Critical review of National Leprosy Eradication

Programme

Presenter Dr Utpal Sharma

Post Graduate Student

Moderator Dr C Barthakur

Assistant Professor

Department of Community MedicineGauhati Medical College

Introduction GoI started NLCP in 1955 based on Dapsone domiciliary

treatment through vertical units implementing SET activities.

In 1970s MDT identified; came into wide use from 1982, following the recommendation by the WHO Study Group, Geneva in October 1981.

Based on recommendations of high power committee in 1981, the NLEP was launched in 1983. ..........objective to arrest the disease activity in all the known cases of leprosy.

However coverage remained limited due to a Range of organizational issues Fear of the disease Associated stigma.

The World Health Assembly in 1991 resolved to eliminate leprosy at a global level by the year 2000.

Cont….

To strengthen the process of elimination in the country, the first World Bank supported project was introduced in 1993.

World Bank funding in NLEP projects

1st Phase - 1993-94 to 2000

- “National Leprosy Elimination project”

- Rs. 290 crores (550)

- Prevalence rate (per 10,000) – 24 (in 1992) 3.7 (in 2001)

- Disability grade 2 and above- 2.7%

- MDT coverage- 99.5%

2nd Phase- 2001-02 to 2004

- Rs. 166.35 crores (249.8)

- MDT drugs free- Rs. 48 crores

- Prevalence rate- 2.4

- Annual detection rate- 3.3

Cont….

The NLEP continued with Govt. of India funds from January 2005 onwards.

Additional support from the WHO and ILEP organizations.

MDT is to be supplied free of cost as of now by NOVARTIS through WHO.

After the global elimination in 2001, remaining 14 countries targeted for elimination on national basis by December, 2005.......

............India was one of these countries. 

The National Health Policy, Govt. of India sets the goal of elimination of leprosy by the year 2005.

Country achieved the goal of elimination of leprosy in the month of December, 2005......

....... As on 31st December 2005, Prevalence Rate recorded in the country was 0.95/10,000 population.

Evolution of NLEP(1955) National Leprosy Control Programme

(1980) Govt. decided to “eradicate” leprosy

1983 National Leprosy Eradication Programmme

1997 Modified Leprosy Elimination Campaign (MLEC)

2001 to 04 SAPEL and LEC

2005 Urban Leprosy Control Programme

2007 Block leprosy awareness campaign (BLAC)

2005-06 Focused leprosy elimination plan (FLEP)

2005 NRHM covers NLEP

2007 Situational activity plan(SAP)

Leprosy meets demanding criteria for elimination:

Practical and simple diagnostic tools: can be diagnosed on clinical signs alone;

Availability of an effective intervention to interrupt its transmission: MDT

A single significant reservoir of infection: humans.

Decentralization of NLEP services

Integration of NLEP with General Health Care

System

Capacity building of GHS functionaries

Early diagnosis & prompt MDT (routine & special

efforts)

Intensified IEC using Local and Mass Media

Prevention of Disability & Medical Rehabilitation

(DPMR)

Monitoring & Evaluation

STRATEGIES FOR ELIMINATION OF LEPROSY IN INDIA

Scenario

WORLD:

Over past 20 yrs,-14 million pts cured;4million since 2000.

Globan burden has declined dramatically (5.2million in 1985 to 2.04 lakh cases in 2002)

PR has dropped by 90%(1985:21.1/10,000 ; 2000:-1)

Has been Eliminated from 119 of 122 countries.

To date, there has been no resistance to MDT

Efforts currently focus on eliminating leprosy at a national level in remaining endemic countries & at a sub-national level from others.

INDIA:

By the end of 1st April 2013,0.92 lakh cases were on record; PR: 0.73/10,000

1.35 lakh new cases detected during the year 2012-13; ANCDR of 10.78 per 100,000 population shows increase in of 4.15% from 2011-12 (10.35).

New cases in 2012-13 ; MB(49.92%), Female (37.72%), Child (9.93%), Visible Deformity (3.45%), ST cases (17.01%) and SC cases (18.49%).

After MDT, case load from 57.6/10,000 in 1981 to -1 at national level in Dec 2005.

Grade II disability amongst the New Leprosy Cases 2012-13; 3.72 / million population while Gr. I cases recorded 4.14/million population.

33 states/UTs, 542 districts (84.7%) out of total 640 districts have achieved the status of elimination.

