an attempt has been made to enlist the lessons learnt from NLEP

1. LESSONS LEARNT FROM
NATIONAL LEPROSY
ERADICATION PROGRAM
Ravi M R
Postgraduate student. Dept. of Community medicine
JSSMC
Moderator: Dr N C Ashok
Professor & Head of the dept.

2. • Leprosy
• Eradication
• Program

4. • Eradication
– Termination of all transmission of infection by
extermination of infectious agent through
surveillance and containment.
• Elimination
• Eradication of Disease from a large geographic
region

5. • Program
– A program is a portfolio comprised of multiple
projects that are managed and coordinated as one unit
with the objective of achieving (often intangible)
outcomes and benefits for the organization.
• Project
– A project is a temporary entity established to deliver
specific (often tangible) outputs in line with predefined
time, cost and quality constraints

6. Brief history - disease and treatment
• written mention of leprosy is dated 600 BC
• first breakthrough occurred in the 1940s with
the development of the drug dapsone
• In the 1960s, M. leprae started to develop
resistance to dapsone
• In the early 1970s, rifampicin and
clofazimine, the other two components of
recommended multidrug therapy (MDT), were
discovered.

7. • In 1981, a WHO Study Group recommended
MDT. MDT consists of 3 drugs: dapsone,
rifampicin and clofazimine and this drug
combination kills the pathogen and cures the
patient

8. Leprosy today
• The diagnosis and treatment of leprosy is easy
• Most endemic countries are striving to fully
integrate leprosy services into existing general
health services.
• Access to information, diagnosis and treatment
with multidrug therapy (MDT) remain key
elements in the strategy to eliminate the
disease as a public health problem

9. • According to official reports received from 115
countries and territories, the global registered
prevalence of leprosy at the end of the first
quarter of 2013 stood at 189,018 cases, while
the number of new cases detected during 2012
was 232,857 (excluding the small number of
cases in Europe).

10. Elimination of leprosy as a public health
problem
• In 1991 WHO's governing body, the World
Health Assembly (WHA) Resolution to
eliminate leprosy by the year 2000
– Elimination of leprosy is defined as a prevalence
rate of less than 1 case per 10 000 persons.
– past 20 years:14 million leprosy patients have been
cured
– Leprosy has been eliminated from 119 countries
out of 122 countries where the disease was
considered as a public health problem in 1985

11. National Leprosy Eradication Program

12. • Centrally sponsored Health Scheme of the
Ministry of Health and Family Welfare, Govt. of
India
• Headed by the Deputy Director of Health Services
(Leprosy ) under the administrative control of the
Directorate General Health Services Govt. of
India
• Supported as Partners by the World Health
Organization, The International Federation of
Anti-leprosy Associations (ILEP) and few other
Non-Govt. Organizations.

13. Backround
• Govt. of India started National Leprosy Control
Programme in 1955 based on Dapsone
domiciliary treatment
• The MDT came into wide use from 1982,
following the recommendation by the WHO
Study Group, Geneva in October 1981.
• Govt. of India established a high power
committee under chairmanship of Dr. M.S.
Swaminathan in 1981 for dealing with the
problem of leprosy.

14. • NLEP was launched in 1983 with the objective
to arrest the disease activity in all the known
cases of leprosy.
• However coverage remained limited due to a
range of organizational issues and fear of the
disease and the associated stigma

15. • In 1991 the World Health Assembly resolved
to eliminate leprosy at a global level by the
year 2000.

16. • Status in the Country
– The year 2012-13 started with 0.83 lakh leprosy
cases on record as on 1st April 2012.
– PR 0.68/10,000
Capital : BANGALORE
Districts : 30
Population : 61130704
(estimated as on Mar
2011)
Leprosy Situation : 0.44
(March 2011 PR/10000)

17. • only 36 districts in 11 States/UTs are having PR > 2/10,000.
These states are
• 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)

20. LESSONS LEARNT FROM
NLEP

21. 1. Political commitment and Program
development
• Universal political commitment is necessary.
• World health assembly uniquely provides the
necessary forum for countries to agree on
global health policies.
• Monitoring and coordinating health programs
by world health organization

22. • Decision to eliminate leprosy made in 1991 by
World health assembly.
• This encouraged number of countries
including India to begin or intensify their own
special programs.

23. • In order to strengthen the process of
elimination in the country, the first World Bank
supported project was introduced in 1993
• The 1st Phase of the World Bank supported
National Leprosy Elimination Project
– started from 1993-94 and completed on 31.3.2000.
– 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

24. • The 2nd Phase of World Bank Project on
NLEP
– started for a period of 3 years from 2001-02
– The project successfully ended on 31st Dec. 2004

25. 2. Importance of special Program
• Leprosy elimination could not have been
achieved if it was not a targeted program with
funds specially allocated for it.
• NLEP functioned with in the existing national
health structure.
• It was obliged to work with the existing health
services & to coordinate its activities with
other programs.

