A Seminar on Leprosy Control in

Nigeria
Presented by:
Nwosu Obinna C - 19040100107
Kalu Ronald C. - 18040100081
Agwah Samuel .S. - 18040100073
Onwuzuruike Chisom E. - 19040100063
Leprosy Control in Nigeria
 Table of Content
• Chapter 1: Introduction
• Definition and Brief History of Leprosy
• Global and National Context of Leprosy
• Significance of Leprosy Control in Public Health

• Chapter 2: Epidemiology of Leprosy in Nigeria

• Current Incidence and Prevalence Rates
• Geographic Distribution and Hotspots
• Demographic Patterns (age, gender, socio-economic factors)

• Chapter 3: Historical Perspective

• Overview of Leprosy Control Initiatives in Nigeria
• Past Challenges and Achievements
• Impact of Historical Policies on Current Scenario

• Chapter 4: Current Status of Leprosy Control Programs

• National Leprosy Elimination Program (NLEP)
• Collaboration with International Organizations
 Table of Content
• Chapter 5: Diagnosis and Treatment
• Early Detection and Diagnosis
• Availability and Accessibility of Treatment
• Multi-Drug Therapy (MDT) and its Role

• Chapter 6: Challenges in Leprosy Control in Nigeria

• Chapter 7: Success Stories and Best Practices
• Highlighting Regions or Programs with Successful Leprosy Control
• Lessons Learned and Transferable Practices
• Community Engagement Models

• Chapter 8: Recommendations
• Chapter 9: Conclusion
• Recap of Key Points
• Emphasis on Progress and Ongoing Challenges
• Call to Action for Continued Efforts in Leprosy Control
 Chapter 1: Introduction
Definition and brief history of leprosy
Leprosy, also known as Hansen’s disease, is a chronic infectious disease caused by the bacterium Mycobacterium
leprae. It primarily affects the skin, nerves, and mucous membranes. The disease can lead to disfigurement and
nerve damage if not treated.
Leprosy has affected humanity for thousands of years. The disease takes its name from the Greek word λέπρᾱ
(léprā), while the term “Hansen’s disease” is named after the Norwegian physician Gerhard Armauer Hansen
remembered for his identification of the bacterium Mycobacterium leprae in 1873 as the causative agent of
leprosy.

Historically, leprosy has been documented since ancient times, with references in texts from China, Egypt, and
India dating back thousands of years. In the Middle Ages, leprosy spread throughout Europe, and leper colonies
were established.
The development of effective antibiotic treatments, such as dapsone, in the mid-20th century significantly
improved outcomes for patients. Today, multidrug therapy is the standard treatment, and leprosy is much less
common, but it persists in some regions, particularly in parts of Africa, Asia, and South America.
 GLOBAL AND NATIONAL CONTEXT OF LEPROSY:

