National Leprosy Eradication Programme

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G. H. A. Hansen (1841-1912) G. H. A. Hansen (1841-1912)
Historical Background/Periodical Development
Prior to formation of Separate state, Maharashtra was the part of Bombay Province till 1960. Post of State Leprosy Officer was in existence since 1943 and was filled in 1949, the main duty then included advising the Govt. on leprosy services based on sample surveys conducted by him. Then the available leprosy services included leprosy asyla run by missionaries to provide sheltered segregation and treatment with hydnocarpus oil. In 1951 treatment with sulphones was initiated.

1942 Leprosy Hospital at Kondhawa taken over by Govt. from the " Mission to Lepers".
1944 Leprosy Hospital Ratnagiri taken over by Govt. from District Local Board.
1950 Scheme for Leprosy Control Work in a limited area under Hind Kushtha Nivaran Sangh.
1953 Leprosy Control Centre established at Ambewadi in district Sangali. Pilot projects for leprosy control started at Vairag dist. Solapur, Mul dist. Chandrapur, Sevagram dist. Wardha.
1955 Treatment with DDS tablets introduced in all local bodies and Govt. hospitals, 1st documentary film on leprosy prepared by Directorate of Publicity. Greater Bombay Leprosy Control Scheme of Bombay Municipal Corporation in collaboration with Gandhi Memorial Leprosy Foundation and State Govt.
1955 – 56 Launch of National Leprosy Control Program throughout the country including state with following principles

i) Detection of all cases especially those of the infectious type at as early as possible

ii) Provision of treatment facilities to all patients so detected and

iii) Health Education to create a favorable atmosphere which will help both in case detection as well as case holding program.
1958 SET centre attached to existing dispensaries and centres started. Thereafter with every 5 year plan SET centres, leprosy control units and urban leprosy centres were established in the entire state.
  Post of state leprosy officer was upgraded to Deputy Director (Health) in 1965 and further upgraded to Joint Director (Health) in 1981


Milestones of NLEP in Maharashtra
1955 – 1956 launch of National Leprosy Control Programme.
1970s Definite cure through MDT was identified
1983 launching of National Leprosy Eradication Programme., Multi Drug Therapy introduced in selected urban area & Wardha district.
1983 – 1997 Remaining districts brought under MDT in phased manner.
1993 – 2000 World Bank Assisted NLEP Project Phase – I

Objectives
1. To support vertical programme structure for endemic dists.
Jan. 1997: Implementation of National Leprosy Elimination.
2. Establishment of Mobile Leprosy Treatment Unit (MLTU) in moderate & low endemic dists.
3. Formation of district leprosy societies.
Jan. 1997: Implementation of National Leprosy Elimination

Strategy
Main Activities–Programme renamed as National Leprosy Elimination Programme with an objective to bring down the P R of leprosy to below 1 per 10,000 population.
1998 Introduction of ROM in the state.
30 Jan 98–5 Feb 98 1st Modified Leprosy Elimination Campaign
 
Main Activities 3 day technical training for GHCS staff, One month IEC Campaign, Active leprosy search with the help of GHC staff
30 Jan 99 – 5 Feb 99 Additional M L E C (1998–99) GOM
30 Jan 2000–6 Feb 2000 II M L E C (1999–2000) GOI
30 & 31 Jan 2000 V R C
Oct 2000 – Mar 2004 World Bank Assisted NLEP Phase–II
2001 – 2002 III M L E C, V R C – 30th &31st Oct.2001
2002 – 2003 IV Modified Leprosy Elimination Campaign.
2003 – 2004 V Modified Leprosy Elimination.
2004 – 2005 Block Leprosy Awareness Campaign
2005 – 2006 Block Leprosy Awareness Campaign II
2005 – 2007 Extended Leprosy Eradication Programme


Objectives
  1. Leprosy patient Leprosy patient
    To reduce the load of infection in community by converting the bacteriologically positive cases to bacteriological negativity in order to interrupt the transmission of infection in the community.
  2. To reduce the prevalence rate of leprosy to a level when leprosy is no longer a major public health hazard i.e less than one case per 10,000 population.
  3. Ultimately to rid the country of the disease.
National Leprosy Control Programme was redesignated as National Leprosy Eradication Programme in 1983 with the introduction of MDT.

