Background Nepal has achieved and sustained the elimination of leprosy as a public health problem since 2009,but 17 districts and 3 provinces with 41%(10,907,128)of Nepal’s population have yet to eliminate the diseas...Background Nepal has achieved and sustained the elimination of leprosy as a public health problem since 2009,but 17 districts and 3 provinces with 41%(10,907,128)of Nepal’s population have yet to eliminate the disease.Pediatric cases and grade-2 disabilities(G2D)indicate recent transmission and late diagnosis,respectively,which necessitate active and early case detection.This operational research was performed to identify approaches best suited for early case detection,determine community-based leprosy epidemiology,and identify hidden leprosy cases early and respond with prompt treatment.Methods Active case detection was undertaken in two Nepali provinces with the greatest burden of leprosy,Madhesh Province(40%national cases)and Lumbini Province(18%)and at-risk prison populations in Madhesh,Lumbini and Bagmati provinces.Case detection was performed by(1)house-to-house visits among vulnerable populations(n=26,469);(2)contact examination and tracing(n=7608);in Madhesh and Lumbini Provinces and,(3)screening prison populations(n=4428)in Madhesh,Lumbini and Bagmati Provinces of Nepal.Per case direct medical and nonmedical costs for each approach were calculated.Results New case detection rates were highest for contact tracing(250),followed by house-to-house visits(102)and prison screening(45)per 100,000 population screened.However,the cost per case identifed was cheapest for house-to-house visits[Nepalese rupee(NPR)76,500/case],followed by contact tracing(NPR 90,286/case)and prison screening(NPR 298,300/case).House-to-house and contact tracing case paucibacillary/multibacillary(PB:MB)ratios were 59:41 and 68:32;female/male ratios 63:37 and 57:43;pediatric cases 11%in both approaches;and grade-2 disabilities(G2D)11%and 5%,respectively.Developing leprosy was not signifcantly diferent among household and neighbor contacts[odds ratios(OR)=1.4,95%confdence interval(CI):0.24-5.85]and for contacts of MB versus PB cases(OR=0.7,95%CI 0.26-2.0).Attack rates were not signifcantly diferent among household contacts of MB cases(0.32%,95%CI 0.07-0.94%)and PB cases(0.13%,95%CI 0.03-0.73)(χ^(2)=0.07,df=1,P=0.9)and neighbor contacts of MB cases(0.23%,0.1-0.46)and PB cases(0.48%,0.19-0.98)(χ^(2)=0.8,df=1,P=0.7).BCG vaccination with scar presence had a signifcant protective efect against leprosy(OR=0.42,0.22-0.81).Conclusions The most efective case identifcation approach here is contact tracing,followed by house-to-house visits in vulnerable populations and screening in prisons,although house-to-house visits are cheaper.The fndings suggest that hidden cases,recent transmission,and late diagnosis in the community exist and highlight the importance of early case detection.展开更多
文摘Background Nepal has achieved and sustained the elimination of leprosy as a public health problem since 2009,but 17 districts and 3 provinces with 41%(10,907,128)of Nepal’s population have yet to eliminate the disease.Pediatric cases and grade-2 disabilities(G2D)indicate recent transmission and late diagnosis,respectively,which necessitate active and early case detection.This operational research was performed to identify approaches best suited for early case detection,determine community-based leprosy epidemiology,and identify hidden leprosy cases early and respond with prompt treatment.Methods Active case detection was undertaken in two Nepali provinces with the greatest burden of leprosy,Madhesh Province(40%national cases)and Lumbini Province(18%)and at-risk prison populations in Madhesh,Lumbini and Bagmati provinces.Case detection was performed by(1)house-to-house visits among vulnerable populations(n=26,469);(2)contact examination and tracing(n=7608);in Madhesh and Lumbini Provinces and,(3)screening prison populations(n=4428)in Madhesh,Lumbini and Bagmati Provinces of Nepal.Per case direct medical and nonmedical costs for each approach were calculated.Results New case detection rates were highest for contact tracing(250),followed by house-to-house visits(102)and prison screening(45)per 100,000 population screened.However,the cost per case identifed was cheapest for house-to-house visits[Nepalese rupee(NPR)76,500/case],followed by contact tracing(NPR 90,286/case)and prison screening(NPR 298,300/case).House-to-house and contact tracing case paucibacillary/multibacillary(PB:MB)ratios were 59:41 and 68:32;female/male ratios 63:37 and 57:43;pediatric cases 11%in both approaches;and grade-2 disabilities(G2D)11%and 5%,respectively.Developing leprosy was not signifcantly diferent among household and neighbor contacts[odds ratios(OR)=1.4,95%confdence interval(CI):0.24-5.85]and for contacts of MB versus PB cases(OR=0.7,95%CI 0.26-2.0).Attack rates were not signifcantly diferent among household contacts of MB cases(0.32%,95%CI 0.07-0.94%)and PB cases(0.13%,95%CI 0.03-0.73)(χ^(2)=0.07,df=1,P=0.9)and neighbor contacts of MB cases(0.23%,0.1-0.46)and PB cases(0.48%,0.19-0.98)(χ^(2)=0.8,df=1,P=0.7).BCG vaccination with scar presence had a signifcant protective efect against leprosy(OR=0.42,0.22-0.81).Conclusions The most efective case identifcation approach here is contact tracing,followed by house-to-house visits in vulnerable populations and screening in prisons,although house-to-house visits are cheaper.The fndings suggest that hidden cases,recent transmission,and late diagnosis in the community exist and highlight the importance of early case detection.