Global Context:
In 1991 the World Health Assembly passed a resolution to “eliminate” leprosy as a public health problem by the year
2000. Elimination of leprosy is defined as a registered prevalence rate of less than 1 case per 10 000 persons. The
target was achieved on time at a global level.
The widespread use of multi-drug therapy and the reduction in duration of treatment dramatically contributed to this
reduction: Over the past 20 years, more than 16 million leprosy patients have been treated. The prevalence rate of the
disease has dropped by 99%: from 21.1 cases per 10 000 people in 1983 to 0.2 cases per 10 000 people in 2015.
A dramatic decrease has been achieved in the global disease burden: from 5.2 million people with leprosy in 1985, to
176,000 people at the end of 2015. With the exception of few countries (with populations of less than 1 million), leprosy
has been eliminated from all countries.
Access and delivery of antibiotics continues to be a problem in the most endemic nations. With the precise
transmission mechanism of leprosy still unknown and a lack of an effective vaccine, leprosy will continue to pose an
ongoing public health problem in the coming decades.
National Context:
In the pre-independence period, the average leprosy prevalence in Nigeria was over 20%. In keeping with
prevailing global concepts and practice at that time, leprosy settlements were set up to safeguard public
health and provide relief to the unfortunate men and women who suffered from the disease. The first of
these settlements was founded by the Presbyterian Church at Itu in present day Akwa Ibom state in 1928.
The second settlement (Uzuakoli Leprosy Centre), once renowned for its global contribution to research in
the chemotherapy of leprosy, is acknowledged by many as one of the Methodist Church’s most enduring
legacies in Nigeria. Other notable settlements that sprang up in the segregation era include Okegbala in
Kwara State; Osiomo in Edo State and Yadakunya in Kano State. No historical account of leprosy in
Nigeria can ignore the cultural and social dimensions.
There were many stories of men and women in the settlements who defied overwhelming odds and
distinguished themselves in various endeavours. One outstanding example is Ikoli Harcourt Whyte who
left a legacy of enduring choral music as well as a shining example of leadership.4 The National TB and
Leprosy Control Programme (NTBLCP) was launched in 1989, but became fully operational in 1991.
Between 1991 and 2012, a total of 111,788 leprosy patients have been successfully treated with MDT, and
in the year 2000, the country achieved the WHO elimination target of less than 1 case per 10 000
population.
With a case detection rate below 0·5 per 10 000, Nigeria may well be described as low endemic for
leprosy. However, there remain pockets of ‘high endemicity’ at sub-national levels, where the leprosy
prevalence is still 1 case per 10 000 population. With a case detection rate below 0·5 per 10 000, Nigeria
may well be described as low endemic for leprosy.
 SIGNIFICANCE OF LEPROSY CONTROL IN PUBLIC HEALTH
The significance of leprosy control in public health is multifaceted and extends across various
dimensions, encompassing medical, social, and community aspects. Here are key points
highlighting the importance:
• Prevention of Disabilities: Leprosy, if left untreated, can lead to nerve damage, resulting in
deformities and disabilities. Leprosy control measures focus on early detection and prompt
treatment, preventing the progression of the disease and minimizing physical impairments. By
preserving the health and functionality of affected individuals, leprosy control contributes to an
improved quality of life.
• Reduction of Social Stigma and Discrimination: Leprosy has historically been associated with
social stigma and discrimination. Public health efforts target not only the medical aspects but also
aim to dispel myths and reduce societal prejudice. By raising awareness and promoting
understanding, leprosy control contributes to the social inclusion of affected individuals, fostering a
more compassionate and supportive community.
• Interrupting Transmission: Leprosy is an infectious disease, and controlling its spread is crucial
for minimizing the overall burden. Leprosy control strategies include early case detection, contact
tracing, and providing appropriate treatment. By interrupting the transmission of the bacterium
Mycobacterium leprae, these measures contribute to preventing new cases and protecting
communities from further infection.
• Global Health Goals: The World Health Organization (WHO) has set global goals for
leprosy elimination. Achieving these objectives requires sustained efforts in leprosy
control, emphasizing the disease’s global significance. By working towards elimination
targets, public health initiatives contribute to broader international health goals and
demonstrate a commitment to addressing neglected tropical diseases.
• Integration into Healthcare Systems: Leprosy control is most effective when
integrated into broader healthcare systems. By incorporating leprosy services into
routine healthcare delivery, communities benefit from a comprehensive approach that
addresses various health needs. This integration promotes efficiency and
sustainability in healthcare efforts, ensuring that leprosy control is part of a broader
public health strategy.
• Research and Innovation: Ongoing research and innovation are essential
components of leprosy control. Advances in diagnostics, treatment methods, and
preventive measures contribute to the continual improvement of control strategies.
Public health initiatives need to remain adaptable, incorporating new findings and
technologies to enhance the effectiveness of leprosy control efforts
 EPIDEMIOLOGY OF LEPROSY IN NIGERIA
Leprosy is one of the major neglected tropical diseases. The disease reached near
elimination back in the year 2000 when the World Health Organisation’s target of less
than 1 case per 10,000 people was achieved worldwide after years of global effort. The
health agency then delisted leprosy as a public health threat.

Nigeria, which established a National Tuberculosis and Leprosy Control Programme

back in 1989 to actively identify cases of leprosy, was among countries that achieved
WHO’s benchmark at the time. But since then, there has been a gradual resurgence of
the disease and it is increasingly becoming a public health concern mostly because it
has been almost forgotten.

According to WHO, more than 200,000 people were infected with the disease globally in
2016 alone. According to the Nigeria Centre for Disease Control, over 3,500 people get
infected with the disease every year in Nigeria and about 25 per cent of them go on to
develop physical disabilities
 Chapter 3: Historical Perspective of leprosy control in Nigeria
Overview of Leprosy Control Initiatives in Nigeria
Leprosy control initiatives in Nigeria are efforts to reduce the burden of leprosy and its
complications, eliminate leprosy as a public health problem, prevent and manage
leprosy-related disability and stigma, and promote the human rights and social inclusion
of persons affected by leprosy. Some of the main leprosy control initiatives in Nigeria are:

• The National Tuberculosis and Leprosy Control Programme (NTBLCP), which

coordinates the leprosy control activities in the country and provides free multidrug
therapy (MDT) to all leprosy patients.
• The National Strategic Plan for Leprosy Control (2020-2024), which outlines the
strategies and activities to achieve zero leprosy transmission, zero leprosy-related
disability, and zero leprosy-related stigma and discrimination in Nigeria.
• The Leprosy Mission Nigeria (TLMN), which provides medical, social, and economic
support to people affected by leprosy and advocates for their rights and dignity.
• The World Leprosy Day, which raises awareness and mobilizes resources for leprosy
Past Challenges and Achievements
When it comes to leprosy control in Nigeria, there have been some challenges in the past.
One issue was the lack of awareness and understanding about leprosy, which led to
stigmatization and discrimination against those affected. This made it harder for them to seek
treatment and support.

Another challenge was the limited healthcare infrastructure in certain areas, which affected
the delivery of leprosy services. Insufficient healthcare facilities, trained staff, and necessary
resources made it difficult to effectively control leprosy.

Additionally, reaching remote and rural areas with leprosy cases posed geographical barriers.
This hindered the timely diagnosis, treatment, and follow-up care for those who needed it.

Thankfully, efforts have been made to address these challenges. Awareness campaigns have
been conducted to educate the public, reduce stigma, and encourage early detection.
The government and non-governmental organizations have also worked on improving
healthcare infrastructure and accessibility, resulting in a decrease in leprosy cases in Nigeria.
Impact of Historical Policies On Current Scenario
In the past, Nigeria had policies that focused on isolating and segregating individuals with leprosy. This
approach aimed to control the spread of the disease but unfortunately led to social and economic
marginalization of affected individuals. The policies created a climate of fear, stigma, and discrimination,
which prevented people from seeking treatment and support.

