National Leprosy Eradication National Leprosy Eradication ProgramProgram(NLEP(NLEP))

Dr. KANUPRIYA CHATURVEDIDr. KANUPRIYA CHATURVEDI

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

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),

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

India

Situation of States as per Prevalence- 2001 Vs 2006

Year Number of States having a PR of

<1 1 – 2 2 – 5 5 - 10

>10

2001 13 3 6 3 12006 25 8 1 Nil Nil

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

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

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

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.

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

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

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

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

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

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

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

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.

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

MDT Dose for Multi-bacillary Leprosy

Adult Child 10-14 yrs. Child 6-9 yrs.Day 1 Day 1 Day 1

Supervised monthly treatment

Supervised monthly treatment

Supervised monthly treatment

Rifampicin 600mg Rifampicin 450mg Rifampicin 300mg

Clofazimine 300mg Clofazimine 150mg Clofazimine 100mg

Depsone 100mg Depsone 50mg Depsone 25mg

Day 2-28 Day 2-28 Day 2-28

Daily Clofazimine 50 mg Clofazimine 50 mg Clofazimine 50 mg

Daily Depsone 100mg Depsone 50mg Depsone 25mgRegimen of three drugs – Rifampicin, Clofazimine and Dapsone for 12 months; first dose of each month to be given in presence

of HW. 

Multi- drug therapy( MDT) for paubacillary leprosy

Adult Child 10-14 yrs. Child 6-9 yrs.

Day 1 Day 1 Day 1

Supervised monthly treatment

Supervised monthly treatment

Supervised monthly treatment

Rifampicin 600mg Rifampicin 450mg Rifampicin 300mg

Dapsone 100mg Dapsone 50mg Dapsone 25mg

Day 2-28 Day 2-28 Day 2-28

Daily Dapsone 100mg Dapsone 50mg Dapsone 25mg

Regimen of two drugs – Rifampicin and Dapsone for 6 months provided in blister packs

Disability prevention and medical rehabilitation plan

Objectives of the rehabilitation plan:1. Persons with lepra reactions are adequately

managed so as to prevent occurrence of disabilities.

2. Persons with disabilities due to leprosy are assisted with care and support to prevent worsening of their existing disabilities

3. Persons with deformities suitable for correction are provided reconstructive surgery services through specialized centers managed by government and voluntary organizations.

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

Problems..

Late detection of patients, many with Late detection of patients, many with visible deformitiesvisible deformities

Poor treatment completion and curePoor treatment completion and cure Fear, prejudice and stigma surrounding Fear, prejudice and stigma surrounding

leprosyleprosy Limited community awareness and Limited community awareness and

involvementinvolvement

…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