Introducing leprosy post-exposure prophylaxis into the health systems of India, Nepal and Indonesia: a case study.

BACKGROUND: Leprosy has a wide range of clinical and socio-economic consequences. India, Indonesia and Nepal contribute significantly to the global leprosy burden. After integration, the health systems are pivotal in leprosy service delivery. The Leprosy Post Exposure Prophylaxis (LPEP) program is ongoing to investigate the feasibility of providing single dose rifampicin (SDR) as post-exposure prophylaxis (PEP) to the contacts of leprosy cases in various health systems. We aim to compare national leprosy control programs, and adapted LPEP strategies in India, Nepal and Indonesia. The purpose is to establish a baseline of the health system's situation and document the subsequent adjustment of LPEP, which will provide the context for interpreting the LPEP results in future. METHODS: The study followed the multiple-case study design with single units of analysis. The data collection methods were direct observation, in-depth interviews and desk review. The study was divided into two phases, i.e. review of national leprosy programs and description of the LPEP program. The comparative analysis was performed using the WHO health system frameworks (2007). RESULTS: In all countries leprosy services including contact tracing is integrated into the health systems. The LPEP program is fully integrated into the established national leprosy programs, with SDR and increased documentation, which need major additions to standard procedures. PEP administration was widely perceived as well manageable, but the additional LPEP data collection was reported to increase workload in the first year. CONCLUSIONS: The findings of our study led to the recommendation that field-based leprosy research programs should keep health systems in focus. The national leprosy programs are diverse in terms of organizational hierarchy, human resource quantity and capacity. We conclude that PEP can be integrated into different health systems without major structural and personal changes, but provisions are necessary for the additional monitoring requirements.

Multidrug therapy in leprosy.

Leprosy is an ancient disease, which was treated by local application of chaulmoogra/hydnocarpus oil during prechemotherapeutic era. Since 1940, dapsone was the only chemotherapeutic agent used for treatment of leprosy for about three decades. Prolonged, interrupted and inadequate use of dapsone monotherapy, leads to development of dapsone-resistant cases. Usefulness of clofazimine was known in 1962. Introduction of rifampicin--a powerful bactericidal drug in 1970 has opened the avenues of multidrug therapy to treat leprosy. Multidrug therapy recommended by World Health Organisation came into practice after 1982. The regimen followed now is for duration of 6 months in paucibacillary and for the duration of 12 months in multibacillary cases. It is proven to be safe and effective. Multidrug therapy for leprosy cases is available in the form of blister calender packs and is available free of cost at all government health facilities. Although more new drugs such as ofloxacin, minocyclin, clarithromycin, etc, are known now but they are used as alternative drugs if a component of combination in multidrug therapy becomes contra-indicated. This article brings the details of various drugs used under multidrug therapy, their characteristics, side-effects, regimens and alternative drugs available for treating leprosy.

Progress towards elimination of leprosy as a public health problem in India and role of modified leprosy elimination campaign.

India (population 943 million) has seen a highly significant decrease in the prevalence of leprosy since the introduction of multi-drug therapy (MDT) in 1981. From a prevalence rate of 57/10,000 of the population in March 1981, the figure has declined to 5.2/10,000 in March 1999. This was possible due to the creation of a completely vertical (specialized) infrastructure for leprosy control in the 218 endemic districts of the country and skeleton vertical staff in the remaining districts, coupled with the recruitment of additional staff on contract basis to provide MDT through vertical staff in endemic districts and mobile treatment units in the moderate and low endemic districts. Despite all efforts, however, new case detection has not shown a decline over the last 14 years due to the presence of hidden (and undiagnosed) cases. Therefore, in order to intensify and hasten progress towards elimination (less than 1 case per 10,000 of the population) in the whole country, it was decided to implement a massive leprosy elimination campaign (LEC) in all the States/Union Territories (UTs). The reports of 22 States/UTs indicate that 415 out of the total of 490 districts in the country were covered by modified LEC (MLEC), with 85% coverage of the population. The campaign used in India was modified from the pattern previously described by the World Health Organization. The detection of hidden or suspected cases took place within a short, intensive period of 6-7 days and relied heavily on house-to-house searches by General Health Care staff trained in leprosy detection and confirmation was made by appropriately trained staff. This MLEC received widespread Government and public support, resulting in the detection of 454,290 hidden cases of leprosy, whilst providing training to a large number of General Health Care staff and volunteers and creating widespread awareness about leprosy and the availability of treatment free of charge for all cases. This programme proved to be one of the most successful health care interventions undertaken in India in recent years, particularly in the states of Bihar and Orissa. Although a few states in India are unlikely to reach the current WHO goal of elimination before end of the year 2000, the results of the MLEC strongly support the possibility that elimination levels will be achieved in the majority of states by the end of the year 2000 and at national level by the end of the year 2002.