Leprosy Eradication Programme Research Articles

Identification of Drug and Vaccine Target in Mycobacterium leprae: A Reverse Vaccinology Approach

Mycobacterium leprae, an infectious agent of chronic infection so-called Leprosy. It is a prime healthconcern in various countries including India. India is currently running one of the extensive leprosy eradication programs in the globe, named as the National Leprosy Eradication Program (NLEP). Still, the situation is getting substandard because of the emergence of resistant strains. In the present study, newer approaches –like computational subtractive proteomics and reverse vaccinology has been applied in order to find out probable drug targets and vaccine candidates. The systematic workflow of the current study consists of a computational approach, where complete proteome of the bacteria is gradually reduced to find out few unique probable drug targets and reverse vaccinology, to find out probable vaccine antigens. Reverse vaccinology approach does not require a pathogen to be grown in the laboratory, encouraging its application to microorganisms that may not be easily cultivated like M. leprae but at least have an accessible genome sequence. This approach facilitates an easier and productive process ofantigen discovery. Results from the present study could facilitate selecting M. leprae proteins for drug design as well as vaccine production pipelines in the future.

Genotyping of Mycobacterium leprae in a Son-and-Father Pair of Patients Indicated the Possible Mode of Leprosy Transmission: a Case Report

Abstract One of the success indicators of the World Health Organization (WHO) leprosy eradication program is the decreasing number of new cases of pediatric leprosy with a grade 2 disability. A case of borderline lepromatous (BL) leprosy with partial claw hand in a 13-year-old boy was reported. On physical examination, we found claw fingers on the fourth and fifth fingers of the left hand accompanied by hypoesthetic erythematous plaques on both cheeks. The patient also presented with the enlargement of bilateral great auricular, ulnar, and peroneal nerves. The bacteriological examination showed the bacterial index 3+ and morphological index 35%. The results of histopathological and serological anti-phenolic glycolipid-I examinations supported the diagnosis of BL type of leprosy. Genotyping of Mycobacterium leprae by variable number tandem repeat of the patient showed 24 copies thymine-thymine-cytosine that were similar to his father, who had been diagnosed with leprosy 12 years before, without adequate therapy. The result indicated the possibility of leprosy transmission from the father to a son. This case report revealed the presence of leprosy in children with a multibacillary infection who have been living with leprosy family members. Genotyping seems to be feasible for epidemiological analysis of leprosy transmission.

Mandating nerve biopsy: A step towards personalizing therapy in pure neuritic leprosy.

Pure neuritic leprosy (PNL) accounts for 5% to 10% of leprosy patients who usually present with asymmetrical neuropathy in the absence of lepra bacilli on slit-skin smears. However, nerve biopsies in PNL lack appropriate categorization in current immunologic terms. We aimed to classify nerve biopsies according to the immune spectrum of leprosy and assess the role of histologic classification of nerve biopsies in treating PNL. Patients from two tertiary care referral centres were enrolled in this incident case study. Patients presenting with mononeuropathy and multiple mononeuropathies presumably with leprosy, without skin lesions, underwent nerve biopsy and slit-skin smear examination. Amongst 78 patients with mononeuropathy, 38 were diagnosed with leprosy on nerve biopsy. Leprosy was classified as tuberculoid in 16, lepromatous in 5 and borderline in 17 patients. Lepra bacilli were present in 15 biopsies. On comparing histologic subtypes with number of nerves involved clinically, a significant number of cases with single nerve involvement showed multibacillary (BB, BL or LL) histology and vice versa. Nerve biopsy helps in diagnosing patients presenting with PNL and aids in classifying it to customize the treatment for best results. Current treatment recommendations for PNL from WHO and National Leprosy Eradication Program are based on clinical assessment only, which are likely to result in inconsistent treatment and possibly relapse in cases where histomorphology shows disparity. Inclusion of nerve biopsy to guide therapy in patients with PNL is suggested.

