National Leprosy Eradication Program - Dr Surendran Venkataraman

National Leprosy
Eradication Programme
(NLEP)
Dr. Surendran Venkataraman
Post Graduate – First Year

Synopsis
 Introduction
 Milestones / history of leprosy control
 Epidemiology- Global , India & Puducherry
 Elimination Strategy
 Major Initiatives
 Twelfth five year plans & National Health Policy 2015 – revision
 Newer Initiatives
 Strategic Action Plans
 Treatment – Classification and MDT regimen
 Leprosy vaccines
 WHO strategies and Surveillance systems
2

Introduction
• NLEP was launched on 1983
• The NLEP is a centrally sponsored Health Scheme of the Ministry of
Health and Family Welfare, Govt. of India
• The Programme is headed by the Deputy Director of Health Services
(Leprosy ) under the administrative control of the Directorate
General Health Services ,Govt. of India
• The Programme is also supported as Partners by
-The World Health Organization
-The International Federation of Anti-leprosy
Associations (ILEP)
- Non-Govt. Organizations.
3

The emblem
• The NLEP Emblem symbolizes
-Beauty and purity in lotus
-Leprosy can be cured and a leprosy patient can be a useful member
of the society in the form of a partially affected thumb
-Normal fore-finger representing the shape of a house
-The symbol of hope and optimism in a rising sun
• The Emblem captures the spirit of hope positive action in the
eradication of Leprosy
4

Source : Training manual for medical officers -NLEP

Milestones of Leprosy
Eradication - India
• 1848 - Leper act, British India
• 1925 – Indian Council of British Empire Leprosy Relief Association established
(BELRA)
• 1948 – Renamed Hind Kusht Nivaran Sangh (HKNS)
• 1955 - National Leprosy Control Programme (NLCP) launched
• 1981 - MDT recommended by WHO as cure
• 1983 - National Leprosy Eradication Programme launched
• 1983 - Introduction of Multidrug therapy (MDT) in Phases
6

Eradication
• 1991 - world health assembly adopts resolution to eliminate leprosy by
2000
• 1993 – world bank assisted NLEP funded project phase-I
• 1998 to 2004 – Modified Leprosy Elimination Campaign
• 2001 to 2004 – NLEP project phase-II
• 2002 – Simplified Information System
• 2004 – leprosy integrated with general health services
Contd…
7

Eradication
• 2005 – Achievement of Elimination of Leprosy at National level,
NRHM covers NLEP
• 2006 – DPMR introduced as a component of NLEP
• 2007 – DPMR guidelines for primary, secondary and tertiary level
• 2011 – Guidelines on DPMR for NLEP revised
• 2012 - Special action plan for 209 high endemic districts in
16 States/Uts
• 2016 – Revised Operational Guidelines for LCDC
Contd…
8

Determinants of leprosy
• AGENT FACTORS – Mycobacterium Leprae, An obligate
Intracellular Parasite , Gram Positive Acid
Fast Bacilli
• SOURCE OF INFECTION - Untreated Leprosy Affected Persons(mostly
LL,BL Cases)
• PORTAL OF EXIT – Upper Respiratory Tract Especially Nose And
Ulcerated & Broken Skin
• TRANSMISSION – Droplets Via Respiratory Tract And Direct
or Indirect Contact Of LL Cases
• PORTAL OF ENTRY – Upper Respiratory Tract
• INCUBATION PERIOD – 5-7 Years
9

Determinants of leprosy Contd…
• HOST FACTORS :
– Usually occur between 10-20 years of age .
- Males are more affected .
- Children are affected more indicates active transmission.
- Occurrence of disease depends on susceptibility/immune status.
• ENVIRONMENTAL FACTORS :
– Humidity favours survival of Mycobacterium leprae
- Viable in dried nasal secretions for 9 days
- viable in moist soil at room temperature for 46 days 10

NLEP Indicators
• PR (Prevalence Rate)
• ANCDR (Annual New Case Detection Rate)
• Multi-Bacillary(MB) proportion
• Female proportion
• Child proportion
• Grade II disability- Disability proportions
• SC & ST cases
• MDT Completion Rate ( both PB & MB)
• Relapses
11

Global Burden of disease
• The “Global leprosy update, 2014: need for early case
detection”, published in September 2015,
was based on annual leprosy statistics received from 121
countries from five WHO regions.
• The data compilation and analysis showed the following:
12

