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. 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 non-medical costs for each approach were calculated. 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 identified 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 significantly different among household and neighbor contacts [odds ratios (OR) = 1.4, 95% confidence 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 significantly different 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) (χ2 = 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) (χ2 = 0.8, df = 1, P = 0.7). BCG vaccination with scar presence had a significant protective effect against leprosy (OR = 0.42, 0.22–0.81). The most effective case identification 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 findings suggest that hidden cases, recent transmission, and late diagnosis in the community exist and highlight the importance of early case detection.

中文翻译：

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评估尼泊尔六个地区的活动性麻风病例识别方法

自2009年以来，尼泊尔已经实现并持续消除了麻风这一公共卫生问题，但占尼泊尔人口41%（10,907,128）的17个区和3个省尚未消除这种疾病。儿科病例和 2 级残疾 (G2D) 分别表明近期传播和晚期诊断，这需要积极和早期的病例检测。进行这项业务研究的目的是确定最适合早期病例检测的方法，确定基于社区的麻风流行病学，并及早发现隐藏的麻风病例并及时治疗。在尼泊尔麻风病负担最严重的两个省份——马德什省（全国病例占 40%）和蓝毗尼省（18%）以及马德什省、蓝毗尼省和巴格马蒂省的高危监狱人口中，开展了积极的病例发现工作。病例发现是通过以下方式进行的：（1）对弱势人群进行挨家挨户走访（n = 26,469）；（2）接触者检查和追踪（n = 7608）；(3) 对尼泊尔马德什省、蓝毗尼省和巴格马蒂省的监狱人口 (n = 4428) 进行筛查。计算每种方法的每个病例的直接医疗和非医疗费用。接触者追踪的新病例检出率最高（250 例），其次是每 10 万人筛查中的挨家挨户访问（102 例）和监狱筛查（45 例）。然而，每宗确诊病例的成本最便宜的是挨家挨户探访 [尼泊尔卢比 (NPR) 76,500/例]，其次是接触者追踪（NPR 90,286/例）和监狱筛查（NPR 298,300/例）。逐户追踪和接触者追踪病例少杆菌/多杆菌 (PB:MB) 比例分别为 59:41 和 68:32；男女比例分别为 63:37 和 57:43；两种方法中儿科病例均为 11%；和 2 级残疾 (G2D) 分别为 11% 和 5%。家庭和邻居接触者之间以及 MB 病例与 PB 病例接触者之间（OR = 0.7，95% CI 0.26- 2.0）。MB病例（0.32%，95% CI 0.07–0.94%）和PB病例（0.13%，95% CI 0.03–0.73）的家庭接触者之间的发病率没有显着差异（χ2 = 0.07，df = 1，P = 0.9） ）以及 MB 病例（0.23%，0.1–0.46）和 PB 病例（0.48%，0.19–0.98）的邻居接触者（χ2 = 0.8，df = 1，P = 0.7）。存在疤痕的情况下接种卡介苗对麻风病具有显着的保护作用（OR = 0.42，0.22-0.81）。这里最有效的病例识别方法是接触者追踪，其次是对弱势群体进行挨家挨户访问和在监狱中进行筛查，尽管挨家挨户访问的成本较低。研究结果表明，社区中存在隐藏病例、近期传播和晚期诊断的情况，并强调了早期病例发现的重要性。