1. Critical review of National Leprosy
Eradication Programme
Presenter
Dr Utpal Sharma
Post Graduate Student
Moderator
Dr C Barthakur
Assistant Professor
Department of Community Medicine
Gauhati Medical College

2. Introduction
 GoI started NLCP in 1955 based on Dapsone domiciliary treatment
through vertical units implementing SET activities.
 In 1970s MDT identified; came into wide use from 1982, following the
recommendation by the WHO Study Group, Geneva in October 1981.
 Based on recommendations of high power committee in 1981, the
NLEP was launched in 1983. ....
......objective to arrest the disease activity in all the known cases of
leprosy.
 However coverage remained limited due to a
 Range of organizational issues
 Fear of the disease
 Associated stigma.
 The World Health Assembly in 1991 resolved to eliminate leprosy at a
global level by the year 2000.

3. Cont….
 To strengthen the process of elimination in the country, the first
World Bank supported project was introduced in 1993.
 World Bank funding in NLEP projects
1st Phase - 1993-94 to 2000
- “National Leprosy Elimination project”
- Rs. 290 crores (550)
- Prevalence rate (per 10,000) – 24 (in 1992) 3.7 (in 2001)
- Disability grade 2 and above- 2.7%
- MDT coverage- 99.5%
2nd Phase- 2001-02 to 2004
- Rs. 166.35 crores (249.8)
- MDT drugs free- Rs. 48 crores
- Prevalence rate- 2.4
- Annual detection rate- 3.3

4. Cont….
 The NLEP continued with Govt. of India funds from January
2005 onwards.
 Additional support from the WHO and ILEP organizations.
 MDT is to be supplied free of cost as of now by NOVARTIS
through WHO.
 After the global elimination in 2001, remaining 14 countries
targeted for elimination on national basis by December, 2005.......
............India was one of these countries.
 The National Health Policy, Govt. of India sets the goal of
elimination of leprosy by the year 2005.
 Country achieved the goal of elimination of leprosy in the month
of December, 2005......
....... As on 31st December 2005, Prevalence Rate
recorded in the country was 0.95/10,000 population.

5. Evolution of NLEP
(1955) National Leprosy Control Programme
(1980) Govt. decided to “eradicate” leprosy
1983 National Leprosy Eradication Programmme
1997 Modified Leprosy Elimination Campaign (MLEC)
2001 to 04 SAPEL and LEC
2005 Urban Leprosy Control Programme
2007 Block leprosy awareness campaign (BLAC)
2005-06 Focused leprosy elimination plan (FLEP)
2005 NRHM covers NLEP
2007 Situational activity plan(SAP)

6. 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.

7.  Decentralization of NLEP services
 Integration of NLEP with General Health Care System
 Capacity building of GHS functionaries
 Early diagnosis & prompt MDT (routine & special efforts)
 Intensified IEC using Local and Mass Media
 Prevention of Disability & Medical Rehabilitation (DPMR)
 Monitoring & Evaluation
STRATEGIES FOR ELIMINATION OF LEPROSY
IN INDIA

8. Scenario

9. WORLD:
 Over past 20 yrs,14 million pts cured;4million since
2000.
 Globan burden has declined dramatically (5.2million in
1985 to 2.04 lakh cases in 2002)
 PR has dropped by 90%(1985:21.1/10,000 ; 2000:1)
 Has been Eliminated from 119 of 122 countries.
 To date, there has been no resistance to MDT
 Efforts currently focus on eliminating leprosy at a national
level in remaining endemic countries & at a sub-national
level from others.

10. INDIA:
 By the end of 1st April 2013,0.92 lakh cases were on record; PR: 0.73/10,000
 1.35 lakh new cases detected during the year 2012-13; ANCDR of 10.78 per
100,000 population shows increase in of 4.15% from 2011-12 (10.35).
 New cases in 2012-13 ; MB(49.92%), Female (37.72%), Child (9.93%), Visible
Deformity (3.45%), ST cases (17.01%) and SC cases (18.49%).
 After MDT, case load from 57.6/10,000 in 1981 to 1 at national level in Dec 2005.
 Grade II disability amongst the New Leprosy Cases 2012-13; 3.72 / million
population while Gr. I cases recorded 4.14/million population.
 33 states/UTs, 542 districts (84.7%) out of total 640 districts have achieved the
status of elimination.
 Only one state and one UT: Chhatisgarh & D&N Haveli with PR 1-2.5/10,000

11. Trend of leprosy in India
The increase in new cases and prevalence during 2012-13 is
attributable to the NLEP strategy to carry out extensive house to
house survey for new case detection and to treat them with MDT to
cut down the transmission potential in the future