KNOWLEDGE OF SLUM COMMUNITY TOWARD LEPROSY: A CROSS-SECTIONAL SURVEY FROM KARAD URBAN BLOCK OF WESTERN MAHARASHTRA, INDIA

Objectives: The objectives of this study are to assess the knowledge of urban slum community toward leprosy and to determine the relationship between sociodemographic variables and knowledge about leprosy.Methods: The study was planned during September 2016 to October 2016, as a community-based cross-sectional survey conducted at Karad urban slum area of state Maharashtra, India. The sample size calculated was a total of 246 slum community members, aged 20–60 years, enrolled randomly and interviewed by utilizing pre-tested structured pro forma. Data collected were analyzed and presented in tabular form. Chi-square test was used to determine the association between study variables.Results: A total of 246 respondents were interviewed of which maximum 42.2% were in the age group 30–40 years. The problem of illiteracy was 25.6% and maximum 67.4% were engaged in daily wage labor force. The overall knowledge about leprosy was poor responded by more than half (55.6%) of the study participants. Maximum, 78% slum dwellers knew about leprosy disease, whereas their knowledge about the cause of disease, sign, and symptoms, infectivity and curability was around 50%. Maximum 68% of participants responded that disease is confined to poor people. The age, education, and occupational status of slum dwellers were significantly associated with knowledge about leprosy.Conclusion: The present study concluded that poor knowledge of slum community toward leprosy could be an important determinant of poor performance of the National Leprosy Eradication Programme at urban community.

Ribonucleotide reductase as a drug target against drug resistance Mycobacterium leprae: A molecular docking study

Leprosy is a chronic infection of skin and nerve caused by Mycobacterium leprae. The treatment is based on standard multi drug therapy consisting of dapsone, rifampicin and clofazamine. The use of rifampicin alone or with dapsone led to the emergence of rifampicin-resistant Mycobacterium leprae strains. The emergence of drug-resistant leprosy put a hurdle in the leprosy eradication programme. The present study aimed to predict the molecular model of ribonucleotide reductase (RNR), the enzyme responsible for biosynthesis of nucleotides, to screen new drugs for treatment of drug-resistant leprosy. The study was conducted by retrieving RNR of M. leprae from GenBank. A molecular 3D model of M. leprae was predicted using homology modelling and validated. A total of 325 characters were included in the analysis. The predicted 3D model of RNR showed that the ϕ and φ angles of 251 (96.9%) residues were positioned in the most favoured regions. It was also conferred that 18 α-helices, 6 β turns, 2 γ turns and 48 helix–helix interactions contributed to the predicted 3D structure. Virtual screening of Food and Drug Administration approved drug molecules recovered 1829 drugs of which three molecules, viz., lincomycin, novobiocin and telithromycin, were taken for the docking study. It was observed that the selected drug molecules had a strong affinity towards the modelled protein RNR. This was evident from the binding energy of the drug molecules towards the modelled protein RNR (−6.10, −6.25 and −7.10). Three FDA-approved drugs, viz., lincomycin, novobiocin and telithromycin, could be taken for further clinical studies to find their efficacy against drug resistant leprosy.

Current Situation of Leprosy in India and its Future Implications.

The global leprosy situation has changed significantly over the last four decades after the introduction of multidrug therapy (MDT) in 1982 with a reduction in prevalence from over 5 million cases in the mid-1980s to less than 200,000 at the end of 2016. The programme in India also saw a reduction from a prevalence rate of 57.8/10,000 in 1983 to less than 1/10,000 by the end of 2005 when India declared to have reached the World Health Organization (WHO) target of elimination as a public health problem. Post 2005, major changes in the programme were made by the National leprosy eradication programme (NLEP) and the global leprosy programme, which may have affected the new case detection (NCD), disability, and child leprosy trends, which continue to show no appreciable regression. This article reviews the current global and Indian leprosy scenario to bring out its achievements and successes, including the impact of Leprosy Case Detection Campaigns (LCDC) on leprosy numbers. The basis and expected benefits of recent introduction of chemo and immune-prophylaxis in the programme are also discussed. It also discusses the shortcomings, the areas of concern, and the need for an inclusive strategy in the Indian leprosy programme that includes an intersectoral collaboration within the country for reaching the desired goal of leprosy eradication.

