NATIONAL LEPROSY ERADICATION PROGRAMME

Introduction
  • Leprosy is probably the oldest disease afflicting the mankind. Possibly it was originated in Africa and spread very early to India and from there to China. There are references in Buddhist literature. In Vedic reference it is mentioned as "Kushth Rog". It has the maximum social stigma attached to it. A common belief that leprosy is due to past sins committed by the person. There is a belief that leprosy is hereditary and incurable. There are many misconceptions about disease that causes social aversion and ostracism against leprosy patients leading to the high deformity. But due to scientific inventions leprosy has been identified a disease that can be eradicated. Hansen of Norway during 873 discovered leprae bacilli, therefore the disease is also known as Hansen's disease. Sulfone drug, e.g. Dapsone was discovered in 1943 for the treatment of leprosy. With the introduction of Multi-Drug Treatment (MDT) during 1981 this disease is very well under control and may be eradicated.

  • The establishment of the Indian Council of the British Empire Leprosy Relief Associated in 1925 (Renamed as Hind Kushth Nivaran Sangh in 1947) laid the foundation of organised leprosy work in India. The availability of Dapsone monotherapy for leprosy laid the foundation of National Leprosy Control Programme in 1955 with the main objective of controlling leprosy through domiciliary treatment with Dapsone. Social obstacles, non-availability of drugs, lack of primary prevention (vaccination) and leprae resistance to Dapsone caused programme failure. In 1981, Govt. of India asked the Indian Scientists to develop a leprosy eradication strategy and subsequently launched the National Leprosy Eradication Programme (NLEP) in the year 1983 with the objective to eliminate leprosy as a public health problem by the year 2000 AD. Later WHO in 1991 adopted a resolution calling for elimination of leprosy as a public health problem by the year 2000 AD (reducing prevalence to less than one case per 10,000 population).
Burden of Leprosy
World

There are around 1.3 million cases of leprosy in the world (1996). Leprosy remains a pubic health problem in 55 countries, but 16 countries account for 91% of the total number of registered cases and five of them (Brazil, India, Indonesia, Myanmar, and Nigeria) account for 82%. Globally60% of the estimated cases are contributed by India.

India
Prevalence Rate (PR) is 3.74/10,000 population (March 2001) which was 57/10,000 in 1981.
Elimination level <1/10,000) achieved in 13 states.
4 State close to achieve elimination
Leprosy is endemic mainly in states of Bihar, Jharkhand, Chattisgarh, U.P., West Bengal, Orissa and M.P. where 64^% are found.
Bihar has 24% of recorded leprosy cases in India.
A total of 5.59 lakh cases were detected in India by 2000-2001 due to intensification of the programme, the highest number of cases detected in any year.
Annual new cases detected were 4 to 7.8 lakh. Out of the total 18.5 % were children.
Deformity cases (Grade-II and above) amount new cases were 2.7%.
MB cases among new cases were 34%.
Single lesion cases among new cases were 10% but vary from area to area. It varies from 22% in Wardha to more than 80% in Tamil Nadu, India.

National Leprosy Eradication Programme (NLEP)
Strategy

1. Early detection through active surveillance by the trained health workers;
2. Regular treatment of cases by providing Multi-Drug Therapy (MDT) at fixed in or centres a nearby village of moderate to low endemic areas/district;
3. Intensified health education and public awareness campaigns to remove social stigma attached to the disease; and
4. Appropriate medical rehabilitation and leprosy ulcer care services.

Recommendation of Midterm Appraisal

A mid term appraisal of World Bank supported NLEP project-Phase I was undertaken in 1997 that highlighted following facts:
1. While programme progress is satisfactory at national level, the progress has been uneven in some states and a lot more needs to be done to attain the goal of elimination of leprosy;
2. Political commitment and bureaucratic support in some of the high endemic areas is required;
3. Intensive campaign approach for leprosy elimination is required in several areas to increase in community awareness and involvement of peripheral general health staff and the community in the programme activities. Leprosy Elimination Campaign (LEC) approach is recommended.
4. MDT drug at every health facilities: although no shortage of drugs was found but there is a need to strengthen the drug delivery to all health facilities so that timely treatment can be started.
5. Involvement of general health care staff is urgently required for moderately and low endemic district.
6. Technical supervision and monitoring was not sufficient in some of the states. There should be full-time supervisors. NLEP constantly require to ensure effective coordination, liaison, and monitoring of programme activities in moderately and low endemic areas.

It recommended that the programme should be given high priority, leprosy elimination campaign should be organized, MDT should be made available in all general hospitals and health centres, monitoring and supervision should be strengthened.

Strategy for Ninth Plan

Target for Ninth Plan of Indian Government is to reduce prevalence of leprosy to 1 per 10,000, for that strategic approach for the National Leprosy Eradication Programmes is as follows:
1. Intensified case detection and MDT coverage in high prevalence states and in areas difficult to access by organizing, MLEC, SAPEL, etc.
2. Strengthening laboratory services in PHC.CHC, establishing surveillance system for monitory time trends in the previously highly endemic areas;
3. Maintain activities in the previously highly endemic areas;
4. Preparing for and initiating horizontal integration of leprosy programme into primary health care system;
5. Providing greater emphasis on disability prevention and treatment through: a) transfer of knowledge and technology to the affected persons, families and community, b) strengthening local treatment facilities for treatment of ulcer/leprosy related deformities, c) supply of aids and appliances to prevent further impairment, and d) developing trained manpower resources and improving facilities for corrective surgery for deformities;
6. Implementation of Modified Leprosy Elimination Campaign (MLEC) and bring public awareness, training of general health care staff and detection of hidden cases;
7. Ensuring rehabilitation of cured patients; and
8. Repeal of discriminatory provision under Marriage Act where leprosy is one of the grounds for divorce.