However, over time, there has been a shift in the approach to leprosy control. Nigeria, like many other
countries, has adopted the World Health Organization's strategy of integrating leprosy services into the
general healthcare system. This approach aims to destigmatize leprosy and ensure that affected
individuals receive comprehensive healthcare services.

These historical policies have had a lasting impact on the current scenario of leprosy control in Nigeria.
Stigma and discrimination still persist, making it challenging for individuals to come forward and seek
early diagnosis and treatment. There is a need for continued efforts to raise awareness, address societal
attitudes, and promote inclusivity in healthcare services.

Nonetheless, Nigeria has made significant progress in leprosy control. Policies and programs have been
implemented to reduce the burden of the disease, enhance access to diagnosis and treatment, and
improve the overall well-being of affected individuals. Collaboration between the government, non-
governmental organizations, and international partners has played a vital role in these efforts.
 Chapter 4: Current Status of Leprosy Control
Programs
National Leprosy Elimination Program (NLEP)
The National Leprosy Elimination Program in Nigeria is a division under the Department
of Public Health of the Federal Ministry of Health that was established in 1989 to
coordinate TB and leprosy control efforts in Nigeria. Its mandate was further expanded
to include Buruli Ulcer control in 2006. It is in collaboration with various stakeholders,
including state governments, NGOs, and international partners.
The main objectives of the program are to:
• Reduce the burden of leprosy and its complications in Nigeria
• Eliminate leprosy as a public health problem (defined as less than 1 case per 10,000
population) at the national and sub-national levels
• Prevent and manage leprosy-related disability and stigma
• Promote the human rights and social inclusion of persons affected by leprosy.

The program has developed a National Strategic Plan for Leprosy Control (2020-2024),
which outlines the strategies and activities to achieve the above objectives, in alignment
with the WHO Road Map for Neglected Tropical Diseases 2021 – 2030 and the WHO
Global Leprosy Strategy.
Collaboration with International Organizations
The NLEP collaborates with various international organizations to achieve its goals and
objectives. Some of these organizations are:

• The World Health Organization (WHO), which provides technical and financial support,
as well as free multidrug therapy (MDT) for all leprosy patients.
• The Leprosy Mission International (TLM), which is a Christian organization that works
with people of all faiths to bring healing and restoration to people affected by leprosy
and other neglected tropical diseases. TLM coordinates leprosy control programmes in
ten states and the Federal Capital Territory, Abuja, and provides services such as
health and disability management, empowerment and livelihoods, advocacy and
communication, and learning and education.
• The Leprosy and Tuberculosis Relief Initiative (LTR), which is a local NGO with strong
international roots that provides relief to persons affected by leprosy and tuberculosis
in North Eastern Nigeria.
• The Damien Foundation and the Sasakawa Health Foundation.
These organizations work together with the NLEP, the Ministry of Health, the
National Tuberculosis and Leprosy Control Programme (NTBLCP), and
other stakeholders to implement the Zero Leprosy Roadmap and Action
Plan, which outlines strategies and activities to bring the country closer to
the targets set by the WHO Global Leprosy Strategy and the WHO Road
Map for Neglected Tropical Diseases 2021 – 2030.

The Roadmap and Action Plan aim to establish regional partnerships for
zero leprosy, increase domestic resource mobilization, re-activate and
decentralize leprosy capacity building in states, increase contact screening
and preventive chemotherapy, increase case-finding programmes, and
improve referral services and social participation for persons affected by
leprosy.
Key Strategies and Interventions.
Some of the key strategies and activities of the program are:
1. Case Detection and Treatment: The NLEP focuses on early case detection through active
case search activities. Trained healthcare workers, community health volunteers, and grassroots
organizations are employed to identify individuals with leprosy symptoms. Once diagnosed,
patients are provided with Multi-Drug Therapy (MDT), which is free of charge and readily available
across the country. MDT effectively treats leprosy and prevents its transmission.

2. Disability Prevention and Rehabilitation: The NLEP emphasizes the prevention of disabilities
arising from leprosy. By detecting cases early and providing timely treatment, the progression of
the disease and potential disability can be minimized. Additionally, rehabilitation services are
provided to individuals with disabilities caused by leprosy. These services include physiotherapy,
reconstructive surgeries, provision of assistive devices, and vocational training, helping affected
individuals regain functionality and reintegrate into society.

3. Capacity-Building and Training: The NLEP invests in training healthcare workers, community
volunteers, and other stakeholders involved in leprosy control. Through workshops, seminars, and
educational materials, they are equipped with the necessary skills and knowledge to identify
leprosy symptoms, provide appropriate treatment, and combat stigma and discrimination
4. Health System Strengthening: The NLEP works towards integrating leprosy services
into the general healthcare system, ensuring that leprosy patients receive
comprehensive care. This integration helps reduce the stigma associated with leprosy
and improves access to essential healthcare services.

5. Advocacy and Awareness: The NLEP collaborates with various organizations to

raise public awareness about leprosy, combat stigma, and promote early detection and
treatment. Educational campaigns are conducted through various media channels,
community outreach programs, and collaboration with religious and traditional leaders.
The goal is to dispel myths, encourage affected individuals to seek help, and foster a
supportive environment for people affected by leprosy.