The objectives of National Leprosy Eradication Programme
  1. Early detection of leprosy cases.
  2. All detected leprosy patient should be brought under regular treatment so as to break the chain of transmission and to cure them without deformity.
  3. Health education regarding scientific information of Leprosy should be given to the leprosy patients, his family and society.
In 1993 to give a boost to NLEP, World Bank Assisted Project was initiated in two phases. Phase I and Phase II objectives are as follows

World Bank Assisted NLEP Project Phase - I
Objectives
  1. To support vertical programme structure for endemic districts.
  2. Establishment of Mobile Leprosy Treatment Unit (MLTU) in moderate and low endemic districts.
  3. Formation of district leprosy societies.
World Bank Assisted NLEP Project Phase- II
Objectives
  1. To achieve elimination by the end of 2005.
  2. To rapidly & effectively integrate vertical programme of leprosy eradication with general health care system. To achieve these objective emphasis should be laid on following points.
    • To detect new cases (Tribal, Difficult Hilly area) at the early stage.
    • To bring them under MDT.
    • To provide health education.
    • Render services of POD to avoid deformity.
    • To provide physiotherapy to needy leprosy patients.
    • To perform reconstructive surgery on needy leprosy patients.
Targeted Milestones for Maharashtra Upto 2012

Mile stones Mar.04 Mar. 05 Dec.05 Mar.06 Mar.07 Mar.09 Mar.12
PR/10000 2.87 1.57 0.94 0.88 0.7 0.6 0.5
No.of districts having PR<1 0 0% 7 20% 29 85% 34 100% 34 100% 34 100% 34 100%
No.of Municipal Corporations having PR<1 1 5% 8 36% 22 100% 22 100% 22 100% 22 100% 22 100%
No. of Blocks having PR <1 33 9.73% 78 23% 118 33% 152 45% 203 60% 271 80% 339 100%
No. of PHCs 232 578 982 1160 1340 1518 1786
having PR<1 -13.06% -32.36% -55% -65% -75% -85% -100%
NCDR 4.3 3.11 1.59 1.59 1.14 0.8 0.75
SC NCDR 5.59 4.54 2.12 2.12 1.53 1 0.75
SC NCDR 7.84 6.91 3.4 3.4 2.45 1.25 0.75
MB proportion of New cases 32.12 36.84 55 55 60 65 70
Disability proportion 1.31 1.3 1 1 0.8 0.5 0.4
Female proportion 40.96 42.13 44 44 45 50 50

Strategy of National Leprosy Eradication Programme
  1. No active searches except for high Prevalence Rate (PR) pockets, Modified Leprosy Elimination Campaign (MLEC), SAPEL/LEC.
  2. Full integration of anti-leprosy activities with GHS in rural as well as urban area.
  3. The Male MPW will include leprosy work in his activities with emphasis on case finding, defaulter identification, health education. The female MPW/ANM and the AWW will refer suspected cases. Treatment follow up will be carried out by the male MPW every month at village and sub centre level. He will also advise new patient and provide POD services.
    4. Leprosy Victims Leprosy Victims
  4. General hospitals, CHCs, PHCs, additional PHCs and dispensary centres will offer leprosy diagnosis and treatment facilities independently. One PME/NMS will be appointed in blocks with high endemic pockets for guidance and support.
  5. Promotion of voluntary reporting by creating enhanced awareness among masses.
  6. Availability of MDT services upto sub-centres.
  7. Accompanied MDT was needy persons.
  8. MDT management at all the health facilities.
Activities
Leprosy Eradication Leprosy Eradication
Establishing and Strengthening of State Leprosy Society (SLS)
The State Leprosy Society has been established on 11th July 2001 under the chairmanship of the Principal Secretary Public Health Department, Maharashtra State, for monitoring and guidance to the District Leprosy Societies. For close monitoring and smooth channelization of MDT funds to the District Leprosy Societies, Budget and Finance Officer and Data Entry Operator, one each, have been appointed on contract basis.

Strengthening of Sample Survey Assessment Unit (SSAU)
The existing SSAU has been strengthened by appointing Epidemiologist & Data Entry Operator, one each, from the World Bank Assistance.

