Since leprosy was declared eliminated in India in 2005, new cases have remained relatively steady; however, an advisory from 2016 from the office of the Director General for leprosy highlighted some concerning trends.
Challenges and Achievements
One of the primary challenges faced by NLEP was quickly and accurately detecting new cases as soon as they emerged, especially in remote, rural areas where cases often cluster among families or communities and remain hidden for extended periods. To improve detection, innovations like multi-drug therapy (MDT) with dapsone, rifampicin and clofazimine were implemented in 2015. Household contact surveys were initiated in 2016 in order to locate unreported and undetected leprosy patients and enhance active case detection by utilising general healthcare services like RBSK (for children under 18), RKSK and CPHC-Ayushman Bharat services among others.
These innovations had an immediate effect, with new cases declining significantly and those suffering Grade II Disability (G2D), or visible deformity, decreasing significantly. Unfortunately, however, funding for leprosy has fallen since India was declared free from leprosy in 2005 - necessitating funds being diverted away from leprosy-specific programs to support other areas of general healthcare; Leprosy charities contend this has limited their ability to fund operations that may save lives.
Data at the state level reveal that leprosy remains highly concentrated across certain states and Union Territories, particularly Dalit and Adivasi communities in Tripura where three out of every four new cases were in these communities - due partly to inattention at state-level and issues associated with data collection.
While these challenges remain, the Government is taking strides to overcome them. Decentralizing planning and monitoring NLEP at district levels as part of Ayushman Bharat implementation. State- and district-level administrators, ASHAs and health workers have played key roles in making India's program successful; their contributions will ensure leprosy elimination occurs soon enough.
India's Fight Against Leprosy
Leprosy prevalence rates have seen dramatic reductions due to ambitious World Health Organization (WHO) elimination goals and concerted efforts of many affected nations, but prevalence rates still exist in some geographic regions more than others. Mycobacterium leprae, the causative organism behind leprosy, spreads slowly; health workers may take years before discovering a new infection; even once diagnosed, many continue spreading it through everyday contact; however multidrug therapy (MDT) treatments provide safe and effective care that prevents future outbreaks while also reducing risks from complications that might otherwise ensue from spreading it further.
However, there remains an obstacle in terms of diagnosis and treatment that prevents us from completely eliminating the disease: treatment typically lasts six to 12 months with regular monitoring for any recurrences or drug-resistant strains; all patients must receive their full course of MDT; however there are barriers which prevent this, including that only a minority of cases are identified each year as well as being disreferred by local health workers or unable to afford their medications.
Another barrier associated with leprosy is stigma and discrimination, despite efforts to minimize it in certain places. Many infected with the disease try to keep their condition a secret due to fear of discrimination or exclusion from social activities and employment opportunities.
India has made significant advances in its fight against leprosy. National and local initiatives and campaigns undertaken over recent years are aiding in improving detection and response times, decreasing cases with deformities, and increasing access to adequate medical treatment.
India must focus its efforts on policy changes and maintaining high-quality services. In particular, its government should prioritize repealing discriminatory laws and eliminating stigma; also improving its capacity to detect new infections while also identifying those at highest risk of recurrence.
The Role and Impact of NLEP
Leprosy is a chronic disease with an extended incubation period and takes time for infected individuals to progress to clinical cases, necessitating swift detection systems to stop transmission in communities and stop leprosy's spread. Unfortunately, Sengupta points out, this hasn't happened adequately across India and as a result leprosy still remains active in various pockets across the nation and new infections continue to arise.
Reasons have been offered as to why this occurs, such as inadequate surveillance and diagnostic capacity; poor follow-up; stigma. Stigma plays an especially crucial role. People diagnosed with leprosy often hide their diagnosis and fail to seek assistance for it, leading them into complications like disfigurement. Furthermore, they fail to care for their skin or children, leading to further transmission and transmission.
To address these challenges, NLEP has undertaken the Leprosy Case Detection Campaign (LCDC), with active searches of leprosy in highly endemic districts based on criteria including more than one new G2D case per 10,000 inhabitants over three years. This campaign forms an integral component of national strategies aimed at eliminating leprosy.
MLCDC involves conducting house-to-house surveys to identify active leprosy patients and enroll them on MDT, accompanied by targeted mass awareness campaigns and ASHAs trained to detect new cases, which they refer to DLH for treatment. Furthermore, mobile health clinics from General Health Services include leprosy services during visits to slums, peri-urban villages and migrant agglomerations areas.
To measure MLCDC's progress, four indicators have been implemented as benchmarks: (1) the proportion of MB cases; (2) new cases diagnosed with G2D; (3) childhood ratio and (4) newly detected solitary lesions. The Dy Director General for NLEP indicates that these indicators demonstrate leprosy isn't being eliminated as planned and intensification efforts should be increased to reach our elimination goal by 2019. Redoubling efforts could include efforts in several key areas:
NLEP: A Successful Strategy for Leprosy Elimination
India's strategy was successful because it focused on using the most effective and accessible tools available: diagnosis with multidrug therapy (MDT), social support to keep individuals from facing discrimination and intensive new case finding. MDT is relatively inexpensive and simple to administer in bulk quantities - thus making it accessible for those in need. Community participation also played a major role in India's successful battle against leprosy.
However, more work needs to be done to eliminate TB. One key obstacle is that once it was no longer a high-profile public health concern, public officials began reducing their efforts resulting in more active cases being reported and increasing India's hopes of eradication.
At that point, a critical blinding disability emerged: Some former leprosy patients who received multidrug treatments years earlier experienced adverse reactions to one or more drugs used to treat them, leading to blindness and mobility loss. Due to not screening and treating their contacts for leprosy as they should have, now more than 100 such blind cases have been identified across India.
Integration of NLEP into general health care services has also meant that resources have been diverted away from it, leading to reduced geographical coverage and unsatisfactory awareness and compliance levels with MDT protocols. Furthermore, this has meant those living with leprosy may not always receive screening for other illnesses which could prove fatal.
Kumar remains optimistic, believing he can still achieve his vision of a world free of leprosy. To that end, his goals include seeing remaining leprosy colonies closed; patients being reintegrated back into communities; the development and testing of a vaccine (which will take place this year); as well as more intensive efforts being made to identify cases in low and moderately endemic districts.
Step one in this fight should be to reenergize our country's efforts by reinvigorating MDR-TRK-Tuberculosis programs, as part of Ayushman Bharat or otherwise integrated within it, so as to integrate into national healthcare systems and ensure efficient distribution and screening of drugs for MDR-TRK-Tuberculosis patients and all contacts.
