Mycobacterium leprae is the cause of leprosy, a chronic infectious disease that mostly affects peripheral nerves. Early diagnosis and treatment of leprosy can avoid impairment as it is a curable illness. Since December 2009, Nepal has successfully eliminated leprosy as a public health problem, with a declaration of complete elimination in 2010. Eleven local levels in Nepal's Jhapa district have a high prevalence of leprosy (more than one case per 10,000 populations) 13 years after the disease was declared. To eliminate leprosy locally, immediate actions that must be taken include quality health services, active case surveillance, identification, and management.
Elimination, Leprosy, Nepal
Leprosy, also known as Hansen’s disease, is a chronic infectious disease caused by Mycobacterium leprae . The disease mainly affects the skin, the peripheral nerves, mucosal surfaces of the upper respiratory tract and the eyes. Leprosy is known to occur at all ages ranging from early infancy to very old age. Leprosy is curable and treatment in the early stages can prevent disability [1]. Leprosy is often known as social disease [2]. Leprosy is curable with a combination of drugs known as multidrug therapy, as the treatment of leprosy with only one anti-leprosy drug (monotherapy) will result in development of drug resistance to that drug [2]. Nepal has achieved the elimination of Leprosy as a public health problem in December 2009 and declared elimination in 2010 [3]. Out of 77 districts of Nepal, 7 districts reported zero prevalence, 56 districts had a prevalence rate < 1 case per 10,000 population and 14 district exceeded prevalence rate of more than one case per 10,000 population.
At the end of Nepali Fiscal Year (FY) 2079/80 (2022/23), a total of 2,523 new leprosy cases and 2,510 leprosy cases were receiving Multi Drug Therapy in Nepal, which makes a registered prevalence rate of 0.8 cases per 10,000 populations at the national level [4]. Among seven provinces of Nepal, Koshi Province of Nepal have total population of 5,045,132 with new case detection rate per 1,000,000 population was 9.93 and 0.9 prevalence rate per 10,000 population. The percentage of child among new cases was 6.6% and 11.3% of Grade 2 Disability (G2D) among new cases [4].
Jhapa is one of the eastern districts of Nepal which lies in Koshi Province surrounded with south and eastern part of district by Indian state Bihar and West Bengal respectively. Jhapa district is among those 14 districts with prevalence rate more than one case per 10,000 populations. Kapilvastu district accounts for highest prevalence of leprosy in Nepal followed by Dhanusa district. Jhapa district accounts for 1.6 case per 10,000 populations [4].
According to annual report of FY 2078/79 (2021/22), health office Jhapa; Arjundhara municipality, Shivasatakshi municipality, Kamal Rural municipality, Damak municipality, Gauriganj Rural municipality, Jhapa Rural municipality, Barhadashi Rural municipality, Birtamod municipality, Haldibari Rural municipality, Bhadrapur municipality, Kachanakawal Rural municipality have prevalence of > 1 case per 10,000 population. Among these local level, Bhadrapur municipality accounts for highest proportion of cases with prevalence of 2.4 cases per 10,000 population and the total number of cases detected in Bhadrapur was 17 [5].
Nepal Leprosy Elimination Program (NLEP) is guided by National Roadmap for Zero Leprosy (2021-2030) and National Leprosy Strategy (2021-2025) with the vision of Leprosy free Nepal. Based on NLEP current approaches are multi-drug therapy for cases, basic leprosy training for health care workers in high endemic districts, review meeting of Leprosy control programme, Information Education and Communication in electronic, print media and advocacy to boost community awareness and stigma reduction. Diagnosis and treatment of cases, contact tracing, 70 th World Leprosy Day celebration, and transport support to released from treatment cases. Recording, reporting, update and case validation was carried out in Jhapa district. Furthermore, development partners also support for leprosy included case detection, treatment, rehabilitation and research.
Inadequate awareness, unfavorable attitude and stigma create a hindrance to leprosy control. Additionally, open boarder with India might be the reason for high prevalence of Leprosy in Jhapa district.
Literature shows progress made in terms of Leprosy elimination has relied in multiple strategies [6].
Political commitment from federal and local level leaders of Jhapa district, implementation of program and strategies for Leprosy elimination, equitable access to quality diagnosis and treatment service to grassroot level, disability care to affected person are the urgent steps to be taken.
Focusing on active surveillance system to monitor and evaluate elimination activities. Extensive contact screening and cover contact with 100% chemoprophylaxis. Contact tracing should not only focus on household contact but it should be extended to entire neighborhoods. Expansion and continuation of Leprosy Post-Exposure Prophylaxis in high-endemic districts.
Special fund for leprosy should allocate by central, provincial and each local level of Jhapa district which should primarily focus on prevention, treatment of case along with rehabilitation.
Formation of Leprosy committee at local level, extensive training to health care workers, health education to residence of Jhapa district, recording and reporting of case, re-appointment of Tuberculosis/Leprosy officer in district with high Leprosy cases, establishment of 10-15 bed Leprosy hospital with skilled based rehabilitation services.
Uninterrupted supply of multi-drug therapy.
Recording and timely reporting of affected cases along with disability requiring rehabilitation.
These multiple leprosy approaches will ultimately lead in improved health. Furthermore, three tiers of government are opportunity for local level to run Leprosy elimination program according to the need of Jhapa district. Stigma and social discrimination are the key challenges in early diagnosis and management of cases. For this, involvement of Leprosy affected person as social mobilizer or counselor may lead to increase service utilization by newly diagnosed case. Open boarder with India is another challenge, health desk and case identification at entry point would help in early diagnosis and management of case. Dapsone resistance might be upcoming challenges in Leprosy elimination, so combination of multi drug therapy under close follow up should commence.
Different promotive, preventive, curative and rehabilitative activities are being carried out at Jhapa district. Awareness to health care workers and local population through Information Education and Communication materials, leprosy day celebration, prophylaxis medicine distribution, contact tracing, rehabilitation activities are being carried out. Jhapa district should work on active case detection, contact tracing, prophylaxis treatment with primary focus on promotive and preventive activities for elimination of Leprosy in ward level. Furthermore, extensive survey of prevalent cases and timely management is required for complete elimination of Leprosy from Jhapa district.