Leprosy Eradication Leprosy Eradication
Training
3 days modular technical training in leprosy was imparted to all general health care staff as a part of integration.

Modified Leprosy Elimination Campaign (MLEC)
With following objectives
  1. To carry out intensive awareness campaign about leprosy in the community.
  2. Detection of hidden leprosy patients and MDT coverage immediately through Voluntary Reporting Centres (VRC) and Active Searches. During MLEC V 4504 VRCS were organized in the state.
Out of the 109119 suspected cases, 2920 new cases were confirmed . Total 5826 cases were detected during V MLEC including active search (4331 PB & 1495 MB cases).

100% validation of all newly detected cases has been accomplished throughout the State except Thane (50% only).

Block Leprosy Awareness Campaign (BLAC)
Two such campaigns were taken up in Nov. 04 and Sept. 05 respectively to provide intensive IEC, leprosy diagnosis, treatment and counseling services in tribal blocks.
Services to Common People
A. Case Detection through
Active Surveys of all sorts have been banned by G O I

B. MDT C. I E C Activities: By G H C & NLEP staff, N G Os D. Prevention of impairment and disabilities (POID)
Deformities and disabilities contribute to the existence of Social Stigma against the disease. Intervention at the right time will prevent occurrence or worsening of deformity and disability. Hence “Care after cure” of deformed patient is a challenge of the decade.

POID at the start and during MDT call for proper recording of base– line information about nerve function, detection and high risk cases and management of reactions. Health education, training of paramedical staff and resources are essential for success of POID. Referral options for specialist POID care are imperative to make an integrated leprosy control system work. For POID, after chemotherapy , the patients must be empowered to understand when and where to request for care of the complications due to leprosy if they arise. High risk cases need periodic follow–up examinations. Patients with established disabilities should receive continued care.

To achieve the concept of “Deformity free patients” POD (Prevention of Deformity) training to selected GHCS staff through POD camps in each district has been initiated.

Key trainers’ training has been organised for faculties In each district 2 POD camps per block are scheduled, 638 completed out of 710 camps in the state. Necessary financial assistance for POD is assured by Govt. of India @ Rs.3150 per camp.

E. Rehabilitation: Medical, Social & Economic
Planning for Rehabilitation
The immediate need is reliable information on practically all aspects of the rehabilitation of leprosy– affected/cured persons for any given area. For this purpose it is probably best to take the district as a unit. Following information shall be needed for this purpose.

Deformity profile
Distribution of sites of loss of sensibility, nature of visible impairments, State of eyes and; presence of ulcer and scars in the feet of the subjects.

Demographic data on the leprosy
affected/cured persons including their family details & mode of subsistence and sources of income.

Information
about affected individuals and their families, their overall socio–economic status and dyshabilitation status” (or participation– limitation status); determining their rehabilitation potentials as per their perceived needs; the physical consequences of the disease, & their activities of daily life (mainly their occupation).

Identify and evaluate
availability and usefulness of the rehabilitation recourses in the immediate neighbourhood and in the district.

Corrective Surgery
Assessment of the fitness and willingness of corrective surgery of the visibly impaired individuals.

The rehabilitation project should be a well planned, time–bound and target–oriented programme and should also cover the “Unrehabilitable” to ensure a minimum level of economic security, including food security for this group.

Simultaneously extensive & initially intensive social awakening programme, using all available strategies and resources should be carried out to touch all levels of the society.

Rehabilitation activities will have to address three different issues, namely
  1. Impoverishment of the affected individual and his/her family.
  2. Activity limitations of affected persons and
  3. Participation restriction involving the affected person and their families.
Urban areas
States health departments generally do not have comprehensive health infrastructure in urban areas. Various authorities and public/private sector agencies have jurisdiction in urban areas, but usually have a very limited health setup. Localized approaches will need to be developed for service delivery in urban areas. These could include

Female patients
Identification of female patients has been a major problem, particularly since almost all leprosy workers are male. During the MLECs it has been the experience that involvement of female community level workers considerably helped to improve access to women, particularly in rural areas. It is envisaged that integration will make it easier to involve female providers and community based workers in helping to detect female patients. Also, for improving case finding in general and identifying female patients in particular, efforts will be made to involve women’s groups, school students suitable NGOs and other such agents.