13. Assam
 By march 2012, a total of 1167 cases were on record; PR 0.35 per 10,000
population
 1147 new cases detected during the year 2012-13; ANCDR of 3.57 per 100,000
population
 New cases in 2012-13 ;MB(74.46%), Female (26.94%), Child (9.24%), Visible
Deformity (6.63%), ST cases (3.92%) and SC cases (8.46%).
 RFT accounts for 990 cases in April 2013- March 2014 with a 83.69% cases
released as cured*
 Out of the 27 districts, 24 boasts of PR<1, rest 3 have PR 1-2
 24 districts of 27 in Assam had ANCDR< 10, rest 3 districts had it between
10-20
*Cured are patients that completed full MDT course in stipulated time.

15. Achievements…
Items.
2013-14
(Apr, 2013 to Dec, 2013).
Remarks.
Total New Case Detection
826 nos. (PB=213 & MB=613)
NCDR for the 3rd
Quarter of 2013-14 (up
to Dec, 2013) =
3.65/100,000
population.
Cases discharged (RFT). 795 nos. (PB=208 & MB=587)
Reaction cases 93 nos. (PB= 4 & MB= 89)
Suspected Relapse cases. 0 no. (PB=0 & MB=0)
Grade-I Disability cases. 68 nos. (PB=16 & MB=52)
Grade-II Disability cases. 55 nos. (PB=6 & MB=49)
Cases under treatment.
1108 nos. (PB=175&MB=933) P.R. (Dec, 2013) = 0.34
per 10,000 population.
RCS done. 16 nos. (Govt.= Nil & NGO= 16).
MCR foot-wears distributed. 238 pairs.
Self Care Kit provided. 16 nos.

16. More news from Assam…..
 NE states reported 747 new cases in a
year till September 30.
 Assam recording the maximum 616
cases,
 Four districts of Assam recorded higher
prevalence of leprosy than the national
average
 Followed by Nagaland (32), Tripura
(23),Sikkim(20),Mizoram (18), Arunachal
Pradesh (17), Meghalaya (15) and
Manipur(6).
 In Assam, the most affected districts
were
• Sivsagar (99)
• Tinsukia(87)
• Sonitpur (42)
• Kamrup Metro(39)
• Cachar district (38)

17. Strength
Easy clinical diagnosis
Leprosy came to be dealt within the public health
terms after the advent of Dapsone
 MDT brought leprosy to the main stream of medicine.
MDT with its finite duration of treatment has proved to
be quite effective in treating millions.
Single dose administration leads to non-infection
The relapse rate with treatment with MDT is very low
(0.1% /year for PB and 0.06% /year for MB).

18. Weakness
 The NLEP didn’t address the involvement of Dermatologist.
 Skin smear examination in leprosy was first to be deleted/made
optional in the leprosy program.
 Top to buttom approch of MDT distribution
 Govt. Of India guidelines on MDT not widely distributed or used at
PHC/CHC level
 Inadequate case detection & immigration not adequately
addressed. Eg. Two dist. of Delhi PR > 5/10,000
 A small number of patients do not show any clinical or
bacteriological improvement with MDT.
 Non availability of vaccine.
.
Inadequate treatment or concomitant, debilitating, intercurrent infection.

19. Opportunities
Free MDT by WHO from 1995 (Novartis)
Funds-World Bank
NGO, INGO (Lepra Society, DANLEP, SIDA,ILEP)
The Goal of NHP 2002 to “Eliminate Leprosy by
2005”

20. Threats
 Social stigma, Discrimination continues.
 Misconceptions
 The disability and loss of productivity are not been
adequately addressed.
 Long incubation period (5-10 yrs)
 Medical science still knows a little about spread of the
disease.

21. Critical appraisal…..
 Social Stigma:
– NLEP failed to address the social stigma associated with the
Leprosy.
– Even in the present time isolation is practiced.
 Leprosy Legislation:
– Certain legislation still exists that construct leprosy as highly
contagious disease.Eg: Hindu Marriage Act 1955
– Leprosy patients cannot contest a civic election or hold a
municipal office.
– Other laws like Motor Vehicle Act of 1939 which restricts leprosy
patients from obtaining a driving license and……
– ………….the Indian Rail Act of 1990 which prohibits leprosy
patients from travelling by train.
Many of these laws were written before the development of MDT and have not
been updated since

22. Cont….
 Simplification of leprosy detection and classification leading to
discontinuation of skin smears….
….missing patients with high bacterial load
 In WHO classification neuritic leprosy is also not included.…..
……..In India, the proportion found to be as high as 18%.
 With introduction of FDT in1992 dependability of skin smear
removed…..
……..resulting cure and communicability of the patient a
doubtful entity.
 ROM therapy for single lesion leprosy discontinued owing to
marginalized advantage over the conventional therapy
………chances of under treatment according to this criteria.

