|Year : 2022 | Volume
| Issue : 1 | Page : 7-11
Assessment of hidden leprosy cases in North Karnataka by leprosy case detection campaign – A mixed-method study
Ooviya Jayaseelan, Deepti M Kadeangadi, MS Shivaswamy
Department of Community Medicine, J. N. Medical College, Belagavi, Karnataka, India
|Date of Submission||17-May-2021|
|Date of Decision||29-Jul-2021|
|Date of Acceptance||21-Aug-2021|
|Date of Web Publication||24-Jan-2022|
Dr. Deepti M Kadeangadi
Department of Community Medicine, J. N. Medical College, Belagavi, Karnataka
Source of Support: None, Conflict of Interest: None
BACKGROUND: Leprosy, also known as Hansen's disease, is a chronic infectious disease, caused by Mycobacterium Leprae. India and Indonesia contributed 92% of the South-East Asia Region's caseload.
AIM: The aim of this study is to identify leprosy cases in the general population by active surveillance.
MATERIALS AND METHODS: As a part of the leprosy survey, the teams comprised healthcare workers and volunteers who performed house-to-house survey and examined all the household members to identify any suspects with hypopigmented and hypoanesthetic patches. The suspects were examined by the medical officer. Clinically suspected leprosy patients were then referred to the district hospital for laboratory confirmation.
RESULTS: Of the 123 screened individuals, 62.5% of the suspects were aware of the presence of skin lesions (hypopigmented patch), 45.8% of them noticed the presence of patch or patches 3 months before this survey. Six of 123 were clinical suspects of leprosy, 83.3% were aware of the availability of treatment for leprosy in the primary health center. Only three among the six knew that leprosy is completely curable. All six had social stigma about leprosy.
CONCLUSION: Despite many awareness campaigns on leprosy, social stigma on leprosy is still prevalent. Healthcare workers need to educate the general population about the modes of spread, availability of the treatment, and myths/false beliefs on leprosy.
Keywords: Leprosy, leprosy case detection campaign, social stigma
|How to cite this article:|
Jayaseelan O, Kadeangadi DM, Shivaswamy M S. Assessment of hidden leprosy cases in North Karnataka by leprosy case detection campaign – A mixed-method study. Indian J Health Sci Biomed Res 2022;15:7-11
|How to cite this URL:|
Jayaseelan O, Kadeangadi DM, Shivaswamy M S. Assessment of hidden leprosy cases in North Karnataka by leprosy case detection campaign – A mixed-method study. Indian J Health Sci Biomed Res [serial online] 2022 [cited 2022 Jul 2];15:7-11. Available from: https://www.ijournalhs.org/text.asp?2022/15/1/7/336309
| Introduction|| |
Leprosy, also known as Hansen's disease, is a chronic infectious disease caused by Mycobacterium Leprae. It is transmitted by droplets from the nose and mouth, during close and frequent contact with the untreated cases. It mainly affects the skin, peripheral nerves, mucosa of the upper respiratory tract, and eyes.
South-East Asian Region accounted for 71% of the new leprosy cases globally. India and Indonesia contributed 92% of the region's caseload. The WHO epidemiological report 2018 reported that of 208,641 global new leprosy cases reported, 120,334 cases were reported from India. Thus, India contributed to about 58% of new cases reported globally.,
The WHO target for elimination of leprosy ≤1/10,000 population, which India achieved in the year 2005. A significant increase of leprosy cases was recorded in 50 districts among seven states in India. Leprosy case detection campaign (LCDC) was launched by the Central Leprosy Division, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. LCDC is a unique initiative under the National Leprosy Control Program.
The first phase of LCDC was conducted in seven states namely Maharashtra, Jharkhand, Bihar, Chhattisgarh, Uttar Pradesh, Madhya Pradesh, and Orissa, between March and April 2016 which showed increasing in the number of leprosy cases with the prevalence rate of 1–1.32/10,000 populations in many districts of the country., There was a continuous increase of ANCDR (annual new case detection rate) in the Belagavi district. Two hundred and fifty-eight leprosy cases were detected in the year 2018–2019 and 192 cases were detected from April to December 2019.
The campaign aimed to identify leprosy cases in the general population by active surveillance. Separate case detection campaign was perceived by the National Leprosy control program mainly for active case detection because of the rise in caseload. State Health and Family Welfare Department of Karnataka state found that there had been a consistent rise in the number of new cases in five districts namely Belagavi, Chitradurga, Haveri, Chamarajanagar, and Koppal. Hence, the survey was carried out in these districts.