The NLEP has made significant progress in reducing the burden of leprosy in Nigeria.
 Chapter 5: Diagnosis and Treatment of Leprosy

Early Detection and Diagnosis

Leprosy case detection primarily relies on passive methods. However, the
National Tuberculosis and Leprosy Control Programme (NTBLCP), in
partnership with other organizations, has introduced active strategies such
as the Leprosy Elimination Campaign (LEC) and mini-LECs.

These initiatives actively seek out leprosy cases in areas where the disease
is highly prevalent. Efforts are currently underway to incorporate leprosy
case detection into the tasks of community volunteers and community-
directed distributors (CDDs) for Ivermectin.
When Should Leprosy Be Suspected?
Leprosy should be suspected in individuals who exhibit any of the following
symptoms or signs:

• Light (hypo-pigmented) or reddish patches on the skin, which is the most

common sign of leprosy.
• Loss or decrease of sensation in the skin patches.
• Numbness or tingling in the hands or feet.
• Weakness in the hands, feet, or eyelids.
• Painful or tender nerves.
• Swelling or lumps in the face or earlobes.
• Painless wounds or burns on the hands or feet.

These symptoms may indicate a possible leprosy infection, and individuals

experiencing these symptoms should seek medical attention for diagnosis and
Cardinal signs of Leprosy
• Definite loss of sensation in a pale (hypo-pigmented) or reddish
skin patch.
• A thickened or enlarged peripheral nerve, with loss of sensation
and/ or
• weakness of muscles supplied by that nerve.
• The presence of acid-fast bacilli in a slit skin smear (SSS.

Suspect Leprosy in an individual who presents with any of the

cardinal signs
 Management of Leprosy in Nigeria
Steps in managing a Leprosy suspect:

• Take full history

• Carry out physical examination of the patient (skin, peripheral
nerves and general assessment); and
• Conduct laboratory examination (Slit Skin Smears) where there
is expertise
 History Taking
Duration of skin patches:
• How long has the skin patch been there?
• How did it start?
• Has it changed?

Leprosy patches usually appear slowly

Itching & Pain:

• Do the patches itch?
• Is there pain?

Leprosy patches do not itch and are usually not painful unless complicated
Sensation:
• Does The person have unusual sensations in his/her hands or feet,
• such as numbness, tingling or a burning feeling?

Unusual sensations in the hands or feet can be suggestive of leprosy

Note that such unusual sensations are not common on the face

Muscle weakness:
• Does the person think that his/her hands or feet have become weaker?
• Does he/she have problems with holding or lifting things and with moving his/her hands and
feet?

Losing strength of the muscles of the eyes, hands or feet, can be a sign of
leprosy

• Does The person have any painless cuts or injuries on their hands or feet?
 Previous medical history:
• Find out as much as you can about the previous medical
history of the patient. Allow adequate time to talk with
patients. They are the people who know their bodies best.

• Has the person experienced any social problems?

( Stigma)

This may be more likely if the person already has some

deformity due to
Leprosy
 Physical Examination

Explain to the patient the procedures you are going to carry out.
Examine
systematically in the following order:

• Examine and test their skin patches (sensation)

• Feel the nerves (enlargement and pain)
• Examine the hands and feet
• Decide whether a slit skin smear is needed (referral to another
clinic or hospital
• may be needed for this)
Skin
• Conditions for proper skin examination
• Explain the process and reasons for the examination to the patient
• Good natural light source
• Privacy
• Examine the whole body from head to toe, also back and front in a
systematic manner

Look for pale/red skin lesions

• leprosy lesions are usually lighter (pale) than the surrounding skin
(macula)
• They may be reddish in colour and can have a raised edge (plaque)
• Leprosy lesions can also be solid and raised (papules and nodules)
Check for loss of sensation on the skin patches

• Leprosy patches usually have a loss of feeling to cotton wool

(except on the
• face). Check to see if the person can feel anything when you
touch the skin
• patches with cotton wool.

Cotton wool test for loss of feeling

• Before you start, show the person what you are going to do
• Use a wisp of cotton wool
Examine the eyes, hands and feet for nerve damage (VMT/ST) and other
disability

Dryness, loss of feeling or weakness (autonomic, sensory or motor neural deficit) are
usually seen. A person with loss of feeling can injure himself or herself without
realizing it, which is why people with leprosy often get wounds and ulcers. Loss of
feeling is rare in other diseases, so it can help to confirm the diagnosis of leprosy.

Check the Eyes

• Check the Visual Acuity of each eye separately using an eye chart; if no chart is available, ask
the person to count fingers at 6 meters; if the person cannot read the top line of the chart, or
count fingers at 6 meters, they are visually impaired and have grade 2 disability in that eye.
• Look For an inability to close one or both eyes(lagophthalmos) and check for normal strength of
eye closure
• Look For any redness of the eye
Check for Sensation on Hands and Feet
• Explain the test to the patient
• Check the sensation on the palms of the hands and the soles of
the feet,
• using a ballpoint pen
• Ask them to close or cover their eyes
• Touch the skin very lightly with the ballpoint
• In each case ask the patient to point to the place you touched
• Test a minimum of four points on each hand and foot
• Note any areas where the pen is not felt by marking with a red
cross DXD
• Note areas where the pen is felt by marking with a blue tick 5YD
 Treatment of Leprosy
It is the policy of the Federal Ministry of Health to treat leprosy
patients with Multi
Drug Therapy (MDT) as recommended by WHO. The
effectiveness of MDT is well
known and relapses are very few. MDT cures the patient within a
short period of time and interrupts the transmission of the disease
rapidly.
 Pre-treatment Patient education/counseling
Patient and relatives should be educated about the following:

