National Leprosy Control Programme (NLCP) & National Leprosy Eradication Programme (NLEP)

Model Answer - 20 Marks | PSM / Community Medicine | University Examination

INTRODUCTION (2 marks)

NATIONAL LEPROSY CONTROL PROGRAMME (NLCP) - 1955 (3 marks)

• Focused on early case detection through surveys and passive surveillance
• Treatment with Dapsone (DDS - Diaminodiphenylsulfone) monotherapy - given for life (20-30 years) or indefinitely
• Domiciliary treatment model - patients treated at home rather than isolated
• Survey, Education, and Treatment (SET) approach
• Leprosy control units and leprosy clinics established as vertical (standalone) infrastructure
• Recognition that leprosy could be treated in the community without isolation/stigmatisation

• Dapsone monotherapy led to widespread drug resistance (M. leprae resistance to dapsone)
• Prolonged treatment (decades) led to poor compliance
• Disease burden remained high despite years of the programme
• No curative endpoint - patients treated for life
• Vertical programme structure was not integrated with general health services

TRANSITION FROM NLCP TO NLEP (2 marks)

NATIONAL LEPROSY ERADICATION PROGRAMME (NLEP) - 1983 (8 marks)

Vision

"The Attainment of Leprosy Free Status for the People of India"

Administrative Status

OBJECTIVES of NLEP

1. To detect all cases of leprosy irrespective of endemicity of the area
2. To treat all detected cases and their complications till cure/recovery
3. To impart training to all categories of health personnel
4. To recommend grant-in-aid to voluntary agencies engaged in anti-leprosy work
5. To promote medico-surgical rehabilitation of disease-arrested deformed cases
6. To encourage research on various aspects of leprosy

1. To reduce Prevalence Rate (PR) < 1/10,000 population at sub-national and district level
2. To reduce Grade II disability % < 1% among new cases at national level
3. To reduce Grade II disability cases < 1 case per million population at national level
4. Zero disabilities among new child cases
5. Zero stigma and discrimination against persons affected by leprosy

STRATEGIES of NLEP

1. Early case detection and prompt MDT treatment
   • Routine passive case detection through health facilities
   • Active case detection: Leprosy Case Detection Campaigns (LCDC)
   • Household contact surveys
   • Special campaigns in high-endemic districts
2. Multi-Drug Therapy (MDT) - core intervention (see below)
3. Integration with General Health Care Services
   • Vertical leprosy services merged into general health infrastructure
   • Services provided at PHCs, CHCs, District Hospitals
   • ASHA involvement in case detection and treatment completion
4. Disability Prevention and Medical Rehabilitation (DPMR)
   • Prevention of reaction-related disability
   • Reconstructive surgery for established deformities
   • Self-care training for patients with ulcers
   • Physiotherapy and vocational rehabilitation
5. IEC / BCC (Information, Education, Communication / Behavioural Change Communication)
   • Reduction of social stigma and discrimination
   • Using local and mass media
   • Encouraging self-reporting to PHCs
   • School health education programmes
6. Involvement of ASHAs
   • Detection of new cases
   • Ensuring treatment completion
   • Providing counselling and community linkage
7. Surveillance and monitoring
   • Integration with IDSP (since 2004)
   • Simplified Information System (since 2002)
   • District-wise monitoring of PR, new case detection rate, Grade II disability rates

MULTI-DRUG THERAPY (MDT) - KEY COMPONENT

• A uniform 3-drug MDT regimen (Rifampicin + Dapsone + Clofazimine) is now used for BOTH PB and MB cases
• This enhances uniformity, addresses drug resistance concerns, and improves operational efficiency
• Duration: PB - 6 months; MB - 12 months (duration maintained)

• Bactericidal against M. leprae rapidly (infectious cases rendered non-infectious within days)
• Prevents drug resistance (multiple drugs with different mechanisms)
• Fixed, short duration improves compliance
• Free supply through all public health facilities
• Relapse rates extremely low (< 0.1% per year)

ORGANISATION / INFRASTRUCTURE

• Central JALMA Institute for Leprosy, Agra (ICMR)
• National Jalma Institute for Leprosy and Other Mycobacterial Diseases
• Regional Leprosy Training and Research Institutes (RLTRIs)

MODIFIED LEPROSY ELIMINATION CAMPAIGNS (MLEC)

• Door-to-door surveys
• School surveys
• Contact surveys
• Camp approach in remote areas

ACHIEVEMENTS AND CURRENT STATUS (2 marks)

• India achieved national-level elimination (PR < 1/10,000) in December 2005, well ahead of some targets
• New Case Detection Rate (NCDR): significantly reduced from >5 lakh cases/year in early 1980s to approximately 1.2-1.5 lakh new cases/year currently
• Grade II disability among new cases has been progressively declining
• Child proportion among new cases serves as a sensitive indicator of active transmission in the community
• India remains the country with the highest absolute number of new leprosy cases globally, highlighting the need for sustained programme efforts

• Hidden/undetected cases in remote/tribal areas
• Social stigma preventing self-reporting
• Drug resistance (rare, but emerging concern - addressed by 2025 revised protocol)
• Post-elimination complacency in health system
• High proportions in certain states (Bihar, Chhattisgarh, Jharkhand, Odisha, West Bengal, Maharashtra)

CONCLUSION (1 mark)

EXAMINER'S SCORING GUIDE (20 marks)

Sources: Park's Textbook of Preventive and Social Medicine (PSM); Harrison's Principles of Internal Medicine 22e (2025); DGHS/MOHFW - NLEP Official Programme Page; National Health Mission Guidelines. The 3-drug uniform MDT protocol (April 2025) is the most recent update - mention this to impress the examiner.