Leprosy Prevalence Rate at Global level, data as of
Jan 2012
16

Leprosy New Case Detection Rate at Global level,
Jan 2012
17

Leprosy Elimination status
India (2014-2015)
Based on the reports received from all the States and UTs for the year of
2014 -15 current leprosy situation in the country is as below:
• Prevalence Rate (PR) of 0.69 per 10,000 population an increase of
1.5% in PR from the previous year.
• Annual New Case Detection Rate (ANCDR) of 9.73 per 100,000
population a decrease in ANCDR by 2.5% from previous year reports.
• Proportion of
- MB (52.82%)
- Female (36.81%)
- Child (9.04%)
- Grade II Deformity (4.61%)
- ST cases (17.88%) and SC cases (18.00%).
19

India (2014-2015)
• 34 States/ UTs had already achieved the level of elimination i.e. PR
less than 1 case per 10,000 population
• One State (Chhattisgarh) and One U.T. (Dadra & Nagar Haveli) has
remained with PR between 2 and 5 per 10,000 population.
• Four other States/UT viz. Odisha, Chandigarh, Delhi and
Lakshadweep which achieved elimination earlier have shown slight
increase in P.R. (1-2), in the current year.
• Proportion of Child case was more than 10% of new case detected in
8 States/Uts.
20

India (2014-2015)
• A total of 532 districts (79.52%) out of total 669 districts have
PR<1/10,000 population.
• The number of districts with PR between 1 to 2/10,000 have
gone up from 74 to 97. Number of districts with PR>2/10,000
have decreased from 41 to 40.
• Out of the total New Cases 93.1% completed their treatment
within the specified period and were released from treatment
(RFT) as cured .
21

Provisional Report 2015-
2016
Epidemiological Situation, as on March, 2016:
• Elimination at State level achieved in 34 States/UTs out of total 36
States/UTs.
• Chhattisgarh State and UT Dadra & Nagar Haveli yet to achieve
elimination.
• Four states namely Delhi, Lakshadweep, Chandigarh and Orissa who
have achieved elimination earlier, showed PR >1/ 10000 population.
• PR of 0.66 per 10,000 population and ANCDR of 9.7 per 1,00,000
population .
• Grade II disability proportion of 4.60%
22

The trend of Prevalence and Annual New Case Detection Rate per 10,000 population since
2001-02 to 2015-16 (provisional) is shown in the Graph- source : NLEP operational guidelines
2016 23

The trend of number of Gr. II disabled cases and % of Gr. II disabled cases i.r.o new leprosy
from 2005-06 to 2015-16 (provisional) – source NLEP operational guidelines 201624

Elimination Status -
Puducherry
• Elimination was achieved in March 2004.
• Prevalence Rate (PR) of 0.18 per 10,000 population
• Annual New Case Detection Rate (ANCDR) of 2.99 per 100,000
population (2014-15)
• Proportion of
- MB (41.46%)
- Female (39.02%)
- Child (4.88%)
- Grade II Deformity (2.44%)
- 93.62% completed their treatment & (RFT) as cured .
25

Elimination Strategy
• Decentralized integrated leprosy services through General Health
Care system.
• Early detection & complete treatment of new leprosy cases.
• Carrying out house hold contact survey in detection of Multibacillary
(MB) & child cases.
• Involvement of Accredited Social Health Activists (ASHAs) in the
detection & completion of treatment of leprosy cases.
26

Elimination Strategy
• Early diagnosis & prompt MDT, through routine and special
efforts.
• Strengthening of Disability Prevention & Medical
Rehabilitation (DPMR) services.
• Information, Education & Communication (IEC ) activities in
the community to improve self reporting to Primary Health
Centre (PHC ) and reduction of stigma.
• Intensive monitoring and supervision at Primary Health
Centre/Community Health Centre.
Contd…
27

Major Initiatives of NLEP
• More focus on new case detection
• Treatment completion rate – an important indicator
• Involvement of ASHA
• Involvement of NGO’s
• Intensive IEC campaign with a theme "Towards leprosy free India”
• Disability Prevention and Medical Rehabilitation (DPMR)
• Integrating NLEP services into NRHM & Referral system
28