• The disease, its cause and prospects

• The disease is curable and treatment is free
• The need to bring their household contacts for examination
• The treatment duration
• The importance of monthly attendance and daily intake of the drugs
• What can be expected from the treatment regarding skin lesions and existing
impairments
• Patient should know about the signs and symptoms of lepra-reaction and the
importance of immediate self-reporting if there is (increase of) nerve function loss
or nerve pain
• If there is definite nerve function loss at diagnosis, the importance of self-care
Obtain feedback from patient at the end of the health
talk:
• Ask patient to recall facts
• Identify possible problems and deal with them
appropriately
 Recommended MDT Regimens
The treatment for leprosy is simple. It is available free, and the medicines are supplied in
special packs that contain the correct dose for one person for four weeks. All that is
needed is to decide which course of treatment the patient needs and to make sure that
they take it regularly.

The two types of leprosy are treated as explained below:

PB patients:
should receive one blister pack of PB MDT every 28 days (the
first dose should be swallowed supervised by the health worker) for a period of
6 months (TOTAL BLISTERS).
• These 6 blisters should be completed within a maximum period of 9 months.
• After completing 6 blisters the patient should be released from treatment(RFT)
MB patients:
should receive one blister of MB MDT every 28 days (the first
dose should be swallowed supervised by the health worker) for a period of 12
months (TOTAL12 BLISTERS), intake of drugs on every day of collection must
be supervised.
• These 12 blisters should be completed within a maximum period of 18 months.
• After completing 12 blisters the patient should be released from treatment
• (RFT)

Stopping MDT
Prior to release from MDTthe health worker should examine the patient and record
all clinical findings on the back page of the Patient Record Card.\
 Chapter 6: Challenges in Leprosy Control in
Nigeria
1.Stigma and Discrimination:
Effect: Stigma surrounding leprosy leads to delayed diagnosis and
treatment as affected individuals may avoid seeking healthcare due to fear
of discrimination.
Impact: Late detection can result in increased transmission of the disease
and more advanced cases, making control efforts challenging.

2.Limited Awareness and Education:

Effect: Lack of public awareness hinders early recognition of leprosy
symptoms and delays help-seeking behaviours.
Impact: Delayed diagnosis and treatment reduce the effectiveness of control
measures and contribute to ongoing transmission within communities.
3.Access to Healthcare Services:
Effect: Limited access to healthcare facilities in certain regions prevents
prompt diagnosis and treatment.
Impact: Prolonged periods without treatment can lead to severe disabilities,
complicating the control of leprosy’s impact on affected individuals.

4.Infrastructure and Resources:

Effect: Inadequate healthcare infrastructure limits the delivery of
comprehensive care, including medications and rehabilitation services.
Impact: Without proper infrastructure, the ability to manage and control
leprosy effectively is compromised, affecting the overall success of control
programs.
5.Geographic Spread:
Effect: Rural and hard-to-reach areas may experience delayed diagnosis and treatment due to
logistical challenges.
Impact: The geographic spread increases the difficulty of implementing timely control measures,
allowing leprosy to persist in specific pockets of the country.

6.Health Workforce Capacity:

Effect: Insufficient trained healthcare professionals specializing in leprosy result in delayed or
inadequate care.
Impact: A shortage of skilled professionals hampers the early identification and treatment of
cases, undermining the effectiveness of leprosy control programs.

7.Multi-Drug Resistant Strains:

Effect: Emergence of multi-drug resistant strains challenges the efficacy of standard treatments.
Impact: Limited treatment options for resistant strains can lead to prolonged infectious periods,
increasing the risk of transmission and complicating control efforts.
8.Integration into General Healthcare Services:
Effect: Lack of integration may lead to isolated leprosy control programs rather than a
comprehensive healthcare approach.
Impact: Integrated services are essential for sustainable control; failure to integrate may result in
fragmented efforts and reduced overall effectiveness.

9.Data Collection and Surveillance:

Effect: Inaccurate or incomplete data hinder the ability to track and manage leprosy cases
effectively.
Impact: Poor data quality compromises the planning and implementation of control strategies,
impeding the overall success of leprosy control programs.

10.Socioeconomic Factors:
Effect: Poverty and resource limitations contribute to the persistence of leprosy in certain
communities.
Impact: Addressing broader socioeconomic factors is essential for sustainable control, as
poverty can create conditions that facilitate the transmission of the disease.
 Chapter 7: Success Stories and Best Practices
PROGRAMS WITH SUCCESSFUL LEPROSY CONTROL
TOWARDS ZERO LEPROSY GLOBAL LEPROSY (Hansen’s disease) STRATEGY 2021–2030
The WHO Global Leprosy Strategy 2021–2030, which was developed
through a consultative process with all major stakeholders, reflects these
epidemiological changes.
Whereas previous strategies focused on the “elimination of leprosy as a
public health problem”, defined as less than one case on treatment per 10
000 population, the new strategy focuses on interrupting transmission and
achieving zero autochthonous cases.
In doing so, the Strategy aims to motivate high-burden countries to
accelerate activities while compelling low-burden countries to complete the
unfinished task of making leprosy history.
In four decades since the introduction of MDT, 18 million people have been treated,
bringing down the registered prevalence by more than 95%. In line with World Health
Assembly Resolution WHA 44.9 (1991)9, global leprosy strategies focused initially on
elimination of leprosy as a public health problem (defined as a registered prevalence of
less than 1 case per 10 000 population).