Only one state and one UT: Chhatisgarh & D&N Haveli with PR 1-2.5/10,000

Trend of leprosy in India

The increase in new cases and prevalence during 2012-13 is attributable to the NLEP strategy to carry out extensive house to house survey for new case detection and to treat them with MDT to cut down the transmission potential in the future

Assam By march 2012, a total of 1167 cases were on record; PR 0.35 per 10,000

population

1147 new cases detected during the year 2012-13; ANCDR of 3.57 per 100,000 population

New cases in 2012-13 ;MB(74.46%), Female (26.94%), Child (9.24%), Visible Deformity (6.63%), ST cases (3.92%) and SC cases (8.46%).

RFT accounts for 990 cases in April 2013- March 2014 with a 83.69% cases released as cured*

Out of the 27 districts, 24 boasts of PR<1, rest 3 have PR 1-2

24 districts of 27 in Assam had ANCDR< 10, rest 3 districts had it between 10-20

*Cured are patients that completed full MDT course in stipulated time.

Achievements…

Items.2013-14

(Apr, 2013 to Dec, 2013).Remarks.

Total New Case Detection826 nos. (PB=213 &

MB=613)

NCDR for the 3rd Quarter of 2013-14 (up to Dec, 2013) = 3.65/100,000 population.

Cases discharged (RFT). 795 nos. (PB=208 & MB=587)

Reaction cases 93 nos. (PB= 4 & MB= 89)

Suspected Relapse cases. 0 no. (PB=0 & MB=0)

Grade-I Disability cases. 68 nos. (PB=16 & MB=52)

Grade-II Disability cases. 55 nos. (PB=6 & MB=49)

Cases under treatment.1108 nos. (PB=175&MB=933)

P.R. (Dec, 2013) = 0.34 per 10,000 population.

RCS done.16 nos. (Govt.= Nil & NGO= 16).

MCR foot-wears distributed. 238 pairs.

Self Care Kit provided. 16 nos.

More news from Assam….. NE states reported 747 new cases in a

year till September 30.

Assam recording the maximum 616 cases,

Four districts of Assam  recorded higher prevalence of leprosy than the national average

Followed by Nagaland (32), Tripura (23),Sikkim(20),Mizoram (18), Arunachal Pradesh (17), Meghalaya (15) and Manipur(6).

In Assam, the most affected districts were • Sivsagar (99)• Tinsukia(87)• Sonitpur (42)• Kamrup Metro(39)• Cachar district (38)

StrengthEasy clinical diagnosis

Leprosy came to be dealt within the public health terms after the advent of Dapsone

MDT brought leprosy to the main stream of medicine.

MDT with its finite duration of treatment has proved to be quite effective in treating millions.

Single dose administration leads to non-infection

The relapse rate with treatment with MDT is very low (0.1% /year for PB and 0.06% /year for MB).

Weakness

The NLEP didn’t address the involvement of Dermatologist.

Skin smear examination in leprosy was first to be deleted/made optional in the leprosy program.

Top to buttom approch of MDT distribution

Govt. Of India guidelines on MDT not widely distributed or used at PHC/CHC level

Inadequate case detection & immigration not adequately addressed. Eg. Two dist. of Delhi PR > 5/10,000

A small number of patients do not show any clinical or bacteriological improvement with MDT.

Non availability of vaccine.

.

Inadequate treatment or concomitant, debilitating, intercurrent infection.

Opportunities

Free MDT by WHO from 1995 (Novartis)

Funds-World Bank

NGO, INGO (Lepra Society, DANLEP, SIDA,ILEP)

The Goal of NHP 2002 to “Eliminate Leprosy by 2005”

Threats Social stigma, Discrimination continues.

Misconceptions

The disability and loss of productivity are not been adequately addressed.

Long incubation period (5-10 yrs)

Medical science still knows a little about spread of the disease.

Critical appraisal….. Social Stigma:

– NLEP failed to address the social stigma associated with the Leprosy.

– Even in the present time isolation is practiced.

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.

– Other laws like Motor Vehicle Act of 1939 which restricts leprosy patients from obtaining a driving license and……

– ………….the Indian Rail Act of 1990 which prohibits leprosy patients from travelling by train.

Many of these laws were written before the development of MDT and have not been updated since

Cont….

Simplification of leprosy detection and classification leading to discontinuation of skin smears….

….missing patients with high bacterial load

In WHO classification neuritic leprosy is also not included.…..……..In India, the proportion found to be as high as 18%.