Case Detection and
Management
-It is expected that the new cases will continue to occur regularly but
the people are still hesitant to come forward to get themselves
diagnosed and treated due to the stigma associated with the disease.
-It is therefore suggested that the States will draw up innovative plans:
• To improve access to services.
• To involve women including leprosy affected persons in case
detection.
• To organize skin camps for detecting leprosy patients while
providing services for other skin conditions.
• To undertake contact survey to identify the source in the
neighbourhood of each child or M.B. case.
• To increase awareness through the ANM, AWW, ASHA and other
Health Workers visiting the villages & people affected by leprosy, to
suspect and motivate leprosy affected persons for early reporting to
the Medical Officer.
29

Involvement of ASHA /AWW
• Early detection of suspected cases of leprosy
• Follow up all cases for completion of treatment in scheduled
time and also look for symptoms of reaction
• Advice and motivate self-care practices by disabled cases
• Spreading awareness
Incentives for ASHA/AWW
1)At confirmation of diagnosis – Rs.250/-
2)on completion of full course of treatment in time
PB- additional Rs.400/-
MB- additional Rs.600/-
30

Involvement Of NGO’s
• The objective is to provide uniformity in diagnosis, treatment and
monitoring through a wider programme base to maximize access to NLEP
services.
• The NGOs will be collaborated for following:
- IEC/BCC and stigma reduction
- Referral of suspects, Diagnosis and provision of multidrug therapy (MDT)
- Follow up of cases and treatment adherence
- Out-patient and In-patient care
- DPMR
- Referral for RCS
- Conduct of RCS
• There are totally 290 NGO’s working in the field of Leprosy and 54 NGO’s
are getting Grant-in-aid from GOI (modified SET schemes-2013).
31

IEC / BCC – “Leprosy Free India”
Objectives:
• To develop effective communication to target audiences by IPC
• To compliment and support the detection and treatment services
• To strive to remove stigma and prevent discrimination
• Active participation of communities & clients
Content:
• Complete curability and
• Non-contagious nature of the disease.
• Availability of quality treatment (with MDT) free of cost at all Govt.
Health facilities
• Correction of deformities is possible through surgery.
• Leprosy affected person on treatment can live a normal life along
with the family. 32

IEC / BCC – “Leprosy Free India”
Central Level :
• through Doordarshan channels and All India Radio.
State level :
• Mass Media –TV, Radio and press in local languages.
• Outdoor Media - Hoardings, Bus panels, Wall paintings, posters, Rallies
including Banners.
• Rural Media - IPC meetings, School talks/quiz, Folk media, Exhibitions
and Health Melas.
• Advocacy - Meetings with Zila Parishad, Mahila Mandals, NGOs etc.
Target audiences:
• Selected communities with deep rooted stigma
• Leprosy Affected Persons
• General Health Care Staffs
• NGO’s and CBO(Community Based Organisations)
• DPO’s (Disabled Peoples Organisations) 33

DPMR
• DPMR introduced as a component of NLEP in 2006
• People affected by leprosy often suffer from deformity of hands,
feet or eyes due to involvement of nerves and resultant muscular
weakness and paralysis (Primary impairment).
• Secondary impairment may occur in the hands, feet and eyes due
to reaction/ nerve damage even during treatment.
The Objectives of the program are:
1.Adequately manage the occurrence of disabilities.
2.Assistance to persons with disabilities and prevent worsening of
existing disabilities.
3.Correction of deformities by ReConstructive Surgery(RCS)34

Three Tier System - Services
• The DPMR activities are planned to be carried out in a three-tier
system i.e.
– the Primary level care (First level),
– Secondary level care (Second level) and
– the Tertiary level care institutions (Third level)
• As on January 2013, there are 94 recognized RCS centres in the
country.
Incentives
• An incentive of Rs.8000 will be paid to all persons affected
by leprosy undergoing major RCS
• Rs.5000 to all govt institutions for providing RCS in their own
institution
• An additional amount of Rs.5000 will be paid to all govt
hospitals/institutions for providing RCS in camps organised outside the
institution
35

12th five year plan(2013-2017)
OBJECTIVES
• Elimination of leprosy i.e. prevalence of less than 1 case per
10,000 population in all districts of the country.
• Strengthen Disability Prevention & Medical Rehabilitation of
persons affected by leprosy.
• Reduction in the level of stigma associated with leprosy.
37

The trend of Prevalence and Annual New Case Detection Rate per 10,000 population since
2001-02 to 2015-16 (provisional) is shown in the Graph- source : NLEP operational guidelines
2016 39