This was achieved at the global level in 2000. Subsequent five-year strategies focused
on further reducing the disease burden through early detection and prompt treatment in
the sustainable context of integrated services. By 2015, the target of elimination as a
public health problem had been achieved in almost all countries, at least at the national
level.

Factors underlying this achievement included political commitment, collaboration with

major partners, and the free availability of MDT drugs. But the very slight downward
trend in new case numbers was showing the limitations of a strategy reliant solely on
case finding and treatment with MDT, and successive strategies had some (albeit limited)
impact in reducing the physical, mental, social and economic consequences of leprosy
on affected individuals and their families.
The WHO Global Leprosy Strategy 2016–20203 sought to redefine
disease burden in terms other than registered prevalence and the
often misinterpreted ‘elimination as a public health problem’.
New targets emphasised a decrease in child cases and new cases
with G2D, thereby promoting early detection and reduction of
transmission, and reduction in the stigma and discrimination
experienced by persons affected by leprosy and their families.
Table 1 shows the progress made towards the 2020 targets in the
strategy.
 NATIONAL LEPROSY ELIMINATION PROGRAM IN
BANGLADESH
Both the incidence and prevalence of leprosy in Bangladesh have shown a decreasing trend in the last 15
years. The National Leprosy Elimination Program (NLEP) in Bangladesh achieved elimination of leprosy
as a public health problem based on a registered prevalence of less than 1 in 10,000 at the end of 1998,
and now aims to achieve this goal at a sub-national (district) level by 2015.

The ‘Post Elimination National Leprosy Control Strategy 2011 – 2015’ has been formulated to sustain the
achievements and improve the quality of clinical services [66].

The objectives of the NLEP are to provide MDT services in all health complexes at the upazila (sub-
district) level and below, to provide MDT to all people with leprosy, and to achieve at least an 85%
treatment completion rate (cure rate) among patients who were put on MDT.

NLEP also aims to reduce the grade 2 disability rate among newly detected cases to less than 5%, and to
implement information, education, and communication activities to increase community awareness about
leprosy, promote voluntary case reporting, and minimize social stigma. NLEP also will establish a simple
and effective recording and reporting system to monitor progress.
Collective efforts have been made to promote awareness for reducing stigma and discrimination
against people affected by leprosy, sustaining the interest of policy makers, and encouraging the
involvement of general health services and other stakeholders, such as NGOs, in leprosy control.

The leprosy elimination activities are integrated into the general health services, and specialized
leprosy staff are retained at certain levels to ensure technical support and guidance. General
medical practitioners and medical, nursing, and paramedical institutions are involved through
training and leprosy orientation activities.

For over 15 years, leprosy services in Bangladesh have been delivered through a partnership of
government health care services and a variety of NGOs involved in leprosy. This collaboration is
organized through the National Leprosy and Tuberculosis Coordinating Committee (LTCC).
NGOs have been assigned certain geographic areas to implement leprosy contro

l according to the NLEP guidelines. NGOs provide manpower, training, and technical resources,
with assistance from the governmental health services at the national and local levels in terms of
clinic facilities, drug distribution, central coordination, supervision, and monitoring. The NLEP has
been developed in consultation with all leprosy NGOs and other national and international
organizations to achieve a “leprosy-free Bangladesh”.
 LESSONS LEARNED AND TRANSFERABLE PRACTICES
Political commitment with adequate resources for leprosy in integrated context:
Government ownership, national policies and strategies are the essential foundation for
progress towards zero leprosy. Health, education, social development and law ministries may all
share responsibility for leprosy activities, so continuous advocacy and communication within
and across ministries are essential to the wellbeing of persons affected by leprosy during and
after treatment. Cross-border collaboration may also be needed to ensure continuity of care and
the interruption of transmission.

Capacity building in the healthcare system for quality services: Staff capacity is, for many
countries, the severest obstacle to achieving zero leprosy. Strategies are needed to build
sustain the capacity of integrated public health and clinical services staff in all aspects of
leprosy prevention, screening, diagnosis, treatment, management of complications, self-care,
rights of persons affected by leprosy and their families, and programme management.
Innovative, e-health approaches should be considered for training and capacity-building.
Organisations of persons affected by leprosy, involved as partners, may encourage early
identification of leprosy and improve treatment adherence. Laboratory capacity for
microbiological analysis, including slit-skin smears, needs to be built up and maintained to
Effective surveillance and improved data management systems: Routine
surveillance systems need to be put in place in all countries to detect hidden cases and
endemic clusters, and to monitor nerve damage, physical impairments and mental health
issues during and after treatment.

Effective data management, ideally based on digital, restricted-access, case-based

health information systems including geolocation data, is needed to accurately record
and report progress towards zero leprosy and enable sound, evidence-based
programmatic decisions.