With introduction of FDT in1992 dependability of skin smear removed…..

……..resulting cure and communicability of the patient a doubtful entity.

ROM therapy for single lesion leprosy discontinued owing to marginalized advantage over the conventional therapy

………chances of under treatment according to this criteria.

Need of newer advents……

Recommended duration of treatment, particularly for MB leprosy is still too long

Dapsone and Clofazimine weak bactericidal …...

……..further shortening the duration of treatment might result in high relapse rate

Administration of the daily components, Dapsone, and Clofazimine cannot be supervised

Resistant to leprosy drug: – Resistance to MDT could be a problem.Petit & Rees (1964), Jacobson & Hasting (1975), Wondroff van Diepen(1982)

– New alternative regimen is lacking presently– No R& D in the field of drugs

Need of a rapid and accurate diagnostic test to detect the disease in early stage to limit diabilities

Cont…

Transmission of infection:

– Transmission continues in spite declared eliminated in 2005

– Elimination campaign…. …….actually a control strategy.

– It may come to the same level as it was before if control measures are relaxed.

– This gives false sense of security………… target of elimination is less than 1 per 10,000

population

Elimination criteria: – Point prevalence ……

……..proxy indicator for leprosy incidence or transmission

– Duration of infection, treatment duration, mortality rate would be affecting prevalence rate.

Cont…

Integration problem:

– Integration into GHS required careful planning and implementation otherwise……

……. needs of leprosy control be pushed aside by pressing health problems like TB & HIV

– Lack of diagnostic experience and decrease index of suspicion with disease becoming rare.

– Deficient healthcare staff (MPWs)…..…….overburdening the existing staff

Cont….

Difficult to reach areas:-Special focused programmes for such

areas…MODIFIED LEPROSY ELIMINATION CAMPAIGN(MLEC) (1997-98)

SPECIAL ACTION PROJECTS FOR THE ELIMINATION OF LEPROSY (SAPEL)

LEPROSY ELIMINATION CAMPAIGNS(LEC) FOR URBAN AREAS

STRATEGIG PLAN OF ACTION (2004-5)

FOCUSED LEPROSY ELIMINATION PLAN (FLEP) 2005-06

SITUATIONAL ACTIVITY PLAN(SAP) 2007

BLOCK LEPROSY AWARENESS CAMPAIGNS (BLAC IV) 2007

Cont….

Leper colonies…a curse – Isolation in leper colonies….– Families more prone to infection….and

succumb to poverty

Social and economic rehabilitation– Bussines loan schemes…..– House building loans……. – Scholarships……. – Vocational training schemes…..

Such colonies should be abolished to reduce stigma

Strategies confined to NGO level….no commitments from govt. side

Last but not the least……

Challenges in “going the last mile”– Level of international attention and

political commitment is declining.

–  Knowledge about diagnosis and treatment is decreasing in many countries.

– While leprosy decreased significantly from 1984 to 2004, a stagnation has occurred from 2005 onwards.

Cont…

Caused by several factors such as:

Difficulty to maintain/increase knowledge about leprosy among health workers

Shift in priorities of national health authorities to diseases with a larger patient burden.

In times of high prevalence, a rough search was sufficient to find patients but…..

…….a more accurate/ integrated approach required to find cases in remote areas.

References Training Manual For Medical Officers;National Leprosy Eradication

Programme Directorate General of Health Services Ministry of Health & Family Welfare Nirman Bhawan, New Delhi,2009

NLEP – Progress Report for the year 2012-13 Central Leprosy Division Directorate General of Health Services, Nirman Bhawan, New Delhi ; 2014

http://www.business-standard.com/article/politics/747-new-leprosy-cases-in-ne-region-centre-worried-113110800546_1.html; last accessed on 2nd March 2014

Programme Implementation Plan (PIP) for 12th Plan Period (2012-13 to 2016-17) CENTRAL LEPROSY DIVISON, Directorate General of Health Services, Ministry of Health & Family Welfare, Govt. of India

WHO document. 2nd. Geneva: WHO; 2003. Final push strategy to elimination of leprosy as a public health problem. Questions and Answers

https://extranet.who.int/iris/restricted/handle/10665/63271 . accessed on 3rd march 2014

Leprosy therapy, past and present: can we hope to eliminate it? P V S Prasad and P K Kaviarasan ; Indian J Dermatol. 2010 Oct-Dec; 55(4): 316–324.

Thank you