Management of migratory patients
Migration of patients leads to disruption in the course of treatment. While a few of the patients may get registered elsewhere, the majority may be lost forever, resulting in deterioration of their condition. Such groups may include seasonal, agricultural or industrial labour, or other nomadic group and such groups should be Role of State leprosy cell/health department Service Centers Available in each District
Leprosy Eradication Work was being performed by following institution under State Govt.

Sr. No. Name of Center Existing No.
1 Urban Leprosy Centres (being merged in dist. nucleus) 428
2 Supervisory Urban Leprosy Unit at urban towns with population > 5 23
3 Leprosy Training Centers (Pune ,Nagpur) 2
6 Govt. Leprosy Hospital (Ratnagiri, Osmanabad, Kolhapur, Pune) 4
7 Temporary Hospitalization Ward at selected civil hospitals ( merged in general wards) 3
8 Non Governmental Organization 46
  SET 10
  Rehabilitation 18
  Hospitals 18
9 RCS Units 
Anandvan, Varora. Chandrapur,
Richardson Leprosy, Miraj, dist. Sangli
Dr. Bandorwala Leprosy Hospital Pune,
Acworth Leprosy Hospital, Vadala, Mumbai
J.J.Hospital, Mumbai
Vimala Dermatological Center,Versova, Mumbai
Leprosy Mission, Kothara, Amaravati All General Hospitals & Govt. Medical Colleges being equipped to provide RCS services in near future		 7

Special Features of National Leprosy Eradication Programme
  1. Only clinical diagnosis.
  2. No bacteriological examination.
  3. No registration without confirmed diagnosis.
  4. Active survey banned.
  5. Promoting voluntary reporting through IEC.
  6. Identification of suspect cases through regular home visits.
  7. SAPEL/LEC for unreached rural and urban areas.
  8. Accompanied MDT.
  9. Simplified information system of 11 indicators.
  10. MDT made available at all Govt./Semi Govt. Hospitals/Health Centres/Dispensaries.
  11. General practitioners being motivated to start anti leprosy services, MDT drugs to be arranged by state.
  12. Training of untrained General Health Care Staff including Medical Officers.
  13. Emphasis on IEC.
Leprosy VictimsLeprosy PatientsLeprosy Patients
Leprosy Patients

Region wise Performance of National Leprosy Eradication Programme
Performance 2008 –2009 (September, 2008)

Circle Active Cases PR/10,000 NCD Oct. 07 to Sept. 08)
Mumbai 2640 0.96 3880
Nasik 1604 0.88 2118
Pune 809 0.51 1172
Kolhapur 327 0.41 466
A’BAD 465 0.58 706
Latur 714 0.72 976
Akola 904 0.79 1276
Nagpur 1824 1.48 2678
State total 9287 0.83 13272

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District Wise Performance of National Leprosy Eradication Programme
District Wise 2008-09 (Aug. 2008)

SR. NO. District Active Cases PR/10,000
1 Raigad 431 1.7
2 Ratnagiri 75 0.38
3 Thane 968 2.49
4 Thane Corp 103 0.71
5 Kalyan Corp 86 0.63
6 New Bombay 68 0.84
7 Ulhasnagar Corp. 56 1.03
8 Mira Bhyander 35 0.58
9 Bhivandi 57 0.83
10 Gr. Bombay 761 0.55
11 Dhule 221 1.4
12 Dhule Corp. 40 1.02
13 Nandurbar 182 1.21
14 Jalgaon 417 1.09
15 Jalgaon Corp. 35 0.83
16 Nasik 330 0.82
17 Nasik Corp 172 1.39
18 Malegaon Corp. 47 1
19 Ahmednagar 146 0.35
20 Ahmednagar Corp. 14 0.24
21 Pune 195 0.46
22 Pune Corp 129 0.44
23 P.C.M.C. 100 0.86
24 Solapur 151 0.44
25 Solapur Corp 42 0.42
26 Satara 192 0.6
27 Kolhapur 150 0.43
28 Kolhapur Corp 32 0.57
29 Sangli 52 0.21
30 Sangli Corp. 39 0.78
31 Sindhudurg 54 0.54
32 Aurangabad 102 0.43
33 Aurangabad Corp. 48 0.48
34 Jalna 107 0.58
35 Parbhani 152 0.88
36 Hingoli 56 0.49
37 Latur 138 0.58
38 Beed 201 0.81
39 Osmanabad 128 0.75
40 Nanded 213 0.76
41 Nanded Corp. 34 0.69
42 Akola 106 0.77
43 Akola Corp. 49 0.97
44 Washim 108 0.92
45 Amravati 145 0.61
46 A'wati Corp. 45 0.71
47 Buldhana 164 0.64
48 Yeotmal 287 1.01
49 Bhandara 263 2.01
50 Gondia 249 1.8
51 Chandrapur 459 1.92
52 Gadchiroli 249 2.23
53 Nagpur 229 0.99
54 Nagpur Corp 176 0.74
55 Wardha 199 1.4
State Total 9287 0.83

