National Leprosy Eradication Program

Contents

• Milestones

• Updates and innovations

• Strategies

• Lessons learnt

• Drawbacks

• Challenges
• Centrally sponsored Health Scheme MoH&FW Govt. of India
• Headed by the Deputy Director of Health Services (Leprosy )
under the DGHS
• Supported as Partners by the WHO, ILEP and few NGO’s
 Chaulmoogra tree, oil

Until late 1940 leprosy was

treated by injecting
chaulmoogra oil in skin
 Early 20 th Century
• 1941: Promine a sulfone
drug used for treatment

• 1950s: Dapsone,
pioneered by Dr. R. G.
Cohrane at Carville

• 1983: MDT introduced

by WHO
 MILESTONES in NLEP in India
1955 Govt. of India launched National Leprosy Control
Programme
1970s Definite cure through MDT was identified
1981 WHO study group recommended use of MDT
1983 Govt. of India launched NLEP and introduced MDT
1991 WHO declaration to eliminate leprosy global
level by 2000.
1993 - 2000 – World Bank supported NLEP – I
The prevalence rate <<< 24/10,000 (1992) to 3.7/10,000 (2001)
 WHO provided MDT drugs free of cost worth Rs. 48.00 cr.
2001 - 2004 – World Bank supported NLEP – II

2005 Elimination of Leprosy at National Level (Dec.2005)

< 1/10,000
2005 NRHM covers NLEP

2006 Focused leprosy elimination plan (FLEP)

2007 Situational activity plan(SAP)

2007 Block leprosy awareness campaign (BLAC)

 Special efforts for leprosy case detection
& prompt MDT

• SAPEL – Special Action Project for Elimination of Leprosy (2001-04)

• LEC – Leprosy Elimination Campaign

For early case detection

Mainly in difficult and inaccessible rural/tribal areas & slums

• MLEC – Modified Leprosy Elimination Campaign

• Five such nation wide campaigns

• Carried out during 1997-98 to 2003-05

• Helped in bringing out 9.9 lakh new cases under treatment in

a short span of time
• As a result of the hard work the country achieved the goal of
elimination of leprosy to less than 1 case per 10,000
population December, 2005

• As on 31st December 2005, Prevalence Rate recorded in the

country was 0.95/10,000 population
 0.39

CHENNAI
Total Population: 78,32,273
Prevalence rate: 0.29
ANCDR/1,00,000: 4.32
MB Rate : 61.70
Child rate: 20.57
Deformity rate: 1.15
Female rate: 36.17
 GOURIPUR
RAIPUR
ASKA

CHENGALPATTU
 Staff attached to District Leprosy Organization

• Deputy Director of Medical Services (Leprosy)

• Medical Officer- Deputy Director (Leprosy)

• Health Educator

• Non Medical Supervisor

• Physio Technicians

• Health Inspectors

• Lab technician
 Clinico-epidemiological factors leading to Multi Case
Family (MCF) in the surveyed village in village
Salaunikhurd in Balodabazar district of Chhattisgarh

1. Delay in detection
2. The patient related (patient hoped that it will be cured on its own)
3. Health system delay can be attributed to the lack of interest and
involvement of ASHA of the village
4. Nature of disease spectrum: De-Novo MB spectrum of cases
 Stigma
• Felt stigma (Guilt or self-blame related to the stigmatized )

• Enacted stigma (e.g. divorce, denying someone access to public

transport)

• Institutional stigma (e.g. separate clinic arrangements for

people affected by leprosy, buildings without elevators,
sidewalks without ramps)
NLEP updates
 Three pronged strategy for early case detection
I. Leprosy Case Detection Campaign (LCDC) specific for high
endemic districts

II. Focussed Leprosy Campaign (FLC) in hot spots of non LCDC

districts

III. Special plan for case detection in hard to reach areas

 Other major innovations introduced were
• Sparsh Leprosy Awareness Campaign

• Post Exposure Prophylaxis (PEP) specific to LCDC districts

• Grade II disability case investigation

• Launch of Nikushth online reporting system with Patient

tracking mechanism

• ASHA based Surveillance for Leprosy Suspects (ABSULS) for

enhanced early case reporting in routine.
 Mycobacterium Indicus Pranii (MIP)

• An exclusive vaccine for leprosy, developed in India

• The protective efficacy of MIP was

• 68.6% at the end of 1st year,

• 59% at the end of 2nd year

• 39.3% at the end of third follow up survey.

