Enhance active and early case detection: Three pronged strategy, (i) Leprosy Case Detection Campaigns (LCDC) (specific for high endemic districts), (ii) Focussed Leprosy Campaigns (FLC) (for hot spots, such as rural and urban areas where G2D case is detected in low endemic districts), (iii) Special plan for case detection in Hard To Reach Areas (HTRA).

Enhance early reporting of cases: (i) Sparsh Leprosy Awareness Campaign (SLAC) (ii) ASHA Based Surveillance for Leprosy Suspects (ABSULS).

Prevention of leprosy amongst contacts: Post Exposure Prophylaxis (PEP) administration to contacts.

Overall strengthening of the programme with special emphasis on monitoring and feedback: (i) Nikusth: an online reporting system with patient tracking mechanism, (ii) G2D case investigation.

To detect cases in the community early, through active case search and early case reporting.

To prevent leprosy and interrupt transmission of disease in the community.

To strengthen the National Leprosy Eradication Programme, India.

Leprosy Case Detection Campaigns (LCDC): In order to supplement the efforts of the state and eliminate leprosy from high endemic areas, LCDCs were initiated in high endemic districts since the year 2016. The criteria for defining high endemic districts initially was a prevalence rate of more than 1∕10,000 population during any of last three years; this was later changed to G2D rate among new cases of more than 3% and an absolute number of G2D cases of more than 2 during the last reporting year.

This is a unique initiative in which house to house visits were conducted by trained search teams including both female and male volunteers to enable physical examination of both the sexes: male by male volunteers and females and children (above 2 years) by female volunteers, in a well-lit room, with minimal clothing to maintain privacy. The suspects were identified as per the case definition of suspects given in the guidelines, followed by confirmation by the MO, PHC. Various committees were formed at each administrative level, National, State, District, Block to plan and implement the LCDCs. Intensive Information Education and Communication (IEC) activities, through various media, were conducted before and during each LCDC. Focused training was provided to health functionaries working under NLEP at each administrative level.

During LCDC days, physical examination of each community member was performed by a trained search team composed of one male and one female volunteer. The search team was responsible for covering a population of 1000 in 14 days, through house-to-house visits as per prearranged micro-plans. Supervision of house-to-house search activities was done through identified field supervisors. Continuous, systematic collection and compilation of reports from the search teams and supervisors was followed through predesigned formats. Central monitors paid visits to States as representatives of the Central Leprosy Division (CLD) to monitor the implementation of the campaigns. The evaluation of LCDCs was performed by independent evaluators identified by the CLD.3,4

Focussed Leprosy Campaigns (FLC): Reporting of even a single G2D case indicates that cases are being detected very late and there may be several hidden cases in the community. Hence, any village or urban area in a low endemic or non-LCDC district, where even a single G2D case is detected, is to be considered as a hot spot. In these hot spots in low endemic districts, which are not selected for LCDC, house-to-house visits within 15 days of the G2D case being identified, are conducted by Accredited Social Health Activists (ASHA) or Multi Purpose Workers (MPW), to examine each resident of the households of the area. The suggestions for case search in different areas are:

Special plan for case detection in Hard To Reach Areas (HTRA): A Hard To Reach Area (HTRA) is an area where it is difficult to establish a good surveillance system for leprosy. In HTRAs it is difficult for a health worker to go and work, and also community members themselves are not able to reach health care institutions to avail services, due to geographical, administrative, political or other reasons.

In order to address the specific healthcare needs of HTRAs, it is suggested that customised village or urban unit plans are prepared. The implementation of HTRA plans in each HTRA unit (there may be several in any urban or rural area) is to be ensured through a specific local HTRA team. HTRA teams are composed of a nodal person who is identified by the local health system and community members who are identified by the nodal person. HTRA units with identical special needs may be assembled as a cluster by States or Union Territories (UT)s. Further, informal Planning, Sensitization and Training workshops for all HTRA teams, preferably within a cluster, are conducted by the State with an emphasis on suspect identification as per the suspect case definition, being followed under NLEP; other topics covered in the training include the proper flow of information, the supply of multi-drug therapy (MDT) and other logistics. After the training, routine HTRA teams identify suspects and refer to local medical practitioners for confirmation. The treatment completion and management of complications is to be ensured through regular supply of MDT to HTRA teams and the establishment of a referral system.