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Expected Community Participation
Community Participation Community Participation
Community Participation Community Participation
Community Participation
Active involvement and support to the programme through
  1. Acquiring basic information on leprosy disease : causation, transmission, treatment, prevention from all available sources viz. health workers, publicity media etc.
  2. Self empowerment on early diagnosis of leprosy patches by inspection of whole body once in six months either with the help of full size mirror or close relatives.
  3. Neither fear a leprosy patient nor to stigmatise the patient even with deformities.
  4. Contribute their might to rehabilitation of leprosy cured persons.
  5. Those who are diagnosed as cases of leprosy should.
    i) Accept leprosy on par with any other disease.
    ii) Regular and 100% compliance with treatment.
    iii) Educate the community members on leprosy basics.
    iv) Follow self care practices for prevention and control of deformity.
  6. Early voluntary reporting and regular treatment completion.
  7. Minimization of stigma.
  8. Acceptance of Leprosy affected persons without prejudice/discrimination.
  9. Motivation of hidden cases to report for treatment.
Achievements of National Leprosy Eradication Programme

Year PR/1 Lac NCDR/1 Lac
1981–82 624 133
1990–91 196 119
1993–94 87 105
2000–01 31 45.5
2001–02 32.7 49.9
2002–03 29.5 48.2
2003–04 28.7 43
2004–05 15.7 31.1
2005–06 6.4 12.9
2006–07 6.1 10.2
2007–08 7.10 11.12
2007–08 (Upto Sept..08) 0.83 11.91

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Role of NGOs
  1. 43 NGOs are actively participating in anti leprosy activities. 10 NGOs work on SET pattern, receive Grant in Aid from GOI directly. 12 NGOs receive funds from ILEP agencies directly.
  2. 17 NGOs work on Hospital Pattern and receive GIA from Govt. of Maharashtra @ Rs.480/bed/month.

    Total number of sanctioned beds in the State are 3171. The patients are hospitalized for treatment of reactions, ulcers, nerve involvement and other complications.
  3. 18 NGOs work for Rehabilitation. They receive GIA from Govt. of Maharashtra @Rs.450/– bed/month.