Childhood leprosy in the postelimination era: A vision achieved or a concern growing at large

Background: The proportion of childhood leprosy has been gaining importance of late as a performance indicator of the National Leprosy Eradication Program. A sizable proportion of the newly detected cases comprises children. The prevalence rate has been used as a measure of existence of infection though leprosy has attained elimination levels in the country. Materials and Methods: A retrospective descriptive study was conducted. Case records of children newly diagnosed with leprosy aged <15 years between April 2005 and October 2015 were studied and included in the study. Findings such as patches, nerve thickness, spectrum of leprosy, grade of deformity, smear status, presence of reaction, histopathological diagnosis, and treatment history were noted. Results: The percentage of childhood leprosy among the newly diagnosed cases in our study was found to be 11.2%. A solitary skin lesion was the most frequent manifestation in 64.4% children. The second most common finding seen in these patients included the presence of thickened nerves in 46.6% children. Smear showed acid-fast bacilli in 8.8% cases. Conclusion: There is an urgent need for improving clinical acumen in diagnosing childhood leprosy. The importance of appropriate and complete treatment along with meticulous surveillance in endemic areas and looking for household contacts needs to be stressed on.

National sample survey to assess the new case disease burden of leprosy in India.

A national sample survey of leprosy was undertaken in partnership with Indian Council of Medical Research (ICMR) institutions, National Leprosy Eradication Programme (NLEP), Panchayati Raj members, and treated leprosy patients to detect new cases of leprosy in India. The objectives of the survey were to estimate the new leprosy case load; record both Grade 1 and Grade 2 disabilities in the new cases; and to assess the magnitude of stigma and discrimination prevalent in the society. A cluster based, cross-sectional survey involving all States was used for the door-to-door survey using inverse sampling methodology. Rural and urban clusters were sampled separately. The population screened for detecting 28 new cases in rural and 30 in urban clusters was enumerated, recorded and analyzed. Data capture and analysis in different schedules were the main tools used. For quality control three tiers of experts were utilized for the confirmation of cases and disabilities. Self-stigma was assessed in more than half of the total new patients detected with disabilities by the approved questionnaire. A different questionnaire was used to assess the stigma in the community. A population of 14,725,525 (10,302,443 rural; 4,423,082 urban) was screened and 2161 new cases - 1300 paucibacillary (PB) and 861 multibacillary (MB) were detected. New case estimates for leprosy was 330,346 (95% Confidence limits, 287,445-380,851). Disabilities observed in these cases were 2.05/100,000 population and 13.9 per cent (302/2161) in new cases. Self-stigma in patients with disabilities was reduced, and the patients were well accepted by the spouse, neighbour, at workplace and in social functions.

Epidemiological perspective of National Leprosy Eradication Programme in Maharashtra: Focusing on “Tribal Hot-spot” of Tribal District

Background:Leprosy or Hansen's disease, a chronic infectious disease caused by Mycobacterium leprae is a serious public health concern because of associated case load, morbidity and stigma attached to it. India achieved elimination of leprosy as a public health problem (prevalence rate [PR]<1 case/10,000 population) at the national level on January 1, 2006, still 19% districts in the country report PR more than one. In Maharashtra, it is found that very few districts within the state or very few pockets within the district are actually having leprosy burden.Objectives:(1) Identification of region-wise actual “hot-spot” districts/pockets within state of Maharashtra.(2) Further drop-down below the district and block to tribal belt for understanding the actual high risk area/belt within the tribal districts.Methods:Secondary data analysis of leprosy patients registered in the State during the period 2008–2015.Results:PR per 10,000 was found more in Vidharbha region followed by rest of Maharashtra and then Marathwada. Analysis showed that, there are tribal districts and tribal area within tribal districts which are having higher leprosy burden as compared to the all other districts indicating need of allocation of programme funds and facilities to these tribal belts for the effective control and elimination of leprosy.Conclusion:National Leprosy Eradication Programme should focus on tribal belt for effective control. Without giving extra attention to these tribal areas within high risk district/pockets efforts of eradication of leprosy by 2018 would be unrealistic and impractical.