26. • Participation of existing health staff in early
detection and treatment of leprosy was
required
• This meant Special training for health service
units.
• As a consequence many thousands of health
staff obtained experience in the execution of
leprosy service activities.

27. • Three important observation with respect to
special program can be made with NLEP
– 1. the provision of community wide disease control
services requires stratergies and management system
– 2. special programme for important health problems
offer the advantages of attracting both resources and
community support
– 3. significant improvement in eficiency & supervision
can be realized which offset the additional cost of a
special program.

28. 3. Providing community wide services.
• In order to reach the leprosy elimination
activities to all or most persons in the
community NLEP adopted various elimination
stratergies.

29. • The National Leprosy Eradication Programme
envisaged the following strategy towards Leprosy
Elimination In India from the year 2001 : -
– 1. Decentralization of NLEP to States & Districts
– 2. Integration of leprosy services with General Health Care
System
– 3. Leprosy Training of GHS functionaries
– 4. Surveillance for early diagnosis & prompt MDT, through
routine and special efforts
– 5. Intensified IEC using Local and Mass Media approaches
– 6. Prevention of Disability & Care

30. • II. Strategic Plan of Action (2004-05)
• During the year 2004-05
• focus was shifted from States to high and medium
endemic Districts and Blocks.
• A strategic plan of action was drawn up with the
following focus :-
– (a) Intensified focused action with strong supervisory
support in 72 high priority districts with PR > 5/10,000 and
16 moderately endemic districts but with more than 2000
leprosy cases detected during 2003-04.
– (b) Increased efforts put on IEC, Training and Integrated
Service Delivery in identified high endemic localities of 86
medium priority districts.

31. • (c) In 836 blocks in the country with PR >
5/10,000 as on 31st March 2004, a two weeks
long Block Leprosy Awareness Campaign
(BLAC-I) was conducted through Intensified IEC
and through Leprosy Counseling Centres at
subcentre level during the period October-
December 2004 to ensure follow up of existing
leprosy patients and self reporting of new cases.
• The outcome of the strategic plan of action
(2004-05) were very encouraging.
Indicators March 2004 March 2005
States achieved
elimination
17 24
Districts with PR >
5/10,000
72 7
Blocks with PR > 5/10,000 836 150

32. • III. Focused Leprosy Elimination Plan (FLEP-
2005)
– Priority areas were identified in March 2005 taking
PR > 3/10,000 population as the cut off point.
– A total of 42 districts & 552 blocks were
identified.

33. • IV. Intensified Supervision And Monitoring
• Officers from the State / UTs, State / Zonal NLEP
Coordinators, State District Technical Support Teams
(DTST) and State Technical Support Teams (STST)
• were advised to visit each and every Primary Health
Centre to monitor the programme activities. Such
supervision ensured
– regular treatment to patients
– followup of patients irregular in taking treatment
– and availability of MDT at all Level.

34. • MODIFIED LEPROSY ELIMINATION
CAMPAIGNS UNDER NLEP
• First started in 1997-98
• Objecives-
– generate mass awareness about leprosy.
– To give training to the general health services staff.
– To detect hidden cases of leprosy.
– The campaign was a roaring success and helped in
detection of as high as 4.5 lakh new leprosy cases who
received treatment with MDT immediately.

35. • The Second Modified Leprosy Elimination
Campaign:1999-2000
– Active case detection through house to hose for 6
days
– in 5 States viz. Bihar, Madhya Pradesh, Orissa,
Uttar Pradesh and West Benga
– In the 7 States of Andhra
– Pradesh, Assam, Gujarat, Maharashtra, Karnataka,
Kerala and Tamil Nadu case detection was passive
through voluntary reporting centers, for 2 days.

36. • The Third Modified Leprosy Elimination
Campaign:2001-2002
– Active case detection through house to house
survey
– In 4 states viz. Madhya Pradesh, Orissa,
Uttaranchal and Tamilnadu case detection was mix
of Active Search and Voluntary Reporting Centre
(VRC) type in different areas as decided by the
States.

37. – In 18 other states only VRCs were opened for 2
days for cases detection,
– while in States/ UTs where elimination have been
achieved only passive detection was done

38. • The Fourth Modified Leprosy Elimination
Campaign
– was planned for the 2nd year of the World Bank
supported Second National Leprosy Elimination
Project and carried out during the year 2002-03

39. • The Fifth Modified Leprosy Elimination
Campaign was considered necessary in 8
endemic states of Bihar, Jharkhand,
Chhattisgarh, Uttar Pradesh, West Bengal,
Maharashtra, Andhra Pradesh and Orissa

40. • Thus special stratergic plan & trained
proffesional was necessary at all levels to
execute effective NLEP activities.
• The community wide programs requires active
outreach by persons skilled in management
and health education in order to ensure
acceptance, and methods such as surveillance
to measure success.

41. 4.Attracting resources and community
support
• Special purpose programs to achieve certain
specific objectives, usually with in finite
period of time are generally better supported
and financed than programs with less explicit
goals.

