizhou province has shown no significant decrease over the past 20 years. Guizhou remains the province with the second highest prevalence in China. The authors conducted a study in which the characteristics of newly detected leprosy cases, found between 2008 and 2012 in Guizhou, were analysed. These cases represented people from pocket areas of leprosy in a generally low endemic environment. The purpose of the study was to understand characters of newly detected cases, strong points and weakness of routine detection approaches for improving the effectiveness of early case detection in the future. The analysis considered data that was collected from a ‘Leprosy Management Information’ report system and also from annual statistical reports of leprosy that reflect the situation throughout the province. 1274 new patients were detected in Guizhou from 2008 to 2012. That number included 58 (4·6%) children (0–14 years old). The average age of patients at diagnosis was 42·6 ^ 16·5 years. The proportion of people with WHO Grade 2 disability (WHO DG2) among new patients was 35·7% and the proportion of people with Grade 1 disability (DG1) constituted 10·1%. The average delay before diagnosis after the onset of symptoms of leprosy was 41·7 ^ 49·8 months. Suspect survey was a major method by which most cases were detected. Trough this method 790 (62·0%) new patients were detected. It was also in this group that the highest proportion of people with WHO DG2 359 of 790 (45·4%) was reported. Self- reporting, diagnosis at a general skin clinic, household contact examination, and spot surveys accounted for 13·0%, 11·8%, 11·5% and 1·7% of other cases detected respectively. It was generally found that cases detected through household contact examinations were earlier cases (delay to diagnosis , 24 months ¼ 70·7%). It was also recorded that fewer of these had WHO DG2 (12·9%). The proportion of men with WHO DG2 was higher than that of females (38·2% compared with 28·8%). Correspondence to: Jinlan Li, Guizhou provincial center for disease control and prevention, 100# Bageyan Road, Guiyang 550004, P. R. China (e-mail: [email protected]) 0305-7518/16/064053+09 $1.00 q Lepra 23 24 J. Li et al. The proportion of Han Chinese new cases with WHO DG2 was significantly higher than that of the main minority group (41·5% compared with 29·2%). The proportion of new cases among the main minority group who self-reported (50%) was significantly higher than those detected through other detection approaches. Detecting leprosy early in low endemic situations where pockets persist was difficult to achieve. The authors suggest that if more early patients are to be detected earlier, the quality of suspect surveys and household contact examination should be improved. Professional training and supervision might affect that result. Greater emphasis should be given to the role of general skin clinics as surveillance sites and advocacy for new health policy that will enhance the detection leprosy should be sustained. Introduction Despite widespread implementation of effective multidrug therapy, about 250,000 new cases of leprosy continue to be detected globally every year. Since leprosy has now been eliminated, as an agenda item in public health offices new impetus is needed from the World Health Organization so that a further reduction in the burden of disease can be effected. Strategy is needed to impact on the incidence of disease, the registered prevalence of disease and on the reduction of the WHO DG2 rate among new cases.1 It is clear that early diagnosis significantly reduces the risk of nerve impairment,2 but how to achieve the early diagnosis of leprosy effectively so that the WHO DG2 rate of new cases is impacted is a critical challenge. Leprosy prevalence in China has been lower than 1/10,000 since 1998.3 However, about 1600 new leprosy cases are still being reported annually in China with a consequence that there are currently 6032 registered leprosy patients residing primarily in Yunnan, Guizhou, Sichuan, Hunan and Guangdong provinces.4 China is one of 18 countries that report more than 1000 new cases per annum and of grave concern to us is the high burden of leprosy as suggested in a 20% WHO DG2 rate among new detected cases.5,6 Guizhou province, with nine prefectures and 88 counties, is a mountainous area located in southwest of China. The population in 2012 was 39,058,858 and 85·5% of the population are agricultural workers. Ethnic minority groups, including Miao, Buyi, Dong, comprise 37·8% of the population. Guizhou remains the province with the second highest