Our study aimed to identify the hidden leprosy cases in the community by active case finding through LCDC and in turn to save leprosy-affected person from developing physical disability.
| Materials and Methods|| |
A Community-based cross-sectional study with mixed-method design.
The LCDC was conducted by the Ministry of Health and Family Welfare Government of India throughout the Belagavi district. In this study, we have included the population residing in the rural field practice areas of Kinaye and Vantamuri and the urban field practice areas of Rukmini Nagar and Ashok Nagar which are under the administration of the Department of Community Medicine, Jawaharlal Nehru Medical College. All the age groups from the study area were included in the study. The house-to-house survey was conducted among residents in the study area.
Qualitative data were collected from the clinical suspects of leprosy. Six clinically suspected leprosy patients were taken as Key informants (K). K1, K2-from one rural healthcare and training center (RHTC), K3-urban healthcare and training center (UHTC), K4-from another RHTC, K5, K6-from another UHTC.
Population of all the age groups residing in the study area was included in the study. Patients who are on multidrug treatment for leprosy and houses which were found to be locked on three consecutive visits, during the house-to-house survey were excluded from the study.
A total of 34,792 households with 183,845 people were surveyed. Medical Officers and Health Supervisors underwent district-level training about LCDC. Medical officers then trained the ASHAs (Accredited Social Health Activists), anganwadi workers, and community volunteers to identify the cases in the field practice areas.
Each team had one health worker (ASHA/anganwadi worker) and one volunteer most preferably, male. 117 teams were formed, from 2 PHCs and 2 UHCs for continuous 14 days, from November 2019 to December 2019. 25 households/day/team– target was covered between 7 a.m. and 11 a.m. during the house-to-house survey.
The teams performed house-to-house survey and examined all the household members by using a predesigned checklist to identify the suspects with hypopigmented and hypoanesthetic patches. The checklist contained few details which the team members needed to look for, i.e. hypo/hyperpigmented skin lesions, hypoanesthetic patches, and scaling should not be present over the skin lesion(s).
Houses which were covered by the team was marked as– L. Households which were locked or if at least one household member was not screened, those houses were marked as– X. After three consecutive visits also, if the particular household member(s) remained absent for the survey, such houses were marked as X. X houses which successfully covered, on the next visits were converted into L (X→L). Health supervisor(s) and medical officer(s) visited the survey sites to supervise and to identify and resolve any difficulties that were encountered during the survey.
34,792 Households – 1,83,845populations of 2 PHCs and 2 UHCs
117 Teams × 14 Days
Identified leprosy suspects (n = 123)
Clinically suspected leprosy cases (n = 6)
Referred to the district hospital for further confirmation
Interaction with the patients to find out the reasons for not consulting any healthcare worker
The clinically suspected leprosy cases who were identified during the house-to-house survey were asked to come to the primary health center covering that area on the same day of the survey. Detailed history and examination of the suspects were done by the postgraduates of the department of community medicine who were posted at that time and it was counter-checked by the medical officer. Examination comprised evaluation of hypo/hyperpigmented patches or reddish patches with sensory examination over the skin lesions for the definite sensory deficit; palpation of peripheral nerves on the wrist, elbows for nerve thickening with the loss of sensation and weakness or paralysis of corresponding muscles.
In the second phase, after the survey, qualitative data were collected from six suspected leprosy cases using key informant interviews with a semi-structured interview guide. The interview lasted for 10 min with each patient.
Coding was done using the triangulation process and analyzed using Microsoft Excel. Descriptive data were expressed in frequency and percentages.
The Institutional ethics committee clearance was obtained for the study. Informed written consent was obtained from all the study participants before each interview. Ethical Clearance was obtained from JNMC Institutional Ethics Committee on Human Subjects Research, J.N.Medical College, Belagavi, India with Ref no MDC/DOME/334 dated 24.12.2019).
| Results|| |
Out of 183,845 populations who were screened, 123 suspects were identified by the healthcare teams and brought to the PHC/UHC for further examination by the postgraduates and medical officers. The medical officers examined the suspects and excluded other skin conditions such as dermatitis, pityriasis alba, and tinea versicolor.