Monitoring of AMR and adverse drug reaction: Testing for AMR should be undertaken
for all relapses and a sample of new and other retreatment MB cases, with the
collaboration of expert laboratories in-country or elsewhere.
Integrated with other pharmacovigilance systems, data should be collected and reported
on adverse reactions to drugs used in leprosy prevention, treatment and reaction
management, as well as potential vaccines.
Contact tracing for all new cases: Alongside its role in the prevention of leprosy, contact
tracing is the most productive tool for finding new cases, and may be the key to leprosy control in
the next ten years. In addition, active case-finding campaigns should be implemented in targeted
populations such as areas of higher endemicity, ‘silent’ areas that are difficult to reach, or among
at-risk groups.

Where possible, contact tracing and case-finding should be undertaken in combination with other
skin NTDs or other relevant diseases and accompanied by training for peripheral health workers.
Effective case-finding may result in an initial rise in new case numbers.

Preventive chemotherapy scaled up: WHO recommends BCG vaccination at birth as an

effective tool for reducing the risk of leprosy. Its use should be maintained, at least in countries or
areas with a high leprosy burden.

Repeat BCG vaccination for leprosy is not recommended22. Trials of other existing and potential
new vaccines, including LepVax (which is in human trial phase in 2020), may result in an
important new tool for leprosy prevention during this strategy period.
Integrated active case-finding in targeted populations: Case-finding campaigns should be
accompanied by innovative and well-targeted community information and awareness activities
that combat myths and encourage early self-referral and positive attitudes towards persons
affected by leprosy.
Ideally, opinion leaders and persons affected by leprosy should be involved in these activities.
Special attention should be given to ensuring that information and programmes are reaching
women and girls, who may have reduced access to diagnosis and treatment due to cultural and
other barriers. Data should be disaggregated by gender to verify this.

Early case detection, accurate diagnosis and prompt treatment with MDT: Early case
detection and prompt treatment with 6-12 months’ MDT (dapsone, clofazimine and rifampicin)
continue to be the mainstay of effective leprosy control. Countries have varying approaches to
the integration of leprosy into healthcare systems.
WHO recommends integrated skin NTD strategies where feasible23, with active coordination in
all relevant aspects of planning, management, programme implementation and monitoring and
evaluation. In line with goals related to universal health coverage, mapping tools should be used,
and surveillance systems developed, at sub-national as well as national level, to ensure
detection of sporadic and hidden cases and monitor progress.
Leprosy programme managers should engage with dermatologists, private practitioners and
Access to comprehensive, well-organised referral facilities: Well-organised referral systems should
provide access to suitably resourced facilities that can manage reactions, offer wound care, deal with other
complications such as damage to the eye, supply assistive devices such as tailor-made footwear along
with training and advice on self-care, and offer reconstructive surgery with associated physiotherapy
services.
Careful attention should be given to ensuring equitable access to services by women and girls and, where
necessary, supporting the costs of travel to the referral centre. A good understanding of referral pathways
is essential, along with efficient communication between primary health units and referral services.

Diagnosis and management of leprosy reactions, neuritis and disabilities: During MDT treatment, a
significant proportion of patients experience complications such as leprosy reactions and nerve damage
leading to new grade-1 (loss of sensation) and/or grade-2 disability (visible impairments). Health staff need
training in nerve function assessment to recognise and treat or promptly refer signs and symptoms of
leprosy reactions and neuritis.
Well-organised referral systems should provide access to suitably resourced facilities that can manage
reactions, offer wound care, deal with other complications such as damage to the eye, supply assistive
devices such as tailor-made footwear along with training and advice on self-care, and offer reconstructive
surgery with associated physiotherapy services.
Careful attention should be given to ensuring equitable access to services by women and girls and, where
necessary, supporting the costs of travel to the referral centre. A good understanding of referral pathways
is essential, along with efficient communication between primary health units and referral services.
Mental wellbeing through basic psychological care and therapeutic counselling:
Leprosy frequently causes emotional distress in affected persons and their family
members and carers, and this can sometimes lead to more severe mental, neurological
and social problems.
Psychological care should be available at all points of care, supported by referral to
therapeutic counselling and other services promoting mental wellbeing. These services
play a crucial role in enabling persons affected by leprosy and their family and
community members to better understand the diagnosis and its impact, cope with
stigma-related events and provide a supportive environment.

Repeal or amendment of discriminatory laws: Laws and regulations allowing

discrimination against persons affected by leprosy should be repealed or amended
without delay and replaced with positive regulations and policy frameworks that facilitate
the inclusion of persons affected in the community.
There should be use of available tools to collect data on the level of social exclusion in
selected communities, and monitor over time to assess the impact of stigma reduction
strategies. Official processes should be in place to register and take action on reports of
discriminatory behaviour.
Interventions and processes to reduce and monitor leprosy-related stigma in
communities:
Stigma and discrimination against persons affected by leprosy and their families are almost as
old as recorded history. Effects may include social exclusion, loss of income, reduced access to
healthcare and education, and reduced mental well-being.

Changing beliefs and prejudices is not easy, though school children may be more receptive than
adults to messages about changing behaviour and attitudes. Reduction in community prejudice
promotes early detection of leprosy and improves acceptance of diagnosis and adherence to
treatment and self-care practices.

Access to social support and rehabilitation:

Persons affected by leprosy should be encouraged and supported to form self-help groups,
ideally including other persons with disabilities or facing social exclusion, for mutual support and
resilience, advocacy, and the development of livelihoods and socioeconomic advancement.