The trend of number of Gr. II disabled cases and % of Gr. II disabled cases i.r.o new leprosy
from 2005-06 to 2015-16 (provisional) – source NLEP operational guidelines 201640

Newer initiative - Leprosy Case
Detection Campaign (LCDC)
• It has been observed that trend of two important indicators of
NLEP i.e.
– Annual New Case Detection Rate (ANCDR) and
– Prevalence Rate (PR) are almost static since 2006 – 2007
• Also, the percentage of grade II disability amongst new cases
detected has been increased from 3.10% (2010 - 2011) to 4.61%
(2014 - 2015)
• This indicates that the cases are being detected late and some
may be undetected
• Hence, in order for early detection of all hidden leprosy cases, the
Central Leprosy Division (CLD) is conducting LCDC in high endemic
districts under NLEP on the lines of Pulse polio Campaign
41

The important activities under LCDC are as under:
• Meetings at each level i.e., National, State, District, Block to plan &
implement the LCDC
• Focused training of all health functionaries from District to Village
level.
• House to house visits by team encompassing one Accredited Social
Health Activist (ASHA) and male volunteer i.e. Field Level Worker
• Intensive IEC activities, through mikes & display of banners/posters
during and before the LCDC
• Supervision of house to house search activities through identified field
supervisors.
• Scheduled meetings with community leaders to resolve any issue came
across during the campaign
• Prompt analyses and feedback on data received from teams and
supervisors which will help to plan corrective actions
42

Others Initiatives
• Newsletters
- Quarterly issue by NLEP launched in Jan 2016
- Two newsletters
• Nikusth - an Online Reporting System with Patient tracking
mechanism is being developed with the help of NIC
• GIS mapping to study and project geographic distribution of disease is
being worked out
• Uniform Multidrug Therapy Regimen (UMDT) – 6 month MDT regimen
(MB & PB) – multicentric study – on works
• Mass Drug Administration
• Monthly administered ROM for MB and PB leprosy
43

Contact surveillance &
Prophylaxis
• Immunoprophylaxis: (varied efficacy)
- BCG vaccine
• Chemoprophylaxis : (57%)
-Single dose rifampicin
• Combined Immuno & chemoprophylaxis: (80%)
44
Source : The combined effect of chemoprophylaxis with single dose rifampicin and
immunoprophylaxis with BCG to prevent leprosy in contacts of newly diagnosed leprosy
cases:

National Health Policy -2015
• To build a systems sensitivity to ensure that the small proportion of skin
lesions which would be a leprosy case is identified in time, treated and
followed up
-sensitization of every provider
-to make a small proportion of providers remain dedicated to this as
resource persons who keep the requisite skills alive within the health system
• The proportion of grade 2 cases amongst new cases will now become the
measure of community awareness and health systems capacity and
dedication to this task
• The proportion of grade 2 cases amongst new cases will now become the
measure of community awareness and health systems capacity and
dedication to this task
45

Strategic Action Plans (SAP)
• Modified Leprosy Elimination Campaign(MLEC)
• Special action Projects for elimination of Leprosy(SAPEL) for rural areas
• Leprosy elimination Campaigns (LEC) for urban area
• Focussed Leprosy elimination Plane(FLEP)
• Block level Awareness Campaign(BLAC) ,Sustained Action Plan
• Intensified Supervision and monitoring by STST and DTST
46

Leprosy Training and Research
institutes
CLTRI
Chengalpattu
RLTRI
Raipur
Aska
Gouripur
47

Treatment classification
characteristic Paucibacillary(PB) Multibacillary(MB)
Skin lesions 1 - 5 6 and above
Peripheral nerve No nerve/only one nerve
involvement
2 or more nerves involved
Skin smear Negative in all sites Positive at any site
Ridley –jobling
classification with BI
Indeterminate, TT, BT with
BI of < 2 in all sites
BB, BL, LL with BI ≥ 2 at
any site48

Disability Grading - WHO
WHO grades 0 1 2
Eyes Normal Corneal Reflex weak Reduced weakness,
lagophthalmos
Hands Normal Loss of feeling in
the palm of the
hand
Visible damage to
the hands such as
claw hands or loss
of tissue
Feet Normal Loss of feeling in
the sole of the foot
Visible damage to
the foot, such as
wound, loss of
tissue or foot drop49