National Tuberculosis Elimination Programme (NTEP)

Model Answer - 20 Marks | PSM / Community Medicine | University Examination

INTRODUCTION (2 marks)

EVOLUTION / HISTORICAL BACKGROUND (3 marks)

1. National Tuberculosis Programme (NTP) - 1962

• Launched in 1962 as the first organised national TB programme
• Based on the District Tuberculosis Centre (DTC) model
• Strategy: Domiciliary treatment, sputum microscopy, BCG vaccination
• Treatment: Non-standardised, irregular drug supply, self-administered
• Problems / Failures of NTP:
  • Treatment success rates unacceptably low
  • High death and default (lost to follow-up) rates
  • Spread of multidrug-resistant TB (MDR-TB)
  • Inadequate drug supply, poor supervision
  • Programme never achieved its targets despite 30 years of operation

2. Revised National TB Control Programme (RNTCP) - 1993/1997

• In 1993, GOI decided to revitalise NTP with international assistance
• RNTCP formulated in 1993; pilot phase launched in 1993; nationwide expansion from 1997
• Adopted the internationally recommended DOTS (Directly Observed Treatment Short-course) strategy
• Fully covered the whole country by March 2006
• Based on WHO Stop TB Strategy (2006)

3. National TB Elimination Programme (NTEP) - 2020

• RNTCP was renamed NTEP in 2020
• GOI committed to eliminate TB by 2025 - 5 years ahead of the global SDG target of 2030
• Aligned with the National Strategic Plan (NSP) 2017-2025 and WHO's End TB Strategy (2014)
• Governed under National Health Mission (NHM) as a Centrally Sponsored Scheme

TIMELINE AT A GLANCE

OBJECTIVES OF NTEP / NSP 2017-2025 (2 marks)

1. Detect all drug-sensitive (DS-TB) and drug-resistant TB (DR-TB) cases, especially from private providers and high-risk undiagnosed populations
2. Treat all diagnosed patients with appropriate anti-TB treatment with patient-friendly systems and social support
3. Prevent emergence of TB in susceptible populations
4. Build and strengthen enabling policies, empowered institutions, human resources, and financial support

• 80% reduction in TB incidence (from 2015 baseline)
• 90% reduction in TB mortality (from 2015 baseline)
• Zero patients facing catastrophic expenditure due to TB

STRATEGIES OF NTEP - THE FOUR PILLARS (D-T-P-B) (6 marks)

Pillar 1: DETECT

• Active Case Finding (ACF):
  • TB Mukt Bharat campaign - high visibility awareness for early case finding
  • Community screening
  • Institutional screening
  • Targeted screening of high-risk groups: prisoners, migrants, PLHIV/AIDS, contacts of confirmed cases, tribal populations, slum dwellers
• Diagnostics:
  • Sputum smear microscopy - at Tuberculosis Diagnostic Centres (TDCs), formerly Designated Microscopy Centres (DMCs)
  • Nucleic Acid Amplification Tests (NAAT) / CB-NAAT (CBNAAT/Xpert MTB/RIF) - first-line test for diagnosis and rifampicin resistance detection; 68.3 lakh NAAT tests done in 2023
  • TRUNAT, LPA (Line Probe Assay) for rapid DR-TB detection
  • Culture & DST (C&DST) for drug resistance pattern
  • Sputum smear serology BANNED since 2012 (poor specificity, not acceptable)
• TB Notification (Mandatory since 2012):
  • All healthcare providers (public AND private) must notify every TB case to District Health Officer monthly
  • NIKSHAY portal used for real-time notification and surveillance
• Private Sector Engagement:
  • Private providers notified and linked for free drug supply
  • Incentives to private practitioners for notification

Pillar 2: TREAT

1. Political will and administrative commitment
2. Diagnosis by quality-assured sputum smear microscopy
3. Adequate supply of quality-assured short-course chemotherapy drugs
4. Directly Observed Treatment (DOT) - all drugs under direct supervision, especially in intensive phase
5. Systematic monitoring and accountability

• Bedaquiline - introduced in India; highly effective against MDR-TB
• Delamanid - for XDR-TB
• Shorter Treatment Regimen (STR) for DR-TB - 9-12 months (vs. old 24 months)
• BPaL / BPaLM regimen (Bedaquiline + Pretomanid + Linezolid ± Moxifloxacin)

• Financial incentive of Rs. 500/month given directly to TB patients throughout treatment for nutritional support
• Transferred via Direct Benefit Transfer (DBT) linked to Aadhaar
• Helps address malnutrition and improves treatment adherence

