PRAMOD KUMAR

LEPROSY

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, an acid-fast, rod-shaped bacillus. The disease mainly affects the skin, the peripheral nerves, mucosa of the upper respiratory tract and also the eyes. Leprosy has struck fear into human beings for thousands of years, and was well recognized in the oldest civilizations of China, Egypt and India. A cumulative total of the number of individuals who, over the millennia, have suffered its chronic course of incurable disfigurement and physical disabilities can never be calculated

• Since ancient times, leprosy has been regarded by the community as a contagious, mutilating and incurable disease. There are many countries in Asia, Africa and Latin America with a significant number of leprosy cases. It is estimated that there are between one and two million people visibly and irreversibly disabled due to past and present leprosy who require to be cared for by the community in which they live.

• Leprosy is curable and treatment provided in the early stages averts disability.

• Multidrug therapy (MDT) treatment has been made available by WHO free of charge to all patients worldwide since 1995, and provides a simple yet highly effective cure for all types of leprosy.

• Elimination of leprosy globally was achieved in the

year 2000 (i.e. a prevalence rate of leprosy less than 1 case per 10 000 persons at the global level). Nearly 16 million leprosy patients have been cured with MDT over the past 20 years.

CLASSIFICATION OF LEPROSY

Leprosy can be classified on the basis of clinical manifestations and skin smear results. In the classification based on skin smears, patients showing negative smears at all sites are grouped as paucibacillary leprosy (PB), While those showing positive smears at any site are grouped as having multibacillary leprosy (MB).

However, in practice, most programmes use clinical criteria for classifying and deciding the appropriate treatment regimen for individual patients, particularly in view of the non-availability or non-dependability of the skin-smear services. The clinical system of classification for the purpose of treatment includes the use of number of skin lesions and nerves involved as the basis for grouping leprosy patients into multibacillary (MB) and paucibacillary (PB) leprosy.

LEPROSY TODAY:• Leprosy control has improved significantly due to national and

subnational campaigns in most endemic countries. Integration of primary leprosy services into existing general health services has made diagnosis and treatment of the disease easy.

• Detection of all cases in a community and completion of prescribed treatment using MDT are the basic tenets of the Enhanced Global Strategy for Further Reducing Disease Burden Due to Leprosy (plan period: 2011–2015).

• National leprosy programmes for 2011–2015 now focus more on

underserved populations and inaccessible areas to improve access and coverage. Since control strategies are limited, national

programmes actively improve case-holding, contact tracing, monitoring, referrals and record management. • According to official reports received from 103 countries from 5

WHO regions, the global registered prevalence of leprosy at the end of 2013 was 180 618 cases. The number of new cases reported globally in 2013 was 215 656 compared with 232 857 in 2012 and 226 626 in 2011.

• The number of new cases indicates the degree of continued transmission of infection in the community. A total of 13 countries reported zero cases in 2013. Global statistics show that 206 107 (96%) of new leprosy cases were reported from 14 countries and only 4% of new cases from the rest of the world. Only these 14 countries reported >1000 new cases in 2013.

Pockets of high endemicity still remain in some areas of many countries but a few are mentioned as reference: Angola, Bangladesh, Brazil, People’s Republic of China, Democratic Republic of Congo, Ethiopia, India, Indonesia, Madagascar, Mozambique, Myanmar, Nepal, Nigeria, Philippines, South Sudan, Sri Lanka, Sudan and the United Republic of Tanzania.

NATIONAL LEPROSY ERADICATION PROGRAM

Leprosy is hereditary and incurable. It causes social aversion and ostracism leading to the high deformity and has the maximum social stigma the Common belief - due to past sins committed by the person. Scientific inventions identified leprosy as a disease that can be eradicated.

IMPORTANT MILESTONES IN NLEP IN INDIA• 1955 – Government of India launched National Leprosy Control

Program• 1983 – Government of India launched NLEP and introduced MDT• 1991 – World Health Assembly resolution to eradicate leprosy by

2000AD.• 1993 - 2000 – World Bank supported NLEP – I• 2001 - 2004 – World Bank supported NLEP – II• 2005 (Jan.) – NLEP continued with Government of India funds &

donor partners support• 2005 (Dec.) – India achieved elimination as a public health problem.• 2005 Dec – Prevalence rate 0.95 /10,000 and government declared

achievement of elimination target.• 2005 – NRHM covers NLEP.• 2012 - Special action plan for 209 high endemic districts 16

States/UTs.