Spatial and temporal trends in new case detection of leprosy in India

India achieved the goal of ‘leprosy elimination’ by reducing the burden of leprosy to less than one case per 10,000 inhabitants in 2005. Sustained and committed efforts by national programmes have led to a decline in the burden of leprosy to a great extent. To examine the spatial clustering of leprosy case detection and spatiotemporal trend using Bayesian space period model. The National Leprosy Eradication Programme (NLEP) data of annual new case detection of leprosy in 34 districts of Maharashtra for eight data years 2007–08 to 2014–15. The presence of spatial dependency was assessed using the case detection rate for each of the eight data years spanning from 2007–2015 using Moran’s I statistic and the variation over space and time was modeled using the Bayesian Space Period model. The Moran’s I value was found to be statistically significant for each of the time period. The period effect was significantly higher than the average in the year 2007(4%), 2009(5%), 2011(6%), 2013(18%) and significantly lower than the average in 2008(7%), 2010(4%), 2012(11%), 2014(9%). The spatial effects varied between 0·579 and 1·52. There was a higher risk of leprosy (50% or more) found in districts of Garhchiroli, Raigad and Warda. The lowest risk of 0·579 was observed in the Nagpur district. The period effect of new case detection of leprosy using the SP model, measured in terms of relative risk shows a seesaw effect at work in districts of Maharashtra. The alternate jump in the risk of leprosy given by the model could be the actual scenario or due to expended activities in the study area. Further in depth investigation needed to ascertain the facts. Observing the spatial Bayesian effect districts Garhchiroli, Raigad and Warda are at greater risk and need priority care.

Evaluation of National Leprosy Eradication Program after Integration into General Health System in Rajkot District, Gujarat from 2003 to 2014.

Background:National Leprosy Eradication Program (NLEP) was launched in 1983 with the goal of elimination of leprosy as a public health problem.Aim:To evaluate the NLEP performance after integration into general health system from April 2003 to March 2014.Material and Methods:A retrospective record based study was conducted by obtaining data from Rajkot district leprosy center. Prevalence rate (PR), new case detection rate (NCDR), proportion of female cases, child cases, multibacillary (MB) cases, Grade II disability among new cases and release from treatment (RFT) cases were evaluated from April 2003 to March 2014 and analyzed by using Chi-square for trend analysis test.Results:The PR of leprosy per 10,000 populations was significantly declined (P < 0.001) from 0.44 in 2003–2004 to 0.15 during March 2014. Reduction in NCDR trend was statistically significant (P < 0.001). The proportion of female cases among newly detected cases showed fluctuation from 36.23% in 2003–2004 to 37.10% in 2013–2014 (P > 0.05). The proportion of child cases also showed significantly declining trend from 12.08% in 2003–2004 to 6.70% in 2013–2014 (P < 0.05). Significant number of MB cases decreased from 122 (2003–2004) to 69 (2013–2014) (P < 0.001). Grade II disability proportion was 1.45% in the year 2003–2004, increased to 5.2% in 2009–2010 and then again decreased to 3.4% in 2013–2014 (P > 0.05). Proportion of patients RFT showed fluctuation from 66.66% (2003–2004) to 45.68% (2009–2010) and then 64.66% (2013–2014) (P < 0.001).Conclusion:The NLEP is having a favorable impact on the problem of leprosy by maintaining the elimination level of leprosy in Rajkot district over a decade.