    Total No of Beneficiaries in the state are 2075. These NGOs provide the protective aids like MCR Chappals, Splints and Goggles, Physiotherapy, Reconstructive Surgery, Vocational Training, Socio economic rehabilitation etc to the patients as per their need.
  4. 2 LRPUs (Leprosy Rehabilitation Promotion Unit) working in the state.
The following activities are entrusted to NGOs in the state
Sr. No. Name of N.G.O. District
1 Vidarbha Maharogi Seva Mandal, Tapovan Amravati
2 Kushtrog Nivaran Samiti, Shantivan Nere Raigad
3 Sarvali Leprosy Welfare Centre,Saravali Thane
4 Kushtrog Nivaran Davakhana, Vadoli Thane
5 Loknayak Jayprakash Narayan, Vasai Thane
6 Anandgram Society, Dudulgaon Pune
7 Sanatorium for leprosy patient, Veermandki Pune
8 Udyog Dham Badrikashram Kushtrog Punarvasan Sanstha, Talegaon Pune
9 Goraput Punarvasan,Wadala  Ahmednagar
10 Ahmednagar District Leprosy Rehabilitation association Ahmednagar
11 Late Karandikar Guruji Balsadan, Savedi Ahmednagar
12 Hanson Memorial Society, Velu Satara
13 Navnirman Samaj Seva Sangh Dhule
14 Marathwada Lokseva Mandal, Nerli * Nanded
15 Richardson Leprosy Hospital, Miraj ** Sangli
16 Maharogi Ashram Kushtsudhar Mandal, Dhamangaon, Kashikhed Amravati
17 Kothara Leprosy Hospital, Achalpur Amravati
18 Leprosy Relief & Rehabilitation Centre, Nimbhora Amravati
19 Maharogi Seva Samiti, Anandvan Warora Chandrapur
20 Mahatma Gandhi Shikshan Sanstha,Chavarda Buldhana
21 Maharogi Seva Samiti, Dattapur Wardha
22 Gandhi Memorial Leprosy Foundation, Hindi Nagar Wardha
23 Eduljee Fremeji Leprosy Home, Traumbe Mumbai
24 Adams Wylie Leprosy Hospital, Mumbai Central (B.L.P.) Mumbai
25 Gurudev Kushtrog Mandir, Amla Vishweshwar. Amravati
26 Ramdevbaba Manav Seva Kushtrog Kendra, Vani Yavatmal
27 Ashwini Medical Foundation, Chinchwad Pune
28 Dr. Babasaheb Ambedkar Medical Trust Pune
29 Ashok Kala Niketan,Dapodi Pune
30 Akhil Bhartiya Kushtrog Nivaran Samiti, Shirur Pune
31 Ackworth Leprosy Hospital, Vadala. Mumbai
32 Hind Kusht Nivaran Sangh, Vadala Mumbai
33 Maharashtra Lokhit Seva Mandal Mumbai
34 Society for Eradication of Leprosy Mumbai
35 Lok Seva Sangam, Sion Mumbai
36 Alert India, Sion Mumbai
37 Dr. Bandorwala Hospital, Kondhwa Pune
38 Pune District Leprosy Committee Pune
39 Dnyan Prabodhini, Khed Shivapur Pune
40 Vikas Sadhak Vahini Pune
41 A.H.M. India Pune
42 Leprosy Mission Hospital, Poladpur Raigad
43 Abhinav Dnyan Mandir, Karjat Raigad
44 Mahatma Gandhi Mission Hospital, C.B.D. Belapur Raigad
45 Mukt Jivan Centre, Shahapur Thane
46 Solapur Comprehensive Leprosy Project Solapur
47 Leprosy Hospital, Solapur Solapur
48 A.C.C. Sevadham Nagapalli Gadhchiroli
49 Pralhad Ruikar Trust, Lanza Yavatmal
50 Vimala Dermatological Centre, Varsova. Mumbai
51 Society for Research Rehabilitation & Education, Vadala. Mumbai
52 Sevadham Trust, Pune Pune

* This NGO also gets grants under Leprosy Rehabilitation & Promotion Unit (LRPU).

** This NGO works as training Centre as well as Leprosy Rehabilitation & Promotion Unit (LRPU).
Important Health Education Messages Role of other Sectors
  1. Role of other Sectors
    Department of Social Justice: To co–ordinate all State Govt. departments in extending available benefits to leprosy afflicted persons in the state, to disburse available grants for various social welfare schemes.
  2. Department of Education: To incorporate lessons on leprosy in the curriculum of school children.
  3. Food and Civil Supplies: To provide benefits under schemes like Antyoday Anna Yojana to deserving leprosy patients.
  4. Department of Urban Development: To provide necessary facilities under schemes like Valmiki Ambedkar Awas Yojana, Slum Improvement Act. Priority employments to leprosy affected persons and their dependants etc.
  5. State Transport Corporation: To co–ordinate efforts of health department in health education viz. allowing various advertisements on leprosy to be displayed in ST stands, Buses. Provide travel concessions to leprosy affected persons.
  6. Information and Publicity: To provide wide publicity to health educational programmes in leprosy.
  7. Prasar Bharati: To broadcast various programmes on health education in leprosy.
  8. Railways: To provide travel concessions to eligible leprosy affected persons. To help in generating awareness by assisting in various programmes of IEC.
Impact