42. 5.Definition of objectives and standards of
performance
• A proper definition of program objective and
the use of these in the program management
can transform a program.
• A fundamental change which occurred in NlEP
was the decision to measure progress in terms
of programs ultimate objective;
– A prevalence of <1/10,000 population

43. • Focus on the objective of PR<1/10,000 meant
that
– Case reporting have to be improved
– Surveillance system intensified.
– Necessary to allocate resources in order to provide
more intensive efforts in the high prevalent states.
A well defined case was set up that aided the
diagnosis at community level.

44. • Logic suggests that all disease control program
shouldprovide
– Continuous measurement of disease incidence and
prevalence.
– Measurement should dictate changes in stratergy
and tactics.

45. 6. Program Management
• Any national program are invariably difficult
to manage.
• NLEP could not operate as a monolithic
structure.
– It has to function as a collegial structure of many
independent national programs.
– Utilizing resources from many different sources.

46. • WHO provided only a portion of the resources
for NLEP & had no authority over national
programe other than moral suasion.
• Decentralized integrated leprosy services
through General Health Care system is one of
the stratergy of NLEP
• Involvement of NGO’s

47. 7. Perssonel Recruitment & Training
• The competence, motivation & experience of
proffesional staff ultimately govern the success
of all program.
• A common understanding by all staff of the
programs basic stratergy and tactics,
measurement of progress are also critical.

48. 8. Financial and other resources.
• Defeciency of resources is a continuing
problem & one that jeopradize the national
effort.
• Till 2005 Nlep was funded by WHO. From jan
2005 onwards Progrms is being continued with
Govt. Of India Funds.

49. • The NLEP took up the Challenge with the
active support of
– The state/UT governments.
– WHO
– International Federation and Antileprosy
Associations
– The Sasakawa Memorial Health Foundation
– Nippon Foundation
– Novartis

50. 9. logistics
• Ensuring continuous and adequate supply of
drugs is one of the pre requisite.
• WHO committed to provide MDT free of cost
in the early part of the program
• As of now ‘Novartis’ is providing free MDT
world wide through WHO
• Vehicles and other resources supplied
ultimately determine wether the program were
able to function

51. To summarize
1. Strong Political commitment
2. The provision of community wide disease control
services requires stratergies and management
system
3. Special programme for important health
problems offer the advantages of attracting both
resources and community support
4. Significant improvement in eficiency &
supervision can be realized which offset the
additional cost of a special program

52. 5. Providing community wide services, reaching
the most unreachable.
6. Intensified supervision and Monitoring
7. Quality control through quality of service
indicators.
8. Involvement of NGO’s to support the
program.
9. Program mangaement

53. Drawbacks Of NLEP
• 1) Social Stigma:
– NLEP failed to address the social stigma associated
with the Leprosy.
– Even in the present time people with leprosy have to
leave their villages or socially isolated.
• 2) Leprosy Legislation:
– certain legislation still exists tha construct leprosy as
highly contagious disease.
– Eg: Hindu Marriage Act 1955
– Leprosy patients cannot contest a civic election or hold
a municipal office.

54. • 3) WHO enthusiasm for simplification of
leprosy management could be harmful as skin
smears essential for identifying patients with
high bacterial load have been discontinued.
• 4) Resistant to leprosy drug:
– Resistance to MDT could be a problem.
– New alternative regimen is lacking presently

55. • 5) Transmission of infection:
– elimination campaign is actually a control
stratergy.
– This gives false sense of security because target of
elimination is less than 1 per 10,000 population
– It may come to the same level as it was before if
control measures are relaxed.

56. • 6) Elimination criteria:
– point prevalence cannot be taken proxy indicator
for leprosy incidence or transmission
– Duration of infection, treatment duration, mortality
rate would be affecting prevalence rate.

57. • 7) Integration problem:
– Integration into general health services required
carefull planning and implementation.
– The needs of leprosy control will swamped by
other pressing health problems like TB & HIV
– Lack of diagnostic experience and decreasee index
of suspicion when the disease becomes rare.

58. • Challenges in “going the last mile”
– the level of international attention and political
commitment is declining.
– knowledge about diagnosis and treatment is
decreasing in many countries.
– While leprosy cases have decreased significantly
from 1984 to 2004 (see figure 1), a stagnation has
occurred from 2005 onwards.

59. – caused by several factors such as
• the difficulty to maintain/increase knowledge about
leprosy among health workers given the small number
of patients
• or the shift in priorities of national health authorities to
diseases with a larger patient burden.
• during times of high prevalence, a rough search was
sufficient to find patients, now a more accurate
approach involving different actors is required today to
find cases in sometimes remote areas.

60. References
• http://www.who.int/lep/en/ 09/10/2013,
21.00hrs
• http://www.who.int/mediacentre/factsheets/fs1
01/en/ 10/10/2013, 16.30 hrs
• Text book of public health and community
medicine. 1st ed. Pune (India). Dept. of
Community Medicine AFMC; 2009
• J Kishore. National Health Programs of India.
10th ed. Century Publication. New Delhi. 2012