• The effect of vaccine is 7-8 years.

• MIP Vaccine in new PB patients and patients already taking
treatment should be 2 doses, 6 months apart.

• In new MB cases, the dosage schedule of MIP Vaccine should

be 3 doses, 0, 6 and 12 months after initiation of therapy.

• The dosage of MIP will be same in all age groups.

• Booster will be given at the time of follow up after 4-5 years.

 SPARSH- Monthly activity schedule
Sep 2018- October 2019

• Leprosy Case Detection Campaign (LCDC): LCDC to be

conducted twice in 251 districts identified on the basis of

Grade II disability (G2D) rate >3%.

 Focussed Leprosy Campaign (FLC)

• Routine FLC in non LCDC districts against each grade II

disability case detected within 15 days of detection

• Clearance of back log of FLCs, if any

 Self-care kits distribution

• Identification and line listing of the PAL needing self-care kits

(assessment through review of last 5 years Patient’s cards of

Persons Affected by Leprosy (PAL) having grade I & II disability

(over Hands and Feet)

 MCR footwear distribution

• Identification and line listing of the PAL requiring MCR footwear

• Distribution of MCR footwear through existing system and work

on Health & Wellness centre involvement for distribution of same

 Re-constructive Surgeries

• An incentive of Rs 8000/- will be paid to all patients affected by

leprosy undergoing RCS.

• Processing of proposal for inclusion of RCS under tertiary care

provisions of Ayushman Bharat, Pradhan Mantri Jan Arogya

Yojana (PMJAY)
RCS centre’s
 SET scheme
(Survey, education and treatment)

• Disability prevention and ulcer care

• IEC

• Referral for RCS

• Research

• Rehabilitation
 Strategies D

a) Decentralization of NLEP to States & Districts

b) Early detection and complete treatment of new leprosy cases
c) Carrying out house hold contact survey (MB, child cases)
d) Involvement of ASHAs in the detection & complete treatment
e) Intensified IEC using Local and Mass Media approaches
f) Disability Prevention & Medical Rehabilitation (DPMR)
g) Monitoring & Evaluation
– Regular - Monthly Reports
– Special Efforts - Independent Evaluation
- Leprosy Elimination Monitoring (LEM)
Current activities under NLEP
National sample
survey

• By national JALMA institute Agra

• Started in 2010.

• House to house survey to access burden of active leprosy

cases, leprosy persons with grade 1 & 2 disability and

magnitude of stigma and discrimination in society.

Involvement
of ASHAs

• Incentives provided for ASHAs for bringing out cases from their

villages

• Rs 250 for confirmed diagnosis of cases

• On completion of treatment within specified time Rs 400 for PB

& Rs 600 for MB.

 Involvement of NGOs

• Help reduce burden of leprosy

• Serve in remote, inaccessible, uncovered, urban slums,

industrial/labour populations and other marginalised

population groups
 Information
education
communication

• IEC help reduction of stigma & discrimination against leprosy

affected persons.

• Carried out through mass media, out door media, rural media &
advocatory meetings.

• More focus on inter personal communication.