PROJECT PHASE-I

The program was initially taken up in endemic districts and was extended to all districts in the country from 1993-94 with world bank assistance. The national rural health mission seeks to provide effective health care in the entire country with special focus on 18 states, which have weak public health indicators. National leprosy eradication program shall be horizontally integrated under the NRHM for improved program delivery. The minimum services available CHC should be: diagnosis of leprosy, treatment of cases, management of reactions and advice of patient on prevention of disability care.

PROJECT PHASE-II

• 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 (Madhya Pradesh, Orissa, Bihar, Uttar Pradesh and West Bengal, Uttaranchal, Chhattisgarh, Jharkhand).

• Part C: Plan for the 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 the general health care system in the 27 low endemic states/UTs.

• To proceed with integration of services as rapidly as possible in the 8 high endemic states.

STRATEGIES

• Decentralization of NLEP to states & Districts.• Integration of leprosy services with general

health care system (GHS).• Leprosy Training of GHS functionaries.• Early diagnosis & prompt MDT, through routine

and special efforts.• Information education and communication (IEC)

using Local & Mass media for reduction of stigma & discrimination.

• Prevention of disability & medical rehabilitation.

• Monitoring & periodic evaluation.• Inter-sectoral collaboration.• Monitoring & evaluation.

ELIMINATION STRATEGY

To eliminate leprosy the government of India has accepted modified leprosy eradication campaigns (MLEC) & Special action projects for the elimination of leprosy (SAPEL) strategic action for the early detection of leprosy cases and mass awareness.

1. Modified Leprosy Elimination Campaigns (MLEC)

The MLEC approach is actually organizing camps for one or two weeks duration in which services like case detection, treatment and referral to reconstruction facilities are available. A wide level information about camps services and about disease disseminated through radio, TV, newspaper, loudspeaker, etc. MLEC has proved quite effective for case finding and has been employed during phase II.

2. Special action projects for the elimination of leprosy(SAPEL)

SAPEL is an in initiative aimed at providing MDT services to patients living in special difficult to access areas or situation or to those belonging to neglected population groups. The most important thing is for the elimination program to reach services.

Under these strategies following activities are carried out:-

A. Early detection leprosy caseB. Intensified health education and public awareness campaigns to remove social stigma attached to the disease.C. Regular treatment of leprosy cases by providing multi-drug therapy at fixed in or centers near to the patient– Most frequently used medicine for the treatment of

leprosy is Rifampicin, Clofazimine & Dapsone.– other drugs ; thioamides & fluroquinoles, minocycline,

macrolides.

D. Disability prevention and medical rehabilitation– Government of India now approved a plan in which

disability care activities of varying grades are to be provided at three levels. Objectives of the program are:-

– Persons with lepra reaction are adequately managed so as to prevent the occurance of disabilities.

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

– Persons with deformities suitable for correction are provided reconstructive surgery services through well- distributed specialized centers managed by both government and NGOs.

PLAN OF ACTION1. Strategic plan of action (2004-2005):-– Intensified focus action with strong supervisory support in 72

high priority districts with PR >5/10000 and 16 moderately endemic districts but with more than 2000 leprosy cases detected during 2003-04.

– Increased efforts put on IEC, training and integrated services delivery in identified high endemic localities of 86 medium priority districts.

– In 836 blocks in the country with PR >5/10000 as on 31st march 2004, a 2 week long block leprosy awareness campaign was conducted.

2. Focused leprosy Elimination plan (FLEP2005)–Priority areas were identified in March 2005

taking PR >3/10000 population as the cutoff point. A total of 42 districts and 552 blocks were identified.

3. Intensified supervisory and monitoring– From the month of Oct-Dec 2005 were utilized

for intensified supervision of program activities in all states and UTs.

– Supervisory officers from the state & UTs, NLEP coordinators, district technical support teams and state technical support team were advised to visit each and every primary health center to monitor the program.

– Such supervision ensured regular treatment to treatment to patients, follow up of patients irregular in taking treatment and availability of MDT at all level.

INVOLVEMENT OF NGOs

• NGOs are involved in leprosy elimination activities for many decades and their contribution has been a positive impact in reducing the prevalence of leprosy.

• There are 290 NGOs working in the field of leprosy throughout the country and NGOs are getting grant-in-aid from govt. of India for survey Education Treatment(SET) in leprosy.

INVOLVEMENT OF WHO & OTHER AGENCIES

• WHO also supports the program by providing anti-leprosy drugs, monitoring, capacity building etc.

• WHO undertaken to meet the full requirements of these drugs in India with assistance of NOVARTIS.