Goal of National Health Policy 2002

"Elimination of Leprosy by 2005"

Project Phase II 2000 onward

The project Implementation Plan (PIP) for the NLEP Phase II
· Part A: National plan setting out the project design for the country
· Part B: Plan for 8 high endemic states
· Part C: Plan for the remaining 27 states and Union Territories

Project Phase II Objectives

1. To achieve elimination of leprosy at national level by the end of the project
2. To accomplish integration of leprosy services with the general health care system in the 27 low endemic states/UTs
3. To proceed with integration of services as rapidly as possible in the 8 high endemic states

Project Phase II Components

1. Decentralisation and Institutional development
2. Strengthening and integration of service delivery
3. Disability care and prevention
4. Information Education and Communication
5. Training

Decentralization of responsibilities to the States: State level societies will be formed in 24 states and funding to the districts will be done by state societies. State societies will not be needed in the 8 smaller states/ Union Territories since the district societies there are adequate for channeling funds.

Integration of Leprosy Control Activities with the general health services: It is recognised that separation of elimination activities from the general health services has actually hindered implementation - it has limited geographical coverage, causing limited access to MDT, unsatisfactory levels of compliance with treatment and subsequent re-registering of these cases as "new". In the 27 low endemic states/ UTs integration will be affected in all districts during the first project year itself.

In the 8 high endemic states a mixed approach has been followed from the first year onward with the general health service staff offering leprosy services that included case finding and treatment. The vertical staff is focusing on covering previously un-reached areas as well as providing support to general health service.

Disability care, Prevention and Rehabilitation

Grading of disabilities
Hand and Feet

Grade 0: No anesthesia, no visual deformity or damage
Grade 1: Anesthesia present, but no visible deformity or damage
Grade 2: Visible deformity or damage present

Eyes

Grade 0: No eye problem due to leprosy; no evidence of visual loss
Grade 1: Eye problem due to leprosy present, but vision not severely affected as a result (vision 6/60 or better; can count finger at six meters)
Grade 2:Severe visual impairment (vision worse than 6/60: inability to count fingers at six meters), lagophthalmos, Iridocyclitis and corneal opacities.
The best way to prevent disabilities is early diagnosis and prompt treatment with MDT. The next step is to recognise signs and symptoms of leprosy reactions with nerve involvement, and start treatment with prednisolone as quickly as possible. Care of eyes, hand and feet is also very important for limiting disabilities.
Nerve damage is common in patient who are not taking treatment regularly, or not come to get treatment, or patients with multiple skin lesions and patients with painful or tender or enlarged nerves. Such patients may come with various complaints - like nerve pain, painless wounds, blisters or simple with an areas where sensation has been lost, difficulty in performing simple tasks like buttoning a shirt, holding a pen, or picking up small objects, or difficulty in walking.
The Ministry of Social Justice and Empowerment administers fairly large budget for socio-economic rehabilitation activities and need to be utilised by effective coordination and referral.

Information, Education and Communication

Objectives of IEC in moderately/low endemic states: This would be to encourage greater voluntary self-reporting, as the strategy for case detection in these states.

Objectives of IEC in high endemic states: In five high endemic states, where active search is conducted during MLEC, the objective of IEC is to create general awareness of MLEC and signs and symptoms of leprosy to provide support for and prepare the ground for MLEC. The targets are clients, influencers, and providers, particularly from general health services and private providers. Special client focus groups of IEC in the next phase are women, children, difficult to reach groups-urban remote areas, etc.

Training

All staff of the general health services in general health services in government hospitals, PHCs, CHCs, are expected to be trained to detect, treat, refer and to prevent and rehabilitate disability.

Involvement of NGOs

NGOs are involved in leprosy elimination activities for many years and their contribution has been a positive impact in reducing the prevalence of leprosy. There are 285 NGOs working in the field of leprosy throughout the country and 54 NGOs are getting grant-in-aid from government of India for SET in leprosy. Beside routine activities, some are also providing facilities for hospitalization and disability and ulcer care. Few NGOs are involved in conducting reconstruction surgeries.

Involvement of WHO

WHO also supports the programme by providing anti-leprosy drugs; WH has undertaken to meet the full requirement of these drugs in India till the year 2005.

Achievements

The prevalence rate of leprosy has declined from 57.3 per10,000 in 1981 to 3.4 per 10,000 in 2001.

Key areas needing strengthening

1. Coordination between WHO, Central Leprosy unit, Government Medical Stores Depots, (GMSDs), and State Leprosy Units (SLUs), to ensure timely procurement of drugs.
2. State shall have to strengthen/develop suitable logistic system.
3. IEC at all level and in all states with more emphasis on endemic states should be launched. The message should be in local language including local people and artists.
4. Disability prevention and ulcer care including supply of footwear and other rehabilitative services.