• Intensive survey (100% slum population
covered)
• Skin camps: 5 per zone
• School survey: 1str to 8th std children
screened, 9th to 12th std - IEC
 Disability prevention and
medical rehabilitation

• Inform patients (specially MB) about common s/s of reactions

• Ask them to come to centre (as soon as possible)
• Start treatment for reaction
• Inform them how to protect insensitive hands/ feet eyes
• Involve family members
• Patients provided with dressing materials, supportive medicines &
MCR footwear
• Correction of disability through reconstructive surgery
 Training

• Training to Medical officers, health workers, lab technicians,

ASHAs conducted every year

• Training of state & district Leprosy officers organized at

Schieffline institute of health research & leprosy centre
Vellore, TN and RLTRI Raipur
 Monitoring & Supervision

• By analysis of monthly progress reports

• Through field visits by supervisory officers

• Programme review meetings held at central, State & District

levels.
 Monitoring & evaluation
• PRIMARY INDICATOR:
- Annual New Case Detection Rate (ANCDR)
- Treatment Completion Rate (cohort analysis)
• INDICATORS FOR CASE DETECTION:
- Proportion of new cases with Gr II disability
- Proportion of child cases(<15yrs) among new cases
- Proportion of MB cases among new cases
- Proportion of Female cases among new cases

• INDICATORS FOR QUALITY OF SERVICE:

- Proportion of new cases correctly diagnosed.
- Proportion of defaulters.
- Number of relapses during a year.
- Proportion of cases with new disabilities.
 Budget and international support

• Since 2005, the program is being conducted with Govt. of

India funds with technical support from WHO & International

federation of anti leprosy association(ILEP)

 Anti Leprosy Activities in India
• Leprosy Mission - founded in 1874 in H.P.
• Hind Kush Nivaran Sangh
• Gandhiji Memorial Leprosy Foundation, Sevagram, Wardha
• The German Leprosy Relief Association
• Damien Foundation
• The Danish Save the Child Fund
• JALMA- taken over by ICMR in 1975 (Japanese leprosy mission for Asia)
• National Leprosy Organisation- 1965
 Lessons learned from NLEP

1. Strong Political commitment

2. Special programme for important health problems offer

the advantages of attracting both resources and
community support

3. Providing community wide services, reaching the most

unreachable

4. Intensified supervision and Monitoring

5. Quality control through quality of service indicators.

6. Involvement of NGO’s to support the program.

 Drawbacks
• Social Stigma
– Even in the present time people with leprosy have to leave their
villages or socially isolated.
• Leprosy Legislation
– Certain legislation still exists that construct leprosy as highly
contagious disease.
– Eg: Hindu Marriage Act 1955
– Leprosy patients cannot contest a civic election or hold a
municipal office.
• Resistant to leprosy drug:

– Resistance to MDT could be a problem.

– New alternative regimen is lacking presently

• Transmission of infection:

– elimination campaign is actually a control strategy.

– It may come to the same level as it was before if control

measures are relaxed.
6) Elimination criteria:

– Duration of infection, treatment duration, mortality rate

would be affecting prevalence rate

 Challenges in “going the last mile”

– The level of international attention and political

commitment is declining

– Knowledge about diagnosis and treatment is decreasing in

many countries.

– While leprosy cases have decreased significantly from 1984

to 2004 (see figure 1), a stagnation has occurred from 2005
onwards.
GLOBAL LEPROSY STARTEGY (2016-2020)

Accelerating towards a leprosy-free world

 3 Pillars

a) Strengthen Govt ownership, Coordination and partnership

b) Stop leprosy and its complications

c) Stop discriminating and promote inclusion

 3 Targets

a) Zero grade 2 disability among children diagnosed with leprosy

b) The reduction of new leprosy cases with G2D to < 1 case per

million population

c) Early detection and complete treatment with MDT remains

the fundamental principle of leprosy control

 References
• http://www.who.int/lep/en/ 09/05/2019, 14.00hrs
• http://www.who.int/mediacentre/factsheets/fs101/en/
08/05/2019, 16.30 hrs
• Text book of public health and community medicine. 1st ed. Pune
(India). Dept. of Community Medicine AFMC; 2009
• J Kishore. National Health Programs of India. 10th ed. Century
Publication. New Delhi. 2012
• Park.K. Text Book of Preventive and Social Medicine.25td ed.
Jabalpur: M/S. Banarasidas Bhonot Publishers;2013.P.60