• WHO has supported all state leprosy cell by providing state NLEP coordinators in 11 states and also zonal NLEP coordinators in the high endemic states of Bihar, Jharkhand, UP, Orissa and Chhattisgarh.

• International Federation of Anti-leprosy Association (ILEP) is involved as partner in the NLEP for the common goal of “A world without Leprosy”.

FOCUS FOR PROGRAM IN FUTURE

• PR on 31st march 2006 was 0.84/10000 at national level. Sustained activity plan-06 was approved by ministry to cover 29 district & 433 blocks as priority areas.

• Sustained activity plan for district (or 433 blocks) with PR >2/10,000 was given under the priority areas.

Priority districtsThese priority districts were divided in two groups taking Delhi separately for suitable and sustainable actions: A. First Group: Six states (Chhattisgarh, Jharkhand, Gujarat, Orissa, and UP & WB) had 25 districts with PR between 2-5/10000 population.• Activities proposed for these 25 districts in 6 states were:• Placement of experienced districts nucleus staff• District technical support team (DTST) with full component of

staff & vehicle should be available.• Orientation for all MOs both at PHC and urban areas.• Situation analysis for – correctness of diagnosis.• IEC activities.• Supervision and monitoring of leprosy activities

B. Second group: Delhi has 4 districts with PR >2/10,000. Leprosy patients reports to 7 dispensaries and 2 hospitals with no fixed catchments areas. These hospitals are unable to follow up the patients for treatment completion leading to accumulation of patients in the registers.

BLOCK LEVEL AWARENESS CAMPAIGN (BLACK)

• The special measures are taken in identified priority areas in a campaign mode during the months of September to November each year. These special measures made huge impact on hidden case detection, better case management, improvement in spreading awareness and generally bringing down the prevalence rate in these high endemic areas.

A. District level• Block level awareness campaign is carried out

for 15 days during sepember- November the state decide the suitable time:

• One supervisiory official to be identified for carrying out situational analysis.

• To work-out the logistic details.• Draw specific plan for supervision by district

officials.• Budget allocation.

B. Block level

• Identify sector primary health care centre or sub centre wise population groups that contributed highest number of cases detected in last 2 years.

• Quality of service provides by all health centers in the block and involvement of all health workers in leprosy program related works.

• Need based intensified IEC activities will be planned for these blocks. Interpersonal communication remains the main focus.

• Need based intensified IEC activities will be planned for these blocks. Interpersonal communication remains the main focus.

• Identify workers and supervisors responsible to carry out each planned activity.

• Work out logistic details.• Finalize record to be kept at block PHC.

Suggested activities in BLACK are:• Team to visit all villages to spread awareness.

• House to house visit by team in identifies endemic villages will be done for IPC.

• Services facilities in all health centers where a Medical officer is available must be ensured. This also includes adequate MDT stock, quality diagnosis particularly of children.

• Need based IEC already planned for these endemic block to be carried out during this period.

THE “FINAL PUSH” STRATEGY FOR ELIMINATION OF LEPROSY

• The main thrust of the leprosy elimination strategy is to:• Expand multi drug therapy (MDT) services to all health

activities.• Ensure 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 so that

individuals with suspicious lesions will report voluntarily for diagnosis and treatment.

• Set targets and time table for activities.

RESEARCH ARTICLEDeterminants of rural women's participation in India's National Leprosy Eradication Programme.• A multistage representative random sample of women and men

from each of the 3 states of Bihar, Uttar Pradesh and West Bengal, from the rural blocks where the Leprosy Mission Hospitals were located were selected during 2010 to identify relevant factors that are preventing active participation of women and suggest corrective steps. Adult men and women were interviewed in depth, using a detailed checklist by the first author. A total of 1239 respondents 634 women and 605 men, were interviewed, only 44 women (7%) claimed that they had earlier participated in leprosy work, about 92% of the women felt that they had the potential to take part in leprosy work, and 70% showed willingness to participate.

Factors that would encourage and facilitate more women to participate in leprosy work, included financial support (32.8%), convincing the family to grant permission (88%), and delegating them to work in proximity to their residences (15%). Some women respondents (11.0%) felt that they would provide their services voluntarily for social good. Women suggested that work should be delegated as per their capabilities and skills, and they should be given proper orientation, training and guidance.

Hardly 5% of ASHA's in the clusters examined participated in leprosy related work, which needs stringent steps to re-orient and encourage them to undertake leprosy related work. It is concluded that rural Indian women are keen to play an important role in the national leprosy eradication program, with minimal support from the government and nongovernmental agencies in a truly community-based approach. This will benefit vast numbers of leprosy affected women as well as others.