Report on a month course in clinical and surgical leprosy for undergraduate students of physiotherapy

The Leprosy Mission Community Hospital Shahdara, India is one of the tertiary care hospital and a referral centre for treatment of leprosy. The Leprosy Mission Hospital, is involved in the training of medical officers, nurses, physiotherapists and other medical and paramedical workers who are involved directly or indirectly under NLEP (National leprosy eradication programme). This report is on the 1 month training programme which is specifically designed for physiotherapists and undergraduate physiotherapy students. This report is based on the data which is collected from the training programme for undergraduate students of physiotherapy during January 2010 to December 2013. The main focus of the training programme was to give an overview of clinical and surgical leprosy. The name of this course was ‘One month training course for physiotherapists in clinical and surgical leprosy’.

Relapse and deformity among 2177 leprosy patients released from treatment with MDT between 2005 and 2010 in South India: A retrospective cohort study

To estimate the incidence of relapse among leprosy patients released after completing multi-drug therapy (MDT) during 2005-2010 under India's National Leprosy Eradication Programme in South India. We conducted a retrospective cohort study of leprosy patients who were released from treatment (RFT) with MDT during April 2005 and March 2010 in four purposely selected districts from South India. We clinically examined them for signs of relapse, persistence and deformity. We collected slit skin smears from those reporting signs of relapse or persistence. We computed relapse rate per 1000 person years by dividing the number of relapses by person years of follow-up and 95% confidence intervals (CI) for rates. We tracked 3791 RFT patients and examined 58% of them. The examined and those who were not examined were similar in terms of leprosy type, year of completing MDT and gender. We identified 58 relapses (relapse rate 6.1 per 1000 person years) among the examined. Majority of these relapses occurred within 3 years post-MDT. Eighteen (31%) of the relapsed patients had deformity. While low level of relapse indicates effectiveness of MDT, the burden of deformity is of concern. For maximizing treatment effectiveness and minimizing transmission, we recommend educating leprosy patients at treatment completion for self-monitoring of signs of relapse and advising them to visit nearby public health facilities or Community health workers for immediate evaluation and intervention.

Containing leprosy: Current epidemiological status, detection and management strategies, and experiences at a tertiary level center

Leprosy, an infectious disease, described since ancient times and endemic in India since then, has been eliminated (elimination defined as a prevalence of less than 1 case per 10,000 population) as a public health problem in December 2005. World Health Organization and National Leprosy Eradication Program (NLEP) have now focused on reducing the disease burden in the population. Data indicates that annual fresh case detection rate remains high with a high incidence of multibacillary cases. A review of present NLEP figures and those reported in a number of studies reflect a discordance and caution by dermatologists. A review of present policy, epidemiological status in the population, and our experience is presented. Data from Base Hospital, Delhi Cantonment, over the past 3 years, including patients treated as well as those on surveillance is presented. A higher incidence of paucibacillary cases was seen, with a high incidence of pure neuritic involvement (15%), reactions (24.7%), and deformities (28.37%). Tenosynovitis was observed with increasing frequency. Future challenges in containing the epidemic to reduce the disease burden in population will require regular assessment of treatment measures, especially the use of fixed drug therapy as well as rehabilitation of the affected. Dermatologists shall play a central role in any such endeavor in the management of this disease.

Psychiatric morbidity among inmates of leprosy homes.

