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

2. 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

3. 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 current leprosy situation in the country has been observed as below.
A total of 1.34 lakh new cases were detected during the year , which gives Annual New Case Detection Rate (ANCDR) of per 100,000 population. This shows ANCDR reduction of 4.36% from during
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 indicates the proportion of MB (48.4), Female (35.2), Child (10.1), Visible Deformity (2.8),

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

5. 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

6. 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

7. 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
modified leprosy elimination campaign
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 and completed on 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 The project involve a cost of Rs crore including World Bank loan of Rs Crore and WHO to provide MDT drugs free of cost worth Rs 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 ( ) and the World Bank ( ). 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, As on 31st December 2005, Prevalence Rate recorded in the country was 0.95/10,000 population.

8. 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

9. 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.

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. MDT Dose for Multi-bacillary Leprosy
Adult
Child 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 mg
Depsone mg
Regimen of three drugs – Rifampicin, Clofazimine and Dapsone for 12 months; first dose of each month to be given in presence of HW.

20. Multi- drug therapy( MDT) for paubacillary leprosy
Adult
Child yrs.
Child 6-9 yrs.
Day 1
Supervised monthly treatment
Rifampicin 600mg
Rifampicin 450mg
Rifampicin 300mg
Dapsone mg
Dapsone mg
Dapsone mg
Day 2-28
Daily Dapsone 100mg
Regimen of two drugs – Rifampicin and Dapsone for 6 months provided in blister packs

21. 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.

22. 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

23. 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

24. …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