TUTORIAL

NLEP & CURRENT TRENDS IN LEPROSY

By: Dr. D R DHAKED

Leprosy, the disease• One of the oldest diseases known to mankind, a major public

health problem in India,

• Primarily affects skin, mucous membranes and peripheral nerves.

• Public health importance of leprosy lies in its capacity to produce deformities as well as psychological and social disabilities.

• Reservoirs are untreated infectious category of patients.

• Spreads mainly by respiratory route i.e. by droplets.

• About 20% of all leprosy patients are of infectious category.

• With Multi Drug Therapy (MDT) consisting of 2 to 3 drugs, infectious patients become non- infectious rapidly.

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.

MILESTONES in NLEP in India

1898 – Leper act Later abolished by British india1948 – Hind Kush Nivaran Sangh

1955 Govt. of India launched National Leprosy Control Programme

1970s Definite cure through MDT was identified

1982 WHO study group recommended use of MDT1983 Govt. of India launched NLEP and introduced MDT1991 WHO declaration to eliminate leprosy global level by 2000.1993 - 2000 – World Bank supported NLEP – I

2001 - 2004 – World Bank supported NLEP – II 2001 Integration of leprosy services with General Health Care System2005 Elimination of Leprosy at National Level (Dec.2005)2005 NRHM covers NLEP2005-06 Focused leprosy elimination plan (FLEP)

2007 Situational activity plan(SAP)

2007 Block leprosy awareness campaign (BLAC)

STRATEGY – LEPROSY ELIMINATION IN INDIA

1.    Decentralization of NLEP to States & Districts STATE LEVEL SOCIETIES are formed & funding to districts is done by

these.2.    Integration of leprosy services with General Health Care System3.    Leprosy Training of GHS functionaries4.    Surveillance for early diagnosis & prompt MDT5.   Intensified IEC using Local and Mass Media approaches

6.    Disability Prevention & Medical Rehabilitation (DPMR)

7.    Monitoring & Evaluation

– Regular - Monthly Reports

– Special Efforts - Independent Evaluation

- Leprosy Elimination Monitoring (LEM)

Current activities under NLEP

• Diagnosis and treatment of leprosy• MDT provided to all PHCs free of cost • Difficult to diagnose cases & complicated

cases referred to district hospitals• ASHAs under NRHM helps bring out leprosy

cases from villages for diagnosis and treatment completion

EARLY DIAGNOSIS & PROMPT MDT• Proper history• Thorough clinical exam.• Lab confirmation

• 95% of cases can be diagnosed clinically even by paramedical workers

• Skin smears assist in detecting suspected infectious cases

• Biopsy/PCR needed rarely

• Detection of 5-10% skin smear +ve leprosy pts is more imp as they infect others.

Classification for Tt: (WHO/FIELD CLASSIFICATION) PB MB

• LEPRA REACTION:May occur before/during/after MDT.Not caused by MDT.Do not stop MDT. Type1 (Reversal reaction) Type2 (ENL)Treat ‘Reaction’ as a Medical Emergency:Rest & AnalgesicsDOC-Prednisolone(40-60 mg)Taper gradually over 12-16 wks.All need a detailed Neuromuscular assessment by a

physiotherapist.

• NEW CASE: – A person having skin patch(es) with a definite loss of

sensation & has not received a course of MDT.• RELAPSE:

– A pt who has completed required course of MDT & who is taken as having been treated, but in whom s/s of leprosy reappear either during surveillance period or thereafter.

A Confirmed case should be treated with MDT again depending upon classification.

• DEFAULTER:– A pt who has not collected MDT for 12 consecutive months. Adequate efforts should be made to trace & persuade each to

return for assessment &Tt before their removal from register.

Training

• Training to Medical officers, health workers, lab technicians, ASHAs conducted every year

• Training of state & district Leprosy officers organized at Schieffline institute of health research & leprosy centre Vellore, TN and RLTRI Raipur

Involvement of NGOs

• Help reduce burden of leprosy• Serve in remote, inaccessible, uncovered,

urban slums, industrial/labour populations and other marginalised population groups.

Information education

communication

• IEC help reduction of stigma & discrimination against leprosy affected persons.

• Carried out through mass media, out door media, rural media & advocatory meetings.

• More focus on inter personal communication.

Disability prevention and medical rehabilitation.

