2. 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. INTRODUCTION
o NLEP was launched in 1983
o Centrally sponsored health scheme (MOHFW)
o Headed by – deputy director of health services(leprosy) under DGHS
o Supported as partners by
o World Health Organization
o The international federation of Anti Leprosy Association (ILEP)
o Non-Govt. Organizations
4. THE EMBLEM
o Symbolizes
o Beauty and purity in lotus
o Leprosy can be cured and a leprosy patient
can be a useful member of the society in the
form of a partially affected thumb.
o Normal fore finger representing the shape of
house
o Rising sun – the symbol of hope and
optimism
5. DEFINITIONS
o Control- disease agent is permitted to persist in the
community at a level where it ceases to be a public health
problem.
o Elimination -Interruption of transmission of disease
o Eradication- Termination of all transmission of infection by
extermination of the infectious agent
o Case : A person showing clinical signs +/-bacteriological
confirmation & not yet completed a full course of treatment
with MDT. (prevalence)
6. DEFINITIONS
o Adequate T/t - completion of a regimen within a
reasonably short period of time.
o Regular T/t - received MDT for at least two-thirds of the months in
any interval of time.
o Defaulter - who has not collected treatment for 12 consecutive
months.
o Relapsed -therapy was terminated, having successfully completed
an adequate course of multidrug therapy, but who subsequently
develops new signs and symptoms
7. NLEP INDICATORS
o PR (Prevalence rate)
o ANCDR ( Annual New case detection rate)
o Multibacillary (MB) Proportion
o Female Proportion
o Child Proportion
o Grade II disability – disability proportion
o MDT completion rate (both PB & MB)
8. LEPROSY ELIMINATION
o Reducing the case load to less than 1 case per
10,000 inhabitants
o by detecting and curing all cases of leprosy
o leading to a reduction in the source of infection and the
disease burden in communities
o so that leprosy is likely to disappear naturally as it already
has from many countries
9. MILESTONES
1848 Leper Act, British India
1925 Indian council of british empire leprosy relief association established
(Belra)
1948 Renamed Hind Kusht Nivaran Sangh (HKNS)
1955 National Leprosy Control Programme (NLCP)
1981 MDT recommended by Who as a cure
1983 National Leprosy Eradication Programme (NLEP)
Introduction of MDT in Phases
10. MILESTONES
1991 World health assembly adopts resolution to eliminate leprosy by
2000.
1993 World bank supported MDT program phase I
1998-2004 Modified leprosy elimination campaign
2001-2004 NLEP project phase II
2002 Simplified information system
2004 Leprosy integrated with general health services
11. MILESTONES
2005 Achievement of elimination of leprosy at national level
NRHM covers NLEP
2006 DPMR inroduced as component of NLEP
2007 DPMR guideline for 1 2 & 3 level
2011 Guidelines of DPMR for NLEP revised
2012 Special action plan for 209high endemic districts in 16 states/ut
2016 Revised Operational guidelines for LCDC
2016-2020 Global leprosy Strategy
12. GLOBAL BURDEN
• The “Global leprosy update, 2014: Need for early case
detection” (Sept 2015)(121 countries from five WHO regions)
13.
14. LEPROSY ELIMINATION STATUS INDIA
(2014-2015)
PR 0.69/10,000 (inc 1.5%) ANCDR 9.73/100,000 ( dec 2.5%)
MB (52.82%) Female (36.81%)
Child (9.04%) Grade II deformity (4.61%)
34 states and UT has already achieved PR < 1case /10,000
One state ( Chhattisgarh) One UT (Dadar & Nagar Haveli) PR = 2 – 5 / 10,000
4 other States/ UT ODISHA, Chandigarh, Delhi and Lakshadweep achieved
elimination earlier ( PR =1-2/10,000)
532 districts(79.52%) out of 669 achieved PR < 1/10,000
Districts with PR 1-2 ( 7497) PR >2 (4140)
Out of total new cases 93.1% = RFT (Released from treatment) as cured.