Initiatives should also be taken to nurture, support and strengthen the capacity of regional and
national community-based organisations and networks of persons affected by leprosy, so that
they can provide meaningful engagement on issues relevant to them at all decision-making
 COMMUNITY ENGAGEMENT MODELS
Effective community engagement is crucial for successful leprosy control. Here are
several community engagement models and strategies that have been employed
globally:
Community-Based Rehabilitation (CBR):
Model: Integrates leprosy services into existing community structures, involving affected
individuals in decision-making and promoting self-reliance.
Approach: Empowers individuals through skill development, education, and social
inclusion, reducing stigma and fostering community support.

Self-Help Groups (SHGs):

Model: Brings together people affected by leprosy to provide mutual support and
empowerment.
Approach: Encourages members to share experiences, access information, and
collectively address common challenges, promoting a sense of community and reducing
isolation.
Community Health Workers (CHWs):
Model: Trains local community members to serve as health advocates and
educators within their communities.
Approach: Enhances awareness, early detection, and adherence to
treatment, leveraging trusted community members to bridge gaps between
healthcare services and the community.

Mobile Health Campaigns:

Model: Utilizes mobile technology to disseminate information and provide
support.
Approach: Sends SMS messages, app-based resources, or telemedicine
services to improve awareness, encourage treatment adherence, and
facilitate communication between healthcare providers and individuals
affected by leprosy.
School-Based Education Programs:
Model: Integrates leprosy education into school curricula.
Approach: Raises awareness among students, teachers, and
parents, reducing stigma and fostering a more informed and
supportive community.

Participatory Learning and Action (PLA):

Model: Involves communities in identifying and solving problems
collaboratively.
Approach: Engages community members in discussions, decision-
making, and planning, ensuring that interventions are culturally
appropriate and address specific community needs.
Media and Advocacy Campaigns:
Model: Uses traditional and digital media for awareness
campaigns.
Approach: Engages mass media, including radio, television, and
social media, to disseminate accurate information, challenge
stereotypes, and reduce stigma associated with leprosy.

Community Events and Celebrations:

Model: Incorporates leprosy awareness into local events and
celebrations.
Approach: Promotes inclusivity and normalizes the presence of
individuals affected by leprosy, fostering positive community
attitudes.
Cultural Sensitivity Workshops:
Model: Addresses cultural beliefs and practices related to leprosy.
Approach: Conducts workshops to sensitively discuss cultural
perceptions, dispel myths, and encourage acceptance and support
within the community.

Collaboration with Faith-Based Organizations:

Model: Partners with religious institutions and leaders.
Approach: Utilizes religious platforms to disseminate information,
reduce stigma, and mobilize community support for leprosy control
initiatives.
 Chapter 8: Recommendations
• In light of the current status of leprosy as a low endemic
disease, its focalised occurrence, and dwindling resource
allocation by government, it is imperative that the programme
be re-organised to take these emerging realities into account.
To optimise efficiency and effectiveness, there is need to
undertake careful mapping of the disease at the LGA level
across the country. This will help in resource allocation as well
as rational targeting of special interventions like periodic
intensified case- finding exercises (mini-LECs).
• The integration of leprosy into the NTD programme provides an
opportunity to leverage resources for its control and needs to
be maximised
• The National Leprosy Technical Working Group needs to be strengthened
and made more functional.
• Zonal referral centres should be identified and strengthened with
competent teams and budgetary provision for running costs. These
centres could be responsible for specialised care including rehabilitative
and reconstructive surgery. Setting appropriate and patient-friendly
referral systems should be negotiated in consultation with representatives
of people affected by leprosy under the platform of IDEA.
• All stakeholders must continue to facilitate the empowerment of the
various IDEA chapters while constantly reminding government of the
unfinished business of leprosy control in the country.
• Other measures with potential benefit for leprosy control include improved
engagement of dermatologists as well as creative pre-service orientation
of medical students, nursing students and students of schools of health
technology
• To improve quality of care in the short and medium term, the
national TB/leprosy guidelines should be revised to incorporate
validation of diagnosis of new cases, relapsed cases and cases
of reaction. Using the ubiquitous mobile phone technology for
registration of new patients and follow-up of treatment should be
explored.
• All stakeholders must continue to support the training and
retraining of National, State and LGA TBL staff and other health
workers in the diagnosis and proper management of leprosy
 Chapter 9: Conclusion
In conclusion, leprosy, a disease with a long history and significant public health
implications, continues to be a challenge in Nigeria. Despite the progress made in
reducing incidence and prevalence rates, certain geographic and demographic hotspots
persist. The National Leprosy Elimination Program (NLEP), in collaboration with
international organizations, has implemented key strategies and interventions to combat
this disease.

The availability and accessibility of Multi-Drug Therapy (MDT) have played a crucial role
in the treatment of leprosy. However, early detection and diagnosis remain critical to
preventing the spread and mitigating the impact of the disease.

While there have been success stories and best practices in leprosy control, particularly
in certain regions and programs, challenges persist. These include socio-economic
factors, stigma, and the need for sustained community engagement.
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3.Nigeria – Leprosy Mission International.

https://www.leprosymission.org/about-us/global-fellowship/nigeria/.
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https://leprosymissionnig.org/about/.

5.Leprosy & Tuberculosis Relief Initiative, Nigeria – LTR Nigeria.

https://www.ltrnigeria.org/.

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