National Leprosy Eradication Program (NLEP) Dr. KANUPRIYA CHATURVEDI 1

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 1 2006 25 8 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 6

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 The 1st Phase of the World Bank supported National Leprosy Elimination Project started from 1993-94 and completed on 31.3.2000. This Project involved a cost of Rs. 550 crores of which World Bank loan was Rs. 292 crores. During this phase, the prevalence rate reduced from 24/10,000 population in 1992 before starting 1st Phase project to 3.7/10,000 by March 2001. The 2nd Phase of World Bank Project on NLEP started for a period of 3 years from 2001-02. The project involve a cost of Rs. 249.8 crore including World Bank loan of Rs. 166.35 Crore and WHO to provide MDT drugs free of cost worth Rs. 48.00 crore. The project successfully ended on 31st Dec. 2004 The National Health Policy, Govt. of India sets the goal of elimination of leprosy i.e. to reduce the no. of cases to < 1/10,000 population by the year 2005. The National Leprosy Eradication Programme took up the challenge with the active support of the State/ UT Governments and dedicated partners in the World Health Organisation, the International Federation of Anti Leprosy Associations (ILEP), the Sasakawa Memorial Health Foundation & the Nippon Foundation, NOVARTIES, DANLEP (1986-2003) and the World Bank (1993-2004). As a result of the hard work and meticulously planned and executed activities, the country achieved the goal of elimination of leprosy as a public health problem, defined as less than 1 case per 10,000 population, at the National Level in the month of December, 2005. As on 31st December 2005, Prevalence Rate recorded in the country was 0.95/10,000 population.

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 Supervised monthly treatment Rifampicin 600mg Rifampicin 450mg Rifampicin 300mg Clofazimine 300mg Clofazimine 150mg Clofazimine 100mg Depsone 100mg Depsone 50mg Depsone 25mg Day 2-28 Daily Clofazimine 50 mg Clofazimine 50 mg Daily Depsone 100mg Depsone 50mg Depsone 25mg Regimen 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 Supervised monthly treatment Rifampicin 600mg Rifampicin 450mg Rifampicin 300mg Dapsone 100mg Dapsone 50mg Dapsone 25mg Day 2-28 Daily Dapsone 100mg 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: Persons with lepra reactions are adequately managed so as to prevent occurrence of disabilities. Persons 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 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 visible deformities Poor treatment completion and cure Fear, prejudice and stigma surrounding leprosy Limited community awareness and involvement

…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