15. MADHYA PRADESH
(MARCH 2015)
• Total 50 districts
Bhopal
Prevalence rate 0.76/10,000
New Cases 6921
ANCDR 9.02/100,000
Gr II Deformity 391
Deformity rate 5.09 per mil
Prevalence Rate 1.5/10,000
New Cases 307
ANCDR 12.26
Gr II Deformity 27
Deformity rate 10.78 per mil
16. RATIONALE FOR ELIMINATION
o Leprosy meets demanding criteria for
elimination
oPractical & simple diagnosis : Clinical signs alone
oAvailability of effective intervention – MDT
oSingle significant reservoir of infection – Human
17. TARGETS
INDICATOR BASELINE
2011-2012
Targets
By March 2017
Prevalence rate
< 1 /10,000
543 districts
(84.6%)
642 districts
(100%)
ANCDR
<10 /100,000
445 districts
(69.3)
642 districts
(100%)
Cure rate Multibacillary
cases (MB)
90.56% 95%
Cure rate paucibacillary
cases (PB)
95.28% 97%
Gr II disability cases in % of
new cases
3.04% 1.98%
(35% reduction)
Stigma Reduction % Reported
(NSS 2010-11)
50% reduction
18. STRATEGY
Decentralized Integrated leprosy services through general health care
system
Early detection and complete treatment of new leprosy cases
Household contact survey
Involvement of ASHA
Strengthening of Disability prevention and medical rehabilitation (DPMR)
Information Education and Communication (IEC) activities to improve self
reporting and reduction of stigma
Intensive monitoring and supervision at PHC /CHC
19. MAJOR INITIATIVES
More focus on new case detection > Prevalence
Treatment Completion rate by states at yearly basis
Contact survey each child / multibacillary case
Organize skin camps to detect case while providing services for
other skin conditions.
Increase awareness through ANM, AWW, ASHA motivation
for early reporting to MO.
District Leprosy Cell
20. o ASHA incentives
– Confirmation of diagnosis Rs. 250/- (without disability)
Rs. 200/- (with disability)
– Completion of full course PB Rs. 400/-
MB Rs. 600/-
Activities:
o Search for suspected cases before disability
o Follow-up of all cases for completion (reaction & referral)
o Self care practices Improves quality of life
o Spreading awareness
21. Disability Prevention & Medical Rehabilitation
(DPMR)
• Introduced in 2006
• Resposibility of DLO & MO of referral centre
Objectives
1. Adequately manage the occurrence of disabilities.
2. Assistance to persons with disabilities and prevent
worsening of existing disabilities.
3. Correction of deformities by ReConstructive Surgery (RCS)
22. Services
• Reaction Management
• Dressing material, supportive medicines and ulcer kits
• Microcellular rubber footware
• Self care practices
• Integrating DPMR services with NRHM (National Rural Health
Mission) facilities
• To develop a referral system
23. Referral services (3 tier system)
Primary
• PHC
• CHC
• Sub divisional hospitals
• Urban leprosy centres
Secondary
• District headquarter hospitals
• District Nucleus units
Tertiary
• Central Government Institutes
(CLTRI Chingalpettu)
(RLTRI at Aska/Gauripur/Raipur)
• ICMR Institute JALMA, Agra.
• ILEP supported Leprosy Hospitals.
• All PMR Institutes and departments of
medical colleges
24. Support Unit
o Orthopaedics and plastic surgery departments of medical colleges.
o Identified NGO institutions
o All National Institutes under Ministry of Social Justice
and Empowerment
o Contractual surgeons skilled in RCS and Rehabilitation
Programmes
Incentives
o Rs. 8000/- will be paid to all patients affected by leprosy undergoing major
reconstructive surgery
o Rs. 5000/- to all govt Institution for providing RCS
o Additional Rs. 5000/- for RCS in camps organised outside the institution.
25.
26. o SET Scheme
o NGOs are involved in disability prevention and ulcer care,
IEC & referral of suspected cases
o For under treatment cases in urban and difficult areas
o IEC(Information,Education & Communication)
o Focus on –
o Behavior change in community against stigma and
discrimination against leprosy affected person
o Making the public aware about
o The availability of MDT
o Correction of deformity through surgery
o Leprosy affected person can live a normal life with family
27.