Context:Leprosy affected people are having high psychological distress and it in turn leads to psychiatric disorders. There is a paucity of literature from our country in this significant health problem.Aims:The aim of this study was to find the prevalence of psychiatric morbidity and its association with sociodemographic and clinical factors among the inmates of leprosy homes.Settings and Design:Study sample was obtained from individuals residing in two leprosy homes of malwa belt of Punjab.Materials and Methods:In screening stage, the study subjects were administered sociodemographic proforma and general health questionnaire (GHQ-12). In the confirmation stage, the study subjects were interviewed in detail and disability assessment was done using World Health Organization disability scale. Final psychiatric diagnosis was made as per ICD-10 criteria's.Statistical Analysis:Statistical analysis was performed using the descriptive statistics, Chi-square test, analysis of variance, and correlation analysis.Results:Majority of the subjects was in the age group 41-50 years, female, married, illiterate, Hindu and were from nuclear families. Nearly, 50.38% of subjects were having GHQ-12 score more than twelve. Nearly, 55.6% subjects were having psychiatric disorders out of which a large number of patients was diagnosed as having dysthymia. The other psychiatric disorders found in the study population were moderate depressive episode, generalized anxiety disorder, mixed anxiety and depressive disorder and schizophrenia unspecified. Psychiatric morbidity was found to be significantly related to age, family status, and duration of leprosy illness and presence of deformities among inmates.Conclusions:This study highlighted that psychiatric disorders were found in a large number among inmates of leprosy homes. Leprosy eradication program must place specific emphasis on psychiatric care of these patients.

Patient satisfaction in national leprosy eradication programme

Background: Leprosy has been a literal scourge through the history of humanity and to eradicate the disease from high endemic countries need leprosy services to be sustained and they remain of good quality. Objective: The present study aimed for getting a reasonable impression of the client’s views on a range of quality aspects of leprosy services rendered by district leprosy control unit under national leprosy eradication programme(NLEP). Methodology: Cross- sectional study was conducted in Satara district of western Maharashtra, India among registered leprosy patients under district leprosy control unit during April -July2008. A sample of 25 % of registered leprosy cases were selected by random sampling method from primary health centers and urban leprosy control units to assess the patient’s satisfaction under the functioning of NLEP. After verbal consent, participants were interviewed at home site using pre-tested structured proforma include socio -demographic and patient satisfaction variables. Data collected was compiled and analyzed by using statistical software. Results: Patient’s overall level of satisfaction was very good i.e. 88.89% with max, 46.03% cases were from age group 35 to 52 years. Max, 47.61% cases were illiterate with high case detection rate, 52.38% was seen males. The proportion of multi-bacillary (MB) and pauci-bacillary (PB) cases was 65.07 % &amp; 34.92 % respectively. Most of the patients were satisfied with anti-leprosy drugs, health education and no physical deformity due to disease underline. 98.41 % patients were satisfied about follow- up and motivation services. Satisfaction about diagnosis of disease by doctors and starting of treatment was 96.82 % and 95.23 % respectively, however satisfaction with rehabilitative services was 14.28%. Significant statistical association was existed between age of leprosy affected cases and their level of satisfaction under NLEP services (?2=15.92,p &lt;0.05*). Conclusion: Elimination of leprosy and very good patient satisfaction towards leprosy services in Satara district indicates successfulness of NLEP. Bangladesh Journal of Medical Science Vol. 12 No. 03 July ’13 Page 305-309 DOI: http://dx.doi.org/10.3329/bjms.v12i3.15430

OA01. 30. Ayurveda gram yojna (AGY) - mainstreaming of health &amp; Ayurveda in rural area: An observational study

