Leprosy Elimination Coping With Insidious Challenges

In human history, Neglected Tropical Diseases (NTDs) are emerging priorities in the global health agenda. While the NTDs continue to disproportionately affect the poorest sections of the society, poor health systems, inadequate water, sanitation and hygiene services in the low-income countries have been the most persistent challenges in prevention and care. Leprosy is one of the age-old NTDs. The human face of leprosy is alarming. According to World Health Organisation (WHO), this chronic infectious disease is primarily caused by a type of bacteria called Mycobacterium leprae. It affects skin, peripheral nerves, mucosa of the upper respiratory tract, and eyes. It is curable and the treatment in the early stages can prevent disability. 

Nepal is committed to the elimination of leprosy as a public health problem. National Leprosy Strategy (2021-2025) has an ambitious target of elimination of leprosy in the country. One of its strategic objectives is to enhance capacity building through training of health workers particularly at the peripheral health facilities. In this context, Leprosy Control and Disability Management Section at Epidemiology and Disease Control Division (EDCD) is coordinating a range of technical partners to provide support for leprosy affected people and their families in the area of social rehabilitation and management. 

Prevention strategy

However, effective implementation of relevant polices, strategies, guidelines and protocols are vital for ensuring leprosy prevention and treatment services at the health facilities and communities. Despite significant progress in clinical case management, more consistent efforts are still needed to further strengthen leprosy surveillance system, supervision, monitoring and evaluation at all levels. This will not only enhance prevention strategy, but also help manage leprosy complications, disability prevention and rehabilitation in the health facilities and communities.   

To this end, strong political commitment is crucial to mobilise adequate domestic resources for leprosy elimination. Health system strengthening should be a priority agenda for political parties and relevant stakeholders to eliminate leprosy in an integrated approach. Meaningful engagement of people affected by leprosy and their networks is necessary to combat prejudice, social discrimination, stigma, and hence ensure protection and promotion of human rights. Therefore, people affected by leprosy and their families are historically facing social, cultural, economic and emotional challenges that have profound effects on their livelihoods for years. 

More notably, social exclusion, loss of income, limited access to healthcare and education, and reduced mental well-being are some of key problems faced by the people affected by leprosy across the country. Unfortunately, provisions of early case detection, diagnosis and prompt treatment facilities are still inadequate in remote areas. Therefore, people affected by leprosy are enormously suffering from social, cultural, economic, emotional and psychological problems as well as disabilities due to delay in treatment and care. Moreover, there is limited access to social support and rehabilitation services at local level.     

Leprosy prevention and treatment interventions should give high priority to vulnerable populations including women, children, migrants, the elderly, and those who are poor, socially marginalised and living in remote areas. Local governments can mobilise more resources to ensure provisions for community-based rehabilitation services which will empower people affected by leprosy for enabling livelihoods and inclusion in the social protection services. More importantly, there are limited efforts of coordination and collaboration with relevant partners to accelerate the progress in eliminating the leprosy. There is limited access to comprehensive referral facilities at local level. 

The role of civil society is significant to reduce leprosy related social discrimination and stigma that are deeply embedded in many communities, including healthcare settings, and result in exclusion and denial of human rights. Apart from this, there are critical research gaps in the area of inclusive approaches in community-based rehabilitation and stigma reduction. There are limited evidences on more effective models to active case detection in different socio-cultural and geographical contexts. There are no comprehensive systematic reviews and studies conducted so far to assess the overall impact of case finding and contact tracing strategies and disabilities. Extra efforts are needed to build the evidence base for better policies, strategies and programmes. 

Cross-border coordination

Therefore, it is high time to progressively implement integrated country-owned zero leprosy roadmaps at all levels. While sectors such as health, education and social development can share responsibilities in leprosy related prevention activities, advocacy within and across ministries is crucial to create synergies in ensuring overall well-being of people affected by leprosy. Again, cross-border coordination and collaboration is necessary to ensure continuity of care and the interruption of the transmission. Evidences suggest that contact tracing is the most useful tool for finding new cases. Therefore, there are critical needs to scale up active case-finding campaigns in targeted populations such as areas of higher endemicity, hard to reach, or among at-risk groups.

Undoubtedly, such campaigns are helpful to encourage early self-referral and promote positive attitudes towards persons affected by leprosy. Eventually, the community-led interventions will help empower the targeted populations to access and utilise the leprosy related prevention, treatment and care services at all levels. To sum up, consistent advocacy with federal, provincial and local governments is necessary to sustain and increase domestic funding for elimination of leprosy across the country. While there are emerging needs to enhance the capacity of front-line health workers in screening, case finding and treatment, it is also crucial to ensure social inclusion and easy access to health care services in the health facilities and communities. 

(PhD in global health, Bhandari writes on health and development issues.)