Lepra reactions
Reversal Reactions ENL
52

MDT Dose Multi-bacillary Leprosy
Day 1 Day 1 Day 1
Supervised monthly
treatment
Supervised monthly
treatment
Supervised monthly treatment
Rifampicin 600mg Rifampicin 450mg Rifampicin 300mg(10mg/kgbw)
Clofazimine 300mg Clofazimine 150mg Clofazimine 100mg(6mg/kgbw)
Dapsone 100mg Dapsone 50mg Dapsone 25mg (2mg/kgbw)
Day 2-28 Day 2-28 Day 2-28
Daily Clofazimine 50 mg Clofazimine 50 mg
alternate days
Clofazimine 50 mg (1mg/kgbw)
alternate days
Daily Dapsone 100mg Dapsone 50mg Dapsone 25mg
Regimen of three drugs – Rifampicin, Clofazimine and Dapsone for 12 months in bister packs;
first dose of each month to be given in presence of health Worker.
53

MDT dose - paucibacillary leprosy
Day 1 Day 1 Day 1
Supervised monthly
treatment
Supervised monthly
treatment
Supervised monthly treatment
Rifampicin 600mg Rifampicin 450mg Rifampicin 300mg (10mg/kgbw)
Dapsone 100mg Dapsone 50mg Dapsone 25mg (2mg/kgbw)
Day 2-28 Day 2-28 Day 2-28
Daily Dapsone 100mg Daily Dapsone 50mg Daily Dapsone 25mg
Regimen of two drugs – Rifampicin and Dapsone for 6 months provided in blister packs,
first dose of each month should be given in the presence of Health worker.
54

Leprosy vaccines
Even after successful MDT ,eradication of leprosy may not achievable
because
• Delay in clearing of dead bacilli after rapid killing by MDT due to
absence/minimal presence of CMI
• Presence of dead bacilli and their products lead to type II
reactions & deformities
• Resulting in relapses in highly bacillated cases after 3-5 years of
MDT
• To overcome disadvantages of MDT & to boost CMI vaccines came
into field
57

Leprosy vaccines
Efficacy of vaccines against leprosy
• BCG – variable in different countries (34-80%)
• ICRC (Indian Cancer Research Centre) vaccine – 65%
• Addition Mycobacterium indicus pranii (MIP) vaccine to chemo
• Lack of Feasibility, multiple injections, problems in storage and
complications of vaccines- not widely used
• Routine coverage of BCG vaccination reduce risk of leprosy
• Multivalent vaccines with high efficacy are under trial
Contd…
58

The Final Push Strategy- WHO
• Expand MDT services to all health care facilities
• Ensuring that all existing and new cases are given
appropriate MDT regimens
• Encourage all patients take treatment regularly and
completely
• Promote awareness in the community on leprosy
• Set targets and time table for activities and make all efforts
to achieve them
• Monitoring and progress towards leprosy elimination
59

• Task Force
• Annual reporting and maintenance of a computerized leprosy
database
• Feed-back and regular publication of progress
• Annual inter-country evaluation meetings
• Epidemiological surveillance system
• Geographic Information Systems (GIS)
WHO-Leprosy surveillance
system
60

Partners
• ICMR
• WHO
• ILEP (International federation of Anti-Leprosy Associations)
• AIFO (Associazione Italiana Amici di Raoul Follereau)
• DFIT (Damien Foundation India Trust)
• Fontilles- India
• GLRA-India (German Leprosy and TB Releif Association)
• NLR (Netherlands Leprosy Releif)
• Novartis
• TLM (The Leprosy Mission)
• Alert-India
• APAL-India (Association of People Affected by Leprosy)
62

References
• NLEP website : http://nlep.nic.in
• WHO website on leprosy : http://www.who.int/lep/en/
• ILEP website : http://www.ilepfederation.org
• National Programmes in India : by J.Kishore
• WHO - Global Leprosy Strategy : 2016–2020
• Draft National Health Policy 2015
• NLEP – Progress Report for the year 2014-15
• Revised Operational Guideline for LCDC – 2016
• NLEP - Training Manual For Medical Officers – 2009
• NLEP newsletter – Inaugural issue & April 2016
• Hind Kusht Nivaran Sangh- Indian Journal of Leprosy
• Epidemiological Indicators of Leprosy - ILEP
65

“
”
Leprosy work is not merely
medical relief: it is
transforming frustration of life
into joy of dedication, personal
ambition inti selfless service
Mahatma Gandhi
Thank You…
66

National Leprosy Eradication Program - Dr Surendran Venkataraman

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