Globally, there are approximately 200,000 new cases of leprosy officially diagnosed each year, but in reality many more cases occur. Nearly 2 in 3 new cases are recorded in India. Leprosy Case Detection Campaigns in India are conducted by the National Leprosy Eradication Programme with the support of NGOs, and are the source of many detected and reported cases.
In terms of method, Leprosy Case Detection Campaigns use a methodology called Active Case Finding (ACF) as distinct from passive case finding. ACF is a door-to-door approach, examining everyone’s skin and feeling their peripheral nerves. This is not simple and can only be successfully executed by well trained staff. The success of ACF depends on a range factors that include adequate lighting during the skin examination, interpersonal communication, gender mix of the outreach team and, importantly, inclusion of the hard-to-reach.
Lepra has found that for every one identified case in a normal government Leprosy Case Detection Campaign, there were two cases missed in the same area, many of whom were women and people belonging to scheduled castes and tribes in hard-to-reach villages. This finding led Lepra to use its long experience in ACF.
The key feature of ACF is finding possible cases and referring them to a specialist who is able to diagnose cases by expert examination or an investigation such as a slit-skin-smear. Upon diagnosis, antibiotics are then administered to treat the leprosy and other medicines can be prescribed for reactions, neuritis and any other problems that may occur. In summary, it is not only finding possible cases, but also the referral to a suitably qualified and equipped specialist who is able to effectively treat them. ACF activity is therefore, by definition, an activity that can successfully link field work with clinical settings. It is the ACF team’s responsibility to follow-up with the person affected by leprosy and ensure they are receiving appropriate and adequate treatment.
Leprosy ACF would not be ethical if it did not include appropriate interventions to address any negative physiological, psychological and socio-economic impacts of leprosy. This is why Lepra’s ACF protocol gives guidance on an appropriate follow-up package that includes clinical, psychological and socio-economic components.
The aim of Lepra’s approach is to help control leprosy by detecting cases early, especially the infectious cases, and so reducing transmission and disability.
Rather than waiting for people to self-report to health services with signs and symptoms of leprosy, which risks late diagnoses, ACF uses outreach strategies to search for undiagnosed cases of leprosy and refer them for confirmation and treatment. Strategies include door-to-door campaigns such as Leprosy Case Detection Campaigns or more targeted strategies.
Lepra’s long field, clinical and research experience has shown that a combined active case finding approach, with carefully planned and executed implementation, can detect up to 300% more leprosy cases compared to Leprosy Case Detection Campaigns, with lower human resources and overall cost. This involves a three-pronged search comprising of Rapid Enquiry Survey, Contact Survey and Focal Survey (1).
A Rapid Enquiry Survey is a one-off house-to-house search used in contained, hard-to-reach areas such as urban slums or hilly areas; in high-risk industries such as brick making; or in high risk areas based on poverty, for example in villages with a high percentage of people living below the poverty line.
A Contact Survey complements a Rapid Enquiry Survey through examining household members of already confirmed leprosy cases for signs[GP2] and symptoms for leprosy. One way to implement this is to identify all people in an area diagnosed and treated with multidrug treatment in the previous five years. This information is typically available in drug registers.
A Focal Survey is a subset of a Contact Survey, focusing on Multibacillary cases, child cases and people with leprosy-related disabilities and examining 25 household surrounding these leprosy cases, in addition to their household members. This is because these three types of leprosy cases are known to be associated with higher transmission.
In addition, in some areas there are villages with highly vulnerable groups such as members of scheduled casts and tribes, who are traditionally missed by door-to-door searches. Special Searches can be employed for these groups, but not usually through house-by-house searches, instead through advertisement by megaphone and information campaigns thereby allowing people to voluntarily report to the team.
An integral part of comprehensive active case finding is the follow up of suspected cases, making sure they report to primary health centres for confirmation and free treatment. This is the key component of ACF that is usually missed, leading to under-reporting even after the case has been identified, and missed opportunities to manage leprosy and prevent disability.
Each identified case should have an opportunity to have their needs assessed and addressed. Some of the services that should be routinely available include morbidity management, disability prevention, complication management, provision of customised disability appliances, reconstructive surgery and social and psychological support.
After ACF and intervention, health services and communities are equipped to recognise signs and symptoms of leprosy and are able to utilise improved systems for referral, treatment, management, disability prevention and social and psychological support. Communities are able to self-organise and advocate for their own rights, support each other and help detect new cases.
At the top level, policy makers are left with a blue print of a self-sustaining model of leprosy detection, treatment and care.
1. Mangeard-Lourme JS, A.; Singh, R.K.; Parasa J.; De Arquer, G.R.; . Enhanced active case-finding, identifying leprosy cases missed by recent detection campaigns in Munger District, Bihar, India. Leprosy Review. 2017;88(4):452–62