National Leprosy Eradication Program (NLEP )

1. National Leprosy Eradication Program(NLEP) Dr. KANUPRIYA CHATURVEDI

2. Lesson Objectives • To know about the magnitude of Leprosy problem in India • To know about the evolution of Leprosy control/elimination in India • To learn about the goals, objectives and strategies for leprosy elimination

3. Disease Burden • The global registered prevalence of leprosy at the beginning of 2006 was 219,826 cases. There are now only six countries that have still to reach the elimination target of 1 case per 10,000 population, at the national level. • Based on the reports received from all the states and UTs in India for the year of 2008-09 current leprosy situation in the country has been observed as below. • A total of 1.34 lakh new cases were detected during the year 2008-09, which gives Annual New Case Detection Rate (ANCDR) of 11.19 per 100,000 population. This shows ANCDR reduction of 4.36% from 11.70 during 2007-08. • A total of 0.86 lakh cases are on record as on 1st April 2009 giving a Prevalence rate (PR) of 0.72 leprosy cases per 10,000 population. • Detailed information on new leprosy cases detected during 2008-09 indicates the proportion of MB (48.4), Female (35.2), Child (10.1), Visible Deformity (2.8),

4. Trend of Leprosy Prevalence & Annual New Case Detection (ANCD) Rates in India

5. Situation of States as per Prevalence- 2001 Vs 2006

6. National Leprosy Eradication Program Started in 1955 as NLCP with the objective of early detection of cases and treatment with Dapsone monotherapy It was made a centrally sponsored programme in 1980 With the advent of Multi Drug Therapy (MDT) for leprosy the cure rates increased It was changed into eradication programme in 1983 with the objective of eradicating the disease by the end of 2000 The ‘elimination’ was defined as attaining a prevalence Rate (PR) of less than 1 case per 10,000 population

7. Milestones of leprosy Eradication • 1955 national leprosy control program • 1983 leprosy eradication program ( MDT started) • 1991 World Health Assembly resolution to eradicate leprosy by 2000 AD. • 1993 world bank supported MDT program phase I • 1997 mid term appraisal • 1998-2004 modified leprosy elimination campaign • 2001-2004 NLEP project phase II • 2002 simplified information system • Nationwide evaluation of Project II • NRHM covers NLEP

8. What does elimination as a public health problem mean? • Reducing the case load to less than 1 case per 10,000 inhabitants • by detecting and curing all cases of leprosy • leading to a reduction in the source of infection and the disease burden in communities • so that leprosy is likely to disappear naturally as it already has from many countries

9. Leprosy - one of the few diseases which can be eliminated • Leprosy meets the demanding criteria for elimination • practical and simple diagnostic tools: can be diagnosed on clinical signs alone; • the availability of an effective intervention to interrupt its transmission: multidrug therapy • a single significant reservoir of infection: humans.

10. Rationale for eliminating leprosy • Technically feasible • Prevents patients going on a downward spiral to poverty and destitution due to leprosy related disabilities • Enhances the credibility of and confidence in local health services • Puts into place structures which can be used for other diseases • Releases resources to manage other diseases • Will consign leprosy to history

11. Highly effective cure available • Multidrug therapy (MDT) • Is a combination of 2 / 3 drugs (clofazimine, rifampicin, dapsone) • Cures patients in 6 months / 12 months depending on form of leprosy • Kills the leprosy bacilli and stops its transmission • Can be delivered under field conditions without special staff and institutions • Is available free of charge from WHO

12. Project phase II 2001 onwards • Part A: National Plan setting out the project design for the country • Part B: Plan for 8 high endemic states ( Madhya Pradesh, Orissa, Bihar, UP, West Bengal, Uttranchal, Chattisgarh and Jharkhand. • Part C: Plan for remaining 27 states and union territories

13. Objectives • To achieve elimination of leprosy at national level by the end of the project • To accomplish integration of leprosy services with general health services in the 27 low endemic states • To proceed with integration of services as rapidly as possible in the 8 high endemic states