28. NEWER INITIATIVES
o LCDC- Leprosy Case Detection Campaign
o To detect the missed leprosy cases
oInitially highly endemic districs of 7 States
oMadhya Pradesh, Uttar Pradesh, Bihar , Chhattishgarh ,
Jharkhand, Odisha & Maharashtra
oBy the end of 2016 , 163 highly endemic districts across
20 states/UT were identified (PR>1any of in last 3 years)
29. o SLAC – Sparsh Leprosy Awareness Campaign
o Launched on 30th January 2017
o To promote awareness and address the issue of stigma and
discrimination
o Chemoprophylaxis of Contacts
o Single dose Rifampicin (SDR)
o Overall risk reduction 57% during first 2 years
o LPEP launched globally (2014)
30. o Prime Components
o Contact tracing – regular or interrupted contact with index
case during the last 1 year.
o Screening
o SDR
o Doses
o In india – under progress in Dadar & Nagar Haveli
o Proposing to launch in districts where LCDC is ongoing
Weight Dose
>35 kg 600 mg
20 – 35 kg 450 mg
<20 kg 10-15 mg/kg
31. o Immunoprophylaxis
o MiP – Mycobacterium Indicus Prani
o Field Project mode in year 2016 under ICMR and NLEP
o Index case – over and above MDT
o Contacts – twice at an interval of 6 months
o Advantages
o Rapid clearance of bacteria and clinical lesions
o Upgraded the lesions histopathologically
o Complete clearance of granuloma
o Reduced reactions and neuritis
o Reduced the duration of MDT
32. o Nikusth
o A web based reporting system
o Reporting and data management of registered
o Keeping track of all the activities being implemented under
NLEP
o News letters
o Quarterly issue by NLEP launched in Jan 2016
o GIS mapping
o Study and project the geographic distribution of disease
33. Need for classification
o Wide variation in the disease presentation, its course,
prognosis and complications
o Decide the line of treatment
o Visualize beyond the present stage of the disease
o Educate the patient and plan for future to prevent deformities
o Determine the infectivity of case
34. Criteria
o Bacteriological criteria
o BI – density of organism in lesional tissue
o Slit smear (gold standard) infective/non infective
o Biopsy (more sensitivie)
o Immunological criteria
o CMI against M. leprae by lepromin test
o Predictor of the course of disease
o Useful in classsifying difficult to classify cases
35. o Histopathological
o Tissue reaction to the injury or insult
o Precisely defined and most definitive
o Tedious to perform, not practicable to apply universally
o Clinical
o Easiest to apply
o Most desirable
36. Madrid classification (1953)
Two types Two groups
Lepromatous type (L)
Macular
Diffuse
Infiltrated
Nodular
Neuritic
Indeterminate group (I)
Macular
Neuritic
Tuberculoid Type (T)
Macular
Minor tuberculoid
Major tuberculoid
neuritic
Borderline ( Dimorphous)
Infiltrated
others
41. o Advantages:
o Easier to comprehend
o Helps to understand the disease in better way
o Based on correlationship of various parameters
o Strengthens the polar and spectral concept
o Drawback
o No specific place for indeterminate and pure neuritic
42. POLAR AND SUBPOLAR FORMS
o LL pole – heterogenous
o LLp stabl,starts as LL and remains the same
o LLs (L1/leproma indefinite) unstable , can upgrade or
originated from downgrading
o TT pole
o TTp originates as polar
o TTs can arise by upgrade or can downgrade
43. WHO 1998
o Paucibacillary
o Only smear negative cases
o Ridley jopling – TT & BT
o Madrid – I & T
o Multibacillary
o Ridley Joplings – BB, BL, LL
o Madrid – B & L
o Any other smear positive case
44. CLASSIFICATION UNDER NLEP(2009)
Characteristics PB MB
Skin lesions One to five lesions
(including single nerve
lesion if present)
Six and above
Peripheral nerve
involvement
No nerve/only one
nerve with or without
one to five lesions
More than one
nerve irrespective
of the number of
skin lesions
Skin smears Negative at all sites Positive at any site
