National Leprosy Eradication Program(NLEP)-1.pptx

Nlep

1. National Leprosy Eradication Program(NLEP ) + Classification of Leprosy DR. ANIL GOUR PG 2 nd Year

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 NLEP was launched in 1983 Centrally sponsored health scheme (MOHFW) Headed by – deputy director of health services(leprosy) under DGHS Supported as partners by World Health Organization The international federation of Anti Leprosy Association (ILEP) Non-Govt. Organizations

4. THE EMBLEM Symbolizes Beauty and purity in lotus Leprosy can be cured and a leprosy patient can be a useful member of the society in the form of a partially affected thumb . Normal fore finger representing the shape of house Rising sun – the symbol of hope and optimism

5. DEFINITIONS Control - disease agent is permitted to persist in the community at a level where it ceases to be a public health problem. Elimination -Interruption of transmission of disease Eradication - Termination of all transmission of infection by extermination of the infectious agent Case : A person showing clinical signs +/-bacteriological confirmation & not yet completed a full course of treatment with MDT. (prevalence)

6. DEFINITIONS Adequate T/t - completion of a regimen within a reasonably short period of time. Regular T/t - received MDT for at least two-thirds of the months in any interval of time. Defaulter - who has not collected treatment for 12 consecutive months. Relapsed - therapy was terminated, having successfully completed an adequate course of multidrug therapy, but who subsequently develops new signs and symptoms

7. NLEP INDICATORS PR (Prevalence rate) ANCDR ( Annual New case detection rate) Multibacillary (MB) Proportion Female Proportion Child Proportion Grade II disability – disability proportion MDT completion rate (both PB & MB)

8. LEPROSY ELIMINATION 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. 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. 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 ( 74 97) PR >2 (4140) Out of total new cases 93.1% = RFT (Released from treatment) as cured.

14. 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

15. RATIONALE FOR ELIMINATION Leprosy meets demanding criteria for elimination Practical & simple diagnosis : Clinical signs alone Availability of effective intervention – MDT Single significant reservoir of infection – Human

16. 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

17. 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

18. 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

19. ASHA incentives Confirmation of diagnosis Rs. 250/- (without disability) Rs. 200/- (with disability) Completion of full course PB Rs. 400/- MB Rs. 600/- Activities: Search for suspected cases before disability Follow-up of all cases for completion (reaction & referral) Self care practices  Improves quality of life Spreading awareness

20. Disability Prevention & Medical Rehabilitation (DPMR) Introduced in 2006 Resposibility of DLO & MO of referral centre Objectives Adequately manage the occurrence of disabilities. Assistance to persons with disabilities and prevent worsening of existing disabilities. Correction of deformities by ReConstructive Surgery (RCS)

21. 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

22. Referral services (3 tier system)

23. Support Unit Orthopaedics and plastic surgery departments of medical colleges. Identified NGO institutions All National Institutes under Ministry of Social Justice and Empowerment Contractual surgeons skilled in RCS and Rehabilitation Programmes Incentives Rs. 8000/- will be paid to all patients affected by leprosy undergoing major reconstructive surgery Rs. 5000/- to all govt Institution for providing RCS Additional Rs. 5000/- for RCS in camps organised outside the institution.

24. SET Scheme NGOs are involved in disability prevention and ulcer care, IEC & referral of suspected cases For under treatment cases in urban and difficult areas IEC( Information,Education & Communication) Focus on – Behavior change in community against stigma and discrimination against leprosy affected person Making the public aware about The availability of MDT Correction of deformity through surgery Leprosy affected person can live a normal life with family

25. NEWER INITIATIVES LCDC - Leprosy Case Detection Campaign To detect the missed leprosy cases Initially highly endemic districs of 7 States Madhya Pradesh, Uttar Pradesh, Bihar , Chhattishgarh , Jharkhand, Odisha & Maharashtra By the end of 2016 , 163 highly endemic districts across 20 states/UT were identified (PR>1any of in last 3 years)

26. SLAC – Sparsh Leprosy Awareness Campaign Launched on 30 th January 2017 To promote awareness and address the issue of stigma and discrimination Chemoprophylaxis of Contacts Single dose Rifampicin (SDR) Overall risk reduction 57% during first 2 years LPEP launched globally (2014)

27. Prime Components Contact tracing – regular or interrupted contact with index case during the last 1 year. Screening SDR Doses In india – under progress in Dadar & Nagar Haveli 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

28. Immunoprophylaxis MiP – Mycobacterium Indicus Prani Field Project mode in year 2016 under ICMR and NLEP Index case – over and above MDT Contacts – twice at an interval of 6 months Advantages Rapid clearance of bacteria and clinical lesions Upgraded the lesions histopathologically Complete clearance of granuloma Reduced reactions and neuritis Reduced the duration of MDT

29. Nikusth A web based reporting system Reporting and data management of registered Keeping track of all the activities being implemented under NLEP News letters Quarterly issue by NLEP launched in Jan 2016 GIS mapping Study and project the geographic distribution of disease

30. Need for classification Wide variation in the disease presentation, its course, prognosis and complications Decide the line of treatment Visualize beyond the present stage of the disease Educate the patient and plan for future to prevent deformities Determine the infectivity of case

31. Criteria Bacteriological criteria BI – density of organism in lesional tissue Slit smear (gold standard)  infective/non infective Biopsy (more sensitivie ) Immunological criteria CMI against M. leprae by lepromin test Predictor of the course of disease Useful in classsifying difficult to classify cases

32. Histopathological Tissue reaction to the injury or insult Precisely defined and most definitive Tedious to perform, not practicable to apply universally Clinical Easiest to apply Most desirable

33. 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

34. Indian Classification (1955) Lepromatous (L) Tuberculoid (T) Maculoanesthetic (MA) Non Lepromatous Polyneuritic (P) Borderline (B) Indeterminate (I)

35. New IAL Classification (1981) Lepromatous (L) Tuberculoid Polyneuritic (P) Borderline (B) Indeterminate (I) Tuberculoid Maculoanesthetic

36. Ridley Jopling Classification Immunological classification Spectral concept of leprosy

37. Ridley Jopling Classification

38. Advantages : Easier to comprehend Helps to understand the disease in better way Based on correlationship of various parameters Strengthens the polar and spectral concept Drawback No specific place for indeterminate and pure neuritic

39. POLAR AND SUBPOLAR FORMS LL pole – heterogenous LLp  stabl,starts as LL and remains the same LLs (L1/ leproma indefinite)  unstable , can upgrade or originated from downgrading TT pole TTp  originates as polar TTs  can arise by upgrade or can downgrade

40. WHO 1998 Paucibacillary O nly smear negative cases Ridley jopling – TT & BT Madrid – I & T Multibacillary Ridley Joplings – BB, BL, LL Madrid – B & L Any other smear positive case

41. 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