• 99DOTS - mobile technology-based adherence monitoring
• NIKSHAY portal - real-time patient tracking, outcome monitoring

Pillar 3: PREVENT

1. Airborne Infection Control (AIC):
   • Administrative measures (triaging, fast-tracking)
   • Environmental controls (ventilation, UV germicidal irradiation)
   • Personal respiratory protection
2. TB Preventive Therapy (TPT) / Isoniazid Preventive Therapy (IPT):
   • For contacts of bacteriologically-confirmed TB cases
   • PLHIV on ART (high-priority group)
   • Children < 5 years exposed to TB
3. BCG Vaccination:
   • Protects against severe childhood TB (miliary TB, TB meningitis)
   • Part of UIP; given at birth
4. Addressing Social Determinants:
   • Intersectoral approach addressing poverty, malnutrition, overcrowding
   • Linking TB with PM Poshan, PMJAY, etc.
5. TB/HIV Co-management:
   • All TB patients screened for HIV
   • All HIV patients screened for TB
   • Co-treatment with ART + Anti-TB therapy

Pillar 4: BUILD

1. Strengthening health system infrastructure
2. Creation of sub-district TB Unit (TU) level - major organisational change
3. Human resource capacity building - training STS, STLS, MO-TC
4. Adequate financial resources for programme implementation
5. Research and innovation - new diagnostics, drugs, regimens, vaccine
6. Policy and legal framework - mandatory notification, ban on serology

ORGANISATION / INFRASTRUCTURE OF NTEP (3 marks)

• MO-TC (Medical Officer - TB Control): overall management of TB programme at TU level
• STS (Senior TB Treatment Supervisor): 1 per TU / block (~1.5-2.5 lakh population); supervises treatment
• STLS (Senior TB Laboratory Supervisor): 1 per 5 DMCs (~5 lakh population); quality control of smear microscopy

FLAGSHIP INITIATIVES (2 marks)

1. PM TB Mukt Bharat Abhiyaan (PMTBMBA) - 2022

• Launched by PM Modi on September 9, 2022
• Ni-kshay Mitra programme - volunteers/organisations adopt TB patients to provide nutritional, diagnostic, and vocational support
• Aims at community participation in TB elimination

2. Nikshay Poshan Yojana (NPY) - 2018

• Rs. 500/month direct cash transfer to all notified TB patients for nutritional support
• Addresses the TB-malnutrition-poverty cycle

3. Jan Aushadhi / Free Drug Supply

• All first and second-line TB drugs supplied free through NTEP
• Daily FDC (Fixed Dose Combinations) in weight bands introduced to replace thrice-weekly regimen

4. CBNAAT / TrueNat Expansion

• Universal DST (Drug Susceptibility Testing) for all TB cases
• Rapid molecular diagnostics replacing conventional smear microscopy as first-line test

STOP TB STRATEGY (WHO, 2006) - adopted by RNTCP

1. Pursuing quality DOTS - expansion and enhancement
2. Addressing TB/HIV and MDR-TB
3. Contributing to health system strengthening
4. Engaging all care providers (public, private, NGO)
5. Empowering patients and communities
6. Enabling and promoting research (diagnostics, treatment, vaccine)

END TB STRATEGY (WHO, 2014) - guiding NTEP

• Vision: Zero deaths, disease and suffering due to TB
• Goal: End global TB epidemic
• 3 Pillars:
  1. Integrated, patient-centred TB care and prevention
  2. Bold policies and supportive systems
  3. Intensified research and innovation
• Milestones by 2025: 75% reduction in TB deaths, 50% reduction in TB incidence
• Target by 2030 (SDG): 90% reduction in deaths, 80% reduction in incidence

CURRENT STATUS & CHALLENGES (1 mark)

• India TB Report 2024: ~1.89 crore sputum smear tests and 68.3 lakh NAAT tests performed in 2023
• Significant increase in case notifications (improved detection)
• Treatment success rate improved to ~87% for new cases
• Bedaquiline rollout for MDR-TB nationwide

• 32% increase in drug-resistant cases (MDR/XDR-TB)
• TB/HIV co-infection burden
• Undetected cases in private sector, tribal areas, urban slums
• COVID-19 pandemic setback (2020-21) - missed cases, treatment interruptions
• Malnutrition and poverty as underlying drivers
• India did not achieve 2025 elimination target - goal extended with renewed commitment

CONCLUSION (1 mark)

EXAMINER'S SCORING GUIDE (20 marks)

High-yield exam points to include:

• "Eliminate TB by 2025 - 5 years ahead of SDG 2030 target"
• NSP targets: 80% incidence reduction, 90% mortality reduction, 0% catastrophic expenditure
• 5 components of DOTS
• NIKSHAY portal - mandatory notification since 2012
• Nikshay Poshan Yojana - Rs. 500/month DBT
• Bedaquiline + Delamanid for DR-TB
• TB serology banned since 2012
• PM TB Mukt Bharat Abhiyaan - Ni-kshay Mitra volunteers

Sources: Park's Textbook of Preventive and Social Medicine; DGHS/MoHFW NTEP guidelines; India TB Report 2024; NSP 2017-2025; iHatePSM (community medicine resource)