- Multi-stakeholder involvement of DSs, GNDs, edu. sector required
Conducting monthly satellite clinics in high-endemicity areas is a strategy to identify new cases of leprosy, while the continued multi-stakeholder involvement of officials at the Divisional Secretariats (DSs), the Grama Niladhari (GN) Divisions, and the education sector is required for new case detection in high-risk communities.
These recommendations were made in a report titled “Usefulness of outreach clinics on active case detection of leprosy in a high-endemic area in Sri Lanka”, which was authored by K. Kalubowila, C. Gajanayaka, C. Hapudeniya, and S. Anujan (all four attached to the Office of the Regional Director of Health Services [RDHS], Colombo), I. Kahawita (attached to the Anti-Leprosy Campaign [ALC]), L. Jayarathna (attached to the District Hospital, Lunawa), S. Vithanage (attached to the Medical Officer of Health [MOH] office, Egoda Uyana), M. Thilakarathna (attached to the MOH office, Moratuwa), and J. Gunathilaka (attached to the MOH office, Ratmalana) and published in Journal of the College of Community Physicians of Sri Lanka 29(2) in August, 2023.
Leprosy is a chronic infectious disease prevalent worldwide. In 2020, there were 127,558 new cases detected globally, including of 8,629 children below 15 years, reporting a new case detection rate of 4.4 per million children. According to the World Health Organisation, among the new cases, 7,198 were detected with Grade Two disabilities (visible deformity or damage), with a new Grade Two disabilities rate of 0.9 per a population of one million.
Leprosy stats in SL
Sri Lanka, according to the ALC’s “Leprosy surveillance system”, reached the leprosy elimination target in 1995 with a reduction of the number of cases by less than one person per population of 10,000. However, H. Weerakoon, H. Banduwardana, R. Ranawaka, P. Bandara, U. Kumara, N. Ariyarathna, and J. Warnasekara’s “Sociodemographic factors, treatment-seeking behaviours and common clinical presentations of leprosy patients in Anuradhapura” found that approximately 2,000 cases are reported annually in Sri Lanka. Last year (in 2022), the incidence of leprosy in Sri Lanka was 0.77 per a population of 10,000. Further, out of the 1,325 patients diagnosed, 154/11.6% were below 14 years of age. Case detection was the highest in the Batticaloa, Gampaha, and Colombo RDHS areas, where 214, 206, and 194 cases were reported, respectively. Although about 250 cases are usually detected in the Colombo RDHS area, the new case detection had declined due to Covid-19.
One-third of them were detected in the Moratuwa DS area, representing 50 new cases in 2022. According to this estimation, 300 new cases need to be identified in the Moratuwa DS this year (in 2023), after adding the cases undetected due to the Covid-19 pandemic to the yearly estimate. Although the mapping of index cases from 2001 to 2021 had shown pockets of leprosy endemics, the extent of such hidden leprosy remains unexplored, thus, it is important to improve case detection in high endemic areas.
Kalubowila et al.’s study looked at the District Hospital, Lunawa. The study identified GN Divisions in the most prevalent MOH areas known for a high prevalence of leprosy, such as Egoda Uyana, Moratuwa, and Ratmalana, by mapping the leprosy cases from 2001 to 2021. A discussion was held initially with the district team, including the RDHS, the Consultant Community Physician, the Medical Officer – Epidemiology, and the Public Health Inspector (PHI) – Leprosy Control, to conduct a satellite clinic to achieve a high level of case detection.
Interventions
The Mayor of the Moratuwa Municipal Council and religious leaders advocated clinic attendance to identify leprosy patients. The community was informed through the public address system and by public health officials to attend the skin clinic if they presented with any undiagnosed dermatological condition. With the support of the District Medical Officer attached to the District Hospital, Lunawa, all essential medicines to treat common skin problems were arranged from the Regional Medical Supplies Division – Colombo. The initial screening was done by the MOH or Medical Officer – District Hospital, Lunawa, to identify leprosy cases, and the suspected patients were seen by the consultant dermatologist attached to the ALC who visited the satellite clinic.
A total of 54 persons were screened at the satellite clinic held on 21 December 2022. The majority was aged 25-45 years (42.9%) followed by those aged 45-60 years (25%). Two-thirds (66.7%) were female. Patients already diagnosed with leprosy did not attend the clinic. Two patients were diagnosed as having leprosy, giving a yield of 0.37 per 10,000 persons screened. One of them was clinically diagnosed at the clinic, while the other became positive out of the five suspected patients who were referred for skin biopsy. Contacts were screened and followed up by PHIs.
Even if leprosy is a slow infectious disease, it can spread in significant numbers in high-risk communities. At the end of 2015, leprosy was eliminated from almost all countries including Sri Lanka, as noted in F. Naaz, P.S. Mohanty, A.K. Bansal, D. Kumar, and U.D. Gupta’s “Challenges beyond elimination in leprosy”. The yield of active case finding as 0.37 per 10,000 persons screened is lesser compared to the incidence reported in 2022 for Sri Lanka. This difference can be attributed to the higher denominator which was used to calculate the national value compared to the number of people who attended the clinic. However, this screening showed the remaining pockets of high endemicity at the Moratuwa DS.
The most diagnosed patients belonged to the Egoda Uyana MOH area (39/72.2%), where most cases were detected in the RDHS Colombo. This could be due to overcrowding, the lack of awareness regarding the disease, and the high transport cost preventing them from seeking medical advice for skin conditions. Thus, the establishment of satellite dermatology clinics in these areas to improve accessibility is highly recommended.
Both patients confirmed as having leprosy being males could be due to the fact that the disease is more common in the male population. Therefore, it is rational to increase awareness among young males in high-risk areas to attend skin clinics if they have suspected lesions. Most persons referred to the clinic were from the Egoda Uyana MOH area (72.2%), followed by the Moratuwa MOH area, denoting that providing awareness about leprosy prior to vigilant screening is essential.
Leprosy is a curable disease, and therefore, by strengthening medical care and improving awareness, a sustainable change in the lives of individuals, families, and communities can be created. Hence, public health officials need to empower individuals and families to rise above the stigma associated with leprosy.