Of the 123 suspects, 62.5% were women, 34.1% of the participants were between 31 and 50 years of age. 24% of the suspects had an education less than primary schooling. Forty-six percent of the suspects belonged to Class IV (lower middle socioeconomic class) as per modified BG Prasad classification and 37.5% were housewives [Table 1].
|Table 1: Sociodemographic characteristics of the study participants (n=123)|
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About 62.5% of the suspects were aware of the presence of skin lesion (hypopigmented patch), 45.8% of them noticed the presence of patch 3 months before this survey, but they did not consult any doctor for their condition or discuss with a healthcare worker. About 37.5% of the suspects were unaware of the presence of patches in their bodies. About 66.7% and 56.3% had itching and scaling respectively, which clearly indicated that the suspects were free from leprosy and instead, were suffering from other skin diseases. About 25% of the suspects had erythema around the skin lesion(s) [Table 2].
|Table 2: Symptoms and signs among the suspects detected by the teams (n=123)|
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[Graph 1] shows the differential diagnosis made by the medical officers among the suspects brought by the teams after screening them. About 48% of the suspects had fungal infections-tinea versicolor, tinea corporis, pityriasis versicolor, and treatment were started accordingly. About 30% of the 123 suspects were suffering from dermatitis and 5.5% of the suspects had symptoms of leprosy.
Six patients, who had shown the symptoms of leprosy, were interviewed using a semi-structured interview guide. In-depth interview was conducted among these clinically suspected patients (the possibility of becoming leprosy positive is >50% among these six clinically suspected patients).
Five of six patients knew at least one symptom of leprosy. About 83.3% were aware of the availability of treatment for leprosy in the PHC/UHC. Only three among these six knew that leprosy is completely curable. All six had social stigma about leprosy [Table 3]. Most of the population belonged to SES– III, IV as per modified B. G. Prasad's classification and the majority of the population had an educational status below High school.
|Table 3: Knowledge about leprosy among clinically suspected leprosy subjects (n=6)|
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K1 mentioned– “I am really worried. By chance, if I become leprosy positive, people will start avoiding me and they will not socialize like before.”
K2 revealed that- “All people are still having social stigma of leprosy.”
K3 mentioned– “I am aware of the availability of treatment for leprosy, even then, I am worried about the people around me who will start neglecting me if I become positive.”
K4 mentioned– “I am worried about my family, they may send me out of the home if I become leprosy positive.”
K5 mentioned that- “I am scared of losing my job if I turned out to be leprosy positive.”
K6 Said- “I know few symptoms of leprosy, but I thought the skin lesion will not be due to leprosy.”
| Discussion|| |
The LCDC was an attempt on pilot basis to involve the general health care staff in NLEP by utilizing ASHA workers and male volunteers to find out leprosy cases/suspects by the house-to-house survey. Passive mode of case detection was followed to identify the leprosy cases before the initiation of LCDC. Then, it changed into an active case detection campaign. The first phase of LCDC was conducted only in seven endemic states in India. Active surveillance was carried out to identify more cases hidden in the community who were not seeking health care and were hesitant to visit the health care centers.
Of the total population residing in the area, 90% of the population was screened. Another 10% were screened because few participants migrated to other places; few participants were working in the field and were not available during the survey period. Few of them were very resistant and did not allow the healthcare workers to examine them even after proper counseling about the screening. Since the screening was conducted between 7 a.m. and 11 a.m., allotted teams were able to meet most of the households before they left for their workplace. The survey team found 123 suspects, of which six were clinically suspected as leprosy; later these six patients were referred to district hospital for lab investigation to confirm leprosy diagnosis.
These six clinically suspected patients' laboratory reports came as negative for leprosy. Among these six patients, two were diagnosed as annular erythematous plaque, one was diagnosed with vitiligo, two were diagnosed with fungal infection, and one was diagnosed with granuloma annulare. Trainings, microplanning, and field activities were conducted according to LCDC, but there was a negligible chance of missing the actual leprosy case in the unscreened population. The present study shows that social stigma about leprosy is prevalent. Since most of the people did not have higher education and belonged to a lower socioeconomic status, this could be a reason as to why they have stigma and worry about discrimination regarding leprosy.
Patients who had tested negative for leprosy were educated about the mode of spread, signs and symptoms, availability of treatment, stigmas, and they were advised to approach any health-care workers if they develop any signs and symptoms of leprosy in the future.
| Conclusion|| |
Although India was declared as a leprosy-eliminated country, there was a rise in leprosy cases in some states of the country. LCDC was an active community-based case detection campaign to identify the missing cases in the community. Strengthening of the public health system at the ground level is a key strategy to identify and treat the patients. Healthcare workers are already educating the general population about the mode of spread, availability of treatment, and eliminating false beliefs on leprosy through this campaign. This campaign provides important information and health education on leprosy but still, there is an underlying social stigma which ensues in the community.
We thank the THO, DHO, Principal, and HOD of the Community Medicine department for their administrative support. We thank all the medical officers and all PHC/UHC staffs, volunteers, and also to all the study participants for their support throughout this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]