Sparsh Leprosy Awareness Campaigns (SLAC): In order to reduce stigma and discrimination, the Sparsh Leprosy Awareness Campaign (SLAC) was introduced and launched on 30th January, 2017 – World Leprosy Day and also Martyrs’ Day of Mahatma Gandhi ji. It became an annual activity wherein nationwide IEC activities targeted to enhance early case detection were conducted through special village level meetings organized by Gram Panchayat (executive committee of Gram Sabha), in cooperation with allied sectors of the health department. Every year the event is organized with a different theme. Major activities conducted in village meetings are given below:

ASHA Based Surveillance for Leprosy Suspects (ABSULS): ABSULS is a routine activity introduced in 2017 with the following objectives:

Accredited Social Health Activist (ASHA) workers, who are representatives of the community to the health system and accountable for the health conditions of approximately two hundred households, are asked to submit the number of suspects identified during the previous month with their signature in the monthly meetings. The surveillance reports submitted by the ASHAs are compiled by the Medical Officer (MO) at the Primary Health Centre (PHC) (usually block level) and submitted to the District Leprosy Officer (DLO). All DLOs submit the block’s compiled reports to the State Leprosy Officer (SLO) and the final surveillance report is submitted by each SLO to CLD. This information is validated through field visits by the immediate supervisor at each level, by random selection. This active surveillance by the community itself and validation even of the absence of cases by the health system, is the gold standard to ensure routine early detection of leprosy cases, mostly without disability.9

After confirmation of a case, the MO PHC informs the Multi-Purpose Worker (MPW) of the concerned Sub-Centre (SC) to take the necessary action.

The MPW visits the house of the confirmed case, along with the ASHA and takes consent from the case regarding identity disclosure and PEP administration to contacts of cases.

Household and close contacts will be identified and screened for leprosy after taking informed consent; any suspect will be referred to the MO for confirmation.

All contacts other than those suspected for leprosy will be screened for any exclusion criteria. Eligible contacts to be administered with PEP after consent.

In case any contact is not available at home, exclusion criteria will be assessed with the help of family members by MPW and prophylactic dose will be handed over to the ASHA, who will take informed consent before administration. In all cases, the administration of PEP is to be directly observed.

Records to be maintained at each level for final submission to CLD.10

NIKUSTH: Nikusth is an online reporting system with a patient tracking mechanism launched by the then Health & Family Welfare Minister, Government of India, which will roll out in all blocks of the country in a phased manner. In this system, data entry at the peripheral level is done, using a comprehensive reporting format formed and digitalised to enable entry into the Nikusth software, for recording and reporting of cases detected through ABSULS, LCDC or otherwise. The strengthened implementation of Nikusth after enabling data entry from all blocks in due course will lead to effective monitoring and patient tracking, creation of a database of cases, early data analysis and prompt feedback.

Under the present reporting system there is a time lag of around 3 weeks to 1 month, but with the introduction of online reporting, the reports will be available as and when the entry is done by peripheral health staff. It is under development during the current time period.

G2D case investigation: States or UTs are advised to investigate all new G2D cases being reported to the healthcare system, within 15 days of reporting. A format for interview of G2D cases has been designed to find out the factors responsible for the delay in reporting. Understanding the most frequent reasons for delay will help in planning better interventions under the programme. It will help in mapping problem areas and defining priorities for appropriate interventions.

The G2D rate among new cases decreased from 4.48/ million population on 31st March, 2015 to 2.65/million population, on 31st March, 2019 which is historically now at its lowest level (Figure 2).

The percentage of child cases among all new cases decreased from 9.04% in 2014–15 to 7.67% in 2018–19, (Figure 3), historically at its lowest level, which suggests that transmission of the disease is being reduced.