14. Elimination strategy • To eliminate the following strategy adopted: • Modified leprosy elimination campaigns ( MLEC): organizing camps for 1 or 2 weeks duration for case detection, treatment and referral • Special action projects for the elimination of leprosy ( SAPEL): initiative for providing MDT services in special difficult to access areas or to neglected population groups

15. Activities • Early detection of leprosy cases • Intensified health education and public awareness campaigns • Regular treatment of leprosy cases providing multi- drug therapy( MDT) at fixed centres near the patient • Disability prevention and medical rehabilitation

16. Early detection of leprosy cases • For the field purpose : • Multi-bacillary leprosy is labeled when there are 6 or more skin patches and/or 2 or more nerves affected. Skin smear is positive. • Paubacillary leprosy is labeled when there 5 or less than 5 skin lesions and/or 1 more nerve affected. Skin smear do not show bacilli

17. Treatment • Rifampicin is given once a month. No toxic effects have been reported in the case of monthly administration. The urine may be coloured slightly reddish for a few hours after its intake, this should be explained to the patient while starting MDT. • Clofazimine is most active when administered daily. The drug is well tolerated and virtually non-toxic in the dosage used for MDT. The drug causes brownish black discoloration and dryness of skin. However, this disappears within few months after stopping treatment. This should be explained to patients starting MDT regimen for MB leprosy. • Dapsone :This drug is very safe in the dosage used in MDT and side effects are rare. The main side effect is allergic reaction, causing itchy skin rashes and exfoliative dermatitis. Patients known to be allergic to any of the sulpha drugs should not be given dapsone.

18. Treatment contd. • Multibacillary (MB) leprosy • For adults the standard regimen is: Rifampicin: 600 mg once a month Dapsone: 100 mg daily Clofazimine: 300 mg once a month and 50 mg daily Duration= 12 months. • Paucibacillary (PB) leprosy • For adults the standard regimen is: Rifampicin: 600 mg once a month Dapsone: 100 mg daily Duration= six months • Single Skin Lesion Paucibacillary leprosy • For adults the standard regimen is a single dose of: Rifampicin: 600 mg Ofloxacin: 400 mg Minocycline: 100 mg

19. MDT Dose for Multi-bacillary Leprosy Regimen of three drugs – Rifampicin, Clofazimine and Dapsone for 12 months; first dose of each month to be given in presence of HW.

20. Multi- drug therapy( MDT) for paubacillary leprosy Regimen of two drugs – Rifampicin and Dapsone for 6 months provided in blister packs

21. Disability prevention and medical rehabilitation plan Objectives of the rehabilitation plan: • Persons with lepra reactions are adequately managed so as to prevent occurrence of disabilities. • Persons with disabilities due to leprosy are assisted with care and support to prevent worsening of their existing disabilities • Persons with deformities suitable for correction are provided reconstructive surgery services through specialized centers managed by government and voluntary organizations.

22. Monitoring and evaluation • The implementation of elimination plans in the most endemic countries is closely monitored so as to detect potential problems that might impede its progress and to identify rapid, yet feasible solutions: • promotion of research in the epidemiology of the disease, including modeling • development of computerized databases on leprosy, including data collection, reports and analysis, estimates and predictions of leprosy problem trends • costing and drug requirements for the elimination of the disease • development of simplified tools for data collection, including guidelines and training material, on essential information for the control of leprosy in the most endemic countries

23. Problems.. • Late detection of patients, many with visible deformities • Poor treatment completion and cure • Fear, prejudice and stigma surrounding leprosy • Limited community awareness and involvement

24. …but some challenges remain • Leprosy remains a public health problem in 9 States • Poor coverage with MDT services in some difficult to reach areas • Hidden cases who continue to spread the infection • Late detection of patients, many with visible deformities • Poor treatment completion and cure • Fear, prejudice and stigma surrounding leprosy • Limited community awareness and involvement