Purpose: To achieve the goal of good rural health the need of incorporation of Ayurveda was realized and Ayurveda Gram Yojna was implemented in Govt. Ayurveda Dispensary of Chhattisgarh. Aims were to achieve good public health in rural area, maintain lifestyle according to Ayurvedic regimen, promote cultivation and use of medicinal plants, control and prevent endemic diseases, make national health program successful in those villages. Method: A comparative study was done before and after implementation of AGY from 2009 to 2012 in Govt. Ayurveda dispensary, Gorpar village. Data was collected from the available reports and the records at the Govt Ayurvedic dispensary regarding the operational mechanism and utilisation of the services and their benefits under the AGY. All the data collected were critically analysed and expressed in means. Result: In Gorpar village AGY was implemented since 2009. Increase in number of patients visiting the dispensary old 147 to 301, Female 1126 to 1745, male 1365 to 2091 before and after respectively. Health camps done 0 and 11 (no. of patients 1156), Yoga camps done 0 and 2, school health camps done 0 and 11 (no of students treated 825), Ayurveda awareness camp done 0 and 3, Plantation of medicinal plant in village 0 and 128, training program for Mitanin 0 and 3 before and after respectively. Before implementation of this yojna there were endemic disease like diarrhea but after implementation there was no any endemic reported. After this yojna dispensary took part in national program like family control program, malaria and T.B. control program, leprosy eradication program. Conclusion: Upgrowing trend shows that Ayurveda gram yojna is effective program for improvement of rural heath through Ayurveda. Beside few shortcomings at the quality, quantity and adequacy of the system strength of the services through it, it has a large and positive impact on the rural health.

Elimination of leprosy &amp; possibility of eradication - the Indian scenario

Elimination of leprosy &amp; possibility of eradication - the Indian scenario

Internal evaluation of national leprosy elimination program in tribal Gujarat

Background:The government launched a National Leprosy Eradication program in 1983, to eliminate leprosy from India. A Modified Leprosy Elimination Campaign was started with the view to early case detection and treatment. In April 2004, a vertical program of leprosy was merged with the general health services and case detection was conducted by the general health workers in India.Materials and Methods:Internal evaluation of leprosy was done in the Panchmanal district of Gujarat through a rapid survey of the 10 Primary Health Care units in the high and low endemic areas. Active and passive surveillance data and records were verified according to the indicators.Results:Analysis of the data and record verification revealed that there was a decrease in the prevalence rate of leprosy, but it had not reached the elimination status. The MB ratio had decreased, but the child ratio remained consistent for the last five years. The disability ratio had also decreased in five years.Conclusion:The National Leprosy Elimination Program had a favorable impact, but at the same time to reach the elimination status there was a need for more stringent Information, Education, and Communication (IEC) activities to be promoted in the community. Active surveillance should be initiated so that hidden cases are not missed in the community.

Integration of Leprosy Elimination into Primary Health Care in Orissa, India

BackgroundLeprosy was eliminated as a public health problem (<1 case per 10,000) in India by December 2005. With this target in sight the need for a separate vertical programme was diminished. The second phase of the National Leprosy Eradication Programme was therefore initiated: decentralisation of the vertical programme, integration of leprosy services into the primary health care (PHC) system and development of a surveillance system to monitor programme performance.Methodology/Principal FindingsTo study the process of integration a qualitative analysis of issues and perceptions of patients and providers, and a review of leprosy records and registers to evaluate programme performance was carried out in the state of Orissa, India. Program performance indicators such as a low mean defaulter rate of 3.83% and a low-misdiagnosis rate of 4.45% demonstrated no detrimental effect of integration on program success. PHC staff were generally found to be highly knowledgeable of diagnosis and management of leprosy cases due to frequent training and a support network of leprosy experts. However in urban hospitals district-level leprosy experts had assumed leprosy activities. The aim was to aid busy PHC staff but it also compromised their leprosy knowledge and management capacity. Inadequate monitoring of a policy of ‘new case validation,’ in which MDT was not initiated until primary diagnosis had been verified by a leprosy expert, may have led to approximately 26% of suspect cases awaiting confirmation of diagnosis 1–8 months after their initial PHC visit.Conclusions/SignificanceThis study highlights the need for effective monitoring and evaluation of the integration process. Inadequate monitoring could lead to a reduction in early diagnosis, a delay in initiation of MDT and an increase in disability rates. This in turn could reverse some of the programme's achievements. These findings may help Andhra Pradesh and other states in India to improve their integration process and may also have implications for other disease elimination programmes such as polio and guinea worm (dracunculiasis) as they move closer to their elimination goals.