• Inform patients (specially MB) about common s/s of reactions

• Ask them to come to centre (as soon as possible)• Start treatment for reaction• Inform them how to protect insensitive hands/ feet

/eyes• Involve family members • Patients provided with dressing materials, supportive

medicines & MCR footwear• Correction of disability through reconstructive surgery

Urban leprosy control

• Implemented in 422 urban areas with population size >1 lakh

• Includes MDT delivery services & follow up of patients with treatment completion, providing supportive medicines and dressing materials.

Monitoring & Supervision

• By analysis of monthly progress reports, • Through field visits by supervisory officers, • Programme review meetings held at central,

State & District levels.

• PRIMARY INDICATOR:- Annual New Case Detection Rate (ANCDR)- Treatment Completion Rate (cohort analysis)

• INDICATORS FOR CASE DETECTION:- Proportion of new cases with Gr II disability- Proportion of child cases(<15yrs) among new cases- Proportion of MB cases among new cases- Proportion of Female cases among new cases

• INDICATORS FOR QUALITY OF SERVICE:- Proportion of new cases correctly diagnosed.- Proportion of defaulters.- Number of relapses during a year.- Proportion of cases with new disabilities.

MONITORING & EVALUATION

New initiatives

• Reconstructive surgery

• Amount of Rs 5000 provided as incentive to leprosy patients from BPL families for undergoing major reconstructive surgeries in identified Govt/NGO institutions

Involvement of ASHAs

• Incentives provided for ASHAs for bringing out cases from their villages

• Rs 100 for confirmed diagnosis of cases• On completion of treatment within specified

time Rs 200 for PB & Rs 400 for MB.

Special activities in High Endemic areas

• Involves training, intensified IEC, case detection & prompt MDT through health care staff

National sample survey

• By national JALMA institute Agra• Started in 2010.• House to house survey to access burden of

active leprosy cases, leprosy persons with grade 1 & 2 disability and magnitude of stigma and discrimination in society.

Budget and international support

• Since 2005, the program is being conducted with Govt. of India funds with technical support from WHO & International federation of anti leprosy association(ILEP)

Anti Leprosy Activities in India• Leprosy Mission - founded in 1874 in H.P.

• Hind Kush Nivaran Sangh• Gandhiji Memorial Leprosy

Foundation, Sevagram, Wardha• The German Leprosy Relief

Association• Damien Foundation• The Danish Save the Child Fund• JALMA- taken over by ICMR in 1975

• National Leprosy Organisation- 1965

Status in India

• 2012-2013 started with 0.83 lakh leprosy cases on record as on 1st April 2012.

• Prevalence rate was 0.68/10,000 population• 33 states/ UT had achieved leprosy

elimination.• A total of 542 districts (84.7%) out of total 640

districts also achieved elimination by March 2012.

Current status

• A total of 1.35 lakh new cases detected during 2012-13

• Annual new case detection rate (ANCDR) was 10.78 per 1,00,000 population

• This shows increase in ANCDR of 4.15% from 2011-12 (10.35)

• A total of 0.92 Lakh cases on record as on 1st April 2013.

• Prevalence rate 0.73/10,000 population• Grade 2 disability rate 3.72/million population• Grade 1 disability constitute 4.14/million

population

Increase in new cases and prevalence during 2012-13 is attributable to NLEP strategy to carry out extensive house to house survey for new case detection

• 13387 new child cases were recorded with child case rate of 1.07/1,00,000 population

• One State (Chhattisgarh) and One U.T. (Dadra & Nagar Haveli) has remained with PR between 2 and 4 per 10,000 population.

• Bihar, Maharashtra and West Bengal which have achieved elimination earlier have shown slight increase in PR (1-1.2) in current year due to effect of SAP-2012

Year wise endemicity of districts on ANCDR basis

14 districts with ANCDR >50/100,000 population are in Chhattisgarh (2), Gujarat (4), Maharashtra (3) WestBengal (1), Dadra & Nagar Haveli (1) Orissa (2) and Delhi (1)

Year wise Status Of Districts on PR basis

• 36 districts in 11 States/UTs are having PR > 2/10,000. • Bihar (3), Orissa (4) Chhattisgarh (8), Uttar Pradesh (1),

Gujarat (8), Madhya Pradesh (1), Nagaland (1), Maharashtra (5), West Bengal (3) D&N Haveli (1) and Delhi (1)

• DPMR Services • Gr.II disability rate >2/million population has been reported in

304 districts (46.84%). • Total 94 (Govt.- 52 and NGO- 42) Institutions have been

recognized for conducting Reconstructive Surgery• During year 2012-13 a total of 2413 RCS (Govt. – 865 and NGO –

1548) were conducted.

THANKYOU