prevalence and new case detection rates in China, an unenviable situation that has remained obdurate against change over the past 10 years. Despite concerted efforts the WHO DG2 rate among newly detected cases in Guizhou is higher than the national average level and is also higher than the other endemic provinces, Yunnan and Sichun. Material and Methods . Records of all the cases detected in Guizhou province from 2008 to 2012 were scrutinised. The detection methods recorded included self-reporting, general skin clinic consultations, suspect surveys, spot surveys and household contact examinations. Spot surveys and household contact examinations at county level were carried out by the centres for disease control and prevention (CDC) at that level. The focus of spot surveys was on general villages from which new cases had been reported within recent history (5 years). Improve early case detection in low endemic areas 25 . Every family member of all the people who had been detected with leprosy in the 10 year period prior to the survey were the subjects of household contact examinations. Doctors from village health units or town level hospitals reported suspect cases among that population. Leprosy among suspects was confirmed on diagnosis in a CDC at either county, prefecture or provincial level. Diagnosis was based on clinical features and bacteriological index. In some cases, where it was available, a histopathology test was also carried out. In accordance with WHO operational guidelines, people presenting with 1–5 skin lesions were classified as PB cases whilst those with more than 5 skin lesions were classified as MB cases. Disability levels were graded according to the WHO disability grading system.7 . Details of all confirmed leprosy cases were written into a Leprosy Patient Medical Record (LPMR). Details included history of disease, medical examinations conducted, nerve function assessment results and laboratory results. The routine treatment record was also recorded in the LPMR as was any other pertinent personal information. The LPMRs were subsequently entered into the national Leprosy Management Information System (LEPMIS) as e-records. The study reviewed the survey data from the annual leprosy statistic reports covering the entire province of Guizhou which was supplemented by information from LPMRs and LEPIMS. All data analysed by using Epi Info (Version 3.5.1). Results 1. NEW CASES CHARACTERISTICS . Between 2008 and 2012, 1274 new patients were detected in 84 of the 88 counties in Guizhou. Of the 9 prefectures in Guizhou, 70·3% of all cases were found in Bijie, Qianxinan, Qiannan and Anshun prefectures. 939 (73·3%) and 335 (26·7%) cases were MB and PB leprosy respectively. 1155 (90·7%) people diagnosed with leprosy were engaged in agricultural work, 72 (5·7%) were students, 23 (1·7%) had other occupations and 24 (1·9%) were unemployed. 937 men and boys had a mean age of 42·6 ^ 16·5 and 337 women and girls had a mean age 40·0 ^ 16·4. 4·6% of all people diagnosed with leprosy were children (,15 years old). According to patient records, the delay between the estimated onset of leprosy symptoms and the confirmed diagnosis was 41·7 ^ 49·78 months. 2. NEW CASES WITH DISABILITY . Of 1274 people, 35·7% were recorded as presenting with WHO DG2 and 10·1% were recorded as presenting with WHO DG1. Of those people with disability, 15·5% were children (,15 years of age). Disability among children was significantly lower than that among people greater than 15 years of age (P ¼ 0·0001). WHO DG2 rate was higher in males than in females (38·2% compared with 28·8%, P ¼ 0·0002) and the rate among Han Chinese was significantly higher than that among 26 J. Li et al. minority groups (41·5% compared with 29·2%, P , 0·0001). As may have been expected, cases found through suspect survey presented with the greatest disability rate (45·4%, 359/790) compared with cases found through other methods. Cases found among household contacts had the lowest WHO DG2 rate (12·9%, 19/147). The cases with . 24 months delay in diagnosis had higher disability rate (Table 1). 3. DETECTION METHODS OF NEW CASES . Suspect Survey was main detection method and accounted for 62% (790/1274) of all new cases found. These cases also presented with the highest disability rate 45·4%, and the greatest period of delay between first signs noticed and diagnosis (50·9%). Self-reporting, presentation at a general skin clinic, household examinations and spot surveys account for 13%, 12%, 11% and 2% of cases found respectively.
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