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.

• Leprosy

• Eradication

• Program

• 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

• 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

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.

• 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

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

• 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).

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

National Leprosy Eradication Program

• 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.

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.

• 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

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

• 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)

• 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)

LESSONS LEARNT FROM NLEP

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

• 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.

• 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

• 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

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.

• 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.

• 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.

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.

• 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

• 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.

• (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

• 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.

• 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.

• 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.

• 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.

• 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.

– 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

• 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

• 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

• 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.

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.

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

• 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.

• Logic suggests that all disease control program shouldprovide– Continuous measurement of disease incidence and

prevalence.–Measurement should dictate changes in stratergy

and tactics.

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.

• 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

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.

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.

• 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

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

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

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

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.

• 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

• 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.

• 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.

• 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.

• 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.

– 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.

References

• http://www.who.int/lep/en/ 09/10/2013, 21.00hrs

• http://www.who.int/mediacentre/factsheets/fs101/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

Thank you