23. Need of newer advents……
 Recommended duration of treatment, particularly
for MB leprosy is still too long
 Dapsone and Clofazimine weak bactericidal …...
……..further shortening the duration of treatment might result in
high relapse rate
 Administration of the daily components, Dapsone, and Clofazimine
cannot be supervised
 Resistant to leprosy drug:
– Resistance to MDT could be a problem.
Petit & Rees (1964), Jacobson & Hasting (1975), Wondroff van Diepen(1982)
– New alternative regimen is lacking presently
– No R& D in the field of drugs
 Need of a rapid and accurate diagnostic test to detect the disease
in early stage to limit diabilities

24. Cont…
 Transmission of infection:
– Transmission continues in spite declared eliminated in 2005
– Elimination campaign….
…….actually a control strategy.
– It may come to the same level as it was before if control measures
are relaxed.
– This gives false sense of security……
…… target of elimination is less than 1 per 10,000
population
Elimination criteria:
– Point prevalence ……
……..proxy indicator for leprosy incidence or transmission
– Duration of infection, treatment duration, mortality rate would be
affecting prevalence rate.

25. Cont…
Integration problem:
– Integration into GHS required careful planning and
implementation otherwise……
……. needs of leprosy control be pushed
aside by pressing health problems like TB & HIV
– Lack of diagnostic experience and decrease index
of suspicion with disease becoming rare.
– Deficient healthcare staff (MPWs)…..
…….overburdening the existing staff

26. Cont….
Difficult to reach areas:
-Special focused programmes for such areas…
MODIFIED LEPROSY ELIMINATION CAMPAIGN(MLEC) (1997-98)
SPECIAL ACTION PROJECTS FOR THE ELIMINATION OF LEPROSY
(SAPEL)
LEPROSY ELIMINATION CAMPAIGNS(LEC) FOR URBAN AREAS
STRATEGIG PLAN OF ACTION (2004-5)
FOCUSED LEPROSY ELIMINATION PLAN (FLEP) 2005-06
SITUATIONAL ACTIVITY PLAN(SAP) 2007
BLOCK LEPROSY AWARENESS CAMPAIGNS (BLAC IV) 2007

27. Cont….
Leper colonies…a curse
– Isolation in leper colonies….
– Families more prone to infection….and succumb to
poverty
Social and economic rehabilitation
– Bussines loan schemes…..
– House building loans…….
– Scholarships…….
– Vocational training schemes…..
Such colonies should be abolished to reduce stigma
Strategies confined to NGO level….no commitments from govt. side

28. Last but not the least……
Challenges in “going the last mile”
– Level of international attention and political
commitment is declining.
– Knowledge about diagnosis and treatment is
decreasing in many countries.
– While leprosy decreased significantly from 1984
to 2004, a stagnation has occurred from 2005
onwards.

30. Cont…
Caused by several factors such as:
Difficulty to maintain/increase knowledge about
leprosy among health workers
 Shift in priorities of national health authorities to
diseases with a larger patient burden.
In times of high prevalence, a rough search was
sufficient to find patients but…..
…….a more accurate/ integrated approach
required to find cases in remote areas.

31. References
 Training Manual For Medical Officers;National Leprosy Eradication Programme
Directorate General of Health Services Ministry of Health & Family Welfare
Nirman Bhawan, New Delhi,2009
 NLEP – Progress Report for the year 2012-13 Central Leprosy Division
Directorate General of Health Services, Nirman Bhawan, New Delhi ; 2014
 http://www.business-standard.com/article/politics/747-new-leprosy-cases-in-ne-
region-centre-worried-113110800546_1.html; last accessed on 2nd March 2014
 Programme Implementation Plan (PIP) for 12th Plan Period (2012-13 to 2016-
17) CENTRAL LEPROSY DIVISON, Directorate General of Health Services,
Ministry of Health & Family Welfare, Govt. of India
 WHO document. 2nd. Geneva: WHO; 2003. Final push strategy to elimination of
leprosy as a public health problem. Questions and Answers
 https://extranet.who.int/iris/restricted/handle/10665/63271 . accessed on 3rd
march 2014
 Leprosy therapy, past and present: can we hope to eliminate it? P V S Prasad
and P K Kaviarasan ; Indian J Dermatol. 2010 Oct-Dec; 55(4): 316–324.

32. Thank you